Standing up for the facts: COVID-19 vaccination, fertility and pregnancy
Dr Viki Male
Dr Viki Male explains how she took matters into her own hands in response to the mixed messaging around COVID-19 vaccination advice and pregnancy.
In 2003, the world was on the brink of a SARS-1 pandemic. As a Year 12 student at the time, I followed developments closely. Although the outbreak eventually died out, my interest in infectious diseases did not. Surely, the big one was coming. And I would be ready for it.
But by the time the big one came, my research has taken me in a different direction. At university, I had become passionately interested in a family of immune cells, called NK cells, that control viral infection. But these cells have another role that captured my imagination: they help the placenta to implant during pregnancy, and my lab is working out how. In March 2020, as immunologists around the world raced to make a vaccine, I shut my lab and went home to spend the next 12 weeks home-schooling my children. I would sit this one out. What use is a reproductive immunologist in a pandemic, anyway?
Some use, it turned out. In December 2020, as the vaccine rollout began, rumours started to circulate that antibodies raised by COVID-19 vaccination would target a placental protein, called Syncytin-1, causing infertility and miscarriages. There was no basis to this claim and if I, a reproductive immunologist, wouldn’t stand up and explain why, then what was the point of me? So I began engaging with the public, first on social media and then in print and broadcast. Here’s what they taught me…
People want the evidence
“There’s no evidence that COVID-19 vaccines harm fertility” was oft-repeated by doctors and scientists. By this, we meant that we had looked for such evidence and not found it. But many people heard this as “we simply haven’t looked”. So I started talking to people specifically about the types of approaches that have been taken to examine post-vaccine fertility and pregnancy rates, and what the studies had found. Similarly, when the vaccines started to be offered in pregnancy, those deciding whether they should accept were, naturally, keen to know exactly what had been done to show that it was safe and effective.
Reproductive health shouldn’t be an afterthought
One of the big challenges of having discussions about the safety of COVID-19 vaccines in pregnancy, particularly early in the year, was the fact that pregnant people had not been included in the clinical trials. This meant that pregnant people were making their decision on whether to get vaccinated in an information vacuum. Data on the safety and effectiveness of vaccination in pregnancy quickly came out from the USA and Israel, where they had taken the view that, given the increased risks of COVID-19 in pregnancy, and the theoretical safety of the vaccine, pregnant people should be offered the vaccine in advance of the completion of clinical trials in this population.
One lesson I hope we take from the pandemic is that pregnant people should be included in trials, and not just for vaccines.
But it need not have been this way. We ought to have anticipated that vaccination in pregnancy would be necessary in the broader population, and designed the trials to assess this. Indeed, a set of guidelines have been developed specifically to allow pregnant participants in vaccines trials during public health emergencies. One lesson I hope we take from the pandemic is that pregnant people should be included in trials, and not just for vaccines. Many people discontinue their life-saving or life-enhancing medication when they become pregnant because they are unsure of its safety. Formal trials will generate the information these people need to make properly informed decisions.
Clear communication saves lives
The UK took a more cautious approach to COVID-19 vaccination in pregnancy: initially, the vaccine was not offered to this group, and then only to those at high risk. This meant that, in April, when the vaccines were offered to all pregnant people, many were hesitant: weren’t we saying before that the vaccines weren’t safe for them? The price of this hesitance is that the infection rate in this group is much higher than it ought to be and, as a result, we are seeing more pregnant people in intensive care, and more preterm deliveries, than we normally would. This could have been avoided with better communication at the time the guidance changed, explaining why this decision had been taken and giving a whole-hearted recommendation of COVID-19 vaccination in pregnancy. Canada, who approved vaccination in pregnancy shortly after we did, took this approach including actively prioritising pregnant people for vaccination. As a result, they have seen higher vaccine uptake than the UK have.
Although the Christmas I celebrate now is fundamentally a pagan one, the Christmas of my childhood revolved around the story of a new baby and his parents, trying to make it in a world that was against them. This Christmas, let’s take a moment to reflect on what the pandemic has taught us about how we can improve the outcomes for babies and their families in the future. And I wish you all a happy and healthy 2022!
Dr Viki Male is a Lecturer in Reproductive Immunology based in Imperial’s Department of Metabolism, Digestion and Reproduction.
We need to give everyone, everywhere, the precious gift of health
Professor Faith Osier
Professor Faith Osier shares her vision for health equity, from tackling vaccine inequity to empowering the next generation of scientists globally.
Almost a year ago to the day, my partner and I woke up our three young children in the middle of the night, readied them for the airport, hurriedly scrambled together the last of our belongings and embarked on a new adventure. We were moving from Heidelberg, a picture-perfect city that often made me feel like I was walking into a tranquil postcard. This had been home for four years and we kept our mixed feelings to ourselves as we ventured into the unknown, London. I was taking up a new position as the Executive Director of IAVI (formerly International AIDS Vaccine Initiative), at Imperial College London. We navigated the intricacies of relocating during lockdown, settled the children into school or rather “joyous home-learning” as was the case at the time, and I began to unpack my new job.
The mission of IAVI resonates strongly within me: “translating science into affordable, globally accessible public health solutions”. The opportunity to turn years of scientific endeavour into interventions that could transform the lives of the most vulnerable on our planet still springs me out of bed every day. I have worked for over 25 years amongst the rural poor in Kilifi, Kenya, studied immune responses to malaria antigens in samples from similar study participants across Africa and appreciated first-hand the impact of ill-health on productivity, livelihoods and hope.
I desperately wanted to give back
My new job gave me that rare opportunity to be part of a team that did exactly that. I remain excited by this prospect. We work on a broad portfolio of diseases that disproportionately affect populations in low- and middle-income countries (LMICs). These include HIV/AIDS, emerging infectious diseases such as Ebola, Marburg, Lassa fever and COVID-19, Tuberculosis and Malaria. Our vision is a world where all people have equitable access to innovative vaccines and therapeutics. I immersed myself wholeheartedly into the world of product development, marvelled at the breadth of partnerships that are central to our mission and strove to ensure that we were as efficient as we could possibly be at the Human Immunology Laboratory in London.
Tackling vaccine inequity
It is hard to believe that a year has already gone by! What wisdom have I gained to share? Incredibly, the COVID-19 pandemic rages on at the end of 2021. Although vaccines have had a major impact on reducing severe morbidity and mortality, Europe is once again the epicentre of the pandemic. Vaccine inequity stares at us unflinchingly. Rich western countries are providing booster shots to their populations, while the majority in resource-constrained economies have not had a single shot.
Vaccines are being hoarded and unfortunately even wasted, while poorer countries remain in abject need.
The Omicron variant is upon us. Although it was identified and sequenced in South Africa, populations in the region suffer without vaccines, and livelihoods are pushed further back by renewed blanket travel restrictions. This vicious cycle continues. We cannot wish this away. Calls for action appear to fall on deaf ears as nationalism takes ascendency. Vaccines are being hoarded and unfortunately even wasted, while poorer countries remain in abject need.
In the short term, let us give more. In the longer term, we as a global community must put in place the infrastructure and mechanisms to ensure that the next pandemic can be controlled much more efficiently and most importantly, equitably. Compared to generations before us, we have the distinct advantage of incredible technological advances in the biopharmaceutical industry and unparalleled global connectivity. We now need to make global solidarity the centrepiece and collectively determine that never again will a pandemic such as COVID-19 devastate our world. Until everyone is safe, no one is safe.
Education is key
I have been thrilled to participate in discussions on vaccine manufacture in Africa and other LMICs. IAVI’s leadership in this regard puts another big smile on my face and brings me to a favourite subject – capacity strengthening. As I reflect on my own scientific career and ponder the global health challenges that have yet to be overcome, it is clear to me that one of our greatest contributions will be to empower the next generation of scientists, globally. This is the health insurance for generations to come.
Without a scientifically astute global workforce, health security remains uncertain.
At Imperial, we have the infrastructure to educate. Let us fortify the mechanisms that extend this precious resource globally, deliberating to reach the less advantaged and keeping our eyes on the long-term goal of equity. Without a scientifically astute global workforce, health security remains uncertain.
Pathogens do not respect borders
The pandemic began during my watch as President of the International Union of Immunological Societies (IUIS). Working with national immunological societies across the globe, we have rallied for greater education, sharing of resources and technologies and contributed to narrowing the equity gap in scientific know-how. Let us all join forces to create a world that gives everyone, everywhere, the precious gift of health and the opportunity to realize their fullest potential. Together, we are an incredible force for the good of humanity.
Professor Faith Osier is Executive Director of the Human Immunology Laboratory, Visiting Professor of Immunology at Oxford University, and President of the International Union of Immunological Societies.
Dr Natsuko Imai reflects on the experience of supporting the Imperial College COVID-19 Response Team who provide key epidemiological insights to help inform the response to the pandemic.
Despite the introduction of “plan B”, I’m sure many of you will agree with me that, the run-up to Christmas this year still feels very different compared to 2020 when non-essential shops were closed, and we could only meet within our households or support bubbles. The swift introduction of measures and the fact we even have a vaccination programme to accelerate in response to the Omicron variant helps to keep me cautiously optimistic.
My colleagues in the MRC Centre for Global Infectious Disease Analysis and I have been working on COVID-19 since January 2020. This was when the virus was still called “novel coronavirus 2019” and only a handful of cases had been reported outside of mainland China. Since our early assessment of the transmissibility and true size of the epidemic in Wuhan City, the SARS-CoV-2 virus has spread to every corner of the world, changing the way we live in ways we could never have imagined.
Before the pandemic, most of my work as the liaison between the Centre and the World Health Organization was co-ordinating analytical support for outbreaks, typically in low- and middle-income countries. Since 2018, I have worked with colleagues on Ebola outbreaks in the Democratic Republic of the Congo, doing rapid real-time analysis to understand – “how bad is the outbreak? How many cases can we expect in the next 3-4 weeks? How many vaccines need to be deployed?”.
With requests for analysis coming in almost daily in the early days, it has been an intense, but scientifically incredible journey.
This year, I have worked on events closer to home, supporting the Centre’s Imperial College COVID-19 response team who provide key epidemiological insights to help inform the response to COVID-19 both in the UK and abroad. With requests for analysis coming in almost daily in the early days, it has been an intense, but scientifically incredible journey. I am especially thankful for the generosity everyone has shown under all kinds of pressures.
With 210 deaths per 100,000 people, the UK is one of the worst affected countries in the world and we have just passed a grim benchmark of 5 million COVID-19 deaths globally. The sheer scale of loss is staggering.
Yet, the pandemic has also brought out the most amazing scientific advancements with not one, but several safe and highly effective COVID-19 vaccines developed in less than a year with almost 80% of the eligible UK population fully vaccinated. Our team’s work informing and assessing England’s “roadmap out of lockdown” policy showed how the rapid roll-out and high uptake of vaccines in England enabled restrictions to be lifted gradually and safely.
It demonstrated how science, when communicated effectively, can catalyse public health action. I was seconded to the Government Office for Science at the height of the pandemic last year. Every single person supporting the Scientific Advisory Group for Emergencies was relentless, almost obsessive, about ensuring the very best science advice was available to ministers. It reassured me that, regardless of the final policy decision, the work produced selflessly by the whole UK research community did make a difference.
“No-one is safe, unless everyone is safe”
However, outside of countries like the UK or USA where booster doses are being rolled out, the picture is very different. Despite the COVAX initiative, millions of frontline workers in LMICs are yet to receive their first dose, let alone their second or third. I feel incredibly conflicted about this. Of course, with increasing evidence that vaccine-induced protection decreases over time, I want vulnerable individuals protected as best as possible. However, from a global public health perspective making sure everyone receives their first and second doses should be the priority. Although the UK has pledged to donate 100 million vaccines by June 2022, global political will to drive urgent action will be critical.
A real “end” to the pandemic can only be achieved through equitable universal access to vaccines.
The emergence of the Delta variant—which drove huge waves of SARS-CoV-2 infection—and now the Omicron variant highlights how, until transmission can be controlled globally, new variants will continue to arise and threaten pandemic control efforts. A real “end” to the pandemic can only be achieved through equitable universal access to vaccines.
With daily reported cases exceeding 45,000 cases in the UK and the rapid rise in Omicron cases, we must also remain vigilant.
So, as we enter the festive period, I will be working from home, testing if seeing friends and family, and encouraging those eligible to get vaccinated. I hope everyone has a restful holiday, and although we are not out of the woods just yet, takes the time to reflect on how far we have come collectively.
Finally, I want to take this opportunity to say a huge thank you to the many wise women around me who have pushed and supported me over the last 24 months. What a rollercoaster!
Dr Natsuko Imai is the World Health Organization liaison for Imperial’s MRC Centre for Global Infectious Disease Analysis and a Research Associate in the School of Public Health.