COVID-19 FAQs: Vaccines

UPDATED: 5/10/22

News, scientific understanding and guidelines about COVID-19 are continually evolving. As such, please note that some information on this page may have changed since its original publication date.

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 there are distinct differences between the two. A vaccine dose is administered as a part of the primary vaccine series; a booster shot is given when immunity to the primary series has likely waned over time.

For the general population, a primary vaccine series consists of 2 doses of an mRNA vaccine (Pfizer-BioNtech or Moderna) or 1 dose of the Johnson & Johnson (J&J) vaccine.

People who are moderately or severely immunocompromised require an additional dose for their primary vaccine series. That means three doses of an mRNA vaccine or 2 doses for those who received the J&J vaccine (1 dose of the J&J vaccine and 1 dose of an mRNA vaccine). According to the CDC, people who are moderately or severely immunocompromised include rheumatology patients being actively treated with high-dose corticosteroids, alkylating agents, antimetabolites, tumor-necrosis factor (TNF) blockers, and other biologic agents and disease modifying drugs that are immunosuppressive or immunomodulatory. You can find more details about vaccine doses and timing for immunocompromised people here.

The CDC also recommends three doses of the Pfizer-BioNtech vaccine for moderately and severely immunocompromised children 5 to 11 years old.

This guidance differs from recommendations about boosters, which aim to restore immunity after the primary vaccination series.

Immunocompromised individuals should receive their first booster (fourth shot) at least 3 months after their third shot and may opt for a second booster (fifth shot) at least 4 months after their first booster. Immunocompromised patients between the ages of 12 and 17 may only opt for the Pfizer-BioNtech booster shot (Moderna is only approved for adults 18 and older).

Immunocompromised patients who received the J&J vaccine should receive an mRNA booster (3rd shot) at least two months after their second dose of an mRNA vaccine. People 12 years and older may opt for a second booster (4th shot) at least 4 months after their first booster. Boosters are not recommended for children between the ages of 5 to 11 at this time.

Those who are not immunocompromised and/or who have non-inflammatory types of arthritis (osteoarthritis) should still receive a booster shot. This includes a booster (third shot) of an mRNA vaccine at least four months after their second dose, or a booster (second shot) of an mRNA vaccine after a first dose with the J&J vaccine. Patients 50 and older or who received the J&J vaccine may also opt for a second mRNA booster (third shot) at least four months after their first booster.

Health experts advise against getting additional doses or boosters that differ from what is recommended by the CDC or FDA without the supervision of a doctor. If you have concerns about vaccine protection, talk to your doctor about the best approach. 

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

A: Preliminary research from the National Institute of Allergy and Infectious Diseases (NIAID) 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, says Alfred Kim MD, PhD, Assistant Professor, Division of Rheumatology, Washington University School of Medicine.

Getting a different mRNA vaccine for your booster has the potential to broaden the immune response and give the body more information to fight infection, says Mike Saag, MD, Professor, Division of Infectious Diseases, University of Alabama at Birmingham. As such, Dr. Saag says he’s a “big advocate for mixing and matching mRNA vaccines.”

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 vaccine response from their primary vaccine series.

Talk to your doctor about mixing and matching vaccines, and what’s right for you.

Question: What is Evulsheld and should I opt for it instead of COVID-19 vaccination?

A: Evulsheld is a combination of two types of monoclonal antibodies that can help prevent COVID-19. It consists of two injections given immediately after another and is administered every six months to offer maximum protection. It may be given two weeks after vaccination.

The FDA has granted Emergency Use Authorization for Evulsheld to individuals 12 years and old who are:

• Immunocompromised or have health conditions that won’t allow their body to develop a strong immune response from a COVID-19 vaccine.
• Take immunosuppressive medications that can blunt COVID-19 response, such as some disease-modifying drugs (DMARDs) to treat arthritis.
• Allergic to ingredients in COVID-19 vaccines.

It’s very important to note: Evulsheld is NOT a replacement for COVID-19 vaccines. Instead, it should be used in addition to vaccines if you do not produce a strong immune response or if you have a severe allergy that prevents you from getting a vaccine, says Alfred Kim MD, PhD, Assistant Professor, Division of Rheumatology, Washington University School of Medicine. Everyone who qualifies to receive a COVID-19 vaccine should do so, he says.

Evidence about Evulsheld’s efficacy for immunocompromised patients is still being studied. However, infection rates appear to decrease for patients who didn’t get an adequate immune response from vaccines, says Dr. Kim. This is especially true for patients on B-cell depleting drugs like rituximab, he says. 

Unfortunately, access to Evulsheld varies state to state. For more information about where to find Evulsheld or if you qualify, talk to your doctor. You can also use this tool to track how much of the drug is available in your state.

Question: Do the COVID-19 vaccines protect against the variants?

A: Evidence suggests that vaccines provide strong protection against severe disease, death and hospitalization among the primary variants in the United States, Delta and Omicron.

While vaccines appear to be are less protective against infection for the Omicron variant, evidence suggests that boosters of the Pfizer-BioNtech and Moderna vaccines deliver stronger protection.

Immunocompromised individuals have another set of vaccine and booster recommendations to enhance protection. Even so, these recipients may experience a blunted vaccine response and may want to stick with a more cautious approach, including social distancing and wearing masks in crowded, indoor spaces. The Arthritis Foundation strongly advocates for vaccination and encourages everyone to seek out the recommended number of primary vaccine doses and booster shots. If you haven’t already done so, talk to your doctor about receiving additional vaccine doses or the pre-exposure drug Evulsheld to maximize protection.

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

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

Based on a small study of 133 fully vaccinated individuals taking immunosuppressive medications, antibody levels and virus neutralization was three times lower than in individuals not taking these medications. The study has not been peer reviewed.

However, study coauthor Alfred Kim MD, PhD, Assistant Professor, Division of Rheumatology, Washington University School of Medicine noted in an interview with Reuters that, “most patients in the study were able to mount antibody responses in response to SARS-CoV-2 vaccination, which is reassuring." 

There is also a difference between “adequate protection” and “perfect protection,” says Dr. Kim. Vaccines in immunocompromised people don’t have to work as robustly as they do in the general population to be effective at preventing severe disease and hospitalization, he says.

Study results showed:

• More modest reductions in patients using TNF inhibitors, methotrexate and sulfasalazine, JAK inhibitors and IL-12/23 inhibitors.
• A 10-fold reduction in patients who used corticosteroids regularly.
• A 36-fold reduction in patients who use B cell inhibitors.

Bottomline: Those who were on corticosteroids and B-cell inhibitors experienced the most signifciant decreases in vaccine protection. To maximize protection, these patients may want to talk to their doctor about additional measures, like the pre-exposure drug, Evulsheld, to bolster protection. Learn more about study results here.

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 only last a day or two.

These side effects can mimic symptoms of COVID-19. Get tested and self-isolate if you experience symptoms more than three days after being vaccinated lasting more than two days. 

However, on December 16, the CDC revised its vaccine recommendations to say that mRNA vaccines be preferred over the Johnson & Johnson vaccine. The CDC cited increasing evidence showing that the vaccine may trigger a rare blood clotting disorder that has resulted in dozens of cases and at least 9 deaths in the United States. The risk was greatest among women 30 to 49, affecting an estimated 1 in 100,000 who had received the company’s shot.

Signs of a blood clot include a severe headache that persists, severe abdominal or leg pain that won’t go away or shortness of breath. If you received the vaccine within the last 30 days and are experiencing any of these symptoms, contact your doctor immediately. If you received the vaccine more than a month ago, the risk for blood clot complications is very low, according to Dr. Anne Schuchat, principal deputy director of the US Centers for Disease Control and Prevention.

Neither the Pfizer or the Moderna vaccines are associated with the risk of blood clotting. However, about 1200 cases of heart inflammation (myocarditis) and pericarditis have been reported following vaccination with one of the mRNA vaccines (Pfizer and Moderna). Young adult males under 30 seem to be most at risk, and most cases occurred after the second dose. Most cases were mild, with symptoms like fatigue, chest pain and abnormal heart rhythm that cleared up on their own.

Experts stress that the benefits of vaccination strongly outweigh the risks and that COVID-19 infection is a major risk factor for heart inflammation and heart damage. In other words, the chances that an unvaccinated person who contracts COVID will experience heart problems is much greater than someone who gets vaccinated with one of the mRNA vaccines.

Rare allergic reactions have also occurred. See below for more information.

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). These events are very rare. The CDC estimates that the rate of anaphylaxis is 11.1 per million doses of the Pfizer-BioNTech vaccine and 2.5 cases per million doses of the Moderna vaccine.

Experts urge that 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.

Still, healthcare workers must be prepared to treat reactions in the rare event they occur. As such, patients are asked to stay for 15 minutes to be monitored after vaccination – which is when most allergic reactions occur.

Those with a history of severe allergic reactions not related to vaccines or injectable medications may still get the vaccine. However, these patients are advised to be monitored for at least 30 minutes after vaccination.

Patients with a history of immediate allergic reactions to vaccines and injectable medications should discuss the risks with their doctor. The CDC advises patients to avoid vaccines containing ingredients that have given them previous severe allergic reactions.

There are two main allergens of concern in the COVID-19 vaccines:

• Polyethylene Glycol (PEG), which is found in the mRNA vaccines. If you are allergic to this ingredient, ask your doctor about getting the J&J vaccine
• Polysorbate, which is found in the J&J vaccine.  Ask your doctor if you can get an mRNA COVID-19 vaccine if you are allergic to this ingredient.

Finally, if you have an immediate allergic reaction after getting the first dose of a COVID-19 vaccine, the CDC advises against getting a second dose. Those with severe allergies to vaccines qualify for Evulsheld, the pre-exposure monclonal antibody that can prevent COVID-19 infection. Please see the question above, "What is Evulsheld...? for more information.

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

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 vaccines on the market are unsafe for these populations.

Both the Pfizer/BioNTech and Moderna, Inc. vaccines are made with mRNA technology, which contain genetic instructions for one part of the coronavirus instead of the entire virus itself. Experts, including Wilbur Chen, MD, vaccine researcher, professor of medicine at the University of Maryland School of Medicine, and Ted Mikuls, MD, MSPH, Umbach Professor of Rheumatology at the University of Nebraska, expect that vaccines made with this technology to be safe for immunocompromised patients and those on immunosuppressant drugs.

However, Mikuls adds that more data is needed understand whether immunosuppressant medications or unchecked disease activity may reduce vaccine effectiveness. Even so, he anticipates the vaccine will provide protection for the vast majority of patients with arthritis and rheumatic diseases.

Experts urge that immunocompromised patients don't delay vaccination, including boosters. 

Some DMARDs have been shown to blunt immune responses to other vaccines such as those for influenza, pneumonia and Hepatitis B. Whether holding or delaying DMARD therapies might lead to improved vaccine responses with available and emerging COVID vaccines is currently unknown.

The American College of Rheumatology (ACR) has released vaccine clinical guidance for rheumatologic patients. 

As data continues to be collected on the effects of vaccines for patients with autoimmune disease, talk to your health care provider about the considerations about getting vaccinated.

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

A: Vaccines don’t always prevent infection, but they prime your immune system to quickly fight the virus and protect you from the worst outcomes of disease. Likewise, the highly contagious Omicron variant has evaded some vaccine protection, and as a result many vaccinated people still became infected. Crucially, all three COVID-19 vaccines on the market still provided exceptional protection against severe illness and hospitalization. 

It should be noted, however, that vaccine protection may be reduced in immunocompromised patients, including those taking immunosuppressive drugs. As such, health experts recommend that people with compromised immune systems receive a booster shot at least three months after their initial vaccine series (3 mRNA doses or 1 J&J dose and 1 mRNA dose). In some cases, patients may opt for a second booster four months after their first booster.

Immunocompromised patient are also encouraged to practice more caution, such as limiting time in crowded indoor spaces and practicing social distancing.

A drug called Evulsheld may also bolster protection for some people who don’t receive adequate vaccine response due to health or medication reasons. If you fit the category for moderately or severely immunocompromised and are concerned about your vaccine response, you may want to talk to your doctor about Evulsheld.

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

A: Researchers say there are still too many unknowns about how long immunity lasts from natural infection. But research shows that vaccine immunity tends to be stronger than natural immunity. So vaccination is strongly urged for people who have had COVID-19, but who have not received a vaccine. For these people, the Mayo Clinic advises waiting about 90 days from the time of the COVID-19 diagnosis to get vaccinated. 

Booster recommendations may be a bit more nuanced for those who have already been vaccinated and/or 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, says Alfred Kim MD, PhD, Assistant Professor, Division of Rheumatology, Washington University School of Medicine.

Still, Dr. Kim says there are benefits to boosting patients with hybrid immunity, especially immunocompromised individuals. While these patients may delay boosters, he recommends that immunocompromised patients pursue a booster dose about six months out or so from infection. This produces a more diverse immune response which will help them fight future variants, he says. 

If you're 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.