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Confusion over temporary vaccine exemption

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With Australia edging closer to easing COVID restrictions amid rising vaccination rates, it is likely that access to certain freedoms will soon be tied to a person’s vaccination status. 
 
But a recent change to a New South Wales Public Health Order means that from 22 September, people who have recovered from COVID-19 will also be eligible to access these freedoms, via a temporary vaccine exemption for up to six months.
 
A NSW Health spokesperson told newsGP the exemption will mean people who have recovered from COVID-19 ‘will have the same freedoms afforded to fully vaccinated people’.
 
‘From 22 September 2021, a person who has recovered from COVID-19 will be issued a medical clearance notice from a medical practitioner or registered nurse confirming that person is no longer infectious,’ the spokesperson said.
 
‘This recognises that based on currently available evidence, most people who have recovered from COVID-19 develop natural protection from re-infection for up to six months.’
 
newsGP contacted the health departments of each state and territory, and understands that similar temporary exemptions will also apply for people who have recovered from COVID-19 in Western Australia, Tasmania and the Northern Territory, but will not apply in South Australia.
 
A response was not received in time for publication from Victoria, Queensland or the Australian Capital Territory.
 
NSW appears to have made the most progress when it comes to natural immunity exemptions, and its COVID-19 vaccine medical contraindication form, currently available to GPs in NSW, already includes the option to apply for a temporary exemption on behalf of the patient.
 
But a spokesperson could not confirm to newsGP how practitioners, including GPs, will be able to confirm whether a patient actually qualifies for the exemption.
 
Sydney GP Dr Michael Tam, who also works as a medical officer at Liverpool Hospital’s vaccination centre, anticipates problems if the department asks GPs to be involved in the process before this aspect has been finalised.
 
‘There isn’t necessarily a clear central database to say this person was diagnosed COVID positive on this particular date,’ he told newsGP.
 
‘After discharge from community isolation, often there isn’t any documentation that the patient can take to their GP to say, “This is what happened to me over the last two-and-a-half weeks”. And so in the absence of that information, that can be a little bit difficult.
 
‘Certainly, at the moment, you sort of have to go with what the patient just says.’
 
Dr Tam says this scenario quickly becomes ‘quite high stakes’ from a medical and risk perspective.
 
‘We really need to have a system that doesn’t allow people to fall through the cracks because it does become potentially quite discriminatory,’ he said.
 
‘And for the GP, you don’t want to just sign something, where if someone lies to them, it could potentially put the community at risk.’
 
Even though there is some uncertainty over how the process will function, RACGP NSW&ACT Chair Associate Professor Charlotte Hespe is in favour of the state’s new policy and said it made sense when weighing up the currently available evidence.
 
‘It’s a great idea because at the end of the day they’re immune,’ she told newsGP.
 
‘We’ve had a number of patients who have said to me “What do I do?” and there’s been a lack of clarity over the timing [of vaccination]. So it’s only fair that you are exempt from being vaccinated until at least the time that ATAGI has said you should be vaccinated by.’
 
As of 9 September, the Australia Technical Advisory Group on Immunisation’s (ATAGI) guidelines state that while past COVID-19 infection is not a contraindication to vaccination, it ‘can be deferred for up to six months after the acute illness’.
 
‘Evidence suggests that past infection reduces the risk of reinfection for at least six months,’ the guidance states.
 
People who are infected with COVID-19 after having their first dose, are also eligible to apply for a six-month exemption for the second dose, after consulting with their healthcare professional.
 
However, NSW Health has said that the exemptions ‘will not apply retrospectively’, and that it is ‘currently working on a process to grant exemptions for people who have been medically cleared prior to this change coming into effect’.
 
According to NSW Health, once a medical clearance has been issued for a period of six months, the person: 

• is considered to be ‘fully vaccinated’
• does not have to be tested for COVID-19 where required under an order
• does not have to self-isolate if they are identified as a close contact of a COVID-19 case.

Dr Tam says this is in line with both the ATAGI and the Communicable Diseases Network Australia (CDNA) guidelines, and that it allows vaccination efforts to focus on those who are at higher risk of severe disease.
 
‘These are individuals who are not going to be putting other people at risk,’ he said. ‘In fact, if they met somebody with COVID, they wouldn’t even be considered a close contact.’
 
According to NSW Health, there are some situations where it may be reasonable for a person who has recovered from COVID-19 to be vaccinated earlier than six months – such as those who are immunocompromised or work in high risk settings – and that the decision should be made ‘in consultation with a relevant health practitioner’.
 
But with the temporary exemption only likely to apply in certain states, there could be complications once interstate borders open up.
 
Associate Professor Hespe says she would like to see more alignment between states when it comes to vaccination guidelines.
 
‘I’m sure, by that stage, people will all just be vaccinated; but one would hope that they are aligning it,’ she said.
 
‘There’s confusion everywhere; different states do everything differently all the time, and that’s what we’ve constantly been navigating, including the Pfizer rollout to 60s and over.’
 
Longer-term medical exemptions
Digital exemption certificates are expected to be available through Services Australia in October.
 
As NSW prepares to ease restrictions, Associate Professor Hespe is among GPs reporting an increase in patients seeking a medical exemption, and says it has been a challenge.
 
‘The certificates have been a bit messy,’ she said.
 
‘One of my patients asked to have an exemption certificate because they have a medical diagnosis of anxiety – and I said “no, that’s not a medical exemption”.
 
‘So we need a lot more clarity on that for GPs because it’s going to be messy and not a very nice space, I predict.’
 
According to the Services Australia website, the only reasons that count as a valid reason for a medical exemption for vaccination, are if the person:

• had anaphylaxis after a previous dose of a vaccine
• had anaphylaxis after a dose of any component of a vaccine
• is significantly immunocompromised (for live vaccines only)
• has natural immunity (for hepatitis B, measles, mumps, rubella and chickenpox only).

When it comes to vaccination for COVID-19, the substances that are known to cause allergic reactions are Polyethylene Glycol (PEG), which is used to manufacture both Pfizer and Moderna, and polysorbate 80, which is chemically related to PEG, and is an ingredient in AstraZeneca.
 
It believed to be only a minority of people who have a contraindication to all three vaccines currently available.
 
The Australasian Society of Clinical Immunology and Allergy (ASCIA) advises that people who have had an adverse reaction to one of the vaccines, or have an allergy to an ingredient ‘should discuss having another type of vaccine that does not contain that ingredient with their clinical immunology/allergy specialist’.
 
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