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Reports of non-GP specialists advising patients to wait for Pfizer


Anastasia Tsirtsakis


9/09/2021 5:44:45 PM

GPs say they feel like gatekeepers of Pfizer, with some patients over 60 presenting with exemption letters despite having no contraindications to AstraZeneca.

GP and older patient
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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Dr Dananjaya Bandara Dissanayake   10/09/2021 6:22:52 AM

I agree totally with Dr Chua. We do have older patients requesting letters from us to go an get Pfizer vaccine from another local GP clinic, when they invite older clients to fill in their no shows for Pfizer vaccine clinic.
Same time, I have met many patients who have been advised by specialist to have Pfizer when they are not eligible.


Dr Angela Christina Bascomb   10/09/2021 6:46:25 AM

Easy solution. Take all the AZ and donate it to India or some other country that is struggling to obtain vaccine - and then allow everyone to have Pfizer if that's their choice. It maybe the only way we'll reach the holy grail of 90% vaccinated and this is a HIGH RISK population, so continuing to hold out and deny them Pfizer is putting their lives at risk. "First do no harm" would imply to me that we should be allowing them to have Pfizer - but this decision has been taken away from us as individual practitioners.


Dr Manu Mittal   10/09/2021 7:49:08 AM

We should refrain from putting incorrect statements about India and other countries especially when we do not have the complete information about them.
India is not struggling to obtain the vaccines. On the other hand, Australia had imported the vaccines from other countries.

In Australia, there are several highly qualified doctors originally from India and can find the statement from Dr. Angela offending.


Dr Andrew Robert Jackson   10/09/2021 8:01:19 AM

My only concern with Astra is that time is running out with loosening of border restrictions etc coming up - having to wait a full three months for the second dose is emerging as a real problem


Dr Effie Parakilas   10/09/2021 8:02:52 AM

Well done for working with integrity and following ATAGI guidelines. A good article, the facts of which I’ll share with patients, thanks.


Dr Kenneth Koh   10/09/2021 8:10:08 AM

I think the answer is not to be the 'gate-keeper', clearly the principle to follow is to firstly do no harm - if the anxiety around AstraZeneca is such that it would trouble the patient greatly, I would give the Pfizer injection.
Also, if other clinics are offering unused Pfizer vaccines to your patients, surely a letter of exemption is not required??


Rural GP   10/09/2021 8:41:28 AM

Thank you Dr Chua and in total agreement. It’s incredibly frustrating when fellow GP’s and specialists undermine your hard work explaining AZ and TTS. They play the “ I will get you the best vaccine, because I care more card” You can only use up that goodwill so often, before you cheapen the whole profession.


Dr Christopher Mark Jones   10/09/2021 9:13:06 AM

I experience these issues at the mass vaccination centre where I work on a sessional basis as an SMO. Apart from the stated contraindications to AZ, under Queensland Government guidelines @ 14/07, Pfizer eligibility also includes “people aged 16 and over with a specific medical condition”
These include:
: Cancers and haematological diseases, currently or in the past
: Transplant recipients
: Chronic inflammatory conditions
: Immunodeficiency conditions
: Chronic kidney, liver, lung or neurological conditions or diabetes
: Severe obesity
: Heart disease and blood pressure disorders
: Severe mental health conditions
This list encompasses a very significant percentage of the over 60s requesting Pfizer and certainly make “eligibility screening “ a lot easier for me, and less distressing for the patients


Dr Joan San   10/09/2021 10:03:51 AM

Spot on Dr Chua


Dr Natalia Peker   10/09/2021 12:27:06 PM

I entirely agree with Dr. Kenneth Koh .
Additionally, patient is patient anywhere without borders: either India or Australia.
It is eye brows rising comment on easy solution.


Dr Rebecca Erfani   10/09/2021 1:47:38 PM

Well done Dr Chua.
If all of us were on the same page we wouldn't have this problem.
One pfizer vaccine that goes into arm of a person who can have Az vaccine leaves a pfizer only eligible person unvaccinated( all 12-17 yo and pregnants).
Yes people over 60 can have pfizer , but there is a shortage.


Dr Min Fang   10/09/2021 4:00:07 PM

1. AZ is a DNA based vaccine using chimpanzee’s adenovirus genetically modify them to make their DNA using our cells to make spike protein.
2. Currently, the vac rate is about 70% for the first dose of the COVID 19 vaccine. From September, Pfizer supply is coming in millions as our national vaccine agreement scheduled and with restrictions placed on vaccinating 12-15 year-olds, there is no obvious Pfizer shortage to deny the elderly equal access to Pfizer. 40 million Pfizer + 10 million moderna = 50 million doses enough to cover the whole Australian population of 25 million (from birth). Pfizer shortage before final quarter of the year - YES, but currently with the above reasons and figures - NO.
3. What will our elderly think of us when they are denied a vaccine that currently has full FDA registration leaving them no option but to take the AZ, which is only provisionally approved? Are they not paying equal tax as us? Or are we not going to grow older than 60?


Dr Tiffane Jane McIntyre   10/09/2021 4:30:09 PM

Dr Chua has perfectly summarised the frustrations we experience every day when discussing Covid vaccine eligibility with our patients
As General Practitioners,our hands are simply tied by the Government guidelines and this is,of course, due to our lack of supply of MRNA vaccines

In regard to the Qld government guidelines for MRNA vaccine eligibility,in the post from Qld Gp who also works at mass immunisation centre,
I have just checked the current eligibility there ,and ,as in all other states, it certainly does not include the group over 60 y.old with the conditions listed


Dr Steven Jon Hambleton   10/09/2021 4:50:12 PM

And.......I am also getting patients who are convinced they can't wear a surgical mask. Preference is not the same as a contraindication.
PS Giving the odd Pfizer to an over 60 in place of discarding a dose, which is entirely acceptable, is not the same as bowing to preference in a vaccine constrained environment. More strength to your arm Dr Chua


Dr Nicholas John Brodie Page   10/09/2021 6:28:37 PM

Oh for heaven’s sake. These old folks should be told that AZ is better for them because Pfizer wears off really quickly in old folks. I have young people coming in for AZ and they have realised that the risk is very low.


Dr Yu Y. Tin   10/09/2021 7:54:35 PM

Same experience as all other GPS giving Covid vaccine. So many patients presenting with letters from GPs in the same LGA recommending Pfizer for their patients. Not one of them met the criteria . I got one letter from the respiratory physician recommending Pfizer because the patient was afraid to have AZ because of the family history of blood clot. I felt like ringing the specialist and telling him to study the TGA guideline and not to put GP in the difficult position.


Dr Cindy Jean Clayton   10/09/2021 9:18:06 PM

Which one do over- 60 doctors elect to have?


Dr Rifaat Roshdy Salama Girgis   11/09/2021 4:58:29 AM

What is forbidden is highly desired? The over 60 patients feel that they are second class citizens and feel that because they are old the government does not value them and it is a plan to get rid of them and save their pension money. I heard that from many over 60’s. If from the start the media did not mar astrazeneca vaccine with the bad reputation they attached to it and if the government did not limit access to both vaccines using the age limit we would have seen all Australians vaccinated by now.
As for anti vaxxers and their followers they will fill up the hospitals once 90 % of the population are vaccinated.


Dr Robert William Micallef   11/09/2021 1:23:08 PM

One of the main things that has fuel vaccine skepticism has been our public health officials thinking they can remove decision making from the normal consent process and insist on certain groups getting certain vaccines. As the patient’s advocate, if a vulnerable patient has expressed their view which is based on facts, their preference for a particular vaccine, it should be made available based on medical need. With current vaccine supplies all patients should be allowed a choice. You can dress it up any which way you like but Australian public health officials have directed one group of the population to get a higher risk vaccine than other groups for public health imperatives and not for the patient’s individual health benefit.


GP   11/09/2021 4:21:09 PM

I have had many coming in with those forms for recommendation for Pfizer vaccine. I make a note they don’t qualify if they don’t meet the criteria. No of requests is on the rise. Most common pretext is a family h/o of clots/stroke/heart disease but no contraindication in personal history.
On the same note I have to say that I receive requests for exemption from wearing masks for having anxiety or asthma etc.


Dr Merlene Lynette Thrift   12/09/2021 12:27:28 PM

Dr Alvin Chua’s article about safety of the AZ vaccine in the elderly seems to understate its CONTRAINDICATIONS & the SPECIAL WARNINGS AND PRECAUTIONS FOR USE as respectively contained in Sections 4.3 and 4.4 of its TGA approved Product Information (PI) (https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2021-PI-01194-1&d=20210912172310101)

In my practice, I have had some psychiatric patients expressing strong anxiety related feeling about the AZ vaccine. I also had patients with DVT post prosthetic procedures expressing similar anxiety related feeling about the AZ vaccine, AND recently, I had a 66-year-old patient with previous serious neurological events including Gillian-Barre also expressing fear about the AZ vaccine.
On what clinical grounds can any caring professional dismiss as nonsense the anxiety and fears of these patients or the recommendations from their specialists?
Rather than belittling the intelligence of our elderly patients, Dr Alvin Chua would do well to relook at the AZ vaccine instruction on its special use this elderly population group as contained in its TGA approved PI – re-printed below from paragraph 5, page 5.

“ Use in the elderly: There are currently limited data available for the efficacy and safety in individuals over 65 years of age. Further information will be collected from ongoing clinical studies and post-market monitoring. The decision to immunise an elderly patient should be decided on a case-by-case basis with consideration of age, co-morbidities, their environment, potential benefits and potential risks.”


Dr Sarah Anne Lockley   20/09/2021 11:47:45 AM

Agree with Dr Koh/Dr Thrift. I’m tired of public servants, politicians, and other medical professionals waving fingers at GPs, paternalistically chiding us that we need to be testing for this, prescribing this, de-prescribing, giving this vaccine, etc, forgetting the unspoken but paramount “other part” of the discussion - THE PATIENT. I don’t run a mini-dictatorship in my office. Many of my patients are well educated or at least capable of making their own decisions. My role is to provide opinion and guidance. But (perhaps fortunately at times) I can’t make the decisions for my patients. Same applies with the COVID-19 immunisation rollout. I can share every piece of information I have. Provide articles, guidance. But ultimately patients make their own decision. My aim is to ensure every eligible patient gets fully vaccinated (2 doses). With a schedule that achieves maximum efficacy (about 90%), ASAP. Media fear mongering & 12 wk AZ course, can make it less appealing.