An evaluation of dermatology patients shielding during the COVID‐19 outbreak

Many governments around the world have enforced social distancing strategies in an effort to prevent the spread of the novel coronavirus, termed SARS‐CoV‐2, which can lead to a fatal respiratory disease known as coronavirus disease 2019 (COVID‐19). On 22 March 2020 the UK government announced that over 1.5 million ‘extremely vulnerable’ adults (those with risk factors making them likely to suffer from more severe symptoms of COVID‐19, such as age > 70 years, or presence of significant comorbidities or concurrent immunosuppression) would have to take additional measures and shield,¹ meaning that they should not leave their homes and must restrict contact with others within their household. Many authors have raised concerns about the psychological and physical wellbeing of such groups, particularly those already considered to be society’s most vulnerable and technology‐poor, such as elderly people.², ³ The UK government and local councils established a new ‘local support system’ to facilitate help with delivery of shopping and medication and to which people who are shielding could sign up.

To understand the experience of our dermatology patients who were advised to shield (in Greater Manchester, UK) we conducted a telephone questionnaire. Retrospective analysis of patient records/pharmacy lists revealed 1071 patients that met the British Association of Dermatologists’ criteria for shielding.⁴ Printed letters were posted to these patients, advising them accordingly. We followed up 8–12 weeks later and attempted to contact 592 patients by telephone; 318 completed the questionnaire, 10 declined to participate and 265 did not answer their phone. Demographics are summarized in Table 1.

Table 1.

Summary of respondents’ background, demographics and list of systemic therapies/biologics^a

Parameter
Sex
Male	181
Female	137
Age, years
Mean	51.8
Median	53
Range	16–87
Ethnicity
White British (including NI, Scotland and Wales)	267
Asian or Asian British (Pakistani)	15
Asian or Asian British (Indian)	11
Not stated	9
White Irish	7
Any other white background	5
Asian or Asian British (Bangladeshi)	1
Mixed (White & Black Caribbean)	1
Other (Chinese)	1
Mixed (White & Asian)	1
Dermatoses
Chronic plaque psoriasis	203
Eczema	74
Hidradenitis suppurativa	20
Other inflammatory disease	12
Chronic spontaneous urticaria	7
Bullous disorders	2
Medication
Biologic
Adalimumab	75
Dupilumab	57
Ustekinumab	51
Ixekizumab	18
Guselkumab	14
Secukinumab	10
Etanercept	8
Omalizumab	7
Brodalumab	5
Infliximab	2
Risankizumab	2
Rituximab	1
Systemic therapies other than biologics
Methotrexate	31
Dimethyl fumarate	10
Azathioprine	5
Ciclosporin	5
MMF	5
Apremilast	3
Interferon‐alfa	1
Combination therapies
Adalimumab and methotrexate	2
Dupilumab and ciclosporin	2
Dupilumab and prednisolone	1
Azathioprine and MMF	1
MMF, prednisolone and mepacrine	1
Ciclosporin and prednisolone	1

MMF, mycophenolate mofetil; NI, Northern Ireland.

^aThose on a single agent had additional high‐risk circumstances/comorbidities.

In total, 96.5% (n = 307) of respondents had received a letter advising them to shield and 93.5% (n = 287) stated that this letter was from the dermatology department at Salford Royal Hospital. Other organizations and medical departments were noted to have also sent out correspondence and notifications advising patients to shield. Patients reported that most of this correspondence had been sent by NHS England (n = 81; this also includes the NHS England text messaging service) followed by the patient’s: general practitioner (n = 59), other hospital department (n = 13), rheumatology department (n = 11), local council (n = 9) and gastroenterology department (n = 1).

Just under half our respondents (46.9%, n = 149) felt that they needed to access additional services to adequately shield but 38.9% (58/149) of them had difficulty doing so. Almost two‐thirds (65.5%; 38/58) reported that delivery slots for their priority online shopping were the most difficult service to access. Others struggled with administration and stated that they had experienced issues getting their names onto ‘priority lists’ or registering on the government website (n = 9). Some reported problems with their regular medication being delivered to their home (n = 5).

Most (84.9%, n = 270) respondents stated that they were shielding. Just over a fifth (22.9%, 11/48) of those who stated that they were not shielding attributed this to ‘home and living circumstances’. For most, this related to being unable to work from home or to their spouse’s work circumstances. Other reasons given included needing to collect their medication or shopping (n = 4), going outside to exercise (n = 11), looking after a sick relative (n = 2) or having concerns regarding their mental wellbeing (n = 7). Only a small number did not fully understand what shielding involved (n = 3) or did not feel the need to shield (n = 4).

Most patients continued to take their immunosuppressive medications such as methotrexate and biologics (89%, n = 283). However, almost 1 in 10 patients stopped (n = 35), with most doing so due to fear of contracting COVID‐19 (n = 14). Others had stopped prior to lockdown (n = 6) for reasons unrelated to COVID‐19, following an illness (n = 6), following discussions with their dermatology consultant (n = 4), because of inability to procure their medication (n = 2), because they were pregnant (n = 1), because they were on a planned break (n = 1) or for undocumented reasons (n = 1). The vast majority of our respondents did not report any symptoms of a cough and/or fever (73.7%, n = 280). Of the 38 respondents that did report symptoms, 4 reported not shielding.

In conclusion, the majority of our highly vulnerable dermatology patients shielded, continued to take their immunosuppressive medication and denied any symptoms of COVID‐19. A large proportion (38.9%) of those who felt the need to access additional services struggled to do so, and most attributed this to limited access to priority online shopping delivery slots. Patients who decided not to shield did so primarily because of home and living circumstances and the need to exercise. With the threat of a second peak of COVID‐19 looming as the UK comes out of lockdown or enters the winter months, more needs to be done to ensure that our most vulnerable patients are able to adequately shield again if required. This includes better communication between primary and secondary care services, improving social support and enhancing access to additional services.

Acknowledgement

RBW and CEMG are supported by the NIHR Manchester Biomedical Research Centre.