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1 Immunizations and Pregnancy Mark H. Sawyer, MD San Diego Immunization Partnership San Diego County Immunization Branch

2 Objectives List vaccines that should be given either during pregnancy or immediately post-partumpartum Describe the epidemiology of pertussis in women of childbearing age and in infants State the recommendations for the use of Tdap vaccine in and around pregnancy Describe how frequently San Diego women are offered vaccines during or after their pregnancies Describe some of the services available for healthcare providers from the San Diego County Immunization Branch

3 Vaccines OB/GYN Need to Primary Importance Know Tdap: Tetanus, diphtheria, & pertussis Influenza HPV: Human Papillomavirus Secondary Importance MMR: measles, mumps, & rubella Hepatitis A Hepatitis B Varicella

4 Percent of women who said that any of their medical caregivers recommended d vaccines for them at these three intervals. 25% 20.9% 22.4% 20% 15% 14.2% 10% 5% n=134 0% Before Pregnancy During Pregnancy After Pregnancy S:\PHS\Immun\Evaluation\RDD 2008\Childhood IZ Survey 2008\Presentations\Post-Partum Survey Results

5 For those who had immunizations recommended to them: Which vaccines were recommended to you? Tdap Influenza 3.3% 21.4% 15.8% 21.4% 50.0% 0% 47.4% MMR 5.3% 10.0% 28.6% HPV 14.3% Hep B 3.6% Varicella Not a vaccine* Don't remember 5.3% 6.7% 13.3% 17.9% 14.3% 21.1% Before Pregnancy During Pregnancy After Pregnancy 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% *Other things named: Rogram, TB Skin Test, RH Factor Before Pregnancy: n=28 During Pregnancy: n=30 After Pregnancy: n=19 S:\PHS\Immun\Evaluation\RDD 2008\Childhood IZ Survey 2008\Presentations\Post-Partum Survey Results

6 Percent of women who chose to receive any of the vaccines if they were offered. 100% 95.0% 93.8% 80% 60% 61.5% 40% 20% 0% Before Pregnancy During Pregnancy After Pregnancy n=20 n=16 n=13 S:\PHS\Immun\Evaluation\RDD 2008\Childhood IZ Survey 2008\Presentations\Post-Partum Survey Results

7 Reports of Pertussis in the U.S ber ar ge Numb ses / Yea Averag of Cas fold 15.5 fold 0 <1 yr 1-4 yrs 5-9 yrs yrs 20+ yrs Age Group Güriş et al. Clin Infect Dis ;28: CDC. MMWR ;51:73-76, 76, 2001;50(53):1-108, 2002;51(53):1-84, 2003;52(54):1-85

8 Age Distribution and Incidence of Reported Pertussis Cases - California cases 400 age-specific rates 70.0 cases ca ses per 10 00, California Dept of Health Services Immunization Branch < 1 yr 1-9 yrs yrs 20+ yrs 0.0

9 Common Clinical Manifestations of Adolescent-Adult Adult Pertussis Cough 97% 3 weeks, 52% 9 weeks Paroxysms 3 weeks in 73% Whoop in 69% Post-tussive tussive emesis in 65% Teens missed average 5 days of school Adults missed average 7 days of work Average 14 days of disrupted sleep De Serres et al. J Infect Dis ;182:174 9.

10 Pertussis as a Cause of Prolonged Cough Illness in Adolescents and Adults Source Locale Years % of Cough Illness Nennig et al. San Francisco Strebel et al. Minn. St. Paul Jackson et al. Seattle Jansen et al. San Diego Wright et al. Nashville Mink et al. Los Angeles Rosenthal et al. Chicago Senzilet LD et al. (2001), Clin Infect Dis 32(12):

11 How is pertussis diagnosed? Four different tests Culture PCR (polymerase chain reaction) DFA (antigen detection) Serology Tests lack sensitivity No single test adequate to reliably diagnose pertussis

12 How is pertussis misdiagnosed? Bronchitis Asthma Gastroesophageal reflux Post-viral bronchospasm Chronic sinusitis Tuberculosis Chlamydia/mycoplasma infection

13 The majority of severe pertussis disease complications occurred among infants 0-2 months of age, California Death Encephalopathy number of cas ses age (months) California Dept of Health Services Immunization Branch

14 Infant Pertussis: Who Was the Source? Bisgard, K. PIDJ. 2004;23: n=264 cases

15 Tdap vaccines Two vaccines available Boostrix (approved for ages 10-64) Adacel Adacel (approved for ages 11-64) Licensed in 2005 Both are composed of: Tetanus toxoid, reduced d diphtheria h i toxoid, and acellular pertussis, adsorbed Only one dose required

16 Tdap Vaccines CDC/AAP recommendations Routine use at years of age Replace Td for all ages Special focus on adults in contact with young infants Post-partum women Consideration during pregnancy Healthcare workers Parents and siblings Grandparents No defined minimum interval from prior Td

17 Tdap and Pregnancy A clinician may choose to administer Tdap to a pregnant woman in certain circumstances, such as during an outbreak of pertussis in the community Pregnancy is not a contraindication to vaccination with Tdap Source: MMWR 2006;55(RR-17)

18 Pertussis Incidence and Vaccine Use, Canada s Northwest Territories rly 00 rage Year es / 10,00 Aver Case Expanded component vaccine Adolescent immunization begins Time Periods Kandola, K. Abstract in Can J Infect Dis Med Microbiol. 2004;15:351. Manuscript in preparation.

19

20 Month of Peak Influenza Activity United States, Pe ercent % 19% 13% 13% 3% 3% 3% Nov Dec Jan Feb Mar Apr May Source: MMWR 2007;56 (RR-6)

21 Pregnancy and Influenza Vaccine Risk of hospitalization more than 4 times higher than among nonpregnant women Risk of complications comparable to nonpregnant women with high risk medical conditions ACIP recommends vaccination with inactivated influenza vaccine for ALL women who will be pregnant during influenza season Source: MMWR 2007;56 (RR-6)

22 For those who chose to receive any vaccines: Which vaccines did you receive? Tdap 21.1% Influenza MMR HPV 12.5% 13.3% 15.8% 10.5% 31.6% 60.6% 62.5% Hep B 10.5% Vri Varicella Pneumonia Not a vaccine* Don't remember 5.3% 12.5% 13.3% 12.5% 21.1% 20.0% 21.1% Before Pregnancy During Pregnancy After Pregnancy 0% 10% 20% 30% 40% 50% 60% 70% *Other things named: Rogram, TB Skin Test, RH Factor Before Pregnancy: n=20 During Pregnancy: n=16 After Pregnancy: n=13 S:\PHS\Immun\Evaluation\RDD 2008\Childhood IZ Survey 2008\Presentations\Post-Partum Survey Results

23 Recommendations Screen each patient for vaccination status Immunize women post-partum partum with Tdap and influenza if they need them Provide vaccines at your clinic If unable to provide vaccines, have a referral system in place

24 Immunization Branch Services for Medical Providers Immunization Management Consultancy Quality Improvement Survey Practice Assessments In-services with assessment results and interventions Immunization Skills Institute Quarterly sessions for Medical la Assistants Support materials Yellow cards Immunization Summary Sheets Immunization Updates San Diego Immunization Registry

25 Information for Health-Care Professionals NNII (www.immunizationinfo.org) VEC (www.vaccine.chop.edu) IAC (www.immunize.org) CDC/NIP (www.cdc.gov/nip) AAP (www.aap.org) AAFP (www.aafp.org/) IVS (www.vaccinesafety.edu) Vaccine Page (www.vaccines.org)

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