Maternal Immunization. Helping our Patients Ride the Wave to Improved Health. Linda O Eckert, MD Professor, Department of Obstetrics and Gynecology Adjunct Professor, Department of Global Health University of Washington. No conflicts of interest. Objectives Maternal Immunization.
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Helping our Patients Ride the Wave to Improved Health
Linda O Eckert, MD Professor, Department of Obstetrics and GynecologyAdjunct Professor, Department of Global HealthUniversity of Washington
Vaccine Coverage Numerator: # 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
ARU = Attack Rate Unvaccinated ARV = Attack Rate Vaccinated
– 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)
The Cost of Getting the FluBy the Numbers
5 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
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
(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
(Neuzil et al. Inf Dis Clin N Am 2001;15:123)
Risk of Developing Illness with Exposure TrimesterOR (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)
Lindsay. Am J Epidemiol 2006;163:838–48.
Cardiopulmonary Hospitalizationsper 10,000
Neuzil et al, Am J Epi 1998;148:1094
The CDC and Prevention Illness’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.
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
Why Vaccinate Pregnant Women?
Risk of acquisition when exposed
Risk of serious sequelae with illness
“Two for One”
Case-control study of infants <12 months admitted to urban hospital (2000–2009):Cases:+ influenza testControls:– influenza test Matched 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%)
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
Benowitz I et al. Clin Infect Dis 2010;51(12):1355–61.
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
Eick AE et al. Arch PediatrAdolesc Med Feb 2011;165(2):E1-E8.
Omer SB, PLOS MED 2011.
Am J Public Health 2012;102:e33. 4. JAMA 2012;308:165
Irving SA et al. ObstetGynecol Jan 2013;121(1):159–65.
So, how are we doing?
Internet panel survey: Illness• Conducted April 3–17, 2012• Women pregnant at any time during 4-month period October 2011–January 2012
Among 1,660 survey respondents,
47%reported had received flu vaccination: 9.9% before pregnancy 36.5% during pregnancy <0.1% after pregnancy
Recommendation and offerinfluenza vaccination(43.7% of women)
No recommendationNo offer
“Continued efforts to encourage providers to routinely recommend and offer influenza vaccination to women who are pregnant or might become pregnant.”
Reasons for Refusal Illness
*Main reason data missing for 43 women
†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?”
Bordetella Illness pertussis
Hack!Hack!! Hack! Hackalougie!! Ahem!!!! Wheeze!!!
Catarrhal: • 1–2 weeks • Mild runny nose • Mild fever • Occasional cough
Paroxysmal: • 1–6 weeksCough: • 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
Pertussis Kills Illness
Oct 2012 ACIP IllnessTdap in PregnancyNew Recommendations
Prenatal care providers implement Tdap immunization program (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine) for all pregnant women with EVERYpregnancy, irrespective of previous Tdap history
Guidance on Use
To 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.
Independent of breast feeding plans
MMWR Feb 22, 2013, Vol 62, #7
Inactivated vaccines can be given in pregnancy when needed:
Hepatitis A, Hepatitis B, Pneumococcus
Live attenuated vaccines can be given post partum
From: DOH PCH Immunization Child Profile
Sent: Friday, July 11, 2014 11:29 AM
Subject: 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.
Lonnie Peterson | Health Educator
Department of Health | Office of Immunization and Child Profile
PO Box 47843 | Olympia, Washington 98501-7843
p 360.236.3529 | f 360.236.3590
www.doh.wa.gov | www.childprofile.org | www.waiis.wa.gov
Approaching the Vaccine Hesitant parents using
Another one with the C-A-S-E strategy
Acknowledge concerns, find point for agreement; respectful tone
Describe what you have done to build knowledge and expertise
Relate what science says
Explain your advice, based on science
About Immunization in Pregnancy and Postpartum:
Share reasons why recommend
Highlight positive personal experiences with vaccination
Use screening form
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
Immunization of ALL Pregnant Women for Flu
Is Safe any trimester
Protects Mom, grows bigger babies, and protects the NEWBORN
Immunization of all Pregnant Women with Tdap
Should be given in the 3rd trimester
to best protect the newborn
Should be given regardless of plans for breastfeeding