Lack of context: Only adenovirus vector vaccines, but not mRNA vaccines, have been associated with rare cases of blood clotting. COVID-19 poses a much greater risk of blood clots than vaccination, particularly for people who already have blood clotting conditions.
RECLAMACION: Medical exemptions are unavailable even for people who “shouldn't get the [COVID-19] vaccine”, including those with a history of blood clotting or an adverse reaction to a prior vaccine
REVIEW
On 11 December 2022, radio host Dan Bongino posted a Facebook video claiming that medical exemptions to COVID-19 vaccines weren’t available even for people with contraindications against these vaccines. A contraindication is any condition that increases the risk of a serious adverse reaction and therefore shouldn’t get the vaccine. Among such contraindications, the video mentioned a history of blood clotting and an adverse reaction to a prior vaccine.
This video, which received more than 570,000 views on Facebook, is an excerpt from a 25 January 2022 episode of The Dan Bongino Show that focused on a COVID-19 panel discussion hosted by U.S. Senator Ron Johnson the day before. A video recording of the meeting received more than four and a half million views on Rumble. However, the discussion was criticized by medical experts for containing multiple false and misleading claims, including that asymptomatic persons don’t transmit the virus, that people who’ve had an infection can’t be reinfected, and that hydroxychloroquine and ivermectin are effective COVID-19 treatments.
Panelists included individuals known for spreading misinformation about COVID-19 vaccines and treatments in the past, such as Peter McCullough, Ryan Cole, Robert Malone, and Pierre Kory. This was also not the first time that Johnson spread COVID-19 misinformation. In June 2021, YouTube suspended Johnson’s account for posting «content that encourages people to use Hydroxychloroquine or Ivermectin to treat or prevent [COVID-19]».
Specifically, the excerpt from the Dan Bongino Show showed psychiatrist Aaron Kheriaty claiming that it was «de facto impossible to get a medical exemption for a COVID-19 vaccine in the state of California». But as we will explain below, this claim is inaccurate and based on misleading arguments.
Bongino didn’t challenge Kheriaty’s claim but endorsed it instead, adding examples of conditions that purportedly should prevent people from receiving the vaccine. Specifically, he listed a history of blood clotting and a previous reaction to other vaccines. But contrary to Bongino’s claim, none of these conditions is on their own a reason to avoid COVID-19 vaccination, as this review explains.
Medical exemptions to COVID-19 vaccines are available for people who have qualifying medical conditions
Kheriaty based his claim that medical exemptions were “de facto impossible” in California on an 18 August 2021 update by the Medical Board of California. It is important to note here that the state of California doesn’t require COVID-19 vaccination for the general population. Only healthcare workers are required to comply with COVID-19 primary vaccination and booster doses. Under certain conditions, an employer can also require COVID-19 vaccination for all employees unless they have a disability-related or religious belief exemption.
The update from the Medical Board of California informed physicians that granting “inappropriate exemptions” to face masks and other COVID-19 measures may subject their licenses to disciplinary actions.
Kheriaty interpreted the update as a “threat” to doctors who granted exemptions to COVID-19 control measures, including vaccines, because the Medical Board didn’t define what constituted an appropriate or inappropriate exemption. However, this is misleading. It is true that the update didn’t list specific conditions that qualify a person for medical exemptions. However, it did explain that an inappropriate medical exemption is one that doesn’t involve adequate examinations and a medical reason that supports the exemption:
“The Medical Board of California (Board) would like to inform licensees and the public that a physician who grants a mask or other exemption without conducting an appropriate prior exam and without a finding of a legitimate medical reason supporting such an exemption within the standard of care may be subjecting their license to disciplinary action”. [emphasis added]
In a comment to Health Feedback, the Medical Board of California said, “The exemptions referred to in the announcement encompass any state-mandated exemption that requires a physician to conduct an appropriate examination, and subsequent finding that the requirement would adversely affect the health of the given patient”.
It also explained that “A physician must exercise appropriate professional judgment and act within the standard of care when determining whether to provide their patient an exemption from a required immunization. Health and Safety Code section 120325 to 120375, for example, discusses what childhood immunizations are required and what procedures a physician must follow when granting a medical exemption from such immunizations. The standard of care is generally defined by the physician community itself and refers to the level of skill, knowledge, and care in diagnosis and treatment ordinarily possessed and exercised by other reasonably careful and prudent physicians in the same or similar circumstances at the time in question”.
The California Department of Public Health website explains what medical conditions qualify for exemptions based on the Interim Clinical Considerations for Use of COVID-19 Vaccines by the U.S. Centers for Disease Control and Prevention (CDC). These conditions include a documented history of severe allergic reaction to a COVID-19 vaccine component or prior COVID-19 vaccine dose. The CDC also recommends that people who developed heart inflammation after a prior COVID-19 vaccine dose generally avoid another dose of any COVID-19 vaccine.
People with a history of blood clotting are recommended to get vaccinated as they are more likely to develop severe COVID-19 and related blood clots
In April 2021, public health authorities identified an association between the Oxford-AstraZeneca and Johnson & Johnson adenovirus vector COVID-19 vaccines and rare cases of blood clots with low platelet counts. The condition, called vaccine-induced immune thrombotic thrombocytopenia (VITT), caused high mortality rates due to severe thrombosis in unusual sites such as the brain[1].
However, blood clotting following COVID-19 vaccination is very rare. As hematologists Sant-Rayn Pasricha and Paul Monagle explained in an article for The Conversation, VITT is “completely different” from the more common clotting in deep veins and the lungs. These routine types of blood clots are generally associated with vessel damage and specific genetic or lifestyle risk factors, such as smoking or sedentarism.
In contrast, studies so far suggest that VITT is caused by an abnormal immune response that targets platelets, which causes them to aggregate and form clots[2-4]. VITT appears to be a random effect not associated with any particular condition, and there’s no evidence so far indicating that a history of blood clotting increases the risk of developing VITT.
Still, some countries like Australia and the U.S., recommend that people with a history of venous blood clots in unusual sites such as the brain and the abdomen, antiphospholipid syndrome, and heparin-induced thrombocytopenia avoid adenovirus vector COVID-19 vaccines as a precautionary measure. The U.K. Health Security Agency states that the Oxford-AstraZeneca vaccine “should be considered in individuals with antiphospholipid syndrome when the benefits of the vaccine outweigh the risk for that individual”.
Due the increased risk of blood clots, the CDC prioritize mRNA vaccines over the Johnson & Johnson vaccine, which is the only viral vector vaccine authorized in the U.S. However, people with an allergy to an mRNA vaccine component or limited access to mRNA vaccines can still receive the Johnson & Johnson vaccine.
But contrary to Bongino’s suggestion that people with blood clotting disorders can’t get COVID-19 vaccines, there is no evidence indicating that COVID-19 vaccination is unsafe for people with these conditions. Furthermore, in cases where adenovirus vector vaccines aren’t recommended, mRNA COVID-19 vaccines are a safe alternative that hasn’t been associated with an increased risk of VITT[5,6].
It is also important to keep in mind that COVID-19 poses a much greater risk of blood clotting than vaccination[7]. This risk is higher in people with a history of blood clots, cardiovascular risk factors, diabetes, or any other factor that increases the risk of blood clotting. Therefore, the North American Thrombosis Forum—a non-profit organization dedicated to thrombosis research and education—«strongly recommends» vaccination for these people.
People who experienced adverse reactions to a prior vaccine can still be vaccinated against COVID-19
The CDC recommends that everyone six months and older gets COVID-19 vaccines unless they have a contraindication to vaccination. The only contraindications to COVID-19 vaccination listed by the CDC are having an allergy to a COVID-19 vaccine component and having experienced a severe allergic reaction after a previous dose.
Bongino didn’t specify what he meant with “an adverse reaction” to a different vaccine, which can range from a mild rash to a severe reaction. But even in the case of severe reactions, this isn’t necessarily a reason to avoid COVID-19 vaccination. For example, a previous allergic reaction to a different vaccine isn’t considered a contraindication but a precaution, which has different implications for COVID-19 vaccination.
A precaution might increase the risk of serious adverse reactions, reduce the immune response, or interfere with diagnosis. However, vaccination in these cases might still be recommended if the benefits outweigh the potential risks. The CDC states that “the benefit of vaccination outweighs the risks for most people” who have had adverse reactions to a prior vaccine.
Conclusion
Contrary to Bongino’s claim, medical exemptions to COVID-19 vaccination are available for people with qualifying medical conditions. But a history of blood clots or an adverse reaction to a prior vaccine aren’t among them.
Adenovirus vector COVID-19 vaccines are associated with a very low risk of blood clotting, but several studies showed that COVID-19 carries a much greater risk of blood clots than vaccination. Furthermore, mRNA vaccines haven’t been associated with blood clotting and are safe for people with a history of blood clots, who are at higher risk of severe COVID-19 and related complications.
UPDATE (23 December 2022):
This review was updated to include a comment by the Medical Board of California. This comment further supports our verdict and did not change it.
REFERENCES
- 1 – Sánchez van Kammen et al. (2021) Characteristics and Outcomes of Patients With Cerebral Venous Sinus Thrombosis in SARS-CoV-2 Vaccine–Induced Immune Thrombotic Thrombocytopenia. JAMA Neurology.
- 2 – Schultz et al. (2021) Thrombosis and Thrombocytopenia after ChAdOx1 nCoV-19 Vaccination. New England Journal of Medicine.
- 3 – Greinacher et al. (2021) Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination. New England Journal of Medicine.
- 4 – Huynh et al. (2021) Antibody epitopes in vaccine-induced immune thrombotic thrombocytopaenia. Nature.
- 5 – Nicholson et al. (2022) No apparent association between mRNA COVID-19 vaccination and venous thromboembolism. Blood Reviews.
- 6 – Berild et al. (2022) Analysis of Thromboembolic and Thrombocytopenic Events After the AZD1222, BNT162b2, and MRNA-1273 COVID-19 Vaccines in 3 Nordic Countries. JAMA.
- 7 – Hippisley-Cox et al. (2021) Risk of thrombocytopenia and thromboembolism after covid-19 vaccination and SARS-CoV-2 positive testing: self-controlled case series study. BMJ.
