COVID-19 vaccine medical exemptions: who qualifies and how to get one

Ontario’s Ministry of Health (MOH) announced its recommendations for valid medical exemptions for the COVID-19 vaccine last month and stipulated that there are very few circumstances under which an exemption can be granted.

Broadly, medical exemptions are granted only if you have certain specified pre-existing conditions that preclude taking the vaccine or you have an adverse reaction to a vaccine after the first shot. These would qualify as contraindications, which the Ministry of Health calls “a situation where a vaccine should not be given as the risks outweigh any potential therapeutic benefit.”

Those who experience serious adverse effects after a COVID-19 vaccine shot or those with medical conditions that may affect their response to the vaccine should see an allergist or immunologist for further assessment. For very serious or rare adverse reactions, the ministry says a thorough investigation should be carried out to make sure the reaction was not caused by some other factor.

The ministry adds that in many cases, subsequent doses of the COVID-19 vaccine can be given under the supervision of an allergist or immunologist.

Who can get a medical exemption?

“True medical exemptions are expected to be infrequent and should be supported by expert consultation,” says the Ministry of Health’s guidance documents.

The following reasons have been approved as valid for medical exemptions:

Pre-existing conditions:

• Severe allergy to a component of a COVID-19 vaccine
  If you are severely allergic to an ingredient in the vaccine you may qualify for a medical exemption only if the allergy was evaluated and documented by an allergist or immunologist followed by a discussion on potential options for vaccination with the same or alternate vaccine. Further, the allergist or immunologist has to conclusively determine that you are unable to receive any COVID-19 vaccine.
• Myocarditis before taking an mRNA vaccine series (those aged 12-17)
  The National Advisory Committee on Immunization (NACI) says if a child is between the ages of 12 to 17 has a history of myocarditis, unrelated to an mRNA COVID-19 vaccine, it is important to consult with their clinical team for recommendations specific to their individual needs. In such a case, a medical exemption can be granted only if discussions have been had with a specialist about potential options for vaccination with an mRNA vaccine or an alternative and the specialist determines that the child is unable to receive any COVID-19 vaccine. “This is a precaution for
  individuals aged 12-17 years old based on recommendations issued by NACI,” says the MOH.
  NACI adds that if the myocarditis diagnosis is remote and the child is no longer regularly seeing a medical professional for cardiac issues, they should get an mRNA vaccine.

Adverse events following immunization (AEFI):

The Ministry of Health says an adverse event refers to “any untoward medical occurrence which follows immunization and which does not necessarily have a causal relationship with the use of a vaccine.”

• Severe allergic reaction or anaphylaxis after taking a COVID-19 vaccine
  If you have a severe allergic reaction like anaphylaxis after taking a COVID-19 vaccine, you may be eligible for a medical exemption if the reaction was evaluated and document by an allergist or immunologist and they discussed potential options for reimmunization with the same vaccine or an alternative. The specialist must also conclusively determine that you’re unable to take any COVID-19 vaccine.
  Those with other types of non-sever allergies do not qualify for a medical exemption.
• Myocarditis or pericarditis after an mRNA COVID-19 vaccine
  If you develop myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the membrane that surrounds the heart) after getting your first vaccine dose, the MOH recommends deferring your second dose until more information and guidance is available. You may be eligible for a medical exemption if the condition was diagnosed following a medical evaluation by an ER doctor or specialist and they determine that you cannot take any COVID-19 vaccine. If the diagnosis is unclear, have a discussion with a specialist on potential options for reimmunization with the same vaccine or an alternative.
  
  
• Thrombosis with thrombocytopenia syndrome (TTS)/VITT4 (blood clots) following the Astra Zeneca/COVISHIELD COVID19 vaccine
  If you developed a rare blood clot following a shot of the Astra Zeneca vaccine, you can complete your vaccine series by taking an mRNA vaccine for your second shot, unless you have a medical exemption for an mRNA vaccine.

• Other serious or adverse events following a COVID-19 vaccine that lead to hospitalization or significant/persistent disability/incapacity
  If you experience any other adverse events that lead to hospitalization or cause a significant or ongoing disability or loss of function, including Guillain-Barré Syndrome (GBS) following a vaccine shot, this should be reported to your public health unit. You may qualify for a medical exemption if the event was medically evaluated and discussions are had with relevant specialists like an allergist, immunologist, Special Immunization Clinic Network or Medical officer of Health, about the risks and benefits of potential immunization options with the same vaccine or an alternative. Further, a specialist has to conclusively determine you are unable to take any COVID-19 vaccine.

Actively receiving monoclonal antibody therapy or convalescent plasma therapy for the treatment/prevention of COVID-19

If you’re receiving monoclonal antibody therapy or convalescent plasma therapy to treat COVID-19 or prevent the disease, you qualify for a time-limited medical exemption while receiving the therapy.

Contraindications to starting an AstraZeneca/COVISHIELD vaccine series

Ontario paused the use of the AstraZeneca/COVIDSHIELD vaccine on May 11 after reports of blood clots following the shots. The ministry says this vaccine should only be used as a first dose in “extenuating circumstances” i.e. only on the recommendation of an allergist/immunologist where a confirmed allergy or other contraindication to an mRNA vaccine exists.

The ministry says those with a history of the following conditions can be immunized with an mRNA vaccine unless they have a medical exemption to doing so (based on the criteria illustrated above):

• Capillary leak syndrome (CLS)
• Cerebral venous sinus thrombosis (CVST) with thrombocytopenia
• Heparin-induced thrombocytopenia (HIT)
• Major venous and/or arterial thrombosis with thrombocytopenia following any vaccine

How to get a medical exemption

In order to get a medical exemption, it must be determined that you’re unable to take any COVID-19 vaccine by a medical professional like an allergist, immunologist or another relevant specialist for the reasons listed above.

You must get a medical exemption document only from a physician or nurse practitioner (a registered nurse who holds an extended certificate of registration under the Nursing Act, 1991).

The document should clearly state the reason why you cannot be vaccinated against COVID-19 with the vaccines currently available and medical information that supports the exemption must be provided.

The document must also include the following details:

• Name and contact information of the physician or nurse practitioner
• A logo or letterhead identifying the physician or nurse practitioner
• A statement that there is a medical reason for your exemption
• Any effective time period for the medical reason which includes the date you are seeking access to a particular business or organization that would otherwise require vaccination.