Amanda Wilde (Host): Welcome to LIFE Cast by Infirmary Health. I'm Amanda Wilde. And with me today are three guests, obstetrician and gynecologist, Dr. Megan Missanelli; pediatrician, Dr. Jessi Kirk; and pediatric pharmacist, Amanda Williams from Infirmary Health. This distinguished panel is here to unravel concerns about vaccinations to help you make informed decisions.

 So, let's get started. Welcome to all three of you. For parents and expecting parents, vaccination hesitation is certainly real. And Dr. Kirk, starting with you, are there any risks to delaying vaccines or doing an alternate vaccine schedule than what is typically recommended?

Jessi Kirk, MD: Thank you so much, Amanda. There's actually two main silos here that we can look at. As you mentioned, delaying vaccines is one of those. And one of the risks of delaying vaccines is that it leaves children unprotected during those crucial times. The younger a child is, the more susceptible they are to these vaccine-preventable diseases. And the longer we delay these vaccines, the more unprotected time they have.

 The second thing we worry about with delaying vaccines is that kids can get some pretty big complications if they get the actual disease that the vaccine is trying to prevent. So, for example, whooping cough or pertussis. In our younger population, up to one in 20 kids that gets pertussis can actually have long-term chronic health problems from it. And up to one in 500 kids that catch the measles disease can actually die from it. And that's in middle and high income countries. So, it can actually be even a higher death rate.

The third reason we don't like to delay vaccines is because it can increase outbreaks and spread of disease in the community. And the fourth reason is it can be time-consuming to do that catch up schedule.

In our second silo, which is why we don't want to use an alternative schedule is because, over 75 years and tens of millions of children, we have a great data set and we know that the safest, most effective way to give vaccines is the schedule that's recommended. If we alternate that schedule, we might decrease herd immunity. We don't know the safety and the efficacy of it. And we just know that it can help stimulate the immune system to give these vaccines and make them as effective as possible if they're given according to the recommended schedule.

Host: Now, when we talk about parents themselves versus children getting vaccines, Dr. Missanelli, who should get an updated Tdap vaccine when pregnant, or having a baby or planning to have a baby?

Megan Missanelli, MD: Yeah. Yeah. Thanks, Amanda. So, the American College of Obstetrics and Gynecologists as well as other several organizations recommend getting the Tdap vaccine between 27 and 36 weeks of pregnancy for every single pregnancy. And the point of giving it during pregnancy is because you've had it before, your immune system has seen it. So, what you're doing is boosting your immune response to it again, and you're flooding your bloodstream with a particular antibody called the IgG antibody. So, that IgG antibody, it's rather special because the placenta actually has a transporter that allows that antibody to cross the placenta and then circulate in the baby's blood. So, what you're doing is you're giving the baby passive immunity by vaccinating yourself during pregnancy. It's important for every mom during every pregnancy to get it again because you're giving that baby passive protection. And then, anybody who's going to be in close contact with the baby that's at risk for giving the baby whooping cough, so, grandparents, parents, like dad anybody who's going to be kissing the baby, sharing spit. I want to make sure you get your Tdap booster if you have not had it. I think it's within 10 years. A lot of people don't know if they have or not, so we just recommend going ahead and getting it with that first baby. But then, some people, because of their profession, they know they've had a booster and that's sufficient.

Jessi Kirk, MD: There's actually a really cute name for this protection of the baby by vaccinating the adults. It's called cocooning. So, we love that.

Host: It's very descriptive. We should say what Tdap is. It's pertussis, which is the P for whooping cough, and help me out, Dr. Missanelli.

Megan Missanelli, MD: So, it's tetanus, diptheria, and acellular pertussis. So again, the reason that people know they've had it is usually if they've stepped on the rusty nail and they go into the ER and then they get the T part of it, the tetanus part of it.

Host: Exactly, I've done that.

Megan Missanelli, MD: I don't know why people step on things, but it actually happens a lot.

Host: Well, we were exploring on some island, and it was a rusty fence and I just scratched my leg on it. But people should wear protection around their legs and arms if they're going to explore places like that. That's my recommendation. But the vaccine we've all heard of is the flu vaccine. People don't seem to have as much hesitance, the people that choose to get that. Amanda, can you get a flu vaccine during pregnancy while you are actually pregnant? Is that okay?

Amanda Williams, PharmD: Yes, Amanda. Again, thank you for having us today. The flu vaccine is perfectly safe during pregnancy as long as we're getting the inactivated vaccine. So, the one to avoid is the nasal spray, the FluMist. That one is a live vaccine. And we are recommending that we do avoid the live vaccines during pregnancy. But that in activated flu vaccine, the shot that we are all very familiar with is completely safe and very much encouraged during pregnancy. Just as Dr. Missanelli mentioned, those antibodies that you are going to generate once you receive that vaccine can also be transferred to the baby. The baby can't get their first flu vaccine until they're six months old, correct, Dr. Kirk?

Jessi Kirk, MD: Yes.

Megan Missanelli, MD: That's true for whooping cough too. So, that's why we want the babies to have and moms to have the Tdap during pregnancies, because those babies can't get that first vaccine until they're about six months. So, the whole point is you want to give them protection when they're the most vulnerable, like Dr. Kirk was saying, in those first few months.

Host: Does the RSV vaccine work the same way?

Amanda Williams, PharmD: The maternal RSV vaccine is called Abrysvo. And it is recommended at 32 to 36 weeks of gestation. And it's the same reasons that we've already talked about for the other vaccines as far as transferring those antibodies to the baby. I'll let Dr. Kirk speak more to our treatment for the baby, but as long as the mom has had the vaccine two weeks minimum prior to delivery, her infant is considered covered and would not need the additional treatment that's available to protect newborns whose mothers are not vaccinated.

Currently, the recommendations on the Abrysvo vaccine are that it is given during the RSV season if you are about to deliver. So generally, that timeframe is considered September to January. Our moms that are slated to deliver during that period of time, that's the recommendation for getting the Abrysvo RSV vaccine.

The season can be longer in other areas. So, there is some question of whether our moms that are in areas that have longer seasons should be getting the vaccine outside of that season. To my knowledge, insurance is currently covering it during that September to January season, and that's when most of the outpatient pharmacies do have that available for administration.

The other piece that I would like to add on this is that there is not currently data on our second pregnancy at this time. So, that's been a very interesting topic of discussion. If mom got the RSV Abrysvo vaccine during her first pregnancy and now she's pregnant again, there's not enough data to recommend another immunization at that time. So, hopefully, we'll get some more information there and that may very well become something like the Tdap that we recommend with every pregnancy, but we don't have that information just yet.

Host: Oh, I was just going to ask that about the Tdap. So, that is recommended during every pregnancy, Dr. Missanelli, is that right?

Megan Missanelli, MD: Yes, that's correct. And what Amanda was saying was correct about RSV. And I think what we're going to run into is that without that robust data set to recommend it in every pregnancy, then we're going to run into the issue of insurance covering it or not. And I think there are certain designated areas-- I'm not sure, you'll have to check me on this-- but my understanding is that the CDC has designated certain areas that are higher risk for year-round transmission. So, they're allowed to give it. But If insurance isn't covering it, then there's going to be moms that are very anxious because they have had a baby with RSV, they've had a baby hospitalized with RSV, they know the importance of getting this vaccine, but then they want to get it every pregnancy, but insurance won't pay for it in that second or third pregnancy. So hopefully, we'll see more data and the dominoes will fall.

Jessi Kirk, MD: I'd love to talk about RSV prevention for infants is slightly different than pregnant mothers because infants don't receive a vaccine, they actually receive a monoclonal antibody called nirsevimab. And a monoclonal antibody just means that instead of you getting a vaccine in your body, having to produce those antibodies, we're just packaging those antibodies up ready to go and putting them into the infant.

Now, mothers that receive the RSV vaccine during pregnancy, at least 14 days before they deliver, their infants don't have to get the monoclonal antibody because they're considered protected for that season. If a mother does not receive an RSV vaccine during her pregnancy, or she receives it less than 14 days from when she delivers, we do recommend that infant getting the monoclonal antibody if they are born during RSV season, which for pediatrics is considered October to March, or if they're about to launch into RSV season.

 And so, that will eventually play into if moms are recommended to get that RSV vaccine each pregnancy or not will determine whether the baby needs the monoclonal antibody that winter. And then, most children don't need a second dose of the monoclonal antibody for the second RSV season unless they have chronic illness like chronic lung disease, immunodeficiency. And that's something you would talk about with your pediatrician one-on-one.

Host: Are there any side effects with the new RSV vaccine?

Amanda Williams, PharmD: They are very similar to the side effects to the seasonal flu vaccine, so arm tenderness at the injection site. There is a risk of an allergic reaction as with anything that we put into our bodies. So, that risk does exist. So, you should be monitored for a short period of time after you receive that vaccine.

And then, there are several rare side effects that are extremely rare, but those people get concerned about. So, there is a risk for Guillain-Barre syndrome, very rare. But it does exist. And then, also severe allergic reaction would be another one on there. And I think the thing to think about when you start getting concerned about these rare but serious side effects is that we need to focus on that first word, they are very rare and the risk of these diseases are not rare. And the challenges that come with those, the hospitalizations, the need for ventilatory support and things like that with RSV, those things are not rare. We're seeing them in our hospitals every year when RSV rolls around.

So, I think sometimes we get caught up on the word side effect and serious, and we let that hold us back from making decisions that are going to protect our child from worse things that could happen to them at a much more higher rate of frequency.

Megan Missanelli, MD: Yeah, well said.

Host: There's one more vaccine I want to ask about, and that is the chickenpox vaccine. Dr. Missanelli, should parents wait before trying to conceive if they've just gotten that vaccine

Megan Missanelli, MD: Well, I guess I would say I would hope that they got it much earlier before they were trying to conceive, because you usually get that in childhood. But yes, if you are getting the chickenpox vaccine, the recommendation from the American Society of Reproductive Medicine is to wait at least one month prior to conception because the varicella vaccine is a live attenuated virus.

So, I like to explain to my patients how the evolution of vaccines happened. And when it first was incepted, it was giving people the virus. And then, we've gotten further and further away from giving people the actual virus, because that still had very high morbidity and mortality. And we've gotten so far as to give you the genetic components to make the antigen so that your immune system can respond to the antigen, and that's what mRNA vaccines are. But the varicella vaccine is a live attenuated virus. So, it's actually live virion particles that then they've inactivated and you give yourself that in the form of the vaccine. And then, that's what mounts your immune response. So because of that, there still is a risk of getting it. So, we recommend waiting at least a month.

And there is a database that you can register for if you are to conceive within one month of getting that vaccine. And now, we've had several decades of data and it shows that there is no risk of congenital varicella after getting it if you do happen to get pregnant within that one month. But nonetheless, if you do just register for the database, then you'll want to be followed more closely by Maternal and Fetal Medicine during the pregnancy, and they'll just do additional ultrasounds usually during the pregnancy.

Host: And then, Dr. Missanelli, just to go back to something we were talking about before, I just want to make sure, with the flu vaccine and the Tdap vaccine, we said that's perfectly fine to get during pregnancy, and also Tdap with every pregnancy. Is it okay to get that done within the first trimester? Is there any kind of timeline we should be aware of?

Megan Missanelli, MD: No, you can absolutely get those within the first trimester, although we just recommend getting Tdap between 27 and 36 weeks, because that's when it was studied. But the flu vaccine, that's really just dependent on flu season, and we want you to get that at any point in the pregnancy, especially if there's high incidence of flu in your area. And it is safe according to Society of Maternal and Fetal Medicine, ACOG, everyone recommends it at any trimester.

Host: And then, Dr. Missanelli, what vaccines should anyone avoid during pregnancy, or are there any?

Megan Missanelli, MD: I would say it's just evidence-based practice. And if we don't have evidence of the safety of it in pregnancy, then we're not going to recommend it. Certainly, we know that there's some benefit to be derived from giving some of these vaccines in terms of benefit to the baby, so that's why we're recommending them during pregnancy.

 I think one of the vaccines I'm interested to see how the data evolves over the next few decades is HPV. Are we going to start recommending HPV vaccine during pregnancy? Because again, that's a safe vaccine to administer during pregnancy. It's not a live attenuated virus, so it's something that you can give, and then would that confer some sort of protection to adolescents? But no, as long as it's not a live attenuated virus, it is safe to administer in pregnancy.

Host: So, I'm going to ask all of you this last question. There's a very persistent rumor that there are links between vaccines and autism. And starting with you, Dr. Kirk, just can you speak to that? And if Dr. Ms. Missanelli and Amanda will, would like to also? I would love to hear your perspectives on that.

Jessi Kirk, MD: I would love to speak on this. It's a question we get quite commonly, actually. So, there has been a lot of studies and a lot of data collected on a possible link between vaccines and autism. And there was one study decades ago, that was the article that cited most often to show that there may be a link. That study was debunked and retracted and the authors admitted that they falsified data.

But I think the more important study to focus on is a study out of Europe. It was multi-country, multi-age children. They were followed over years and years of their life. It followed both vaccinated and unvaccinated children and looked at their rates of autism. Now, statistically, there was no significant difference between the rates of autism and the vaccinated and the unvaccinated children. However, if you looked at the raw numbers, not the statistics, the vaccinated children actually had a slightly lower number of children with autism. And so, that study was bigger. It was more scientifically inclined, it was more official. And so, we can with medical certainty say that there is no link between vaccines and autism. It's not a question, it's a fact. And so, I'm so glad we're able to reassure parents in that way.

Host: Amanda, do you find you're still seeing that hesitance when it comes to vaccines with children as a pharmacist?

Amanda Williams, PharmD: Yes, unfortunately, there is still a hesitancy among our parents. I think social media plays into that a lot. We think that we go to TikTok College and we know everything that we need to know. I think as a parent, you're constantly questioning each decision that you make. Am I doing the best thing for my child? Is this the safest thing for my child? What kind of long-term impact will this have on my child? And when we go to resources like social media, they can say anything they want to say and none of it has data behind it. So, I really would encourage you to go speak with your pediatrician when you're considering childhood vaccines, your OB when you're considering vaccines during pregnancy. That's your source of truth.

There is plenty of data, as Dr. Kirk said, to debunk the whole myth that autism is a side effect of receiving vaccines in childhood. We have plenty of data to support that. And I think, again, as I said earlier, the larger picture that we need to look at is look at the measles outbreak, look at the other diseases that we think are gone, and they're not, because we now have everyone being concerned about whether vaccines are safe again. We can protect our children and I think, as a parent, you need to make sure that you're using a reputable resource to get your information and not getting hung up on those rare things when there are just as scary things that are not rare that you could be protecting your child from.

Megan Missanelli, MD: Within the last six months, I have seen more vaccine hesitancy in my clinic, in my prenatal care counseling than I have in probably the last six years. There's always been a vaccine hesitancy. I mean, I got my master's in Public Health at UAB, and I remember having these conversations because Jenny McCarthy was one of the most vocal proponents of the myth that vaccines cause autism. And again, we have robust data that says very definitively vaccines do not cause autism. And if you talk to any parent with a child with autism spectrum disorder, they know how incredibly complex this neurodevelopmental disorder is. And to blame one specific exposure on this complex disease process, I think, is incredibly disingenuous.

And now, we're seeing things that we thought we had taken care of and we'd gotten out in front of. And then, I think with the mishandling of COVID, there was just a lot of medical mistrust that was then brought up to the surface again. So, it's a battle that we all, as knowledgeable physicians, need to continue to wage. I provide resources to my patients in clinic. I give them a list of good online resources that are outside of social media. And I encourage them to like check the credentials of the people that they're following so that they can figure out why exactly these people are saying this and if they have any kind of background in medical science or basic science to be able to say the things that they're saying.

Jessi Kirk, MD: I would encourage people who have questions about vaccines for themselves and their children to speak to their healthcare providers, like Amanda Williams said. Your healthcare team has your best interest at heart. Medical practices do not get paid to give vaccines. We actually typically lose money on it. And so if they're recommending it, they really truly believe it's what's best for you and your family. And so, please have trust in that. Find a provider or a practitioner that you trust and make that team decision for what's best for you and your family. And understand that we really do care for you and your children, and we want to recommend what's best for you and your family.

Host: That's interesting that you don't make money off vaccines, but people who promote anti-vax actually do have a financial incentive to do that if you look into it. So, that's just something for people to know too.

I think the main thing is what you said, talk to the people you trust and your doctors, your pharmacists. I'd like to thank you all for this great conversation today on vaccines and vaccine hesitation. And thank you all for the work that you do with Infirmary Health.

Jessi Kirk, MD: Thank you for covering this important topic.

Megan Missanelli, MD: Yeah. Thank you.

Host: That was pediatrician Dr. Jessi Kirk, obstetrician and gynecologist, Dr. Megan Missanelli, and pediatric pharmacist, Amanda Williams. For more information, visit infirmary health.org. If you enjoyed this podcast, please share it on your social channels and explore our library for more topics that interest you. Thanks for listening to LIFE Cast from Infirmary Health.