Commentary on “Maternal immunization: Clinical experiences, challenges, and opportunities in vaccine acceptance”

Abstract

Immunization during pregnancy is an important and effective public health strategy. Obstetrician-gynecologists should start thinking of themselves as vaccinators and develop systems approaches to facilitate vaccination for women both during and outside of pregnancy. The importance of a strong provider recommendation is key.

Keywords:

• immunization
• influenza
• pertussis
• vaccination
• vaccine
• pregnancy

Immunizations are the most effective tool we have to prevent infectious disease, and in this month's Human Vaccines and Immunotherapeutics, Moniz and Beigi¹ rightly point out that vaccination during pregnancy is currently under-utilized as a public health strategy. According to the Advisory Committee on Immunization Practices (ACIP) guidelines, all women should receive the influenza and tetanus-diptheria-acellular pertussis (Tdap) vaccines during pregnancy. These vaccines are safe and highly effective in protecting against influenza-related maternal morbidity and mortality, as well as complications of pertussis in infants. Despite this, immunization rates are disappointingly low in pregnancy; for example only 15–50% of pregnant women were vaccinated against the flu in recent years, far short of the 80% goal for Healthy People 2020.¹

The authors point out several important factors related to vaccine acceptance during pregnancy. Pregnant women may decline vaccinations because of lack of perceived susceptibility to disease, misinformation about vaccine effectiveness, and concerns about vaccine safety. Several strategies to increase vaccine acceptance are recommended, including patient education, provision of a strong provider recommendation, normalizing vaccination by making it a routine part of care, and maximizing convenience for patients.

These are all appropriate strategies for increasing vaccine acceptance. As all of these approaches depend on “buy-in” from health care providers, it is also important to consider the barriers to vaccination from a provider perspective. Whereas family practice physicians have always played a key role in vaccination as providers of primary care, obstetrician-gynecologists (ob-gyns) may not necessarily see themselves as vaccinators. In fact, we know that ob-gyns are less likely than family practice physicians to offer vaccines and discuss the importance of vaccines.² This is unfortunate because many women in the United States receive prenatal care from an ob-gyn rather than a family practice physician. Outside of pregnancy, healthy young women may also be due for other vaccines, for example a measles-mumps-rubella (MMR) booster pre-conception or the human papilloma virus (HPV) series, and an annual gynecologic exam may be the only contact that these women have with the healthcare system. Therefore it is imperative that ob-gyns take advantage of prenatal visits, but also pre-conception, postpartum, and routine annual exam visits. Incorporating immunization at all of these time points should effectively normalize vaccination and lead to an uptick in vaccination rates during pregnancy.

From a systems perspective, it is important that vaccination is a priority throughout an entire healthcare organization. At the individual clinic level, this means that the importance of vaccination should be understood by both providers and nursing staff. When comparing nurse versus physician-led vaccination protocols, evidence suggests that nurses are better at remembering to offer vaccination, but have a higher refusal rate; whereas physicians are less likely to offer vaccination, but when they do there is a higher acceptance rate.³ A protocol that combines immunization recommendations from both nursing staff and providers is likely to have the highest acceptance rate from patients. On a larger scale, healthcare systems need to provide the necessary infrastructure to facilitate vaccination. This may include educational initiatives for providers and staff, prompts in the electronic medical record, and improvements in workflow efficiency. The capacity to vaccinate patients’ family members during a visit; for example, providing the Tdap vaccine to family members of pregnant women, is another approach that will increase vaccination rates by maximizing convenience for patients and their families.

We emphatically agree with these authors in the power of a strong recommendation for vaccination, from either providers or nursing staff. In our practice, a simple wording change on the part of nursing staff—informing patients they are due for a vaccine today, rather than stating it is optional—increased the percent of women who accepted vaccines, such that most are already immunized by the time a provider enters the room. The small number of patients who initially are hesitant with nursing staff almost always accept vaccination when a provider subsequently addresses their concerns. Contrary to what one may think, these conversations usually do not take more than 1–2 minutes and are easily accomplished in a busy clinic day. We suspect that some providers may worry about anti-vaccine sentiment and think that speaking with these patients about immunization is a lost cause or will take up too much time, but in reality most patients have a simple concern that is easily addressed.

It is likely that the number of vaccines recommended in pregnancy will only increase in the future. Pregnancy-specific vaccines for group B streptococcus (GBS) and respiratory syncytial virus (RSV) to decrease the incidence of GBS sepsis and RSV in infants are currently in development,¹ and we are acquiring more data about the safety of HPV vaccination in pregnancy.⁴ Ob-gyn physicians have a growing and critical role to play in ensuring that women are appropriately immunized, both during pregnancy and throughout their lifespan.

Disclosure of Potential Conflicts of Interest

No potential conflicts of interest were disclosed.