1. Give it Your Best Shot: Adult Vaccinations for Ob-Gyn Providers
Originally presented on Wednesday, December 3, 2014

2. Learning Objectives
By the end of the webinar participants will be able to:
Identify at least 3 adult vaccines recommended for routine use in their adult patients
Address the most common concerns and misconceptions around vaccines
Identify, locate, and provide patient resources
Incorporate immunizations into routine practice

3. Vaccines Are Not Just For Children
Adult vaccination saves lives!
Each year in the United States, ~ 60,000 adults die from vaccine preventable diseases or their complications
Pneumonia and influenza together are the 7th leading cause of death in the United States
The CDC sets routine adult vaccine recommendations based upon recommendations made by the Advisory Committee on Immunization Practices (ACIP) and endorsed by professional societies
These recommendations are published as immunization schedules and are updated annually

4. Adult Vaccination Rates Are Low
Most adults are NOT aware that they need vaccines
Many missed opportunities for vaccination occur because ob-gyn’s and other providers do not routinely assess vaccination status and do not routinely recommend vaccination
A recommendation from their own provider is the strongest predictor of whether a patient gets vaccinated!

5. significantly higher when recommended and offered by provider

6. Set the Example Make sure you and your family are vaccinated
Office culture is important:
Educate yourself and your entire staff about vaccinations
Make sure everyone in your office is vaccinated

7. Vaccination Opportunities for Obstetrician-Gynecologists
Vaccination should be made part of routine care:
Pre-conception planning
Prenatal care
Two patients to protect, mother and child
Post-partum care
Well-woman care
Pre-op planning

8. Thinking About Vaccines
Prevention of what disease?
What is the antigen?
Is there an adjuvant? If so, what is the adjuvant?
What is the vaccine efficacy?
Is the vaccine safe?
Is the vaccination given as a single dose or a series?
Are there unique pregnancy-related issues to consider?

9. Adult Vaccine Recommendations
Before vaccines can be manufactured and distributed in the US, they must be approved/ licensed by the FDA
Licensure is based on extensive safety and efficacy studies presented to the FDA
After licensure, the CDC sets routine adult vaccine schedules based upon recommendations made by the Advisory Committee on Immunization Practices (ACIP) and endorsed by professional societies
The Adult Immunization Schedules include specific guidance such as the age(s) when the vaccine should be given, the number of doses needed, the amount of time between doses, and precautions and contraindications

12. Adult Vaccination - Pre-Vaccination Counseling
Federal law requires that patient education Vaccine Information Statements (VIS) be distributed prior to vaccination
Elements of a Risk/Benefit discussion
Recommendations/Indications
Contraindications
Vaccine efficacy
Duration of efficacy
Side effects
What other vaccinations should/could be given

13. Pregnancy Vaccination Recommendations
Routine
Inactivated influenza vaccine (IIV)
Tdap (TT/Td)
Contraindicated
MMR
Varicella
Live attenuated influenza vaccine (LAIV)
Pregnancy not a contraindication
Pneumococcal PS/C
Hepatitis B
Hepatitis A
Meningococcal PS/C
Inactivated poliovirus
Yellow fever
CDC.gov Vaccines in Pregnancy

14. Maternal Immunization: Benefit to the Fetus/Newborn
To boost maternal levels of pathogen-specific antibodies
To provide the young infant with sufficient concentrations of antibodies
To protect against infections occurring during a period of increased vulnerability, until able to adequately respond to active immunization or infectious challenge

15. Live Virus Vaccines and Pregnancy
Routine live virus vaccination is contraindicated during pregnancy.
Risk to a developing fetus from maternal vaccination is primarily theoretical.
Only smallpox (vaccinia) vaccine has been shown to injure a fetus.
Do not give live virus vaccines to pregnant women or women planning to become pregnant in the following 4 weeks.
If pregnant and susceptible, vaccinate as early in the postpartum period as possible.
Screening for rubella immunity and varicella immunity is part of routine prenatal care.

16. Common Myths About Vaccines
Myth 1: Vaccines make you sick Response: Because vaccines are made with a killed or very weakened virus you can not get ill from vaccines. Myth 2: Vaccines cause autism Response: Many studies have been conducted reviewing mercury (thimerosal), vaccines and autism. No study has ever shown a positive relationship between vaccines, mercury and subsequent autism diagnosis. The only vaccines that contain thimerosal are multi-dose vial presentations of influenza vaccines. Myth 3: I’m young and healthy so I don’t need vaccines Response: Even healthy adults can become severely ill from vaccine preventable diseases.

17. Common Myths About Vaccines
Myth 4: Vaccines could pose a risk to my unborn baby Response: Vaccines recommended in pregnancy have proven to be safe in all trimesters. Since 2004 the CDC and ACOG have recommended vaccinations such as influenza during any trimester. Myth 5: Vaccines will cause birth defects or miscarriage Response: Vaccines recommended in pregnancy have under gone rigorous testing and vaccines such as influenza have been given to millions of pregnant women over decades. No relationship has been shown between influenza vaccination and birth defects and miscarriage.

18. Influenza Vaccination

19. Clinical Influenza Common Signs/Symptoms: Fever Headache Myalgia
Nonproductive cough
Standard definition – Influenza-like illness (ILI) = fever (>100 ˚F) and cough and/or sore throat in the absence of a known cause.
Stomach symptoms - nausea, vomiting, and diarrhea
More common in children than adults.
50% of infected individuals have subclinical infections but are still contagious
Individuals are contagious for 1-4 days before symptom onset and for 5-10 days after initial symptoms begin.

20. Influenza Vaccination Recommendations
The Centers for Disease Control and Prevention (CDC) and ACOG recommends routine annual influenza vaccination for all persons aged 6 months and older who do not have contraindications.
Vaccination should occur before the onset of influenza activity in the community
Health care providers should offer vaccination as soon as it becomes available
Vaccination should be offered as long as influenza viruses are circulating i.e. October through May
Persons with a history of egg allergy who have experienced only hives after exposure to egg should receive influenza vaccine.
Source:

21. Influenza Vaccination Contraindications
Anaphylactic reaction to a previous dose or to egg protein, gelatin or other vaccine component
Precaution in moderate to severe illness
Not contraindications:
Minor illnesses (diarrhea, upper respiratory tract infection with or without fever)
Antimicrobial therapy

22. Pregnancy: Influenza Complications
Maternal risks (compared to non-pregnant women):
4x higher rates of complications/hospitalizations
Increased mortality, especially in the third trimester.
Increased risk of premature labor and delivery
Fetal Risks:
Viremia rare, transplacental passage infrequent
Maternal hyperthemia may place fetuses at risk for birth defects (VSD, cleft lip, neural tube defects) and preterm birth
In Bangladeshi study, maternal influenza vaccination associated with higher birth-weight

23. Childhood: Influenza Complications
Children < 24 months have increased risk for morbidity and mortality
Newborns < 6 months cannot be vaccinated; protection is from maternal vaccination and cocooning
90% of influenza-related pediatric deaths occur in unvaccinated children
40% of children hospitalized for influenza had no identified underlying medical conditions

24. Influenza Vaccination Recommendations: Pregnant Women
ACOG CO 608: Influenza Vaccination During Pregnancy, Sept
Influenza vaccination is an essential part of prenatal and preconception care.
Pregnant women have increased morbidity and mortality from influenza.
Neonates have increased morbidity and mortality from influenza and cannot be vaccinated until 6 months.
Vaccination of pregnant women results in passive transfer of protective antibodies to neonates and therefore protection from influenza.
Keeping mom healthy during pregnancy protects fetus from early delivery.

25. Influenza Vaccine Efficacy
Protective antibodies are produced within 2 weeks.
Varies from season-to-season
70-90% effective in preventing clinical illness when vaccine matches circulating strains
50-77% effective against laboratory confirmed illness when vaccine strains are antigenically dissimilar to circulating strains
Efficacy varies among different populations:
Significantly less effective among the elderly.
Vaccinating children protects entire communities
80% coverage in pediatric age groups confers significant protection among those who did not receive the vaccine
Efficacy not diminished in pregnancy
Limited data
Gestational age effect may exist

26. Seasonal Influenza Vaccines: Something Old, Something New
The “Flu Shot“
Traditional trivalent inactivated influenza vaccine protected against 3 influenza virus strains (2 influenza A and 1 Influenza B)
Quadrivalent vaccine protects against 4 strains (2 influenza A and 2 influenza B)
Old nomenclature: Trivalent Inactivated Vaccine = TIV
New nomenclature: Inactivated Influenza 3 = IIV3
New Quadrivalent Vaccine: IIV4
New recombinant vaccines will be available that are manufactured using cell-based technologies, instead of chicken embryos (RIV3)
New cell culture-base influenza vaccine: potential for faster manufacturing, less egg protein (ccIIV3)

27. Seasonal Influenza Vaccines: Something Old, Something New
The Nasal-Spray Flu Vaccine (Flu-mist)
Live Attenuated Influenza Vaccine (LAIV).
Quadrivalent vaccine starting this influenza season: LAIV4
Weakened (attenuated) virus
LAIV has the potential to produce mild signs or symptoms related to attenuated influenza virus infection
Approved for use in healthy, non-pregnant people 2-49 years-old

29. Tdap Vaccination

30. Diphtheria, Tetanus and Pertussis
There are 4 combination vaccines used:
DTaP, Tdap, DT, and Td
2 of these (DTaP and DT) are given to children < 7 years-old
2 of these (Tdap and Td) are given to older children and adults
Upper-case letters in these abbreviations denote full-strength doses of diphtheria (D) and tetanus (T) toxoids and pertussis (P) vaccine. Lower-case “d” and “p” denote reduced doses of diphtheria and pertussis used in the adolescent/adult-formulations

31. Tdap Vaccination Recommendations
For non-pregnant adults, Tdap needs to be given only once:
Td every 10 years.
Substitute Tdap for Td if Tdap never given
Family members and caregivers (fathers, grandparents, and babysitters) should be up-to-date with their Tdap vaccine

32. Pertussis Clinical case definition:
Cough illness lasting at least 2 weeks with one of the following: paroxysms of coughing, inspiratory "whoop," or post-tussive vomiting, without other apparent cause (as reported by a health professional)
Causative organism:
Bordetella pertussis, a gram-negative bacterium
Uniquely human pathogen
Incubation 7-10 days, catarrhal stage followed by paroxysm of coughing that can continue for 4-6 weeks
Substantial weight loss and sleep disturbances
Highly infectious, secondary attack rate exceeds 80%
Despite high childhood vaccination levels, the reports of pertussis cases have steadily increased in the United States
One of the leading causes of vaccine preventable deaths world-wide

33. Pertussis and Pregnancy
Pertussis can cause serious and sometimes life-threatening complications in infants, especially within the first 6 months of life.
In infants younger than 1 year of age who get pertussis, about half are hospitalized. The younger the infant, the more likely treatment in the hospital will be needed. 
Tdap vaccination recommended during every pregnancy, preferably at 27 to 36 weeks, to protect the newborn/young infant
Why weeks?
Antibody levels decline after immunization
Maternal immunization timed in order to have peak transplacental passage of IgG antibodies

34. Tdap Vaccination During Pregnancy
ACOG CO #566: Update on Immunization During Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination June 2013
A dose of Tdap vaccine should be given to all pregnant women between weeks gestation during every pregnancy.
Transplacental transfer of maternal pertussis antibodies from mother to infant provides some protection against pertussis in early life, before infants are able to receive the primary DTaP series.
Immune response to the vaccine peaks 2 weeks after administration, Tdap vaccine is recommended between weeks gestation to optimize antibody transfer and protection at birth. 

36. This graph shows reported pertussis incidence (per 100,000 persons) by age group in the United States from Infants aged <1 year, who are at greatest risk for severe disease and death, continue to have the highest reported rate of pertussis. School-aged children 7-10 years continue to contribute a significant proportion of reported pertussis cases.

37. Continued Epidemic Results in Increased Reported Pertussis Cases
During 2012, 48,277 cases of pertussis were reported to CDC. Most reported cases since The majority of deaths occurred among infants younger than 3 months of age
In 2012, 49 states and Washington, D.C. reported increases in disease compared with the same time period in 2011.
Overall reporting of pertussis declined during 2013 with 28,639 reported cases. While 13 states and Washington, D.C. reported an increase in pertussis cases compared with 2012, the majority of states reported fewer cases in 2013

38. Recent Safety and Efficacy Updates
Study looking at safety of the Tdap vaccine during pregnancy was published in the Journal of the American Medical Association 11/11/14
Researchers used administrative and electronic health record data from two California Vaccine Safety Datalink sites
Found that Tdap vaccination during pregnancy was not associated with increased risk for hypertensive disorders of pregnancy, preterm birth, or having a baby who is small for his or her gestational age.
Efficacy
Recent UK experience: reduction in infant pertussis, with success attributed to both transplacental antibody protection and cocooning
11/11/14 JAMA study:

39. Pneumococcal Vaccination

40. Pneumococcal Disease
Invasive disease from Streptococcus pneumoniae (pneumococcus) is a major cause of illness and death in the general population
There are ~ 500,000 cases of invasive pneumococcal disease in the US annually resulting in 40,000 deaths.
There are nearly 100 strains of S. pneumoniae, many of which have become antibiotic resistant
The emergence of multi-drug resistant pneumococcus underscores the importance of primary prevention through vaccination
Pneumococcal pneumonia is a known serious secondary sequela of influenza viral infections

41. Pneumococcal Vaccination Recommendations
Immune competent adults < 65 years of age should receive the pneumococcal polysaccharide vaccine (PPSV23)
Immune compromised adults and those > 65 years of age should receive the pneumococcal conjugate vaccine (PCV13) as well as PPSV23
Providers should make every effort to vaccinate medically high-risk women before they become pregnant
For pregnant women who have never been vaccinated:
Asthmatics, diabetics, and smokers should receive PPSV23 during pregnancy
Women with immune deficiencies should receive PCV13 followed by PPSV23

42. Measles, Mumps, Rubella Vaccination

43. Rubella: Pregnancy Risks
Congenital Rubella Syndrome (CRS)
Infection may affect all organs:
Deafness, cataracts, heart defects, microcephaly, mental retardation, bone alterations, liver and spleen damage
May lead to fetal death or premature delivery.
Severity of damage to fetus depends on gestational age
Defects rare after 20 weeks gestation
Up to 85% of infants affected if maternal infection occurs during first trimester

44. Rubella Epidemic: United States, 1964-1965
12.5 million rubella cases
2,000 encephalitis cases
11,250 abortions (surgical/spontaneous)
2,100 neonatal deaths
20,000 Congenital Rubella Syndrome (CRS) cases:
Deaf – 11,600
Blind – 3,580
Mentally retarded – 1,800

45. Congenital Rubella: Near Eradication is a Vaccination Success Story
Since licensure of vaccine (1969), rates of CRS have dropped dramatically
An average of 5-6 cases annually of CRS in the United States since the 1980s

46. Measles-Mumps-Rubella Vaccine
The primary objective of rubella immunization for women is to prevent fetal rubella infection during pregnancy and subsequent congenital rubella syndrome (CRS) in newborns
1 dose MMR should be adequate for protection
Avoid pregnancy for 4 weeks after vaccination
For women of childbearing age, regardless of year of birth, determine immunity and vaccinate as part of pre-conception counseling or postpartum program

47. Measles, A Resurgence of an Eradicated Infection
From January 1, 2014 through August 29, 2014, more cases in the United States than any year in the past 2 decades
High incidence has occurred despite the fact that indigenous circulation of measles virus was declared eliminated in the United States in 2000 and in the Americas in 2002.
Two reasons for resurgence
Travel to countries were there is substantial circulating virus
Failure of parents to vaccinate children
Highly contagious, herd immunity threshold 92%-94% to prevent sustained spread of the disease
Measles remains a leading cause of death in children
Globally, more than 20 million people still get measles each year, and about 145,700 of those infected died in 2013

48. Orenstein W, Seib K. N Engl J Med 2014;371:1661-1663.
Measles Cases in the United States, 1994–2014.
Measles Cases in the United States, 1994–2014. The 2012, 2013, and 2014 data are provisional data reported to the Centers for Disease Control and Prevention National Center for Immunization and Respiratory Diseases. The 2014 data are for January 1 to August 29.
Orenstein W, Seib K. N Engl J Med 2014;371:

49. Measles-Mumps-Rubella Vaccine
Vaccine first offered in 1963
Adults born before 1957 are likely to be immune
Administer 2 doses of MMR for adults without a vaccination history and with any of the following:
Born after 1956
Persons vaccinated with killed measles vaccine from
Students in post-secondary education institutions
Healthcare workers
Susceptible international travelers
Consider those with previously documented 2-dose vaccine regimens adequately vaccinated.
New guidelines: Re-vaccination of adequately vaccinated seronegative, immune competent individuals not recommended.

50. Varicella vaccination

51. Congenital Varicella Congenital varicella syndrome:
Chorioretinitis, congenital cataracts, cerebral cortical atrophy, variable degrees of limb atrophy, skin scarring, and gastroesophageal reflux
In contrast to other pathogens, maternal infection rarely results (<1%) in congenital varicella

52. Varicella Vaccine Live attenuated virus vaccine FDA-approved in 1995
7 vaccine effectiveness studies since licensure:
71-100% effective against disease of any severity
95-100% effective against moderate and severe disease

53. Varicella and Pregnancy
Chickenpox is far more devastating in adults than in children
Adults are 10x more likely than children to be hospitalized with the severe consequences of chickenpox (such as pneumonia or encephalitis)
Risks may be even greater in pregnancy
In the era before vaccination, 11,000 hospitalizations and 100 deaths annually in the United States
2% risk of congenital varicella if infection occurs between weeks of gestation
Acute varicella in pregnant women from 5 days before to 2 days after delivery results in severe varicella infection in an estimated 17%--30% of newborn infants

54. Varicella Vaccine Recommendations
Prenatal assessment of women for evidence of varicella immunity
Susceptible women should be vaccinated post-delivery and post-termination of pregnancy
Assumed immunity:
Documentation of age-appropriate vaccination
Born before 1980 (for all populations except pregnant women)
Varicella disease verified by a health care worker
Herpes zoster verified by a health care worker
Serologic evidence of immunity*
Varicella serology: Commercially available serology lack sensitivity in detecting vaccine-induced immunity and might give false negative results
Single dose regimens: No longer considered adequate!!
The 2nd dose should be given 4-8 weeks after the 1st

55. Herpes Zoster vaccination

56. Herpes Zoster Vaccination Recommendations
A single dose of zoster (shingles) vaccine for adults 60 years old or older, whether or not the patient reported a prior episode of shingles.
Persons with chronic medical conditions may be vaccinated unless a contraindication or precaution exists for their condition.
The vaccine is administered subcutaneously as a single dose.
No need to verbally screen for a history chickenpox infection or to conduct laboratory testing for serologic evidence of prior varicella infection. 
The vaccine to prevent herpes zoster (also referred to as shingles or zoster), consists of attenuated (Oka-strain) varicella virus at a concentration at least 14 times that found in the vaccine to prevent varicella (chickenpox). The zoster vaccine cannot be used in children and cannot be used in place of varicella vaccine.

57. Contraindications: Herpes Zoster Vaccine
A person should not get shingles vaccine who:
Has ever had a life-threatening allergic reaction to gelatin, the antibiotic neomycin, or any other component of shingles vaccine
Has a weakened immune system because of current:
AIDS or another disease that affects the immune system,
treatment with drugs that affect the immune system, such as prolonged use of high-dose steroids,
cancer treatment such as radiation or chemotherapy,
cancer affecting the bone marrow or lymphatic system, such as leukemia or lymphoma
Is pregnant, or might be pregnant. Women should not become pregnant until at least 4 weeks after getting shingles vaccines

58. Hepatitis B Vaccination

59. Hepatitis B Virus Transmission
Hepatitis B is highly contagious!
Hepatitis B is found in blood as well as in other body fluids such as tears, saliva, semen, and vaginal secretions:
Hepatitis B can be transmitted vertically (from mother to child)
Hepatitis B can be transmitted sexually
Hepatitis B can be transmitted through other close (non-sexual) contact
The hepatitis B virus (HBV) is 100x more infectious than HIV
The silent nature of the disease makes it difficult to know who is infected, and therefore, from whom you could catch the virus

60. Hepatitis B Vaccination Recommendations
ACIP recommends Hepatitis B vaccine for all adults who have not been infected with the virus or immunized with the vaccine
Vaccination based on individual risk assessments is no longer recommended
Recombinant vaccine
Infants have been routinely inoculated with the hepatitis B vaccine since 1991

61. Hepatitis B Vaccine 3 doses: 0, 1, and 6 months
Testing for adequacy of response:
Anti-HBsAg > 10 SRU one month after 3rd dose
2nd series if response to first series inadequate
Risk factors for inadequate response: increasing age, male, smokers, obesity, immunosuppressive illness, genetic non-responsiveness
No diminished vaccine efficacy in pregnancy

62. Hepatitis B Vaccination and Pregnancy: Maternal Indications
Unvaccinated adults at risk for hepatitis B should be vaccinated; pregnancy is not a contraindication
Those at risk include women who:
Are sex partners of people infected with hepatitis.
Inject street drugs
Have > 1 sex partner
Are < 60 years-old and have diabetes
Have jobs that expose them to human blood or other body fluids
Are household contacts of hepatitis-infected people
Have HIV
Other pregnant women who want protection may be vaccinated

63. Hepatitis B Virus Disease Risk
In adults following acute HBV infection, the majority of cases are self-limited:
Approximately 95%-99% of healthy adults will clear the infection and most will develop antibodies
In newborns exposed to HBV, the majority of infections will be chronic:
Up to 95% of children fail to produce an antibody response that is adequate to control an infection
There is a strong correlation between chronic HBV infection and the development of chronic liver disease and hepatocellular carcinoma
The interruption of mother-to-child HBV transmission is a public health imperative

64. Hepatitis B Vaccination and Newborns
HBsAg+ screening routine part of prenatal care
Goal: identify infants at risk for perinatal HBV
At risk newborns: receive passive and active immunization within 12 hours of birth
Active/passive immunization of the newborn less successful in children born to women with high viral loads
CDC recommends that all newborns regardless of maternal HBV status, should have the HBV vaccine series initiated before they leave the hospital

65. Human Papillomavirus Vaccination

66. Human Papillomavirus
Human papillomavirus (HPV) is the most common sexually transmitted infection.
Approximately 20 million Americans are currently infected with HPV, and 6 million people will become infected this year.
While 90% of these infections will be cleared by the body’s natural immune response, some types of HPV can cause genital warts and cancer of the following: cervix, vulva, vagina, penis, anus, and head and neck (tongue, tonsils, and throat).
Approximately 70% of cervical cancers result from infection with HPV genotypes 16 and 18.

67. Human Papillomavirus (HPV) Vaccination Recommendations
There are two FDA approved HPV vaccines, HPV4 and HPV2
HPV vaccination is recommended for both females and males aged 11 or 12 years
HPV vaccination can be given as a “catch-up” to women through age 26
Ob-gyns have a unique opportunity to vaccinate young women in the catch up group (19-26) and educate mothers about the importance of vaccinating their children
HPV vaccine is a preventive vaccine not a therapeutic vaccine
HPV vaccination is not recommended during pregnancy
HPV vaccination can be given to lactating women

68. Human Papillomavirus Vaccination
ACOG CO 588: Human Papillomavirus Vaccination, March 2014
Approximately 70% of all cases of cervical cancer are caused by HPV genotypes 16 and 18, and 90% of cases of genital warts are caused by HPV genotypes 6 and 11.2
Ob–gyns have the opportunity to educate mothers about the importance of vaccinating their children at the recommended age.
Ob-gyns are critical to vaccinating adolescent girls and young women during the catch-up period. 

69. HPV Vaccination Facts
Millions of HPV vaccine doses have been given over the past 8 years and have proven to be effective and safe
Clinical trials showed the vaccines provided close to 100% protection against precancers and for HPV4, genital warts.  
Since the vaccine was first recommended in 2006, there has been a 56% reduction in HPV infections among teen girls in the US, even with very low HPV vaccination rates. 1
HPV vaccines save lives!
According to the CDC, if health care providers increase HPV vaccination coverage to 80%, it is estimated that an additional 53,000 cases of cervical cancer could be prevented during the lifetime of those younger than 12 years 2
Human papillomavirus vaccination coverage among adolescent girls, 2007–2012, and postlicensure vaccine safety monitoring, 2006– United States. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep 2013;62:591–5

70. The Ob-Gyn’s Role in Immunization
Studies continue to show that a provider recommendation is the most influential factor in a patient’s decision to receive an immunization1
Ob‐gyns have a long‐standing role of providing primary and preventive care to women and are a major source of ambulatory care for women, accounting for 44% of preventive care visits for women over age 182
Pregnant women see their ob-gyn regularly throughout the course of their prenatal and postpartum care allowing for multiple opportunities to vaccinate. 1.
2. Stormo AR, Saraiya M, Hing E, Henderson JT, Sawaya GF. Women’s Clinical Preventive Services in the United States: Who Is Doing What?. JAMA Intern Med. Published online July 07, doi: /jamainternmed

71. Importance of Provider Recommendation
The National Foundation for Infectious Diseases conducted a survey of U.S. adults to gauge awareness of vaccines1:
87% said they are very or somewhat likely to get a vaccine if their doctors recommend it.
55% would not get a vaccine unless it was recommended by their doctors.
Women who received both a health care provider recommendation and an offer for vaccination were twice as likely to be vaccinated as those who received a health care provider recommendation, but no offer.
1- National Foundation for Infectious Diseases. Call to action: adult vaccination saves lives. Bethesda (MD): NFID; Available at: Retrieved April 8, 2013.

72. Vaccination Opportunities for Obstetricians-Gynecologists
Influenza vaccine for all women including those who are pregnant
Tdap vaccine for all adults who have not been vaccinated and all women during each pregnancy
Pneumococcal vaccine for high risk women including those who are pregnant
Hepatitis B vaccine for all at risk women including those who are pregnant
MMR vaccine for women who were not previously vaccinated. Should give before or after pregnancy
Varicella vaccine for women who were not previously vaccinated or have not had chickenpox. Should give before or after pregnancy
HPV vaccine for girls and women ages Not recommended during pregnancy
Graphic courtesy of the National Foundation for Infectious Diseases.

73. Steps For Obstetricians to Improve Practice Standards
ASSESS immunization status of patients:
Stay informed. Get the latest CDC recommendations for immunization of adults.
Implement protocols and policies. Ensure that patients' vaccine needs are routinely reviewed and patients get reminders about vaccines they need.
Strongly RECOMMEND vaccines that patients need:
Share tailored reasons why vaccination is right for the patient.
Highlight positive experiences with vaccination.
Address patient questions and concerns.
Remind patients that vaccines are the best protection against a number of common and serious diseases.
Explain the potential costs of getting sick.
ADMINISTER needed vaccines or REFER your patients to a vaccination provide:
Offer the vaccines you stock.
Refer patients to providers in the area that offer vaccines that you don't stock.
DOCUMENT vaccines received by your patients.

74. Conclusions
Adults need vaccines too and Ob-Gyns have an opportunity to educate and vaccinate their patients’ and their patients’ families
Pregnant women are at particular risk of serious complications from vaccine preventable diseases
Ob-gyns should integrate immunizations into their routine assessment and practice with both pregnant and non-pregnant patients

75. Resources for Vaccine Recommendations and Vaccine Information
ACIP Vaccine Recommendations
CDC Vaccines & Immunizations
HHS National Vaccine Program Office:
National Foundation for Infectious Disease:

76. Resources for Vaccine Safety Surveillance
Once vaccines are licensed in the United States, CDC actively monitors the safety of these vaccines through several systems
Vaccine Adverse Event Reporting System (VAERS): an early warning public health system where people can report vaccine concerns, that helps CDC and FDA detect possible side effects or adverse events following vaccination.
Vaccine Safety Datalink (VSD): a collaboration between CDC and several healthcare organizations which uses de-identified health records to monitor and evaluate adverse events following vaccination.
Clinical Immunization Safety Assessment (CISA) Network: a collaboration between CDC and several medical research centers in the US to conduct research into how adverse events might be caused by vaccines.

77. ACOG Resources for Business Practice
On-Demand webinar: ACOG Immunization & Clinical Strategies for Ob-Gyn Practices.
Immunization Resources for Ob-Gyns: A Comprehensive Toolkit
ACOG CO 558: Integrating Immunizations into Practice
Visit immunizationforwomen.org for more business practice information, including:
Reimbursement
Vaccine purchasing resources
Standing Orders
Utilizing Electronic Health Records
Routine forms: VIS forms, VAERS
State Registry Contacts

78. ACOG Resources for Incorporating Immunizations into Routine Practice
Immunizationforwomen.org

79. ACOG Resources: Committee Opinions on Immunizations
ACOG Immunization for Women Website:
ACOG CO 558: Integrating Immunizations into Practice, 2013:
ACOG Committee Opinion 608 Influenza Vaccination in Pregnancy, 2014:
ACOG CO 566: Update on Immunization During Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination, 2013:
ACOG CO 588: Human Papillomavirus Vaccination, 2014:

80. ACOG’s Immunization Department
Immunizationforwomen.org
Immunization Program:
Debra Hawks, MPH, Senior Director Practice Activities, Obstetrics, & Immunization
Sarah Patterson Carroll, MPH, Immunization Manager
Valerie Echeveste, Immunization Program Specialist
Megan McReynolds, Director Obstetrics Practice Bulletins,
Immunization, and HIV