Any reasons I should not get a COVID-19 vaccine?

Almost everyone should get the COVID-19 vaccine as soon as it is available to you. There is a very short list of people who should not get the vaccine at this time.

Contraindications:

The US Center for Disease Control lists the following “contraindications” (i.e. reasons not to get the vaccine) to both the Pfizer-BioNTech and Moderna COVID-19 vaccines:

• Severe allergic reaction (e.g. anaphylaxis) after a previous mRNA COVID-19 vaccine or any of its components
• Immediate allergic reaction of any severity to a previous dose of an mRNA COVID-19 vaccine or any of its components (including polyethylene glycol [PEG])
• Immediate allergic reaction of any severity to polysorbate (due to potential cross-reactive hypersensitivity with the vaccine ingredient PEG)

If you fall under any of these 3 categories (i.e. you have had an allergic reaction to a previous dose of mRNA COVID-19 vaccine or to PEG or polysorbate), you should schedule evaluation by an allergist-immunologist to determine if you can safely receive the vaccine under observation in a setting with advanced medical care available.

It should be noted that, as of the CDC’s MMWR report dated 1/15/21, the case rate of anaphylaxis due to the COVID-19 vaccine is exceedingly low (11.1 cases per million vaccine doses).

Precautions:

The CDC considers a history of any immediate allergic reaction to any other vaccine or injectable therapy (i.e., intramuscular, intravenous, or subcutaneous vaccines or therapies not related to a component of mRNA COVID-19 vaccines or polysorbate) as a precaution but not a contraindication to vaccination for both the Pfizer-BioNTech and Moderna COVID-19 vaccines. These persons should be counseled about the unknown risks of developing a severe allergic reaction and balance these risks against the benefits of vaccination. Deferral of vaccination and/or consultation with an allergist-immunologist may be considered until further information on the risk of anaphylaxis is available. 

It is still recommended to receive vaccine if you:

• Have had a severe allergic reaction to anything else, including food allergies or bee stings, this is NOT a contraindication or precaution to vaccination and it is recommended that you schedule your vaccination as soon as you can, informing the vaccine site of your allergy history. To be safe, you should confirm with the vaccination site that they are fully complying with CDC recommendations to observe patients for at least 15 minutes after vaccination and to have epinephrine injection and advanced medical care available in case of anaphylaxis. 
• Have been previously infected with COVID-19. According to the CDC, “Data from clinical trials indicate that mRNA COVID-19 vaccines are safe in persons with evidence of a prior SARS-CoV-2 infection. Vaccination should be offered to persons regardless of history of prior symptomatic or asymptomatic SARS-CoV-2 infection. Viral testing to assess for acute SARS-CoV-2 infection or serologic testing to assess for prior infection solely for the purposes of vaccine decision-making is not recommended.”

Reasons to delay or consider delaying your vaccine:

• Acute COVID-19 infection: Vaccination of persons with known current SARS-CoV-2 infection should be deferred until the person has recovered from the acute illness (if the person had symptoms) and criteria have been met for them to discontinue isolation. 
• Infection within the last 90 days: While there is otherwise no recommended minimum interval between infection and vaccination, current evidence suggests that reinfection is uncommon in the 90 days after initial infection. Thus, persons with documented acute SARS-CoV-2 infection in the preceding 90 days may delay vaccination until near the end of this period, if desired.
• Persons who previously received passive antibody therapy, Currently, there are no data on the safety and efficacy of mRNA COVID-19 vaccines in persons who received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment. Based on the estimated half-life of such therapies as well as evidence suggesting that reinfection is uncommon in the 90 days after initial infection, vaccination should be deferred for at least 90 days, as a precautionary measure until additional information becomes available, to avoid potential interference of the antibody therapy with vaccine-induced immune responses.

Information from the CDC on vaccination of persons with underlying medical conditions:

• Pregnancy: If pregnant people are part of a group that is recommended to receive a COVID-19 vaccine (e.g., healthcare personnel), they may choose to be vaccinated. A conversation between the patient and their clinical team may assist with decisions regarding the use of a mRNA COVID-19 vaccine, though a conversation with a healthcare provider is not required prior to vaccination. When making a decision, pregnant people and their healthcare providers should consider the level of COVID-19 community transmission, the patient’s personal risk of contracting COVID-19, the risks of COVID-19 to the patient and potential risks to the fetus, the efficacy of the vaccine, the side effects of the vaccine, and the lack of data about the vaccine during pregnancy.
• Lactating people: There are no data on the safety of COVID-19 vaccines in lactating people or the effects of mRNA COVID-19 vaccines on the breastfed infant or milk production/excretion. mRNA vaccines are not thought to be a risk to the breastfeeding infant. A lactating person who is part of a group recommended to receive a COVID-19 vaccine (e.g., healthcare personnel) may choose to be vaccinated.
• Children & Adolescents: Adolescents aged 16–17 years are included among persons eligible to receive the Pfizer-BioNTech COVID-19 vaccine under the EUA. While vaccine safety and efficacy data in this age group are limited, there are no biologically plausible reasons for safety and efficacy profiles to be different than those observed in persons 18 years of age and older. Adolescents aged 16–17 years who are part of a group recommended to receive a COVID-19 vaccine may be vaccinated with the Pfizer-BioNTech COVID-19 vaccine with appropriate assent. Children and adolescents younger than 16 years of age are not authorized to receive the Pfizer-BioNTech COVID-19 vaccine at this time. Children and adolescents younger than 18 years of age are not authorized to receive the Moderna COVID-19 vaccine at this time.
• Immunocompromised Persons: Immunocompromised individuals may receive COVID-19 vaccination if they have no contraindications to vaccination. However, they should be counseled about the unknown vaccine safety profile and effectiveness in immunocompromised populations, as well as the potential for reduced immune responses and the need to continue to follow all current guidance to protect themselves against COVID-19 (see below). Data are not currently available to establish vaccine safety and efficacy in these groups. Persons with stable HIV infection were included in mRNA COVID-19 vaccine clinical trials, though data remain limited. Antibody testing is not recommended to assess for immunity to COVID-19 following mRNA COVID-19 vaccination.
• Persons with Autoimmune Conditions: Persons with autoimmune conditions who have no contraindications to vaccination may receive an mRNA COVID-19 vaccine. No data are currently available on the safety and efficacy of mRNA COVID-19 vaccines in persons with autoimmune conditions, though these persons were eligible for enrollment in clinical trials. No imbalances were observed in the occurrence of symptoms consistent with autoimmune conditions or inflammatory disorders in clinical trial participants who received an mRNA COVID-19 vaccine compared to placebo. 
• Persons with a history of Guillain-Barré syndrome: To date, no cases of Guillain-Barré syndrome (GBS) have been reported following vaccination among participants in the Pfizer-BioNTech or Moderna COVID-19 vaccines clinical trials. With few exceptions, ACIP’s general best practice guidelines for immunization does not include the history of GBS as a contraindication or precaution to vaccination. Persons with a history of GBS may receive an mRNA COVID-19 vaccine unless they have a contraindication to vaccination. Any occurrence of GBS following mRNA COVID-19 vaccination should be reported to VAERS.
• Persons with a history of Bell’s palsy: Cases of Bell’s palsy were reported following vaccination in participants in both the Pfizer-BioNTech and Moderna COVID-19 vaccines clinical trials. However, the FDA does not consider these to be above the frequency expected in the general population and has not concluded that these cases were causally related to vaccination. Post-authorization safety surveillance will be important to further assess any possible causal association. In the absence of such evidence, persons with a history of Bell’s palsy may receive an mRNA COVID-19 vaccine unless they have a contraindication to vaccination. Any occurrence of Bell’s palsy following mRNA COVID-19 vaccination should be reported to VAERS. 

Jennifer Abrams, MD, January 19, 2021