Maternal benefits of immunization during pregnancy

Association between community-level political affiliation and peripartum vaccination

BACKGROUND

Political affiliation has been associated with vaccine uptake, but whether this association holds in pregnancy, when individuals are recommended to receive multiple vaccinations, remains to be studied.

OBJECTIVE

This study aimed to examine the association between community-level political affiliation and vaccinations for tetanus, diphtheria, and pertussis; influenza; and COVID-19 in pregnant and postpartum individuals.

STUDY DESIGN

A survey was conducted about tetanus, diphtheria, and pertussis and influenza vaccinations in early 2021, with a follow-up survey of COVID-19 vaccination among the same individuals at a tertiary care academic medical center in the Midwest. Geocoded residential addresses were linked at the census tract to the Environmental Systems Research Institute 2021 Market Potential Index, which ranks a community in comparison to the US national average. The exposure for this analysis was community-level political affiliation, defined by the Market Potential Index as very conservative, somewhat conservative, centrist, somewhat liberal, and very liberal (reference). The outcomes were self-reported vaccinations for tetanus, diphtheria, and pertussis; influenza; and COVID-19 in the peripartum period. Modified Poisson regression was used and adjusted for age, employment, trimester at assessment, and medical comorbidities.

RESULTS

Of 438 assessed individuals, 37% lived in a community characterized by very liberal political affiliation, 11% as somewhat liberal, 18% as centrist, 12% as somewhat conservative, and 21% as very conservative. Overall, 72% and 58% of individuals reported receiving tetanus, diphtheria, and pertussis and influenza vaccinations, respectively. Of the 279 individuals who responded to the follow-up survey, 53% reported receiving COVID-19 vaccination. Individuals living in a community characterized by very conservative political affiliation were less likely to report vaccinations for tetanus, diphtheria, and pertussis (64% vs 72%; adjusted risk ratio, 0.83; 95% confidence interval, 0.69-0.99); influenza (49% vs 58%; adjusted risk ratio, 0.79; 95% confidence interval, 0.62-1.00); and COVID-19 (35% vs 53%; adjusted risk ratio, 0.65; 95% confidence interval, 0.44-0.96) than those in a community characterized by very liberal political affiliation. Individuals living in a community characterized by centrist political affiliation were less likely to report vaccinations for tetanus, diphtheria, and pertussis (63% vs 72%; adjusted risk ratio, 0.82; 95% confidence interval, 0.68-0.99) and influenza (44% vs 58%; adjusted risk ratio, 0.70; 95% confidence interval, 0.54-0.92) than those in a community characterized by very liberal political affiliation.

CONCLUSION

Compared with pregnant and postpartum individuals living in communities characterized by very liberal political beliefs, those living in communities characterized by very conservative political beliefs were less likely to report vaccinations for tetanus, diphtheria, and pertussis; influenza; and COVID-19, and those in communities characterized by centrist political beliefs were less likely to report vaccinations for tetanus, diphtheria, and pertussis and influenza. Increasing vaccine uptake in the peripartum period may need to consider engaging an individual's broader sociopolitical milieu.

Health Systems Determinants of Delivery and Uptake of Maternal Vaccines in Low- and Middle-Income Countries: A Qualitative Systematic Review

Maternal vaccination is considered a key component of the antenatal care package for improving maternal and child health. Low- and middle-income countries (LMICs) fall short of global targets to prevent maternal and neonatal deaths, with a disproportionate burden of vaccine-preventable diseases. Strategies towards ending preventable maternal mortality necessitate a health systems approach to adequately respond to this burden. This review explores the health systems determinants of delivery and uptake of essential maternal vaccines in LMICs. We conducted a qualitative systematic review of articles on maternal vaccination in LMICs, published between 2009 and 2023 in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Thematic analysis was conducted to identify key themes in the literature, interpreted within a conceptual framing that explores the systems determinants influencing maternal vaccines. Our search yielded 1309 records, of which 54 were included, covering 34 LMICs. Most of the included studies were from South America (28/54) and included pregnant women as the primary study population (34/54). The studies explored influenza (25/54) and tetanus toxoid (20/54) vaccines predominantly. The findings suggest that systems hardware (lack of clear policy guidelines, ineffective cold-chain management, limited reporting and monitoring systems) are barriers to vaccine delivery. Systems software (healthcare provider recommendations, increased trust, higher levels of maternal education) are enablers to maternal vaccine uptake. Findings show that formulation, dissemination and communication of context-specific policies and guidelines on maternal vaccines should be a priority for decision-makers in LMICs.

Characteristics and perceptions associated with COVID-19 vaccination hesitancy among pregnant and postpartum individuals: A cross-sectional study

OBJECTIVE

To assess the frequency and associated characteristics of COVID-19 vaccine hesitancy among pregnant and postpartum individuals.

DESIGN

Cross-sectional study.

SETTING

Prenatal care at a single academic tertiary care centre.

POPULATION

Pregnant and postpartum individuals enrolled in prenatal care at a single academic tertiary care centre from 22 March 2021 to 2 April 2021, concurrent with state guidelines recommending COVID-19 vaccination in pregnancy.

METHODS

We used logistic regression to identify characteristics associated with COVID-19 vaccine hesitancy, and adjusted for: age, parity, race, trimester of pregnancy, and chronic comorbidities.

MAIN OUTCOME MEASURES

COVID-19 vaccine hesitancy, defined as uncertainty or refusal of the vaccine, despite the availability of vaccine services, in accordance with the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) on vaccine hesitancy.

RESULTS

Of the 485 individuals screened and approached, 456 (94%) enrolled and completed the survey (435/456, 95% pregnant). The frequency of COVID-19 vaccine hesitancy was 46% (95% CI 41%-51%). Sociodemographic characteristics, including non-Hispanic Black race, younger age, lower education, public health insurance receipt, parity >1, and reported substance use, were associated with a higher odds of COVID-19 vaccine hesitancy, but not clinical risk conditions. Individuals who had a family or friend vaccinated for COVID-19, prior or planned vaccination for tetanus, diphtheria and acellular pertussis (Tdap) and/or influenza, and who perceived that vaccination benefited the baby were less likely to express COVID-19 vaccine hesitancy.

CONCLUSIONS

COVID-19 vaccine hesitancy was frequent among pregnant and postpartum individuals. Those who may face barriers to accessing healthcare services were more likely to report vaccine hesitancy. These results can inform interventions to increase COVID-19 vaccine uptake in pregnancy.

TWEETABLE ABSTRACT

COVID-19 vaccination hesitancy is frequent among pregnant and postpartum individuals, and those who face barriers to accessing healthcare services are more likely to report COVID-19 vaccine hesitancy.

Association of initial COVID-19 vaccine hesitancy with subsequent vaccination among pregnant and postpartum individuals

Objective

To examine the association between initial COVID‐19 vaccine hesitancy and subsequent vaccination among pregnant and postpartum individuals.

Design

Prospective cohort.

Setting

A Midwestern tertiary‐care academic medical center. Individuals completed a baseline vaccine hesitancy assessment from 22 March 2021 to 2 April 2021, with subsequent ascertainment of vaccination status at 3–6 months follow‐up.

Methods

We used multivariable Poisson regression to estimate the relative risk of vaccination by baseline vaccine hesitancy status, and then characteristics associated with vaccination.

Main outcome measures

Self‐report of COVID‐19 vaccination, and secondarily, consideration of COVID‐19 vaccination among those not vaccinated.

Results

Of 456 individuals (93% pregnant, 7% postpartum) initially surveyed, 290 individuals (64%; 23% pregnant, 77% postpartum) provided subsequent vaccination status (median = 17 weeks). Of these 290 individuals, 40% (116/290) reported COVID‐19 vaccine hesitancy upon enrolment, of whom 52% reported subsequent vaccination at follow‐up. Few individuals transitioned during the study period from vaccine hesitant to vaccinated (10%); in comparison, 80% of those who were not vaccine hesitant were vaccinated at follow‐up (aRR 0.19, 95% CI 0.11–0.33). Among those who remained unvaccinated at follow‐up, 38% who were vaccine hesitant at baseline were considering vaccination, compared with 71% who were not vaccine hesitant (aRR 0.48, 95% CI 0.33–0.67). Individuals who were older, parous, employed and of higher educational attainment were more likely to be vaccinated, and those who identified as non‐Hispanic black, were Medicaid beneficiaries, and were still pregnant at follow‐up were less likely to be vaccinated.

Conclusions

COVID‐19 vaccine hesitancy persisted over time in the peripartum period, and few individuals who reported hesitancy at baseline were later vaccinated. Interventions that address vaccine hesitancy in pregnancy are needed.

COVID‐19 vaccination hesitancy among pregnant and postpartum individuals persists over time, and few of the individuals who reported hesitancy were later vaccinated.

Association between social vulnerability and influenza and tetanus-diphtheria-acellular pertussis vaccination in pregnant and postpartum individuals

BACKGROUND

Despite current guidelines recommending universal vaccination, the frequency of vaccination in pregnancy for influenza and tetanus-diphtheria-acellular pertussis remains low.

OBJECTIVE

This study aimed to evaluate the association between community-level social vulnerability and influenza and anticipated tetanus-diphtheria-acellular pertussis vaccinations among pregnant and postpartum individuals.

STUDY DESIGN

We conducted a cross-sectional survey of vaccine hesitancy in the peripartum period among pregnant and postpartum participants enrolled in prenatal care at a single tertiary care center from March 22, 2021, to April 02, 2021. Participant addresses were geocoded using ArcGIS and linked at the census tract level. The primary exposure was community-level social vulnerability as measured by the US Centers for Disease Control and Prevention's Social Vulnerability Index. This index incorporates 15 census variables to produce a composite score and subscores across 4 major thematic domains (socioeconomic status, household composition and disability, minority status and language, and housing type and transportation). The scores range from 0 to 1, with higher values indicating greater social vulnerability. The primary outcomes were self-reported influenza vaccination during the current influenza season and having received or planning to receive the tetanus-diphtheria-acellular pertussis vaccination in pregnancy. We used multivariable logistic regression and adjusted for age, self-reported race and ethnicity, parity, trimester of pregnancy, and chronic comorbid conditions.

RESULTS

Of 456 assessed individuals (95% pregnant individuals and 5% postpartum individuals), the frequency of influenza vaccination was 58% (95% confidence interval, 53-62), and the anticipated tetanus-diphtheria-acellular pertussis vaccination was 72% (95% confidence interval, 68-76). Individuals from communities with a higher Social Vulnerability Index were less likely to report vaccination in pregnancy than those from communities with a lower Social Vulnerability Index. Specifically, for each 0.1-unit increase in the Social Vulnerability Index, the odds of influenza vaccination (adjusted odds ratio, 0.23; 95% confidence interval, 0.11-0.46) and anticipated tetanus-diphtheria-acellular pertussis vaccination (adjusted odds ratio, 0.24; 95% confidence interval, 0.11-0.53) decreased by >70%. By domain, the Social Vulnerability Index subscores of socioeconomic status (influenza adjusted odds ratio, 0.20 [95% confidence interval, 0.10-0.40]; tetanus-diphtheria-acellular pertussis adjusted odds ratio, 0.25 [95% confidence interval, 0.12-0.53]) and housing type and transportation (influenza adjusted odds ratio, 0.41 [95% confidence interval, 0.19-0.84; tetanus-diphtheria-acellular pertussis adjusted odds ratio, 0.39 [95% confidence interval, 0.18-0.87) were inversely associated with a lower odds of influenza and tetanus-diphtheria-acellular pertussis vaccinations.

CONCLUSION

Pregnant and postpartum individuals living in areas with higher social vulnerability were less likely to report influenza and anticipated tetanus-diphtheria-acellular pertussis vaccinations in pregnancy. The Social Vulnerability Index could be used as a tool to improve vaccine equity and address disparities in vaccination in pregnancy.

WHO global vaccine safety multi-country collaboration project on safety in pregnancy: Assessing the level of diagnostic certainty using standardized case definitions for perinatal and neonatal outcomes and maternal immunization

Standardized case definitions strengthen post-marketing safety surveillance of new vaccines by improving generated data, interpretation and comparability across surveillance systems. The Global Alignment of Immunization Safety Assessment in Pregnancy (GAIA) project developed standardized case definitions for 21 key obstetric and neonatal terms following the Brighton Collaboration (BC) methodology. In this prospective cohort study, we assessed the applicability of GAIA definitions for maternal immunization exposure and for low birth weight (LBW), preterm birth, small for gestational age (SGA), stillbirth, neonatal death, neonatal infection, and congenital microcephaly. We identified the missing data elements that prevented identified cases and exposures from meeting the case definition (level 1-3 of BC diagnostic certainty). Over a one-year period (2019-2020), all births occurring in 21 sites (mostly secondary and tertiary hospitals) in 6 Low Middle Income Countries and 1 High Income Country were recorded and the 7 perinatal and neonatal outcome cases were identified from routine medical records. Up to 100 cases per outcome were recruited sequentially from each site. Most cases recruited for LBW, preterm birth and neonatal death met the GAIA case definitions. Birth weight, a key parameter for all three outcomes, was routinely recorded at all sites. The definitions for SGA, stillbirth, neonatal infection (particularly meningitis and respiratory infection) and congenital microcephaly were found to be less applicable. The main barrier to obtaining higher levels of diagnostic certainty was the lack of sonographic documentation of gestational age in first or second trimester. The definition for maternal immunization exposure was applicable, however, the highest level of diagnostic certainty was only reached at two sites. Improved documentation of maternal immunization will be important for vaccine safety studies. Following the field-testing of these 8 GAIA definitions, several improvements are suggested that may lead to their easier implementation, increased standardization and hence comparison across studies.

Is the Immunization of Pregnant Women against COVID-19 Justified?

Maternal immunization against some infectious diseases can offer significant advantages for women, preventing maternal morbidity and mortality, or for offspring, preventing fetal disease and conferring passive immunity to neonates. Recently, clinical trials specifically to evaluate the immunogenicity, safety, and tolerability of some of the available coronavirus disease 2019 (COVID-19) vaccines in pregnant and lactating women have been planned, initiated and, in some cases, completed. This paper discusses whether the immunization of pregnant women against COVID-19 is justified and presents knowledge about the immunogenicity and safety of mRNA COVID-19 vaccines for these subjects. The results of recent studies indicate that pregnant women are at increased risk of developing severe disease compared with nonpregnant women of the same age. Studies carried out with mRNA vaccines indicate that the immunogenicity, safety and tolerability of these preventive measures in pregnant women are not different from those in nonpregnant women of the same age. Moreover, antibodies are efficiently transferred through the placenta and can be detected in breastmilk, suggesting a potential prevention of infection in the child. All these findings authorize the use of mRNA vaccines in pregnant women to protect both the mother and the child. However, further studies with larger sample size and with follow-up of the pregnant women vaccinated during different periods of pregnancy and their children are needed to better characterize the immune response of pregnant women, to define when these vaccines should be administered to obtain the best protection, and to measure vaccine efficacy against virus variants in both mothers and infants. COVID-19 vaccines based on different technological platforms cannot presently be used, and their role in pregnant women should be clarified.

Protective vaccinations during pregnancy - adult Poles knowledge in this area

BACKGROUND

The vaccine is a preparation of biological origin containing antigens that stimulate the body's immune system to produce acquired immunity. Vaccines can contain killed or "live" (attenuated) microorganisms as well as fragments of these (antigens). Although many vaccines are used routinely in pregnancy to provide a seroprotective immune response for mother, fetus and neonate there is much controversy over their use during this unique time. The aim of the study was to find out about the knowledge of adult Poles on the use of preventive vaccinations during pregnancy.

METHODS

The study involved 700 people (100%) aged 18 to 80 years ([Formula: see text] = 32.16 ± 16.46). Most of the respondents were women (511; 73%). The study consisted of 9 questions about preventive vaccinations of pregnant women and 5 questions about members of the studied group. The aforementioned questions formed the basis of the preparation of the presented article.

RESULTS

A significant part of respondents (322; 46%) did not have knowledge on the topic of safeness of using preventive vaccinations during pregnancy, 196 (28%) respondents believed that such procedure is not safe. Most of the respondents (371; 53%) did not know about the possibility of using "live" vaccines during pregnancy. 14 (2%) of respondents believed that pregnancy should be terminated in case of administration of a "live" vaccine to a pregnant woman. According to 294 (42%) respondents, vaccinations with "live" vaccines should be completed at least 3 months before the planned pregnancy. The subjects were not aware of the issue of post-exposure vaccination against tetanus and rabies among pregnant women. The respondents' responses were divided on the issue of the safest trimester of pregnancy for vaccine administration. Almost 1/3 of the respondents (203; 29%) indicated the third trimester as the safest for their performance.

CONCLUSION

The knowledge of the surveyed group, the majority of whom were women, about the use of vaccinations before and during pregnancy was unsatisfactory. There is a need to educate the public about the benefits and risks of performing or avoiding preventive vaccinations during pregnancy.

Pregnant women & vaccines against emerging epidemic threats: Ethics guidance for preparedness, research, and response

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.

The Protective Role of Maternal Immunization in Early Life

With birth, the newborn is transferred from a quasi-sterile environment to the outside world. At this time, the neonatal immune system is inexperienced and continuously subject to a process of development as it encounters different antigenic stimuli after birth. It is initially characterized by a bias toward T helper 2 phenotype, reduced T helper 1, and cytotoxic responses to microbial stimuli, low levels of memory, and effector T and B cells and a high production of suppressive T regulatory cells. The aim of this setting, during fetal life, is to maintain an anti-inflammatory state and immune-tolerance. Maternal antibodies are transferred during pregnancy through the placenta and, in the first weeks of life of the newborn, they represent a powerful tool for protection. Thus, optimization of vaccination in pregnancy represents an important strategy to reduce the burden of neonatal infections and sepsis. Beneficial effects of maternal immunization are universally recognized, although the optimal timing of vaccination in pregnancy remains to be defined. Interestingly, the dynamic exchange that takes place at the fetal-maternal interface allows the transfer not only of antibodies, but also of maternal antigen presenting cells, probably in order to stimulate the developing fetal immune system in a harmless way. There are still controversial effects related to maternal immunization including the so called "immunology blunting," i.e., a dampened antibody production following infant's vaccination in those infants who received placentally transferred maternal immunity. However, clinical relevance of this phenomenon is still not clear. This review will provide an overview of the evolution of the immune system in early life and discuss the benefits of maternal vaccination. Current maternal vaccination policies and their rationale will be summarized on the road to promising approaches to enhance immunity in the neonate.

Pregnant women's perceptions of risks and benefits when considering participation in vaccine trials

INTRODUCTION

Despite historical exclusion, there has been recent recognition of the need to address the health of pregnant women in research on vaccines against emerging pathogens. However, pregnant women's views and decision-making processes about vaccine research participation during infectious disease outbreaks remain underexplored. This study aims to examine women's decision-making processes around vaccine research participation during infectious disease outbreaks.

METHODS

We conducted qualitative semi-structured in-depth interviews with pregnant and recently pregnant women (n = 13), eliciting their views on four hypothetical Zika Virus vaccine research scenarios and probing their decision-making processes around participation. After recorded interviews were transcribed, thematic analysis was conducted based on a priori and emergent themes.

RESULTS

Most women interviewed were accepting of vaccine research scenarios. Three broad themes-evidence, risk, and trust-characterized women's decision-making processes. Women varied in how different types and levels of evidence impacted their considerations, which risks were most salient to their decision-making processes, and from whom they trusted recommendations about vaccine research participation. Exemplary quotes from each theme are presented, and lessons for vaccine development during the current COVID-19 pandemic and future outbreaks are discussed.

CONCLUSION

Some pregnant women are accepting of participation in vaccine research during infectious disease outbreaks. Incorporating their priorities into trial design may facilitate their participation and generation of evidence for this important population.

Preparing to introduce new maternal immunizations in low- and lower-middle-income countries: A report from the Bill & Melinda Gates Foundation convening "Allies in Maternal and Newborn Care"; May 3-4, 2018

New strategies will be critical to reduce infant mortality and severe morbidity - there are still 5.2 million newborn deaths and stillbirths each year. The decline in newborn mortality has not kept pace with the reduction in under-five deaths and is slowest in low- and lower-middle-income countries (LMICs). Maternal immunization is a promising intervention to protect infants when they are most vulnerable - in utero and their first few months of life, before they can receive their own vaccines. Successfully introducing new vaccines for pregnant women in LMICs will require collaboration between two fields - (1) immunization and (2) maternal, newborn and child health - that use different service delivery approaches, operate under different policy and funding paradigms, and are not always integrated. In May 2018, stakeholders from these distinct communities convened to identify challenges and opportunities associated with delivering new maternal immunizations. Participants agreed that antenatal care is a logical platform. However, in many resource-constrained settings, antenatal care providers are already overburdened, and most women do not receive the recommended number of antenatal visits. Implementing maternal immunization could help increase antenatal care attendance by offering an additional safe and effective intervention that women value. Substantial effort is needed to demonstrate the benefits of maternal immunization to decision-makers and providers, and to ensure that countries and health systems are ready for introduction. To that end, participants identified the following priorities: assure coherence of policies for introducing new vaccines for pregnant women and strengthen maternal health interventions; generate demand for existing, recommended, and new maternal vaccines; conduct socio-behavioral, health systems and implementation research to shape optimal vaccine delivery strategies; and strengthen antenatal and perinatal care quality. To achieve these aims, collaboration across fields will be essential. Given that new maternal vaccines are advancing in clinical development, time is of the essence.

BCG Vaccination at Birth and Rate of Hospitalization for Infection Until 15 Months of Age in Danish Children: A Randomized Clinical Multicenter Trial

BACKGROUND

The bacillus Calmette-Guérin (BCG) vaccine against tuberculosis might reduce the non-tuberculosis-related child mortality rate in low-income settings. We tested the hypothesis that BCG vaccination at birth would reduce early childhood hospitalization for infection in Denmark, a high-income setting. Hospitalization for infection was a secondary outcome in a randomized trial with the primary aim to estimate the potential non-specific effects of BCG vaccination at birth on all-cause hospitalization.

METHODS

A total of 4262 children included in the Danish Calmette Study were assigned randomly to either receive the BCG vaccine or not and were followed through the Danish National Patient Register. The outcome was number of hospitalizations for infection until the age of 15 months. Data were analyzed by Cox regression in intention-to-treat (ITT) and per-protocol (PP) analyses.

RESULTS

In the ITT analysis, we observed 588 hospitalizations for infection (mean, 0.28 hospitalization per child) among the 2129 children allocated to receive the BCG vaccine and 595 hospitalizations for infection (mean, 0.28 hospitalization per child) among the 2133 children allocated to the control group (hazard ratio [HR], 0.99 [95% confidence interval (CI), 0.85-1.15]). The PP analysis yielded an HR of 1.00 (95% CI, 0.86-1.16).Predefined interaction ITT analyses showed that among 740 children with a BCG-vaccinated mother, the HR for BCG-vaccinated children was 0.65 (95% CI, 0.45-0.94); the HR for children who had a non-BCG-vaccinated mother was 1.10 (95% CI, 0.93-1.29) (P = .01, test of no interaction). Cesarean delivery modified the effect of BCG vaccination (HRs, 0.73 [95% CI, 0.54-0.99] in children born by cesarean section vs 1.10 [95% CI, 0.92-1.30] in other children; P = .02). When the outcome was defined as time to first hospitalization, the HR for premature children after BCG vaccination was 1.81 (95% CI, 0.95-3.43), whereas the HR was 0.94 (95% CI, 0.82-1.08) for children born at term (P = .05).

CONCLUSION

BCG vaccination did not affect the rate of hospitalization for infection up to the age of 15 months in Danish children. In future studies, the role of maternal BCG-vaccination, premature birth, and cesarean delivery needs further exploration.

Enhancing uptake of influenza maternal vaccine

INTRODUCTION

Influenza vaccination during pregnancy can offer many benefits to both mother and infant. Despite recommendations from the Advisory Committee on Immunization Practices, vaccine coverage rates among pregnant women during pregnancy are below 40% in the United States. There is a need for a greater understanding of what interventions can improve vaccine uptake among pregnant women.

AREAS COVERED

This review synthesizes the existing evidence on the effectiveness of interventions to improve maternal influenza vaccine uptake. These interventions are examined within the framework of the three psychological propositions: thoughts and feelings, social processes and changing behavior directly.

EXPERT COMMENTARY

A number of promising and effective interventions were identified in this review. Nudge-based interventions that build on favorable intentions to vaccinate such as provider prompts and standing orders have demonstrated significant success in improving influenza vaccine uptake. However, substantial gaps in the literature still exist. Provider recommendations are the most important predictor of vaccine receipt among pregnant women, yet few studies evaluated intervening to improve the dialogue between patient and provider. With the potential for even more vaccines to be added to the maternal immunization schedule, it is vitally important to understand how to improve uptake.

Maternal immunisation to improve the health of HIV-exposed infants

HIV-exposed but uninfected (HEU) infants are at an increased risk of many infectious diseases that can contribute to the high mortality seen among HEU children. Maternal immunisation could be a promising strategy to reduce infections in HEU infants. However, very little research has explored the effect of HIV on the immunogenicity and effectiveness of vaccines given during pregnancy. We review the available evidence on maternal immunisation among women living with HIV (WLWH) for all vaccines recommended, considered, or being investigated for routine or risk-based use during pregnancy. Of the 11 vaccines included, only three have been investigated in WLWH. Available evidence suggests that maternal HIV infection limits the immunogenicity of several vaccines, leaving HEU infants more susceptible to infection during their first few months of life. Whether maternal immunisation reduces the infectious morbidity and mortality associated with infectious diseases in HEU children remains unknown. We conclude the Review by identifying future research priorities.

RSV prophylaxis in premature infants

Infants born prematurely before 37 weeks of gestational age (GA) have particular anatomical, immunological and metabolic characteristics that predispose them, even in the absence of diseases at birth, to severe morbidity. Respiratory syncytial virus (RSV) is the leading cause of hospitalization for lower respiratory tract infections (LRTI) in the first year of life, as well as an important cause of respiratory outcomes as recurrent wheezing in industrialized countries or mortality in developing countries. Prematurity is an important risk factor for hospitalization for severe RSV disease, but epidemiological, environmental and demographic risk factors also play a role in RSV infection. Currently, there is no effective antiviral therapy for the treatment of RSV infection, nor the possibility of using maternal immunization or vaccination of children to prevent infection, although numerous preclinical and clinical studies are still ongoing. Passive immunization with palivizumab has been shown to be safe and effective in preventing RSV hospitalization in children at greater risk of contracting a serious infection. Costs associated with palivizumab prophylaxis and its monthly intramuscularly administration has prompted many health institutions of different countries to implement specific recommendations, with the aim of protecting at risk infants for whom RSV infection is likely to cause serious illness or death. The cost-effectiveness ratio of prophylaxis, related to reduce hospitalization costs and the impact of the burden of RSV disease worldwide, greatly affects the drafting and the adoption of specific recommendations and the adherence to them, concerning the passive immunization with palivizumab.

Infections in Pregnancy and the Role of Vaccines

Pregnant women are at risk for infection and may have significant morbidity or mortality. Influenza, pertussis, zika, and cytomegalovirus produce mild or asymptomatic illness in the mother, but have profound implications for her fetus. Maternal immunization can prevent or mitigate infections in pregnant women and their infants. The Advisory Committee of Immunization Practices recommends 2 vaccines during pregnancy: inactivated influenza, and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis during pregnancy. The benefits of MMR, varicella, and other vaccines are reviewed. Novel vaccine studies for use during pregnancy for prevention of illness are explored.

Practice and attitudes towards immunization among Lebanese obstetricians and gynecologists

We designed our study to evaluate the knowledge and immunization practices among Lebanese obstetricians and gynecologists (OBGYN) for women of different age groups. Anonymous questionnaires were used to assess the knowledge and immunization practices among OBGYN. The survey was conducted at the annual meeting of the Lebanese Society of Obstetrics and Gynecology on November 13-15, 2014. Data collected included demographics, type of practice, academic background and familiarity with vaccine guidelines. Descriptive statistical methods were used to evaluate the responses. The response rate was 54.8% (114/208). Only 62.3% (71/114) recommend vaccination(s) to pregnant women with only 25.9% of those who recommend the Tdap vaccine for pregnant women giving it during the recommended third trimester. In addition, 52.6% are unaware of the CDC/ACIP immunization schedule for women in general. However, 83.0% (93/112) of respondents are willing to integrate vaccination in their practice. Our study highlights several gaps in the knowledge of Lebanese OBGYN regarding vaccination in addition to practices that are not in full accordance with common guidelines. Measures should be taken to spread proper awareness of the proper guidelines among Lebanese practitioners.

Assessing the Evidence for Maternal Pertussis Immunization: A Report From the Bill & Melinda Gates Foundation Symposium on Pertussis Infant Disease Burden in Low- and Lower-Middle-Income Countries

Implementation of effective interventions has halved maternal and child mortality over the past 2 decades, but less progress has been made in reducing neonatal mortality. Almost 45% of under-5 global mortality now occurs in infants <1 month of age, with approximately 86% of neonatal deaths occurring in low- and lower-middle-income countries (LMICs). As an estimated 23% of neonatal deaths globally are due to infectious causes, maternal immunization (MI) is one intervention that may reduce mortality in the first few months of life, when direct protection often relies on passively transmitted maternal antibodies. Despite all countries including pertussis-containing vaccines in their routine childhood immunization schedules, supported through the Expanded Programme on Immunization, pertussis continues to circulate globally. Although based on limited robust epidemiologic data, current estimates derived from modeling implicate pertussis in 1% of under-5 mortality, with infants too young to be vaccinated at highest risk of death. Pertussis MI programs have proven effective in reducing infant pertussis mortality in high-income countries using tetanus-diphtheria-acellular pertussis (Tdap) vaccines in their maternal and infant programs; however, these vaccines are cost-prohibitive for routine use in LMICs. The reach of antenatal care programs to deliver maternal pertussis vaccines, particularly with respect to infants at greatest risk of pertussis, needs to be further evaluated. Recognizing that decisions on the potential impact of pertussis MI in LMICs need, as a first step, robust contemporary mortality data for early infant pertussis, a symposium of global key experts was held. The symposium reviewed current evidence and identified knowledge gaps with respect to the infant pertussis disease burden in LMICs, and discussed proposed strategies to assess the potential impact of pertussis MI.

Fundamentals of Clinical Pharmacology With Application for Pregnant Women

Medication use is common in pregnancy, yet for most medications the optimal formulation and dosage have not been described specifically for pregnant women. Often, adverse effects are only discovered anecdotally or after extensive off-label use occurs. Since pharmacologic research that includes pregnant women is sparse and animal studies are often not applicable to the human fetus, providers must use knowledge of drug behavior and normal physiologic changes of pregnancy to personalize treatment for pregnant women. In this review, we present an overview of the basic concepts of clinical pharmacology: pharmacokinetics, pharmacodynamics, and pharmacogenomics. The normal physiologic changes of pregnancy are presented as a framework to understand alterations in drug behavior. A clinical vignette that addresses 4 pregnancy scenarios involving medications-preterm birth, vaccination, herpes simplex virus infection, and codeine toxicity-is provided to illustrate application of core clinical pharmacologic concepts. Discussion of relevant literature illustrates the challenges of offering individualized pharmacologic therapy in pregnancy.

Strategies To Boost Maternal Immunization To Achieve Further Gains In Improved Maternal And Newborn Health

Despite the indisputable successes of the United Nations Millennium Development Goals, which include goals on improving maternal health and reducing child mortality, millions of mothers and newborns still die tragically and unnecessarily each year. Many of these deaths result from vaccine-preventable diseases, since obstacles such as cost and accessibility have hampered efforts to deliver efficacious vaccines to those most in need. Additionally, many vaccines given to mothers and children under age five are not suitable for newborns, since their maturing immune systems do not respond optimally during the first few months of life. Maternal immunization-the process by which a pregnant woman's immune system is fortified against a particular disease and the protection is then transferred to her unborn child-has emerged as a strategy to prevent many unnecessary maternal and newborn deaths. We review vaccines that are already used for maternal immunization, analyze vaccines under development that could be used for maternal immunization strategies in the future, and recommend that policy makers use maternal immunization for improved maternal and newborn health.

Nurses Improve Their Communities' Health Where They Live, Learn, Work, and Play

Nurses are often recognized for their volunteer efforts following disasters and international humanitarian crises. However, little attention is paid to the activities of nurses who promote a culture of health in their communities through local volunteer work. In this article, we describe nurses' perceptions of how they promote health in their communities through formal and informal volunteer work. Using 315 written responses to an open-ended question included in a 2016 survey of the career patterns of nurses in the U.S., we utilized conventional content analysis methods to code and thematically synthesize responses. Two broad categories of nurse involvement in volunteer activities arose from the participants' responses to the open-ended question, "Please tell us what you have done in the past year to improve the health of your community": 17% identified job-related activities, and 74% identified non-job-related activities. 9% of respondents indicated they do not participate in volunteer work. Job-related activities included patient education, educating colleagues, and "other" job-related activities. Non-job-related activities included health-related community volunteering, volunteering related to a specific population or disease, family-related volunteering, church activities, health fairs, raising or donating money, and travelling abroad for volunteer work. Nurses are committed to promoting a culture of health in their communities both at work and in their daily lives. Leveraging nurses' interest in volunteer work could improve the way nurses engage with their communities, expand the role of nurses as public health professionals, and foster the social desirability of healthful living.

Vaccination of special populations: Protecting the vulnerable

One of the strategic objectives of the 2011-2020 Global Vaccine Action Plan is for the benefits of immunisation to be equitably extended to all people. This approach encompasses special groups at increased risk of vaccine-preventable diseases, such as preterm infants and pregnant women, as well as those with chronic and immune-compromising medical conditions or at increased risk of disease due to immunosenescence. Despite demonstrations of effectiveness and safety, vaccine uptake in these special groups is frequently lower than expected, even in developed countries with vaccination strategies in place. For example, uptake of the influenza vaccine in pregnancy rarely exceeds 50% in developed countries and, although data are scarce, it appears that only half of preterm infants are up-to-date with routine paediatric vaccinations. Many people with chronic medical conditions or who are immunocompromised due to disease or aging are also under-vaccinated. In the US, coverage among people aged 65years or older was 67% for the influenza vaccine in the 2014-2015 season and 55-60% for tetanus and pneumococcal vaccines in 2013, while the coverage rate for herpes zoster vaccination among those aged 60years or older was only 24%. In most other countries, rates are far lower. Reasons for under-vaccination of special groups include fear of adverse outcomes or illness caused by the vaccine, the inconvenience (and in some settings, cost) of vaccination and lack of awareness of the need for vaccination or national recommendations. There is also evidence that healthcare providers' attitudes towards vaccination are among the most important influences on the decision to vaccinate. It is clear that physicians' adherence to recommendations needs to be improved, particularly where patients receive care from multiple subspecialists and receive little or no care from primary care providers.

Occupational Health Update: Focus on Preventing the Acquisition of Infections with Pre-exposure Prophylaxis and Postexposure Prophylaxis

Health care personnel are commonly exposed to infectious agents via sharp injuries (eg, human immunodeficiency virus, hepatitis B virus, and hepatitis C virus), direct patient care (eg, pertussis and meningococcus), and the contaminated environment (eg, Clostridium difficile). An effective occupational program is a key aspect of preventing acquisition of an infection by offering the following: (1) education of health care personnel regarding proper handling of sharps, early identification and isolation of potentially infectious patients, and hand hygiene; (2) assuring immunity to vaccine-preventable diseases; and, (3) immediate availability of a medical evaluation after a nonprotected exposure to an infectious disease.