Provider insight on surmounting specialty practice challenges to improve Tdap immunization rates among pregnant women

Trends and characteristics of Tdap vaccination during pregnancy in Ontario, Canada: a retrospective cohort study

BACKGROUND

In February 2018, Canada's National Advisory Committee on Immunization (NACI) recommended tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccination during pregnancy to protect newborns against pertussis infection. We sought to describe pre- and postrecommendation trends in Tdap vaccination coverage among pregnant Ontario residents.

METHODS

Using linked health administrative databases, we conducted a population-based retrospective cohort study of all pregnant individuals who gave birth in Ontario hospitals between April 2012 and March 2020. We described Tdap vaccination patterns in pregnancy for the entire study period and before and after the NACI recommendation. We used log-binomial regression to identify characteristics associated with Tdap vaccination during pregnancy.

RESULTS

Among the 991 850 deliveries included, 7.0% of pregnant individuals received the Tdap vaccination during pregnancy. Vaccine coverage increased from 0.4% in 2011/12 to 29.2% in 2019/20. Coverage was highest among individuals who were older, had no previous live births, had adequate prenatal care and received maternity care primarily from a family physician. After adjustment, characteristics associated with lower coverage included younger maternal age, having a multiple birth, residing in a rural location and higher area material deprivation. In 2019/20, 71.0% of vaccinated individuals received the Tdap vaccination during the recommended gestational window (27-32 wk). Stratified analyses of the pre- and postrecommendation cohorts yielded similar findings to the main analyses with a few gradient differences after adjustment.

INTERPRETATION

During pregnancy, Tdap vaccination coverage increased substantially in Ontario between 2011/12 and 2019/20, most notably after recommendations for universal Tdap vaccination during pregnancy began in Canada. To further improve vaccine coverage in the obstetric setting, public health strategies should consider tailoring their programs to reach subpopulations with lower vaccine coverage.

Vaccination in pregnancy against pertussis and seasonal influenza: key learnings and components from high-performing vaccine programmes in three countries: the United Kingdom, the United States and Spain

BACKGROUND

Pertussis and seasonal influenza are responsible for significant maternal, neonatal, and infant morbidity and mortality, but vaccine coverage rates (VCR) for both pertussis (administered as a tetanus, diphtheria, acellular pertussis [Tdap] vaccination) and seasonal influenza in pregnancy remain generally low. Only a small number of countries, including Spain, the United Kingdom (UK), and the United States (US), have high Tdap and seasonal influenza VCRs in pregnancy. The purpose of this study was to identify the key factors that contributed to the high VCRs observed in these countries.

METHODS

The experience from both Tdap and seasonal influenza vaccination programmes during pregnancy were documented in Spain, the UK, and the US using a three-step approach. A literature review yielded 157 publications, and a further 117 documents were selected through desk research. A published five-pillar VCR framework for influenza was amended to evaluate the specific contributing factors leading to high Tdap and seasonal influenza VCRs among pregnant women.

RESULTS

The analysis identified components that contributed to higher VCR in pregnant women across three different healthcare systems in Spain, UK, and US. The combination of several key interventions in each country led to a rapid increase in VCR that reached near-optimal levels (i.e. 75% for seasonal influenza) within a few years. As well as inclusion in national immunisation programme and vaccine reimbursement, key components that were identified included the mobilisation of health authorities, prenatal care Healthcare Professionals (HCP) and scientific societies, the inclusion of vaccination in antenatal medical guidance, the provision of educational material to HCPs, and a strong disease awareness driven by recent pertussis outbreaks in each country.

CONCLUSIONS

Although there is no simple, universal solution to improving sub-optimal VCRs, the list of components identified in this study from three countries with high-performing Tdap and seasonal influenza vaccination programmes provides a basis for public health and medical stakeholders in other countries to define strategies to successfully implement national vaccination programmes for pregnant women.

Determinants of policy and uptake of national vaccine programs for pregnant women: results of mixed method study from Spain, Italy, and India

An important strategy for addressing maternal and newborn risks of disease is through vaccinating pregnant women. We conducted a mixed-methods study including a narrative literature review of drivers of maternal vaccination and key informant interviews in Spain, Italy, and India to characterize different approaches to national maternal immunization programs. Fifty-nine respondents participated in the study conducted between November 2018 and January 2019. Policies in Spain and Italy both reflect a life-course approach to vaccination, but recommendations and how they ensure uptake differs. Italy was focused on tracking of progress and mandates to ensure compliance in all regions, while Spain, an early adopter, relied more on advocacy and building provider acceptance. India includes Td in their national program, but the political will and advocacy for other vaccines are not seen. Needs for improving rates of maternal vaccination include education of health-care providers and pregnant women, use of central registries to track progress, stronger global guidance for use of vaccines, and engagement of champions, particularly obstetrician-gynecologists (ob-gyns). Health security concerns can also be leveraged to build political priority and needed platforms to detect disease and deliver vaccines in some countries. Understanding what drives a country’s maternal immunization program decisions and the success of implementation is useful in designing strategies to share best practices and guide support to strengthen platforms for maternal vaccination.

Safety of Maternal Immunization Against Pertussis: A Systematic Review

The WHO recommends vaccination of all children against pertussis. However, newborn infants remain vulnerable to infection. Pertussis vaccination during pregnancy has been introduced in several countries to protect newborns via transplacental transfer of maternal pertussis antibodies to the infant. We reviewed the impact of maternal pertussis vaccination on the health of pregnant women, the developing fetus, and health of the newborn. We searched PubMed/MEDLINE, EMBASE, Scopus (Elsevier), Cochrane Database of Systematic Reviews, ProQuest, and Science Direct to identify studies that assessed the safety of maternal pertussis vaccination. Twenty-seven English language publications published between January 1995 and December 2018 were included in this review. Pregnant women receiving pertussis vaccines did not have increased rates of systemic or local reactions. There were no safety concerns with repeat vaccination with other tetanus-containing vaccines or their concomitant administration with influenza vaccines. Maternal pertussis vaccination did not adversely affect pregnancy, birth or neonatal outcomes. This review confirms the safety of maternal pertussis vaccination during pregnancy. FUNDING: Sanofi Pasteur. Plain language summary available for this article.

Embedding the delivery of antenatal vaccination within routine antenatal care: a key opportunity to improve uptake

Improving the uptake of vaccination in pregnancy has been highlighted as a priority by the World Health Organisation, yet establishing the optimal location for delivery of the antenatal vaccination program remains a topic of debate internationally. In many countries, antenatal vaccines are usually delivered within Primary Care (under the lead of general practitioners [GPs] or family physicians), yet this often presents a logistic barrier to accessing vaccination, and increasing evidence demonstrates that embedding vaccination within routine antenatal care visits may significantly improve uptake. In this commentary, we discuss recent evidence to support this approach, including anonymous feedback from patients and staff at our own institution, in which a dedicated midwife-led vaccine clinic has recently been set up. Furthermore, we highlight a number of individual and institution-level barriers which would need addressing before this approach can be routinely adopted, and suggest targets for future education and research.