1. Maternal Influenza Review Program: Identifying Barriers to Maternal Immunization Ellen Hutchins, ScD, MPH, Sarah Patterson Carroll, MPH, and Debra Hawks, MPH American Public Health Association Annual Meeting Chicago, Illinois November 2, 2015 This project was made possible through cooperative agreement number 1U38OT000161 from the Centers for Disease Control and Prevention (CDC) and the Association of State and Territorial Health Officials (ASTHO).

2. Presenter Disclosers Ellen Hutchins, ScD, MPH The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose

3. Program Implemented by the American College of Obstetricians and Gynecologists (ACOG) ACOG is a medical specialty society which includes 95% of board-certified ob-gyns and has over 58,000 members. Ob-gyns provide 44% of preventive care visits for women over age 18. ACOG has a strong history of promoting routine vaccination of women in ob-gyn practices. 85% of deliveries attended by ob-gyns

4. Vulnerable Populations Project ACOG was funded by CDC through ASTHO to identify and address barriers to influenza immunization in pregnant women. Coordinated with ASTHO and other project partners to disseminate ACOG resources on Influenza Vaccination in Pregnancy. Conducted a pilot project adapting the Fetal and Infant Mortality Review (FIMR) methodology to examine maternal influenza cases that resulted in hospitalization. Program called Maternal Influenza Review Program (MIRP).

5. Pregnant women are more severely affected by influenza compared to the general population. Are more likely to develop severe illness and to die than the general population. Increased severity of influenza believed related to physiologic changes in pregnancy. Maternal influenza can affect infant outcomes; increased rates of fetal death and prematurity have also been documented. Description of Problem: Influenza During Pregnancy

6. Description of Problem: Maternal Influenza Immunization Rates Many pregnant women remain unvaccinated, and are hospitalized each year with influenza or complications from influenza. 2014-15 median overall rate for seasonal influenza vaccination coverage among pregnant women was 50.3%. ACOG and CDC recommend influenza vaccination for women who will be pregnant during influenza season.

7. Maternal Influenza Review Program: Description of Project Pilot project utilized the FIMR methodology. Selected 4 states which each reviewed approximately 15 cases of pregnant women hospitalized with influenza during 2012-13. Retrospective review of quantitative and qualitative data via chart abstraction and maternal interview. ACOG developed a training guide, data abstraction and maternal interview forms. Goal: Identify potentially preventable systems and educational barriers resulting in hospitalization of pregnant women due to influenza and make recommendations for improvement.

8. Fetal and Infant Mortality Review What FIMR is: Identifies local system weaknesses and issues Used to better understand all factors leading to an infant death Includes and highly values input from mothers who have lost an infant through the maternal interview Facilitates community action and improves systems Is a continuous quality improvement model

9. States Funded Colorado Department of Public Health Minnesota Department of Health New York State Department of Health Rhode Island Department of Health

10. Project Protocol 1) Case Identification An “influenza case” was defined as diagnosed influenza in a hospitalized pregnant women at any stage of gestation upon discharge during the 2012-13 influenza season. 2) Data Abstraction States collected information on maternal influenza care, prenatal care, labor and delivery, newborn care, post-partum/reproductive health care, and pediatric care (birth – 6 months). Provided with data abstraction forms with immunization module 3) Maternal Interview Each state made concerted efforts to interview the mothers using the Maternal Interview Abstraction form. Identifying information was de-identified.

11. Project Protocol 4) Case Review State convened a Case Review Team (CRT) Developed recommendations to address some of the systems issues identified during case reviews. Considered ways to implement some of the developed recommendations. 5) Summary of Findings & Recommendations for Systems Improvement Based on the Case Review Team findings and recommendations, ACOG’s Immunization staff and Immunization Expert Work Group, will develop a summary report with recommendations for increasing maternal influenza immunization.

12. Eligible Cases Colorado 39 pregnant women hospitalized with influenza in 5-county Denver area Minnesota 23 pregnant women hospitalized with influenza in Minneapolis- St. Paul New York 28 pregnant women hospitalized with influenza in 15 county capital area and Western regions Rhode Island 23 pregnant women hospitalized with influenza in Providence county.

13. Data Abstraction Summarized relevant medical and psychosocial chart information on each case. Including immunization history in pregnancy. Data abstraction provides an in-depth look at care each woman received. Since one of goals of case review is to identify systems issues that may have contributed to woman contracting influenza in pregnancy, all related medical and psychosocial information about hospitalization for influenza may be important to the review. Abstractor does not include any identifying information on the data abstraction form. A case summary is then developed for the case review meeting which consists of most important medical and maternal interview findings.

14. Maternal Interview Important to get information about woman’s hospitalization in her own words. States had difficulty reaching some of the women. Number of maternal interviews conducted: CO:11, RI: 7, MN: 5, and NY: 12. All 4 states found maternal interviews informative. Provided additional information not found in charts, such as why they refused flu vaccine, when and where received vaccine, and if it was offered at subsequent visits.

15. Case Review Case Review Team (CRT) reviewed and analyzed de-identified case review summary developed for the meeting which consisted of relevant findings from both the medical record data abstraction and maternal home interview. Members included individuals who will bring diversity, influence, commitment, and consumer participation. CRT developed recommendations to address systems issues identified during case review. Discussed ways to implement some of the recommendations.

16. StateCRTVaccinatedUnvaccinatedUnknown Colorado171070 Minnesota181521 New York12930 Rhode Island11740 Summary of Vaccination Data Obtained

17. Recommendations Further training of providers to better identify influenza among pregnant women. Educate patients on the risks of influenza during pregnancy, risk reduction, and provide a strong recommendation for vaccination. Educate urgent care clinics on how to manage pregnant patients with flu-like symptoms and to understand the guidelines for administering antiviral medication to pregnant women. Need for better integration of care between primary care, ob- gyn, and hospital.

18. Recommendations Additional patient education needed for those refusing vaccine. Need for providers to also educate about risks of not getting immunized. Educate patient about limiting her contact with those sick or not vaccinated. Provide more options for free flu vaccines for pregnant women and their partners who may not have insurance.

19. Summary Recommendations ACOG has identified several common themes and recommendations: Systems Level Inconsistent documentation of immunization recommendations Lack of consistency among providers in regards to infection control regulations in labor and delivery units Under-education of urgent care center and emergency room staff on the assessment and treatment of pregnant women presenting with influenza- like-illness. This includes differentiating between normal side effects of pregnancy and symptoms of influenza.

20. Summary Recommendations Many ob-gyns do not offer influenza vaccine in their offices. Patients trust their ob-gyn; referring patients elsewhere increases the risk of women going unvaccinated. Ob-gyns need to start recommending and offering influenza vaccine. Inability of family members to get vaccinated due to insurance coverage issues or provider’s inability to vaccinate family (i.e. ob not being able to vaccinate a father or a pediatrician not being able to vaccinate a parent) Immunizations need to be further integrated into EMRs and tailored for ob- gyn providers Adult immunization registries are underused but may be a good way to document and track immunization records

21. Summary Recommendations Educational Concerns over vaccine safety among patients need to be addressed Similarly, misconceptions about influenza vaccine need to be debunked. i.e. “the flu vaccine isn’t effective” or “the flu vaccine will make me sick” Messaging needs to focus on the increased risk of severe illness and complications during pregnancy Providers need to take time to discuss influenza vaccine with their patients and if patients decline, need to have the conversation at each subsequent visit

22. Conclusion All 4 states agreed that this pilot study using the FIMR methodology was very informative, and provided them with useful information that could be used to improve systems issues. Having the case review information de- identified made it easier to discuss systems issues. States are hopeful that there will be an opportunity to convene a Community Action Team to implement many of their recommendations. Two of the states, CO and RI are currently doing this. In future years of the project ACOG will create a toolkit for other states to use as resource to implement their own MIRP program.

23. Special Thanks To: Colorado Department of Public health Rhode Island Department of Health New York Department of Health Minnesota Department of Health The Association of State and Territorial Health Officials The Centers for Disease Control and Prevention National Fetal and Infant Mortality Review Program