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Infections and infestations

Coronavirus - COVID-19

Last revised in September 2025

Coronavirus or COVD-19 is a new viral illness which causes pneumonia

Coronavirus - COVID-19: Summary

  • Coronavirus disease (COVID-19) is an infectious disease caused by a novel betacoronavirus known as severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2).
  • The National Institute for Health and Care Excellence (NICE) defines:
    • 'Acute COVID-19' as signs and symptoms of infection consistent with COVID-19 for up to 4 weeks.
    • 'Ongoing symptomatic COVID-19' as signs and symptoms of COVID-19 infection from 4–12 weeks.
    • 'Post-COVID-19 syndrome' as signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks, and are not explained by an alternative diagnosis.
    • 'Longer term effects of COVID-19' or 'long COVID' as signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 4 weeks, and are not explained by an alternative diagnosis.
  • COVID-19 virus spreads from an infected person's mouth or nose by droplets or aerosols from sneezing, coughing, speaking, singing, or breathing.
  • Risk factors for severe infection include increasing age, male sex, co-morbidities, health and social care workers, and Black and Asian ethnic groups.
  • Infection may be asymptomatic or mild, to severe with complications including acute respiratory distress syndrome; venous thromboembolism; acute myocardial or kidney injury; and sepsis.
  • A diagnosis of COVID-19 should be suspected in a person with:
    • Fever or chills.
    • A new, continuous cough; breathlessness.
    • A loss or change to sense of smell or taste.
    • Fatigue; muscle aches and pains; headache.
    • Sore throat; blocked or runny nose.
    • Loss of appetite; diarrhoea; nausea and/or vomiting.
  • If a person has suspected or confirmed COVID-19, assessment for severe illness includes identifying:
    • Severe breathlessness; haemoptysis; hypoxia.
    • Cyanosis; feeling cold and clammy; pale or mottled skin.
    • Collapse or syncope.
    • New confusion; drowsiness.
    • Reduced urine output.
  • If a person has suspected or confirmed COVID-19, hospital admission should be arranged if the person:
    • Is moderately or severely unwell.
    • Has a suspected acute or life-threatening complication.
  • If a person has suspected COVID-19 and hospital admission is not needed, management includes advice to:
    • Take a lateral flow test if a person is at highest risk of becoming seriously ill.
    • Try to stay at home and avoid contact with other people, for all other people.
    • Self-manage symptoms and consider self-monitoring at home.
  • If a person has confirmed COVID-19 and hospital admission is not needed, management includes advice:
    • About antibody and antiviral treatments for people at highest risk of becoming seriously ill.
    • To try to stay at home and avoid contact with other people, for all other people.
    • To self-manage symptoms and consider self-monitoring at home.
    • To notify any confirmed case to the local health protection team.
  • Advice for all people to live safely with COVID-19 includes:
    • Getting vaccinated, ensuring adequate ventilation, good hygiene, and when to consider wearing a face covering or mask.
    • Accessing mental health support, if needed.
    • Entry requirements and travel warnings when travelling abroad.
    • Support at work, self-employment and benefits.

Have I got the right topic?

From birth onwards.

This CKS topic covers the diagnosis and primary care management of suspected or confirmed COVID-19 infection. It also includes information on COVID-19 vaccination, and general advice on living with COVID-19.

This CKS topic is largely based on guidance from the National Institute for Health and Care Excellence (NICE) rapid guidelines on managing COVID-19 and the long-term effects of COVID-19, guidance from the UK Health Security Agency (UK HSA), and the GOV.UK and NHS websites.

There are separate CKS topics on Chest infections - adult, Common cold, Cough - acute with chest signs in children, Feverish children - risk assessment and management, Influenza - seasonal, Long-term effects of coronavirus (long COVID), Otitis media - acute, Sinusitis, and Sore throat - acute.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

September 2025 — minor update. Updated with vaccines available for autumn 2025. 

Previous changes

October 2024 — minor update. Available vaccines updated in line with autumn 2024 vaccination campaign.

February 2024 — minor update. Link added to the JCVI statement on COVID-19 vaccination in spring 2024.

December 2023 — minor update. Acute disseminated encephalomyelitis (ADEM) has been added as a possible adverse effect of Vaxzevria® vaccination in line with the updated SPC.  The recommendation to consider benzodiazepine for managing anxiety or agitation, and the recommendations on medicines for end of life care have been removed from this topic in line with the updated NICE guideline COVID-19 rapid guideline: Managing COVID-19.

November 2023 — minor update. Information about the potential adverse effects of myocarditis and pericarditis associated with COVID vaccines updated in line with manufacturers' summary of product characteristics.

October 2023 — minor update. Information added about the potential adverse effects of myocarditis and pericarditis associated with the COVID-19 Janssen Ad26.COV2-S vaccine in line with the updated manufacturer's Summary of Product Characteristics.

September 2023 — minor update. Additional information added about the potential adverse effect of myocarditis in line with the updated manufacturer's Summary of Product Characteristics.

August 2023 — minor update. Information that Spikevax vaccine is indicated for people aged 6 months and over has been added to this topic in line with the manufacturer's updated Summary of Product Characteristic

March 2023 — minor update. Several uncommon adverse effects of the Vaxzevria and Comirnaty vaccines were added in line with the manufacturer's SPC. 

March 2023 — minor update. Information that the Spikevax bivalent vaccine is now licensed for use in people aged over 6 years has been added to this topic in line with the updated manufacturer's Summary of product characteristics.  

February 2023 — minor update. The section on available vaccines has been updated with details of new bivalent vaccines.

January 2023 — minor update. Added new contraindication and adverse effect of the Janssen COVID-19 vaccine in line with an update to the manufacturer's SPC. 

December 2022 — minor update. Revised the age criteria for Spikevak (formerly COVID-19 Vaccine Moderna) as this has been extended to 12 and older. The information that Comirnaty 3 micrograms/dose mRNA COVID-19 vaccine has now been licensed for use in infants and children aged 6 months to 4 years has also been added. 

November 2022 — minor update. Heavy menstrual bleeding added as a possible adverse effect of booster vaccinations in line with the updated manufacturer's Summaries of Product Characteristics for Comirnaty and Spikevax vaccines. Recommendations on assessment and management of suspected long COVID have been removed from this topic and links added to the new CKS topic on Long-term effects of coronavirus (long COVID). 

September 2022 — minor update. Information that two bivalent booster vaccines (targeting the original strain and Omicron) are now available has been added to this topic. Additionally that clinicians should be aware that administration of Novavax COVID-19 vaccine should be separated from administration of influenza vaccine by at least 7 days. This is based on an update to chapter 19 of the green book. 

May to July 2022 — this is a new CKS topic. A literature search was conducted in April 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials. The recommendations have been made in line with current evidence in the literature. 

Update

New evidence

Evidence-based guidelines

  • Department of Health and Social Care (2022) COVID-19 vaccines for autumn 2022: JCVI advice, 15 August 2022. Department of Health and Social Care. www.gov.uk [Free Full-text]
  • UKHSA (2022) National protocol for Comirnaty 10 microgram/dose COVID-19 mRNA vaccine. UK Health Security Agency. www.gov.uk [Free Full-text]
  • NHS England (2022) Updated patient group direction for Comirnaty 10 microgram/dose COVID-19 mRNA vaccine for children 5-11 years. UK Health Security Agency. www.england.nhs.uk [Free Full-text]
  • UKHSA (2022) JCVI advises use of additional bivalent vaccine for autumn booster campaign. www.gov.uk [Free Full-text]
  • WHO (2022) Therapeutics and COVID-19: living guideline. World Health Organization. www.who.int [Free Full-text]
  • UKHSA (2022) COVID-19 vaccination: a guide on pregnancy and breastfeeding. UK Health Security Agency. www.gov.uk [Free Full-text]
  • UKSHA (2022) National protocol for Comirnaty® 10 microgram/dose COVID-19 mRNA vaccine. UK Health Security Agency. www.gov.uk [Free Full-text]
  • WHO (2023) Therapeutics and COVID-19. World Health Organisation. www.who.int [Free Full-text]
  • MHRA (2023) COVID-19 vaccines and medicines: updates for January 2023 www.gov.uk [Free Full-text]
  • NIHR (2023) A pause in methotrexate treatment boosted the immune response to the COVID-19 vaccine https://evidence.nihr.ac.uk [Free Full-text]
  • MHRA (2023) COVID-19 vaccines and medicines: updates for February 2023. Medicines and Healthcare Products Regulatory Agency. www.gov.uk [Free Full-text]
  • DHSC (2023) COVID-19 vaccination of children aged 6 months to 4 years: JCVI advice, 9 December 2022. Department of Health and Social Care. www.gov.uk [Free Full-text]
  • MHRA (2023) Last updated 04/23 - Summary of Product Characteristics for COVID-19 Vaccine Janssen. Medicines and Healthcare Products Regulatory Agency. www.gov.uk [Free Full-text]
  • UKHSA (2023) COVID-19: the green book, chapter 14a. UK Health Security Agency. www.gov.uk [Free Full-text]
  • UKHSA (2023) COVID-19 vaccination: information for healthcare practitioners. UK Health Security Agency. www.gov.uk [Free Full-text]
  • NICE (2023) Casirivimab plus imdevimab, nirmatrelvir plus ritonavir, sotrovimab and tocilizumab for treating COVID-19. National Institute for Health and Care Excellence https://www.nice.org.uk/ [Free Full-text]
  • UKHSA (2023) JCVI advises on eligible groups for 2023 autumn booster. UK Health Security Agency. www.gov.uk [Free Full-text]
  • DHSC (2023) COVID-19 autumn 2023 vaccination programme: JCVI update, 7 July 2023. Department of Health and Social Care. www.gov.uk [Free Full-Text]
  • UKHSA (2023) National protocol for COVID-19 vaccine (adults). UK Health Security Agency. www.gov.uk [Free Full-Text]
  • WHO (2023) WHO updates guidelines on treatments for COVID-19. World Health Organisation. www.who.int [Free Full-text]
  • NICE (2023) COVID-19 rapid guideline: managing COVID-19. National Institute for Health and Care Excellence. https://www.nice.org.uk/ [Free Full-text]
  • UKHSA (2024) National protocol for COVID-19 vaccine (adults). UK Health Security Agency. www.gov.uk [Free Full-Text]
  • UKHSA (2024) National protocol for COVID-19 vaccine (5 to 17 years of age). UK Health Security Agency. www.gov.uk [Free Full-Text]
  • UKHSA (2024) A guide to the spring 2024 COVID-19 vaccination campaign. UK Health Security Agency. www.gov.uk [Free Full-Text]
  • UKHSA (2024) National flu and COVID-19 surveillance reports: 2023 to 2024 season. UK Health Security Agency. www.gov.uk [Free Full-Text]
  • UKHSA (2024) COVID-19: guidance for people whose immune system means they are at higher risk. UK Health Security Agency. www.gov.uk [Free Full-Text]
  • DHSC (2024) COVID-19 vaccination in 2025 and spring 2026: JCVI advice. Department of Health and Social Care. www.gov.uk [Free Full-Text]
  • Payne, R., Pring, T., Hey, M., et al. (2024) Muscle weakness post-COVID: a practical guide for primary care. British Journal of General Practice. https://bjgp.org [Free Full-text]
  • NHS England (2025) Flu and COVID-19 Seasonal Vaccination Programme: autumn/ winter 2025/26. NHS England https://www.england.nhs.uk [Free Full-text]

HTAs (Health Technology Assessments)

Economic Appraisals

No new economic appraisals relevant to England since 1 April 2022.

Systematic reviews and meta-analyses

  • Albuquerque, A.M., Eckert, I., Tramujas, L., et al. (2022) Effect of tocilizumab, sarilumab, and baricitinib on mortality among patients hospitalized for COVID-19 treated with corticosteroids: a systematic review and meta-analysis. Clinical Microbiology and Infection. www.sciencedirect.com [Free Full-text]
  • Holmer, H.K. (2022) Major Update 2: Antibody Response and Risk for Reinfection After SARS-CoV-2 Infection—Final Update of a Living, Rapid Review.  Annals of Internal Medicine. https://www.acpjournals.org/ [Free Full-text]
  • Graña, C., Ghosn, L., Evrenoglou, T., et al. (2022) Efficacy and safety of COVID‐19 vaccines. Cochrane Database of Systematic Reviews. www.cochranelibrary.com [Free Full-text] 
  • Mackey, K., Kansagara, D., and Vela, K. (2023) Update Alert 10: Risks and Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers on SARS-CoV-2 Infection in Adults. Annals of Internal Medicine. https://www.acpjournals.org/ [Free Full-text]
  • UKHSA (2023) COVID-19 Omicron variant: infectious period and asymptomatic and symptomatic transmission. UK Health Security Agency. www.gov.uk [Free Full-text]
  • Poole-Wright, K., Guennouni, I., Sterry, O., et al. (2023) Fatigue outcomes following COVID-19: a systematic review and meta-analysis. BMJ Open. https://bmjopen.bmj.com/ [Abstract]
  • Najafabadia, B.T., Raynera, D.G., Shokraee, K., et al. (2023) Obesity as an independent risk factor for COVID‐19 severity and mortality. Cochrane Database of Systematic Reviews. www.cochranelibrary.com [Free Full-text] 
  • Alami, A., Krewski, D., Farhat, N., et al. (2023) Risk of myocarditis and pericarditis in mRNA COVID-19-vaccinated and unvaccinated populations: a systematic review and meta-analysis. BMJ Open https://bmjopen.bmj.com/ [Free Full-text]
  • Cheema, H.A., Jafar, U., Shahid, A., et al. (2024) Colchicine for the treatment of patients with COVID-19: an updated systematic review and meta-analysis of randomised controlled trials. BMJ Open. https://bmjopen.bmj.com/ [Abstract]
  • Rafati, A., Jameie, M., Amanollahi, M., et al. (2024) Association of New-Onset Seizures With SARS-CoV-2 Vaccines: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. JAMA Neurology. https://jamanetwork.com/ [Abstract]
  • Reis, S., Faske, A., Monsef, I., Langer, F., et al. (2024). Anticoagulation in COVID-19 patients–An updated systematic review and meta-analysis. Thrombosis Research. [Abstract]

Primary evidence

  • Tartof, S.Y., Slezak, J.M. Puzniak, L., et al. (2022) BNT162b2 vaccine effectiveness against SARS-CoV-2 omicron BA.4 and BA.5. The Lancet Infectious Diseases. www.thelancet.com [Free Full-text]
  • Sadarangani, M., Soe, P., Shulha, H.P., et al. (2022) Safety of COVID-19 vaccines in pregnancy: a Canadian National Vaccine Safety (CANVAS) network cohort study. Lancet. www.thelancet.com [Free Full-text]
  • Watanabe, A., Yasuhara, J., Iwagami, M., et al. (2022) Peripartum outcomes associated with COVID-19 vaccination during pregnancy a systematic review and meta-analysis. JAMA Pediatrics. www.jamanetwork.com [Free Full-text]
  • UKHSA (2023) COVID-19: reported SARS-CoV-2 deaths in England. www.gov.uk [Free Full-text]
  • Lin, D.Y., Xu, Y., Gu, Y., et al. (2023) Effects of COVID-19 vaccination and previous SARS-CoV-2 infection on omicron infection and severe outcomes in children under 12 years of age in the USA: an observational cohort study. Lancet Infect Disease https://www.thelancet.com [Free Full-text]
  • Lee, I.T., Cosgrove, C.A., Moore, P., et al. (2023) Omicron BA.1-containing mRNA-1273 boosters compared with the original COVID-19 vaccine in the UK: a randomised, observer-blind, active-controlled trial. Lancet Infect Disease https://www.thelancet.com [Free Full-text]
  • Brown, R.L., Benjamin, L., Lunn, M.P., et al. (2023) Pathophysiology, diagnosis, and management of neuroinflammation in covid-19. British Medical Journal. [Free Full-text]
  • EMC (2023) Comirnaty 3 micrograms/dose concentrate for dispersion for injection COVID-19 mRNA Vaccine (nucleoside modified). Electronic Medicines Compendium. [Free Full-text]
  • EMC (2023) COVID-19 Vaccine Janssen suspension for injection. Electronic Medicines Compendium. [Free Full-text]
  • Cao, B., Wang, Y., Lu, H., et al. (2024) Oral Simnotrelvir for Adult Patients with Mild-to-Moderate Covid-19. New England Journal of Medicine. https://www.nejm.org/ [Free Full-text]
  • Feldstein LR, Britton A, Grant L, et al. (2024) Effectiveness of Bivalent mRNA COVID-19 Vaccines in Preventing SARS-CoV-2 Infection in Children and Adolescents Aged 5 to 17 Years. JAMA. https://jamanetwork.com/journals/jama [Free Full-text]
  • Norman M, Magnus MC, Söderling J,et al. (2024) Neonatal Outcomes After COVID-19 Vaccination in Pregnancy. JAMA. https://jamanetwork.com/journals/jama [Free Full-text]
  • Yotsuyanagi, H., Ohmagari, N., Doi, Y., et al. (2024). Efficacy and Safety of 5-Day Oral Ensitrelvir for Patients With Mild to Moderate COVID-19: The SCORPIO-SR Randomized Clinical Trial. JAMA Network Open, 7(2), e2354991-e2354991. [Free Full-text]
  • Hviid, A., Nieminen, T. A., Pihlström, N., et al. (2022). Booster Vaccination with SARS-CoV-2 mRNA Vaccines and Myocarditis Risk in Adolescents and Young Adults: A Nordic Cohort Study of 8.9 Million Residents. medRxiv, 2022-12. [Free Full-text]
  • Faksova, K., Walsh, D., Jiang, Y., et al. (2024). COVID-19 vaccines and adverse events of special interest: A multinational Global Vaccine Data Network (GVDN) cohort study of 99 million vaccinated individuals. Vaccine. [Free Full-text]
  • Bennett, C., Woo, W., Bloch, M., et al. (2024) Immunogenicity and safety of a bivalent (omicron BA.5 plus ancestral) SARS-CoV-2 recombinant spike protein vaccine as a heterologous booster dose: interim analysis of a phase 3, non-inferiority, randomised, clinical trial. Lancet Infectious Diseases. https://www.thelancet.com/ [Free Full-text]
  • Mercadé-Besora, N., Li, X., Kolde, R., Trinh, N. T., Sanchez-Santos, M. T., Man, W. Y., ... & Català, M. (2024). The role of COVID-19 vaccines in preventing post-COVID-19 thromboembolic and cardiovascular complications. Heart. [Free Full-text]
  • Einarsdottir, M.J., Kibiwott Kirui, B., Li, H., et al. (2024) Impact of chronic oral glucocorticoid treatment on mortality in patients with COVID-19: analysis of a population-based cohort. BMJ Open. https://bmjopen.bmj.com/ [Free Full-text]
  • Kirwan, P.D., Hall, V. J., Foulkes, S., et al. (2024). Effect of second booster vaccinations and prior infection against SARS-CoV-2 in the UK SIREN healthcare worker cohort. The Lancet Regional Health–Europe, 36. https://www.thelancet.com/ [Free Full-text]
  • Khalid, M.B., Zektser, E., Chu, E., et al. (2024). A randomized double-blinded trial to assess recurrence of systemic allergic reactions following COVID-19 mRNA vaccination. Journal of Allergy and Clinical Immunology. [Free Full-text]
  • Kirsebom, F.C.M., Stowe, J., Bernal, J.L., et al. (2024). Effectiveness of Autumn 2023 COVID-19 vaccination and residual protection of prior doses against hospitalisation in England, estimated using a test-negative case-control study. Journal of Infection, 106177. [Abstract]
  • Dutcher, E.G., Epel, E.S., Mason, A.E., et al. (2024) COVID-19 Vaccine Side Effects and Long-Term Neutralizing Antibody Response : A Prospective Cohort Study. Annals of Internal Medicine. https://www.acpjournals.org [Free Full-text]
  • de Barros, E. Silva, P.G.M., Macedo, A.V.S., Bronhara, B., et al. (2024) Effect of Apixaban on Clinical Outcomes in Outpatients With COVID-19: The APOLLO Randomized Clinical Trial. Circulation. https://www.ahajournals.org [Abstract]
  • Figueroa, A. L., Torres, D., Reyes-Acuna, C., Matherne, P., et al. (2024). Safety and immunogenicity of a single-dose omicron-containing COVID-19 vaccination in adolescents: an open-label, single-arm, phase 2/3 trial. The Lancet Infectious Diseases. [Abstract]

New policies

  • Summary of legal mechanisms for administering Covid-19 and influenza vaccines. This document summarises the legal mechanisms which enable administration of Covid-19 and influenza vaccines. It can be used as an aid to identify which mechanism is most suitable for use based on local staffing mix and preferred models for delivery. See more here.

New safety alerts

No new safety alerts since 1 April 2022.

Changes in product availability

  • The MHRA has authorized the use of the Sanofi Pasteur COVID-19 vaccine See more here.
  • The MHRA has authorized Pfizer/BioNTech COVID-19 vaccine for use in infants and children aged 6 months to 4 years. See more here.
  • The MHRA has issued a Conditional Marketing Authorization for Spikevax bivalent Original/Omicron booster vaccine. See more here.
  • New product: Comirnaty Original/ Omnicron BA.1 15/15 microgramd (riltozinameran, tozinameran) per dose dispersion for injection COVID-19 mRNA vaccine. See more here. 
  • New product: Evusheld 150 mg / 150 mg (tixagevimab/ cilgavimab) solution for injection is licensed for pre-exposure prophylaxis in adults. See more here.
  • New product: VidPrevtyn Beta solution and emulsion for injection is indicated as a booster for active immunization to prevent COVID-19 in adults who have previously received an mRNA or adenoviral vector COVID-19 vaccine. See more here.
  • New product: Comirnaty Omicron XBB.15 injection COVID-19 mRNA Vaccine (nucleoside modified). This mRNA vaccine 30 micrograms/dose formulation, encoding the viral spike protein of SARS-CoV-2 Omicron XBB.1.5, is licensed for the active immunisation to prevent COVID-19 caused by SARS-CoV-2, in individuals 12 years of age and older. See more here. The 10 micrograms/dose vaccine is licensed for active immunisation to prevent COVID-19 caused by SARS-CoV-2, in children aged 5 to 11 years. This is a multidose vial with a blue cap and must not be diluted before use. One vial (2.25 mL) contains 6 doses of 0.3 mL. See more here. The 3 micrograms/dose vaccine is licensed for active immunisation to prevent COVID-19 caused by SARS-CoV-2, in infants & children aged 6 months to 4 years. This multidose vial with maroon cap must be diluted before use. One vial (2.6 mL) contains 10 doses of 0.2 mL after dilution. See more here.
  • New product: Spikevax XBB.1.5 0.1 mg/mL (andusomeran) dispersion for injection (MDV). Spikevax XBB.1.5 is licensed for active immunisation to prevent COVID-19 caused by SARS-CoV-2 in individuals 6 months of age and older. The multidose vial contains 5 doses of 0.5 mL each or 10 doses of 0.25 mL each. See more here.
  • New products: Comirnaty LP.8.1 (Mrna encoding lp.8.1) – various strengths and formulations. This vaccine, available in different strengths and formulations, is licensed for active immunisation to prevent COVID-19 caused by SARS-CoV-2. See more here. 
  • New product: Nuvaxovid JN.1 PFS dispersion for injection COVID-19 Vaccine (recombinant, adjuvanted). This is licensed for active immunisation to prevent COVID-19 caused by SARS-CoV-2 in individuals 12 years of age and older. It should be used in accordance with official recommendations. See more here.
  • New product spikevax LP.8.1 (Mrna-1273.251) 0.1 mg/mL dispersion for injection is indicated for active immunisation to prevent COVID-19 caused by SARS-CoV-2 in individuals 6 months of age and older. See more here.

Goals and outcome measures

Goals

To support primary healthcare professionals to:                                                                       

  • Understand the background of the disease.
  • Be aware of the possible signs and symptoms of COVID-19 infection.
  • Assess a person with suspected or confirmed COVID-19 infection and offer appropriate management in primary care, including people in the highest risk clinical subgroups.
  • Arrange hospital admission or specialist referral for people with suspected or confirmed COVID-19 infection or a possible complication, if clinically indicated.
  • Provide appropriate management for people with COVID-19 infection at the end of life.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP — Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Coronavirus disease is an infectious disease caused by a novel betacoronavirus known as severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2). The disease associated with it is now referred to as 'COVID-19' [WHO, 2022; UKHSA, 2022a].
    • On 31 December 2019, the World Health Organization (WHO) was informed of a cluster of cases of pneumonia of unknown cause in Wuhan City, Hubei Province, China.
    • On 11 March 2020, the WHO announced a COVID-19 global pandemic due to the rapid spread and severity of cases worldwide. SARS-CoV-2 is felt to be zoonotic in origin, but the source of the original outbreak has not been identified. The original virus strain has mutated over time causing new variants with differing abilities to spread and cause severe disease.
      • Variants of concern continue to be identified and a renewed WHO nomenclature was adopted on 31 May 2021 for COVID-19 variants using the Greek alphabet, to make communication easier and to ensure labels were non-stigmatizing.
      • The UK Health Security Agency (HSA) publication Investigation of SARS-CoV-2 variants: technical briefings provides additional information on novel SARS-CoV-2 variants.
  • The National Institute for Health and Care Excellence (NICE) provides the following definitions [NICE, 2022a]:
    • 'Acute COVID-19' is defined as signs and symptoms of infection consistent with COVID-19 for up to 4 weeks.
    • 'Ongoing symptomatic COVID-19' is defined as signs and symptoms of COVID-19 infection from 4 weeks up to 12 weeks.
    • 'Post-COVID-19 syndrome' is defined as signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks, and are not explained by an alternative diagnosis. It usually presents with clusters of symptoms which may overlap, fluctuate, and change over time, and affect any body system.
    • 'Longer term effects of COVID-19' or 'long COVID' defines signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 4 weeks, and are not explained by an alternative diagnosis.

What is the cause?

  • Genetic analysis of SARS-CoV-2 shows that it is an RNA virus which is genetically distinct from SARS coronavirus, but shares some genetic sequences with bat coronaviruses in China [UKHSA, 2026].
  • COVID-19 virus spreads from an infected person's mouth or nose by droplets from sneezing, coughing, speaking, singing, or breathing [WHO, 2022].
    • These particles range from larger respiratory droplets to smaller aerosols, and are transmitted between people when they are inhaled or come into contact with the eyes, nose, or mouth [UKHSA, 2022a].
    • The risk of transmission is highest if a person is in close proximity to an infected person (especially within 2 metres) and/or in a poorly ventilated indoor space [UKHSA, 2022a].
    • Indirect transmission may occur due to contact with surfaces contaminated with the virus (fomite transmission) [UKHSA, 2022a].
    • Perinatal transmission has been documented, however, the exact mode of transmission is not known [UKHSA, 2026].
  • The incubation period for SARS-CoV-2 varies depending on the circulating variant, and is about 3 days for the Omicron variant [UKHSA, 2022a].
  • Several risk factors have been associated with an increased risk of severe infection and/or death, including [UKHSA, 2026; UKHSA, 2022b]:
    • Increasing age.
    • Male sex.
    • Co-morbidities such as obesity, diabetes, hypertension, severe asthma, and chronic obstructive pulmonary disease.
    • Health and social care workers.
    • Lower socioeconomic status.
    • Black, Asian, and minority ethnic (BAME) origin.

How common is it?

The global number of confirmed cases of COVID-19 is changing rapidly. 

  • The UK Health Security Agency (HSA) publishes a UK summary of coronavirus cases and an interactive map, which is updated on weekdays at 4pm.
  • The World Health Organization (WHO) publishes daily COVID-19 dashboard maps which provide global and UK interactive data on new cases, cumulative cases, deaths, and vaccination rates.
  • The UK Office for National Statistics (ONS) publishes regular Coronavirus (COVID-19) infection survey results, which include the percentage of people testing positive for COVID-19 in private residential households with regional and age breakdowns. It also publishes a statistical bulletin of the estimated prevalence of self-reported long COVID symptoms.

What are the complications?

  • Possible complications of COVID-19 infection vary depending on the circulating variant, the person's age, comorbidities, and risk of immunosuppression, and may include:
    • Acute respiratory distress syndrome (ARDS) — this is the leading cause of death due to respiratory failure [UKHSA, 2022a].
    • Venous thromboembolism — a hypercoagulable state may increase the risk of arterial and venous thromboembolism. See the CKS topics on Deep vein thrombosis and Pulmonary embolism for more information [NICE, 2022b; UKHSA, 2022a].
    • Cardiovascular — most commonly heart failure, acute myocardial injury, acute coronary syndrome, and arrhythmias. See the CKS topics on Angina, Heart failure - chronic, and Palpitations for more information [NICE, 2022b; UKHSA, 2022a].
    • Acute kidney injury — may be caused by volume depletion, viral infection leading to kidney tubular injury, thrombotic vascular processes, glomerular pathology, or rhabdomyolysis. See the CKS topic on Acute kidney injury for more information [NICE, 2022b; UKHSA, 2022a].
    • Acute liver injury — may be due to viral infection, drug toxicity, systemic inflammation, hypoxia, or haemodynamic factors. See the CKS topic on Jaundice in adults for more information.
    • Sepsis. See the CKS topics on Neutropenic sepsis and Sepsis for more information [UKHSA, 2022a].
    • Paediatric multisystem inflammatory syndrome in children (MIS-C) — this rare condition may present with persistent fever, signs of inflammation, and evidence of single or multiorgan failure [RCPCH, 2022; UKHSA, 2022a].
    • Multiorgan failure [UKHSA, 2022a].
    • Neurological — may include acute stroke disease, ataxia, seizures, encephalopathy, encephalitis, meningoencephalitis, cerebral venous sinus thrombosis, peripheral neuropathy, and myopathy [UKHSA, 2022b].
    • Secondary bacterial pneumonia — bacterial secondary or co-infection is rare, with an increased risk in people who are immunosuppressed. See the CKS topics on Chest infections - adult and Cough - acute with chest signs in children for more information [NICE, 2022b].
  • For information on possible long-term sequelae and complications of long COVID, see the CKS topic on Long-term effects of coronavirus (long COVID).

What is the prognosis?

The prognosis of COVID-19 infection varies depending on the person's age, ethnicity, comorbidities as well as the circulating variant [UKHSA, 2026].

  • Most people with COVID-19 infection will have a mild-to-moderate respiratory illness and will recover without needing specialist treatment [WHO, 2022].
  • People in highest risk clinical subgroups are more likely to develop more serious illness or complications [WHO, 2022].
  • In the UK, seroprevalence studies have shown an increased infection fatality ratio (derived from combined mortality data with infection rates) in older age-groups [UKHSA, 2026].

Diagnosis of COVID-19

When should I suspect a diagnosis of COVID-19?

COVID-19 infection can cause a spectrum of illness varying from asymptomatic infection, to mild upper respiratory tract infection (URTI), to severe pneumonia and other complications.

  • Suspect a diagnosis of COVID-19 if a person presents with:
    • A high temperature, fever, or chills.
    • A new, continous cough (frequent cough for more than an hour, or 3 or more coughing episodes in 24 hours).
    • A loss or change to sense of smell or taste.
    • Shortness of breath.
    • Feeling tired or exhausted; muscle aches and pains.
    • Headache (that is unusual or longer lasting than usual).
    • Sore throat.
    • Blocked or runny nose.
    • Loss of appetite.
    • Diarrhoea.
    • Nausea and/or vomiting.
    • Note: COVID-19 infection in children and young people under the age of 18 years is usually mild and a short-lived illness. 
    • Note: about one-third of people with COVID-19 are asymptomatic.
    • Note: older and/or immunocompromised people may present with atypical symptoms, such as delirium and reduced mobility.
  • If a person has symptoms suggestive of COVID-19 infection, most people are no longer advised to get tested, and tests are no longer free for most people.

Basis for recommendation

The information on when to suspect COVID-19 is based on the UK Health Security Agency (HSA) documents People with symptoms of a respiratory infection including COVID-19 [UKHSA, 2022c] and COVID-19: epidemiology, virology and clinical features [UKHSA, 2022a], and information on the NHS website.

How should I assess a person with suspected or confirmed COVID-19?

If a person has a suspected or confirmed diagnosis of COVID-19, assess the person using face-to-face, telephone, or video consultations, depending on individualized risks and benefits using clinical judgement.

  • Assess for signs and symptoms suggesting severe illness and risk of early deterioration, such as:
    • Progressively worsening breathlessness; severe difficulty breathing or breathlessness at rest.
    • Haemoptysis.
    • Cyanosis (blue lips or face).
    • Feeling cold and clammy with pale or mottled skin.
    • Collapse or syncope.
    • New confusion.
    • Drowsiness.
    • Reduced urine output.
    • Hypoxia (reduced oxygen saturation levels measured by pulse oximetry).
      • Oxygen levels of 92% or less in room air in adults (suggests severe hypoxia).
      • Oxygen levels greater than 4% lower than usual levels (suggests severe hypoxia).
      • Oxygen levels of 93–94% in room air in adults (suggests moderate hypoxia).
      • Oxygen levels below 91% in room air at rest in children and young people aged 17 years and under (suggests severe hypoxia).
      • Consider using 'exertion oximetry' tests (such as the 40-step walk and one-minute sit-to-stand tests) if oxygen saturation is at least 93% and the person is aged 65 years or more and/or at highest risk of serious illness, to assess for oxygen desaturation on exercise — a 3% or greater reduction in oxygen saturation level is considered significant.
    • Note: if using a pulse oximeter at home, consider the use of the NHS England Self-monitoring COVID-19 diary which also provides information on how to use a pulse oximeter, recording and acting on results.
    • Note: be aware that some pulse oximeters may under- or over-estimate oxygen saturation levels, especially if the level is borderline. Levels may be over-estimated in people with dark skin.
  • See the section on Assessment in the CKS topic on Long-term effects of coronavirus (long COVID) for people with new or ongoing symptoms 4 weeks or more after acute COVID-19 infection.

Basis for recommendation

The recommendations on assessment are based on the National Institute for Health and Care Excellence (NICE) guideline COVID-19 rapid guideline: managing COVID-19 [NICE, 2022b]; the joint NICE, Scottish Intercollegiate Guidelines Network (SIGN), and Royal College of General Practitioners (RCGP) guideline COVID-19 rapid guideline: managing the long-term effects of COVID-19 [NICE, 2022a], and the NHS England guidance Pulse oximetry to detect early deterioration of patients with COVID-19 in primary and community care settings [NHSE, 2021].

Assessment of acute COVID-19

  • The information on signs and symptoms suggesting severe illness and risk of early deterioration is based on a consensus recommendation in the NICE rapid guideline on managing COVID-19 [NICE, 2022b].
  • The recommendation to consider reversible causes of breathlessness is based on the NICE rapid guideline on managing COVID-19 [NICE, 2022b].
  • The information on pulse oximetry readings suggesting moderate or severe hypoxia in adults is based on the NHSE guidance on pulse oximetry [NHSE, 2021].
  • The information on pulse oximetry readings suggesting hypoxia in children is based on a consensus recommendation in the NICE rapid guideline on managing COVID-19 [NICE, 2022b].
  • The recommendation to consider using exertion oximetry tests in adults and a self-monitoring COVID-19 diary is based on the NHSE guidance on pulse oximetry [NHSE, 2021].
    • This notes that people most at risk of poor outcomes are best identified by home pulse oximetry, as remote home monitoring can help identify 'silent hypoxia' (hypoxia without significant symptomatic breathlessness) and people at risk of rapid deterioration.
  • The information that pulse oximetry may under- or over-estimate oxygen saturation levels is based on the NICE rapid guideline on managing COVID-19 [NICE, 2022b].

Management

Scenario: Suspected COVID-19

From birth onwards.

How do I manage a person with suspected COVID-19?

If a person has symptoms suggestive of COVID-19 infection:

Highest risk clinical subgroups

People with the following clinical conditions are at highest risk of getting seriously ill from COVID-19 infection [DHSC, 2022]:

  • Down's syndrome or other chromosomal disorders known to affect immune competence.
  • Certain types of solid cancer, and/or received or receiving treatment for certain types of cancer.
  • Haematological diseases (such as some forms of leukaemia, lymphoma, myeloma, myelodysplastic syndrome, myelofibrosis, sickle cell disease) and recipients of haematological stem cell transplant.
  • Renal disease (including renal transplant recipients, non-transplant renal patients who are immunosuppressed, chronic kidney disease [CKD] stage 4 or 5).
  • Liver disease (some forms of cirrhosis especially decompensated liver disease, liver transplant recipients, liver disease on immunosuppressive therapy).
  • Other solid organ transplant recipients.
  • Immune-mediated inflammatory disorders (including people taking some forms of immunotherapy, biologics, JAK-inhibitors, corticosteroids, uncontrolled or clinically active disease, major organ involvement).
  • Immune deficiencies (including common variable immune deficiency, severe combined immunodeficiency).
  • HIV or AIDS (if immunosuppressed, have uncontrolled or untreated HIV, or acute presentation of AIDS-defining diagnosis).
  • Rare neurological and neurodisability conditions (multiple sclerosis, motor neurone disease, myasthenia gravis, or Huntington's disease).

Note: for a comprehensive list of clinical conditions, see the most up-to-date Department of Health and Social Care independent advisory group report.

Basis for recommendation

The recommendations on management of suspected COVID-19 are based on the National Institute for Health and Care Excellence (NICE) guideline COVID-19 rapid guideline: managing COVID-19 [NICE, 2022b]; the joint NICE, Scottish Intercollegiate Guidelines Network (SIGN), and Royal College of General Practitioners (RCGP) guideline COVID-19 rapid guideline: managing the long-term effects of COVID-19 [NICE, 2022a], the NHS England guidance Pulse oximetry to detect early deterioration of patients with COVID-19 in primary and community care settings [NHSE, 2021], the UK Health Security Agency (HSA) guidance People with symptoms of a respiratory infection including COVID-19 [UKHSA, 2022c] and COVID-19: guidance for people whose immune system means they are at higher risk [UKHSA, 2022d], and information on the NHS website.

  • The recommendations to arrange hospital assessment if there is hypoxia causing breathlessness is based on the NICE rapid guideline on managing COVID-19 [NICE, 2022b] and the NHSE guidance on using pulse oximetry [NHSE, 2021].
  • The recommendation to arrange hospital assessment if there is a suspected complication is pragmatic, based on what CKS considers to be good clinical practice.
  • The recommendation for people at highest risk of becoming seriously ill to do lateral flow tests is based on the HSA guidance for this risk group [UKHSA, 2022d]. 
  • The recommendations on self-care advice if hospital assessment is not indicated is based on the NICE rapid guideline on managing COVID-19 [NICE, 2022b], the HSA guidance on respiratory infections [UKHSA, 2022c], and information on the NHS website.
    • The NICE rapid guideline notes that encouraging hydration and maintaining optimal fluids status reducing the risk of developing acute kidney injury (AKI).
  • The recommendations if a person is a close contact are based on the HSA guidance on respiratory infections [UKHSA, 2022c] and information on the NHS website.
  • The recommendation to advise about expected symptoms and recovery times is based on the joint NICE/SIGN/RCGP rapid guideline on the management of the long-term effects of COVID-19 [NICE, 2022a].

Scenario: Confirmed COVID-19

From birth onwards.

How do I manage a person with confirmed COVID-19?

If a person has a confirmed diagnosis of COVID-19 infection following a positive test result (if in an eligible group for testing):

  • Arrange hospital admission if indicated following clinical assessment.
    • If hypoxia (reduced oxygen saturation levels) is a likely cause of breathlessness, consider arranging admission to secondary care.
      • If there is severe hypoxia and/or the person is severely ill, consider arranging urgent hospital admission.
      • If there is moderate hypoxia and the person is not severely ill, consider arranging hospital assessment, the urgency depending on clinical judgement.
  • Arrange hospital admission or specialist referral if there is a suspected complication, depending on clinical judgement.
  • If hospital admission is not clinically indicated and the person is at highest risk of becoming seriously ill with COVID-19 infection:
    • Advise that antibody and antiviral treatments may be offered in the community by NHS England if all of the following addititional criteria apply:
      • The person is aged over 12 years.
      • The person is symptomatic and not improving.
      • Note: if treatment is indicated, the person should be automatically contacted by NHS England within 24 hours of a positive test result. If this does not happen, arrange urgent referral to the local COVID-19 medicines delivery unit (CMDU), depending on local referral pathways.
    • Advise on sources of information and support, such as:
  • If hospital admission is not clinically indicated and an adult is not at highest risk of becoming seriously ill with COVID-19 infection:
    • Advise to try to stay at home and avoid contact with other people for 5 days after the day the test was taken.
    • Advise to avoid meeting people at higher risk of becoming seriously unwell from COVID-19, for 10 days after the day the test was taken.
  • If a child or young person aged under 18 years is not at highest risk of becoming seriously ill with COVID-19 infection:
    • Advise to try to stay at home and avoid contact with other people for 3 days after the day the test was taken.
  • Advise on sources of information and support, such as the NHS resources on:
  • Advise on common new or ongoing symptoms after COVID-19, and expected recovery times.
  • Ensure any confirmed case of COVID-19 is notified to the local health protection team.

Highest risk clinical subgroups

People with the following clinical conditions are at highest risk of getting seriously ill from COVID-19 infection [DHSC, 2022]:

  • Down's syndrome or other chromosomal disorders known to affect immune competence.
  • Certain types of solid cancer, and/or received or receiving treatment for certain types of cancer.
  • Haematological diseases (such as some forms of leukaemia, lymphoma, myeloma, myelodysplastic syndrome, myelofibrosis, sickle cell disease) and recipients of haematological stem cell transplant.
  • Renal disease (including renal transplant recipients, non-transplant renal patients who are immunosuppressed, chronic kidney disease [CKD] stage 4 or 5).
  • Liver disease (some forms of cirrhosis especially decompensated liver disease, liver transplant recipients, liver disease on immunosuppressive therapy).
  • Other solid organ transplant recipients.
  • Immune-mediated inflammatory disorders (including people taking some forms of immunotherapy, biologics, JAK-inhibitors, corticosteroids, uncontrolled or clinically active disease, major organ involvement).
  • Immune deficiencies (including common variable immune deficiency, severe combined immunodeficiency).
  • HIV or AIDS (if immunosuppressed, have uncontrolled or untreated HIV, or acute presentation of AIDS-defining diagnosis).
  • Rare neurological and neurodisability conditions (multiple sclerosis, motor neurone disease, myasthenia gravis, or Huntington's disease).

Note: for a comprehensive list of clinical conditions, see the most up-to-date Department of Health and Social Care independent advisory group report.

Basis for recommendation

The recommendations on management of confirmed COVID-19 are based on the National Institute for Health and Care Excellence (NICE) guideline COVID-19 rapid guideline: managing COVID-19 [NICE, 2022b]; the joint NICE, Scottish Intercollegiate Guidelines Network (SIGN), and Royal College of General Practitioners (RCGP) guideline COVID-19 rapid guideline: managing the long-term effects of COVID-119 [NICE, 2022a], the NHS England guidance Pulse oximetry to detect early deterioration of patients with COVID-19 in primary and community care settings [NHSE, 2021], the UK Health Security Agency (HSA) guidance People with symptoms of a respiratory infection including COVID-19 [UKHSA, 2022c], COVID-19: guidance for people whose immune system means they are at higher risk [UKHSA, 2022d], and Notifiable diseases and causative organisms: how to report [UKHSA, 2022e]; the Department of Health and Social Care independent advisory group report Defining the highest-risk clinical subgroups upon community infection with SARS-CoV-2 when considering the use of neutralising monoclonal antibodies (nMABs) and antiviral drugs [DHSC, 2022], and information on the NHS website.

  • The recommendations to arrange hospital assessment if there is hypoxia causing breathlessness is based on the NICE rapid guideline on managing COVID-19 [NICE, 2022b] and the NHSE guidance on using pulse oximetry [NHSE, 2021].
  • The recommendation to arrange hospital assessment if there is a suspected complication is pragmatic, based on what CKS considers to be good clinical practice.
  • The information about possible antibody and antiviral treatments in the community for people at highest risk of becoming seriously ill is based on the NICE rapid guideline on managing COVID-19 [NICE, 2022b], the Department of Health and Social Care independent report [DHSC, 2022], and information on the NHS website.
    • Antibody and antiviral treatments can help some people who are clinically high-risk manage symptoms and reduce the risk of serious complications from COVID-19 infection if managed in the community.
  • The recommendations to stay at home for adults and children not at highest risk of becoming seriously ill are based on the HSA guidance for people with symptoms of a respiratory infection [UKHSA, 2022c].
    • Children are expected to have a reduced infectivity period for COVID-19 compared with adults.
  • The recommendation to advise about expected symptoms and recovery times is based on the joint NICE/SIGN/RCGP rapid guideline on the management of the long-term effects of COVID-19 [NICE, 2022a].
  • The recommendation to notify any confirmed case of COVID-19 is based on the HSA guidance on notifiable diseases [UKHSA, 2022e].

Scenario: General advice

From age 18 years onwards.

What general advice should I give?

Basis for recommendation

The information on general advice is based on the UK Health Security Agency (HSA) guidance Living safely with respiratory infections, including COVID-19 [UKHSA, 2022f] and Reducing the spread of respiratory infections, including COVID-19, in the workplace [UKHSA, 2022g], together with information on the NHS and GOV.UK websites.

Scenario: Palliative care

From age 18 years onwards.

What general issues should I consider at the end of life?

If a person is palliative receiving end of life care with symptoms or complications from COVID‑19 infection:

  • Assess the person's physical and emotional needs, and offer advice and support to the person and family/carers.
  • Offer management for any symptoms such as breathlessness, cough, anxiety, and agitation.
  • When prescribing and supplying anticipatory medicines at the end of life:
    • Take into account potential waste, medicines shortages, and lack of administration equipment by prescribing smaller quantities or by prescribing a different medicine, formulation, or route of administration when appropriate.
    • If there is a shortage of health and care staff, consider prescribing subcutaneous, rectal, or long-acting formulations, and consider asking family and/or carers to help administer medications, if they wish and have been provided with appropriate training.

Basis for recommendation

The recommendations on managing symptoms at the end of life are based on the National Institute for Health and Care Excellence (NICE) guidance COVID-19 rapid guideline: managing COVID-19 [NICE, 2022b]. They are also pragmatic, based on what CKS considers to be good clinical practice.

How should I manage anxiety, delirium, and agitation at the end of life?

If a person is receiving end of life care with symptoms of anxiety, delirium, and/or agitation:

  • Assess and treat any underlying or reversible causes of symptoms, such as hypoxia, metabolic or electrolyte imbalance, co-infections, uncontrolled pain, urinary retention, and constipation.

Basis for recommendation

The recommendations on managing anxiety, delirium, and agitation are based on the National Institute for Health and Care Excellence (NICE) guidance COVID-19 rapid guideline: managing COVID-19 [NICE, 2022b]. They are also pragmatic, based on what CKS considers to be good clinical practice.

Scenario: Immunization

From age 18 years onwards.

Who should be offered a COVID-19 vaccine?

Basis for recommendation

The recommendations on who to immunize are based on the UK Health Security Agency (HSA) guidance COVID-19: the green book, chapter 14a [UKHSA, 2026] and COVID-19 vaccination programme. Information for healthcare practitioners [UKHSA, 2022b], together with the joint National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), and Royal College of General Practitioners (RCGP) guideline COVID-19 rapid guideline: managing the long-term effects of COVID-19 [NICE, 2022a].

What COVID-19 vaccines are available?

The information below is up-to-date at the time of publication of this CKS topic. See the UK Health Security Agency (HSA) guidance COVID-19: the green book, chapter 14a and the NHS England website (www.england.nhs.uk) information Primary care guidance for more information on the criteria for a third primary dose of COVID-19 vaccine, booster doses of vaccine, and the recommended vaccination schedule for all groups.

  • In the UK, the following vaccines targeting the S protein have been authorized for supply.
    • Two vaccines use an mRNA platform (Pfizer BioNTech BNT162b2 vaccine, Comirnaty®) and Moderna mRNA-1273 COVID-19 vaccine (Spikevax®). These vaccines have no whole or live virus involved, and the vaccines cannot cause disease. The mRNA naturally degrades after a few days.
      • Comirnaty 3 micrograms/dose mRNA COVID-19 vaccine is licensed for use in infants and children aged 6 months to 4 years.
    • Two vaccines use an adenovirus vector (AstraZeneca COVID-19 ChAdOx1-S vaccine/Vaxzevria®) and COVID-19 Janssen Ad26.COV2-S (recombinant, less widely used). The adenovirus is modified so it cannot replicate in human cells, and cannot cause disease.
  • In the UK, one additional vaccine uses a recombinant S protein as an antigen.
    • This vaccine uses an adjuvant derived from tree bark (Novavax Nuvaxovid®, less widely used).
  • The recommended vaccines for the autumn 2025 campaign are monovalent products containing mRNA for the spike protein of the JN.1 sub-lineage of the Omicron variant strain of the SARS-CoV-2 virus. For people aged:
    • Eligible people aged 12 or over — a 0.3 ml dose (30mcg) of Pfizer BioNTech COVID-19 vaccine (Comirnaty® KP.2)
    • Eligible children aged 5-11 years — a 0.3 ml (10mcg) dose of Pfizer BioNTech paediatric COVID-19 vaccine (Comirnaty® 10 LP.8.1)
    • Eligible children aged 6 months - 4 years — 0.3 mL (3mcg) dose of Pfizer BioNTech infant COVID-19 vaccine (Comirnaty® 3 LP.8.1).
      • A second dose may be required for those who have not been previously vaccinated.

Basis for recommendation

The information on available vaccines is based on the UK Health Security Agency (HSA) guidance COVID-19: the green book, chapter 14a [UKHSA, 2026] and COVID-19 vaccination programme. Information for healthcare practitioners [UKHSA, 2022b].

What are the contraindications and cautions?

There are few people who cannot receive the Pfizer BioNTech, Moderna, or AstraZeneca COVID-19 vaccines. If there is any uncertainty, seek specialist advice from the local immunization or health protection team.

  • Do not give the same vaccine to people who have had a confirmed anaphylactic reaction to a previous COVID-19 vaccine.
    • If a person received AstraZeneca vaccine, an alternative vaccine may be given in any setting, with observation for 30 minutes.
    • If a person received an mRNA vaccine, seek specialist advice if there was a possible previous anaphylactic reaction.
    • If there has been a possible previous allergic reaction to any component (excipient) of the COVID-19 vaccine, seek specialist advice.
    • See the UK Health Security Agency (HSA) guidance COVID-19: the green book, chapter 14a for more detailed information on management of people with a history of allergy.
    • Do not give the Janssen COVID-19 vaccine if the person has a history of confirmed thrombosis with thrombocytopenia syndrome after receiving the Janssen COVID-19 vaccine. 
  • Postpone immunization if a person is acutely unwell until they have fully recovered.
    • This is to avoid wrongly attributing any signs or symptoms of acute illness (including COVID-19) to the adverse effects of the vaccine.
    • If a person has a minor illness without fever or systemic illness, immunization should not be postponed.
  • If a person has suspected COVID-19 infection, they should not attend for vaccination, to avoid infecting other people.
    • Vaccination of a person who may be infected, asymptomatic, or incubating COVID-19 infection is unlikely to have a negative effect on the illness.
    • Ideally vaccination of adults and children at highest risk of serious illness should be deferred until clinical recovery and at least 4 weeks after onset of symptoms or 4 weeks from the first positive PCR result, depending on clinical judgement.
  • Prolonged symptoms of COVID-19 is not a contraindication to COVID-19 vaccine.
    • If there is evidence of current deterioration, vaccination may be deferred to avoid incorrectly attributing any change in the person’s underlying condition to the vaccine.

Basis for recommendation

The information on contraindications and cautions is based on the UK Health Security Agency (HSA) guidance COVID-19: the green book, chapter 14a [UKHSA, 2026].

What are the adverse effects?

COVID-19 vaccines are black triangle drugs, and any adverse reactions should be reported to the Medicines and Healthcare products Regulatory Agency (MHRA) using the Coronavirus Yellow Card reporting site.

  • Common or very common potential adverse effects include:
    • Local injection site reactions, such as pain, swelling, redness, tenderness; fatigue; headache; chills; myalgia; arthralgia; fever. 
    • Lymphadenopathy (in the axillary, supraclavicular, or cervical areas on the ipsilateral side to injection).
  • Rare or uncommon potential adverse effects include:
    • Myocarditis and pericarditis
      • There is an increased risk for myocarditis and pericarditis following vaccination with COVID vaccines.
      • These conditions can develop within just a few days after vaccination and have primarily occurred within 14 days. They have been observed more often after the second dose compared to the first dose, and more often in younger males. The risk profile appears to be similar for the second and the third dose.
      • Advise vaccinated people to seek immediate medical attention if they develop symptoms indicative of myocarditis or pericarditis, such as acute and persisting chest pain, shortness of breath, or palpitations following vaccination.
    • Vaccine-induced immune thrombocytopenia and thrombosis (VITT)
      • Has been reported after administration of the AstraZeneca vaccine. The majority of cases occur between 4 and 28 days following COVID-19 vaccine.
      • Presents with unusual venous thrombosis, including cerebral venous sinus thrombosis, portal vein thrombosis, and sometimes arterial thrombosis. Symptoms may include new-onset severe headache, may be worse when lying down or bending over; may be associated with blurred vision, nausea and vomiting, speech disturbance, weakness, drowsiness, or seizures; new unexplained bruising or bleeding; breathlessness, chest pain, leg swelling, or persistent abdominal pain.
      • If suspected, refer the person to an Emergency department, or arrange an urgent same-day full blood count (FBC) if not acutely unwell, and refer to an Emergency department the same day if thrombocytopenia is confirmed.
      • The benefits of vaccination outweigh this small risk for adults aged 40 years and over and adults who are at highest risk of serious illness from COVID-19.
      • The GOV.UK patient leaflet COVID-19 vaccination and blood clotting which includes information on signs and symptoms to be aware of and when to seek urgent medical advice, may be helpful.
    • Acute disseminated encephalomyelitis (ADEM) — extremely rare cases have been reported following vaccination with the AstraZeneca vaccine, although a causal relationship has not been established. Cases with fatal outcome have been reported.
      • Healthcare professionals should be alert to signs and symptoms of brain and spinal cord inflammation (uni- or bilateral weakness in the extremities, numbness or tingling, changes in mental state or level of consciousness, visual impairment, or seizures).
    • Guillain-Barré syndrome
      • Very rarely reported within six weeks of AstraZeneca vaccination.
    • Capillary leak syndrome
      • Very rarely reported within 4 days of AstraZeneca vaccination in people with a previous history of this condition.
    • Transverse myelitis
      • An adverse effect of the Janssen COVID-19 vaccine of unknown frequency. 
    • Dizziness
      • An uncommon adverse effect of the Comirnaty vaccine.
    • Paraesthesia and hypoaesthesia 
      • An uncommon adverse effect of the Vaxzevria vaccine.
  • Other adverse effects (unknown frequency) include:
    • Heavy menstrual bleeding (Comirnaty, Spikevax). 
    • Cutaneous vasculitis (Vaxzevria). 

Basis for recommendation

The information on possible vaccine adverse effects is based on the UK Health Security Agency (HSA) guidance COVID-19: the green book, chapter 14a [UKHSA, 2026], Myocarditis and pericarditis after COVID-19 vaccination: clinical management guidance for healthcare professionals [UKHSA, 2022h], and Information for healthcare professionals on blood clotting following COVID-19 vaccination [UKHSA, 2022i]; and the National Institute for Health and Care Excellence (NICE) publication COVID-19 rapid guideline: vaccine-induced immune thrombocytopenia and thrombosis (VITT) [NICE, 2022c].

What should I advise for women who are pregnant or breastfeeding?

  • If a woman is pregnant:
    • If she is over the age of 18 years, the Pfizer BioNTech or Moderna vaccines should be offered.
    • If she is under the age of 18 years, the Pfizer BioNTech vaccine should be offered.
    • If she has already received a dose of the AstraZeneca vaccine, she can complete the course with the same vaccine or an mRNA vaccine.
    • Note: routine questioning about last menstrual period (LMP) or pregnancy testing is not required before offering the COVID-19 vaccine.
  • If a woman finds out she is pregnant after she has started a course of vaccine:
    • She may complete vaccination during pregnancy, and should complete vaccination at the recommended interval.
  • If a woman is breastfeeding:
    • Advise there is no known risk associated with a non-live COVID-19 vaccine while breastfeeding.
  • Advise on sources of information and support, such as:

Basis for recommendation

The information about pregnancy and breastfeeding is largely based on the UK Health Security Agency (HSA) guidance COVID-19: the green book, chapter 14a [UKHSA, 2026].

  • The information on preferred vaccines in pregnancy is based on the more extensive experience of use of these vaccines in pregnancy.
  • The HSA guidance notes that there is no risk to the mother or fetus in giving inactivated, recombinant vaccines, or in giving the AstraZeneca live adenovirus vector, as this is non-replicating so cannot cause infection. There has been no evidence of adverse birth outcomes in pregnant women receiving a COVID-19 vaccine compared with unvaccinated women.
  • For breastfeeding women, safety data have shown no evidence of mRNA detected in breast milk of recently vaccinated women, and protective antibodies were detected in breast milk.

How are COVID-19 vaccines administered?

  • COVID-19 vaccines are administered by intramuscular (IM) injection into the upper arm or anterolateral thigh.
    • People with bleeding disorders can be given IM injection —  if the person receives medication or treatment to reduce bleeding (for example treatment for haemophilia), IM vaccination can be scheduled shortly after this medication or treatment is administered. Use a fine needle (23 or 25 gauge) for the vaccination, followed by firm pressure applied to the site without rubbing for at least 2 minutes.
  • Facilities for the management of anaphylaxis should always be available whenever a vaccine is given. 
  • If the vaccination course is interrupted or delayed, resume the course using the same vaccine (if known), but do not repeat the first dose. 
    • If a person has started a schedule and attends for vaccination at a site where the same vaccine is not available, or if the first vaccine is unknown, it is reasonable to offer a single dose of a locally available product to complete the primary course.
  • There is no evidence for any safety concerns with the co-administration of COVID-19 vaccine with other vaccines, and interference between inactivated vaccines with different antigenic content is likely to be limited.
    • Be aware that co-administration may make the attribution of adverse effects more difficult.
    • Be aware that administration of Novavax COVID-19 vaccine should be separated from administration of influenza vaccine by at least 7 days.

       

  • Note: this information is correct at the time of publication of this topic, but may change over time.

Basis for recommendation

The recommendations on administering vaccines are based on the UK Health Security Agency (HSA) guidance COVID-19: the green book, chapter 14a [UKHSA, 2026] and COVID-19 vaccination programme. Information for healthcare practitioners [UKHSA, 2022b].

  • The HSA green book guidance notes that for people with a previous incomplete vaccination schedule, if a mixed schedule is given including mRNA and adenovirus vectored vaccines, a good immune response is expected, but there may be a higher rate of adverse effects.

Supporting evidence

This topic is largely based on the National Institute for Health and Care Excellence (NICE) guideline COVID-19 rapid guideline: managing COVID-19 [NICE, 2022b]; the joint NICE, Scottish Intercollegiate Guidelines Network (SIGN), and Royal College of General Practitioners (RCGP) guideline COVID-19 rapid guideline: managing the long-term effects of COVID-19 [NICE, 2022a], the UK Health Security Agency (HSA) guidance COVID-19: the green book, chapter 14a [UKHSA, 2026], COVID-19 vaccination programme. Information for healthcare practitioners [UKHSA, 2022b], and other guidance from the HSA, and various guidance from NHS England and the NHS website. The rationale for recommendations is summarized in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of coronavirus.

Search dates

Unrestricted - April 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Coronavirus, COVID-19

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • DHSC (2022) Defining the highest-risk clinical subgroups upon community infection with SARS-CoV-2 when considering the use of neutralising monoclonal antibodies (nMABs) and antiviral drugs: independent advisory group report. Department of Health and Social Care. http://www.gov.uk [Free Full-text]
  • NHSE (2021) Pulse oximetry to detect early deterioration of patients with COVID-19 in primary and community care settings. NHS England. http://www.england.nhs.uk [Free Full-text]
  • NICE (2022a) COVID-19 rapid guideline: managing the long-term effects of COVID-19. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • NICE (2022b) COVID-19 rapid guideline: Managing COVID-19. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • NICE (2022c) COVID-19 rapid guideline: vaccine-induced immune thrombocytopenia and thrombosis (VITT). National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • RCPCH (2022) Paediatric multisystem inflammatory syndrome temporally associated with COVID-19 (PIMS): guidance for clinicians. Royal College of Paediatrics and Child Health. http://www.rcpch.ac.uk [Free Full-text]
  • UKHSA (2022a) COVID-19: epidemiology, virology and clinical features. UK Health Security Agency. http://www.gov.uk [Free Full-text]
  • UKHSA (2022b) COVID-19 vaccination programme. Information for healthcare practitioners. UK Health Security Agency. http://www.gov.uk [Free Full-text]
  • UKHSA (2022c) People with symptoms of a respiratory infection including COVID-19. UK Health Security Agency. http://www.gov.uk [Free Full-text]
  • UKHSA (2022d) COVID-19: guidance for people whose immune system means they are at higher risk. UK Health Security Agency. http://www.gov.uk [Free Full-text]
  • UKHSA (2022e) Notifiable diseases and causative organisms: how to report. UK Health Security Agency. https://www.gov.uk [Free Full-text]
  • UKHSA (2022f) Living safely with respiratory infections, including COVID-19. UK Health Security Agency. http://www.gov.uk [Free Full-text]
  • UKHSA (2022g) Reducing the spread of respiratory infections, including COVID-19, in the workplace. UK Health Security Agency. https://www.gov.uk [Free Full-text]
  • UKHSA (2022h) Myocarditis and pericarditis after COVID-19 vaccination: clinical management guidance for healthcare professionals. UK Health Security Agency. http://www.gov.uk [Free Full-text]
  • UKHSA (2022i) Information for healthcare professionals on blood clotting following COVID-19 vaccination. UK Health Security Agency. http://www.gov.uk [Free Full-text]
  • UKHSA (2026) COVID-19: the green book, chapter 14a. UK Health Security Agency. http://www.gov.uk [Free Full-text]
  • WHO (2022) Coronavirus disease (COVID-19). World Health Organization. http://www.who.int [Free Full-text]
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