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Regan AK, Sullivan SG, Arah OA. Maternal influenza vaccination and associated risk of fetal loss: A claims-based prospective cohort study. Vaccine 2024; 42:126256. [PMID: 39260053 DOI: 10.1016/j.vaccine.2024.126256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/26/2024] [Accepted: 08/20/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND Although numerous studies support the safety of influenza vaccination during pregnancy, fewer studies have evaluated the risk of miscarriage or considered the effect of prior immunization. METHODS Using national de-identified administrative claims data from the Optum Labs Data Warehouse, we conducted a claims-based cohort study of 117,626 pregnancies between January 2009 and December 2018. We identified pandemic A(H1N1)pdm09 and seasonal influenza vaccinations using CPT codes. Fetal loss was defined as miscarriage, medical termination, or stillbirth as identified by ICD-10-CM diagnostic codes. Cox proportional hazard models treating influenza vaccination as a time-varying exposure, weighted for loss-to-follow-up and stratified by baseline probability of vaccination, were used to model the risk of fetal loss by exposure to influenza vaccine. RESULTS About 31.4 % of the cohort had a record of influenza vaccination; 10.0 % were vaccinated before pregnancy only, 17.8 % during pregnancy only, and 3.6 % before and during pregnancy. The risk of miscarriage was 39 % lower among those vaccinated during pregnancy compared to unvaccinated (adjusted hazard ratio, aHR 0.61; 95 % CI 0.50, 0.74) and was similar for medical termination or stillbirth (HR 0.69; 95 % CI 0.45, 1.03 and aHR 0.99; 95 % CI 0.76, 1.30, respectively). Similar results were observed for women who received the vaccine before and during pregnancy. We observed little to no association between vaccination before pregnancy and risk of miscarriage (HR 0.98; 95 % CI 0.76, 1.26), medical termination (HR 1.02; 95 % CI 0.46, 2.24), or stillbirth (HR 1.14, 95 % CI 0.77, 1.69). DISCUSSION Influenza vaccination was not associated with an increased risk of fetal loss. These results support the safety of influenza vaccine administration even when administered before or early during pregnancy.
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Affiliation(s)
- Annette K Regan
- School of Nursing and Health Professions, University of San Francisco, San Francisco, CA, United States; Department of Epidemiology, Fielding School of Public Health, UCLA, Los Angeles, CA, United States.
| | - Sheena G Sullivan
- Department of Epidemiology, Fielding School of Public Health, UCLA, Los Angeles, CA, United States; WHO Collaborating Centre for Reference and Research on Influenza, Royal Melbourne Hospital, and Department of Infectious Diseases, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Onyebuchi A Arah
- Department of Epidemiology, Fielding School of Public Health, UCLA, Los Angeles, CA, United States; Department of Statistics and Data Science, UCLA, Los Angeles, CA, United States; Practical Causal Inference Lab, UCLA, Los Angeles, CA, United States; Department of Public Health, Research Unit for Epidemiology, Aarhus University, Aarhus, Denmark
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Ayouni I, Mbangiwa T, Amponsah-Dacosta E, Noll S, Kagina BM, Muloiwa R. Acceptance and uptake of vaccines against tetanus, influenza, pertussis, and COVID-19 among pregnant and postpartum women in low- and middle-income countries: a systematic review and meta-analysis protocol. Syst Rev 2024; 13:227. [PMID: 39237969 PMCID: PMC11375862 DOI: 10.1186/s13643-024-02645-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 08/22/2024] [Indexed: 09/07/2024] Open
Abstract
BACKGROUND Pregnant women, fetuses, and neonates are particularly vulnerable to vaccine-preventable diseases (VPDs). These VPDs are associated with high morbidity and mortality among expectant mothers and their fetuses and neonates. Vaccination during pregnancy can protect the expectant mother from VPDs to which she may be especially vulnerable while pregnant. In addition, the passive transfer of maternal neutralizing immunoglobulin G (IgG) and secretory immunoglobulin A (IgA) also protects the fetus against congenital infections and may further protect the neonate from infection during the first few months of life. Despite this, coverage of recommended maternal vaccines remains suboptimal globally, especially in resource-constrained settings. Determinants of vaccine acceptance and uptake are frequently understudied in low- and middle-income countries (LMICs) and among specific groups such as pregnant and postpartum women. This proposed systematic review will assess the acceptance and uptake of vaccines against tetanus, influenza, pertussis, and COVID-19 among pregnant and postpartum women in LMICs. METHODS A Boolean search strategy employing common and medical subject heading (MeSH) terms for tetanus, influenza, pertussis, and COVID-19 vaccines, as well as vaccine acceptance, hesitancy, together with uptake, pregnancy, and postpartum, will be used to search electronic databases for relevant literature published between 2009 and 2024. Only studies conducted in LMICs that investigated determinants of acceptance, hesitancy, and uptake of tetanus, influenza, pertussis, and COVID-19 vaccines among pregnant and postpartum women will be eligible for inclusion in the review. The quality and the risk of bias of all eligible full-text articles will be assessed using the Joanna Briggs Institute's (JBI) critical appraisal tools. DISCUSSION This protocol proposes a systematic review and meta-analysis that aims to assess the uptake of maternal vaccines and to systematically appraise and quantify determinants of the acceptance and uptake of recommended vaccines during pregnancy and postpartum in LMICs. A better understanding of these factors and how they influence maternal vaccine decision-making will enable public health practitioners as well as global and national policymakers to design more effective interventions as we look towards expanding the scope and reach of maternal immunization programs.
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Affiliation(s)
- Imen Ayouni
- Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Tshepiso Mbangiwa
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Edina Amponsah-Dacosta
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Susanne Noll
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Benjamin M Kagina
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Rudzani Muloiwa
- Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Chaudhari T. Vaccinations in the newborn. Best Pract Res Clin Obstet Gynaecol 2021; 76:66-82. [DOI: 10.1016/j.bpobgyn.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 09/15/2020] [Accepted: 09/26/2020] [Indexed: 02/07/2023]
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Pereira CG, Santos RF, Faria APV, Silva TPRD, Pena ÉD, Matozinhos FP. Reliability of information available on popular websites about vaccination of pregnant women. Rev Esc Enferm USP 2021; 55:e20200517. [PMID: 34498661 DOI: 10.1590/1980-220x-reeusp-2020-0517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/12/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To analyze the reliability of information available on popular websites about vaccination of pregnant women according to the recommendations of the Brazilian Ministry of Health. METHOD Descriptive and comparative study. For data collection, a checklist composed of information on recommended, contraindicated, and indicated vaccines in special situations during pregnancy, according to the Ministry of Health, was elaborated. RESULTS None of the analyzed websites presented all the recommended information. Contraindications, most common adverse events, simultaneous administration of vaccines, information on the DT vaccine, and recommended vaccines in special situations were presented by a minority of websites. CONCLUSION Information available on websites about the vaccination of pregnant women is not always based on the recommendations and misinformation may interfere with the acceptance of this practice. The importance of the professionals of the multidisciplinary team as information mediators, particularly the nurse, is emphasized, as is the need for regulating the production and dissemination of information on the internet.
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Affiliation(s)
| | - Raquel Freire Santos
- Universidade Federal de Minas Gerais, Escola de Enfermagem, Belo Horizonte, MG, Brazil
| | - Ana Paula Vieira Faria
- Universidade Federal de Minas Gerais, Escola de Enfermagem, Programa de Pós-Graduação em Enfermagem, Belo Horizonte, MG, Brazil
| | - Thales Philipe Rodrigues da Silva
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Programa de Pós-Graduação em Ciências da Saúde, Saúde da Criança e do Adolescente, Belo Horizonte, MG, Brazil
| | - Érica Dumont Pena
- Universidade Federal de Minas Gerais, Escola de Enfermagem, Departamento de Enfermagem Materno Infantil e Saúde Pública, Belo Horizonte, MG, Brazil
| | - Fernanda Penido Matozinhos
- Universidade Federal de Minas Gerais, Escola de Enfermagem, Departamento de Enfermagem Materno Infantil e Saúde Pública, Belo Horizonte, MG, Brazil
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Otieno NA, Malik FA, Nganga SW, Wairimu WN, Ouma DO, Bigogo GM, Chaves SS, Verani JR, Widdowson MA, Wilson AD, Bergenfeld I, Gonzalez-Casanova I, Omer SB. Decision-making process for introduction of maternal vaccines in Kenya, 2017-2018. Implement Sci 2021; 16:39. [PMID: 33845842 PMCID: PMC8042952 DOI: 10.1186/s13012-021-01101-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 03/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maternal immunization is a key strategy for reducing morbidity and mortality associated with infectious diseases in mothers and their newborns. Recent developments in the science and safety of maternal vaccinations have made possible development of new maternal vaccines ready for introduction in low- and middle-income countries. Decisions at the policy level remain the entry point for maternal immunization programs. We describe the policy and decision-making process in Kenya for the introduction of new vaccines, with particular emphasis on maternal vaccines, and identify opportunities to improve vaccine policy formulation and implementation process. METHODS We conducted 29 formal interviews with government officials and policy makers, including high-level officials at the Kenya National Immunization Technical Advisory Group, and Ministry of Health officials at national and county levels. All interviews were recorded and transcribed. We analyzed the qualitative data using NVivo 11.0 software. RESULTS All key informants understood the vaccine policy formulation and implementation processes, although national officials appeared more informed compared to county officials. County officials reported feeling left out of policy development. The recent health system decentralization had both positive and negative impacts on the policy process; however, the negative impacts outweighed the positive impacts. Other factors outside vaccine policy environment such as rumours, sociocultural practices, and anti-vaccine campaigns influenced the policy development and implementation process. CONCLUSIONS Public policy development process is complex and multifaceted by its nature. As Kenya prepares for introduction of other maternal vaccines, it is important that the identified policy gaps and challenges are addressed.
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Affiliation(s)
- Nancy A. Otieno
- Division of Global Health Protection, Centre for Global Health Research, Kenya Medical Research Institute, PO Box 1578-40100, Kisumu, Kenya
| | - Fauzia A. Malik
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA 30322 USA
| | - Stacy W. Nganga
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA 30322 USA
| | - Winnie N. Wairimu
- Centre for Global Health Research, Kenya Medical Research Institute, PO Box 1578-40100, Kisumu, Kenya
| | - Dominic O. Ouma
- Centre for Global Health Research, Kenya Medical Research Institute, PO Box 1578-40100, Kisumu, Kenya
| | - Godfrey M. Bigogo
- Division of Global Health Protection, Centre for Global Health Research, Kenya Medical Research Institute, PO Box 1578-40100, Kisumu, Kenya
| | - Sandra S. Chaves
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, PO Box 606-00621, Nairobi, Kenya
| | - Jennifer R. Verani
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, PO Box 606-00621, Nairobi, Kenya
| | - Marc-Alain Widdowson
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, PO Box 606-00621, Nairobi, Kenya
| | - Andrew D. Wilson
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA 30322 USA
| | - Irina Bergenfeld
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA 30322 USA
| | - Ines Gonzalez-Casanova
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA 30322 USA
| | - Saad B. Omer
- Department of Medicine, Division of Pediatrics, Emory University School of Medicine, 1518 Clifton Rd NE, Atlanta, GA 30322 USA
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McMorrow ML, Rossi L, Meiring S, Bishop K, Itzikowitz R, Isaacs W, Stellenboom F, Walaza S, Hellferscee O, Treurnicht FK, Zar HJ, Tempia S, Cohen C. A Retrospective observational cohort study of the effect of antenatal influenza vaccination on birth outcomes in Cape Town, South Africa, 2015-2016. Influenza Other Respir Viruses 2021; 15:446-456. [PMID: 33452708 PMCID: PMC8189187 DOI: 10.1111/irv.12836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/17/2020] [Accepted: 12/19/2020] [Indexed: 02/05/2023] Open
Abstract
Background There are conflicting data concerning the impact of antenatal influenza vaccination on birth outcomes including low birthweight (LBW), preterm birth, small for gestational age (SGA), and stillbirth. Methods We conducted a retrospective observational cohort study of infants born to women residing in Mitchells Plain, Cape Town. Infants were born at 4 health facilities during May 28 – December 31, 2015 and April 15 – December 31, 2016. We performed crude and multivariable logistic regression, propensity score (PS) matching logistic regression, and inverse probability of treatment weighted (IPTW) regression to assess vaccine effectiveness (VE) against LBW, preterm birth, SGA, and stillbirth adjusting for measured confounders. Results Maternal vaccination status, antenatal history, and ≥1 birth outcome(s) were available for 4084/5333 (76.6%) pregnancies, 2109 (51.6%) vaccinated, and 1975 (48.4%) unvaccinated. The proportion LBW was lower in vaccinated (6.9%) vs. unvaccinated (12.5%) in multivariable [VE 0.27 (95% CI 0.07‐0.42)], PS [VE 0.30 (95% CI 0.09‐0.51)], and IPTW [VE 0.24 (95% CI 0.04‐0.45)]. Preterm birth was less frequent in vaccinated (8.6%) than unvaccinated (16.4%) in multivariable [VE 0.26 (0.09‐0.40)], PS [VE 0.25 (95% CI 0.09‐0.41)], and IPTW [VE 0.34 (95% CI 0.18‐0.51)]. The proportion SGA was lower in vaccinated (6.0%) than unvaccinated (8.8%) but not in adjusted models. There were few stillbirths in our study population, 30/4084 (0.7%). Conclusions Using multiple analytic approaches, we found that influenza vaccination was associated with lower prevalence of LBW (24‐30%) and preterm birth (25‐34%) in Cape Town during 2015‐2016.
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Affiliation(s)
- Meredith L McMorrow
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Influenza Program, Centers for Disease Control and Prevention, Pretoria, South Africa.,United States Public Health Service, Rockville, Maryland, USA
| | - Liza Rossi
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Susan Meiring
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Katherine Bishop
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Raphaela Itzikowitz
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Washiefa Isaacs
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Faakhiera Stellenboom
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Sibongile Walaza
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Orienka Hellferscee
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa.,School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Florette K Treurnicht
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.,Medical Research Council Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Stefano Tempia
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Influenza Program, Centers for Disease Control and Prevention, Pretoria, South Africa.,Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa.,MassGenics, Duluth, Georgia, USA
| | - Cheryl Cohen
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Krubiner CB, Faden RR, Karron RA, Little MO, Lyerly AD, Abramson JS, Beigi RH, Cravioto AR, Durbin AP, Gellin BG, Gupta SB, Kaslow DC, Kochhar S, Luna F, Saenz C, Sheffield JS, Tindana PO. Pregnant women & vaccines against emerging epidemic threats: Ethics guidance for preparedness, research, and response. Vaccine 2021; 39:85-120. [PMID: 31060949 PMCID: PMC7735377 DOI: 10.1016/j.vaccine.2019.01.011] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 01/07/2019] [Indexed: 12/22/2022]
Abstract
Zika virus, influenza, and Ebola have called attention to the ways in which infectious disease outbreaks can severely - and at times uniquely - affect the health interests of pregnant women and their offspring. These examples also highlight the critical need to proactively consider pregnant women and their offspring in vaccine research and response efforts to combat emerging and re-emerging infectious diseases. Historically, pregnant women and their offspring have been largely excluded from research agendas and investment strategies for vaccines against epidemic threats, which in turn can lead to exclusion from future vaccine campaigns amidst outbreaks. This state of affairs is profoundly unjust to pregnant women and their offspring, and deeply problematic from the standpoint of public health. To ensure that the needs of pregnant women and their offspring are fairly addressed, new approaches to public health preparedness, vaccine research and development, and vaccine delivery are required. This Guidance offers 22 concrete recommendations that provide a roadmap for the ethically responsible, socially just, and respectful inclusion of the interests of pregnant women in the development and deployment of vaccines against emerging pathogens. The Guidance was developed by the Pregnancy Research Ethics for Vaccines, Epidemics, and New Technologies (PREVENT) Working Group - a multidisciplinary, international team of 17 experts specializing in bioethics, maternal immunization, maternal-fetal medicine, obstetrics, pediatrics, philosophy, public health, and vaccine research and policy - in consultation with a variety of external experts and stakeholders.
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Affiliation(s)
- Carleigh B Krubiner
- Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD, USA.
| | - Ruth R Faden
- Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD, USA; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ruth A Karron
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Margaret O Little
- Kennedy Institute of Ethics, Georgetown University, Washington, D.C., USA
| | - Anne D Lyerly
- University of North Carolina Center for Bioethics, Chapel Hill, NC, USA
| | - Jon S Abramson
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Richard H Beigi
- Magee-Womens Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Anna P Durbin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | | | | | - Carla Saenz
- Pan American Health Organization, Washington, D.C., USA
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Macias Saint-Gerons D, Solà Arnau I, De Mucio B, Arévalo-Rodríguez I, Alemán A, Castro JL, Ropero Álvarez AM. Adverse events associated with the use of recommended vaccines during pregnancy: An overview of systematic reviews. Vaccine 2020; 39 Suppl 2:B12-B26. [PMID: 32972737 DOI: 10.1016/j.vaccine.2020.07.048] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 06/02/2020] [Accepted: 07/22/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Maternal immunization is aimed at reducing morbidity and mortality in pregnant women and their newborns. Updated evidence synthesis of maternal-fetal outcomes is constantly needed to ensure that the risk-benefit of vaccination during pregnancy remains positive. METHODS An overview of systematic reviews (OoSRs) was performed. We searched The Cochrane Library, MEDLINE and EMBASE for SRs including recommended vaccines for maternal immunization reporting the following: abortion, stillbirth, chorioamnionitis, congenital anomalies, microcephaly, neonatal death, neonatal infection, preterm birth (PTB), low birth weight (LBW), maternal death and small for gestational age (SGA) from 2010 to April 2019. Quality and overlap of SRs was assessed. RESULTS Seventeen SRs were identified, eight of them included meta-analysis; quality was high in three SRs, moderate in six SRs, low in two SRs, and critically low in six SRs. Stillbirth and PTB were the most frequently reported outcomes by 15 and 13 SRs, respectively, followed by abortion (9 SRs), congenital anomalies (9 SRs), SGA (8 SRs), neonatal death (8 SRs), LBW (4 SRs), chorioamnionitis (3 SRs), maternal death (1 SR). SRs included mainly observational evidence for influenza and Tdap vaccines (11 SRs and 4 SRs, respectively); limited evidence was found for hepatitis (1 SR), yellow fever (1 SR), and meningococcal (1 SR) vaccines. Most of the SRs found no effect. Eight SRs found benefit/protection of influenza vaccine (for stillbirth, neonatal death, preterm birth, LBW), or Tdap vaccine (for preterm birth and SGA); one found a probable risk (chorioamnionitis/Tdap). The SRs for Hepatitis B, meningococcal and yellow fever vaccines were inconclusive. CONCLUSIONS Definite risks were not identified for any vaccine and outcome; however better evidence is needed for all outcomes and vaccines. The available evidence in the SRs to support vaccine safety was based mainly on observational data. More RCTs with adequate reporting of maternal-fetal outcomes and larger high-quality observational studies are needed.
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Affiliation(s)
- Diego Macias Saint-Gerons
- Department of Medicine, University of Valencia/INCLIVA Health Research Institute and CIBERSAM, Valencia, Spain; Department of Health Systems and Services (HSS)/Unit of Medicines and Health Technologies (MT), Pan American Health Organization PAHO/WHO, Washington DC, USA
| | - Iván Solà Arnau
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER of Epidemiology and Public Health, Spain
| | - Bremen De Mucio
- Department of Preventive Medicine, School of Medicine, University of the Republic, Montevideo, Uruguay
| | - Ingrid Arévalo-Rodríguez
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal, IRYCIS, CIBER of Epidemiology and Public Health, Madrid, Spain
| | - Alicia Alemán
- Department of Preventive Medicine, School of Medicine, University of the Republic, Montevideo, Uruguay
| | - José Luis Castro
- Department of Health Systems and Services (HSS)/Unit of Medicines and Health Technologies (MT), Pan American Health Organization PAHO/WHO, Washington DC, USA
| | - Alba María Ropero Álvarez
- Department of Family, Gender and Life Course, Immunization Unit, Pan American Health Organization PAHO/WHO, Washington DC, USA.
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Schwarz TF, McPhee RA, Launay O, Leroux-Roels G, Talli J, Picciolato M, Gao F, Cai R, Nguyen TLA, Dieussaert I, Miller JM, Schmidt AC. Immunogenicity and Safety of 3 Formulations of a Respiratory Syncytial Virus Candidate Vaccine in Nonpregnant Women: A Phase 2, Randomized Trial. J Infect Dis 2019; 220:1816-1825. [PMID: 31418022 PMCID: PMC6898794 DOI: 10.1093/infdis/jiz395] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 07/31/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Respiratory syncytial virus (RSV) is a common cause of respiratory tract illness and hospitalization in neonates and infants. RSV vaccination during pregnancy may protect offspring in their first months of life. METHODS This randomized, observer-blind, multicenter, phase 2 study evaluated the immunogenicity and safety of an RSV candidate vaccine in healthy nonpregnant women aged 18-45 years. Four hundred participants were randomized (1:1:1:1) to receive a single intramuscular dose of vaccine containing 30 µg, 60 µg, or 120 µg of RSV fusion protein engineered to preferentially maintain a prefusion conformation (RSV-PreF vaccine) or placebo. RESULTS Thirty days postvaccination, RSV-A neutralizing antibody geometric mean titers (GMTs) increased 3.75-, 4.42- and 4.36-fold; RSV-B neutralizing antibody GMTs 2.36-, 2.54- and 2.76-fold; and palivizumab competing antibody (PCA) concentrations 11.69-, 14.38- and 14.24-fold compared with baseline levels in the 30 µg, 60 µg, and 120 µg RSV-PreF groups, respectively. Antibody titers and PCA concentrations at day 30 were significantly higher with the 120 µg compared to the 30 µg RSV-PreF vaccine. All RSV-PreF vaccine formulations and the placebo had similar reactogenicity profiles. No serious adverse events were considered to be related to the RSV-PreF vaccine. CONCLUSIONS The 3 formulations of the investigational RSV-PreF vaccine were well-tolerated and induced RSV-A and RSV-B neutralizing antibodies and PCAs in healthy, nonpregnant women. CLINICAL TRIALS REGISTRATION NCT02956837.
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Affiliation(s)
- Tino F Schwarz
- Institute of Laboratory Medicine and Vaccination Centre, Klinikum Würzburg Mitte, Würzburg, Germany
| | | | - Odile Launay
- Université de Paris, Inserm, clinical investigation center 1417, Assistance Publique–Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Geert Leroux-Roels
- Center for Vaccinology, Ghent University and University Hospital, Belgium
| | - Jaak Talli
- Ravi-ja Uuringukeskus Innomedica OÜ, Tallinn, Estonia
| | | | - Feng Gao
- GlaxoSmithKline (GSK), Rockville, Maryland
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10
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Ortiz JR, Neuzil KM. Influenza vaccine programs for children in low- and middle-income countries: current status and way forward. Expert Rev Vaccines 2019; 18:711-724. [DOI: 10.1080/14760584.2019.1635462] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Justin R Ortiz
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kathleen M Neuzil
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
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Kochhar S, Edwards KM, Ropero Alvarez AM, Moro PL, Ortiz JR. Introduction of new vaccines for immunization in pregnancy - Programmatic, regulatory, safety and ethical considerations. Vaccine 2019; 37:3267-3277. [PMID: 31072733 PMCID: PMC6771279 DOI: 10.1016/j.vaccine.2019.04.075] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 04/18/2019] [Accepted: 04/24/2019] [Indexed: 12/11/2022]
Abstract
Immunizing pregnant women is a promising strategy to reduce infectious disease-related morbidity and mortality in pregnant women and their infants. Important pre-requisites for the successful introduction of new vaccines for immunization in pregnancy include political commitment and adequate financial resources: trained, committed and sufficient numbers of healthcare workers to deliver the vaccines; close integration of immunization programs with antenatal care and Maternal and Child Health services; adequate access to antenatal care by pregnant women in the country (especially in low and middle-income countries (LMIC)); and a high proportion of births occurring in health facilities (to ensure maternal and neonatal follow-up can be done). The framework needed to advance a vaccine program from product licensure to successful country-level implementation includes establishing and organizing evidence for anticipated vaccine program impact, developing supportive policies, and translating policies into local action. International and national coordination efforts, proactive planning from conception to implementation of the programs (including country-level policy making, planning, and implementation, regulatory guidance, pharmacovigilance) and country-specific and cultural factors must be taken into account during the vaccines introduction.
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Affiliation(s)
- Sonali Kochhar
- Global Healthcare Consulting, New Delhi, India; Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands; Department of Global Health, University of Washington, Seattle, USA.
| | - Kathryn M Edwards
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, TN, USA
| | - Alba Maria Ropero Alvarez
- Comprehensive Family Immunization Unit, Department of Family, Health Promotion and Life Course (FPL). Pan American Health Organization (PAHO/WHO), Washington DC, USA
| | - Pedro L Moro
- Immunization Safety Office, Division Of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, USA
| | - Justin R Ortiz
- Department of Global Health, University of Washington, Seattle, USA; Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
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12
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Safety and immunogenicity of a respiratory syncytial virus fusion glycoprotein F subunit vaccine in healthy adults: Results of a phase 1, randomized, observer-blind, controlled, dosage-escalation study. Vaccine 2019; 37:2694-2703. [DOI: 10.1016/j.vaccine.2019.04.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 04/02/2019] [Accepted: 04/04/2019] [Indexed: 11/18/2022]
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13
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Trushakova S, Kisteneva L, Guglieri-López B, Mukasheva E, Kruzhkova I, Mira-Iglesias A, Krasnoslobodtsev K, Morozova E, Kolobukhina L, Puig-Barberà J, Burtseva E. Epidemiology of influenza in pregnant women hospitalized with respiratory illness in Moscow, 2012/2013-2015/2016: a hospital-based active surveillance study. BMC Pregnancy Childbirth 2019; 19:72. [PMID: 30770729 PMCID: PMC6377748 DOI: 10.1186/s12884-019-2192-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 01/15/2019] [Indexed: 12/18/2022] Open
Abstract
Background To better understand the impact of seasonal influenza in pregnant women we analyzed data collected during four seasons at a hospital for acute respiratory infection that specializes in treating pregnant women. Methods This was a single-center active surveillance study of women 15–44 years of age hospitalized for acute respiratory diseases between 2012/2013 and 2015/2016 in Moscow, Russian Federation. Women had to have been hospitalized within 7 days of the onset of symptoms. Swabs were taken within 48 h of admission, and influenza was detected by reverse transcription-polymerase chain reaction. Results During the four seasons, of the 1992 hospitalized women 1748 were pregnant. Laboratory-confirmed influenza was detected more frequently in pregnant women (825/1748; 47.2%) than non-pregnant women (58/244; 23.8%) (OR for influenza = 2.87 [95% CI, 2.10–3.92]; p < 0.001). This pattern was homogenous across seasons (p = 0.112 by test of homogeneity of equal odds). Influenza A(H1N1)pdm09 was the dominant strain in 2012/2013, A(H3N2) in 2013/2014, B/Yamagata lineage and A(H3N2) in 2014/2015, and A(H1N1)pdm09 in 2015/2016. Influenza-positive pregnant admissions went to the hospital sooner than influenza-negative pregnant admissions (p < 0.001). The risk of influenza increased by 2% with each year of age and was higher in women with underlying conditions (OR = 1.52 [95% CI, 1.16 to 1.99]). Pregnant women positive for influenza were homogeneously distributed by trimester (p = 0.37 for homogeneity; p = 0.49 for trend). Frequencies of stillbirth, delivery, preterm delivery, and caesarean delivery did not significantly differ between influenza-positive and influenza-negative hospitalized pregnant women or between subtypes/lineages. Conclusions Pregnant women are at increased risk for hospitalization due to influenza irrespective of season, circulating viruses, or trimester. Electronic supplementary material The online version of this article (10.1186/s12884-019-2192-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Svetlana Trushakova
- Ministry of Health of the Russian Federation, FSBI "N.F. Gamaleya NRCEM", 16, Gamaleya str, Moscow, Russia Moscow, 123098, Russian Federation.
| | - Lidiya Kisteneva
- Ministry of Health of the Russian Federation, FSBI "N.F. Gamaleya NRCEM", 16, Gamaleya str, Moscow, Russia Moscow, 123098, Russian Federation
| | - Beatriz Guglieri-López
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica (FISABIO) de la Comunidad Valenciana, Avda Catalunya 21, 46020, Valencia, Spain
| | - Evgenia Mukasheva
- Ministry of Health of the Russian Federation, FSBI "N.F. Gamaleya NRCEM", 16, Gamaleya str, Moscow, Russia Moscow, 123098, Russian Federation
| | - Irina Kruzhkova
- Ministry of Health of the Russian Federation, FSBI "N.F. Gamaleya NRCEM", 16, Gamaleya str, Moscow, Russia Moscow, 123098, Russian Federation
| | - Ainara Mira-Iglesias
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica (FISABIO) de la Comunidad Valenciana, Avda Catalunya 21, 46020, Valencia, Spain
| | - Kirill Krasnoslobodtsev
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica (FISABIO) de la Comunidad Valenciana, Avda Catalunya 21, 46020, Valencia, Spain
| | - Ekaterina Morozova
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica (FISABIO) de la Comunidad Valenciana, Avda Catalunya 21, 46020, Valencia, Spain
| | - Ludmila Kolobukhina
- Ministry of Health of the Russian Federation, FSBI "N.F. Gamaleya NRCEM", 16, Gamaleya str, Moscow, Russia Moscow, 123098, Russian Federation
| | - Joan Puig-Barberà
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica (FISABIO) de la Comunidad Valenciana, Avda Catalunya 21, 46020, Valencia, Spain
| | - Elena Burtseva
- Ministry of Health of the Russian Federation, FSBI "N.F. Gamaleya NRCEM", 16, Gamaleya str, Moscow, Russia Moscow, 123098, Russian Federation
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The Fourth International Neonatal and Maternal Immunization Symposium (INMIS 2017): Toward Integrating Maternal and Infant Immunization Programs. mSphere 2018; 3:3/6/e00221-18. [PMID: 30404933 PMCID: PMC6222055 DOI: 10.1128/msphere.00221-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
This report provides an overview of the proceedings of the 4th International Maternal and Neonatal Immunization Symposium, where presentations focused on the state-of-the-art research on the development and implementation of vaccines given during pregnancy for the protection of mothers and infants. Prevention of serious infections in pregnant mothers, newborns, and young infants through immunization during pregnancy and in early life has the potential to further reduce maternal and neonatal morbidity and mortality worldwide. In the past decade, research in this field has advanced substantially, from the understanding of the biology and immunology of pregnancy and early life, to the active development of several candidate vaccines, for which challenges and opportunities for global implementation are under consideration. Experts from academia, industry, regulatory and funding agencies, public health, and international organizations met in Brussels (Belgium) from 10 to 12 September 2017, at the 4th International Neonatal and Maternal Immunization Symposium (INMIS), to review the most relevant advances in maternal and neonatal immunization. The overarching focus of the conference was to identify the path forward to achieve integration of maternal and early life immunization strategies for the successful implementation of vaccines in antenatal care and pediatric programs for reduction of maternal and infant mortality worldwide. IMPORTANCE This report provides an overview of the proceedings of the 4th International Maternal and Neonatal Immunization Symposium, where presentations focused on the state-of-the-art research on the development and implementation of vaccines given during pregnancy for the protection of mothers and infants.
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Larson Williams A, Mitrovich R, Mwananyanda L, Gill C. Maternal vaccine knowledge in low- and middle-income countries-and why it matters. Hum Vaccin Immunother 2018; 15:283-286. [PMID: 30252609 PMCID: PMC6422451 DOI: 10.1080/21645515.2018.1526589] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 09/13/2018] [Indexed: 11/26/2022] Open
Abstract
Maternal vaccines have the potential to reduce the global burden of neonatal morbidity and mortality by accessing the infant immune system before a vaccine administered in childhood would be effective. Maternal vaccines for influenza, tetanus, and pertussis have been shown to reduce neonatal disease and mortality, and other candidate vaccines for group B streptococcus and respiratory syncytial virus are being developed to continue this trend. However, safe and effective maternal vaccines will only successfully reduce neonatal illness if mothers decide to receive them. Maternal knowledge, attitudes, and beliefs around vaccines are key determinants to vaccine acceptance or vaccine hesitancy, and yet this issue is often understudied in low and middle-income country settings. A deeper understanding of these factors and how they influence maternal decision-making will allow public health practitioners and global and national policymakers to design more effective interventions. Addressing barriers to immunization at the policy and programmatic levels such as mothers' knowledge, attitudes, and beliefs of maternal vaccines is essential to increasing vaccination rates at a global scale and reducing global vaccine-preventable neonatal deaths.
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Affiliation(s)
- Anna Larson Williams
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Rachel Mitrovich
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | | | - Chris Gill
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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16
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Beran J, Lickliter JD, Schwarz TF, Johnson C, Chu L, Domachowske JB, Van Damme P, Withanage K, Fissette LA, David MP, Maleux K, Schmidt AC, Picciolato M, Dieussaert I. Safety and Immunogenicity of 3 Formulations of an Investigational Respiratory Syncytial Virus Vaccine in Nonpregnant Women: Results From 2 Phase 2 Trials. J Infect Dis 2018; 217:1616-1625. [PMID: 29401325 PMCID: PMC5913599 DOI: 10.1093/infdis/jiy065] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/30/2018] [Indexed: 12/31/2022] Open
Abstract
Background Respiratory syncytial virus (RSV) causes bronchiolitis and pneumonia in neonates and infants. RSV vaccination during pregnancy could boost preexisting neutralizing antibody titers, providing passive protection to newborns. Methods Two observer-blinded, controlled studies (RSV F-020 [clinical trials registration NCT02360475] and RSV F-024 [NCT02753413]) evaluated immunogenicity and safety of an investigational RSV vaccine in healthy, nonpregnant 18-45-year-old women. Both studies used a licensed adult formulation of combined tetanus toxoid-diphtheria toxoid-acellular pertussis (Tdap) vaccine as a control. RSV F-020 evaluated immunogenicity and safety: participants were randomized (1:1:1:1) to receive 1 dose of RSV-prefusion F protein (PreF) vaccine containing 30 µg or 60 µg of nonadjuvanted RSV-PreF, 60 µg of aluminum-adjuvanted RSV-PreF, or Tdap. RSV F-024 evaluated safety: participants were randomized 1:1 to receive 1 dose of 60 µg of nonadjuvanted RSV-PreF or Tdap. Results Both studies showed similar reactogenicity profiles for RSV-PreF and Tdap. No serious adverse events were considered vaccine related. In RSV F-020, geometric mean ratios of RSV-A neutralizing antibody levels at day 30 versus prevaccination were 3.1-3.9 in RSV-PreF recipients and 0.9 in controls. Palivizumab-competing antibody concentrations increased >14-fold in RSV-PreF recipients on day 30. RSV antibody titers waned after day 30 but remained well above baseline through day 90. Conclusions All formulations of RSV-PreF boosted preexisting immune responses in 18-45-year old women with comparable immunogenicity. The RSV-PreF safety profile was similar to that of Tdap vaccine.
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Affiliation(s)
- Jiři Beran
- Vaccination and Travel Medicine Centre, Hradec Králové, Czech Republic
| | | | - Tino F Schwarz
- Klinikum Würzburg Mitte, Standort Juliusspital, Würzburg, Germany
| | | | | | | | - Pierre Van Damme
- Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp
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Influenza immunization of pregnant women in resource-constrained countries: an update for funding and implementation decisions. Curr Opin Infect Dis 2018; 30:455-462. [PMID: 28777109 DOI: 10.1097/qco.0000000000000392] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW In 2018, Gavi, the Vaccine Alliance, is expected to review the strategy of maternal influenza immunization for potential investment in low-income countries. RECENT FINDINGS Clinical trial data confirm the efficacy of maternal influenza immunization to prevent influenza disease in both mothers and their infants during the first months of life. Trial and observational data indicate no significant adverse events in mothers or newborns. High-quality disease burden data, particularly for seasonal influenza in low-income and middle-income countries, are limited. Thus, the anticipated impact of maternal influenza immunization programs on severe illness is unclear. However, assessments of the public health value of investment in maternal influenza immunization should extend beyond calculations of disease prevention and include broader effects such as improving health systems for antenatal care delivery, preventing inappropriate antibacterial prescribing, building a platform for other vaccines to be used during pregnancy, and strengthening systems to regulate, procure, and distribute influenza vaccines in response to a future pandemic. SUMMARY A global investment in a maternal influenza immunization strategy would prevent influenza disease in pregnant women and their infants. It would also provide additional public health value by strengthening antenatal care systems and improving country pandemic preparedness.
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Nunes MC, Madhi SA. Influenza vaccination during pregnancy for prevention of influenza confirmed illness in the infants: A systematic review and meta-analysis. Hum Vaccin Immunother 2017; 14:758-766. [PMID: 28708952 DOI: 10.1080/21645515.2017.1345385] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Infants younger than 6 months of age are at particular risk for serious illness from influenza infection. Currently available influenza vaccines are, however, not licensed for use in infants <6 months old. Influenza vaccination during pregnancy elicits robust antibody responses in the women that will protect the infants against influenza infection during the first few months of life. We aimed to determine the impact of influenza vaccination during pregnancy to prevent laboratory-confirmed influenza infection and influenza-associated hospitalisations in infants <6 months old. An electronic search identified all studies assessing the proposed outcomes in infants after administration of influenza vaccine during pregnancy. Two meta-analyses were performed accordingly to studies restricting the evaluation to influenza-associated hospitalisations or not. Four randomized control trials and 3 observational studies reported on the prevention of laboratory-confirmed influenza infection in infants <6 months old. Maternal influenza vaccination was associated with a 48% [95% confidence interval (CI): 33 to 59] reduced risk of infants having laboratory-confirmed influenza infection. Four observational studies reported on the prevention of hospitalizations associated with laboratory-confirmed influenza infection and the pool estimate was 72% (95%CI: 39% to 87%). Receipt of influenza vaccine during pregnancy was associated with decreased risk of laboratory-confirmed influenza infection in the infants.
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Affiliation(s)
- Marta C Nunes
- a Medical Research Council: Respiratory and Meningeal Pathogens Research Unit , University of the Witwatersrand , Johannesburg , South Africa.,b Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases , University of the Witwatersrand , Johannesburg , South Africa
| | - Shabir A Madhi
- a Medical Research Council: Respiratory and Meningeal Pathogens Research Unit , University of the Witwatersrand , Johannesburg , South Africa.,b Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases , University of the Witwatersrand , Johannesburg , South Africa.,c National Institute for Communicable Diseases: A Division of National Health Laboratory Service , Centre for Vaccines and Immunology , Johannesburg , South Africa
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Influenza epidemiology and immunization during pregnancy: Final report of a World Health Organization working group. Vaccine 2017; 35:5738-5750. [PMID: 28867508 PMCID: PMC8274347 DOI: 10.1016/j.vaccine.2017.08.037] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 08/17/2017] [Indexed: 12/05/2022]
Abstract
From 2014 to 2017, the World Health Organization convened a working group to evaluate influenza disease burden and vaccine efficacy to inform estimates of maternal influenza immunization program impact. The group evaluated existing systematic reviews and relevant primary studies, and conducted four new systematic reviews. There was strong evidence that maternal influenza immunization prevented influenza illness in pregnant women and their infants, although data on severe illness prevention were lacking. The limited number of studies reporting influenza incidence in pregnant women and infants under six months had highly variable estimates and underrepresented low- and middle-income countries. The evidence that maternal influenza immunization reduces the risk of adverse birth outcomes was conflicting, and many observational studies were subject to substantial bias. The lack of scientific clarity regarding disease burden or magnitude of vaccine efficacy against severe illness poses challenges for robust estimation of the potential impact of maternal influenza immunization programs.
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Katz MA, Gessner BD, Johnson J, Skidmore B, Knight M, Bhat N, Marshall H, Horne DJ, Ortiz JR, Fell DB. Incidence of influenza virus infection among pregnant women: a systematic review. BMC Pregnancy Childbirth 2017; 17:155. [PMID: 28558777 PMCID: PMC5450114 DOI: 10.1186/s12884-017-1333-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 05/18/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) considers pregnant women to be a risk group for severe influenza disease. We conducted a systematic review to evaluate influenza disease incidence in pregnant women in order to inform estimates of influenza vaccine impact for low-resource countries. METHODS We performed electronic literature searches, targeting studies on the following outcomes in pregnant women: attack rate, hospitalization rate, intensive care unit admission rate, mortality rate, and disability-adjusted life years lost. Only original studies published in peer-reviewed journals that had laboratory confirmation for influenza virus infection and included population-based incidence rates with denominator data were included. We summarized study characteristics in descriptive tables and outcome-specific Forest plots. We generated summary incidence rates using random effects models and assessed statistical heterogeneity by visual examination of Forest plots, and by χ 2 and I2 tests. RESULTS We identified 1543 articles, of which nine articles met the study inclusion criteria. Five were case series, three were cohort studies, and one was a randomized controlled trial. Eight studies were from high-income countries, and one was from an upper middle-income country. Six studies reported results for pandemic influenza, and three reported seasonal influenza. Statistical heterogeneity was high for all outcomes, and methodologies and duration of surveillance varied considerably among studies; therefore, we did not perform meta-analyses. CONCLUSIONS Study quality was very low according to GRADE criteria. More data on influenza disease incidence in pregnant women, particularly in low- and middle-income countries and for seasonal influenza disease, are needed to inform public health decision-making.
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Affiliation(s)
- Mark A. Katz
- Department of Health Systems Management, Medical School for International Health, Ben Gurion University of the Negev, Beer Sheva, Israel
- University of Michigan School of Public Health, Ann Arbor, MI USA
| | - Bradford D. Gessner
- Agence de Médecine Préventive, Paris, France
- Agence de Médecine Préventive, Anchorage, AK USA
| | | | | | - Marian Knight
- National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, United Kingdom
| | - Niranjan Bhat
- Vaccine Access and Delivery Program, PATH, Seattle, WA USA
| | - Helen Marshall
- Vaccinology and Immunology Research Trials Unit, Discipline of Paediatrics, Women’s and Children’s Hospital and University of Adelaide, Adelaide, Australia
- Robinson Research Institute, University of Adelaide, North Adelaide, Australia
| | - David J. Horne
- Department of Medicine, University of Washington, Seattle, USA
- Harborview Medical Center, University of Washington, Seattle, WA USA
| | - Justin R. Ortiz
- Initiative for Vaccine Research, World Health Organization, Geneva, Switzerland
| | - Deshayne B. Fell
- Better Outcomes Registry & Network (BORN), CHEO Research Institute, Ottawa, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
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Fell DB, Bhutta ZA, Hutcheon JA, Karron RA, Knight M, Kramer MS, Monto AS, Swamy GK, Ortiz JR, Savitz DA. Report of the WHO technical consultation on the effect of maternal influenza and influenza vaccination on the developing fetus: Montreal, Canada, September 30-October 1, 2015. Vaccine 2017; 35:2279-2287. [PMID: 28343772 DOI: 10.1016/j.vaccine.2017.03.056] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/13/2017] [Accepted: 03/16/2017] [Indexed: 12/24/2022]
Abstract
In 2012, the World Health Organization (WHO) released a position paper on influenza vaccination recommending that pregnant women have the highest priority for seasonal vaccination in countries where the initiation or expansion of influenza immunization programs is under consideration. Although the primary goal of the WHO recommendation is to prevent influenza illness in pregnant women, the potential benefits of maternal immunization in protecting young infants are also recognized. The extent to which maternal influenza vaccination may prevent adverse birth outcomes such as preterm birth or small-for-gestational-age birth, however, is unclear as available studies are in disagreement. To inform WHO about the empirical evidence relating to possible benefits of influenza vaccination on birth outcomes, a consultation of experts was held in Montreal, Canada, September 30-October 1, 2015. Presentations and discussions covered a broad range of issues, including influenza virus infection during pregnancy and its effect on the health of the mother and the fetus, possible biological mechanisms for adverse birth outcomes following maternal influenza illness, evidence on birth outcomes following influenza illness during pregnancy, evidence from both observational studies and randomized controlled trials on birth outcomes following influenza vaccination of pregnant women, and methodological issues. This report provides an overview of the presentations, discussions and conclusions.
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Affiliation(s)
- Deshayne B Fell
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Canada; Children's Hospital of Eastern Ontario (CHEO) Research Institute, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada.
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, 525 University Avenue, Suite 702, Toronto, ON M5G 2L3, Canada.
| | - Jennifer A Hutcheon
- Department of Obstetrics & Gynaecology, University of British Columbia, Shaughnessy Building C408A, 4500 Oak Street, Vancouver, BC V6N 3N1, Canada.
| | - Ruth A Karron
- Center for Immunization Research, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Old Road Campus, Oxford OX3 7LF, United Kingdom.
| | - Michael S Kramer
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 4018 Ste-Catherine St W, Room K-116, Westmount, QC H3Z 1P2, Canada.
| | - Arnold S Monto
- Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, 1700 SPH I, Ann Arbor, MI 48109-2029, USA.
| | - Geeta K Swamy
- Department of Obstetrics and Gynecology, Duke University, 2608 Erwin Rd, Suite 210, Durham, NC 27710, USA.
| | - Justin R Ortiz
- Initiative for Vaccine Research, World Health Organization, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland.
| | - David A Savitz
- Departments of Epidemiology and Obstetrics and Gynecology, Brown University, 47 George Street, Providence, RI 02912, USA.
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Beeler JA, Lambach P, Fulton TR, Narayanan D, Ortiz JR, Omer SB. A systematic review of ethical issues in vaccine studies involving pregnant women. Hum Vaccin Immunother 2016; 12:1952-1959. [PMID: 27246403 PMCID: PMC4994733 DOI: 10.1080/21645515.2016.1186312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 04/19/2016] [Accepted: 04/30/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Immunization during pregnancy can provide protection for mother and child. However, there have been only a limited number of studies documenting the efficacy and safety of this strategy. AIMS To determine the extent and nature of subject matter related to ethics in maternal immunization by systematically documenting the spectrum of ethical issues in vaccine studies involving pregnant women. METHOD We conducted a systematic literature review of published works pertaining to vaccine and therapeutic studies involving pregnant women through searches of PubMed, EMBASE, Web of Science, the Cochrane Database, and ClinicalTrials.gov. We selected literature meeting the inclusion criteria published between 1988 and June 2014. We systematically abstracted subject matter pertaining to ethical issues in immunization studies during pregnancy. Immunization-specific ethical issues were matched and grouped into major categories and subcategories. RESULTS Seventy-seven published articles met the inclusion criteria. Published articles reported findings on data that had been collected in 26 countries, the majority of which were classified as high-income or upper-middle-income nations according to World Bank criteria. Review of these publications produced 60 immunization-specific ethical issues, grouped into six major categories. Notably, many studies demonstrated limited acknowledgment of key ethical issues including the rights and welfare of participants. Additionally, there was no discussion pertaining to the ethics of program implementation, including integration of maternal immunization programs into existing routine immunization programs. CONCLUSION This review of ethical issues in immunization studies of pregnant women can be used to help inform future vaccine trials in this important population. Consistent documentation of these ethical issues by investigators will facilitate a broader and more nuanced discussion of ethics in immunization of pregnant women - offering new and valuable insights for programs developed to prevent disease in newborn children in low- and middle-income countries.
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Affiliation(s)
- Jennifer A. Beeler
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Philipp Lambach
- Initiative for Vaccine Research, World Health Organization, Geneva, Switzerland
| | - T. Roice Fulton
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Divya Narayanan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Justin R. Ortiz
- Initiative for Vaccine Research, World Health Organization, Geneva, Switzerland
| | - Saad B. Omer
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Emory Vaccine Center, Emory University, Atlanta, GA, USA
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Saso A, Kampmann B. Vaccination against respiratory syncytial virus in pregnancy: a suitable tool to combat global infant morbidity and mortality? THE LANCET. INFECTIOUS DISEASES 2016; 16:e153-63. [DOI: 10.1016/s1473-3099(16)00119-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 01/31/2016] [Accepted: 02/11/2016] [Indexed: 01/20/2023]
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Hutcheon JA, Savitz DA. Invited Commentary: Influenza, Influenza Immunization, and Pregnancy-It's About Time. Am J Epidemiol 2016; 184:187-91. [PMID: 27449413 DOI: 10.1093/aje/kww042] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 03/31/2016] [Indexed: 11/14/2022] Open
Abstract
Immunization of pregnant women against influenza has the potential to reduce adverse fetal outcomes by reducing prenatal exposure to influenza illness. However, as touched on by Fell et al. (Am J Epidemiol. 2016;184(3):163-175) and Vazquez-Benitez et al. (Am J Epidemiol. 2016;184(3):176-186) in this issue of the Journal, observational studies in which the causal effect of maternal influenza illness and influenza immunization on fetal health are evaluated are prone to bias because of the complex temporal nature of influenza illness seasonality, influenza immunization schedules, and gestation itself. Immortal time bias is introduced by an "anytime-in-pregnancy" exposure definition because the shortened pregnancy duration associated with many adverse fetal outcomes limits the opportunity to become exposed, whereas including follow-up time during which pregnancies are no longer at risk of an adverse outcome (e.g., gestational time after 37 weeks in studies of preterm birth) can lead to overestimation of any true benefits of immunization (or harms from influenza illness). We present a framework to avoid time-related biases in the study of influenza illness and immunization in pregnancy and advise that investigations of fetal benefit from maternal influenza immunization should only be undertaken when information is available on the calendar time of influenza virus circulation and the gestational age at which maternal influenza immunization occurred.
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Hutcheon JA, Fell DB, Jackson ML, Kramer MS, Ortiz JR, Savitz DA, Platt RW. Detectable Risks in Studies of the Fetal Benefits of Maternal Influenza Vaccination. Am J Epidemiol 2016; 184:227-32. [PMID: 27365363 PMCID: PMC4967598 DOI: 10.1093/aje/kww048] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/03/2016] [Indexed: 12/22/2022] Open
Abstract
Maternal influenza vaccination prevents influenza illness in both mothers and newborns. Results from some recent studies have suggested that influenza vaccination might also prevent adverse pregnancy outcomes, such as preterm birth. However, it is challenging to conduct epidemiologic studies to evaluate the benefits to the fetus of maternal influenza vaccination because the causal benefit of vaccination is likely only experienced by the small fraction of the cohort in whom influenza illness is prevented by vaccination. The plausibility of detecting true differences in risks between groups under such conditions is rarely discussed. We aimed to inform the interpretation of studies in which the fetal benefits of maternal influenza vaccination are evaluated by estimating detectable risk ratios and necessary sample sizes for different study scenarios. Estimates of rates of influenza illness, vaccine effectiveness, vaccine uptake, and preterm birth and of the association of influenza illness with preterm birth were identified from the published literature. We calculated detectable risk ratios for preterm birth in vaccinated versus unvaccinated women and the associated sample size requirements. Our results demonstrated that under most scenarios, plausible differences between groups will be extremely challenging to detect (risk ratios for preterm birth of 0.9 to 1.0) and will require sample sizes infeasible for prospective epidemiologic research. This suggests that the large fetal benefits from influenza vaccination observed in epidemiologic studies are unlikely to be causal.
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Affiliation(s)
- Jennifer A. Hutcheon
- Correspondence to Dr. Jennifer A. Hutcheon, Department of Obstetrics and Gynaecology, University of British Columbia, Shaughnessy Building C408A, 4500 Oak Street, Vancouver, BC V6N 3N1, Canada (e-mail: )
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Regan AK, Klerk ND, Moore HC, Omer SB, Shellam G, Effler PV. Effectiveness of seasonal trivalent influenza vaccination against hospital-attended acute respiratory infections in pregnant women: A retrospective cohort study. Vaccine 2016; 34:3649-56. [PMID: 27216758 DOI: 10.1016/j.vaccine.2016.05.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 05/06/2016] [Accepted: 05/12/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pregnant women are at risk of serious influenza infection. Although previous studies indicate maternal influenza vaccination can prevent hospitalisation in young infants, there is limited evidence of the effect in mothers. METHODS A cohort of 34,701 pregnant women delivering between 1 April 2012 and 31 December 2013 was created using birth records. Principal diagnosis codes from hospital emergency department (ED) and inpatient records were used to identify episodes of acute respiratory illness (ARI) during the 2012 and 2013 southern hemisphere influenza seasons. Cox regression models were used to calculate adjusted hazard ratios (aHRs) by maternal vaccination status, controlling for Indigenous status, socioeconomic level, medical conditions, and week of delivery. RESULTS 3,007 (8.7%) women received a seasonal influenza vaccine during pregnancy. Vaccinated women were less likely to visit an ED during pregnancy for an ARI (9.7 visits per 10,000 person-days vs. 35.5 visits per 10,000 person-days; aHR: 0.19, 95% CI: 0.05-0.68). Vaccinated women were also less likely to be hospitalised with an ARI compared to unvaccinated women (16.2 hospitalisations per 10,000 person-days vs. 34.0 hospitalisations per 10,000 person-days; aHR: 0.35, 95% CI: 0.13-0.97). CONCLUSIONS Influenza vaccination during pregnancy was associated with significantly fewer hospital attendances for ARI in pregnant women.
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Affiliation(s)
- Annette K Regan
- School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, Western Australia, 6009, Australia; Communicable Disease Control Directorate, Western Australia Department of Health, Perth, WA, 6008, Australia.
| | - Nicholas de Klerk
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Subiaco, Western Australia, 6008, Australia
| | - Hannah C Moore
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Subiaco, Western Australia, 6008, Australia
| | - Saad B Omer
- Rollins School of Public Health, Emory University, Atlanta, GA, 30322, United States
| | - Geoffrey Shellam
- School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, Western Australia, 6009, Australia
| | - Paul V Effler
- School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, Western Australia, 6009, Australia; Communicable Disease Control Directorate, Western Australia Department of Health, Perth, WA, 6008, Australia
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Cassidy C, MacDonald NE, Steenbeek A, Ortiz JR, Zuber PLF, Top KA. A global survey of adverse event following immunization surveillance systems for pregnant women and their infants. Hum Vaccin Immunother 2016; 12:2010-2016. [PMID: 27159639 PMCID: PMC4994761 DOI: 10.1080/21645515.2016.1175697] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Strengthening antenatal care as a platform for maternal immunization is a priority of the World Health Organization (WHO). Systematic surveillance for adverse events following immunization (AEFI) in pregnancy is needed to identify vaccine safety events. We sought to identify active and passive AEFI surveillance systems for pregnant women and infants. Representatives from all National Pharmacovigilance Centers and a convenience sample of vaccine safety experts were invited to complete a 14-item online survey in English, French or Spanish. The survey captured maternal immunization policies, and active and passive AEFI surveillance systems for pregnant women and infants in respondents' countries. The analysis was descriptive. We received responses from 51/185 (28%) invited persons from 47/148 (32%) countries representing all WHO regions, and low, middle and high-income countries. Thirty countries had national immunization policies targeting pregnant women. Eleven countries had active surveillance systems to detect serious AEFI in pregnant women and/or their infants, including six low and middle-income countries (LMIC). Thirty-nine countries had passive surveillance systems, including 23 LMIC. These active and passive surveillance programs cover approximately 8% and 56% of the worldwide annual birth cohort, respectively. Data from one active and four passive systems have been published. We identified 50 active and passive AEFI surveillance systems for pregnant women and infants, but few have published their findings. AEFI surveillance appears to be feasible in low and high resource settings. Further expansion of AEFI surveillance for pregnant women and sharing of vaccine safety information will provide additional evidence in support of maternal immunization policies.
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Affiliation(s)
- Christine Cassidy
- a School of Nursing, Faculty of Health Professions, Dalhousie University , Halifax , Nova Scotia , Canada
| | - Noni E MacDonald
- b Department of Pediatrics , Dalhousie University , Halifax , Nova Scotia , Canada.,c Canadian Center for Vaccinology, IWK Health Center , Halifax , Nova Scotia , Canada
| | - Audrey Steenbeek
- a School of Nursing, Faculty of Health Professions, Dalhousie University , Halifax , Nova Scotia , Canada.,c Canadian Center for Vaccinology, IWK Health Center , Halifax , Nova Scotia , Canada
| | - Justin R Ortiz
- d Initiative for Vaccine Research, World Health Organization , Geneva , Switzerland
| | - Patrick L F Zuber
- d Initiative for Vaccine Research, World Health Organization , Geneva , Switzerland
| | - Karina A Top
- b Department of Pediatrics , Dalhousie University , Halifax , Nova Scotia , Canada.,c Canadian Center for Vaccinology, IWK Health Center , Halifax , Nova Scotia , Canada
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Russell CJ, Hurwitz JL. Sendai virus as a backbone for vaccines against RSV and other human paramyxoviruses. Expert Rev Vaccines 2015; 15:189-200. [PMID: 26648515 DOI: 10.1586/14760584.2016.1114418] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Human paramyxoviruses are the etiological agents for life-threatening respiratory virus infections of infants and young children. These viruses, including respiratory syncytial virus (RSV), the human parainfluenza viruses (hPIV1-4) and human metapneumovirus (hMPV), are responsible for millions of serious lower respiratory tract infections each year worldwide. There are currently no standard treatments and no licensed vaccines for any of these pathogens. Here we review research with which Sendai virus, a mouse parainfluenza virus type 1, is being advanced as a Jennerian vaccine for hPIV1 and as a backbone for RSV, hMPV and other hPIV vaccines for children.
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Affiliation(s)
- Charles J Russell
- a Department of Infectious Diseases , St. Jude Children's Research Hospital , Memphis , TN , USA.,b Department of Microbiology, Immunology and Biochemistry , University of Tennessee Health Science Center , Memphis , TN , USA
| | - Julia L Hurwitz
- a Department of Infectious Diseases , St. Jude Children's Research Hospital , Memphis , TN , USA.,b Department of Microbiology, Immunology and Biochemistry , University of Tennessee Health Science Center , Memphis , TN , USA
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