People receiving immunosuppressive therapies or with immune compromise
The COVID-19 vaccine trials largely excluded patients receiving immunosuppressive therapies, including regular systemic corticosteroids, disease-modifying antirheumatic drugs (DMARDS), monoclonal antibodies, cancer therapies and intravenous immunoglobulin. However, no increased risk of adverse events is expected among immunocompromised patients. None of the vaccines are live vaccines.
Further research is required to assess the efficacy of the COVID-19 vaccines in these populations, and particularly a patient’s ability to mount protective responses following vaccination while immunosuppressed. Ongoing public health measures, including hand hygiene, mask-wearing and social distancing, are key to preventing COVID-19 infection in immunocompromised patients.
Individual advice regarding vaccine efficacy for specific subpopulations or specific immunosuppressive medications is beyond the scope of this review and requires input from multiple subspecialty stakeholders. Expert consensus statements and other sources of advice on COVID-19 vaccination for rheumatology, haematology and oncology patients are listed in Box 1, and treating specialists should be consulted.
People living with HIV
Subanalyses of vaccine data for people living with HIV (PLWH) are awaited from the Pfizer and Oxford-AstraZeneca trials. At present, expert opinion supports COVID-19 vaccination for PLWH.
Pregnant and breastfeeding women
Pregnant and breastfeeding women were excluded from trials of all three vaccines. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) recommends against routine vaccination of pregnant and breastfeeding women because of the paucity of safety data. However, RANZCOG notes there are no current signals of safety concern for any of the trialled vaccines.24,25 Overseas obstetrics societies encourage pregnant women with an immunosuppressive comorbidity such as a solid- organ transplant, congenital heart disease or requirement for dialysis to have an individualised discussion with their healthcare provider.26 A decision aid for women who are pregnant, breastfeeding or planning pregnancy is available from the Department of Health (www.health.gov.au/resources/publications/covid-19-vaccination-covid-19-vaccination-decision-guide-for-women-who-are-pregnant-breastfeeding-or-planning-pregnancy).
The vaccines were not trialled in children aged under 16 years and have not been approved for paediatric administration.
People with allergies
People with food, nut, egg, antibiotic or latex allergies can safely receive either the Pfizer or Oxford-AstraZeneca vaccine. People with known allergies to vaccine ingredients should not receive the relevant vaccine.18 These include PEG (Pfizer vaccine) and polysorbate 80 (Oxford-AstraZeneca vaccine).27 A full list of vaccine excipients is available in the Product Information.13,14
Emerging SARS-COV-2 strains and future vaccine directions
New variants of SARS-COV-2 are emerging. Subanalyses of the AstraZeneca vaccine studies reported 74.6% efficacy against the B.1.1.7 (‘UK’ or ‘Kent’) variant but noted that only a small number of people were infected with this variant in the initial trials (N = 34).8 Pfizer has examined the effect of vaccine antibodies against the B.1.1.7 variant and found no difference in neutralisation effect compared with the vaccine effect on wildtype SARS-CoV-2.28