vaccinations in pregnancy.ppt
TRANSCRIPT
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Vaccinations
in PregnancyDr .Ashraf FoudaDamietta General Hospital
E-mail:[email protected]
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Adult immunization rates
have fallen short of national
goals, partly because ofmisconceptions about the
safety and benefits ofcurrent vaccines.
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The danger of these
misconceptions is magnifiedduring pregnancy, when:
1. Concerned physicians are hesitantto administer vaccines and
2. Patients are reluctant to acceptthem.
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The administration of
vaccines during pregnancyposes a number of concerns
about the risk of transmittinga virus to a developing fetus.
This risk is primarilytheoretic.
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The risk oftransmitting a virus to
a developing fetusis primarily theoretical
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Routine vaccines that
generally are safe duringpregnancy include:
1. Diphtheria,2. Tetanus,
3. Influenza, and
4. Hepatitis B
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Other vaccines,such as:
1.Meningococcal and
2.Rabies,may be considered.
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Vaccines that are contraindicated
include:,1. Measles, Mumps, and Rubella;
2. Varicella; and3. (BCG)bacille Calmette-Gurin.
(because of the theoretic risk
of fetal transmission)
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Theoretic risks of
vaccination must be
weighed against the
risks of the diseaseto mother and fetus.
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Inadvertent
administration of anyof these vaccinations,
isnot considered anindication for
termination of the
pregnancy
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Live-virus vaccinesare therefore
generallycontraindicated
in pregnant women.
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if a live-virus vaccine is
inadvertently given to a pregnant
woman, or if a woman becomes
pregnant within four weeks after
vaccination,she should be counseled about
potential effects on the fetus.
Center for Disease Control and
Prevention (CDC)
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Physicians should reassuretheir patients that
no vaccines arecontraindicated during
breastfeeding
Immunization during
breastfeeding is safe
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Tetanus andDiphtheria
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Diphtheria is an infection
of the nasal, pharyngeal,laryngeal, or other mucous
membranes that can causeneuritis, myocarditis,
thrombocytopenia, and
ascending paralysis
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Tetanus infection cancause production of a
neurotoxin, leading totetanic muscle
contractions.
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Tetanustoxoidis routinely
recommendedfor susceptible
pregnant women.
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While no evidence exists to prove
that tetanus and diphtheria toxoids
are teratogenic,
waiting until the second trimester
of pregnancy to administer toxoidsis a reasonable precaution,
minimizing any concern about thetheoretic possibility of such
reactions.
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Previously vaccinatedpregnant women who have
not received a Tdvaccination within the past10 years should receive a
booster dose.
Tetanus and Diphtheria
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Pregnant women who
are not immunized oronly partially immunized
should complete theprimary series.
Tetanus and Diphtheria
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Influenza
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Fever, malaise, myalgia, andupper respiratory tract symptoms
or infections characterize influenzainfection.
Most severe complications are theresult of pneumonia secondary toinfluenza infection.
Influenza
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The influenza vaccine is
a killed virus preparationwith an annually
adjusted antigenicmakeup.
Influenza
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It should be
administered annuallybetween October and
December to high-riskpatients.
Influenza
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The vaccine should be
administered to all pregnant
women who will be in the
second or third trimester of
pregnancy during the influenza
season
Influenza
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Women in their second or thirdtrimesters have higher morbidity, frominfluenza infection.
Immunization should be avoided inmost patients during the first trimester
to avoid a coincidental associationwith spontaneous abortion, which iscommon in the first trimester.
Influenza
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Hepatitis A
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It is acquired via thefecal-oral route
by person-to-personcontact or ingestion ofcontaminated food or
water.
Hepatitis A
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Safety during pregnancy hasnot been determined.
Because hepatitis A vaccine isproduced from inactivated
virus, the risk to the developingfetus is expected to be low.
Hepatitis A
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Administration of immuneglobulin is strongly
recommended;which is considered safe during
pregnancy and is more than 85% effective in preventing acutehepatitis
Hepatitis A
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Hepatitis B
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Transmitted through:1.Contact with infected
blood,2.Sexual activity, and
3.Sharing of intravenousneedles.
Hepatitis B
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The risk of developing chronic illness
associated with complications
(cirrhosis, hepatocellular carcinoma,and a chronic carrier state)
has been a key factor in the
recommendation for
universal vaccination of all children
Hepatitis B
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Risk factors for a pregnant woman include:
1. Having multiple sexual partners,
2. Using or abusing intravenous drugs,3. Having occupational exposure, and
4. Being a household contact of acutelyinfected persons or persons with a
chronic carrier state.
Hepatitis B
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The hepatitis B vaccine containsviral surface antigen produced by
recombinant DNA technology.It is administered in three doses,at birth and at one and six monthsof age, and has minimal to no sideeffects.
Hepatitis B
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Because it containsnoninfectious hepatitis B
surface antigen particles andit cause no risk to the fetus,
neither pregnancy nor lactationis a contraindication tovaccination.
Hepatitis B
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Pneumococcal
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Streptococcus pneumoniaeis a gram-positive diplococci
that is a major cause of1. Pneumonia,
2. Meningitis, and3. Bacteremia.
Pneumococcal
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Risk factors for pneumococcalinfection in pregnant women include
1. Diabetes,2. Cardiovascular disease,
3. Immunodeficiency,4. Asthma.
Pneumococcal
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The current vaccine includespurified capsular
polysaccharidewomen at high risk should be
given this vaccination before,but not during, pregnancy.
Pneumococcal
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The safety of the vaccineduring pregnancy has not
been evaluated, although noadverse outcomes have beenreported among newborns
whose mothers wereinadvertently vaccinated.
Pneumococcal
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Polio
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Enterovirus with three different strainsthat cause disease.
Exposure may result in asymptomaticinfection as well as nonparalytic and
paralytic disease.Asymptomatic patients can transmit
the disease to susceptible persons
Polio
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The disease continues to be a
problem worldwide, but all recent
domestic polio cases have beencaused by the strains of virus
found in the oral polio vaccine(OPV).
Polio
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This situation has resulted in achange in the recommendation foruse of inactivated polio vaccine (IPV),
instead of OPV or a combination ofOPV-IPV for all routine vaccinations.
IPV is inactivated by formaldehyde,and its use has eliminated vaccine-associated polio infection.
Polio
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Although no adverse effectshave been documented with
OPV or IPV in pregnantwomen or their fetuses,both vaccines should be
avoided during pregnancy ona theoretic basis.
Polio
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The CDC states that IPV may beadministered in accordance with
the recommended schedules foradults if a pregnant woman is atincreased risk for infection and
requires immediate protectionagainst polio.
Polio
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Varicella
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Varicella vaccination is
contraindicated during
pregnancy because ofpotential adverse effects
on the fetus.
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The varicella-zoster viruscauses chickenpox and rarely
cause serious complications,(as encephalitis and
pneumonia).Up to 15 % of infected persons
have herpes zoster later in life
Varicella
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The varicella vaccine
contains live
attenuated varicella-zoster virus.
Varicella
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Women who are vaccinated shouldavoid becoming pregnant for one
month following each injection.The presence of pregnant household
members does not constitute acontraindication to vaccination ofothers within the house.
Varicella
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If a susceptible pregnantwoman is exposed to
varicella, however,administration of varicella-
zoster immune globulinshould be stronglyconsidered.
Varicella
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Theoretic risks to the fetus are verysmall, and exposure to the varicella
vaccine is not an indication fortermination of pregnancy.
Data from more than 300 deliveries
indicate no birth defects compatiblewith congenital varicella syndrome.
Varicella
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Meningococcal
i l
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In the USA, meningococcal disease isthe leading cause of bacterial
meningitis in children ages twothrough 18 years.
Meningococcal vaccine contains thepurified polysaccharide of four
serogroups of Neisseria meningitidis
Meningococcal
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Routine vaccination is recommendedfor high-risk groups, including
1. Military recruits,2. Patients with terminal complement
component deficiencies, and3. Persons with anatomic or functional
asplenia
Meningococcal
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Vaccination also may benefit travelers toareas in which N. meningitidis is endemic
or epidemic, such as sub-Saharan Africa.Studies have shown that the
meningococcal vaccine is safe andefficacious when given to pregnant
women
Meningococcal
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Measles,
Mumps,
andRubella
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It is caused by the measlesvirus, typically presents with:
1. Fever,2. Coryza,
3. Generally ill appearance, and4. Confluent, erythematous,
maculopapular rash
Measles
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Mortality occurs in1-2 per 1,000 cases,often secondary to
pneumonia orencephalitis.
Measles
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Measles, mumps, and
rubella vaccineshould not be given to
pregnant women,because of potential
adverse effects on thefetus.
M
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Mumps results from infection withthe mumps virus and can lead to
parotitis, meningoencephalitis, andorchitis.
Neurologic complications, such asdeafness, can also occur as aresult of mumps infection.
Mumps
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Rubella
Rubella, or German
measles, is caused
by the rubella virus.
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Women should be counseled to avoidbecoming pregnant within four weeks
of vaccination by MMR.Pregnancy has been considered a
contraindication to vaccination with
the rubella vaccine because ofpotential adverse effects on the fetus.
Measles, Mumps, and Rubella
Measles Mumps and Rubella
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For women who received rubella vaccine within
three months of conception.
Pregnancy outcomes in 683 vaccine recipients
showed no evidence that the rubella vaccinecaused any fetal abnormalities or congenital rubella
syndrome.
However, rubella-specific IgM has been detected incord blood, suggesting possible subclinical
infection.
Measles, Mumps, and Rubella
l d b ll
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Because of the theoretic risk,guidelines state that precautions
should be used to prevent rubellavaccine administration duringpregnancy, but pregnancy testingbefore vaccination is notconsidered to be necessary.
Measles, Mumps, and Rubella
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Other Vaccinations
V i ti t i ll t
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Vaccinations typically notadministered on a routine basisby family physicians and othervaccines of interest include:
anthrax, smallpox, rabies,Japanese encephalitis, yellow
fever, BCG, typhoid, cholera,and plague.
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ANTHRAX
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Anthrax is caused by thespore-forming bacterium
Bacillus anthracis,occurring inhumans in three forms:
1. Cutaneous,2. Inhalational, and
3. Gastrointestinal
ANTHRAX
ANTHRAX
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The potential use of anthrax inacts ofbioterrorism has long
been a concern because of its:1. Stability,
2. High mortality, and
3. High potential for respiratorytransmission.
ANTHRAX
ANTHRAX
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The anthrax vaccine isprepared from a bacteria-
free culture containing thethree major toxin
components produced bythe bacteria
ANTHRAX
ANTHRAX
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The recommended immunizationschedule consists of:
1. Three injections given at two-week intervals,
followed by another2. Three doses at six-month
intervals.
ANTHRAX
ANTHRAX
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No studies have addressed thesafety of the anthrax vaccine
during pregnancy.As with other non live- virus
vaccines, anthrax vaccine does notcarry theoretic risks of fetalinfection.
ANTHRAX
ANTHRAX
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Vaccination should beconsidered on a case-by-casebasis and administered onlywhen the potential benefits
outweigh the potential risksto the mother and fetus.
ANTHRAX
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SMALLPOX
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Smallpox is an
orthopoxvirus, was certified
as eradicated in 1980,
and
no longer occurs naturally.
SMALLPOX
SMALLPOX
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Prodromal symptoms include ahigh fever and oral lesions thatulcerate, followed by a macularrash.
The rash becomes raised, then
umbilicated and pustular,particularly when on the face and
extremities
SMALLPOX
SMALLPOX
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Recent world events havebrought to light the threat
of terrorists who mayrelease smallpox, and have
prompted an evaluation ofvaccination policies
SMALLPOX
SMALLPOX
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Vaccinia vaccine should
not be administered topregnant women for
routine nonemergencyindications.
SMALLPOX
SMALLPOX
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Smallpox infection amongpregnant women has
been reported to result ina more severe infection
than among nonpregnantwomen.
SMALLPOX
SMALLPOX
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The vaccine has not been shownto be teratogenic or to causecongenital malformations, but the
virus has been reported to causefetal infection on rare occasion,
with subsequent risk ofskin lesions, preterm delivery,
stillbirth, or infant death.
SMALLPOX
SMALLPOX
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Women should thereforeactively avoid becomingpregnant for at least four
weeks after vaccination and
until the scab has completelyhealed and fallen off.
SMALLPOX
SMALLPOX
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Vaccination should also be avoidedfor household or close contacts of
women who are pregnant.Inadvertent vaccination duringpregnancy, however, should notbe considered a reason toterminate the pregnancy
SMALLPOX
SMALLPOX
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The safety of breast milk aftermaternal vaccination has not beenstudied, so women who are
breastfeeding should not receivethe vaccine.
Household contacts ofbreastfeeding infants theoretically
can be immunized
SMALLPOX
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RABIES
RABIES
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Rabies is a viral infectiontransmitted most commonly by
the saliva of infected animals.Nonspecific prodromal symptoms
progress to encephalitis markedby confusion, hallucinations.
RABIES
RABIES
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Dysregulation of the autonomicnervous system and involvement of
the brainstem and cranial nerves leadto the classic "foaming at the mouth"appearance.
Three forms of inactivated rabiesvaccines are available, all considered
equally safe and efficacious
RABIES
RABIES
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Passive immunization is achieved
through administration of humanrabies immune globulin (HRIG).
Indications for pre-exposureimmunization depend on thelikelihood of exposure.
It may be considered in animalworkers and travelers to enzootic
areas who anticipate animal exposure
RABIES
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With any animal bites or
wild animals, the animalshould be euthanized,
and the brain tested forinfection.
RABIES
RABIES
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Bites from normally actingdogs, cats warrant a 10-day
observation period,with prophylaxis and
euthanization of the animaldeferred.
RABIES
RABIES
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In patients who have not been immunizedpreviously, 20 IU per kg of HRIG is givenat the wound site for high-risk bites or iftesting is positive.
Patients with previous vaccinations do notneed HRIG but do require revaccinationon a modified schedule.
There have been no identified associationsbetween rabies vaccination and fetalabnormalities
S
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JAPANESE ENCEPHALITIS
JAPANESE ENCEPHALITIS
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Japanese encephalitis (JE) is theleading cause of viralencephalitis in Asian countries,
With one quarter of caseshaving a fatal outcome, and
Residual neuropsychiatricsequelae occurring in up to onehalf of survivors.
JAPANESE ENCEPHALITIS
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Most human infections
occur in rural areas, where
flooded rice fields support
large populations of the
Culex mosquitoes that
transmit the virus
JAPANESE ENCEPHALITIS
JAPANESE ENCEPHALITIS
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Travelers to rural parts of Asia have ahighly variable risk of acquiring JE
infection, estimated at approximately1 in 5,000 per month.
In the case of short-term travel to
urban areas, however, risks ofacquiring JE infection are less thanone per million.
JAPANESE ENCEPHALITIS
JAPANESE ENCEPHALITIS
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@Vaccination is
recommended onlyfor travelers with
a significant risk ofexposure.
JAPANESE ENCEPHALITIS
JAPANESE ENCEPHALITIS
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The vaccine is an inactivated virusvaccine that produces a 99% rate
of seroconversion after threedoses.
No specific data are availableregarding JE vaccine safety inpregnancy.
JAPANESE ENCEPHALITIS
JAPANESE ENCEPHALITIS
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Since JE infection during thefirst and second trimesters has
been associated withintrauterine infection andmiscarriage,
the vaccine is notrecommended during this time
JAPANESE ENCEPHALITIS
JAPANESE ENCEPHALITIS
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Infections during thethird trimester have notbeen associated withadverse outcomes in
newborns.
JAPANESE ENCEPHALITIS
JAPANESE ENCEPHALITIS
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Vaccination should beconsidered before conception
in a woman who will betraveling to high-risk areas
while pregnant, in conjunctionwith optimized mosquito-bite
precautions.
JAPANESE ENCEPHALITIS
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YELLOW FEVER
YELLOW FEVER
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Yellow fever is a viral hemorrhagicfever syndrome spread by
mosquitoes in parts of SouthAmerica and Africa.
The yellow fever vaccine is a live,attenuated virus grown in chickembryos.
YELLOW FEVER
YELLOW FEVER
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It is indicated for use in
laboratory workersinvolved with the virusand in persons planning totravel to endemic areas.
YELLOW FEVER
YELLOW FEVER
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No specific evidence is available todemonstrate the safety of yellowfever immunization during
pregnancy.Since theoretic concerns of fetal
infection exist, however,vaccination is generally notrecommended during pregnancy.
YELLOW FEVER
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When travel cannot bepostponed and mosquito
exposure is likely,
yellow fever vaccinationmay be considered.
YELLOW FEVER
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BCG VACCINE
BCG VACCINE
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Mycobacterium tuberculosiscauses more than 8 millionnew cases of tuberculosis
(TB) annually,the majority of them indeveloping countries.
BCG VACCINE
BCG VACCINE
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BCG(bacille Calmette-Gurin)
vaccine is a live vaccinederived from a strain ofMycobacterium bovis.
BCG VACCINE
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It is likely that the BCG vaccinehas been given to thousands of
pregnant women in othercountries.
While no harmful fetal sideeffects have been identified todate.
BCG VACCINE
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Use of the BCG
vaccine isnot recommendedduring pregnancy.
BCG VACCINE
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TYPHOID
TYPHOID
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Most cases of typhoid fever indeveloped countries occur in
travelers who recently havereturned from high-risk areas,
such as South America, India,and western Africa
TYPHOID
TYPHOID
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Transmission ofSalmonella typhi
is significantly increased withtravel during
local epidemics andingestion of food from streetvendors.
TYPHOID
TYPHOID
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Primary prevention consists of:
1. Hand washing,
2. Drinking only safe water,
3. Peeling all fruits and
vegetables, and4. Eating well-cooked foods.
TYPHOID
TYPHOID
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The two types of typhoid vaccination inuse today are a live attenuated oral
vaccine and a parenteral polysaccharidevaccine.
Both forms require that immunization becompleted at least two weeks before
exposure.
TYPHOID
TYPHOID
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Its use is contraindicated in:1. Infants,
2. Immunocompromised persons, and3. Those with abnormal gastrointestinal
function, as well as4. Pregnant women.
TYPHOID
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Neither form of
typhoid vaccine isofficially
recommended duringpregnancy.
TYPHOID
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CHOLERA
CHOLERA
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Cholera is an acute diarrheal diseaseendemic to Africa, Asia, and LatinAmerica.
It is caused by a toxin from Vibriocholerabacteria, which live in, and
are transmitted by, the fecal-oralroute from contaminated watersources.
CHOLERA
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Two improved oral vaccines are available :1. a killed, whole cell recombinant vaccine and
2. a live, attenuated strain.
Both are more effective, better tolerated, andlonger lasting than the parenteral vaccine.
These may be considered for use inpopulations at immediate risk of a choleraepidemic or for travelers to areas of high
endemicity
CHOLERA
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No specific information exists onthe safety of parenteral cholera
vaccination during pregnancy.Because cholera during pregnancyis a serious illness, exposureshould be minimized duringpregnancy whenever possible.
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PLAGUE
PLAGUE
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Plague, a disease caused by Yersiniapestis, is naturally hosted by rodents andtheir fleas.
It occurs more commonly in semi-ruralareas of Africa, Asia, and South America.
The plague vaccine is no longercommercially available in the UnitedStates.
PLAGUE
PLAGUE
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It was recommended only for use intravelers to endemic areas who had ahigh risk of exposure to wild rodents and
fleas. Its efficacy was not well studied.
All persons with definite exposure shouldreceive a seven-day course of appropriateantibiotics (often doxycycline, or
trimethoprim-sulfamethoxazole)
PLAGUE
PLAGUE
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The effects of plague vaccine on thedeveloping fetus are not known.
Pregnant women should avoid high-risk
situations and use insecticides and otherprotective measures.
Prophylactic antibiotics that are safeduring pregnancy may be considered inwomen with a substantial risk of infection.
PLAGUE
Preconceptional
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Preconceptional
immunization of pregnantwomen to prevent disease
in the offspring ispreferred to vaccination
of pregnant women.
The benefits of
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The benefits of
immunization to thepregnant woman and her
neonate usuallyoutweigh the theoretic
risks of adverse effects.
The theoretic risks of
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The theoretic risks of
the vaccination ofpregnant women withkilled virus vaccines
have not beenidentified.
f
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Vaccination of womenduring the postpartum
period, especially forrubella and varicella,
should be encouraged.
Women susceptible to
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Women susceptible to
rubella should bevaccinated with
measles
mumps
rubellaon postpartum discharge
from the hospital.
Generally,
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y,
live-virus vaccinesare contraindicated for
pregnant women becauseof the theoretical risk of
transmission of the vaccinevirus to the foetus.
Whether live or inactivated
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vaccines are used,vaccination of pregnant
women should be considered
on the basis ofthe risk of the vaccination vs.
the benefits of protection in aparticular circumstance.
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