Aviva, first I must say I absolutely love you and your book The Natural Pregnancy Book. I am now pregnant and faced with an important decision. In my job I am required to get a flu shot, and I don’t know if that’s safe for pregnancy, or what I can do to refuse it. Can you help me clarify? Thank you. With Gratitude, J
Thank you J! This is a timely question, and one that I suspect is on the minds of a lot of my pregnant readers now that we are entering flu season and this year’s flu shot (9a combination shot that provides protection against H1N1 and seasonal flu) is available.
Whether to vaccinate during pregnancy can be a tough decision to make. And, some employers, particularly in the health professions, are strict about their employees getting vaccinated for flu.
The Top Down Recommendations
The Centers for Disease Control (CDC) and the American College of Obstetricians and Gynecologists (ACOG), the two primary groups that issue recommendations to doctors caring for pregnant women, unequivocally recommend that all women who are pregnant during flu season – roughly October through the end of March – receive the flu vaccine unless they have a health contraindication, such as a severe allergy to eggs since the vaccine contains egg proteins. ACOG has stated that “preventing influenza during pregnancy is an essential element of prenatal care, and the most effective strategy for preventing influenza is annual immunization.”
Note that prior to 1995, the CDC did not recommend universally vaccinating all pregnant women in any trimester; the recommendation was to vaccinate only those pregnant women with pre-existing medical conditions.
The CDC and ACOG assert the following importance of vaccinations in pregnancy:
- Physiologic changes in pregnancy make pregnant women more susceptible to the flu and to serious complications should flu occur, particularly pneumonia
- Flu can lead to high fevers, and high fevers in the first trimester have been associated with an increased rate of birth defects
- Flu during pregnancy seems to increase the risks of miscarriage, premature birth, and low birth weight.
- Babies are at high risk of complications from the flu, but cannot get vaccinated until they are 6 months old. Babies born to pregnant women who have received the flu shot are less likely to develop flu and related complications
- Flu shots have not been shown to cause harm to mom or baby in any trimester
Are the Risks of Flu in Pregnancy Really that Serious?
Working in the hospital during the winter of 2009 was frightening. There was a new strain of flu going around and the medical community had no idea how bad it was going to be. The CDC and the media predicted a catastrophic epidemic with dire outcomes. I did, in fact, see two pregnant women very sick with H1N1 flu. One ended up in our ICU; she eventually died. Her pregnancy had already been complicated by severe asthma and obesity. Serious, sad, and scary things can happen.
But the overwhelming data suggests that these are the exception, not the rule, and the exceptions are usually associated with an already complicated medical situation (i.e., asthma and obesity way up the ante on pregnancy risk) rather than happening to the average healthy pregnancy woman.
This is not how the media portrays things. There is a lot of fear mongering in medicine. As a public, we have a skewed, media-driven, fear-based view of our health and of disease prevalence. And it is impossible to ignore the fact that there are massive profits to be made by the very limited number of pharmaceutical companies producing the influenza vaccine.
According to Jennifer Margulis, a controversial and articulate health journalist, in her article “What the Doctor Isn’t Telling You about Pregnancy and the Flu Vaccine,” the data generally presented on flu prevalence and severity of outcomes in pregnant women compared to the general population is highly inflated, not to mention conflated with reports on pneumonia, which are not separated from influenza data. Not being a girl to take anyone else’s word for it, even a brilliant girl’s, and a bit of a science nerd myself, I went to the CDC website as well as a major primary source article, “Vaccination During Pregnancy: A Critical Assessment of the Recommendations of the Advisory Committee on Immunization Practices (ACIP)” to get the scoop. (The ACIP is the CDC’s vaccine advisory group.)
For starters, I wanted to get actual data on flu death rates in the US. Guess what the CDC website reports? They don’t know. No seriously, and I quote them: “CDC does not know exactly how many people die from seasonal flu each year.” They give a really wide range or numbers, hedge a lot, avoid estimating, give a lot of reasons that they just can’t give an exact number, and then finally state, “CDC believes that the range of deaths over the past 31 years (~3,000 to ~49,000) is a more accurate representation of the unpredictability and variability of flu-associated deaths.” And this is all-comers, not just pregnant women. In fact, a study cited on the CDC website states that “about 90% of influenza associated deaths occur among adults 65 years and older.” Clearly NOT pregnant women!
In a review of CDC flu-related maternal death statistics between 1998-2005, Callaghan et al estimate an average of 5 influenza-related maternal deaths per year. In 2009, with H1N1, this number was considerably higher, with an estimate of 28 in the first quarter of the year, which would encompass about 50% of the flu season.
Now I don’t want to minimize the death of any pregnant woman – this is a serious event. But to put it in perspective, 1,000 women would have to be vaccinated to prevent even just 1-2 pregnant women from being hospitalized for influenza related treatment. (Ayoub and Yazbak)
Additionally, when folks have a fever, aches, and cold symptoms they almost always say they have “the flu.” But as a doctor, I know that this is rarely actually the case; most folks with flu-like symptoms actually just have gnarly upper respiratory infections – usually a bad cold. In fact, many cases reported as flu are not the flu, so the actual numbers of people even reported as having the flu are highly unreliable. Confirmatory testing is rarely done.
Further, according to Margulis, “The scientific evidence that pregnant women are actually dying from influenza is all but nonexistent, even when pneumonia and influenza are lumped together.” The largest scientific study to date included 49,585 pregnant women who were part of the Kaiser Permanente healthcare organization in Northern California over five flu seasons, as well as 48,639 live births among the same pool during the same time period. The authors concluded that, “Hospital admission with a principal diagnosis of influenza or pneumonia was an extremely rare event for the women in the study population.” Only nine women (out of almost 50,000) were admitted, which is 0.018 percent, or less than one in 5,000; and of those nine women, all had pneumonia. All nine women recovered with no complications. (Black)
Equally intriguing is that the “Kaiser Permanente study found no difference in the incidence of flu or flu-like illness in those who received the flu vaccine compared to those who did not. It also found no benefit to the infants of women who had been vaccinated.” In fact, two studies have found that that there were significantly more hospitalizations related to flu-like illness of women who were vaccinated than of women who weren’t. (Munoz, Neuzil)
Regarding the claim that influenza in pregnancy is more serious than in the general population, and that it increases risks to the fetus, the ACIP’s recent policy cites only limited evidence, which actually showed that for those pregnant women who actually contracted the flu based on serologic evidence of infection, influenza infection had no significant impact on labor outcomes, health of the newborn, or maternal wellbeing.
Is the Flu Vaccine Safe in Pregnancy?
Many women decline to receive the flu vaccine because they are worried about introducing chemicals and medications into their systems – and their baby’s – during the precious months when their babies are growing and developing. And since we all pretty much know somebody who said they got the flu right after getting the flu shot – actually more likely to be vaccine side effects, but nonetheless, enough to make a lot of people think the vaccine makes you sick. In 2009, the highest recorded number of pregnant received the flu vaccine, and this was still only 50%.
Many are skeptical about both the safety and the effectiveness of the flu vaccine, and after what turned out to be as much media hype as reality about the dangers of H1N1 a few years ago, even more women are concerned.
Potential problems with the flu shot:
- Because the vaccine, and the strain of flu vary from year to year, the vaccination is more – or less – effective in any given year. In some years the vaccine may only be effective in as many as 50% of case. So bottom line, it often doesn’t work!
- Allergic reactions can happen; i.e., folks with severe egg allergy cannot get this vaccine
- A rare reaction called Guillaine-Barre Syndome (GBS) occurs in 20-40 people who receive the flu shot annually
- Side effects are relatively common and include fever, aches, and redness/soreness at the injection site
- Most flu vaccines still contain thimerosol, that mercury derived preservative that has been removed from most vaccinations due to risk of mercury neurotoxicity from exposure through vaccinations and other environmental sources.
Overall the rates of overt adverse reactions, such as GBS, are rare, though it is true that many people who receive the vaccine do report flu-like symptoms in the days immediately post-vaccination. The greater concern is not severe acute reactions, but the long-term unknown effects of fetal vaccine exposure, and the reality is that they are just not well-studied. We know that thimerosal is a neurotoxin, and that the fetus accumulates mercury from the mother’s system; therefore it is ideal to accept only thimerosol-free vaccines during pregnancy. Some manufacturers produce single dose injections that are free or, or contain only minimal amounts of this chemical. According to Ayoub and Yazbak, “Because the benefits of influenza vaccination during pregnancy appear lacking, a safety-benefit analysis should not tolerate any risk to vaccine recipients or their offspring, even at a theoretical level.”
If You Do Choose the Vaccine
Choosing to get the flu vaccine is a reasonable decision and not one to beat yourself up about. There area few things you can do to optimize safety:
- Do NOT get the nasal spray vaccine during pregnancy. It is made with live virus and is not considered safe in pregnancy. The flu shot is made from an inactivated virus, and is the only recommended vaccination for use in pregnancy.
- Don’t get vaccinated if you have a fever or otherwise feel unwell
- Don’t get the flu vaccine if you have a moderate to severe egg allergy
- ASK YOUR DOCTOR FOR A THIMEROSAL FREE flu vaccine. They are available and it may need to be special ordered for you. The thimerosal-free versions usually come as a single dose injection; the multi-vial preparations are much more likely to contain the preservative.
If You Choose Not to Receive the Vaccine
I’ve had the flu. The-honest-to-goodness-bones-hurt-so-much-I-wanted-to-cry real influenza bug. It was awful. My 14-year-old daughter had it, too. We spent 4 days in bed together sleeping, taking herbal tinctures, and whining. I watched Sex and the City for the first time. I could barely laugh. Then we got better. I never want to have the flu again.
If you choose not to vaccinate, you have somewhat more chance of getting the flu – how much more is unclear. As I said, the vaccine sometimes only works 50% of the time and success varies from year to year as does the vaccine viral strains. It’s statistically better than a crapshoot but unpredictable. Knowing the symptoms and when to call your doctor is important. Any pregnant woman with a high fever should call her physician immediately. Ditto if she is having any breathing difficulty or severe headache, either of which can be a symptom of a medical emergency.
Hand hygiene – washing with soap and water or using an alcohol based hand cleanser like Purell, can greatly reduce transmission. I do not recommend antimicrobial hand soaps, which actually increased bacterial resistance and probably cause more problems than they solve.
A healthy diet, adequate sleep, and minimizing stress go a long way to preventing illness and supporting resilience. Several herbal medicines and supplements are safe for use in pregnancy and can also boost your immune system. My 2 favorites for cold and flu prevention are Elderberry syrup and Zinc. Elderberry syrup can be taken daily; 2 tablespoons is a recommended dose. Zinc tablets can be taken in doses of 20-40 mg daily.
Garlic and ginger, also safe in pregnancy, make good daily additions to the diet, and yellow and orange vegetables such as winter squashes and sweet potatoes are rich in vitamin A which helps to keep the respiratory passage tissue healthy and optimize its immune functions. Finally, echinacea is an herbalist’s favorite for preventing upper respiratory infections and has demonstrated safety during pregnancy. A typical dose for prevention is 5 ml of the liquid extract twice daily.
No matter what, make the best choice for YOU. Take your own situation into consideration: Are you likely to have frequent exposures to sick patients or children due to your work? Do you have underlying medical conditions that make you more vulnerable to illness? There is no right or wrong answer. The most important thing is to make a deliberate, educated choice.
American College of Obstetricians and Gynecologists, Committee Opinion No. 468, “Influenza Vaccination During Pregnancy,” Obstetrics & Gynecology. October 2010;116(4):1006–1007.
Black, SB, et al., “Effectiveness of Influenza Vaccine during Pregnancy in Preventing Hospitalizations and Outpatient Visits for Respiratory Illness in Pregnant Women and Their Infants,” American Journal of Perinatology. October 2010; 21(6): 33–339.
Callaghan WM, Chu SY, Jamieson DJ. Deaths from seasonal influenza among pregnant women in the United States, 1998-2005. Obstetrics and Gynecology. May 2010;115 (5):919-23.
Estimating Seasonal Influenza-Associated Deaths in the United States: CDC Study Confirms Variability of Flu. http://www.cdc.gov/flu/about/disease/us_flu-related_deaths.htm
Knox, R. “CDC to Urge Swine Flu Vaccine for Pregnant Women,” National Public Radio, All Things Considered (29 July 2009): www.npr.org/templates/story/story.php?storyId=111320170
Margulis, J. What the Doctor Isn’t Telling You about Pregnancy and the Flu Vaccine. Dec 07, 2011v. http://mothering.com/pregnancy-birth/what-doctor-isn’t-telling-you-about-pregnancy-and-flu-vaccine
Munoz, FM et al., “Safety of Influenza Vaccination During Pregnancy,” American Journal of Obstetrics & Gynecology. April 2005; 192(4): 1098–1106.
Neuzil, KM et al., “Impact of Influenza on Acute Cardiopulmonary Hospitalizations in Pregnant Women,” American Journal of Epidemiology 1 December 1998: 148(11): 1094–1102.