Is Cholera Vaccine safe while breastfeeding?

Summary of use during breastfeeding

Breastfeeding results in a markedly decreased risk of severe cholera in breastfed infants and maternal cholera vaccination increases it further. The Centers for Disease Control and Prevention and several health professional organizations state that vaccines given to a nursing mother do not affect the safety of breastfeeding for mothers or infants and that breastfeeding is not a contraindication to cholera vaccine. Breastfed infants should be vaccinated according to the routine recommended schedules.[1,2]

Effects on the breastfed infant

Limited data indicate that breastfeeding can enhance the response of the infant to certain vaccine antigens.[2,11] Breastfeeding alone results in a 70% lower risk of severe cholera among breastfed infants up to 30 months with continued breastfeeding.[12]

Administration of oral cholera vaccine to the mother decreased the risk of cholera in their breastfed infants by 47% in one study. The authors hypothesized that vaccination of the mothers reduced their transmission of cholera to their infants.[5]

Effects on milk supply

Relevant published information was not found as of the revision date.

Levels in milk

Maternal Levels. Administration of injectable cholera vaccine increases milk secretory IgA antibodies against cholera in the breastmilk in some reports.[3,4] Oral cholera vaccines result in a much lower increase in breastmilk anticholera antibodies.[5,6]

Ten nursing women in Sweden and ten in Pakistan were given subcutaneous injections of bivalent whole-cell cholera vaccine (Swedish National Bacteriological Laboratory) between 1 and 10 months postpartum, followed by a booster dose 14 days later. Before immunization only two of the Swedish women had detectable levels of antibodies against V. cholerae lipopolysaccharide in milk, and then in low titer. In the Pakistani women, titers of IgA antibodies against this antigen were found in 6 out of 10 of the prevaccination milk samples, suggesting earlier natural exposure. Vaccination did not result in greater than twofold rises of specific lgA,-lgG, or IgM antibodies in the milk of any of the Swedish women, nor did the booster immunization induce any milk antibody response. In the Pakistani women, the first dose of vaccine gave rise to significantly increased lgA antibody titers in 7 out of 10 of the milk samples. No significant increase was seen in IgG or IgM antibodies. This suggests that vaccination against cholera in persons living in nonendemic areas should include one or more oral doses of antigen for priming.[7]

Six mothers were given 3 doses of injectable inactivated whole cholera vaccine (Swedish National Bacteriological Laboratory) at 3-week intervals. Milk IgA antibody titers peaked in the first milk sample taken 2 weeks after the first vaccination. Only one of the 6 mothers had an enhanced response after the second vaccination. IgA antibodies were polymeric and short-lived (4 to 6 weeks).[8]

Twenty-one lactating Pakistani women were vaccinated with 3 doses of injectable inactivated whole cholera vaccine (Swedish National Bacteriological Laboratory) at 3-week intervals alone or in combination with oral Salmonella typhi vaccine. Milk IgA antibodies to V. cholerae LPS increased for 2 to 4 weeks in those given one or both vaccines. Combination of the 2 vaccines did not have any untoward effect on the antibody response in serum or in secretions against V. cholerae or S. typhi.[9]

Infant Levels. An open-label study in Bangladesh compared the serum immune response to administration of an oral cholera vaccine (Dukoral; containing killed cholera organisms and cholera subunit B) found that withholding breastfeeding for 3 hours before giving the vaccine resulted in a greater antibody response in infants between 10 and 18 months of age. In infants between 6 and 9 months of age, no difference in antibody response was seen between infants who had breastfeeding withheld and those who did not.[10]