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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 Gynecology Adjunct Professor, Department of Global Health University of Washington. No conflicts of interest. Objectives Maternal Immunization.

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Maternal Immunization

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  1. 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

  2. No conflicts of interest

  3. ObjectivesMaternal Immunization • Review Indications for Flu Vaccine • Review Indications for Tdap • Discuss strategies to increase uptake

  4. 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 ARU VE = ARU = Attack Rate Unvaccinated ARV = Attack Rate Vaccinated

  5. 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

  6. Influenza Why care?

  7. Flu Kills

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

  9. Why are pregnant women considered high-risk?

  10. 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)

  11. 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.

  12. Effect of Pregnancy on Influenza-Related Hospitalizations Cardiopulmonary Hospitalizationsper 10,000 Neuzil et al, Am J Epi 1998;148:1094

  13. 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.

  14. 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 .

  15. Vaccinating momsprotects the infant: Why Vaccinate Pregnant Women? Risk of acquisition when exposed Risk of serious sequelae with illness “Two for One”

  16. Vaccination Against Influenza in PregnancyProtects 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.

  17. 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 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.

  18. 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 Omer SB, PLOS MED 2011. www.cdc.gov/flu/protect/pregnant/htm Am J Public Health 2012;102:e33. 4. JAMA 2012;308:165

  19. Trivalent Inactivated Influenza Vaccine and SABNO 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.

  20. Flu vaccine in Pregnancy So, how are we doing?

  21. Internet panel survey: • 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

  22. VACCINATIONCOVERAGE HEALTHCARE PROVIDER Recommendation and offerinfluenza vaccination(43.7% of women) 73.6% 47.9% Recommendation only No recommendationNo offer 11.1% “Continued efforts to encourage providers to routinely recommend and offer influenza vaccination to women who are pregnant or might become pregnant.”

  23. Reasons for Refusal ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) *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?”

  24. Bordetella pertussis Hack!Hack!! Hack! Hackalougie!! Ahem!!!! Wheeze!!!

  25. Bordetella pertussis • Highly infectious • Incubation period 7–10 days (range 4–21) • Insidious onset of symptoms • Fever minimal

  26. Bordetella 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

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

  28. Pertussis CasesWashington State 20124,744 2011 807 http://www.doh.wa.gov/Portals/1/Documents/Pubs/348-254-PertussisUpdate.pdf

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

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

  31. Oct 2012 ACIP Tdap 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

  32. Current Status Tdap in Pregnant Women • 2.6% • Only of women vaccinated in pregnancy(April 2012) http://www.cdc.gov/vaccines/acip/meetings/slides-oct-2012.html

  33. Other Immunizations in pregnancy Inactivated vaccines can be given in pregnancy when needed: Hepatitis A, Hepatitis B, Pneumococcus Live attenuated vaccines can be given post partum MMR, varicella

  34. News Release: Measles Cases on the Rise in WA 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 www.doh.wa.gov | www.childprofile.org | www.waiis.wa.gov

  35. Dealing with Vaccine Hesitancy Approaching the Vaccine Hesitant parents using C-A-S-E http://www.immunizeusa.org/media/29064/making_the_case_for_vaccines_mnaap.pdf Another one with the C-A-S-E strategy http://www.sanantonio.gov/Portals/0/Files/health/HealthServices/NIIW%20Presentations/R.%20Carlyle_CASE%20Model%20Presentation.pdf 

  36. 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 science http://www.immunizeusa.org/media/29064/making_the_case_for_vaccines_mnaap.pdf

  37. 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…”

  38. 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”…

  39. 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”…

  40. 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

  41. 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

  42. For tips on setting up immunizations in your office www.immunizationsforwomen.org

  43. So, in summary: 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

  44. 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

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