Covid vaccine Q&A: Chronic diseases and pregnancy edition

Receiving a Covid-19 vaccine in Phnom Penh, Cambodia, in February. Photo: CNS/Cindy Liu, Reuters

• I have ‘3 highs’, would I suffer from great side effect after vaccination?
• I am pregnant, would vaccination lead to miscarriage?
• I have cancer and now on treatment, is it really ok to do vaccination?

Having chronic diseases, but not yet dated for follow up?
No worries, let the Catholic doctor to fix for you!

Family medicine edition

Rheumatic diseases edition

Pregnancy edition

Surgical patient edition

Cancer patient edition

Psychiatric edition

Family medicine edition

Question 1: Can individuals with chronic diseases have COVID-19 vaccination？

Answer:  Yes.

• Chronic diseases are not contraindications for Comirnaty Vaccine [1] 
• For CoronaVac, drug company suggested patients to have injection after their chronic diseases are controlled [2]

(Note:  Common diseases such as hypertension, hyperlipidaemia and diabetes mellitus were also examples of chronic diseases)

Question 2: Will COVID-19 vaccination increase the rate of cardiovascular events？

Answer: No

• Israeli and US studies reported that persons receiving the BioNTech vaccine were not at increased risk of myocardial infarction, pulmonary embolism, or cerebrovascular events in the 42 days and 21 days following vaccination [3]. 
• Singapore Medical Journal has also published a review that the rate of acute myocardial infarction was similar in the group of individuals who are vaccinated compared with normal individuals. [4]

References

1. https://www.covidvaccine.gov.hk/zh-HK/chronicDiseases
2. https://www.covidvaccine.gov.hk/pdf/CoronaVac_ENG_PI_brief.pdf
3. https://jamanetwork.com/journals/jama/fullarticle/2786667
4. http://www.smj.org.sg/sites/default/files/RA-2021-326-epub.pdf

Rheumatic diseases edition

Are patients with rheumatic diseases:  

Question 1. …at higher risk of serious complications from COVID-19?

Answer: YES

• Apart from increased mortality, they have higher rates of rheumatic disease flare up and other complications (1).

Question 2: at higher risk of side effects from COVID-19 vaccines?

Answer: NO

• COVID-19 vaccines were not shown to have increased risk of side effects in any particular rheumatic disease or drug therapy in local study (2).

Question 3. …at higher risk of severe disease flare-up after COVID-19 vaccination?

Answer: NO

• Flare-ups after COVID-19 vaccination are uncommon and mild. Recent study conducted by HKU suggested that Comirnaty might be associated with mild flare-ups, but medications were not required and patients returned to normal state spontaneously. CoronaVac was not associated of increased flare-ups (3).

Note: Rheumatic diseases mean inflammatory diseases associated with abnormal attack by a person’s own immune system, including Systemic Lupus Erythematosus (SLE), Rheumatoid arthritis, ankylosing spondylitis, scleroderma, dermatomyositis and vasculitis etc. Approximately 7 % of the population suffered from autoimmune diseases. UK study found that patients suffering from autoimmune diseases e.g., rheumatoid arthritis, SLE and psoriasis have higher mortality from COVID than normal individuals. In addition, elderly, patients with other chronic illnesses or on long term steroids are having more serious consequences.

References:

1. Tan EH, Sena AG, Prats-Uribe A, You SC, Ahmed WU, Kostka K, et al. COVID-19 in patients with autoimmune diseases: characteristics and outcomes in a multinational network of cohorts across three countries. Rheumatology (Oxford). 2021;60(SI): D137-S150.

2. Li YK, Lui MPK, Yam LL, Cheng CS, Tsang THT, Kwok WS, Chung HY. COVID-19 vaccination in patients with rheumatic diseases: vaccination rates, patient perspectives, and side effects. Immun Inflamm Dis. 2022 Jan 31. Doi:10.1002/iid3.589.

3. Connolly CM, Ruddy JA, Boyarsky BJ, Barbur I, Werbel WA, Geetha D, et al. Disease flare and reactogenicity in patients with rheumatic and musculoskeletal diseases following two-doses SAR-CoV-2 messenger RNA vaccination. Arthritis Rheumatol. 2022;74(1):28-32.

Pregnancy edition

Question 1: Should pregnant women be vaccinated with COVID-19 vaccines?

Answer: Yes. 

• A detailed review of studies undertaken by the European Medicines Agency (EMA) involving 6,500 pregnancies at different stages suggested that COVID-19 mRNA vaccines do not increase the risk of pregnancy complications, miscarriages, preterm births or adverse effects in the unborn babies [1]. 

Question 2: Which vaccine is recommended for pregnant women?

Answer: mRNA vaccine (The current option in Hong Kong is Comirnaty) is recommended. 

• CoronaVac is an inactivated SARSCoV-2 vaccine and its safety data in pregnant and lactating women have not been published in the medical literature so far. 
• Despite 11/2/2022, the CoronaVac (Sinovac) company removed ‘Pregnancy and lactation’ from its ‘Contraindications’ list to “Precaution” list [2], CoronaVac (Sinovac) use in pregnant and lactating women is now authorised by the Hong Kong Government, Comirnaty (BioNTech) remains as the preferred choice of vaccine for pregnant and lactating women based on the available published data. 

Question 3:  Will pregnancy affect the effectiveness of the vaccine?

Answer: No. 

• Vaccine effectiveness and safeness is expected to be similar in pregnant women as in other adults.

Question 4: Can pregnant women still get COVID-19 after vaccination?

Answer: Yes. Vaccination does not preclude pregnant women from being infected, but data shows that vaccination provides a high level of protection against severe complications and hospitalization, even decreases rate of premature delivery due to COVID-19. Vaccinated pregnant women experience milder symptoms such as fever and cough.

BioNTech Comirnaty (3)	unvaccinated	Partially vaccinated	Fully vaccinated
Risk of infection	77.4%	11.5%	11.1%
Hospitalization	19.5%	8.3%	5.1%
Critical care admission	2.7%	0.2%	0.2%
Risk of Preterm birth			Reduce 2-fold
Hospitalization among infants aged <6 months			Reduce 61%

Question 5: Are the side effects of vaccination more severe in pregnant women?

Answer: No. 

• The most common side effects in pregnant women are the same as those vaccinated people overall, including injection site reactions, fatigue, headache, redness and swelling at the injection site, muscle pain and chills, are usually mild or moderate with improvement within a few days of vaccination.
• Pregnant women are safe to take Paracetamol to relieve symptoms.

Question 6: Does the COVID-19 vaccine increase the risk of miscarriage or infertility?
Answer: No

• There is no evidence to suggest that COVID-19 vaccine increases the risk of miscarriage or infertility.
• According to clinical observation, many ladies experienced 2-3 months irregular menstruation after injection, due to hormonal disturbance. It is suggested to continue pregnancy planning after menstruation returns to normal

Question 7: When should I get vaccinated during pregnancy?

Answer: It is advised for pregnant women to be vaccinated at the earliest opportunity. 

• If one is concerned about the baby’s development during the first 12 weeks of pregnancy, it is also reasonable to be vaccinated after 12 weeks’ gestation. 

Question 8:  Will vaccination affect the health of the baby?

Answer: COVID-19 vaccines can effectively protect pregnant women and babies. 

• According to latest data, Covid vaccines do not bring risk to babies in the womb.

Question 9: What are the risks for pregnant women infected with COVID-19?

Answer: 

• Both foreign and local studies suggested that pregnant women infected with COVID-19 are at higher risk of premature births and smaller babies. 
• Foreign study has also shown that the coronavirus may adhere to the placenta, and there is about 2% chance of infecting the baby.

Note: Recommended by the Hong Kong College of Obstetricians and Gynaecologists (HKCOG) [4], the Department of Health (DOH) of Hong Kong Special Administrative Region and the Centre for Health Protection (CHP), expectant mothers are encouraged to take 2 doses of vaccinations and a vaccine booster shot 6 months after, for longer-term protection against serious illness from COVID-19.

References:

1. European Medicines Agency. COVID-19: latest safety data provide reassurance about the use of mRNA vaccines during pregnancy. https://www.ema.europa.eu/en/news/covid-19- latest-safety-data-provide-reassurance-about-use-mrna-vaccines-during-pregnancy. Accessed 19 January 2022. 

2. https://www.covidvaccine.gov.hk/pdf/COVID19VaccinationFactSheet_CoronaVac_ENG.pdf

3. UK Health Security Agency. COVID-19 vaccine surveillance report. Week 47. 25 November 2021. 

4. http://www.hkcog.org.hk/hkcog/news_4_65.html

Surgical patient edition

Question 1: When an elective surgical operation is indicated, is it recommended for COVID vaccination? 

Answer:  Yes.

• An elective surgical operation like inguinal hernia repair is not a contraindication to COVID vaccination. The recommendation for the separation between the date of vaccination and the day the elective procedure is at least 1 week or 2-week. 

Question 2: Is it recommended to get the COVID vaccination after recent surgical operations (including emergency surgery or cancer surgery)? 

Answer:  Yes, if recovered.

• For discharged patients who are feeling well and have fully recovered after surgery, COVID vaccination is recommended. 
• However, if there are postoperative complications, such as wound infection, it is recommended to complete the treatment of postoperative complications before vaccination.

References: 

1. For surgeons and surgical teams treating patients during COVID-19 – endorsement of the Academy statement (UK Surgical Royal College) 
2. Influence of COVID-19 vaccines on surgical practice – a rapid review commissioned by Royal Australasian College of Surgeons

Cancer patients edition

Question 1: Do cancer patients need COVID vaccination?

Answer: Yes, they need COVID vaccination. 

• Due to the disease itself and side effects of cancer treatment, the immune system of cancer patients is weaker, and the need for protection and hence COVID vaccination is even higher. 
• Study showed that cancer patients suffer from a higher rate of severe disease or mortality than the general population. The risk of severe disease and mortality could be up to 5-61% compared with 2-3% among normal population (1). 
• Patients with haematological malignancy like leukaemia or lymphoma, lung cancer, male gender, distant metastases, other concurrent medical illness, being on chemotherapy or B cell depleting agents like Rituximab (normally used in treatment of B cell lymphoma)　are at even a higher risk (1).
• Including those who have completely recovered from their diseases, cancer patients are more at risk than normal individuals, especially during the first year since the cancer diagnosis (2).

Question 2: Can patients with cancer receive COVID vaccination and is it safe?

Answer: Certainly they can, and it is very safe.

• Various studies showed that cancer patients shared similar side effects of COVID vaccines with the general population (1). 
• One study on Comirnaty vaccine reported that among 3813 people with history of cancer, only 2 of them had severe related adverse events (one ventricular arrhythmia and one lymphadenopathy) which were resolved. Other common and mild adverse events were similar to other people (3). 

Question 3: Is it efficacious for patients with cancer to receive the COVID vaccine?

Answer: Yes, good efficacy can be achieved if a second or third dose is given. 

• In general, owing to a weaker immunity, the efficacy of COVID vaccine is lower in cancer patients including a lower level of neutralising antibody. 
• Study demonstrated that only 29% of cancer patients developed antibody response after first dose of Comirnaty vaccine compared with 84% of normal people, but it increased to 86% after second dose. 
• Therefore, it is highly important for cancer patients to complete the 2 doses of vaccine for better protection, or even consider receiving the third booster dose earlier. (People with cancer or haematological malignancy who are on active immunosuppressive treatment now or within past 12 months could receive the third dose at least 28 days from the second dose and it is unnecessary to wait until after 90 days) (5, 6)

Question 4: Can cancer patients on active treatment receive COVID vaccination and what is the suitable timing?

Answer: Yes, vaccination can be given for patients already on chemotherapy or radiotherapy. 

• For patients on chemotherapy, vaccination can be given before commencement of chemotherapy, or before the next cycle (when white cell count recovers).
• For patients on radiotherapy, targeted therapy or immunotherapy, there is no specific restriction on the timing of vaccination. 

* it would be best vaccination at least 14 days before the initiation of oncological treatment in order to have adequate protection, provided this would not cause a significant delay in treatment.

• Currently, there is no evidence showing that COVID vaccine would significantly affect any cancer treatment. However, oncological treatment may suppress the immune function and may reduce the efficacy of COVID vaccines. 
• One study showed that the antibody response to COVID vaccines was 92% among cancer patients receiving chemotherapy compared with 99% in normal people; while it dropped to only 76% among patients receiving B cell depleting agents (7). 
• In another larger study, clinical effectiveness was 57% among patients on chemotherapy, 76% among those receiving hormonal therapy and 85% among patients not on any active treatment (8). 
• For patients on chemotherapy, they could receive the vaccines when the white blood cell count recovers then rest for 2-3 days until the side effects of vaccines subside before moving on to the next chemotherapy cycle (9). 
• In conclusion, although the efficacy of COVID vaccination is lower for patients receiving active oncological treatment, they could still derive protection and benefit from the vaccines and, hence, it is still recommended for them to receive COVID vaccination (1). 

References

1. https://www.esmo.org/covid-19-and-cancer/covid-19-vaccination
2. Williamson EJ, Walker AJ, Bhaskaran K et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020; 584 (7821): 430-436.
3. Thomas SJ, Perez JL, Lockhart SP et al. 1558O COVID-19 vaccine in participants (ptcpts) with cancer: Subgroup analysis of efficacy/safety from a global phase III randomized trial of the BNT162b2 (tozinameran) mRNA vaccine. Annals of Oncology 2021; 32: S1129.
4. Ben-Aharon I, Waldhorn I, Holland R et al. 1559O Efficacy and toxicity of BNT162b2 vaccine in cancer patients. Annals of Oncology 2021; 32: S1130.
5. https://www.covidvaccine.gov.hk/pdf/Third_dose_supplementary_sheet_ENG.pdf https://www.covidvaccine.gov.hk/pdf/Third_dose_supplementary_sheet_CHI.pdf

• Current arrangement for the third dose of COVID 19 Vaccine. https://www.covidvaccine.gov.hk/en/faq
• Thakkar A, Gonzalez-Lugo JD, Goradia N et al. Seroconversion rates following COVID-19 vaccination among patients with cancer. Cancer Cell 2021; 39 (8): 1081-1090.e1082.
• Wu JTY, La J, Branch-Elliman W et al. 1562MO Effectiveness of COVID-19 vaccination in cancer patients: A nationwide Veterans Affairs study. Annals of Oncology 2021; 32: S1131.
• https://www.asco.org/sites/new-www.asco.org/files/content-files/covid-19/2021-MSK-COVID19-VACCINE-GUIDELINES.pdf

Psychiatric edition

Question 1:  In patients with severe mental illness, is there a higher risk of COVID-19 infection? 

Answer: YES

• patients with severe mental illness (psychotic disorders, bipolar affective disorders, major depressive disorder, and other illnesses severe enough to affect functioning) have poorer immunity. There is a higher risk of severe disease, and death (2-3 times compared to the general population) from COVID-19 infection. 

Question 2: In patients with severe mental illness, is it safe to get the COVID-19 vaccine? 

Answer:  YES, there is no increased risk of side effects or relapse found to date. 

Question 3: How can I handle COVID-19 vaccine anxiety?

Answer: Psychological stress is actually reduced after vaccination.  Acknowledge your anxiety and make a conscious decision to seek out information from trusted sources and avoid misinformation.  The risk of COVID-19 infection is much higher than the perceived risk from COVID-19 vaccines. Sometimes, finding a higher motivation for vaccination, such as preventing transmission to children or the elderly in the family or society, helps in decision-making.   

Question 4: What can I do to improve the protection from COVID-19 vaccines? 

1. Loneliness and social isolation in all ages are linked to a poor immune response. Social connection by phone, video, online, and even by mail, can improve immunity in both persons. The quality and depth of the relationship are more important than the quantity.  

2. Health behaviours such as exercise, nutrition, and sleep improve the protection from vaccination by enhancing the body’s immune response.  The World Health Organization recommends 150 minutes a week of moderate-intensity exercises, such as walking, for optimal physical and mental health. A diet low in fat, sugar, and unprocessed foods, as well as adequate sleep, increases the body’s production of antibodies after vaccination.

References: 

1. Madison, AA et al.  Psychological and Behavioral Predictors of Vaccine Efficacy: considerations for COVID-19.  Perspectives on Psychological Science. 2021 Jan; 16 (2): 191-203 
2. Mazereel, V et al. COVID-19 vaccination for people with severe mental illness: What, Why, and How?  Lancet Psychiatry. 2021 May; 8(5): 444–450
3. McCallum K.  5 Tips for handing COVID-19 vaccine anxiety.  www.houstonmethodist.org 2021 Feb 
4. Perez-Arce, F et al.  COVID-19 vaccines and mental distress. PLOS One.  2021 Sept 8