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Immunizations for Pregnant Women: Tdap and Influenza Vaccines Perinatal Services Coordinator (PSC) Annual Meeting November 6, 2014 Eileen Yamada, MD, MPH.

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Presentation on theme: "Immunizations for Pregnant Women: Tdap and Influenza Vaccines Perinatal Services Coordinator (PSC) Annual Meeting November 6, 2014 Eileen Yamada, MD, MPH."— Presentation transcript:

1 Immunizations for Pregnant Women: Tdap and Influenza Vaccines Perinatal Services Coordinator (PSC) Annual Meeting November 6, 2014 Eileen Yamada, MD, MPH California Department of Public Health Immunization Branch

2 Overview Influenza Influenza Immunization Recommendations for Pregnant and Postpartum Women Pertussis Tdap Recommendations for Pregnant Women Resources

3 Influenza

4 Signs and Symptoms of Influenza Fever Cough Sore throat Headache Muscle or Body Aches Runny or stuffy nose Fatigue Some people may have vomiting and diarrhea (more common in children than adults)

5 Influenza Complications Viral pneumonia Bacterial pneumonia Ear infections Sinus infections Dehydration Worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes Death

6 Impact of Seasonal Influenza-US ~3,000-49,000 influenza deaths per year* ~ 226,000 (range 55,000-431,000) excess hospitalizations per year** Complications, hospitalizations, and deaths typically greatest among persons 65 years and older, children younger than 5 years, pregnant women, and persons with high-risk medical conditions. Prevention and control of seasonal influenza with Vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2013-14. MMWR 2013Aug 8;62(RR-7):1-43. *Between 1976-77 and 2006-07 **1979-80 through 2000-01

7 Populations at High Risk for Complications from Influenza Persons younger than 5 years (especially < 2 years) Persons 65 years of age and older Anyone with chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension), kidney, liver, neurological, hematologic, metabolic or endocrine disorders (including diabetes mellitus), or have immunosuppression Women who are or will be pregnant during the influenza season Persons younger than 19 years on long-term aspirin therapy (might be at risk for Reye’s syndrome) American Indians and Alaska Natives Persons who are morbidly obese (BMI ≥40) http://www.cdc.gov/flu/about/disease/high_risk.htm

8 Increased Risks Among Pregnant and Postpartum Women Even generally healthy women are at increased risk of complications from influenza when they are pregnant  Changes in immune, heart, and lung function during pregnancy make them more likely to get seriously ill from influenza  Serious illness in the pregnant mother can also be dangerous to her fetus because it increases the chance for serious problems such as premature labor and delivery www.cdc.gov/flu

9 Pregnant women in the second and third trimester are at high risk for severe complications due to influenza, including hospitalization, serious medical complications and adverse pregnancy outcomes. http://www.cdc.gov/v accines/pubs/preg- guide.htm

10 Increased Risks Among Pregnant and Postpartum Women Increased severity of influenza among pregnant women reported during the pandemics of 1918-1919, 1957- 1958, and 2009-2010.  Severe infections among postpartum women (delivered within previous 2 weeks) were also observed during 2009-2010 2,3  Pregnant women had disproportionately high risk of mortality due to 2009 influenza A (H1N1) 2,3  Pregnant women who were treated with antivirals more than 4 days after symptom onset were more likely to be admitted to an ICU than those treated within 2 days after symptom onset 3 1 Prevention and control of seasonal influenza with Vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2013-14. MMWR 2013;62(RR-7):1-43. 2 Louie JK et al. NEJM 2010; 362:27-35. 3 Siston AM, et al. JAMA 2010; 303:1517-1525.

11 Influenza Diagnosis and Treatment Early antiviral treatment may save lives Clinical signs and symptoms are non- specific, and ~30% of influenza infections are asymptomatic. If influenza is circulating, pregnant women should be tested for FLU Consider early antiviral treatment for pregnant women while awaiting lab testing (PCR) However, the best way to prevent influenza is influenza immunization!

12 Influenza typeHemagglutinin subtype Geographic source A/California/7/04 (H3N2) Year of isolation Isolate numberNeuraminidase subtype Influenza virus

13 Composition of the Influenza Vaccine for the 2014-15 Season* Trivalent Strains:  A/California/7/2009 (H1N1)-like (2009 H1N1)  A/Texas/50/2012-like (H3N2)  B/Massachusetts/2/2012-like B/Yamagata lineage Additional B strain for quadrivalent vaccines  B/Brisbane/60/2008-like B/Victoria lineage Epperson, S et al. Influenza Activity — United States, 2013–14 Season and Composition of the 2014–15 Influenza Vaccines. MMWR Weekly. 2014; 63(22):483-490. *FDA recommended the same strains as for the 2013-14 influenza vaccine

14 ACIP Recommendations: Influenza Immunization (2014-15) Routine annual influenza vaccination is recommended for all persons aged 6 months and older who do not have contraindications. Health care providers should offer vaccination soon after vaccine becomes available and offer vaccine as long as influenza viruses are circulating. http://www.cdc.gov/mmwr/pdf/rr/rr6207.pdf

15 Influenza Vaccine Recommendations for Pregnant Women Since 2004, both the Advisory Committee on Immunization Practices (ACIP) and the American College of Obstetricians and Gynecologists have recommended influenza vaccination for all women who are or will be pregnant during the influenza season, regardless of trimester. Pregnant women are recommended to receive an injectable influenza vaccine, rather than the live, intranasal influenza.  Postpartum women, including breastfeeding mothers, may receive either the injectable or live, intranasal flu vaccine.

16 Thimerosal and Influenza Vaccines Health and Safety Code, Section 124172:  Since 2006, influenza vaccines containing greater than a specified amount of mercury shall not be given to a pregnant women or child younger than 3 years of age, except in certain situations.  CDC Excerpt at http://www.cdc.gov/vaccines/hcp/vis/vis- statements/flu-hcp-info.pdf “LAIV, RIV, and most single-dose vials or syringes of IIV are thimerosal-free. Accumulating evidence shows no increased risks from exposure to thimerosal-containing vaccines. Persons recommended to receive IIV may receive any age- and risk factor-appropriate vaccine preparation, depending on availability.”

17 Benefits Influenza vaccination among pregnant women can reduce their risk for respiratory illness and reduce the risk for influenza in their infants aged <6 months.  Earliest age that infants may be immunized against influenza is 6 months. Zaman et al. N Engl J Med 2008;359:1555-64. Madhi et al. N Engl J Med 2014; 371:918-931.

18 Safety Millions of doses of influenza vaccine have been given to pregnant women over many years. Epidemiologic and clinical studies support the safety of inactivated influenza vaccines in pregnant women and their infants. Influenza vaccines have not be shown to cause adverse pregnancy or fetal outcomes. Munoz. Am J Obstet Gynecol. 2012;207(Suppl. 3): S33-37. wwww.cdc.gov/flu

19 Clinician Recommendation and Offer of Influenza Vaccine Associated with Higher Rates of Influenza Immunization (2013-14) Women who reported receiving a clinician recommendation and offer of influenza vaccination had higher vaccination rates (70.5%) compared to:  Women who reported receiving a clinician recommendation but no offer (32.0%)  Women who reported receiving no recommendation (7.9%)

20 Pregnant Women: Reasons for Receiving Vaccination To protect their infant from influenza (31.1%) To protect themselves from influenza (23.3%) Because their clinician recommended influenza vaccination (14.8%)

21 Pregnant Women Should Receive Seaonal Influenza Vaccine Vaccinating pregnant women protects both mom and baby from severe influenza infection. Maternal vaccination is critical, because babies under 6 months of age are vulnerable to severe influenza vaccination and are too young to get vaccinated. Pregnant women are at increased risk of severe illness from influenza, including hospitalizations and death Physician recommendation is a key strategy to achieve higher rates of vaccination in pregnant women.

22 Influenza Immunization Important To protect pregnant women against influenza, vaccination of not only the pregnant woman but all household members, including children, should occur.

23 Influenza Vaccine Resources Influenza Vaccine Identification Guide:  http://eziz.org/assets/docs/IMM-859.pdf http://eziz.org/assets/docs/IMM-859.pdf Vaccine Information Statements (VIS)  http://www.cdc.gov/vaccines/hcp/vis/index.html http://www.cdc.gov/vaccines/hcp/vis/index.html ACIP Influenza Vaccine Recommendations  2014-15 http://www.cdc.gov/mmwr/pdf/wk/mm6332.pdfhttp://www.cdc.gov/mmwr/pdf/wk/mm6332.pdf  2013-14 (full) http://www.cdc.gov/mmwr/pdf/rr/rr6207.pdfhttp://www.cdc.gov/mmwr/pdf/rr/rr6207.pdf List of influenza vaccines and CPT codes  http://www.immunize.org/catg.d/p4072.pdf http://www.immunize.org/catg.d/p4072.pdf California Influenza Surveillance (www.cdph.ca.gov)www.cdph.ca.gov CDC Influenza Surveillance (www.cdc.gov/flu)www.cdc.gov/flu Other resources on eziz.org!

24 http://www.cdc.gov/flu/pdf/freeresources/pregnant/flushot_pregnant_factsheet.pdf

25

26 Pertussis (Whooping Cough)

27 Background: Pertussis Acute respiratory infection cause by the Bordetella pertussis, gram-negative coccobacillus Classic pertussis*: 3 phases  Catarrhal phase (1-2 weeks)-runny nose, intermittent cough; high fever is uncommon  Paroxysmal phase (4-6 weeks)-spasmodic cough, posttussive vomiting, and inspiratory whoop  Convalescent phase (2-6 weeks, can last months)- symptoms slowly improve *Infants may not have the typical presentation

28 Complications Complications: hypoxia, pneumonia, weight loss, seizures, encephalopathy and death Infants < 12 months are more likely to have complications from pertussis, particularly those 2 months or younger

29 Reported pertussis-related deaths by age-groups, U.S., 1980-2009 Age-group1980-1989 1 1990-1999 1 2000-2009 2 0-1 month3868152 2-3 month111623 4-5 month552 6-11 month741 1-4 years1322 5-10 years163 11-18 years003 >18 years128 Total77*103194 1 Vitek CR et al. Pediatr Infect Dis J 2003; 22(7):628-34. 2 National Notifiable Diseases Surveillance System, CDC, 2009 * Includes one case with unknown age

30 California Pertussis Cases (10/7/14) Over 8700 cases of pertussis were reported as of October 7, 2014, to CDPH.  More cases then had been reported in all of 2013  At least 312 hospitalizations in 2014 3 deaths reported in 2014 (all were infants 2 months of age or younger at onset of pertussis) Cyclical peaks in incidence occur every 3-5 years  Last California peak in 2010 with over 9100 cases reported to CDPH http://www.cdph.ca.gov/programs/immunize/Pages/PertussisSummaryReports.aspx

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34 Pertussis incidence per 100,000 population, by county – California, 2014*

35 Waning Immunity Immunity from pertussis disease and immunization is not lifelong and wanes over time Recent data suggests that immunity in those who received only acellular pertussis wanes more quickly than in persons who received whole cell pertussis vaccines  Acellular pertussis vaccines were recommended to replace the whole cell pertussis vaccines for the 4 th and 5 th doses in 1992 and was recommended to replace all doses in 1997 Klein NP, et al. NEJM. 2012; 367:1012-9. Misegades LK, et al. JAMA. 2012; 308(20):2126-2132. Tartof SY, et al. Pediatrics 2013; 131; e1047. Klein NP, et al. Pediatrics 2013; 131; e1716.

36 Pertussis Control Goals Prevention of severe disease and deaths in infants  Infants less than 6 months of age are most likely to be hospitalized  Infants less than 3 months of age are most likely to die from pertussis infection

37 Key Strategy Immunize pregnant women during each pregnancy. Optimal timing is between 27 and 36 weeks gestation.  Make sure to immunize with DTaP on-time (routinely recommended at 2 months of age)  Immunization as early as 6 weeks can be important especially in infants whose mothers did not receive Tdap during the 3 rd trimester

38 ACIP and ACOG Recommendations: Tdap with Each Pregnancy Goal:  To reduce the burden of pertussis in infants who are most vulnerable http://www.cdc.gov/mmwr/pdf/wk/mm6207.pdf http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee- on-Obstetric-Practice/Update-on-Immunization-and-Pregnancy-Tetanus-Diphtheria- and-Pertussis-Vaccination

39 Background: Tdap with Each Pregnancy After receipt of Tdap, a minimum of 2 weeks is required to mount a maximal immune response to the vaccine antigens Data indicate that maternal antipertussis antibodies are short-lived; therefore, Tdap vaccination in one pregnancy will not provide high levels of antibodies to protect newborns in subsequent pregnancies. http://www.cdc.gov/mmwr/pdf/wk/mm6207.pdf

40 Optimal Timing of Tdap: Third Trimester Active transport of maternal IgG to the fetus via the placenta does not substantially take place before 30 weeks of gestation Therefore, to optimize transport of antipertussis antibodies from mother to infant, ACIP recommends vaccination during the third trimester This recommendation was made to increase the likelihood of optimal protection for the pregnant woman and her infant during the first few months of the infant’s life, when the child is too young for vaccination but at the highest risk for severe illness and death http://www.cdc.gov/mmwr/pdf/wk/mm6207.pdf

41 ACOG and ACIP Recommendations Tdap should be administered during each pregnancy, irrespective of the patient’s prior history of receiving Tdap. To maximize maternal antibody response and passive antibody transfer to the infant, optimal timing for Tdap administration is between 27 and 36 weeks gestation. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee- on-Obstetric-Practice/Update-on-Immunization-and-Pregnancy-Tetanus-Diphtheria- and-Pertussis-Vaccination http://www.cdc.gov/mmwr/pdf/wk/mm6207.pdf

42 Cocooning For women not previously vaccinated with Tdap, if Tdap is not administered during pregnancy, Tdap should be administered immediately postpartum. However, this will not provide the direct protection to the infant as when mother is immunized during the 3 rd trimester of pregnancy ACIP continues to recommend that adolescents and adults (e.g., parents, siblings, grandparents, child care providers, HCP) who have or anticipate having close contact with an infant aged <12 months should receive a single dose of Tdap to protect against pertussis if they have not received Tdap previously. It is anticipated that ACIP will discuss its revaccination recommendations for high-risk populations at its upcoming meeting(s). http://www.cdc.gov/mmwr/pdf/wk/mm6207.pdf

43 Medi-Cal Provider Bulletin: July 2014 Providers of prenatal care must implement a Tdap immunization program for all pregnant women. Medi-Cal Questions? Call 1-800-541-5555

44 General and Disease-Specific Resources

45 EZIZ.org

46 Resources

47 Pregnancyshotsca.org

48 Materials For Providers Dozens of electronic, print, audio and video resources for various audiences available at www.eziz.org/pertussis-promo- materials www.eziz.org/pertussis-promo- materials

49 Materials for Patients Order FREE copies from your LHD listed on: bit.do/immunization

50 Webinars ACOG  Immunization Business and Clinical Strategies for Ob-Gyn Practices http://www.acog.org/About- ACOG/ACOG-Departments/Immunizationhttp://www.acog.org/About- ACOG/ACOG-Departments/Immunization CDPH Increasing Tdap Immunization Rates and Running an Efficient Immunization Practice: Tips from Obs http://eziz.org/resources/pertussis-promo- materials/tdap-webinar-obs/http://eziz.org/resources/pertussis-promo- materials/tdap-webinar-obs/

51 Educational Resources eziz.org  http://eziz.org/resources/flu-promo-materials/ http://eziz.org/resources/flu-promo-materials/ Centers for Disease Control and Prevention  http://www.cdc.gov/flu/protect/vaccine/pregnant.htm http://www.cdc.gov/flu/protect/vaccine/pregnant.htm  http://www.cdc.gov/vaccines http://www.cdc.gov/vaccines ACOG  ACOG Immunization Toolkits http://www.acog.org/About- ACOG/ACOG-Departments/Immunization/Tool-Kitshttp://www.acog.org/About- ACOG/ACOG-Departments/Immunization/Tool-Kits

52 Resources California  Provider resources http://www.eziz.orghttp://www.eziz.org  CDPH Immunization Branch http://www.getimmunizedca.org http://www.getimmunizedca.org  Immunizations for a Healthy Pregnancy www.pregnancyshotsca.org  California Immunization Coalition: http://www.immunizeca.org http://www.immunizeca.org National  CDC http://www.cdc.gov/vaccineshttp://www.cdc.gov/vaccines  Immunization Action Coalition http://www.immunize.org http://www.immunize.org  ACOG www.immunizationforwomen.orgwww.immunizationforwomen.org National

53 Shotbyshot.org Is a collection of stories from people who have been touched by vaccine-preventable diseases…real-life stories, told by survivors, family members, friends, and health care providers...stories touch us, educate us, and remind us of the value of prevention.

54 Pertussis: Gavin’s Story http://shotbyshot.org/pertussis/gavins-story/ http://shotbyshot.org/pertussis/gavins-story/

55 Ian’s Story: Influenza (Courtesy Families Fighting Flu) http://shotbyshot.org/influenza/the-story-of-ian/

56 Cairweb.org Register online for enrollment or training webinars Providers may contact their local CAIR representative

57 Acknowledgements Staff of CDPH Immunization Branch  Janice Louie, MD, MPH (former)  Robert Schechter, MD  Kathleen Winter, MPH  Jennifer Zipprich, PhD, MPH  Amanda Roth, MPH, MSW (former)  Rebeca Boyte, MPH

58 Questions?


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