Comment: Very few medical exemptions for vaccines legitimate

By Faye Flam / Bloomberg Opinion

A pervasive myth floating around social media holds that lots of people can’t be vaccinated, or shouldn’t be, or are ineligible due to medical conditions. Even the mainstream media sometimes gives us that impression. A recent New York Times opinion essay, for example, proclaimed that in addition to those refusing vaccines, “…millions more, of course, are children under 12 and those disqualified by underlying health conditions.”

It’s true there are millions of children, but who are these other millions, or perhaps less than millions, disqualified for underlying health conditions? Lots of people might think they are in this group, but not because of any doctors’ orders.

Alfred Kim, a doctor who specializes in immune disorders at Washington University in St. Louis, told me several months ago that some of his immune-compromised patients were afraid to get the shots, but that the shots posed no particular danger to them. The danger was that they might still get sick with the virus despite getting vaccinated, but there was no question they would be better off getting the shots.

Art Krieg, also a specialist in immune disorders, agreed. When I asked him if there were any health conditions that make the vaccine unadvisable or would make someone “disqualified,” he said, “Absolutely not; there is no health condition where you should not get the vaccine.”

Now there may be a gray area, where people and their doctors could be free to choose whether to get the second shot or be allowed to get past any vaccine requirements with just a single shot of the two-dose regimens. This is different from the claim that hordes of people in the U.S. desperately want a vaccine but can’t get one for medical reasons.

One group that’s been considered for exemption or a single shot would be teenage boys, since the data show the vaccine comes with a small elevated risk of myocarditis, a potentially dangerous inflammation of the heart, especially after the second shot. The risk is rare, but so is severe covid-19 among teens. While the Centers for Disease Control says it’s OK to give people who got myocarditis after the first shot a second one, a number of experts disagree.

Another group that might reasonably be considered exempt would be people who have had covid-19, though such people are under no circumstances disqualified. Krieg said research looking at antibody levels found they are only a tenth as high in people who’ve had covid-19 compared with those who’ve been fully vaccinated. Add to that the fact that some people might wrongly think they’ve had the virus, and there’s also a possibility that some asymptomatic cases might not have had enough of an infection to build up immunity.

So for people who’ve tested positive but not gotten very sick, Krieg said, “They really need the protection of a vaccine which gives much stronger immune responses than the natural protection that most people get after being infected.”

Other vaccines are known to induce better immunity than the disease does, said Paul Offit, director of the Vaccine Education Center and professor of pediatrics at the Children’s Hospital of Philadelphia. Vaccines against HPV and tetanus are two examples. He also said he wished there were better data collected comparing natural infections with vaccinations and looking at rates of infection, hospitalization and death. Some experts have concluded that people who’ve had covid-19 should get just one shot of the mRNA vaccines, which normally require two.

The only people Offit said might be considered medically disqualified would be partially vaccinated people who had a severe allergic reaction to the first shot. But how common is this?

I asked Elizabeth Phillips, a doctor at Vanderbilt Medical Center who specializes in allergies. She said the initial data on health-care workers showed that the severe form of allergy known as anaphylaxis happened in about 11 out of every million vaccines given. But now that the vaccines have reached the wider population, it looks closer to 5 in a million.

Earlier in the vaccine rollout, she said she and her team were called in to look at people at possible risk from their history of allergic reactions. After examining 29,000 people with a history of allergic reactions, they identified three whose cases warranted delay, and everyone else was vaccinated safely. The three were given further tests and then vaccinated with no incident.

“There are still a lot of unanswered questions,” Phillips said, “but we have a fairly good idea how to manage this safely.” A massive current study on allergic reactions by the National Institutes of Health could provide useful data if people are offered a third shot in the coming months.

Phillips has also studied people who’ve had a severe allergic reaction to the first shot of the Moderna or Pfizer vaccines. In a group of 159 such people in the study, most got the second shot with no reaction. About 20 percent had an allergic reaction to the second shot but it responded quickly to the use of an antihistamine. The Journal of the American Medical Association published the results last month.

It’s important data, since many people need to be fully vaccinated to carry out their nursing home or health-care jobs, and the study showed how to manage the allergy risk.

What do these findings mean for those responsible for communicating public health information? While it might seem good-intentioned to motivate healthy people to get their shots to protect this mythical group of disqualified individuals, it could backfire. If people wrongly assume that whatever health conditions they have render them among the disqualified, they are worsening the risks to themselves as well as to those who are trying to help them.

Faye Flam is a Bloomberg Opinion columnist and host of the podcast “Follow the Science.” She has written for the Economist, the New York Times, the Washington Post, Psychology Today, Science and other publications.