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What do we know so far about the COVID-19 vaccines during or before pregnancy and breastfeeding?

None of the three leading vaccine manufacturers (Pfizer, Moderna, and AstraZeneca) have reported data about the COVID-19 vaccine on knowingly pregnant or breastfeeding individuals. As a result, we have a limited understanding of how effective the three leading vaccines are for pregnant and breastfeeding people, and if there are specific risks.  Given this lack of data, some regulators and public health entities have not included pregnant people in their vaccine recommendations to the public with some specifically warning pregnant individuals against taking the vaccine. The WHO was one of these entities until Friday, January 29. Previously their guidance said that the vaccine was "currently not recommended" for pregnant women unless they are at high risk of exposure.  While their guidance, in practice, is still similar, recommending pregnant people with comorbidities or at high risk of exposure may be vaccinated in consult with doctors, they’ve directly noted that we “don’t have any specific reason to believe there will be specific risks that would outweigh the benefits of vaccination for pregnant women.” Until there is more data on COVID-19 vaccines and pregnancy, this trend of mixed guidance across different regulatory bodies and countries is likely to if and as vaccines continue to get approved.  Pregnant people who do receive a vaccine may be able to produce an immunity to the virus from the vaccine that can cross the placenta which would help keep the baby protected after birth. Regarding safety, however, when you receive an mRNA vaccine for COVID-19 you expel the mRNA particles from your body within days, so if pregnant it’s unlikely to cross the placenta and impact the baby. The process for collecting this data will involve analyzing the impacts of the vaccines on individuals who receive a vaccination and later discover that they’re pregnant. Countries are coordinating internal reporting and monitoring systems to record and track this information.  The clinical trials had some participants enrolled who didn’t know they were pregnant at the time of vaccination, but there were not enough of those cases to have enough data for definitive conclusions. For example, in Phase 2/3 of the Pfizer and BioNTech vaccine study, 23 pregnancies were reported through November 14, 2020. Twelve were in the vaccine group and 11 in the placebo group. Two adverse events occurred in pregnancies in the placebo group, including miscarriage. These initial data do not raise concern for lack of vaccine safety in pregnancy and breastfeeding, but more data is needed to safely recommend the use of this vaccine by pregnant and breastfeeding individuals. The U.S. FDA also recommended in June 2020 that the pharmaceutical companies developing COVID-19 vaccines first conduct developmental and reproductive toxicity (DART) studies of their vaccine before enrolling pregnant or breastfeeding people, or women not actively avoiding pregnancy, in their trials.  Pfizer and BioNTech have directly stated that they are conducting DART studies, which will provide us with more information on the safety and efficacy of their vaccine for pregnant and breastfeeding individuals. On December 13, the American College of Obstetricians and Gynecologists released a position paper advocating for the inclusion of pregnant women in vaccine rollouts and not waiting for further data collection. While the group advocates for obtaining informed consent from pregnant and lactating women receiving the vaccine, they feel the benefits of protection outweigh the risks. The U.S. Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), and the Society for Maternal-Fetal Medicine support the use of new mRNA COVID-19 vaccines in pregnant and breastfeeding individuals when they become eligible for receiving the vaccine. As of January 26, 2021, the World Health Organization also supports pregnant and breastfeeding women receiving the Moderna mRNA vaccine if they choose. Before more data is available, it is best for pregnant and breastfeeding individuals to speak with their doctors about the best way to proceed. While it is unlikely that a doctor would recommend a pregnant or breastfeeding person get vaccinated before more data is available unless they were high risk, every risk profile is different and is worth discussing with a care provider.

Can someone be infected with COVID-19 more than once?

We are still learning a lot about what kind of immunity a person has after being infected with COVID-19, and how long that immunity lasts. A a small number of people have reportedly become reinfected with virus following an initial infection and research is ongoing. According to the US Centers fo Disease Control and Prevention (CDC), "reinfection means a person was infected (got sick) once, recovered, and then later became infected again. Based on what we know from similar viruses, some reinfections are expected. We are still learning more about COVID-19." In a press conference on December 4th, 2020, the World Health Organization acknowledged emerging evidence that suggests that COVID-19 immunity is unlikely to be lifelong, which suggests reinfection may be possible. The most reliable way to measure immunity to COVID-19 is unclear, and, whether from infection or vaccination, scientists still do not know how long immunity to COVID-19 may last. Though reinfection has been documented, there are many ongoing questions about whether or not reinfection poses an ongoing risk, how common it is, and what kind of immunity to the virus people might obtain once they have been infected. Currently researchers believe that most people will be protected from reinfection for up to six months following infection, but research is ongoing. There are multiple pre-print studies with large participant groups that suggest immunity does last for up to six months but decreases over time. Antibodies decrease more quickly in young adults who have had an asymptomatic infection. Pre-print studies have also suggested that reinfection is possible. It is important to note that there is a shortage of peer-reviewed papers (so other scientific experts are not yet able to rigorously study the data or full results). It is also important to note that antibody levels may not be a strong indicator of immunity against the virus and likelihood of reinfection. To prevent infection, reinfection, and spread of COVID-19, experts recommend frequent hand washing, social distancing (6 feet/2 meters apart), avoidance of crowded areas (especially indoors), wearing a face mask (though the U.S. CDC now suggests wearing a cloth mask over a surgical mask or a high grade respirator), and staying home when you are sick or know that you have been exposed to COVID-19.
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