Who can’t have a COVID vaccine and how do I get a medical exemption?

As Australia works towards getting 80% of over-16s fully vaccinated against COVID and higher, there’s more pressure to mandate vaccination across a range of sectors.

Some sectors in certain states and territories already have a COVID vaccine mandate in place, such as health and aged-care staff. Victoria last week mandated COVID vaccination for all authorised workers in the state^[1], which has been a tough but necessary decision^[2]. Governments and businesses are also considering mandates for many other groups.

Vaccine passports are also on the way, meaning you’ll need to show proof of being fully vaccinated to do things like travel internationally, and to visit venues in hospitality, entertainment, retail and others in certain states and territories.

But there are some people who can’t get a COVID vaccine for medical reasons, though these are very rare. So what are these conditions, and if you have one of them, how can you prove it?

Permanent exemptions

It’s recommended all Australians over 12 receive two doses of a COVID vaccine. We have robust data now on these vaccines, so we know they’re safe and effective. Serious adverse events are very rare.

There are few situations where someone can’t have a COVID vaccine for medical reasons. The criteria to receive a permanent medical exemption^[3] are very narrow and rarely required.

The only criteria are:

For live vaccines, such the measles, mumps, and rubella (MMR) and varicella vaccines, people who are significantly immunocompromised can get a permanent medical exemption. But this isn’t relevant for COVID vaccines because they’re not live vaccines.

There are some conditions^[4] people commonly believe may require a vaccine exemption, but the following are not reasons to be exempt from COVID vaccination:

• egg allergy, even severe

• a chronic underlying medical condition – these individuals are often at higher risk of more serious disease from COVID, such as people who are immunocompromised who can still receive the COVID vaccines because they’re not live vaccines

• family history of any adverse events following immunisation.

Temporary exemptions

There are some situations when a COVID vaccine may need to be temporarily deferred. For example, if someone has an acute illness with a fever of 38.5℃ or over. However, this would usually be for a short period only and wouldn’t require them to obtain a written temporary medical exemption.

But there are also some “acute major medical illnesses” where people may be able to get a temporary immunisation medical exemption form^[5]. This needs to assessed and given by a medical provider, and only temporarily exempts you from a COVID vaccine.

Last week ATAGI, the Australian Technical Advisory Group on Immunisation, which provides medical advice to the federal government on the use of vaccines including COVID vaccines, released expanded guidance on which of these conditions may warrant a temporary medical exemption^[6].

Read more: Soon you'll need to be vaccinated to enjoy shops, cafes and events — but what about the staff there?^[7]

These exemptions include people with acute major medical conditions such as major surgery or hospital admission for a serious illness.

Temporary exemptions are only recommended to be provided for up to six months. Ideally, they’re reviewed within six months to see whether the person has recovered and can now be safely vaccinated. They’re also only given if another COVID vaccine isn’t suitable or available.

Temporary exemptions may also be specific to a certain vaccine, such as:

• if a person has a history of heart inflammation (myocarditis or pericarditis) attributed to a previous dose, or has had another illness causing heart inflammation in the past six months, or acute decompensated heart failure. This is only for mRNA vaccines, including those by Pfizer and Moderna

• if a person has a history of specific very rare bleeding and clotting conditions including: capillary leak syndrome, cerebral venous sinus thrombosis, heparin-induced thrombocytopenia, idiopathic splanchnic thrombosis, or antiphospholipid syndrome (with thrombosis and/or miscarriage). This is only for the AstraZeneca vaccine.

If possible and safe, individuals who can’t get one of the above vaccines for one of these reasons should receive an alternative COVID vaccine.

Temporary exemptions may also be for people who:

• have had COVID, until they’ve completely recovered. ATAGI recommends vaccination can be deferred for up to six months, because past infection reduces the chance of reinfection for at least this amount of time^[8]. However, they don’t need to delay vaccination if they’ve recovered from COVID and their job requires them to be vaccinated, or they’re at higher risk of COVID due to exposure or personal risk. Having chronic symptoms following COVID, known as “long COVID”, isn’t a medical reason not to receive a COVID vaccine. If people who’ve recently had COVID are unsure about whether to get vaccinated, they should talk to their medical provider about the best time to proceed with vaccination

• have had a serious adverse event from a previous COVID vaccine dose that can’t be attributed to another cause. An adverse event is considered serious if the person is hospitalised or it causes persistent or significant disability. These events need to be reported to the adverse event surveillance system^[9] in the person’s state or territory and/or to Australia’s medical regulator, the Therapeutic Goods Administration (TGA). They’re carefully assessed on a case-by-case basis by an experienced specialist to work out how likely a recurrence of the serious adverse event is if another dose of COVID vaccine is given

• are assessed to be a risk to themselves or others during the vaccination process. For example, this could be due to a severe neurodevelopmental condition such as autism spectrum disorder. Specialist services may be available that can help facilitate safe vaccination for these individuals, such as with the assistance of distraction or awake sedation.

Pregnancy isn’t a valid reason for exemption, in the absence of any of the criteria listed above.

How would I get an exemption, if I’m eligible?

COVID vaccine medical exemptions can be obtained from general practitioners, paediatricians, clinical immunologists, infectious disease, general or public health physicians, gynaecologists or obstetricians.

If someone thinks they qualify for an exemption based on the above, it’s often best to visit a GP first to discuss.

The federal government will introduce a certificate system for people to prove they have a medical exemption^[10] later this month. These would be available through the Services Australia app.

With mandates looming, GPs and other providers will feel pressure to dispense exemptions to people not wanting to be vaccinated. Employers will be seeking clarity about who can receive one. This can often cause distress and conflict if the request for an exemption is denied, for both the provider and patient.

Also, if mandates aren’t applied equally and fairly, there’s a risk of compounding disadvantage.

These mandates are made at a jurisdictional level, so there may also be differences regarding which groups are affected depending on the state or territory.

The stakes are high for those who remain unvaccinated, so it’s vital employers, individuals and medical providers are aware of the new ATAGI clinical guidance^[11] regarding the medical exemption criteria and that jurisdictions provide additional clarity about the process.

References

1. ^{^} all authorised workers in the state (www.theage.com.au)
2. ^{^} tough but necessary decision (www.theage.com.au)
3. ^{^} permanent medical exemption (www.servicesaustralia.gov.au)
4. ^{^} some conditions (immunisationhandbook.health.gov.au)
5. ^{^} immunisation medical exemption form (www.servicesaustralia.gov.au)
6. ^{^} may warrant a temporary medical exemption (www.health.gov.au)
7. ^{^} Soon you'll need to be vaccinated to enjoy shops, cafes and events — but what about the staff there? (theconversation.com)
8. ^{^} reduces the chance of reinfection for at least this amount of time (www.health.gov.au)
9. ^{^} adverse event surveillance system (www.health.gov.au)
10. ^{^} for people to prove they have a medical exemption (www.smh.com.au)
11. ^{^} new ATAGI clinical guidance (www.health.gov.au)