Dr. Blair Bigham:
I'm Blair Bigham.
Dr. Mojola Omole:
And I'm Mojola Omole. This is the CMAJ podcast,
Dr. Blair Bigham:
Jola, today's podcast is inspired by an article in CMAJ entitled, “SARS-CoV-2 vaccination in pregnancy”. Now, for many pregnant people, the decision to vaccinate, especially during the COVID pandemic, was especially fraught. It was a new vaccine. People weren't so sure about what COVID was, and it was pretty scary for a lot of people.
Dr. Mojola Omole:
I would say that vaccinations in pregnancy are just fraught in general. Some people don't even take Tylenol for pain. I, on the other hand, believed in Zofran and Gravol. So everyone has a different pregnancy journey. And so, I think vaccines are a huge part of the consideration that someone makes regarding what they're going to do to help protect themselves, but also, thinking of the other being inside of them.
Dr. Blair Bigham:
Absolutely. So today we're going to talk to the author of this paper to learn more about how pregnant people are at risk of severe COVID-19. We know that they're at higher risk than the general public, and what that vaccine can do to protect them, and to protect their infants as well when they're born.
Dr. Mojola Omole:
And we're going to expand beyond just the COVID vaccine and pregnancy and just look at the buffet of vaccines that are available for fall this year. And also just ask some basic questions that patients are likely to ask their primary care practitioners.
Dr. Blair Bigham:
So let's start by speaking with the author of this practice article, and then we'll get to an associate medical officer of health.
Dr. Mojola Omole:
Okay, let's get into it. So we now have Dr. Scott Halperin. He's the co-author of the practice paper in the CMAJ, entitled, “SARS-CoV-2 vaccination in pregnancy”. He's the Director of the Canadian Center for Vaccinology and a Professor of Pediatrics, Microbiology-Immunology at Dalhousie University. Thank you so much for joining.
Dr. Scott Halperin:
That's my pleasure. Happy to be here.
Dr. Mojola Omole:
So how well do you think physicians, primary care practitioners, understand the importance of COVID vaccination during pregnancy?
Dr. Scott Halperin:
I think there's a lot of awareness, but I don't think there can be too much. I think it's very important that this information and the importance of vaccination during pregnancy is highlighted and reemphasized over and over again, particularly because people are becoming more and more complacent about COVID. And that complacency doesn't occur just in the public, it also occurs amongst practitioners. There's COVID exhaustion and people don't want to hear about it, and they just say, "Well, okay, we're done with COVID." But people are getting pregnant again and again. And for people who are becoming pregnant, COVID is a risk and vaccination during pregnancy is a way of protecting them and their developing fetus and even their newborn once it's born.
Dr. Mojola Omole:
I guess, the first thing that came to mind as you said that the COVID vaccine, the COVID fatigue, was that it's now different for a lot of us, what we see in the hospital? That many people have COVID, the elderly, the young people, and they do fine. We're not talking about long COVID, but that people aren't dying or having severe respiratory complications that we noted before. But in people who are pregnant, how is this different?
Dr. Scott Halperin:
It's different because people's immune system changes when they're pregnant. In order to maintain a pregnancy, a normal process is that the immune system changes over the course of the pregnancy. So the immune system has to adapt or the fetus would be rejected as a foreign material. And if there was not a change in the way the immune system works, the pregnancy would be rejected. So some of that puts the woman at more risk of certain infections, and at certain times of pregnancy, and that then puts the fetus at risk. So it's important to get vaccinated during pregnancy to protect the mother herself. Now, what we've also found out is that the antibodies that the mother generates during pregnancy are transferred to the fetus, and that protects the fetus in the first several months of life because as we know that we can't use the vaccines until a baby is six months of age. And, although we know that COVID is less severe in children, the very young infants are at a higher risk.
So anything we can do to protect them is important. Now, they don't typically die of COVID, but they can get sick enough to be hospitalized and that can be quite traumatic on both the infant as well as the family.
Dr. Mojola Omole:
So you mentioned that COVID can be quite serious in pregnancy. What is the difference in risk? If you can quantify, is there a number, a percentage of worsened outcomes in pregnancy versus non-pregnancy?
Dr. Scott Halperin:
Yeah, for the outcomes of the pregnancy itself, bad outcomes tend to be two to three times higher in pregnant women than non-pregnant women. The risk to the woman herself can be, while the risk is still low, it's anywhere from eight to 10 times higher for the woman who's pregnant who develops COVID compared to the same age, same status woman who is not pregnant. So that doesn't mean that there are tons and tons of people who are pregnant who are getting severe disease, but it's much, much higher than a woman who's not pregnant. Just remember, most pregnant women are in that very healthy age range from 16 to 40 years of age where COVID is not that high-risk. But if you're pregnant, it's anywhere from eight to 10 times higher.
Dr. Mojola Omole:
Thank you for going all the way up to 40 to account for the geriatric pregnancies that most people in medicine have. So talking about the COVID vaccine, when should it be given? When it's given in pregnancy?
Dr. Scott Halperin:
The COVID vaccine is most effective when given in mid-range of pregnancies because the complications tend to be in the second half of pregnancy. And also, the antibodies that are going to be delivered to the young infant, that protects the newborn, obviously these are passive antibodies, and we don't want them to start to decrease in titer by the time the delivery is there. Having said that though, we really encourage people to get immunized against COVID when they're pregnant, whenever they have access to healthcare simply because you don't want to miss the opportunity. It's far better to get immunized a little earlier in pregnancy than miss it completely and not get immunized at all. So while the data does show that the highest risk to the mother is in later pregnancy and therefore, the vaccine closer to mid to the last trimester is better, there's certainly protection that occurs if the vaccine is given early in pregnancy.
Dr. Mojola Omole:
I just got my flu shot the other day at the hospital. Can someone who's getting the COVID vaccine in pregnancy also get the flu shot at the same time or should that be separated? Is there a timing for that?
Dr. Scott Halperin:
It can be given at the same time, but it also can be separated. We tend to like to give vaccines at the same time only because one of the biggest risks in terms of vaccine delivery and program delivery is missed opportunities. Someone gets a vaccine, and you say, "Oh, I'll give you the X one next visit," and then things happen, and the person doesn't have a next visit. That tends not to occur as much in pregnancy because once somebody is... If they're receiving prenatal care, typically they're on a routine schedule of getting visits. So can, there are those other opportunities to give both vaccines at separate visits. But still, people forget, and the woman forgets that she didn't have the other vaccine, the healthcare provider forgets to give it. So my preference is always giving them the same visit to make sure that they don't get missed.
Dr. Mojola Omole:
What do we know about the safety of giving the COVID vaccine in pregnancy?
Dr. Scott Halperin:
Well, there've been millions of doses given. So we have a lot of information now in terms of observational information. Unfortunately, there were not randomized controlled trials of the COVID vaccines in women who are pregnant before the vaccine was released. But having said that, we've collected a lot of data through vaccine registries of women who were immunized during pregnancy, and it has a very good safety profile. So that's both safety in the woman. So the adverse events are no greater in women who are pregnant than they are in non-pregnant women in terms of soreness or any more severe adverse events. And the outcomes for the fetus, the newborn are also, there's no increase in the risk of, for example, stillbirths or spontaneous abortions or prematurity or any of those types of pregnancy outcomes. So a very safe vaccine during pregnancy.
Dr. Mojola Omole:
Are there any vaccines that we should be cautious about with people who are pregnant?
Dr. Scott Halperin:
Absolutely. So particularly live virus vaccines are either used with caution or contraindicated during pregnancy. And a good example of that is the rubella vaccine. It's very important for women to be immune to rubella, and one of the reasons we immunize against rubella is to prevent congenital rubella syndrome, which can cause cardiac lesions, cause deafness and blindness. So very severe outcomes. And by using rubella vaccine and having women immune to rubella before they get pregnant, that's virtually eliminated congenital rubella syndrome in Canada. We routinely screen for rubella antibodies to see who is immune, and if we find a woman is not immune to rubella while she's pregnant or during pregnancy when we're doing that screening, we don't give the rubella vaccine to her during pregnancy. We wait and we give it to her as soon as she delivers. That doesn't protect the current pregnancy, but it ensures that she's protected for her next pregnancy. So a live virus vaccine like rubella, we don't give it all during pregnancy.
Dr. Mojola Omole:
In the end, what information is crucial for physicians to understand about pregnancy and the COVID vaccine? What's their key takeaway?
Dr. Scott Halperin:
I think the key takeaway is even a bit broader than COVID is that pregnancy is an important time to be discussing vaccines with their patients, with the women who are pregnant. And those vaccines include COVID, they include the pertussis, tetanus vaccine, and they include influenza vaccine. All of those vaccines protect the mother, they also protect the infant when the infant's born for the first several months, and some of them have improved outcomes for the fetus as well. So improved fetal growth having been immunized during pregnancy. So it's very important that they understand that immunization during pregnancy should be the norm. It's not an exception, it's the norm. And there are going to be other vaccines like an RSV vaccine for pregnant women as well. So this is something they need to become very comfortable with and also, to then translate that comfort in the encouragement for immunization during pregnancy to pregnant women. The most important factor over all surveys that have been done in terms of a person and including pregnant women's decision whether or not to be immunized is a good strong recommendation with an explanation why from their healthcare provider.
So the healthcare provider is in a critical position in terms of helping a woman make a decision and it is the woman's decision, but providing the information so she can make an informed decision. And that's a conversation that's very important to have.
Dr. Mojola Omole:
Thank you so much for joining us today.
Dr. Scott Halperin:
Thank you for having me. It was a pleasure.
Dr. Mojola Omole:
Dr. Scott Halperin is the Director of the Canadian Center for Vaccinology and Professor of Pediatrics and Microbiology-Immunology at Dalhousie University.
Dr. Blair Bigham:
We'll be right back after a short break.
Dr. Blair Bigham:
Welcome back. We're going to look beyond the COVID vaccine and pregnancy to the full suite of fall vaccines this year. Influenza, COVID, and RSV vaccines are all available and I get a little bit confused about who's supposed to have what, who could have what, can you get them all at the same time? So to help us navigate these conversations and how we can talk to our patients about vaccines, we are joined by Dr. Trevor Arnason. He is an Associate Medical Officer of Health with Ottawa Public Health. Thank you so much for joining us today.
Dr. Trevor Arnason:
Thanks for having me.
Dr. Blair Bigham:
So walk me through the three fall vaccines that are currently available. But let's start just by prioritizing this. I know this is a little bit of an unprofessional question or not an ideal question, but if you could only get one, which one would you get?
Dr. Trevor Arnason:
That's a tough question because I think it depends on who you are. But I'll go through each of the three vaccines that we're talking about right now. COVID has a new updated vaccine from Pfizer and Moderna have both created a new vaccine for this fall that has the XBB. 1.5 variant. So that's closer to the variants that are circulating right now in the community. And that vaccine is being recommended for pretty much everybody who's been six months since their last vaccine booster or since they were infected with COVID-19. The next vaccine that we'll talk about is the flu vaccine, so that's the same vaccine that comes out every year. We have high dose versions for older adults, and we have the regular quadrivalent flu vaccine that's in Ontario and many provinces recommended for everybody at some point, but we tend to prioritize for high-risk groups.
And then the last vaccine that we're talking about is the RSV vaccine, which is a new vaccine this year. And as much as we think of RSV as a disease of children in the pediatric world, the vaccine this year is targeted only for older adults, and it's only approved in Canada for older adults over 60.
Dr. Blair Bigham:
Okay. And I didn't know there were two different flu vaccines. There's a high dose one? Tell me about that.
Dr. Trevor Arnason:
Yeah. So this has been something that we've rolled out the past few years. There are vaccines that are specifically designed for older adults who tend to not have as good of an immune response to the flu vaccine annually. And we see a lot of morbidity and mortality in that age group with flu, so there has been an effort to increase the dose in the vaccines that we give to older adults.
Dr. Blair Bigham:
Is it just a higher dose? Do they just draw out more in the syringe…
Dr. Trevor Arnason:
Yeah. So there's one that's a higher dose, and there's one that's adjuvanted.
Dr. Blair Bigham:
Oh, okay.
Dr. Trevor Arnason:
So that has an additional component in it, which helps to boost the immune system a little bit. But so far, it's only recommended for those in older adult age groups over 65, whereas we often get questions about people with immune compromising conditions of whether they should be taking these vaccines. Currently, we don't use those vaccines in that way in our provincial programs.
Dr. Blair Bigham:
Okay. So while we're talking about the flu vaccine, every year we hear, "Oh, the flu vaccine was a good match this year. They've predicted what was going to be in the community." What about this year, what are your thoughts on whether or not this is going to put a dent in influenza in the community?
Dr. Trevor Arnason:
I think the experts in influenza vaccine and influenza in general always say, "Don't make any predictions about the influenza vaccine season because that's a good way to be wrong."
Dr. Blair Bigham:
Okay. Fair enough.
Dr. Trevor Arnason:
So it is a really difficult thing. What we do is we try to look at what happened in the Southern Hemisphere. So we monitor very closely with our surveillance in the Southern Hemisphere because the flu travels during our summer, it travels south and we can get an idea from Australia and New Zealand and other places what we're going to be seeing. And that's where they base the vaccine strains for the coming year.
Dr. Blair Bigham:
Gotcha.
Dr. Trevor Arnason:
So we've had quite a few years of practice with this now, and I think it will be a good match this year. Whether we have a perfect match or not, really, it is of concern. But at the end of the day, likely we will have some protection from the vaccine at a population level, especially all of the highest risk groups that we're looking at get vaccinated. It will prevent a lot of hospitalizations and deaths.
Dr. Mojola Omole:
Even if it's not a perfect match or a close enough match, it would still have that effect?
Dr. Trevor Arnason:
Yeah. So it can be a very poor match, we have seen seasons like that. Fortunately, not in recent years. And it's a gradient, nothing in life is perfect. Nothing in medicine is perfect and we never have a perfect vaccine.
Dr. Mojola Omole:
You've never been in my operating room. It's perfect.
Dr. Trevor Arnason:
Yeah. Aside from that, we tend to go on gradients of good or good enough. And most years the flu vaccine prevents a lot of illness and death, and that's what we're trying to do. And some years unfortunately, it has other ideas, and it changes. And the technology we use for flu vaccine is a bit of an older technology that requires growing the vaccines. And so we have to start that process many months in advance and that requires predicting based on what's going on in the Southern Hemisphere for the next year.
Dr. Blair Bigham:
So we have this sort of higher dose and adjuvant dose for people over 65. What about the age range for everybody else? How wide is that age range when it comes to influenza vaccines?
Dr. Trevor Arnason:
So pretty much anyone over six months of age can get an influenza vaccine. And the group that we really try to emphasize should be thinking about it is young children or their parents. In this case, usually they're not thinking about it themselves. But children five and under can have particularly severe consequences of flu infection. And unfortunately, there've been some instances where children have died in Canada from the flu, and it has been quite surprising to family members and the public that this is something that happens. And so we really try to encourage the pediatric population to be vaccinated. They're a high risk group and the vaccine is available to them across the country. Aside from that, there's a long list of individuals who for different reasons would benefit from the flu vaccine. Primarily, older adults as we said, and people with immune compromising conditions, but also other comorbidities, underlying conditions like cardiovascular disease, lung issues.
But there's also particular populations, indigenous persons face a greater burden of influenza illness and so the vaccines recommended for that population. There's also healthcare workers who may not themselves be at the highest risk of complications, but have the ability to spread the flu to their patients who might be the most vulnerable. So that's another reason to get vaccinated. And basically, what we've done in some provinces is added this all up and seen almost everybody has a reason to get flu vaccine, so why don't we just offer it to everybody? And that's what we do with universal influenza immunization programs in Ontario and some other provinces where anyone can really go to get their flu vaccine.
Dr. Blair Bigham:
So let's transition to talk about the COVID vaccine. And first, can you get the flu vaccine and the COVID vaccine at the same time?
Dr. Trevor Arnason:
Yes. So this year we are offering COVID vaccines and flu vaccines at the same time. There's a lot of concern from patients about co-administration, which is getting vaccines at the same time. It's something we do all the time in pediatrics and in kids, we often have visits where they get three vaccines at the same time. And that's three separate needles. Those aren't the most fun visits, but they do happen on a regular basis. And then adults, we were cautioning around COVID vaccine being administered with other vaccines primarily because it was a new vaccine and we were concerned that if we were seeing side effects that were new, we wouldn't be able to identify them as different from what vaccines they were taking or if it was the combination of vaccines that was causing the problem. As such, we decided to tell people to be on the cautious side and not get both of the vaccines at the same time. But now, we have a couple of years of experience with COVID vaccines, we have many years of experience with flu vaccines.
And we're confident this year that giving the COVID vaccine with the flu vaccine is going to be perfectly safe and we are encouraging people to do it because it enables us to get both done at the same time without multiple visits to multiple different places.
Dr. Blair Bigham:
I hear some people tell me that they got both at the same time and it totally wiped them out. Would they have been wiped out if they had just gotten one, or is there some sort of an effect for some people were getting both at the same time does give you that, whatever, immune response is where you're just totally out?
Dr. Trevor Arnason:
It's a common question. It's definitely possible. I think at a population level, you do start to see with more antigens in one vaccine or giving multiple vaccines at the same time you are going to see a higher rate of those events. And these are the non-serious events. They're very unpleasant, they're serious to individuals, but from a medical perspective, they're not landing people in hospital or risking death-
Dr. Blair Bigham:
Right.
Dr. Trevor Arnason:
... which would be anaphylaxis from vaccination. These are just the sore arm, the fatigue, maybe a bit of myalgias. These things, yes. They could be a bit more with two doses and so, if people feel that way and they think it'll be easy to get them separately, you could wait two weeks in between the vaccines. We're also telling people that the RSV vaccine, which is new, isn't to be co-administered with the flu and COVID vaccine, which is a common question we're getting as well. It's the new one, so same rationale as we used to do for COVID was we want to make sure that it stands alone in terms of our monitoring of adverse events, that if we discover that there's a certain type of reaction that's happening with the vaccines, we'll know it's from the RSV vaccine because it was separated by two weeks. Whereas with the COVID one, now, we're comfortable that we're not going to learn anything new about it after we've given hundreds and millions of doses of this vaccine.
Dr. Mojola Omole:
Who's eligible for the RSV vaccine?
Dr. Trevor Arnason:
So currently, it's only people over the age of 60 are eligible. What people often think about is eligibility though is sometimes synonymous in the province with what is paid for by the provincial government. That can vary from province to province. Most provinces are probably not going to pay for RSV vaccines for many people this season, because the vaccine is brand new. As a result, a lot of people are confused as to why they have to pay for a vaccine, but it's just like any other medication that's not covered by provincial government plan or another plan. They would have to go to a pharmacy and pay. And I'm hearing in Ontario it's around $250 for that RSV vaccine. In Ontario, however, they have decided to pay for the vaccine for individuals over 60 who are living in long-term care homes.
Dr. Blair Bigham:
Last year I heard a lot about kids ending up in hospital and swamping the pediatric ICUs with RSV ending up on high flow. Is this a vaccine that could one day be available for children as well?
Dr. Trevor Arnason:
Certainly, the vaccine developers are looking at this from the perspective of a pediatric vaccine. I've had similar experiences to many out there when I did my residency training in pediatrics. It was in December one year and I remember a ward almost full of children with RSV and thinking, "We really need a vaccine." And they've been working on this specifically for children for many years. I think it was a bit of a surprise to some of us that the older adult one got approved first and went through the pipeline first. But now, they're trying to develop new vaccines for children as well for RSV. So waiting for approval. And in the US, they have approved a vaccine for children.
Dr. Blair Bigham:
So if we wanted to simplify it, everyone should get an influenza shot, everyone should get a COVID shot.
Dr. Trevor Arnason:
Yeah.
Dr. Blair Bigham:
And RSV is a new opportunity for people over 60 in a nursing home.
Dr. Mojola Omole:
If you're eligible.
Dr. Trevor Arnason:
Correct.
Dr. Mojola Omole:
Or you want to pay $250-
Dr. Mojola Omole:
I think that is such an equity issue because I'm thinking that people-
Dr. Trevor Arnason:
It is.
Dr. Blair Bigham:
Yeah.
Dr. Mojola Omole:
... what you were saying was that, I was like the people who are most likely to have problems with RSV... 'Cause for example, I live in a multi-generational home. My mom lives with me, my son is in daycare, so he probably will bring it home and she's 80. Right? And obviously, I'm in a position to pay two $250, but initially, I was like, "Oh, my God. That's $250." Right?
Dr. Trevor Arnason:
Oh, yeah. That's the paradox of vaccination. So the individuals who we always want to get vaccinated the most face the most barriers to getting vaccines. And that's why the publicly funded programs offer an opportunity for public health, family doctors, others to work together to really try to get vaccines to individuals who would benefit from the most. And I think the COVID vaccine campaign has been a really great opportunity to shine a light on that, that we have to do a lot of extra effort to bring vaccines to people as opposed to just saying, "Oh, it's now licensed. Go get it." $250 is a huge barrier for many people. But yes, COVID vaccines and flu vaccines for everyone. And then if you're over 60, consider the RSV vaccine. But just recognize that it's not government funded, and the cost and other access barriers may mean that this is not the season you get it.
Dr. Blair Bigham:
Well, thank you so much, Trevor. This has been very clarifying. I appreciate your time so much. Dr. Trevor Arnason is associate medical officer of health with Ottawa Public Health.
Dr. Mojola Omole:
So Blair, let's just first talk about the article about pregnancy and COVID vaccinations. in pregnancy. What are your thoughts after listening to Dr. Halperin?
Dr. Blair Bigham:
It's reassuring. I mean, it reflects what I saw during the pandemic in two senses. First of all, in the ICU, we were intubating pregnant women. It was not infrequent, and they desatted faster than I've seen anybody desat in my entire life. It was a really hairy situation to have to intubate pregnant women.
Dr. Mojola Omole:
Can I just step in? I just want to say though that your experience is not reflected in what's seen in the media and what most people are seeing.
Dr. Blair Bigham:
Right.
Dr. Mojola Omole:
I think that that is part of the problem. I still think, I hear other people will say, people also in medicine, “Oh, COVID is over. It's fine. Everyone gets it and you'll be fine.” Because I think, in large part, that we've been vaccinated and most people will be fine.
Dr. Blair Bigham:
Well, even before people were getting vaccinated, I had friends who were pregnant during the COVID pandemic who had substantial pressure placed on them by their social networks not to get vaccinated. People just thought it was too unknown. It was just a lot of weight for someone to carry because they were now making this decision, not just for them, it wasn't that they were going to get COVID and end up intubated, it was that they just didn't know if this was right or wrong for their baby.
Dr. Mojola Omole:
I know that as someone who was pregnant before, it is very nerve wracking to take anything, unless you're me. And so, I think one thing that we need to always keep in mind, that we do probably need to do a better job as a medical community of conveying, is that this is very safe for anyone to get vaccinated, and especially if you are pregnant to be vaccinated, that it's very safe to get in pregnancy.
Dr. Blair Bigham:
Absolutely. As is the flu shot. And you can get them both at the same time. I really found that summary really helpful to know that people of all ages should just go out and get both shots this winter.
Dr. Mojola Omole:
Yes. And I think for me, the one that is still burning me a little bit is the RSV that is not free for people. And the population that's probably going to get the most help from it, who are at a high risk of having consequences from RSV infection, probably cannot afford $250 to get a shot. There's a lot of people who might not be able to afford $250.
Dr. Blair Bigham:
Kids get RSV all the time. Like, we just see it nonstop all winter in the emergency department. And, yeah, they might not get that sick, some of them do, but they might not. But they can certainly bring it home and get other people sick.
Dr. Mojola Omole:
Yes, I live in a multigenerational home, and so my concern is always my 80 year-old mother who was like, “Oh my God, $250.” But there you go. I'm ponying up the money. She'll be fine. But for her, she just thought, what about our other friends who are in the same position as her, who won't be able to afford $250?
Dr. Blair Bigham:
Hopefully, we see some movement on that. That's it for this week on the CMAJ podcast. Thanks so much for listening. This particular episode is a pretty important one to get the message out. Please do share our podcast with your colleagues, your patients, and anybody else who has two ears or even one ear. Many thanks to our fantastic producer, Neil Morrison from Podcraft Productions. I'm Blair Bigham.
Dr. Mojola Omole:
I'm Mojola Omole. Until next time, be well.