Influenza and pertussis vaccination during pregnancy - attitudes, practices and barriers in gynaecological practices in Germany

Vaccination coverage during pregnancy and factors associated with refusal of recommended vaccinations: An Italian cross sectional study

Background

The vaccines recommended during pregnancy are the Tdap, the influenza vaccine, and, during the SARS-CoV-2 pandemic, the vaccine against COVID-19. This survey aimed at determining vaccination coverage among pregnant women and adverse events, reasons for vaccine refusal, and factors associated with vaccine uptake.

Methods

A single-center cross-sectional study was conducted on women who delivered between March and April 2022 at Careggi University Hospital in Florence, Italy. Information on the vaccinations (Tdap, influenza and COVID-19) received during pregnancy were collected through in-person interviews.

Results

Among 307 enrolled women (response rate 99 % on a study population of 310 eligible women), 74 % of patients were vaccinated with Tdap, 82 % against COVID-19, and only 33 % against influenza. Vaccination coverage for Tdap and COVID-19 was significantly higher among Italian than foreign patients (80 % vs 51 %, p < 0.001 and 86 % vs 69 %, p = 0.002, respectively), and for Tdap was higher among patients followed in the private vs public care setting. The main reasons behind refusal of vaccinations were low risk perception of influenza (41 %), insufficient information received from the prenatal care provider regarding the Tdap (35 %), and, for the COVID-19, fear of vaccine side effects (64 %), and concerns about effects on the fetus (70 %).

Conclusions

Adherence to the influenza vaccine was low because of reduced perception of the disease risks. The difference in vaccination coverage between Italians and foreigners is an example of healthcare disparity. Better information provided to patients about vaccines' efficacy and safety is advisable to increase acceptance of recommended vaccines.

Assessing the Impact of the COVID-19 Pandemic on Pregnant Women's Attitudes towards Childhood Vaccinations: A Cross-Sectional Study

The COVID-19 pandemic has globally disrupted immunisation practices, impacting vulnerable populations such as pregnant women (PW), who harbour concerns about future children's immunisations. This study aimed to assess the pandemic's impact on PW's attitudes towards childhood vaccinations. During three consecutive flu seasons from October 2019 to January 2022, a cross-sectional study was conducted in a large Italian teaching hospital using a questionnaire. The chi-square test was performed to compare each season. Across the 2019-2020 to 2021-2022 seasons, course attendance by PW surged from 105 to 340. Significant shifts in vaccination intentions were noted, including a 7.5% decrease in measles vaccination intent (p = 0.02) and a 10% decrease in that of pertussis (p = 0.004) from 2019-2020 to 2020-2021. While perceived contagion risk decreased, disease severity perceptions increased, with few significant differences. A statistically significant reduction was noted in the proportion of participants suspecting economic motives behind NHS workers' promotion of childhood vaccinations. Furthermore, the pandemic period saw an increase in the perceived utility of non-institutional websites and the advice of physicians outside the NHS. These findings will help develop evidence-based, tailored interventions and communication strategies to address vaccine hesitancy and ensure optimal vaccination coverage among children born during and after the pandemic.

Interventional study to improve pertussis and influenza vaccination uptake in pregnant women

OBJECTIVES

Pertussis and influenza are endemic infections and associated with relevant morbidity and mortality in newborns and young infants. The Swiss Federal Office of Public Health has recommended influenza vaccination since 2011 and pertussis vaccination in pregnancy (ViP) since 2013 and expanded to repetition in each pregnancy since 2017. ViP is safe and effective in preventing severe diseases, but implementation is a challenge. We hypothesized that the proportion of women receiving ViP is persistently low despite existing national recommendations. Our primary objective was to compare the proportion of pertussis and influenza vaccine recommendations for and its acceptance by pregnant women before and after an information campaign tailored to obstetricians. Secondly, we aimed to identify reasons for missing or declining ViP.

STUDY DESIGN

We conducted a prospective, single-center, single-arm implementation study in the maternity ward at the University Women's Hospital Basel. We performed standardized interviews with women hospitalized for postpartum care before (October to December 2019, Phase 1, n = 262) and after an information campaign (October to December 2020, Phase 2, n = 233) and compared categorical variables using chi-squared or Fisher's exact test and continuous variables using Whitney Mann U test.

RESULTS

We found no significant differences in the proportion of recommendation for pertussis ViP (80 % vs. 84 %, p = 0.25) and implementation (76 % vs. 78 %, p = 0.63) between Phase 1 and 2. Main reasons for missing or declining vaccinations were lack of recommendation (62.8 %) and safety concerns regarding the unborn child (17.7 %). In contrast, the proportion of recommendation for influenza ViP (45 % vs. 63 %, p < 0.001) and implementation (29 % vs. 43 %, p < 0.001) increased significantly.

CONCLUSION

Proactive recommendations by obstetricians play a key role in the implementation of ViP but is still insufficient in our setting. We believe that future efforts should aim to explore possible hurdles that impede recommendations by obstetricians for ViP. The focus should be on the needs and experiences of obstetricians in private practice, but also other health care professionals involved in care of pregnant women. Local campaigns do not seem effective enough, therefore national campaigns with new strategies are desirable.

Attitudes and behaviors of maternal Tdap vaccination in Panama, Peru, and Colombia: An international cross-sectional study

INTRODUCTION

Despite a recommendation by PAHO for Tdap vaccination in pregnant women since 2019, uptake remains suboptimal across Latin America. This study evaluated the knowledge and attitudes of women towards maternal Tdap vaccination in Colombia, Peru, and Panama to identify the critical behavioral and social drivers of Tdap vaccine uptake during pregnancy.

METHODS

A cross-sectional online survey was undertaken between December 8, 2022, and January 11, 2023, targeting women in Colombia, Peru, or Panama with a child 12 months or under. We collected data on respondents' demographics, social and behavioral determinants of vaccine acceptance, determinants of vaccine uptake (using the validated 5As taxonomy), and previous vaccination experience.

RESULTS

In the 938 respondents who completed the survey (Panama, n = 325; Peru, n = 305; Colombia, n = 308), 73-80 % had received the influenza vaccine, whereas only 30-39 % had received a Tdap vaccine. Significant correlates of Tdap vaccine uptake common to all three countries included a health professional recommendation, knowledge of the vaccine and location of vaccination, perceived vulnerability to pertussis infection, perceived importance of immunization, and receipt of a reminder. In specific countries, nonvaccinated women were more likely to cite issues with ease of access (Panama, Colombia), affordability (opportunity costs; Peru, Colombia), and understanding the rationale for vaccination in pregnancy (Panama, Colombia).

CONCLUSION

To increase maternal Tdap vaccine uptake, health professionals should be encouraged to recommend vaccination consistently, and pregnant women should receive reminders explaining why and where to be vaccinated.

The Obstetrician's Role in Pregnant Women's Decision-Making Process Regarding Influenza and COVID-19 Vaccination

Pregnant women are considered to be a population vulnerable to influenza and COVID-19 infections, and the latest guidelines consistently recommend that they receive influenza and COVID-19 vaccinations. A cross-sectional questionnaire-based study was conducted among pregnant women in Poland to determine which factors have the greatest impact on their decision to vaccinate against influenza and COVID-19. A total of 515 pregnant women participated in the study. Among them, 38.4% (n = 198) demonstrated a positive attitude toward influenza vaccination, and 64.3% (n = 331) demonstrated a positive attitude toward COVID-19 vaccination. Logistic regression analysis revealed that the strongest influence on positive attitudes toward COVID-19 vaccination is having it recommended by an obstetrician-gynecologist (OR = 2.439, p = 0.025). The obstetrician-gynecologist's recommendation to vaccinate against influenza also significantly influences the decision to vaccinate (OR = 5.323). The study results also show a strong correlation between the obstetrician-gynecologist as a source of information on influenza and vaccination and participants' positive attitudes toward vaccination (OR = 4.163). Obstetricians have a significant influence on pregnant women's decisions regarding vaccinations. Further recommendations to vaccinate and awareness-raising among obstetricians may be needed to increase the vaccination rate of pregnant women in Poland.

Barriers to and facilitators of populational adherence to prevention and control measures of COVID-19 and other respiratory infectious diseases: a qualitative evidence synthesis

AIMS

To summarise the evidence on barriers to and facilitators of population adherence to prevention and control measures for coronavirus disease 2019 (COVID-19) and other respiratory infectious diseases.

METHODS

A qualitative synthesis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis and the Cochrane Effective Practice and Organization of Care: Qualitative Evidence Synthesis. We performed an electronic search on MEDLINE, Embase and PsycINFO from their inception to March 2023.

RESULTS

We included 71 studies regarding COVID-19, pneumonia, tuberculosis, influenza, pertussis and H1N1, representing 5966 participants. The measures reported were vaccinations, physical distancing, stay-at-home policy, quarantine, self-isolation, facemasks, hand hygiene, contact investigation, lockdown, infection prevention and control guidelines, and treatment. Tuberculosis-related measures were access to care, diagnosis and treatment completion. Analysis of the included studies yielded 37 barriers and 23 facilitators.

CONCLUSIONS

This review suggests that financial and social support, assertive communication, trust in political authorities and greater regulation of social media enhance adherence to prevention and control measures for COVID-19 and infectious respiratory diseases. Designing and implementing effective educational public health interventions targeting the findings of barriers and facilitators highlighted in this review are key to reducing the impact of infectious respiratory diseases at the population level.

Knowledge and Practice of Gynecologists About Tdap and Influenza Vaccination: A Cross-Sectional Study

BACKGROUND

Infants are vulnerable to diphtheria and pertussis in their early months. In this initial period, maternally derived antibodies provide significant protection to newborns. Similarly, influenza poses a significant risk of morbidity and mortality for pregnant mothers and infants. It has been observed that, despite the evident recommendations, the uptake of these vaccines is still not optimal.

METHODOLOGY

The current study was undertaken as a cross-sectional survey among the practicing gynecologists of North India voluntarily. A structured questionnaire was made available online to 300 practicing gynecologists either on their WhatsApp or email addresses. The data were compared based on urban and rural practices. A record was also made of the participants' type of practice setup, e.g., working in a primary health setting, a district hospital, or a teaching institute.  Results: Of the 148 participants who responded to the survey, 45.3% and 64.2%, respectively, administered influenza and Tdap vaccines to their patients. The main barriers cited by the respondent doctors were the non-affordability, non-availability, and non-inclusion of vaccines in the national immunization program and a lack of awareness among the practitioners (Spearman correlation 0.4; p<0.000).

CONCLUSION

The results of this survey suggest that increasing awareness among gynecologists and the public and improving the availability of vaccines and their inclusion in the national program could most likely increase the practice of the recommendation or administration of the Tdap vaccine in pregnant females.

Factors influencing healthcare professionals' confidence in vaccination in Europe: a literature review

Health-care professionals (HCPs) have a fundamental role in vaccination, their own beliefs and attitudes affecting both their uptake and recommendation of vaccines. This literature review (n = 89) summarises evidence on HCPs’ perceptions of the risks and benefits of vaccination, trust, and perceptions of mandatory vaccination in Europe. HCPs across studies believed that vaccination is important to protect themselves and their patients. However, beliefs that some diseases such as influenza are less risky were reported by some HCPs as a reason for not getting vaccinated. Concerns about both short- and long-term side effects were identified among HCPs in most studies, such as those affecting the immune or neurological system. Mistrust toward health authorities and pharmaceutical industry was reported in some studies. The question of mandatory vaccination revealed mixed opinions, with some favoring self-determination and others viewing vaccination as a duty. This review highlights key factors influencing HCPs’ confidence in vaccination in Europe.

Understanding drivers of influenza vaccine hesitancy among pregnant women in China: evidence from an extended theory of planned behavior

BACKGROUND

Pregnant women have a low uptake of influenza vaccination, although being recommended as a priority.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional questionnaire survey in China from June to July 2021. Hierarchical regression analysis and structural equation modeling were performed based on the extended theory of planned behavior, in which attitudes, subjective norms, perceived behavioral control, and intention each affect the vaccine hesitancy; four variables of response efficacy, knowledge, vulnerability, and severity were added as extended dimensions; vaccination history played a moderator role in this model-to test the validity of the framework.

RESULTS

Totally, 1283 pregnant women participated in this study. The intention existed as a mediator between attitude [β_indirect=0.142 (95% confidence interval (CI): 0.084, 0.206), P<0.001], subjective norms [β_indirect=0.568 (95%CI: 0.424, 0.754), P<0.001], perceived behavioral control [β_indirect=0.070 (95%CI: 0.025, 0.118), P=0.004] and vaccine hesitancy. Further, the differences in indirect effect between the two dimensions of attitude (P<0.001), perceived behavioral control (P<0.001), and subjective norms were each statistically significant. Vaccination history did not moderate the association between attitude (P=0.679), subjective norms (P=0.645), and hesitancy.

CONCLUSIONS

The subjective norms dimension has a strong association with influenza vaccine hesitancy. Vaccination history had limited ability to reduce hesitancy during pregnancy.

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.

dTap vaccination uptake during pregnancy: Pregnant women-focused and health professionals-focused predictors in the Veneto Region (Italy)

BACKGROUND

Despite recommendations, the uptake of dTap maternal vaccination is still low in many countries. The reasons for this must be investigated both on the patient's and the healthcare professionals' sides.

METHODS

A record linkage study was performed linking Birth Assitance Certificates and dTap mothers' vaccination records (5183 deliveries) to describe the influence of socioeconomical and obstetrical-gynecological factors after the recommendations concerning dTap vaccination in pregnancy issued by the Italian Ministry of Health (August 2018). An interview was also administered to a subgroup of 656 new mothers on the occasion of the first vaccination of their newborns, in order to assess the dTap vaccination advice received from maternal care providers during pregnancy. A generalized linear model (binomial family, log link) was implemented to give a correct estimate of the mother's relative risk of being vaccinated.

RESULTS

Several pregnant women-focused factors are evident, but the most important ones are related to maternal care providers' practices: after mutual adjustment, the explicit advice towards dTap maternal vaccination given by the Obstetrician-Gynecologist or the Midwife is associated with a 12-fold increase in the dTap coverage.

CONCLUSIONS

Multiprofessional training is essential to make Obstetricians-Gynecologists and Midwives more confident in recommending dTaP maternal immunization.

Prevalence of and factors associated with receipt of provider recommendation for influenza vaccination and uptake of influenza vaccination during pregnancy: cross-sectional study

BACKGROUND

Seasonal influenza vaccination has been recommended for pregnant women in Germany since 2010. The aim of this study was to examine prevalence and determinants of receipt of provider recommendation for influenza vaccination as well as influenza vaccination uptake during pregnancy.

METHODS

We analysed data from the "KUNO Kids Health Study", a prospective birth cohort. During the study period (5th July 2015 to 27th June 2018) data were collected from participating mothers by interview and questionnaire. According to Andersen's behavioural model of health services use potential influencing factors describing the circumstances and characteristics of the mothers and their pregnancies which are potentially affecting whether women receive a recommendation for a vaccination or whether they utilize influenza vaccination were classified into three domains: 'predisposing characteristics', 'enabling resources' and 'need'. Using multivariable logistic regression models odds ratios (OR) and corresponding 95% confidence intervals (95% CI) were calculated.

RESULTS

As a combined result across three flu seasons, 368 of 1814 (20.3%) women received an influenza vaccination recommendation during pregnancy. Having had a high-risk pregnancy increased the odds of receiving a vaccination recommendation (OR = 1.3; 95% CI = 1.0-1.6; p = 0.045). In contrast, pregnancy onset in summer (OR = 0.7; 95% CI = 0.5-1.0; p = 0.027), autumn (OR = 0.4; 95% CI = 0.3-0.5; p < =0.001) or winter (OR = 0.5; 95% CI = 0.3-0.6; p < =0.001) (compared to spring) as well as mother's birthplace outside Germany (OR = 0.6; 95% CI = 0.4-0.9; p = 0.023) reduced the chance of getting a vaccination recommendation. Two hundred forty-two of one thousand eight hundred sixty-five (13%) women were vaccinated against influenza during pregnancy. Having received a vaccination recommendation was strongly associated with vaccination uptake (OR = 37.8; 95% CI = 25.5-55.9; p < =0.001). Higher health literacy status was also associated with a higher chance of vaccination uptake (OR = 1.7; 95% CI = 1.2-2.6; p = 0.008), whereas pregnancy onset in autumn (compared to spring) reduced the chance (OR = 0.5; 95% CI = 0.3-0.8; p = 0.008).

CONCLUSIONS

At 13% the uptake rate of influenza vaccination is low. Having received a recommendation to vaccinate was strongly associated with uptake but only one fifth of all mothers report such a recommendation. Raising awareness in physicians regarding vaccinating during pregnancy seems to be of essential importance to increase vaccine uptake and to prevent influenza-related complications in pregnant women.

[Vaccination during pregnancy]

Hintergrund

Schwangere, Feten und Säuglinge weisen aufgrund von Besonderheiten ihres Immunsystems eine erhöhte infektionsbedingte Morbidität und Mortalität auf, die durch den Einsatz von Impfungen während der Schwangerschaft reduziert werden kann.

Ziel

In diesem Beitrag werden die Wirkungsweise, die Evidenz der zu erwartenden Effekte, Kontraindikationen und mögliche Nebenwirkungen von Impfungen in der Schwangerschaft erläutert.

Methode

Es wurde eine selektive Literaturrecherche unter besonderer Berücksichtigung der Empfehlungen der Ständigen Impfkommission am Robert Koch-Institut (STIKO) und einschlägiger Leitlinien durchgeführt.

Ergebnisse

Impfungen in der Schwangerschaft schützen die werdende Mutter vor schweren Verläufen einzelner Infektionskrankheiten und damit verbundenen Schwangerschaftskomplikationen. Zudem vermitteln sie dem Neugeborenen durch die vertikale Übertragung mütterlicher Antikörper einen passiven Immunschutz vor lebensbedrohlichen Infektionen. Für die Impfung mit inaktivierten Impfstoffen gegen Tetanus, Influenza und Pertussis sind Wirksamkeit und Sicherheit gut belegt. Impfungen mit Lebendvakzinen sind wegen ihres theoretischen Risikos für den Fetus kontraindiziert. Die Datenlage zur Anwendung der Impfstoffe gegen die „coronavirus disease 2019“ (COVID 19) ist noch limitiert.

Diskussion

Impfungen in der Schwangerschaft zielen auf den direkten Schutz der Schwangeren durch aktive Immunisierung und/oder des Kindes durch natürliche passive Immunisierung. Schwangere sollten von einer indizierten Impfung zum eigenen Schutz und dem des Kindes nicht ausgeschlossen werden. Zusätzliche sinnvolle Maßnahmen zum Schutz der Gesundheit von Mutter und Kind sind die Impfung enger Kontaktpersonen sowie das Schließen relevanter Impflücken junger Erwachsener, insbesondere bei Frauen im gebärfähigen Alter.

'My primary purpose is to protect the unborn child': Understanding pregnant women's perceptions of maternal vaccination and vaccine trials in Europe

Despite the important benefits of maternal vaccination for pregnant women and newborns, vaccination uptake is low in many European countries. Differences in vaccination policies and recommendations, as well as concerns about vaccine safety can partly explain inadequate coverage rates and women's hesitancy to get vaccinated during pregnancy. This study aims to explore pregnant women's experiences, decision-making processes and perceptions towards maternal vaccination and maternal vaccine trials in France, Germany, Italy, Spain and the United Kingdom. Qualitative interviews and focus groups were conducted with 258 pregnant women identified through local research panels and snowballing. Topic guides translated in local languages were designed to explore women's awareness and perceptions of maternal vaccination, and willingness to participate in vaccine trials during pregnancy. A thematic analysis was conducted. Pregnant women were found to have low awareness about maternal vaccination, with many reporting not having received a recommendation to vaccinate from their doctors. Strong trust in health professionals indicate that strengthened recommendations could improve vaccination uptake. Vaccination decision-making in pregnancy was described in the context of a highly emotional period, generating anxiety and fears around the safety of vaccines. Pregnancy was also discussed as a period during which women develop nurturing and protective identities. However, depending on the information they received as well as influences from experts, families and peers, women either perceived vaccination as a threat to their babies' safety or as a means to protect them. Attitudes towards maternal vaccine trials were less ambiguous, with most pregnant women strongly rejecting the notion of taking part in trials. While strategies to improve pregnant women's awareness and perceptions of maternal vaccination are needed, it is equally important to understand why healthcare professionals may not be recommending vaccination. More coordinated strategies across Europe could help strengthen communication and trust in maternal vaccination.

Healthcare Providers' Vaccine Perceptions, Hesitancy, and Recommendation to Patients: A Systematic Review

Despite vaccines' effectiveness in reducing the rate of preventable diseases, vaccine hesitancy has threatened public health and economies worldwide. Healthcare providers' (HCP) communications and behavior strongly influence patient receptivity and uptake. The goal of this review was to examine HCP vaccine perceptions, knowledge, and reservations and how these attitudes affect their recommendations and vaccination practices. Primary research studies published by 16 September 2020 were searched in PubMed, Web of Science, Embase, CINAHL, and PsycINFO. A 14-item scale was developed for survey study and risk of bias appraisal (SSRBA). In total, 96 papers from 34 countries were included, covering 17 vaccines (HPV and influenza vaccines the most studied). Recommendation was positively associated with provider knowledge and experience, beliefs about disease risk, and perceptions of vaccine safety, necessity, and efficacy. HCP vaccination attitudes and practices varied across specialties, vaccines, and countries; demographic impact was inconclusive. Barriers included anticipation of patient/parental concerns or refusal, lacking clear guidelines, time constraints, and cost. For HPV, vaccines were more often recommended to older, female adolescents and by physicians who discussed sexual health. HCPs are vital advocates for patients and the public, but studies indicated a prevalence of provider hesitancy pertaining to inadequate knowledge, low vaccine confidence, and suboptimal uptake themselves. Improving HCP knowledge and assuring their access to information they deem trustworthy are essential to supporting HCPs' role as "trusted messengers" to promote vaccine acceptance.

Experience and attitudes on vaccinations recommended during pregnancy: survey on an Italian sample of women and consultant gynecologists

Active immunization in pregnancy is recommended for the influenza and the tetanus, diphtheria, and acellular pertussis (Tdap) vaccines. Evidence indicates vaccine effectiveness in preventing influenza-related hospitalizations and pertussis in early infancy. We investigate vaccine uptake in pregnant and non-pregnant women through a sample of young women and consultant gynecologists, along with the potential predisposing and/or enabling factors affecting attitudes to vaccination (knowledge, beliefs, barriers). A cross-sectional study was conducted between June and September 2019, with a sample of 251 women and 14 consultant gynecologists at the Local Health Authority (ASL01) of the Abruzzo Region (Italy), using an anonymous, self-report questionnaire survey. Among the participants, 5.6% of women had received influenza vaccination, 16.4% had received Tdap during pregnancy and only 1.2% had received both vaccines. The assessment of the psychometric attitudinal variables has suggested a more positive willingness to receive Tdap than influenza vaccine among women, as the former is considered more important for the maternal and neonatal health. Health care workers have reported vaccine safety concerns, lack of information, and misconceptions about the need for vaccination as barriers to immunization in pregnant women. The results of this study will contribute to defining the goals and strategies to increase vaccine uptake under the current recommendations, through promoting effective training programs for all health care workers involved (gynecologists, obstetricians, public health physicians).

Barriers and Facilitators Associated With Vaccine Acceptance and Uptake Among Pregnant Women in High Income Countries: A Mini-Review

Vaccination during pregnancy is a safe and effective intervention to protect women from potentially severe consequences of influenza and reduce risk of influenza and pertussis in their infants. However, coverage remains variable. In this mini-review we update findings from a 2015 systematic review to describe results from recent studies in high income countries on the uptake of influenza and pertussis vaccination in pregnancy, reasons for vaccine hesitancy and barriers to increasing uptake, from maternal and healthcare provider (HCP) perspectives. Studies reported highly variable uptake (from 0% to 78%). A main facilitator for uptake among pregnant women was receiving a recommendation from their HCP. However, studies showed that HCP awareness of guidelines did not consistently translate into them recommending vaccines to pregnant women. Safety concerns are a well-established barrier to uptake/coverage of maternal immunization; 7%-52% of unvaccinated women gave safety concerns as a reason but these were also present in vaccinated women. Knowledge/awareness gaps among pregnant women and lack of confidence among HCPs to discuss vaccination were both important barriers. Several studies indicated that midwives were more likely to express safety concerns than other HCPs, and less likely to recommend vaccination to pregnant women. Women who perceived the risk of infection to be low were less likely to accept vaccination in several studies, along with women with prior vaccine refusal. Findings highlight the importance of further research to explore context-specific barriers to vaccination in pregnancy, which may include lack of vaccine confidence among pregnant woman and HCPs, and policy and structural factors.

Vaccination in Pregnancy

BACKGROUND

Vaccination during pregnancy can protect both the expecting mother and the unborn and newborn child from infectious diseases.

METHODS

This review is based on publications retrieved by a selective literature search on the immunological particularities of infectious diseases affecting pregnant women, unborn children, and neonates, with particular attention to the guidelines of the German Standing Committee on Vaccinations (Ständige Impfkommission, STIKO) and the pertinent guidelines.

RESULTS

Vaccination during pregnancy protects the expecting mother from a severe course of a number of different infectious diseases. Vaccination with inactivated vaccines against influenza, tetanus, and pertussis is effective, safe, and well tolerated. Women who are pregnant or of child-bearing age should be immunized against tetanus according to the STIKO recommendations. All pregnant women from the second trimester onward should receive an inactivated quadrivalent influenza vaccine. The immunity acquired after vaccination with an acellular pertussis vaccine is present only for a limited time. In a cohort study involving 72,781 pregnant women, pertussis vaccination during pregnancy was found to yield 91% protection against pertussis for their subsequently born children in the first three months of life. Further types of vaccine can also be given during pregnancy if indicated. Additional reasonable measures to protect the health of mother and child include the vaccination of other persons in close contact as well as the closure of relevant vaccination gaps among young adults, particularly women of child-bearing age. Treating physicians play a crucial role in encouraging vaccine acceptance by their patients.

CONCLUSION

Maternal immunization is a safe and effective strategy for giving neo - nates passive immune protection against life-threatening infections by the vertical transmission of maternal antibodies until they are able to build up their own adaptive immunity.

Evaluating the Association of Stillbirths After Maternal Vaccination in the Vaccine Safety Datalink

OBJECTIVE

To evaluate whether the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommended influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccinations in pregnancy are associated with increased risk of stillbirth.

METHODS

We performed a case-control study in the Vaccine Safety Datalink that was matched 1:4 on site, month, and year of last menstrual period, comparing the odds of vaccination in pregnancies that ended in stillbirth (defined as fetal loss at or after 20 weeks of gestation) compared with those that ended in live birth from January 1, 2012, to September 30, 2015. We included patients with singleton pregnancies that ended in stillbirth or live birth who had at least one prenatal care visit, pregnancy dating information, and continuous health plan enrollment for the duration of pregnancy. Medical records for all stillbirths were reviewed. We were statistically powered to detect an odds ratio (OR) of 1.37 when evaluating the association between influenza or Tdap vaccination and stillbirth. We also examined stillbirth rates in pregnant patients aged 14-49 years in the Vaccine Safety Datalink between 2007 and 2015.

RESULTS

In our matched analysis of 795 confirmed stillbirths in the case group and 3,180 live births in the control group, there was no significant association between influenza vaccination during pregnancy and stillbirth (343/795 [43.1%] stillbirths in the case group vs 1,407/3,180 [44.3%] live births in the control group, OR 0.94, adjusted OR 0.95, 95% CI 0.79-1.14, P=.54) and no significant association between Tdap vaccination during pregnancy and stillbirth (184/795 [23.1%] stillbirths in the case group vs 746/3,180 [23.5%] live births in the control group, OR 0.97, aOR 0.96, 95% CI 0.76-1.28, P=.91). From 2007 to 2015, the stillbirth rate in the Vaccine Safety Datalink was 5.2 per 1,000 live births and stillbirths.

CONCLUSION

No association was found between vaccination during pregnancy and the odds of stillbirth. These findings support the safety of ACIP recommendations for vaccination during pregnancy.

Knowledge and attitudes towards maternal immunization: perspectives from pregnant and non-pregnant mothers, their partners, mothers, healthcare providers, community and leaders in a selected urban setting in South Africa

BACKGROUND

Maternal immunization has prevented millions of child deaths globally; nevertheless, incomplete vaccination remains a public health concern in South Africa, where almost half of child deaths occur during neonatal period. This study explored the knowledge and attitudes inhibiting vaccine acceptancy during pregnancy.

METHODS

Key informant and semi-structured interviews were conducted with pregnant women receiving antenatal care at community clinics, antenatal care staff, women enrolled in maternal immunization trials, community leaders and non-pregnant women residing in Soweto. Focus Group Discussions were also held with the mothers and husbands/partners of the pregnant women (n = 55).

RESULTS

The study established good knowledge, a positive attitude and high acceptability of maternal immunization among pregnant women, non-pregnant women, antenatal staff as well as church and community leaders. Men were the least positive about maternal immunization. Aside from antenatal staff, there was poor knowledge regarding the types of vaccinations administered and the health benefits of immunization across all the study groups. Reasons adduced for poor knowledge about the types of vaccinations include lack of communication on maternal immunization during antenatal sessions or clinic visits and power dynamics that tend to exist between healthcare workers and patients.

CONCLUSION

Ensuring that healthcare workers provide useful information on immunization during antenatal visits as well as include men in education sessions regarding the benefit of vaccination may increase patients' confidence and immunization uptake.

Vaccinations and Chronic Diseases: Knowledge, Attitudes, and Self-Reported Adherence among Patients in Italy

The aims of this cross-sectional survey were to evaluate the knowledge, attitudes, and self-reported adherence to recommended vaccinations among a random sample of patients with chronic conditions presenting for a medical visit in out-patient clinics in Italy. Patients who were healthcare workers (HCWs), those with diabetes, those who had received information by Internet, physicians, and friends/relatives, and those who needed more information were more likely to know that the influenza vaccine is recommended for patients with chronic diseases. More than half (58.2%) and 8.9% self-reported to have received at least one recommended vaccination and more than one, respectively. Patients who believed that vaccine-preventable diseases (VPDs) were dangerous for them, those who had received information by physicians, and those who needed information were more likely to have received at least one recommended vaccination. This behavior was less likely in married patients, those who were worried about the side effects of the vaccines, and those who suffered from renal failure. The results highlight the need to implement effective vaccination programs in order to decrease the complication of VPDs in at-risk population.

The faces of influenza vaccine recommendation: A Literature review of the determinants and barriers to health providers' recommendation of influenza vaccine in pregnancy

INTRODUCTION

WHO recommends influenza vaccination for pregnant women and health providers (HPs), yet global uptake for both is persistently low. Research suggests that HPs greatly influence uptake of influenza vaccine in pregnant women. Our review studies HPs' recommendation of influenza vaccine to pregnant women, determinants and barriers to recommendation, and the role that HPs may play in global influenza vaccine coverage.

METHODS

We undertook a comprehensive global review of literature relating to HPs' recommendation of seasonal influenza vaccines to pregnant women and the determinants and barriers to recommendation and how this may vary by country and context. We evaluated data from each study including frequency of HP recommendation, vaccine coverage, determinants and barriers to recommendation, and the odds of recommending. We tracked the frequency of determinants and barriers to recommendation in heat maps and organized data by world regions and income classifications.

RESULTS

From 32 studies in 15 countries, we identified 68 determinants or barriers to HPs' recommendation. Recommendation rates were highest (77%) in the Americas and lowest in South East Asia (18%). A HP's own influenza vaccine status was a main determinant of recommendation in multiple country contexts and from different provider types. Financial barriers to recommendation were present in higher-income countries and policy-related barriers were highlighted in lower-income countries. HP perceptions of safety, efficacy, and the utility of vaccine were the most frequently cited barriers, relevant in almost every context.

CONCLUSIONS

HP recommendation is important to influenza vaccine implementation in pregnant women. A HP's own status is an important recommendation determinant in multiple contexts. Vaccine program implementation plans should consider the impact of HPs' knowledge, awareness and vaccine confidence on their own uptake and recommendation practices, as well as on the uptake among pregnant women. Addressing safety and efficacy concerns is relevant in all contexts for HPs and pregnant women.

Influenza Vaccination Experiences of Pregnant Women as a Predictor of the Intention to Become Vaccinated in Future Pregnancies in Spain

A good perception of the vaccines administered during pregnancy favors immunization coverage, which is still not optimal for the influenza vaccine. To understand the predisposition towards vaccination in future pregnancies, a study was performed that evaluated the experiences of women with the vaccine or influenza. A cross-sectional study was conducted through telephone interviews given to a total of 683 postpartum women in two health departments from the Valencia Community (Spain). This interview asked about their intention of becoming vaccinated in future pregnancies and whether they were favor or against vaccination. Most of them, 98.5% (n = 673 [95% CI: 97.6–99.4]) (p < 0.001) declared having received the systematic vaccines throughout their lives. The ones who were vaccinated against influenza, 91.9% (n = 387 [95% CI: 89.2–94.6]) (p < 0.001) manifested they would do so in future pregnancies. The probability of future non-vaccination was modeled, which was related to an unfavorable opinion towards vaccines (OR = 4.07 [95% CI: 2.01–8.24]) (p < 0.001), having suffered from influenza during pregnancy (OR = 3.84 [95% CI: 1.41–10.42]) (p < 0.05), and not having been vaccinated during previous pregnancies (OR = 38.47 [95% CI: 23.58–62.76]) (p < 0.001). Vaccination during pregnancy increases the intent of vaccination in the future.

Vaccines are underused in pregnancy: what about knowledge, attitudes and practices of providers?

Introduction.

To investigate actual knowledge of official recommendations towards seasonal influenza (SID), and Tetanus-diphtheria acellular-pertussis (Tdap) vaccines in obstetrics/gynecologists (OBGYN).

Methods.

PubMed and EMBASE databases were searched. A meta-analysis was performed to calculate odds ratio (OR) and 95% confidence interval (CI) among case controls, cross-sectional studies, either questionnaire or laboratory exams based.

Results.

A total of 6 studies met inclusion criteria, including 1323 OBGYN from 5 different countries. Overall, around 99% of sampled professionals were aware that official recommendations towards SID in pregnancy do exist, compared to 92% for Tdap, with significant heterogeneity (I² > 95%, p < 0.001). Concerns about vaccine safety was reported by 10% of respondents for Tdap, and by 6.0% for SID, but again available studies were substantially heterogenous (I² = 86.7% and 86.0%, p < 0.001). Eventually, 93% of respondents actively recommended SID in pregnancy, compared to 88% for Tdap (I² 98.8% and I² 95.9%, respectively p < 0.001). The evidence of significant publication bias was initially subjectively identified from the funnel plot, and then objectively confirmed through the regression test for all analyses.

Conclusions.

These results suggest an appropriated understanding of official recommendation among sampled OBGYN, with high shares of professionals actively promoting vaccination practices among their patients. Despite the high heterogeneity and the significant publication bias we identified, our results also hint towards extensive knowledge gaps of OBGYN, and particularly regarding unmotivated concerns about vaccine safety. As a consequence, appropriate information and formation campaigns should be appropriately tailored. (www.actabiomedica.it)