Prenatal multiple immunization

A Randomized Controlled Trial of the Safety and Immunogenicity of Tetanus, Diphtheria, and Acellular Pertussis Vaccine Immunization During Pregnancy and Subsequent Infant Immune Response

Background

Immunization of pregnant women with tetanus-diphtheria-acellular pertussis vaccine (Tdap) provides protection against pertussis to the newborn infant.

Methods

In a randomized, controlled, observer-blind, multicenter clinical trial, we measured the safety and immunogenicity of Tdap during pregnancy and the effect on the infant's immune response to primary vaccination at 2, 4, and 6 months and booster vaccination at 12 months of age. A total of 273 women received either Tdap or tetanus-diphtheria (Td) vaccine in the third trimester and provided information for the safety analysis and samples for the immunogenicity analyses; 261 infants provided serum for the immunogenicity analyses.

Results

Rates of adverse events were similar in both groups. Infants of Tdap recipients had cord blood levels that were 21% higher than maternal levels for pertussis toxoid (PT), 13% higher for filamentous hemagglutinin (FHA), 4% higher for pertactin (PRN), and 7% higher for fimbriae (FIM). These infants had significantly higher PT antibody levels at birth and at 2 months and significantly higher FHA, PRN, and FIM antibodies at birth and 2 and 4 months, but significantly lower PT and FHA antibody levels at 6 and 7 months and significantly lower PRN and FIM antibody levels at 7 months than infants whose mothers received Td. Differences persisted prebooster at 12 months for all antigens and postbooster 1 month later for PT, FHA, and FIM.

Conclusions

This study demonstrated that Tdap during pregnancy results in higher levels of antibodies early in infancy but lower levels after the primary vaccine series.

Clinical Trials Registration

NCT00553228.

Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP)

This report compiles and summarizes all recommendations from CDC's Advisory Committee on Immunization Practices (ACIP) regarding prevention and control of tetanus, diphtheria, and pertussis in the United States. As a comprehensive summary of previously published recommendations, this report does not contain any new recommendations and replaces all previously published reports and policy notes; it is intended for use by clinicians and public health providers as a resource. ACIP recommends routine vaccination for tetanus, diphtheria, and pertussis. Infants and young children are recommended to receive a 5-dose series of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccines, with one adolescent booster dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. Adults who have never received Tdap also are recommended to receive a booster dose of Tdap. Women are recommended to receive a dose of Tdap during each pregnancy, which should be administered from 27 through 36 weeks' gestation, regardless of previous receipt of Tdap. After receipt of Tdap, adolescents and adults are recommended to receive a booster tetanus and diphtheria toxoids (Td) vaccine every 10 years to assure ongoing protection against tetanus and diphtheria.

Improving rates of maternal immunization: Challenges and opportunities

OBJECTIVES

An increasing number of vaccines are recommended or are being developed for use during pregnancy to protect women, fetuses, and/or newborns. For vaccines that are already recommended, vaccine uptake is variable and well below desired target. We reviewed the literature related to factors that affect a healthcare provider's recommendation and a woman's willingness to be vaccinated during pregnancy.

DESIGN

A scoping review of published literature from 2005 to 2015 was undertaken and all relevant articles were abstracted, summarized, and organized thematically.

RESULTS

Barriers and facilitators were identified that either decreased or increased the likelihood of a healthcare provider offering and a pregnant woman accepting vaccination during pregnancy. Concern about the safety of vaccines given during pregnancy was the most often cited barrier among both the public and healthcare providers. Other barriers included doubt about the effectiveness of the vaccine, lack of knowledge about the burden of disease, and not feeling oneself to be at risk of the infection. Major facilitators for maternal immunization included specific safety information about the vaccine in pregnant women, strong national recommendations, and healthcare providers who both recommended and provided the vaccine to their patients. Systems barriers such as inadequate facilities and staffing, vaccine purchase and storage, and reimbursement for vaccination were also cited. Evidence-based interventions were few, and included text messaging reminders, chart reminders, and standing orders.

CONCLUSIONS

In order to have an effective vaccination program, improvements in the uptake of recommended vaccines during pregnancy are needed. A maternal immunization platform is required that normalizes vaccination practice among obstetrical care providers and is supported by basic and continuing education, communication strategy, and a broad range of research.

Epidemiological and immunological reasons for pertussis vaccination in adolescents and adults

The resurgence of pertussis has been the subject of considerable debate. Hypotheses to explain increased reporting in developed countries have focused mainly on three aspects: (1) increased recognition of the disease in adolescents and adults; (2) waning of vaccine-induced immunity and (3) loss of vaccine efficacy due to an antigenic shift of Bordetella pertussis. Waning immunity after vaccination or natural infection combined with the absence of regular boosters either in the form of vaccine boosters or natural exposure to B. pertussis - due to the low circulation of the bacterium in well-immunized populations - has been suggested to explain this shift in the age distribution of pertussis. The highest incidence of the disease is currently reported among adolescents and adults who may additionally serve as the source of infection for susceptible infants. Immunological and epidemiological data indicates the need for a universal booster vaccination against pertussis for adolescents and adults.

Neonatal administration of idiotype or antiidiotype primes for protection against Escherichia coli K13 infection in mice

Antibodies directed against the capsular polysaccharides (Ps) of encapsulated pathogenic bacteria can protect the host against infection with such organisms. The immune response to Ps, however, does not develop until relatively late in ontogeny. We have, therefore, studied alternative ways to stimulate anti-Ps antibody responses in neonates, namely priming with idiotype (Id) and anti-Id. We believe that these studies provide the first demonstration of the use of an anti-Id antibody to prime for protection against a bacterial infection and the first demonstration of the ability of a monoclonal anti-Id to prime for protection against any microbial infection. We have used a monoclonal IgM Id, anti-K13 capsular antibody, and a monoclonal IgG1 anti-Id in studies of the effects of administration of anti-Id or Id within 24 h after birth on the ability of mice to respond to subsequent immunization and challenge with live bacteria. These studies show that neonatal administration of 1 micrograms of Id or 50 ng of anti-Id lead to significantly enhanced protection in mice immunized at 4 wk of age and challenged at 5 wk with an intraperitoneal injection of 20-30 LD50 of E. coli 06:K13:H1, as compared with unprimed or antigen (Ps)-primed controls. Mice primed at birth, immunized at 12 wk of age, a time when they can respond fully to Ps itself, and challenged 1 wk later, were still significantly protected by anti-Id priming but no longer showed the effects of Id. We conclude that administration of protective Id early in life may serve a dual function in providing immediate passive protection as well as priming for protective antibodies upon subsequent antigen exposure.