An immunization update

As ob.gyns., we pride ourselves on being primary care providers as well as specialists. A central obligation of the primary care physician is the prevention of disease, and immunization of vaccine-preventable diseases is an essential component of prevention. In fact, nothing is more effective at preventing infectious diseases than immunization.

Immunization has not traditionally been as central to our role as it has been for pediatricians, who have long viewed vaccines as a core component of their care. However, although there are certain vaccines that pediatricians can give more easily than we can, such as the human papillomavirus vaccine, there are other vaccines that ob.gyns. can more easily provide. For example, we are better positioned than pediatricians to protect newborns from pertussis.

No other physician, moreover, is better situated to vaccinate vulnerable populations than is the ob.gyn. We are important sources of information and advice for adolescents, adults, and pregnant women. We therefore have a critically important opportunity to identify the diseases that put our patients and their progeny at greatest risk, and a responsibility to make immunization an integral part of our practices.

Numerous investigations and reports addressing vaccine implementation strategies have relevance for both obstetric and gynecologic patients, and studies addressing successful strategies for immunization of pregnant women in particular have increased since the 2009 H1N1 influenza pandemic.

Last spring, the Committee on Obstetric Practice and Committee on Gynecologic Practice of the American College of Obstetricians and Gynecologists published guidance on how to successfully incorporate immunizations into routine care and develop an immunization culture (Committee Opinion No. 558, Obstet. Gynecol. 2013;121:897-903).

Among the key points:

• Make direct recommendations. Talk to your patients directly. Recommend individual immunizations. A provider recommendation has been shown to be one of the strongest influences on patient acceptance. Tell patients, "You should have this vaccine," or "It is important for you," or "I’m telling you as your health care specialist that this vaccine is in your best interest."

Physician scripts for several immunizations are available on ACOG’s immunization website, immunizationforwomen.org, and numerous other sources.

• Designate a vaccine coordinator. As the "vaccine champion," this person orders and receives the vaccines, ensures that the vaccines are stored properly, and has knowledge of appropriate billing codes for vaccination services. He or she also maintains contact with the state health department’s immunization program manager, who can answer physicians’ questions and help practices.

• Institute standing orders. Such orders allow for an indicated vaccine to be administered to patients without an individual physician order. For example, every pregnant woman who shows up during flu season should have a standing order for the influenza vaccination.

Evaluate your prompts, paper or electronic, to remind providers and staff which patients need to be immunized. Hold everyone accountable.

• Get yourself and your staff immunized. Educate staff about the safety and efficacy of immunizations, and ensure that your office health care providers, your entire staff, and you are immunized as recommended. If your staff or you are not immunized, it can be hard to convince patients to receive a vaccine. As ACOG’s Committee Opinion on "Integrating Immunizations into Practice" highlights, moreover, office personnel who express their own uncertainty or lack of knowledge to patients can negatively affect patients’ willingness to receive a vaccine. Additionally, being a potential source of infection for your patients violates ethical obligations.

Research has shown that educational efforts for office staff can markedly increase office immunization rates. In one study of the H1N1 influenza pandemic of 2009, educational sessions for ob.gyns’ staff were part of a multifaceted approach that led to a high vaccine acceptance rate of 76% in an ethnically diverse population of 157 obstetrics patients (Infect. Dis. Obstet. Gynecol. 2011;2011:746214 [doi: 10.1155/2011/746214]). The educational sessions for staff were instituted proactively prior to availability of the vaccine.

Influenza vaccination

Influenza affects 10%-20% of the U.S. population annually, and pregnant women are more likely to have serious complications should they contract the virus. Pregnant women are at least 4-5 times more likely to be hospitalized and equally more likely to die from infection, and their infants are more likely to have influenza-related respiratory illnesses and die.

A 2010 study of the 2009 H1N1 pandemic showed that although pregnant women in the United States represent 1%-2% of the population, they accounted for up to 7%-10% of the hospitalized patients, 6%-9% of the ICU patients, and 6%-10% of the patients who died (N. Engl. J. Med. 2010:362:1708-19).

A study published in early 2013 showed that vaccination was 70% successful in preventing 2009 H1N1 influenza infection in pregnant women in Norway during the pandemic, and that the risk of fetal death nearly doubled among women who contracted influenza (N. Engl. J. Med. 2013;368:333-40). Of almost 120,000 pregnant women in the study, approximately half had received the flu vaccine.

Studies of earlier influenza pandemics and large epidemiologic studies of otherwise healthy pregnant women who contracted nonpandemic seasonal influenza have similarly demonstrated how pregnant women and their infants disproportionately experience severe sequelae.

We need to inform our pregnant patients that the influenza vaccine protects their newborns as well as themselves. We must also work harder to dispel misconceptions about the safety of the vaccine.

One barrier to pregnant women receiving the 2009 H1N1 influenza vaccine was perceived risks to the fetus (Am. J. Obstet. Gynecol. 2011;204:S124-7). The source of much of this concern stems from the fact that some influenza vaccines contain trace amounts of the preservative thimerosal.

Influenza vaccines that contain a mercury-free preservative are available, but pregnant women should be informed that the Centers for Disease Control and Prevention (CDC), the Institute of Medicine, and numerous other health organizations have concluded that the thimerosal used in the vaccine is safe. The only flu vaccine that pregnant women should not receive is the attenuated vaccine.

An additional concern for some is that the influenza vaccine contains chicken egg protein, an allergen for some individuals. However, the CDC’s Advisory Committee on Immunization Practices now recommends that individuals who have only had hives after exposure to egg should receive the influenza vaccine, though physicians should take extra precautions, such as observing these patients for at least 30 minutes after administering the vaccine (www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm).

With influenza immunization, we should celebrate our successes. As described in ACOG’s Committee Opinion on integrating vaccinations, vaccination of pregnant women increased nationwide to a level of approximately 50% in 2009, a significant increase over pre-pandemic rates of approximately 15%. Rates during the 2011-2012 influenza season remained approximately 47%.

Such improvement shows that immunization is achievable in our practices. However, rates hovering around half of all pregnant women are still just slightly north of mediocre. We should continue to make the benefits of vaccination clear to staff and patients, and the algorithm for implementation simple.

Given that the flu season begins in October and can run into spring – and that it takes about 2 weeks for production of protective antibody levels – it is rare that a pregnant woman will not need the vaccine.

Full recommendations for the prevention and control of influenza in 2013-2014 were expected at the time of this writing to be published in the Morbidity and Mortality Weekly Report.

Tdap

Pertussis is highly infectious, and infants who contract the bacterium have increased rates of whooping cough attacks and are at the greatest risk for severe disease and death. Pertussis outbreaks have become common in the United States, and can be difficult to identify and manage. Infants continue to have the highest reported rates.

When immunization is an integral part of one’s office (with standing orders, etc.), administering a dose of Tdap during each pregnancy to prevent pertussis in infants – as is recommended in the CDC immunization schedule released in January 2013 – should be relatively simple during prenatal office visits.

The postpartum "cocooning" approach recommended by the CDC in 2006 and supported by ACOG has been practically and logistically difficult to implement. While the concept is sound, it has proved too cumbersome overall to vaccinate every family member and caregiver who will have close contact with an infant. Merely having the parents vaccinated immediately postpartum – the other part of cocooning – has been difficult enough.

The new recommendations draw upon the proven paradigm of maternal vaccination for newborn benefit and the relative ease of immunization during prenatal care visits. Ob.gyns. should administer a dose of Tdap during each pregnancy – optimally between 27 and 36 weeks’ gestation – irrespective of the patient’s prior history of receiving Tdap.

Infants do not start their vaccination series against these pathogens until age 2 months; maternal immunization in late pregnancy leads to high transplacental antibody transfer, which will protect infants until they receive their own vaccines.

Although the optimal timing for maternal Tdap immunization is later in pregnancy, the vaccine may be given at any time if necessitated by clinical circumstance. For example, if a woman steps on a rusty nail during her first trimester and has not had a tetanus booster in the prior 5 years, or if a local school reports an epidemic, she should receive the Tdap vaccine immediately.

Cocooning is now the default; if Tdap is not administered during pregnancy for some reason, it should be administered immediately postpartum, with as much cocooning as possible.

The challenge with the Tdap vaccine is that few people who live outside areas where pertussis epidemics have occurred know someone who has had the bacterial disease. Education and a direct recommendation for the vaccine are therefore critical.

Human papillomavirus, hepatitis B

HPV vaccines are not recommended for use in pregnant women, and although ob.gyns. are not the central players with these vaccines, we still have an important role to play in HPV immunization. We can help backstop pediatricians and facilitate the recommended "catch-up" for females aged 13-26 years who were not immunized at the recommended starting age of 11 or 12 years.

Unfortunately, the three-dose HPV vaccine series was misframed in the United States as a vaccine to prevent a sexually transmitted infection, rather than being framed, as it was in other countries, as a vaccine to prevent cancer. The unintended consequence has been widespread unwillingness of many U.S. parents to vaccinate their young daughters – a phenomenon that has challenged pediatricians and limited uptake of the vaccine.

For ob.gyns., the catch-up role means that many of their patients who are potential candidates for the vaccines are already sexually active and carrying HPV. Still, ob.gyns. should review the vaccine history with their patients and administer remaining or all doses as needed.

Both of the available vaccines – the quadrivalent HPV vaccine and the bivalent HPV vaccine – protect against viral genotypes 16 and 18, which are associated with 70% of cervical cancers. The quadrivalent vaccine provides extra protection against genotypes 6 and 11, which are associated with 90% of genital warts cases. Both vaccines protect against vulvar, vaginal, anal, and penile dysplasias.

The HPV vaccines have been used broadly throughout the world. In Australia, where vaccine coverage has been high, there is now evidence of herd immunity, with the number of males presenting with new diagnoses of genital warts declining even though females are the ones being vaccinated.

With respect to hepatitis B infection, sexual transmission is the most common mode of transmission in the United States, and in this sense, ob.gyns. have an important opportunity to ensure that women at risk for hepatitis B infection are vaccinated. Ob.gyns. should take a history of a sexually transmitted infection, in particular, as a trigger for action. It should be second nature for us to tell a patient who had gonorrhea 2 years ago that we recommend the hepatitis B vaccine for her.

A history of a sexually transmitted infection is only one of the risk factors for hepatitis B – others include recurrent or current injection drug use, previous incarceration, and exposure to blood products – but it is the one that most clearly calls us into a public health role. A significant number of women who see us during any given year do not see any other physicians or health care providers, so we cannot depend on other providers to take the lead on immunization.

Remember, you cannot always learn of a history of a sexually transmitted infection by simply asking, have you ever had a sexually transmitted infection? Women should be given a list of specific sexually transmitted infections and asked whether they’re ever had any of them. Research has shown that women commonly do not equate pelvic inflammatory disease or Trichomonas vaginalis, for instance, with sexual transmission.

Dr. Minkoff serves as chairman of the department of obstetrics and gynecology at Maimonides Medical Center, and is a distinguished professor of obstetrics and gynecology at SUNY Downstate Medical Center, both in Brooklyn, N.Y. Dr. Minkoff reported that he has no disclosures relevant to this Master Class.

As ob.gyns., we pride ourselves on being primary care providers as well as specialists. A central obligation of the primary care physician is the prevention of disease, and immunization of vaccine-preventable diseases is an essential component of prevention. In fact, nothing is more effective at preventing infectious diseases than immunization.

Immunization has not traditionally been as central to our role as it has been for pediatricians, who have long viewed vaccines as a core component of their care. However, although there are certain vaccines that pediatricians can give more easily than we can, such as the human papillomavirus vaccine, there are other vaccines that ob.gyns. can more easily provide. For example, we are better positioned than pediatricians to protect newborns from pertussis.

No other physician, moreover, is better situated to vaccinate vulnerable populations than is the ob.gyn. We are important sources of information and advice for adolescents, adults, and pregnant women. We therefore have a critically important opportunity to identify the diseases that put our patients and their progeny at greatest risk, and a responsibility to make immunization an integral part of our practices.

Numerous investigations and reports addressing vaccine implementation strategies have relevance for both obstetric and gynecologic patients, and studies addressing successful strategies for immunization of pregnant women in particular have increased since the 2009 H1N1 influenza pandemic.

Last spring, the Committee on Obstetric Practice and Committee on Gynecologic Practice of the American College of Obstetricians and Gynecologists published guidance on how to successfully incorporate immunizations into routine care and develop an immunization culture (Committee Opinion No. 558, Obstet. Gynecol. 2013;121:897-903).

Among the key points:

• Make direct recommendations. Talk to your patients directly. Recommend individual immunizations. A provider recommendation has been shown to be one of the strongest influences on patient acceptance. Tell patients, "You should have this vaccine," or "It is important for you," or "I’m telling you as your health care specialist that this vaccine is in your best interest."

Physician scripts for several immunizations are available on ACOG’s immunization website, immunizationforwomen.org, and numerous other sources.

• Designate a vaccine coordinator. As the "vaccine champion," this person orders and receives the vaccines, ensures that the vaccines are stored properly, and has knowledge of appropriate billing codes for vaccination services. He or she also maintains contact with the state health department’s immunization program manager, who can answer physicians’ questions and help practices.

• Institute standing orders. Such orders allow for an indicated vaccine to be administered to patients without an individual physician order. For example, every pregnant woman who shows up during flu season should have a standing order for the influenza vaccination.

Evaluate your prompts, paper or electronic, to remind providers and staff which patients need to be immunized. Hold everyone accountable.

• Get yourself and your staff immunized. Educate staff about the safety and efficacy of immunizations, and ensure that your office health care providers, your entire staff, and you are immunized as recommended. If your staff or you are not immunized, it can be hard to convince patients to receive a vaccine. As ACOG’s Committee Opinion on "Integrating Immunizations into Practice" highlights, moreover, office personnel who express their own uncertainty or lack of knowledge to patients can negatively affect patients’ willingness to receive a vaccine. Additionally, being a potential source of infection for your patients violates ethical obligations.

Research has shown that educational efforts for office staff can markedly increase office immunization rates. In one study of the H1N1 influenza pandemic of 2009, educational sessions for ob.gyns’ staff were part of a multifaceted approach that led to a high vaccine acceptance rate of 76% in an ethnically diverse population of 157 obstetrics patients (Infect. Dis. Obstet. Gynecol. 2011;2011:746214 [doi: 10.1155/2011/746214]). The educational sessions for staff were instituted proactively prior to availability of the vaccine.

Influenza vaccination

Influenza affects 10%-20% of the U.S. population annually, and pregnant women are more likely to have serious complications should they contract the virus. Pregnant women are at least 4-5 times more likely to be hospitalized and equally more likely to die from infection, and their infants are more likely to have influenza-related respiratory illnesses and die.

A 2010 study of the 2009 H1N1 pandemic showed that although pregnant women in the United States represent 1%-2% of the population, they accounted for up to 7%-10% of the hospitalized patients, 6%-9% of the ICU patients, and 6%-10% of the patients who died (N. Engl. J. Med. 2010:362:1708-19).

A study published in early 2013 showed that vaccination was 70% successful in preventing 2009 H1N1 influenza infection in pregnant women in Norway during the pandemic, and that the risk of fetal death nearly doubled among women who contracted influenza (N. Engl. J. Med. 2013;368:333-40). Of almost 120,000 pregnant women in the study, approximately half had received the flu vaccine.

Studies of earlier influenza pandemics and large epidemiologic studies of otherwise healthy pregnant women who contracted nonpandemic seasonal influenza have similarly demonstrated how pregnant women and their infants disproportionately experience severe sequelae.

We need to inform our pregnant patients that the influenza vaccine protects their newborns as well as themselves. We must also work harder to dispel misconceptions about the safety of the vaccine.

One barrier to pregnant women receiving the 2009 H1N1 influenza vaccine was perceived risks to the fetus (Am. J. Obstet. Gynecol. 2011;204:S124-7). The source of much of this concern stems from the fact that some influenza vaccines contain trace amounts of the preservative thimerosal.

Influenza vaccines that contain a mercury-free preservative are available, but pregnant women should be informed that the Centers for Disease Control and Prevention (CDC), the Institute of Medicine, and numerous other health organizations have concluded that the thimerosal used in the vaccine is safe. The only flu vaccine that pregnant women should not receive is the attenuated vaccine.

An additional concern for some is that the influenza vaccine contains chicken egg protein, an allergen for some individuals. However, the CDC’s Advisory Committee on Immunization Practices now recommends that individuals who have only had hives after exposure to egg should receive the influenza vaccine, though physicians should take extra precautions, such as observing these patients for at least 30 minutes after administering the vaccine (www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm).

With influenza immunization, we should celebrate our successes. As described in ACOG’s Committee Opinion on integrating vaccinations, vaccination of pregnant women increased nationwide to a level of approximately 50% in 2009, a significant increase over pre-pandemic rates of approximately 15%. Rates during the 2011-2012 influenza season remained approximately 47%.

Such improvement shows that immunization is achievable in our practices. However, rates hovering around half of all pregnant women are still just slightly north of mediocre. We should continue to make the benefits of vaccination clear to staff and patients, and the algorithm for implementation simple.

Given that the flu season begins in October and can run into spring – and that it takes about 2 weeks for production of protective antibody levels – it is rare that a pregnant woman will not need the vaccine.

Full recommendations for the prevention and control of influenza in 2013-2014 were expected at the time of this writing to be published in the Morbidity and Mortality Weekly Report.

Tdap

Pertussis is highly infectious, and infants who contract the bacterium have increased rates of whooping cough attacks and are at the greatest risk for severe disease and death. Pertussis outbreaks have become common in the United States, and can be difficult to identify and manage. Infants continue to have the highest reported rates.

When immunization is an integral part of one’s office (with standing orders, etc.), administering a dose of Tdap during each pregnancy to prevent pertussis in infants – as is recommended in the CDC immunization schedule released in January 2013 – should be relatively simple during prenatal office visits.

The postpartum "cocooning" approach recommended by the CDC in 2006 and supported by ACOG has been practically and logistically difficult to implement. While the concept is sound, it has proved too cumbersome overall to vaccinate every family member and caregiver who will have close contact with an infant. Merely having the parents vaccinated immediately postpartum – the other part of cocooning – has been difficult enough.

The new recommendations draw upon the proven paradigm of maternal vaccination for newborn benefit and the relative ease of immunization during prenatal care visits. Ob.gyns. should administer a dose of Tdap during each pregnancy – optimally between 27 and 36 weeks’ gestation – irrespective of the patient’s prior history of receiving Tdap.

Infants do not start their vaccination series against these pathogens until age 2 months; maternal immunization in late pregnancy leads to high transplacental antibody transfer, which will protect infants until they receive their own vaccines.

Although the optimal timing for maternal Tdap immunization is later in pregnancy, the vaccine may be given at any time if necessitated by clinical circumstance. For example, if a woman steps on a rusty nail during her first trimester and has not had a tetanus booster in the prior 5 years, or if a local school reports an epidemic, she should receive the Tdap vaccine immediately.

Cocooning is now the default; if Tdap is not administered during pregnancy for some reason, it should be administered immediately postpartum, with as much cocooning as possible.

The challenge with the Tdap vaccine is that few people who live outside areas where pertussis epidemics have occurred know someone who has had the bacterial disease. Education and a direct recommendation for the vaccine are therefore critical.

Human papillomavirus, hepatitis B

HPV vaccines are not recommended for use in pregnant women, and although ob.gyns. are not the central players with these vaccines, we still have an important role to play in HPV immunization. We can help backstop pediatricians and facilitate the recommended "catch-up" for females aged 13-26 years who were not immunized at the recommended starting age of 11 or 12 years.

Unfortunately, the three-dose HPV vaccine series was misframed in the United States as a vaccine to prevent a sexually transmitted infection, rather than being framed, as it was in other countries, as a vaccine to prevent cancer. The unintended consequence has been widespread unwillingness of many U.S. parents to vaccinate their young daughters – a phenomenon that has challenged pediatricians and limited uptake of the vaccine.

For ob.gyns., the catch-up role means that many of their patients who are potential candidates for the vaccines are already sexually active and carrying HPV. Still, ob.gyns. should review the vaccine history with their patients and administer remaining or all doses as needed.

Both of the available vaccines – the quadrivalent HPV vaccine and the bivalent HPV vaccine – protect against viral genotypes 16 and 18, which are associated with 70% of cervical cancers. The quadrivalent vaccine provides extra protection against genotypes 6 and 11, which are associated with 90% of genital warts cases. Both vaccines protect against vulvar, vaginal, anal, and penile dysplasias.

The HPV vaccines have been used broadly throughout the world. In Australia, where vaccine coverage has been high, there is now evidence of herd immunity, with the number of males presenting with new diagnoses of genital warts declining even though females are the ones being vaccinated.

With respect to hepatitis B infection, sexual transmission is the most common mode of transmission in the United States, and in this sense, ob.gyns. have an important opportunity to ensure that women at risk for hepatitis B infection are vaccinated. Ob.gyns. should take a history of a sexually transmitted infection, in particular, as a trigger for action. It should be second nature for us to tell a patient who had gonorrhea 2 years ago that we recommend the hepatitis B vaccine for her.

A history of a sexually transmitted infection is only one of the risk factors for hepatitis B – others include recurrent or current injection drug use, previous incarceration, and exposure to blood products – but it is the one that most clearly calls us into a public health role. A significant number of women who see us during any given year do not see any other physicians or health care providers, so we cannot depend on other providers to take the lead on immunization.

Remember, you cannot always learn of a history of a sexually transmitted infection by simply asking, have you ever had a sexually transmitted infection? Women should be given a list of specific sexually transmitted infections and asked whether they’re ever had any of them. Research has shown that women commonly do not equate pelvic inflammatory disease or Trichomonas vaginalis, for instance, with sexual transmission.

Dr. Minkoff serves as chairman of the department of obstetrics and gynecology at Maimonides Medical Center, and is a distinguished professor of obstetrics and gynecology at SUNY Downstate Medical Center, both in Brooklyn, N.Y. Dr. Minkoff reported that he has no disclosures relevant to this Master Class.

As ob.gyns., we pride ourselves on being primary care providers as well as specialists. A central obligation of the primary care physician is the prevention of disease, and immunization of vaccine-preventable diseases is an essential component of prevention. In fact, nothing is more effective at preventing infectious diseases than immunization.

Immunization has not traditionally been as central to our role as it has been for pediatricians, who have long viewed vaccines as a core component of their care. However, although there are certain vaccines that pediatricians can give more easily than we can, such as the human papillomavirus vaccine, there are other vaccines that ob.gyns. can more easily provide. For example, we are better positioned than pediatricians to protect newborns from pertussis.

No other physician, moreover, is better situated to vaccinate vulnerable populations than is the ob.gyn. We are important sources of information and advice for adolescents, adults, and pregnant women. We therefore have a critically important opportunity to identify the diseases that put our patients and their progeny at greatest risk, and a responsibility to make immunization an integral part of our practices.

Numerous investigations and reports addressing vaccine implementation strategies have relevance for both obstetric and gynecologic patients, and studies addressing successful strategies for immunization of pregnant women in particular have increased since the 2009 H1N1 influenza pandemic.

Last spring, the Committee on Obstetric Practice and Committee on Gynecologic Practice of the American College of Obstetricians and Gynecologists published guidance on how to successfully incorporate immunizations into routine care and develop an immunization culture (Committee Opinion No. 558, Obstet. Gynecol. 2013;121:897-903).

Among the key points:

• Make direct recommendations. Talk to your patients directly. Recommend individual immunizations. A provider recommendation has been shown to be one of the strongest influences on patient acceptance. Tell patients, "You should have this vaccine," or "It is important for you," or "I’m telling you as your health care specialist that this vaccine is in your best interest."

Physician scripts for several immunizations are available on ACOG’s immunization website, immunizationforwomen.org, and numerous other sources.

• Designate a vaccine coordinator. As the "vaccine champion," this person orders and receives the vaccines, ensures that the vaccines are stored properly, and has knowledge of appropriate billing codes for vaccination services. He or she also maintains contact with the state health department’s immunization program manager, who can answer physicians’ questions and help practices.

• Institute standing orders. Such orders allow for an indicated vaccine to be administered to patients without an individual physician order. For example, every pregnant woman who shows up during flu season should have a standing order for the influenza vaccination.

Evaluate your prompts, paper or electronic, to remind providers and staff which patients need to be immunized. Hold everyone accountable.

• Get yourself and your staff immunized. Educate staff about the safety and efficacy of immunizations, and ensure that your office health care providers, your entire staff, and you are immunized as recommended. If your staff or you are not immunized, it can be hard to convince patients to receive a vaccine. As ACOG’s Committee Opinion on "Integrating Immunizations into Practice" highlights, moreover, office personnel who express their own uncertainty or lack of knowledge to patients can negatively affect patients’ willingness to receive a vaccine. Additionally, being a potential source of infection for your patients violates ethical obligations.

Research has shown that educational efforts for office staff can markedly increase office immunization rates. In one study of the H1N1 influenza pandemic of 2009, educational sessions for ob.gyns’ staff were part of a multifaceted approach that led to a high vaccine acceptance rate of 76% in an ethnically diverse population of 157 obstetrics patients (Infect. Dis. Obstet. Gynecol. 2011;2011:746214 [doi: 10.1155/2011/746214]). The educational sessions for staff were instituted proactively prior to availability of the vaccine.

Influenza vaccination

Influenza affects 10%-20% of the U.S. population annually, and pregnant women are more likely to have serious complications should they contract the virus. Pregnant women are at least 4-5 times more likely to be hospitalized and equally more likely to die from infection, and their infants are more likely to have influenza-related respiratory illnesses and die.

A 2010 study of the 2009 H1N1 pandemic showed that although pregnant women in the United States represent 1%-2% of the population, they accounted for up to 7%-10% of the hospitalized patients, 6%-9% of the ICU patients, and 6%-10% of the patients who died (N. Engl. J. Med. 2010:362:1708-19).

A study published in early 2013 showed that vaccination was 70% successful in preventing 2009 H1N1 influenza infection in pregnant women in Norway during the pandemic, and that the risk of fetal death nearly doubled among women who contracted influenza (N. Engl. J. Med. 2013;368:333-40). Of almost 120,000 pregnant women in the study, approximately half had received the flu vaccine.

Studies of earlier influenza pandemics and large epidemiologic studies of otherwise healthy pregnant women who contracted nonpandemic seasonal influenza have similarly demonstrated how pregnant women and their infants disproportionately experience severe sequelae.

We need to inform our pregnant patients that the influenza vaccine protects their newborns as well as themselves. We must also work harder to dispel misconceptions about the safety of the vaccine.

One barrier to pregnant women receiving the 2009 H1N1 influenza vaccine was perceived risks to the fetus (Am. J. Obstet. Gynecol. 2011;204:S124-7). The source of much of this concern stems from the fact that some influenza vaccines contain trace amounts of the preservative thimerosal.

Influenza vaccines that contain a mercury-free preservative are available, but pregnant women should be informed that the Centers for Disease Control and Prevention (CDC), the Institute of Medicine, and numerous other health organizations have concluded that the thimerosal used in the vaccine is safe. The only flu vaccine that pregnant women should not receive is the attenuated vaccine.

An additional concern for some is that the influenza vaccine contains chicken egg protein, an allergen for some individuals. However, the CDC’s Advisory Committee on Immunization Practices now recommends that individuals who have only had hives after exposure to egg should receive the influenza vaccine, though physicians should take extra precautions, such as observing these patients for at least 30 minutes after administering the vaccine (www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm).

With influenza immunization, we should celebrate our successes. As described in ACOG’s Committee Opinion on integrating vaccinations, vaccination of pregnant women increased nationwide to a level of approximately 50% in 2009, a significant increase over pre-pandemic rates of approximately 15%. Rates during the 2011-2012 influenza season remained approximately 47%.

Such improvement shows that immunization is achievable in our practices. However, rates hovering around half of all pregnant women are still just slightly north of mediocre. We should continue to make the benefits of vaccination clear to staff and patients, and the algorithm for implementation simple.

Given that the flu season begins in October and can run into spring – and that it takes about 2 weeks for production of protective antibody levels – it is rare that a pregnant woman will not need the vaccine.

Full recommendations for the prevention and control of influenza in 2013-2014 were expected at the time of this writing to be published in the Morbidity and Mortality Weekly Report.

Tdap

Pertussis is highly infectious, and infants who contract the bacterium have increased rates of whooping cough attacks and are at the greatest risk for severe disease and death. Pertussis outbreaks have become common in the United States, and can be difficult to identify and manage. Infants continue to have the highest reported rates.

When immunization is an integral part of one’s office (with standing orders, etc.), administering a dose of Tdap during each pregnancy to prevent pertussis in infants – as is recommended in the CDC immunization schedule released in January 2013 – should be relatively simple during prenatal office visits.

The postpartum "cocooning" approach recommended by the CDC in 2006 and supported by ACOG has been practically and logistically difficult to implement. While the concept is sound, it has proved too cumbersome overall to vaccinate every family member and caregiver who will have close contact with an infant. Merely having the parents vaccinated immediately postpartum – the other part of cocooning – has been difficult enough.

The new recommendations draw upon the proven paradigm of maternal vaccination for newborn benefit and the relative ease of immunization during prenatal care visits. Ob.gyns. should administer a dose of Tdap during each pregnancy – optimally between 27 and 36 weeks’ gestation – irrespective of the patient’s prior history of receiving Tdap.

Infants do not start their vaccination series against these pathogens until age 2 months; maternal immunization in late pregnancy leads to high transplacental antibody transfer, which will protect infants until they receive their own vaccines.

Although the optimal timing for maternal Tdap immunization is later in pregnancy, the vaccine may be given at any time if necessitated by clinical circumstance. For example, if a woman steps on a rusty nail during her first trimester and has not had a tetanus booster in the prior 5 years, or if a local school reports an epidemic, she should receive the Tdap vaccine immediately.

Cocooning is now the default; if Tdap is not administered during pregnancy for some reason, it should be administered immediately postpartum, with as much cocooning as possible.

The challenge with the Tdap vaccine is that few people who live outside areas where pertussis epidemics have occurred know someone who has had the bacterial disease. Education and a direct recommendation for the vaccine are therefore critical.

Human papillomavirus, hepatitis B

HPV vaccines are not recommended for use in pregnant women, and although ob.gyns. are not the central players with these vaccines, we still have an important role to play in HPV immunization. We can help backstop pediatricians and facilitate the recommended "catch-up" for females aged 13-26 years who were not immunized at the recommended starting age of 11 or 12 years.

Unfortunately, the three-dose HPV vaccine series was misframed in the United States as a vaccine to prevent a sexually transmitted infection, rather than being framed, as it was in other countries, as a vaccine to prevent cancer. The unintended consequence has been widespread unwillingness of many U.S. parents to vaccinate their young daughters – a phenomenon that has challenged pediatricians and limited uptake of the vaccine.

For ob.gyns., the catch-up role means that many of their patients who are potential candidates for the vaccines are already sexually active and carrying HPV. Still, ob.gyns. should review the vaccine history with their patients and administer remaining or all doses as needed.

Both of the available vaccines – the quadrivalent HPV vaccine and the bivalent HPV vaccine – protect against viral genotypes 16 and 18, which are associated with 70% of cervical cancers. The quadrivalent vaccine provides extra protection against genotypes 6 and 11, which are associated with 90% of genital warts cases. Both vaccines protect against vulvar, vaginal, anal, and penile dysplasias.

The HPV vaccines have been used broadly throughout the world. In Australia, where vaccine coverage has been high, there is now evidence of herd immunity, with the number of males presenting with new diagnoses of genital warts declining even though females are the ones being vaccinated.

With respect to hepatitis B infection, sexual transmission is the most common mode of transmission in the United States, and in this sense, ob.gyns. have an important opportunity to ensure that women at risk for hepatitis B infection are vaccinated. Ob.gyns. should take a history of a sexually transmitted infection, in particular, as a trigger for action. It should be second nature for us to tell a patient who had gonorrhea 2 years ago that we recommend the hepatitis B vaccine for her.

A history of a sexually transmitted infection is only one of the risk factors for hepatitis B – others include recurrent or current injection drug use, previous incarceration, and exposure to blood products – but it is the one that most clearly calls us into a public health role. A significant number of women who see us during any given year do not see any other physicians or health care providers, so we cannot depend on other providers to take the lead on immunization.

Remember, you cannot always learn of a history of a sexually transmitted infection by simply asking, have you ever had a sexually transmitted infection? Women should be given a list of specific sexually transmitted infections and asked whether they’re ever had any of them. Research has shown that women commonly do not equate pelvic inflammatory disease or Trichomonas vaginalis, for instance, with sexual transmission.

Dr. Minkoff serves as chairman of the department of obstetrics and gynecology at Maimonides Medical Center, and is a distinguished professor of obstetrics and gynecology at SUNY Downstate Medical Center, both in Brooklyn, N.Y. Dr. Minkoff reported that he has no disclosures relevant to this Master Class.