COVID-19 - guidance on clinically extremely vulnerable children and young people

Introduction

Since March 2020, governments and public health agencies have issued advice and guidance to people who are considered to be clinically extremely vulnerable and at highest risk of severe disease due to SARS-CoV-2 infection. 

In June 2020 RCPCH worked with paediatric specialties to identify the clinical categories that would indicate which children and young people would be at the highest risk of severe disease, and so who may, from time to time, be advised to shield. Shielding has not been advised in the UK since Spring 2021.

August 2021 update

Governments in England and Wales have updated guidance for children and young people with underlying health conditions. They will now be advised following the same guidance as the rest of the population on how to stay happy, healthy and well during the pandemic, and will no longer be seen as “clinically extremely vulnerable” (CEV) and will be removed from the Shielded Patient List. In Scotland, the list is being retained.

How was the decision made?

Since the COVID-19 pandemic started in 2020, much more is understood about the risk for children and young people with underlying health conditions. 

In the early phases of the pandemic when data was scarce, the College drew upon the expertise and experience of paediatricians to help to identify the criteria for understanding which children and young people might be at greater risk of severe infection and serious disease if they were infected with SARS-CoV-2. 

Over time, a clearer sense of the direct impact of COVID on children and young people with underlying conditions has emerged, with research suggesting that the risk of severe COVID in children and young people in England was very low.1

Following a recommendation from the UK chief medical officers (CMOs), children and young people in England and Wales are no longer considered to be clinically extremely vulnerable, and they will not be asked to shield in the future.

What next in England and Wales?

Rather than shielding, CMOs are asking paediatricians to return to the approach taken before the pandemic: providing advice on a case by case basis to those children and young people who would be at the greatest risk from a virus like SARS-CoV-2. 

A very small number of children and young people – those with severely compromised immune systems due to their clinical condition or the treatment required to manage it – are more vulnerable than the rest of the population to being very unwell from all infections, including SARS-CoV-2. It has always been the case that clinical teams caring for these children and young people would advise about steps needed to limit their exposure to infections, to take extra care with hygiene and contact, and avoiding busy places.  

For others, the advice is to follow the same guidance as the rest of the population to stay safe and prevent the spread of coronavirus.

What does this mean for children and young people who were classed as ‘clinically extremely vulnerable’ over the last year?

We know that many children and young people, and their families, have sacrificed much over the last year to manage the risk of COVID. Shielding has been difficult, and it has caused anxiety and distress. Taking extra precautions meant children and young people, and their families missed out on a lot - across their education, work and social lives.  While it is reassuring that research is showing us that the risks are very low, some children, young people and families may need extra support to adjust to not having to shield or of not being considered extremely vulnerable. The resources below may provide some support and help over the next few weeks and months.

What about COVID vaccinations?

Whilst children under 16 years old are not routinely invited for vaccination, the JCVI has prioritised some specific clinical groups who would benefit from the vaccination. Being eligible for vaccination does not mean that a child or young person is considered to be clinically extremely vulnerable or needs to shield. This is similar to the prioritisation of some adults in early phases of the vaccination programme who were not CEV.

Is shielding changing for adults? What about young people turning 18?

It was recently announced that the shielding programme will also end for those aged 18 and over in England. 

Further details around this announcement are available here. 

What about the RCPCH advice?

While the shielded patient list remains in place for children and young people in parts of the UK, the RCPCH CEV criteria, developed in 2020 to provide paediatric expertise and input to governments’ shielding policies are available in the download area. 

Resources and sources of further help for children, young people and families

England

• NHS England - information on how to access mental health help and support
• Every Mind Matters - for advice and practical steps that can be taken to support wellbeing and manage mental health
• Hub of Hope - local sources of mental health support and services, both from the NHS and from other organisations
• Let’s talk loneliness - a variety of tips, advice and further resources for children for those feeling lonely
• NHS England blogs – practical tips for young people and families and carers

Northern Ireland

• NI Direct - includes a useful list of contact numbers
• Family Support NI - Official site with support services listed
• CYPSP - Website set up specifically to support children and young people with their mental health and well-being and including a ‘text-a-nurse’ feature

Scotland

• Gov.Scot - Coronavirus (COVID-19): advice for people at highest risk
• Parent Club: Coronavirus and Parent Club: Wellbeing & Mental Health - Up-to-date guidance from the Scottish Government on child health and education
• Young Scot: Aye Feel - information from Young Scot on looking after your emotional wellbeing 
• SAMH – information and support for children and young people around mental health 

Wales

• Mental Health Helpline for Wales  - Offering a confidential listening and support service online, on the phone and by text
• Information, advice and advocacy helpline for children and young people in Wales including Covid 19 info and advice. Phone, text, online and blogs

Background notes

In June 2020 RCPCH worked with paediatric specialties to refine the initial government criteria that identified those who were clinically extremely vulnerable. This was based on clinical expertise, consensus and early experience in the pandemic. The criteria fell into two groups – one that suggested all those in the group should be considered clinically extremely vulnerable, and a second that emphasised the need for a case by case consideration of individual risk, i.e. some of the CYP in the group might be considered CEV. 

The CMOs approved the CEV criteria and they informed the shielded patient list (SPL). The SPL was used by the four UK governments to determine who should be advised to adopt extra caution and measures to limit their personal exposure to SARS-CoV-2 because of the risk of serious illness. 

This helped to focus shielding policy on those at greatest risk and reduce the numbers on the initial list. There has been a uniform approach across the UK, with variation only being seen in when and where shielding would be advised. The criteria for adults have been refined over the last year, and early this year England’s CMO adopted a risk threshold that determines whether someone is classed as CEV.  Shielding has not been advised in the UK since Spring 2021.

• 1. The Deputy Chief Medical Officer commissioned research on data from the first year of the pandemic. The preprints from this analysis have been published as follows: i) Deaths in children and young people in England following SARS-CoV-2 infection during the first pandemic year: a national study using linked mandatory child death reporting data ii) Risk factors for intensive care admission and death amongst children and young people admitted to hospital with COVID-19 and PIMS-TS in England during the first pandemic year iii) Which children and young people are at higher risk of severe disease and death after SARS-CoV-2 infection: a systematic review and individual patient meta-analysis