416 - COVID Vaccine Exemptions, Screening for Chlamydia and Gonorrhea

From the Centers for Disease Control and Prevention

1) Medical Contraindications/Exemptions for COVID-19 Vaccination

Earlier this month, we reviewed contraindications for influenza vaccination. As the nation discusses mandatory COVID-19 vaccination, we primary care clinicians are being asked to certify contraindications and precautions for these vaccines.

The only true contraindications for any of the COVID-19 vaccines are:

• Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a component of the COVID-19 vaccine.
• Immediate allergic reaction of any severity after a previous dose or known (diagnosed) allergy to a component of a COVID-19 vaccine.

Patients with these reactions should not get the same type of COVID-19 vaccine (but see precautions below). There is a list of chemical components in each vaccine at the link below (see “Reference”).

There are also precautions for COVID-19 vaccination. If a precaution exists, a patient may get the vaccine, but preferably in a prepared medical setting with supplies and personnel capable of recognizing and addressing anaphylaxis (outpatient offices are OK for this with the proper preparation). These patients should be observed for 30 minutes rather than the usual 15.

Precautions:

• Any immediate allergic reaction to other vaccines or injectable therapies.
• A history of a contraindication to mRNA vaccines is a precaution to Janssen vaccine and vice versa.

It is important to discuss these precautions with the patient to reach a shared decision - discussing risk for acquiring COVID-19, risk of severe COVID-19 illness, and unknown risk of anaphylaxis in people with such reactions to other vaccinations.

The following are considered NEITHER contraindications NOR precautions:

• Other environmental allergies
• Latex allergy
• “COVID arm” (delayed local reaction, even if large) – use the other arm for the second dose.
• Chronic diseases (asthma, immunodeficiency, autoimmune illness, etc.). If anything, these are indications for the vaccine.
• Pregnancy and lactation

Other situations:

• Patients with a history of Guillain-Barre syndrome (GBS) should be offered an mRNA vaccine (Pfizer or Moderna), if available, instead of an adenovirus vector vaccine (Janssen). The risk of GBS from COVID-19 vaccination is very low (though not zero) overall.
• Women < 50 years of age, pregnant or not, should consider getting an mRNA vaccine due to a risk of thrombosis with thrombocytopenia syndrome (TTS) with the adenovirus vector (Janssen) vaccine.
• Patients with a history of thrombosis/thrombocytopenia should be offered an mRNA vaccine within 90 days of their TTS illness, or any COVID-19 vaccine after that time.
• Patients who acquire myocarditis or pericarditis after the first dose of vaccine (which is rarer than with the second dose) should defer the second dose until more data is available about the increased risk.
• Patients with resolved myocarditis or pericarditis of other etiology can still get any COVID-19 vaccine.
• Bell’s palsy – a history of this is not a contraindication, but if Bell’s palsy develops after COVID-19 vaccine, it should be reported to VAERS.
• Inflammation around dermal fillers – cases of this have been reported after COVID vaccine, but there is no known contraindication to vaccination in patients with dermal fillers.

John’s Comments:

Our obligation is to certify true medical contraindications as well as any serious medical concern we have that would exempt the patient from vaccination. This latter context is where care is needed to not simply amplify our patients’ misplaced concerns or perpetuate misinformation. The monitoring of these vaccines is extensive, so bookmark the reference link below and check it frequently for new information.

The CDC includes an interesting footnote to its ingredients table: “None of the vaccines contain eggs, gelatin, latex, or preservatives. All COVID-19 vaccines are free from metals such as iron, nickel, cobalt, lithium, rare earth alloys or any manufactured products such as microelectronics, electrodes, carbon nanotubes, or nanowire semiconductors.” It makes me sad that the CDC feels the need to write that, but that’s where we are, I guess.

Reference:

• Interim Clinical Considerations for Use of COVID-19 Vaccines | CDC [Internet]. 2021 [cited 2021 Sep 14]. Link

From the USPSTF and the CDC

2) Screening for Chlamydia and Gonorrhea

Chlamydia and gonorrhea are among the most common sexually transmitted infections (STIs) in the US. The rate of chlamydia infection among women is nearly double the rate among men based on 2019 CDC data. Gonorrhea infection is more prevalent in men than in women. Infection rates are highest among adolescents and young adults of both sexes. In 2019, 61% of all reported chlamydia infections, and in 2018 54% of new gonococcal infections, were among persons aged 15 to 24 years.

Chlamydial and gonococcal infections in women are usually asymptomatic and may lead to pelvic inflammatory disease (PID) and its associated complications, such as ectopic pregnancy, infertility, and chronic pelvic pain. Infection in men may lead to urethritis and epididymitis. However, men are often also asymptomatic.

The USPSTF recently updated and affirmed their 2014 recommendation for the screening for chlamydia and gonorrhea. Recommendations include:

For sexually active women, including pregnant persons, screen for chlamydia and gonorrhea if they are:

• 24 years or younger
• 25 years or older and at increased risk for infection (B)

Women 25 years or older are at increased risk if they have:

• A previous or coexisting STI
• A new or more than 1 sex partner
• A sex partner having sex with other partners at the same time
• A sex partner with an STI
• Inconsistent condom use when not in a mutually monogamous relationship
• A history of exchanging sex for money or drugs
• A history of incarceration

For sexually active men:

• The evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men. (I)

The UPSTF recommendation notes there are no good studies regarding screening intervals and suggests a reasonable approach would be to screen patients whose sexual history reveals new or persistent risk factors since the last negative test result.

The recently updated CDC guidelines for screening in men differ from the USPSTF guidelines. For men who have sex with men (MSM), the CDC recommends the following:

• Screen at least annually for sexually active MSM at sites of contact (urethra, rectum) regardless of condom use
• Screen every 3 to 6 months if at increased risk (i.e., MSM on PrEP, with HIV infection, or if they or their sex partners have multiple partners)

The USPSTF and CDC recommend using the nucleic acid amplification tests (NAATs) for screening for both infections. The tests have both high sensitivity and specificity. The FDA has approved NAATs for use on urogenital and extragenital sites, including urine, endocervical, vaginal, male urethral, rectal, and pharyngeal specimens. Urine testing with NAATs is at least as sensitive as testing with endocervical specimens, clinician- or self-collected vaginal specimens, or urethral specimens in clinical settings. The same specimen can be used to test for chlamydia and gonorrhea.

Mark’s Comments:

As was noted in our September 3^rd edition of Take 3, the CDC sexually transmitted disease surveillance report released in April found that in 2019, the last year for which data were available, the overall number of reported cases of STIs increased for the sixth consecutive year. We have no idea how the COVID pandemic will impact this, but do worry that the “roaring 20’s” mentality that has been written about will increase incidence even more.

One piece of information that I’m still trying to get my head around is that according to the CDC, two published studies that incorporated modeling techniques estimated that only about 10% of men and 5-30% of women with laboratory-confirmed chlamydial infection develop symptoms. Additionally, the prevalence of asymptomatic gonorrheal infections is estimated in different studies to be up to 70% of women and up to 60% of men. This is very different than what I was taught about theses STIs, particularly with regard to men. While the evidence according to the USPSTF is not robust enough to recommend screening in men, it certainly makes me have a much lower threshold to screen in higher risk men, particularly now that we use the NAATs testing rather than the historically terrifying urethral swab. Remember, an “I” recommendation doesn’t say “don’t do it,” only that we don’t know if it helps or not.

References:

• USPSTF: Chlamydia and Gonorrhea Screening. September 14, 2021. Link
• USPSTF. Screening for Chlamydia and Gonorrhea: USPSTF Recommendation Statement. JAMA September 14, 2021 Volume 326, Number 10: 949-956. Link
• CDC STI Treatment Guidelines 2021: Screening Recommendations and Considerations Referenced in Treatment Guidelines and Original Sources – by disease. Updated 15 September 2021. Link

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org