MATERNAL VACCINATION. Dr Sushena Krishnaswamy

Transcription

1 MATERNAL VACCINATION Dr Sushena Krishnaswamy CVU November 2017

2 Outline 1. Principles 2. Flu- infant benefit 3. Pertussis- optimal timing, cocooning 4. How we re faring 5. Strategies to improve uptake 6. RSV and GBS

3 Vaccination during pregnancy: not a new concept Tetanus 1960s Influenza 1960s 2010 Pertussis 2015 RSV Group B Streptococcus

4 The benefits of maternal immunisation Through short term passive immunity until active immunisation maternal antibody (IgG) transfer across placenta first detected at 13 weeks gestation increases throughout pregnancy so majority in last 4 weeks Lackritz et al Maternal Immunization Safety Monitoring in LMIC: A roadmap for program development. Report by Bill and Melinda Gates Foundation and GAPPS 2017

5 INFLUENZA

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7 3 for 1 benefit of influenza vaccination during pregnancy Maternal Efficacy same as in general population (44-73%) Fetal systematic reviews since 2014: no adverse fetal outcomes a/w maternal vaccination preterm birth low birth weight Infantl % decrease in lab-proven flu in infants <6months old 29% decrease in resp illness with fever in infants <6 months old 81% decrease in hospitalisations for influenza in infants <6 months old 1 Fell BJOG 2014, 2 Bratton CID 2015, 3 McMillan Vaccine 2015, 4 Polyzos Obstet & Gynecol 2015, 5 Nunes Am J Perinatology Zaman NEJM 2008, 7 Shakib Pediatrics 2016, 8 Nunes CID 2017

8 PERTUSSIS

9 Clinical question #1 A woman presents at 24 weeks requesting pertussis vaccine. This is her first pregnancy. What do you do? A. Vaccinate her and advise her that protection may not be as high compared with if she waits until after 28 weeks B. Vaccinate her and advise her protection may be higher than if she waits until after 28 weeks C. Tell her to return after 28 weeks Courtesy Michelle Giles

10 What do the guidelines say? US: weeks A lia: weeks UK: weeks

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12 Abu Raya Vaccine 2014

13 Naidu AJOG 2016

14 CID 2016:62 (7) 1 April Eberhardt CID 2016

15 Clinical question #2 A woman presents at 24 weeks requesting pertussis vaccine. Her last pregnancy was complicated by preterm labour at 29 weeks. What do you do? A. Vaccinate her and advise her that protection may not be as high as if she waits until after 28 weeks B. Vaccinate her and tell her protection may be higher than if she waits until after 28 weeks C. Tell her to return at 28 weeks Courtesy Michelle Giles

16 Naidu AJOG 2016

17 Abu Raya CID 2016

18 Eberhardt CID 2016:62 (7) 1 April

19 Eberhardt CID 2017

20 Clinical question #3 A GP calls for advice. He is seeing a pregnant woman in her first trimester. This is her second pregnancy, she had a baby 11 months ago. She received a pertussis vaccine late in the 3 rd trimester of her last pregnancy. The GP is asking does she really need another given she had one just over 12 months ago? Courtesy Michelle Giles

21 Abu Raya JID 2015

22 Median half life of maternal Ab in infants was 47 days importance of first dose at 6 weeks of age Higher the cord blood Ab titre at birth, the greater proportion with high Ab titres at 2 months of age

23 Clinical question #4 How important is it to recommend partners or grandparents receive the pertussis vaccine in addition to pregnant women? Maternal vaccination protects infant from all sources of infection

24 Moderate association between women and partner dtpa (kappa = 0.55) 83% of partners vaccinated if woman vaccinated vs 26% if not 22.4% of newborns discharged to household where neither parent vaccinated Pub Hosp A Pub Hosp B Pub Hosp C Privte Hosp A Private Hosp B Woman Pertussis Vaccine Woman Influenza Vaccine Partner pertussis vaccine

25 Vaccine Uptake other contacts 76% of households reported 1 additional contact 37% of adult contacts usually resident overseas 53% of adult contacts vaccinated acc to guidelines

26 Vaccine Uptake other contacts 76% of households reported 1 additional contact 37% of adult contacts usually resident overseas 53% of adult contacts vaccinated acc to guidelines Uptale (%) * * * Partner Grandparents Siblings Other Mother vaccinated Mother not vaccinated OR: 10.5 (95% CI 5.5, 20.1), p= <0.001

27 Vaccine Uptake other contacts 76% of households reported 1 additional contact 37% of adult contacts usually resident overseas 53% of adult contacts vaccinated acc to guidelines Uptale (%) * * * Uptake (%) ** * * Partner Grandparents Siblings Other 0 Partner Grandparents Siblings Other Mother vaccinated Mother not vaccinated Australian resident Overseas resident OR: 10.5 (95% CI 5.5, 20.1), p= <0.001 OR: 0.06 (95% CI ), p<0.01

28 SO HOW ARE WE GOING?

29 Flu: 60% dtpa: 70% Flu: 40% dtpa: 86% ATSI Flu: 39% dtpa: 22% FluMum ( ) 6 ATSI Flu: 45% 67% dtpa: Flu: 70% 46% 74% dtpa: 50% Flu: 46% dtpa: 74% Flu: 46% dtpa: 82% Flu: 55% dtpa: 70% 1 Regan PHAA 2016; 2 Danchin Vaccine 2017; 3 Overton CDC Bulletin 2016; 4 Krishnaswamy (unpublished); 5 Krishnaswamy EJOGRB 2016; 6 Andrews PHAA 2016

30 IMPROVING UPTAKE

31 Barriers and enablers of uptake of maternal vaccination Barriers Inconsistent HCP recommendation Safety concerns Cost Access to vaccination What can we do? - Improve access: standing orders, pharmacist-delivered vaccination - Incorporation of vaccination into routine antenatal care - DISCUSS VACCINATION!!!

32 Key Messages Maternal pertussis immunisation provides protection to newborn from all possible sources Focus should be on maternal vaccination and cocooning if that doesn t occur 2 nd trimester probably better than 3 rd Maternal immunisation may not afford protection to newborn if: Mother not vaccinated during pregnancy (uptake important) Not enough time to transfer immunity Late vaccination (7-14 days before delivery) Premature delivery (8-9%)

33 Key Messages HCP recommendation is the strongest driver of vaccination: WE NEED TO BE DISCUSSING VACCINATION There s no one model that fits all maternity services Alternative immunisation providers may increase access Pharmacists Standing orders

34 Why RSV and GBS vaccines?

35 33.1 million cases RSV associated ALRI 20% in infants < 6 months old (27 million) 3.2 million cases RSV associated hospital admissions 59, 600 in hospital deaths in children under 5yo 50% in infants < 6 months old Shi Lancet 2017

36 RSV Most common viral cause of ALRI in children<5yo globally <2yo: croup, bronchiolitis, pneumonia >2yo: asymptomatic, URTI Older adults: pneumonia All adults have Ab from prior infection Wane rapidly Don t prevent reinfection

37 GBS colonised mother 20 30% of women 50% 50% Non colonised newborn Colonised newborn 98% 1 2% Asymptomatic Early onset sepsis, pneumonia, meningitis

38 Group B Strep Problems with intrapartum prophylaxis Screening misses up to 10% of colonised women Unnecessary antibiotic use only 0.5 1% of colonized women give birth to infants who develop early onset GBS Problems associated with antibiotic use Antibiotic resistance, altered microbiome and C.diff Doesn t reduce incidence of late onset GBS disease Doesn t prevent disease in mother

39 Acknowledgments Michelle Giles Jim Buttery Euan Wallace Karen Bellamy Joanne Hickman Funding: Australian Government Research Training Program scholarship, Victorian Department of Health and Ageing, Glaxo Smith Kline