FEATURE
fication for vaccinating pregnant women comes from observation-
al studies that clinical influenza results in more severe outcomes
among pregnant women than among non-pregnant women, espe-
cially for disease during pandemics but also for seasonal influenza.
Influenza vaccines are efficacious against influenza – like illness
and laboratory – confirmed influenza in pregnant women and
their infants. Influenza safety data has been reviewed recently and
conclude that benefits of routine influenza vaccinations during
pregnancy are multiple and far outweigh any theoretical risks to
the mother or fetus.
PNEUMOCOCCAL (PPSV23)
Streptococcus pneumonia is a major cause of pneumonia, menin-
gitis and otitis media in young children, adults and persons who
are immunodeficient. It may be a primary pathogen or a second-
ary invader after influenza infections. It is estimated that invasive
pneumococcal disease causes 40,000-50,000 cases of illness and
5,000 deaths among persons of all ages in the United States. The
case-fatality rate of 36 percent is present in patients with pneumo-
coccal bacteremia and has not changed in 60 years.
Worldwide, pertussis is a significant disease burden with 20 to 40
million cases annually and an estimated 200,000-400,000 deaths,
mostly in young children. The estimated annual number of cases
in the United States from 1934 – 1943 was 200,752 with 4,034 an-
nual deaths. With the introduction of whole-cell vaccines in the
1920’s the number of deaths declined and <1,000 patients were
diagnosed with pertussis in 1976. However, the number of cases
has been increasing since then. In 2010 there were >9100 cases in
California alone with 10 neonatal deaths under the age of three
months. ACIP has not included pregnancy alone as a universal recom-
mendation for the 23-valent pneumococcal polysaccharide vac-
cine (PPSV23) but recommends the vaccine if the patient has one
of 21 risk indications. (Table 3) PPSV 23 vaccine can be admin-
istered at any time during pregnancy. One-time re-vaccination is
recommended for persons with very high risk conditions in five
years. Patients remember PPSV23 as the “pneumonia shot” to dif-
ferentiate it from the “flu shot.” The conditions in the risk recom-
mended list are frequently seen in pregnant women and making
it part of the MIP helps to remind the clinicians of the need for
PPSV23. Pregnancy data is not available for the Prevnar 13 pneu-
mococcal vaccine.
Young infants suffer a substantial disease burden with the
highest incidence of hospitalization and mortality rates (Table 2). TABLE 3: ADULTS WHO ARE RECOMMENDED TO RECEIVE
PNEUMOCOCCAL POLYSACCHARIDE VACCINE (PPSV23) (14)
PERTUSSIS
Studies have demonstrated that maternal immunizations from
20-35 weeks gestation will result in umbilical cord concentrations
of pertussis toxin IgG that are twice the level found in maternal
serum and will provide protection against pertussis in the infant
for three to six months of life.
ACIP now recommends that pregnant women should receive
one dose of Tdap vaccine during each pregnancy at 20 weeks to 35
weeks of gestation with preference from 27-35 weeks. If the preg-
nant patient does not receive Tdap during pregnancy she should
receive it post-partum.
Tdap is the second maternal vaccine to be included in the MIP,
having been added in 2008, and is now receiving increasing atten-
tion as the cases of Pertussis increase in the United States.
Risk
Co-morbid Medical
Conditions
Heart Disease
Chronic Lung Disease
Asthma
Diabetes Mellitus
Cerebrospinal Fluid Levels
Cochlear Implants
Alcoholism
Chronic liver disease
Cigarette smoking
Functional or anatomic Hemoglobinopathies
asplenia
Congenital or acquired asplenia
Splenectomy
Immuno Compromised
TABLE 2: HOSPITALIZATION AND COMPLICATIONS AMONG
18,564 INFANTS AGED LESS THAN 12 MONTHS WITH
PERTUSSIS (2000 TO 2006) UNITED STATES (10)
COMPLICATIONS
Example
Congenital or acquired immune
deficiencies
HIV Infection
Chronic renal disease
Nephrotic syndrome
Leukemias
Hodgkin’s disease
Disease requiring immosuppressive
drugs
Solid organ transplants
Multiple myeloma
# % Hospitalization 9078 61 Apnea 8348 56 Pneumonia 1578 12.8 HEPATITIS B
Seizures 186 1.3 Deaths 145 0.8 The current ACIP recommendations include administering the
HBV vaccine to all persons universally prior to age 19 includ-
ing unvaccinated pregnant women and to persons who have any
Some patients had more than 1 complication
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NOVEMBER 2018
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