MEDICAL ADVISORY: COVID-19 Vaccine Strongly Recommended for Pregnant, Breastfeeding or Individuals Trying to Conceive 

Issued by:   M. Mustafa Hirji, MD, MPH, FRCPC, Medical Officer of Health & Commissioner (Acting)

As the evidence evolves, it is becoming clear that pregnant and postpartum individuals represent a population at increased risk of COVID-19-related morbidity. Severe COVID-19 infection during pregnancy has important implications for both maternal and fetal health. Although most pregnant individuals who become infected with SARS-CoV-2 will have mild-to-moderate symptoms and many can be asymptomatic, both Canadian and international data from large studies spanning multiple jurisdictions demonstrate that approximately 7-11% of pregnant women will require hospitalization for COVID-related morbidity and between 1-4% of pregnant women require admission to an intensive care unit (ICU).

Analysis as of October 3, 20201 from the Institute for Clinical Evaluative Sciences (ICES) on vaccine uptake shows that Niagara is well below the provincial average in vaccinating pregnant individuals. Specifically, Niagara is seventh lowest out of 34 health units in Ontario, with only 57% of pregnant individuals that have received a first dose of COVID-19, and only 49% having received a second dose.

Given the risk of infection severe illness from COVID-19 is increased in pregnancy with pregnant women disproportionately admitted into ICU or put on ventilators, Public Health is asking health care providers to make a strong recommendation for patients in these populations to get fully vaccinated:

• Pregnant individuals
• Breastfeeding individuals
• Individuals trying to conceive  

Risk of Exposure

All people who are unvaccinated are almost certain to get infected as society moves to lift social restrictions and allow the virus to spread freely. Cases among fully vaccinated individuals are far less likely (8-fold). Serious illness (e.g. needing hospitalization or being on a ventilator) is very rare among fully vaccinated people (25 times less likely than an unvaccinated person). Almost all people hospitalized are unvaccinated.

COVID-19 Vaccination Strongly Recommended by Experts

Both the Society of Obstetricians and Gynaecologists of Canada and the National Advisory Committee on Immunization (NACI) recommend pregnant or breastfeeding individuals get a complete series with an mRNA COVID-19 vaccine. Individuals can get vaccinated against COVID-19 in any stage during pregnancy or while breastfeeding.

Unless otherwise contraindicated, couples or individuals planning to conceive should receive the COVID-19 vaccination as soon as possible. If your patient is on fertility treatments, ask them to talk to their fertility specialist.

Evidence Shows mRNA COVID-19 Vaccines are Safe during Pregnancy and While Breastfeeding, and Do NOT Impact Fertility  

Initially, health care providers had only limited data that could support evidence-informed recommendations about the COVID-19 vaccine for pregnant and breastfeeding populations. At that time, the Ministry decision-making tools emphasized the need for health care providers to talk to their patient about the risks and benefits so patients could make an informed choice.  

We now have the evidence to show the mRNA COVID-19 vaccines are safe for these populations. As well, we have evidence of significantly increased risk for pregnant women and their unborn child if they do get COVID-19 infection.

Pregnant Individuals and Their Babies

Data now includes a year of outcomes for pregnant people and their babies. No safety concerns were identified in a study of more than 35,000 pregnant people who received an mRNA COVID-19 vaccine within 30 days of conception. The latest preliminary data from Ontario do not suggest an increased risk for concerns during pregnancy, or complications for the baby at birth.

Breastfeeding Individuals

Recent data shows that mRNA from vaccines do not transfer into human milk. Anti-COVID-19 antibodies produced by the breastfeeding person have been shown to transfer through the milk and provide protection to the infant for the first months of life.

Female and Male Fertility

According to Public Health Ontario, to date there is no evidence of an association between COVID-19 vaccination and menstrual irregularities. Several clinic studies are in progress and the evidence will continue to be monitored. There is also no evidence to date to suggest that COVID-19 vaccination impacts male fertility. Studies evaluating male sperm parameters before and after receiving two doses of mRNA vaccine have not demonstrated differences. Evidence has however shown a rare impact on male fertility after COVID-19 infection.

Pregnancy, breastfeeding and fertility concerns are not medical exemptions to COVID-19 vaccination. For information on medical reasons that do apply for exemptions, read Public Health’s memo, Ministry of Health guidance, and the College of Physicians and Surgeons of Ontario FAQs for Physicians.

Make a Strong Recommendation for Your Patients to be Vaccinated

• Routinely assess the vaccination status of your patients
• Validate patients who have already been vaccinated. They have received mixed messages and may feel uncertain about their decision. Letting them know they have made the best choice to protect themselves and their baby may give them peace of mind and help them influence others in their circle to get vaccinated.
• Recommend COVID-19 vaccination for those who are  unvaccinated and those who have received only one dose
• Document the discussion in their medical record if they do not receive the vaccine or are delaying their second dose
• During subsequent office visits, address ongoing questions and concerns and offer vaccination again
• Assist patients on how they can get their vaccine
  • If your office is not a COVID-19 vaccine administration site, visit Public Health’s vaccine clinic schedule for upcoming clinic dates and a link to COVID-19 pharmacy vaccine locations
  • Family physicians working in Patient Enrolment Models are eligible to use billing code Q007 if they help patients arrange for COVID-19 vaccination. (Please note, this is not intended for situations where family physicians provide general information around how to access or register for an appointment or where a family physician administers vaccine to the patient and bills for the vaccination service.) Please contact HCPengagement@niagararegion.ca for more information.
• Reinforce the importance of other prevention measures, including wearing a face covering and physical distancing regardless of the setting

Other Vaccines Recommended During Pregnancy

The National Advisory Committee on Immunization (NACI) recommends that COVID-19 vaccines may be given at the same time as, or any time before or after, other vaccines, including live, non-live, adjuvanted or unadjuvanted vaccines.

• Vaccines administered during the same visit should be administered at different injection sites
• Read our previous Medical Advisory for additional information on concomitant administration of COVID-19 vaccine with other vaccines

Give or recommend your patients receive the COVID-19 vaccine at the earliest opportunity.

Acellular pertussis vaccine (one dose of Tdap) should be administered in every pregnancy, ideally between 27 and 32 weeks of gestation. Adults 18 years of age and older are eligible to receive a single publicly funded dose of the Tdap vaccine, irrespective of receiving a prior dose of Tdap in adolescence.

Inactivated influenza vaccination is particularly recommended for all pregnant women as they are amongst those at high risk of influenza-related complications or hospitalization.

Niagara Region Public Health is not holding community influenza clinics this year, so please vaccinate clients in your office or direct them to a pharmacy.

More Information

• Encourage patients to visit Public Health’s new COVID-19 Vaccination: Fertility, Pregnancy & Breastfeeding webpage
• Ask at Every Visit: Quick Reference Tool to build confidence and reduce barriers to COVID-19 vaccination
• Download copies of Vaccine safety - pregnancy, planning for pregnancy and breastfeeding for your patients
• BORN: COVID-19 Numbers to Know (Ontario)
• If you have questions about this memo, please call Public Health Monday to Friday, 8:30 a.m. to 4:15 p.m.
  • For the COVID-19 Primary Care Info-Line call at 905-688-8248 or 1-888-505-6074, press 7, then 1 for physicians
  • For Niagara Parents, call 905-684-7555 or 1-888-505-6074 ext. 7555 or try our live chat
• Midwives who need to refer their patients for influenza and Tdap vaccination can:
  • Advise their patients to see their primary care provider. If they don’t have one, there is a list of family physicians in Niagara who are accepting new patients.
  • Take note of participating pharmacies offering influenza vaccine
  • Be aware that influenza and Tdap vacations are also available through walk-in clinics