Childhood immunisations after COVID-19 infection

It is important to resume children's routine immunisations as soon as possible after COVID-19 infection.

Children can continue to receive their routine childhood and other immunisations as soon as they are no longer acutely unwell with COVID-19 and have been cleared to leave isolation. There is no need to wait.

For COVID-19 vaccine, it is recommended to wait at least 3 months after a positive COVID-19 test, if asymptomatic, or 3 months after recovery from symptoms. This is because the immune response to the infection itself will provide some protection. For a child at higher risk of reinfection and who has not completed the full vaccine course, COVID-19 vaccine can be given sooner than 3 months, based on clinical discretion.

Is there a need to aspirate before giving the COVID vaccine?

We are aware that occasionally consumers are requesting that the vaccinators aspirate the needle [pull back slightly to check for any minor blood vessels] prior to administration of the COVID vaccine. While this is currently not best practice and may be more uncomfortable for the patient, there is no danger associated with accommodating the consumer's requests.

Can people who have had rheumatic fever and rheumatic heart disease have the COVID-19 vaccine?

It is important for people age 12 years and older with underlying health conditions, including rheumatic heart disease, to be vaccinated against COVID-19. Although most healthy children and young people have mild COVID-19, those with certain medical conditions are at increased risk from severe COVID-19. These include heart conditions, like (non-acute) rheumatic heart disease.

People with other pre-existing heart conditions, including congenital heart disease and a history of Kawasaki disease, are also highly recommended to have the COVID-19 vaccine. Other groups highly recommended COVID-19 vaccine from aged 12 years include those with respiratory conditions (eg, asthma and cystic fibrosis), nervous system disabilities (like cerebral palsy) and diabetes (type 1 or type 2).

To find out more about COVID-19 immunisation for children aged 12 and over, see the Kids Health page here

The video below features Blues rugby player Matt Johnson sharing his story about rheumatic fever and his choice to be vaccinated against COVID-19.

 

 

Medical appointments and treatment planning with vaccination

Some people experience swollen lymph nodes in their armpit and neck after vaccination. This is where the immune response is taking place and is expected. Swollen lymph nodes are also detected by screening tests for cancers, so it is important to inform your radiographers or oncologist if you have been vaccinated recently.

Some treatments can reduce your immune response to the vaccine. If you are severely immunosuppressed, you may like to discuss the timing of your COVID-19 vaccination with your specialist to try to time it between treatments to provide the best possible protection. It is important not to delay treatments or avoid vaccinations.

It is also important for the people around you, in your household, to have the vaccine when it is offered to them to widen your protection.

  • For information about Cancer care and COVID-19 vaccine see Te Aho o Te Kahu (Cancer Control Agency) information here.
  • For information about COVID-19 vaccination and treatments for autoimmune disease from Arthritis New Zealand, see video here.

Can COVID-19 vaccines be safely given to frail and elderly people?

There are no safety concerns around giving COVID-19 vaccine to older and frail adults. Multiple COVID-19 vaccine candidates have shown to protect against severe disease in older age groups. A guidance statement has been produced.

Guidance statement for COVID-19 vaccination of frail elderly 
Guidance has been prepared to clarify the use of the COVID-19 vaccination for the frail elderly.
In general, it is recommended that all eligible adults, including the frail and elderly with comorbidities are offered vaccination against COVID-19, if there are no contraindications to its administration, to provide protection for the individual as well as their community.
As with all clinical interventions, there needs to be an individual risk/benefit appraisal and shared decision making between clients, whanau, surrogate decision makers, and clinicians on the individual and collective benefits and risk of COVID-19 vaccination. For frail elderly people with a prognosis of a short number of weeks (including those in terminal decline or on an end of life care pathway) the individual risk/benefit appraisal will be particularly important.
 

A single dose of COVID-19 vaccine substantially reduced (over 70%) the risk of COVID-19-related hospitalisation in elderly, frail patients with extensive co-existing conditions in the UK. By 2 weeks after the second dose effectiveness against symptomatic COVID-19 in adults aged over 70 years was 85-93%. This is important, as increasing age is a risk factor for severe COVID-19.

Following reports of deaths of frail, elderly adults in residential care facilities after COVID-19 vaccination, independent reviews by both the CDC and the WHO concluded that the mortality rate in this population is typically high and a substantial number of deaths will occur coincidentally following vaccination. For further information, click here.

When vaccinating an elderly person who has an intercurrent or comorbid condition, it is wise to ensure they are stabilised or as well as possible before they have the vaccine. Following vaccination ensure good hydration and careful management of potential systemic adverse events, such as fever. It is advisable for them to be with someone else for 24 hours after receipt of the vaccine to help manage such adverse events.


Reference

  • Shrotri M, Krutikov M, Palmer T, et al. Vaccine effectiveness of the first dose of ChAdOx1 nCoV-19 and BNT162b2 against SARS-CoV-2 infection in residents of long-term care facilities in England (VIVALDI): a prospective cohort study. The Lancet Infectious Diseases. 2021 Jun 23.

Can I have a COVID-19 vaccination before a CT scan?

It is important to advise your oncologist or radiographer if you have received the COVID-19 vaccine recently. This is because the vaccine can cause the lymph nodes in your armpit and neck to swell which can be detected by CT scans used to diagnose and monitor cancers.

This is particularly detected by FDG PET/CT scans, in which you are given a contrast medium containing a type of radioactive sugar that is taken up by active cells. When an immune response to a vaccine takes place, the cells in the lymph nodes near the injection site become very active and take up a lot of this sugar. Depending on the type of cancer, you may be able to request the injection on the opposite side to your tumour. If possible, have the vaccination at least 2 weeks before a scheduled scan or as soon as you can afterwards. Do not delay any treatment.

See also https://covid.immune.org.nz/faq/covid-19-vaccine-may-cause-swelling-local-lymph-nodes-does-affect-mammogram-results


Reference

McIntosh LJ, Bankier AA, Vijayaraghavan GR, et al. COVID-19 Vaccination-Related Uptake on FDG PET/CT: An Emerging Dilemma and Suggestions for Management. American Journal of Roentgenology. 2021. doi: 10.2214/AJR.21.25728
 

People with compromised immune systems or receiving treatment for cancer

Many people take medication that suppresses their immune system, especially for the treatment of cancer, severe asthma, autoimmune diseases, or following organ transplantation. Others have medical conditions that can affect the immune system, such as HIV infection or kidney failure.

These conditions put you at increased risk from COVID-19, and although you may not respond as strongly to the vaccine as someone with a fully functioning immune system, it is safe for you to receive the COVID-19 vaccine and it will provide some protection against COVID-19, particularly against severe, life-threatening disease.

It is important and safe for those receiving active treatment with immunosuppressive medications to have the COVID-19 vaccine. If you are severely immunocompromised, it is recommended to talk to your GP or specialist to discuss the optimal timing for vaccination before the vaccine appointment. Ideally, vaccination should be conducted prior to any planned immunosuppression.

It is also important for the people around you, in your household, to have the vaccine when it is offered to them to widen your protection.

For information about Cancer care and COVID-19 vaccine see Te Aho o Te Kahu (Cancer Control Agency) information here.

For information about COVID-19 vaccination and treatments for autoimmune disease from Arthritis New Zealand, see video here.

If the person has had a dose of COVID-19 vaccine overseas

If you were partially vaccinated overseas with one dose of Comirnaty (Pfizer/BioNTech) vaccine, you will need to have another dose 6 weeks after your previous dose (or at least 3 weeks if you are at high risk of exposure to individuals with COVID-19). There is no maximum time limit between doses, so you do not need to repeat the first dose or receive a third dose.

Although, different COVID-19 vaccines are not interchangeable, it is recommended that if you have received one dose of any two-dose COVID-19 vaccine (including Vaxzevria/Covishield/AstraZeneca, or Spikevax/Moderna) outside of New Zealand that you have one dose of Comirnaty (Pfizer/BioNTech) at least 4 weeks after the first vaccine dose.

If you received one dose of COVID-19 Vaccine Janssen, you are considered fully immunised. However, in certain groups (such as border workers) at high risk of exposure to people infected with COVID-19 virus, may be advised to have a further dose of the Pfizer vaccine at least 4 weeks later.

Can I delay receiving my second dose of Comirnaty?

To be fully immunised with Comirnaty requires two doses given at least 21 days apart. The current recommendation is for the two doses to be given six weeks apart. A delay for longer than six weeks is not considered harmful, however it is important to remember that two vaccine doses are needed for full protection, particularly against the Delta variant.

It is not yet known, for how long the first dose provides protection. If you are at risk of exposure to SARS-CoV-2, it is advisable to have the second dose when recommended. During clinical trials, the vaccine efficacy against symptomatic COVID-19 between the first and second doses was around 50% compared with 90% within 2 days of the second dose increasing to 95% after a week. Recent real-world data has shown that protected against SARS-CoV-2 infection was around 62 to 91% from 14 days after dose one and 68 to 97 % from 14 days after dose two in frontline workers.

What if the person has an allergy or is allergic to latex?

Comirnaty™ is latex-free. The vial stopper is made with synthetic rubber (bromobutyl), not natural rubber latex.

The only contraindication for Comirnaty is a history of anaphylaxis to a previous dose of this vaccine or its contents. Find more information on severe allergic reactions after immunisation here, and the contents of Comirnaty here.

Those with a history of immediate allergic response to another product or vaccine can receive this vaccine but are asked to wait to be observed for a little longer after vaccination. 

Individuals who have anaphylaxis following a previous dose of Comirnaty can be offered an other COVID-19 vaccine (currently, Astrazeneca COVID-19 vaccine) if not contraindicated.
 

Do we need a gap between MMR, influenza or other vaccines and COVID-19 vaccination?

Since we are now much more familiar with the side effects of the COVID-19 vaccine, other vaccines can be given at the same time or immediately before or after COVID-19 vaccination.

COVID-19 vaccine can been given at the same time or close to other vaccinations on the National Immunisation Schedule, including MMR (measles, mumps, rubella vaccine), influenza (flu), human papillomavirus vaccine (HPV, Gardasil 9), whooping cough and tetanus (Tdap, Boostrix) and meningococcal vaccines. If given at the same time, the vaccines at separate places on your arms and with different syringes. 

When visiting your GP or pharmacist, ask if there are any other vaccines you can have - you may have missed them in the past. Pregnant women are also recommended to have influenza and whooping cough vaccines. Young adults may have missed MMR and HPV.

The only exception to this is the shingles vaccines, Zostavax, for which a seven day gap is recommended. This is to ensure the immune response to both vaccines is good. Zostavax can still be given at the same time as the influenza vaccine. 

The Varicella vaccine, which is a lower concentration and used mainly with children so their immune systems are much better than those over 50, can also be given at the same time as the COVID-19 vaccine.

Not that the mass COVID-19 vaccination clinics, including drive-through sites, are not likely to have other vaccines, so ask your usual health provider for advice.

What is the acceptable timeframe between the first and second doses of the Comirnaty vaccine?

To be fully immunised with Comirnaty requires two doses given at least 21 days apart and preferably 6 weeks apart.

Vaccinators are advised not to give the second dose earlier than this, and while longer spacing is acceptable, the recommended spacing is for the second dose to be given at 6 weeks after the first dose.

People at highest risk of exposure to others with COVID-19 are advised to have their second dose at least 21 days after the first to provide more immediate protection. Everyone else can allow 6 weeks between doses to provide a strong immune response and good protection after the second dose. See here for more information.

A closer spacing (at least 21 days) may also be advised for people who are due to commence planned immunosuppressive treatments for longer than 28 days, to provide a good immune response before treatment starts. Do not delay treatment or vaccination. Those who are already receiving such treatments are advised to allow 6 weeks between doses to give the best immune response.

What is the guidance around receiving a COVID-19 vaccine and having a general anaesthetic?

Based on first principles and our experience with other vaccines, there is no expectation that an anaesthetic would affect the safety or immune response to the mRNA COVID-19 vaccine.

After surgery, you can have any vaccination as soon as you are recovered and well. It is preferable to avoid booking a vaccination within 48 hours of any major elective surgery in case responses to the vaccine, such as fever, cause delay in surgery or anaesthesia. Do not delay any urgent surgery after vaccination.

The general recommendation when planning vaccination with any vaccine is explained in Section 3.1.3 in the Immunisation Handbook 2020.

In certain circumstances, in situations where it is the pragmatic best option for an individual, it is safe to vaccinate in surgery while under anaesthetic.

Is the Comirnaty vaccine safe and effective for people living with HIV?

The vaccine has been through rigorous testing to ensure safety and efficacy and is now being used widely overseas without any serious concerns appearing. People with HIV were included in clinical trials though efficacy and safety data specific to this group are not yet available.

With some vaccines people living with HIV can produce a weaker immune response. People living with HIV are encouraged to be vaccinated. People with HIV were included in clinical trials for the Pfizer vaccine, although the data specific to this group is not yet available there are no safety concerns.

Based on what we know about people living with HIV and their response to other vaccines:

  • those with a suppressed viral load are likely to have some protection from the COVID-19 vaccine
  • they may have a weaker response to some vaccines, including the COVID-19 vaccine

For people who are newly diagnosed and starting HIV treatment are advised to take advice from their specialist about the timing of their vaccination. Any medication being taken for HIV is not expected to change how effectiveness of the COVID-19 vaccine. The vaccine will not affect HIV medications.​

Vaccination after COVID-19 infection

Vaccination is being offered to people who have had SARS-CoV-2 infection.

Data from clinical trials and from countries with a lot of COVID-19 cases have shown the vaccines to be safe and effective for those who have had COVID-19 ie SARS-CoV-2 infection. This includes those who were asymptomatic.

IMAC recommends that if someone has had COVID-19 infection, then they should start or continue their vaccination from 3 months after recovery; if they have had a positive test but were asymptomatic, then vaccination can start 3 months after the first positive test. 

NOTE: In all instances, if there are clinical reasons for vaccinating earlier, they can be vaccinated from 4 weeks post-infection.

For all other vaccinations, including flu, vaccination can commence from when the person is no longer acutely unwell.