Committee opinion no.564: ethical issues with vaccination for the obstetrician-gynecologist

ACOG Committee Opinion No. 772: Immunization Implementation Strategies for Obstetrician-Gynecologists

Immunization against vaccine-preventable diseases is an essential component of women's primary and preventive health care. Many studies have shown that a recommendation from an obstetrician-gynecologist or other health care provider for a vaccine is one of the strongest influences on patient acceptance. Obstetrician-gynecologists and other health care providers should develop a standard process for assessing and documenting the vaccination status of patients and for recommending and administering vaccines. If allowed by state law, obstetrician-gynecologists and other health care providers are encouraged to institute standing orders for indicated immunizations. Obstetrician-gynecologists and other health care providers are encouraged to stock and, ideally, administer commonly recommended vaccines in their offices. Studies show that immunization rates are higher when a health care provider can offer and administer the vaccine during the same visit, as opposed to recommending vaccination and referring the patient elsewhere to receive the vaccine. Given the demonstrated efficacy and safety of vaccines and the large potential for prevention of many infectious diseases that affect adolescents, adults, pregnant women, and newborns, obstetrician-gynecologists should include immunizations as an integral part of their practice. This Committee Opinion has been revised to incorporate additional strategies for obstetrician-gynecologists to consider implementing to enhance their immunization programs.

Who's the Target: Mother or Baby?

Maternal immunization for prevention of morbidity and mortality of pregnant women and their neonates due to infectious diseases is ongoing worldwide. The complexity of vaccine research and development in this population is challenging. Not only do vaccines for pregnant women require evidence of immunogenicity, potency, stability, and limited reactogenicity, they must also provide efficacy in decreasing morbidity for the pregnant woman, her fetus, and the neonate, demonstrate safety or lack of evidence of harm, and offer benefit or potential benefit of vaccination during pregnancy. Since the 19th century, evidence of protective effects of vaccination during pregnancy has been documented. Pandemic influenza and pertussis outbreaks in recent years have affected a paradigm shift in vaccine research and development as well as current policy regarding immunization in pregnancy. Studies of the immune system in pregnant women and neonates have shown that immune changes associated with pregnancy in women do not interfere with maternal vaccine responses, multiple factors are important in transplacental transfer of antibodies, and maternal antibodies are beneficial to neonates. In recent years, guidelines have been developed by expert panels to help design studies for maternal vaccinations and for harmonization of data collection, analysis, and adverse event reporting. Further research into maternal and neonatal immunology, transplacental antibody transfer, and epidemiology of diseases is needed, especially as new vaccines to respiratory syncytial virus, cytomegalovirus, and Group B streptococcus are developed. Maternal vaccinations have the potential to change the epidemiology of infectious diseases in reproductive health and pediatrics and may lead to new clinical applications to improve global maternal and neonatal health.

Committee Opinion No. 661: Integrating Immunizations Into Practice

Immunization against vaccine-preventable diseases is an essential component of women's primary and preventive health care. Despite the importance of vaccination and clear guidance from public health agencies, rates of vaccination lag behind national goals. Obstetrician-gynecologists can play a major role in reducing morbidity and mortality from a range of vaccine-preventable diseases, including pertussis, influenza, human papillomavirus, and hepatitis. Given demonstrated vaccine efficacy and safety, and the large potential for prevention of many infectious diseases that affect adults, pregnant women, and newborns, obstetrician-gynecologists should include immunizations as an integral part of their practice. To do so, they must embrace their role as important sources of information and advice on immunization for adults, adolescents, and pregnant women, and advance their patients' well-being with continued efforts to augment immunization services in their offices. Increasing awareness combined with the many suggestions in this document will work to enhance immunization uptake.

Maternal immunization: Optimizing protection for the mother and infant

Immunizing the pregnant woman to protect both the mother and her infant from infection has been utilized increasingly over the last decade. New outbreaks of pandemic influenza and the resurgence of pertussis have resulted in policy changes and shifts in health authority recommendations for a number of vaccines aimed to protect both pregnant women and their infants in the first months of life. The ability of maternal immunoglobulin IgG antibodies to be transported readily across the healthy intact placenta depends on many different factors including gestational age in the pregnancy, nature and timing of the immunization and presence of maternal HIV or malaria infections. In this paper, the history of maternal immunization is described, and specifically the studies that prompted the recommendations for tetanus, influenza, pertussis, and, when needed, meningococcus vaccines in pregnant women are reviewed. Ongoing research may result in new maternal vaccines against other pathogens including respiratory syncytial virus and group B streptococcus. Both scientific and regulatory considerations remain challenging in licensure of vaccines specifically for maternal immunization.

Policy considerations for improving influenza vaccination rates among pregnant women

BACKGROUND

Influenza exposure during pregnancy can cause severe health problems for both the mother and her offspring, including an increased risk of mortality. Influenza vaccination during all trimesters of pregnancy is safe and effective, and recommended by professional organizations such as the American College of Obstetrics and Gynecology. Despite these recommendations, the U.S. vaccination rates remain low in this high-risk population.

METHOD

A policy analysis based on the five-part method identified by Teitelbaum and Wilensky () addresses factors to consider in identifying the best voluntary policy options to improve the vaccination rates. The authors provide discussion of the background, landscape, and stakeholder interests and the pros and cons of two voluntary policy options to increase vaccination. The policy options include: (a) financial incentives for providers and (b) an education emphasis for providers and staff.

CONCLUSIONS

The authors conclude that based on considerations of cost, provider preference, and practicality of implementation, a continuing educational intervention is the preferred policy venue to increase vaccination rates.