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by Dr. C.H. Weaver M.D. updated 10/2021

COVID-19 Vaccines

The Pfizer-BioNTech COVID‐19, Moderna and Johnson & Johnson vaccines are available for active immunization to prevent COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 

The United States Food and Drug Administration amended the emergency use authorizations for the Moderna and the Pfizer-BioNTech Covid-19 vaccines  to allow people with compromised immune systems unable to mount an adequate immune response against the virus to get a third “booster” dose. The hope is that the booster dose will provide patients with improved protection similar to people without weakened immune systems. The amended EUAs apply only to third doses of the Pfizer and Moderna vaccines. New research in immunocompromised patients published shows that the Moderna vaccine increases antibody levels and research from Israel shows a booster dose reduces the risk of severe infection and hospitalization.34,36

Initially prioritized for essential workers, people over age 65 and individuals with underlying health conditions that increase the risk for severe COVID-19 vaccines are widely available throughout the United States to most individuals seeking vaccination and should be considered because vaccination prevents COVID-19 in cancer patients.

Latest Data on Vaccine Effectiveness 

The VOICE study measured responses to Moderna’s two-dose mRNA-1273 vaccine. The study enrolled 791 patients with solid tumors from hospitals throughout the Netherlands and placed them in four cohorts: individuals without cancer; patients with cancer treated with immunotherapy; patients treated with chemotherapy; and patients treated with a chemo-immunotherapy combination. The patients received antibody tests 28 days after the second shot. Adequate antibody levels – by the researchers’ own definition – were found in 84% of patients receiving chemotherapy, 93% receiving immunotherapy, and 89% receiving a chemo-immunotherapy combination, compared to 99.6% of individuals without cancer.38

Effective in Cancer Patients 

The relative risk of developing COVID-19 was more than 20 times higher for unvaccinated patients with cancer than for vaccinated patients with cancer, according to findings from a real-world study in over 1000 patients presented at the European Society for Medical Oncology Congress 2021. The relative risk of developing COVID-19 was 21.5 times higher among unvaccinated patients than among vaccinated patients. Most vaccinated patients reported no side effects (39%) or mild ones (43%) and 2.4% reported severe side effects typically lasted 1 to 3 days. The most common were sore arm, headache, fatigue, and increased temperature. Less common were swollen lymph nodes (0.7%) and allergic reactions (0.7%).35

'Lagging' Response

The two-dose Pfizer-BioNTech COVID-19 vaccine provides an effective immune response and is safe in people undergoing treatment for certain types of cancer, according to a study published in the June 2021, JAMA Oncology. Compared to individuals without cancer however, people with breast, colon and lung cancers, appear to have a "lagging" immune response to the vaccine.

Israeli researchers compared antibody responses after vaccination with the Pfizer-BioNTech vaccine in 232 adults receiving chemotherapy or radiation treatment for cancer with those of 220 healthy adults. After the first dose, 29% of the cancer patients had detectable antibodies in their blood, compared with 84% of those without the disease and 86% had detectable levels in their blood after the second dose. The researchers, who are monitoring the cancer patients for six months to determine if their immune response declines and a booster dose is needed.

How Do the Vaccines Work?

A vaccine is designed to trigger a controlled immune system response that trains the body to fight a foreign invader (virus, bacteria) if the body encounters the invader again in the future. The coronavirus is studded with spike proteins that protrude and allow the virus to enter your cells where they start replicating. Spike proteins are recognized as “foreign” and serve as a target for the immune system.

The two vaccines are the first of a new type of vaccine based on messenger RNA (mRNA). Instead of injecting a weakened or killed virus into the body, mRNA vaccines teach cells how to make a protein—or even just a piece of a protein—that triggers an immune response.

How is the vaccine given?

The vaccine is injected into the muscle of your upper arm. The vaccine is given in 2 doses at 21 days interval and we expect patients receiving the vaccine to be immune 2-3 weeks after their second dose of vaccine.

How effective are the mRNA vaccines?

Both vaccines appear highly effective resulting in a measurable immune response in over 94% of vaccinated individuals by seven days after getting the second dose. Because it takes your body about two weeks to make enough antibodies to mount a response to the virus an immune response is evident as early as 14 days after the first dose, but the effectiveness was only about 50%.1-3

The Food and Drug Administration (FDA) has expanded the Emergency Use Authorization (EUA) for the Pfizer-BioNTech COVID-19 Vaccine to include adolescents 12 to 15 years of age. Previously, the vaccine had only been authorized to prevent COVID-19 in patients 16 years of age and older.22

As for effectiveness, analysis of immunogenicity data showed that immune responses to the vaccine in the adolescent group (n=190) were non-inferior to those observed in older participants (16 to 25 years; n=170). Additionally, a review of COVID-19 cases that occurred 7 days after the second dose among 12 to 15 year olds without evidence of prior SARS-CoV-2 infection demonstrated that the vaccine was 100% effective in preventing COVID-19. No cases occurred among the 1005 participants who received the vaccine, while 16 were reported among the 978 placebo recipients.

How Long Does Immunity Last?

The answer to this question has long been awaited and the early evidence looks good. Top line data from the phase 3 study evaluating the Pfizer-BioNTech COVID-19 vaccine released in April 2021 shows that it is highly effective beyond 6 months after the second dose - vaccine efficacy was observed to be 91.3%. The vaccine was 100% effective at preventing severe COVID-19 disease and 100% effective in preventing the COVID-19 B.1.351 South Africa variant.19

Antibodies elicited by the Moderna COVID-19 vaccine also persisted through 6 months after the second dose, according to new data published in The New England Journal of Medicine.(20) According to Moderna the vaccine may be effective up to one year.

Single dose vaccination with Pfizer was found to be 63% effective in residents of nursing homes suggesting the importance of getting both vaccine doses.21

Many people who have been infected with SARS-CoV-2 will probably make antibodies against the virus for most of their lives according to researchers who have identified long-lived antibody-producing cells in the bone marrow of people who have recovered from COVID-19. Antibodies recognize and help to inactivate viral particles after a new infection. The short-lived cells that produce the antibodies are called plasmablasts and they recede soon after virus is cleared from the body. Longer-lasting memory B cells watch for reinfection and produce antibodies should the virus reappear and bone marrow plasma cells (BMPCs) that reside in the bone marrow can produce antibodies for decades.

Researchers tracked antibody production in 77 people who had recovered from mostly mild cases of COVID-19. As expected, SARS-CoV-2 antibodies decreased in the four months after infection. But this decline slowed, and up to 11 months after infection, the researchers could still detect antibodies that recognized the SARS-CoV-2 spike protein. The scientists found low but detectable populations of BMPCs whose formation had been triggered by the individuals’ coronavirus infections 7–8 months before. While it’s unclear what antibody levels will look like in the long term and whether they offer protection, it is now clear that BMPCs can produce antibodies a year after infection. The persistence of antibody production following vaccination or infection however does not ensure long-lasting immunity to COVID-19. SARS-CoV-2 variants may avoid the protective effects of antibodies and additional “booster” immunizations may be needed to restore antibody levels.23,24

Update on COVID-19 Booster Shot

dddPfizer-BioNTech COVID-19 vaccine administration of a “booster” vaccine 6 months after the primary 2-dose series elicits high neutralization titers against both the wild type and the Beta variant (B.1.351) Corona Virus. A third dose further boosts antibody titers against the Delta variant, and new research shows that the booster reduces the risk of severe illness and hospitalization from.36

Moderna: Moderna reports its vaccine is 93% effective six months after the second dose. It’s important to understand however that immunity against the coronavirus will continue to wane and eventually diminish vaccine efficacy. To improve vaccine effectiveness Moderna also believes a booster shoot will likely be necessary prior to the winter season. Study results suggest a booster dose produced a “robust” antibody response against three variants, including delta. Israel has already announced the country would give booster doses to its elderly population.33

Vaccine effectiveness diminishes over time, and a booster “may be needed within six to 12 months after full vaccination. Pfizer representatives have met with U.S. officials to press their case for emergency authorization of a third dose.28 Initially the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention said that Americans who have been fully vaccinated “do not need a booster shot,” because the vaccines remain highly effective against severe disease and death. In fact, CDC director Rochelle Walensky reported that more than 99% of U.S. COVID-19 deaths in June were in unvaccinated people.29

So who’s right? and why wouldn't you develop the booster program as early as possible just to be cautious? This is especially true for immunocompromised individuals like cancer patients who are most at risk of dying from COIVD-19? How long does immunity last among the fully vaccinated? If you have immunity, you don't need a booster. Data from Israel published Sept 15, 2021 shows that a booster reduces the risk of severe infection and hospitalization.36

A study of COVID vaccine boosters suggests Moderna or Pfizer works best and both were approved by the FDA in October 2021 - reversing the previous position.

A study by the National Institutes of Health suggested people who got the J&J vaccine as their initial vaccination against the coronavirus may get their best protection from choosing an mRNA vaccine as the booster. If you got the Johnson & Johnson vaccine as your first COVID-19 shot, a booster dose of either the Moderna or Pfizer-BioNTech vaccine apparently could produce a stronger immune response than a second dose of J&J's vaccine. And if you started out with either Pfizer or Moderna, it probably doesn't matter that much.

The bodies adaptive immune system targets specific viruses by producing antibodies against a unique virus like COVID-19 to protect us in both the short and long term. When the bodies B and T lymphocyte cells respond to a virus they create germinal centers in the lymph nodes which is where plasma cells learn how to make antibodies to fight the COVID-19 infection. The germinal centers also produce memory cells which go into action and eliminate an infection when your re-exposed. Recent research suggests germinal centers take 15 weeks or longer to form after vaccination and their production of memory cells may provide longer term immunity to COVID-19 lasting years.30 Studies have shown however that the levels of neutralizing antibodies generated by the COVID vaccines do decline over time.31

Israel’s Ministry of Health has reported a decrease in vaccine effectiveness over time to 64% for preventing both infection and symptomatic illness but remains 93% effective in preventing serious illness and hospitalization.32 Although the vaccine may no longer be producing levels of antibodies that protect people entirely from infection, the long-term memory response is still working and protecting people from serious illness and death. 

Pfizer said that a third dose of its vaccine elicits an antibody response five to 10 times higher than after two doses. Measuring antibody levels as a surrogate endpoint for effectiveness to guide policy however may be the wrong measure – what we really care about is preventing serious illness. The U.K. government in fact recently announced that they are considering using actual serious COVID illness as a benchmark for guiding policy instead of infection as measured by antibodies. 

Currently non-immunocompromised fully vaccinated individuals appear to have the best available protection against serious illness from COVID-19 and focusing on getting the unvaccinated vaccinated should remain a priority. But what’s the harm in being prepared for the time when boosters may be needed? Developing a booster and getting safety data should be a priority especially for those most at risk. Our responsibility should be to protect those who are most vulnerable. 

Johnson & Johnson COVID Vaccine

The Johnson & Johnson vaccine candidate unlike Pfizer and Moderna, uses a human adenovirus that has been modified to no longer replicated in humans and cannot cause disease. The vaccine is reported to be 66% effective in preventing moderate to severe COVID-19 at 28 days post-vaccination. The vaccine is reported to be 85% effective in preventing severe/critical COVID-19. Moreover, the vaccine demonstrated complete protection against COVID-19 related hospitalization and death at 28 days post vaccination. Onset of protection was observed as early as day 14 and there were no reported COVID-19-related deaths in vaccinated individuals.

Vaccine roll out was halted due to concerns about blot clots occurring in several women of child bearing age, including one fatality.9,10 On Friday, April 23, 2021 the US FDA Advisory Committee on Immunization Practices voted to recommend resuming the use of the Johnson& Johnson COVID-19 vaccine based on their assessment that the benefits clearly outweigh the risks. Currently there are 6 reported cases of blood clots including one fatality in women between age 18 and 48 in the first 6.8 million vaccine doses administered.

AstraZeneca Vaccine

AstraZeneca has reported that its COVID-19 vaccine had a 79% efficacy rate at preventing symptomatic COVID and was 100% effective in stopping severe disease and hospitalization across all ages including people over 65. On Thursday, the European Medicines Agency concluded after an investigation that the vaccine did not raise the overall risk of blood clots.

The AstraZeneca vaccine is different than the Moderna and Pfizer vaccines. It is a “viral vector” vaccine. The vaccine uses a harmless cold virus that normally infects chimpanzees to carry the COVID spike protein’s genetic material into the body, which produces some harmless protein that primes the immune system to react to the real COVID virus.37

COVID Vaccination and Cancer – Answers to Frequently Asked Questions

Are doctors recommending vaccination to all cancer patients?

Having cancer regardless of treatment status is a risk factor for worse outcome from infections including influenza and COVID-19. The short answer is yes once COVID-19 vaccines become more widely available. In terms of prioritization, and according to CDC guidelines, cancer patients will be part of the phase II wave of vaccination which will occur sometime in February. The vaccine is given in 2 doses at 21 days interval and we expect patients receiving the vaccine to be immune 2-3 weeks after their second dose of vaccine.

  • [Vaccine effectiveness in lymphoma-myeloma patients](Vaccine Effectiveness in Cancer Patients)

For newly diagnosed cancer patients - will the goal be to vaccinate before treatment?

Ideally, it is best to vaccinate before treatment as the immune response to the vaccine may be impaired in patients receiving chemotherapy. The vaccine is optimally administered at least two weeks before chemotherapy starts.

If on chemotherapy or immunotherapy will treatment be changed in anyway in order to vaccinate?

Other than timing, there should be no major changes to your plan of treatment relative to vaccine administration. It is important to note that other measures taken by your treating physician about the safety of administering the vaccine such as blood counts, concern regarding allergic reactions and others should be taken in consideration to decide on timing and appropriateness of vaccination.

How soon can vaccination occur after completion of chemotherapy or immunotherapy?

There have been conflicting results regarding the immunogenicity of immunization on the first day of the chemotherapy cycle, with one study showing poor immune protection but another study showing good protection from the flu vaccine. Since there is not enough data for the COVID vaccine, we assume similarities and recommend vaccination at the one-week mark from the start of the chemotherapy cycle.

Regarding immunotherapy, studies are relatively conflicting, but a recent study suggests that the flu vaccine does not worsen the toxicities of this type of therapy. Since COVID-19 infection can be very severe and potentially lethal for patients undergoing chemotherapy or immunotherapy, we will be recommending vaccination for all patients with cancer as we continue to study this question further.

What SARS-CoV-2 vaccines are approved for use in immunocompromised patients?

No current clinical trials of a COVID-19 vaccine have enrolled immunocompromised patients. Thus, the effectiveness and safety of a SARS-CoV-2 vaccine has not been established in the different immunocompromised patient populations.

Is it safe to receive a COVID-19 vaccine if someone has undergone a stem cell transplant?

In patients who have had a stem cell transplant, their immune systems are incapable of reacting to a vaccine for at least three months following the actual transplant - most centers recommend delaying all vaccines for at least three months following stem cell transplant,

Why might some cancer patients not respond to vaccines?

In order for the vaccine to generate protective immunity functional host immunity is required. The host must be able to correctly present the antigen to the immune system so B and T cell activation can occur, and plasma B cell antibody generated. People lacking functional adaptive immune cells may be unable to generate a fully protective immune response to a SARS-CoV-2 vaccine.

According to the American Society of Hematology the following immunocompromised patients could have attenuated or absent response to a SARS-CoV-2 vaccine.4

  • Immunodeficiencies involving adaptive immunity
  • Splenectomy or functional asplenia (sickle cell disease)
  • B cell directed therapies against CD20 or CD22, bispecific agents like blinatumomab, CD19 or CD22-directed CAR-T cell therapies and BTK inhibitors)
  • T cell directed therapies (antithymocyte globulin, alemtuzumab)
  • Many chemotherapy regimens
  • High-dose corticosteroids
  • Stem Cell Transplant patients - especially within the first 3-6 months after autologous and often longer after allogeneic.
  • Graft-vs.-host disease (GVHD)
  • Low white blood cell counts. (neutropenia ANC<500/μL, lymphopenia ALC<200/μL)

According to a study published in JAMA Oncology the COVID vaccine does work for many people receiving treatment for cancer, even with a lower immune response than those without the disease. In the study doctors compared the immune response to the Pfizer-BioNTech vaccine in 102 cancer patients with those of 78 people who did not have the disease. They found that 90% of patients being treated for cancer and given the two-dose Pfizer-BioNTech vaccine tested positive for antibodies against the coronavirus two weeks after their second shot. The levels of antibodies were about 70% lower than those of people without cancer, but they were still high enough to provide protection against infection according to the researchers. Cancer patients who produced antibodies following vaccination still had levels above the minimum threshold for protection against the virus.22

Are there and theoretical concerns with RNA vaccines in immunocompromised patients?

Theoretical concerns for their use include a hyper-inflammatory response, which was described in some animal models.5 This effect has not been demonstrated in humans. Another concern is the development of autoimmune syndromes related to the increased type I interferon response elicited by an mRNA/DNA vaccine.6

Given patients with chronic lymphocytic leukemia, lymphoma or myelodysplasia and patients after allogeneic hematopoietic cell transplantation may be prone to other immune-mediated complications, there is some concern that generating anti-SARS-CoV-2 antibodies in these patients could lead to immune enhancement and a systemic inflammatory response akin to what is seen with multisystem inflammatory syndrome in children (MIS-C).

If immunocompromised patients were not included in the vaccine trials and are less likely to respond to a SARS-CoV-2 vaccine, should they still receive it?

Most experts recommend vaccination as long as the vaccine is safe for use, even if the expected protection rate is lower than the general population because the risks of getting COVID-19 infection in patients with cancer is significant.

The risks and benefits for immunocompromised patients receiving a SARS-CoV-2 vaccine should be weighed on a case-by-case basis, with consideration of the incidence of infection in the community. This will depend on the approved vaccine formulation available, level of immunosuppression the patient has received, and the underlying reason for immunosuppressive therapy (e.g., cancer treatment, transplantation).

When should patients on immunosuppressive therapy by vaccinated?

Vaccination is recommended at least 2-4 weeks prior to the planned immunosuppressive therapy, transplant or splenectomy. If the patient is receiving or has received immunosuppressive therapy, consider vaccination 6 months after the patient has been taken off therapy to increase the likelihood of developing immunity. After hematopoietic cell transplantation vaccines are generally started after 3-6 months.

What Don't we know about the Vaccines?

  • Does vaccination protect against asymptomatic cases of COVID-19?
  • Does vaccination prevent transmission of COVID-19?
  • How long does protection last?
  • Until this data is available, it’s important to remember that getting vaccinated is not a passport to a pre-COVID life. People who are vaccinated still need to wear face masks and practice social distancing.
  • We are still learning about potential longer term side effects including blood clots, myocarditis and other forms of inflammation. 

Who should not get vaccinated?

The fact sheet says that you should not get the Pfizer-BioNTech COVID-19 vaccine if you:

  • had a severe allergic reaction after a previous dose of this vaccine.
  • had a severe allergic reaction to any ingredient of this vaccine

What if I have a history of allergies?

The American College of Allergy, Asthma, and Immunology released a statement offering guidance to patients with allergies7 and updated its guidelines regarding the risk for allergic reactions with COVID-19 vaccines on March 25th, 2021.

All individuals planning to be vaccinated should be screened to determine the possible risk for allergic reaction and those with a history of severe allergic reaction to other vaccines should be referred to an allergist/immunologist for further evaluation. Anyone with a severe or immediate allergic reaction of any severity within 4 hours of receiving the first COVID-19 shot should not receive the second dose and may be referred to an allergist/immunologist.

People who have received dermal fillers may develop swelling at or near the site of filled injection following mRNA COVID-19 vaccination; this occurs infrequently and seems to be temporary. Individuals receiving the mRNA COVID-19 vaccine should expect local and systemic post vaccination symptoms, which are expected side effects and not allergic reactions.

  • Allergic reactions to vaccines, in general, are rare with the incidence of anaphylaxis estimated at 1.31 in 1 million doses given.
  • Individuals with common allergies to medications, foods, inhalants, insects, and latex are no more likely than the general public to have an allergic reaction to the Pfizer-BioNTech COVID-19 vaccine. Those patients should be informed of the benefits of the vaccine versus its risks.
  • The Pfizer-BioNTech COVID-19 vaccine should be administered in a health care setting where anaphylaxis can be treated. All individuals must be observed for at least 20-30 minutes after injection to monitor for any adverse reaction. All anaphylactic reactions should be managed immediately, with epinephrine as the first line treatment.
  • The Pfizer-BioNTech COVID-19 vaccine should not be administered to individuals with a known history of a severe allergic reaction to polyethylene glycol as it is a component of this vaccine that is known to cause anaphylaxis.
  • Data related to risk in individuals with a history of allergic reactions to previous vaccinations and/or mast cell activation syndrome/idiopathic anaphylaxis is very limited and evolving. A decision to receive the Pfizer-BioNTech COVID-19 vaccine should be undertaken by you with your physician or other provider administering the vaccine using their professional judgment balancing the benefits and risks associated with taking the vaccine.

What are the vaccine’s side effects?

The most common side effects reported in the clinical trials were pain at the injection site, fatigue, and fever. Serious side effects have been rare but may include blood clots in women of childbearing age and myocarditis in younger individuals. Reported side effects of the vaccines include:

· Injection site pain

· Tiredness

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· Headache

· Muscle pain

· Chills

· Joint pain

· Fever

· Injection site swelling

· Injection site redness

· Nausea

· Feeling unwell

· Swollen lymph nodes (lymphadenopathy)

What is known about the risk of myocarditis and COVID vaccination?

The Food and Drug Administration is expected to add a warning to the Centers for Disease Control and Prevention’s fact sheet about the risk of myocarditis and pericarditis following the second dose of the Pfizer and Moderna vaccine.

Myocarditis is characterized as inflammation of the heart muscle. Pericarditis is inflammation of the tissue surrounding the heart. Symptoms may include chest pain, shortness of breath and heart palpitations. Individuals developing myocarditis are typically under age 30 and symptoms appear 4-8 days after vaccination, more commonly after the second dose of the mRNA vaccine.

The CDC says 323 cases of heart inflammation have been confirmed after the second dose of the Pfizer or Moderna vaccine. More than 250 possible cases are still being investigated. According to the voluntary, self-reporting Vaccine Adverse Event Reporting System, the rate of myocarditis among adolescents 12 through 17 who received a COVID-19 vaccine was 1.8 per 100,000. For boys, it was 3.2 per 100,000. Higher rates of myocarditis have not been reported in individuals receiving the single-dose Johnson & Johnson vaccine, which does not use the mRNA technology.

Vaccination may also prevent long-term symptoms, and a hyper-inflammatory condition called MIS-C, which strikes an estimated 1 of every 3,200 children infected with SARS-CoV-2 (SN: 5/12/20).

For more information visit the CDC and VAERS website.

https://vaers.hhs.gov/reportevent.html

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html

https://www.cdc.gov/vaccines/covid-19/clinical-considerations/myocarditis.html

Are you recommending the vaccine to patients with cancer, lymphoma, and leukemia?

Having cancer regardless of treatment status is a risk factor for a worse outcome from infections including influenza and COVID-19. The short answer is yes, COVID-19 vaccination is being recommended for all individuals with cancer and blood malignancies. According to CDC guidelines, cancer patients were part of the phase II wave of vaccination.

Is there a difference between the Pfizer, Moderna and JNJ vaccines?

The Pfizer and Moderna vaccines appear to have similar effectiveness and no differences between the two are yet apparent. These vaccines are given in 2 doses at 21 day intervals. We expect patients receiving the first vaccine dose to be developing immunity within 2 weeks and to achieve their full immune responses 2-3 weeks after their second dose of vaccine. The JNJ vaccine only requires a single injection but appears slightly less effective.

Are both vaccine doses necessary?

According to data released on March 12th 2021 the Pfizer-BioNTech vaccine provides less protection in cancer patients after a single dose than in healthy individuals but the second dose of the vaccine at three weeks improves protection significantly.

The two-dose Pfizer-BioNTech COVID-19 vaccine provides an effective immune response and is safe in people undergoing treatment for certain types of cancer. Compared to individuals without cancer however, people with breast, colon and lung cancers, appear to have a "lagging" immune response to the vaccine.

Israeli researchers compared antibody responses after vaccination with the Pfizer-BioNTech vaccine in 232 adults receiving chemotherapy or radiation treatment for cancer with those of 220 healthy adults. After the first dose, 29% of the cancer patients had detectable antibodies in their blood, compared with 84% of those without the disease and 86% had detectable levels in their blood after the second dose. The researchers, who are monitoring the cancer patients for six months to determine if their immune response declines and a booster dose is needed.25

Pfizer currently recommends 21 days between vaccine doses but because the UK's vaccine strategy currently involves a 12-week gap between doses doctors were able to assess vaccinated individual’s immune response following a single dose.

The immune response to the vaccine was evaluated in 54 healthy volunteers and 151 elderly patients with cancer or leukemia by measuring blood antibody and T cells levels to determine the level of immune response generated against the coronavirus. Three weeks after one dose of the vaccine an antibody response was found in 39% of solid cancer patients and just 13% of people with blood cancer. The response in healthy volunteers was 97%.In the solid cancer patients who received a second dose three weeks after the first, the antibody response shot up to 95% within two weeks of the boost.

Further evidence of the need for a boost was shown by the fact that antibody levels only increased to 43% in people with solid cancers and 8% in those with blood cancer five weeks after their first dose. It was 100% in healthy volunteers.

The data provides the first real-world evidence of immune effectiveness following one dose of the Pfizer vaccine in immunocompromised patients. Following the first dose, most cancer patients remained immunologically unprotected up until at least five weeks following primary injection. The poor one dose effectiveness can be rescued with an early booster at day 21.

These results suggest that the vaccines may well not protect patients with cancer as well as those without cancer and that cancer patients should continue to observe social distancing and shielding. The study did not evaluate single dose vaccines but suggests delayed immune responses in cancer patients are probable.10

Long-term side effects have not been defined for SARS-CoV-2 vaccines and will be available once phase 3 trials have followed longer. A national monitoring system exists for reporting vaccine-related adverse events.

What about 'mixing and matching' the vaccines?

There is no evidence yet on whether switching vaccines makes any difference. There are already trials underway to test whether this might work for the Covid-19 vaccines.14

Timing of Vaccination

It is recommended that all patients with cancer receive the COVID-19 vaccine, however there are some individuals who may need to wait to ensure that their immune system responds to the vaccine. The NCCN advises patients who have undergone an allogeneic or autologous transplant or chimeric antigen receptor T (CAR-T) cell therapy to wait a minimum of 3 months to receive the vaccine.11

Can I get the vaccine while receiving chemotherapy?

Yes. Having cancer regardless of treatment status is a risk factor for worse outcome from infections with influenza and COVID-19. Some individuals with suppressed immune systems may not respond to the vaccine as well as others but this is not a reason not to get the vaccine. Patients who received intensive cytotoxic chemotherapy and experienced a resulting decrease in absolute neutrophil count should wait until the neutrophil count recovers to receive the vaccine. It is also advised that patients who underwent a major surgery wait a few days to be vaccinated. All other patients with cancer, regardless of their type of treatment, should receive the vaccine as soon as it is made available to them, according to the NCCN.11

What if I am about to start chemotherapy?

If possible, it is advised to delay starting chemo until 2 weeks after completing the Covid 19 vaccine series in order to max out the protective benefit from the vaccine.

· Learn more about vaccination here.

Is it safe to receive a COVID-19 vaccine if someone has undergone a stem cell transplant?

In patients who have had a stem cell transplant, their immune systems are incapable of reacting to a vaccine for at least three months following the actual transplant - most centers recommend delaying all vaccines for at least three months following stem cell transplant.

I have lymphoma and I received my second vaccine dose two weeks ago. Someone told me I would only be good about 50% instead of 95% is this true?

Lymphoma patients definitely can have a lower vaccine response and 50% is possible. Lower response rates are more likely if you are on therapy or on maintenance.

Should Rituxan (or other chemo) maintenance be held during COVID vaccination?

The answer to this is unknown but B-cell suppression typically lasts for at least 9 months after the completion of Rituxan. I would discuss with your oncologist whether Rituxan can be held safely for a prolonged period of time. If not, I would proceed with the COVID-19 vaccine whenever you can get it. Unfortunately, we still do not know the efficacy of the COVID vaccine for lymphoma patients who are actively receiving therapy.

I have been in remission from lymphoma for 2 1/2 years, has my immune system fully recovered to take the COVID-19 vaccine?

Assuming you are not on any type of maintenance therapy your immune system is completely or nearly completely recovered and the CDC and other MD groups would recommend vaccination at this time.

I have cancer, should I get the Flu Vaccine as well?

There are no data regarding the timing of the flu vaccine and the COVID19 vaccine, but I would probably not get the flu vaccine until at least a few weeks after the Covid vaccine. In the future make sure you obtain the flu vaccine very year early in the flu season.

I’ve had multiple types of chemo, radiation and stem cell transplant. My immune system did not recover, and I’ve been getting IVIG since 3/2020. Are there recommendations on when to get the vaccine?

There are no firm guidelines as to when to receive the COVID-19 vaccine in relation to an IVIG infusion. For my own patients, I am trying to do this at least 2-3 weeks after IVIG.​

Is there an estimate of the efficacy of the vaccine in the immunocompromised (percentage-wise)?

No data yet - it is however likely to be less effective than it is in people with a normal immune system - this however is not a reason to not get vaccinated.

​I have a blood cancer and am on chemotherapy and have compromised immune system and take prolia for bones, is it ok to get covid vaccine. I am 83 yrs old in ok health.

The short answer is yes, the vaccines however were not evaluated in patients with blood disorders and compromised immune systems so we are not certain how effective they will be - the CDC is recommending cancer patients should get the vaccine. You should however discuss vaccination with the doctor.

Vaccine Safety & Side Effects

I am concerned about the safety of the two RNA vaccines in general. Are there any studies on the safety and efficacy in lymphoma patients and these vaccines?

So far data shows excellent safety, most of vaccines adverse events occur on short term historically and there had been no concerns with the mRNA vaccines and enough follow up now in terms of safety, we don’t have data on efficacy among patients with MPN, there is zero harm as the vaccine does not contain any virus killed or attenuated.

What is known about the risk of myocarditis and COVID vaccination?

The Food and Drug Administration is expected to add a warning to the Centers for Disease Control and Prevention’s fact sheet about the risk of myocarditis and pericarditis following the second dose of the Pfizer and Moderna vaccine.

Myocarditis is characterized as inflammation of the heart muscle. Pericarditis is inflammation of the tissue surrounding the heart. Symptoms may include chest pain, shortness of breath and heart palpitations. Individuals developing myocarditis are typically under age 30 and symptoms appear 4-8 days after vaccination, more commonly after the second dose of the mRNA vaccine.

The CDC says 323 cases of heart inflammation have been confirmed after the second dose of the Pfizer or Moderna vaccine. More than 250 possible cases are still being investigated. According to the voluntary, self-reporting Vaccine Adverse Event Reporting System, the rate of myocarditis among adolescents 12 through 17 who received a COVID-19 vaccine was 1.8 per 100,000. For boys, it was 3.2 per 100,000. Higher rates of myocarditis have not been reported in individuals receiving the single-dose Johnson & Johnson vaccine, which does not use the mRNA technology.

Vaccination may also prevent long-term symptoms, and a hyper-inflammatory condition called MIS-C, which strikes an estimated 1 of every 3,200 children infected with SARS-CoV-2 (SN: 5/12/20).

For more information visit the CDC and VAERS website.

https://vaers.hhs.gov/reportevent.html

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html

https://www.cdc.gov/vaccines/covid-19/clinical-considerations/myocarditis.html

My friend says that the Pfizer mRNA vaccine may cause covid19 illness in some people, is it true?

Absolutely not, there is no virus in the vaccine​.

Do the vaccines cause local injection site side effects?

Immediate injection-site reactions have been observed in 84% of individuals after the first dose and reports suggest that delayed injection-site reactions on or after day 8 occur in ~1% after the second dose. Reactions consist of redness, swelling and tenderness, typically resolve over 4 to 5 days and are due to a delayed-type or T-cell–mediated hypersensitivity. Neither local injection-site reactions nor delayed-type hypersensitivity reactions are contraindications to subsequent vaccination.17,18

Covid vaccination seems to cause adenopathy. I received the vaccine ...currently waiting for second dose...I have a PET scan scheduled for recent diagnosis of follicular lymphoma for two weeks after second dose. Will the vaccine give false positive for more aggressive cancer?

It is very unlikely that the PET/CT will show findings consistent with a higher-grade lymphoma. However, if you’re concerned about this possibility, you can speak with your oncologist about deferring the PET/CT for another two weeks.

I am Vaccinated, Now What?

Because cancer patients may not attain a full immune response the risk of infection with COVID-19 remains at some level. Hand washing, distancing, and mask wearing should continue especially in parts of the country where a “surge” in infections is occurring until we learn more about immunity and COVID risk in vaccinated cancer patients.

How long after vaccination does immunity take to develop?

It seems that some protection starts to appear about 2 weeks after the first dose, and then this increases over time. But we don’t yet know how long protection lasts. Individuals can prolong immunity with a second booster dose to make sure the immune system can consolidate the protection.

Do the vaccines prevent you from spreading coronavirus?

Evidence is starting to emerge showing that vaccination can also reduce the spread of infection. Studies of healthcare workers getting the Pfizer vaccine in Israel have reported both a drop in illness and in infections.

CDC Updates Travel Guidance for Individuals Fully Vaccinated Against COVID-19

Individuals are considered fully vaccinated at least 2 weeks after they have received the COVID-19 vaccine. Fully vaccinated individuals can travel within the United States (US) without having the need for COVID-19 testing or post-travel self-quarantine. While traveling, fully vaccinated individuals should take proper COVID-19 precautions such as wearing a mask, avoiding crowds when in public, social distancing, and washing hands frequently.15

Can you still get ill with Covid-19 after vaccination?

The Covid-19 vaccines are very good but they’re not perfect. Estimates of peak efficacy are above 90%, but not quite 100%. Therefore, vaccinated individuals can still become infected. If you do get ill, it’s much less likely to be as severe. Immunity takes at least 2-3 weeks to properly develop after getting your first vaccine dose. New coronavirus variants are also emerging that might be able to avoid immunity.

The "Ask the Experts About COVID-19 and Cancer" Series

References:

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