Clinical Review

Women’s Health: A realistic vaccination program for all patients, including gravidas

OBG Manag. 2003 December;15(12):37-47

‘Delegate’ is the key to success for this simple screening and vaccination protocol, which uses free forms available online. A detailed chart covers vaccination during pregnancy.

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References

1. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1997;46:1-24.

2. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine Preventable Diseases. 7th ed. Atlanta, Ga: US Department of Health and Human Services; 2002;205-217.

3. Healthy People 2010. Office of Disease Prevention and Health Promotion. US Department of Health and Human Services. Available at: www.healthypeople.gov Accessed September 23, 2003.

4. Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2002;51:1-24.

5. Zimmerman RK, Middleton DB, Burns IT, Clover RD. Vaccines across the life span, 2003. J Fam Pract. 2003;52:S14.-

6. Nichols KL, Lind A, Margolis KL, et al. The effectiveness of vaccination against influenza in healthy, working adults. N Engl J Med. 1995;333:889-893.

7. Moyer LA, Mast EE. Hepatitis B: virology, epidemiology, disease, and prevention, and an overview of viral hepatitis. Am J Prev Med. 1994;10(suppl):45-55.

8. American Academy of Pediatrics Measles. In: Pickering LK, ed. 2000 Red Book: Report of the Committee on Infectious Diseases. Elk Grove Village, Ill: American Academy of Pediatrics; 2000;385-396.

9. Centers for Disease Control and Prevention. Notice to readers: Final 2001 reports of selected notifiable diseases. MMWR Morb Mortal Wkly Rep. 2002;51:710,723-730.

10. Centers for Disease Control and Prevention Varicella-related deaths—United States, 2002. MMWR Morb Mortal Wkly Rep. 2003;52:545-547.

11. American College of Obstetricians and Gynecologists Committee Opinion #282: Immunization During Pregnancy. Washington, DC: ACOG; January 2003.

12. Centers for Disease Control and Prevention General recommendations on immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). MMWR Morbid Mortal Wkly Rep. 2002;51:2.-

13. Neuzil KM, Reed GW, Mitchel EF, Simonsen L, Griffin MR. Impact of influenza on acute cardiopulmonary hospitalizations in pregnant women. Am J Epidemiol. 1998;148:1094-1102.

14. West DJ, Margolis HS. Prevention of hepatitis B virus infection in the United States: a pediatric perspective. Pediatr Infect Dis J. 1992;11:866-874.

15. Davis TC, Fredrickson DD, Arnold CL, et al. Childhood vaccine risk/benefit communication in private practice office settings: a national survey. Pediatrics. 2001;107:e17.-

16. Centers for Disease Control and Prevention. Reasons reported by Medicare beneficiaries for not receiving influenza and pneumococcal vaccination—United States, 1996. MMWR Morb Mortal Wkly Rep. 1999;48:556-559.

17. Centers for Disease Control and Prevention. Prevention of hepatitis A through active or passive immunization. MMWR Morbid Mortal Wkly Rep. 1999;48:RR-12.

18. Gardner P, Schaffer W. Immunizations of adults. N Engl J Med. 1993;328:1252-1258.

19. Treanor JJ, Kotloff K, Betts RF, et al. Evaluation of trivalent, live, cold-adapted (CAIV-T) and inactivated (TIV) influenza vaccines in prevention of virus infection and illness following challenge of adults with wilde-type influenza A (H1N1), A (H3N2), and B viruses. Vaccine. 2000;18:899-906.

20. Beyer WEP, Palache AM, de Jong JC, Osterhaus ADME. Cold-adapted live influenza vaccine vs inactivated vaccine: systemic vaccine reactions, local and systemic antibody response, and vaccine efficacy. A meta-analysis. Vaccine. 2002;20:1340-1353.

21. Nichol KL, Mendelman PM, Mallon KP, et al. Effectiveness of live, attenuated intranasal influenza virus vaccine in healthy, working adults: a randomized controlled trial. JAMA. 1999;282:137-144.

22. FluMist [package insert]. Gaithersburg, Md: MedImmune, Inc; 2003.

23. Asano Y, Nakayama H, Yazaki T, Kato R, Hirose S. Protection against varicella in family contacts by immediate inoculation with varicella vaccine. Pediatrics. 1977;59:3-7.

24. Salzman MB, Garcia C. Postexposure varicella vaccination in siblings of children with active varicella. Pediatr Infect Dis J. 1998;17:256-257.

25. Arbeter AM, Starr SE, Plotkin SA. Varicella vaccine studies in healthy children and adults. Pediatrics. 1986;78:746-756.

KEY POINTS

Adults, not children, incur a greater risk of death due to vaccine-preventable diseases.
During flu season, almost half of the hospitalizations and deaths for cardiopulmonary conditios in healthy pregnant women are due to influenza.
Screening all gravidas for hepatitis B surface antigen would prevent chronic hepatitis B viral infection in 6,000 neonates every year.
Only 54% of community-dwelling elderly persons are immunized against Streptococcus pneumoniae, which has a 55% to 60% mortality rate in persons aged 70 or older.
Influenza is more likely to cause death in middle-aged persons with multiple medical conditions than in healthy elderly persons.

Because of our unique access to women at all stages of life—who often consult no other physician—Ob/Gyns are well positioned to proclaim and bestow the benefits of vaccination.

For women who are pregnant or planning to conceive, benefits extend to the neonate through the first 4 to 6 months of life. For all women, especially those with coexisting chronic diseases, immunization stands to reduce mortality and serious morbidity.

This article details a simple 6-step plan for an immunization program in a typical practice. A key success factor is to minimize disruption by delegating authority for the program to a specific person or persons.

‘Success’ leaves adults at greater risk than children

Few doctors in any specialty pay regular attention to immunization. Over the past 20 years in particular, the United States has lacked a comprehensive adult vaccination program. As a result, many gynecologic patients today are underimmunized.

The tremendous success of childhood immunization has rendered diseases such as polio and measles “invisible” and fostered the perception that vaccination beyond childhood is no longer necessary. As a result, adults, not children, are now at greater risk of death due to vaccine-preventable disease (TABLE 1).

Another reason behind underimmunization is disproportionate media attention to adverse reactions, which discourages people from getting vaccinated.

Ob/Gyns and other clinicians face these challenges:

Establishing an office routine for screening all patients and giving vaccinations.
Informing ourselves and our patients of the benefits of vaccination in specific groups.
Providing reliable information about possible adverse effects.

TABLE 2 details targeted populations, dos-ing, and safety in pregnancy for vaccines recommended for adults.

TABLE 1

Estimated preventable deaths with complete vaccination of targeted adult populations

DISEASE	ESTIMATED ANNUAL DEATHS AMONG ADULTS (n)	ESTIMATED VACCINE EFFICACY*(%)	CURRENT USE† (%)	ADDITIONAL PREVENTABLE DEATHS PER YEAR (n)
Pneumococcal infection	40,000	60	14	20,640
Influenza	20,000	70	30	9,800
Hepatitis B	5,000	90	10^‡	4,050
Hepatitis A	100	95	10	86
Measles, mumps, rubella	<30	95	Variable	<30
Tetanus/diphtheria	<25	99	40^§	<15
Varicella	≥9	NA	53-90^\|\|	≥9
*Indicates efficacy in immunocompetent adults. Among elderly and immunocompromised patients, efficacy is estimated to be lower.
† The percentage of targeted groups who have been immunized according to current recommendations. Rates vary among different targeted groups.
‡ Highly variable (range, 1% to 60%) among different targeted groups.
§ Estimate based on seroprevalence data.
\|\| Among children 19 to 35 months of age.
Adapted from the Centers for Disease Control and Prevention^10,17and from Gardner P, Schaffer W¹⁸with permission of the Massachusetts Medical Society (copyright 1993, Massachusetts Medical Society. All rights reserved)

The sobering facts: Morbidity and mortality rates of vaccine-preventable iseases

Streptococcus pneumoniae causes roughly 3,000 to 6,000 cases of meningitis, 50,000 cases of bacteremia, and 500,000 cases of pneumonia each year in the United States.¹ In people over age 70, the mortality rate is 55% to 60%.² Compounding the risk is the increase in penicillin-resistant pneumococci. Still, only 54% of elderly patients get immunized against pneumonia—well below the goal of 90% set by Healthy People 2010³ for noninstitutionalized elderly.

Influenza causes approximately 20,000 deaths each year, but that figure can reach 40,000 or more in some epidemics.⁴ The death rate begins to rise in midlife and is greatest in persons with chronic medical conditions such as cardiovascular disease, chronic obstructive lung disease, asthma, and diabetes. In fact, influenza has a higher fatality rate in middle-aged persons with multiple medical conditions than in healthy persons 65 years of age or older.

Only a fraction of persons aged 50 to 65 with a high-risk condition are immunized against influenza.

Influenza and pneumonia together are the seventh leading cause of death nationally and the fifth leading cause in older adults.⁵ A study of working adults aged 18 to 64 showed that flu vaccination decreased episodes of upper-respiratory illness by 25% and reduced doctor visits for such illness by 44%.⁶

Ample quantities of flu vaccine are available this flu season. The past 3 seasons, shortages compelled the Centers for Disease Control and Prevention (CDC) to recommend a graduated vaccination schedule to ensure that the neediest individuals were immunized first, while supplies were adequate.

Each year the CDC, the US Food and Drug Administration (FDA), and vaccine manufacturers review the vaccine supply and notify physicians of projected shortages.