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Linda O Eckert, MD Professor, Department of Obstetrics and Gynecology Adjunct Professor, Department of Global Health University of Washington Helping our.

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Presentation on theme: "Linda O Eckert, MD Professor, Department of Obstetrics and Gynecology Adjunct Professor, Department of Global Health University of Washington Helping our."— Presentation transcript:

1 Linda O Eckert, MD Professor, Department of Obstetrics and Gynecology Adjunct Professor, Department of Global Health University of Washington Helping our Patients Ride the Wave to Improved Health

2 No conflicts of interest

3  Review Indications for Flu Vaccine  Review Indications for Tdap  Discuss strategies to increase uptake

4 Vaccine Coverage Numerator: # in target group fully immunized by ______ Denominator: Total # in target group Vaccine Efficacy Reduction in incidence of disease among vaccinated vs unvaccinated (ARU minus ARV) x 100 ARU ARU = Attack Rate Unvaccinated ARV = Attack Rate Vaccinated VE =

5 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 Why care?

7 Flu Kills

8

9 The Cost of Getting the Flu By 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

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11 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

12 Lindsay. Am J Epidemiol 2006;163:838–48. Risk of Developing Illness with Exposure TrimesterOR (95% CI) First1.12 (0.79–1.59) Second1.30 (0.97–1.73) Third1.84 (1.31–2.59) Postpartum2.28 (1.43–3.68)

13 Cardiopulmonary Hospitalizations per 10,000 Neuzil et al, Am J Epi 1998;148:1094

14  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):

15  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 /Immunization-in-Pregnancy-and-Postpartum-May-2014.pdf

16 Risk of acquisition when exposed Risk of serious sequelae with illness Why Vaccinate Pregnant Women? “Two for One”

17  Case-control study of infants <12 months admitted to urban hospital (2000–2009): Cases: + influenza test Controls: – influenza test Matched by age/admit date  Of infants admitted at <6 months, number of moms immunized 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

18  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

19  Reduced risk of prematurity by 40% 1  Increased birth weight by 200 gm 2  Another study: n=22, 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 anomalies 4 1.Omer SB, PLOS MED www.cdc.gov/flu/protect/pregnant/htmwww.cdc.gov/flu/protect/pregnant/htm 3.Am J Public Health 2012;102:e JAMA 2012;308:165

20  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.

21 So, how are we doing?

22 Internet panel survey: Conducted April 3–17, 2012 Women pregnant at any time during 4-month period October 2011–January % reported had received flu vaccination : 9.9%before pregnancy 36.5%during pregnancy <0.1%after pregnancy Among 1,660 survey respondents,

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

24 ( ) * 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

25 Bordetella pertussis Hack! Hack!! Hack! Hackalougie!! Ahem!!!! Wheeze!!!

26  Highly infectious  Incubation period 7–10 days (range 4–21)  Insidious onset of symptoms  Fever minimal

27 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

28 Pertussis Kills

29 2012 4,

30

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32 Oct 2012 ACIP Tdap in Pregnancy New Recommendation s Oct 2012 ACIP Tdap in Pregnancy New Recommendation s Updated Recommendation Prenatal 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 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. MMWR Feb 22, 2013, Vol 62, #7 Independent of breast feeding plans

33  Only of women vaccinated in pregnancy (April 2012) 2.6%

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

36 From: DOH PCH Immunization Child Profile Sent: Friday, July 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 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. 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 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.measles webpage. Thank you, Lonnie Peterson | Health Educator Department of Health | Office of Immunization and Child Profile PO Box | Olympia, Washington p | f | | News Release: Measles Cases on the Rise in WA

37 Approaching the Vaccine Hesitant parents using C-A-S-E Another one with the C-A-S-E strategy ions/R.%20Carlyle_CASE%20Model%20Presentation.pdf

38 C orroborate: Acknowledge concerns, find point for agreement; respectful tone A bout Me: Describe what you have done to build knowledge and expertise S cience: Relate what science says E xplain/Advise: Explain your advice, based on science he_case_for_vaccines_mnaap.pdf

39  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…”

40  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”…

41  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”…

42 About Immunization in Pregnancy and Postpartum: Share reasons why recommend Highlight positive personal experiences with vaccination Address questions Use screening form ename/ /Vaccination-Talking-Points-for- Midwives-Apr-2014.pdf ename/ /Vaccination-Talking-Points-for- Midwives-Apr-2014.pdf

43 American College of Nurse-Midwives: CDC Immunization and Pregnancy chart: CDC web page, Vaccines for Pregnant Women: Plain Talk booklet for help in talking with patients about vaccine concerns: pdf pdf

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45 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 3 rd trimester to best protect the newborn Should be given regardless of plans for breastfeeding

46  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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