Support for COVID-19 Vaccines

From the American College of Rheumatology and the Arthritis Center of Nebraska

Modified March 23, 2021

Vaccinations are in the news again due to the approval of several vaccines (more than 135 in development) against SARS-CoV-2 (i.e., the novel coronavirus that causes COVID-19). Rheumatologists have a long history of recommending specific vaccinations to our patients. This is because patients with rheumatologic conditions frequently take medicines which may:

1. Make them more susceptible to infections
2. Reduce their ability to mount an effective immune response following vaccination, and
3. Increase the risk associated with live vaccines.

The Rheumatologists at the Arthritis Center of Nebraska have been following the intensive efforts of the international scientific and medical community to develop a vaccine against COVID-19. These vaccines are rigorously tested in clinical trials, to prove the vaccine’s efficacy and safety. We know that any vaccine which is approved for use in the United States will have robust and extensive data showing that it is safe and effective against COVID-19.

There are 3 types of coronavirus vaccines:

The first is an mRNA-based vaccine, which is a very new technology. A snip of coronavirus mRNA (its genetic code) is placed in a lipid nanoparticle. When injected, it is taken up by the human’s own cells, and for a period of time (about 8 days), these cells make a portion of the viral coating protein, and express it on the human’s cell surface. This produces a vigorous immune response (something we want). And since it is only one small portion of the virus, it is not infectious. The recently approved Pfizer and Moderna vaccines are mRNA vaccines. They are easy to produce in large quantities, but mRNA can break down easily, so the vaccine must be stored in very cold conditions. Most doctors’ offices do not have the equipment to store these mRNA vaccines. That is why we cannot administer them.

The second is a protein-based vaccine. The Johnson & Johnson vaccine is made more traditionally, and includes a small protein portion of the Coronavirus spike protein. It only requires one injection. There are differences in these vaccines, regarding the efficacy of preventing any COVID-19 infection. However, the differences are, so far, trivial. With the experience in the USA so far, they all prevent 100% of the serious infections that might lead to hospitalization, the need for ventilation or death. In Nebraska, there have been no cases of COVID-19 in people that have been fully vaccinated.

A third type of vaccine, like the one made by AstraZeneca, contains a snip of the viral RNA, blended into an Adenovirus. This virus is not infectious in humans, but will generate a vigorous immune response. It is not yet approved here in the USA. But there has been a lot of press about this vaccine. It does not seem very effective against the South African variant of the Coronavirus. And there are reports of blood clots after the vaccine. The European Union has determined that blood clots are not happening more often than one would expect, but these reports cast some shade on this vaccine. It is a live vaccine, and if it is approved here, should be avoided in our rheumatology patients that are immune suppressed.

Side effects include a sore arm at the injection site, and flu like symptoms (fever, muscle aches, headache, and fatigue) in 10-50%. Side effect symptoms usually last only 2 days or so. The experience of mass vaccination in the USA has so far been well tolerated, with the only new caution to avoid vaccination in people with severe environmental allergies (defined as a person that carries an EpiPen wherever they go).

The Moderna, Pfizer and J&J vaccines are not live vaccines, and they are perfectly safe to give to our rheumatic disease patients, even the ones that are immune suppressed. There is a small risk of a temporary inflammatory arthritis flare. About 5% of inflammatory arthritis patients will flare after the shingles vaccine, and we suspect the risk of flare is similar. Patients taking medications, including prednisone, hydroxychloroquine, leflunomide, azathioprine, Enbrel, Humira, Simponi, Cimza, Remicade, Actemra, Talz, and Cosentyx can be vaccinated without any change in their dosing regimens. Patients on Methotrexate, Orencia, Rituxan, or Xeljanz may not have a good response to the vaccine, unless we temporarily modify the dosing of these drugs. We recommend that patients on methotrexate and Xeljanz, hold the methotrexate for 1 week after the first (all the vaccines) and second dose (Pfizer and Moderna) vaccine. For those patients on Rituxan/rituximab infusions, we recommend waiting until 4 months after your last infusion, to start the vaccine series. If you are on Orencia, we recommend avoiding dosing the Orencia for 1 week before and 1 week after the First Dose of the vaccine only. The second dose of the vaccine, if needed does not interfere with when you are due for the next Orencia shot or infusion.
All other rheumatic disease drugs are safe to continue.

A few additional things to know about vaccinations:

How effective are most vaccines?

Most vaccines offer some protection against infection but do not give patients complete immunity. However, even partial protection will be helpful both to patients and the general public. Partial protection may mean that most but not all vaccinated people develop immunity, or that some people develop partial immunity, so that even if they develop COVID-19 infection, the symptoms of that infection will be less severe. For now, we are still recommending that patients that are immunized follow masking and social distancing guidelines in public.

How long will protection last after I am vaccinated?

We do not yet know how long patients are protected from reinfection after having COVID-19. There have been a small number of cases reported where a patient clearly developed a second COVID-19 infection, after having an initial previously documented infection. We have even less information about how long protection will last following a vaccine against COVID-19. All people receiving vaccines against COVID-19, or recovering from COVID-19, should understand that prior infection or vaccination may not provide long lasting protection from future infections.