Master Class

An immunization update


 

As ob.gyns., we pride ourselves on being primary care providers as well as specialists. A central obligation of the primary care physician is the prevention of disease, and immunization of vaccine-preventable diseases is an essential component of prevention. In fact, nothing is more effective at preventing infectious diseases than immunization.

Immunization has not traditionally been as central to our role as it has been for pediatricians, who have long viewed vaccines as a core component of their care. However, although there are certain vaccines that pediatricians can give more easily than we can, such as the human papillomavirus vaccine, there are other vaccines that ob.gyns. can more easily provide. For example, we are better positioned than pediatricians to protect newborns from pertussis.

No other physician, moreover, is better situated to vaccinate vulnerable populations than is the ob.gyn. We are important sources of information and advice for adolescents, adults, and pregnant women. We therefore have a critically important opportunity to identify the diseases that put our patients and their progeny at greatest risk, and a responsibility to make immunization an integral part of our practices.

Numerous investigations and reports addressing vaccine implementation strategies have relevance for both obstetric and gynecologic patients, and studies addressing successful strategies for immunization of pregnant women in particular have increased since the 2009 H1N1 influenza pandemic.

Last spring, the Committee on Obstetric Practice and Committee on Gynecologic Practice of the American College of Obstetricians and Gynecologists published guidance on how to successfully incorporate immunizations into routine care and develop an immunization culture (Committee Opinion No. 558, Obstet. Gynecol. 2013;121:897-903).

Among the key points:

Make direct recommendations. Talk to your patients directly. Recommend individual immunizations. A provider recommendation has been shown to be one of the strongest influences on patient acceptance. Tell patients, "You should have this vaccine," or "It is important for you," or "I’m telling you as your health care specialist that this vaccine is in your best interest."

Physician scripts for several immunizations are available on ACOG’s immunization website, immunizationforwomen.org, and numerous other sources.

Designate a vaccine coordinator. As the "vaccine champion," this person orders and receives the vaccines, ensures that the vaccines are stored properly, and has knowledge of appropriate billing codes for vaccination services. He or she also maintains contact with the state health department’s immunization program manager, who can answer physicians’ questions and help practices.

Institute standing orders. Such orders allow for an indicated vaccine to be administered to patients without an individual physician order. For example, every pregnant woman who shows up during flu season should have a standing order for the influenza vaccination.

Evaluate your prompts, paper or electronic, to remind providers and staff which patients need to be immunized. Hold everyone accountable.

Get yourself and your staff immunized. Educate staff about the safety and efficacy of immunizations, and ensure that your office health care providers, your entire staff, and you are immunized as recommended. If your staff or you are not immunized, it can be hard to convince patients to receive a vaccine. As ACOG’s Committee Opinion on "Integrating Immunizations into Practice" highlights, moreover, office personnel who express their own uncertainty or lack of knowledge to patients can negatively affect patients’ willingness to receive a vaccine. Additionally, being a potential source of infection for your patients violates ethical obligations.

Research has shown that educational efforts for office staff can markedly increase office immunization rates. In one study of the H1N1 influenza pandemic of 2009, educational sessions for ob.gyns’ staff were part of a multifaceted approach that led to a high vaccine acceptance rate of 76% in an ethnically diverse population of 157 obstetrics patients (Infect. Dis. Obstet. Gynecol. 2011;2011:746214 [doi: 10.1155/2011/746214]). The educational sessions for staff were instituted proactively prior to availability of the vaccine.

Influenza vaccination

Influenza affects 10%-20% of the U.S. population annually, and pregnant women are more likely to have serious complications should they contract the virus. Pregnant women are at least 4-5 times more likely to be hospitalized and equally more likely to die from infection, and their infants are more likely to have influenza-related respiratory illnesses and die.

A 2010 study of the 2009 H1N1 pandemic showed that although pregnant women in the United States represent 1%-2% of the population, they accounted for up to 7%-10% of the hospitalized patients, 6%-9% of the ICU patients, and 6%-10% of the patients who died (N. Engl. J. Med. 2010:362:1708-19).

A study published in early 2013 showed that vaccination was 70% successful in preventing 2009 H1N1 influenza infection in pregnant women in Norway during the pandemic, and that the risk of fetal death nearly doubled among women who contracted influenza (N. Engl. J. Med. 2013;368:333-40). Of almost 120,000 pregnant women in the study, approximately half had received the flu vaccine.

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