Immunize
Covid-19 Vaccine
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Covid-19 Vaccine
, Covid19 Immunization, Corona Virus 19 Vaccination
Background
Encourage
Vaccination
in all adult patients (approval in children is pending study as of spring 2021)
All U.S.
Vaccine
s are considered safe
Patients should get whichever
Vaccine
is available
Efficacy does favor the mRNA
Vaccine
s as of late 2021
Any of the U.S.
Vaccine
s may be used in
Immunocompromised
patients (none are live virus, no "viral shedding")
However, immune response to
Vaccination
may be blunted especially if on chronic
Corticosteroid
s
The covid
Vaccine
s are safe in pregnancy and
Lactation
Shimabukuro (2021) N Engl J Med 384(24):2273-82 +PMID: 33882218
No
Vaccine
contains fetal cells (social media myth)
None of the
Vaccine
s are associated with
Infertility
(social media myth)
(2021) Presc Lett 28(4): 19 [PubMed]
Preparations
SARS
-CoV-2 Viral Vector
Vaccine
s
Johnson/Johnson-Janssen
Vaccine
(Ad26.Cov2.S)
Uses
Adenovirus
vector to introduce cellular RNA
Modified viral vector that is considered harmless (not a
Live Vaccine
)
Protocol
Initial: Single
Intramuscular Injection
Booster: Give at least 2 months after initial dose
Indicated in all patients over age 18 years (due to lower efficacy than the mRNA
Vaccine
s)
Compared with mRNA
Vaccine
s, this
Vaccine
is far more stable
May be stored in refrigerator for months
Efficacy data is difficult to compare with mRNA
Vaccine
s
This
Vaccine
was tested after emergence of variant strains (e.g. South Africa)
Efficacy: 60-70% overall (much of which was likely variant strains)
Prevents severe
Covid19
(ICU admission or death) in 85%
Adverse Effects
Thrombocytopenia
Venous thrombosis (e.g.
Cerebral Venous Thrombosis
, splanchnic vein thrombosis)
Rare (50.4 cases in 16.4 million doses)
Atypical thrombosis sites
Seen primarily in women age <50 years, 1-2 weeks after
Vaccine
May be autoimmune induced condition similar to HIT and TTP
Heparin Induced Thrombocytopenia
(HIT)
Thrombotic Thrombocytopenic Purpura
(TTP)
Guillain Barre Syndrome
Rare (268 cases in 16.4 million doses)
Primarily in men (esp. >50 years old)
References
(2021) Presc Lett 28(3): 13
(2021) Presc Lett 28(5): 25
Preparations
SARS
-CoV-2 mRNA
Vaccine
s
Two mRNA
Vaccine
s (Pfizer, Moderna) released and FDA approved in U.S., December 2020
Expect flu-like symptoms (
Fatigue
, myalgias), especially after second dose
Both initial U.S. Covid-19 Vaccines are mRNA
Vaccine
s with a unique mechanism
https://berthub.eu/articles/posts/reverse-engineering-source-code-of-the-biontech-pfizer-vaccine/
mRNA is taken up by cells, translated to covid spike protein which is then expelled extracellularly
Antibody
forms to
COVID-19
spike protein after 2
Vaccine
doses spaced 21-28 days apart
The mRNA is fragile and degrades soon after injection, and does NOT affect DNA
Dosing: Adults
Pfizer-BioNTech 30 mcg (0.3 ml/dose) IM given 21 days apart
Must be diluted with 1.8 ml preservative-free saline
Gently invert
Vaccine
to mix (do not shake)
Moderna 0.5 ml/dose IM (undiluted) given 28 days apart
Gently swirl
Vaccine
to mix (do not shake)
Dosing: Children (age 5 to 12 years)
Pfizer-BioNTech 10 mcg IM given 21 days apart
Precautions
mRNA
Vaccine
s must be stored at low
Temperature
s
Pfizer-BioNTech
https://www.cdc.gov/vaccines/covid-19/info-by-product/pfizer/downloads/storage-summary.pdf
Initial: -80ºC to -60ºC (-112ºF to -76ºF)
Up to 2 weeks: -25°C to -15°C (-13°F to 5°F)
Up to 5 days at standard refrigerator
Temperature
Moderna
https://www.cdc.gov/vaccines/covid-19/info-by-product/moderna/downloads/storage-summary.pdf
Initial: -50°C and -15°C (-58°F and 5°F) for unpunctured vials
Up to 30 days: 2° to 8°C (36° to 46°F) for unpunctured vials
Up to 12 hours: 2°F and 25°C (36°F to 77°F) for punctured vials
Avoid other
Vaccine
s within 14 days (to avoid confusion in reactions, and ensure maximal efficacy)
If more than 50% of dose leaks with injection, give a full dose in opposite arm
Second
Vaccine
dose may be given up to 4 days before recommended schedule and up to 42 days after
However, give second dose even if >42 days from first dose, and repeating series not recommended
Third
Vaccine
dose indications
Immunocompromised
patients
Third dose (not considered booster) given >28 days from second mRNA
Vaccine
(Pfizer or Moderna)
Booster Dose (Pfizer or Moderna)
Patients may switch mRNA
Vaccine
s (mix and match approach)
Booster not needed if patient received a third dose due to
Immunocompromised
state
Booster dose not recommended for ages 5 to 12 years as of fall 2021
Dose
Pfizer: Full dose (0.3 ml)
Moderna: Half dose (0.25 ml) or if unavailable, give full dose
Indications (>6 months after second dose)
Age >65 years old
Longterm care residents
Comorbidity (e.g. Diabetes,
Obesity
) and age 50 to 64 years (and consider for age 18 to 49 years)
Occupational Exposure (e.g. Healthcare workers, teachers)
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html
Contraindications
Severe
Allergic Reaction
to
Polyethylene glycol
, polysorbate or first Covid
Vaccine
dose
Severe
Allergic Reaction
to other injectable medications is not an absolute contraindication
Observe for 30 minutes after
Vaccination
(typically 15 minutes)
Epinephrine
injection should be available
Convalescent Plasma or Covid
Monoclonal Antibody
in last 90 days
Prevents adequate
Vaccine
immune response
COVID-19
Infection within last 90 days is not a contraindication to
Vaccination
However, repeat infection in subsequent 90 days is unlikely (may delay
Vaccine
)
Efficacy
Both mRNA
Vaccine
s (Pfizer, Moderna) appear to have 95% effectiveness
However, initial efficacy data preceded emergence of more transmissible variant strains
Immunity
appears to wane after dosing, and booster doses recommended in adults as of Fall 2021
mRNA
Vaccine
s are 5 fold more effective than natural
Immunity
in preventing
Covid19
reinfection
Safety
Appears safe in
Immunocompromised
state, pregnancy,
Breast
feeding
Pfizer
Vaccine
has been FDA approved down to age 5 years and older as of 2021
Adverse Effects
Anaphylaxis
Risk 2-5 per million vaccinated patients
Myocarditis
or
Pericarditis
Risk 70 per one million males ages 12 to 17 years old
Resources
CDC Covid19
Vaccine
Adverse Effects
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/adverse-events.html
References
(2021) Presc Lett 28(2): 7
(2021) Presc Lett 28(11): 61
(2021) Presc Lett 28(12): 67-8
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