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EBCOG position statement on COVID-19 vaccination for pregnant and breastfeeding women

      Abstract

      Covid 19 pandemic has led to significant mortality and long term morbidity globally. Pregnant women are at increased risk of severe illness from COVID 19 infection. There is an urgent need for all health authorities and Governments to offer vaccination to all pregnant women especially those with high risk pregnancy.

      Keywords

      The risks of Covid-19 infection during pregnancy and breastfeeding

      There is now strong evidence that pregnant women are at increased risk for severe illness from COVID-19 when compared with non-pregnant women, particularly when infection occurs during the third trimester of pregnancy [
      • Zambrano L.D.
      • Ellington S.
      • Strid P.
      • et al.
      Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status - United States, January 22-October 3, 2020. CDC COVID-19 Response Pregnancy and Infant Linked Outcomes Team.
      ,
      • Allotey J.
      • Stallings E.
      • Bonet M.
      • et al.
      Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis.
      ,
      • Delahoy M.J.
      • Whitaker M.
      • O’Halloran A.
      • et al.
      Characteristics and maternal and birth outcomes of hospitalized pregnant women with laboratory-confirmed COVID-19 - COVID-NET, 13 states, March 1-August 22, 2020. COVID-NET Surveillance Team.
      ]. The risk of intensive care unit admission is around 1% in this population, and the risk of invasive mechanical ventilation around 0.3 % [
      • Zambrano L.D.
      • Ellington S.
      • Strid P.
      • et al.
      Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status - United States, January 22-October 3, 2020. CDC COVID-19 Response Pregnancy and Infant Linked Outcomes Team.
      ,
      • Allotey J.
      • Stallings E.
      • Bonet M.
      • et al.
      Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis.
      ]. These values are circa three times higher than those of the non-pregnant population of the same age. While the absolute risk of death from COVID-19 in pregnant women remains low, at about 0.15 % in symptomatic patients, it is around 70 % higher than that of non-pregnant women of the same age [
      • Zambrano L.D.
      • Ellington S.
      • Strid P.
      • et al.
      Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status - United States, January 22-October 3, 2020. CDC COVID-19 Response Pregnancy and Infant Linked Outcomes Team.
      ,
      • Allotey J.
      • Stallings E.
      • Bonet M.
      • et al.
      Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis.
      ]. Maternal conditions such as age over 40 years, obesity, chronic hypertension, and preexisting diabetes are additional risk factors for severe disease [
      • Zambrano L.D.
      • Ellington S.
      • Strid P.
      • et al.
      Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status - United States, January 22-October 3, 2020. CDC COVID-19 Response Pregnancy and Infant Linked Outcomes Team.
      ,
      • Allotey J.
      • Stallings E.
      • Bonet M.
      • et al.
      Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis.
      ,
      • Panagiotakopoulos L.
      • Myers T.R.
      • Gee J.
      • et al.
      SARS-CoV-2 infection among hospitalized pregnant women: reasons for admission and pregnancy characteristics - eight U.S. health care centers, March 1-May 30, 2020.
      ].
      There is also evidence that COVID-19 infection during pregnancy increases the risk of preterm birth about three-fold, mainly due to iatrogenic preterm delivery [
      • Zambrano L.D.
      • Ellington S.
      • Strid P.
      • et al.
      Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status - United States, January 22-October 3, 2020. CDC COVID-19 Response Pregnancy and Infant Linked Outcomes Team.
      ,
      • Allotey J.
      • Stallings E.
      • Bonet M.
      • et al.
      Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis.
      ]. Vertical transmission of SARS-CoV-2 [
      • Blumberg D.A.
      • Underwood M.A.
      • Hedriana H.L.
      • Lakshminrusimha S.
      Vertical transmission of SARS-CoV-2: what is the optimal definition?.
      ] occurs in approximately 2.5 % of pregnant women and appears to be mainly limited to cases of third-trimester infection [
      • Goh X.L.
      • Low Y.F.
      • Ng C.H.
      • Amin Z.
      • Ng Y.P.M.
      Incidence of SARS-CoV-2 vertical transmission: a meta-analysis.
      ].
      For all the reasons described above, pregnant women need to be considered a high-risk population for serious COVID-19 infection, and there are clear benefits for both mother and fetus of avoiding this disease during pregnancy [
      • Chervenak F.A.
      • McCullough L.B.
      • Bornstein E.
      • Johnson L.
      • Katz A.
      • et al.
      Professionally responsible coronavirus disease 2019 vaccination counseling of obstetrical and gynecologic patients.
      ,
      • Nassar A.H.
      • Visser G.H.A.
      • Nicholson W.K.
      • et al.
      FIGO safe motherhood, newborn health committee. FIGO statement: vaccination in pregnancy.
      ]. Breastfeeding women are believed to have similar risks of serious disease as non-pregnant women.

      Covid-19 vaccines

      Currently authorized COVID-19 vaccines in Europe use different technologies, including messenger RNA (mRNA), viral vectors, and recombinant proteins produced in a baculovirus system. However, none of them use live viruses, therefore they are not capable of causing disease [,
      • Rasmussen S.A.
      • Kelley C.F.
      • Horton J.P.
      • et al.
      Coronavirus Disease 2019 (COVID-19) Vaccines and pregnancy: what obstetricians need to know.
      ]. Other vaccines that do not use live viruses show no evidence of increased risk during human pregnancy and breastfeeding [

      Centers for Disease Control and Prevention. Information about COVID-19 Vaccines for People who Are Pregnant or Breastfeeding. Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html.

      ].
      Existing vaccines do not interact with individuals’ DNA or cause genetic mutations [,
      • Rasmussen S.A.
      • Kelley C.F.
      • Horton J.P.
      • et al.
      Coronavirus Disease 2019 (COVID-19) Vaccines and pregnancy: what obstetricians need to know.
      ,

      Centers for Disease Control and Prevention. Information about COVID-19 Vaccines for People who Are Pregnant or Breastfeeding. Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html.

      ]. Animal studies did not reveal any safety concerns regarding female reproduction, embryo-fetal or neonatal development [,

      Centers for Disease Control and Prevention. Information about COVID-19 Vaccines for People who Are Pregnant or Breastfeeding. Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html.

      ].
      All these vaccines were rigorously evaluated in randomised controlled trials, but pregnancy and breastfeeding were exclusion criteria [,
      • Rasmussen S.A.
      • Kelley C.F.
      • Horton J.P.
      • et al.
      Coronavirus Disease 2019 (COVID-19) Vaccines and pregnancy: what obstetricians need to know.
      ,

      Centers for Disease Control and Prevention. Information about COVID-19 Vaccines for People who Are Pregnant or Breastfeeding. Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html.

      ]. There is limited data from pregnant women who were inadvertently enrolled in these trials, but it is reassuring on the safety of vaccination in pregnancy [,

      Centers for Disease Control and Prevention. Information about COVID-19 Vaccines for People who Are Pregnant or Breastfeeding. Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html.

      ]. Self-reported information after ongoing COVID-19 vaccination in the USA (86 956 pregnant women, as of the 12th April 2021 [

      Centers for Disease Control and Prevention. V-safe COVID-19 Vaccine Pregnancy Registry. Available at: https://www.cdc.gov/coronavirus/2019-nocv/vaccines/safety/vsafepregnancyregistry.html.

      ], of which 35 691 have been the subject of a publication [
      • Shimabukuro T.T.
      • Kim S.Y.
      • Myers T.R.
      • et al.
      Preliminary findings of mRNA Covid-19 vaccine safety in pregnant persons.
      ]) has not revealed any safety issues, but follow-up is naturally short. It is strongly believed that COVID-19 vaccines do not cause any harm to newborns by way of breastmilk [
      • Dooling K.
      • Marin M.
      • Wallace M.
      • et al.
      The Advisory Committee on Immunization Practices’ updated interim recommendation for allocation of COVID-19 vaccine - United States, December 2020.
      ].
      In a small prospective study [
      • Gray K.J.
      • Bordt E.A.
      • Atyeo C.
      • Deriso E.
      • Akinwunmi B.
      • Young N.
      • et al.
      COVID-19 vaccine response in pregnant and lactating women: a cohort study.
      ] comparing 84 pregnant, 31 breastfeeding, and 16 non-pregnant women vaccinated with a mRNA vaccine, vaccine-induced immune responses were similar, and higher antibody titers were found after vaccination than after infection in pregnancy. Vaccine-generated antibodies were found in umbilical cord blood and breast milk samples, showing a potential for fetal and neonatal immunization with maternal vaccination.
      Of late, several cases of cerebral vessels thrombotic (CVT) events following immunization with COVID-19 viral vector vaccines (Astra Zeneca and Johnson & Johnson) have been reported, more commonly in women. Nevertheless, they remain a rare event, with an incidence of about 4.1 per million compared with the incidence of 39.0 per million people with a diagnosis of Covid [
      • Torjesen Ingrid
      Risk of cerebral blood clots from Covid 19 is 10 times that from vaccination, study finds.
      ]. The European Medicine Agency (EMA) and the United Kingdom Medicines & Healthcare products Regulatory Agency (MHRA) have stated that the benefits of vaccination clearly outweigh the risks. Currently there is no evidence on the risk of thrombotic events following immunization with COVID-19 viral vector vaccines in pregnancy, a well-known prothrombotic state. Women should be counseled as regards this potential risk, and healthcare professionals should have a low threshold for investigation, if a thrombotic event is suspected [
      • British Society for Haematology
      Guidance produced by the expert haematology panel (EHP) focused on vaccine induced thrombosis and thrombocytopenia (VITT).
      ,
      • The Royal College of Emergency Medicine
      The society for acute medicine & the royal college of physicians joint guidance.
      ].

      EBCOG position

      All vaccination during pregnancy is naturally optional, but healthcare providers need to advise women about the risks of acquiring COVID-19 infection in pregnancy, as well as the limited existing evidence on the benefits and potential side effects of existing vaccines, as a basis to shared decision-making on this issue. EBCOG acknowledges that a clear indication from healthcare providers would improve adherence to vaccination programs and reduce women’s anxiety with the decision [
      • Chervenak F.A.
      • McCullough L.B.
      • Bornstein E.
      • Johnson L.
      • Katz A.
      • et al.
      Professionally responsible coronavirus disease 2019 vaccination counseling of obstetrical and gynecologic patients.
      ], but this is not possible with the currently existing evidence.
      EBCOG acknowledges that there is limited evidence on the long-term safety of COVID-19 vaccination during pregnancy, and that there is a need for more robust data before it can be recommended to all pregnant women. Nevertheless, the possibility of vaccination should be offered to all pregnant women, after being adequately informed of the benefits and risks. EBCOG urges all Health Authorities and Governments to make vaccination available to all pregnant women wishing to take them.
      In women with the co-morbidities listed above, and in those at higher-risk of exposure to the disease, EBCOG considers that the benefits are likely to outweigh the predictable risks, and therefore vaccination should be recommended to high-risk pregnant women, in the absence of contraindications. There is currently insufficient data regarding the preferential use of a particular COVID-19 vaccine.

      EBCOG supports that COVID-19 vaccination be recommended to all breastfeeding women, in the absence of a specific contraindication

      The position statement has been approved by the officers group of EBCOG and the executive board of EBCOG.

      References

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        Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis.
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      3. Centers for Disease Control and Prevention. V-safe COVID-19 Vaccine Pregnancy Registry. Available at: https://www.cdc.gov/coronavirus/2019-nocv/vaccines/safety/vsafepregnancyregistry.html.

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        Preliminary findings of mRNA Covid-19 vaccine safety in pregnant persons.
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        COVID-19 vaccine response in pregnant and lactating women: a cohort study.
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        • Torjesen Ingrid
        Risk of cerebral blood clots from Covid 19 is 10 times that from vaccination, study finds.
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        • British Society for Haematology
        Guidance produced by the expert haematology panel (EHP) focused on vaccine induced thrombosis and thrombocytopenia (VITT).
        (Available at:)2021
        • The Royal College of Emergency Medicine
        The society for acute medicine & the royal college of physicians joint guidance.
        (Available at:)2021