maternal immunization
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
MATERNAL IMMUNIZATION
Linda O Eckert, MD Professor, Department of Obstetrics and Gynecology
Adjunct Professor, Department of Global HealthUniversity of Washington
Helping our Patients Ride the Wave to Improved Health
No conflicts of interest
ObjectivesMaternal Immunization
Review Indications for Flu Vaccine Review Indications for Tdap
Discuss strategies to increase uptake
Measuring Success
Vaccine CoverageNumerator: # 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
ARUARU = Attack Rate Unvaccinated ARV = Attack Rate Vaccinated
VE =
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
InfluenzaWhy care?
Flu Kills
http://theweek.com/article/index/234770/the-cost-of-getting-the-flu-by-the-numbers
The Cost of Getting the FluBy the Numbers5 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
Why are pregnant women considered high-risk?
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
(Neuzil et al. Inf Dis Clin N Am 2001;15:123)
(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
Stage of Pregnancy Modifies Outpatient Influenza-like Illness
(N = 8,323 Healthy Pregnant/Postpartum Women, 1991–1997)
Lindsay. Am J Epidemiol 2006;163:838–48.
Risk of DevelopingIllness with Exposure
Trimester OR (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)
Effect of Pregnancy on Influenza-Related Hospitalizations
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10
15
20
25
Notpregnant
1sttrimester
2ndtrimester
3rdtrimester
Post-partum
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Neuzil et al, Am J Epi 1998;148:1094
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.
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
Vaccinating momsprotects the
infant:
Risk of acquisition when exposed Risk of serious sequelae with illness
Why Vaccinate Pregnant Women?
“Two for One”
Vaccination Against Influenza in PregnancyProtects Infants
Case-control study of infants <12 months admitted to urban hospital (2000–2009): Cases: + influenza test
Controls: – influenza testMatched 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%)
Benowitz I et al. Clin Infect Dis 2010;51(12):1355–61.
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
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
Eick AE et al. Arch Pediatr Adolesc Med Feb 2011;165(2):E1-E8.
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
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
1. Omer SB, PLOS MED 2011.2. www.cdc.gov/flu/protect/pregnant/htm 3. Am J Public Health 2012;102:e33. 4. JAMA 2012;308:165
Trivalent Inactivated Influenza Vaccine and SAB
NO Relationship Case-Control study of 6 healthcare organizations
in Vaccine Safety Datalink Women 18–44 yo with SAB at 5–16 wks EGA, 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. Obstet Gynecol Jan 2013;121(1):159–65.
Flu vaccine in Pregnancy
So, how are we doing?
Internet panel survey: • Conducted April 3–17, 2012• Women pregnant at any time during
4-month period October 2011–January 2012
47% reported had received flu vaccination: 9.9% before pregnancy
36.5% during pregnancy<0.1% after pregnancy
Among 1,660 survey respondents,
Recommendation and offerinfluenza vaccination
(43.7% of women)73.6%
47.9%
11.1%
Recommendation only
No recommendationNo offer
VACCINATIONCOVERAGE
HEALTHCARE PROVIDER
“Continued efforts to encourage providers to routinely recommend and offer influenza vaccination to women who are pregnant or might become pregnant.”
( )( )( )( )( )( )
( )( )( )( )( )( )
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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?”
Reasons for Refusal
Bordetella pertussis
Hack! Hack!! Hack! Hackalougie!! Ahem!!!! Wheeze!!!
Bordetella pertussis Highly infectious Incubation period 7–10 days (range 4–
21) Insidious onset of symptoms Fever minimal
Bordetella pertussis—The IllnessThree Stages of Disease
Catarrhal: • 1–2 weeks• Mild runny nose• Mild fever• Occasional cough
Paroxysmal: • 1–6 weeks Cough: • 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
http://www.kingcounty.gov/healthservices/health/news/2012/12121801.aspx
Pertussis Kills
PERTUSSIS CASESWASHINGTON STATE
20124,7442011 807
http://www.doh.wa.gov/Portals/1/Documents/Pubs/348-254-PertussisUpdate.pdf
http://www.doh.wa.gov/Portals/1/Documents/Pubs/348-254-PertussisUpdate.pdf
http://www.doh.wa.gov/Portals/1/Documents/Pubs/348-254-PertussisUpdate.pdf
Oct 2012 ACIP Tdap in PregnancyNew Recommendations
Updated RecommendationPrenatal care providers implement Tdap immunization program (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine) for all pregnant women with EVERY pregnancy, irrespective of previous Tdap history
Guidance on UseTo 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.
MMWR Feb 22, 2013, Vol 62, #7Independent of
breast feeding
plans
Current Status Tdap in Pregnant Women
Only of women vaccinated in pregnancy (April 2012)
http://www.cdc.gov/vaccines/acip/meetings/slides-oct-2012.html
2.6%
OTHER IMMUNIZATIONS IN
PREGNANCYInactivated vaccines can be given in
pregnancy when needed:Hepatitis A, Hepatitis B, PneumococcusLive attenuated vaccines can be given
post partumMMR, varicella
From: DOH PCH Immunization Child Profile
Sent: Friday, July 11, 2014 11:29 AMSubject: 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 EducatorDepartment of Health | Office of Immunization and Child ProfilePO Box 47843 | Olympia, Washington 98501-7843p 360.236.3529 | f 360.236.3590www.doh.wa.gov | www.childprofile.org | www.waiis.wa.gov
News Release: Measles Cases on the Rise in WA
DEALING WITH VACCINE HESITANCY
Approaching the Vaccine Hesitant parents using
C-A-S-Ehttp://www.immunizeusa.org/media/29064/making_the_case_for_vaccines_mnaap.pdf
Another one with the C-A-S-E strategyhttp://www.sanantonio.gov/Portals/0/Files/health/HealthServices/NIIW%20Presentations/R.%20Carlyle_CASE%20Model%20Presentation.pdf
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 sciencehttp://www.immunizeusa.org/media/29064/making_the_case_for_vaccines_mnaap.pdf
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…”
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”…
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”…
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
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
FOR TIPS ON SETTING UP IMMUNIZATIONS IN YOUR
OFFICE
www.immunizationsforwomen.org
SO, IN SUMMARY:Immunization of ALL Pregnant Women for Flu
• Is Recommended• Is Safe any trimester• Protects Mom, grows bigger babies, and
protects the NEWBORNImmunization 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
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