Thank you to all who attended and contributed to the webinar, the tenth in our series. It covered developments in our knowledge about the Covid vaccines and how people with suppressed immune systems are responding, as well as a discussion about how to keep safe while getting back to some normal activities and safety at work.
We were joined by two kidney doctors, Dr Rachel Middleton from Salford Care Organisation and Dr Michelle Willicombe from Imperial College Healthcare NHS Trust, as well as Dr Jonathan Leach, a GP and NHS England Medical Director for Covid Vaccination. Amy Gordon, a specialist employment lawyer, spoke on safety at work.
The meeting was chaired by our Kidney Care UK policy director, Fiona Loud.
We would like to say a big thank you to our speakers for their advice and answering your questions.
Please do keep checking the Kidney Care UK Covid-19 guidance for updates.
- Covid cases are falling and fewer people with kidney disease are becoming severely ill and dying with Covid. It is still important to take measures such as wearing face masks to reduce your risk
- When deciding about which activities to return to, balance the risk from Covid with the risk to mental and physical health, as well as quality of life, from isolation.
- People on dialysis and with CKD have a boost in antibody levels after each dose of vaccine. People who are immunosuppressed respond less well, but it still important to have all vaccinations offered as it is not possible to determine who will respond to each dose.
- Government scientists are still assessing whether Evusheld is effective against current variants of Covid and who would benefit from the treatment.
- Although specific legislation around Covid safety in the workplace has ended, people with kidney disease may be offered protection from the Equality Act 2010 and also general health and safety legislation.
What is the current situation regarding Covid and kidney patients?
Dr Middleton explained that it is now difficult to give accurate numbers of cases and outcomes for people who contract Covid. This is because lateral flow tests are no longer freely available to all and also because some of the research studies that analysed case numbers have ended. However, the data that we do have show case numbers are falling. Hospital admissions and deaths from Covid are also falling. There are around 6,000 people in hospital with Covid currently, but half of these were admitted for another reason not because they were very ill with Covid.
In terms of the future, Dr Middleton said although the situation was much better than it had been, we should expect further waves of the virus with new variants (viruses that are slightly different from the original Covid-19 virus, but not so different that they are considered a new virus). It is impossible to say whether new variants will cause more or less mild illness or how easily they will transmit between people. It is likely to be a few years before the virus becomes endemic –when the virus does not cause any disruption to daily life and case numbers are wholly manageable. The Chief Medical Officer has said we are likely to have seasonal surges of Covid over the next few years, in a similar way to the flu virus.
Asked about people with kidney disease who had never tested positive for Covid, Dr Middleton advised it was quite likely that they had had it asymptomatically (without symptoms), highlighting the many kidney patients found to be positive when tested in her hospital despite having no symptoms.
What should I do to reduce my risk from Covid?
Many people wanted to know what people with kidney disease should be doing now to keep themselves safe. Dr Middleton reminded people that the situation was improving and there are now fewer cases and also effective treatments. We are not quite yet out of the woods as Covid can still pose a risk. However, if you have been shielding yourself, now is probably a good time to think about going out a little bit and re-introducing some of your favourite activities.
Dr Middleton stressed there are no hard and fast safety rules and people should think about what level of risk they are comfortable with. This includes the risk of not going back to previously enjoyed activities. The risk of Covid needs to be balanced with the risk to mental health of being in isolation, or the risk to physical health of not getting any exercise. People might like to think about the activities that are most important to them and consider what they could do to reduce risk while doing them.
In terms of meeting up with people, Dr Middleton highlighted that it is safer to meet people outdoors, but if you do meet indoors you could adopt some simple measures like keeping a window open and avoiding people who have a high temperature.
As Covid is an airborne virus (carried through particles suspended in the air), it remains sensible to wear a mask if you can but you do not need to wipe down internet deliveries or shopping as it is less likely to be spread this way.
One person asked about the safety of attending a church service, where few people were likely to wear masks. Dr Middleton explained that although this may present some risk, it is possible to make it a safer activity if it is something that is very important you. For example, you could attend a service that is likely to be quieter, sit in a quiet spot within the church, ideally near a door, wear a mask and take hand gel. By following these measures, you could reduce your risk of exposure to Covid-19 to help keep yourself safe.
An update on Covid vaccinations
Dr Leach highlighted that since the Covid vaccines had been developed, 123 million doses had been provided. In total, 3.3 million out of the 5.5 million people who are eligible for the Spring booster had received this dose.
Spring booster – timing and eligibility
Dr Leach confirmed that the following groups are offered the Spring dose:
- adults aged over 75 years old
- people who are resident in a care home
- people who are immunosuppressed. The immunosuppressed group includes people with kidney transplants, but also those who take immunosuppressive medication for another reason.
- Household contacts of people who are immunosuppressed are not offered the Spring booster.
As with all the vaccines, the Spring booster is not compulsory but is recommended in order to be best protected from Covid.
We also heard clarification on the recommended timing of the Spring booster. Dr Leach explained it is recommended that people receive the Spring dose six months after their last booster, but it is possible to receive it from three months. This is because the evidence indicates that the vaccine will offer better protection if the gap between doses is closer to six months, but that sometimes it might be sensible to give the dose at three months. For example, a GP may spend a day in a care home to vaccinate all residents and, while there, may vaccinate people who are between three to six months after their last dose, rather than making repeated trips to the home. Dr Leach advised that it may be best to aim for gap closer to six months between your last dose and your Spring dose because it may give better protection, but if you felt you wanted to have it earlier it is possible to receive it from three months.
Fiona highlighted that a number of people had experienced problems in accessing their Spring booster, with vaccination centre staff not recognising that they are eligible. Dr Leach said that a permissive approach had been encouraged across all staff, whereby patients could bring any letter, prescription or medicine box which demonstrated the person had a suppressed immune system in order to access the vaccine. If an individual encounters a problem when trying to get a COVID-19 vaccine, it is important they report it so that the NHS can resolve the issue and prevent it happening again.
Will I be offered more vaccinations in the future?
Dr Leach reiterated that the Covid pandemic is not yet over and further surges are anticipated although we don’t know what these will look like. It is likely that additional vaccine doses will be recommended for Autumn.
Moving beyond this, the JCVI (the Joint Committee on Vaccination and Immunisation) will continue to keep the need for further vaccinations under careful review and recommend to Government how best to use vaccination to protect individuals and the population. The work scientists are currently doing to develop vaccines which can be adapted to protect against future variants will hopefully become part of Covid protections.
Are multiple doses of vaccine safe?
Dr Leach confirmed that research studies of the vaccines to date do not show any evidence of harm from multiple doses of vaccine. Dr Middleton also confirmed that there is no indication that multiple doses would do any harm to the kidney, including transplanted kidneys. She highlighted the number of vaccines that have been given over the last couple of years, which have not shown any evidence of harm.
For people who have had a severe reaction to previous doses of Covid vaccines, Dr Leach explained that he would take a detailed history and assess whether that person should have another dose, potentially with a different type of vaccine. As a safety measure, Dr Leach has sat with his patients with severe allergies for 30 minutes following the Covid vaccine to check for a reaction, although to date they have all been fine.
An update on vaccine research
Dr Willicombe gave an overview of the latest research into the response of kidney patients to the Covid vaccines. She explained that laboratory data (examining blood samples of people who have received the vaccines) showed that people with CKD and on dialysis experienced a boost in antibody levels after each dose, which was reassuring. The data for people who are immunosuppressed was not quite so encouraging, but still showed that it was important to have all doses of the vaccine. After the first two vaccine doses, about half of patients had an antibody response. And after the third and fourth dose, around half of the patients who had not yet responded went on to make antibodies. The body also produces T-cells following vaccination, which can provide an important layer of defence against Covid in addition to (and in the absence of) antibodies. Dr Willicombe explained that laboratory data indicates that around 1 in 5 people with kidney disease who are immunosuppressed (and had not had a Covid infection in the past) showed a T-cell response following vaccination.
Reassuringly, far fewer people with kidney disease are being hospitalised with severe Covid and dying, showing that Covid is now a less severe disease in kidney patients as it is in the general population. Dr Willicombe is expecting updated figures soon, which will help illustrate this positive change.
Treatments for Covid
In terms of the new treatments for Covid, a monoclonal antibody treatment called Sotrovimab is often the first choice for kidney patients at higher risk who have tested positive.
A treatment called Paxlovid is also available but is often not suitable for people with kidney disease.
A drug called Remdesivir is the second line treatment for many (if the first line treatment is not suitable or does not work), followed by a drug called Monulpiravir.
The reduction in hospitalisations and deaths are due in part to the success of these treatments.
People who are at highest risk from Covid and test positive will be considered for treatment with one of these drugs. There is some indication that Sotrovimab may not be effective against current variants, although prescribing policy in the UK has not yet changed. Your doctor will decide which one should be offered first, based on your individual condition and the latest evidence. The treatments are unlikely to be offered to people who test positive for Covid but do not have any symptoms, because they are likely to get better by themselves and, on balance, it is better to avoid taking unnecessary medications. Previously, people at highest risk from Covid were given PCR tests to take if they developed symptoms, but now people should take a Government issued LFT (lateral flow test) in order to access an assessment for treatment. Read our guide to accessing Covid treatments for kidney patients for full details on how to access the treatments in your country.
Many people asked if it was possible to access the treatments if they developed Covid while abroad. The panel explained that it is not possible to be prescribed them in advance of travel, and access to the treatments will depend on the prescribing policy of each country.
There was a huge amount of interest in the development of preventative treatments such as Evusheld. This drug is a long-acting mononclonal antibody and evidence suggests it can reduce people’s risk of contracting Covid.
The UK MHRA (Medicines and Healthcare products Regulatory Agency) have issued emergency approval, but it is not yet available on the NHS. Government and the NHS is currently assessing how well Evusheld works in preventing Omicron and its variants, to make sure it is worthwhile prescribing it. There is some evidence that it may not be effective against BA4 and 5, which are making up a greater proportion of Covid cases. They are also looking at which patient groups would benefit most and the best way of delivering the treatment. The results of the tests are expected very soon. Dr Willicombe’s view was that this type of antibody treatment may be most beneficial for people who have not produced antibodies in response to vaccination, and this relatively small group could be identified through antibody testing by clinical teams.
Fiona reassured attendees that Kidney Care UK is doing everything it can to raise awareness of the important of preventative treatments to people living with kidney disease and calling for progress in decision making about how and when to make treatments available, once their effectiveness has been proven.
Safety at work update
Amy Gordon explained that, in terms of current working safely guidance, specific Covid guidance has been replaced with more general public health advice published on 1st April. This current advice reflects that restrictions have been lifted but recognises ongoing management of Covid and other airborne infections is important, particularly for those people at higher risk. Within the specific guidance for people at higher risk from Covid, employers are advised they may wish to consider people who are immunosuppressed in their workforce management.
Some of the specific Covid measures that have gone include requirements to wear masks, to reduce contact between people within the workplace, to carry out a specific Covid risk assessment and for people to work from home if they can. General health and safety rules, including maintaining cleanliness and ensuring good ventilation, still apply and can help to reduce the risk of airborne viruses including Covid.
The guidance for higher risk people includes trying to avoid meeting people who have tested positive for Covid for 10 days after the positive test and also avoiding people who have symptoms. This will require cooperation from employers and is something that could form the basis of a discussion and agreement on how this could be achieved.
Amy explained this area of employment law falls into health and safety legislation and equality legislation.
Health and safety at work legislation requires employers to take reasonably practical steps to assess and protect against risk. This involves carrying out risk assessment and taking appropriate action. It can also provide protection against dismissal or detriment to individuals who feel they have to take steps to protect themselves (under Section 100), for example if a person felt they had to remain at home to protect themselves it may be considered unfair if the employer dismissed them because they had done so.
Health and Safety legislation includes a specific requirement to provide a workplace with fresh air or an alternative method for providing clean and healthy air if fresh air is not possible. If you have concerns about this, Amy recommended you approach your employer (or occupational health team if you have one) to discuss your concerns. Air-conditioning is a technical area, where it might be appropriate to get expert advice, and it might be that your employer could do this to ensure they are meeting regulations.
Attendees were interested to hear how the Equality Act 2010 may support them. This law means that is unfair for an employer to discriminate against anyone on the grounds of a protected characteristic, including disability. This means an employer can’t treat a person with a disability less favourably than others and also cannot introduce a policy into the workplace that puts a person with a disability at a disadvantage, unless the employer can demonstrate there is a sound reason for doing so. The Equality Act also places a duty on an employer to help them do their job if their condition puts them at a substantial disadvantage. Amy explained that people with kidney disease might be able to ask for a reasonable adjustment within the workplace, because they are at higher risk from Covid. What the reasonable adjustment is will depend on the individual circumstances of the employee and their workplace and role.
The Equality Act 2010 and kidney patients
Amy explained that people with kidney disease may be considered to be disabled and therefore protected by the Equality Act. The definition of disability in relation to the Act is a legal concept, rather than one determined by a specific medical diagnosis. You are disabled under the Act if you have a physical or mental impairment that has a substantial and long-term impact on performing day-to-day activities. Long term means the impairment exists for 12 months or more. The impact on day-to-day activities should be considered before treatment, so if a person did not have access to treatment, would their impairment have a substantial impact on their day to day activities? Amy advised that most people with kidney transplants are likely to meet the criteria. If you have access to an occupation health team, they would be able to provide further advice.
In response to a question from a self-employed therapist, we heard that self-employed people do not have the same duties as a business under the Health and Safety Act, but they have to make sure they are not putting themselves or others at risk. So although it is not binding, it would be advisable for the individual to follow guidance on cleanliness and ventilation to help them meet this requirement. Although there is no requirement do a risk assessment, it would be a useful exercise in order to review what potential risks may be and how to minimise these risks. The results should be communicated to clients in order that they can comply with these measures.
Co-workers with Covid
If a co-worker has Covid, individuals should think about what level of risk they feel comfortable with and what feels like the right decision for them.
Now regulations have changed, an employee with Covid cannot be compelled to stay away from the workplace. However, the employer needs to consider the competing rights of their workforce and will need to consider the rights of the person who is at higher risk. As a minimum the employer should be putting in whatever control measures they can to prevent the individual passing on the virus to others. Amy recommended a person with kidney disease in this situation should speak to their employer about how they feel and their anxiety about sharing a workplace with someone with Covid and try to collaboratively reach an agreement on what protective measures can be put in place, e.g. working from a different location. If being absent from work feels like the right solution, it would be important to discuss this with your employer to seek pre-approval.
What about people who share a house with someone who is immunosuppressed?
We had a number of questions regarding employment law which may apply to a relative/household member of person with a disability (e.g. person with a kidney transplant). Although this is a more complex area, Amy explained the Equality Act 2010 does prevent discrimination on the basis of association with a disabled person. Indeed there has been an employment tribunal where the court agreed that requiring a person who cared for someone with a disability to return to the office would put them at a substantial disadvantage. Although this does not set a precedent, it gives an indication of where case law in this area is going.
Considerations before entering a dispute
Amy raised the difficulty and challenge of entering a dispute with your employer and highlighted that there are many good employers out there. While it will not be possible for everyone to do this, feeling your employer is not supporting you as you would like may be a prompt to have a look around and see if there are opportunities that would fulfil your career and personal aims whilst working for an employer who is a better fit for you, for example those that support working from home.
Fiona thanked the panellists and reminded everyone to keep checking Kidney Care UK’s online Covid-19 guidance, which is updated regularly.
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