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Covid Vaccine Q&A

There has been a lot of discussion in the media of both a third dose of COVID-19 vaccine and ‘booster’ programmes. This has caused some confusion; the following aims to explain who is eligible for each programme and how they differ from each other. Note: we understand that this advice currently applies across the UK.

The third dose. Who is eligible for the third vaccination?

The third dose can be given as a priority to anyone aged 12 and over who is considered clinically immunocompromised at the time they were first vaccinated. The third dose must be 8 weeks or more after the second dose of the vaccine. The JCVI advice says this should include people with acute and chronic leukaemias, who are undergoing treatment, or who will not achieve a cure within 12 months. Also included is anyone who has had a stem cell transplant in the last 2 years and those who received immunosuppressive chemotherapy or radiotherapy in the 6 months prior to vaccination. Please check with your consultant or specialist nurse if you are unsure if this applies to you.

What is the evidence for needing a third dose of the vaccine if you are immunocompromised?

Blood cancer patients were prioritised for the COVID-19 vaccine earlier this year, due to many patients being clinically extremely vulnerable to COVID-19. Research has shown that those blood cancer patients who are immunosuppressed due to their condition and/or treatments, are less likely to have responded to the vaccine people with working immune systems. More work is needed to know which blood cancer patients are most likely to benefit from this. However, some protection is better than none, so it is recommended that you get the third dose you are offered in the hope you will see some benefits.

Should I bother with a third vaccine if I have not made antibodies to the vaccines so far?

We would encourage everyone who is eligible to take up the offer of the third vaccine. There is some evidence that it increases an immune response, including in people who did not make many antibodies. Some protection is better than none.

You do not need to test for antibodies before you have the third vaccine. Even if you have responded to the first two vaccines, we would encourage you to take up the third. Antibodies are only part of the immune system and the role of other parts of the immune system isn’t yet fully understood. It is possible that the third vaccine may yet boost your immune response further.

Is the third dose the same as the booster vaccine?

No. The third dose for the immunocompromised is an addition to the primary course (first two doses of the vaccine) to try and raise the level of immunity among the immunocompromised to match the immunity of the rest of the population. Booster vaccines are likely to then be given on top of this in the New Year, approximately 6 months after the immunocompromised have received their third dose.

If you are not eligible for a third dose as per the criteria outlined above, please go to the section about booster vaccines further down this article. Please contact your specialist consultant or nurse if you are not sure which group you fall into, as they are responsible for identifying people who need the third dose.

When and where will I receive my third vaccine?

The third dose will be delivered at any time from the 13th of September. You will be contacted by letter to confirm your eligibility. Specialist consultants and nurses are primarily responsible for identifying people who are eligible for this third dose, so you should contact your medical team if you do not receive this letter soon, and you believe you count as someone who is immunosuppressed. GPs may also be able to help, but this will depend on their level of knowledge about your condition. The third dose is expected to be arranged by the GP practices where they have been delivering COVID-19 vaccines. However, we are aware not all GP practices are delivering vaccines themselves – they have been asked to highlight their eligible patients to wider authorities so you should receive further information on where to go.

Important: if you are eligible for a third vaccine, do not book a “booster” dose by calling 119 or using the online system. You should be sent a letter directly with official instructions, please follow these instead.

The vaccine given will most likely be Pfizer or Moderna. This is because most people who are immunocompromised received AstraZeneca as their first vaccine, and evidence suggests that a different vaccine for the third dose makes for a better immune response. Under 18’s will only receive Pfizer.

Will I also get a booster vaccine later?

Yes. This third vaccine is considered part of your first course of vaccination, so you will have 3 doses instead of the usual 2 doses. You will then be recommended to have a booster in approximately 6 months’ time, too. 

Important: anyone who lives in the same household as you is now eligible for a booster dose, if it has been more than 6 months since they had their second dose. See next section for details.

Booster vaccine programme for all other CLL patients:

If you are not considered immunocompromised as a result of your diagnosis and/or treatment, you will also shortly be offered another COVID-19 vaccination too. This is a “booster” dose, similar to how you will have a booster jab of tetanus if you cut yourself and have not had the jab in a long time.

What is the evidence for this?
Recent studies have indicated that, even in those who have responded well to the vaccine, immunity has declined over time slightly. This is fairly normal and happens with other vaccines too (e.g. tetanus). Therefore, to try to avoid another spike of infection, the governments have decided that the most vulnerable to COVID-19 should have a boost of their immunity at 6 months after vaccination, to try to restore their immunity to its original level.

Who is eligible for the booster dose?
The booster programme covers many people. Here are the criteria as set out by the JCVI:

  • those living in residential care homes for older adults
  • all adults aged 50 years or over
  • frontline health and social care workers
  • all those aged 16 to 49 years with underlying health conditions that put them at higher risk of severe COVID-19 (as set out in the green book), and adult carers
  • adult household contacts of immunosuppressed individuals

You may fall into more than one of these categories, but we understand that all leukaemia patients will qualify under the “underlying health conditions” criteria. Please check with your consultant or specialist nurse if you are at all unsure.

You can only have a booster dose if you are more than 6 months after your second vaccine.

When and where will I receive my booster dose?

The booster doses are planned to begin from the week of 20th of September. You will be contacted by the NHS to confirm your eligibility. The booster doses are expected to be delivered in all COVID-19 vaccine centres and instructions should be in the communications to you. Do not call to book via your GP.

The vaccine given will most likely be Pfizer or Moderna.

Does the Oxford Astra Zeneca vaccine cause blood clots?

Regulators in the UK and Europe have concluded that they may be an association between the vaccine and a very small number of cases of an extremely rare type of brain blood clot. This is not yet certain and there are several investigations going on to try to find out the true extent.

Initial results seem to indicate that people under 30 are the most likely to have a blood clot following the vaccination, and the majority are female. The reasons for this are unclear, but the under 30’s so far vaccinated often have other medical conditions that may make them more vulnerable.

How many of these clots have been reported?

In the UK at the time of writing, 79 cases have been reported and 19 have died. It is not yet known if this is a higher number than would be expected under normal conditions, but it is suspected to be the case.

What changes are being made?

People under 30 will now receive one of the other types of vaccine (currently Pfizer or Moderna).

I’ve been invited for a vaccine. Should I go?

Yes. The advice from all regulators is to have whatever vaccine you are offered. If you are under 30 you will be offered an alternative to the Astra Zeneca vaccine. The vast majority of CLL patients are over 30, so this will not apply. However, there are still a number of CLL patients who are between 30 and 60. Current evidence suggests that this group have an extremely low risk of getting blood clots.

I’ve had the first Astra Zeneca vaccine. What should I do?

The advice remains to get your second dose, whatever your age. The risk/benefit is greatly in favour of doing this. Although information is still unclear, there have been no reported cases of the blood clot after the second dose.

Can I refuse the Astra Zeneca Jab?

Under current regulations, you can’t choose which vaccination to have. Those under 30 will be offered alternative types.

What are the signs of a blood clot after being vaccinated?

The signs tend to develop between four and fourteen days after vaccination. The main sign is a severe headache which lasts for a few days and usual pain killers such as paracetamol have no effect. Another sign may be red specks under the skin away from the injection site, shortness of breath, swollen legs and bruising.

Reactions such as mild flu-like symptoms, aching muscles and joints and chills are common symptoms and usually resolve after a few days. These should not be confused with the symptoms of possible blood clots, and these should be referred to a doctor for treatment.

Are these blood clots treatable?

Yes. The British Society of Haematology says that this is very treatable if caught early. The main treatment will usually be intravenous immunoglobulin followed by blood thinners.

How do the vaccines work?

Vaccines work by preventing people from becoming severely ill and by stopping the spread of illness to others.

The advice from the Joint Committee for Vaccine and Immunisation (JCVI), the group which advises the government on vaccines, is that everyone who is offered a vaccine should have it. Our clinical advisers have also confirmed that this is the case.

However, it is not yet known whether any of these vaccines can prevent people from passing on the virus to other people who have not yet been vaccinated.

For this reason, if you do receive a vaccine, it is important you continue to observe social distancing and other actions to make sure that you do not spread COVID-19 unknowingly to non-vaccinated people. The vaccine will also take up to five weeks from the initial jab until it has become effective.

Is the vaccine safe?

Although the vaccines which will be available soon have been developed very quickly, they have to pass through a very stringent test and approval procedure. They must all be approved by the Medicines and Healthcare products Regulatory Agency (MHRA) following a thorough review of all the clinical data.
The advice from the Joint Committee for Vaccine and Immunisation (JCVI), the group which advises the government on vaccines, is that everyone who is offered the Pfizer or Oxford vaccine should have it. Our clinical advisers have also confirmed that this is the case.

None of the first three vaccines which will become available, the Pfizer-BioNTech, the Oxford – Astra Zeneca vaccine or the Moderna vaccine is a live vaccine. They are therefore suitable for CLL patients, who must not receive live vaccines.

Other vaccines are awaiting approval, and we will provide further information when approval is granted, should this be different from other vaccines in development.

If you have any concerns about receiving the vaccine, we advise that you speak to your medical team about it once you have received your invitation.

 

Will it work?

It is still not clear what degree of immunity CLL patients will receive from the vaccine. It is known that CLL patients do not respond as well to the flu vaccine, for example, as people with normal immune systems.
However, this does not mean that you will get no response at all, and some response, however small, would provide at least some protection. Our advice is, therefore, that you should have the vaccine if invited, provided there are no contra-indications, such as allergic response or pregnancy. Under 16s are also advised not to have it. Please check with your medical team if in any doubt.

It is also important that you receive both doses of the vaccine. Whilst some protection is acquired from the first dose, the second dose is needed for full protection, which is likely to be particularly important to those affected by CLL.

Has the vaccine been tested on CLL patients?

We understand that neither the Pfizer vaccine nor the Oxford vaccine was tested in immunocompromised patients. However, our current advice is that those affected by CLL should have the vaccination when invited to do so. About 40% of the people vaccinated in the Pfizer trial were over 55, and it is thought that it works well in this population.

This study looked at 167 people with chronic lymphocytic leukaemia who had received both doses of the Pfizer vaccine 21 days apart. Of these 167 people, an antibody response was only seen in 39.5%. Those who were in remission following treatment had a better response than those who were on active treatment. While these results are worrying, it’s important to remember that antibody response is only one piece of the puzzle and other factors which weren’t measured in this study, might also be important in protecting people from covid. More research is needed to understand this.

However, it’s important to understand that your immune system worsens with age and is even more damaged in CLL patients. Any vaccine will not work as well as in the general population but may give at least some protection. Further research is required to establish what degree of protection.

Can I have more than one vaccine?

Both the Pfizer-BioNTech and Oxford vaccines have been approved for a specific dosing schedule only. Although this has been modified to increase the gap between the first and second doses, It is not possible for individual clinicians or others giving the vaccine to decide to give extra doses, as this has not been tested in trials.  Although there is a trial to see if a different vaccine can be given for the second dose, this is not approved, so both vaccinations will be from the same manufacturer.

 

I’ve had Covid – should I still be vaccinated?

It is not yet certain how much immune response will be generated by natural infection, and it’s also not clear how long this response will remain in the body.

Some studies have suggested that antibodies are short-lived after infection, and there have been cases of reinfection reported, although rare. Therefore, it is recommended that you still have the vaccination, as this has been designed to give lasting protection.

I am currently on chemo treatment – can I have the vaccine?

This is a group in which the Pfizer-BioNTech vaccine or the Oxford vaccine has not been specifically tested. We do not yet know who was tested in the trials for other vaccines in development. With other vaccines, such as childhood vaccinations or flu, there are specific times when these should be had whilst you are on chemotherapy, to give the vaccines the best chance of working. If you are invited for the vaccine during a course of chemotherapy, please speak to your team if you are unsure when is the most appropriate time to have it.

When can I have the vaccine?

The government has published a list of priorities for receiving the vaccine. You can find the full list here: Priority groups for coronavirus (COVID-19) vaccination: advice from the JCVI, 2 December 2020 – GOV.UK (www.gov.uk)

The highest priority is currently health and social care workers and those over the age of 80. This will then be followed by other age groups, down to priority level 4, where any person who is considered clinically extremely vulnerable to COVID-19 (including CLL patients) will be invited at the same time as those aged 70-74. It’s known that age is the biggest risk factor for serious illness from COVID-19, and it is anticipated that many CLL patients will fall into the over 75 categories. Additionally, you may meet the criteria because of your work.

NOTE: the exception to this advice is those who are pregnant or planning to become so within three months of vaccination, and children under 16, both of whom are currently advised not to have the vaccine.

As each group is invited to start having a vaccine, you will receive a letter to inform you of this. Please do not contact your GP to request an earlier vaccination, as this will not be possible. We will look to update our advice as each new group is invited.

It may be some time before all groups are vaccinated. This is the largest mass vaccination programme ever undertaken by the NHS. Additionally, there are just three vaccines currently approved, but only the Oxford and Pfizer ones are being used at the moment.  The Pfizer-BioNTech vaccine and the Oxford Astra Zeneca vaccine. A total of about 140 million doses have been ordered but extra doses and other vaccines will be needed to cover the whole population of vulnerable and elderly people, and more still if the vaccine was to be rolled out to the wider population. Therefore, we need to use the doses already available to cover as many people as possible, which is why the second vaccination is being delayed.

Please continue to follow all guidance on reducing COVID-19, including after you have had the full vaccine.

If I have had the vaccine, can I stop social distancing?

No, we advise you to continue to follow all guidelines to reduce the spread of COVID-19 until the government advises otherwise. As mentioned in previous questions, we do not know how effective the vaccine will be in those affected by CLL and we also do not know if the vaccine will prevent you from passing COVID-19 to other people who are not yet vaccinated. This applies to everyone, regardless of whether you have completed your full course of vaccination or whether your family has also received the vaccine.

I have an allergy – is the vaccine right for me?

It has been reported that two of the first recipients of the Pfizer-BioNTech vaccine had experienced an anaphylactoid reaction after receiving the vaccine. This kind of reaction is where the person develops a range of symptoms including a rash, breathlessness, and a drop in blood pressure. It is important to note that this is not the same as an anaphylaxis reaction, which can be fatal. The two people affected had severe allergies, which meant that had to carry an epi-pen at all times. The NHS is no longer giving jabs to people with “significant” allergies; this is defined as “any person with a history of immediate-onset anaphylaxis to a vaccine, medicine or food”.

If you are unsure if this applies to you, please check with your GP or medical team before having the vaccine.