|LETTER TO THE EDITOR
|Year : 2021 | Volume
| Issue : 1 | Page : 34-38
COVID-19 vaccine hesitancy in oncology patients
Ingris Marie Valero Sardina1, Milind Kumar1, Roshan Joseph2
1 Department of Oncology, Southern Medical Clinic, San Fernando, Trinidad and Tobago
2 Department of Emergency Medicine, Southern Medical Clinic, San Fernando, Trinidad and Tobago
|Date of Submission||24-Oct-2021|
|Date of Acceptance||16-Nov-2021|
|Date of Web Publication||06-Jan-2022|
Dr. Milind Kumar
Department of Oncology, Southern Medical Clinic, San Fernando.
Trinidad and Tobago
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sardina IM, Kumar M, Joseph R. COVID-19 vaccine hesitancy in oncology patients. Bengal J Cancer 2021;1:34-8
| Introduction|| |
Vaccination remains one of the topmost and successful medical interventions saving millions of lives every year from various diseases due to successful immunization programs.
Regardless of the proven importance and benefit, the childhood vaccines have been blamed historically for many problems such as autism, allergies, sudden deaths, neurological side effects, and vilification of vaccine causing “vaccine scare” leading to less coverage of population and subsequent outbreaks. Measles outbreak worldwide in 2019 was an example of the same. This prompted World Health Organization (WHO) to declare vaccine hesitancy as one of 10 major threats in 2019.
Currently, the world is facing an unprecedented global pandemic by novel coronavirus COVID-19 since the outbreak first reported as mysterious pneumonia at Wuhan, China from December 2019 and has accounted for 173 million cases and 3.72 million deaths worldwide to date.
Social distancing, quarantine, mask, and handwashing were the measures applied to slow down the rates of infection with varying amounts of success. The vaccines were awaited anxiously, and the development was followed keenly by media, members of public, healthcare providers, and scientists alike.
| Discussion|| |
BNT162b2 (Pfizer–BioNTech) messenger RNA vaccine was the first COVID-19 vaccine to receive emergency use listing by US FDA on December 11, 2020 and WHO on December 31, 2020. Subsequently mRNA-1273 (Moderna), ChAdOx1 nCov-19 (AstraZeneca), a recombinant chimpanzee adenoviral vector encoding the spike glycoprotein of SARS-CoV-2; Ad26.COV2.S (Johnson & Johnson/Janssen), a recombinant adenovirus type 26 vector encoding SARS-CoV-2 spike glycoprotein, inactivated COVID-19 vaccine BIBP developed by Sinopharm/China National Pharmaceutical Group, and inactivated COVID-19 vaccine, Sinovac-CoronaVac, developed by Sinovac/China National Pharmaceutical Group have received approvals by WHO as emergency use listing.
After the launch of vaccines, countries had to prioritize high-risk population and health-care workers over rest of population due to gap in supply and demand. Vaccine uptake has been robust in some countries, whereas other countries have faced issues of vaccine refusal so much so that vaccines had to be destroyed due to being unutilized by expiry date with the aim to rebuild trust in these vaccines.
If vaccination programs to be effective along with the formation of “herd immunity,” then at least vaccination rates should be in the 80%–95% range.,
According to data from ourworldindata.org, more than 2 billion doses have been administered. USA and UK have encouraging data of more than 40% population fully immunized. Still, we are a long way to immunize the world population to a 70%–80% level to achieve herd immunity.
Vaccine hesitancy may hinder in abilities of countries to achieve herd immunity as well.
It has been shown that active patients with cancer have a higher chance of developing a serious form of COVID-19 disease with higher mortality compared to the healthy cohort.,,
Also, patients with cancer who are actively being treated have a higher risk of death from COVID-19 compared to patients who are in remission.
Also, the severity of COVID- 19 may probably be relatable to cancer types, treatment administered, stages, and comorbidity associates.,
Patients with cancer have been included in the high-risk population but generally the coverage of patients with cancer taken COVID-19 vaccine is less than desired. The lack of information, discussion with health-care providers to make a shared decision, lack of easy availability, and vaccine hesitancy are some of the reasons.
The main reasons for vaccine hesitancy are as follows:
Fear of unacceptable side effects. Due to negative press about side effects and potential risk of death associated with COVID-19 vaccine, there has been difficulty to encourage patients about the safety of vaccine. Clotting has been a rare but recognized side effect of COVID-19 vaccines.
COVID-19 disease itself causes bleeding and clotting disorders, but with ChAdOx1 nCov-19 (AstraZeneca) vaccination, vaccine-induced thrombocytopenia was recognized which can, in turn, lead to cerebral venous thrombosis and splanchnic vein thrombosis usually seen within a week to two after vaccination. It is suggested to confirm the diagnosis by PF4-dependent ELISA or a PF4-enhanced platelet-activation assay, although intravenous immune globulin and starting anticoagulation may be started on clinical grounds.
According to review by the European Medical Agency (EMA) Committee of 62 cases of cerebral venous sinus thrombosis and 24 cases of splanchnic vein thrombosis reported in EU drug safety database (EudraVigilance) as of March 22, 2021, 18 of which were fatal out of 25 million people had received the vaccine in EEA and UK. They concluded that reported combination of blood clots and low blood platelets is very rare side effect of ChAdOx1nCov-19 (AstraZeneca) COVID-19 vaccine and maintained that the overall benefits of the vaccine in preventing COVID-19 outweigh the risks of side effects.
Other mild side effects such as muscle aches, chills, fever, headache, nausea, fatigue, soreness of injected arm, and redness at injection site are common and resolve within 24–48 h of vaccination. Paracetamol may be taken ideally post-vaccination after developing symptoms.
According to study on the BNT162b2 Pfizer vaccine, reactions were less common and milder in older adults than in younger adults. Systemic reactogenicity was more common and severe after the second dose than after the first dose, although local reactogenicity was similar after the two doses. Severe fatigue was observed in approximately 4% of BNT162b2 recipients. Overall, reactogenicity events were transient and resolved within a couple of days after onset. Lymphadenopathy, which generally resolved within 10 days, is likely to have resulted from a robust vaccine-elicited immune response. The incidence of serious adverse events was similar in the vaccine and placebo groups (0.6% and 0.5%, respectively).
Long-term side effects are exceedingly rare for any vaccines. Risk of anaphylaxis reported with both mRNA vaccines is estimated to be 2.5–4.9 cases per million doses administered.
There is confusion among population due to projected difference in effectiveness and side effects profile between various vaccines. Due to negative reports of clotting associated with ChAdOx1 nCov-19 (AstraZeneca) and Ad26.COV2.S (Johnson & Johnson/Janssen), many individuals express a preference to wait till they have access to mRNA vaccines.
On the contrary, there is the emergence of COVID-19 mutations contributing to the second wave worldwide and different protection levels are probable with different vaccines to different mutants. This is an ongoing area of active research. According to a study, BNT162b2 Pfizer vaccine may be producing neutralizing antibodies five times lower levels to SARS-CoV-2 B.1.617.2 (Delta variant––first detected in India) as compared to original COVID-19 strain.
This evolving information landscape many times contradictory creates a difficult interpretation for both health-care workers and public to decide especially if they want to be able to choose the best vaccine for them.
Lack of trust on science behind the vaccine. The speed with which vaccines were developed was unrealistic and even if it took a few months to develop still there was not enough belief in the pharmaceuticals and research approval processes. It was widely believed that trials were done in haste and “corners” were cut for emergency approvals. That we all are being experimented upon has been a common idea. Also, if vaccine development were so easy then why similarly was not done for other viruses like AIDS have been queried. Also, if the trust is low in government, media, and pharmaceuticals, it has a direct bearing on less acceptance of vaccines.
The reason for a relatively fast development of vaccine is manifold. The mRNA technology used is not a new technology and was used to develop the Ebola vaccine.
Another factor was that the scientists were familiar with the coronavirus group of viruses such as SARS and MERS. The research on these coronaviruses was used to develop a vaccine against COVID-19. Also, normally the time is taken to develop a new vaccine as costs are borne by a company as opposed to major funding efforts by many governments and private entities which help remove the financial barrier to develop the vaccine. In addition, all the mandatory steps in vaccine approvals were taken, and then only emergency authorization was given by USA, EMA, and WHO.
Social media misinformation. Social media has been a major source of news and opinion building in information age. Ease of sharing content, opinions, and global connectivity has propelled social media. Once information is online, it is difficult to retract it and the information gets to keep on shared with an increasing global audience. The counter-narrative or explanation typically is not shared or has less inflammatory value than “fake news.” The link between measles vaccine and autism was initially put forth by British gastroenterologist Andrew Wakefield, which was later retracted but social media took it and even today this continues to be shared in social media.
For COVID-19, fake news has been circulating with claims that all the vaccinated people would die in 2 years, the government is implanting chips to control and track people, one can get COVID-19 from the vaccine, that COVID-19 is a hoax created to make money, and it does not exist. That it was designed in Chinese labs and accidentally leaked is still contested in mainstream media.
Also, hackers such as to use these fake news pages as “click baits” and with use of trackers and spyware such as to collect insecure information and use it later to hack the unsuspecting victims. This information needs to be given to public as well.
Efficacy concerns. The vaccine would produce antibodies in 70%–90% of patients immunized according to various phase 2/3 trials for BNT162b2 Pfizer vaccine, mRNA-1273 Moderna, and ChAdOx1 nCov-19 AstraZeneca vaccines in healthy volunteers. These trials did not include cancer patients on active treatment and data are limited on specific groups like cancer patients.
According to recommendations from medical and nursing societies, patients with cancer are high priority to receive COVID-19 vaccinations. European Society of Medical Oncology (ESMO) calls for COVID-19 vaccination urgently requested government and providers worldwide to prioritize COVID-19 vaccination for patients with cancer. According to Prof. Solange Peters (ESMO President), all patients should be vaccinated, including the frail and elderly, those on chemotherapy, immunotherapy, hormonal therapy, or targeted therapy, underlining the message that the different vaccines approved are safe and the risk–benefit ratio in favor of vaccination for patients with cancer (ESMO policy document).
Patients with cancer on active treatment like chemotherapy may be immunosuppressed and contracting the virus can be fatal for them. Vaccination may be scheduled just prior to the next chemotherapy. However, data on immunogenicity andefficacy/effectiveness of vaccine in patients with cancer on active chemotherapy are limited including the optimal timing of vaccine with regard to chemotherapy cycle.
Also, according to US Centre for Disease Control guidance all patients with cancer are eligible for COVID vaccines regardless of if on active cancer-directed therapy.
According to interim analysis from MDAC of 6388 patients, after BNT162b2 mRNA COVID-19 vaccine, patient-reported symptoms were available from 4714 patients with a median age of 67 years (range 16–95 years) after two doses. It was seen that seniors reported lower mean scores vs. middle aged on 22 of 36 symptoms including injection site pain, palpitations, itch, rash, malaise, fevers/chills, arthralgia, myalgia, headache, pain, fatigue, nausea, disturbed sleep, and distress (P < 0.05). Also the patients with prior immune checkpoint inhibitors had higher severity of itch and rash (P < 0.05) from baseline after both doses 1 and 2 compared to patients without systemic treatment. After the first dose, patients with prior immune checkpoint inhibitors had a higher increase in fatigue, malaise, itch, rash, myalgia, and anorexia from their baseline as compared to patients, not on any systemic treatment (P < 0.05). Of the total 6388 patients, 616 had a COVID-19 test at any time post-dose 1: Very low number of patients contracted COVID-19 post-vaccination. Only 23 (0.36%) tested positive of whom 20 (0.3%) were between doses 1 and 2; two (0.031%) were within 7 days post-dose 2; and one patient (0.016%) tested positive 16 days after dose 2, requiring admission. This report confirms that COVID-19 vaccine is well tolerated and is efficacious in patients with cancer on active treatment.
These data reassure the safety and efficacy in cancer patients with COVID-19 vaccine, although long-term results are awaited from this cohort.
In cancer patients due to immunosuppression once vaccine is administered, the antibodies response might be less as compared to population, but we are still waiting for further data to further or refute this hypothesis.
The following are the strategies to tackle vaccine hesitancy in cancer patients:
- Clear recommendation: Making a strong recommendation from the oncologist/health-care provider team is needed.
- Explore the reason for hesitancy in a gentle supportive manner: Express empathy and maintain patient–provider relationship
- Share the facts about vaccination in general population and the cancer society’s recommendations: Discussion about cancer stage and treatment options is imperative. If patient has completed cancer-directed therapy, then the patient would be at par with normal population and should be immunized. The patients on active chemotherapy need to have discussion with oncologist and plan for vaccine ideally a few days prior to the next cycle once neutrophil counts are normal may be advised, although we do not have enough data to make recommendation for optimal timing of vaccination during chemotherapy cycles. Acknowledge unknown risks or lack of long-term robust data of efficacy in cancer patients on chemotherapy.
- Acknowledge and support patient’s ownership of decision: The patient should not feel compelled or threatened to opt for vaccine.
Other steps advised are to engage with communities and community leaders, to share experiences by healthcare providers and leaders by taking the vaccine themselves, and tap into people’s desire to protect friends and family.
According to Thomson and Watson, the root causes of suboptimal vaccination are the 5 As: Access, Affordability, Awareness, Acceptance, and Activation. This is applicable to patients with cancer also. Governments worldwide need to embrace social media with a view to provide information.
Also use of social media platforms such as Facebook, Instagram, and Twitter to counter fake news and using conventional media to educate masses on need for vaccination is a positive step. It has been observed that people who are more social media users have a higher rate of vaccine hesitancy (40% refusal rates) compared to individuals who use conventional media as the primary source of information (18% refusal rate). If health-care professionals, government, and policymakers can harness the power of social media to support vaccinations, then it could be a powerful tool to encourage mass vaccination drives.
According to an online survey conducted within inspire online community, the patients with cancer were more interested in COVID-19 vaccine compared to population. A total of 750 patients with cancer of which 38% were on active treatment with the most common cancers represented being prostate (30%), thyroid (24%) ovarian (20%), bladder (8%), and breast (4%). Approximately 80% indicated that they would “definitely” or “most probably” get the COVID-19 vaccine. The subset of patients with significantly greater interest was in people with prostate (85%), bladder (82%), and ovarian cancer (81%). On the other end of spectrum were breast cancer (23%) and thyroid cancer (30%) who were uncertain, or they would “probably” or “definitely” not get vaccinated. Older age, male sex, and college graduates were significantly more likely to get vaccinated. Younger respondents were more concerned about side effects and overall, 54% of patients were worried about side effects. In total, 158 participants who indicated against vaccinating, 23% were concerned that research and development was rushed and 11% were concerned about negative interaction with the compromised immune system.
If these patients can be counseled and reassured, we can decrease vaccine refusal in these high-risk cases.
| Conclusion|| |
Oncology patients are particularly vulnerable group in these times of COVID-19 pandemic. We need to be more supportive of our patients and be able to counsel them to consider vaccination both for their safety and community at large as well.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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