With an increasing number of professional groups mandated under the COVID-19 Public Health Response (Vaccinations) Order 2021 to be fully vaccinated against Sars-Cov2 we are seeing a rise in the number of requests for a COVID-19 vaccine exemption to be confirmed by a patient’s GP.
Such an exemption is a highly important legal document that is very likely to be challenged at the very least in an employment tribunal. A recent case involving a border worker was escalated to an appeal court. It is also possible that refusal to grant such a certificate may be legally challenged, this is a minefield.
Experts in Australia have stated almost no-one will be medically exempt from receiving a COVID-19 vaccine and there is no reason to expect New Zealand to be any different.
Whilst we await definitive statements from the Medical Protection Society, RNZCGP, Immunisation Advisory Centre and Ministry of Health on the circumstances in which a vaccine exemption is appropriate it is important to note that the Immunisation Advisory Centre advise that people who have experienced an anaphylaxis to the first dose of Comirnaty (the Pfizer vaccine) can still safely receive a second dose under the supervision of a specialist immunology clinic.
It is expected that only 4-5 people in a million will experience an anaphylaxis following Comirnaty vaccination, the most likely component triggering the allergic response is Polyethylene Glycol (PEG or macrogol) one of the “fat” components of the vaccine. It is a compound also used in a variety of products including cosmetics and various foodstuffs several case reports describe patients whose allergic response is triggered by multiple products. PEG allergy probably occurs in 0.01 per cent of the population.
If a patient presents with a story of multiple allergies and anxiety about the first dose of vaccine the recommendation is to observe them for 30 minutes post vaccination. If this is unacceptable to them consult with an immunologist or call the Immunisation Advisory Centre medical advice line (clinical queries: 0800 466 863).
Myocarditis or pericarditis following the vaccination is an extremely rare event, it is more common in males and more common after the second vaccination. The Immunisation Advisory Centre state: “People who develop myocarditis or pericarditis attributed to their first dose of Comirnaty are advised to defer further doses. They should be referred to IMAC for clinical advice about alternate vaccine options. Vaccination is not advised for anyone with current active cardiac inflammation”.
In addition to warning about anaphylaxis and advice on myocarditis and pericarditis the Medsafe data sheet regarding the Comirnaty vaccination states the only contraindication to the medication is hypersensitivity to any of the vaccine components, and that “vaccination should be postponed in individuals suffering from acute severe febrile illness or acute infection. The presence of a minor infection and/or low-grade fever should not delay vaccination”. Care should also be taken with people who have a bleeding tendency because of bruising following injections of any kind, and people with a stress reaction to injections need to be cared for.
If asked for a COVID-19 vaccination exemption it is important to explore the reasons why the request has been made and to try to resolve any anxiety that the patient may have. Their reasons may be very complex and a request for an exemption may reveal other anxieties about work or home that may need further counselling and support. It is always important to connect and understand the world as seen by your patient.
Taking time to understand the request at the start may save a great deal of time later on and a simple refusal is rarely satisfactory, patients are more likely to complain about your behaviour and seek help elsewhere.
If the person does have a genuine medical reason to be anxious about the vaccination it is recommended to speak to a medical advisor at the Immunisation Advisory Centre on 0800 466 863 and document their advice before providing a letter stating clearly the advice given by whom and when. A letter template to help is below in the files and links section.
There will be circumstances when a vaccination deferment awaiting a further opinion or resolution of an acute febrile illness might be appropriate in which case ensure the letter is clearly time limited and the reason for the deferment is clearly stated.
As always, I’m happy to be another source of advice, supporting you in your decision making. Please don’t hesitate to get in touch.
Jo Scott-Jones, Medical Director
027 475 0488