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Updated COVID vaccine advice: What GPs need to know


Anastasia Tsirtsakis


10/06/2021 5:34:38 PM

The new advice comes after news of a death with a ‘likely’ link to the AstraZeneca vaccine.

COVID vaccine consent form.
The Australian Technical Advisory Group on Immunisation is continuing to update its advice around the COVID vaccinations.

One death and four new cases of thrombosis with thrombocytopenia syndrome (TTS) have a ‘likely’ link to the AstraZeneca vaccine in the past week, according to the Therapeutic Goods Administration’s (TGA) latest safety report.
 
The 52-year-old woman from New South Wales reportedly died after developing cerebral venous sinus thrombosis.
 
The news comes as the Australian Technical Advisory Group on Immunisation (ATAGI) updated its latest advice for timing influenza and COVID-19 vaccines, halving its recommended window between vaccinations from a minimum of 14 days to seven.
 
The advice, which applies to both AstraZeneca and Pfizer, has been welcomed by Melbourne GP Dr Magdalena Simonis, whose state has been facing a COVID outbreak since just before the beginning of winter.
 
‘We’ve been in a double-bind situation of knowing that we need to vaccinate [against COVID] rapidly and also needing to cover our communities against the flu because symptoms can appear very similar in the first instance,’ she told newsGP.
 
‘But this is a new territory, and we have had to tread very slowly and carefully when introducing new things to our vaccination programs, and so we had to step back and wait to see what the effects and aftereffects of the [COVID] vaccines would be.’
 
Dr Simonis says the shorter timeframe between vaccinations also gives GPs the opportunity to check in with patients, to note any health issues or potential side effects they may have experienced.
 
‘For example, “I’ve got a sore arm” or “I still have aching joints” or “I had a really bad headache for three days”,’ she said.
 
‘It gives you the opportunity to give them the assurance that you’re there for any follow-up discussion. So all of that becomes demystified.’
 
In certain situations, however, the advisory group has said an interval shorter than seven days, including co-administration of the vaccines, ‘is acceptable’. This includes instances where: 

  • there is increased risk of COVID-19 or another vaccine-preventable disease (eg COVID-19 outbreak, influenza outbreak, tetanus-prone wound)
  • logistical issues (eg difficulty scheduling visits to maintain the seven-day interval).
It was also announced last month that aged care residents no longer have to adhere to the recommended two-week interval.
 
While either vaccine can be administered first, ATAGI has suggested that GPs prioritise COVID-19 vaccines for patients who are currently eligible.

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ATAGI’s current advice for AstraZeneca as the recommended vaccine for those aged over 50 remains. (Image: AAP)
 
ATAGI has also updated its advice for pregnant women, recommending that they be routinely offered the Pfizer vaccine at any stage of pregnancy.
 
‘This is because the risk of severe outcomes from COVID-19 is significantly higher for pregnant women and their unborn baby,’ an ATAGI statement reads.
 
‘Global surveillance data from large numbers of pregnant women have not identified any significant safety concerns with mRNA COVID-19 vaccines given at any stage of pregnancy.
 
‘Furthermore, there is also evidence of antibody in cord blood and breastmilk, which may offer protection to infants through passive immunity.’
 
The advisory group has also assured that women who are trying to become pregnant do not need to delay vaccination, or avoid becoming pregnant after vaccination.
 
Dr Simonis said the recommendation is sure to be a relief for many women, including those working in healthcare.
 
‘We expected this because we knew that … the World Health Organization recommendation has been that Pfizer is safe in pregnancy,’ she said.
 
‘In the US, UK and Italy, findings there haven’t been any increased ill effects like clotting or negative outcomes with babies born.’
 
ATAGI’s current advice for AstraZeneca as the recommended vaccine for those aged over 50 remains. But some hesitancy continues in the community.
 
The RACGP has been advised of older patients presenting to a state-run mass vaccination hub to receive Pfizer, with a letter from their GP detailing pre-existing conditions such as deep vein thrombosis (DVT) and atrial fibrillation (AF), but have been turned away.

Based on advice from ATAGI, the only contraindications to receiving AstraZeneca are:
 
  • a history of cerebral venous sinus thrombosis
  • a history of heparin-induced thrombocytopenia
  • a history of idiopathic splanchnic (mesenteric, portal and splenic) venous thrombosis
  • anti-phospholipid syndrome with thrombosis.
It is also recommended that people should not receive a second dose of AstraZeneca if they have experienced:
 
  • anaphylaxis to a previous dose of the vaccine, or to an ingredient of the vaccine
  • thrombosis with thrombocytopenia occurring after the first dose
  • other serious adverse events attributed to the first dose.
For people aged under 50 who received their first dose of AstraZeneca without any serious adverse events, it remains advised that they can receive the second dose.

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Dr Magdalena Simonis says the relaxed TGA advertising regulations for COVID vaccines came as a relief for GPs.
 
During the Department of Health’s (DoH) recent webinar, First Assistant Secretary for the COVID-19 Primary Care Response, Dr Lucas de Toca, said it is not yet known whether eligibility for Pfizer will be opened to all age groups.
 
‘We don’t know what the situation will be later in the year. We do know that we will have more access to other vaccines, or so we hope. But ultimately, the policy at the moment is this,’ he said.
 
‘So the choice is not really right now AstraZeneca or Pfizer if you’re 50 years and over. Their choice is a good COVID-19 vaccine like the AstraZeneca one or no vaccine for the foreseeable future.
 
‘But it is a difficult and tricky conversation.’
 
Canberra GP Dr Clara Tuck Meng Soo said mixed messaging from the Federal Government, with Federal Health Minister Greg Hunt seemingly advising older patients that they could hold out for Pfizer later in the year, has added to the challenge for GPs.
 
‘At the moment, I would say [to patients] that we have no information about how that might change, and I tend to actually try to discuss with them what the reasons are for their current hesitancy,’ she said.
 
‘[But] I think going through the information we have really helps them, and I found that another thing that has been really persuasive for my patients is actually telling them that I’ve actually had the AstraZeneca vaccine myself. That does help a lot.’
 
To assist GPs in addressing vaccine hesitancy, the TGA has announced new arrangements that allow health professionals to develop their own materials about COVID vaccination, provided the content is consistent with Government messaging and does not contain:
 
  • references to specific brands of vaccines, or compare different COVID-19 vaccines
  • statements that COVID-19 vaccines cannot cause harm or have no side effects
  • any statement that is false or misleading
  • promotion of any vaccine that has not been approved by the TGA.
According to the regulator, the new arrangements, which will be in place until the end of 2022, will give health professionals ‘more flexibility to contribute to the national conversation about vaccination’ to enhance vaccine uptake ‘by publicly supporting vaccination and counter misinformation’.
 
Dr Simonis said the news came as a relief for GPs, giving them the confidence to use the knowledge they have acquired.
 
GPs found themselves in a really tricky situation … because the media were taking certain messages around the side effects and potential risks, but not putting them in the perspective that we have,’ she said.
 
‘So that media impact overrode our professional authority and our professional voice … making it harder for us to achieve the outcomes because the community out there was losing faith and confidence.
 
‘So this now is an opportunity for us.
 
‘It’s flu season coupled with the opportunity now to issue the vaccines in close succession and have this continuing conversation with our patients to reinforce their confidence in this process. Then they can also encourage others to come and have their vaccines.’
 
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Dr Ian   11/06/2021 6:41:07 AM

At the first symptom or sign of possible Thrombosis with Thrombocytopenia that is Headache more than mild and persisting
Chest Pain Abdominal pain any Shortness of breathe -
a D dimer ought be performed and repeated weekly from day 4 after the vaccine .
This has to be discussed .
Headache is the dilemma .
It is common after vaccination with Oxford-AstraZeneca but how often by day 3 or 4 and how long does it last and is it ameliorated by paracetamol or NSAIDS .


Dr Vishal Kohli   11/06/2021 7:45:00 AM

I thought we weren't allowed to "promote" either vaccine. By saying "I've had the [brand] vaccine" aren't you doing just that? When my patients ask me if ive had it, I tell them im not allowed to say. My choice either way will sway them. Either yes I got it, so my patient will get it too. Or no I didn't get it, well ok, "so my dr didn't get it, so I won't either".


Following Recommendations   11/06/2021 12:44:35 PM

I think this is one of the most important pieces to be strongly noted from this article - Based on advice from ATAGI, the only contraindications to receiving AstraZeneca are:
•a history of cerebral venous sinus thrombosis
•a history of heparin-induced thrombocytopenia
•a history of idiopathic splanchnic (mesenteric, portal and splenic) venous thrombosis
•anti-phospholipid syndrome with thrombosis.

Referring patients inappropriately to Pfizer clinics potentially delays vaccination and increases hesitancy.


Dr Mark Robert Miller   12/06/2021 1:04:19 AM

"It is also recommended that people should not receive a second dose of AstraZeneca if they have experienced:
anaphylaxis to a previous dose of the vaccine, or to an ingredient of the vaccine
thrombosis with thrombocytopenia occurring after the first dose
other serious adverse events attributed to the first dose."

What is the current definition to this last line "other serious adverse events attributed to the first dose" is thrombosis without thrombocytopenia classed as a serious ADR and is it ATAGI or the GP who decides if the ADR is vaccine attributable? Given we are not provided with individual feedback on any notified ADR to vaccine that I am aware of from the process of notification, this third line requires more detailed clarification. Also then what is the protocol for a recommended second dose in this situation, a single dose is not as effective as two doses? Also mixing vaccine seems to be holding up around the globe as something worthy of further research.