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Risk of thrombocytopenic, haemorrhagic and thromboembolic disorders following COVID-19 vaccination and positive test: a self-controlled case series analysis in Wales
Scientific Reports, Volume: 12, Issue: 1
Swansea University Authors: Fatemeh Torabi , Stuart Bedston, Emily Lowthian, Ashley Akbari , Rhiannon Owen , Rich Fry , Lucy Griffiths , Gareth Davies , Joe Hollinghurst, Jane Lyons, Hoda Abbasizanjani , Michael Gravenor , Ronan Lyons
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DOI (Published version): 10.1038/s41598-022-20118-6
Abstract
There is a need for better understanding of the risk of thrombocytopenic, haemorrhagic, thromboembolic disorders following first, second and booster vaccination doses and testing positive for SARS-CoV-2. Self-controlled cases series analysis of 2.1 million linked patient records in Wales between 7th...
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2022
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<?xml version="1.0"?><rfc1807><datestamp>2022-10-27T12:02:47.2270248</datestamp><bib-version>v2</bib-version><id>61394</id><entry>2022-10-01</entry><title>Risk of thrombocytopenic, haemorrhagic and thromboembolic disorders following COVID-19 vaccination and positive test: a self-controlled case series analysis in Wales</title><swanseaauthors><author><sid>f569591e1bfb0e405b8091f99fec45d3</sid><ORCID>0000-0002-5853-4625</ORCID><firstname>Fatemeh</firstname><surname>Torabi</surname><name>Fatemeh Torabi</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>c79d07eaba5c9515c0df82b372b76a41</sid><firstname>Stuart</firstname><surname>Bedston</surname><name>Stuart Bedston</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>db5bc529b8a9dfca2b4a268d14e03479</sid><firstname>Emily</firstname><surname>Lowthian</surname><name>Emily Lowthian</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>aa1b025ec0243f708bb5eb0a93d6fb52</sid><ORCID>0000-0003-0814-0801</ORCID><firstname>Ashley</firstname><surname>Akbari</surname><name>Ashley Akbari</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>0d30aa00eef6528f763a1e1589f703ec</sid><ORCID>0000-0001-5977-376X</ORCID><firstname>Rhiannon</firstname><surname>Owen</surname><name>Rhiannon Owen</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>d499b898d447b62c81b2c122598870e0</sid><ORCID>0000-0002-7968-6679</ORCID><firstname>Rich</firstname><surname>Fry</surname><name>Rich Fry</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>e35ea6ea4b429e812ef204b048131d93</sid><ORCID>0000-0001-9230-624X</ORCID><firstname>Lucy</firstname><surname>Griffiths</surname><name>Lucy Griffiths</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>98490239b86cc892a382416d048cdb3c</sid><ORCID>0000-0001-9005-1618</ORCID><firstname>Gareth</firstname><surname>Davies</surname><name>Gareth Davies</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>d7c51b69270b644a11b904629fe56ab0</sid><firstname>Joe</firstname><surname>Hollinghurst</surname><name>Joe Hollinghurst</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>1b74fa5125a88451c52c45bcf20e0b47</sid><ORCID/><firstname>Jane</firstname><surname>Lyons</surname><name>Jane Lyons</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>93dd7e747f3118a99566c68592a3ddcc</sid><ORCID>0000-0002-9575-4758</ORCID><firstname>Hoda</firstname><surname>Abbasizanjani</surname><name>Hoda Abbasizanjani</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>70a544476ce62ba78502ce463c2500d6</sid><ORCID>0000-0003-0710-0947</ORCID><firstname>Michael</firstname><surname>Gravenor</surname><name>Michael Gravenor</name><active>true</active><ethesisStudent>false</ethesisStudent></author><author><sid>83efcf2a9dfcf8b55586999d3d152ac6</sid><ORCID>0000-0001-5225-000X</ORCID><firstname>Ronan</firstname><surname>Lyons</surname><name>Ronan Lyons</name><active>true</active><ethesisStudent>false</ethesisStudent></author></swanseaauthors><date>2022-10-01</date><deptcode>HDAT</deptcode><abstract>There is a need for better understanding of the risk of thrombocytopenic, haemorrhagic, thromboembolic disorders following first, second and booster vaccination doses and testing positive for SARS-CoV-2. Self-controlled cases series analysis of 2.1 million linked patient records in Wales between 7th December 2020 and 31st December 2021. Outcomes were the first diagnosis of thrombocytopenic, haemorrhagic and thromboembolic events in primary or secondary care datasets, exposure was defined as 0–28 days post-vaccination or a positive reverse transcription polymerase chain reaction test for SARS-CoV-2. 36,136 individuals experienced either a thrombocytopenic, haemorrhagic or thromboembolic event during the study period. Relative to baseline, our observations show greater risk of outcomes in the periods post-first dose of BNT162b2 for haemorrhagic (IRR 1.47, 95%CI: 1.04–2.08) and idiopathic thrombocytopenic purpura (IRR 2.80, 95%CI: 1.21–6.49) events; post-second dose of ChAdOx1 for arterial thrombosis (IRR 1.14, 95%CI: 1.01–1.29); post-booster greater risk of venous thromboembolic (VTE) (IRR-Moderna 3.62, 95%CI: 0.99–13.17) (IRR-BNT162b2 1.39, 95%CI: 1.04–1.87) and arterial thrombosis (IRR-Moderna 3.14, 95%CI: 1.14–8.64) (IRR-BNT162b2 1.34, 95%CI: 1.15–1.58). Similarly, post SARS-CoV-2 infection the risk was increased for haemorrhagic (IRR 1.49, 95%CI: 1.15–1.92), VTE (IRR 5.63, 95%CI: 4.91, 6.4), arterial thrombosis (IRR 2.46, 95%CI: 2.22–2.71). We found that there was a measurable risk of thrombocytopenic, haemorrhagic, thromboembolic events after COVID-19 vaccination and infection.</abstract><type>Journal Article</type><journal>Scientific Reports</journal><volume>12</volume><journalNumber>1</journalNumber><paginationStart/><paginationEnd/><publisher>Springer Science and Business Media LLC</publisher><placeOfPublication/><isbnPrint/><isbnElectronic/><issnPrint/><issnElectronic>2045-2322</issnElectronic><keywords/><publishedDay>30</publishedDay><publishedMonth>9</publishedMonth><publishedYear>2022</publishedYear><publishedDate>2022-09-30</publishedDate><doi>10.1038/s41598-022-20118-6</doi><url/><notes>Data availability:The Statistical Analysis plan of this work is available at: https://github.com/HDRUK/DaCVaP/blob/main/Wales/SAP/Workplan%20-%20Vaccine%20Safety.pdf. We also made the code and data to reproduce figures available at: https://github.com/HDRUK/DaCVaP/tree/main/Wales. The main patient-level data sources used in this study are available in the SAIL Databank at Swansea University, Swansea, UK, but as restrictions apply, they are not publicly available. All proposals to use SAIL data are subject to review by an independent Information Governance Review Panel (IGRP). Before any data can be accessed, approval must be given by the IGRP. The IGRP gives careful consideration to each project to ensure proper and appropriate use of SAIL data. When access has been granted, it is gained through a privacy protecting safe haven and remote access system referred to as the SAIL Gateway. SAIL has established an application process to be followed by anyone who would like to access data via SAIL at https://www.saildatabank.com/application-process/.</notes><college>COLLEGE NANME</college><department>Health Data Science</department><CollegeCode>COLLEGE CODE</CollegeCode><DepartmentCode>HDAT</DepartmentCode><institution>Swansea University</institution><apcterm/><funders>This work was supported by the Medical Research Council [MR/V028367/1]; Health Data Research UK [HDR-9006] which receives its funding from the UK Medical Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), British Heart Foundation (BHF) and the Wellcome Trust; and Administrative Data Research UK which is funded by the Economic and Social Research Council [grant ES/S007393/1]. This work was supported by the Wales COVID-19 Evidence Centre, funded by Health and Care Research Wales. This research is part of the Data and Connectivity National Core Study, led by Health Data Research UK in partnership with the Office for National Statistics and funded by UK Research and Innovation. We also acknowledge the support of the HDR UK BREATHE Hub, funded by the Industrial Strategy Challenge Fund through a grant via Health Data Research UK.</funders><projectreference/><lastEdited>2022-10-27T12:02:47.2270248</lastEdited><Created>2022-10-01T09:13:19.7508472</Created><path><level id="1">Faculty of Medicine, Health and Life Sciences</level><level id="2">Swansea University Medical School - Medicine</level></path><authors><author><firstname>Fatemeh</firstname><surname>Torabi</surname><orcid>0000-0002-5853-4625</orcid><order>1</order></author><author><firstname>Stuart</firstname><surname>Bedston</surname><order>2</order></author><author><firstname>Emily</firstname><surname>Lowthian</surname><order>3</order></author><author><firstname>Ashley</firstname><surname>Akbari</surname><orcid>0000-0003-0814-0801</orcid><order>4</order></author><author><firstname>Rhiannon</firstname><surname>Owen</surname><orcid>0000-0001-5977-376X</orcid><order>5</order></author><author><firstname>Declan T.</firstname><surname>Bradley</surname><order>6</order></author><author><firstname>Utkarsh</firstname><surname>Agrawal</surname><order>7</order></author><author><firstname>Peter</firstname><surname>Collins</surname><order>8</order></author><author><firstname>Rich</firstname><surname>Fry</surname><orcid>0000-0002-7968-6679</orcid><order>9</order></author><author><firstname>Lucy</firstname><surname>Griffiths</surname><orcid>0000-0001-9230-624X</orcid><order>10</order></author><author><firstname>Jillian</firstname><surname>Beggs</surname><order>11</order></author><author><firstname>Gareth</firstname><surname>Davies</surname><orcid>0000-0001-9005-1618</orcid><order>12</order></author><author><firstname>Joe</firstname><surname>Hollinghurst</surname><order>13</order></author><author><firstname>Jane</firstname><surname>Lyons</surname><orcid/><order>14</order></author><author><firstname>Hoda</firstname><surname>Abbasizanjani</surname><orcid>0000-0002-9575-4758</orcid><order>15</order></author><author><firstname>Simon</firstname><surname>Cottrell</surname><order>16</order></author><author><firstname>Malorie</firstname><surname>Perry</surname><order>17</order></author><author><firstname>Richard</firstname><surname>Roberts</surname><order>18</order></author><author><firstname>Amaya</firstname><surname>Azcoaga-Lorenzo</surname><order>19</order></author><author><firstname>Adeniyi Francis</firstname><surname>Fagbamigbe</surname><order>20</order></author><author><firstname>Ting</firstname><surname>Shi</surname><order>21</order></author><author><firstname>Ruby S. M.</firstname><surname>Tsang</surname><order>22</order></author><author><firstname>Chris</firstname><surname>Robertson</surname><order>23</order></author><author><firstname>F. D. 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2022-10-27T12:02:47.2270248 v2 61394 2022-10-01 Risk of thrombocytopenic, haemorrhagic and thromboembolic disorders following COVID-19 vaccination and positive test: a self-controlled case series analysis in Wales f569591e1bfb0e405b8091f99fec45d3 0000-0002-5853-4625 Fatemeh Torabi Fatemeh Torabi true false c79d07eaba5c9515c0df82b372b76a41 Stuart Bedston Stuart Bedston true false db5bc529b8a9dfca2b4a268d14e03479 Emily Lowthian Emily Lowthian true false aa1b025ec0243f708bb5eb0a93d6fb52 0000-0003-0814-0801 Ashley Akbari Ashley Akbari true false 0d30aa00eef6528f763a1e1589f703ec 0000-0001-5977-376X Rhiannon Owen Rhiannon Owen true false d499b898d447b62c81b2c122598870e0 0000-0002-7968-6679 Rich Fry Rich Fry true false e35ea6ea4b429e812ef204b048131d93 0000-0001-9230-624X Lucy Griffiths Lucy Griffiths true false 98490239b86cc892a382416d048cdb3c 0000-0001-9005-1618 Gareth Davies Gareth Davies true false d7c51b69270b644a11b904629fe56ab0 Joe Hollinghurst Joe Hollinghurst true false 1b74fa5125a88451c52c45bcf20e0b47 Jane Lyons Jane Lyons true false 93dd7e747f3118a99566c68592a3ddcc 0000-0002-9575-4758 Hoda Abbasizanjani Hoda Abbasizanjani true false 70a544476ce62ba78502ce463c2500d6 0000-0003-0710-0947 Michael Gravenor Michael Gravenor true false 83efcf2a9dfcf8b55586999d3d152ac6 0000-0001-5225-000X Ronan Lyons Ronan Lyons true false 2022-10-01 HDAT There is a need for better understanding of the risk of thrombocytopenic, haemorrhagic, thromboembolic disorders following first, second and booster vaccination doses and testing positive for SARS-CoV-2. Self-controlled cases series analysis of 2.1 million linked patient records in Wales between 7th December 2020 and 31st December 2021. Outcomes were the first diagnosis of thrombocytopenic, haemorrhagic and thromboembolic events in primary or secondary care datasets, exposure was defined as 0–28 days post-vaccination or a positive reverse transcription polymerase chain reaction test for SARS-CoV-2. 36,136 individuals experienced either a thrombocytopenic, haemorrhagic or thromboembolic event during the study period. Relative to baseline, our observations show greater risk of outcomes in the periods post-first dose of BNT162b2 for haemorrhagic (IRR 1.47, 95%CI: 1.04–2.08) and idiopathic thrombocytopenic purpura (IRR 2.80, 95%CI: 1.21–6.49) events; post-second dose of ChAdOx1 for arterial thrombosis (IRR 1.14, 95%CI: 1.01–1.29); post-booster greater risk of venous thromboembolic (VTE) (IRR-Moderna 3.62, 95%CI: 0.99–13.17) (IRR-BNT162b2 1.39, 95%CI: 1.04–1.87) and arterial thrombosis (IRR-Moderna 3.14, 95%CI: 1.14–8.64) (IRR-BNT162b2 1.34, 95%CI: 1.15–1.58). Similarly, post SARS-CoV-2 infection the risk was increased for haemorrhagic (IRR 1.49, 95%CI: 1.15–1.92), VTE (IRR 5.63, 95%CI: 4.91, 6.4), arterial thrombosis (IRR 2.46, 95%CI: 2.22–2.71). We found that there was a measurable risk of thrombocytopenic, haemorrhagic, thromboembolic events after COVID-19 vaccination and infection. Journal Article Scientific Reports 12 1 Springer Science and Business Media LLC 2045-2322 30 9 2022 2022-09-30 10.1038/s41598-022-20118-6 Data availability:The Statistical Analysis plan of this work is available at: https://github.com/HDRUK/DaCVaP/blob/main/Wales/SAP/Workplan%20-%20Vaccine%20Safety.pdf. We also made the code and data to reproduce figures available at: https://github.com/HDRUK/DaCVaP/tree/main/Wales. The main patient-level data sources used in this study are available in the SAIL Databank at Swansea University, Swansea, UK, but as restrictions apply, they are not publicly available. All proposals to use SAIL data are subject to review by an independent Information Governance Review Panel (IGRP). Before any data can be accessed, approval must be given by the IGRP. The IGRP gives careful consideration to each project to ensure proper and appropriate use of SAIL data. When access has been granted, it is gained through a privacy protecting safe haven and remote access system referred to as the SAIL Gateway. SAIL has established an application process to be followed by anyone who would like to access data via SAIL at https://www.saildatabank.com/application-process/. COLLEGE NANME Health Data Science COLLEGE CODE HDAT Swansea University This work was supported by the Medical Research Council [MR/V028367/1]; Health Data Research UK [HDR-9006] which receives its funding from the UK Medical Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), British Heart Foundation (BHF) and the Wellcome Trust; and Administrative Data Research UK which is funded by the Economic and Social Research Council [grant ES/S007393/1]. This work was supported by the Wales COVID-19 Evidence Centre, funded by Health and Care Research Wales. This research is part of the Data and Connectivity National Core Study, led by Health Data Research UK in partnership with the Office for National Statistics and funded by UK Research and Innovation. We also acknowledge the support of the HDR UK BREATHE Hub, funded by the Industrial Strategy Challenge Fund through a grant via Health Data Research UK. 2022-10-27T12:02:47.2270248 2022-10-01T09:13:19.7508472 Faculty of Medicine, Health and Life Sciences Swansea University Medical School - Medicine Fatemeh Torabi 0000-0002-5853-4625 1 Stuart Bedston 2 Emily Lowthian 3 Ashley Akbari 0000-0003-0814-0801 4 Rhiannon Owen 0000-0001-5977-376X 5 Declan T. Bradley 6 Utkarsh Agrawal 7 Peter Collins 8 Rich Fry 0000-0002-7968-6679 9 Lucy Griffiths 0000-0001-9230-624X 10 Jillian Beggs 11 Gareth Davies 0000-0001-9005-1618 12 Joe Hollinghurst 13 Jane Lyons 14 Hoda Abbasizanjani 0000-0002-9575-4758 15 Simon Cottrell 16 Malorie Perry 17 Richard Roberts 18 Amaya Azcoaga-Lorenzo 19 Adeniyi Francis Fagbamigbe 20 Ting Shi 21 Ruby S. M. Tsang 22 Chris Robertson 23 F. D. Richard Hobbs 24 Simon de Lusignan 25 Colin McCowan 26 Michael Gravenor 0000-0003-0710-0947 27 Colin R. Simpson 28 Aziz Sheikh 29 Ronan Lyons 0000-0001-5225-000X 30 61394__25596__a1fb92b22a8b4ad79a3b92095451ce4c.pdf 61394_VoR.pdf 2022-10-27T12:01:00.8931417 Output 1596735 application/pdf Version of Record true This article is licensed under a Creative Commons Attribution 4.0 International License true eng http://creativecommons.org/licenses/by/4.0/ |
title |
Risk of thrombocytopenic, haemorrhagic and thromboembolic disorders following COVID-19 vaccination and positive test: a self-controlled case series analysis in Wales |
spellingShingle |
Risk of thrombocytopenic, haemorrhagic and thromboembolic disorders following COVID-19 vaccination and positive test: a self-controlled case series analysis in Wales Fatemeh Torabi Stuart Bedston Emily Lowthian Ashley Akbari Rhiannon Owen Rich Fry Lucy Griffiths Gareth Davies Joe Hollinghurst Jane Lyons Hoda Abbasizanjani Michael Gravenor Ronan Lyons |
title_short |
Risk of thrombocytopenic, haemorrhagic and thromboembolic disorders following COVID-19 vaccination and positive test: a self-controlled case series analysis in Wales |
title_full |
Risk of thrombocytopenic, haemorrhagic and thromboembolic disorders following COVID-19 vaccination and positive test: a self-controlled case series analysis in Wales |
title_fullStr |
Risk of thrombocytopenic, haemorrhagic and thromboembolic disorders following COVID-19 vaccination and positive test: a self-controlled case series analysis in Wales |
title_full_unstemmed |
Risk of thrombocytopenic, haemorrhagic and thromboembolic disorders following COVID-19 vaccination and positive test: a self-controlled case series analysis in Wales |
title_sort |
Risk of thrombocytopenic, haemorrhagic and thromboembolic disorders following COVID-19 vaccination and positive test: a self-controlled case series analysis in Wales |
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f569591e1bfb0e405b8091f99fec45d3_***_Fatemeh Torabi c79d07eaba5c9515c0df82b372b76a41_***_Stuart Bedston db5bc529b8a9dfca2b4a268d14e03479_***_Emily Lowthian aa1b025ec0243f708bb5eb0a93d6fb52_***_Ashley Akbari 0d30aa00eef6528f763a1e1589f703ec_***_Rhiannon Owen d499b898d447b62c81b2c122598870e0_***_Rich Fry e35ea6ea4b429e812ef204b048131d93_***_Lucy Griffiths 98490239b86cc892a382416d048cdb3c_***_Gareth Davies d7c51b69270b644a11b904629fe56ab0_***_Joe Hollinghurst 1b74fa5125a88451c52c45bcf20e0b47_***_Jane Lyons 93dd7e747f3118a99566c68592a3ddcc_***_Hoda Abbasizanjani 70a544476ce62ba78502ce463c2500d6_***_Michael Gravenor 83efcf2a9dfcf8b55586999d3d152ac6_***_Ronan Lyons |
author |
Fatemeh Torabi Stuart Bedston Emily Lowthian Ashley Akbari Rhiannon Owen Rich Fry Lucy Griffiths Gareth Davies Joe Hollinghurst Jane Lyons Hoda Abbasizanjani Michael Gravenor Ronan Lyons |
author2 |
Fatemeh Torabi Stuart Bedston Emily Lowthian Ashley Akbari Rhiannon Owen Declan T. Bradley Utkarsh Agrawal Peter Collins Rich Fry Lucy Griffiths Jillian Beggs Gareth Davies Joe Hollinghurst Jane Lyons Hoda Abbasizanjani Simon Cottrell Malorie Perry Richard Roberts Amaya Azcoaga-Lorenzo Adeniyi Francis Fagbamigbe Ting Shi Ruby S. M. Tsang Chris Robertson F. D. Richard Hobbs Simon de Lusignan Colin McCowan Michael Gravenor Colin R. Simpson Aziz Sheikh Ronan Lyons |
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Journal article |
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Scientific Reports |
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12 |
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2022 |
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Swansea University |
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2045-2322 |
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10.1038/s41598-022-20118-6 |
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Springer Science and Business Media LLC |
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Faculty of Medicine, Health and Life Sciences |
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facultyofmedicinehealthandlifesciences |
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Faculty of Medicine, Health and Life Sciences |
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facultyofmedicinehealthandlifesciences |
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Faculty of Medicine, Health and Life Sciences |
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Swansea University Medical School - Medicine{{{_:::_}}}Faculty of Medicine, Health and Life Sciences{{{_:::_}}}Swansea University Medical School - Medicine |
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description |
There is a need for better understanding of the risk of thrombocytopenic, haemorrhagic, thromboembolic disorders following first, second and booster vaccination doses and testing positive for SARS-CoV-2. Self-controlled cases series analysis of 2.1 million linked patient records in Wales between 7th December 2020 and 31st December 2021. Outcomes were the first diagnosis of thrombocytopenic, haemorrhagic and thromboembolic events in primary or secondary care datasets, exposure was defined as 0–28 days post-vaccination or a positive reverse transcription polymerase chain reaction test for SARS-CoV-2. 36,136 individuals experienced either a thrombocytopenic, haemorrhagic or thromboembolic event during the study period. Relative to baseline, our observations show greater risk of outcomes in the periods post-first dose of BNT162b2 for haemorrhagic (IRR 1.47, 95%CI: 1.04–2.08) and idiopathic thrombocytopenic purpura (IRR 2.80, 95%CI: 1.21–6.49) events; post-second dose of ChAdOx1 for arterial thrombosis (IRR 1.14, 95%CI: 1.01–1.29); post-booster greater risk of venous thromboembolic (VTE) (IRR-Moderna 3.62, 95%CI: 0.99–13.17) (IRR-BNT162b2 1.39, 95%CI: 1.04–1.87) and arterial thrombosis (IRR-Moderna 3.14, 95%CI: 1.14–8.64) (IRR-BNT162b2 1.34, 95%CI: 1.15–1.58). Similarly, post SARS-CoV-2 infection the risk was increased for haemorrhagic (IRR 1.49, 95%CI: 1.15–1.92), VTE (IRR 5.63, 95%CI: 4.91, 6.4), arterial thrombosis (IRR 2.46, 95%CI: 2.22–2.71). We found that there was a measurable risk of thrombocytopenic, haemorrhagic, thromboembolic events after COVID-19 vaccination and infection. |
published_date |
2022-09-30T04:20:12Z |
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11.037166 |