Vaccination Status May Be Considered To Get ICU Beds

[smitcompton]

Hi,

sometimes my thinking is simple . Why would I want to give a priority ICU bed to someone who didn't care If others lived or died. Un-vaccinated persons, except children, go to the back of the line.

Annette

 

[HollyJane]

I don't disagree totally but you also have some dr's waiting for more conclusive data too. My sister has active Leukemia and did get the OK a only a couple weeks ago for the vaccine. But prior to that? it was a no because they felt data was lacking.

Science isn't a one trick pony and is a moving target, especially with covid which changes sometimes daily.

My mom's dr still has not given her OK for it (my mom has lupus, can't take lots of stuff, and has not been well for a while now) for now, the plan is to keep her as protected as possible. Everyone else in the house is vaccinated. her home health nurse is also vaccinated which helps a lot. I believe we're starting to wear her down though (my mom wants to get it).

That's the case with my friend with Lupus. She only just recently got the go ahead from her doctors to get the vaccine. I don't like the idea of her getting knocked on because she followed the advice of the specialists caring for her condition instead of internet, media or other presence.

 

[smitcompton]

Hi,
Hollujane-- You think your friend is bein knocked on in this thread? You think that people here don't understand there may be people who cannot for medical reasons take the vaccine? Wow, I'm dumbfounded. Pease send your friend my apologies for this misunderstanding..

Annette

 

[Arcadian]

That's the case with my friend with Lupus. She only just recently got the go ahead from her doctors to get the vaccine. I don't like the idea of her getting knocked on because she followed the advice of the specialists caring for her condition instead of internet, media or other presence.

My mom's Lupus is very active in the most unfortunate of cases. I understand why her docs are hesitant. We try to provide as much data as we can because my mom really wants to be vaccinated.

I'm hopeful that no one poopoos people who happen to be in these types of positions. My sister's go ahead has to do with the fact that she is currently taking all her vaccinations as she had a few years of literally none because of the transplant and the complications after.

Yes there ARE people who are vaccine hesitant, which I feel is different from being completely antivax. Those that are hesitant can be brought along, those who are completely anti are straight up hard headed I get pretty pissed considering ivermectin is something I use for deworming my dogs and its now hard to find (stupidly so) For those who question that, Gigi came to me with hooks, which tend to be very resistant to most meds. Its been over 6 months and yes, still positive for hooks, so we continue using ivermectin as the main protocol monthly.

 

[HollyJane]

I feel for you

My mom's Lupus is very active in the most unfortunate of cases. I understand why her docs are hesitant. We try to provide as much data as we can because my mom really wants to be vaccinated.

I'm hopeful that no one poopoos people who happen to be in these types of positions. My sister's go ahead has to do with the fact that she is currently taking all her vaccinations as she had a few years of literally none because of the transplant and the complications after.

Yes there ARE people who are vaccine hesitant, which I feel is different from being completely antivax. Those that are hesitant can be brought along, those who are completely anti are straight up hard headed I get pretty pissed considering ivermectin is something I use for deworming my dogs and its now hard to find (stupidly so) For those who question that, Gigi came to me with hooks, which tend to be very resistant to most meds. Its been over 6 months and yes, still positive for hooks, so we continue using ivermectin as the main protocol monthly.

I feel for you and your mom. My friend very much wanted to get the vaccine earlier on, but her Lupus flaired up pretty bad after her dad died (not covid related).

There is some claim in this thread that medical contraindications to the vaccine are extremely rare and largely a myth, but I think most of us know at least one person who has been given advice by their medical team to wait on getting the vaccine.

 

[wildcat03]

I feel for you


I feel for you and your mom. My friend very much wanted to get the vaccine earlier on, but her Lupus flaired up pretty bad after her dad died (not covid related).

There is some claim in this thread that medical contraindications to the vaccine are extremely rare and largely a myth, but I think most of us know at least one person who has been given advice by their medical team to wait on getting the vaccine.

The fact that true, absolute medical contraindications are rare is NOT a myth. There is a difference between absolute contraindications and getting crummy or outdated medical advice. Despite the fact that 22 groups that care for pregnant and lactating individuals have formed an alliance and published a statement that pregnant women should be vaccinated, there are STILL OBs and midwives who advise their patients not to get the vaccine. On a quick search, it appears that the American College of Rheumatology has made similar recommendations (back in February).

The question of how to ration care has become very real. As I stated before, unvaccinated COVID patients take up an ICU bed and staff for weeks to months. During that time, the average ICU bed probably would have turned over every 3-7 days. At night while I'm up feeding my newborn I usually see at least 1-2 posts on my "EM docs" Facebook group that reads as follows, "Is there anyone with an ICU bed and a general surgeon available? I have a guy in his 40s with necrotizing fasciitis (so-called "flesh eating bacteria") with a lactate of 14 (predictor of high mortality). All our local hospitals are full. Please let me know soon, otherwise I'm going to have to go tell him and his wife he's going to die"

It's not that we WANT to deny anyone care, it's that we are suffering moral injury from HAVING to deny care to people who are critically ill but salvageable because unvaccinated people are consuming the available resources. I don't know what the answer is for the unvaccinated folks who have received crappy medical advice.

On another note, I frequently have patients who receive their primary care in my health system tell me "my doctor told me not to get the shot yet." I know these doctors (well - I've been here for almost 7.5 years). Inevitably I look in the chart and the doctor's note is exactly the opposite advice- the patient should be vaccinated ASAP. Again, I don't know how to reconcile this or what the answer is. But I can tell you that after 18 months, the answer is not to pile more onto the frontline workers. We've lost so much and so many - integral members of our team who never had the opportunity to be vaccinated, because they died of COVID before it was available. Other coworkers exiting the field because they could take verbal and emotional abuse from patients, the shenanigans of administrators but COVID became too much. It's about time this country starts showing some empathy for those who have shown up throughout this crisis.

 

[wildcat03]

Here is the document from the American College of Rheumatology

https://www.rheumatology.org/Portals/0/Files/COVID-19-Vaccine-Clinical-Guidance-Rheumatic-Diseases-Summary.pdf

If it were my family member, I'd be all over the doctor asking why he/she was ignoring his/her specialty specific guidance for vaccination. I'll admit that's probably not the most diplomatic approach, but I have found similar approaches helpful in clarifying whether a physician was just poorly informed or had some specific (usually incorrect) information contributing to vaccine hesitance:

 

[AprilBaby]

God bless you and your fellow workers Wildcat!

 

[sbfairy]

The fact that true, absolute medical contraindications are rare is NOT a myth. There is a difference between absolute contraindications and getting crummy or outdated medical advice. Despite the fact that 22 groups that care for pregnant and lactating individuals have formed an alliance and published a statement that pregnant women should be vaccinated, there are STILL OBs and midwives who advise their patients not to get the vaccine. On a quick search, it appears that the American College of Rheumatology has made similar recommendations (back in February).

The question of how to ration care has become very real. As I stated before, unvaccinated COVID patients take up an ICU bed and staff for weeks to months. During that time, the average ICU bed probably would have turned over every 3-7 days. At night while I'm up feeding my newborn I usually see at least 1-2 posts on my "EM docs" Facebook group that reads as follows, "Is there anyone with an ICU bed and a general surgeon available? I have a guy in his 40s with necrotizing fasciitis (so-called "flesh eating bacteria") with a lactate of 14 (predictor of high mortality). All our local hospitals are full. Please let me know soon, otherwise I'm going to have to go tell him and his wife he's going to die"

It's not that we WANT to deny anyone care, it's that we are suffering moral injury from HAVING to deny care to people who are critically ill but salvageable because unvaccinated people are consuming the available resources. I don't know what the answer is for the unvaccinated folks who have received crappy medical advice.

On another note, I frequently have patients who receive their primary care in my health system tell me "my doctor told me not to get the shot yet." I know these doctors (well - I've been here for almost 7.5 years). Inevitably I look in the chart and the doctor's note is exactly the opposite advice- the patient should be vaccinated ASAP. Again, I don't know how to reconcile this or what the answer is. But I can tell you that after 18 months, the answer is not to pile more onto the frontline workers. We've lost so much and so many - integral members of our team who never had the opportunity to be vaccinated, because they died of COVID before it was available. Other coworkers exiting the field because they could take verbal and emotional abuse from patients, the shenanigans of administrators but COVID became too much. It's about time this country starts showing some empathy for those who have shown up throughout this crisis.

OMG, all of this!!!! Especially the part about the ICU bed turnover. I'm so glad you pointed that out. This is why we are holding ICU patients in the ER for days. At this point we've actually closed down half of our fast track rooms and have moved some of our holds there until a bed becomes available. Of course, we still have holds in the ER. Recently in Houston 3 free standing ERs closed down until further notice because they were overwhelmed with Covid patients. The free standing ERs are not equipped to take care of ICU or long term patients and cannot find anybody to take them as a transfer. I really believe that many people just don't know how close our healthcare system is to collapse here in Texas.

 

[wildcat03]

God bless you and your fellow workers Wildcat!

Thanks. I feel a bit embarrassed to be on maternity leave at the moment and not on the front lines. But I am ever so grateful to have brought my son into the world safely.

 

[AprilBaby]

This is my kids local hospital reality. Choice.

 

[Calliecake]

Thank you for posting this @AprilBaby. A 50 year old man I worked with died of Covid a two days ago. He had two children under the age of 8 and was a great guy. I pray he had a nurse as kind as this woman taking care of him.

What we are putting our hospital workers thru is terrible.

 

[Austina]

What a powerful video of the reality of Covid. It’s a shame that there are still people who simply refuse to see and understand the reality of the situation we’re in.

 

[kindred]

I haven't come close to finishing this thread but I just read this article and it makes me so rage filled at those who refuse to get vaccinated for no good reason. I am not taking about those who genuinely can't get vaccinated.

Veteran dies of treatable illness as COVID fills hospital beds, leaving doctors "playing musical chairs"

The surge in new COVID cases is putting an enormous strain on hospitals, jeopardizing patients who cannot get the medical attention they need because of a lack of space.

www.cbsnews.com

 

[HollyJane]

The fact that true, absolute medical contraindications are rare is NOT a myth. There is a difference between absolute contraindications and getting crummy or outdated medical advice. Despite the fact that 22 groups that care for pregnant and lactating individuals have formed an alliance and published a statement that pregnant women should be vaccinated, there are STILL OBs and midwives who advise their patients not to get the vaccine. On a quick search, it appears that the American College of Rheumatology has made similar recommendations (back in February).

The question of how to ration care has become very real. As I stated before, unvaccinated COVID patients take up an ICU bed and staff for weeks to months. During that time, the average ICU bed probably would have turned over every 3-7 days. At night while I'm up feeding my newborn I usually see at least 1-2 posts on my "EM docs" Facebook group that reads as follows, "Is there anyone with an ICU bed and a general surgeon available? I have a guy in his 40s with necrotizing fasciitis (so-called "flesh eating bacteria") with a lactate of 14 (predictor of high mortality). All our local hospitals are full. Please let me know soon, otherwise I'm going to have to go tell him and his wife he's going to die"

It's not that we WANT to deny anyone care, it's that we are suffering moral injury from HAVING to deny care to people who are critically ill but salvageable because unvaccinated people are consuming the available resources. I don't know what the answer is for the unvaccinated folks who have received crappy medical advice.

On another note, I frequently have patients who receive their primary care in my health system tell me "my doctor told me not to get the shot yet." I know these doctors (well - I've been here for almost 7.5 years). Inevitably I look in the chart and the doctor's note is exactly the opposite advice- the patient should be vaccinated ASAP. Again, I don't know how to reconcile this or what the answer is. But I can tell you that after 18 months, the answer is not to pile more onto the frontline workers. We've lost so much and so many - integral members of our team who never had the opportunity to be vaccinated, because they died of COVID before it was available. Other coworkers exiting the field because they could take verbal and emotional abuse from patients, the shenanigans of administrators but COVID became too much. It's about time this country starts showing some empathy for those who have shown up throughout this crisis.

The stuff about pregnant and lactating women has nothing to do with me friend, and she didn't follow "outdated" medical advice. Due to a significant flair up after her Dad died and her treatments, it was recommended she wait until that resolved before getting vaccinated. She did, and she has now been vaccinated.

I'm a front line health care worker too, and covid made my job HELL, particularly since it happened less than 6 months after both my father AND my husband died. HELL, I tell you.

I can see in your posts how stressed, angry, frustrated and scared you are. I was at that point this time last year.

While my situation hasn't really improved for me, how I am living it is. I could NOT continue on as I did last year.

Oh, and just to add, lately I've been working extra - 6 days a week. While I do provide patient care at times, I'm largely in a supervisory/managerial position, so I get to deal with staffing, which has been challenging to say the least.

 

[chemgirl]

The stuff about pregnant and lactating women has nothing to do with me friend, and she didn't follow "outdated" medical advice. Due to a significant flair up after her Dad died and her treatments, it was recommended she wait until that resolved before getting vaccinated. She did, and she has now been vaccinated.

I'm a front line health care worker too, and covid made my job HELL, particularly since it happened less than 6 months after both my father AND my husband died. HELL, I tell you.

I can see in your posts how stressed, angry, frustrated and scared you are. I was at that point this time last year.

While my situation hasn't really improved for me, how I am living it is. I could NOT continue on as I did last year.

Oh, and just to add, lately I've been working extra - 6 days a week. While I do provide patient care at times, I'm largely in a supervisory/managerial position, so I get to deal with staffing, which has been challenging to say the least.

Nobody is faulting your friend for following her doctor’s advice.

My issue is with your assertion that these cases are not rare or that we all probably know someone with a legitimate medical reason to avoid vaccination.

Of people I know:

A friend’s brother was vaccinated within a month of receiving an organ transplant.

A friend was vaccinated 2 weeks after receiving a bone graft while undergoing treatment for jaw cancer.

My father in law was vaccinated within a month of heart valve replacement surgery.

A friend lost her job and couldn’t afford her medication for rheumatoid arthritis. She was in an active flare and her doctor still urged her to get vaccinated.

A friend has had allergic reactions to certain medications and was vaccinated at a hospital and monitored for an hour.

I have active Colitis and Hashimoto’s. I was told to get vaccinated ASAP and was given authorization to be vaccinated before the rest of my age cohort.

Other friends have celiac disease, diabetes, hemophilia, and one was recently a kidney donor. They are all vaccinated.

Plenty of people online use these situations as reasons to avoid vaccination when I know that these people in my life were all told to be vaccinated by their respective specialists.

The only situation I can think of in my life where a doctor wanted someone unvaccinated is my DH. He was being evaluated as a possible stem cell/bone marrow donor and they were hesitant to use a vaccinated donor because there was no data available. They rushed his testing so they would know if he was an appropriate donor before he became eligible to be vaccinated. It’s unethical for the donor program to ask DH to wait to be vaccinated so vaccine eligibility was used as an exclusion criteria for a short period of time. The case worker still fully expected him to get vaccinated as soon as he met the age of eligibility for our province.

 

[wildcat03]

The stuff about pregnant and lactating women has nothing to do with me friend, and she didn't follow "outdated" medical advice. Due to a significant flair up after her Dad died and her treatments, it was recommended she wait until that resolved before getting vaccinated. She did, and she has now been vaccinated.

I'm a front line health care worker too, and covid made my job HELL, particularly since it happened less than 6 months after both my father AND my husband died. HELL, I tell you.

I can see in your posts how stressed, angry, frustrated and scared you are. I was at that point this time last year.

While my situation hasn't really improved for me, how I am living it is. I could NOT continue on as I did last year.

Oh, and just to add, lately I've been working extra - 6 days a week. While I do provide patient care at times, I'm largely in a supervisory/managerial position, so I get to deal with staffing, which has been challenging to say the least.

First, the pregnancy discussion was a similar situation- specialty guidelines say one thing, individual doctors tell patients another one. Who is right? The data supports ACOG. You conveniently ignored my link to the ACR statement which states that people with rheumatologic and autoimmune disease SHOULD be vaccinated. I'm not sure why you are so perseverative about this when your friend had a temporary delay in vaccination and is now vaccinated? Plenty of people have had to delay vaccination for one reason or another, but it has now been fully available to the entire US population age 16+ for 4+ months so I suspect most people have had an opportunity.

On another note, I think it is extraordinarily presumptuous and somewhat rude of you to make assumptions regarding my mental state and mental health. You know absolutely NOTHING of me, so I'd appreciate if your refrain from such comments.

I'm sorry you find being an administrator so stressful. I can very honestly from experience say that it is far less so than being hands on patient care during multiple surges.

 

[wildcat03]

Veteran dies of treatable illness after waiting hours for ICU bed

Daniel Wilkinson, 46, who served two deployments in Afghanistan, died Sunday of gallstone pancreatitis, a treatable illness, after waiting hours for an ICU bed, KPRC reported. Wilkinson’…

www.google.com

Shared this in another thread but it also belongs here. Heartbreaking.

 

[Lookinagain]

Veteran dies of treatable illness after waiting hours for ICU bed

Daniel Wilkinson, 46, who served two deployments in Afghanistan, died Sunday of gallstone pancreatitis, a treatable illness, after waiting hours for an ICU bed, KPRC reported. Wilkinson’…

www.google.com

Shared this in another thread but it also belongs here. Heartbreaking.

Heartbreaking and extremely scary that if someone needs non-COVID related, lifesaving attention, they may not get it, all because someone who could have gotten vaccinated didn't. There must, or at least, should be some solution to this. I know you can't boot a non-vaccinated COVID patient out of an ICU bed, but hard-hearted as it may sound, you be be able to, at least in my opinion.

This on top of the burnout of medical professionals is just tragic.

 

[Diamond Girl 21]

True.

What Are The Medical Exemptions For Not Getting A Covid-19 Vaccine?

Many people have claimed that they are medically exempt from Covid-19 vaccination. But for virtually all of them, this isn't true.

www.forbes.com

“ there are no definite medical exemptions to vaccination with Covid-19 vaccines and the people for which this is a murky gray area likely number only in the thousands in the U.S., a tiny fraction of a percent of the population, not millions of people as some have claimed. Most people are unlikely to ever meet or know someone with a health condition which might qualify them for a medical exemption from vaccination against Covid-19 and these people should consult with a physician to discuss their options.”

The messages are very mixed. I was originally warned the vaccines could cause me serious issues. Every person needs to weigh the benefits versus risks to determine what is right for their particular situation. The struggle is real. There are no definite medical exemptions??? Who is deciding this??? Do these people know more about me than my personal physicians???

How about all the healthy people get their vaccines, so others who have issues don't have to risk our health/lives?

Sorry, I am beyond frustrated. Not at you Missy.❤

 

[Matata]

I was originally warned the vaccines could cause me serious issues. Every person needs to weigh the benefits versus risks to determine what is right for their particular situation. The struggle is real. There are no definite medical exemptions??? Who is deciding this???

Warned by whom? Your doctor? If so, is/was your doctor up to date on the latest info coming from whichever physicians board/group advises on your particular health issue? The people stating there are few medical exemptions to vaccines are doctors.

The odds of becoming infected while unvaccinated are vastly higher than those who are vaccinated.
The odds of becoming seriously ill, becoming hospitalized, dying are vastly higher than the vaccinated.

How about all the healthy people get their vaccines, so others who have issues don't have to risk our health/lives?

The odds of 100% vaccination happening globally is unlikely. There will continue to be variants. There will continue to be new viruses. It seems to me that anyone with a condition that is so serious it puts them at risk for a covid vaccine is also highly at risk for covid.

The messages about medical exemptions are not mixed but very clear that there are few medical reasons to remain unvaccinated.

 

[Asscherhalo_lover]

Veteran dies of treatable illness after waiting hours for ICU bed

Daniel Wilkinson, 46, who served two deployments in Afghanistan, died Sunday of gallstone pancreatitis, a treatable illness, after waiting hours for an ICU bed, KPRC reported. Wilkinson’…

www.google.com

Shared this in another thread but it also belongs here. Heartbreaking.

That's infuriating. This is what needs to be avoided.

 

[Diamond Girl 21]

Warned by whom? Your doctor? If so, is/was your doctor up to date on the latest info coming from whichever physicians board/group advises on your particular health issue? The people stating there are few medical exemptions to vaccines are doctors.

The odds of becoming infected while unvaccinated are vastly higher than those who are vaccinated.
The odds of becoming seriously ill, becoming hospitalized, dying are vastly higher than the vaccinated.


The odds of 100% vaccination happening globally is unlikely. There will continue to be variants. There will continue to be new viruses. It seems to me that anyone with a condition that is so serious it puts them at risk for a covid vaccine is also highly at risk for covid.

The messages about medical exemptions are not mixed but very clear that there are few medical reasons to remain unvaccinated.

To be clear, I am not anti vaccine. I'm getting vaccinated. Without going into my personal medical history, I was previously advised that the vaccines could be a problem for me specifically by multiple specialists. I just don't appreciate broad generalizations.

 

[Matata]

I'm getting vaccinated. Without going into my personal medical history, I was previously advised that the vaccines could be a problem for me specifically by multiple specialists.

All my digits are crossed that you don't have serious side-effects to the vaccine. Keep us posted if you feel comfortable doing so.

 

[Diamond Girl 21]

All my digits are crossed that you don't have serious side-effects to the vaccine. Keep us posted if you feel comfortable doing so.

Thank you.

 

[Bonfire]

Veteran dies of treatable illness after waiting hours for ICU bed

Daniel Wilkinson, 46, who served two deployments in Afghanistan, died Sunday of gallstone pancreatitis, a treatable illness, after waiting hours for an ICU bed, KPRC reported. Wilkinson’…

www.google.com

Shared this in another thread but it also belongs here. Heartbreaking.

This hospital f#*&@! up royally!

 

[wildcat03]

This hospital f#*&@! up royally!

There was no hospital f--- up. The patient presented to a facility that did not have the resources to care for him (this is common - not every hospital has every specialty). The barrier to care was that the patient needed both an ICU bed AND a specific type of GI sub specialist. But with ICUs so full...it was hard to find a hospital that had the capacity and the resources to care for him. In normal times this would be a quick phone call. In COVID times this became a several hour ordeal of trying to find resources outside of usual referral patterns.

If anything this was a lack of vaccination, lack of mask mandate f--- up.

 

[Bonfire]

I get it @wildcat03, this is what my daughter does as a critical care paramedic. She flies on many Flight For Life cases as well. I know there is a lot that goes into transfers:
bed availability, doctor acceptance and specialist availability. The veteran stuff gets messy too with the VA.

After talking with my DD, I apologize and take back my comment about the local hospital f@#&ing up. With Covid overcrowding everything, 7 hours to organize a transfer is actually pretty fast according to her. Lots of delayed waiting on a bed or accepting Doc. It happens to her a lot.
So sad a young man lost his life in this situation.

 

[missy]

The messages are very mixed. I was originally warned the vaccines could cause me serious issues. Every person needs to weigh the benefits versus risks to determine what is right for their particular situation. The struggle is real. There are no definite medical exemptions??? Who is deciding this??? Do these people know more about me than my personal physicians???

How about all the healthy people get their vaccines, so others who have issues don't have to risk our health/lives?

Sorry, I am beyond frustrated. Not at you Missy.❤

I get it, I understand. I am sorry we are all dealing with this especially those of us who have challenging medical histories. Here is some more info FYI. It is all a work in progress. But one thing I will say is getting the vaccine seems safer in almost all cases than getting Covid 19.


"
According to recommendations made by the ACIP, people with some, but not all, underlying medical conditions may still receive the FDA-authorized or FDA-approved COVID-19 vaccines(CDC, Interim Clinical Considerations 2020). Below is a list of underlying medical conditions and the current recommendations regarding the safety of the authorized/approved COVID-19 vaccines in people with these conditions:

• Current or past COVID-19: Those with an active infection can be vaccinated after they've recovered from acute illness and are able to discontinue isolation. This applies to those with active infection before the first dose and to those who develop SARS-CoV-2 infection between the first and second dose.
  
  People with a history of SARS-CoV-2 infection can also be vaccinated (see the caveat for those who received passive antibody therapy). In fact, about 10% of people included in the Johnson & Johnson vaccine trial had a previous SARS-CoV-2 infection (FDA Fact Sheet for Administering Janssen COVID-19 Vaccine, 2021).
  
  A person who has had COVID very likely has some protection against re-infection, particularly from the strain of the virus they caught. In fact, a study of healthcare workers at the Cleveland Clinic who had experienced COVID showed that, regardless of whether or not they were subsequently vaccinated, none were reinfected within about 10 months of having COVID, while infections occurred among unvaccinated workers who had not had COVID. Important limitations of the study were that few elderly or immunosuppressed individuals were included (average age was 39), children were not included, and the results may not be generalizable to people with a history of asymptomatic COVID-19 since only symptomatic workers were tested for COVID (Shrestha, medRxiv 2021 — preprint).
  
  There are several good reasons why someone who has had COVID should get vaccinated:
  • Reinfection is possible: In a general population about 1 out of 1,000 COVID patients have gotten it again; among Marine recruits, this has been shown be as high as 10%.
  • Vaccines can generate stronger immune responses: People who had mild infections tend to have lower neutralizing antibody activity than people who have been vaccinated.
  • Immunity can wane over time: Antibody levels fall with time, and one study showed that seven months after infection, 20% of people with previous COVID did not have memory B cells, which are needed to mount a new antibody response.
  • New strains of the virus continue to emerge: Vaccination — particularly the first dose of an mRNA vaccine (Pfizer and Moderna) — has been shown to increase neutralizing antibody titers to the original and new strains by 10 to 1,000-fold among people who had COVID months before. On the other hand, the ability of natural infection to increase neutralizing antibody titers to new strains has been shown to vary significantly, with non-hospitalized (i.e., less severe) convalescent patients showing significantly lower binding titers compared to hospitalized patients and vaccine recipients.
  • The vaccines, particularly the mRNA vaccines, have been shown to be safe and effective so far. This is based on millions of doses. Just be aware that, after the first shot, people who have had COVID are more likely to have temporary side effects (such as fever, headache, chills, muscle or joint pain) than people who have not had COVID.
  A study in Kentucky among 738 adults who developed COVID-19 between March and December 2020 found that those who, subsequently, did not get vaccinated had 2.34 times the odds of being reinfected during the period of May 1 through June 30, 2021 compared to those who had gotten fully vaccinated. Although not conclusive evidence, this suggests that full vaccination offers added protection to those with previous infection (Cavanaugh, MMWR Morb Mortal Wkly Rep 2021).
  
  Other evidence suggests that vaccination of people previously infected with the original (Wuhan) strains may better protect them against variant strains. Blood collected from people at about 4 to 8 months after infection only weakly neutralized the original (Wuhan) strain. Furthermore, in only about half of people did it neutralize the B.1.351 (South African) strain. However, following a single dose of Pfizer or Moderna mRNA vaccine, neutralizing antibody titers against both strains increased 1,000-fold (Stamatatos, medRxiv — preprint). Similarly, research among 63 people who had been infected with SARS-CoV-2 within the previous 12 months found that getting at least the first dose of the Pfizer or Moderna mRNA vaccines resulted in neutralizing antibody titers against the B.1.1.7 (U.K.), B.1.351 (South African) and B.1.526 (New York) variants that were at least ten times higher than in people with previous infection who had not been vaccinated (Wang, medRxiv 2021 — preprint).
  
  Keep in mind that the rate of vaccine-related side effects — particularly systemic ones (e.g., fever, headache, chills, muscle or joint pain) — after the first dose of the Pfizer or Moderna vaccine appears to be greater for people previously infected with SARS-CoV-2 than for those who have not been infected. A study among 83 people previously infected (i.e., seropositive) and 148 people not previously infected (i.e., seronegative) found that systemic side effects occurred more often in people who were seropositive compared with those who were seronegative. Local side effects (e.g., pain, swelling, redness), however, were similar among the two groups (Krammer, medRxiv — preprint). According to the FDA, the safety profile of the J&J vaccine was similar between people previously infected and those who were uninfected (FDA, Janssen COVID-19 Vaccine Frequently Asked Questions 2021).
  
  People previously infected with SARS-CoV-2 may have only a muted response to the seconddose of the mRNA vaccines. Research among 13 people who were seropositive (average age 41) and 19 people who were seronegative (average age 39) found that antibody response was robust after the first and second dose of the Pfizer vaccine in people who were seronegative, but antibody response was robust after only the first dose and muted after the second dose in people who were seropositive. In fact, at one week after the second dose, people previously infected with SARS-CoV-2 had fewer antigen-specific antibody-secreting cells in circulation compared to after the first dose, suggesting poorer antigen-specific immune response. Reasons for the muted response after the second dose in people previously infected was unclear, but the researchers postulated that optimal strategies for vaccination may differ for those previously infected compared with those who were not (Samanovic, MedRxiv — preprint).
  
  In fact, other researchers have postulated that people previously infected with SARS-CoV-2 may require only one dose of mRNA vaccines, as antibody response to the first dose in seropositive people was shown to be similar to or greater than that in seronegative people after the second dose (Krammer, medRxiv — preprint). However, other research found that antibody response to the first dose of mRNA vaccines (Pfizer or Moderna) was high only for those who had experienced many COVID symptoms (5 on average) and were already antibody positive, and not for those who had experienced only mild symptoms, suggesting that two doses may be necessary even among people who were previously infected with SARS-CoV-2 (Demonbreun, medRxiv 2021 — preprint). Because the efficacy of a single dose in people previously infected with SARS-CoV-2 is still unknown, the CDC continues to recommend that two-dose vaccination series be offered to persons regardless of history of prior SARS-CoV-2 infection.
  
  The CDC states that reinfection is uncommon for up to 90 days after first infection, and research among healthcare workers found that those with a history of SARS-CoV-2 infection appeared to be protected from re-infection for about 5 to 6 months post-infection (Lumley, N Engl J Med 2020; Hall, medRxiv — preprint). People previously infected with COVID seem to develop persistent cellular immunity, as shown in one study in New York among people with a history of COVID (mainly mild) who showed highly functional memory T cell responses at 6 months after infection (Breton, bioRxiv 2021 — preprint). However, another study in Washington state among people with a history of mild COVID showed that while antibodies against the virus declined rapidly starting at four months after infection, levels of specific memory B cells in the bone marrow (which can produce antibodies against COVID upon re-exposure) could be detected in about 80% of the people at seven months after initial infection, suggesting that the remaining 20% may not have developed a strong immune response upon initial infection and therefore could still benefit from vaccination (Turner, Nature 2021).
  
  Less than 66% of people who had experienced mild COVID-19 infections in the Netherlands were shown to have sufficient antibodies to neutralize variants such as B.1.351 (South African) and P.1 (Brazilian), although they had sufficient antibodies to neutralize B.1.1.7 (U.K.). In contrast, all but one person vaccinated with the Pfizer vaccine, and all people hospitalized with COVID-19 (i.e., those with severe infection), had sufficient antibodies to neutralize all three variants (Caniels, medRxiv 2021 — preprint).
  
  Another study among people with detectable antibodies from previous infection showed that about 1 out of 1,000 became reinfected within a few months of initial infection (Abu-Raddad, medRxiv — preprint). The reinfection rate was much higher in a study of 3,076 U.S. Marine Corp recruits: 10% of those with a history of COVID became re-infected during basic training, but this was much lower than the 45% of those without previous infection who became infected (Letizia, Lancet Respir Med 2021).
  
  However, for those who received monoclonal antibodies or convalescent plasma as treatment for COVID-19 before receiving any vaccine, vaccination should be deferred for at least 90 days after passive antibody therapy as a precaution. Similarly, those who receive passive antibody therapy after the first vaccine dose but before the second dose should defer the second dose for at least 90 days after therapy. For those receiving antibody therapy unrelated to COVID-19 treatment, there is no recommended deferral period for COVID-19 vaccination.
• History of multisystem inflammatory syndrome in children (MIS-C) or adults (MIS-A): The CDC states that people with a history of these conditions (which can occur as a result of COVID-19) may choose to be vaccinated, although it is recommended that they delay vaccination for 90 days after the date of diagnosis. Although it is not required that these individuals speak with their doctor before being vaccinated, the CDC explains that having a conversation with one's doctor may help with the decision. The CDC notes that it is unclear whether people who have had this condition are at risk of recurrence in response to vaccination (CDC, Interim Clinical Considerations 2021).
• Exposure to SARS-CoV-2: People who have been exposed to SARS-CoV-2 can be vaccinated, but most should defer vaccination until their quarantine period has ended to prevent exposing healthcare personnel to SARS-CoV-2. The exception to this is those living in long-term care facilities, correctional and detention facilities, homeless shelters, and other congregate settings where potential exposure is likely to occur over long periods of time. These individuals can be vaccinated when it's available, regardless of possible exposure, provided COVID-19 is not strongly suspected. In people in congregate settings who are strongly suspected of being infected after exposure, vaccination can be delayed pending test results.
• Shingles: The CDC's recommendations do not explicitly address the use of the mRNA COVID-19 vaccines in those with a history of shingles, but it is not a contraindication. The CDC does recommend that people with moderate or severe active shingles delay COVID vaccination until their illness has improved unless the benefits of COVID vaccination outweigh the risks (for example, in people with high risk of exposure or high risk of severe disease) (CDC, COVID-19 Vaccine FAQs for Healthcare Professionals).
  
  The CDC also recommends that older adults do not delay or discontinue shingles vaccination due to the pandemic, although vaccination for COVID and shingles should be separated by at least 14 days. Be aware that some side effects of the shingles vaccine (Shingrix) (e.g., headache, fatigue, fever, muscle pain) can mimic symptoms of COVID, but the shingles vaccine does not cause respiratory symptoms. If a shingles vaccine recipient develops respiratory symptoms or a fever lasting more than 72 hours, they should contact their doctor and consider getting tested for COVID (CDC, FAQ About Shingrix).
• Heart conditions and chronic pulmonary disease: People with heart conditions or chronic pulmonary disease — including heart failure, stroke, coronary artery disease, cardiomyopathies, and pulmonary hypertension — may get vaccinated with the mRNA vaccines if they have no other contraindications and they have been counseled by their doctor on the risks. Although mRNA vaccine safety and effectiveness has not been well studied in this population, people with chronic pulmonary disease (but not pulmonary hypertension) made up about 6% of the participants in the Pfizer trial, while people with heart disease made up about 5% of the participants in the Moderna trial. Approximately 12% of U.S. participants in the J&J pre-authorization clinical trial had hypertension, and 3% had serious heart conditions (FDA Vaccines and Related Biological Products Advisory Committee). People with heart conditions and chronic pulmonary disease have an increased risk of severe illness from COVID-19 (CDC, People with Medical Conditions) and are consequently included in phase 1c of the vaccine roll-out. Most experts believe the benefit of being vaccinated outweighs any risks. The American Heart Association has stated, "people with cardiovascular risk factors, heart disease, and heart attack and stroke survivors should get vaccinated as soon as possible because they are at much greater risk from the virus than they are from the vaccine."
• Genetic heart conditions: The CDC does not explicitly advise on use of COVID-19 vaccines in people with genetic heart conditions such as familial arrhythmias (e.g., long QT syndrome (LQTS), Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia (CPVT) or short QT syndrome (SQTS)), but the vaccines are not contraindicated in people with these conditions. Experts affiliated with the Sudden Arrhythmia Death Syndromes (SADS) Foundation have stated, "If you are 16 or older, you can get the vaccine, you should get the vaccine, it is safe for your heart." These experts do, however, caution that people with Brugada syndrome who experience a fever after vaccination promptly take acetaminophen or ibuprofen, as fevers can increase the risk of arrhythmias.
• Anemia: The CDC has designated sickle cell disease and thalassemia as high-risk conditions for COVID-19 and thus people with these conditions should consider getting vaccinated. However, as noted by the American Society of Hematology, people with these conditions may have lower response to the vaccine. While the CDC does not explicitly advise on the use of COVID-19 vaccines in people with other types of anemia, the vaccines are not contraindicated in people with these conditions. According to the European Hematology Association, information about the efficacy and safety of the COVID-19 vaccines in people with iron deficiency anemia is limited, but these people are advised to get vaccinated, although it is recommended that they correct iron deficiency before getting a shot. According to the American Society of Hematology, cases of new-onset aplastic anemia or relapse among recovered patients with aplastic anemia have been reported after COVID-19 vaccination, but risk-versus-benefit considerations favor vaccination in these patients, although the organization notes that those on immunosuppressants may not respond to vaccination.
• Blood thinners: People taking antiplatelet drugs such as aspirin or clopidogrel (Plavix) or anticoagulants drugs such as warfarin (Coumadin), apixaban (Eliquis), rivaroxaban (Xarelto), or dabigatran (Pradaxa) may be vaccinated, but experts recommend letting the person giving the vaccine know that these medications are being taken, as bleeding may take longer to stop after the shot, although there is no evidence that the vaccine itself will increase bleeding.
  
  Other steps recommended by the ACIP to reduce the risk of bruising or bleeding in people taking blood thinners include 1) requesting the smallest needle possible (23-gauge or smaller) and 2) scheduling vaccination prior to taking their blood thinner or, if that's not possible, skipping one dose prior to vaccination. Some experts also recommend that people on warfarin get INR measured 2 to 5 days before vaccination. If INR is above 3, these people should talk with their doctor about whether it would be appropriate to decrease the next two doses of warfarin or to delay vaccination until INR is 3 or less (MedPage Today, 3/14/21).
• Statin therapy: Statin therapy might reduce immune response after the first dose, but not the second dose, of mRNA COVID-19 vaccines, particularly among older people. A study in the U.K. found that, among people ages 65 to 79, antibody levels to the vaccine 28 days or more after the first dose were about 25% lower for those on statins than those not on statins. However, there was no significant difference in antibody levels at 14 days after the second dose, highlighting the importance of getting the second dose (Shrotri, medRxiv 2021 — preprint).
• Immune thrombocytopenia (ITP): The CDC's recommendations do not explicitly address the use of the mRNA COVID-19 vaccines in those with a history of thrombocytopenia. However, the American Society of Hematology (ASH) states that the expected benefits of the mRNA COVID-19 vaccine likely outweigh the risks in these patients, although the society notes that vaccines — including the mRNA COVID-19 vaccine — can occasionally result in a drop in platelet count in a person with otherwise stable thrombocytopenia. A study among 52 people with chronic ITP found that severe worsening of thrombocytopenia occurred in only 12% of these patients, with onset typically occurring two to five days after the shot. All recovered from thrombocytopenia within about two days, with treatment consisting of mainly corticosteroids. Two of the six people who experienced this adverse event had experienced worsened thrombocytopenia after other vaccinations (Kuter, Br J Haematol 2021). Although new-onset severe acute thrombocytopenia has been reported following mRNA COVID-19 vaccination, the ASH states that post-vaccine thrombocytopenia is extremely rare or coincidental. However, people with ongoing thrombocytopenia or those with a history of unstable platelet counts should talk with their doctor about obtaining platelet counts before and after vaccination.
• Immunocompromised or taking immunosuppressants: People who are immunocompromised — which includes those taking corticosteroids (such as prednisone) or other immune weakening medicines — may get vaccinated (with mRNA or adenovirus vaccines), although the vaccines may be less effective in these individuals. According to a summary of data by the CDC, the mRNA vaccines have been shown to be 71% to 80% effective against SARS-CoV-2 infection, and the Pfizer vaccine has been shown to be 75% effective against symptomatic SARS-CoV-2 infection at seven or more days after the second dose in people who are immunocompromised (corresponding effectiveness among the general population has been reported to be 90% and 94%, respectively). An analysis of adults hospitalized in the U.S. between March 11 and May 5, 2021 showed that effectiveness of the Pfizer or Moderna vaccines in preventing COVID-19 hospitalizations among those who were immunocompromised (e.g., those with cancer, HIV, AIDS, splenectomy, organ transplant, an autoimmune condition, etc.) was only about 63% compared to 91% among those without immunosuppression (Tenforde, Clin Infect Dis 2021).
  
  THIRD DOSE: Due to potential reduced immune response among people who are moderately and severely immunocompromised, the FDA revised the Emergency Use Authorization for Pfizer and Moderna COVID-19 vaccines on August 12, 2021 to allow for emergency use of third doses in these patients. This group, as defined by the CDC, includes organ transplant patients on immunosuppressive therapy, cancer patients on active or recent treatment, CAR-T-cell or hematopoietic stem cell transplant recipients, those with advanced or untreated HIV infection, those with severe primary immunodeficiency (e.g., DiGeorge, Wiskott-Aldrich syndromes), and those receiving high-dose corticosteroid (i.e., at least 20 mg/day) or other immunosuppressive or immunomodulatory therapies. Patients with these conditions can receive a third dose at least 28 days after completing the two-dose regimen preferably of the same vaccine (although an alternate mRNA vaccine can be given if the vaccine used for the initial two-dose series is unavailable). The Pfizer vaccine can be given as a third dose to people 12 years and older and Moderna can be given to people 18 or older. These "third doses" are the same vaccines and doses given as the first two doses.

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[missy]

@Diamond Girl 21 part 2:


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• Various immunosuppressants and immunomodulatory drugs appear to reduce antibodyresponse to vaccination. A study of 133 adults with chronic inflammatory disease found that the largest average reductions in antibody responses to full vaccination, compared to healthy adults, occurred with patients on B cell depleting therapies such as ocrelizumab and rituximab (36-fold reduction) and glucocorticoids such as prednisone (10-fold reduction). Janus kinase inhibitors and antimetabolites, particularly methotrexate, caused smaller reductions, and TNF inhibitors, IL-12/23 inhibitors, and integrin inhibitors had only modest impacts in this study (Deepak, medRxiv 2021 — preprint).
  
  Similarly, a study among 64 adults with chronic inflammatory disease and 21 immunocompetent healthcare workers who were fully vaccinated with the Pfizer vaccine showed that, at 3 months after the second dose, 100% of the immunocompetent individuals generated neutralizing antibodies against the Delta variant, while only 87% of those on methotrexate, 42% of those on azathioprine, mycophenolate mofetil and/or cyclophosphamide, and none of those on rituximab generated neutralizing antibodies against the Delta variant (Hadjadj, medRxiv 2021 — preprint).
  
  A study among 658 transplant recipients found that, at around 29 days after the second dose of Pfizer or Moderna, 54% of these patients on immunosuppressants had detectable antibody levels. Those taking the antimetabolites mycophenolate mofetil, mycophenolic acid, or azathioprine were less likely to have antibodies compared to those taking other immunosuppressants (43% versus 82%) (Boyarsky, JAMA 2021).
  
  On the other hand, a study among 865 people with inflammatory bowel disease being treated with the immunosuppressant infliximab showed that, after the second dose of the Pfizer or AstraZeneca vaccines, 85% of study participants overall developed antibodies (Kennedy, Gut 2021).
  
  In addition to evidence of reduced antibody response (humoral immunity) to vaccination among immunosuppressed individuals (as described above), there is some evidence of reduced cellular immunity (which is also thought to affect vaccine-mediated immunity) among those receiving the antimetabolite methotrexate. A study found that only 62% of patients taking methotrexate had adequate antibody response to the Pfizer vaccine versus 92% on other immunosuppressants. In addition, those receiving methotrexate showed poor induction of activated CD8+ T cells, indicating reduced or at least delayed cellular immune response (Haberman, medRxiv 2021 — preprint).
  
  However, another study that evaluated humoral and cellular immunity among seven immunocompromised patients on immunosuppressants (tacrolimus, belatacept, steroids, bortezomib, mycophenolate mofetil, leflunomide, and dimethyl fumarate) who had been vaccinated found that, among those who failed to develop antibody response, most developed cellular immunity, with the frequency of specific CD4 and CD8 T cells approaching or exceeding that observed in healthy people. The researchers speculated that the increase in T cells among immunocompromised individuals may compensate for impaired antibody response (Sindi, medRxiv 2021 — preprint).
  
  Similarly, a study among 37 people taking ocrelizumab for multiple sclerosis or rituximab for rheumatic disease (with or without other immunosuppressants) also found that, at 30 days after receiving the second dose of the Pfizer or Moderna vaccine, 96% of those on ocrelizumab and 82% of those on rituximab had detectable vaccine-specific T cells (a measure of cellular immunity) compared, surprisingly, to only 67% of healthy controls, while antibody response was detectable in only 62% of those on ocrelizumab and 73% of those on rituximab compared to 100% in healthy controls (Madelon, medRxiv 2021 — preprint).
  
  Despite the possibility of reduced immune response in people who are immunocompromised, antibody testing to assess for immunity following COVID-19 vaccination is not recommended for anyone for several reasons: It has not been determined what antibody levels, if any, correlate with protection; not all antibody tests will detect immune response resulting from vaccination, as only tests that focus on antibodies to viral spike proteins — not the nucleocapsid — will detect immune response from the authorized or approved vaccines; many antibody tests for COVID-19 do not quantify the amount of antibodies but only indicate if they are detectable; antibody testing does not measure cellular immune response, which is also thought to affect vaccine-mediated immunity; and the cost of antibody testing (about $50 to $130) may not be covered by insurance and/or may require referral from your doctor (CDC, Interim Clinical Considerations 2021). (See more information about tests that help measure antibody response to vaccines.)
• Splenectomy or functional asplenia: People who do not have a functioning spleen are considered immunocompromised and, in one study, were shown to have a higher risk of hospitalization or death from COVID if infected than people with spleens (Bojesen, Infect Dis 2021). There is broad expert consensus that the benefit of the vaccine in such people outweighs any risks. However, since such people may have blunted immune response, they should continue to follow COVID-19 precautionary measures even after getting vaccinated (BC Centre for Disease Control, 3/5/2021; ATAGI, 3/2021; IDSA, 3/5/2021).
• Liver disease: People with chronic liver disease, hepatitis B, or hepatitis C were eligible for inclusion in the Pfizer, Moderna, and J&J pre-authorization clinical trials, but the safety and efficacy of the vaccines in these specific groups has not yet been reported. However, as noted by the American Association for the Study of Liver Disease (AASLD), people with chronic liver disease are considered to be a high-risk group for which the CDC recommends vaccination be given provided no other contraindications to the vaccine exist.
  
  A study in Israel among 88 people with non-alcoholic fatty liver disease (average age 57) who received two doses of the Pfizer vaccine showed that all but one individual achieved good or excellent immune response to vaccination at least seven days after the second dose. However, those with an excellent response were a bit younger (55 on average) than those with a good response (62 on average). Excellent responders were also less likely to have advanced fibrosis than good responders (23% vs. 48%) (Hakimian, International Liver Congress 2021, Abstract OS-2854).
  
  A study among nearly 10,000 U.S. veterans (average age 69) with liver cirrhosis who received either the Pfizer or Moderna mRNA COVID-19 vaccine and nearly 10,000 others who remained unvaccinated showed that, starting at 7 days after the second dose, vaccine efficacy against infection was 78.6%, which is slightly lower than reported efficacy among the general population. However, vaccine efficacy against COVID-19-related hospitalization or death was 100% for both outcomes, suggesting that the vaccines protect against severe disease even among patients with cirrhosis (John, JAMA Intern Med 2021).
  
  Liver transplant recipients are advised to get vaccinated at least 3 months after transplantation, if possible, although it may be given as early as 6 weeks post-transplant in people with other risk factors. Liver transplant recipients with active acute cellular rejection (ACR), those being treated for ACR, or those receiving high daily doses of corticosteroids should delay vaccination until the episode is resolved, as intense immunosuppression to treat ACR may reduce immune response to vaccination.
  
  If possible, people scheduled to receive a liver transplant should try to receive the second dose of the mRNA vaccine at least 2 weeks prior to transplant, but transplant should not be delayed to complete the vaccine series.
• Kidney disease: There is not enough information to confirm the safety and efficacy of the vaccines specifically in people with kidney disease, although a small percentage of people in the pre-authorization clinical trials did have kidney disease. According to the CDC, patients with chronic kidney disease (CKD) (including those with end-stage renal disease) are at an increased risk for severe COVID-19 and are recommended to be prioritized for COVID-19 vaccination. Experts have stated that the mRNA vaccines (Pfizer and Moderna vaccines) and vaccines with replication-defective vectors (J&J vaccine) can reasonably be assumed to be safe in people with CKD (Windpessl, Nat Rev Nephrol 2021).
  
  A study of 186 dialysis patients in the U.S. (average age 6 found that most patients (89%) had detectable antibody levels at two weeks or more after the second dose of mRNA vaccines. Non-response was associated with immunosuppressed states and hospitalization during the vaccine series (Lacson, medRxiv 2021 — preprint). A similar study among 81 people with kidney disease on hemodialysis found that, at 3 weeks after the second dose of the Pfizer vaccine, only 9% of those in the hemodialysis group did not develop antibodies at all. Non-response to the Pfizer vaccine did not significantly correlate with non-response to hepatitis B vaccine immune response. However, this study did find that antibody levels were much lower among people on hemodialysis compared to a healthy control group, with an average antibody titer of 171 U/mL for the dialysis group compared to 2,500 U/mL for the control group ("robust antibody response" was defined as a titer >200 U/mL) (Simon, medRxiv 2021 — preprint). Similarly, a study among 81 people on intermittent hemodialysis found that, at three weeks after the second dose of the Pfizer vaccine, 95% of patients had detectable humoral (antibody) and cellular immune response, although both antibody levels and T cell response were lower among those on dialysis compared to a healthy, vaccinated control group. Furthermore, neutralization efficacy against the original (Wuhan) virus and several variants of concern (including B.1.1.7, B.1.351, and B.1.429) was reduced among people on dialysis compared to the control group (Strengert, medRxiv 2021 — preprint).
  
  Although people with kidney disease who are on hemodialysis may have increased bleeding risks due to elevated levels of urea in the blood and use of blood thinners, a preliminary study in France among 90 people on hemodialysis taking oral anticoagulants and/or heparin found that getting vaccinated before or during dialysis was not associated with bleeding complications (Giot, Clin Kidney J 2021).
  
  The safety and effectiveness of COVID-19 vaccines in people with autoimmune kidney diseases on chronic immunosuppression (e.g., systemic lupus erythematosus) is unknown, as these people were not included in any of the vaccine trials. Although the CDC's recommendations do not explicitly address the use of the COVID-19 vaccine in people with autoimmune kidney diseases, it does state that people with autoimmune conditions may receive any authorized or approved COVID-19 vaccine. As immunosuppressants may reduce response to vaccination, people with autoimmune kidney diseases who are taking these medications — particularly those taking rituximab — should talk with their doctor to consider interrupting or delaying treatment or using an alternative immunosuppressant to maximize vaccine response. People with active autoimmune kidney diseases should consider delaying vaccination.
  
  Recipients of kidney transplants are encouraged to get vaccinated, as there is evidence that kidney transplant recipients with COVID-19 may have a higher mortality rate compared to nontransplant people with COVID-19 (Caillard, Am J Transplant 2021). While there is not enough data to confirm the safety and effectiveness of the COVID-19 vaccines in these people, a study among 187 solid organ transplant recipients, of whom 52% were kidney transplant patients, found that the rate of side effects at one week after the first dose of the mRNA COVID-19 vaccines was generally consistent with what was observed in the pre-authorization trials, and no reports of transplant rejection occurred (Boyarsky, Transplantation 2021).
  
  Immune response may be significantly reduced in transplant recipients due to use of anti-rejection drugs (Windpessl, Nat Rev Nephrol 2021). A third dose may be beneficial in some of these patients. A study in France among 159 kidney transplant recipients who had weak or no antibody response after receiving two doses of the Moderna COVID-19 vaccine showed that administering a third dose about 51 days after the second achieved antibody response in 49% of them when measured one month later. Those who with a weak response after the second dose were more likely to achieve antibody response with the third dose compared to those who had no immune response after the second dose (81.3% vs. 27.4%), while those taking tacrolimus, mycophenolate, and steroids were less likely to develop an antibody response compared to those on other regimens (35% vs. 63%) (Benotmane, JAMA 2021).
  
  People scheduled for kidney transplant surgery who decide to be vaccinated after consulting with their doctor should try to complete their vaccination series at least two weeks before surgery or to delay vaccination until at least 3 months after.
• Cancer: The CDC's recommendations do not explicitly address the use of COVID-19 vaccines in people with cancer or a history of cancer, but cancer is not included as a contraindication. The American Society of Clinical Oncology and Association for Clinical Oncology (ASCO)indicate that cancer patients, those undergoing cancer treatment, and cancer survivors may be offered the mRNA COVID-19 vaccine if they have no other contraindications and they have been counseled by their healthcare provider on the risks. Both ASCO and the American Association for Cancer Research (AARC) are advocating for cancer patients to receive priority status for the vaccine given their increased risk for severe infection.
  
  The efficacy of COVID-19 vaccines in people with cancer is still unknown, however it may be particularly important that cancer patients receive the second dose of an mRNA vaccine. A study in the U.K. among 151 people with cancer found that only 38% (21 out of 56) of those with solid tumors and 18% (8 out of 44) of those with blood cancers had an antibody response at 3 weeks after the first dose of the Pfizer vaccine (compared to 94% of people without cancer), but this rose to 95% (18 out of 19) of people with solid tumors and 60% (3 out of 5) of people with blood cancers two weeks after the second dose (compared to 100% of people without cancer). Non-response after the first dose was somewhat more common among those who received the vaccine within 15 days of cancer treatments, including immune checkpoint inhibitors (Monin, Lancet Oncol 2021).
  
  Another study among 201 fully vaccinated cancer patients (average age 66 years) showed that antibody response was 95% with the Pfizer vaccine, 94% with Moderna, and 85% with J&J. When grouped by cancer type, the antibody response was 98% for solid tumors and 85% for blood cancers. Response rate was highest among those on hormonal therapy (100%) and immune-checkpoint inhibitor therapy (e.g., Keytruda, Libtayo, Opdivo, etc.) (97%). Response rates were lower for active cytotoxic chemotherapy (89%) and for those vaccinated following highly immune-suppressive therapies, including stem cell transplant (74%), anti-CD20 antibody therapy (e.g., rituximab) (70%) or chimeric antigen receptor (CAR) T cell therapy(e.g., Kymriah, Yescarta) (0%) (Thakkar, Cancer Cell 2021). In fact, a case of a fatal SARS-CoV-2 infection has been reported for a fully vaccinated multiple myeloma patient who was in remission after B cell maturation antigen (BCMA)-targeted CAR T therapy. The patient had failed to generate humoral or cellular immune response to vaccination. An analysis of antibody response among 139 fully vaccinated multiple myeloma patients found that, among the 22 patients who did not develop antibodies, 20 (91%) were receiving anti-CD38 antibody regimens or BCMA-targeted CAR T therapy (Aleman, medRxiv 2021 — preprint).
  
  The National Comprehensive Cancer Network has provided recommendations for COVID-19 vaccination for cancer patients based on the patient's cancer type and treatment. Those undergoing hematopoietic cell transplantation (HCT) / cellular therapy are recommended to delay vaccination until at least 3 months after therapy. People with blood cancers who are receiving intensive cytotoxic chemotherapy are recommended to delay vaccination until absolute neutrophil count recovery. People with blood cancers who are on long-term maintenance therapy or those with marrow failure, as well as people with solid tumors who are receiving chemotherapy, targeted therapy, checkpoint inhibitors, or radiation are advised to get the vaccine when available.
  
  The committee notes that the optimal timing of vaccination in relation to cycles of chemotherapy or immune checkpoint inhibitors is unknown, but it recommends that vaccination be given to chemotherapy patients when available (regardless of timing of cycle) and suggests that it be given to people receiving immune checkpoint inhibitors on the same day as immunotherapy. Although some experts have raised concerns that COVID-19 vaccines might cause or worsen immune-related side effects in people on immune checkpoint inhibitors, an observational study among 134 cancer patients on immune checkpoint inhibitors including pembrolizumab (Keytruda), durvalumab (Imfinzi), cemiplimab (Libtayo), atezolizumab (Tecentriq) and nivolumab (Opdivo) with or without ipilimumab (Yervoy), some of whom had previously had immune checkpoint-inhibitor-related side effects prior to vaccination, showed that side effects after the first and second dose of the Pfizer mRNA vaccine were similar in type and frequency to those reported among healthy controls, and no new immune-related side effects (such as immune-related myositis, a condition that causes muscle inflammation) or worsening of existing immune-related side effects were observed (Waissengrin, Lancet Oncol 2021).
  
  A study of 67 people in Pittsburgh with hematologic (blood) cancers found that 46% did not produce antibodies to mRNA vaccines. Patients with B-cell chronic lymphocytic leukemia (CLL) were at a particularly high risk, as only 23% had detectable antibodies despite the fact that nearly 70% of these patients were not undergoing cancer therapy (Agha, medRxiv 2021 - preprint).
  
  People with cancer or those with suspected cancer should be aware that swelling of the lymph nodes is a possible side effect of the mRNA COVID-19 vaccines and may interfere with imaging (see above for details).
  
  Be aware that two cases of skin reactions at sites where radiation treatment was recently administered have been reported. One case involved a 68-year-old man who had had radiation therapy 6 months prior to being vaccinated. Five days after his second vaccine dose, the man experienced pain, burning sensation, redness, and mild skin exfoliation on his back where he had been irradiated. This resolved within a few days after treatment with topical steroids and pain-relievers. The other case involved a 64-year-old man who had received his first COVID-19 vaccine dose five days prior to completing radiation therapy. Six days after his second vaccine dose, the man experienced skin redness and itching at one of the radiation sites. The reaction resolved over the following week without treatment. Experts note that the benefit of vaccination outweighs the risk of this side effect (Soyfer, Int J Radiat Oncol Biol Phys 2021).
  
  Overall, an observational study among 232 cancer patients and 261 healthy controls found that side effects of the Pfizer vaccine were similar among both groups, with the most common reactions in cancer patients being pain at the injection site (69%), fatigue (24%), muscle and joint pain (13%), and headache (10%) (Goshen-Lago, JAMA Oncol 2021).
• Autoimmune conditions: Although there is only limited data to confirm the safety of the vaccines in people with these conditions, an observational study in Europe of 1,519 people with rheumatic and musculoskeletal disease (including rheumatoid arthritis, axial spondyloarthritis, psoriatic arthritis, systemic lupus erythematosus, polymyalgia rheumatica, and others) — most of whom were on disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, TNF-inhibitors, antimalarials, rituximab, and others — showed that side effects to vaccination (primarily with Pfizer or Moderna) were similar to those in the general population, and only 5% of these individuals experienced disease flares (Machado, Ann Rheum Dis 2021). Furthermore, a study among 246 people in the U.S. with inflammatory bowel disease (IBD) who received at least one dose of an mRNA vaccine showed that the frequency of reported adverse events was similar to that among the general population, with the most common side effects being injection-site reaction, fatigue, headache, and fever/chills (Botwin, Am J Gastroenterol 2021).
  
  The efficacy of the COVID-19 vaccines among people with systemic autoimmune rheumatic diseases (SARDs) conditions is not well known, although there is some evidence that the vaccines may be less effective against severe disease in this population. A very small study in Boston among 16 people with SARDs (e.g., rheumatoid arthritis, dermatomyositis, systemic lupus erythematosus, ankylosing spondylitis, psoriatic arthritis and others) — most of whom were on DMARDs — who experienced a breakthrough infection despite being fully vaccinated showed that, compared to the general population, the people with SARDs were much more likely to require hospitalization (38% vs. 10%) or die (13% vs 2%). In addition, 94% of the breakthrough infections were symptomatic (Cook, medRxiv 2021 — preprint).
  
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