When should patients be vaccinated, and with which version of the COVID-19 Vaccine? Learn all about how each type of vaccine works and which patients with bone marrow failure diseases should be vaccinated.
Leigh Clark: 00:00 Hi, everyone. This is Podcast for Patients, with the Aplastic Anemia and MDS International Foundation. I'm Leigh Clark, Director of Patient Services. Our podcast series is brought to you with special thanks to our patients, families, and caregivers like you, and our corporate sponsors.
00:21 Thank you so much to everyone for supporting this important series. Today, we're gonna be talking about, uh, COVID vaccines and an update on COVID-19 with Dr Veronica Dioverti, who is an infectious disease specialist at Johns Hopkins in Baltimore, Maryland. Thank you so much, Dr. Dioverti, for joining us today.
Dr. Veronica Dioverti: 00:47 Thank you for inviting.
Leigh Clark: 00:49 So, we'll get started. What are the types of vaccines that are currently available?
Dr. Veronica Dioverti: 00:56 So, there are three types of vaccines that are currently available in the United States. So, the messenger RNA vaccine, the protein sub-unit vaccine, and the vector vaccine. The messenger RNA vaccine is essentially a small molecule that tells your body how to make proteins, and so it contains a [inaudible 00:01:18] that tells your cells to make very small, harmless proteins from COVID-19 that are just like those in the virus.
01:26 These small proteins are then recognized to be different from your own, normal proteins, so that your immune system reacts against them, and triggers an antibody response. So, those two vaccines include the Pfizer Biotech vaccine and the Moderna vaccine.
01:43 The protein subunit vaccine includes Novavax, which also contains a very small viral protein subunit, also unique to COVID-19, and then when it enters your body, the immune system again reacts to it and triggers a nice antibody response.
01:59 And lastly, the vector vaccine such as the Janssen, or Johnson & Johnson, they use another virus to deliver harmless proteins that are unique to COVID-19, but the virus has been made safe and cannot cause an infection. Some things that are very important to remember, so first of all, you cannot and will not get COVID-19 from the vaccine. All these vaccines contain very small viral particles that are dead, therefore cannot cause an infection. The side effects that you get from the vaccines are not from the virus itself, but rather from your immune system's inflammatory reaction to the vaccine components.
02:41 Secondly, the vaccine will not change or damage your own genetic information. And lastly, even though you're vaccinated, you should continue to practice safe measures. So that is wearing masks, washing hands, and maintaining social distancing. The goal of the vaccines are to protect you from severe forms of the infection. You can still get infected if you're vaccinated, but will likely only have very mild symptoms.
03:09 And if you get infected and remain asymptomatic, you can still pass the virus to other people and be contagious. And so, the safety measures are still to keep both you and those around you safe.
Leigh Clark: 03:26 Who is eligible for vaccination?
Dr. Veronica Dioverti: 03:30 Just like, anybody older than six months of age is eligible. But different types of vaccine were granted approval for different ages, and so ultimately, eligibility depends on the age, the type of vaccine under consideration, and prior vaccination status. If you were previously vaccinated and had an a- adverse reaction to that particular vaccine type, that could also determine your eligibility in terms of types of vaccine you could get, too.
04:04 For example, there's a very particular situation with the Jannsen, or Johnson & Johnson COVID-19 vaccine, which is authorized for adults ages 18 years and older, for the primary series dose, in- in certain limited situations, because of the risk of thrombosis with thrombocytopenia syndrome, called TTS.
04:28 And so essentially, this vaccine can be given or offered when there's an absolute contraindication to messenger RNA vaccines, so the Moderna and the Pfizer, and to Novavax, or when a person would otherwise remain unvaccinated for COVID-19, due to limited access to other types of COVID-19 vaccines. Or, when a person wants to receive Johnson & Johnson COVID-19 vaccine despite the safety concerns identified.
Leigh Clark: 05:04 When are you considered up to date on your vaccinations?
Dr. Veronica Dioverti: 05:09 So, whether you're up to date with vaccine also depends on your age, the type of vaccine you first received, and the length of time since your last dose. If you are immunocompromised, meaning that your immune [inaudible 00:05:25 ] for several different reasons, then that also determines the numbers and types of vaccine you have to get to be considered up to date.
05:34 So, prior to jumping into a vaccination schedule, I just want to quickly review the different conditions that will put you in the category of immunocompromised. And so, those patients are actively receiving treatment for solid tumors and hematologic malignancy. Those patients that have hematologic malignancies that have been associated with poor vaccine responses, regardless of current treatment status.
06:02 And so, it doesn't matter if you're in chemo, or not, if you have, for example, chronic lymphocystic leukemia, Non-Hodgkin's lymphoma, multiple myelomas and others, you are still considered immunocompromised, then, for the vaccine. Solid organ transplants, recipients taking immunosuppressive therapy, so those include kidney, lungs, hearts and others. If you have previously received a stem cell transplant, or chimeric antigen receptor T cell therapies that are known as CAR T cell therapy. If you have a moderate or severe primary immune deficiency, meaning that you were born with that. And the most common example of common variable immunodeficiency, if you have either advanced, or untreated HIV infection.
06:50 And then, there are a number of different medications that can, uh, make your immune system weak, and that includes, for example, taking Prednisone or a steroid, 20 milligrams or more, per day, for more than two weeks, and there are many other immunomogilitory, or immunotherapy, and the biggest example of that is Rituximab.
07:15 And so, now that we've reviewed that, let's just briefly go over the vaccination schedule. Now, we know that the most common vaccine in the US are the messenger RNA vaccines, again, Pfizer, Moderna. So, we're gonna review the schedule for those that are immunocompromised and over 12 years of age. So, for the messenger RNA vaccines, the current schedule for both Moderna and Pfizer includes the first dose three weeks after a Pfizer, and four weeks after Moderna, there's the second dose.
07:51 About four weeks after those, there's a third dose, and if we wait two months, then we can get the new bivalent messenger RNA booster. We call it bivalent to differentiate it from the older vaccine version, which is monovalent, meaning that it only covers the ancestral COVID-19, the first strain that came out. The bivalent contains the more recent variant, which is Omicron. So, it includes the newer variants. So that's for the messenger RNA vaccine schedule.
08:28 If you have gotten Novavax, you would have gotten your first dose, followed by a second dose about three weeks later, and then if you wait two months after your last dose, you can get the new bivalent booster. Now, keep in mind that the bivalent booster is only messenger RNA vaccine. There's no other kind right now.
08:50 If you got the Janssen, you would have been over 18 years of age, which is the only approved age for the Janssen, or Johnson & Johnson vaccine. You would have gotten one dose, about four weeks later, a dose of messenger RNA vaccine, the Pfizer or Moderna, and then two months later, the bivalent booster. The big difference with the immunocompetent individuals, so those with normal immune systems, is that the primary series consists now of only two doses of the older, monovalent vaccine, followed by the new bivalent.
09:29 Now, a lot of you may have gotten three doses of the monovalent, so that's totally fine as well. Ideally, you should complete the primary series with the same product that you started, but if that's unavailable, or contraindicated for whatever reason, perhaps you had a severe reaction, than any other of the vaccines given 28 days after the first dose is totally fine.
09:56 People who have had a recent COVID-19 infection could consider delaying the primary series, or the booster for up to three months from symptom onset, or first positive test.
Leigh Clark: 10:12 Thank you so much for that great answer, 'cause it can be very confusing, when patients are up to date. So, thank you for that. And what do patients need to know about the new variants?
Dr. Veronica Dioverti: 10:26 That's a good question. The first and the most important thing to keep in mind, monoclonal antibodies do not work against the new variants. Monoclonal antibodies are artificially made antibodies that are targeted against COVID-19, and we have had many of them, over the years. However, some of the newer strains have developed mutations that make them resistant or not susceptible to some of those wonderful antibodies, that we've been losing one by one, over the past three years.
11:01 So currently, there are only two that are available, and each one has a little bit of a different indication. So, first off, is Tixagevimab/cilgavimab, or better known as Evusheld. This one is used for pre-exposure prophylaxis, meaning that it is given before you get infected, in order to protect you. All immunocompromised patients have been eligible, and most have received at least one, if not two doses, and these are usually intramuscular injections, one in each thigh, that are given every six months.
11:37 Right now, however, it's only active against 10 to 15% of current variants, and although the FDA has not officially pulled out this particular monoclonal antibody, we have been very, very cautious about teaching our patients that even if they get it, there's some 85 to 90% possibility that they would still get COVID-19, and get sick from it.
12:01 The second monoclonal antibody that we have is called Bezlotoxumab, which is the only monoclonal antibody for treatment of active COVID-19 infection. However, same as with Evusheld, it's no longer effective, particularly not as monotherapy, but still remains available.
12:22 Second, we have to keep in mind that there are still treatment options available for immunocompromised non-hospitalized patients that have a COVID-19 infection. All of our anti-viral therapies remain active, even against the newer variants. And so, if you are sick with COVID, and you, um, fall into the high-risk category for progression, and that includes immunocompromised patients, patients with chronic heart, kidney and lung condition, patients with diabetes and obesity, and I would refer you to the CDC website to look at all the high-risk criteria.
13:04 But there are options for treatment. So, the first one is called Nirmatrelvir/ritonavir, better known as Paxlovid, which is an oral antiviral medication that needs to be given with- within five days of symptom onset, and- and the total, uh, duration of treatment is for five days. The second option is called Remdesivir, which a lot of you may be familiar with, as we have been using that in the hospital setting, you know, where patients are sick with COVID, but this one is an intravenous antiviral agent, that can be given for high risk patients, non-hospitalized, once a day for three days in a row. Because it is intravenous, it requires a prepared infusion center, with capability of receiving patients with active COVID-19. So it probably requires a larger hospital infusion center. Some hospitals have been offering this treatment in their emergency rooms, but with current situation with many other viruses, this is not advisable.
14:09 And lastly, the third option is moluniravir, which is another oral antiviral option that also needs to be start within five days of symptom onset. One very, very important thing to know about Paxlovid. It has significant drug interactions with many medications that we commonly use, and depending at the level of interaction, we may need to dose adjust a medication, to discontinue the medication that's interfering, or, depending on what the kind of medication is, we would need to look for an alternative COVID-19 therapy. So it is exceedingly important that if you do end up testing positive for COVID, because of symptoms, that you reach out to your primary care doctor, or your oncologist, give them an accurate list of your medications, so that we can do a full review to make sure it is safe for you to take Paxlovid. And if it's not, then we can look for alternatives.
Leigh Clark: 15:11 Thank you so much, Dr Dioverti, for sharing your time and your expertise with all of us today. You can find out more about COVID-19 and bone marrow failure diseases on our website, which is www.aamds.org, you can also find our more information about bone marrow failure by visiting us on our Facebook, Instagram and Twitter, or give us a call at our helpline, at 800-747-2820. This concludes our podcast.