The government has released guidance on shielding and protecting people who are clinically extremely vulnerable from COVID-19. The government’s latest three tier system of local restrictions came into place in England on December 2.

This guidance was updated on 26 November and comes into force on 2 December. It is for everyone who has been identified as clinically extremely vulnerable (via letter from the NHS or GP).

The guidance has been updated to support the clinically extremely vulnerable in protecting themselves from exposure to coronavirus . It replaces previous guidance on shielding that was in place during the 4-week period of National Restrictions. The guidance is set out in 2 parts:

• Updted advice on protecting the clinically extremely vulnerable, based on the tiers of local restrictions in your area. The advice sets out the additional things people at the highest risk from COVID-19 are advised to do to keep themselves safe for each tier.
• Updated shielding advice that is more targeted and will only apply in some of the worst affected areas and only for a limited period of time. People are only advised to follow shielding advice if they receive a new written shielding notification.

What has changed

On 2 December the country is moving back to a tiered system of local restrictions. The government has reinstated this guidance for clinically extremely vulnerable people linked to these tiers.

It offers additional advice to the clinically extremely vulnerable over and above the rules for the tiers, which apply to everyone. According to the government, the guidance aims to strike a better balance between providing practical steps to help keep people in this category safe while reducing some of the potentially harmful impacts on mental and social wellbeing that were associated with previous strict shielding. It sets out the steps clinically extremely vulnerable people can take to protect themselves for each local tier.

In the future, the government will only reintroduce formal shielding advice in the very worst affected local areas and for a limited period of time. This will only apply to some, but not all, Tier 3 areas and will be based on advice from the Chief Medical Officer. The government will write to those affected separately to inform them if they are advised to shield. The guidance states that people in this category are not advised to follow formal shielding advice again unless they receive a new shielding notification advising them to do so.

Advice during the Christmas period

It is recognised that many people may want to be with their friends and family over the festive period. As a result, the government will be changing some restrictions on social contact, allowing the formation of a ‘Christmas bubble’ in which people can spend time indoors and outdoors, including inside a home, with people from up to three households.

This will only apply for a very limited period of time, from 23 December to 27 December.

Those who are clinically extremely vulnerable can choose to be part of a Christmas bubble but it does involve greater risks as the number of people you have contact with will be increasing.

It is important that you and the other people in your Christmas bubble consider these risks carefully before agreeing to form a bubble. Forming a Christmas bubble is a personal choice and should be balanced against the increased risk of infection, says the guidance.

Advice is set out for those in this category who do decide to form a Christmas bubble.

SAGE advice on reducing the risk of coronavirus transmission in the home

Advice from the Scientific Advisory Group for Emergencies (SAGE) has been published to help households safely plan for gatherings in the home. The advice from SAGE includes how to make a household plan. This is a practical plan to help you prepare for social interactions in the home, which is agreed by all those who will be attending. Preparing a household plan will help to reduce your risk of transmitting COVID-19, says the document.

A checklist of ten points is summarised below:

1. Consider whether meeting up is essential and cannot be postponed or replaced by safer forms of interaction.

Identify where in-person interactions could be replaced by online events or postponed until an appropriate future date, for example when in a lower tier.

2. Consider replacing indoor events with outdoor activities or using larger spaces to host events.

Outdoor and larger spaces may provide more physical space and better ventilation compared to households with less space.

3. Remember most infections happen indoors in private homes where people get close to friends and family.

Within the home we may be more likely to assume people and places we know are safe.

4. Take special care to protect people who are particularly vulnerable to serious consequences from infection.

This includes older people and those with underlying health conditions. It is also important to reduce the risk of infection among those who have close contact with particularly vulnerable people, for example carers or nurses.

5. Ensure people who are emotionally vulnerable have social support.

Special care should be taken to interact safely with people who are socially isolated, including meeting outside if possible, online or by phone.

6. People who have very little contact with others are unlikely to be infected and may be able to meet together safely.

People who have to self-isolate or quarantine should not meet with anyone. If people have to self-isolate due to COVID-19 symptoms or a positive test, or quarantine because they have been in contact with a confirmed case, then it is essential to do so regardless of the occasion.

7. Limit interactions to the same small group of people as much as possible.

This reduces the probability that someone will come into contact with the virus and limits how far the virus can spread if there is transmission. Meeting two groups of different people in the same week increases the risk of spreading the virus compared with meeting the same group of people twice. Limiting or avoiding interactions with other people in the 7-14 days before meeting, and reducing travel across different parts of the country can further reduce the likelihood of transmission.

8. Limit the time spent together, especially if meeting indoors.

Indoor interactions should be restricted as much as possible and reserved for short duration quality time. Children should meet vulnerable relatives, including grandparents, outside where possible; brief meetings such as walking or playing outside are safest.

9. Think about the space your event will take place in, and how people will interact.

You will need to think about cleaning, ventilation (fresh air) and the layout of rooms to allow for social distancing. Think about hygiene and any activities associated with the event, such as games or serving food. Transmission through airborne, droplet and surface contact routes can be reduced by following guidance on reducing the spread of COVID-19 in your household. Children should meet older or vulnerable relatives outside where possible. Brief outside meetings such as walking or playing are safest.

10. Agree the plan with friends and family before the event so that everyone knows the safest way to meet.

A plan is likely to be most successful if it is agreed in advance. This includes explaining it to children. Examples of household plans published by SAGE are available.

COVID-19 Winter Plan

(England)

This is the government’s plan for managing COVID-19 through the end of 2020 and into the start of 2021.

It presents a programme for suppressing the virus, protecting the NHS and the vulnerable, keeping education and the economy going and providing a route back to normality. The plan sets out the Government’s approach to ending the national restrictions on 2 December.

The government’s three objectives are:

• Suppressing the spread of infection.
• Finding new and more effective ways of managing the virus and enabling life to return closer to normal.
• Minimising damage to the economy and society, jobs and livelihoods. And ensuring education is safeguarded in nurseries, schools, colleges and universities.

Over the coming months, the government will be able to rely less on economic and social restrictions and more on solutions provided by scientific progress. These include:

• Vaccines
• Effective treatments for COVID-19.

These scientific advances provide the route back to normality, says the plan, and should reduce the need for economic and social restrictions in the spring. However, until these have been deployed, the government must continue to use other tools to suppress the virus.

The COVID-19 Winter Plan also sets out how we will lift national restrictions in England on 2 December. On 2 December, across all of England, regardless of tier:

• The stay at home requirement will end, with travel being permitted again subject to guidance in each tier.
• Shops, personal care, gyms and the wider leisure sector will reopen.
• Collective worship, weddings and outdoor sports can resume.
• People will no longer be limited to seeing only one other person in outdoor public spaces – the rule of 6 will now apply outdoors as it did in the previous set of tiers.

COVID-19 vaccination programme

Public Health England has issued several information leaflets addressing various questions and setting out guidance in relation to the coronavirus vaccination programme.

COVID-19 Vaccination: Why You Are Being Asked to Wait 

This leaflet is to help healthcare professionals answer questions on the eligibility and availability of the COVID-19 vaccine.

COVID-19 Vaccination: What to Expect After Vaccination

This leaflet is intended for healthcare practitioners to give to individuals who are being immunised. It addresses areas including:

• side effects
• can you catch COVID-19 from the vaccine?
• can you go back to normal activities after having your vaccine?
• what to do next.

COVID-19 Vaccination: a Guide for Social Care Staff

All frontline health and social care workers are being offered the COVID-19 vaccine which will help protect you against the COVID-19 disease.

This leaflet is for social care workers and includes information on the COVID-19 vaccine.

COVID-19 Vaccination: Guide for Healthcare Workers

This leaflet is for healthcare workers and includes information on the COVID-19 vaccine.

COVID-19 Vaccination: Guide for Older Adults

This leaflet explains about the COVID-19 vaccination, who is eligible and who needs to have the vaccine to protect them from Coronavirus.

COVID-19 Vaccination: Women of childbearing age, currently pregnant, planning a pregnancy or breastfeeding

The information in this document is for all women of childbearing age, those currently pregnant, planning a pregnancy or breastfeeding on coronavirus vaccination.

It states that the Pfizer-BioNTech COVID-19 vaccine has not yet been assessed in pregnancy, so it has been advised that until more information is available, those who are pregnant should not have this vaccine.

While the evidence so far reviewed by the MHRA raises no concerns for safety in pregnancy, because of the new formulation of this particular vaccine the MHRA wants to see more non-clinical data before finalising the advice in pregnancy.

It is standard practice when waiting for such data on any medicine, to avoid its use in those who may become pregnant or who are breastfeeding. This will be kept under review as more evidence becomes available.

These are the key points that should be considered until there is more evidence:

• If you are pregnant you should not be vaccinated – you can be vaccinated after your pregnancy is over.
• If you think you may be pregnant you should delay vaccination until you are sure you are not.
• If you are planning to get pregnant in the next 3 months, you should delay your vaccination.
• If you know you are not pregnant you can start the two-dose course now and you should avoid getting pregnant until at least 2 months after the second dose.
• If you have had the first dose and then become pregnant you should delay the second dose until after the pregnancy is over.

Women who are breastfeeding are advised to finish breastfeeding and then have the vaccine. If breastfeeding when the first dose is administered, the advice is not to have the second dose until breastfeeding is finished.

Tiered approach

On 2 December, England moved back into a regional, tiered approach. Stronger measures will be introduced in each tier to keep the virus under control. See below for full details.

Christmas

The plan also references Christmas, whereby the government will allow some increased social contact for everyone (supported by guidance on how to celebrate safely) over the Christmas period.

However, it is stressed that this will not be risk-free: COVID-19 continues to pose a very real threat to the UK population throughout the end of the year and into 2021. This means that it will not be possible to celebrate Christmas in the “normal way.” Meeting up with other households will increase the risk of catching COVID-19 and passing it on to others.

There must be ‘personal responsibility’ during the Christmas period to limit the spread of the virus, with particular caution exercised with those who are vulnerable.

The plan is available in full here.

Staying mentally well

The Staying mentally well: winter plan 2020 to 2021 sets out the support that will be in place in the immediate term to help support individuals to stay well during the second wave of the coronavirus and winter months ahead.

While this plan applies to England only (as mental health is a devolved matter), it notes that mental health remains a UK-wide priority and all 4 nations are taking steps to address the mental health impact of the COVID-19 pandemic. We are continuing to collaborate across the UK, share learning and ensure all nations can benefit from new initiatives where possible.

The plan points out that as little as 30 minutes’ exposure to natural light per day can improve mental health and help maintain a healthy sleep pattern. As such, the government therefore recommend going outside at least once a day, preferably to a natural environment or green space such as a park, during daylight hours to maximise these benefits. Public Health England’s ‘Better Health’ campaign offers tips to move more and get active outside.

Wellbeing and work

Employers play a crucial role in ensuring employees are supported to take positive actions to improve wellbeing at work, says the plan. The ‘talking toolkit’ developed by the Health and Safety Executive (HSE) is a useful resource to help employers both to have effective conversations with employees on how to prevent work-related stress and then use these discussions to inform tangible actions in the workplace (for example, complete a stress risk assessment).

As we move into winter, guidance and best practice will be available to employers via the Mental Health at Work website.

Staying Mentally Well: Winter Plan 2020 to 2021 available in full here.

New three tier system

The original tier system which was in place between September and October was replaced on 2 December with a regionally-differentiated approach, where different tiers of restrictions apply in different parts of the country. These tiers will be strengthened compared to the previous tiers in order to prevent a return to growing infections.

There are 3 tiers for local restrictions:

• Tier 1: Medium alert;
• Tier 2: High alert;
• Tier 3: Very High alert.

The guidance sets out what you can and cannot do in each tier.

Tre is separate guidance for households with a possible or confirmed coronavirus infection and additional advice at each tier will be provided shortly for people who are clinically extremely vulnerable to coronavirus.

There is also separate guidance for support and childcare bubbles, which apply across all tiers.

Making a Christmas bubble with friends and family.

All tiers

Across all tiers, everyone:

• Must wear a face covering in most indoor public settings, unless they have an exemption;
• Should follow the rules on meeting others safely;
• Should attend school or college as normal, unless they are self-isolating. Schools, universities, colleges and early years settings remain open in all tiers;
• Should walk or cycle where possible, plan ahead and avoid busy times and routes when travelling;
• Must follow the gathering limits at their tier except for in specific settings and circumstances. These exemptions are detailed at the end of this guidance.

Visits to care homes can take place with arrangements such as substantial screens, visiting pods, and window visits. Regular testing will be offered to up to 2 family members or friends per resident by Christmas, which – when combined with other infection-control measures such as PPE – will support indoor visits with physical contact. Detailed guidance will be published shortly.

All businesses and venues that are open are expected to follow COVID-19 secure guidelines to protect customers, visitors and workers. In all tiers, the following businesses and venues can remain open:

• Essential and non-essential retail, including indoor and outdoor markets and car boot sales;
• Certain leisure and sporting facilities such as gyms, sports courts and facilities, leisure centres, fitness and dance studios, golf courses, swimming pools, riding centres, outdoor playgrounds – subject to relevant social contact rules in each tier. Indoor group activities and classes should not take place at tier 3;
• Personal care and close contact services such as hairdressers and barbers, beauty salons, tattoo parlours, nail salons, spas and beauty services, massage parlours and tanning salons;
• Public buildings, such as libraries, community centres and halls. They should not host events for private hire, such as birthday parties or most other social activities in tier 3;
• Allotments, recycling and waste centres, public toilets, car parks;
• Essential public services such as the NHS and medical services, courts, and jobcentre plus sites;
• Places of worship – communal worship can now resume, subject to relevant social contact rules in each tier.

Everyone who can work from home should do so. Where people cannot do so – including, but not limited to, people who work in critical national infrastructure, construction, or manufacturing – they should continue to travel to their workplace. Public-sector employees working in essential services, including education settings, should continue to go into work where necessary

Tier 1: Medium alert

In tier 1:

• you must not socialise in groups larger than 6 people, indoors or outdoors, other than where a legal exemption applies.  This is called the ‘rule of 6’
• businesses and venues can remain open, in a COVID secure manner, other than those which remain closed by law, such as nightclubs
• hospitality businesses selling food or drink for consumption on their premises are required to:
  • provide table service only, for premises that serve alcohol
  • close between 11pm and 5am (hospitality venues in airports, ports, on transport services and in motorway service areas are exempt)
  • stop taking orders after 10pm
• hospitality businesses and venues selling food and drink for consumption off the premises can continue to do so after 10pm as long as this is through delivery service, click-and-collect or drive-through
• early closure (11pm) applies to casinos, cinemas, theatres, concert halls, museums, bowling alleys, amusement arcades, funfairs, theme parks, adventure parks and activities and bingo halls. Cinemas, theatres and concert halls can stay open beyond 11pm in order to conclude performances that start before 10pm
• public attendance at outdoor and indoor events (performances and shows) is permitted, limited to whichever is lower: 50% capacity, or either 4,000 people outdoors or 1,000 people indoors
• public attendance at spectator sport and business events can resume inside and outside, subject to social contact rules and limited to whichever is lower: 50% capacity, or either 4,000 people outdoors or 1,000 people indoors
• places of worship remain open, but you must not attend or socialise in groups of more than 6 people while there, unless a legal exemption applies
• weddings and funerals can go ahead with restrictions on numbers of attendees – 15 people can attend wedding ceremonies and receptions, 30 people can attend funeral ceremonies, and 15 people can attend linked commemorative events
• organised outdoor sport, physical activity and exercise classes can continue
• organised indoor sport, physical activity and exercise classes can continue to take place, if the rule of 6 is followed. There are exceptions for indoor disability sport, sport for educational purposes, and supervised sport and physical activity for under-18s, which can take place with larger groups mixing
• if you live in a tier 1 area and travel to an area in a higher tier you should follow the rules for that area while you are there. Avoid travel to or overnight stays in tier 3 areas other than where necessary, such as for work, education, youth services, to receive medical treatment, or because of caring responsibilities. You can travel through a tier 3 area as part of a longer journey
• for international travel see the Foreign, Commonwealth and Development Office travel advice for your destination and the travel corridors list

Tier 2: High alert

This is for areas with a higher or rapidly rising level of  infections, where some additional restrictions need to be in place.

In tier 2:

• you must not socialise with anyone you do not live with or who is not in your support bubble in any indoor setting, whether at home or in a public place
• you must not socialise in a group of more than 6 people outside, including in a garden or a public space – this is called the ‘rule of 6’
• businesses and venues can continue to operate, in a COVID-Secure manner, other than those which remain closed by law, such as nightclubs
• pubs and bars must close, unless operating as restaurants. Hospitality venues can only serve alcohol with substantial meals
• hospitality businesses selling food or drink for consumption on their premises are required to:
  • provide table service only, in premises which sell alcohol
  • close between 11pm and 5am (hospitality venues in airports, ports, transport services and motorway service areas are exempt)
  • stop taking orders after 10pm
• hospitality businesses and venues selling food and drink for consumption off the premises can continue to do so after 10pm as long as this is through delivery service, click-and-collect or drive-through
• early closure (11pm) applies to casinos, cinemas, theatres, museums, bowling alleys, amusement arcades, funfairs, theme parks, adventure parks and activities, and bingo halls. Cinemas, theatres and concert halls can stay open beyond 11pm in order to conclude performances  that start before 10pm
• public attendance at outdoor and indoor events (performances and shows) is permitted, limited to whichever is lower: 50% capacity, or either 2,000 people outdoors or 1,000 people indoors
• public attendance at spectator sport and business events can resume inside and outside, subject to social contact rules and limited to whichever is lower: 50% capacity, or either 2,000 people outdoors or 1,000 people indoors
• places of worship remain open but you must not socialise with people from outside of your household or support bubble while you are indoors there, unless a legal exemption applies
• weddings and funerals can go ahead with restrictions on numbers of attendees – 15 people can attend wedding ceremonies and receptions, 30 people can attend funeral ceremonies, and 15 people can attend linked commemorative events such as wakes  or stonesettings.
• organised outdoor sport, and physical activity and exercise classes can continue
• organised indoor sport, physical activity and exercise classes will only be permitted if it is possible for people to avoid mixing with people they do not live with (or share a support bubble with). There are exceptions for indoor disability sport, sport for educational purposes and supervised sport and physical activity for under-18s, which can take place with larger groups mixing
• you can continue to travel to venues or amenities which are open, but should aim to reduce the number of journeys you make where possible
• if you live in a tier 2 area, you must continue to follow tier 2 rules when you travel to a tier 1 area. Avoid travel to or overnight stays in tier 3 areas other than where necessary, such as for work, education, youth services, to receive medical treatment, or because of caring responsibilities.You can travel through a tier 3 area as a part of a longer journey
• for international travel see the Foreign, Commonwealth and Development Office travel advice for your destination and the travel corridors list

Tier 3: Very High alert

This is for areas with a very high or very rapidly rising level of infections, where tighter restrictions are in place.

In tier 3:

• you must not meet socially indoors or in most outdoor places with anybody you do not live with, or who is not in your support bubble, this includes in any private garden or at most outdoor venues
• you must not socialise in a group of more than 6 in some other outdoor public spaces, including parks, beaches, countryside accessible to the public, a public garden, grounds of a heritage site or castle, or a sports facility – this is called the ‘rule of 6’
• hospitality settings, such as bars (including shisha venues), pubs, cafes and restaurants are closed – they are permitted to continue sales by takeaway, click-and-collect, drive-through or delivery services.
• accommodation such as hotels, B&Bs, campsites, and guest houses must close. There are several exemptions, such as for those who use these venues as their main residence, and those requiring the venues where it is reasonably necessary for work or education and training
• indoor entertainment and tourist venues must close. This includes:
  • indoor play centres and areas, including trampolining parks and soft play
  • casinos
  • bingo halls
  • bowling alleys
  • skating rinks
  • amusement arcades and adult gaming centres
  • laser quests and escape rooms
  • cinemas, theatres and concert halls
  • snooker halls
• indoor attractions at mostly outdoor entertainment venues must also close (indoor shops, through-ways and public toilets at such attractions can remain open). This includes indoor attractions within:
  • zoos, safari parks, and wildlife reserves
  • aquariums, visitor attractions at farms, and other animal attractions
  • model villages
  • museums, galleries and sculpture parks
  • botanical gardens, biomes or greenhouses
  • theme parks, circuses, fairgrounds and funfairs
  • visitor attractions at film studios, heritage sites such as castles and stately homes
  • landmarks including observation decks and viewing platforms
• leisure and sports facilities may continue to stay open, but group exercise classes (including fitness and dance) should not go ahead. Saunas and steam rooms should close
• there should be no public attendance at spectator sport or indoor performances and large business events should not be taking place. Elite sport events may continue to take place without spectators
• large outdoor events (performances and shows) should not take place, with the exception of drive-in events
• places of worship remain open, but you must not attend with or socialise with  anyone outside of your household or support bubble while you are there, unless a legal exemption applies
• weddings and funerals can go ahead with restrictions on the number of attendees – 15 people can attend wedding ceremonies, wedding receptions are not allowed, 30 people can attend funeral ceremonies, 15 people can attend linked commemorative events
• organised outdoor sport, and physical activity and exercise classes can continue, however higher-risk contact activity should not take place
• organised indoor sport, physical activity and exercise classes cannot take place indoors. There are exceptions for indoor disability sport, sport for educational purposes and supervised sport and physical activity for under-18s
• you can continue to travel to venues or amenities which are open, but should aim to reduce the number of journeys you make where possible
• avoid travelling to other parts of the UK, including for overnight stays other than where necessary, such as for work, education, youth services, to receive medical treatment, or because of caring responsibilities. You can travel through other areas as part of a longer journey
• for international travel see the Foreign, Commonwealth and Development Office travel advice for your destination and the travel corridors list

Full list of local restriction tiers by area

This information sets out the full list of local restriction tiers by area from 2 December 2020.

Decisions on which area goes into which tier are primarily based on 5 key epidemiological indicators:

• case detection rates in all age groups
• case detection rates in the over-60s
• the rate at which cases are rising or falling
• positivity rate (the number of positive cases detected as a percentage of tests taken)
• pressure on the NHS, including current and projected occupancy.

The indicators are designed to provide a full picture of what is happening with the virus in any area so that suitable action can be taken.

Click here for the full list of local restriction tiers by area, from Wednesday 2 December 2020.

‘Hands. Face. Space’ and ventilation

New film shows importance of ventilation to reduce spread of COVID-19.

A new public information campaign has been launched by the government to highlight how letting fresh air into indoor spaces can reduce the risk of infection from coronavirus by over 70%. The campaign, which forms part of wider ‘Hands. Face. Space’ guidance, sees the release of a new short film created with scientists and an engineer at Leeds University.

The film illustrates how coronavirus lingers in the air in spaces with no fresh air, increasing the risk of people breathing in infected particles, and how the risk can be reduced significantly by regularly ventilating enclosed areas.

Research shows that being in a room with fresh air can reduce your risk of infection from particles by over 70%, as fresh air dilutes the particles.

As people start to spend more time indoors, experts are recommending that people either:

• Open windows for short, sharp bursts of 10 to 15 minutes regularly throughout the day;
• Leave windows open a small amount continuously.

This is to remove any infected particles lingering in the room.

Additionally, it is advised that any household systems that use outdoor air, including kitchen or bathroom extractor fans, are used correctly and regularly as an additional method to remove infected particles.

Airing indoor spaces is particularly important when:

• People have visitors (when permitted) or tradespeople in their home, for example for construction or emergencies;
• Someone from a support bubble is meeting with another household indoors;
• A care worker is seeing a patient indoors;
• Someone in the household has the virus, as this can help prevent transmission to other household members.