Third dose of Pfizer/Moderna for immunocompromised individuals
- Be aware, the U.S. Food and Drug Administration (FDA) amended its emergency use authorizations (EUAs) for Pfizer and Moderna COVID-19 vaccines to allow an additional (third) dose for certain immunocompromised people.
- Be aware, the Advisory Committee on Immunization Practices (ACIP) authorized an additional (third) dose of Pfizer and Moderna COVID-19 vaccines under a revised EUA for certain people who are immunocompromised due to medical conditions or immune suppressive treatment. Do not offer additional (third) doses to other fully vaccinated people.
- Call and recall patients you determine are immunocompromised and received Pfizer or Moderna vaccine and offer an additional (third) dose of COVID-19 vaccine.
- Offer the same vaccine product (i.e., Pfizer or Moderna) the person originally received.
- Be aware, people who got Johnson & Johnson/Janssen (J&J) COVID-19 vaccine are not eligible for an additional dose. Data is insufficient to support recommending an additional dose for J&J recipients. The Centers for Disease Control and Prevention (CDC) and FDA are actively working to provide further guidance on this issue.
- On July 27, the Centers for Disease Control and Prevention (CDC) issued a health advisory declaring an urgent need to increase the percentage of the population fully vaccinated against COVID-19. Promote COVID-19 vaccine and vaccinate everyone 12 years or older, including those who are pregnant, lactating or who may become pregnant.
- Be aware, Governor Inslee announced all state employees and workers in private healthcare and long-term care settings must be fully vaccinated by October 18, 2021.
- Be aware Governor Inslee announced all employees working in our state’s public and private K–12 schools must be fully vaccinated by October 18, 2021. The order allows employees to obtain a medical or religious exemption if needed.
- Be aware, the Food and Drug Administration (FDA) extended the shelf life of Johnson & Johnson (Janssen) (J&J) COVID-19 vaccine from 4½ months to 6 months when the vaccine has been refrigerated at temperatures of 36° to 46° Fahrenheit (2° to 8° Celsius). Visit the J&J lot expiry checker to determine the updated expiration of your vaccine.
- Be aware, the Secretary of Health updated statewide masking guidance; the existing statewide mask mandate will be expanded to once again include vaccinated individuals in indoor settings effective Monday, August 23 to prevent the spread of the COVID-19 Delta variant.
ROUTINE VACCINATIONS FOR CHILDREN AND TEENS
- Be aware, routine vaccinations among children and teens are down. Many children and adolescents are behind on their vaccinations. Call, schedule, and recall patients behind on any vaccinations to ensure more of our communities are protected against vaccine-preventable illness.
Third dose for immunocompromised individuals
The spread of the more infectious SARS-CoV-2 Delta variant across the United States has led to increased breakthrough COVID-19 cases. Immunocompromised people are:
- More likely to get severely ill from COVID-19.
- At higher risk of prolonged SARS-CoV-2 infection and shedding.
- More likely to transmit SARS-COV-2 to household contacts.
- More likely to have a breakthrough infection.
Forty-four percent of hospitalized breakthrough cases met the definition for potential immunocompromise. Vaccine effectiveness studies among immunocompromised people show decreased antibody response when compared to the general population.
Immunocompromised people have medical conditions or are receiving treatment associated with moderate to severe immune compromise, including:
- Active or recent treatment for solid tumor or hematologic malignancies.
- Receipt of solid-organ and taking immunosuppressive therapy.
- Receipt of CAR-T cell or hematopoietic stem cell transplant (within 2 years of transplantation or taking immunosuppression therapy).
- Moderate or severe primary immunodeficiency (e.g., DiGeorge, Wiskott-Aldrich syndromes).
- Advanced or untreated HIV infection.
- Active treatment with high-dose corticosteroids (i.e., greater than 19 mg prednisone or equivalent per day), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, tumor-necrosis (TNF) blockers or other biologic agents that are immunosuppressive or immunomodulatory.
- Chronic medical conditions such as asplenia and chronic renal disease may be associated with varying degrees of immune deficit.
Based on this definition, about 2.7% of U.S. adults will be eligible for an additional (third) dose of mRNA vaccine.
Following a thorough safety review weighing the benefits and risks, ACIP recommends an additional (third) dose of Pfizer or Moderna COVID-19 vaccine for people who meet the above definition of immunocompromised.
- The additional (third) dose should be the same vaccine product (i.e., Pfizer or Moderna) a person originally received.
- If the vaccine product a person originally received is unavailable, an alternate mRNA vaccine product may be used.
- The additional (third) dose should be administered at least 28 days after completion of the initial primary series.
- Serologic testing to assess immune response is not currently recommended.
- COVID-19 vaccination should occur at least 2 weeks before initiation of immunosuppressive therapies.
- Data is insufficient to support recommending booster doses for J&J recipients. The CDC and FDA are actively working to provide further guidance on this issue.
- Counsel immunocompromised people about their potential for reduced immune response to COVID-19 vaccine and the need to follow COVID-19 infection prevention measures, including:
- Wear a mask.
- Maintain physical distance.
- Increase ventilation.
- Avoid crowds.
- Encourage close contacts to get fully vaccinated.
It is important to remind younger people who are not immunocompromised that the original vaccine schedules still offer excellent protection against severe COVID-19 infection. In Washington, 94% of COVID-19 deaths (and over 99% of deaths in people under age 65) February through June 2021, were people who were not fully vaccinated.
- Clinician outreach and communication activity (COCA) call on additional dose of mRNA COVID-19 vaccine for moderately or severely immunocompromised people, Tuesday, Aug. 17, 2021, 2 p.m. Eastern Time (ET).
- Updated Moderna COVID-19 vaccine fact sheet—FDA.
- Updated Pfizer COVID-19 vaccine fact sheet—FDA.
- Updated J&J COVID-19 vaccine fact sheet for recipients and caregivers—FDA.
- Updated pre-vaccination screening forms—CDC.
- Aug. 13, 2021 ACIP meeting notes—CDC.
- Updated COVID-19 vaccine clinical considerations—CDC.
Urgent call to increase vaccinations
On July 27, CDC issued a health advisory declaring an urgent need to increase the percentage of the population fully vaccinated against COVID-19. Promote COVID-19 vaccine and vaccinate everyone 12 years or older against COVID-19, including people who are pregnant, lactating or who may become pregnant. All 3 FDA-authorized COVID-19 vaccines are shown to be effective against COVID-19. They provide strong protection against variants, including the Delta variant, prevent severe illness and hospitalization, and lower the risk of death. Between February and June 2021, 97.4% of COVID-19 cases were among those not fully vaccinated. The most important thing we can do is focus on encouraging anyone who is not fully vaccinated to get fully vaccinated.
Prevent vaccine-preventable illness in children and teens
Routine vaccine orders are down compared to pre-pandemic levels. We must do more to protect children and teens as they prepare to return to school.
Disinformation campaigns are effective at spreading misinformation about vaccines. Parental hesitancy is a strong predictor of whether a teen will be vaccinated. Predictors of high levels of hesitancy include lower education level, poverty and whether parents received a strong endorsement from their pediatrician.
To increase vaccine acceptance in adolescents:
- Incorporate messaging that speaks both to parents and adolescents.
- Ask open-ended questions to encourage dialogue.
- Focus on the positives of vaccination.
- Engage trusted messengers to give clear and consistent pro-vaccine guidance.
- Send automated reminders to encourage setting up appointments for vaccination. Send recall notifications if patients miss appointments—studies show recalls can raise vaccination rates by an average of 11%. The Washington Immunization Information System (IIS) and many electronic health record systems can pull reports for your patients to send messages via phone or text.
- Structure outreach to be inclusive of people at highest risk for low vaccine coverage rates.
- Encourage division between children and parents.
- Give up if your message is unsuccessful the first time.
- Use heavy handed fear-based messaging.
- Minimize concerns.
- Use jargon or confrontation.
For more on this subject, consult the American Academy of Pediatrics guide to increasing pediatric immunization rates: Practical Approaches to Optimize Adolescent Immunization, American Academy of Pediatrics.
Trainings on increasing vaccine confidence
Addressing vaccine hesitancy among Russian- and Ukrainian-speaking patients, self-paced training with continuing medical education (CME) credits available.
Washington Chapter of American Academy of Pediatrics presents Increasing Family Confidence in COVID-19 Vaccines, Wednesdays, 30-minute discussions.
Vaccinate people who are pregnant, lactating or who may become pregnant
This week, the CDC followed the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) to release a strong recommendation that people who are pregnant, lactating or who may become pregnant should be vaccinated against COVID-19. The announcement came amidst growing evidence of the safety and effectiveness of COVID-19 vaccination during pregnancy outweighing any known or potential risks and the high risk for severe illness during pregnancy. To date, only 23.3% of pregnant people have received at least one dose of a COVID-19 vaccine and there are significant racial and ethnic disparities in that data. Black pregnant people have the lowest rates of vaccination at 10.9%. New findings from CDC’s v-safe pregnancy registry suggest that getting an mRNA COVID-19 vaccine during early pregnancy DOES NOT increase the risk for miscarriage. These early findings are reassuring and can help guide discussions with your pregnant patients about COVID-19 vaccination. Furthermore, previous findings from three safety monitoring systems did not find any safety concerns for pregnant people who were vaccinated late in pregnancy, or for their babies.
- Key messages and talking points, CDC.
- Provider considerations for engaging in COVID-19 vaccine counseling with pregnant and lactating patients, SMFM.
COVID-19 vaccine guidance
- Make COVID-19 vaccination a new vital sign. Review all patients’ vaccination records and help them get up to date with all vaccines. You can administer COVID-19 vaccine simultaneous with, or within any number of days of, other vaccines. Send reminder messages and phone calls for vaccine appointments.
- Do not administer any doses of vaccine beyond the doses recommended by the Advisory Committee on Immunization Practices (ACIP), even if your patient requests it. Currently, ACIP does not recommend any additional doses of Moderna or Pfizer vaccine after getting J&J vaccine.
- Do not offer or administer a different COVID-19 vaccine brand for a second dose.
- Do not turn people away at the end of the day to avoid opening a new vial to save just a few doses. For tips to minimize vaccine waste, see the Washington State Department of Health (DOH) general vaccine wastage guidance.
- Support equitable access to vaccine. DOH created multiple community-specific resources for outreach and engagement. Additional ways to achieve equitable access are:
- Reach out to eligible patients, especially those from communities highly impacted by COVID-19.
- Meet people where they are with the goal of “vaccines going to people, not people going to vaccines.”
- Partner with local, trusted community organizations and groups and the Health Department to coordinate vaccination events. Use DOH’s Equitable Vaccine Site Placement Planning Tool.
- Include COVID-19 vaccine promotional messages with all information you share with patients. Post messages widely throughout your offices and work settings. You can order free COVID-19 vaccine outreach materials from DOH including signage, handouts, buttons and stickers in multiple language. You should receive materials in 3 to 5 days.
- COVID-19 vaccine locator, DOH.
- COVID-19 vaccine for providers
- COVID-19 vaccine provider toolkit and resources, DOH.
- COVID-19 vaccination for providers, CDC.
- Clinical considerations for COVID-19 vaccination and guidance for managing anaphylaxis, CDC.
- COVID-19 vaccine quick reference guide for healthcare professionals, CDC.
- COVID-19 vaccine training module on best practices for providers, CDC.
- Janssen (Johnson & Johnson) health alert, CDC.
- Vaccine-induced immune thrombotic thrombocytopenia frequently asked questions, American Society of Hematology (ASH).
- Diagnosis and management of vaccine-induced immune thrombotic thrombocytopenia webinar, ASH and CDC.
- April 15, 2021 Clinician Outreach and Communication Activity (COCA) call: Janssen (Johnson & Johnson) COVID-19 vaccine and cerebral venous sinus thrombosis with thrombocytopenia update for clinicians on early detection and treatment, CDC.
- Association of mRNA vaccines with myocarditis and pericarditis after vaccination:
- Follow-up of patients with myocarditis, consult recommendations, American Heart Association and the American College of Cardiology.
- Clinical considerations: Myocarditis and pericarditis after receipt of mRNA COVID-19 vaccines among adolescents and young adults, CDC.
- COVID-19 subcommittee of the World Health Organization (WHO) Global Advisory Committee on Vaccine Safety (GACVS) reviews cases of mild myocarditis reported with COVID-19 mRNA vaccines, WHO news release, May 26, 2021.
- Myocarditis and pericarditis following mRNA COVID-19 vaccination, CDC.
- Selected adverse events reported after COVID-19 vaccination, CDC.
- Myocarditis and pericarditis resources for the public, CDC.
COVID-19 test processing
Labs report varying amounts of time to process COVID-19 tests. To support faster turnaround, we encourage providers to use in-state labs. The table below shows COVID-19 test processing times for in-state private labs.
|LAB||TIME TO PROCESS TEST||TESTS PROCESSED DAILY|
|FidaLab||24 to 48 hours||400|
|Kaiser||24 hours||700 to 800|
|LabCorp||24 to 48 hours||Unknown|
|Northwest Pathology||24 to 48 hours||20,000|
|Quest||24 to 48 hours||700|
|UW Virology||24 to 48 hours||6,000 to 8,000|
|Atlas Genomic||16 hours||10,000|
Share the following materials with patients.
- What to do if you have COVID-19.
- What to do if you may have been exposed to COVID-19.
- What to do if you have COVID-19 symptoms and have not been tested or exposed.
- Our COVID-19 page for healthcare providers.
- Washington COVID-19 risk assessment dashboard.
- CDC guidance for healthcare providers and facilities.
- DOH COVID-19 data dashboard.
- DOH COVID-19 page.
- CDC COVID-19 page.
- SARS-CoV-2 sequencing and variants in Washington.
Contacting the Whatcom County Health Department Communicable Disease Program
360-778-6100 Main Call Line – available M-F 8:30am to 4:30pm
360-715-2588 Afterhours Answering Service – available after 4:30pm and weekends
360-778-6150 Communicable Disease Report Line – 24 hours a day 7 days a week
360-778-6103 Confidential Communicable Disease Fax – 24 hours a day 7 days a week
1500 N State Street, Bellingham WA 98225