Embolic and thrombotic events after COVID-19 vaccination

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Post-vaccination embolic and thrombotic events, also termed vaccine-induced prothrombotic immune thrombocytopenia (VIPIT), [1] vaccine-induced immune thrombotic thrombocytopenia (VITT), [2] [3] or thrombosis with thrombocytopenia syndrome (TTS) [4] are rare types of blood clotting syndromes that were initially observed in a number of people who had previously received the Oxford–AstraZeneca COVID-19 vaccine (AZD1222) [lower-alpha 1] during the COVID-19 pandemic. [1] [8] It was subsequently also described in the Janssen COVID-19 vaccine (Johnson & Johnson) leading to suspension of its use until its safety had been reassessed. [9]

Contents

In April 2021, AstraZeneca and the EMA updated their information for healthcare professionals about AZD1222, saying it was "considered plausible" that there was a causal relationship between the vaccination and the occurrence of thrombosis in combination with thrombocytopenia and that, "although such adverse reactions are very rare, they exceeded what would be expected in the general population". [8] [10] [11] [12]

Signs and symptoms

The thrombosis events associated with the COVID-19 vaccine may occur 4-28 days after its administration and mainly affects women under 55. [1] [3] [13] Several relatively unusual types of thrombosis were specifically reported to be occurring in those with the reaction: cerebral venous sinus thrombosis and thrombosis of the splanchnic veins. [14] [15] Cerebral venous sinus thrombosis may cause severe headache, stroke-like symptoms (weakness of a limb and/or facial muscles), seizures and coma. [16] Splanchnic vein thrombosis may cause abdominal pain, accumulation of fluid in the abdominal cavity, and gastrointestinal bleeding. [17] [18]

Other forms of thrombosis, such as the more common pulmonary embolism, may also occur. Arterial thrombosis has also been reported. [19] The low platelet count may manifest as petechia (tiny blood spots under the skin) beyond the site of the injection. [14]

Disseminated intravascular coagulation (DIC), diffuse formation of blood clots throughout the blood vessels of the body, has been reported as part of the syndrome. [20] DIC may cause a range of symptoms, including abnormal bleeding, breathlessness, chest pain, neurological symptoms, low blood pressure, or swelling. [21]

COVID-19 vaccines have some adverse effects that are listed as common in the two or three days following vaccination which are usually mild and temporary. [14]

Causes

The rare simultaneous occurrence of thrombocytopenia (low blood platelets) with blood clots after vaccination raised the original concern about this condition.[ citation needed ] In many cases where acute thrombosis and thrombocytopenia have been found together after COVID-19 vaccination, an antibody against platelet factor 4 has been identified. [22] This phenomenon is mostly encountered in some people who have been administered heparin, but none of the reported cases had received heparin. [22] More rarely, this phenomenon had previously been described as an autoimmune phenomenon in people who had not been exposed to heparin. [23] One striking feature of thrombocytopenia in the presence of anti-PF4 antibodies is the propensity of some to develop thrombosis, a phenomenon called heparin-induced thrombocytopenia if heparin is involved. [24]

Thrombocytopenia is generally a common symptom after or during many viral infections, [25] and it "has been consistently reported" after intravenous administration of adenoviral gene transfer vectors, [26] although its mechanisms are not yet clear.

There is no confirmed causal link to the syndrome and any COVID-19 vaccination,[ citation needed ] however EMA is conducting investigations into AZD1222 and the Janssen COVID-19 vaccine (J&J) for possible causal links. [27]

On 7 April 2021 the EMA noted one "plausible explanation" for the combination of blood clots and low blood platelets is "an immune response, leading to a condition similar to one seen sometimes in patients treated with heparin", that is heparin induced thrombocytopenia (HIT). [28]

Diagnosis

In the United Kingdom, professional societies led by the Royal College of Emergency Medicine have issued a guideline for suspected cases. Someone presenting with concerning symptoms between five and 28 days after administration of the vaccine is assessed for a possible thrombotic complication, with a full blood count (which includes a platelet count) as the initial investigation. If the platelet count is decreased, determination of the D-dimer and fibrinogen levels may be performed, with hematology expert advice recommended if these are elevated above specific cut offs. [19]

Management

Guidelines from professional societies recommend treatment with alternative anticoagulants instead of heparin, as there is a possibility that it may aggravate the phenomenon. [29] [30] Alternative options as the directly-acting oral anticoagulants (DOACs), argatroban, fondaparinux or danaparoid depending on the circumstances. [29] Platelet transfusion is discouraged, as this too may aggravate thrombosis. [29] UK guidelines by the British Society for Haematology recommend the administration of intravenous immunoglobulin (IVIG) to reduce levels of the pathogenic antibody. [29] Low fibrinogen levels may require correction with fibrinogen concentrate or cryoprecipitate. [29]

Epidemiology

The Paul Ehrlich Institute has recorded 31 cerebral venous sinus thromboses (CVST) and nine deaths out of 2.7 million vaccinated in Germany with the AZD1222. [31] On 2 April 2021 the UK's Medicines and Healthcare products Regulatory Agency reported 22 cases of CVST and a further eight cases of clotting problems both associated with a low level of blood platelets following a "rigorous review" of its Yellow Card reporting. The institute also reported finding no events of this type which occurred after vaccination with the Pfizer–BioNTech COVID-19 vaccine. [32] The EMA had earlier said that a link between certain very rare blood clots and the AstraZeneca vaccine is "not proven, but is possible". [32]

Observations in Germany of these rare events seemed to relate mostly women aged under 55. However, because Germany had previously restricted AZD1222 to under 65s, the population vaccinated there with AZD1222 was comparatively younger, and consequently contained a higher proportion of women taking the contraceptive pill. As CVSTs are more likely in women using hormonal contraceptives, this inherent risk factor may be an influence on the reported preponderance of women experiencing these events following vaccination. [31] [2] The UK, in contrast, has applied its Pfizer and AZD1222 vaccines generally to older groups first, then by decreasing age. [31]

The UK MHRA reporting regards AZD1222 to 9 June 2021 recording 71 deaths out of 390 cases (18%) in the context of 24.6 million first doses administered. [33] [34]

Regulatory status

According to the European Medicines Agency (EMA), as of 28 March 2021, the reported number of cases of embolic and thrombotic events after vaccination was lower than the rate of such events in the general population overall. However, the specific syndrome - of embolic and thrombotic events in combination with low levels of blood platelets - presenting in post-vaccination cases raised the possibility of an association between the vaccine and the relatively rare syndrome. The EMA also said that there is no proof that these events are caused by the vaccines, but that the possibility could not yet be ruled out completely. [8] Accordingly, the EMA advised that people who received the vaccine and experienced symptoms suggestive of thrombosis, including shortness of breath, blurred vision and severe or persistent headache, should seek medical attention. [8]

In a press briefing in the Afternoon of 7 April 2021 by Emer Cooke executive director of the EMA began by stating "Our safety committee, the Pharmacovigilance and Risk Assessment Committee (PRAC) of the European Medicines Agency, has confirmed that the benefits of the AstraZeneca vaccine in preventing COVID-19 overall outweigh the risks of side effects. COVID-19 is a very serious disease with high hospitalization and death rates and every day COVID is still causing thousands of deaths across the EU. This vaccine has proven to be highly effective, it prevents severe disease and hospitalization, and it is saving lives. Vaccination is extremely important in helping us in the fight against COVID-19 and we need to use the vaccines we have to protect us from the devastating effects". [35] She went on to say "The PRAC after a very in-depth analysis has concluded that the reported cases of unusual blood clotting following vaccination with the AstraZeneca vaccine should be listed as possible side effects of the vaccine". [36] At the same briefing Dr. Samina Strauss of PRAC confirmed "our conclusion is that these clotting disorders are very rare side effects of the vaccine". [37]

The UK MHRA also held a news conference on 7 April 2021 and while there was no proof the AZD1222 vaccination caused the rare blood clots but indicated the possibility of a link was getting stronger. [38] The UK was to offer under 30s alternative vaccines. [38] The reasoning was because in the 20-29 age range the benefits to individual of vaccination were less as their likelihood of harm from COVID-19 was less and closer to the potential risk of harm from the vaccine (at a medium exposure risk with COVID-19 infection cases running at a rate of 60 per 100,000). [39] [38] For higher age groups the benefit to risk ratio increased. [38]

Also on 7 April 2021 an interim statement from the WHO said its advisory body, GACVS, found any "causal relationship" between the rare blood clot cases and AZD1222 to be "plausible but is not confirmed". [40]

On 20 April 2021 the safety committee of the EMA (PRAC) found a "possible link to very rare cases of unusual blood clots with low blood platelets" for the J&J Janssen vaccine; and required that these rare events, similar to those noted for AZD1222, should be listed as a very rare side effect. The EMA states the overall risk-benefit for the J&J vaccine remains positive. [41]

History

Organizations

Global vaccine safety comes under the remit of the World Health Organization (WHO), and in particular its Global Advisory Committee on Vaccine Safety (GAVCS). Other drug regulatory agencies significantly involved include:

Syndrome identification

A number of COVID-19 vaccines began to become approved and available at scale in late 2020 with vaccinations beginning to ramp up at scale from the beginning of 2021, among them the Oxford–AstraZeneca COVID-19 vaccine, based on an adenovirus vector and internally termed AZD1222.

On 11 March 2021 the EMA issued a statement noting Denmark had suspended AZD1222 vaccinations due to a vaccinated patient dying with blood clots. While noting there had been reports of other vaccinated people having blood clots and that its safety committee was already reviewing such cases, the number of thromboembolic events in vaccinated people was no higher than in the general population. [43]

The World Health Organization (WHO) Global Advisory Committee on Vaccine Safety thought necessary on 19 March 2021 to issue a statement relating to safety signals related to AZD1222 relating to thromboembolic events and thrombocytopenia following review of available data and conclusions included that AZD1222 "a positive benefit-risk profile, with tremendous potential to prevent infections and reduce deaths across the world". [44]

In its safety update of 29 March 2021 the EMA indicated it had initiated investigations into the very rare cases of specific embolic and thrombotic events in combination with thrombocytopenia (low levels of blood platelets) and related bleeding including disseminated intravascular coagulation and cerebral venous sinus thrombosis (CVST), noting any link with AZD1222 was not proven but could not be excluded. [8] The EMA also initiated an assessment for all COVID-19 vaccines used in the EU for immune thrombocytopenia (ITP), described as low blood platelet levels that could lead to bruising and bleeding, as a possible side effect, whilst also stating that up to this point no link with any COVID-19 had been established. [8]

On 7 April 2021 the EMA determined that that unusual blood clots with low blood platelets should be listed as very rare side effects of AZD1222, with WHO and UK EHRA issuing generally similar statements on the same day. None of the agencies found a confirmed causal link between the vaccine and these incidents at the time, but were listing them out of an abundance of caution. [14] [38] [40]

A highlight of minutes of the EMA's Pharmacovigilance Risk Assessment Committee (PRAC) concluding 9 April 2021 indicating they also were investigating four cases of unusual blood clots with low blood platelets, including 1 death, amongst people who had taken the Janssen COVID-19 vaccine (J&J). The J&J vaccine was approved but not yet deployed in the EU, though vaccinations are in progress in the USA. PRAC has determined that it is currently not clear if there is a causal association. Should regulatory action prove necessary, PRAC have indicated the likely outcome would be an update to product information characteristics. [45]

Vaccination campaign responses

Early reports of the events of concern seemed to indicate the presentation rate for the specific blood clots of concern might be higher for women of younger ages, [2] UK MHRA found examples across all genders and ages, [34] [ better source needed ] their data skewing towards these specific blood clots being more prevalent in AZD1222 vaccinated persons of younger ages. [39]

The WHO has continued to stress the administration of vaccines is based on risk versus benefit analysis. [40] Some variables that may be factored into such analysis include risk of an individual from catching COVID-19, which relate to the infection rate in that area, and the benefits to that individual if vaccinated and exposed to COVID-19 which varies with age, versus whatever the risks of vaccination are to that individual. [39]

Regional and national responses

The advisory panel for the government of Ontario, Canada has recommended against the use of heparin for management of thrombosis after vaccination until more is known. [46]

In response to the concerns over the adverse effects relating to rare blood clotting types Germany has suspended use of the AZD1222 in those under 60 years of age; in contrast to a period previously having suspended use of AZD1222 to over–65s due to limited data of the efficacy of the vaccine to this age group at that time. [47]

Following a few days of suspended use of AZD1222, the Ministry of Health, Welfare and Sport of the Netherlands decided to continue administering the vaccine only to persons above the age of 60. [48]

On 8 April 2021, the Australian Technical Advisory Group on Immunisation (ATAGI) advised the Australian Government that the Pfizer COVID-19 vaccine is recommended over AZD1222 for adults aged under 50 years. The advice is "based on the increasing risk of severe outcomes from COVID-19 in older adults (and hence a higher benefit from vaccination) and a potentially increased risk of thrombosis with thrombocytopenia following AstraZeneca vaccination in those under 50 years." [15] AZD1222 is still recommended by ATAGI for people over 50, and those under 50 who have already had their first dose with no ill effects. [15] In the state of Victoria, there were reports of some, aged under 50, being turned away from vaccination centres, despite having confirmed appointments. It is understood a special consent process will be developed by the Australian Government for people under 50 who choose to receive the AZD1222 vaccine. [49]

Studies

A study convened by a group of British hematologists on March 19, 2021, just 2 days after the acknowledgement of the condition, published its finding The New England Journal of Medicine, establishing case definition criteria. The study included 294 patients who presented with symptoms of thrombocytopenia and thrombosis after receipt of the first dose of the Oxford–AstraZeneca COVID-19 vaccine, showing an independent association between baseline platelet count and the presence of intracranial hemorrhage. The study established that 85% of the patients effected by the condition were aged younger than 60 years, and that those patients with a history of thrombosis or prothrombotic disorders did not appear to be at increased risk. The study showed an overall mortality rate of 22% and set out plans for additional research to determine the genetic factors that may increase risk of the condition and identify potential therapeutic agents. [50]

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Heparin-induced thrombocytopenia Low platelet count due to heparin, associated with a risk of thrombosis

Heparin-induced thrombocytopenia (HIT) is the development of thrombocytopenia, due to the administration of various forms of heparin, an anticoagulant. HIT predisposes to thrombosis because platelets release microparticles that activate thrombin, thereby leading to thrombosis. When thrombosis is identified the condition is called heparin-induced thrombocytopenia and thrombosis (HITT). HIT is caused by the formation of abnormal antibodies that activate platelets. If someone receiving heparin develops new or worsening thrombosis, or if the platelet count falls, HIT can be confirmed with specific blood tests.

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Cerebral venous sinus thrombosis Presence of a blood clot in the dural venous sinuses or cerebral veins

Cerebral venous sinus thrombosis (CVST), cerebral venous and sinus thrombosis or cerebral venous thrombosis (CVT), is the presence of a blood clot in the dural venous sinuses, the cerebral veins, or both. Symptoms may include severe headache, visual symptoms, any of the symptoms of stroke such as weakness of the face and limbs on one side of the body, and seizures.

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References

Notes

  1. The Oxford–AstraZeneca COVID-19 vaccine is codenamed AZD1222, [5] and later supplied under trade names, including Vaxzevria [6] and Covishield. [7]

Footnotes

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  2. 1 2 3 Greinacher, Andreas; Thiele, Thomas; Warkentin, Theodore E.; Weisser, Karin; Kyrle, Paul A.; Eichinger, Sabine (9 April 2021). "Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination". New England Journal of Medicine. 384 (22): 2092–2101. doi: 10.1056/NEJMoa2104840 . PMC   8095372 . PMID   33835769.
  3. 1 2 Cines, Douglas B.; Bussel, James B. (16 April 2021). "SARS-CoV-2 Vaccine–Induced Immune Thrombotic Thrombocytopenia". New England Journal of Medicine. 384 (23): 2254–2256. doi: 10.1056/NEJMe2106315 . PMC   8063912 . PMID   33861524.
  4. Long, Brit; Bridwell, Rachel; Gottlieb, Michael (2021). "Thrombosis with thrombocytopenia syndrome associated with COVID-19 vaccines". The American Journal of Emergency Medicine. 49: 58–61. doi:10.1016/j.ajem.2021.05.054. ISSN   0735-6757. PMC   8143907 . PMID   34062319.
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