Immunization in pregnancy and breastfeeding: Canadian Immunization Guide

For health professionals

Notice

Last partial content update: September 2023

This chapter was updated to incorporate guidance from the following National Advisory Committee on Immunization (NACI) Statements and the new CIG Ebola virus vaccine chapter:

This information is captured in the table of updates.

Last complete chapter revision: April 2018

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Please note: The National Advisory Committee on Immunization (NACI) recognizes that not all people giving birth or breastfeeding will identify as women or mothers. For the purposes of this chapter, the terms "woman", "women", "mother" and "maternal" are used, but should be considered to also apply to those individuals who do not specifically identify as female gender but are the parent gestating the fetus or breastfeeding the infant.

Introduction

Pregnancy provides an opportunity for health care providers to evaluate immunization status. Pregnancy is associated with an altered immune response and, for some infectious diseases, an increased risk of infection and an increased risk of severe outcomes once infected. The fetus, neonate and young infant can also be affected by infections that can result in congenital abnormalities, impaired fetal growth or severe neonatal illness.

One of the challenges of developing guidelines for immunization during pregnancy and breastfeeding is the scarcity of studies to support evidence-based recommendations. Only a few methodologically robust studies of vaccine administration in pregnancy and breastfeeding exist; most safety data available are derived from active surveillance or from registries where outcomes are passively reported.

When considering vaccination in pregnancy, it is important to distinguish between live and non-live vaccines. There is no theoretical reason to suspect that non-live vaccines are associated with an increased risk of adverse events when administered during pregnancy and data from active and passive surveillance systems confirm safety for several vaccines. Live vaccines should generally not be given during pregnancy because of the theoretical risk of harm to the fetus if transmission of the vaccine strain to the fetus occurs.

The objective of vaccination during pregnancy is to protect the mother and the fetus and newborn. Even though pregnancy is an immunologically altered state, response to vaccines is adequate. Clinical trials of pertussis, tetanus toxoid, and non-live polio vaccine administered during pregnancy have demonstrated normal adult immunologic responses.

Ideally, the immunization status of individuals of child-bearing age should be reviewed regularly and vaccines updated as needed. Live vaccines, for example, can be given during reproductive planning, prior to conception, with the advice to avoid pregnancy for at least 28 days following immunization.

Benefits of immunization in pregnancy for the mother

Vaccines recommended for the protection of a pregnant woman's health include:

  • Non-live influenza vaccine
  • acellular pertussis vaccine (given as tetanus toxoid, diphtheria toxoid, acellular pertussis vaccine)
  • hepatitis B vaccine if susceptible and with ongoing exposure risks
  • hepatitis A vaccine if a close contact of a person with hepatitis A or if travelling to an endemic area
  • meningococcal vaccine in an outbreak setting or post-exposure, or if indicated by medical condition
  • pneumococcal vaccine if indicated by medical condition
  • any other non-live vaccine if indicated by exposure (e.g., rabies), travel (e.g., non-live typhoid vaccine) or by medical condition (e.g., asplenia).

Safety of immunization in pregnancy for the mother

Non-live vaccines are considered safe when administered in pregnancy. Reactions following vaccination with non-live vaccines are usually limited to the injection site. No increase in anaphylactic reactions or events that might induce preterm labour has been observed following immunization with non-live vaccines.

Benefits of immunization in pregnancy for the fetus and infant

The beneficial effects of immunization during pregnancy for the fetus as well as the newborn infant have been well documented. Vaccination during pregnancy protects the mother from vaccine-preventable diseases that may otherwise be acquired and be transmitted to the fetus or infant. In addition, protective concentrations of antibodies are transferred to the fetus transplacentally, resulting in increased infant protection in the early postnatal period. The majority of transplacental antibody transfer occurs during the third trimester and the half-life of these antibodies in the newborn is typically 4 to 6 weeks. Transplacentally acquired antibody concentrations progressively decrease during the first year of life.

Safety of immunization in pregnancy for the fetus and infant

There is no theoretical reason to anticipate adverse events in the fetus or infant following vaccination with non-live vaccines during pregnancy. There are no published data indicating that currently authorized non-live vaccines are teratogenic or embryotoxic or have resulted in specific adverse pregnancy outcomes.

The National Advisory Committee on Immunization (NACI) has concluded that vaccines that contain thimerosal (now only in multi-dose vials of influenza vaccine and hepatitis B vaccine) are safe in pregnancy and should be used if indicated.

In general, live attenuated viral or bacterial vaccines are contraindicated in pregnancy, as there is a theoretical risk to the fetus; however, when benefits outweigh this theoretical risk, vaccination with a live attenuated vaccine may be considered (e.g., during a rubella outbreak).

Immunization during pregnancy

Table 1 and Table 2 provide a summary of recommendations for immunization during pregnancy.

Recommended vaccines

Non-live influenza vaccine

All pregnant women, at any stage of pregnancy, should receive non-live influenza vaccine during each pregnancy, because of their increased risk of influenza-associated morbidity; evidence of adverse neonatal outcomes associated with maternal influenza; evidence that vaccination in pregnancy decreases risk of stillbirth and protects newborns from influenza and influenza-related hospitalization; and evidence that infants born during the influenza season to recipients of influenza vaccine are less likely to be premature, small for gestational age, or of low birth weight.

There is a robust body of evidence demonstrating the safety of the majority of non-live influenza vaccines used during pregnancy. There is limited published clinical data pertaining to safety of vaccination with RIV4 during pregnancy to inform vaccine-associated risks for this population. Active surveillance following influenza vaccination during pregnancy has not shown evidence of harm to the mother or fetus associated with influenza immunization. Although the cumulative sample size of these studies is relatively small, particularly for immunization in the first trimester, passive surveillance has not raised any safety concerns, despite widespread use of influenza vaccine in pregnancy over several decades. Surveillance following the use of both adjuvanted and unadjuvanted pandemic H1N1 influenza (pH1N1) vaccine in more than 100,000 pregnant women in Canada and almost 500,000 pregnant women in Europe did not reveal any safety concerns.

During the influenza season, if influenza vaccine was not received during pregnancy it should be given as early as possible post-partum, preferably before discharge from hospital.

Refer to the Canadian Immunization Guide chapter on influenza and Statement on seasonal influenza vaccine for additional information.

Pertussis vaccine (given as tetanus toxoid, diphtheria toxoid, acellular pertussis vaccine)

All pregnant women should be given tetanus toxoid, diphtheria toxoid, acellular pertussis (Tdap) vaccine during every pregnancy, irrespective of their Tdap immunization history. Immunization with Tdap in pregnancy has been shown to be safe and effective in preventing neonatal and infant pertussis infection. High levels of antibody are transferred to the fetus, protecting the newborn from pertussis during the first two months of life when the morbidity and mortality from pertussis infection is highest. The vaccine should ideally be provided between 27 and 32 weeks of gestation. Immunization between 13 and 26 weeks of gestation may be considered in situations where there may be an increased risk of preterm delivery. Although it is preferable that immunization is administered in sufficient time before birth (i.e., 4 weeks) to allow optimal transfer of maternal antibodies, if not given earlier it should be given at any time until delivery, to provide partial protection and prevent maternal pertussis infection and subsequent transmission to the newborn.

Administration of tetanus toxoid in pregnancy has been shown to prevent neonatal tetanus infection and death in countries with high rates of neonatal tetanus.

Refer to Pertussis vaccine, Tetanus toxoid, and Diphtheria toxoid chapters in Part 4 for additional information.

Hepatitis B (HB) vaccine

All pregnant women should be routinely tested for hepatitis B surface antigen (HBsAg) in each pregnancy (unless they are already known to be hepatitis B virus (HBV) immune or carriers of HBV), so that the newborn can be given HB prophylaxis if indicated.

Acute HB infection in a pregnant woman may result in severe disease for the mother and chronic infection in the infant. A pregnant woman who has no markers of HB infection (HB antibody and HbsAg negative) but who is at high risk of HB acquisition should be offered a complete HB vaccine series at the first opportunity during the pregnancy and should be tested for antibody response. Immunization with HB vaccine in pregnancy has been shown to be safe.

Refer to Hepatitis B vaccine in Part 4 for additional information.

Vaccines that may be indicated

Haemophilus influenzae type b (Hib) vaccine

Hib vaccine should be considered in pregnancy if indicated for a medical condition at high risk for Hib disease. Although Hib vaccine has not been studied in pregnancy, there is no theoretical reason to suspect that adverse events to mother or infant will occur. Refer to Haemophilus influenzae type b vaccine in Part 4 and Immunization of immunocompromised persons and Immunization of persons with chronic diseases in Part 3 for additional information.

Hepatitis A (HA) vaccine

Hepatitis A can cause severe disease in pregnancy, and the vaccine should be considered for pregnant women when indicated for post-exposure prophylaxis, for travel to endemic areas or for other exposure risks. The efficacy and safety of hepatitis A vaccines given during pregnancy has not been studied in clinical trials, but there is no evidence of, or theoretical reason to suspect an increased risk of adverse events to the mother or the infant. Refer to Hepatitis A vaccine in Part 4 for additional information.

Meningococcal vaccine

Conjugate quadrivalent meningococcal vaccine and meningococcus B vaccine should be considered in pregnancy, if indicated in circumstances such as a medical condition at high risk for meningococcal disease; travel to a high risk area; post-exposure prophylaxis; or during an outbreak. Although these vaccines have not been studied in pregnancy, there is no theoretical reason to suspect that adverse events to mother or infant will occur.

Refer to Meningococcal vaccine in Part 4 and Immunization of immunocompromised persons and Immunization of persons with chronic diseases in Part 3 for additional information.

Pneumococcal vaccine

Pregnant women at high risk of invasive pneumococcal disease can, if indicated, be vaccinated with the appropriate pneumococcal vaccines. There is no evidence to suggest a risk to the infant, fetus or to the pregnancy from immunization with pneumococcal vaccine in pregnancy.

Refer to Pneumococcal vaccine in Part 4 and Immunization of immunocompromised persons and Immunization of persons with chronic diseases in Part 3 for additional information.

Poliomyelitis vaccine

Non-live poliomyelitis vaccine (IPV) may be considered for non-immune pregnant women who are at increased risk of exposure to wild poliovirus. Limited data have not revealed an increased risk of adverse events associated with IPV vaccine administered in pregnancy and there is no theoretical reason to suspect an increased risk of adverse events.

Refer to Poliomyelitis vaccine in Part 4 for additional information.

Rabies vaccine

If a pregnant woman has had a potential exposure to rabies, since rabies is invariably fatal, post-exposure prophylaxis should be provided.

If pre-exposure prophylaxis is indicated, it is prudent to delay immunization until after pregnancy unless there is an increased risk of rabies exposure during the pregnancy, in which case the vaccine should be given. Limited data have not shown an increased risk of adverse events in pregnancy, and there is no theoretical reason to suspect that adverse events will occur.

Refer to Rabies vaccine in Part 4 for additional information.

Travel vaccines

Japanese encephalitis (JE) acquired during pregnancy carries the risk of intrauterine infection and miscarriage. Pregnant women who must travel to areas where the risk of JE infection is high should be immunized as the risk of disease outweighs the unknown risk of vaccination. Non-live typhoid vaccine should be considered when indicated for travel to endemic areas if risk factors for severe disease are present. Cholera and enterotoxigenic Escherichia coli (ETEC) travellers' diarrhea vaccine should be considered for those at risk of severe disease if infection occurs.

These are non-live vaccines and there is no theoretical reason to suspect increased risk of post-immunization adverse effects in the mother or fetus. However, because these vaccines have not been studied in pregnancy, administration should be considered only in high risk situations after evaluation of the benefits and risks. Live typhoid vaccine should not be used in pregnancy.

Refer to vaccine-specific chapters in Part 4 for additional information.

Immunoglobulin

Immunoglobulin products may be administered in pregnancy as required for pre- or post-exposure prophylaxis (measles, varicella, HA, HB, tetanus, rabies) or as replacement therapy. There is no known or theoretical risk to the fetus or to a pregnant woman from their administration.

Vaccines not recommended

Human papillomavirus vaccine (HPV)

HPV vaccines are not currently recommended for use in pregnancy. Although HPV vaccine has not been causally associated with adverse outcomes of pregnancy or adverse events to the developing fetus, data on efficacy and safety of HPV vaccination in pregnancy are limited. It is recommended that initiation of the HPV vaccine series be delayed until after completion of pregnancy. If a vaccine dose has inadvertently been administered during pregnancy, no intervention is indicated, but completion of the series should be delayed until after pregnancy.

Vaccine recipients and health care providers are encouraged to report any exposure to HPV9 vaccine during pregnancy to the vaccine manufacturer (Merck Canada Inc.) at 1-800-567-2594. Exposure to HPV2 vaccine during pregnancy should be reported to the vaccine manufacturer (GlaxoSmithKline Inc.) at 1-800-387-7374.

Refer to Human papillomavirus vaccine in Part 4 for additional information.

Recombinant herpes zoster vaccine (RZV)

This vaccine should be used with precaution in those who are pregnant (as there are no data on its use in this population), or breastfeeding (as the effect on breast-fed infants of vaccination in those who are breastfeeding has not been studied). The safety and efficacy in individuals younger than 18 years of age has not been studied, and there are limited data on its use in immunocompromised individuals 50 years of age and older.

Refer to Herpes zoster (shingles) vaccine in Part 4 for additional information.

Generally contraindicated vaccines

Administration of live attenuated vaccines is generally contraindicated in pregnancy because there is a theoretical risk of infection of the fetus.

Measles-mumps-rubella (MMR) vaccine

Although MMR vaccine is generally contraindicated in pregnancy, in situations when potential benefits may outweigh risks, such as during measles or rubella outbreaks, vaccination may be considered. Rubella infection during pregnancy frequently gives rise to congenital rubella syndrome which can result in miscarriage, stillbirth or fetal malformations. Measles during pregnancy results in a higher risk of premature labour, spontaneous abortion and low birth weight infants. To date, there is no evidence demonstrating a teratogenic or other adverse effect from MMR vaccine given during pregnancy. Inadvertent immunization with MMR vaccine is therefore not a reason for pregnancy termination.

Pregnant women without documented laboratory evidence of rubella immunity or prior immunization with a rubella-containing vaccine should be serologically screened for rubella antibodies. Those who are seronegative should receive MMR vaccine, with the first dose given in the immediate post-partum period before discharge from hospital (unless they have received Rh immunoglobulin (RhIg) or other blood products recently). If indicated for measles or mumps protection, a second dose of MMR should be given 4 weeks or more after the first. For post-partum MMR immunization of women who received RhIg or other blood products, refer to Blood products, human immunoglobulin and timing of immunization in Part 1.

Refer to Measles vaccine, Mumps vaccine, and Rubella vaccine in Part 4 for additional information including guidance on post-exposure prophylaxis with measles immunoglobulin for susceptible pregnant women exposed to measles.

Monovalent varicella vaccine

Monovalent varicella vaccine, a live attenuated vaccine, is contraindicated in pregnancy because there is a theoretical risk to the fetus; however, there is no evidence to demonstrate a teratogenic or other adverse event from varicella vaccination in pregnancy. Inadvertent immunization with varicella vaccine is not a reason for pregnancy termination.

Pregnant women without documented laboratory evidence of varicella immunity or prior immunization with 2 doses of varicella vaccine should be serologically screened for varicella antibodies. Those who are seronegative should receive univalent varicella vaccine in the immediate post-partum period prior to hospital discharge unless they have received Rh immunoglobulin (RhIg). A second dose should be given 4 weeks or more after the first. For additional information regarding post-partum MMR immunization of women who received RhIg or other blood products, refer to Table 1 in Blood products, human immunoglobulin and timing of immunization in Part 1.

Refer to Varicella (chickenpox) vaccine in Part 4 for additional information, including post-exposure prophylaxis with varicella zoster immunoglobulin for pregnant women exposed to varicella.

Yellow fever (YF) vaccine

Yellow fever virus can cause severe infection in pregnancy and transmission to the fetus has been reported. YF vaccine should be avoided in pregnancy unless benefit outweighs risk. Pregnant women should be considered for YF immunization only if they are travelling to an area at high risk of YF transmission, travel cannot be postponed and a high level of protection against mosquito exposure is not feasible. Since seroconversion rates following YF vaccine are lower during pregnancy, post-immunization serology may be considered. Studies including several hundred women who received YF vaccine during pregnancy, using both active and passive surveillance methods, have not shown significant adverse events. Inadvertent immunization with YF vaccine is therefore not a reason for pregnancy termination.

A waiver or Certificate of Medical Contraindication to Vaccination should be provided if a pregnant woman travels to a country that is not an area of high risk but requires documentation of YF vaccination. Refer to Yellow fever vaccine in Part 4 and to CATMAT's Statement on pregnancy and travel for additional information.

Other live attenuated vaccines

The use of other live attenuated vaccines during pregnancy must be evaluated on the basis of the individual risk and benefit. If an alternative non-live vaccine is available, such as in the case of influenza or typhoid vaccine, it should be used instead of a live attenuated vaccine.

Bacille Calmette-Guérin (BCG) vaccine has not been studied in pregnant women and should not be given during pregnancy, although no harmful effects of BCG vaccination on the fetus have been observed.

Live replicating Smallpox vaccine is contraindicated during pregnancy in non-emergency situations. It may be considered for a pregnant woman in the highly unlikely event of a high-risk exposure. Smallpox vaccine can very rarely lead to fetal vaccinia resulting in stillbirth or neonatal death. If a woman becomes pregnant within 4 weeks after smallpox vaccination she should be counselled regarding possible risk to the fetus.

There are limited safety data from the use of Ebola virus vaccine in pregnant and breastfeeding people, or in people who became pregnant after receiving the vaccine. The safety of the vaccine has not been established in pregnant or breastfeeding people. Nevertheless, given the seriousness of Ebola virus disease, the vaccine may be considered for pregnant individuals who have had an exposure to Ebola virus, occupational or otherwise, in Canada. Pregnancy should be avoided for 2 months following vaccination. Women of child-bearing potential should use an effective contraceptive method.

Refer to vaccine-specific chapters in Part 4 for additional information.

Immunization of household contacts of pregnant women

Pregnancy in a household does not affect immunization indications for any other members of the household. Indeed, pregnancy should be used as an opportunity to update immunization of susceptible household contacts, including live vaccines such as rotavirus, MMR, MMRV, varicella and LAIV.

In the unlikely event of a household contact being vaccinated against smallpox, extreme precautions should be taken to prevent transfer of the vaccinia virus to unvaccinated household and other close contacts, pregnant or not. Such precautions can include isolation of the vaccinee from pregnant household contacts until the vaccine scab falls off.

Immunization during breastfeeding

Table 1 and Table 2 provide a summary of recommendations for immunization of breastfeeding women.

Immunization of breastfeeding women

In general, routinely recommended vaccines can be safely administered to breastfeeding women. There are limited data available regarding the effects of immunization of breastfeeding women on their infants; however, there have been no reported adverse events related to administration of routine vaccines. There is no evidence that immunization during breastfeeding will adversely influence the maternal or infant immune response.

Annual influenza vaccination is recommended during breastfeeding if not given during that pregnancy. Women who are breastfeeding should be vaccinated with Tdap, Td, hepatitis B, hepatitis A, HPV, pneumococcal, meningococcal, Hib, IPV, rabies, non-live typhoid, MMR, varicella, and cholera-traveler's diarrhea vaccines if indicated.

Japanese encephalitis (JE) vaccine has not been studied in breastfeeding. It is an non-live vaccine and there is no theoretical reason to suspect increased risk of adverse effects in the mother or infants. Breastfeeding women who must travel to areas where the risk of JE infection is high should be immunized if the risk of disease outweighs the unknown risk of vaccination to the woman and her breastfeeding infant.

Vaccines not recommended during breastfeeding

There are a few instances when vaccination is not recommended during breastfeeding. There have been three reported cases of probable transmission of YF vaccine strain virus from mothers to their infants through breastfeeding, resulting in meningoencephalitis in the infants. Therefore, in general, breastfeeding mothers should not be vaccinated. If, for entry to a country, a yellow fever vaccination certificate is required and there is no risk of acquiring yellow fever in the regions to be visited, a waiver or Certificate of Medical Contraindication to Vaccination should be sought. If travelling is to a highly endemic area and travel cannot be postponed, then the risk of vaccination causing disease in the breastfeeding infant should be weighed against the risk of yellow fever infection in the mother and infant and the parents counselled about these risks.

Safety of oral typhoid vaccine in breastfeeding women is not known. Non-live typhoid vaccine should be used.

Caution should also be exercised when considering BCG vaccine because it is a live vaccine and it is not known whether BCG vaccine is excreted in human milk.

Breastfeeding mothers should not receive live replicating smallpox vaccine in non-emergency situations. It is not known whether the vaccine virus (vaccinia) is excreted in human milk. If smallpox vaccine must be given as post-exposure prophylaxis to a breastfeeding woman, breastfeeding and other close contact with the baby should be avoided until the scab has separated from the vaccination site.

It is not known if the Ebola vaccine virus is secreted in human breast milk and there is no data available regarding the effects of vaccinating breastfeeding women on their infants. As a precaution, women should avoid breastfeeding, and their infants should not have contact with maternal blood and body fluids, where feasible, for at least six weeks following vaccination, unless vaccination with Ebola virus vaccine is also indicated for the infant.

Refer to Immunization of travellers in Part 3 and to vaccine-specific chapters in Part 4 for additional information.

Immunization of breastfed infants

Infants who are breastfed should receive all recommended vaccines according to the routine immunization schedule. There is no evidence that the transfer of antibodies in human milk affects the efficacy of live attenuated vaccines in breastfed infants if these are given at the appropriate age.

Infants of breastfeeding women initiating monoclonal antibody treatment after delivery should be immunized according to routinely recommended schedules. Transfer of monoclonal antibodies through breast milk is limited, and the minimal quantities that are ingested are likely to be broken down in the infant's gastrointestinal tract.

For information on the immunization of infants exposed to immunosuppressive therapy in the womb, whether breastfeeding or not, refer to Immunization of immunocompromised persons in Part 3.

Table 1: Summary of Recommendations for Immunization in Pregnancy and Breastfeeding - Non-live vaccines
(Vaccines are listed in alphabetical order.)
Refer to vaccine-specific chapters in Part 4 for additional information.
Vaccine Use in pregnancy Use in breastfeeding Comments
Cholera and travellers' diarrhea Use if indicated if risk of severe disease is high Use if indicated
  • No data on use during pregnancy or breastfeeding
Haemophilus influenzae b (Hib) Recommended for those with health conditions predisposing to severe Hib disease Recommended for with health conditions predisposing to severe Hib disease
Hepatitis A Use if indicated Use if indicated
  • No data on efficacy and safety during pregnancy or breastfeeding
  • Should be considered in pregnancy when potential benefits outweigh risks such as for post-exposure prophylaxis or for travel to high risk endemic area
Hepatitis B Recommended for seronegative pregnant women at high risk of exposure to hepatitis B Use if indicated
  • Can be used safely during pregnancy and breastfeeding
Herpes zoster (recombinant) Currently not recommended Use if indicated
  • No data on use during pregnancy or breastfeeding
  • Unlikely to be used in pregnancy or breastfeeding, given age indication (≥ 50 yr)
Human papillomavirus (HPV) Currently not recommended Use if indicated
  • Limited data on use during pregnancy and breastfeeding
Influenza (non-live) Recommended in every pregnancy Recommended if not vaccinated during that pregnancy
  • Can be used safely during pregnancy and breastfeeding
  • Limited data on safety of RIV4 during pregnancy
Japanese encephalitis Use if indicated (for high-risk situations) Use if indicated (for high-risk situations)
  • No data on safety or efficacy during pregnancy or breastfeeding

Meningococcus quadrivalent conjugate

Meningococcus B

Recommended for those with health conditions predisposing to meningococcal disease; travel to a high-risk area; post-exposure prophylaxis; during an outbreak Recommended for those with health conditions predisposing to meningococcal disease; travel to a high-risk area; post-exposure prophylaxis; during an outbreak
  • No data on use during pregnancy or breastfeeding
  • Refer to Meningococcal Vaccine in Part 4 for a listing of high risk conditions.

Pertussis:

(given as Tetanus- diphtheria-acellular pertussis- Tdap)

Recommended in every pregnancy, irrespective of immunization history Recommended if no dose yet received in adulthood
  • No evidence of risk to fetus or pregnancy
  • Recommended between 27 and 32 weeks of gestation
  • Immunization between 13 and 26 weeks of gestation may be considered in certain circumstances
  • Should be given at least 4 weeks before delivery but may be given at any time up to delivery if not given earlier
Pneumococcal conjugate Recommended for those with immunocompromising conditions predisposing to invasive pneumococcal disease Recommended for those with immunocompromising conditions predisposing to invasive pneumococcal disease
  • Limited data on use during pregnancy or breastfeeding
  • Refer to Pneumococcal vaccine in Part 4 for a listing of immunocompromising conditions for which this vaccine is indicated.
Pneumococcal polysaccharide (Pneu-P-23) Recommended for those with health conditions predisposing to invasive pneumococcal disease Recommended for those with health conditions predisposing to invasive pneumococcal disease
  • No data on use during pregnancy or breastfeeding
  • Refer to Pneumococcal vaccine in Part 4 for a listing of high risk conditions
Polio (non-live) Use if indicated Use if indicated
  • Limited data on use during pregnancy or breastfeeding
Rabies Use if indicated for post-exposure prophylaxis Use if indicated
  • Limited data on use in pregnancy or breastfeeding
Typhoid (non-live) Use if indicated Use if indicated
  • No data on use during pregnancy or breastfeeding
Table 2: Summary of Recommendations for Immunization in Pregnancy and Breastfeeding - Live attenuated vaccines
(Vaccines are listed in alphabetical order.)
Refer to vaccine-specific chapters for more information.
Vaccine Use in pregnancy Use in breastfeeding Comments
Bacille Calmette-Guérin Contraindicated Generally, should not be used
  • No studies on use in pregnancy or breastfeeding
  • No harmful effects on the fetus have been observed
Ebola virus Generally contraindicated Generally contraindicated
  • Limited safety data on use in pregnancy or breastfeeding
  • May be considered in high risk situations (e.g. post-exposure prophylaxis following an occupational exposure to Ebola virus in Canadian healthcare or laboratory settings)
  • Pregnancy should be avoided for 2 months following vaccination
  • Breastfeeding should be avoided for 6 weeks post-immunization
Influenza (live attenuated) Contraindicated Use if indicated
  • No data on use during pregnancy
  • Live attenuated influenza vaccine has a similar or lower efficacy than non-live influenza vaccine in adults
  • In adults, non-live influenza vaccine is preferred if chronic health condition
Measles-mumps-rubella Generally contraindicated Recommended if not immune
  • Immunize rubella-susceptible women immediately post-partum
  • No known fetal effects; theoretical risk
  • May be indicated in pregnancy if non-immune in outbreak situation
  • Inadvertent immunization is not a reason for pregnancy termination
Smallpox (live replicating)

Generally contraindicated

Consider in high risk situation such as post- exposure

Generally contraindicated

Consider in high risk situations (e.g., post-exposure, outbreak)

  • May cause fetal infection
  • Suspend breastfeeding until scab falls off
  • Close contacts who are vaccinated should be isolated from pregnant women and from newborns until scab falls off
Typhoid (oral) Contraindicated Not recommended
  • In individuals requiring protection, non-live typhoid vaccine should be used
Varicella Contraindicated Recommended if not immune
  • Immunize varicella-susceptible women immediately post-partum
  • No known fetal effects; theoretical risk
  • Inadvertent immunization is not reason for pregnancy termination
Yellow fever Generally contraindicated Generally contraindicated
  • Immunization only if travel to area with high risk of transmission is unavoidable and high level of mosquito protection is not feasible
  • Seroconversion rates lower during pregnancy; post-immunization serology may be considered
  • Limited data on fetal safety
  • Inadvertent immunization is not reason for pregnancy termination
  • Serious infections with vaccine strain transmitted to infants by breastfeeding have been reported. Risk of vaccination causing disease in the breastfeeding infant should be weighed against the risk of yellow fever infection in the mother and infant and the parents counselled about these risks

Selected References

1. Advisory Committee on Immunization Practices Centers for Disease Control and Prevention (CDC). Guiding Principles for Development of ACIP Recommendations for Vaccination During Pregnancy and Breastfeeding. Morb Mortal Weekly Rep. 2008;57(21):580-.

2. Ali A, Kazi AM, Cortese MM, Fleming JA, Moon S, Parashar UD, et al. Impact of withholding breastfeeding at the time of vaccination on the immunogenicity of oral rotavirus vaccine--a randomized trial. PloS one. 2015;10(6):e0127622.

3. Badell ML, Meaney-Delman D, Tuuli MG, Rasmussen SA, Petersen BW, Sheffield JS, et al. Risks Associated with Smallpox Vaccination in Pregnancy: A Systematic Review and Meta-analysis. Obstet Gynecol. 2015;125(6):1439-51.

4. Badilla X, Morice A, Avila-Aguero ML, Saenz E, Cerda I, Reef S, et al. Fetal risk associated with rubella vaccination during pregnancy. Pediatr Infect Dis J. 2007;26(9):830-5.

5. Bentlin MR, De RAM, Almeida B, Coelho KIR, Ribeiro AF, Siciliano MM, et al. Perinatal transmission of yellow fever, Brazil, 2009. Emerging Infectious Diseases. 2011;17(9):1779-80.

6. Berenson AB, Patel PR, Barrett AD. Is administration of the HPV vaccine during pregnancy feasible in the future? Expert Review of Vaccines. 2014;13(2):213-9.

7. Bonde U, Joergensen JS, Lamont RF, Mogensen O. Is HPV vaccination in pregnancy safe? Human Vaccines & Immunotherapeutics. 2016;12(8):1960-4.

8. Cao Q, Pan H, Fu C, Liu B, Liu H, Huang G. Safety of post-exposure rabies prophylaxis during pregnancy: A follow-up study from Guangzhou, China. Human Vaccines & Immunotherapeutics. 2013;9(1):0-1.

9. Castillo-Solórzano C, Reef SE, Morice A et al. Rubella vaccination of unknowingly pregnant women during mass campaigns for rubella and congenital rubella syndrome elimination, the Americas 2001-2008. J Infect Dis 2011;204 (Suppl 2):S713-7.

10. Cavalcanti DP, Salomão MA, Lopez‐Camelo J, Pessoto MA, Campinas Group of Yellow Fever Immunization during Pregnancy. Early exposure to yellow fever vaccine during pregnancy. Tropical Medicine & International Health. 2007;12(7):833-7.

11. Chu HY, Englund JA. Maternal immunization. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2014;59(4):560-8.

12. Couto AM, Salomão MR, Schermann MT, Mohrdieck R, Suzuki A, S M Deotti Carvalho, et al. Transmission of Yellow Fever Vaccine Virus Through Breast-Feeding - Brazil, 2009. Morb Mortal Weekly Rep. 2010;59(5):130-2.

13. Gall SA, Poland GA. A maternal immunization program (MIP): Developing a schedule and platform for routine immunization during pregnancy. Vaccine. 2011;29(51):9411-3.

14. KellerStanislawski B., Englund J.A., Kang G., Mangtani P., Neuzil K., Nohynek H., et al. Safety of immunization during pregnancy: A review of the evidence of selected inactivated and live attenuated vaccines. Vaccine. 2014 12 Dec 2014;32(52):7057-64.

15. Kuhn S, Twele-Montecinos L, MacDonald J, Webster P, Law B. Case report: Probable transmission of vaccine strain of yellow fever virus to an infant via breast milk. CMAJ. 2011;183(4):E243-5.

16. Ling J, Koren G. Challenges in vaccinating infants born to mothers taking immunoglobulin biologicals during pregnancy. Expert review of vaccines. 2016;15(2):239-56.

17. Marinho PS, Cunha AJ, Junior JA, Prata-Barbosa A. A review of selected Arboviruses during pregnancy. Maternal Health, Neonatology and Perinatology. 2017;3.

18. Markowitz LE, Dunne EF, Saraiya M, Chesson HW, Curtis CR, Gee J, et al. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 2014;63(RR-05):1.

19. Marques RC, Dórea JG, Bernardi JVE. Thimerosal exposure (from tetanus-diphtheria vaccine) during pregnancy and neurodevelopment of breastfed infants at 6 months. Acta Paediatrica, International Journal of Paediatrics. 2010;99(6):934-9.

20. McMillan M, Clarke M, Parrella A, Fell DB, Amirthalingam G, Marshall HS. Safety of Tetanus, Diphtheria, and Pertussis Vaccination During Pregnancy: A Systematic Review. Obstet Gynecol. 2017 Mar;129(3):560-73.

21. Monath TP. Review of the risks and benefits of yellow fever vaccination including some new analyses. Expert Review of Vaccines. 2012 April 2012;11(4):427-48.

22. Moreira J,Edson D., Block SL, Ferris D, Giuliano AR, Iversen O, Joura EA, et al. Safety Profile of the 9-Valent HPV Vaccine: A Combined Analysis of 7 Phase III Clinical Trials. Pediatrics. 2016;138(2):e20154387-.

23. Moro PL, MD, Museru OI, RN, Niu M, MD, Lewis P, MSPH, Broder K, MD. Reports to the Vaccine Adverse Event Reporting System after hepatitis A and hepatitis AB vaccines in pregnant women. Obstet Gynecol. 2014; 2013;210(6):561.e1,561.e6.

24. Neuzil KM, Reed GW, Mitchel EF, Simonsen L, Griffin MR. Impact of influenza on acute cardiopulmonary hospitalizations in pregnant women. Am J Epidemiol. 1998;148(11):1094-102.

25. Omer SB. Maternal immunization. N Engl J Med. 2017;376(13):1256.

26. Price CS, Thompson WW, Goodson B, Weintraub ES, Croen LA, Hinrichsen VL, et al. Prenatal and infant exposure to thimerosal from vaccines and immunoglobulins and risk of autism. Pediatrics. 2010;126(4):656-64.

27. Raya BA, Edwards KM, Scheifele DW, Halperin SA. Pertussis and influenza immunisation during pregnancy: a landscape review. Lancet Infect Dis. 2017 Jul;17(7):e209-22.

28. Regan AK, de Klerk N, Moore HC, Omer SB, Shellam G, Effler PV. Effect of Maternal Influenza Vaccination on Hospitalization for Respiratory Infections in Newborns: A Retrospective Cohort Study. Pediatr Infect Dis J. 2016;35(10):1097-103.

29. Regan AK, Moore HC, de Klerk N, et al. Seasonal trivalent influenza vaccination during pregnancy and the incidence of stillbirth: population- based retrospective cohort study. Clin Infect Dis 2016;62:1221-7.

30. Sawyer M, Liang JL, Messonnier N, Clark TA, Centers for Disease Control and Prevention (CDC). Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine (Tdap) in Pregnant Women - Advisory Committee on Immunization Practices (ACIP), 2012. Morb Mortal Weekly Rep. 2013;62(7):131-5.

31. Shields KE, Galil K, Seward J, Sharrar RG, Cordero JF, Slater E. Varicella Vaccine Exposure During Pregnancy: Data from the First 5 Years of the Pregnancy Registry. Obstetrics & Gynecology. 2001;98(1):14-9.

32. Steinhoff MC, Omer SB, Roy E, Arifeen SE, Raqib R, Dodd C, et al. Neonatal outcomes after influenza immunization during pregnancy: A randomized controlled trial. CMAJ. 2012;184(6):645-53.

33. Svanstrom H, Pasternak B, Hviid A, Molgaard-Nielsen D, Scheller NM. Quadrivalent HPV vaccination and the risk of adverse pregnancy outcomes. N Engl J Med. 2017;376(13):1223.

34. Swamy G.K., Beigi RH. Maternal benefits of immunization during pregnancy. Vaccine. 2015 25 Nov 2015;33(47):6436-40.

35. Swamy GK, Heine RP. Vaccinations for pregnant women. Obstet Gynecol. 2015 Jan;125(1):212-26.

36. Tamma PD, MD, Ault KA, MD, del Rio C, MD, Steinhoff MC, MD, Halsey NA, MD, Omer, Saad B., MBBS, MPH, PhD. Safety of influenza vaccination during pregnancy. Obstet Gynecol. 2009;201(6):547-52.

37. Thomas RE, Lorenzetti DL, Spragins W, Jackson D, Williamson T. The safety of yellow fever vaccine 17D or 17DD in children, pregnant women, HIV+ individuals, and older persons: Systematic review. Am J Trop Med Hyg. 2012;86(2):359-72.

38. Toback SL, Beigi R, Tennis P, Sifakis F, Calingaert B, Ambrose CS. Maternal outcomes among pregnant women receiving live attenuated influenza vaccine. Influenza and Other Respiratory Viruses. 2012;6(1):44-51.

39. Traiber C, Amaral PC, Ritter VRF, Winge A. Infant meningoencephalitis caused by yellow fever vaccine virus transmitted via breastmilk. J Pediatr. 2011.

40. Wilson E, Goss MA, Marin M, Shields KE, Seward JF, Rasmussen SA, et al. Varicella Vaccine Exposure during Pregnancy: Data from 10 Years of the Pregnancy Registry. J Infect Dis. 2008;197(2):S178-84.

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