MATERNAL IMMUNIZATION

Linda O Eckert, MD Professor, Department of Obstetrics and Gynecology

Adjunct Professor, Department of Global HealthUniversity of Washington

Helping our Patients Ride the Wave to Improved Health

No conflicts of interest

ObjectivesMaternal Immunization

Review Indications for Flu Vaccine Review Indications for Tdap

Discuss strategies to increase uptake

Measuring Success

Vaccine CoverageNumerator: # in target group fully

immunized by ______

Denominator:Total # in target group

Vaccine EfficacyReduction in incidence of disease among vaccinated vs unvaccinated

(ARU minus ARV) x 100

ARUARU = Attack Rate Unvaccinated ARV = Attack Rate Vaccinated

VE =

Vaccine Recommendations: Who Sets Them?

USA:

– Advises CDC on policy– Publishes in Morbidity and Mortality

Weekly Report (MMWR)– Other bodies usually follow

(ACOG, AAP…)

Global: Strategic Advisory Group of Experts on immunization

– Advises WHO on immunization policy– Publishes in Weekly Epidemiological

Record (WER)SAGE

InfluenzaWhy care?

Flu Kills

http://theweek.com/article/index/234770/the-cost-of-getting-the-flu-by-the-numbers

The Cost of Getting the FluBy the Numbers5 to 20 Percentage of US residents who get the flu every year

200,000 People hospitalized from flu-related complications each year

$87.1 billion Annual loss to US economy due to influenza and its repercussions

$16.3 billion Annual toll on businesses due to influenza

70 million Workdays missed by Americans last year due to the flu

Between 3,000 and 49,000 Flu-related deaths in America each year

Why are pregnant women considered high-risk?

Historical Pandemic ReportsPregnant Women: INCREASED MORBIDITY

1918: — Mortality associated with infection during pregnancy ~51%, with highest rates in later stages of pregnancy

1957: — 50% of women of childbearing age who died of influenza were pregnant — 10% of all influenza deaths that season

were in pregnant women, most in latter half of pregnancy

(Neuzil et al. Inf Dis Clin N Am 2001;15:123)

(Harris. JAMA 1919;14:978)

(Freeman, Barno. AJOG 1959;78:1172;

Greenberg et al. AJOG 1958;76:897)

Case reports of complications since then, many in later stages of pregnancy

Stage of Pregnancy Modifies Outpatient Influenza-like Illness

(N = 8,323 Healthy Pregnant/Postpartum Women, 1991–1997)

Lindsay. Am J Epidemiol 2006;163:838–48.

Risk of DevelopingIllness with Exposure

Trimester OR (95% CI)First 1.12 (0.79–1.59)

Second 1.30 (0.97–1.73)Third 1.84 (1.31–2.59)

Postpartum 2.28 (1.43–3.68)

Effect of Pregnancy on Influenza-Related Hospitalizations

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3rdtrimester

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Neuzil et al, Am J Epi 1998;148:1094

The CDC and Prevention’s Advisory Committee on Immunization Practice recommends influenza vaccination for all women who will be pregnant through the influenza seasons (Oct–May in the US)— Supported by ACOG’s Committee on OB Practice

No evidence of adverse consequences with inactivated influenza vaccine in pregnant women or their offspring

Vaccination early in season at any GA is optimal, but unvaccinated pregnant women should be immunized at any time during influenza season

ACOG Committee Opinion. Oct 2010;116(4):1006-7.

Assess the woman’s vaccination status Offer inactivated flu vaccine and Tdap during

pregnancy

ACNM recognizes he crucial role of midwives in improving the health of our nation and the world by actively promoting immunization for the families to whom they provide care

.

Position Statement: American College of Nurse-Midwives

http://midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000289/Immunization-in-Pregnancy-and-Postpartum-May-2014.pdf

Vaccinating momsprotects the

infant:

Risk of acquisition when exposed Risk of serious sequelae with illness

Why Vaccinate Pregnant Women?

“Two for One”

Vaccination Against Influenza in PregnancyProtects Infants

Case-control study of infants <12 months admitted to urban hospital (2000–2009): Cases: + influenza test

Controls: – influenza testMatched by age/admit date

Of infants admitted at <6 months, number of momsimmunized in pregnancy:

Cases: 2/91 (2.2%)Controls: 31/156 (19.9%)

Benowitz I et al. Clin Infect Dis 2010;51(12):1355–61.

Influenza vaccine given to pregnant women is 91.5% effective in preventing

hospitalization of their infants for influenza in the 1st 6 months

of life

Maternal Influenza VaccinationEffect on Influenza Virus Infection in Young

Infants Observational cohort study of 1,169 mother-infant pairs

with mothers who delivered over 1-3 influenza seasons— Main exposure: maternal seasonal influenza vaccination

41% in influenza and 39% in hospitalization for infants born to influenza-vaccinated women

Eick AE et al. Arch Pediatr Adolesc Med Feb 2011;165(2):E1-E8.

Maternal influenza vaccination significantly associated with: • Influenza antibody titers through 2-6 mos of age

• Risk influenza and hospitalization up to 6 mos of age

Babies Stay Longer, Grow BiggerWhen Mom gets Flu Shot

Reduced risk of prematurity by 40%1

Increased birth weight by 200 gm2

Another study: n=22,340.3 Babies whose mom got flu vaccine LESS LIKELY to be

• Small for Gest Age (RR 0.9)• <32 weeks (RR 0.73)• Experience fetal death (RR 0.66)• AND NO increase in anomalies4

1. Omer SB, PLOS MED 2011.2. www.cdc.gov/flu/protect/pregnant/htm 3. Am J Public Health 2012;102:e33. 4. JAMA 2012;308:165

Trivalent Inactivated Influenza Vaccine and SAB

NO Relationship Case-Control study of 6 healthcare organizations

in Vaccine Safety Datalink Women 18–44 yo with SAB at 5–16 wks EGA, fall 2005 or 2006 243 cases matched with 243 controls by LMP/health

organization— Mean EGA at demise = 7.8 wks

Primary analysis:Exposed 1–28 days before SAB

Irving SA et al. Obstet Gynecol Jan 2013;121(1):159–65.

Flu vaccine in Pregnancy

So, how are we doing?

Internet panel survey: • Conducted April 3–17, 2012• Women pregnant at any time during

4-month period October 2011–January 2012

47% reported had received flu vaccination: 9.9% before pregnancy

36.5% during pregnancy<0.1% after pregnancy

Among 1,660 survey respondents,

Recommendation and offerinfluenza vaccination

(43.7% of women)73.6%

47.9%

11.1%

Recommendation only

No recommendationNo offer

VACCINATIONCOVERAGE

HEALTHCARE PROVIDER

“Continued efforts to encourage providers to routinely recommend and offer influenza vaccination to women who are pregnant or might become pregnant.”

( )( )( )( )( )( )

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*Main reason data missing for 43 women§Weighted percentage†Women asked two questions: 1) “Since August 2011, during your visits to the doctor/medical professional, did your doctor

or other health professional personally recommend that you get a flu vaccination?”2) “Since August 2011, during your visits to the doctor/medical professional, did your doctor or other health professional offer the flu vaccination to you?”

Reasons for Refusal

Bordetella pertussis

Hack! Hack!! Hack! Hackalougie!! Ahem!!!! Wheeze!!!

Bordetella pertussis Highly infectious Incubation period 7–10 days (range 4–

21) Insidious onset of symptoms Fever minimal

Bordetella pertussis—The IllnessThree Stages of Disease

Catarrhal: • 1–2 weeks• Mild runny nose• Mild fever• Occasional cough

Paroxysmal: • 1–6 weeks Cough: • Bursts of numerous, rapid coughs

followed by long inspiratory effort (“whoop” in young children)• Can have vomiting/cracked ribs• ~15 spells/24 hrs, worse at night

Convalescence: • Weeks to months

http://www.kingcounty.gov/healthservices/health/news/2012/12121801.aspx

Pertussis Kills

PERTUSSIS CASESWASHINGTON STATE

20124,7442011 807

http://www.doh.wa.gov/Portals/1/Documents/Pubs/348-254-PertussisUpdate.pdf

http://www.doh.wa.gov/Portals/1/Documents/Pubs/348-254-PertussisUpdate.pdf

http://www.doh.wa.gov/Portals/1/Documents/Pubs/348-254-PertussisUpdate.pdf

Oct 2012 ACIP Tdap in PregnancyNew Recommendations

Updated RecommendationPrenatal care providers implement Tdap immunization program (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine) for all pregnant women with EVERY pregnancy, irrespective of previous Tdap history

Guidance on UseTo maximize maternal antibody response and passive antibody transfer to infant, optimal timing for Tdap is at 27–36 wks gestation.If not previously vaccinated or given during pregnancy, administer immediately postpartum.

MMWR Feb 22, 2013, Vol 62, #7Independent of

breast feeding

plans

Current Status Tdap in Pregnant Women

Only of women vaccinated in pregnancy (April 2012)

http://www.cdc.gov/vaccines/acip/meetings/slides-oct-2012.html

2.6%

OTHER IMMUNIZATIONS IN

PREGNANCYInactivated vaccines can be given in

pregnancy when needed:Hepatitis A, Hepatitis B, PneumococcusLive attenuated vaccines can be given

post partumMMR, varicella

From: DOH PCH Immunization Child Profile

Sent: Friday, July 11, 2014 11:29 AMSubject: News Release: Measles Cases on the Rise in WA This message is being sent to local health immunization coordinators  

The Department of Health issued a news release yesterday on the continued rise of measles in our state. So far this year, we’ve had 27 measles case, up from 5 reported in 2013. The most recent cases reported in the past month have been in King County (11 confirmed cases) and Pierce County (2 confirmed cases). This is the third measles outbreak in our state this year. The news release includes lists of places visited by cases while they were contagious. More information about measles and its vaccine can be found on the department’s measles webpage. Thank you, Lonnie Peterson | Health EducatorDepartment of Health | Office of Immunization and Child ProfilePO Box 47843 | Olympia, Washington 98501-7843p 360.236.3529 | f 360.236.3590www.doh.wa.gov | www.childprofile.org | www.waiis.wa.gov

 

News Release: Measles Cases on the Rise in WA

DEALING WITH VACCINE HESITANCY

Approaching the Vaccine Hesitant parents using

C-A-S-Ehttp://www.immunizeusa.org/media/29064/making_the_case_for_vaccines_mnaap.pdf

Another one with the C-A-S-E strategyhttp://www.sanantonio.gov/Portals/0/Files/health/HealthServices/NIIW%20Presentations/R.%20Carlyle_CASE%20Model%20Presentation.pdf 

WHAT IS C-A-S-E• Corroborate:

• Acknowledge concerns, find point for agreement; respectful tone

• About Me:• Describe what you have done to build

knowledge and expertise • Science:

• Relate what science says• Explain/Advise:

• Explain your advice, based on sciencehttp://www.immunizeusa.org/media/29064/making_the_case_for_vaccines_mnaap.pdf

Examples of C-A-S-E

Corroborate: “we both want you to stay healthy and have a healthy baby”…”I am so glad we get to talk together about vaccines in pregnancy…”

About me: “I just attended a recent conference about vaccines”… “I just read the most recent update on use of flu vaccine in pregnancy from XXX {fill in whatever applies}” “We just got asked questions about vaccines on our recent board recertification…”

Examples of C-A-S-E

Science: “Flu vaccine in pregnancy has been studied since the 1970’s”… “Vaccines have been studied more than almost any medicine or product we use, and are one of the safest…” Studies of pregnant women and their babies done all around the world show the same thing: Pregnant women get the flu more easily, get sicker when they get it, and THE BEST news is that you can decrease your baby’s chance of catching the flu and ending up in the hospital”…

Examples of C-A-S-E

Explain/Advise: “I strongly recommend you get this vaccine in pregnancy because…” “When I was pregnant I got this vaccine….” “I believe in following the advice of the American College of Nurse-midwives”…

TALKING POINTS FOR MIDWIVES

About Immunization in Pregnancy and Postpartum:

• Share reasons why recommend• Highlight positive personal

experiences with vaccination• Address questions• Use screening form

http://www.midwife.org/acnm/files/ccLibraryFiles/Filename/000000004051/Vaccination-Talking-Points-for-Midwives-Apr-2014.pdf

MORE RESOURCES

American College of Nurse-Midwives: www.midwife.org/Immunization-Resources-for-Midwives

CDC Immunization and Pregnancy chart: www.cdc.gov/vaccines/pubs/downloads/f_preg_chart.pdf

CDC web page, Vaccines for Pregnant Women: www.cdc.gov/vaccines/adults/rec-vac/pregnant.html

Plain Talk booklet for help in talking with patients about vaccine concerns: http://here.doh.wa.gov/materials/plaintalk/15_PlainTalk_E13L.pdf 

FOR TIPS ON SETTING UP IMMUNIZATIONS IN YOUR

OFFICE

www.immunizationsforwomen.org

SO, IN SUMMARY:Immunization of ALL Pregnant Women for Flu

• Is Recommended• Is Safe any trimester• Protects Mom, grows bigger babies, and

protects the NEWBORNImmunization of all Pregnant Women with Tdap • Is Recommended• Should be given in the 3rd trimester

to best protect the newborn • Should be given regardless of plans for

breastfeeding

Acknowledgments

Public Health Seattle and King County Washington State Department of Health American College of Nurse Midwives VAX Northwest WithinReach Immunization Action

Coalition of Washington

Jan Englund at Children’s Hospital, Seattle ACOG Expert Immunization Advisory

Group