Rubella vaccine is of particular concern for pregnant women. Thus, it is reasonable to ask any premenopausal patient if she is pregnant. If she is pregnant and has no antibodies to rubella, she should receive the MMR vaccine postpartum at the time of hospital discharge.
If she is not pregnant, she should be vaccinated and advised to postpone pregnancy for 4 weeks. In addition, when indicated, the patient’s children and other household contacts should be immunized against MMR and varicella.
Influenza is a significant concern for the pregnant patient. A retrospective cohort study found that, during flu season, almost half of the hospitalizations and deaths for cardiopulmonary conditions in healthy pregnant women are attributable to influenza.13 Thus, inactivated influenza vaccine is recommended for gravidas who are in the second or third trimester of pregnancy during flu season.
Hepatitis B. According to ACOG, the Advisory Committee on Immunization Practices, and other organizations, all pregnant women should be screened for hepatitis B surface antigen (HBsAg), preferably at an early prenatal visit.
Screening all pregnant women in the United States would detect about 22,000 HBsAg-positive women and prevent chronic HBV infection in 6,000 neonates each year.14 Gravidas whose initial test is negative but who are at high risk for infection should be tested again late in pregnancy.
TABLE 2 gives specifics on immunization in pregnancy.
STEP 1Assign an advocate in charge of vaccination
Any office-based vaccination program requires an enthusiastic advocate—a nurse, physician, or, better yet, several health professionals who understand that an immunization program is key to improved medical care. The advocate’s job is to promote the benefits of vaccination among both staff and patients.
In a pediatric setting, physicians and nurses cite lack of time as the main reason they do not communicate with patients about the importance of immunization15—and that time shortage is likely a barrier when adult vaccination is at issue, as well. For example, 57% of medical patients interviewed gave the same reason for their failure to get immunized against pneumonia: No one told them it was recommended for their age group.16 By assigning this responsibility to one individual or several persons as a team, it becomes more likely that the issue will be addressed.
Each office visit presents an opportunity. Women with chronic illnesses are most likely to benefit from pneumonia and influenza vaccines, and women who are planning to conceive should be up to date on MMR, tetanusdiphtheria, and varicella (TABLE 2)
STEP 2Use free questionnaires for history-taking, records
Both new and established patients should have their immunization history reviewed. Unfortunately, an accurate history may be difficult to obtain, since patients receive their vaccinations from different providers and often do not keep adequate records. The most reliable sources of information are the patient, her previous physician and, sometimes, her parents.
Necessary information includes the type of immunization received, when it was administered, whether there were adverse reactions and, if so, what they entailed.
History of allergies to eggs, neomycin, or streptomycin should be determined, as these contraindicate certain vaccines (TABLE 2)
One way to help determine whether further immunization is needed is to have the patient complete an immunization questionnaire for review by a nurse or medical assistant.
Adult screening forms are available free of charge from the CDC online at www.cdc.gov/nip/recs/adult_vac_scrn_hcp.pdf. Forms for recording immunizations also are available through the CDC (at www.cdc.gov/nip) and the Immunization Action Coalition (at www.immunize.org).
STEP 3Develop policies for the fundamentals
Immunization will be simplified if the office has protocols for both general administration and specific vaccines.
- Before administering a vaccine, take precautions to prevent the spread of disease. These include washing hands carefully with soap and water before the vaccination is given. Although gloves are not routinely required, they are advisable if there are open lesions on the hands or there is a chance of coming into contact with infectious body fluids.
- Syringes and needles should be sterile, disposable, and used for only 1 injection.
- Never mix different vaccines in the same syringe unless they are specifically licensed for such use.
- For the specifics of administering each agent, consult the manufacturer’s package insert. The recommended dose varies among different vaccines and, sometimes, for the same vaccine produced by different manufacturers.
Follow the manufacturer’s recommen dations on administration route (intramuscular, subcutaneous, intradermal) and injection site. In adults, always give injections into the deltoid muscle, never the gluteus muscle.
Deviation from the recommended route and site can result in inadequate protection. For example, the immunogenicity of HBV is significantly lower when it is injected into the gluteal rather than the deltoid muscle.