Until now, COVID vaccines have been available to pregnant women as part of the twice-yearly booster programme, but this offer is being withdrawn .
Authors
- Sheena Cruickshank
Professor in Immunology, University of Manchester
- Christina Pagel
Professor of Operational Research, Director of the UCL Clinical Operational Research Unit, UCL
The UK's vaccine body, the Joint Committee for Vaccination and Immunisation (JCVI), has recommended that from spring 2025, pregnant women will no longer be eligible for free COVID vaccines. This is a concern for several reasons.
First, there is the direct vaccine benefit of reducing the chance of COVID infection and the consequences of infection in pregnancy. Pregnant women are at higher risk of severe COVID infection than women who are not pregnant, which can be significantly reduced by vaccination .
Severe COVID infection in pregnancy also carries risks for the unborn baby , including miscarriage and stillbirth . Although the risk with the currently circulating virus variants is lower, the risk remains to both mother and baby from COVID . The good news is that vaccination not only protects the mother should she be infected, but also reduces the risk of both very preterm birth and stillbirth for her baby.
Second, there is the indirect benefit of vaccination in pregnancy in protecting newborns in those vital early months. Infants do not have fully developed immune systems, and a COVID infection is their first time meeting the virus. As such, they are very vulnerable to COVID infections, as they are to other respiratory infections . (Thankfully, there are safe and effective vaccines for flu , whooping cough and respiratory syncytial virus RSV .)
COVID vaccines for children under the age of four (from the age of six months ), while approved for use in the UK, are not, nor have been, made available - in contrast to countries such as the US .
A recent study , co-authored by one of us (Christina Pagel), looked at all hospitalisations in England of children with a COVID diagnosis or positive test between August 2020 and 2023. Admissions where COVID did not contribute to the reason for being in hospital (such as swallowing a toy or breaking a limb) were excluded.
Overall, infants accounted for 43% of all admissions in children under 18 (19,700 out of 45,900), rising to 64% of admissions in the most recent era as older children saw some benefit of "acquired immunity" (protection from having had a previous infection).
Of these admitted infants, only 10% had any underlying conditions that would normally be considered risk factors for severe COVID infection. While most infants were in hospital for only a short time - about two days - a significant minority required intensive care. For instance, between August 2022-23, about 5% needed intensive care and eight babies died.
A new study , which has not yet been published in a peer-reviewed journal, further categorised risks to different age groups for COVID hospital admissions in England. It showed that the risk for A&E attendance, hospital admission and severe hospital admission (requiring oxygen ventilation and hospitalisation for more than two days) was highest in babies under six months old - higher even than for people over 90 years old.
While much lower than for the youngest babies, the risk for babies aged six months to one year was also higher than most other age groups - comparable with adults in their 70s or 80s.
The good news is that babies can be protected from COVID in the first six months of life, if the mother has been recently vaccinated. This is because if the mother is vaccinated, she can pass on protective antibodies to the developing baby during pregnancy. These antibodies will wane over time, but if the mother is then able to breastfeed she can pass on antibodies that are found in breast milk .
These antibodies can make a massive difference. Data from the US showed that the overwhelming majority of infants hospitalised with COVID (95%) and all those who died from COVID were from unvaccinated mothers. It is for these reasons that vaccination against COVID during pregnancy has been recommended around the world, including in Ireland , the US and, until now, the UK .
JCVI's workings not clear
It's not clear how JCVI assessed the cost-effectiveness that has led to the change in recommendation to withdraw the COVID vaccine in pregnancy.
The cost-effectiveness model JCVI has been using for COVID vaccine decisions has only just been published, and is still in preprint form . JCVI's criteria focus on preventing deaths, and the preprint only considered deaths in people 15 years and older, while the hospitalisation data used grouped children aged nought to four years . This age grouping masks the much higher vulnerability of very young babies that other papers have shown.
A further concern about the JCVI analysis is that it seems to prioritise preventing deaths above all other considerations. For its decision on pregnancy eligibility, the committee used unpublished data from the Intensive Care National Audit and Research Centre, which shows that there were no deaths in pregnancy in the last 18 months. Although this is excellent news, this data does not appear to include consideration of miscarriage, stillbirth and health risks to the baby.
While, of course, death matters a lot, and pregnant mothers and babies very rarely die from COVID, hospitalisation and severe hospitalisation are nonetheless also important outcomes to avoid.
COVID remains at significant levels throughout the year . We would urge the JCVI to look at the wider data sets published on infant health as well as mortality and either revise its criteria on vaccination in pregnancy, or provide a much more detailed and transparent explanation for why it has been discontinued.
Sheena Cruickshank is affiliated with independent SAGE
Christina Pagel is a member of Independent SAGE and vice president of the UK Operational Research Society.
