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Reports of non-GP specialists advising patients to wait for Pfizer
GPs say they feel like gatekeepers of Pfizer, with some patients over 60 presenting with exemption letters despite having no contraindications to AstraZeneca.
Hundreds of thousands of Australians aged over 60 have yet to receive a single dose of a COVID-19 vaccine, some of whom are holding out for an mRNA vaccine.
Adelaide GP and practice owner Dr Alvin Chua is at his wits’ end.
One of his patients aged over 60 with risk factors for severe COVID-19 had been anxious to receive AstraZeneca, fearing the rare risk of thrombosis with thrombocytopenia syndrome (TTS) due to their history of deep vein thrombosis (DVT).
As the condition is not a contraindication to receiving the spike-protein-based vaccine, Dr Chua spent a number of consultations talking through the risks and benefits of vaccination and the patient had finally consented – at least until they went to see their orthopaedic surgeon ahead of a scheduled arthroscopy.
‘The agreement was that [they would] have the vaccine in six or eight weeks [when] you’re past the DVT risk associated with post-op,’ Dr Chua told newsGP.
‘But when [they] saw the orthopod [orthopaedic surgeon] for follow-up and mentioned that [they were] going to get AstraZeneca but were anxious about it, the specialist essentially told [them], “Oh, just wait for the Pfizer. It’s better”.
‘This undid all the advice and long consults we’d had over the preceding week.’
This is not the only time one of Dr Chua’s patients has been recommended or referred for Pfizer by a non-GP specialist. He has seen exemption letters from haematologists, rheumatologists and even psychiatrists requesting a patient be given Pfizer, contrary to Australia Technical Advisory Group on Immunisation (ATAGI) guidelines.
And he is not alone.
RACGP Victoria Deputy Co-Chair Dr Bernard Shiu told newsGP he counts himself lucky, as most non-GP specialists in his region ‘trust us to make the right decision with our patients’. However, that has not always been the case.
While he acknowledges that navigating the timing of vaccination alongside certain treatments may require external input, he says that is rare and GPs are well-placed to make the decision with their patients.
‘It is quite interesting with the non-GP specialists,’ Dr Shiu said. ‘One of my patients who is on dialysis had the recommendation coming from her renal specialist to receive Pfizer.
‘This puts us in a difficult position, especially as we want to protect these very vulnerable patients, but they are only mentally prepared to have the Pfizer.’
Dr Chua says it has become ‘very frustrating’ for GPs who are being made to feel that they are gatekeepers of the mRNA vaccine.
‘It’s like, “Hello, have you actually read the ATAGI guidelines? It’s not up to us”,’ he said. ‘We’re catering to needs, not necessarily wants, and unfortunately I don’t think that message is getting across loud and clear.
‘If ATAGI are the ones that give us the guidelines, then that should be the rule of thumb for all of us, not just GPs.’
According to ATAGI’s clinical guidance, there are very few contraindications to AstraZeneca. They include:
- anaphylaxis after a previous dose of AstraZeneca or to any component of the vaccine, including polysorbate 80
- TTS after a previous dose of AstraZeneca
- history of capillary leak syndrome
- any other serious adverse event attributed to a previous dose of AstraZeneca that has been reported to state adverse programs and/or the Therapeutic Goods Administration (TGA) and has been determined following review by, and/or on the opinion of, an experienced immunisation provider/medical specialist.
Precautionary conditions for AstraZeneca, where Pfizer or Moderna are recommended instead, include a history of:
- cerebral venous sinus thrombosis (CVST)
- heparin-induced thrombocytopenia (HIT)
- idiopathic splanchnic (mesenteric, portal, splenic) thrombosis
- antiphospholipid syndrome with thrombosis.
More than half a million Australians aged over 60 are yet to receive a single COVID vaccine dose, despite having been eligible for months and the availability of millions of AstraZeneca doses. Reports indicate many are waiting for Pfizer or Moderna mRNA vaccines.
Concerns over TTS are commonly cited for the hesitation, but
data shows the risk for those aged 60–69 is just 1.4 per 100,000, while an individual’s risk of developing a blood clot is
5–10 times higher if they contract COVID.
There has been one TTS death in Australia among people aged over 60 (a 72-year-old woman), compared with
1017 COVID fatalities at a rate of 1.1 deaths for every 10 confirmed COVID cases.
Dr Chua says some people at his clinic booking through HotDoc have ‘blatantly lied’ in their attempts to access Pfizer, and others have managed to get a dose of the mRNA vaccine through state-run vaccination hubs.
‘It’s become very frustrating for a lot of us because we’re saying it until we’re blue in the face, “No, you have to have your AstraZeneca” or “We can’t give you [an alternative]”,’ he said.
‘Then the next moment they go around the corner to the State Government vaccination hub or their specialist says this.
‘And realistically – no disrespect – but I dare say, when was the last time an orthopod gave a COVID vaccine? Or any vaccine, for that matter?
‘I don’t profess to be an expert in areas I’m not, but I would dare say that a GP would be in their place to say that they would know a heck of a lot more about immunology, about the response to vaccinations, the safety profile compared to say an orthopaedic surgeon.’
Prime Minister Scott Morrison issued a letter to unvaccinated Australians over 60 this week, encouraging them to be vaccinated as soon as possible and not to wait for Pfizer. The move was welcomed by GPs during
a Q&A webinar hosted by the Department of Health on Thursday.
But Dr Chua said it is vital that all specialist colleges are on the same page, and that they are held accountable.
‘At the end of the day we’re trying give the message – and I firmly believe it – that the best vaccine is the one you can get in your arm right here, right now,’ he said.
‘Not the one you can get in six months’ time or whenever the Government decides to get more Pfizer.’
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