anthrax: special considerations for pregnant and postpartum women communication and training...

Anthrax: Special Considerations forPregnant and Postpartum Women

Communication 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.

Workgroup Members

Renee Brown-Bryant

Jacqueline Grant

Juliette Kendrick

Catherine Ruhl

Laura Ann Smith

Etobssie Wako

Linda West

Marianne Zotti

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?

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

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


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


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 women 1,2,3

Pandemic H1N1 Influenza (pH1N1) would adversely affect her pregnancy1

1Fridman et al, 2011; 2Goldfarb et al, 2011; 3SteelFisher et al, 2011

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-effects31Lynch et al, 2011; 2Fisher et al, 2011; 3Fridman et al, 2011; 4Goldfarb et al, 2011

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

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

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

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

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

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

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


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

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

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


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


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

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

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 years1Stein et al, 2004; 2Jefferds et al, 2002

Priority issues identified by local providers in 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


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


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


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

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

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

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;

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

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.


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.



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


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

QUESTION 5: WHAT SHOULD THE PRIORITIES BE FOR FUTURE RESEARCH IN THIS AREA?

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


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

anthrax: special considerations for pregnant and postpartum women communication and training...

Documents

behavior of pregnant

postpartum women communication

postpartum women focus

high risk pregnant

influenza vaccinations

influenza vaccine

ph1n1 response slide

issues specific