COVID-19 FAQs: Vaccines

News, scientific understanding and guidelines about COVID-19 are continually evolving. This information is current as of Jan. 9, 2023.

Question: What are the booster or vaccine dose recommendations for people with arthritis?

A: The terms “booster” and “dose” are often used interchangeably when talking about COVID-19 vaccines, but they aren’t the same. A vaccine dose is administered as a part of the primary vaccine series; a booster shot is given when immunity from the primary series begins to fade, usually within four to six months.

For most people, a primary vaccine series consists of two doses of an mRNA vaccine (Pfizer-BioNtech or Moderna), two doses of Novavax or one dose of the Johnson & Johnson vaccine. (Note: The FDA sharply limited use of the J&J vaccine in May 2022 due to safety concerns.)

People who are immunocompromised, either from a medical condition like inflammatory arthritis or because they take drugs that suppress the immune system, need more protection because they don’t fight infections or respond to vaccines as well as others.

Immunocompromised adults, including those with arthritis taking immune-suppressing medications, should have an additional dose of their primary vaccine series. That means a total of three doses of an mRNA vaccine. If your primary series was the one-dose J&J vaccine, your second shot — the equivalent of a third mRNA dose — should be an mRNA vaccine. If you received two Novavax shots, the third should be the new bivalent booster, which was designed to fight the original coronavirus as well as its variants. The guidelines for children and teens are more complicated and depend on the child’s age and type of vaccine. The CDC also has guidance for immunocompromised adults and children.

Question: What is the bivalent booster shot?

A: Booster shots are meant to “boost” immunity when vaccine protection naturally fades over time. But as the virus continues to mutate, the original boosters are no longer as effective against new subvariants. One study involving more than 200,000 patient records found that protection from the first monovalent vaccines and boosters dropped by half when new subvariants emerged. In response, the FDA rolled out single-shot bivalent boosters from Pfizer and Moderna in September 2022. If it’s time for you to get a booster — usually four to six months after your last shot — you’re encouraged to get the bivalent vaccine, no matter how many other boosters you’ve had.

Question: Should I get a different vaccine for my booster than I received for my primary vaccine series?

A: Preliminary research suggests that mixing and matching vaccines may enhance immune response. While more data is needed to assess the effectiveness, especially for immunocompromised patients, there is certainly no harm in getting another kind of mRNA vaccine for your booster shot, according to rheumatologist Alfred Kim, MD, an assistant professor at Washington University School of Medicine.

Michael Saag, MD, a professor at the University of Alabama at Birmingham says he’s a “big advocate for mixing and matching mRNA vaccines” because it has the potential to broaden the immune response.

Ultimately, the decision to get a different booster shot is up to you. Some people may opt for the same vaccine they received in their primary series because they know how they’ll respond. Other immunocompromised patients may decide they want to try another mRNA booster if they didn’t get a robust response from their primary vaccine series.

Question: What is Evusheld and should I opt for it instead of a COVID-19 vaccine?

A: Evusheld was a combination of two types of monoclonal antibodies. It was designed to help prevent COVID-19 infection in immunocompromised people who didn't respond well to vaccines or were allergic to some of their ingredients.

The FDA withdrew emergency use authorization for Evusheld in January 2023 because it doesn't offer protection against the coronavirus as it has evolved. The FDA alerted health care providers to its diminished effectiveness in December 2022.

Question: Will my arthritis drug reduce the COVID-19 vaccine response?

A: Although research is limited, there is evidence that some drugs used for autoimmune arthritis may reduce the vaccine response.

According to a small study of 133 fully vaccinated patients taking immunosuppressive medications, antibody levels and virus neutralization were three times lower than in people not taking them. Patients on corticosteroids and rituximab (Rituxan) experienced the most significant decreases in vaccine protection.

The American College of Rheumatology (ACR) recommends stopping most immunosuppressant drugs for one to two weeks after the third vaccine to increase immune response. That includes:
•    Conventional disease-modifying drugs (DMARDs) such as methotrexate and sulfasalazine
•    Biologics like abatacept (Orencia)
•    JAK inhibitors (Xeljanz, Olumiant, Rinvoq)
•    Apremilast (Otezla)
•    Belimumab (Benlysta)

The jury is still out about tumor necrosis factor (TNF) blockers (like Enbrel and Humira ) and interleukin inhibitors, such as IL-6 ( Actemra and Kevzara ), IL-1 ( Kineret and Ilaris ), IL-17 ( Cosentyx and Taltz ) and IL-23 ( Skyrizi and Tremfya ). So far, the evidence doesn’t seem to show that these drugs have much effect on vaccine response. Hydroxychloroquine (Plaquenil) does not interfere with COVID-19 vaccines.

Question: What are the possible side effects of a COVID-19 vaccine?

A: COVID-19 vaccines can cause mild side effects, such as pain, redness or swelling where the shot was given, fever, fatigue, headache, chills and muscle or joint pain. These side effects are normal and signs that your immune system is building protection against the virus. Most side effects occur within the first three days of vaccination and usually last only a day or two. If you experience symptoms more than three days after a vaccine, talk to your doctor.

Less common side effects include:

• Life-threatening blood clots linked to the Johnson & Johnson vaccine. At least 60 cases have been identified, nine of which were fatal, mainly in young women. The clots block blood vessels and occur along with low platelets — an unusual combination because platelets normally help blood clot. The FDA severely limited the use of the J & J vaccine in May 2022.
• Myocarditis (inflammation of the heart muscle) is a rare complication of the Pfizer and Moderna vaccines. It mainly strikes young men within a week of the second dose. Most recover fully within a few days.  Myocarditis from COVID-19 itself is more likely to cause serious problems, although at least one person died from vaccine-related myocarditis.
• Reactivation of herpes zoster (shingles) with mRNA vaccines. There have been many reports of shingles after the Pfizer and Moderna vaccines, including from the World Health Organization (WHO). One study of nearly 500 patients with inflammatory autoimmune arthritis reported that six developed shingles for the first time after the COVID-19 vaccine. A much larger study involving more than 1.3 million people who received the vaccine were matched with controls who didn’t. The study found no difference in shingles reactivation between the two groups; it didn’t look specifically at people with arthritis.

Question: How do I know if I’m allergic to the COVID-19 vaccine?

A: Some people who have received mRNA COVID-19 vaccines have experienced severe allergic reactions (anaphylaxis). The CDC estimates that anaphylaxis occurs in about 11.1 cases per million doses of the Pfizer-BioNTech vaccine and 2.5 cases per million doses of the Moderna vaccine.

Experts say the fear of anaphylaxis should not deter people from getting vaccinated. The risk of developing severe outcomes from COVID-19 is much higher than the risk of an allergic reaction from the vaccine. Patients with a history of immediate allergic reactions to vaccines and injectable medications should discuss the risks with their doctor, but in most cases shouldn’t get them.

If you have an immediate allergic reaction after getting the first dose of a COVID-19 vaccine, don’t get a second dose.

Question: Are COVID-19 vaccines safe for people with autoimmune diseases?

A: There is no advisory against vaccinating people with autoimmune diseases, and experts say there is no reason to believe that the current COVID-19 are unsafe for immunocompromised people or those taking drugs that suppress the immune system.

Question: How strong is immunity from COVID-19 vaccination?

A: Vaccines don’t always prevent infection, but they prime your immune system to fight the virus and protect you from the worst disease outcomes. The highly contagious omicron variant has evaded some vaccine protection, and many vaccinated people can still become infected. The updated COVID-19 booster, which protects against both the original coronavirus strain and omicron subvariants, can help protect against severe illness and hospitalization. Newer subvariants, including XBB.1.5, may evade even the booster, though it’s too early to know for sure.

Question: Are vaccines recommended for people who have already had the virus or have tested positive for antibodies? What about boosters?

A: Research shows that vaccine immunity tends to be stronger than natural immunity, so vaccination is encouraged for people who have had COVID-19 but haven’t been vaccinated. The ideal waiting period isn’t clear, but some experts recommend allowing at least 90 days between infection and vaccination.

Booster recommendations may be a bit more nuanced for those who have already been vaccinated and boosted but who have been recently infected with COVID-19. For these people, the combination of vaccination and infection results in “hybrid immunity,” which produces a long-term protective response similar to an additional booster dose, according to Alfred Kim, MD, an assistant professor at Washington University School of Medicine. In fact, a recent study found that hybrid immunity is four times stronger than the vaccination alone and lasts longer — up to eight months.

If you’ve recently recovered from COVID-19, talk to your doctor about the best timing for your next booster.

Question: Are the COVID-19 vaccines safe for children with JA?

A: See COVID-19 FAQS: Juvenile Arthritis .