What Are The Medical Exemptions For Not Getting A Covid-19 Vaccine?

Vaccine mandates and vaccine passports are an incredibly controversial topic of discussion, with many people claiming that they have medical conditions which make them exempt from vaccination. Several large companies have recently moved to introduce vaccine requirements for staff, including Facebook, Cisco and Walmart as well as the federal government and local governments. Additionally, New York requires all healthcare workers to be vaccinated and in San Francisco, people must show evidence of Covid-19 vaccination to access venues such as bars, restaurants and movie theaters.

Whether you agree with them or not, vaccine requirements have arrived and one opinion which seems to be fairly universally held, is that people with genuine medical conditions preventing them from getting vaccinated against Covid-19 should not be subject to these mandates or passports and doing so would be discriminatory. But what are these medical conditions and how many people do they affect? Well, the answer might surprise you:

There are no known medical conditions which absolutely prevent a person from getting a Covid-19 vaccine.

However, as with everything during the pandemic nothing is simple and there are rare circumstances where people should consult with physicians to help them make an informed decision and manage any potential risk. One of these health conditions which is somewhat of a murky gray area is known severe allergies either to previous vaccines or to the first shot of a Covid-19 vaccine and the CDC currently provides guidance on what people with these allergies should do.

“Around 5 in a million people experience what appears to be a severe allergic reaction to the Covid-19 vaccines,” said David Stukus, MD, a Professor of Pediatrics in the Division of Allergy and Immunology at Nationwide Children’s Hospital in Columbus, Ohio. “We initially thought that individuals with allergy to vaccine ingredients called polyethylene glycol, or polysorbate may have been those experiencing reactions because there are virtually no other components of the mRNA vaccines or Johnson & Johnson that are really identified as causes of allergic reaction. But after investigation, these don’t appear to be the cause of this very rare anaphylaxis,” added Stukus.

Anaphylaxis, which can also be caused by everything from bee stings to certain foods for some people, is a potentially life-threatening condition if untreated and studies are ongoing at the National Institutes of Health and other academic centers to identify the cause of these rare allergic reactions to Covid-19 vaccines. If you’ve had a Covid-19 vaccine and been asked to wait for 15-30 minutes after your shot, monitoring for a severe immune reaction such as anaphylaxis is the main reason. But although this sounds scary, if every single person in the U.S. got a Covid-19 vaccine, only 1,600 people would experience this and it is easily treatable.

“Anaphylaxis can occur very rapidly after vaccine administration. It is very easily treatable with epinephrine, and other medications. And all of the people who had reported anaphylaxis recovered eventually, I’m not aware of any person who has died from anaphylaxis after a Covid-19 vaccine,” said Stukus.

To put this in context, the chance of getting an allergic reaction from a Covid-19 shot is similar to having been struck by lightning since the pandemic started, where the chances are 2 in a million, annually. Stukus also suggests that some reactions initially identified as an allergic, anaphylactic response may not even be that in reality.

“Many of these suspected allergic reactions simply aren’t due to allergy, but they have symptoms that can mimic an allergic reaction. There’s something called a vagal response which has similar symptoms – you can pass out, you get very sweaty, you get pale, you feel tingly, you can vomit, you feel pretty awful, but its not an allergic response,” said Stukus.

A recent study of 159 people who did have a certified severe allergic reaction to a Covid-19 vaccine found that 4 out of 5 of them didn’t have the same reaction when they got their second shot. For the 20% of people who did – these reactions were easily managed with medication.

“After several billion doses of the various Covid-19 vaccines across the world and hundreds of millions of doses in the United States alone, we are not seeing increased risk for allergic reactions for anybody with food, environmental medication venom or latex allergies. People who have a history of anaphylaxis can safely receive these vaccines, but they may wish to receive it in a medical facility where they can be monitored for 30 minutes with epinephrine available, just in case, more for peace of mind than anything else,” said Stukus.

So people with known allergies to vaccine components should have a discussion with a physician about their options, but it is not an automatic exemption from getting vaccinated against Covid-19 and there will be options to help them get vaccinated safely.

But what about people with other serious health conditions that can compromise their immune systems, such as people on treatment for cancer?

“There are no specific contraindications for people with cancer, although in some cases, patients might not mount an effective immune response,” said Dr Benjamin G. Neel, M.D., Ph.D. Professor of Medicine at NYU School of Medicine and Director of the Laura and Isaac Perlmutter Cancer Center.

There is a big difference between possible safety risks from Covid-19 vaccines and them simply not working as intended. For people with cancer, there have been no indications that the vaccines are unsafe or that they are more likely to get side effects but plenty of evidence that people with cancer are at more risk of severe outcomes including death should they get Covid-19.

“We strongly recommend that all of our cancer patients get the vaccine, although some patients, particularly those with blood cancers, might not develop a strong immune response to two doses of the vaccine and could benefit from a third dose,” added Neel.

Most people with cancer do mount an immune response to the vaccines, although people on certain treatments, particularly those targeting blood cells which make antibodies may not mount an effective immune response to them. Hence individual oncologists may recommend a delay to Covid-19 vaccination, not based on safety concerns, but simply because the vaccines have a low chance of showing benefit.

“Our patients should not get live virus vaccines but that is not an issue with any Covid-19 vaccines that are currently approved,” said Gwen Nichols, MD, Chief Medical Officer of the Leukemia and Lymphoma Society (LLS). “Some physicians have told cancer patients particularly those receiving lymphocyte-depleting therapies (anti-CD20 antibody treatments, and others) to wait until completion of therapy to be vaccinated, but in light of the current surge, there are fewer reasons to hold off vaccination,” said Nichols.

This message is echoed by the American Cancer Society. “We continue to encourage everyone who is eligible to get vaccinated, including cancer patients and caregivers in consultation with their health care providers, along with continued use of masks while we are seeing so many areas with high levels of community transmission,” said CEO, Karen Knudsen, MD.

Booster shots are now recommended for immunocompromised people which includes many people with cancer, after evidence that a third shot may be able to improve a poor or absent initial immune response.

As for everything else? Well, there really are no other known medical conditions which clearly warrant consideration for a vaccine exemption in those > 12 years old who are currently eligible.

Phobia of needles has been found to be a cause of vaccine hesitancy in some people and The American Psychological Society is one of several organizations which has shared tips and guidelines for how best to support and accommodate people who have a needle phobia. However, the vaccine is not dangerous for people with needle phobias and this is highly unlikely to be considered a valid reason for an exemption.

In addition, the vaccines have been linked very rarely with the development of heart inflammation in teenagers, especially males, but the current recommendations are that the risks associated with Covid-19 are higher in this age group than the risk from the vaccine and the CDC currently recommends the vaccine for all people aged 12 and over.

So, there are no definite medical exemptions to vaccination with Covid-19 vaccines and the people for which this is a murky gray area likely number only in the thousands in the U.S., a tiny fraction of a percent of the population, not millions of people as some have claimed. Most people are unlikely to ever meet or know someone with a health condition which might qualify them for a medical exemption from vaccination against Covid-19 and these people should consult with a physician to discuss their options.

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Janelle B. Smith

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