1. health and fitness
2. disease
3. cold and flu

I
Immunizations
i ti
and
d
Pregnancy
Mark H. Sawyer, MD
S Diego
San
Di
Immunization
I
i ti Partnership
P t
hi
San Diego County Immunization Branch
Objectives





List vaccines that should be ggiven either duringg
pregnancy or immediately postpost-partum
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
Vaccines OB/GYN Need to
Know

Primary Importance
Tdap: Tetanus, diphtheria, & pertussis
 Influenza
 HPV: Human Papillomavirus


Secondary Importance
MMR: measles, mumps, & rubella
 Hepatitis
p
A
 Hepatitis B
 Varicella

Percent of women who said that any of their medical caregivers
recommended
d d vaccines
i
ffor them
th att th
these th
three iintervals.
t
l
25%
20.9%
22.4%
20%
14.2%
15%
10%
5%
0%
n=134
Before Pregnancy
g
y
Duringg Pregnancy
g
y
After Pregnancy
g
y
S:\PHS\Immun\Evaluation\RDD 2008\Childhood IZ Survey 2008\Presentations\Post-Partum Survey Results
For those who had immunizations recommended to them:
Which vaccines were recommended to you?
y
Tdap
21.4%
3.3%
15.8%
21.4%
Influenza
MMR
28.6%
10.0%
5.3%
50 0%
50.0%
47.4%
14 3%
14.3%
HPV
3.6%
Hep B
Varicella
5.3%
Not a vaccine*
13.3%
Don't remember
6.7%
0%
5%
10%
Before Pregnancy
17.9%
During Pregnancy
14.3%
After Pregnancy
21.1%
15%
20%
25%
30%
35%
40%
*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
45%
50%
55%
Percent of women who chose to receive any of the
vaccines
i
if they
h were offered.
ff d
100%
95.0%
93.8%
80%
61.5%
60%
40%
20%
%
0%
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
Reports of Pertussis in the U.S.
1990--1993
1990
1994--1996
1994
1997--2000
1997
2001--2003
2001
9000
18.8
fold
8000
Averag
ge Numb
ber
of Cas
ses / Yea
ar
2004
7000
15.5
fold
6000
5000
4000
3000
2000
1000
0
<1 yr
1-4 yrs
5-9 yrs
Age Group
10--19 yrs
10
Güriş
riş et al. Clin Infect Dis.
Dis. 1999;28:12301999;28:1230-1237.
CDC. MMWR
MMWR.. 2002;51:73
2002;51:73--76, 2001;50(53):1-108, 2002;51(53):1-84, 2003;52(54):1-85
20+ yrs
Age Distribution and Incidence of Reported Pertussis Cases - California 2004
4 50
8 0 .0
c a se s
4 00
age-specific ra te s
3 50
7 0 .0
3 00
ca s e s
5 0 .0
2 50
4 0 .0
2 00
3 0 .0
1 50
2 0 .0
1 00
1 0 .0
50
0
California Dept of Health
<
Services Immunization Branch
0 .0
1 yr
1-9 yrs
1 0 -1 9 yrs
20 + yrs
c a se s pe r 1 0 0,0 0
6 0 .0
Common Clinical Manifestations of
Ad l
AdolescentAdolescent
-Adult
Ad l Pertussis
P
i

Cough 97%  3 weeks,
weeks 52%  9
weeks

Paroxysms  3 weeks in 73%

Whoop in 69%

Post--tussive emesis in 65%
Post

Teens missed average 5 days of
school

Adults
Ad l missed
i d average 7 days
d
off
work

Average 14 days of disrupted
sleep
De Serres et al. J Infect Dis.
Dis. 2000;182:174–
2000;182:174–9.
Pertussis as a Cause of Prolonged Cough
Illness in Adolescents and Adults
Locale
Years
% off Cough
C h
Illness
Nennig et al.
San Francisco
1994--1995
1994
12
Strebel et al.
Minn.—
Minn.
—St. Paul
1995--1996
1995
13
Jackson et al.
Seattle
1983--1987
1983
15
Jansen et al.
San Diego
1993--1994
1993
17
Wright et al.
Nashville
1992--1994
1992
21
Los Angeles
1986--1989
1986
26
Chicago
1993--1994
1993
26
Source
Mink et al.
Rosenthal et al.
Senzilet LD et al. (2001), Clin Infect Dis 32(12):1691-1697
How is pertussis diagnosed?

Four different tests






Culture
PCR (polymerase chain reaction)
DFA (antigen detection)
Serology
l
Tests lack sensitivity
No single test adequate to reliably diagnose
pertussis
How is pertussis misdiagnosed?







B
Bronchitis
hiti
Asthma
Gastroesophageal reflux
Post--viral bronchospasm
Post
Chronic sinusitis
T b
Tuberculosis
l i
Chlamydia/mycoplasma infection
The majority of severe pertussis disease complications occurred among infants
0-2 months of age, California 1995 - 2004
16
15
Death
Encephalopathy
14
12
number of casses
n
12
10
8
7
6
5
4
3
2
1
1
0
0
0
0
0
0
0
0
0
1
2
3
4
5
6
age (months)
California Dept of Health Services
Immunization Branch
Infant Pertussis: Who Was the
Source?
Bisgard, K. PIDJ. 2004;23:985
2004;23:985--9.
n=264 cases
Tdap vaccines



Two vaccines available
 Boostrix (approved for ages 1010-64)
 Adacel
Ad l (approved for ages 11 - 64)
Licensed in 2005
Both are composed of:


Tetanus
T
toxoid,
id reduced
d d diphtheria
di h h i toxoid,
id
and acellular pertussis, adsorbed
Only one dose required
Tdap Vaccines
CDC/AAP recommendations
d i



Routine use at 11
11--12 years of age
Replace Td for all ages 1111-64
Special focus on adults in contact with young infants






Post-partum women
PostConsideration during pregnancy
Healthcare workers
Parents and siblings
Grandparents
No defined minimum interval from prior Td
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)
Pertussis Incidence and Vaccine Use, 1993 – 2004
Canada’s Northwest Territories
Expanded
component
vaccine
12
Averrage Yearrly
Case
es / 10,00
00
10
Ad l
Adolescent
t
immunization
begins
8
6
4
2
0
1993--1996
1993
1997
1997--2000
2001
2001--2002
2003
2003--2004
Time Periods
Kandola, K. Abstract in Can J Infect Dis Med Microbiol. 2004;15:351. Manuscript in preparation.
Month of Peak Influenza Activity
United States, 19761976-2006
50
45%
45
40
Pe
ercent
35
30
25
19%
20
13%
15
13%
10
5
3%
3%
3%
Apr
May
0
Nov
Dec
Jan
Source: MMWR 2007;56 (RR-6)
Feb
Mar
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
i fl
influenza
vaccine
i for
f ALL women who
h will
ill be
b
pregnant during influenza season
Source: MMWR 2007;56 (RR-6)
For those who chose to receive any vaccines:
Which vaccines did y
you receive?
21.1%
Tdap
31.6%
Influenza
60.6%
62.5%
15.8%
13.3%
12.5%
10.5%
MMR
HPV
10.5%
Hep B
V ri ll
Varicella
Pneumonia
5.3%
Before Pregnancy
21.1%
20.0%
*
Not a vaccine*
12.5%
Don't remember
13.3%
12.5%
0%
10%
During Pregnancy
21.1%
20%
After Pregnancy
30%
40%
50%
*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
60%
70%
Recommendations




Screen each patient for vaccination status
Immunize women postpost-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
Immunization Branch Services
for Medical Providers

Immunization Management Consultancy




Immunization Skills Institute


Q
Quarterly
l sessions
i
ffor Medical
M di l A
Assistants
i
Support materials




Quality Improvement Survey
Practice Assessments
In--services with assessment results and interventions
In
Yellow cards
Immunization Summary Sheets
Immunization Updates
San Diego Immunization Registry
Information for Health
Health--Care
Professionals
NNII (www.immunizationinfo.org)
VEC (www.vaccine.chop.edu)
IAC (www.immunize.org)
CDC/NIP (www
(www.cdc.gov/nip)
cdc gov/nip)
AAP (www.aap.org)
AAFP (www.aafp.org/)
(www aafp org/)
IVS (www.vaccinesafety.edu)
Vaccine
V i P
Page (www.vaccines.org)
(
i
)