Third vaccine dose for those with severe immunosuppression

COVID-19 is a very infectious respiratory disease which can cause serious illness in people who have a severely weakened immune system (severe immunosuppression). If you are an individual who has a severely weakened immune system due to an underlying health condition or medical treatment you may not have made a good immune response to the first two doses of COVID-19 vaccination. You are being offered a third primary dose of the vaccine, as recommended by JCVI, to improve your levels of immunity to give you better protection.  

This third dose of vaccine is being offered to individuals aged 12 years and over who had severe immunosuppression at the time of their first or second dose of COVID-19 vaccination. This includes those who had or have: 

Individuals with primary or acquired immunodeficiency states at the time of vaccination due to conditions including:

• acute and chronic leukaemias, and clinically aggressive lymphomas (including Hodgkin’s lymphoma) who were under treatment or within 12 months of achieving cure
• individuals under follow up for chronic lymphoproliferative disorders including haematological malignancies such as indolent lymphoma, chronic lymphoid leukaemia, myeloma, Waldenstrom’s macroglobulinemia and other plasma cell dyscrasias (note: this list is not exhaustive)
• immunosuppression due to HIV/AIDS with a current CD4 count of <200 cells/µl for adults or children
• primary or acquired cellular and combined immune deficiencies – those with lymphopaenia (<1,000 lymphocytes/ul) or with a functional lymphocyte disorder
• those who had received an allogeneic (cells from a donor) or an autologous (using their own cells) stem cell transplant in the previous 24 months
• those who had received a stem cell transplant more than 24 months ago but had ongoing immunosuppression or graft versus host disease (GVHD)
• persistent agammaglobulinaemia (IgG < 3g/L) due to primary immunodeficiency (for example, common variable immunodeficiency) or secondary to disease/therapy

Individuals on immunosuppressive or immunomodulating therapy at the time of vaccination including:

• those who were receiving or had received immunosuppressive therapy for a solid organ transplant in the previous 6 months
• those who were receiving or had received in the previous 3 months targeted therapy for autoimmune disease, such as JAK inhibitors or biologic immune modulators including B-cell targeted therapies (including rituximab but in this case the recipient would be considered immunosuppressed for a 6-month period), T-cell co-stimulation modulators, monoclonal tumour necrosis factor inhibitors (TNFi), soluble TNF receptors, interleukin (IL)-6 receptor inhibitors, IL-17 inhibitors, IL 12/23 inhibitors, IL 23 inhibitors (note: this list is not exhaustive)
• those who were receiving or had received in the previous 6 months immunosuppressive chemotherapy or radiotherapy for any indication

Individuals with chronic immune-mediated inflammatory disease who were receiving or had received immunosuppressive therapy prior to vaccination including:

• high-dose corticosteroids (equivalent to ≥ 20mg prednisolone per day) for more than 10 days in the previous month
• long-term moderate dose corticosteroids (equivalent to ≥10mg prednisolone per day for more than 4 weeks) in the previous 3 months
• non-biological oral immune modulating drugs, such as methotrexate >20mg per week (oral and subcutaneous), azathioprine >3.0mg/kg/day, 6-mercaptopurine >1.5mg/kg/day, mycophenolate >1g/day in the previous 3 months
• certain combination therapies at individual doses lower than above, including those on ≥7.5mg prednisolone per day in combination with other immunosuppressants (other than hydroxychloroquine or sulfasalazine) and those receiving methotrexate (any dose) with leflunomide in the previous 3 months

Individuals who had received high-dose steroids (equivalent to >40mg prednisolone per day for more than a week) for any reason in the month before vaccination.

Individuals who had received brief immunosuppression (≤40mg prednisolone per day) for an acute episode (for example, asthma / COPD / COVID-19) and individuals on replacement corticosteroids for adrenal insufficiency are not considered severely immunosuppressed sufficient to have prevented response to the primary vaccination

We have contacted a number of our colleagues who provide care for individuals who meet the criteria for a third primary dose and have sent letters to those individuals we are aware of. However, we know that sometime individual people may have been missed. If you think you should have received a third primary dose letter and have not please contact the vaccination team at vcc@gov.gg and we will send you a letter and form for your doctor to complete to request your vaccine.

If you are unsure if you require a third dose of the vaccine, speak to the specialist involved in your care.

At this time you will need this 1 extra dose to help improve your protection. Like your previous doses, the vaccine will be given in your upper arm. 

A booster vaccination may also be needed at a later date.

The third dose should be given at least eight weeks after the second dose, but timing will depend on any treatment you may be having.  

Where possible, the third dose should be delayed until at least two weeks after the period of immunosuppression or if you are receiving a series of treatments at a point between treatments that your immune system is strongest. The timing of your third dose should be discussed with your specialist.  

If you’ve had a very severe reaction to the previous dose of the vaccine, you should discuss this with your doctor. 

You will be offered an mRNA vaccine, unless you have a clinical contraindication to this. This will either be either a Pfizer or Moderna vaccine.

Any side effects experienced will usually be similar to those you experienced with your primary course of vaccines.

Very common side effects include: 

• having a painful, heavy feeling and tenderness in the arm where you had your injection for several days after the vaccine 
• feeling tired 
• headache 
• general aches, or mild flu like symptoms 

A mild fever may occur for two to three days but a high temperature is unusual and may indicate you have COVID-19 or another infection. You can take the normal dose of paracetamol (follow the advice in the packaging) and rest to help you feel better. Do not exceed the normal dose. A less common side effect is swelling of the local glands in the neck and armpit, this starts a few days after the vaccine and may last for up to two weeks. 

These symptoms normally last less than a week.

You can report any side effects online at: coronavirus-yellowcard.mhra.gov.uk/ or via the Yellow Card app.

If you have not received a COVID-19 vaccine yet or have missed your second dose you should have them as soon as possible. 

You will still need the third dose but the timing of it will depend on any treatment you may be having. You can discuss this with your specialist.