1. Influenza Vaccination of Pregnant Women
Bernard Gonik, M.D.
Professor and Fann Srere Chair
of Perinatal Medicine
Wayne State University School of Medicine
Detroit, Michigan
38th National Immunization Conference

2. Influenza Infection 10% of U.S. adults annually
Similar range in pregnancy (2-22%)
Neuzil etal Infect Dis Clin N Am 2001; 15:123
Griffiths etal J Epidemiol Comm Health 1980; 34:124

3. Influenza Morbidity/Mortality in Pregnancy
Pandemics of 1918 and 1957
50% complicated by pneumonia
50% mortality rate
Recent flu case reports and SARS data in pregnancy show higher risks
Mixed data for fetus/neonate with both short and long-term concerns
Harris JAMA 1919;
Freeman etal AJOG 1959; 78:172
Gonik etal IDSOG (abstract) 2003

4. Perinatal Outcomes Associated with Respiratory Diseases in Pregnancy
8 flu seasons, 297 admissions (5.1:1000)
Significant comorbidities (per 1000)
Asthma (59.7)
≥ age 35 (11.2)
3rd trimester (7.3)
No difference in perinatal outcomes
Hartert etal AJOG 2003; 189:1705

5. Influenza-Associated Hospital Morbidity and Mortality in Women
Morbidity and mortality related to influenza are much higher in pregnant women than in non-pregnant women.
Maletic-Neuzil et al. Am. J. Epidemiology 1998; 148:

6. Current CDC/ACIP Recommendations
All women who will be in the 2nd and 3rd trimester during the flu season, and those with underlying high risk conditions regardless of pregnancy stage, should be vaccinated (endorsed by ACOG Committee Opinion No. 282, January 2003)
Trivalent inactivated influenza vaccine should be used
Live-attenuated vaccine is contraindicated

7. Presumed Vaccine Safety
Collaborative Perinatal Project (1960’s)
2291 doses
Swine flu vaccine studies (1970’s)
290 doses
No reported fetal/neonatal adverse events

8. Influenza Vaccine Immunogenicity
Englund Vaccine 2003; 21:3462

9. Influenza Vaccine Usage
Pregnancy <10%
Reproductive-age women 16%
≥ age %
Englund Vaccine 2003; 21:3460

10. Influenza Vaccination Rates-U.S. National Health Interview Survey 2002
Population
Vaccination Rate (%)
Age yrs
34.0
Age yrs (low risk)
29.7
Age > 65 yrs
65.6
Age yrs (high risk)
23.1
Age yrs (high risk)
43.6
Pregnant women
12.4
Healthcare workers
38.4

11. Provision of Vaccine in Ob/Gyn Practice
Provided at Practice
Offered to OB or PP patients
Offered to GYN patients
Referred elsewhere
Not offered/
not referred
Rubella 52 45 27 25
Influenza 50 44 39 28 24
Hepatitis B 35 29 40
Tetanus-diphtheria 32 30
Pneumo-coccal 21 9 18
Varicella 20 15 16 47 33
Values are %
Schrag etal Obstet Gynecol 2003;

12. Reasons OB/GYN Practices Not Offering Flu Vaccine (56%)
Reimbursement 52%
No pt literature 46%
Liability 45%
Ambiguous guidelines 30%
Patient refusal* 26%
*Yeager study – 71% accepted
Vaccine efficacy 25%
Lack of time 20%
Vaccine safety 17%
Patient’s don’t need 14%
Schrag etal Obset Gynecol 2003; 101:704
Yeager etal Am J Perinatal 1999; 16:283

13. Influenza Vaccination in Pregnancy Survey
242 postpartum women; 113 OB physicians
Estimated vaccine rate 8%
Physicians more likely to give vaccine
Received vaccine
Know CDC guidelines
Have vaccine in office
Patients more likely to receive vaccine
Previous history of flu/vaccine
Know additional risk
Discussed with OB physician
Physician/Patient discussion (74% vs. 22%)
Silverman etal J Repro Med 2001; 46:989

14. Ob/Gyn VPD Knowledge, Attitude and Practice Patterns
840 Michigan ACOG Fellows (RR 43%)
Acknowledged VPD responsibility 85%
Screen for VPD %
Gave vaccines 6-25%
VPD knowledge 7-57%
(better with females, < years in practice, knowledge and PCP designation)
Gonik etal Obstet Gynecol 2000; 98:81

15. Educational Interventions
Grand Rounds-styled lectures
(532 providers/16 programs)
Office-based in-services (15 sessions)
Joint venture with CDC, MDCH, M-ACOG, MSU extension program, WSU
Resource materials/contacts

16. Gonik et al. AJOG 2001; 185:S162

17. Gonik et al. AJOG 2001; 185:S162

18. Gonik et al. AJOG 2001; 185:S162

19. Gonik et al. AJOG 2001; 185:S162

20. Take Home Messages Educate HCP/Patient
Vaccine self-benefits
CDC recommendations
Pregnancy-specific risks
Passive antibody transfer to neonate
Encourage office vaccine program
Billing, coding
Storage, documentation
VIS