ACOG committee update on Immunization in Pregnancy

The American College of Obstetricians and Gynecologists (ACOG) has released updated guidelines for Tetanus, Diphtheria, and Pertussis Vaccination (Tdap) in pregnancy.

The Committee Opinion No. 718 was published in September issue of Journal of Obstetrics and Gynecology.

This update is especially important to reduce pertussis infection in newborn through passive immunization. Infants 3 months and younger face high risk of pertussis infection and the earliest possible shot they can receive is at 6 weeks of age, thereby leaving a window when they are vulnerable for infection from close family itself.

Increasing research and study data available since 2013, have shown that if mother receives Tdap during the late second or early third trimester (with at least 2 weeks from the time of vaccination to delivery), it is   highly effective in protecting the infant against neonatal pertussis.

The recommendations state that:

1) All pregnant women should be vaccinated with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap)during each pregnancy between 27–36-weeks-of-gestation period if possible.

2) All pregnant women should be reassured about safety of vaccine during each pregnancy, so that the newborn can be protected against pertussis till he starts with his own vaccination series.

3) All obstetric health care provider should carry the vaccine and administer it to the women during prenatal visits.

4) All family members, caregivers should also be offered the vaccination if not already received. The ideal time for them to receive the vaccine is 2 weeks before the expected arrival of the baby.

5) If not received during pregnancy the women should be vaccinated postpartum, if she has not received Tdap as adolescent, adult or during the previous pregnancy.

6) In certain circumstances, the women can be given the vaccine outside the 27–36 weeks of gestation window like pertussis outbreak in the community or managing a wound.

7) If she receives the vaccine outside the 27–36 weeks of gestation window, she need not be again given a second dose during 27–36 weeks.

Full Text of Committee Opinion. 

Maternal vaccines uptake during pregnancy remains low despite years of efforts.

 

courtesy istock. 

The development of new vaccines and the safety data now available for old vaccines ensures that more and more patients should receive the required vaccination in pregnancy. This is important in disease prevention and transfer of passive immunity to the unborn child.

The uptake of two commonly recommended influenza and the tetanus-diphtheria-acellular pertussis (Tdap) vaccine remains low despite being advised since years. The most recent national data was presented at 47^thNational Immunization Conference (NIC) hosted by CDC in Atlanta, Georgia.

The data showed that Tdap vaccination coverage is only 10% in pregnancy while the influenza vaccination rate among pregnant women is about 50%, with 14% of women being vaccinated in the 6 months before pregnancy and 36% during pregnancy.

In a survey sent out by Sean O’Leary, MD, of the department of pediatrics, section of infectious diseases, at the University of Colorado, Denver and his colleagues, it was seen that only 75% of gynecologists routinely administered the Tdap vaccine, and 85% routinely administered the influenza vaccine to their pregnant patients.

Reimbursement-related issues topped the list of barriers, while lack of time during the antenatal visits, refusal by the patients and inability to maintain the stock of vaccines were other issues.

Dr O’Leary  said “Immunization delivery in the ob.gyn. setting may present different challenges than more traditional settings for adult vaccination, such as family medicine or internal medicine offices.”

Vaccines recommended for all pregnant women

The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommends a dose of Tdap during each pregnancy, irrespective of the patient’s prior history of receiving Tdap. Optimal timing for Tdap administration is between 27 weeks and 36 weeks of gestation to maximize the maternal antibody response and passive neonatal transfer.

Influenza vaccination is recommended if patient is pregnant during the flu season.

courtesy: shot of prevention 

Vaccines recommended for selected pregnant women who are at risk or  traveling to high risk areas.

Hepatitis A: The vaccine carries no known risks to the developing fetus.  

Hepatitis B: vaccine can be given in pregnancy in some circumstances. Limited data suggest that developing fetuses are not at risk for adverse events when hepatitis B vaccine is administered to pregnant women. [1]

Pneumococcus: safe if given in second and third trimester.[2]

General principles of Immunization in Pregnancy

The ACOG recommends routine assessment of immunization status of all pregnant women and administration of indicated vaccines.

Robust data and growing body of evidence demonstrate that administering inactivated virus or bacterial vaccines or toxoids is safe during pregnancy.

Live attenuated vaccines (eg, measles-mumps-rubella [MMR], varicella, and live attenuated influenza vaccine) do pose a theoretical risk (although never documented or proved) to the fetus and generally should be avoided during pregnancy.

Women who have inadvertently received immunization with live or live-attenuated vaccines during pregnancy should not be counselled to terminate the pregnancy because of a teratogenic risk.

Women who are breastfeeding can still be immunized (passive-active immunization, live or killed vaccines)

---

[1] https://www.cdc.gov/vaccines/pregnancy/hcp/guidelines.html

[2] http://www.uptodate.com/contents/vaccination-during-pregnancy-beyond-the-basics

Power of Vaccinations in pregnancy.

Vaccinating pregnant women serves the dual purpose of protecting the women as well as her unborn child. Maternal immunization has emerged as a successful strategy to transfer immunity to unborn child and preventing many unnecessary deaths.

United Nations Millennium Development Goals includes reducing maternal and neonatal mortality by reducing vaccine preventable diseases as one of its important goal.

An e-poster during the 2016 ACOG clinical meeting dealt with the clinical importance of increasing acceptance for vaccination during pregnancy.

Dr. Emmie Strassberg from the Geisinger Health System in Danville, Pennsylvania presented results of a survey which showed that the rate of acceptance for the influenza vaccination was 70.1%, compared with 76.3% for the Tdap vaccination.

The study also showed that physician recommendation was the strongest predictor for Tdap vaccine acceptance (P<.001) and educational material distributed among patient increases the influenza vaccine acceptance (P<.001).

Specific Vaccinations in pregnancy depends on age, lifestyle, medical conditions you may have, such as asthma or diabetes, type and locations of travel, and previous vaccinations.

It is advocated that physicians and patients should make sure that the immunizations are up to date before planning to become pregnant.

According to CDC the vaccines recommended in pregnancy are:

Vaccines Before Pregnancy

Most women are vaccinated with MMR in childhood but it is better to confirm. If you need to be vaccinated with Rubella, you should avoid pregnancy for at least a month and ideally till you confirm your immunity by a blood test.

Vaccines During  Pregnancy

Whooping Cough: (Pertussis) is one of the most common vaccine preventable disease. According to CDC all pregnant women should receive a dose of Tdap during each pregnancy, preferably at 27 through 36 weeks. In addition, all family members and caregivers (like babysitters or grandparents) of infants should also get vaccinated with Tdap. After delivery once the baby is 2 months old he should get his pertussis vaccine as recommended by pediatrician.

In June 2013, ACOG weighed in on this issue in a Committee Opinion (#566) from its Committee on Obstetric Practice, agreeing on the importance of a Tdap vaccination for pregnant women due to the safety concerns about pertussis. 

Flu: Pregnant women who get flu, can have serious complications like premature labor, babies that are small for gestational age, hospitalization, and, rarely, death. A woman can be vaccinated with the inactivated flu vaccine at any time during any trimester. The Centers for Disease Control and Prevention (CDC) affirms that pregnant women who get vaccinated for the flu not only receive protection personally but also so do their babies for up to 6 months after their birth. In addition, everyone who cares for the baby should also be vaccinated.

Hepatitis B vaccine:  All pregnant women should be screened for hepatitis B. If she tested negative than vaccination can be considered if she is high risk for the infection. A series of three doses is required to have immunity. The 2nd and 3rd doses are given 1 and 6 months after the first dose. If she tests positive for the disease, then the baby should receive within 12 hours of birth first dose for vaccine and Hepatitis B immunoglobulin (HBIG).

Other vaccines:  Some women may need other vaccines like Hepatitis A and meningococcal vaccine depending upon the life style and travel requirements. These can be administered when needed.

Travel vaccines: Depending on your destination you could need additional vaccines. However, there are some vaccines that should be avoided during pregnancy, so it's best to weigh the risks and benefits of vaccination based on your destination.

References:

http://content.healthaffairs.org/content/35/2/309.abstract

http://www.cdc.gov/pertussis/pregnant/mom/vaccinate-baby.html

http://www.cdc.gov/flu/about/qa/misconceptions.htm