Irony: a state of affairs or an event that seems deliberately contrary to what one expects and is often amusing as a result. -dictionary.com

Vaccine, by Julianna Paradisi

On a recent Saturday afternoon I received the Johnson and Johnson/Janssen COVID-19 vaccine. The following Tuesday, its further administration was put on pause, “out of an abundance of caution,” after reports that six women between the ages of 18 and 48 developed a rare but serious form of blood clot six to 13 days after receiving the vaccine. One of the six women died.

There is nothing amusing about the irony that people seeking protection from COVID-19 may have developed a life-threatening adverse reaction from the vaccine. For health care providers, and perhaps especially for nurses, such events are heartbreaking.

Lifting the J&J pause.

On Friday, April 23, the Centers for Disease Control and Prevention (CDC) and the FDA lifted the 10-day pause on the J&J vaccine, without restrictions, instead issuing a fact sheet to medical providers warning them of the potential for the extremely rare but serious blood clots.

When the pause was lifted, over 7 million people had received the vaccine, with additional confirmed cases of blood clots that had been reported bringing the total to 15 (1.9 cases per 1 million vaccinations). All occurred in women. The oldest was age 59. Three died, including one in my home state of Oregon.

These rare blood clots are called cerebral venous sinus thromboses (CVST) and exist in combination with low levels of platelets; it’s this thrombocytopenia that makes them rare in otherwise healthy people. Heparin worsens the condition and is contraindicated in the treatment of CVST.

Whether or not vector vaccines such as the J&J stimulate an antibody that causes CVST in some individuals is still being studied. The Pfizer and Moderna vaccines use mRNA, a different technology, and have not been linked to CVST.

Why it matters that the Johnson and Johnson vaccine is available.

You might ask: since neither the Pfizer or Moderna vaccines are associated with CVST, why use the Johnson and Johnson vaccine at all?

The Johnson and Johnson vaccine’s unique “one and done” feature is beneficial for people, such as myself, who want to be fully immunized with a single dose; this group also includes the millions of people, often older adults, who face challenges in traveling to immunization sites in their states. In addition, the J&J vaccine does not require ultra-cold storage, making it suitable for sending to locations where the specialized freezers the more fragile Pfizer and Moderna vaccines require are unavailable.

Risk vs. benefit: a nurse and cancer survivor on medication side effects.

While reported adverse reactions to COVID-19 vaccines contribute to the distrust many people already have about them, the risk of CVST from the Johnson and Johnson vaccine remains very low.

During the pause that came shortly after I received the J&J vaccine, I continued my normal activities, without worry. As a cancer survivor, perhaps I’m less anxious about potential side effects than the general public. Signing consent forms acknowledging potential adverse reactions is something I’ve already reconciled within myself.

Further, for oncology nurses, discussing patients’ concerns about the side effects of their chemotherapy regimens is part of the job. When addressing adverse reaction concerns, my own or a patient’s, it’s helpful to frame them within a “benefit versus risk” approach.

For example, many medications, especially those used in oncology, come with the potential for adverse reactions such as weakening heart muscle, possible secondary cancers, and even blood clots. But their use is beneficial when weighed against the more likely lethal outcome of an aggressive cancer. Humble Zofran (ondansetron), used to lessen chemotherapy-induced nausea and vomiting, can cause prolonged QT intervals potentially leading to fatal arrhythmias in some individuals, yet it’s widely used because its benefit to patients when dosed correctly outweighs the potential risk of arrhythmia.

The irony of working in health care is knowing that treatment intended to sustain life can potentially also cause harm. That’s why unexpected outcomes of all medications are reported and monitored.

Signs and symptoms of CSVT.

If you plan to receive the Johnson and Johnson vaccine, or are a nurse caring for patients who have, familiarize yourself with the symptoms and treatment of CVST. Educate patients to call their health care provider for urgent medical care if they have any of these symptoms:

  • Severe headache or backache
  • New neurologic symptoms
  • Severe abdominal pain
  • Shortness of breath
  • Leg swelling
  • Tiny red spots on the skin (petechiae)
  • New or easy bruising

Before starting anticoagulation therapy, make it your practice to ask patients presenting with symptoms of a blood clot, particularly women, whether they have received the Johnson and Johnson vaccine. Since many people receive the Johnson and Johnson vaccine at pharmacies, it may not be included in their medical record. After receiving mine, I contacted my primary care provider’s office requesting that it be added to my electronic health record.

As you read this post, over two weeks have passed since I received the Johnson and Johnson vaccine. As the number of new COVID-19 infections continues to rise, I have reconciled myself to risk versus risk: my risk of COVID-19 infection with its severe, potential side effects, ironically including blood clots, is greater than my risk of CVST. My gratitude that I have been vaccinated outweighs my concerns about CVST.