There are currently 3 vaccines for COVID19 that have received emergency use authorization (EUA) by the FDA and are being distributed across the country.

  • There are 2 mRNA vaccines that have been available now for several months. Both require an initial injection and then a second injection (booster) at a later date.
    • The vaccine developed by Pfizer and BioNTech and requires that it be kept at extremely cold temperatures ( -94º F) for 2 hours before its administration. The second dose of this vaccine is given at 21 days.
    • The vaccine developed by Moderna in association with the NIH (National Institutes of Health) requires only refrigeration. The second dose of this vaccine is given at 28 days.
  • A 3rd vaccine from Johnson & Johnson (J&J) was approved by the FDA on 2/27/2021. It requires only regular refrigeration and is given as a single injection. A booster dose (2nd shot) is not required. On 4/13/2021 the FDA and CDC recommended a pause in the use of this vaccine until further information is available regarding a possible association with an uncommon condition in which blood clots develop in the brain.
    .

  • The J&J vaccine is similar to traditional vaccines that use an inactivated virus which can enter cells but not replicate. The virus has been designed to carry the genetic material (DNA) that makes a protein (S or spike protein) that is found on the surface of the SARS CoV2 virus. This DNA is then injected into the cell nucleus which makes the mRNA that moves to the cytoplasm where the S protein is made and released. This triggers an immune response so the body will make antibodies and instruct other cells to recognize this foreign protein if you were to become infected with the SARS CoV-2 virus in the future. For more information about how this vaccine works please see this excellent article from the New York Times: https://www.nytimes.com/interactive/2020/health/johnson-johnson-covid-19-vaccine.html
  • The Pfizer and Moderna vaccines: This is a new type of vaccine that does not use DNA and also does not include a live or inactivated virus to introduce the genetic information into our cells. Instead, these 2 vaccines package the genetic information in a small sphere of lipids (liposomes) which enter our cells. The mRNA genetic information contained in the liposomes does not need to enter the cell nucleus. This information is translated in the outer cell cytoplasm to make the S (spike) protein found on the surface of the SARS CoV2 virus that causes COVID19. Similar to the J&J vaccine it then  triggers an immune response so your body will make antibodies and instruct other cells to recognize this foreign protein if you were to become infected with the SARS CoV-2 virus in the future. For more information about how this vaccine works please see this excellent article from the New York Times: https://www.nytimes.com/interactive/2020/health/pfizer-biontech-covid-19-vaccine.html

Like many other vaccines, it is not uncommon for vaccines to cause low grade fever, muscle and joint pain as well as headache for up to several days. Although unpleasant this is not harmful to you and is not indicative of an allergic reaction. Some individuals may experience more prominent side effects following the second dose of the Pfizer or Moderna vaccine.

Administration of the J& J vaccine in the US has paused until further studies look at a possible association with cerebral venous thrombosis (also called cerebral venous sinus thrombosis or CVST). As of 4/14/2021 there have been 6 reports of CVST occurring in individuals given the J& J vaccine. This disease has also been seen in individuals in Europe who were given the AstraZeneca vaccine which has some similarities to the J&J vaccine but which is not approved in the US.  CVST has not been reported with the Pfizer or Moderna mRNA vaccines. All 6 cases were seen in women ages 16-48 with symptoms appearing within 6-13 days of receiving the J& J vaccine. Many also had a low platelet count.

CVST is an uncommon condition that previously was seen in no more than 1 person out of 100,000 -200,000. It is felt to be due to the formation of blood clots in the veins that blocks drainage of blood from the brain and can lead to headaches, stroke, seizures, confusion and/or coma. That the condition has only been observed in women of child bearing potential and associated with low platelets suggests an underlying defect in blood clotting. Although the mechanism is not known there is speculation that it could be associated with generation of autoantibodies to phospholipids or more common in those with a pre-existing hypercoagulable state possibly linked to use of oral contraceptives or other estrogen compounds.  A statement by the director of the Center for Biologics Evaluation and Research (CBER) at the FDA also alerted individuals to be aware of “shortness of breath, pain in the legs, pain in the abdomen”. These are not typical symptoms of CVST but could be seen if clotting occurred in other parts of the body such as the legs, lung or abdomen. To our knowledge clots in other locations have not been reported with the J&J vaccine.

All people who receive the vaccine should be monitored for 15 minutes at the location where they receive the vaccine.  If you have had severe allergic reactions to foods such as shellfish or medications it has been suggested that you be monitored for 30 minutes. If you carry an Epi pen or similar device it may be prudent to bring it with you when you are vaccinated.

  • For all 3 vaccines currently available: Individuals who have had severe allergic reactions to vaccines and other injections in the past including anaphylaxis that lead to trouble breathing and may have required hospitalization.
  • For the mRNA ( Pfizer and Moderna) vaccines:
    • Individuals who experienced a severe allergic reaction to the first COVID19 vaccine should not receive the booster vaccine.
    • Individuals with a known allergy to polyethylene glycol (PEG) or polysorbate (which may cross-react with PEG)
  • For the J&J vaccine: we are awaiting further guidance from the FDA and CDC. It is possible that vaccine distribution could be halted permanently, it could resume without further restrictions if an association with CVST is not found or it could be resumed with restrictions on who should not get the vaccine ( for example women of child bearing potential, those with low platelets or autoimmune diseases where the risk of clotting is increased).

All 3 vaccines are highly effective in lowering the likelihood of severe disease and death from COVID19.  We currently would not recommend any specific vaccine over another unless further restrictions are imposed on the J&J vaccine. The clinical trials of the mRNA vaccines have demonstrated 90-95% efficacy within 1-2 weeks of receiving the second (booster) injection. Although the clinical trials of the J&J vaccine had a lower overall efficacy rate in the United States of 72%, it showed 86 % efficacy against severe forms of COVID-19 and 100% efficacy against hospitalization and death. Comparing the efficacy rates of the mRNA (Pfizer and Moderna) vaccines to the J&J vaccine is also problematic since the mRNA vaccine trials were performed earlier in the pandemic when there were fewer people in the general population who had the virus and the virus variants were not as prevalent. If the trials were performed at the same time in the same population of individuals it is possible that the overall efficacy rates might be quite similar.

  • Individuals with autoimmune rheumatic diseases with or without a compromised immune system who are on medication(s) to treat their disease:  There does not appear to be a contraindication to being vaccinated at this time (aside from what is posted above) and AOCC providers are recommending that you obtain the vaccine when it becomes available to you. Please refer to the last section of this document for specific recommendations regarding possible changes to the dosing of your medication at the time you receive your vaccine.  The American College of Rheumatology also recommends that most patients with autoimmune rheumatic disease obtain the vaccine (https://www.rheumatology.org/Portals/0/Files/COVID-19-Vaccine-Clinical-Guidance-Rheumatic-Diseases-Summary.pdf)
  • Pregnant women and those who are breast feeding: Pregnant women and those who are breast feedingand are part of a group recommended to get the shots — for instance, health-care workers — might want to consider talking with their medical providers beforehand. Pregnant people have been excluded from coronavirus vaccine trials, so there is no data on the safety of the vaccines for them, or its effects on the breastfed infant. The American College of Obstetricians and Gynecologists says a conversation with a clinician may be helpful but should not be required. Pregnant people who get infected with the coronavirus are at greater risk of death and severe illness than those who are not pregnant, even as the overall risk remains small. The Pfizer-BioNTech and Moderna vaccines do not contain live virus, or any enhancers to boost an immune response, and are not thought to be a risk to the breastfeeding infant. They do not alter human DNA in the people who get it and cannot cause any genetic changes. Also, this type of vaccine breaks down quickly and doesn’t enter the nucleus of the cell. Pfizer said it is planning to report to the FDA by the end of the year on a developmental and reproductive toxicity study in animals that could help clarify any risks.”(https://www.washingtonpost.com/health/interactive/2020/covid-vaccines-what-you-need-to-know) .  For additional helpful information the CDC website has a page dedicated to women who are pregnant or trying to conceive (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html ).
  • Children under the age of 12: Not recommended at this time. It is not known if the dose of the vaccine and timing of the second booster vaccine should be different or whether there should be more than 2 doses given. Pfizer is currently conducting a trial in children under the age of 12 that might have clinical results to submit to the FDA for approval by late 2021.
  • Prior COVID19 infection: We do not know for certain how long immunity/protection from re-infection lasts but a study in the New England Journal of Medicine suggests that it is a minimum of 6 months. (https://www.reuters.com/article/uk-health-coronavirus-reinfection/covid-19-reinfection-unlikely-for-at-least-6-months-study-finds-idUKKBN28015E) . You should still get this vaccine if you already have had COVID19 but it is recommended that you wait at least 30 -90 days from when you tested positive. Some studies suggest that in those who have had prior COVID19 infection the second (booster) dose of the mRNA vaccine, leads to a negligible increase in antibody levels compared to the first dose. Nevertheless, most public health officials still recommend that you receive both doses of the mRNA vaccine if you have been previously infected with COVID19.

  • COVID-19 vaccination will help you from getting COVID-19
  • COVID-19 vaccination is a safer way to help build protection as compared to getting the infection which can cause serious illness and even death. Additionally, some patients with initially mild infections have developed long term/chronic symptoms that can significantly impair normal daily activities.
  • COVID -19 vaccinations are an important tool to help stop the pandemic.

  • You can gather indoors with fully vaccinated people without wearing a mask.
  • You can gather indoors with unvaccinated people from one other household (for example, visiting with relatives who all live together) without masks, unless any of those people or anyone they live with has an increased risk for severe illness from COVID-19.
  • If you’ve been around someone who has COVID-19, you do not need to stay away from others or get tested unless you have symptoms.
    • However, if you live in a group setting (like a correctional or detention facility or group home) and are around someone who has COVID-19, you should still stay away from others for 14 days and get tested, even if you don’t have symptoms.
  • Fully vaccinated people can travel at low risk to themselves. A person is considered fully vaccinated two weeks after receiving the last recommended dose of vaccine. Fully vaccinated people can travel within the United States and do not need COVID-19 testing or post-travel self-quarantine as long as they continue to take COVID-19 precautions while traveling – wearing a mask, avoiding crowds, socially distancing, and washing hands frequently.
  • Fully vaccinated people can travel internationally without getting a COVID-19 test before travel unless it is required by the international destination.
    • Fully vaccinated people do not need to self-quarantine after returning to the United States, unless required by a state or local jurisdiction.
    • Fully vaccinated people must still have a negative COVID-19 test result before they board a flight to the United States and get a COVID-19 test 3 to 5 days after returning from international travel.
    • Fully vaccinated people should continue to take COVID-19 precautions while traveling internationally.

  • You should still take steps to protect yourself and others in many situations, like wearing a mask, staying at least 6 feet apart from others, and avoiding crowds and poorly ventilated spaces. Take these precautions whenever you are:
    • In public
    • Gathering with unvaccinated people from more than one other household
    • Visiting with an unvaccinated person who is at increased risk of severe illness or death from COVID-19 or who lives with a person at increased risk
  • You should still avoid medium or large-sized gatherings.
  • You should still delay domestic and international travel. If you do travel, you’ll still need to follow CDC requirements and recommendations.
  • You should still watch out for symptoms of COVID-19, especially if you’ve been around someone who is sick. If you have symptoms of COVID-19, you should get tested and stayhome and away from others.
  • You will still need to follow guidance at your workplace.
  • Unvaccinated travelers should still get tested 1-3 days before domestic travel and again 3-5 days after travel. They should stay home and self-quarantine for 7 days after travel or 10 days if they don’t get tested at the conclusion of travel. CDC discourages non-essential domestic travel by those who are not fully vaccinated.

After several months of a phased role out of the vaccine for specific groups at high risk for exposure and/or high risk for infection, the vaccine will soon be available for all adults 16 years of age or older. Registration for the vaccine for all adults will start on March 31st 2021 in South Carolina and April 7th 2021 in North Carolina. As vaccine supplies are still limited it is expected that it will take several months before all who want the vaccine arevaccinated.

We have provided links here for information that is currently available for:

North Carolina residents: Vaccine supply is limited but vaccines are available by appointment through:

An additional potential resource for individuals who want to be paired with vaccine sites that have additional vaccine doses available (“standby list”) is Dr. B ( www.hidrb.com ). This requires use of a cell phone and flexibility to contact the site within several minutes of being called as well as having transportation that day to go to the designated vaccine site. 

South Carolina residents: Vaccine supply is limited but vaccines are available by appointment through:

An additional potential resource for individuals who want to be paired with vaccine sites that have additional vaccine doses available (“standby list”) is Dr. B ( www.hidrb.com ). This requires use of a cell phone and flexibility to contact the site within several minutes of being called as well as having transportation that day to go to the designated vaccine site.

How do the NC and SC COVID19 vaccine distribution and guidelines differ? 

  NC SC
Current Group 4 “patients at high risk” includes patients on any type of immunosuppressant drug not just patients with organ transplants on medications to prevent graft rejection Yes No
Current Group 4 “group settings” includes college students living indorms Yes No
“Front line workers” designation does not require a specific job or work sector. If a person decides job meets requirement of frequentdose exposure (<6 ft) and ongoing ( >15 minutes) then they are eligible. No Yes
Available through county specific health departments Yes No
Available at select Harris Teeter pharmacies Yes No
Available at select Publix pharmacies No Yes

  • Group 1:
    • Health care workers
    • Residents and staff of long term care facilities including skilled nursing facilities, adult, family and group homes.
  • Group 2: everyone 65 years of age and older (currently able to register for vaccine)
  • Group 3: frontline essential workers as defined by CDC include: first responders such as firefighters and police officers; education and childcare workers such as teachers and support staff; corrections officers; food and agricultural workers; manufacturing workers; US Postal Service workers; grocery store workers; public transport workers.)
  • Group 4: adults at increased risk of severe illness and adults at high risk for exposure. In the following order:
    • People 16-64 years of age with one or more chronic conditions that put them at increased risk for COVID19. The original list included only those at “risk of severe disease” including cancer, chronic kidney disease, COPD, serious heart disease, immunocompromised state from organ transplant and medications to prevent graft rejection, obesity ( BMI > 30), pregnancy, smoking, Type 2 diabetes, sickle cell disease. The updated  CDC list can now be interpreted to also include patients on drugs that “weaken the immune system “ which would include prednisone (any dose), and many of the other medications we use for treatment of rheumatoid arthritis, lupus, Sjogren’s syndrome, psoriatic arthritis, ankylosing spondylitis, scleroderma, poly and dermatomyositis as well as many types of vasculitis.
    • Anyone in a close living setting such as prisons, homeless shelters, migrant or fishery housing not previously vaccinated
    • Other essential workers including government employees who have not yet been vaccinated. As defined by the CDC this would include the following: people who work in transportation and logistics, food service, housing construction and finance, information technology, communications, energy, law, media, public safety and public health staff who are non from line healthcare workers
  • Group 5: (Begin April 7, 2021)
    • All North Carolinians age 16 and up. ( Pfizer vaccine is approved for those who are 16 years of age and older; Moderna vaccine and J&J vaccine are approved for those who are 18 years of age and )

Phase 1a (Began December 2020):

  • Residents and staff of long term care facilities
  • Hospitalized patients who are 65 years of age and older as long as they do not currently have COVID-19 and a provider feels it is indicated for them.
  • Health care workers “at high risk for exposure and mission-critical to the overarching goal of preventing death”. Employers are encouraged to reach out to their local hospitals no later than 1/15/2021 with a list of names and contact information of employees who want to be vaccinated.  Individuals in phase 1a to be vaccinated can also contact their local hospitals to request and schedule an appointment no later than 1/15/2021. They will be required to present proof of occupation at the time of vaccination.  Healthcare workers in Phase 1a include the following:  anesthesiology assistants, registered cardiovascular invasive specialists, and operating room staff; athletic trainers; American Sign Language (ASL) and other interpreters in healthcare facilities;  autopsy room staff, coroners, embalmers, and funeral home staff at risk of exposure to bodily fluids;  chiropractors;  dentists and dental hygienists and technicians; dietary and food services staff in healthcare facilities;  environmental services staff in healthcare facilities;  harbor pilots;  home health and hospice workers;  hospital transport personnel;  laboratory personnel and phlebotomists; licensed dietitians; medical assistants; medical first responders (paid and volunteer): EMS, fire department and law enforcement personnel who provide emergency medical care; nurses, nurse practitioners, and nurse’s aides/ assistants; opticians and optometrists and assistants/ technicians; persons providing medical care in correctional facilities and correctional officers; pharmacists and pharmacy technicians; physical and occupational therapists and assistants; physicians, including medical house staff (i.e., interns, residents, fellows), and physician assistants; podiatrists; public health healthcare workers who are frequently interacting with persons with potential COVID-19 infection; radiology technicians; respiratory care practitioners, such as respiratory therapists; speech language pathologists and assistants and audiologists; students and interns of the above categories

Phase 1b (Began March 8, 2021):

  • All people 55 years of age and older
  • Frontline essential workers: As defined by CDC including the following groups: first responders such as firefighters and police officers; education and childcare workers such as teachers and support staff; corrections officers; food and agricultural workers; manufacturing workers; US Postal Service workers; grocery store workers; public transport workers.
  • People with increased risk for severe COVID-19 disease
    • People aged 16-54 with one or more of the following high-risk medical conditions:
      • Cancer (current, not a history of cancer), chronic kidney disease (any stage), chronic lung disease, diabetes (Type 1 and Type 2), Down syndrome, heart disease (congestive heart disease, coronary artery disease, cardiomyopathy, pulmonary hypertension), HIV/AIDS, solid organ transplant, obesity (BMI >30), pregnancy, sickle cell disease.
    • People who have a developmental or other severe high-risk disability that makes developing severe life-threatening illness or death from COVID-19 infection more likely
  • Frontline workers with increased occupational risk
    • Frontline workers with increased occupational risk are people who:
      • Must be in-person at their place of work, and
      • Perform a job that puts them at increased risk of exposure due to their frequent, close (less than6 feet) and ongoing (more than 15 minutes) contact with others in the work environment
        • A person's eligibility for a COVID-19 vaccine isn't based on a specific job or work sector. If a person decides that they meet job risk using the criteria above, they are eligible.
        • Some examples of people who may be frontline workers based on risk may include school staff and daycare workers, criminal justice staff, government employees, manufacturing workers, grocery store workers, and law enforcement officers.
  • Individuals at increased risk in settings where people are living and working in close contact
    • Residents and workers in group home settings for the mentally or physically disabled or those with behavioral or substance abuse conditions
    • Workers and residents in homeless shelters
    • Workers and residents in community training homes
    • State and local correctional facility staff with direct inmate contact
    • Correctional and immigration detention facility inmates
    • Migrant farmworkers living in shared housing or reliant on shared transportation
  • All workers in healthcare and community health settings who have routine, direct patient contact and were not vaccinated in Phase 1a

Phase 2 (Begin March 31, 2021):

  • All South Carolinians aged 16 and up. (Pfizer vaccine is approved for those who are 16 years of age and older; Moderna vaccine and J&J vaccine are approved for those who are 18 years of age and older.)

The American College of Rheumatology (ACR) recommendations were released in mid-February 2021 and can be viewed here: https://www.rheumatology.org/Portals/0/Files/COVID-19- Vaccine-Clinical-Guidance-Rheumatic-Diseases-Summary.pdf

Based on our experience with other vaccines, AOCC providers are offering specific guidance regarding drugs where the dosing or timing of the injection might be altered to ensure optimal efficacy of the vaccine. Our recommendations differ slightly from those of the ACR when it comes to methotrexate, mycophenylate/Cellcept, JAK inhibitors, Orencia and Rituxan. Absent strong scientific data, AOCC is taking a more conservative approach to maximize the potential of a more vigorous antibody response to the vaccine. As more information becomes available we will update our recommendations accordingly.

  • No changes need to be made for dosing or timing of the following oral medications:
    • Arava (leflunomide)
    • Azathioprine
    • NSAIDs ( non-steroidals) such as Advil/ibuprofen/Motrin, Aleve/naproxen/Naprosyn, celecoxib, diclofenac, etodolac, indomethacin, meloxicam, nabumetome, sulindac
    • Plaquenil (hydroxychloroquine)
    • Prednisone in doses of less than 10 mg daily. For patients on Prednisone in doses of 10 mg/day or higher please discuss this with your AOCC provider.
    • Sulfasalazine
  • No changes need to be made for dosing or timing of the following injectable medications:
    • Actemra
    • Benlysta
    • Cimzia
    • Cosentyx
    • Enbrel
    • Humira
    • Kevzara
    • Skyrizi
    • Stelara
    • Simponi
    • Taltz
    • Tremfya
  • No changes need to be made for dosing or timing of the following infusion medications:
    • Actemra
    • Benlysta
    • Remicade or infliximab biosimilars Inflectra, Avsola, Renflexis
    • Simponi Aria
  • METHOTREXATE: LIKELY WILL IMPACT RESPONSE TO COVID19 VACCINE. To avoid this, we suggest that you lower the dose to 7.5 mg a week for the 2 weeks following the vaccine and the booster if you are receiving the Pfizer or Moderna vaccine. If you are getting the J&J single vaccine, just lower the dose to 7.5 mg for 2 weeks after the vaccine. If you are on oral (pill) methotrexate that would be the equivalent of 3 pills and for the injectable methotrexate it would be 0.3 cc/ml. If you are taking a branded injectable methotrexate such as Rasuvo or Rheumatrex speak with your provider for specific guidance.
  • INFUSIONS AND INJECTIONS OF ORENCIA (ABATACEPT): LIKELY WILL IMPACT RESPONSE TO COVID19 VACCINE.
    • Infusion of Orencia: Wait 4 weeks after last Orencia infusion to receive the vaccine. Resume Orencia infusion 2 weeks after the 2nd injection/booster (Pfizer or Moderna) or 2 weeks after the single vaccine injection ( J&J)
    • Injections of Orencia:
      • For Pfizer and Moderna vaccine: Hold Orencia 1 week prior to vaccine and resume 2 weeks after the vaccine. Do the same thing for the booster.
      • For J&J vaccine: Hold Orencia 1 week prior to vaccine and resume 2 weeks after the vaccine.
    • INFUSIONS OF RITUXIMAB (RITUXAN, TRUXIMA, RUXIANCE). LIKELY WILL IMPACT RESPONSE TO COVID19 VACCINE (assuming this is typically infused every 6 months or less frequently)
      • For Pfizer vaccine: The initial vaccine and booster at 21 days should be scheduled so that there is at least 2 weeks between your booster and your next rituximab infusion. For patients receiving rituximab every 6 months, plan to receive your first vaccination at 4 months and 2 weeks after your last dose of rituximab. Your booster vaccine would then be given 21 days later allowing at least 2 additional weeks before your next course of rituximab.
      • For Moderna vaccine: The initial vaccine and booster at 28 days should be scheduled so that there is at least 2 weeks between your booster and your next rituximab infusion. For patients receiving rituximab every 6 months, plan to receive your first vaccination at 4 months after your last dose of rituximab. Your booster vaccine would then be given 28 days later allowing at least 2 additional weeks before your next course of rituximab.
      • For the J&J vaccine: Since this is a single injection, for patients receiving rituximab every 6 months, plan to receive your vaccine 5 months – 5 months and 2 weeks after your last dose of rituximab and allow at least 2 weeks before receiving your next infusion of rituximab.
    • Olumiant, Rinvoq or Xeljanz (JAK inhibitors): potentially could impact response to vaccine.
      • Pfizer and Moderna vaccines: stop 2 days before your vaccine and remain off for 2 weeks,then resume and again stop 2 days before the booster and remain off for an additional 2 weeks after the booster.
      • J&J vaccine: stop 2 days before your vaccine and remain off for 2 weeks.
    • Mycophenylate/Cellcept: potentially could impact response to vaccine. There is evidence that this medication can affect the cells in the immune system that generate antibody responses to vaccines. For example, its effect on the pneumococcal vaccine has been studied in a small number of patients with lupus where it blunted the response in some individuals on 1500 mg or more daily. Its effect may be long lasting and stopping drug for an extended time could lead to flare of your disease. Some have recommended stopping drug for 1 week but we do not know if that is a sufficient time. Please discuss with your provider since recommendations here need to be individualized based on your age, dose of drug, other medications you may be on and the rheumatic disease for which you are being treated.

For more information: 

Lupus.org: COVID-19 Vaccine and Lupus

Creaky Joints: Can you get a COVID Vaccine if you are Immunocompromised?

COVID-19 Vaccine Information: North Carolina Department of Health & Human Services

AOCC is pleased to welcome Gordon K. Lam, MD, FACR.

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