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COVID-19 Vaccine Updates
With input from Dr Monica Vasudev
1553: Minutes of Virtual Meeting of CMAAO NMAs on “Anecdotal examples of various post-vaccine side effects”
3rd April, 2021, 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 Angelique Coetzee, President South African Medical Association; 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; Dr Prakash Budhakoty, Nepal Medical Association; Dr Tashi Tenzin, Bhutan Medical Association
Invitees: Dr Russell D’Souza, Australia UNESCO Chair in Bioethics; 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.
- Norway was first to report, in mid-January, 33 deaths short time after COVID vaccine (Pfizer-BioNTech mRNA vaccine). All of them were elderly (≥75 years) and frail individuals. UK’s Medicines and Healthcare Products Regulatory Agency reported 227 deaths shortly after Pfizer vaccine and 275 deaths after AstraZeneca vaccine, through February 28. The Paul Ehrlich Institute in Germany reported deaths of 7 elderly people shortly after receiving the Pfizer vaccine. The US, which has three vaccines (Pfizer + Moderna + J&J), reported 1637 deaths till March 8. All deaths were in comorbid patients, either evident or silent.
- Deaths will occur after a vaccine; trends should be analyzed.
- Twelve European countries and Thailand temporarily put their vaccine campaign with AstraZeneca vaccine on hold and later stated that the benefits were more than the risks. Every patient must be evaluated and decision should be taken on a case-to-case basis.
- Austria was the first country to report coagulation disorders (venous thromboembolism).
- Thirty-nine deaths out of 71 deaths reported in India (till 13thMarch) were related to cardiovascular disease.
- Three patterns have been observed: Venous thrombosis presenting as pulmonary embolism, arterial thrombosis presenting as sudden cardiac event and frail people, who die suddenly after the vaccine.
- COVID-19 is an acute manageable immunogenic thrombogenic inflammatory contagious novel viral disease causing a pandemic.
- The COVID-19 vaccine is an acute thromboinflammatory non-replicative non-contagious viral protein. Like the natural infection, vaccines too may cause inflammation, thrombosis and immune reactions. However, unlike the vaccine, the natural viral protein will not cause allergy (anaphylaxis). The vaccine will cause allergic reactions.
- The natural virus is unpredictable and is longer lasting, while the vaccine is predictable and the effect lasts for short time (up to 4 days).
- Whole virus killed virus is used in Sinopharm vaccine and Covaxin. The S gene has been used is Moderna and Pfizer vaccines. AstraZeneca and Sputnik vaccine have converted S gene into DNA.
- AstraZeneca vaccine is a viral vector vaccine and has used chimp adenovirus, which enters the cell, but does not replicate. The Sputnik vaccine has used two adenovirus vectors (5 and 26), while the J&J vaccine has used adenovirus 26.
- The AstraZeneca vaccine is showing more reactogenicity vs. other vaccines as double reactions are occurring in the body. The adenovirus also provokes the immune system by switching off the cell’s alarm response.
- Anaphylaxis occurs with 15-30 minutes of the vaccine.
- Allergy is caused by a protein (PEG or polysorbate 80). Serious allergic reactions occur one in a million. Their incidence is very low in India.
- Non Ig-E mediated (complement-mediated) reactions may occur after 6 hours: angioneurotic edema, rash, urticaria; not fatal and can be prevented by montelukast + levocetirizine.
- Local injection site BCG like reactions (type 4 reaction) may occur between 2ndand 4th day, which usually fade after the 6th Such reactions may occur even remotely. No scar develops.
- Delayed local injection-site reactions to vaccine may occur, though they are uncommon (T-cell mediated reactions) (NEJM).
- Other reactions observed include aphthous ulcers, petechial rash, ear eczema, painful lymphadenitis (axillary), episcleritis, recurrent urticaria, seizures, neurological pain, tremors, spinal pain, TIA, transient blurring of vision. All recovered.
- Delayed allergic reactions, unrelated to type 4 hypersensitivity reactions, may occur.
- The virus can precipitate underlying inflammation: rheumatoid arthritis, adult chickenpox, herpes zoster.
- A case of death due to rupture of abdominal aortic aneurysm 10 days after receiving a COVID-19 vaccine has been reported in Thailand.
- Post vaccine loss of smell and taste in a person who developed loss of smell and taste post-COVID also.
- Sympathetic overactivity can manifest as accelerated hypertension and transient atrial fibrillation.
- Transient hyperglycemia after the vaccine has been reported.
- Vaccine-induced thrombocytopenia with superficial clots has been reported; purpuric rash; conditions that cause thrombocytopenia include DIC, TTP, hemolytic uremic syndrome, heparin-induced thrombocytopenia. Such patients need rivaroxaban and not heparin. Therefore, check platelets after the 4th If platelets start decreasing after Day 4, immediately start rivaroxaban.
- A case of posterior tibial artery thrombosis after the vaccine has been reported.
- Post-COVID, post-vaccine systemic inflammation with normal pulmonary function (no pneumonia on HRCT chest) may occur manifesting as rising CRP and high fever.
- Inflammation can be prevented: Prevent Th17 response by preloading with vitamin D; if routine inflammation with raised CRP, preload with colchicine; if very high LDL, preload with statin; if cardiac manifestations, preload with doxycycline; in high risk patients, preload with aspirin.
- In Bangladesh, the number of cases and deaths are a cause of concern.
- The UK variant will become the predominant wild virus strain globally.
- The reinfection (clinical) rate is 4.5% in India. In the West, it is less than 1%.
- 30% vaccine failure with AstraZeneca/Covishield has been reported; 40% with Sinopharm vaccine and 5% with Pfizer/Moderna vaccines.
- If corona infection occurs within 14 days of the vaccine, it is considered as primary infection with similar mortality. If the infection occurs after 14 days of the vaccine, it is considered as breakthrough infection; no mortality has been reported.
- In Hong Kong, 14 deaths have been reported after receiving the vaccine. These deaths have been described as incidental unrelated to the vaccine, but could be triggered by the vaccine. All deaths were related to thromboembolic events (strokes, heart attacks).
- Bhutan had 2 deaths after 4-5 days of Covishield vaccine; one 44-year-old due to alcohol withdrawal causing seizure and sustained severe bleeding in brain; the other one above 80-year-old man with severe bronchial asthma. But these were not declared as due to vaccine.
- South Africa is administering the single dose J&J vaccine. More than 200,000 healthcare workers have received the vaccine so far, although vaccination is continuing at a slower pace. 18 side effects have been reported; there has been one case of anaphylactic shock, which resolved. Now persons older than 65 years with comorbidities are being enrolled for the vaccine after 1-2 weeks. Spread of the infection after the Easter holiday is anticipated.
- Pakistan is using the Sinopharm vaccine; the country has procured Sputnik vaccine, but is used by the private sector. Vaccination is slow. Pakistan also has the single dose Cansino vaccine. No complications have been reported.
- Singapore has administered 1.3 million vaccinations; 375,000 have received two doses, 100,000 thousand have received the first dose.
Dr KK Aggarwal
President CMAAO, HCFI and Past National President IMA