Vaccination Status May Be Considered To Get ICU Beds

[missy]

@Diamond Girl 21 here is Part 3.
PS has a character limit per post...this is why I have to break it up into parts.

"

• The reduced effectiveness of the COVID-19 vaccines among people with SARDs correlates with reduced and/or delayed antibody response observed among people with these or other inflammatory conditions (e.g., Crohn's disease, ulcerative colitis, rheumatoid arthritis, psoriatic arthritis, spondyloarthropathy, systemic lupus erythematosus, etc.), particularly among those taking immunosuppressants, as shown in several laboratory studies (Wong, medRxiv 2021 — preprint; Geisen, Ann Rheum Dis 2021; Moyon, medRxiv 2021 — preprint).
  
  Despite the potential of sub-optimal vaccine response, the British Society of Gastroenterology and IBD Clinical Research Group recommend that people with inflammatory bowel disease (IBD) (such as those with Crohn's disease or ulcerative colitis) be vaccinated if they have no other contraindication. Similarly, the Singapore Chapter of Rheumatologists strongly recommends that people with rheumatic diseases (e.g., rheumatoid arthritis) and their household contacts get vaccinated, preferably during inactive disease (Santosa, medRxiv 2021 — preprint).
  
  The American College of Rheumatology (ACR)provides timing guidance for those on immunomodulatory therapy:
  • Rituximab: Initiate vaccine series about four weeks prior to next scheduled rituximab cycle; after vaccination, hold off on medication for two to four weeks after final vaccine dose (if possible).
  • Mycophenolate or Janus kinase inhibitors such as tofacitinib (XELJANZ): Hold off on medication for one week after any vaccine dose.
  • Methotrexate: Hold off on medication for one week after each dose of mRNA vaccine (i.e., Pfizer or Moderna) or for two weeks after a single-dose COVID vaccine (i.e., J&J).
  • Subcutaneous abatacept: Hold off on medication for one week before and one week after the first but not the second vaccine dose.
  • Intravenous abatacept: Time vaccination so that the first vaccine dose will occur four weeks after infusion; the next infusion should then be delayed for one additional week, and no medication adjustment needs to be made for the second vaccine dose.
  • Intravenous cyclophosphamide: Time administration to occur about one week after each vaccine dose (if possible).
  • Other immunomodulatory medicines (hydroxychloroquine, glucocorticoids, sulfasalazine, oral cyclophosphamide, and others): Continue immunomodulatory therapy and vaccination with no timing modifications.
  • All patients with stable disease are also advised to avoid taking acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) for 24 hours prior to vaccination, regardless of immunomodulatory therapy used. The ACR notes, however, that its guidance is not meant to supersede the judgment of rheumatologists, so be sure to discuss vaccination with your doctor before getting your shot.
    
    Unrelated to vaccination, it is worth noting that people with autoimmune diseases or chronic inflammatory diseases who were taking systemic (i.e., not topical) corticosteroids (such as prednisone) when hospitalized with COVID-19 were nearly seven times as likely to require ventilation or die than other COVID-19 patients, according to a study at Mt. Sinai hospital in New York. Patients treated with other medications did not have this increased risk, leading the researchers to suggest that doses of corticosteroids "...should ideally be tapered to the lowest possible dose weighing the risks and benefits of these therapies in the individual patient" (Ungaro, ACR Open Rheum 2020).
• Psoriasis: The CDC does not provide information regarding COVID-19 vaccines for people with psoriasis, but the National Psoriasis Foundation recommends that people with psoriatic disease get vaccinated when the mRNA vaccine becomes available to them. Use of oral or biologic treatments for psoriasis (including immunosuppressants) can be continued without interruption, although these medications may reduce response to the vaccine.
• Eczema: The CDC's recommendations do not explicitly address the use of the COVID-19 vaccine in people with eczema, although it does state that people with autoimmune conditions may receive any authorized or approved COVID-19 vaccine. Experts have been quoted as stating that people with eczema, including those with flaring eczema, may be vaccinated, although people with flaring eczema should consider avoiding the shot in the area with flaring. Use of oral (but not topical) immunosuppressants may reduce vaccine efficacy, but there is no evidence that these medications increase the risk of side effects. While it is unknown if dupilumab affects the efficacy of the COVID-19 vaccine, it does not seem to reduce the response to other vaccines (National Eczema Association, 3/1/21).
• Mast cell activation syndrome (MCAS): The CDC's recommendations do not explicitly address the use of the COVID-19 vaccine in those with MCAS, a condition associated with some autoimmune conditions. The American College of Allergy, Asthma, and Immunologystates that there is limited data related to the safety of the mRNA COVID-19 vaccine in people with MCAS, so people with this condition should consult with their doctor to weigh the risks and benefit. Physician advisors from The Mast Cell Disease Society Medical Advisory Board recommend that patients with mast cell disease who choose to be vaccinated carry an Epi-Pen with them to the vaccination site and remain at the site for 30 minutes after being vaccinated.
  
  Although the CDC advises that people with an immediate allergic reaction after getting a shot of a Covid-19 vaccine not get a second shot, one patient with cholinergic urticaria, a common mast cell disorder, who experienced anaphylaxis within 3 minutes of receiving the first dose of the Pfizer vaccine was still able to receive the second dose after being evaluated by an allergist / immunologist. Her anaphylaxis was non-IgE-mediated, and she was able to receive the second dose without taking antihistamines prior to vaccination. Her second dose was given in a cool room without excessive clothing, and she experienced only temporary nausea and sense of warmth (Park, Mil Med 2021).
• Multiple sclerosis (MS): The CDC's recommendations do not explicitly address the use of the COVID-19 vaccines in those with MS. However, the National Multiple Sclerosis Societyreleased guidance stating that most people with relapsing and progressive forms of MS, as well as people living in the same household as someone with MS, should be vaccinated. The Society states that the mRNA vaccines are unlikely to worsen symptoms or cause MS relapse, although it notes that fever caused by the vaccine might worsen symptoms temporarily.
  
  The Society also recommends that people with MS on disease-modifying therapy (DMT) should continue treatment unless advised otherwise by their doctor. People on certain DMTs such as ofatumumab (Kesimpta), alemtuzumab (Lemtrada), cladribine (Mavenclad), ocrelizumab (Ocrevus), or rituximab (Rituxan) may need to work with their doctor to coordinate the timing of their vaccine with their DMT dose. It was reported that a person in Boston with MS who received an infusion of ocrelizumab (which depletes B-cells — white blood cells involved in antibody production) 5 months prior to the first dose of the Pfizer vaccine and, again, 9 days after the second dose, failed to develop antibodies when tested 28 days after the second dose of the Pfizer vaccine. MS patients on this type of therapy have had blunted antibody responses to COVID itself. It is possible that another type of immune response involving T cells might, however, provide some protection (Khayat-Khoei, J Neurol 2021).
  
  An analysis of antibody response among 125 people with MS found that, at about 4.5 to 6.5 weeks after the second dose of the Pfizer vaccine, 100% of those not taking disease-modifying therapy, as well as 100% of those taking cladribine (Mavenclad), had high antibody response. However, only about 23% of those taking ocrelizumab (Ocrevus) and 4% of those taking fingolimod (Gilenya) showed antibody response. In light of the results, the researchers suggest postponing cladribine and ocrelizumab treatments, respectively, for 4.4 weeks and 9 weeks before vaccination, and not vaccinating patients on fingolimod until their lymphocyte count is above 1000?cells/mm3 (Achiron, Ther Adv Neurol Disord 2021). Guidelines developed by neurology experts from Canada and several European countries state that people with MS who have not yet started cladribine treatment should postpone therapy for two to four weeks after COVID-19 vaccination, but those already undergoing cladribine treatment should receive the vaccine when available, regardless of timing of subsequent cladribine dose or lymphocyte counts (Rieckmann, medRxiv 2021 — preprint).
• Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS): The CDC's recommendations do not explicitly advise on the use of COVID-19 vaccines in people with this condition, but these vaccines are not contraindicated in people with this condition. People with this condition should talk with their doctor to weigh the risks and benefits.
• Parkinson's disease: The CDC does not explicitly advise on use of COVID-19 vaccines in people with Parkinson's disease, but neurology experts suggest that people with Parkinson's disease may get these vaccines if they do not have other contraindications. This recommendation is based on the following: (1) the risk of severe COVID-19 or related complications may be higher for those with Parkinson's disease — in fact, worsened motor and non-motor symptoms have been reported in people with Parkinson's disease and COVID-19 (Sulzer, NPJ Parkinsons Dis 2020), and a recent study among 79,049 adults with COVID-19 found that the risk of dying was about 30% higher for those with Parkinson's disease compared to those without (Zhang, Mov Disord 2020); (2) there are no known or expected interactions between the mRNA COVID-19 vaccines and Parkinson's disease progression or therapies for Parkinson's disease; and (3) the mRNA vaccines do not appear to cause unexpected adverse effects in this population (Bloem, J Parkinson Dis 2021).
  
  The International Parkinson and Movement Disorder Society (MDS) has stated that the mRNA vaccines (as well as vector vaccines such as the J&J vaccine) would not be expected to affect Parkinson's disease therapy, progression or related inflammation. Based on this, the organization recommends that people with Parkinson's disease get the vaccine as soon as it is available to them. Similar recommendations have also been made by the American Parkinson Disease Association. [For information about supplements used for Parkinson's disease, see our answer to the question, "Do supplements help with Parkinson's disease treatment or prevention?"]
• Peripheral neuropathy: The CDC does not explicitly advise on use of COVID-19 vaccines in people with peripheral neuropathy, but experts associated with the Foundation for Peripheral Neuropathy (FPN) suggest that people with peripheral may get the vaccine after consulting with their neurologist and primary care physician. According to the FPN's Scientific Advisory Board Chairman, people with peripheral neuropathy should consider getting the vaccine when it is available to them since "the risks of COVID-19 far outweigh the risks of developing increased or new [peripheral neuropathy] symptoms."
• Neurological conditions — including dementia and Alzheimer's, neuromuscular and neuroinflammatory diseases, and epilepsy: The CDC does not explicitly advise on use of COVID-19 vaccines in people with neurological conditions, and there is little data regarding the safety and efficacy of the vaccines in such people. However, the American Academy of Neurology recommends that eligible patients with these diseases be offered the vaccine, and the Alzheimer's Association strongly encourages the vaccines for people living with Alzheimer's or other dementias. To date there has been no evidence of increased risk of seizures following vaccination in those with a history of epilepsy (Marsh, Neurology 2021).
• Migraine: Although people with migraines and other headache disorders were likely included in the pre-authorization clinical trials for the COVID-19 vaccines, information regarding the safety of the vaccines in these people has not been reported, and the CDC does not explicitly advise on use of COVID-19 vaccines in people with migraines. However, experts state there is no reason to think that injectable treatments for migraine, including onabotulinumtoxinA or calcitonin gene-related peptide (CGRP) pathway monoclonal antibodies (mAb) would influence immune response to any of the COVID-19 vaccines, although people administering CGRP pathway mAb into their arm should consider injecting this treatment into the opposite arm post-vaccination until local side effects from the vaccine resolve. Experts also note that there is no reason to think that the COVID-19 vaccines will impair the efficacy of injectable migraine treatments, and there is no need to re-time or delay these therapies in people getting the vaccine.
  
  Although most people are recommended to avoid prophylactic use of NSAIDs and acetaminophen prior to vaccination, people who require these medications for treatment of migraine and other headache disorders may continue to do so if needed (Gelfand, Headache 2021).
• Osteoporosis: The CDC does not explicitly advise on use of COVID-19 vaccines in people with osteoporosis, but the vaccines are not contraindicated in people with this condition. Osteoporosis does not appear to be a risk factor for severe COVID-19 (although the disease typically correlates with increased age, which is a risk factor), but experts still advise those with osteoporosis to get vaccinated. People with osteoporosis who are taking oralbisphosphonates (e.g., alendronate, risedronateor ibandronate), teriparatide, abaloparatideor raloxifene are recommended to not discontinue treatment before, during or after vaccination. However, experts suggest that those receiving intravenous bisphosphonatesshould separate vaccination and bisphosphonate administration by one week since either treatment has the potential to cause an inflammatory reaction. Similarly, experts recommend that people receiving denosumab or romosozumab separate treatment and vaccination by four to seven days, since any of these may cause injection site reactions, although romosozumab may be given without a delayed interval if the drug is administered into the abdomen or thigh. Denosumab is recommended to be given in the opposite arm or at another site such as the abdomen or thigh following the four to seven-day interval (Tsourdi, J Bone Miner Res 2021).
• Very frail elderly: Although fatalities were reported among frail, elderly people in Norway and Germany shortly after they received the Pfizer vaccine, an expert committee concluded that the evidence does not indicate that the vaccine contributed to fatalities or other unexpected adverse events; it considers the risk-benefit balance of the vaccines to be favorable in the elderly. Similarly, the Norwegian Medicines Agency has stated, "There is no certain connection between these deaths and the vaccine" (Torjesen, BMJ 2021). In addition, a review of adverse effects reported in the U.S. with the two mRNA vaccines through mid-January 2021 indicated that there is no clear correlation between vaccination and risk of death in older adult residents of long-term care facilities (CDC, COVID-19 Vaccine Safety Update 2021). Nevertheless, the WHO has recommended that very frail elderly people with life expectancies of less than 3 months be individually assessed, as the risks may outweigh the benefit in this population.
  
  Be aware that severe frailty has been associated with a three-fold increased risk of death and a seven-fold increased care level upon discharge for those hospitalized for COVID-19 compared to those who are not frail (Geriatric Medicine Research Collaborative, Age Ageing 2021; Blomaard, Age Ageing 2021), highlighting the potential importance of vaccination in this population.
  
  While very few people over the age of 80 were included in the preauthorization clinical trials, an analysis of data from 100 people ages 80 to 96 years who received the Pfizer mRNA vaccine found that 98% had high antibody response at two weeks after the second dose, with evidence of efficacy against both the original (Wuhan) virus and Brazilian P.1 variant based on neutralization assays, suggesting that the vaccine is likely effective even among very elderly people, although cellular immune response was observed in only 63% of these people (Parry, SSRN preprint 2021). However, research in Germany that included 71 elderly people (average age 81) and 123 younger healthcare workers (average age 34) who received two doses of the Pfizer vaccine found that both antibody (humoral) and cellular immune responses were delayed and less robust among the older compared to the younger people. About 91% of the healthcare workers had antibodies with neutralizing capacity at two weeks after the second dose compared to only 46% of elderly people, although at four weeks after the second dose, 90% of elderly people had neutralizing antibody response. A lower percentage of elderly people showed strong cellular immunity at four weeks after the second dose compared to the younger individuals (51% vs. 85%, respectively) (Schwarz, Emerg Infect Dis 2021).
  
  Research in Belgium that included 40 elderly nursing home residents who had been vaccinated with the Pfizer vaccine showed that, among those with no history of COVID-19prior to vaccination, none had detectable neutralizing antibodies against the Beta (B.1.351 or South African) variant, suggesting that some elderly individuals may be more prone to breakthrough infections, particularly with variants of concern. However, the authors noted that the poor antibody response may be linked with frailty and comorbidities rather than age itself (Pannus, medRxiv 2021 — preprint).
  
  According to data from the CDC, there were 31% more deaths involving COVID-19 in the U.S. among people ages 50 to 64 than those 85+ in May 2021. This is a dramatic reversal from December 2020, when there were 2.5 times as many COVID deaths among those 85+ than those 50 to 64. This change is likely be attributed to the higher vaccination rate among the elderly.
• Diabetes: The CDC has noted that diabetes (type 1 or type 2) is a risk factor for severe COVID. Diabetes is not a contraindication for COVID-19 vaccination. In fact, about 3,000 people with diabetes were included in each of the preauthorization trials for COVID vaccines authorized or approved for use in the U.S (Pal, Diabetes Metab Syndr 2021). There are no known interactions between the COVID-19 vaccines and medications for diabetes, and experts recommend that people with diabetes continue their medications before and after getting vaccinated. However, it may be wise for people taking insulin to avoid injecting the medication into the site of the vaccine shot for several days after getting their shot. Also, because it is possible that immune response induced by vaccination may cause blood sugar levels to increase, people with diabetes should monitor their blood sugar levels for at least 48 hours after getting their shot (Baton Rouge General, 1/26/21).
• Obesity: The CDC does not explicitly advise on COVID-19 vaccination in people who are obese, but this condition is not a contraindication and obesity is a risk factor for severe COVID. There is some concern that people who are obese may not generate as high or as persistent of an immune response to COVID vaccination compared to otherwise healthy people, as people who are obese have shown lower immune response to other vaccines such as the tetanus and hepatitis vaccines compared to those who are not obese (Eliakim, Autoimmunity 2006; Painter, Vaccine 2015), and there is evidence that immunity induced by other vaccines such the flu vaccine decreased more significantly at one year after vaccination among obese people compared to those who were not (Sheridan, Int J Obes 2012). Nevertheless, pre-authorization trials for the Pfizer and Moderna vaccines found that vaccine efficacy in preventing symptomatic COVID was similar among those who were obese and those who were not (Polack, N Eng J Med 2020; Baden, N Engl J Med 2021), although these trials were not specifically designed to detect differences between these groups.
• History of Guillain-Barré syndrome (GBS): According to the CDC, people with a history of GBS (which affects nerves) may receive any of the authorized or approved COVID-19 vaccines (CDC, Interim Clinical Considerations 2021).
  
  Although no cases of GBS were reported in the mRNA COVID-19 pre-authorization trials, and only one case was reported 10 days after vaccination in the J&J preauthorization trial (one case was also reported in the placebo group) (Márquez Loza, Neurology 2021), 341 cases (69 J&J, 126 Moderna, 142 Pfizer, and 4 unknown) of GBS after vaccination have been reported to VAERS as of 6/25/21. One case of Guillain-Barré syndrome was also reported in an 82-year-old woman who received the Pfizer vaccine two weeks prior to symptom onset. The patient recovered after three doses of intravenous immunoglobulin (Waheed, Cureus 2021). Furthermore, two publications documenting a total of 11 cases of GBS following vaccination with the AstraZeneca vaccine (which is somewhat similar to the J&J vaccine) found that facial paralysis affecting both sides of the face was more common and more severe than what is typical for GBS, and the frequency of GBS was estimated to be 1.4 to 10 times greater than what would be expected (Allen, Ann Neurol 2021; Maramattom, Ann Neurol 2021) ).
• History of Bell's palsy: People with a history of Bell's palsy may still be vaccinated.
  
  Cases of Bell's palsy have been reported among people who received the mRNA vaccines or J&J vaccine. However, an analysis showed that the rate of reports of facial paralysis after mRNA COVID-19 vaccination was not higher than that observed with other viral vaccines, and if an association between facial paralysis and mRNA COVID-19 vaccines exists, the risk is likely very low, as with other viral vaccines (Renoud, JAMA Intern Med 2021). Similarly, a real-world study in Israel examining cases of Bell's palsy from January 1 to February 28, 2021 found no association between recent vaccination with the Pfizer vaccine and risk of Bell's palsy. There was also no evidence of increased incidence of Bell's palsy during that time period compared to the same time period in previous years (Shemer, JAMA Otolaryngol Head Neck Surg 2021). Furthermore, data has shown that the risk of Bell's palsy was nearly seven times higher after COVID-19 infection compared to after vaccination (Tamaki, JAMA Otolaryngol Head Neck Surg 2021).
• Dermal (skin) fillers: People who have a history of dermal filler use may receive the COVID-19 vaccine if they have no other contraindications, although temporary swelling at or near the site of filler injection may occur. No additional precautions are needed, but people with dermal fillers should contact their doctor if they develop swelling at the site of dermal filler following vaccination. Medical treatment, including corticosteroid therapy, may be given to resolve symptoms if swelling occurs.
  
  While this reaction has been reported with only the Moderna vaccine (although a case of swelling under the eye has been reported after the Pfizer vaccine for a person who had a tear trough filler), the American Society for Dermatologic Surgery notes that similar reactions have been triggered by viral and bacterial illness, certain dental procedures, and other vaccines such as the flu vaccine. In fact, one person with dermal fillers who experienced swelling after the Moderna vaccine had experienced a similar reaction to the flu vaccine in the past. According to a survey conducted by the International Society for Dermatologic and Aesthetic Surgery (ISDS), out of 106 people with previous dermal filler injections, only 5% reported local pain at the site of previous filler injection after receiving at least one dose of the COVID vaccine. It should be noted that the majority of those surveyed had received the Pfizer vaccine, some had received vaccines not authorized in the U.S., and only one received the Moderna vaccine (Gotkin, J Drugs Dermatol 2021).
  
  COVID itself can cause swelling around dermal fillers, as reported in a 50-year-old woman who was diagnosed with COVID-19 at 15 days after her last injection with a hyaluronic acid dermal filler. Symptoms including swelling of the lips, cheeks, and around the eyes, as well as burning sensation of the lips, persisted for weeks after the infection despite treatment (Munavalli, Arch Dermatol Res 2021).
  
  Among those with dermal fillers who experienced reactions to the Moderna vaccine, one had received dermal fillers 2 weeks prior to vaccination, and another had received dermal fillers 6 months before. Since many dermal fillers are reabsorbed by the body within 12 to 24 months of placement, the risk of reaction after this duration seems less likely. However, dermal fillers that use synthetic ingredients such as polymethylmethacrylate (e.g., Bellafill) are not re-absorbed and may theoretically lead to a reaction years after dermal filler placement.
• Surgery: The CDC does not explicitly advise on COVID-19 vaccination in people who have undergone or who are planning to undergo surgery. According to the Royal College of Surgeons of England, essential urgent surgery should take place regardless of vaccination status. The organization also strongly encourages people to get vaccinated prior to elective surgery to minimize postoperative COVID-19 risks. It recommends that people separate the date of vaccination from that of surgery by about a week to help ensure that any symptoms that may occur can be correctly attributed to either vaccination or the operation. Similarly, the Mayo Clinic states that it is not necessary to postpone COVID-19 vaccination until after surgery but that people should try to get vaccinated at least several days prior to surgery to avoid the potential of vaccine-induced fever on the day of surgery (which may cause the surgery to be postponed).
  
  People may also consider being vaccinated after surgery, but they should consult with their doctor prior to scheduling their vaccination appointment to ensure that they will be well enough to do so. MD Anderson Cancer Center states that people with cancer who have undergone surgery should wait for 2 weeks after surgery before getting vaccinated.
• People with a history of thrombosis or risk factors for thrombosis: The Johnson & Johnson (J&J) vaccine has been associated with cases of blood clots and low platelets. Although the exact cause of these events is unclear, it appears to be similar to heparin-induced thrombocytopenia, a rare immune-mediated syndrome. Until more is known, people with a history of an immune-mediated syndrome characterized by blood clots and low platelets should not get the J&J vaccine if it has been 90 days or less since their illness resolved. Instead, they should opt for one of the mRNA vaccines. If it has been more than 90 days since illness resolved, these individuals can get the J&J vaccine (CDC, Interim Clinical Considerations 2021).
• Pregnant or lactating: Pregnancy or recent pregnancy has been associated with increased risk of severe COVID-19 illness. Furthermore, getting COVID-19 during pregnancy has been associated with an increased risk of preterm birth (8.8% vs. 5.6% for pregnant women without COVID) and associated respiratory disorders (such as respiratory distress syndrome or need for mechanical ventilation for the infant at birth) (Norman, JAMA 2021).
  
  Based on the increased risk for severe illness and pregnancy complications, and the growing evidence of safety and likely efficacy of the COVID-19 vaccine during pregnancy, the CDCrecommends that individuals who are pregnant, trying to become pregnant, or who might become pregnant in the future, as well as those who are breast-feeding, get vaccinated. This recommendation aligns with earlier recommendations from professional medical organizations, including the American College of Obstetricians and Gynecologists (ACOG).
  
  
  "

 

[Diamond Girl 21]

@Diamond Girl 21 here is Part 3.
PS has a character limit per post...this is why I have to break it up into parts.

"

• The reduced effectiveness of the COVID-19 vaccines among people with SARDs correlates with reduced and/or delayed antibody response observed among people with these or other inflammatory conditions (e.g., Crohn's disease, ulcerative colitis, rheumatoid arthritis, psoriatic arthritis, spondyloarthropathy, systemic lupus erythematosus, etc.), particularly among those taking immunosuppressants, as shown in several laboratory studies (Wong, medRxiv 2021 — preprint; Geisen, Ann Rheum Dis 2021; Moyon, medRxiv 2021 — preprint).
  
  Despite the potential of sub-optimal vaccine response, the British Society of Gastroenterology and IBD Clinical Research Group recommend that people with inflammatory bowel disease (IBD) (such as those with Crohn's disease or ulcerative colitis) be vaccinated if they have no other contraindication. Similarly, the Singapore Chapter of Rheumatologists strongly recommends that people with rheumatic diseases (e.g., rheumatoid arthritis) and their household contacts get vaccinated, preferably during inactive disease (Santosa, medRxiv 2021 — preprint).
  
  The American College of Rheumatology (ACR)provides timing guidance for those on immunomodulatory therapy:
  • Rituximab: Initiate vaccine series about four weeks prior to next scheduled rituximab cycle; after vaccination, hold off on medication for two to four weeks after final vaccine dose (if possible).
  • Mycophenolate or Janus kinase inhibitors such as tofacitinib (XELJANZ): Hold off on medication for one week after any vaccine dose.
  • Methotrexate: Hold off on medication for one week after each dose of mRNA vaccine (i.e., Pfizer or Moderna) or for two weeks after a single-dose COVID vaccine (i.e., J&J).
  • Subcutaneous abatacept: Hold off on medication for one week before and one week after the first but not the second vaccine dose.
  • Intravenous abatacept: Time vaccination so that the first vaccine dose will occur four weeks after infusion; the next infusion should then be delayed for one additional week, and no medication adjustment needs to be made for the second vaccine dose.
  • Intravenous cyclophosphamide: Time administration to occur about one week after each vaccine dose (if possible).
  • Other immunomodulatory medicines (hydroxychloroquine, glucocorticoids, sulfasalazine, oral cyclophosphamide, and others): Continue immunomodulatory therapy and vaccination with no timing modifications.
  • All patients with stable disease are also advised to avoid taking acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) for 24 hours prior to vaccination, regardless of immunomodulatory therapy used. The ACR notes, however, that its guidance is not meant to supersede the judgment of rheumatologists, so be sure to discuss vaccination with your doctor before getting your shot.
    
    Unrelated to vaccination, it is worth noting that people with autoimmune diseases or chronic inflammatory diseases who were taking systemic (i.e., not topical) corticosteroids (such as prednisone) when hospitalized with COVID-19 were nearly seven times as likely to require ventilation or die than other COVID-19 patients, according to a study at Mt. Sinai hospital in New York. Patients treated with other medications did not have this increased risk, leading the researchers to suggest that doses of corticosteroids "...should ideally be tapered to the lowest possible dose weighing the risks and benefits of these therapies in the individual patient" (Ungaro, ACR Open Rheum 2020).
• Psoriasis: The CDC does not provide information regarding COVID-19 vaccines for people with psoriasis, but the National Psoriasis Foundation recommends that people with psoriatic disease get vaccinated when the mRNA vaccine becomes available to them. Use of oral or biologic treatments for psoriasis (including immunosuppressants) can be continued without interruption, although these medications may reduce response to the vaccine.
• Eczema: The CDC's recommendations do not explicitly address the use of the COVID-19 vaccine in people with eczema, although it does state that people with autoimmune conditions may receive any authorized or approved COVID-19 vaccine. Experts have been quoted as stating that people with eczema, including those with flaring eczema, may be vaccinated, although people with flaring eczema should consider avoiding the shot in the area with flaring. Use of oral (but not topical) immunosuppressants may reduce vaccine efficacy, but there is no evidence that these medications increase the risk of side effects. While it is unknown if dupilumab affects the efficacy of the COVID-19 vaccine, it does not seem to reduce the response to other vaccines (National Eczema Association, 3/1/21).
• Mast cell activation syndrome (MCAS): The CDC's recommendations do not explicitly address the use of the COVID-19 vaccine in those with MCAS, a condition associated with some autoimmune conditions. The American College of Allergy, Asthma, and Immunologystates that there is limited data related to the safety of the mRNA COVID-19 vaccine in people with MCAS, so people with this condition should consult with their doctor to weigh the risks and benefit. Physician advisors from The Mast Cell Disease Society Medical Advisory Board recommend that patients with mast cell disease who choose to be vaccinated carry an Epi-Pen with them to the vaccination site and remain at the site for 30 minutes after being vaccinated.
  
  Although the CDC advises that people with an immediate allergic reaction after getting a shot of a Covid-19 vaccine not get a second shot, one patient with cholinergic urticaria, a common mast cell disorder, who experienced anaphylaxis within 3 minutes of receiving the first dose of the Pfizer vaccine was still able to receive the second dose after being evaluated by an allergist / immunologist. Her anaphylaxis was non-IgE-mediated, and she was able to receive the second dose without taking antihistamines prior to vaccination. Her second dose was given in a cool room without excessive clothing, and she experienced only temporary nausea and sense of warmth (Park, Mil Med 2021).
• Multiple sclerosis (MS): The CDC's recommendations do not explicitly address the use of the COVID-19 vaccines in those with MS. However, the National Multiple Sclerosis Societyreleased guidance stating that most people with relapsing and progressive forms of MS, as well as people living in the same household as someone with MS, should be vaccinated. The Society states that the mRNA vaccines are unlikely to worsen symptoms or cause MS relapse, although it notes that fever caused by the vaccine might worsen symptoms temporarily.
  
  The Society also recommends that people with MS on disease-modifying therapy (DMT) should continue treatment unless advised otherwise by their doctor. People on certain DMTs such as ofatumumab (Kesimpta), alemtuzumab (Lemtrada), cladribine (Mavenclad), ocrelizumab (Ocrevus), or rituximab (Rituxan) may need to work with their doctor to coordinate the timing of their vaccine with their DMT dose. It was reported that a person in Boston with MS who received an infusion of ocrelizumab (which depletes B-cells — white blood cells involved in antibody production) 5 months prior to the first dose of the Pfizer vaccine and, again, 9 days after the second dose, failed to develop antibodies when tested 28 days after the second dose of the Pfizer vaccine. MS patients on this type of therapy have had blunted antibody responses to COVID itself. It is possible that another type of immune response involving T cells might, however, provide some protection (Khayat-Khoei, J Neurol 2021).
  
  An analysis of antibody response among 125 people with MS found that, at about 4.5 to 6.5 weeks after the second dose of the Pfizer vaccine, 100% of those not taking disease-modifying therapy, as well as 100% of those taking cladribine (Mavenclad), had high antibody response. However, only about 23% of those taking ocrelizumab (Ocrevus) and 4% of those taking fingolimod (Gilenya) showed antibody response. In light of the results, the researchers suggest postponing cladribine and ocrelizumab treatments, respectively, for 4.4 weeks and 9 weeks before vaccination, and not vaccinating patients on fingolimod until their lymphocyte count is above 1000?cells/mm3 (Achiron, Ther Adv Neurol Disord 2021). Guidelines developed by neurology experts from Canada and several European countries state that people with MS who have not yet started cladribine treatment should postpone therapy for two to four weeks after COVID-19 vaccination, but those already undergoing cladribine treatment should receive the vaccine when available, regardless of timing of subsequent cladribine dose or lymphocyte counts (Rieckmann, medRxiv 2021 — preprint).
• Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS): The CDC's recommendations do not explicitly advise on the use of COVID-19 vaccines in people with this condition, but these vaccines are not contraindicated in people with this condition. People with this condition should talk with their doctor to weigh the risks and benefits.
• Parkinson's disease: The CDC does not explicitly advise on use of COVID-19 vaccines in people with Parkinson's disease, but neurology experts suggest that people with Parkinson's disease may get these vaccines if they do not have other contraindications. This recommendation is based on the following: (1) the risk of severe COVID-19 or related complications may be higher for those with Parkinson's disease — in fact, worsened motor and non-motor symptoms have been reported in people with Parkinson's disease and COVID-19 (Sulzer, NPJ Parkinsons Dis 2020), and a recent study among 79,049 adults with COVID-19 found that the risk of dying was about 30% higher for those with Parkinson's disease compared to those without (Zhang, Mov Disord 2020); (2) there are no known or expected interactions between the mRNA COVID-19 vaccines and Parkinson's disease progression or therapies for Parkinson's disease; and (3) the mRNA vaccines do not appear to cause unexpected adverse effects in this population (Bloem, J Parkinson Dis 2021).
  
  The International Parkinson and Movement Disorder Society (MDS) has stated that the mRNA vaccines (as well as vector vaccines such as the J&J vaccine) would not be expected to affect Parkinson's disease therapy, progression or related inflammation. Based on this, the organization recommends that people with Parkinson's disease get the vaccine as soon as it is available to them. Similar recommendations have also been made by the American Parkinson Disease Association. [For information about supplements used for Parkinson's disease, see our answer to the question, "Do supplements help with Parkinson's disease treatment or prevention?"]
• Peripheral neuropathy: The CDC does not explicitly advise on use of COVID-19 vaccines in people with peripheral neuropathy, but experts associated with the Foundation for Peripheral Neuropathy (FPN) suggest that people with peripheral may get the vaccine after consulting with their neurologist and primary care physician. According to the FPN's Scientific Advisory Board Chairman, people with peripheral neuropathy should consider getting the vaccine when it is available to them since "the risks of COVID-19 far outweigh the risks of developing increased or new [peripheral neuropathy] symptoms."
• Neurological conditions — including dementia and Alzheimer's, neuromuscular and neuroinflammatory diseases, and epilepsy: The CDC does not explicitly advise on use of COVID-19 vaccines in people with neurological conditions, and there is little data regarding the safety and efficacy of the vaccines in such people. However, the American Academy of Neurology recommends that eligible patients with these diseases be offered the vaccine, and the Alzheimer's Association strongly encourages the vaccines for people living with Alzheimer's or other dementias. To date there has been no evidence of increased risk of seizures following vaccination in those with a history of epilepsy (Marsh, Neurology 2021).
• Migraine: Although people with migraines and other headache disorders were likely included in the pre-authorization clinical trials for the COVID-19 vaccines, information regarding the safety of the vaccines in these people has not been reported, and the CDC does not explicitly advise on use of COVID-19 vaccines in people with migraines. However, experts state there is no reason to think that injectable treatments for migraine, including onabotulinumtoxinA or calcitonin gene-related peptide (CGRP) pathway monoclonal antibodies (mAb) would influence immune response to any of the COVID-19 vaccines, although people administering CGRP pathway mAb into their arm should consider injecting this treatment into the opposite arm post-vaccination until local side effects from the vaccine resolve. Experts also note that there is no reason to think that the COVID-19 vaccines will impair the efficacy of injectable migraine treatments, and there is no need to re-time or delay these therapies in people getting the vaccine.
  
  Although most people are recommended to avoid prophylactic use of NSAIDs and acetaminophen prior to vaccination, people who require these medications for treatment of migraine and other headache disorders may continue to do so if needed (Gelfand, Headache 2021).
• Osteoporosis: The CDC does not explicitly advise on use of COVID-19 vaccines in people with osteoporosis, but the vaccines are not contraindicated in people with this condition. Osteoporosis does not appear to be a risk factor for severe COVID-19 (although the disease typically correlates with increased age, which is a risk factor), but experts still advise those with osteoporosis to get vaccinated. People with osteoporosis who are taking oralbisphosphonates (e.g., alendronate, risedronateor ibandronate), teriparatide, abaloparatideor raloxifene are recommended to not discontinue treatment before, during or after vaccination. However, experts suggest that those receiving intravenous bisphosphonatesshould separate vaccination and bisphosphonate administration by one week since either treatment has the potential to cause an inflammatory reaction. Similarly, experts recommend that people receiving denosumab or romosozumab separate treatment and vaccination by four to seven days, since any of these may cause injection site reactions, although romosozumab may be given without a delayed interval if the drug is administered into the abdomen or thigh. Denosumab is recommended to be given in the opposite arm or at another site such as the abdomen or thigh following the four to seven-day interval (Tsourdi, J Bone Miner Res 2021).
• Very frail elderly: Although fatalities were reported among frail, elderly people in Norway and Germany shortly after they received the Pfizer vaccine, an expert committee concluded that the evidence does not indicate that the vaccine contributed to fatalities or other unexpected adverse events; it considers the risk-benefit balance of the vaccines to be favorable in the elderly. Similarly, the Norwegian Medicines Agency has stated, "There is no certain connection between these deaths and the vaccine" (Torjesen, BMJ 2021). In addition, a review of adverse effects reported in the U.S. with the two mRNA vaccines through mid-January 2021 indicated that there is no clear correlation between vaccination and risk of death in older adult residents of long-term care facilities (CDC, COVID-19 Vaccine Safety Update 2021). Nevertheless, the WHO has recommended that very frail elderly people with life expectancies of less than 3 months be individually assessed, as the risks may outweigh the benefit in this population.
  
  Be aware that severe frailty has been associated with a three-fold increased risk of death and a seven-fold increased care level upon discharge for those hospitalized for COVID-19 compared to those who are not frail (Geriatric Medicine Research Collaborative, Age Ageing 2021; Blomaard, Age Ageing 2021), highlighting the potential importance of vaccination in this population.
  
  While very few people over the age of 80 were included in the preauthorization clinical trials, an analysis of data from 100 people ages 80 to 96 years who received the Pfizer mRNA vaccine found that 98% had high antibody response at two weeks after the second dose, with evidence of efficacy against both the original (Wuhan) virus and Brazilian P.1 variant based on neutralization assays, suggesting that the vaccine is likely effective even among very elderly people, although cellular immune response was observed in only 63% of these people (Parry, SSRN preprint 2021). However, research in Germany that included 71 elderly people (average age 81) and 123 younger healthcare workers (average age 34) who received two doses of the Pfizer vaccine found that both antibody (humoral) and cellular immune responses were delayed and less robust among the older compared to the younger people. About 91% of the healthcare workers had antibodies with neutralizing capacity at two weeks after the second dose compared to only 46% of elderly people, although at four weeks after the second dose, 90% of elderly people had neutralizing antibody response. A lower percentage of elderly people showed strong cellular immunity at four weeks after the second dose compared to the younger individuals (51% vs. 85%, respectively) (Schwarz, Emerg Infect Dis 2021).
  
  Research in Belgium that included 40 elderly nursing home residents who had been vaccinated with the Pfizer vaccine showed that, among those with no history of COVID-19prior to vaccination, none had detectable neutralizing antibodies against the Beta (B.1.351 or South African) variant, suggesting that some elderly individuals may be more prone to breakthrough infections, particularly with variants of concern. However, the authors noted that the poor antibody response may be linked with frailty and comorbidities rather than age itself (Pannus, medRxiv 2021 — preprint).
  
  According to data from the CDC, there were 31% more deaths involving COVID-19 in the U.S. among people ages 50 to 64 than those 85+ in May 2021. This is a dramatic reversal from December 2020, when there were 2.5 times as many COVID deaths among those 85+ than those 50 to 64. This change is likely be attributed to the higher vaccination rate among the elderly.
• Diabetes: The CDC has noted that diabetes (type 1 or type 2) is a risk factor for severe COVID. Diabetes is not a contraindication for COVID-19 vaccination. In fact, about 3,000 people with diabetes were included in each of the preauthorization trials for COVID vaccines authorized or approved for use in the U.S (Pal, Diabetes Metab Syndr 2021). There are no known interactions between the COVID-19 vaccines and medications for diabetes, and experts recommend that people with diabetes continue their medications before and after getting vaccinated. However, it may be wise for people taking insulin to avoid injecting the medication into the site of the vaccine shot for several days after getting their shot. Also, because it is possible that immune response induced by vaccination may cause blood sugar levels to increase, people with diabetes should monitor their blood sugar levels for at least 48 hours after getting their shot (Baton Rouge General, 1/26/21).
• Obesity: The CDC does not explicitly advise on COVID-19 vaccination in people who are obese, but this condition is not a contraindication and obesity is a risk factor for severe COVID. There is some concern that people who are obese may not generate as high or as persistent of an immune response to COVID vaccination compared to otherwise healthy people, as people who are obese have shown lower immune response to other vaccines such as the tetanus and hepatitis vaccines compared to those who are not obese (Eliakim, Autoimmunity 2006; Painter, Vaccine 2015), and there is evidence that immunity induced by other vaccines such the flu vaccine decreased more significantly at one year after vaccination among obese people compared to those who were not (Sheridan, Int J Obes 2012). Nevertheless, pre-authorization trials for the Pfizer and Moderna vaccines found that vaccine efficacy in preventing symptomatic COVID was similar among those who were obese and those who were not (Polack, N Eng J Med 2020; Baden, N Engl J Med 2021), although these trials were not specifically designed to detect differences between these groups.
• History of Guillain-Barré syndrome (GBS): According to the CDC, people with a history of GBS (which affects nerves) may receive any of the authorized or approved COVID-19 vaccines (CDC, Interim Clinical Considerations 2021).
  
  Although no cases of GBS were reported in the mRNA COVID-19 pre-authorization trials, and only one case was reported 10 days after vaccination in the J&J preauthorization trial (one case was also reported in the placebo group) (Márquez Loza, Neurology 2021), 341 cases (69 J&J, 126 Moderna, 142 Pfizer, and 4 unknown) of GBS after vaccination have been reported to VAERS as of 6/25/21. One case of Guillain-Barré syndrome was also reported in an 82-year-old woman who received the Pfizer vaccine two weeks prior to symptom onset. The patient recovered after three doses of intravenous immunoglobulin (Waheed, Cureus 2021). Furthermore, two publications documenting a total of 11 cases of GBS following vaccination with the AstraZeneca vaccine (which is somewhat similar to the J&J vaccine) found that facial paralysis affecting both sides of the face was more common and more severe than what is typical for GBS, and the frequency of GBS was estimated to be 1.4 to 10 times greater than what would be expected (Allen, Ann Neurol 2021; Maramattom, Ann Neurol 2021) ).
• History of Bell's palsy: People with a history of Bell's palsy may still be vaccinated.
  
  Cases of Bell's palsy have been reported among people who received the mRNA vaccines or J&J vaccine. However, an analysis showed that the rate of reports of facial paralysis after mRNA COVID-19 vaccination was not higher than that observed with other viral vaccines, and if an association between facial paralysis and mRNA COVID-19 vaccines exists, the risk is likely very low, as with other viral vaccines (Renoud, JAMA Intern Med 2021). Similarly, a real-world study in Israel examining cases of Bell's palsy from January 1 to February 28, 2021 found no association between recent vaccination with the Pfizer vaccine and risk of Bell's palsy. There was also no evidence of increased incidence of Bell's palsy during that time period compared to the same time period in previous years (Shemer, JAMA Otolaryngol Head Neck Surg 2021). Furthermore, data has shown that the risk of Bell's palsy was nearly seven times higher after COVID-19 infection compared to after vaccination (Tamaki, JAMA Otolaryngol Head Neck Surg 2021).
• Dermal (skin) fillers: People who have a history of dermal filler use may receive the COVID-19 vaccine if they have no other contraindications, although temporary swelling at or near the site of filler injection may occur. No additional precautions are needed, but people with dermal fillers should contact their doctor if they develop swelling at the site of dermal filler following vaccination. Medical treatment, including corticosteroid therapy, may be given to resolve symptoms if swelling occurs.
  
  While this reaction has been reported with only the Moderna vaccine (although a case of swelling under the eye has been reported after the Pfizer vaccine for a person who had a tear trough filler), the American Society for Dermatologic Surgery notes that similar reactions have been triggered by viral and bacterial illness, certain dental procedures, and other vaccines such as the flu vaccine. In fact, one person with dermal fillers who experienced swelling after the Moderna vaccine had experienced a similar reaction to the flu vaccine in the past. According to a survey conducted by the International Society for Dermatologic and Aesthetic Surgery (ISDS), out of 106 people with previous dermal filler injections, only 5% reported local pain at the site of previous filler injection after receiving at least one dose of the COVID vaccine. It should be noted that the majority of those surveyed had received the Pfizer vaccine, some had received vaccines not authorized in the U.S., and only one received the Moderna vaccine (Gotkin, J Drugs Dermatol 2021).
  
  COVID itself can cause swelling around dermal fillers, as reported in a 50-year-old woman who was diagnosed with COVID-19 at 15 days after her last injection with a hyaluronic acid dermal filler. Symptoms including swelling of the lips, cheeks, and around the eyes, as well as burning sensation of the lips, persisted for weeks after the infection despite treatment (Munavalli, Arch Dermatol Res 2021).
  
  Among those with dermal fillers who experienced reactions to the Moderna vaccine, one had received dermal fillers 2 weeks prior to vaccination, and another had received dermal fillers 6 months before. Since many dermal fillers are reabsorbed by the body within 12 to 24 months of placement, the risk of reaction after this duration seems less likely. However, dermal fillers that use synthetic ingredients such as polymethylmethacrylate (e.g., Bellafill) are not re-absorbed and may theoretically lead to a reaction years after dermal filler placement.
• Surgery: The CDC does not explicitly advise on COVID-19 vaccination in people who have undergone or who are planning to undergo surgery. According to the Royal College of Surgeons of England, essential urgent surgery should take place regardless of vaccination status. The organization also strongly encourages people to get vaccinated prior to elective surgery to minimize postoperative COVID-19 risks. It recommends that people separate the date of vaccination from that of surgery by about a week to help ensure that any symptoms that may occur can be correctly attributed to either vaccination or the operation. Similarly, the Mayo Clinic states that it is not necessary to postpone COVID-19 vaccination until after surgery but that people should try to get vaccinated at least several days prior to surgery to avoid the potential of vaccine-induced fever on the day of surgery (which may cause the surgery to be postponed).
  
  People may also consider being vaccinated after surgery, but they should consult with their doctor prior to scheduling their vaccination appointment to ensure that they will be well enough to do so. MD Anderson Cancer Center states that people with cancer who have undergone surgery should wait for 2 weeks after surgery before getting vaccinated.
• People with a history of thrombosis or risk factors for thrombosis: The Johnson & Johnson (J&J) vaccine has been associated with cases of blood clots and low platelets. Although the exact cause of these events is unclear, it appears to be similar to heparin-induced thrombocytopenia, a rare immune-mediated syndrome. Until more is known, people with a history of an immune-mediated syndrome characterized by blood clots and low platelets should not get the J&J vaccine if it has been 90 days or less since their illness resolved. Instead, they should opt for one of the mRNA vaccines. If it has been more than 90 days since illness resolved, these individuals can get the J&J vaccine (CDC, Interim Clinical Considerations 2021).
• Pregnant or lactating: Pregnancy or recent pregnancy has been associated with increased risk of severe COVID-19 illness. Furthermore, getting COVID-19 during pregnancy has been associated with an increased risk of preterm birth (8.8% vs. 5.6% for pregnant women without COVID) and associated respiratory disorders (such as respiratory distress syndrome or need for mechanical ventilation for the infant at birth) (Norman, JAMA 2021).
  
  Based on the increased risk for severe illness and pregnancy complications, and the growing evidence of safety and likely efficacy of the COVID-19 vaccine during pregnancy, the CDCrecommends that individuals who are pregnant, trying to become pregnant, or who might become pregnant in the future, as well as those who are breast-feeding, get vaccinated. This recommendation aligns with earlier recommendations from professional medical organizations, including the American College of Obstetricians and Gynecologists (ACOG).
  
  
  "

This information is very helpful. Thank you so much Missy.❤

 

[AprilBaby]

Great work Missy!

 

[qubitasaurus]

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.

I am sorry that sounds truly hard to take, I can barely imagine trying to struggle through the unfolding new horrific baseline for normality, while dealing with the grief of losing your support network.

For what it is worth for the people responding, I am 38/39 weeks pregnant and it was not recommended for pregnant women to get vaccinated here until a few months ago. There is an expert comity for covid 19 vaccination and they make all formal decisions on who is eligible and who is not -- and pregnant women were cleared once the data was available around the middle of this year.

I am painfully aware that in 6-12 months the data will become available for whether these children of vaccinated mothers, attain their 6/9/12 month cognitive developmental milestones at the same pace as their peers. Since this is a critical piece of the puzzle and it's currently not available; I simply live knowing that it was a gamble one way or another.

Admittedly there was basically zero covid cases here for a lot of 2021 -- containing the outbreak so they had time to get as much data as possible and make an informed decision was another one of the things the government here did for me. I'm aware that this came at a great cost.