Immunization Practices in Pregnant Women VERBAL DISCLOSURE. 10 Major Vaccines Recommended for Routine Use in Adults

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1 Immunization Practices in Pregnant Women VERBAL DISCLOSURE Richard L. Sweet, M.D. Professor and Director UC Davis Women s Center for Health Richard L. Sweet, M.D. Merck (Gardasil): Speakers panel GSK (Cervarix): Advisory Board; Speakers panel Sanofi-Pasteur: Speakers panel 10 Major Vaccines Recommended for Routine Use in Adults Td/TdaP HPV MMR Varicella Influenza Pneumococcal polysacchaaride Hepatitis A Hepatitis B Meningococcal Zoster Factors Contribute Poor Levels of Adult Immunization Concerns over safety and efficacy of vaccines General public Health-care workers Uncertainty about specific recommendations Liability concerns Inadequate reimbursement for immunizations Poorly informed public Lack of delivery infrastructure system Inadequate mechanisms to remove financial barriers for uninsured (e.g., Vaccine for Children s Program) Provider attitudes 1

2 Guiding Principles for Development ACIP Recommendations for Vaccination During Pregnancy and Breast Feeding April 2008 Advisory Committee on Immunization Practices Workshop on Use Vaccines During Pregnancy and Breast Feeding Guiding Principles ACIP Recommendations Vaccination during pregnancy Challenging Evidence-base to guide decisions extremely limited Provide guidance help standardize Process of policy formulation Format and language of recommendations Guiding Principles ACIP Recommendations Vaccination during pregnancy Contraindication Condition in recipient that risk serious adverse reaction Maternal, fetal or neonatal Vaccine will not be administered Direct evidence or strong biologic plausibility and suggestive evidence that risk elevated Guiding Principles ACIP Recommendations Vaccination during pregnancy Precaution Condition that might risk for serious adverse reaction or might compromise ability of vaccine to produce immunity Usual circumstances vaccination deferred Might be indicated because benefits outweigh risks No supporting evidence, but there is some biologic plausibility Lack of data to support safety 2

3 Pregnancy Recommendations Vaccination recommended All pregnant women should be vaccinated Inactivated influenza vaccine Pregnancy not contraindication or precaution Routine vaccination recommendations should be applied to pregnant women Td, Hepatitis B, Meningococcal polysaccharide Pregnancy Recommendations Pregnancy a precaution Under normal circumstances deferred Only given when benefits outweigh risks Hepatitis A, IPV, yellow fever, rabies Pregnancy a contraindication Vaccine not administered Not ordinarily a reason for pregnancy termination MMR, varicella, live-attenuated influenza Vaccination During Pregnancy Risk to developing fetus from vaccination of mother during pregnancy is theoretical No evidence exists of risk to fetus Inactivated virus or bacterial vaccines Toxoids Live vaccines administered to pregnant women pose a theoretical risk to fetus Live, attenuated virus and live bacterial vaccines generally contraindicated in pregnancy Vaccination During Pregnancy Live-attenuated viruses generally contraindicated Measles Mumps Poliomyelitis Rubella Varicella Yellow fever CDC MMWR 2011;60:

4 Vaccination During Pregnancy Benefits of vaccinating pregnant women usually outweigh potential risks when Likelihood of disease exposure high Infection pose risk to mother or fetus Vaccine unlikely do harm CDC MMWR 2011;60:26-27 Immunization Breast Feeding Women Safe for breast feeding mother and her infant Breast feeding does not adversely affect immunization Breast feeding not contraindication for any vaccine Breast Feeding and Vaccination Neither inactivated nor live-virus vaccines affect safety of breast feeding Live viruses in vaccines can replicate in vaccine recipients Majority live viruses in vaccines are not excreted in breast milk Varicella vaccine virus not been found in human milk Rubella vaccine virus might be excreted in human milk, virus usually doesn t infect infant (if does infection well tolerated because virus attenuated) CDC MMWR 2011;60:26 Breast Feeding and Vaccination Inactivated, recombinant, subunit, polysaccharide, and conjugate vaccines and toxoids No risk for lactating mothers or their infants Breast feeding contraindication smallpox vaccine Yellow fever vaccine should be avoided Exception can t avoid or postpone travel areas endemic for yellow fever CDC MMWR 2011;60:26 4

5 Vaccination Pregnant Women Recommended Hepatitis B a at risk of infection Influenza b routine DT c if indicated (no booster past 10 yrs) Dtap c not contraindicated, but data not available Hepatitis A a if indicated a Recombinant b inactivated virus c - toxoid CDC 2010 Yellow Book (Travelers Health) Vaccination Pregnancy: Precaution Normal circumstances deferred Given when benefits outweigh risks Japanese encephalitis a travel area risk high Meningococcal b travel endemic area/outbreaks MCV4 preferred adults (no data pregnant women) MPSV4 can be administered Pneumococcal b chronic diseases, smokers, immunosuppressed Polio a travel endemic area Rabies a indications not altered by pregnancy Typhoid (ViCPS) b travel endemic area Yellow fever c travel area high risk a Inactivated virus b Polysaccharide c live attenuated virus CDC 2010 Yellow Book (Travelers Health) Vaccines Contraindicated in Pregnancy Tuberculosis (BCG) theoretical risk disseminated TB MMR a Unvaccinated women delay travel to countries measles endemic till after pregnancy Unvaccinated with documented exposure IgG within 6 days HPV b Varicella a Hepatitis B Vaccine Available in U.S. since 1981 Multiple formulations Recombivax and Comvax (Merck) Engerix-B, Pedatrix & Twinrix (GlaxoSmithKline) All produced by recombinant techniques to generate HBsAg protein in yeast a Live-attenuated virus b - Recombinant CDC 2010 Yellow Book (Travelers Health) 5

6 Immunization Strategy to Eliminate HBV Infection Transmission U.S. Universal vaccination infants beginning at birth Prevention of perinatal HBV infection Routine screening HBsAg all pregnant women Immnoprophylaxis infants born to HBsAg-positive women and infants born to women with unknown HBsAg status Routine vaccination previously unvaccinated children and adolescents Vaccination previously unvaccinated adults at increased risk for HBV infection ACIP MMWR 2006;54:1-33 Hepatitis B Vaccine Recommended Adult Vaccination Medical indications End stage renal disease (hemodialysis) Persons seeking evaluation or treatment for STD/STI HIV infection Chronic liver disease Hepatitis B Vaccine Recommended Adult Vaccination Occupational indications HCW and public safety workers exposed to blood or other potentially infectious body fluids Behavioral indications Sexually active, not long-term monogamous (>1 sex partner previous 6 mos) Current/recent IDUs MSM 6

7 Hepatitis B Vaccine Recommended Adult Vaccination Other indications Household contacts and sex partners persons with chronic HBV infection Clients and staff members institutions for developmentally disabled All clients of STD clinics International travelers to countries with high or intermediate prevalence chronic HBV infection Any adult seeking protection from HBV infection Hepatitis B Vaccine Efficacy high (90-95%) for both vaccines licensed in U.S. Protection against HB infection achieved with antibody level 10m IU/ml Excellent long term efficacy Currently routine booster dose not recommended Recommended Dosing of Hepatitis B Vaccine Vaccine Age Group Dose mcg (ml) # of Doses Schedule Recombivax HB 0-19 years 5 mcg (0.5) 3 Infants: birth, 1-4 mos., 6-18 mos. Alternative for older children: 0, 1-2, 4 mo. Engerix-B (GlaxoSmithKline) years 10 mcg (1.0) 2 0, 4-6 mo. 20 years 10 mcg (1.0) 3 0, 1, 6 mo. Hemodialysis and immunocompromised patients 40 mcg (1.0) a (0.5) 4 0, 1, 2 and 12 mo years 10 mcg 3 Infants: birth, 1-4 mo., 6-18 mos. Alternative for older children: 0, 1-2, 4 mo. 20 years 20 mcg (1.0) 3 0, 1, 6 mo. Hepatitis B Vaccine Requires 3 doses for immunity 0, 1, 6 months Antibody testing 1-3 mos after last dose Side effects minimal Hemodialysis and immunocompromised patients 40 mg (2.0)b 4 0, 1, 2 and 12 mo. a Special formulation b ml dose at one site 7

8 Hepatitis B Vaccine Contraindications Hypersensitivity to components (yeast) Complications Injection site reactions (up to 22%) Anaphylaxis rare Pregnancy/Lactation Safe Hepatitis A Formalin inactivated virus Havrix; Vaqta Indication pre-exposure prophylaxis Recommendations Hepatitis A Vaccine Children All children at age 1 year (12-23 mos) Catch-up vaccination unvaccinated aged 2-18 yrs Persons at Increased Risk HAV Infection Persons traveling to or working in countries high or intermediate endemicity 1 st dose as soon as travel contemplated MSM Users injection and non-injection drugs Occupational risk HAV infected primates HAV in research lab Clotting-factor disorders Chronic liver disease 8

9 Recommendations Hepatitis A Vaccine Recommended unvaccinated persons providing home or day care for international adoptee 99% from countries with intermediate or high endemicity to hepatitis A Hepatitis A Vaccine Recommended Dosing Schedule Vaqta 12 mos-18 yrs 19 yrs Havrix 12 mos-18 yrs 19 yrs Dose 25U 50U 720ELU 1440ELU Vol.(ml) # Doses Schedule (mos) 0, , , , 6-12 Twinrix 18 yrs 720ELU/20µg , 1, 6 MMWR 2006;55:1-23 Hepatitis A Vaccine Contraindications Allergy to any vaccine component Complications Local reactions: 21-56% Fever 4% Rarely anaphylaxis, Guillain-Barre Pregnancy/Lactation Not specifically contraindicated Make sure clearly needed Safe in breast-feeding mothers Varicella Immunization Incidence varicella since introduction vaccine 1995 Varicella outbreaks continued to occur Protection with single dose waned with time Severity and incidence breakthrough disease with time (2 X as likely > 5 yrs) 2 nd dose varicella vaccine proportion children with protective antibody titers Improved cellular immune response 9

10 Varicella Immunization June 2005, ACIP recommended 2 nd dose in outbreak settings for persons had only 1 dose June 2006, ACIP recommended Routine 2-dose varicella vaccination for children 1 st dose mos. 2 nd dose 4-6 yrs. Catch-up dose children, adolescents, and adults previously received 1 dose Varicella Vaccination Recommended Adult Immunization All adults without evidence immunity 2 doses varicella vaccine (not previously vaccinated or received only 1 dose) Special consideration Close contact persons at high risk for severe disease HCWs & family contacts of immunocompromised persons Varicella Vaccination Recommended Adult Immunization High risk for exposure or transmission Teachers young children Childcare employees Residents/staff-institutional settings College students Military personnel Adolescents/adults living in household with children Non-pregnant women childbearing age International travelers MMWR 2006;55:1-4 Varivax: Dosage and Administration Children 2 doses (0.5 ml) SQ 1 st dose mos 2 nd dose 4-6 yrs Adolescents and adults 2 doses (0.5 ml) SQ wks 10

11 Varicella Vaccine Use in Pregnancy Contraindicated in pregnancy Theoretic risk viremia Not an indication for termination Varivax Pregnancy Registry Avoid pregnancy for 1 mo (3 mos) post injection Pregnant household member NOT contraindication Not contraindicated in nursing mother Pregnancy Registry for Varivax Mar 1995-Mar women enrolled (629 pregnancy outcomes) 131 live births to varicella-zoster virusseronegative women No evidence congenital varicella syndrome (rate 0%; 95% CI 0-6.7%) Major birth defects in 3 (3.7%; %) Wilson et al JID 2008;197(Suppl 2):S178) ACIP Recommendations Prenatal Assessment and Postpartum Vaccination Women should be assessed prenatally for evidence of varicella immunity Upon completion or termination of pregnancy Women without evidence varicella immunity should receive 1 st dose vaccine before discharge 2 nd dose 4-8 wks later Pneumococcal Infection Invasive Pneumococcal Disease (IPD) Meningitis Bacteremia Pneumonia (leading cause CAP) Pre-vaccine > 550,000 cases IPD annually in U.S. 40,000 deaths per year Emergence antibiotic-resistant S. pneumoniae 11

12 ACIP Recommendation 23-Valent Pneumococcal Vaccine Candidates for Vaccination All patients 65 who have not received vaccine past 5 yrs Residents nursing homes or chronic care facilities, irregardless of age Persons smoke cigarettes Routine use not recommended American Indians/Alaska natives Patients years with high-risk conditions High Risk Conditions for Pneumococcal Vaccine Chronic heart or lung disease (asthma), diabetes, or kidney disease Compromised immunity (Hodgkin s, leukemia, lymphoma, multiple myeloma, generalized malignancy, HIV/AIDS, organ or bone marrow transplant, long-term corticosteroids, cancer drugs or radiation therapy Alcoholism, cirrhosis or chronic liver disease Sickle cell anemia or splenectomy CSF leaks Pneumococcal Vaccine Dosage 0.5 ml IM or SC Revaccination Pneumococcal Vaccine ACIP does not recommend routine revaccination for most persons for whom PPSV 23 indicated 2 nd dose PPSV 23 5 years after 1 st dose Aged yrs with functional or anatomic asplenia Immunocompromising conditions 12

13 Pneumococcal Vaccine Use during Pregnancy or Breast Feeding Safety not been determined No reason suspect have adverse effect Not contraindicated in pregnancy Use limited to pregnant women at high risk not previously vaccinated Safe in breast feeding women Seasonal H 1 N 1 Avian Influenza Influenza Vaccination primary method preventing influenza and its severe complications Inactivated influenza vaccines Live, Attenuated Influenza Vaccine Intranasal spray Healthy persons aged 5-49 yrs ACIP neither amantadine nor rimantadine used for treatment of Influenza A in U.S. Influenza Epidemics in U.S. occur during winter months Rates of infection highest among children Rates serious illness and death highest Persons aged 65 years Children < 2 years Persons any age with medical conditions place them risk complications 13

14 Recommendations Influenza Vaccination Annual vaccination all persons 6 months age Including all adults/pregnant women Healthy, non-pregnant adults < 50 yrs age without high-risk medical conditions Intranasal live attenuated influenza vaccine (FluMist) -or- Inactivated vaccine Adults 65 years Receive standard influenza vaccine -or- High-dose (Fluzone) influenza vaccine ACIP Recommendations Influenza Vaccination trivalent vaccines contain A/California/7/2009 (H1N1)-like Ag A/Perth/16/2009 (H3N2)-like Ag B/Brisbane/60/2008-like Ag Newly approved inactivated trivalent vaccine containing 60 mcg hemagglutin antigen per influenza vaccine virus strain Fluzone-High-Dose Alternative persons aged 65 yrs ACIP Recommendation Vaccination of susceptible women of childbearing age should Be part of routine general medical and gynecologic outpatient care Take place in all Family-planning settings Be provided routinely before discharge from any hospital, birthing center or other medical facility, unless a specific contraindication exists Influenza Pregnant Women Influenza-associated excess deaths among pregnant women during pandemics % develop pneumonia of these > 50% died case fatality 27% ½ women child bearing age who died were pregnant 14

15 Influenza Pregnant Women Pregnancy risk complications HR, SV O 2 consumption lung capacity and tidal volume Changes immunologic function Influenza Pregnant Women Impact during 17 interpandemic seasons RR hospitalization selected cardiorespiratory conditions 1.4 wks to 4.7 wks Compared women 1-6 mos. postpartum Women in 3rd trimester hospitalized rate comparable nonpregnant women with high-risk medical condition - 250/100, hospitalizations prevented per 1,000 pregnant women vaccinated Neuzil et al Am J Epidem 1998;148: Odds Ratio for Cardiopulmonary Event Occurring During Influenza Season Among Women Aged Years Enrolled In Medicaid Pregnancy status Cases (n=4369) Prevalence (%) Controls (n=21,345) Postpartum OR (95% CI) Nonpregnant ( ) Week ( ) Week ( ) Week ( ) Week ( ) Week ( ) Week ( ) Week ( ) Neuzil et al Am J Epi 1998;148: Severity 2009 H1N1 Infection Pregnant Women April 15 May 18, % pregnant women required hospitalization Pregnant women > 4 times more likely to be hospitalized for H1N1-related complications than general population Pregnant women 13% deaths from H1N1 Most healthy prior to influenza Jamieson DJ et al Lancet 2009;374:

16 Severity of 2009 Pandemic Influenza (H1N1) Virus Infection in Pregnant Women, NYC Hospitalization rate higher pregnant women 55 vs. 7.7 per 100,000 population Pregnant women represented 6.4% hospitalized cases 4.3% deaths Severe illness with oseltamivir treatment 2d 1 of 30 (3.3%) 3-4d 3 of 14 (21.4% 5d 4 of 9 (44.4%) Ceanga AA et al Obstet Gynecol 2010;115: Influenza Vaccination During Pregnancy Essential element prenatal care Most effective strategy for preventing influenza ACIP recommends Influenza vaccination all women who will be pregnant through influenza season (Oct-May) ACOG Committee Obstetric Practice supports this recommendation No study to date has shown an adverse consequence of inactivated influenza vaccine in pregnant women or their offspring ACOG Committee Opinion No. 468 Oct Survey Data Participation Obstetrician-Gynecologists in Influenza Vaccination Programs Vaccination rates in pregnancy Seasonal influenza 15-25% (MMWR 2009;58:896-7) H1N1 38% (MMWR 2010;59:44-8) Pregnant women have lowest vaccine coverage rates of all adults Safety of Influenza Vaccination in Pregnancy During seasonal influenza epidemics, previous pandemics, and H1N1 pandemic Pregnancy places healthy women at increased risk serious complications/deaths from influenza No study has demonstrated risk of maternal complications or adverse fetal outcomes associated inactivated influenza vaccination No scientific evidence exists that thimerosalcontaining vaccines cause adverse events among children born to women who received influenza vaccine during pregnancy Tamma PD et al AJOG

17 Common Myth: The Flu Vaccine Causes the Flu Influenza Vaccine Side Effects Symptom Vaccine % Placebo % P Fever NS Cough NS Coryza NS Fatigue NS Malaise NS Myalgia NS Headache NS Sore arm <.001 Poland GA JAMA 1990; 264: Influenza Vaccination Optimal time during Oct-Nov Peak levels Dec-Mar Dosage Adults - single 0.5 ml IM MMR Vaccine and Autism Retrospective cohort study all children born in Denmark Jan 91-Dec ,655 (82%) of 537,303 children received MMR vaccine Rel. risk autistic disorder vaccinated children vs. unvaccinated 0.92 ( ) Strong evidence against hypothesis MMR vaccination causes autism Madsen et al NEJM 2002;347:

18 MMR Vaccination and Pervasive Developmental Disorders Case-control study UK Gen. Practice Research Database 1,294 cases and 4,469 controls MMR vaccine 1,010 cases (78.1%) 3,671 controls (82.1%) OR association MMR and pervasive dev. disorder 0.85 ( ) Findings similar Restricted children with autism Vaccinated prior 3 rd birthday Smooth et al Lancet 2004;364:963-9 MMR Vaccine Pregnancy/Lactation Contraindications pregnancy Inadvertent administration not an indication for termination of pregnancy No reported cases CRS after vaccine Low risk congenital anomalies with measles, mumps Safe for use breast-feeding mothers Tetanus, Diphtheria, Pertussis Td/Tdap Adults with uncertain history of complete primary vaccination with tetanus and diphtheria toxoidcontaining vaccines Begin 1 vaccination series of 3 doses Td First 2 doses at least 4 weeks apart Third dose 6-12 months after 2 nd Tdap can substitute for any one of doses Booster dose Td adults completed 1 series if last vaccination 10 years previously Tdap should replace a single dose of Td adults < 65 years who have not previously received dose of Tdap Tetanus Toxoid, Reduced Diptheria Toxoid and Acellular Pertussis (Tdap) Vaccine Despite sustained high coverage childhood pertussis vaccination Pertussis remains poorly controlled in U.S. 16,858 cases/12 infant deaths reported ACIP vaccination with Tdap all adolescents and adults Tdap coverage Adolescents 56% Adults < 6% October 2010 ACIP recommended expanded use Tdap MMWR Jan 14, 2011/Vol. 60/No. 1 18

19 Pertussis - California Incidence pertussis cyclical Peaks occur every 3-5 years in U.S. Last peak ,000 cases nationally 3,000 cases in CA (8 deaths) Rates from first half year persist CA has highest annual rate of pertussis since 1963 and most cases since 1958 MMWR 2010;59:817 CDPH Pertussis Immunization Recommendations August 3, 2010 Immunity to pertussis from disease or vaccine wears off over time Leaving fully immunized children susceptible again by adolescence Immunization rates are low for the recommended Tdap booster vaccine 44% adolescents in CA 6% adults in U.S. CDPH Pertussis Immunization Recommendations August 3, 2010 Strongly recommends Tdap booster for all adolescents and adults ( 10 years age) who have not received documented dose Including those > 64 years age Regardless when received last Td booster CDPH Pertussis Immunization Recommendations August 3, 2010 Immunization with Tdap Especially Important Women of childbearing age Preferably prior to pregnancy Else during or immediately after pregnancy Other close contacts of infants Other family members Caregivers Health care workers Particularly those have direct contact with pregnant women and infants Patients with wounds who are 7 years old Receive Tdap when immunization indicated to prevent tetanus 19

20 Tdap Vaccine Licensed June 2005 Standard tetanus-diphtheria toxoids, with acellular pertussis component added Single 0.5 ml dose once in a lifetime Add protection against Pertussis Replace next dose Td May administer as soon as 2 yrs after last Td booster Two products licensed Adacel (11-64 yrs) Boostrix (10-64 yrs) Recommendation Tdap Vaccination One-time dose Tdap to adults aged < 65 yrs to replace one of 10-year Td boosters Not received Tdap previously -or- Vaccine status unknown Give as soon as feasible to all Post partum women Close contacts infants < 12 months age (grandparents, child-care providers) Health-care personnel with direct patient contact Recommendation Tdap Vaccination Adults 64 yrs not previously received Tdap and have close contact infant < 12 mos. Other adults 65 yrs may receive Tdap Tdap can be administered regardless of interval since most recent Td Recommendation Tdap Vaccination Adults uncertain or incomplete history of completing 3-dose primary vaccination series with Td Begin or complete primary vaccination series Substitute one-time dose Tdap for one of Td doses 20

21 Recommendation Tdap Vaccination Pregnant and most recent Td 10 yrs previous Administered Td during 2 nd or 3 rd trimester Pregnant and most recent Td < 10 yrs previous Administer Td immediate post partum Physician discretion Td deferred during pregnancy and Tdap substituted post partum -or- Tdap administered to pregnant women after informed discussion Prevention Pertussis, Tetanus and Diphtheria Pregnant and Postpartum Women ACIP 2008 Available evidence does not address safety of Tdap for pregnant women, their fetuses, or pregnancy outcomes sufficiently Available data do not indicate Tdap-induced transplacental-maternal antibodies provide early protection against pertussis to infants Interfere with infant s immune response to routinely administered pediatric vaccines 21

22 Vaccination During Pregnancy Pregnant women evaluated for immunity to rubella and varicella Susceptible women vaccinated immediately after delivery Pregnant women tested for presence HBsAg HBsAg positive Infants HB1G and 1 st vaccine dose 12 hours after birth CDC MMWR 2011;60:26-27 Vaccination During Pregnancy Persons receive MMR do not transmit vaccine viruses to contacts Transmission varicella vaccine virus to contacts rare MMR & varicella vaccine should be administered when indicated to children and other household contacts of pregnant women Infants living in household with pregnant women should be vaccinated with rotavirus vaccine according usual schedule CDC MMWR 2011;60:26-27 Vaccination During Pregnancy Td/Tdap Last dose tetanus-toxoid containing vaccine > 10 years previously Generally receive Td rather Tdap while pregnant Tdap not contraindicted in pregnancy Dox Td during pregnancy Ensures adequate tetanus immunity in mom Prevents disease in mother and infant Vaccination During Pregnancy Td/Tdap Regardless of recent Td, pregnant women who have not received Tdap should receive dose Tdap ASAP after delivery Ensure pertussis immunity Reduce risk transmission to newborn Pregnant women not vaccinated or only partially vaccinated against tetanus should complete primary series CDC MMWR 2011;60:26-27 CDC MMWR 2011;60:

23 Vaccination During Pregnancy Influenza vaccine Women in 2 nd and 3 rd trimester at risk hospitalization from influenza Routine vaccination recommended for all women who are or will be pregnant during influenza season Early Oct late Mar Polio vaccine (IPV) Can be administered to pregnant women who are at risk for exposure to wild-type poliovirus infection CDC MMWR 2011;60:26-27 Vaccination During Pregnancy Hepatitis A vaccine Pneumococcal polysaccharide Meningococcal conjugate Meningococcal polysaccharide ) Considered for ) women at risk ) for these ) infections Yellow fever vaccine Pregnant women who must travel to areas where risk high receive yellow fever vaccine Limited theoretical risk from vaccination outweighed substantially by risk of yellow fever infection Hepatitis B vaccine Not contraindicated in pregnancy Given to pregnant woman who has indication for HB vaccine CDC MMWR 2011;60:26-27 Vaccination During Pregnancy Smallpox (vaccinia) vaccine Only vaccine known to harm fetus when administered to a pregnant woman Should not be administered to a household contact of a pregnant woman Measles, Mumps, rubella and Varicella containing vaccines Children born to mothers vaccinated with rubella vaccine during pregnancy Rubella antibody levels in unvaccinated infants No cases congenital rubella or varicella syndrome or abnormalities attributable to fetal infection observed Reasonable practice ask women if they are or might become pregnant in next 4 weeks Routine pregnancy testing before administering live-virus vaccine not recommended CDC MMWR 2011;60:26-27 Which of the following immunizations is contraindicated for breast feeding women? A. Tdap B. HPV C. Varicella D. MMR E. None of the above T d a p 0% H P V 3% V a r i c e l l a 5% 4% M M R 88% N o n e o f t h e a b... 23

24 Immunizations recommended for pregnant women include: 80% A. Tetanus-diptheria toxoid B. HPV C. Influenza D. Rubella E. A and C 2% 1% 15% 2% T e t a n u s - d i p t h e... H P V I n f l u e n z a R u b e l l a A a n d C 24