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Krubiner CB, Faden RR, Karron RA, Little MO, Lyerly AD, Abramson JS, Beigi RH, Cravioto AR, Durbin AP, Gellin BG, Gupta SB, Kaslow DC, Kochhar S, Luna F, Saenz C, Sheffield JS, Tindana PO. Pregnant women & vaccines against emerging epidemic threats: Ethics guidance for preparedness, research, and response. Vaccine 2021; 39:85-120. [PMID: 31060949 PMCID: PMC7735377 DOI: 10.1016/j.vaccine.2019.01.011] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 01/07/2019] [Indexed: 12/22/2022]
Abstract
Zika virus, influenza, and Ebola have called attention to the ways in which infectious disease outbreaks can severely - and at times uniquely - affect the health interests of pregnant women and their offspring. These examples also highlight the critical need to proactively consider pregnant women and their offspring in vaccine research and response efforts to combat emerging and re-emerging infectious diseases. Historically, pregnant women and their offspring have been largely excluded from research agendas and investment strategies for vaccines against epidemic threats, which in turn can lead to exclusion from future vaccine campaigns amidst outbreaks. This state of affairs is profoundly unjust to pregnant women and their offspring, and deeply problematic from the standpoint of public health. To ensure that the needs of pregnant women and their offspring are fairly addressed, new approaches to public health preparedness, vaccine research and development, and vaccine delivery are required. This Guidance offers 22 concrete recommendations that provide a roadmap for the ethically responsible, socially just, and respectful inclusion of the interests of pregnant women in the development and deployment of vaccines against emerging pathogens. The Guidance was developed by the Pregnancy Research Ethics for Vaccines, Epidemics, and New Technologies (PREVENT) Working Group - a multidisciplinary, international team of 17 experts specializing in bioethics, maternal immunization, maternal-fetal medicine, obstetrics, pediatrics, philosophy, public health, and vaccine research and policy - in consultation with a variety of external experts and stakeholders.
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Affiliation(s)
- Carleigh B Krubiner
- Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD, USA.
| | - Ruth R Faden
- Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD, USA; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ruth A Karron
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Margaret O Little
- Kennedy Institute of Ethics, Georgetown University, Washington, D.C., USA
| | - Anne D Lyerly
- University of North Carolina Center for Bioethics, Chapel Hill, NC, USA
| | - Jon S Abramson
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Richard H Beigi
- Magee-Womens Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Anna P Durbin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | | | | | - Carla Saenz
- Pan American Health Organization, Washington, D.C., USA
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Gerber N, Flynn PA, Holzer RJ. Coronary Artery Dilation in an Asymptomatic Pediatric Patient with COVID19 Antibodies. Pediatr Cardiol 2021; 42:460-462. [PMID: 33547936 PMCID: PMC7865102 DOI: 10.1007/s00246-021-02566-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/27/2021] [Indexed: 12/17/2022]
Abstract
We describe a 16-year-old asymptomatic male who presented with coronary artery dilation (z score + 2.3) identified on echo performed solely for presence of COVID-19 antibodies. This case raises the question of whether cardiac screening should be considered for all patients with a history of COVID-19.
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Affiliation(s)
- Nicole Gerber
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New York, USA ,New York Presbyterian-Weill Cornell Medical Center, New York, USA
| | - Patrick A. Flynn
- Division of Pediatric Cardiology, Department of Pediatrics, New York, USA ,New York Presbyterian-Weill Cornell Medical Center, New York, USA
| | - Ralf J. Holzer
- Division of Pediatric Cardiology, Department of Pediatrics, New York, USA ,New York Presbyterian-Weill Cornell Medical Center, New York, USA
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3
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Buchwald AG, Teguete I, Doumbia M, Haidara FC, Coulibaly F, Diallo F, Sow SO, Blackwelder WC, Tapia MD. Clinical Evaluations Have Low Sensitivity for Identifying Preterm Infants in a Clinical Trial in a Limited Resource Setting. Glob Pediatr Health 2019; 6:2333794X19857402. [PMID: 31263743 PMCID: PMC6595652 DOI: 10.1177/2333794x19857402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 02/24/2019] [Accepted: 05/24/2019] [Indexed: 11/20/2022] Open
Abstract
Preterm birth is a primary outcome of interest in maternal vaccination trials but determination of gestational age is challenging in limited-resource settings. This study compares the New Ballard Score and fundal height measurements with the current standard of early ultrasound for sensitivity of predicting preterm birth. A trial of maternal influenza vaccination was conducted in Bamako, Mali. The New Ballard Score and fundal height were collected on 4038 infants born in the trial, ultrasound data were available for 1893 of those infants. New Ballard Score and fundal height were compared, consecutively, to all ultrasound results, early ultrasound results from the first trimester, and the date of last menstrual period for estimation of gestational age. Sensitivity of the New Ballard Score for identifying preterm infants was 0.33 compared with early ultrasound and 0.1 compared with the last menstrual period based estimates of gestational age. Sensitivity of low birth weight alone was 0.43 compared with early ultrasound. New Ballard Score estimated gestational age within 1 week of ultrasound more frequently than fundal height (53% compared with 7.6%, respectively) yet New Ballard Score identified few infants as preterm (1.8% vs 5.8% by early ultrasound), and was biased toward categorizing low birth weight infants and infants requiring hospitalization as preterm. New Ballard Score is not an ideal measure for identifying preterm births in low-resource settings. Despite the time and cost of training required for correct measurement of New Ballard Score, measurement of low birth weight alone performed better than New Ballard Score for identifying preterm infants.
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Affiliation(s)
- Andrea G Buchwald
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Moussa Doumbia
- Centre pour le Developpement des Vaccins-Mali, Bamako, Mali
| | | | | | | | - Samba O Sow
- Centre pour le Developpement des Vaccins-Mali, Bamako, Mali
| | | | - Milagritos D Tapia
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
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4
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Kochhar S, Edwards KM, Ropero Alvarez AM, Moro PL, Ortiz JR. Introduction of new vaccines for immunization in pregnancy - Programmatic, regulatory, safety and ethical considerations. Vaccine 2019; 37:3267-3277. [PMID: 31072733 PMCID: PMC6771279 DOI: 10.1016/j.vaccine.2019.04.075] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 04/18/2019] [Accepted: 04/24/2019] [Indexed: 12/11/2022]
Abstract
Immunizing pregnant women is a promising strategy to reduce infectious disease-related morbidity and mortality in pregnant women and their infants. Important pre-requisites for the successful introduction of new vaccines for immunization in pregnancy include political commitment and adequate financial resources: trained, committed and sufficient numbers of healthcare workers to deliver the vaccines; close integration of immunization programs with antenatal care and Maternal and Child Health services; adequate access to antenatal care by pregnant women in the country (especially in low and middle-income countries (LMIC)); and a high proportion of births occurring in health facilities (to ensure maternal and neonatal follow-up can be done). The framework needed to advance a vaccine program from product licensure to successful country-level implementation includes establishing and organizing evidence for anticipated vaccine program impact, developing supportive policies, and translating policies into local action. International and national coordination efforts, proactive planning from conception to implementation of the programs (including country-level policy making, planning, and implementation, regulatory guidance, pharmacovigilance) and country-specific and cultural factors must be taken into account during the vaccines introduction.
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Affiliation(s)
- Sonali Kochhar
- Global Healthcare Consulting, New Delhi, India; Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands; Department of Global Health, University of Washington, Seattle, USA.
| | - Kathryn M Edwards
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, TN, USA
| | - Alba Maria Ropero Alvarez
- Comprehensive Family Immunization Unit, Department of Family, Health Promotion and Life Course (FPL). Pan American Health Organization (PAHO/WHO), Washington DC, USA
| | - Pedro L Moro
- Immunization Safety Office, Division Of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, USA
| | - Justin R Ortiz
- Department of Global Health, University of Washington, Seattle, USA; Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
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5
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Abstract
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.
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Affiliation(s)
- Alisa Kachikis
- 1 Department of Obstetrics and Gynecology, University of Washington , Seattle, Washington
| | - Linda O Eckert
- 1 Department of Obstetrics and Gynecology, University of Washington , Seattle, Washington.,2 Department of Global Health, University of Washington , Seattle, Washington
| | - Janet Englund
- 3 Department of Pediatrics, Pediatric Infectious Diseases, Seattle Children's Hospital, University of Washington , Seattle, Washington
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Cutland CL, Lackritz EM, Mallett-Moore T, Bardají A, Chandrasekaran R, Lahariya C, Nisar MI, Tapia MD, Pathirana J, Kochhar S, Muñoz FM. Low birth weight: Case definition & guidelines for data collection, analysis, and presentation of maternal immunization safety data. Vaccine 2017; 35:6492-6500. [PMID: 29150054 PMCID: PMC5710991 DOI: 10.1016/j.vaccine.2017.01.049] [Citation(s) in RCA: 202] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 01/13/2017] [Indexed: 01/09/2023]
Affiliation(s)
- Clare L Cutland
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Johannesburg, South Africa; Department of Science and Technology National Research Foundation, Vaccine Preventable Diseases, South Africa; Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Eve M Lackritz
- Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), Seattle Children's Research Institute, Seattle, WA, USA
| | | | - Azucena Bardají
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic - University of Barcelona, Barcelona, Spain
| | | | - Chandrakant Lahariya
- Department of Community Medicine, GR Medical College and Associated Hospitals, Gwalior, MP, India
| | - Muhammed Imran Nisar
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Milagritos D Tapia
- University of Maryland School of Medicine, Center for Vaccine Development, MD, USA
| | - Jayani Pathirana
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Johannesburg, South Africa; Department of Science and Technology National Research Foundation, Vaccine Preventable Diseases, South Africa; Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sonali Kochhar
- Global Healthcare Consulting, India; Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Flor M Muñoz
- Baylor College of Medicine, Departments of Pediatrics, Molecular Virology and Microbiology, Houston, TX, USA
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7
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Boatin AA, Eckert LO, Boulvain M, Grotegut C, Fisher BM, King J, Berg M, Adanu RMK, Reddy U, Waugh JJS, Gupta M, Kochhar S, Kenyon S. Dysfunctional labor: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2017; 35:6538-6545. [PMID: 29150059 PMCID: PMC5710983 DOI: 10.1016/j.vaccine.2017.01.050] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 01/13/2017] [Indexed: 01/30/2023]
Affiliation(s)
- Adeline A Boatin
- Department of OB/GYN, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
| | | | | | - Chad Grotegut
- Division of Maternal-Fetal Medicine, Duke University, USA
| | - Barbra M Fisher
- Maternal Fetal Medicine, Northwest Perinatal Centre, Women's Healthcare Associates, LLC, Portland, USA
| | | | - Marie Berg
- Institute of Health Care Science, University of Gothenburg, Gothenburg, Sweden
| | | | - Uma Reddy
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, USA
| | - Jason J S Waugh
- Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | | | - Sonali Kochhar
- Global Healthcare Consulting, India; Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sara Kenyon
- Reader in Evidence Based Maternity Care, Institute for Applied Health Research, University of Birmingham, United Kingdom
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8
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Household costs and time to seek care for pregnancy related complications: The role of results-based financing. PLoS One 2017; 12:e0182326. [PMID: 28934320 PMCID: PMC5608189 DOI: 10.1371/journal.pone.0182326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 07/16/2017] [Indexed: 11/19/2022] Open
Abstract
Results-based financing (RBF) schemes-including performance based financing (PBF) and conditional cash transfers (CCT)-are increasingly being used to encourage use and improve quality of institutional health care for pregnant women in order to reduce maternal and neonatal mortality in low-income countries. While there is emerging evidence that RBF can increase service use and quality, little is known on the impact of RBF on costs and time to seek care for obstetric complications, although the two represent important dimensions of access. We conducted this study to fill the existing gap in knowledge by investigating the impact of RBF (PBF+CCT) on household costs and time to seek care for obstetric complications in four districts in Malawi. The analysis included data on 2,219 women with obstetric complications from three waves of a population-based survey conducted at baseline in 2013 and repeated in 2014(midline) and 2015(endline). Using a before and after approach with controls, we applied generalized linear models to study the association between RBF and household costs and time to seek care. Results indicated that receipt of RBF was associated with a significant reduction in the expected mean time to seek care for women experiencing an obstetric complication. Relative to non-RBF, time to seek care in RBF areas decreased by 27.3% (95%CI: 28.4-25.9) at midline and 34.2% (95%CI: 37.8-30.4) at endline. No substantial change in household costs was observed. We conclude that the reduced time to seek care is a manifestation of RBF induced quality improvements, prompting faster decisions on care seeking at household level. Our results suggest RBF may contribute to timely emergency care seeking and thus ultimately reduce maternal and neonatal mortality in beneficiary populations.
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Beeler JA, Lambach P, Fulton TR, Narayanan D, Ortiz JR, Omer SB. A systematic review of ethical issues in vaccine studies involving pregnant women. Hum Vaccin Immunother 2016; 12:1952-1959. [PMID: 27246403 PMCID: PMC4994733 DOI: 10.1080/21645515.2016.1186312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 04/19/2016] [Accepted: 04/30/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Immunization during pregnancy can provide protection for mother and child. However, there have been only a limited number of studies documenting the efficacy and safety of this strategy. AIMS To determine the extent and nature of subject matter related to ethics in maternal immunization by systematically documenting the spectrum of ethical issues in vaccine studies involving pregnant women. METHOD We conducted a systematic literature review of published works pertaining to vaccine and therapeutic studies involving pregnant women through searches of PubMed, EMBASE, Web of Science, the Cochrane Database, and ClinicalTrials.gov. We selected literature meeting the inclusion criteria published between 1988 and June 2014. We systematically abstracted subject matter pertaining to ethical issues in immunization studies during pregnancy. Immunization-specific ethical issues were matched and grouped into major categories and subcategories. RESULTS Seventy-seven published articles met the inclusion criteria. Published articles reported findings on data that had been collected in 26 countries, the majority of which were classified as high-income or upper-middle-income nations according to World Bank criteria. Review of these publications produced 60 immunization-specific ethical issues, grouped into six major categories. Notably, many studies demonstrated limited acknowledgment of key ethical issues including the rights and welfare of participants. Additionally, there was no discussion pertaining to the ethics of program implementation, including integration of maternal immunization programs into existing routine immunization programs. CONCLUSION This review of ethical issues in immunization studies of pregnant women can be used to help inform future vaccine trials in this important population. Consistent documentation of these ethical issues by investigators will facilitate a broader and more nuanced discussion of ethics in immunization of pregnant women - offering new and valuable insights for programs developed to prevent disease in newborn children in low- and middle-income countries.
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Affiliation(s)
- Jennifer A. Beeler
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Philipp Lambach
- Initiative for Vaccine Research, World Health Organization, Geneva, Switzerland
| | - T. Roice Fulton
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Divya Narayanan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Justin R. Ortiz
- Initiative for Vaccine Research, World Health Organization, Geneva, Switzerland
| | - Saad B. Omer
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Emory Vaccine Center, Emory University, Atlanta, GA, USA
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10
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Patwardhan M, Eckert LO, Spiegel H, Pourmalek F, Cutland C, Kochhar S, Gonik B. Maternal death: Case definition and guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2016; 34:6077-6083. [PMID: 27426627 PMCID: PMC5139803 DOI: 10.1016/j.vaccine.2016.03.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/15/2016] [Indexed: 11/02/2022]
Affiliation(s)
- M Patwardhan
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA.
| | - L O Eckert
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - H Spiegel
- Henry Jackson Foundation, Bethesda, MD, USA
| | - F Pourmalek
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - C Cutland
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Johannesburg, Department of Science and Technology National Research Foundation, Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - B Gonik
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
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Osterholm M, Moore K, Ostrowsky J, Kimball-Baker K, Farrar J. The Ebola Vaccine Team B: a model for promoting the rapid development of medical countermeasures for emerging infectious disease threats. THE LANCET. INFECTIOUS DISEASES 2016; 16:e1-e9. [PMID: 26526664 PMCID: PMC7106346 DOI: 10.1016/s1473-3099(15)00416-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 10/26/2015] [Indexed: 12/04/2022]
Abstract
In support of accelerated development of Ebola vaccines from preclinical research to clinical trials, in November, 2014, the Wellcome Trust and the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota established the Wellcome Trust-CIDRAP Ebola Vaccine Team B initiative. This ongoing initiative includes experts with global experience in various phases of bringing new vaccines to market, such as funding, research and development, manufacturing, determination of safety and efficacy, regulatory approval, and vaccination delivery. It also includes experts in community engagement strategies and ethical issues germane to vaccination policies, including eight African scientists with direct experience in developing and implementing vaccination policies in Africa. Ebola Vaccine Team B members have worked on a range of vaccination programmes, such as polio eradication (Africa and globally), development of meningococcal A disease vaccination campaigns in Africa, and malaria and HIV/AIDS vaccine research. We also provide perspective on how this experience can inform future situations where urgent development of vaccines is needed, and we comment on the role that an independent, expert group such as Team B can have in support of national and international public health authorities toward addressing a public health crisis.
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Affiliation(s)
- Michael Osterholm
- Center for Infectious Disease Research and Policy, University of Minnesota, Minneapolis, MN, USA.
| | - Kristine Moore
- Center for Infectious Disease Research and Policy, University of Minnesota, Minneapolis, MN, USA
| | - Julie Ostrowsky
- Center for Infectious Disease Research and Policy, University of Minnesota, Minneapolis, MN, USA
| | - Kathleen Kimball-Baker
- Center for Infectious Disease Research and Policy, University of Minnesota, Minneapolis, MN, USA
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Fulton TR, Narayanan D, Bonhoeffer J, Ortiz JR, Lambach P, Omer SB. A systematic review of adverse events following immunization during pregnancy and the newborn period. Vaccine 2015; 33:6453-65. [PMID: 26413879 PMCID: PMC8290429 DOI: 10.1016/j.vaccine.2015.08.043] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 08/07/2015] [Accepted: 08/11/2015] [Indexed: 01/31/2023]
Abstract
In 2013, the WHO Strategic Advisory Group of Experts on Immunization (SAGE) requested WHO to develop a process and a plan to move the maternal immunization agenda forward in support of an increased alignment of data safety evidence, public health needs, and regulatory processes. A key challenge identified was the continued need for harmonization of maternal adverse event following immunization (AEFI) research and surveillance efforts within developing and developed country contexts. We conducted a systematic review as a preliminary step in the development of standardized AEFI definitions for use in maternal and neonatal clinical trials, post-licensure surveillance, and other vaccine studies. We documented the current extent and nature of variability in AEFI definitions and adverse event reporting among 74 maternal immunization studies, which reported a total of 240 different types of adverse events. Forty-nine studies provided explicit AEFI case definitions describing 35 separate types of AEFIs. We identified variability in how AEFIs were determined to be present, in how AEFI definitions were applied, and in the ways that AEFIs were reported. Definitions for key maternal/neonatal AEFIs differed on four discrete attributes: overall level of detail, physiological and temporal boundaries and cut-offs, severity strata, and standards used. Our findings suggest that investigators may proactively address these inconsistencies through comprehensive and consistent reporting of AEFI definitions and outcomes in future publications. In addition, efforts to develop standardized AEFI definitions should generate definitions of sufficient detail and consistency of language to avoid the ambiguities we identified in reviewed articles, while remaining practically applicable given the constraints of low-resource contexts such as limited diagnostic capacity and high patient throughput.
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Affiliation(s)
- T Roice Fulton
- Departments of Global Health and Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322, USA.
| | - Divya Narayanan
- Departments of Global Health and Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322, USA.
| | - Jan Bonhoeffer
- University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, 4056 Basel, Switzerland; Brighton Collaboration Foundation, Spitalstrasse 33, 4056 Basel, Switzerland.
| | - Justin R Ortiz
- Initiative for Vaccine Research, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland.
| | - Philipp Lambach
- Initiative for Vaccine Research, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland.
| | - Saad B Omer
- Departments of Global Health and Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322, USA; Department of Pediatrics, Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA 30307, USA; Emory Vaccine Center, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA.
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13
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Keller-Stanislawski B, Englund JA, Kang G, Mangtani P, Neuzil K, Nohynek H, Pless R, Lambach P, Zuber P. Safety of immunization during pregnancy: a review of the evidence of selected inactivated and live attenuated vaccines. Vaccine 2014; 32:7057-64. [PMID: 25285883 DOI: 10.1016/j.vaccine.2014.09.052] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 09/19/2014] [Accepted: 09/20/2014] [Indexed: 01/12/2023]
Abstract
Vaccine-preventable infectious diseases are responsible for significant maternal, neonatal, and young infant morbidity and mortality. While there is emerging scientific evidence, as well as theoretical considerations, indicating that certain vaccines are safe for pregnant women and fetuses, policy formulation is challenging because of perceived potential risks to the fetus. This report presents an overview of available evidence on pregnant women vaccination safety monitoring in pregnant women, from both published literature and ongoing surveillance programs. Safety data were reviewed for vaccines against diseases which increase morbidity in pregnant women, their fetus or infant as well as vaccines which are used in mass vaccination campaigns against diseases. They include inactivated seasonal and pandemic influenza, mono- and combined meningococcal polysaccharide and conjugated vaccines, tetanus toxoid and acellular pertussis combination vaccines, as well as monovalent or combined rubella, oral poliomyelitis virus and yellow fever vaccines. No evidence of adverse pregnancy outcomes has been identified from immunization of pregnant women with these vaccines.
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Affiliation(s)
| | - Janet A Englund
- Seattle Children's Hospital, Division of Infectious Diseases, 4800 Sand Point Way N.E., R5441, Seattle, WA 98105, USA.
| | - Gagandeep Kang
- Christian Medical College, Vellore 632 004, Tamil Nadu, India.
| | - Punam Mangtani
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
| | - Kathleen Neuzil
- University of Washington, PATH, Street: 2201 Westlake Avenue, Suite 200, Seattle, WA 98121, Seattle, WA 98109, USA; National Institute for Health and Welfare THL, P.O. Box 30, FI-00271 Helsinki, Finland.
| | - Hanna Nohynek
- National Institute for Health and Welfare THL, P.O. Box 30, FI-00271 Helsinki, Finland.
| | - Robert Pless
- Public Health Agency of Canada, 130 Colonnade Road, A/L 6502A, Ottawa, ON, K1A 0K9, Canada.
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Safety of cotrimoxazole in pregnancy: a systematic review and meta-analysis. J Acquir Immune Defic Syndr 2014; 66:512-21. [PMID: 24853309 DOI: 10.1097/qai.0000000000000211] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Cotrimoxazole is widely prescribed to treat a range of infections, and for HIV-infected individuals it is administered as prophylaxis to protect against opportunistic infections. Some reports suggest that fetuses exposed to cotrimoxazole during early pregnancy may have an increased risk of congenital anomalies. We carried out this systematic review to update the evidence of cotrimoxazole safety in pregnancy. METHODS Three databases and 1 conference abstract site were searched in duplicate up to October 31, 2013, for studies reporting adverse maternal and infant outcomes among women receiving cotrimoxazole during pregnancy. This search was updated in MEDLINE via PubMed to April 28, 2014. Studies were included irrespective of HIV infection status or the presence of other coinfections. Our primary outcome was birth defects of any kind. Secondary outcomes included spontaneous abortions, terminations of pregnancy, stillbirths, preterm deliveries, and drug-associated toxicity. RESULTS Twenty-four studies were included for review. There were 232 infants with congenital anomalies among 4196 women receiving cotrimoxazole during pregnancy, giving an overall pooled prevalence of 3.5% (95% confidence interval: 1.8% to 5.1%; τ² = 0.03). Three studies reported 31 infants with neural tube defects associated with first trimester exposure to cotrimoxazole, giving a crude prevalence of 0.7% (95% confidence interval: 0.5% to 1.0%) with most data (29 neural tube defects) coming from a single study. The majority of adverse drug reactions were mild. The quality of the evidence was very low. CONCLUSIONS The findings of this review support continued recommendations for cotrimoxazole as a priority intervention for HIV-infected pregnant women. It is critical to improve data collection on maternal and infant outcomes.
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