With input from Dr Monica Vasudev

1507: Minutes of Virtual Meeting of CMAAO NMAs on “Post-COVID vaccine reactions: Country Experiences”

20^th March, Saturday, 9.30am-10.30am

Participants: Member NMAs: Dr KK Aggarwal, President CMAAO; Dr Yeh Woei Chong, Singapore Chair CMAAO; Dr Alvin Yee-Shing Chan, Hong Kong, Treasurer, CMAAO; Dr Ravi Naidu, Malaysia Immediate Past President CMAAO; Dr Marthanda Pillai, India, Member World Medical Council; Prof Ashraf Nizami, President Pakistan Medical Association; Dr Marie Uzawa Urabe, Japan Medical Association; Dr Md Jamaluddin Chowdhury, Bangladesh Medical Association; Dr Qaiser Sajjad, Secretary General, Pakistan Medical Association; Dr Akhtar Husain, South African Medical Association

Invitees: Dr S Sharma, Editor IJCP Group

Key points from the discussion

• CMAAO Mantra: “In susceptible high-risk (pro inflammatory and/or pro-coagulative) individuals, reactogenic vaccines can trigger transient thromboinflammation lasting first few (up to four) days”.
• In susceptible individuals, the vaccine can cause thromboinflammation.
• European regulator has allowed the vaccine but with a caveat that the benefits are more than the risks.
• Once the virus enters the body, the body may initiate a Th2 response, which is an allergic response. It can be type 1 IgE mediated as immediate anaphylaxis. It can be non-IgE complement-mediated reaction with allergic manifestations (angioneurotic edema, rash, urticaria) after 6 hours. These allergic reactions can be prevented by premedication with montelukast, levocetirizine, ranitidine/famotidine and aspirin as per standard non-IgE-mediated protocol.
• Type 4 local skin reactions (similar to lepromin test or tuberculin test) to the vaccine are very common and can be confused with local cellulitis. They appear as indurated raised inflammatory skin lesion after 3 days at the injection site or even remotely from the injection site on the same hand; some people can develop type 3 reaction (Arthus reaction) with skin, joint and kidney involvement. These are allergic reactions.
• The virus in the vaccine will enter the cell by endocytosis.
• The response will be the same whether the COVID virus or vaccine virus enters the body. But, unlike the natural infection, in vaccine, the response is limited as the virus is non-replicative. The systemic inflammation may occur but is stable and under control. Hence, some degree of reactogenicity is expected after the vaccine. It will be seen only for up to 4 days.
• After taking the vaccine, at least the next few days, no other injection, which contains PEG or polysorbate, should be taken.
• Anaphylaxis is more common with the second dose.
• The vaccine can precipitate underlying allergy or inflammation. A case of rheumatoid arthritis precipitated by the vaccine has been reported (Lancet). Worsening of rheumatoid arthritis has been reported (anecdotal evidence). Vaccine has precipitated herpes zoster and Bell’s palsy.
• Vaccine can precipitate inflammation in the body. Severe lymphadenitis (on the 3^rd/4^thday), episcleritis (on 6^th/7^th day) and left eye conjunctivitis have been reported.
• Arterial thrombosis can also occur after the vaccine because of precipitation of inflammation. Thrombotic thrombocytopenic purpura (TTP) has been reported after 1 week of vaccination (bleeding + clots + falling platelets occur together).
• Individuals who have had COVID and are given the vaccine have shown signs of systemic inflammation with fever >101 and sudden rise in CRP.
• The virus vaccine can convert normal state to proinflammatory state and to inflammatory state. It can convert proinflammatory to inflammatory and thrombotic state and prothrombotic to thrombotic state.
• A case of Bell’s palsy has been reported in a clinic staff from Singapore after the first dose of Pfizer vaccine.She has been advised to defer the second dose for 2 weeks.
• There is lot of anxiety in London about the AztraZeneca vaccine, especially after reports of several European countries suspending the vaccine.
• Women have more allergic reactions compared to men. Therefore, their symptoms should not be ignored.
• All those patients who had COVID and needed an anticoagulant or patients who will be put on anticoagulation prior to surgery may also be put on anticoagulant when they go for their vaccination. In low risk patients, aspirin may be given, but in high risk patients, anticoagulation may be needed.
• In high risk individuals, colchicine may prevent the hyperinflammation induced systemic inflammation.
• In India, the second phase of vaccination has started. The number of cases has been increasing since January. More than 4 crore people have been vaccinated. There have not been many side effects. The incidence of thrombosis/hemorrhage is not much. The chances of adverse reactions are more in susceptible persons with comorbidities.
• If CRP is rising and if the platelets are falling, this is indicative of triad of clotting, bleeding and low platelets. Three reasons have been commonly described for this - TTP, DIC and hemolytic uremic syndrome. This list now also includes post-COVID vaccine in susceptible persons.
• In Bangladesh, 2 deaths have occurred 2 days after vaccination. Both were older than 70 years.
• Individuals on immunomodulators or immunosuppressant may require multiple doses.
• Pakistan is using the Sinopharm vaccine; no side effects have been reported.
• In Japan, more than 100,000 people have received the vaccine; only 37 incidents of anaphylaxis have been reported. Two were serious, but they survived.
• Malaysia is using the Pfizer vaccine; the only complaint so far is a sore arm. Probably the serious side effects are not being highlighted to avoid panic.
• South Africa is using the single dose Johnson & Johnson vaccine; 200,000 vaccinations for health workers. Very few minor side effects have been reported through email; one case of severe reaction, but recovered. South Africa will also get the Pfizer vaccine next month.
• Inadequate antibodies may cause disease (COVID-19) enhancement.
• Delaying the second dose in immunocompromised persons may be risky for the person if he/she actually develops COVID-19.
• Vaccine can be likened to any other prescription drug, weigh the benefits vs. the risks, take appropriate precautions and give the vaccine. Give it under observation with proper consent.
• The benefits are more than the risks; hence, as leaders of medical associations, we should encourage people to take the vaccine.
• The people should be informed about the types of reactions that may occur after the vaccination.
• All vaccines protect against severe disease. Hence, people should not just take into consideration the efficacy data when choosing a vaccine.
• Vaccination of a large cohort is important to save humanity from the current pandemic.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA