Workgroup Members

1. Anthrax: Special Considerations forPregnant and Postpartum WomenCommunication and Training Workgroup The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

2. Workgroup Members • Renee Brown-Bryant • Jacqueline Grant • Juliette Kendrick • Catherine Ruhl • Laura Ann Smith • Etobssie Wako • Linda West • Marianne Zotti

4. Questions • What are the primary concerns of pregnant/postpartum women related to vaccinations and treatment? • What did the Pandemic H1N1 Influenza (pH1N1) response reveal about factors that may influence health care providers to support vaccination and treatment recommendations for pregnant/postpartum women? • What factors may affect adherence to antimicrobial inhalational anthrax prophylaxis among anthrax exposed populations? • What factors do we need to consider for training health care providers regarding anthrax and pregnant/postpartum women? • What should the priorities be for future research in this area?

5. QUESTION 1: WHAT ARE THE PRIMARY CONCERNS OF PREGNANT/POSTPARTUM WOMEN RELATED TO VACCINATIONS AND TREATMENT? • Focus is on pregnant and postpartum women • Focus is not specific to anthrax • Much of this background is from pH1N1 response

6. Issues to Consider • Issues specific to pregnant and postpartum women • Critical message components associated with influenza vaccinations among pregnant/postpartum women • Influence of Obstetric (OB) providers on behavior of pregnant women

7. Issues specific to pregnant and postpartum women • Pregnant women are an at-risk population that needs pre-event planning to facilitate good health outcomes 1,2 • Pregnancy is a teachable moment due to the pregnant woman’s strong motivation to protect the fetus3 • High risk pregnant and postpartum women reported caregiving responsibilities for immediate and extended family members after Hurricane Katrina4 • High risk pregnant and postpartum women tended to trust information related to Hurricane Katrina from influential community and/or family members, churches or shelters more than other sources4 1Callaghan et al, 2007; 2 Pandemic & All-Hazards Preparedness Act, 2006; 3 McBride, Emmons & Lipkus, 2003; 4DRH Topline Report, 2008

8. Issues specific to pregnant and postpartum women • Pregnant women were more likely to obtain the influenza vaccine if they believed that • it was very safe or benefits the infant 1,2,3 • pregnant women get sicker than other women1,2,3 • Pandemic H1N1 Influenza (pH1N1) would adversely affect her pregnancy1 1Fridman et al, 2011; 2Goldfarb et al, 2011; 3SteelFisher et al, 2011

9. Critical message components associated with influenza vaccinations among pregnant and postpartum women • Communication to pregnant women needs to include1 • detailed descriptions of the vaccine’s or medication’s benefits or lack of risk to the fetus • risks associated with breastfeeding • clear rationale about why a medicine or vaccine is necessary • Barriers to receiving the Influenza vaccine included • concerns about fetal and maternal health2,3,4 • inadequate knowledge about the importance of the vaccine2 • not knowing where to get the vaccine2 • fear of side-effects3 1Lynch et al, 2011; 2Fisher et al, 2011; 3Fridman et al, 2011; 4Goldfarb et al, 2011

10. Influence of OB providers on behavior of pregnant women • Health care providers were identified by pregnant women as their major source of information about what they should or should not do during pregnancy1 • The pregnant woman’s health care provider was a trusted source of information about the 2009 pH1N12 • Recommendations to receive pH1N1 and seasonal influenza immunizations from health care providers were associated with pregnant women being vaccinated3,4,5 1Aaronson, Mural & Pfoutz, 1988; 2Lynch et al, 2011; 3Ahluwalia, et al, 2010; 4Ding, et al, 2011; 5Tong, et al, 2008

11. Workgroup Recommendations • Pilot test all communication materials and messages for both pregnant and postpartum women • Ensure that messages address pregnant and postpartum women’s primary concerns • Benefits or lack of risk to the fetus • Clear rationale about why a medicine or vaccine is necessary • Implications for breastfeeding among postpartum women with anthrax or who receive antibiotics and/or vaccines • Risks to other family members

12. QUESTION 2: WHAT DID THE pH1N1 RESPONSE REVEAL ABOUT FACTORS THAT MAY INFLUENCE HEALTH CARE PROVIDERS TO SUPPORT VACCINATION AND TREATMENT RECOMMENDATIONS FOR PREGNANT/POSTPARTUM WOMEN? • Focus is on health care providers and pH1N1 response

13. Issues to Consider • Provider knowledge, attitudes, and behavior • Public health support for local physicians pertaining to CDC pH1N1guidance • Public health support to local communities pertaining to CDC pH1N1guidance

14. Provider knowledge, attitudes, and behavior • From focus groups of obstetricians/gynecologists, family physicians, certified nurse midwives and nurse practitioners regarding pH1N1:1 • Most were aware of the CDC guidance • There were mixed perceptions of pH1N1 as a severe threat among pregnant women • Some providers expressed confusion about vaccination schedules and vaccine safety during the first trimester • Some expressed concern about presumptive treatment of sick pregnant women • Primary trusted sources of information were CDC, professional organizations, and state and local public health 1Mersereau et al, 2012

15. Public health support for local physicians pertaining to CDC pH1N1guidance • Local public health and medical care providers gave suggestions below to facilitate use of CDC pH1N1guidance: 1 • The CDC website has been a tremendous resource to clinicians, particularly the “information box” with dates and times that notifies readers of updated information or changes in guidance. • OB/GYNs are very concerned about adverse effects to their pregnant patients from vaccination. • The CDC website should link to websites of professional societies to provide reliable information on locations where pregnant patients can be vaccinated. 1Meeting notes, “Considerations for Pregnant Women, Newborns and Children in an Anthrax Response: Medical/Public Health Collaboration,” September 7, 2011, Atlanta, Georgia

16. Public health support for local communities pertaining to CDC pH1N1guidance • GA Public Health Districts (examples of activities): • Fact sheets with summaries of CDC changes for primary care and OB providers • Vaccine distribution to physician offices, colleges, others such as Job Corps • Distribution of antivirals to hospitals • Distribution of antivirals to hospital ERs and pharmacies for vulnerable populations • Local school-based vaccination clinics and drive through vaccination sites • Fact sheets for patients (English and Spanish) • Letters to schools and camps • Call lines with triage messages

17. Workgroup Recommendations • Pilot test all communication materials and messages for OB professionals (including physicians, nurse midwives, nurse practitioners, physician assistants, and registered nurses) • Develop strategies for communication with OB professionals that include CDC, professional organizations, and state and local public health

18. QUESTION 3: WHAT FACTORS MAY AFFECT ADHERENCE TO ANTIMICROBIAL INHALATIONAL ANTHRAX PROPHYLAXIS AMONG ANTHRAX EXPOSED POPULATIONS? • Focus is not on pregnant and postpartum women

19. Issues to Consider • 2001 response: Public health communication issues • 2001 response: Health care provider communication with exposed populations • 2001 response: Other influences on adherence behavior • Priority issues identified by local providers in 2011

20. 2001 response: Public health communication issues • Initially both Senate and postal workers relied on public health for information and guidance1,2 • Repeated visits by public health staff to worksites promoted adherence among postal workers3 • Postal workers reported that they wanted public health information in a variety of formats, both written and orally, as well as information from the media3,4 • Trust in information from public health eroded due to confusion, unclear or inaccurate messages, disorganization, inability or perceived unwillingness of public health staff to answer questions, and a perception of unfair treatment among postal workers1,2,3,4 1Blanchard et al, 2005; 2Stein et al, 2004; 3Jefferds et al, 2002; 4Quinn et al, 2005

21. 2001 response: Public health communication issues • Perceived lack of empathy in officials contributed to diminished trust1 • Communication lessons learned included a need to: 1,2 • identify priority audiences and how to reach them • use local communication channels • explain contradictions and mistakes 1Quinn et al, 2005; 2Chess, Calia & O’Neill, 2004

22. 2001 response: Health care provider communication with exposed populations • Less than half the Senate and postal workers reported that their physicians supported recommendations by public health1 • Private physician advice to take their medications appeared to positively influence adherence1,2 • Conversely, private physician recommendations to not take their medications negatively affected adherence1,2 1Stein et al, 2004; 2Blanchard et al, 2005

23. 2001 response: Other influences on adherence behavior • Both Senate and postal workers experienced difficulty in judging their risk1 • Adherence was positively affected by coworkers, friends, and family members who encouraged workers to begin antibiotics and to continue taking them1 • Among postal workers, perceived increased risk for developing the disease and >5 physical signs of stress were associated with adherence2 • Among postal workers, adherence was negatively affected by2 • perceptions of adverse drug effects, potential long-term adverse effects, and low risk for developing anthrax • difficulties in remembering to take medications • age <45 years 1Stein et al, 2004; 2Jefferds et al, 2002

24. Priority issues identified by local providersin 2011 • Local medical care providers identified priority issues to promote use of CDC guidance pertaining to anthrax and pregnant and postpartum women:1 • CDC should strongly emphasize and communicate valid information to clinicians about the severity of their pregnant patients not receiving treatment during an event. This approach will be critical to obtaining clinician support and endorsement. For example, CDC’s emphasis on the 60% mortality rate from anthrax would be a strong motivator. • CDC should provide the evidence base for guidance or clearly articulate the rationale for the absence of supporting data for its recommendations to assure transparency. • Regardless of the communication channel, clinicians will need rapid answers to many questions regarding exposure (e.g., Is it better to over-treat or under-treat pregnant women initially?) Meeting notes, “Considerations for Pregnant Women, Newborns and Children in an Anthrax Response: Medical/Public Health Collaboration,” September 7, 2011, Atlanta, Georgia

25. Workgroup Recommendations • Develop critical background documents needed to guide communication • Scientific guidance regarding anthrax treatment and prevention • Talking points for both the exposed and the worried well populations • Strategies to promote long-term drug adherence among pregnant and postpartum women • A resource describing antibiotic use during pregnancy • The pregnancy estimation document to help to determine the number of pregnant women to reach in a geographic area • Any surveillance data about pregnant women and anthrax

26. Workgroup Recommendations • Identify priority audiences who may influence the behaviors of pregnant and postpartum women • Develop a broad-based strategy that includes messages to pregnant and postpartum women, their health care providers, local and state public health, and a variety of other partners • Develop short, concise, and flexible communication materials because guidelines are likely to change during an event

27. Workgroup Recommendations • Leverage DRH and other CDC partnerships with professional and nonprofit organizations and state and local public health • Develop pre-event training for OB professionals regarding anthrax in pregnant and postpartum women and prevention and treatment recommendations

28. QUESTION 4: WHAT FACTORS DO WE NEED TO CONSIDER FOR TRAINING HEALTH CARE PROVIDERS REGARDING ANTHRAX AND PREGNANT and POSTPARTUM WOMEN?

29. Issues to Consider • Bioterrorism and emergency preparedness are priority topics for most medical specialties • Health care providers may need an incentive to seek training related to anthrax • Health care providers have limited time for training

30. Bioterrorism and emergency preparedness are priority topics for most medical specialties • A study revealed that bioterrorism and emergency preparedness are priority topics for most medical specialties1 • Following bioterrorism preparedness training of 578 physicians, residents, and third and fourth year medical students, 94% agreed that the training increased their understanding of bioterrorism, but only 42% stated that they were prepared to respond2 • ACOG issued a Committee on Obstetric Practice Opinion on Management of Asymptomatic Pregnant or Lactating Women Exposed to Anthrax in 2002 and reaffirmed it in 2009 1Lane et al, 2012; 2Switala et al, 2011;

31. Bioterrorism and emergency preparedness are priority topics for most medical specialties • The American Medical Association convened organizational leaders from medical specialties, nursing, public health, physician emergency medical services, and the Uniformed Services University to develop a new educational framework for disaster medicine and public health preparedness1 • 7 core learning domains, • 19 core competencies • 73 specific competencies • All above targeted at 3 broad health personnel categories • Emergency preparedness and disaster response core competencies have been identified for perinatal and neonatal nurses2 1Subbarao et al, 2008; 2Jorgensen et al, 2010

32. Health care providers may need an incentive to seek training related to anthrax • Local public health and medical care providers gave the suggestions pertaining to motivating clinicians:1 • Specific actions should be taken to motivate clinicians in various MCH fields (e.g., OB/ GYNs, neonatologists and pediatricians) to attend pre-event training and receive education on anthrax as an actual threat. For example, existing preparedness activities at the local level should be expanded to include pre-event training for clinicians. • The ACOG Educational Committee should be extensively involved in creating new emergency preparedness and response requirements for clinicians. 1Meeting notes, “Considerations for Pregnant Women, Newborns and Children in an Anthrax Response: Medical/Public Health Collaboration,” September 7, 2011, Atlanta, Georgia

33. Health care providers have limited time for training • Local public health and medical care providers gave the suggestions for training busy clinicians:1 • Continuing medical education (CME) should be offered through professional societies for clinicians to complete a preparedness course. Hospital medical staff meetings should be utilized as a forum to disseminate EPR information. An emergency preparedness and response video for clinicians should be developed and widely disseminated. • Professional associations (e.g., AAP, ACOG and ACP) should be encouraged to disseminate basic pre-event training materials to their members to guide discussions with their patients. • Pre-event training should clarify whether clinicians or public health will be expected to handle MCH patients during an event. 1Meeting notes, “Considerations for Pregnant Women, Newborns and Children in an Anthrax Response: Medical/Public Health Collaboration,” September 7, 2011, Atlanta, Georgia

34. Workgroup Recommendations • Develop a ‘public health communication 101’ course to guide OB professionals’ understanding of risk communication • Leverage existing mechanisms for providing CMEs and CEUs pertaining to anthrax • Work with professional organizations to insert preparedness articles within existing training/certification (board) processes • Publish preparedness articles in journals that promote CMEs and CEUs • Develop online training modules for CMEs and CEUs that can be distributed through channels such as WebMD and Medscape

35. Workgroup Recommendations • Plan and develop rapid or ‘just-in-time’ training pertaining to anthrax and pregnant and postpartum women that includes: • A team who is responsible for daily content updates • Easily modifiable slide presentations for the public and for OB professionals • Talking points that are time sensitive • Is adaptable for a variety of training modalities

36. Question 5: What should the priorities be for future research in this area?

37. Need for More Data • Little known data exists about knowledge of anthrax or attitudes towards medications or vaccines among pregnant and postpartum women • Data concerning provider knowledge and support of public health recommendations in 2001 event were reported by exposed populations, not the health care providers • Little known data exists about OB professionals’ knowledge of anthrax or attitudes towards anthrax medications or vaccines for pregnant and postpartum women

38. Workgroup Recommendations • Conduct qualitative and/or quantitative research to assess knowledge about inhalational anthrax and attitudes toward vaccines, antibiotics and other treatments • Among pregnant/postpartum women, their families and community leaders • Among OB professionals