General Immunization Webinar

Give it Your Best Shot: Adult Vaccinations for Ob-Gyn Providers
Originally presented on Wednesday, December 3, 2014 at 12-1pm ET

Download presentation slides.The presentation slides available for download are the original slides that were used in the presentation on December 3, 2014.

The webinar, “Give it your Best Shot: Adult Vaccinations for Ob-Gyn Providers” provides an overview of general immunization recommendations and explains the importance of immunizing patients for all necessary vaccines, particularly those who are pregnant. The presentation details ACOG and CDC’s current immunization recommendations, addresses the most common concerns and misconceptions around vaccines, and explains the importance of immunizations for adults and pregnant women.

Upon completion of the presentation, the participants will be able to:

  • Identify at least three adult vaccines recommended for routine use in their adult patients
  • Address the most common concerns and misconceptions around vaccines
  • Identify, locate, and provide patient resources
  • Incorporate immunizations into routine practice

This webinar is supported by an independent educational grant from Merck, Inc. ACOG does not allow companies to influence ACOG’s programs, publications, or advocacy positions.

Transcript

Moderator:       

Hello, everyone and thank you for joining us today.  This is Joy from Blue Sky, and I'll be the operator for today's presentation. Today's webcast, organized by the American College of Obstetricians and Gynecologists, is the second in a series of four immunization webinars from ACOG.

Today's webcast is titled “Give It Your Best Shot, Adult Vaccinations for OB-GYN Providers,” and will detail ACOG and CDC's immunization recommendations, address the most common concerns and misconceptions around vaccines and explain the importance of immunizing patients for all necessary vaccines, especially those who are pregnant.

Future webinars will include Tdap vaccination on January 21st, 2015 and Human Papillomavirus vaccination on March 4th, 2015.

Before we get started, I would like to take a moment to acquaint you with a few features of this web event technology. At any time, you may adjust your audio using any computer volume settings that you may have.  Please hold all questions until the end of the presentation. On the bottom of your screen, you will see the text chat window. There is a large window which holds all of your sent messages and a smaller textbox at the bottom where you will type in your questions.  To send a question, click in the text box and type your text. When finished, click the "send" button.  All questions that you submit are only seen by today's presenters.  Your questions will be responded to in the order in which they were received and will be addressed at the end of the presentation. If you experience technical difficulties at any time during this webcast, please use the "help" button that is shown on your screen. The faculty and planning committee wish to disclose the following information (displayed on slide).

Now please let me introduce our program faculty for today's webcast.  Dr. Rhoda Sperling has formal training in Ob-Gyn infectious diseases and epidemiology.  She is currently vice chair of research in the Department of Obstetrics Gynecology and Reproductive Science at the Icahn School of Medicine at Mount Sinai. She is a professor in the Icahn School of Medicine with a joint appointment in Ob- Gyn and medical infectious diseases.  She is a member of ACOG's immunization expert working group and is ACOG's liaison to the Immunization Action Coalition and to the ACIP adult vaccine working group.

Dr. Barbra Fisher is trained in obstetrics and gynecology as well as board certified in maternal fetal medicine.  During her fellowship, her research and clinical interest focused on immunization and infections during pregnancy with a special interest of influenza during pregnancy. She is currently in practice at Northwest Perinatal Center in Portland, Oregon and holds an adjunct clinical faculty position at the University of Colorado.  She is a member of ACOG's immunization expert working group and is an active participant in the Quality Improvement Committee of Women's Healthcare Associates, the parent company of Northwest Perinatal, providing expert input on immunizations during the continuum of women's health.

Here are the learning objectives for this presentation (displayed on slide).

And, now, ladies and gentlemen, without further ado, Dr. Rhoda Sperling.

Rhoda Sperling, MD:     

Hi, welcome, everyone.  Vaccines aren't just for children.  Adult vaccinations saves lives.  Each year in the United States, about sixty thousand adults actually die from vaccine preventable diseases or their complications. If you just look at pneumonia and influenza together, they are in fact the seventh leading cause of death in the United States.  In the U.S., the Advisory Committee on Immunization Practices sets the standards of how we use vaccines for both the adult population and the pediatric population.  These recommendations are published, annually as immunization schedules and are readily available.

One of the issues with adult vaccination is, in fact, that most adults are not aware that they need vaccines.  There are many missed opportunities for vaccination which occur because Ob-Gyns and other providers do not routinely assess vaccination status and do not routinely recommend vaccination as part of their visit. Just remember, a recommendation from someone's own provider is the strongest predictor of whether a patient, in fact, gets vaccinated.  This point is well illustrated in this graphic.  If you look at the highest vaccine rates, the first bar- the highest vaccination rates for influenza during pregnancy –is when the provider recommends and actually offers the vaccine at that same time, with vaccination rates that approach 70 percent.

It's important, also, to set an example, to make sure that you and your family are adequately vaccinated and that your office culture supports vaccination and routine vaccination, and that includes education for your entire staff including the nonprofessional staff and also making sure that everyone in the office, knows about adult vaccination and is offered their adult vaccinations.

So, looking at vaccination opportunities for OB-GYN providers, we can make it part of routine care in preconception planning, in prenatal care where we have two patients to protect, both mother and child, as part of routine postpartum care, as part of routine well woman care and certainly as part of pre-op planning.

So, when we're thinking about vaccines, we have to think about the “why to” as well as the “how to” and what are we trying to prevent? What is the disease we're trying to prevent? What is the antigen in the vaccine? Is there an adjuvant? Is there something that's been added to the vaccine to enhance the immune response?

This is particularly important with, recombinant vaccines.  What is the vaccine efficacy profile?  What is the vaccine safety profile? And, again, how do we give the vaccine?  Is it given as a single dose? Is it an IM dose?  Is it given as a series of two or three vaccines?  What is the timing and spacing of the vaccines and are there unique pregnancy related issues to consider?

Before vaccines, can be manufactured and distributed in this country, they have to be approved and licensed by the Food and Drug Administration.  Licensure is based on extensive safety and efficacy studies that get presented to the FDA, but licensure is not based on how the vaccines are used. As I mentioned before, the Advisory Committee on Immunization Practices makes recommendations to the CDC, and the CDC sets those routine adult vaccine schedules.  And those vaccine schedules, before they get rolled out, get endorsed by professional societies like ACOG.

The adult immunization schedules are detailed and they provide specific guidance such as the age when the vaccine should be given, the number of doses that are needed, the amount of time between doses, precautions and contraindications. And I want to briefly show you the tables that are available, and it's generally several tables and table footnotes which make up the schedules.

So the first table, and somewhat difficult to see, the columns are the ages.  So there are age specific recommendations for vaccines. The next table talks about disease specific recommendations or condition specific recommendations.  So, if you look at the far left column there's the specific pregnancy related recommendations.

One thing I want to bring to people's attention is the pre- vaccination counseling which is legally required.  Federal law requires that patient education, vaccine information statements, in fact, be distributed prior to vaccination for all patients.  If folks are not aware about the Immunize.org website, there are vaccination information statements that are available there in over 30 different languages.

The vaccine information statements incorporate elements of risk benefit discussion which include recommendations and indications, contraindications, vaccine efficacy, duration of effi- efficacy, side effects and what other vaccines should or could be given at the same time.

When you're looking at pregnancy specific recommendations, that far left column in the immunization schedule, there are routine vaccines that are recommended during pregnancy. Specifically recommended during pregnancy are the inactivated influenza vaccine and Tdap which Dr. Fisher will be detailing.

There are vaccines that are contraindicated during pregnancy. Those are the live virus vaccines, measles, mumps, rubella, varicella, the live attenuated influenza vaccine. Then there are the group of vaccines where pregnancy is not a contraindication.  And, you know, pregnant women are adults and if they require a vaccine, they should be given it. There's not a contraindication.

And part of the theory behind, maternal immunization is to benefit not just the mom but also the fetus and newborn.  So, by vaccinating mom you can boost maternal levels of pathogen specific antibodies.  These antibodies cross the placenta and will provide the young infant with sufficient concentrations of antibodies. This is particularly important to protect newborns during a period of increased vulnerability when they can't adequately respond to their own active immunizations. I'd like to turn things over, now, to Dr. Fisher who's going to be talking about vaccines and pregnancy.

Barbra Fisher, MD:         

Thank you, Dr. Sperling.  Welcome, everyone, and thank you for joining us today.

Live virus vaccines and pregnancy.  So routine live virus vaccination is contraindicated during pregnancy and that's because of the primarily theoretical risk to the developing fetus. Only small pox vaccine has been shown to injure a fetus, and it's important, thus, to not give live virus vaccines to pregnant women or women planning to become pregnant in the following four weeks.

If a patient is pregnant and susceptible, for example, somebody is pregnant and you realize they've never had varicella and they don’t have immune antibodies showing that they've had varicella previously, it's important to vaccinate as early as possible in the postpartum period as they're a captive audience and you know they're not pregnant right after they delivered.

Screening for rubella immunity and varicella immunity is part of routine prenatal care for these reasons because we can't do the MMR or varicella vaccines during pregnancy.

There are many common vaccine myths, listed here on this slide and the next one are common myths that we have all probably heard with some suggested responses to patient concerns.

The most common myth I hear in my practice is myth number two listed here, that vaccines cause autism, and one suggested response is the following.  Many studies have been conducted reviewing mercury or thimerosal, vaccines and autism.  There's never been a study showing a positive relationship between vaccines, mercury and subsequent autism diagnosis.  The only vaccines that contain thimerosal are multi-dose vial presentations in influenza vaccine.

Other common myths include vaccines make you sick. I'm young and healthy, so I don’t need vaccines. Vaccines can pose a risk to my unborn baby, and vaccines will cause birth defects or miscarriage.  Feel free to look through these common myths and evidence based responses in terms of speaking with your patients.

We next move on to a more general conversation about immunizations in our practices to illness specific vaccinations, and we begin with a discussion of influenza vaccine.

So, first of all, it's important to understand the clinical illness of influenza.  Influenza is common, and its hallmarks are the signs and symptoms listed here on this slide.  Of importance, 50 percent of infected individuals have some clinical infections and may not realize they're sick, but they're still contagious and can infect others who could have severe illness.

The CDC recommendations for influenza vaccination endorsed by ACOG, American Academy of Pediatrics and other organizations is to immunize all individuals older than six months without contraindications.  This vaccination would ideally be given prior to influenza outbreaks and continue throughout the influenza season.  And there are only a few instances of true contraindications of giving an influenza vaccine to an individual over the age of six months old.

Here on the next slide are true contraindications for which patients should not receive influenza vaccination, and they include anaphylactic reaction to prior dose or to egg protein, gelatin or other vaccine components, or precaution should be given in a setting of moderate to severe disease. For patients presenting with only mild or minor illness, including diarrhea, upper respiratory tract infection with or without fever or an antimicrobial therapy for other infections such as yeast infection or urinary tract infection, providing influenza vaccination during that office visit is not a true contraindication.

During pregnancy, both the mother and the fetus are at risk for complications related to influenza infections.  There are increased risks for both morbidity and mortality for the pregnant woman compared to the non-pregnant woman.  For the fetus, while viremia is rare, there may be increased risk for birth defects related to hypothermia, and for this reason, it's very important to vaccinate pregnant women or women planning to become pregnant during influenza season to avoid these complications.

For children, there's increased risk as well for both morbidity and mortality, especially for children less than 24 months of age.

Children less than six months of age cannot be vaccinated. Thus, protection is conferred from both maternal vaccination and cocooning.

American College of Obstetrics and Gynecology has recently updated their committee opinion related to influenza vaccination and pregnancy with the most updated version published in September of 2014.  The highlights of this committee opinion are listed here, and they include the following, influenza vaccination is an essential part of prenatal and preconception care.  Pregnant women have increased morbidity and mortality from influenza, and neonates, as well, have increased morbidity and mortality from influenza and cannot be vaccinated until six months of age. Vaccination of pregnant women results in passive transfer of protective antibodies to neonates and, therefore, protection from influenza, and keeping mom healthy during pregnancy protects a fetus from early delivery.

There are a few salient points about the efficacy of influenza vaccine. Protected antibodies are usually seen within two weeks and vary from season to season with the vaccine development on each season taking into account projected circulating strains.  The influenza vaccination is less effective in the elderly and the efficacy is not diminished in pregnancy.  There may be a gestational age effect.

Seasonal vaccinations, there's some old. There's some new. The traditional flu shot was a trivalent vaccination, and prior to 2013, 2014, was what was available commercially. The trivalent vaccine included, immunization against two influenza A strains and one influenza B strain.

Starting in 2013- 2014, there was a quadrivalent vaccine produced which protects against four strains including two influenza A strains and two influenza B strains.  It's important to know that CDC as well as ACOG does not have a strong opinion about the trivalent versus quadrivalent vaccine, and either is appropriate and okay to offer to your patients.

I know in our practice, there was a shortage of the quadrivalent vaccination availability this season, and we are currently providing trivalent vaccination in my practice here in Portland, Oregon which is a perfectly okay thing to do by CDC and ACOG.

There are also new techniques that are emerging for producing vaccinations and those include recombinant vaccines and new cell culture based vaccines.

Finally, there is a live virus vaccine for influenza, but it's approved only for use in healthy, non-pregnant individuals, between the ages of two and 49 years old.  So the live virus vaccine is not acceptable for kids between six months old and two years old, and it's not acceptable for pregnant patients.

And, finally, over time, we can see here in this chart pregnant women vaccine percentage rates, over time, looking at 2001 through 2010 as well as in the light gray line, non-pregnant women.  As we see over time influenza vaccination rates are increasing, but we should note we still have a long way to go. In the 2010- 2011 season, only about 40 percent of women nationally were being vaccinated.  So we have a lot of work to go. We'd love to see this number approach 100 percent.

We now move on to vaccination against tetanus, diphtheria and pertussis or Tdap vaccination.  Though it is important to appreciate that there are multiple combination vaccinations available which offer protection against diphtheria, tetanus and pertussis, and, as you see here, there are four combination vaccines used, DTaP, Tdap, DT and Td. Two of these vaccines are given to children less than seven years old, and two of these are given to older children or adults.  As explained here, the uppercase and lowercase letters have meaning to them and you can read that here.

The Tdap vaccination recommendations are the following.  For non-pregnant adults, Tdap needs to be given only once; with tetanus diphtheria (Td) every ten years and substitute Tdap for the Td if Tdap has never been given. Family members and caregivers, this might include fathers, grandparents, babysitters, and daycare workers, should be up to date with their Tdap vaccination.

What is pertussis?  Pertussis is an infection caused by bordetella pertussis, a gram negative bacterium which causes a respiratory illness characterized by a whooping cough that is very contagious and is one of the leading causes of vaccine preventable deaths worldwide.

Pertussis is a serious infection for newborns, and babies are not given his or her first vaccination against pertussis until two months of age.  This infection can cause serious and sometimes life- threatening complications in infants, especially during the first six months of age and especially in the first two months of a baby's life when they can't, themselves, be vaccinated.

Because newborns less than two months old cannot be vaccinated, this vaccination in pregnancy has been studied extensively, and we now know that Tdap vaccinations during pregnancy, preferably in the third trimester between 27 to 36 weeks, can protect the newborn and young infant.

Why 27 to 36 weeks?  Antibodies cross transplacentally from mom to fetus, and the antibody levels decline after immunization. The maternal immunization is timed to have peak transplacental passage of IGG antibodies to protect the newborn or the newborn who can't yet be vaccinated themselves have transplacentally passed antibodies from the pregnant mom. ACOG has updated their recommendations just over a year ago regarding Tdap vaccination during pregnancy similar to updated guidelines about influenza vaccination.

Highlights of the committee opinion include the following.  The dose of Tdap vaccine should be given to all pregnant women between 27 to 36 weeks gestation during every pregnancy. The prior recommendations were to ask the pregnant lady when she last had the vaccination and then judge accordingly, but the new guidelines make things very simple, every pregnancy, every woman, new vaccine.

Transplacental transfer of maternal pertussis antibodies from mother to infant provides some protection against pertussis in early life before the infants can have their own primary DTaP series, and immuno response to the vaccine peaks two weeks after administration and, therefore, the 27 to 36 weeks gestational age was chosen.

In this 2011 CDC surveillance graph, it is shown that hospitalization and death related to pertussis infection primarily affects the young or the neonates in the earliest times of life.  So pregnancy is a fabulous opportunity to try to prevent neonatal pertussis disease.

Over the past 20 years, there has been a resurgent of pertussis cases as we see here. On the Y axis is incidence rate of pertussis, infection per 100,000, and you can see, over time, there's been various spikes, and the most recent spike has been in the year 2013.

On this next slide is a map of the United States which is also surveillance data from the CDC.  We see here that in 2012, there were almost 50,000 cases of pertussis reported to the CDC which is the most reported cases since 1955. The majority of deaths occurred in children younger than three months of age.  In 2012, 49 states and Washington, D.C. reported increases in disease compared with the same time period in 2011 and overall reporting of pertussis declined during 2013 with almost 30,000 cases reported.  It's really, really important to vaccinate pregnant women to try to avoid these complications for children.

Finally, we might ask the question about safety and efficacy about the vaccination and pregnancy, and, very recently, last month, in the Journal of the American Medical Association, there was an excellent article published looking at safety data of Tdap vaccination in pregnancy. In addition, a recent UK experience showed a reduction in infant pertussis with success attributed of transplacental antibody protection and cocooning.

I now turn the talk back over to the Dr. Sperling.  Thank you for listening.

Rhoda Sperling, MD;     

Thanks, Dr. Fisher.  That was a wonderful review.  I'm going to be talking about several other vaccines until the end of the webinar, and I'm going to be emphasizing the ‘why to’. Why should we be concerned about these diseases?  Why should we be vaccinating pregnant women?  Why should we be focusing on incorporating adult vaccination into the OB-GYN practice?

So, first, I want to talk about pneumococcal disease.  Invasive disease from strep pneumonia is a major cause of illness and death in the United States.  There are approximately a half a million cases of invasive pneumococcal disease in the U.S. annually resulting in 40,000 deaths.

There are over 100 strains of strep pneumonia, and many of them have become increasingly resistant to antibiotics and so the emergence of multidrug resistant pneumococcus underscores the importance of a prevention strategy that doesn’t involve antibiotic use, a prevention strategy through vaccination.  And we all know that pneumococcal pneumonia is one of the most serious secondary sequella of an influenza viral infection.

So the pneumococcal vaccine recommendations have changed and you'll note, if you look at the 2015 immunization schedules, there's a more aggressive recommendation to vaccinate people for pneumococcal pneumonia.  There are two vaccines that are available, the pneumococcal conjugate vaccine, PCV13, and the pneumococcal polysaccharide vaccine, PPSV23.

In the past, women, pregnant women and adults were given the PPSD23 vaccine, and the PCV13 vaccine was used primarily for children, but the current recommendations have us giving both of those vaccines to people who are immunosuppressed.  And both of those vaccines to people who were over age 65.

And for pregnant women, who have never been vaccinated, they should still just get the PPSV23 vaccine, and the indications to vaccinate pregnant women are asthmatics, diabetics, smokers.
We should make every effort to vaccinate these medically high risk people even before they become pregnant, but, again, often, we see these patients for the first time during pregnancy and we should stick to those adult recommendations and offer PPSD23 during pregnancy.

Now switching gears to measles, mumps, rubella the combined MMR vaccine.  So MMR is a live virus vaccine, and live vaccines are contraindicated during pregnancy.  But the use of live virus vaccines as part of postpartum vaccination programs is extremely important, and that is actually to prevent congenital infection.

So I want to talk a little bit, give a historical perspective about congenital rubella and also talk a little bit about congenital varicella.

Congenital rubella syndrome is something that's not seen very much anymore.  It was an infection that affected many different organs causing deafness, cataracts, heart defects, microcephaly, mental retardation with a severity of damage to the fetus dependent upon gestational age and with maternal infections before 20 weeks of gestation fetal infections were extremely common. With again, 85 percent of infants being affected if a maternal infection occurred during the first trimester.

So, if you look back at the numbers from the last rubella epidemic in the United States, which was in 1964-1965. There were 20,000 cases that winter of congenital rubella syndrome including 11,000 children who were born with deafness, over 3,000 that were blind, 1,800 with mental retardation and if you contrast that to what's happened since an aggressive postpartum vaccine program, (which has occurred since the licensure of this vaccine in 1969), if you look, since the 1980s, the average number of cases are five to six cases annually with congenital rubella syndrome.

So we're talking about, as I mentioned, you know 11 thousand cases – I'm sorry, 20,000 cases a year and now we're talking about five to six cases a year.  So it has to be considered a major public health success.

And, again, I mentioned that the primary objective of rubella immunization for women is to prevent fetal rubella infection and to prevent congenital rubella syndrome.  A single dose of MMR should be adequate for protection against rubella.  Because it's a live virus vaccine the recommendation is to avoid pregnancy for four weeks after vaccination.  And for women of childbearing age, regardless of the year of birth, we should be determining immunity and vaccinating as part of preconception counseling or postpartum programs.

In contrast to rubella, where we feel that this is a huge public health success, I want to talk a little bit about measles and a resurgence of something we had considered an eradicated infection.

From January of this year through August of this year (2014), there were more cases in the United States of measles than any year in the past two decades.  The high incidences occurred despite the fact that the indigenous circulation of measles virus was declared eliminated in the U.S. in 2000 and in the Americas in 2002.

So the question is why this resurgence?  And there really are two reasons, one is travel from countries where there's still substantially circulating virus and also failure for parents to vaccine children.  To remind people that measles is highly contagious, you need significant herd immunity, over 90 percent of a population needs to be vaccinated to have herd immunity to prevent sustained spread of the disease, and measles is a fatal disease.  It remains a leading cause of death in children. Globally, there have been more than 20 million people who get measles each year, and approximately 150,000 of those affected die.  So, you know, we're talking about again something of great public health concern.

This is a good graphic way of depicting this information.  If you look at the idea of where measles was declared eliminated in the United States, this was 2000 and the Americas in 2002. You can look where we are in 2014 with a true resurgence of this, and there's a wonderful review article that was recently published in the New England Journal of Medicine several weeks ago.

In terms of the measles, the recommendation is to administer two doses of MMR to those who are susceptible. So a single vaccine dose was adequate for rubella, but a single dose is not adequate for measles protection. People need to be vaccinated in a two dose vaccine series to be considered adequately vaccinated.

Talking again about another live virus vaccine, varicella. Congenital varicella syndrome is also seen.  The general syndrome consists of chorioretinitis, congenital cataracts, cerebral cortical atrophy and a characteristic type of skin scarring and limb atrophy.

In contrast to other pathogens maternal infections actually rarely occurs.  So, if we contrast it to rubella with a maternal first trimester infection attack rate of 85 percent, congenital varicella occurs only about one percent of the time after maternal infection.

Varicella vaccine, again, I mentioned, is a live attenuated virus vaccine.  It's been FDA approved in this country since 1995, and there have been multiple studies looking at vaccine effectiveness since licensure.  The vaccine's not 100 percent effective, it's 70 to 100 percent effective against disease of any severity, 95 to 100 percent effective against moderate and severe disease. So, when it doesn’t completely protect, it certainly reduced the morbidity and mortality associated with disease.

A few things about varicella and pregnancy, chicken pox is far more devastating in adults than in children.  Adults are ten times more likely than children to be hospitalized with severe consequences of chicken pox such as pneumonia or encephalitis. Those risks are probably even greater during pregnancy, especially in the latter half of pregnancy, and, in the era before vaccination, there were 11,000 hospitalizations and 100 deaths annually in the U.S. from varicella.

In terms of the vaccine recommendations, part of prenatal assessment of women includes evidence of varicella immunity. Susceptible women should be vaccinated post-delivery and post- termination of pregnancy and assuming immunity in someone who's born before 1980 for all populations except pregnant women. And we use varicella serology as part of our assessment of evidence of varicella immunity but just to give people a reminder that the commercially available serology lacks the sensitivity in detecting vaccine induced immunity and might give false negative results.

We know from the efficacy studies that a single dose regimen is no longer considered adequate. So the adequate regime for varicella vaccines is a two dose regime that should be given eight – I'm sorry – four to eight weeks after the first vaccine dose.

So, again, for measles, a single dose is, I'm sorry, a two dose regime is needed.  For rubella, a single dose regime is needed.  For varicella, a two dose regime is needed.

I want to talk briefly about herpes zoster. Herpes Zoster is the same antigen as the chicken pox vaccine but in concentrations 14 times higher. The Zoster vaccine can't be used in children and can't be used in the place of varicella vaccine and it's recommended as a single dose vaccine to boost immunity in people over the age of 60 in order to prevent the recurrence of shingles.

In terms of contraindications of the Herpes Zoster vaccine, a person should not get the shingles vaccine if they've ever had a life threatening allergic reaction to gelatin, the antibiotic Neomycin or any of the components of the vaccines, or if they have a weakened immune system because of AIDS or treatment of drugs that affect the immune system such as prolonged use of high dose steroids, cancer treatments such as radiation or chemotherapy and cancer affecting bone marrow lymphatic systems such as leukemia or lymphoma.

I want to switch gears now and talk a little bit about Hepatitis B vaccination.  It's important to talk about the Hepatitis B virus transmission first. Hepatitis B is highly contagious.  It's found in the blood as well as other body fluids such as tears, saliva, semen and vaginal secretions. Hepatitis B can be transmitted vertically from mother to child.  It can be transmitted sexually.  It could be transmitted through other close person to person, nonsexual contact. Hepatitis B virus is 100 times more infectious than HIV, and the silent nature of this disease makes it difficult to know who's infected and, therefore, from whom you can catch this virus.

In this country infants have been routinely inoculated with hepatitis B vaccine since 1991.  It's a recombinant vaccine.  It's not a live virus vaccine, and catchup vaccination is recommended for anyone who is not vaccinated in infancy.

It's a three dose vaccine series.  You can test for adequacy of response after the third dose and revaccinate with the second series.  There are risk factors for inadequate responses including increase in age, male gender, smokers, obesity, the use of immunosuppressive agents, and there are people who are felt to be genetic non-responders.  There's no evidence of diminished vaccine efficacy in pregnancy.

In terms of using this vaccine during pregnancy, again, unvaccinated adults at risk for hepatitis B should be vaccinated with pregnancy, again, not a contraindication.  There are no safety concerns about using this vaccine during pregnancy. And so the question is who are those women who are at highest risk?  There are people who are injection drug users, people with multiple sexual partners, people who have occupations that expose them to blood or other body fluids, people who are household contacts with Hepatitis infected patients, people who are HIV infected.  And, again, there's a caveat that anyone who wants protection against hepatitis B should be offered vaccination.

One of the ways that we also use hepatitis B vaccine is to prevent mother to child hepatitis B transmission.  So it's important to sort of think through the science behind hepatitis B disease risk from mother to child.

In adults, following an acute infection, the majority of cases are in fact self-limited.  Over 95 percent of healthy adults will clear an infection and most will develop protective antibodies.

That's not what happens in newborns.  In newborns exposed to hepatitis B, the majority of infections, in fact, will become chronic. The numbers are very, very high.  Up to 95 percent of children fail to produce an antibody response that controls an infection, and they go on to develop chronic hepatitis B. And there's a strong correlation between chronic hepatitis B infection and the development of chronic liver disease and a pad of cellular carcinoma.  So the interruption of mother to child HBV transmission is really a public health imperative.

Hepatitis B screening is a routine part of prenatal care.  The goal is to identify mothers who are hepatitis B surface antigen positive and, therefore, identify infants at risk for perinatal HBV, and those at risk newborns should receive passive and active immunization within 12 hours of birth.

Again the recommendation is for all children – forget about mom's hepatitis B status – to receive active immunization, to receive the vaccine.  But the children who are born to women who are hepatitis B surface antigen positive, in addition to getting vaccinated, should also receive passive hyperimmunoglobulin.

And, again, a reminder that the CDC recommends that all newborns, regardless of mom's HBV status, should actually receive their first HBV vaccine series before they leave the hospital, and that's not necessarily the standard in all institutions, but it should be.

I want to briefly talk about HPV because I know that this a focus of a future webinar.  Just to remind people that HPV is the most common sexually transmitted infection. There are, you know, depending on whose guesstimate, there's 20 million – maybe a low number – of folks who are currently infected with HPV.  The vast majority of folks will clear a HPV infection, but those who don’t clear an infection are at risk of developing cancers. The HPV associated cancers include cervix, vulvar, vaginal, penal, anus and head and neck cancers. When we look at the highest risk HPV types, the HPV 16 and 18 genotype, approximately 70 percent of the cervical cancers are associated with infections with HPV 16 and 18.

There are now two FDA approved HPV vaccines, the HPV4 which is Gardasil and the HPV2 which is Cervarix. The HPV4 vaccine, protects against, HPV 6, 11, 16 and 18. The HPV2 vaccine prevents against HPV 16 and 18 only.

Although HPV vaccination’s recommended for both females and males, females can receive either HPV4 or HPV2, but males are only recommended to receive HPV4 because the FDA only licensed and approved that vaccine and only had data for males for the HPV4 vaccine.

The obstetric and gynecologic community has a unique opportunity to vaccinate women in the catchup period, the 19 to 26 age group and also to educate mothers about the importance of vaccinating their children.

Just a couple of things to remember. The HPV vaccine is a preventive vaccine not a therapeutic vaccine, so people need to be vaccinated before their exposure.  It's not recommended during pregnancy, but there are no specific safety warnings or safety concerns if someone inadvertently gets vaccinated and is pregnant and the vaccine can be given safely to women who are lactating.

There is a recent ACOG committee opinion from March of this year which reinforces some of the points that I just made.

When we look at what's happened since the rollout of this vaccine, millions of doses have been given worldwide and have proven to be effective and safe.  Clinical trials have shown remarkable efficacy, actually close to 100 percent protection against pre- cancers and cancers.

And since the vaccine was first recommended in 2006, there's been over 50 percent reduction in HPV infections among teen girls in the United States, and this is even with suboptimal vaccination rates.  So with HPV vaccines, we know we'll saves lives.

According to the CDC, if healthcare providers increase HPV vaccine coverage to 80 percent, it's estimated that an additional 50,000 cases of cervical cancer could be prevented during the lifetime of those that are younger than 12 years of age. So this is a real opportunity to, again, to aggressively offer vaccines that we know can be lifesaving.

Just want to talk about some of the things that make for good vaccinations.  Studies show that a provider recommendation is the most influential factor in patients' decision to receive an immunization. Ob-Gyn’s have a longstanding role of providing primary and preventive care to women and are a major source of ambulatory care for women accounting for 44 percent preventive care visits for those over age 18. Pregnant women see their Ob-Gyn regularly throughout the course of their prenatal and postpartum care, and therefore, there are many opportunities to vaccinate and many opportunities for vaccine discussions.

And this again, reinforces the importance of provider recommendations.  Information from the National Foundation for Infectious Diseases, they did a survey of adults to engage their awareness of vaccines and the acceptability of vaccines. 87 percent said they are very or somewhat likely to get a vaccine if their doctors recommend.  55 percent said they wouldn’t get a vaccine unless it was recommended by their doctor.

And, again, women who receive both a healthcare provider recommendation and an actual offer, like roll up your sleeve, we can get your vaccine today, were twice as likely to be vaccinated as those who received a recommendation but not an offer.  So it's important  to recommend it, but also to have it readily available.

So, again, just taking a step back, we went through a lot of things, but just talking about the vaccination opportunities for Ob-Gyn’s. Here are some of the major vaccine opportunities, influenza vaccine for all women including those who are pregnant, Tdap vaccine for all adults who have not been vaccinated and all women during each pregnancy, pneumococcal vaccine for high risk women including those who are pregnant, hepatitis B vaccine for all at risk women, again, including those who are pregnant. MMR vaccine for women who were not previously vaccinated but this can't be given during pregnancy.  It should be given either before or after pregnancy, the same thing about varicella vaccine. And, again, unique opportunities for HPV vaccinations of girls and women between the ages of nine to 26, again, not recommended during pregnancy.

So how do we, as obstetricians and gynecologists improve practice standards to include vaccination?  We need to assess immunization status of patients.  We need to stay informed.  We need to get the latest CDC recommendations for immunization of adults.  As I mentioned, these guidelines change from year to year.

We need to implement protocols and policies that ensure that patient vaccines are routinely reviewed and that patients get reminders about vaccines that they need. We need to strongly recommend vaccines that patients need. We need to tailor the reasons why vaccinations are right for the patient. We need to know the how to and why to. We need to highlight positive experiences with vaccines.  We need to address patients' questions and legitimate concerns about safety.  We need to remind patients that vaccines are the best protection against a number of common and very serious illnesses including some that are resurging. We need to explain the potential cost of getting sick. We need to administer needed vaccines or refer patients to a vaccination provider.  We need to offer the vaccines and, again, document the vaccines that are received.

And just, in conclusion, again, adults need vaccines too and Ob- Gyn’s have an opportunity to educate and vaccinate.  Pregnant women have a particularly high risk of serious complications from vaccine preventable diseases, and Ob-Gyn’s should integrate immunizations into their routine assessment and their routine practice for both pregnant and non-pregnant patients.

I just want to briefly talk about other resources that are available before we go through question and answers.  There are resources for vaccine recommendations that are readily available at the Advisory Committee on Immunization website at the CDC website and the National Vaccine Program. There are resources that are available for vaccine safety.  The CDC monitors safety after licensure of vaccine, primarily through these three different systems.  People need to report adverse events to the vaccine adverse event reporting system.  It's the responsibility of providers.

ACOG did a wonderful business practice webinar walking through not the why to, by the how to, the logistics of vaccination programs and vaccination billings.  And I would encourage people, who are interested in the business practice information, to see that webinar which has been archived.

There are wonderful resources that are available at the Immunization for Women website.  There are wonderful other resources that ACOG has been working on and producing, and again, I would use the resources of the Immunization Department. I have the honor and pleasure of working with these folks on a regular basis, and they’re a wonderful resource for all of us.

So I'd like to turn things over now to question and answer.

Moderator:       

Thank you, Dr. Sperling and Dr. Fisher.  We will now open the line for questions for both of our presenters. You can submit a question by using the question block on the bottom of your screen.

Barbara Fisher, MD:      

Hi.  This is Dr. Fisher, and I'll start with this first question.  Thank you for asking this question. The question is as follows, "If a 32 week gestational age mom with triplets had a Td vaccination in September, can she get a Tdap now?"

Yes.  The important thing is the immunization against pertussis to protect the newborn.  So, if she only had tetanus previously without pertussis during this pregnancy, it is OK to get the Tdap now.  If she accidentally or for other reasons, had a Tdap during pregnancy, we would not recommend another pertussis immunization or vaccination during the current pregnancy. Thank you for asking that question.

Rhoda Sperling, MD:                     

The next question is, if multi-dose flu vaccine vials are okay to use in Ob-Gyn practice. In general, we sort of, you know, the use of multi-dose vials for anything is usually discouraged.

Multi-dose flu vials often have thimerosal and depending upon what state you live in, some states require pregnant women to be vaccinated with thimerosal free vaccines. So I think that although thimerosal's safety issues have not been borne out in the literature, that is out there that vaccines should be free of thimerosal. Single dose vial vaccines are free of thimerosal, and multi-dose vials often contain thimerosal.

Barbra Fisher, MD:         

Next question is the following.  "If you received two doses of MMR that are documented, but in a prenatal panel it says rubella non-immune, how do you handle this?"

This is a nuance in the CDC guidelines that the ACOG Immunization Expert Working Group spent some time talking about and thinking about because I think it is a subtly not known to all. But if a woman has had two documented doses of MMR, they do not need a third immunization. So, for patients who are rubella non-immune on their prenatal panel, it is important to assess a good vaccination history, and once you've had two MMRs, it's not necessary to be immunized again.

If they have had one MMR boost, let's say, following a previous pregnancy and then they're still non-immune, please give the second MMR.  But, after two, they are considered done.

Rhoda Sperling, MD:     

The next question how often a patient can have Tdap. "We have many patients who have a pregnancy every one to two years, should we offer it at each pregnancy?"

The recommendation, so far, is in fact, to offer it each pregnancy. The safety surveillance will continue, but again, I would not discourage someone from getting it.  If it turns out to be an annual Tdap because of a yearly pregnancy, that should be fine.

Barbra Fisher, MD:         

The next question says, "Our office was given flu vaccine that is category C by the state for MediCal prenatal patients.  Can you speak to the safety of its use?"

The influenza vaccine, as long it's not a live virus vaccine, rather we want to give an inactivated vaccination to pregnant women, is appropriate.  I'm not sure the exact vaccination and the company and why it is FDA category C, but, absolutely immunize.  The benefit of immunization outweighs any potential risks, and the benefit of immunization against influenza versus the risk of getting infection, it far outweighs it.  So I would say, yes, please give it as long as it's not live vaccine.

Rhoda Sperling, MD:     

Yeah and I just want to add something to that.  I mean the live, attenuated influenza vaccine, the replication of that attenuated virus is actually in the nasopharyngeal passages.There is not a viremic stage.  So, although this is a live virus vaccine, because there's not a virus in the circulation, there really is not a chance of transplacental passage.  It's more of a theoretical thing that we avoid live virus vaccines during pregnancy.

So I get lots of questions about people who are inadvertently you know, received it.  They had a LAIV during flu season and found out that they were pregnant.  Is there any concern?  And there is no concern, and there's actually no concern if someone gets other live virus vaccines inadvertently in the beginning of pregnancy in terms of known pregnancy safety problems.

Barbra Fisher, MD:         

Dr. Sperling, would you like to take the next one about hepatitis?

Rhoda Sperling, MD:     

I don’t see another.  You'd have to read it to me, I don’t see a question.

Barbra Fisher, MD:         

“Do you need to repeat the hepatitis vaccine series in healthcare workers?”

Rhoda Sperling, MD:     

If they are negative, serologically, yes.  Hepatitis B is one of the few vaccines that we have a serologic correlative immunity. So, if the healthcare worker appears to be susceptible the recommendation is to revaccinate.

The question is, if you're revaccinated what do you do then?  Folks who are immunosuppressive, the recommendation, in fact, is to vaccinate with a double dose of vaccine.

Barbra Fisher, MD:         

The next question, "What are the risks if administered after 36 weeks?"  I'm going to hope that the question asker meant pertussis.

It is okay to give the pertussis vaccination after 36 weeks.  We are protecting both the mom and the baby with the vaccination.  It used to be given only in the postpartum period.

The benefit of third trimester vaccination is transplacental antibodies passed in the body to the fetus, so it confer protections in the newborn with the peak antibodies two weeks later.  So, at 36 weeks, there's still a good chance that the fetus will obtain antibodies unless she goes into preterm labor a few days later.

Even so, if you protect the mom who's spending, hopefully, a lot of time with her new baby breastfeeding and such, it is still worth giving.  So please no missed opportunities as well as someone who is late to care or had no prenatal care, it's appropriate and recommended to give it in the postpartum period while the patient's in the hospital.

Rhoda Sperling, MD:     

Yeah.  And I would add to that, if I had a choice of giving it to a pregnant woman who's 36 weeks or waiting for the postpartum period, I would give to 36 weeks because you're going to get some transplacental passage, and you're also going to protect the mom.

And the UK study, that was recently published, showed that the effectiveness of the 27 to 36 week vaccine was probably both in terms of transplacental passage of antibodies as well as cocooning, as well as, you know, preventing mother from getting sick.

So I think that things work, by both methods. You know, again, you're providing transplacental passage of antibodies, but you're also protecting the baby by protecting mom.

All right. Next question, "For a patient scheduled for elective surgery, how long should they wait to have surgery after a flu shot to reduce the risk of Guillain-Barre syndrome?"

I'm not aware of any recommendation to wait any length of time because of Guillain-Barre risk.  I mean they should get the flu shot. You know, our recommendation here at Mount Sinai is as part of sort of, you know, the preadmission planning because people will be offered vaccinations on the way out of the hospital, and we would like to make sure that they're vaccinated on their way into the hospital to protect them, and it takes about two weeks to have antibodies.

Barbra Fisher, MD:         

The next question, "Of those vaccines indicated during pregnancy, including flu, Tdap, pneumococcal, hepatitis B, must any of them be given only after the first trimester?"

As we talked about the ideal time to give the Tdap would be in the third trimester.  Otherwise, they're all safe and okay to give in the first trimester. Some patients have worries about miscarriage and influenza.  I think the important thing is to time the influenza vaccination to the seasonal influenza circulating in the community.

If a patient is finishing their first trimester and it's not quite flu season, it is appropriate to wait, but if they are in their first trimester in November, December, it is safe to give it and it's better to give it, and there are only theoretical risks of miscarriage related to the vaccine, not borne out by evidence.

Rhoda Sperling, MD:     

Okay.  For prenatal patients who are rubella equivocal or non- immune, what precautions do you instruct them to take?

I think that there's no specific instructions to give that patient other than to know that they are, in fact susceptible to rubella.  The good thing is that we don’t have a lot of circulating rubella. This is a huge public health success, but that it's important for them to be vaccinated postpartum and to remind them that they are susceptible.

Barbra Fisher, MD:         

The next question, "Can we give Tdap, hepatitis B and influenza vaccination all at the same time on the same day to a pregnant woman?"

Rhoda Sperling, MD:     

Yes.  Yes.

Barbra Fisher, MD:         

Yes.  It's perfectly okay to do that. Yeah.

Rhoda Sperling, MD:     

With three exclamation marks.  Thank you again.  I think that's the last – our last comment.  Is there any other questions?  What I would want is if there are other questions, or information that we haven’t touched upon please contact us and we'd be able to provide that information to you.

Moderator:       

Okay. Great. Thank you very much to our presenters and attendees.

If you have any outstanding questions that were not answered today, please contact ACOG's Immunization Department at Immunization@ACOG.org.

This concludes our program for today. Please join us for the next webinar, Tdap vaccination, on January 21st from 12 to 1:00 P.M. Eastern Standard Time.

Thank you for joining us and we'll see you next time.

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