Every pregnant woman must be vaccinated

During the first wave of the COVID-19 epidemic in India, we had not realised that pregnant women could have serious problems with the COVID-19 disease. During the second wave, our obstetric colleagues tell us that some pregnant women had suffered adversely with COVID-19.

One problem is that pregnant women with COVID-19 tend to deliver prematurely. Many a time, a medical decision for inducing early labour and delivery would become necessary; also, for treating severe COVID-19, doctors may need to give medicines that are otherwise contraindicated in pregnancy.  Babies born prematurely require prolonged neonatal intensive care and are vulnerable to serious bacterial and fungal infections.  Prematurity is by itself a leading cause of neonatal morbidity and mortality.

Another problem is that a small proportion of women may suffer severe disease due to COVID-19, requiring admission in intensive care units including ventilation. They have an unexpectedly high risk of mortality. These are anecdotal stories and when asked, all obstetricians tell us the same story that they have witnessed in this second wave.

A medical decision for inducing early labour and delivery would become necessary; also, for treating severe COVID-19, doctors may need to give medicines that are otherwise contraindicated in pregnancy. Babies born prematurely require prolonged neonatal intensive care and are vulnerable to serious bacterial and fungal infections.  

A multinational study conducted in 18 countries, recently published in the Journal of American Medical Association (JAMA Pediatrics), reported a higher frequency of medical complications (pre-eclampsia/eclampsia) in pregnant women with COVID-19 compared to pregnant women without COVID-19. There was also a significantly higher number of deaths in pregnant women with COVID-19. Deaths were also more common in resource-limited countries because of suboptimal health care access.

There are no published reports in medical journals regarding the impact of COVID coronavirus infection among expectant mothers in India during the second wave. Brazil has reported several hundreds of deaths of pregnant women, attributing the problem to the Gamma variant (earlier called B.1.1.28 or P.1 that emerged first in Brazil) of SARS-CoV-2.  Unfortunately, in India there has hardly been any discussion regarding COVID-19 during pregnancy and the need for improving antenatal services to prevent the disease.

There is no doubt that we must urgently protect all pregnant women from COVID-19. The best way to offer such protection is by vaccination. Our country must change the current policy not to vaccinate during pregnancy, but allow, indeed promote, vaccinating pregnant women as a high priority.

The decision to exclude pregnant women from vaccination was based on lack of safety data in pregnant women rather than any specific safety concerns for the fetus

Pregnant women were excluded from recruitment as volunteers in Phase III vaccine trials in all countries, including India. The policy decision to exclude pregnant women from the vaccination was based on lack of safety data in pregnant women rather than any specific safety concerns for the fetus.

Over one lakh pregnant women in USA have been inoculated with the Pfizer BioNTech or Moderna mRNA vaccines with a good safety record. The Royal College of Obstetricians and Gynaecologists in UK has recommended that mRNA vaccine (Pfizer/Moderna) should be preferred over the chimpanzee adenovirus-vectored Oxford-AstraZeneca COVID-19 vaccine for pregnant women. There is a rare but serious (even life-threatening) blood clotting risk, predominantly in women, associated with the AstraZeneca vaccine.

The mRNA vaccines are currently not available in India. However, we believe that among the available vaccines in India, Covaxin, being an inactivated viral vaccine, would be quite safe for inoculating pregnant women with two doses, four weeks apart.

There is a rare but serious (even life-threatening) blood clotting risk, predominantly in women, associated with the AstraZeneca vaccine. The mRNA vaccines are currently not available in India. However, among the available vaccines in India, Covaxin, being an inactivated viral vaccine, would be quite safe for inoculating pregnant women with two doses, four weeks apart.

Coronavirus infection may occur during any time of pregnancy – first, second or third trimester; hence severe COVID-19 may occur in any trimester.  Therefore, protection is needed early and vaccination should not be delayed for any reason.  We recommend to the policy makers that the first dose of the Covid-19 vaccine be administered as early as possible, as part of antenatal care. The second dose needs to be timed after four weeks.

Routine antenatal care in pregnancy includes immunisation with tetanus-diphtheria toxoid (Td) vaccine, under the Universal Immunisation Programme. Two doses a month apart are given to women without documented evidence of previous tetanus and diphtheria immunisation, particularly in the first pregnancy.  Those with a record of previous immunisation, such as in the second or subsequent pregnancy within three years, only one booster dose of Td vaccine is sufficient. COVID-19 vaccine and Td vaccine can be injected at different sites (like the two arms) during the same clinic visit.

If the pregnant woman does not like two injections on one day, COVID-19 vaccine must be prioritised and given first, followed by Td vaccine after an interval of two weeks

If the pregnant woman does not like two injections on one day, COVID-19 vaccine must be prioritised and given first, followed by Td vaccine after an interval of two weeks. However, the second dose of COVID-19 vaccine must be given four weeks after the first dose, for the sake of early protection -- robust protection starts only two weeks after the second dose of COVID-19 vaccine.  The clinical need for protection from Td vaccine is after delivery – for the baby and mother – hence some delay in Td vaccination is acceptable.

We need an immediate policy revision, and decision, by the Government of India to vaccinate all pregnant women early in pregnancy. Meanwhile, those who are able to postpone pregnancy until after taking two doses of a COVID vaccine are advised to choose that alternative. All members of families with a pregnant woman should take all precautions not to bring home the coronavirus infection.

(Dr Dhanya Dharmapalan is Consultant in Pediatric Infectious Diseases, Navi Mumbai. Dr T Jacob John is retired Professor of Clinical Virology, Christian Medical College, Vellore, and Past President of the Indian Academy of Pediatrics. Views are personal)

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