COVID Vaccination Information for Patients

• Some diseases (including rheumatoid arthritis) are caused by the body’s immune system, which usually protects us from infection. When the immune system is affected by arthritis or drugs to treat the condition, the risk from COVID-19 may be increased.
• If you get vaccinated, you will be less likely to get COVID-19. Even if you do get COVID-19 when vaccinated, it is more likely to be a milder illness. 
• People who catch COVID-19 can become very unwell. There is increasing information that being unvaccinated not only makes you more likely to get infected but also that you are more likely to become sick or die if you are infected. 

• Three COVID-19 vaccines are currently available in Australia – AstraZeneca (Vaxzevria/Oxford), Pfizer (Comirnaty) and Moderna (Spikevax) vaccines. All of these are suitable for rheumatology patients whose immune system may not be strong. The AstraZeneca vaccine is a viral vector vaccine. The Pfizer and Moderna vaccines use messenger RNA (mRNA). 
• The COVID-19 vaccines available in Australia are safe for people with arthritis and people taking drugs that suppress the immune system, even if the condition is active. This is because none of these is a “live” vaccine.
   

• The Australian Technical Advisory Group on Immunisation (ATAGI) currently recommends the use of the Pfizer or Moderna vaccine over the AstraZeneca vaccine in people aged 12-60 years. 
• The AstraZeneca vaccine can be used in adults aged 18-60 years where the benefits are likely to outweigh the risks for that individual and the person has made an informed decision based on an understanding of the risks and benefits.
• People over the age of 60 can receive any of the COVID-19 vaccines (provided that they don’t have the conditions listed below) as the benefits of the AstraZeneca vaccine continue to outweigh the risk of adverse effects in this age group.
• Children aged 5-11 years will be able to receive the Pfizer vaccine from 10 January 2022.
• The Pfizer or Moderna vaccines are the preferred vaccine in patients with: a past history of cerebral venous sinus thrombosis (CVST), a past history of heparin-induced thrombocytopenia (HIT), a past history of idiopathic splanchnic (mesenteric, portal, splenic) vein thrombosis and antiphospholipid syndrome with thrombosis. 
• People who have had their first dose of the COVID-19 AstraZeneca vaccine without any serious adverse events or allergic reactions can safely be given their second dose. This includes adults under the age of 60. 
• The Pfizer and Moderna vaccines should not be given if you have had a serious adverse event (including myocarditis and/or pericarditis) or an allergic reaction to a previous dose. In some people with rare inflammatory heart disorders (e.g., recent or current myocarditis, endocarditis, pericarditis or rheumatic fever) or severe heart failure, the mRNA vaccines (Moderna and Pfizer) may not be suitable. Discuss with your specialist if you have concerns. Note that the mRNA vaccines are safe to use in people with most common forms of heart disease (including angina or a history of heart attacks).

• In Australia anyone aged >12 years can now receive the vaccine. 
  
• Children aged 5-11 years will be able to receive the Pfizer vaccine from 10 January 2022.

• All of the vaccines are very good at stopping severe symptoms and hospitalisation caused by COVID-19 after 2 doses.
• All of the vaccines require a second dose:
  • AstraZeneca  usually 4-12 weeks after the first dose. 
  • Pfizer vaccine usually 21 days after the first dose. 
  • Moderna vaccine usually 28 days after the first dose.
• The first dose does provide some protection. The second dose gives more long-term protection from COVID-19. 

• A third primary dose is usually given 2-6 months (28 days can be considered in exceptional circumstances) after the second dose in people who may not have had a strong immune response to the 2 initial doses due to their medical conditions and/or medications. This third primary dose “completes the primary course” for these people. Some people with AIRD on immunosuppressant therapy will fall into this category. 
• A third primary dose is different to a booster dose. A booster dose refers to an additional vaccine dose after the primary vaccine course is complete which for most people is 2 doses. This is usually given ≥ 4 months after the second dose. 
• All patients with AIRD should have a booster dose after the third primary dose OR, if not eligible for the third primary dose, after the second primary dose. All booster doses can currently be administered > 4 months after the previous dose. This timing will reduce to 3 months from 31 January 2021.
• More information on booster doses can be found here.

• Not all people with rheumatological diseases will need a third primary dose, however ATAGI are recommending a third primary dose for people who might not have had a complete response to the first two doses due to the use of the following immunosuppressive therapies:
• High dose corticosteroid treatment equivalent to >20mg/day of prednisone for ≥14 days in a month, or pulse corticosteroid therapy
• Multiple immunosuppressants where the combination is considered to be severely immunosuppressive
• At least one of the following conventional synthetic DMARDs:
  • methotrexate (>10mg/week)
  • leflunomide
  • mycophenolate
  • azathioprine (>1mg/kg/day)
  • cyclosporine
  • cyclophosphamide
  • tacrolimus
• At least one of the following biological or targeted synthetic DMARDs:
  • janus kinase (JAK) inhibitor (for e.g., baricitinib, tofacitinib, upadacitinib)
  • abatacept
  • rituximab

Some other treatments or combinations of treatments and/or conditions might also qualify for a third vaccine dose - ask your specialist or GP if you are uncertain. 
 

• Pfizer or Moderna are preferred for the third primary dose however you can receive AstraZeneca for your third primary dose if you have already been vaccinated with AstraZeneca or if you have had a significant adverse reaction after a previous Pfizer or Moderna dose.
• The third primary dose is usually given 2-6 months (28 days can be considered in exceptional circumstances) after the second dose of vaccine. 
• Talk to your rheumatologist about the timing of your medicines around your third primary dose as you did with the previous doses.
• The ATAGI recommendations can be found here

• Some people who are taking drugs that suppress the immune system may be given advice to continue avoiding exposure to COVID-19 after they have had the vaccine. This is because their medications could mean their immune system doesn't respond as strongly to the vaccine as people who don't take these drugs.
• This does not mean you should stop your treatment, because this can result in a flare of your condition which puts you at greater risk from COVID-19.
• Everyone in Australia needs to continue to follow Government advice on reducing the spread of COVID-19, even after they have had the vaccine.

• The administration of any other vaccine on the same day as the COVID-19 vaccine is generally not recommended. 
• The preferred minimal interval between the COVID-19 vaccine and the influenza vaccine is 7 days (previously 14 days). In some situations a shorter interval is acceptable (including co-administration). 
• You do not need to delay your influenza vaccine until you complete the course of COVID-19 vaccines.

• To ensure the best response to the COVID-19 vaccine, it is recommended that vaccination is performed towards the end of a rituximab dosing cycle or before initiation of rituximab therapy.
• Please discuss the timing with your rheumatologist.

• There is some evidence that responses to the COVID-19 vaccine are reduced in people treated with methotrexate.
• Therefore, interruption of methotrexate therapy during COVID-19 vaccination may be considered, but only in patients with stable rheumatic disease at low risk of flare, or those for whom protection from COVID-19 is of particular importance.
• This decision to hold methotrexate for one or two doses following each vaccination should be individualised and discussed with your treating rheumatologist.

• More information on the use of other immunomodulatory medicines with the COVID-19 vaccine is available here.

• There is currently no evidence to support separating the doses of denosumab and the COVID-19 vaccine.
• If they are to be given on the same day it would be advised to use different injection sites for both to minimise the possibility of an injection site reaction.

• Surgery guidelines recommend people do not have major surgery and vaccines within one week of each other. This is because both surgery and the vaccine can cause a fever.

• The Australian Government recommends the use of either the Pfizer or Moderna vaccine in pregnant women at any stage of their pregnancy. This is because the risk of severe outcomes from COVID-19 is significantly higher for pregnant women and their unborn baby. Women who are trying to become pregnant do not need to delay vaccination or avoid becoming pregnant after vaccination. More information can be found here.
• All 3 vaccines can be given to women who are breastfeeding. Breastfeeding women do not need to stop breastfeeding to receive the vaccine. More information can be found here. You can talk to your midwife and/or rheumatology healthcare team if you are not sure what to do.

• Children > 12 years are eligible to receive either the Pfizer or Moderna COVID-19 vaccine. More information can be found here. 
• Children 5-11 years will be able to receive the Pfizer vaccine from 10 January 2022. More information can be found here.

• Some people will get mild side effects. These can include pain where the injection goes in, tiredness, headache and aching of muscles. Serious reactions like allergic reactions are extremely rare. People with a history of severe allergic reactions can be vaccinated but should be monitored for 30 minutes after receiving the vaccine.  If you have any concerns about the vaccine, ask your doctor, nurse or pharmacist. 
• You should seek medical advice as soon as possible if:
  • You have any of the following symptoms, particularly around 4 to 42 days after vaccination with AstraZeneca: headache that persists beyond 48 hours after vaccination, or appears later than 48 hours after vaccination. Simple painkillers may alleviate headache initially, but it persists, blurred vision, weakness of face or limbs, confusion or seizure, shortness of breath, chest pain, persistent abdominal pain, leg swelling or a pin-prick rash or bruising not at the injection site that cannot be explained.
  • You experience chest pain, pressure or discomfort, irregular heartbeat, skipped beats or ‘fluttering’, fainting, shortness of breath or pain when breathing after the Pfizer or Moderna vaccine. 

• Not everybody will have side effects from the COVID-19 vaccine. If you don’t get any side effects this does not mean that the vaccine did not work.

• ATAGI and the Thrombosis and Haemostasis Society of Australia and New Zealand (THANZ) released a statement on the 23 May 21 regarding thrombosis with thrombocytopenia syndrome (TTS) with the AstraZeneca vaccine. This statement outlines that there is unlikely to be an increased risk of TTS in people with the following conditions, and people in these groups can receive the AstraZeneca vaccine:
  • History of blood clots in typical sites
  • Increased clotting tendency that is not immune mediated
  • Family history of blood clots
  • History of ischaemic heart disease or stroke
  • Current or past thrombocytopenia (low platelet count)
  • Those receiving anticoagulation therapy (for e.g. apixaban, dabigatran, rivaroxaban, warfarin)
• However, if you have a past history of; CVST, HITT, idiopathic splanchnic (mesenteric, portal, splenic) vein thrombosis and antiphospholipid syndrome with thrombosis, the Pfizer vaccine is recommended.
• TTS can now be treated very effectively. Due to better awareness, early diagnosis and appropriate treatment, the outcome and prognosis of the majority of those who have experienced this syndrome is good. More information can be found here

• There is no evidence that taking low-dose aspirin before having a COVID-19 vaccine will reduce your risk of blood clots.

• Continue to take your medicines as prescribed by your doctor. There is no reason to stop or change your dose of blood thinners before the COVID-19 vaccine.

• People who have had COVID-19 can be vaccinated with a COVID-19 vaccine. This provides extra protection against future infections. 
• If you are infected with COVID-19, you should wait until you have recovered before having a COVID-19 vaccination. If you have ongoing symptoms for > 6 months after being infected with COVID-19 you will need to speak to your doctor regarding the timing of the vaccination.