Breastfeeding and Coronavirus Disease 2019 (COVID-19) Vaccination: Position Statement of Indian Academy of Pediatrics Advisory Committee on Vaccination and Immunization Practices



## E e e e n n n n n d d d d d a a a a a t t t t t i i i i i o o o o o n n n n n s s s s s
T he development and implementation of coronavirus disease 2019 (COVID-19) vaccination program has been one of the recent and most prominent demonstrations of the power of modern science. As of 14 May, 2021, in India, a total of 13986142 (1 dose) and 39784951 (2 doses) have been administered . Ever since the initiation of the COVID -19 vaccination program in India, pregnant and breastfeeding women had been excluded from the vaccination program. Recently, the Government of India (GoI) has published a circular, recommending administration of COVID-19 vaccines in breastfeeding women. Failure to include pregnant and lactating women in the phase 3 studies of the mRNA vaccines, Astra-Zeneca vaccine and Covaxin (Bharat Biotech Ltd) and consequent lack of safety data, were the cited reasons for excluding this group. If this cohort of pregnant and breastfeeding mothers continued to be excluded, a significant population of the country, including frontline workers, would have been left unprotected. Hence, the recent recommendation from the GoI is a welcome step.

## Objective
The objective of this recommendation is production of an evidence-based document to guide the pediatricians to give advice to breastfeeding mothers regarding the safety of COVID-19 vaccines in lactating women.

## Process
Formulation of key question was done under the chairmanship of President of the Indian Academy of Pediatrics (IAP). It was followed by review of literature regarding efficacy and safety of COVID-19 vaccines in breastfeeding women. The recommendations of other international and national professional bodies were also deliberated in detail. The available data was discussed in the Advisory Committee on Vaccines and Immunization Practices (ACVIP) focused WhatsApp group. Opinion of all members was taken and the final document was Justification: In India, till recently, breastfeeding women have been excluded from the coronavirus disease (COVID-19) vaccination program, rendering a significant population of the country, including frontline workers, ineligible to derive the benefits of the COVID-19 vaccine rollout. Objective: The objective of this recommendation is production of an evidence-based document to guide the pediatricians to give advice to breastfeeding mothers regarding the safety of COVID-19 vaccines in lactating women. Process: Formulation of key question was done under the chairmanship of president of the IAP. It was followed by review of literature regarding efficacy and safety of COVID-19 vaccines in breastfeeding women. The recommendations of other international and national professional bodies were also deliberated in detail. The available data was discussed in the ACVIP focused WhatsApp group. Opinion of all members was taken and the final document was prepared after achieving consensus. Recommendations: The IAP/ACVIP recommends the administration of COVID-19 vaccines to all breastfeeding women. The IAP/ACVIP endorses the recent recommendation of the Government of India, to consider all breastfeeding women as eligible for COVID-19 vaccination.

## Keywords

## Breastfeeding and covid-19 vaccines
The theoretical risk of COVID-19 vaccination in breastfeeding mothers and the potential harm to the infant is unknown. However, it is to be noted that none of the vaccines available for the COVID-19 contains live virus.
There is no plausible biological mechanism to explain how an inactivated vaccine, given to the mother, would cause harm to a breastfed baby.
The COVID-19 vaccines presently available in India, i.e., Covishield and Covaxin are classified as inactivated (non-live) vaccines. Theoretically, administration of these vaccines to breastfeeding women should not render any harm to the breastfed infant. While the safety of adenovirus vectors in pregnancy and lactation is not established, wild adenoviral infections are present worldwide and have not been associated with teratogenic effects in the fetus or newborns [bib_ref] Committee for Medicinal Products for Human Use (CHMP), Ema [/bib_ref]. With the exception of small pox and yellow fever vaccines no other vaccine is contraindicated during breast feeding [bib_ref] Committee On Drugs. The transfer of drugs and therapeutics into human breast..., Sachs [/bib_ref].
Breast milk is a rich source of antibodies for the infant. Milk produced by infected mothers is a source of anti-SARS-CoV-2 IgA and IgG and neutralizes SARS-CoV-2 activity.
Studies have shown that maternal vaccination with the mRNA vaccine results in high titers of RBD-IgG binding antibodies and neutralizing antibodies as measured by the pseudovirus neutralizing tests (NT50), in maternal serum. High titers of RBD-IgG binding antibodies, neutralizing antibodies as measured by the NT50 and robust T-cell responses, as measured by ELISPOT and intra-cellular cytokine staining, have been demonstrated in the breast milk of mothers vaccinated with the mRNA vaccines [bib_ref] Immunogenicity of COVID-19 mRNA Vaccines in Pregnant and Lactating Women, Collier [/bib_ref]. In another study, involving six lactating women who received two doses of SARS-CoV-2 vaccine, significantly elevated levels of SARS-CoV-2 specific IgG and IgA antibodies in breast milk was observed, beginning at Day 7 after the initial vaccine dose, with an IgG-dominant response. These SARS-CoV-2 specific immunoglobulins and products of the T-cell responses in breast milk may be protective for infants.
There is a paucity of data on immunological parameters in breastmilk following the administration of the AstraZeneca COVID-19 vaccine in lactating women. Thus, merely the absence of data should not exclude lactating women from getting the benefits of COVID-19 vaccination.

## Recommendations from other professional bodies
Many international and national recommending bodies have now recommended administration of COVID-19 vaccines in breastfeeding women .
While some have recommended the COVID-19 vaccines in breastfeeding women who are in the priority groups, after fully informing them about the benefits and risks of vaccination, some authorities have recommended the vaccine for all breastfeeding women. All have emphasized that breast feeding should be continued after vaccination.

## Table i recommendations for coronavirus disease 2019 (covid-19) vaccine for lactating women by various national and international bodies

## Agency recommendation
World Health OrganizationDevelopmental and health benefits of breastfeeding should be considered along with the mother's clinical need for immunization against COVID-19. WHO does not recommend discontinuing breastfeeding after vaccination.
American College of Obstetricians and COVID-19 vaccines should be offered to lactating individuals similar to non-lactating Gynecologistsindividuals.
International Federation of Gynecology Supports offering COVID-19 vaccination to pregnant and breastfeeding women. and ObstetricsFederation of Obstetric and Gynae-COVID-19 vaccine should extend to pregnant and lactating women. The very real cological Societies of Indiabenefits of vaccinating pregnant and lactating women seem to far outweigh any theoretical and remote risks of vaccination.
Australian and New Zealand health Recommend COVID-19 vaccines in breast feeding women. They have emphasized that authoritiesthere are no concerns about their safety in breastfeeding women or their babies.
Italian Scientific Society [bib_ref] Breastfeeding and COVID-19 vaccination: Position statement of the Italian scientific societies, Davanzo [/bib_ref] Decision whether or not to administer the COVID-19 vaccine to the breastfeeding woman should be made after mutual agreement between her and the health professionals, considering specific health, social, familiar and work conditions.