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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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Maternal immunization

Maternal Immunization

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

Objectives maternal immunization
ObjectivesMaternal Immunization

  • Review Indications for Flu Vaccine

  • Review Indications for Tdap

  • Discuss strategies to increase uptake

Measuring success
Measuring Success

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


VE =

ARU = Attack Rate Unvaccinated ARV = Attack Rate Vaccinated

Vaccine recommendations who sets them
Vaccine Recommendations: Who Sets Them?


– 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)



Why care?

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

Historical pandemic reports pregnant women increased morbidity
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

(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)

Stage of Pregnancy Modifies Outpatient Influenza-like Illness(N = 8,323 Healthy Pregnant/Postpartum Women, 1991–1997)

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.

Effect of pregnancy on influenza related hospitalizations
Effect of Pregnancy on IllnessInfluenza-Related Hospitalizations

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.

Assess the woman’s vaccination status Illness

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


Vaccinating moms protects the infant
Vaccinating moms Illnessprotects the infant:

Why Vaccinate Pregnant Women?

Risk of acquisition when exposed

Risk of serious sequelae with illness

“Two for One”

Vaccination against influenza in pregnancy protects infants
Vaccination Against Influenza in Pregnancy IllnessProtects Infants

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 effect on influenza virus infection in young infants
Maternal Influenza Vaccination IllnessEffect 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

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.

Babies stay longer grow bigger when mom gets flu shot
Babies Stay Longer, Grow Bigger IllnessWhen 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

Omer SB, PLOS MED 2011.

Am J Public Health 2012;102:e33. 4. JAMA 2012;308:165

Trivalent inactivated influenza vaccine and sab no relationship
Trivalent Inactivated Influenza Vaccine and SAB IllnessNO Relationship

  • Case-Control study of 6 healthcare organizationsin Vaccine Safety Datalink

  • Women 18–44 yo with SAB at 5–16 wksEGA, 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. ObstetGynecol Jan 2013;121(1):159–65.

Flu vaccine in pregnancy
Flu vaccine in Pregnancy Illness

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)



Recommendation only

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

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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?”

Bordetella Illness pertussis

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

Bordetella pertussis
Bordetella pertussis Illness

  • Highly infectious

  • Incubation period 7–10 days (range 4–21)

  • Insidious onset of symptoms

  • Fever minimal

Bordetella pertussis the illness three stages of disease
Bordetella Illness pertussis—The IllnessThree Stages of Disease

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

Pertussis cases washington state

Pertussis Cases IllnessWashington State


2011 807



Oct 2012 ACIP IllnessTdap in PregnancyNew Recommendations

Updated Recommendation

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

Current status tdap in pregnant women
Current Status IllnessTdap in Pregnant Women

  • 2.6%

  • Only of women vaccinated in pregnancy(April 2012)

Other immunizations in pregnancy

Other Immunizations in pregnancy Illness

Inactivated vaccines can be given in pregnancy when needed:

Hepatitis A, Hepatitis B, Pneumococcus

Live attenuated vaccines can be given post partum

MMR, varicella

News Release: Measles Cases on the Rise in WA Illness

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.

Thank you,

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 | |

Dealing with vaccine hesitancy

Dealing with Vaccine Hesitancy Illness

Approaching the Vaccine Hesitant parents using


Another one with the C-A-S-E strategy 

What is c a s e

What is C-A-S-E Illness


Acknowledge concerns, find point for agreement; respectful tone

About Me:

Describe what you have done to build knowledge and expertise


Relate what science says


Explain your advice, based on science

Examples of c a s e
Examples of C-A-S-E Illness

  • 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 e1
Examples of C-A-S-E Illness

  • 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 e2
Examples of C-A-S-E Illness

  • 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

Talking Points for Midwives Illness

About Immunization in Pregnancy and Postpartum:

Share reasons why recommend

Highlight positive personal experiences with vaccination

Address questions

Use screening form


More resources

More resources Illness

American College of Nurse-Midwives:

CDC Immunization and Pregnancy chart:

CDC web page, Vaccines for Pregnant Women:

Plain Talk booklet for help in talking with patients about vaccine concerns:

For tips on setting up immunizations in your office

For tips on setting up immunizations in your office Illness

So in summary

So, in summary: Illness

Immunization of ALL Pregnant Women for Flu

Is Recommended

Is Safe any trimester

Protects Mom, grows bigger babies, and protects the NEWBORN

Immunization 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 Illness

  • 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