Third Jab

T

This is the third Jab advice and this is not the same as booster advice.


Updated JCVI guidance for vaccinating immunosuppressed individuals with a third
primary dose


The Joint Committee on Vaccination and Immunisation (JCVI) has issued updated
guidance in relation to COVID-19 vaccinations for individuals aged 12 years and over with
severe immunosuppression. This letter sets out the actions we are asking systems to take
from today to begin vaccinating this group with a third dose as part of their primary
vaccination course by 13 September 2021.


The guidance states:


“At the current time, JCVI advises that a third primary dose be offered to individuals aged
12 years and over with severe immunosuppression in proximity of their first or second
COVID-19 vaccine doses in the primary schedule.

Severe immunosuppression at the time of vaccination is defined using the guidance [in Annex A] and timings stated below.”


“For those aged 18 years and over, JCVI advises a preference for mRNA vaccines
for the third primary dose

For those aged 12 to 17 years the Pfizer-BNT162b2 vaccine remains the preferred choice, as
set out in JCVI advice of 4 August 2021.” (Not sure why Moderna gives higher response than Pfizer)

“The specialist involved should advise on whether the patient fulfils the eligibility
criteria and on the timing of any third primary dose. In general, vaccines administered
during periods of minimum immunosuppression (where possible) are more likely to
generate better immune responses. The third primary dose should ideally be given at least
8 weeks after the second dose, with special attention paid to current or planned
immunosuppressive therapies guided by the following principles:
• where possible, the third primary dose should be delayed until 2 weeks after the period
of immunosuppression, in addition to the time period for clearance of the therapeutic
agent
• if not possible, consideration should be given to vaccination during a treatment ‘holiday’
or at a nadir of immunosuppression between doses of treatment”
It is important to note that JCVI have advised this forms part of the primary vaccination
schedule for an individual and therefore further advice will be provided on a booster
vaccination in due course for these individuals.

ACTIONS NOW REQUIRED
The vaccination of eligible individuals will require a co-ordinated approach between
primary and secondary care to ensure we are able to reach all eligible individuals in this
cohort.

Next steps: guidance for secondary care
We are asking all consultants to identify patients within their care who are in the
JCVI’s definition as being eligible for a third primary dose and to consider the
optimal timing for administering a third dose, based on the JCVI’s advice.
The full
list of eligible individuals is listed in Annex A and a template letter to issue to eligible
patients is in Annex B.
• Within this, it is recognised that for some individuals who are on regular, long term
immunosuppressive therapy or where the degree of immunosuppression is
relatively constant that the specific timing of vaccination is likely to be less
important. Such individuals do require vaccination.
If the individual is receiving care within a hospital that operates as a hospital hub
and there is available vaccine supply, we recommend the individual receives the
vaccine on site
in line with the consultant’s recommendation on timing.
• If it is not possible to offer the individual a vaccine on site, consultants should write
clear advice to the individual’s GP specifying the optimal timing and any interaction
with their current treatment
(a template letter can be found in Annex C). The
individual should then receive their vaccination through a PCN grouping-led site.

The Phase 1 & 2 Enhanced Service specification for general practice COVID-19
vaccinations contains provision for sites to follow JCVI guidance on the vaccination
requirements, including dose schedule, for different patient groups, and therefore
no change to this contractual document is required to enable PCN-groupings to
administer a third dose to these patients.
It is also recommended that individuals are reminded that household contacts of
those who are immunosuppressed are advised to be vaccinated. Individuals aged
17 ¾ and over can book via the National Booking System and children aged 12 and
over should speak to their registered GP practice, who will then invite them to
attend their GP-led Local Vaccination Service.
Further details are here for adults
and here for children aged 12-15.

• In parallel, we are asking all GP practices to identify individuals on their registered
list against the eligibility definition provided by the JCVI.
This will be supported by
provision of searches (we expect these to be available by the end of September),
but where practices can identify individuals themselves in advance of this, they
should.
Once these individuals have been identified, practices should offer them a third
primary dose through their PCN with consideration to the optimal timing and
interaction with any treatment as set out by the JCVI.

As above, those who are on regular immunosuppressive medication or have relatively stable immunosuppression can
be called for vaccination by PCNs 8 weeks since their first dose

.
• Practices that are not delivering the COVID-19 vaccination enhanced service
should share a list of eligible patients with their local commissioner so they can
arrange for these patients to be offered an appointment at another provider (e.g.
another PCN-led vaccination site or Hospital Hub) by 17 September. This request is
necessary for the reasons of public interest.

Recording a third dose in point of care systems
• We are working on a solution to be able to capture third doses in point of care
systems and will provide further information to systems w/c 6 September. We
expect this solution will be operationalised by 13 September ready to begin
vaccinating by then.

About the author

MouseDoctor

17 comments

  • Hit me up 🙂
    Though I don’t understand, how (if on Ocrevus) this will work any better if the first two didn’t generate a response (mine didn’t when I did the Roche Anti-SARS-CoV-2 (S) and had AZ)
    Are the mRNA working better than AZ for potential responses that can’t yet be measured?
    Also out of interest, do you think getting actual covid would create better protection going forward for someone on continuous treatment like Ocrevus, rather than vaccines, or would we have the same response to it as we have to the vaccines?

    • Much like AZ, mRNA will only really work with at least partially reconstituted B-cells. Whether or not T-cells do much seems mostly unclear.

      FWIW, I had Pfizer 8 months after the last ocrelizumab infusion and did not seroconvert. Then had another Ocrevus infusion – might have waited longer had we known about delta 😐

  • Timely. Thanks for that. Particularly as I’m due my next infusion next week.

    After my positive antibody result at the weekend, I am starting to wonder if I am your gold dust participant that made antibodies 6.75 months after the previous dose of ocrelizumab 😉

    If so, I am a little surprised bearing in mind I’d probably still qualify for a third jab as my lymphocytes haven’t been above 1 in a long time. They were all of 0.7 at the time of the last infusion, a month after the second jab. They’d hit the dizzying heights (for me) of 0.9 the previous time they were tested.

  • Thanks for flagging this up MD as found it easily online to have a read of.
    Does look as if a lot of us will be scooped up via the list on Annex A.
    Those of us with lymphopaenia are included and spotted mention of rituximab.
    Hope therefore the roll out in conjunction with the flu jab happens soon; though hating the thought of yet more pressure on the NHS!

    • I think you are supposed to have at least 2-3 weeks between the flu jab and covid vaccination.

      My mum lives in NZ. Because they’ve just been through winter she had to have her flu jab at the start of winter then wait for her covid jab (yes, that means at 73 she only had her second dose a few weeks ago – her region had a really slow roll out)

    • In Australia where flu season and start of Covid-19 vaccine rollout coincided, the recommendation was initially 14 days between flu (or any other vaccine)and wither Covid-19 dose. This was mainly to be able to isolate any adverse effects to Covid-19 or flu vaccine. This has now Ben reduced to y days between a Covid-19 and any other vaccine.

  • Can someone help by creating a guide/ table as Professor G did when COVID first started, or direct me to one, if it already exists?

    I have just finished the second does of cladribine and I am keen to understand how long I need to wait before dose 3 of the c19 vaccine and also the flu jab. Perhaps there are more than one answer.. I.e optimal time/ minimum time

    Thanks

    • There is a questio if there is not minimal time, but I would avoid jab shortly after the second monthhly dose 2-3 months after that and there is avery good chance of a response

  • Can we mix the vaccines and could this have a better chance of protection then? My blood test showed 0.4 at last infusion if relevant. I am a social worker who is being pressured into carrying out home visits to new clients and concerned about the risk or maybe just overacting?

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