Influenza and pertussis vaccination in pregnancy: Portrayal in online media articles and perceptions of pregnant women and healthcare professionals

"Figuring stuff out myself" - a qualitative study on maternal vaccination in socially and ethnically diverse areas in England

BACKGROUND

Maternal vaccinations against Influenza, Pertussis, and Covid-19 are recommended in the UK, and vaccines against further infections may become available soon. However, many pregnant women, especially in socially and ethnically diverse areas, have low vaccine uptake. Qualitative studies on the reasons and possible solutions are needed that are inclusive of disadvantaged and minority ethnic groups. We therefore aimed to understand the complex interplay between structural and behavioural factors contributing to the low maternal vaccine uptake in socially and ethnically diverse areas in London in the Covid-19 context.

METHODS

In 2022, we conducted semi-structured interviews and a focus group discussion among a purposive sample of 38 pregnant/recently pregnant women and 20 health service providers, including 12 midwives. Participants were recruited in ethnically diverse London boroughs. We followed a critical realist paradigm and used a thematic analysis approach.

RESULTS

The sample included participants who took all, some or none of the maternal vaccines, with some participants unsure whether they had taken or been offered the vaccines. Decision-making was passive or active, with the expectation for pregnant women to do their 'own research'. Participants described various individual, social and contextual influences on their decision-making as they navigated the antenatal care system. Missing or conflicting information from providers meant knowledge gaps were sometimes filled with misinformation from unreliable sources that increased uncertainties and mistrust. Both pregnant women and providers described structural and organisational factors that hindered access to information and vaccinations, including lack of training, time and resources, and shortcomings of health information systems and apps. Some participants described factors that facilitated vaccination uptake and many made recommendations for improvements.

CONCLUSIONS

Our study showed how structural and organisational factors can compound uncertainties around maternal vaccination among socially and ethnically diverse populations. Results highlight the need for more reliable resources, streamlined workflows, improved electronic information systems and training in their use. Roles and responsibilities should be clarified with potential greater involvement of nurses and pharmacists in vaccine provision. Education and communication should consider individual (language/digital) skills and needs for information and reassurance. Further research is needed to co-produce solutions with service users and providers.

COVID-19 vaccine acceptance among pregnant women: a hospital-based cross-sectional study in Sudan

Introduction

Pregnancy increases the risk of developing a severe illness due to COVID-19 infection. To the best of our knowledge, no previous study has been conducted on COVID-19 vaccine acceptance among pregnant women in Sudan. Hence, this study aimed to determine COVID-19 vaccination acceptance and its predictors among pregnant women.

Methods

A cross-sectional study was conducted among 623 pregnant women attending Gadarif maternity hospital in eastern Sudan through a structured questionnaire. Data were obtained on sociodemographic characteristics, obstetric and health-related characteristics, COVID-19 infection, and vaccination-related information, as well as beliefs about and acceptance of COVID-19 vaccination.

Results

COVID-19 vaccine acceptance among the pregnant women was 2.7%. The vaccine acceptance was higher if their husband's education was secondary school or higher [adjusted odds ratio [AOR] 4.30, 95% confidence interval (CI) 1.11-16.65, p = 0.035] and discussion of COVID-19 vaccine with the pregnant women by a health care professional in the hospital (AOR 5.46, 95% CI 1.94-15.35, p < 0.001). The most common reasons for resistance to the vaccine were concerns about the side effects of the vaccine for the mother and her baby.

Conclusion

Acceptance of the COVID-19 vaccination among the pregnant women was very low. Discussions with pregnant women and their husbands by health care professionals regarding the safety of COVID-19 vaccine for the mother and her baby are highly recommended.

Acceptance of recommended vaccinations during pregnancy: a cross-sectional study in Southern Italy

Background

Vaccine administration is a recommended, safe, and effective measure to protect pregnant women against vaccine-preventable diseases (VPDs). Despite available guidance, maternal immunization rates for vaccination against influenza and with the reduced antigen content tetanus-diphtheria-acellular pertussis vaccine (Tdap) in Italy remain incredibly low. The primary goal of the study was to explore what Italian pregnant women knew about VPDs and immunization during pregnancy and what factors affected their decision to be vaccinated.

Methods

This cross-sectional study took place between October 2021 and April 2022 in the Southern part of Italy. All consecutive pregnant women, from those attending the selected facilities on randomly selected days, were approached to request participation. The inclusion criteria for participation were age ≥18 years, the ability to understand, speak, and read Italian, and being pregnant at any gestational age. The questionnaire, using a combination of checkboxes and free text answers, consisted of 32 items divided into five parts and lasted ~10 min.

Results

The results showed that 61% knew that the influenza vaccine is recommended and 48.7% knew that influenza could be risky during pregnancy; 74.1% wrongly reported that the Measles-Mumps-Rubella (MMR) vaccine is recommended during pregnancy. Seven out of 10 pregnant women believed that strong evidence supported the safety of vaccinations during pregnancy, and more than half (55.6%) thought they were at increased risk of severe illness with COVID-19. Women in the sample believed that vaccines received during pregnancy pose a risk of adverse events to the unborn child with a median value of 6 (IQR 3-9), on a scale ranging from 1 to 10. Similarly, the fear of contracting pertussis and influenza during pregnancy showed a median value of 6 (IQR 3-9) and 5 (IQR 3-8), respectively. Only 21.1% and 36.5% of women received influenza and Tdap vaccines during pregnancy.

Conclusion

Unrealistic risk perception with a negative attitude toward vaccines in pregnancy and a low percentage of vaccinated pregnant women confirm the urgency of training women to make informed choices to increase overall vaccine uptake.

Characteristics associated with influenza vaccination uptake in pregnancy: a retrospective cohort study

BACKGROUND

Pregnant women are at increased risk from influenza, yet maternal influenza vaccination levels remain suboptimal.

AIM

To estimate associations between sociodemographic and health characteristics and seasonal influenza vaccination uptake among pregnant women, and to understand trends over time to inform interventions to improve vaccine coverage.

DESIGN AND SETTING

Retrospective cohort study using linked electronic health records of women in North West London with a pregnancy overlapping an influenza season between September 2010 and February 2020.

METHOD

A multivariable mixed-effects logistic regression model was used to identify associations between characteristics of interest and the primary outcome of influenza vaccination.

RESULTS

In total, 451 954 pregnancies, among 260 744 women, were included. In 85 376 (18.9%) pregnancies women were vaccinated against seasonal influenza. Uptake increased from 8.4% in 2010/11 to 26.4% in 2017/18, dropping again to 21.1% in 2019/20. Uptake was lowest among women aged 15-19 years (11.9%; reference category) or ≥40 years (15.2%; odds ratio [OR] 1.17, 95% confidence interval [CI] = 1.10 to 1.24); of Black (14.1%; OR 0.55, 95% CI = 0.53 to 0.57) or unknown ethnicity (9.9%; OR 0.42, 95% CI = 0.39 to 0.46); who lived in more deprived areas (OR least versus most deprived [reference category] 1.16, 95% CI = 1.11 to 1.21); or with no known risk factors for severe influenza.

CONCLUSION

Seasonal influenza vaccine uptake in pregnant women increased in the decade before the COVID-19 pandemic, but remained suboptimal. Targeted approaches are recommended to reducing inequalities in access to vaccination and should focus on women of Black ethnicity, younger and older women, and women living in deprived areas.

Knowledge, attitudes, and practices regarding seasonal influenza vaccination during pregnancy in Costa Rica: A mixed-methods study

BACKGROUND

Influenza increases stillbirth risk, morbidity and mortality in pregnant women. Vaccination protects pregnant women against severe disease and indirectly protects their infants, but coverage among pregnant women remains low worldwide. We aimed to describe knowledge, attitudes, and practices (KAP) regarding seasonal influenza vaccination among postpartum women and prenatal care physicians in Costa Rica.

METHODS

We conducted cross-sectional KAP surveys to women one to three days after childbirth at Costa Rican Social Security Fund maternity hospitals, and obstetricians and general practitioners who provided prenatal care in 2017. Principal components analysis, multiple imputation, and logistic regression were used to examine associations between influenza vaccination and demographics, prenatal care, and sources of information-separately for postpartum women and physicians. We also held two focus groups of six healthcare workers each to further describe vaccination KAP.

RESULTS

We surveyed 642 postpartum women and 146 physicians in maternity hospitals in five Costa Rican provinces of whom 85.5 % (95 % CI: 82.6 %-88.0 %) and 57.9 % (95 % CI: 49.6 %-65.7 %) were vaccinated for influenza, respectively. Factors associated with influenza vaccination for postpartum women included tetanus vaccination (aOR: 3.62, 95 % CI: 1.89-6.92); received vaccination recommendations from clinicians during prenatal check-ups (aOR: 3.39, 95 % CI: 2.06-5.59); had other children in household vaccinated for influenza (aOR: 2.25, 95 % CI: 1.08-4.68); and secondary/university education (aOR: 0.15-0.31) with no formal education as reference. For postpartum women, reasons for vaccination were perceived benefits for mother and infant, whereas not being offered vaccines was most cited for non-vaccination. Most prenatal care physicians recommended influenza vaccines during prenatal check-ups but believed vaccination causes flu-like symptoms.

CONCLUSION

Vaccination campaigns and provisions of free vaccines effectively increased knowledge and coverage among women in Costa Rica. To improve access, women should be offered vaccines during prenatal care appointments. Educating healthcare workers about vaccine benefits for themselves and patients is needed to mitigate safety concerns.

Knowledge, Perceptions, Attitudes and Practices of Midwives Regarding Maternal Influenza and Pertussis Vaccination: A Qualitative Study

The coverage of maternal vaccination against pertussis and, particularly, influenza is lower than expected. The lack of recommendation from healthcare providers conditions non-vaccination in pregnant women. The purpose was to determine the knowledge, perceptions, attitudes and practices of midwives regarding maternal influenza and pertussis vaccination. A qualitative descriptive study based on semi-structured, face-to-face interviews with seventeen midwives was conducted, including purposive sampling and thematic analyses. Midwives had disparate knowledge and perceptions about the severity of influenza and pertussis in pregnant women, and influenza was not considered very serious. The vaccines were generally considered safe. However, because midwives did not have enough information about the safety of the influenza vaccine, there was a tendency not to recommend it. While most midwives had a positive attitude toward vaccination, their advocation for vaccination against influenza was not as clear as it was for pertussis. Not wanting to influence the decision and assuming an informative–facilitating role also led providers to recommend the influenza vaccine less frequently. Midwives are among the main sources of professional advice for pregnant women. Addressing their understanding and professional practices regarding maternal vaccination is key to change the attitude of pregnant women and thus increase vaccine uptake among them, particularly for influenza.

Influenza and Pertussis Maternal Vaccination Coverage and Influencing Factors in Spain: A Study Based on Primary Care Records Registry

The purpose was to determine the coverage of maternal vaccination against influenza and pertussis, and the characteristics associated with being vaccinated, in a health area of Catalonia, Spain. Some 36,032 anonymized and computerized clinical records registries of pregnant women from Primary Care Centres (e-CAP database) were analysed, from between 2015 and 2018. Vaccination coverage and the association with sociodemographic variables and clinical conditions were estimated using a Poisson regression model. Maternal vaccination coverage against influenza ranged between 11.9% in 2015 and 6.8% in 2018, following a decreasing trend (p < 0.001). Coverage with the tetanus toxoid, diphtheria toxoid, and acellular pertussis vaccine varied between 49.8% in 2016 and 79.4% in 2018, following an increasing trend (p < 0.001). Having living children and suffering from obesity were factors associated with not being vaccinated against both infections. The predictive variables of vaccination against influenza were diabetes (IRR: 2.17, 95% CI: 1.42−3.30) and asthma (IRR: 2.05, 95% CI: 1.76−2.38); and for pertussis, it was asthma (IRR: 1.10, 95% CI: 1.03−1.17). Different socio-demographic factors and chronic conditions in pregnant women were associated with maternal vaccination, and which will have to be taken into account in clinical practice when implementing strategies to improve the coverage of the programme.

Views and experiences of maternal healthcare providers regarding influenza vaccine during pregnancy globally: A systematic review and qualitative evidence synthesis

BACKGROUND

The World Health Organization (WHO) recommends that pregnant women receive influenza vaccination; however, uptake of the vaccine remains low. Maternity health care professionals (MHCPs) play an important role in motivating pregnant women to receive the influenza vaccine. However, factors such as MHCPs' views and knowledge about the vaccine, and time constraints due to workload may influence MHCPs' practices and opinions about women receiving the influenza vaccine during pregnancy. To date, the qualitative evidence exploring MHCPs' views and experiences around influenza vaccine uptake in pregnant women has not been synthesised.

AIM

To systematically review and thematically synthesise qualitative evidence that explores the views and experiences of MHCPs involved in the provision of the maternal influenza vaccine worldwide.

METHODS

Five databases (MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science) were searched, supplemented with searches of included paper reference lists and grey literature. Study selection was conducted by up to three researchers applying pre-specified inclusion/exclusion criteria. Quality assessment was undertaken, data were extracted, coded and synthesised to develop descriptive and analytical themes.

RESULTS

Eight studies involving 277 participants were included. Seventeen descriptive themes were interpreted, embedded within six analytical themes. MHCPs perceived that maternal influenza vaccination delivery can be facilitated by trusting relationships, good communication, knowledge about the vaccine leading to confidence in recommending vaccine, electronic vaccination prompts, and presence of national guidelines. However, workload, time constraints, MHCP's perception of pregnant women's concerns, and social/cultural/environmental influences could prevent the likelihood of delivery of influenza vaccine. Knowledgeable MHCPs who were regularly updated about vaccination based on scientific evidence were more confident when discussing and recommending the influenza vaccine to pregnant women. In addition, the presence of national policies and guidelines and electronic prompts for maternal influenza vaccination would enhance the delivery of the vaccine.

CONCLUSION

Our findings suggest that approaches to enhance the vaccination uptake rate in pregnant women include addressing MHCPs barriers to discussing influenza vaccination through education, sufficient time for discussions, and electronic prompts about vaccination, as well as evidence based local and national guidelines.

Influences on Pregnant Women's and Health Care Professionals' Behaviour Regarding Maternal Vaccinations: A Qualitative Interview Study

The uptake of maternal influenza and pertussis vaccinations is often suboptimal. This study explores the factors influencing pregnant women's and health care professionals' (HCPs) behaviour regarding maternal vaccinations (MVs). Pregnant/recently pregnant women, midwives, pharmacists and general practice staff in Waikato, New Zealand, were interviewed. The analysis used the behaviour change wheel model. Interviews of 18 women and 35 HCPs revealed knowledge about MVs varied with knowledge deficiencies hindering the uptake, particularly for influenza vaccination. HCPs, especially midwives, were key in raising women's awareness of MVs. Experience with vaccinating, hospital work (for midwives) and training increased HCPs' knowledge and proactivity about MVs. A "woman's choice" philosophy saw midwives typically encouraging women to seek information and make their own decision. Women's decisions were generally based on knowledge, beliefs, HCPs' emphasis and their perceived risk, with little apparent influence from friends, family, or online or promotional material. General practice's concentration on children's vaccination and minimal antenatal contact limited proactivity with MVs. Busyness and prioritisation appeared to affect HCPs' proactivity. Multi-pronged interventions targeting HCPs and pregnant women and increasing MV access are needed. All HCPs seeing pregnant women should be well-informed about MVs, including how to identify and address women's questions or concerns about MVs to optimise uptake.

COVID-19 Vaccine Acceptance of Pregnant and Lactating Women (PLW) in Czechia: An Analytical Cross-Sectional Study

Pregnant and lactating women (PLW) represent a particular population subset with increased susceptibility for COVID-19 morbidity and mortality, even though the evidence about the safety and efficacy of COVID-19 vaccines was delayed due to their initial exclusion from development trials. This unclear situation could have led to increased COVID-19 vaccine hesitancy levels among PLW; therefore, this study aimed to evaluate the attitudes of Czech PLW towards COVID-19 vaccines and the determinants of their attitudes. An analytical cross-sectional survey-based study was carried out in the University Hospital Brno (South Moravia, Czechia) between August and October 2021. The study utilised a self-administered questionnaire (SAQ) adapted from previous instruments used for the same purpose. The SAQ included closed-ended items covering demographic characteristics, clinical and obstetric characteristics, attitudes towards COVID-19 vaccination, and potential psychosocial predictors of vaccine acceptance. Out of the 362 included participants, 278 were pregnant (PW) and 84 were lactating women (LW). The overall COVID-19 vaccine acceptance (immediate and delayed) level was substantially high (70.2%), with a significant difference between PW (76.6%) and LW (48.8%). Out of the 70.2% who agreed to receive the vaccine, 3.6% indicated immediate acceptance, and 66.6% indicated delayed acceptance. Only 13.3% of the participants indicated their acceptance of their physician's vaccination recommendation during pregnancy or while lactating, and 62.2% were against it. Our results agreed with the recent studies that revealed that PW tended to have a high level of COVID-19 vaccine acceptance, and they were also inclined to resist professional recommendations because they predominantly preferred to delay their vaccination. The pregnancy trimester, education level, employment status, and previous live births were significant determinants for COVID-19 vaccine acceptance. The most commonly preferred vaccine type was mRNA-based vaccines, followed by viral vector-based and inactivated virus vaccines. The first top priority of PLW was vaccine safety for their children, followed by vaccine safety for the PLW and vaccine effectiveness. Regarding psychosocial predictors, media/social media, trust in the government, the pharmaceutical industry, and healthcare professionals, partners, and a positive risk-benefit ratio were significant promoters for COVID-19 vaccine acceptance. Findings from this study suggest that promotional interventions targeting PLW should use web platforms and focus on vaccine safety evidence, the expected benefits of vaccines and potential harms of the infection.

Improving uptake of vaccines in pregnancy: A service evaluation of an antenatal vaccination clinic at a tertiary hospital in the UK

Background

Vaccination against pertussis and seasonal influenza is recommended for all pregnant women in the UK. More recently COVID-19 vaccination has also been offered to women in pregnancy.

Objectives

To evaluate the uptake of vaccines in pregnant women within a midwife-led immunisation clinic and to assess factors influencing pregnant women's decisions about accepting vaccination.

Methods

Uptake of vaccines amongst pregnant women referred to a single UK centre for antenatal care between 01/01/19 and 02/10/19 was assessed. Interviews with 20 pregnant women explored views of antenatal vaccination and experiences of the vaccination service.

Findings

Amongst 4420 women, uptake was 90.6% for pertussis and 78.8% for influenza vaccines. Factors influencing vaccine-related decision-making amongst 20 interviewed women were: healthcare professional recommendation, perceived susceptibility and risk of infection, and previous experience of vaccination and vaccine-preventable disease.

Conclusions and Implications for Practice

Uptake of pertussis and influenza vaccines within a secondary care immunisation service was higher than the national or regional average. The model of vaccine delivery was associated with high levels of satisfaction. This model of vaccine delivery could be implemented elsewhere to increase vaccine uptake, and should be considered for delivery of COVID-19 vaccines in the future.

Categorizing Vaccine Confidence With a Transformer-Based Machine Learning Model: Analysis of Nuances of Vaccine Sentiment in Twitter Discourse

Background

Social media has become an established platform for individuals to discuss and debate various subjects, including vaccination. With growing conversations on the web and less than desired maternal vaccination uptake rates, these conversations could provide useful insights to inform future interventions. However, owing to the volume of web-based posts, manual annotation and analysis are difficult and time consuming. Automated processes for this type of analysis, such as natural language processing, have faced challenges in extracting complex stances such as attitudes toward vaccination from large amounts of text.

Objective

The aim of this study is to build upon recent advances in transposer-based machine learning methods and test whether transformer-based machine learning could be used as a tool to assess the stance expressed in social media posts toward vaccination during pregnancy.

Methods

A total of 16,604 tweets posted between November 1, 2018, and April 30, 2019, were selected using keyword searches related to maternal vaccination. After excluding irrelevant tweets, the remaining tweets were coded by 3 individual researchers into the categories Promotional, Discouraging, Ambiguous, and Neutral or No Stance. After creating a final data set of 2722 unique tweets, multiple machine learning techniques were trained on a part of this data set and then tested and compared with the human annotators.

Results

We found the accuracy of the machine learning techniques to be 81.8% (F score=0.78) compared with the agreed score among the 3 annotators. For comparison, the accuracies of the individual annotators compared with the final score were 83.3%, 77.9%, and 77.5%.

Conclusions

This study demonstrates that we are able to achieve close to the same accuracy in categorizing tweets using our machine learning models as could be expected from a single human coder. The potential to use this automated process, which is reliable and accurate, could free valuable time and resources for conducting this analysis, in addition to informing potentially effective and necessary interventions.

Reliability of information available on popular websites about vaccination of pregnant women

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.

Understanding factors that influence the decision to be vaccinated against influenza and pertussis in pregnancy: A qualitative study

AIMS AND OBJECTIVES

To identify how pregnant women perceive pertussis and influenza and the factors that influence their decision to be vaccinated.

BACKGROUND

Suffering from influenza during pregnancy increases complications in the pregnant woman, foetus and newborn. Pertussis in children under six months of age causes severe complications. Maternal vaccination against influenza and pertussis is effective and safe. However, vaccination rates are insufficient.

DESIGN

We conducted a qualitative descriptive study, using semi-structured interviews. This research adheres to the COREQ guidelines and checklist.

METHODS

We carried out 18 semi-structured face-to-face interviews with pregnant women, using intentional sampling and thematic analysis.

RESULTS

We identified an overarching theme, 'factors that influenced participants' decision to be vaccinated or not', which was composed of four subthemes that were in turn made up of 12 categories. The factors that influenced participants' decision to be vaccinated against influenza and pertussis were related to their knowledge of and their perception of risk for these diseases. Participants perceived the risk of pertussis to be greater, and they focused their concern on the newborn. The recommendations and convictions of nurse-midwives were the most important factors encouraging vaccination. Participants trusted their nurse-midwives and most reported that they would have been vaccinated if their midwife had recommended it. Other factors were linked to lack of information, fear and concerns about economic interests.

CONCLUSIONS

The convictions and actions of the nurse-midwife in recommending vaccination to pregnant women are decisive. Strategies to improve vaccination rates should be directed to helping health professionals understand how their practice affects the final decision of pregnant women.

RELEVANCE TO CLINICAL PRACTICE

Understanding the factors that limit vaccination rates among pregnant women provides valuable information to nurse-midwives that can help to improve vaccination strategies and practices. Increased maternal vaccination rates would reduce morbidity and mortality among pregnant women and newborns.

Uptake of vaccination in pregnancy

Maternal immunisation is a public health strategy that aims to provide protection against certain infections to both mother and her foetus or newborn child. Vaccination of pregnant women induces vaccine-specific antibodies that lead to the subsequent transfer of these antibodies across the placenta or through breastfeeding to the offspring. At present, vaccinations in pregnancy are limited to pertussis, tetanus, diphtheria, polio, and the seasonal Influenza vaccine. Recently, some countries have incorporated routine antenatal vaccinations in their national immunisation programmes. Future vaccines targeted at pregnant women such as respiratory syncytial virus (RSV) and Group B streptococcus (GBS) are under development. The recently approved Covid-19 vaccines have no safety data for use in pregnancy at present, but have been considered in the UK in extremely vulnerable pregnant women or pregnant frontline health and social care workers.

In this article, we review the evidence supporting maternal immunisation and discuss the uptake of vaccines in pregnant women, challenges of recording the data on vaccine coverage, and consider reasons behind the present levels of uptake and strategies for future improvements.

Factors that influence vaccination decision-making among pregnant women: A systematic review and meta-analysis

BACKGROUND

The most important factor influencing maternal vaccination uptake is healthcare professional (HCP) recommendation. However, where data are available, one-third of pregnant women remain unvaccinated despite receiving a recommendation. Therefore, it is essential to understand the significance of other factors and distinguish between vaccines administered routinely and during outbreaks. This is the first systematic review and meta-analysis (PROSPERO: CRD 42019118299) to examine the strength of the relationships between identified factors and maternal vaccination uptake.

METHODS

We searched MEDLINE, Embase Classic & Embase, PsycINFO, CINAHL Plus, Web of Science, IBSS, LILACS, AfricaWideInfo, IMEMR, and Global Health databases for studies reporting factors that influence maternal vaccination. We used random-effects models to calculate pooled odds ratios (OR) of being vaccinated by vaccine type.

FINDINGS

We screened 17,236 articles and identified 120 studies from 30 countries for inclusion. Of these, 49 studies were eligible for meta-analysis. The odds of receiving a pertussis or influenza vaccination were ten to twelve-times higher among pregnant women who received a recommendation from HCPs. During the 2009 influenza pandemic an HCP recommendation increased the odds of antenatal H1N1 vaccine uptake six times (OR 6.76, 95% CI 3.12-14.64, I2 = 92.00%). Believing there was potential for vaccine-induced harm had a negative influence on seasonal (OR 0.22, 95% CI 0.11-0.44 I2 = 84.00%) and pandemic influenza vaccine uptake (OR 0.16, 95% CI 0.09-0.29, I2 = 89.48%), reducing the odds of being vaccinated five-fold. Combined with our qualitative analysis the relationship between the belief in substantial disease risk and maternal seasonal and pandemic influenza vaccination uptake was limited.

CONCLUSIONS

The effect of an HCP recommendation during an outbreak, whilst still powerful, may be muted by other factors. This requires further research, particularly when vaccines are novel. Public health campaigns which centre on the protectiveness and safety of a maternal vaccine rather than disease threat alone may prove beneficial.

Current practice and attitudes towards vaccination during pregnancy: a survey of GPs across England

Background

Antenatal vaccines are commonly delivered in primary care, yet the views of GPs regarding these programmes have been neglected in research to date.

Aim

To establish the attitudes and current practice of GPs towards antenatal vaccination and their views on the optimal location for delivery of this service.

Design and setting

A multicentre online survey questionnaire.

Method

A questionnaire was sent to GPs across England between December 2018 and January 2019.

Results

The majority of 1586 responders considered antenatal vaccination safe (96% for influenza, 89% pertussis). GPs were significantly less confident in their knowledge of pertussis compared with influenza vaccination (64% versus 80% were confident, P <0.001), and many desired further education (59% versus 48%, P <0.001). Few (37%) discussed vaccination with pregnant women regularly, but most (80%) felt their recommendation would influence decision making. Those with greater confidence in their knowledge of pertussis and influenza vaccination, and who were >2 years since qualifying, discussed vaccination significantly more often (odds ratio [OR] 3.52, P <0.001; OR 2.34, P = 0.001; OR 1.76, P = 0.003, respectively), regardless of whether they routinely saw pregnant women. Most (83%) reported that antenatal vaccination was GP led in their region, yet only 26% thought it should be primarily GP based. GPs expressed disconnect from antenatal care, and many suggested that midwives and/or secondary care should take greater responsibility for the delivery of antenatal vaccination.

Conclusion

There is support among GPs to embed vaccination programmes within routine antenatal care. Further educational resources, specifically designed for the needs of GPs, are needed to facilitate opportunistic discussion with pregnant women about vaccination.

The effectiveness of influenza vaccination in pregnancy in relation to child health outcomes: Systematic review and meta-analysis

OBJECTIVES

To determine the effectiveness of influenza vaccination during pregnancy on child health outcomes.

DESIGN

Systematic review/meta-analysis.

DATA SOURCES

Clinical Trials.gov, Cochrane Library, EMBASE, Medline, Medline in process, PubMed and Web of Science, from 1st January 1996 to 29th June 2018. An updated Medline search was performed 30th June 2018 to 31st October 2019.

METHODS

Randomised controlled trials (RCTs) and observational studies reporting health outcomes of infants and children born to women who received inactivated influenza vaccine during pregnancy. The primary outcome was infant laboratory confirmed influenza (LCI). Secondary outcomes included influenza-like illness (ILI), other respiratory illnesses, primary care, clinic visit or hospitalisations due to influenza illness and long-term respiratory childhood outcomes.

RESULTS

19 studies were included; 15 observational studies and 4 primary RCTs with an additional 3 papers reporting secondary outcomes of these RCTs. In a random effects meta-analysis of 2 RCTs including 5742 participants, maternal influenza vaccination was associated with an overall reduction of LCI in infants of 34% (95% confidence interval 15-50%). However, there was no effect of maternal influenza vaccination on ILI in infants ≤6 months old. Two RCTs were excluded from the meta-analysis for the outcome of LCI in infants (different controls used). Both of these studies showed a protective effect for infants from LCI, with a vaccine efficacy of up to 70%. Overall observational studies showed an inverse (protective) association between maternal influenza vaccination and infant LCI, hospitalisation and clinic visits due to LCI or ILI in infants and other respiratory illness in infants ≤6 months old.

CONCLUSIONS

This systematic review supports maternal influenza vaccination as a strategy to reduce LCI and influenza-related hospitalisations in young infants. Communicating these benefits to pregnant women may support their decision to accept influenza vaccination in pregnancy and increase vaccine coverage in pregnant women.

REGISTRATION

PROSPERO CRD42018102776.

Vaccinating pregnant women against influenza needs to be a priority for all countries: An expert commentary

BACKGROUND

In 2012, the World Health Organization recommended influenza vaccination for all pregnant women worldwide and the prioritisation of pregnant women in national influenza vaccination programmes. Nevertheless, vaccination rates in pregnant women often remain much lower than national targets.

OBJECTIVES

To assess the benefits and risks associated with influenza infection and vaccination during pregnancy, and to consider obstacles that work against influenza vaccine uptake during pregnancy.

RESULTS

There is strong evidence that maternal and foetal outcomes can be compromised if women develop influenza infections during pregnancy. Influenza vaccines have been administered to millions of pregnant women and have demonstrated benefits in terms of disease prevention in mothers and their infants. There is a consensus amongst several recommending authorities that influenza vaccines may be safely administered during all stages of pregnancy. Healthcare professionals are recognised as the most important influencers of vaccine uptake, being well placed to recommend vaccination and directly address safety concerns.

CONCLUSIONS

Despite data supporting the value of influenza vaccination during pregnancy, vaccine uptake remains low globally. Low uptake appears to be largely due to ineffective communication with pregnant women about the risks and benefits of influenza vaccination. A graphical abstract is available online.

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.

Predictors of tetanus, diphtheria, acellular pertussis and influenza vaccination during pregnancy among full-term deliveries in a medically underserved population

OBJECTIVE

To evaluate predictors of vaccination among women who received tetanus, diphtheria, and acellular pertussis vaccination (Tdap), influenza vaccination, and Tdap and influenza vaccinations.

STUDY DESIGN

In a retrospective cohort study of all full-term (≥37 weeks gestation) deliveries between July 1, 2016 and June 30, 2018 at a single, safety-net institution, we used multinomial logistic regression models to compare predictors of vaccination among women who received Tdap only, influenza only, and both Tdap and influenza vaccines.

RESULTS

Among 3132 full-term deliveries, women were primarily non-Hispanic black (67.5%), between the ages of 21-34 (65.3%), and multiparous (76.0%). The rates of only influenza or Tdap vaccination were 10.3% and 21.6%, respectively; 43.3% of women received both vaccines, and 24.9% of women did not receive either vaccine. In the adjusted models, Hispanic ethnicity was positively associated with receipt of all types of vaccination and non-Spanish language interpreter use was positively associated with receipt of Tdap vaccination and Tdap and influenza vaccination. A parity of greater than three and inadequate and unknown prenatal care adequacy were negative predictors of all types of vaccination. Pre-existing hypertension was negatively associated with Tdap vaccination, and HIV-positive status was negatively associated with influenza vaccination and Tdap and influenza vaccination.

CONCLUSION

Compared to the national rate of both Tdap and influenza vaccination (32.8%), a higher proportion of women received both vaccines in our study population. Vaccine uptake may be affected by race/ethnicity, use of interpreter services, parity, pre-existing comorbidities, and prenatal care adequacy. The lower rate of influenza vaccination compared to Tdap vaccination suggests that other factors, such as vaccine hesitancy and mistrust, may be differentially impacting influenza vaccination uptake in our predominantly minority population. Future provider and public health approaches to vaccine promotion should incorporate culturally appropriate strategies that address vaccine-related beliefs and misconceptions.