COVID-19 update: Asking the experts

The National Institute for Health and Care Excellence (NICE) has published new guidance on COVID-19 treatments:

• Final guidance does not recommend Evusheld as preventative pre-exposure treatment (prophylaxis) - updated as of 05/05/2023.
• Final guidance reduces the number of treatments (post-exposure) available to three: nirmatrelvir plus ritonavir, tocilizumab, and sotrovimab (where nirmatrelvir plus ritonavir is not suitable).

Reduced treatments may concern people which is why it’s helpful to understand the current COVID-19 situation and what it means for people with lymphoma.

Following JCVI advice, the government have announced that people aged 75 years and older, residents in care homes for older people, and those aged 5 years and over with a weakened immune system will be offered a booster of coronavirus (COVID-19) vaccine this spring. Booster doses will be offered around 6 months after a previous dose. People will be offered appointments between April and June.

We spoke to experts: Dr Sarah Jarvis (General Practitioner), Dr Sean Lim (Associate Professor and Honorary Consultant in Haematological Oncology), Dr Cathy Burton (Consultant Haematologist), Dr Jessica Martin (Medical Lead for Infection & Prevention Control) and Dr Anne Melhuish (Consultant Virologist) to get their views on the current situation, as well as what the future looks like for people with low immunity.

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The situation on the ground and hospitalisation rates

Dr Sean Lim: “We have seen an increase in the number of cases of COVID-19, but the rates are still much, much lower than the start of the pandemic.  The people who are being hospitalised for COVID-19 tend to be those who are either undergoing or have recently completed systemic treatment for their lymphoma. Whilst these patients needed hospitalisation, they also tend to be far less sick.”

Dr Cathy Burton, Dr Jessica Martin & Dr Anne Melhuish: "The risks are much reduced compared to early 2020 when the pandemic started. In general, most hospitalised patients are either very elderly or have underlying respiratory problems."

"Variants are very closely monitored by the UK Health Security Agency (UKHSA) using genetic sequencing.  There are no variants of concern presently."

The level of risk for the immunocompromised and how the situation has changed from a year ago

Dr Sean Lim: “The actual risk for each individual is difficult to estimate and depends on multiple factors such as age, what other illnesses they may have, the number of COVID-19 vaccine doses they have received, and the type of anti-cancer treatment they have been given. Overall, I think the risk has reduced over the past year as a result of COVID-19 vaccination, but the reduction in risk in an immuncompromised individual is not as big as the reduction of risk  in a ‘healthy’ individual.”

Dr Sarah Jarvis: “Firstly, we must acknowledge that COVID-19 is still here and hasn’t gone away. The majority of current cases are variations of Omicron and the evidence shows Omicron does not cause more disease than previous strain (Alpha and Delta). Thus far, those infected with the original Omicron strain are less likely to end up in hospital – how much less likely has varied with the different subvariants of Omicron. We need to bear in mind that vaccines have made a huge difference, even among people who are immunocompromised or have low immunity, particularly where they have had 3+ doses.”

Dr Cathy Burton, Dr Jessica Martin & Dr Anne Melhuish: "The (lymphoma) patients who appear to be particularly vulnerable are those who have received a bone marrow transplant, CAR-T cell therapy and those who are heavily treated with rituximab or obinatuzumab. It is thought that the associated B-cell depletion (reduction in immune cells) makes it difficult for the body to fight the COVID-19 virus. Patients who have not been vaccinated would also be at greater risk of severe infection."

COVID-19 treatments and protective measures to reassure people

Dr Sean Lim: “We recognise the immunocompromised still need better protective measures but overall, the risk of being really unwell with COVID-19 is much less now than it was. The antivirals are less likely to be affected by new virus variants.  It is true that the antibodies elicited by vaccination might be less effective as a result of new variants, but the vaccines also elicit protection through T-cells.  These T-cells protect against severe COVID-19 and are not affected by the ever-changing variants.”

Dr Cathy Burton, Dr Jessica Martin & Dr Anne Melhuish: "Some patients are eligible for anti-viral therapy if they get COVID-19, even if their symptoms are mild and they are not poorly enough to come to hospital. Your clinical teams will be able to assess whether you need to have this treatment. The medication will lessen the severity of COVID infection for most people. You should contact your haematology team as soon as you think you may have COVID-19 as this medication needs to be given promptly."

Dr Sarah Jarvis: “It appears that Evusheld and some of the monoclonal antibodies do not offer the same level of protection as they did to previous variants. However, there are still treatments available. If you are clinically vulnerable, you should be contacted by the NHS about possible treatments if you are infected with COVID. If you aren’t contacted, ring your specialist team, NHS 111 or your GP surgery to discuss possible options.

How to keep safe and COVID booster programmes

Dr Cathy Burton, Dr Jessica Martin & Dr Anne Melhuish: 

• Get vaccinated as soon as it is offered - attend for boosters
• Follow general advice for respiratory viruses, eg avoiding people known to be ill, consider wearing a mask in crowded places/public transport, wash hands frequently.
• Consider open windows when people visit your home, or ask visitors to wear a face covering
• If it feels right for you, work from home if you can. If you cannot work from home, speak to your employer about what arrangements they can make to reduce your risk
• You may wish to be more careful in the months after bone marrow transplant, CAR-T therapy, rituximab or obinatuzumab.
• If you do become unwell you should test for COVID-19 and, if positive, contact your haematology team. They can refer you to clinic if you need to access anti-viral medication.
• Infection and prevention control in hospitals is closely monitored and regulated. Therefore all NHS Trusts have the appropriate infection prevention procedures in place and patients should not be concerned about attending hospitals for appointments, investigations etc. you can help yourself and others by following the local guidance when you attend hospital.

Dr Sarah Jarvis: “It’s important to keep up to date with incidence figures so you’re aware when COVID-19 rates are higher. Ensuring you have all vaccinations is important. There will be new booster available in Spring and likely in Autumn 2023 for those with low immunity. However, it is likely this won’t be through primary care so if you are clinically vulnerable, we would encourage people to have that conversation with their hospital healthcare team.

It is likely that vaccinations and boosters will become a regular thing, just like flu vaccinations. Vaccinations continue to offer really good protection against severe disease. Whilst immunity wanes quite fast, we are incredibly lucky to have vaccines and options available. The NHS continue to stay on top of variants and there is a huge amount of research continuing about the impact of vaccinations, boosters and previous infections on immunity.”

Dr Sean Lim: “I suspect COVID-19 vaccination will follow the path of annual flu vaccination, except it may be offered on a 6-monthly basis.  This is likely to carry on until we find better ways of identifying who continues to have a higher risk of hospitalisation from COVID-19 despite vaccination, and how best to protect these individuals.”

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It's clear from the experts that whilst COVID-19 hasn’t gone away and those with lower immunity do require more protection than others, the risk of getting seriously ill has decreased. Ensuring your vaccinations and boosters are up-to-date is the best way of protecting yourself against serious illness. We are in a better position than we have been previously, and work continues to ensure those with lower immunity are protected against COVID-19 in the future. 

Government guidance for people at higher risk: COVID-19: guidance for people whose immune system means they are at higher risk - GOV.UK (www.gov.uk)

More information on vaccinations and boosters: Lymphoma Action | COVID-19 vaccination and boosters (lymphoma-action.org.uk)

More information on staying safe and reducing your risk of catching COVID: Lymphoma Action | Staying safe and reducing your risk of COVID-19 (lymphoma-action.org.uk)

Incidence trends in COVID-19 cases: England Summary | Coronavirus (COVID-19) in the UK (data.gov.uk)

Updated: 5 May