Contributors: Michael Power, PhD, Emily Kahn, PhD, Jennifer

Williams, MSN, MPH, Denise Jamieson, MD, MPH, Kitty MacFarlane, CNM, MPH,

Jay Schulkin, PhD, Yujia Zhang, PhD, and William Callaghan, MD, MPH

Attitudes and Practices of Obstetrician-Gynecologists

Regarding Influenza Vaccination in Pregnancy

National Center for Chronic Disease Prevention and Health Promotion

Division of Reproductive Health

Dmitry Kissin, MD, MPHDivision of Reproductive Health, CDC

Disclaimer

The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy

Background Pregnant women are at high risk for influenza-

related complications, including severe disease

Neonates are at high risk for morbidity and mortality from respiratory infections, but active immunization for influenza is not successful in newborns or infants <6 months of age

Use of influenza vaccine in pregnancy can benefit both the woman and her infant

Inactivated influenza vaccine is recommended for all women who will be pregnant during influenza season

Vaccination can occur in any trimester of pregnancy

Study Objectives

Assess knowledge, attitudes and practices of U.S. obstetrician-gynecologists regarding influenza vaccination during pregnancy

Assess barriers and facilitators to influenza vaccination during pregnancy among U.S. obstetrician-gynecologists

Study Methods Study population and sampling:

Random sample of U.S. obstetrician-gynecologists ACOG fellows or junior fellows in ACOG database Only ob-gyns currently involved in obstetric patient care

Survey: Self-administered mail survey (cover letter and pre-paid

envelope) Questions about basic demographics, experience with ILI in

their practice, attitudes and practices re: influenza vaccinations

No incentives were offered

Timeline: Initial mailing in February 2010, right after the peak of

H1N1 pandemic Follow-up survey to non-respondents at 4- to 5-week

intervals

3,116Surveys mailed

3,096Ob-gyns received survey

1,310Ob-gyns

completed survey

873Ob-gyns provided obstetric

care

20Surveys returned as undeliverable

1,784 Did not respond

2 Declined

participation

34,985Ob-gyns in ACOG

database

437Did not provide obstetric care

42.3%(1,310/3,096)

Response rate

Enrollment

Characteristics of Participating Ob-GynsCharacteristics % or Mean (Range)

SexFemaleMale

51.148.9

Average age, years 49 (30-85)

Average years in practice 17 (0.5-52)

Practice type

Group ob-gynSoloMultispecialty groupUniversity faculty & practiceOther

48.116.412.411.211.9

Considers primary care an important part of practice

Very importantImportantNot important

45.849.43.8

Average est. % patients eligible for Medicaid

33.4

Average est. % patients by race/ethnicity

Non-Hispanic whiteNon-Hispanic African AmericanHispanicAsian or Pacific IslanderNative AmericanMultiracialOther

54.915.217.85.31.32.61.0

Observing Serious Conditions Attributed to ILI

Proportion of ob-gyns who reported observing at least one of the serious conditions in their practices that they attributed to influenza-like illness (ILI)

Attitudes and Practices re: Influenza Vaccination

Characteristics

Seasonal

influenza

vaccine

2009 H1N1 influenza vaccine

Offering influenza vaccination to pregnant patients

Routinely offeredNot offered, but referredNeither offered or referred

77.621.11.1

85.613.31.2

Offering influenza vaccination to specific groups of pregnant patients

Healthy low-riskHigh-risk with chronic conditionPre-pregnancy obesity

75.375.371.0

83.482.477.5

Recommending influenza vaccination to pregnant patients

Do not recommendRecommend during any trimesterRecommend during 2nd or 3rd trim.

0.588.910.6

0.589.99.6

Requirements for med. staff to receive influenza vaccination

RequiredStrongly encouragedNot required

33.863.22.9

33.962.43.3

Received influenza vaccination themselves

YesNo

91.78.3

89.810.2

Year(s) Population Screen, recommend and offer vaccine Reference

1999 ob/gyns, n=31348% screen; 39% offer

vaccineGonik et al, 2000

2000 ob/gyns, n=113 67% offer vaccine Silverman, 2001

2001 ob/gyns, n=562 44% offer vaccine Schrag et al, 2003

2001-02ob/gyns, n=20; fam. physicians,

n=66

68% (ob/gyns) and 90% (fam. physicians) store

vaccineWallis et al, 2004

2004 ob/gyns, n=37 73% offer vaccine Wu et al, 2006

2004 ob/gyns, n=41352% (1st trim) and 95% (2-3rd

trim) recommendBettes et al, 2005

2007 ob/gyns, n=394 52.5% offer vaccine Power et al, 2009

2006-09 ob HCW, n=26765% recommend, 52% and

40% offer vaccineBroughton et al, 2009

2009-10 ob/gyns, n=85877.6% offer seasonal and 85.6% offer H1N1 vaccine

Kissin et al, in press

Do obstetricians and other providers offer

influenza vaccine to pregnant women?

Reasons for Not Offering Influenza Vaccine

Seasonal influenza vaccine

2009 H1N1 influenza vaccine

Not adequately reimbursed by insurance 34.9% 31.7%

No adequate storage and handling facilities for vaccines 28.0% 35.8%

Vaccine offered by closely affiliated clinic 21.7% 28.5%

Managed care contract does not cover the cost of vaccines and vaccine administration

20.1% 17.1%

Belief that vaccines should be administered by another provider, such as an internist or family practitioner

15.3% 14.6%

Sources of Guidance re: Influenza Vaccination for Pregnant Women

Source of GuidancePercentage of ob-

gyns using the source

ACOG 60.8%

CDC 54.1%

Public Health Department 18.8%

Own practice 11.9%

Scientific literature 5.6%

Media 3.9%

Predictors of Offering Influenza Vaccine

CharacteristicsRoutinely offered

vaccine (%)

Adjusted Prevalence

Ratio

All 85.6 -

Practice type

Group ob-gynSoloMultispecialty groupUniversity faculty & practiceOther

86.666.998.191.888.0

Ref0.81.11.11.0

Considers primary care an important part of practice

Very importantImportantNot important

88.484.673.2

1.21.1Ref

Observed serious conditions attributed to ILI

Yes (at least one)No

91.183.0

1.1Ref

Received influenza vaccination themselves

YesNo

87.269.6

1.2Ref

Summary Most ob-gyns routinely offered influenza

vaccinations to their patients

A considerable proportion of ob-gyns did not offer vaccination or did not recommend vaccination in the first trimester of pregnancy

Barriers to recommending and administering influenza vaccination among ob-gyns included financial and logistical concerns (inadequate reimbursement, absence of storage and handling facilities)

Solo practice providers were less likely to offer influenza vaccination, but more likely to consider primary care a very important part of their practice

Recommendations

Utilize available approaches to increase vaccination during pregnancy: Engage in educational and promotion activities for

obstetric providers Collaborate with professional organizations on provider

education Promote standing orders for influenza vaccinations Address financial (insurance coverage and

reimbursement), administrative and logistical concerns (especially among solo practice providers)

Encourage providers to be vaccinated themselves

Design, implement and evaluate interventions to improve vaccination coverage among pregnant women

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank You!

Division of Reproductive Health

National Center for Chronic Disease Prevention and Health Promotion

Additional Slides

Seasonal influenza vaccination coverage for pregnant women,

NHIS, 1997-2009

11.18.4 7.6

10.0 10.412.4 12.8

14.4 13.2 12.314.7

24.2

11.3

0

10

20

30

40

50

60

n=372

n=335

n=332

n=337

n=294

n=319

n=315

n=156

n=180

n=126

n=123

n=113

n=177

Seasonal and H1N1 influenza vaccination coverage for

pregnant women, 2009-10

47.6%44.5% 42.9% 42.7% 42.0%

0

10

20

30

40

50

60

70

80

BRFSSNHFS Harvard

Poll

n=163

n=161

n=260

n=255

n=514

Healthy People 2020 Goal

Barriers for obstetricians and other providers to vaccinate pregnant

women FINANCIAL: Inadequate reimbursement, cost of

purchase and storage1-8

LOGISTICAL: Not part of usual practice, lack of vaccine availability, lack of time, lack of comfort with administration, lack of staffing1,3,5-8

LEGAL: Liability concerns3,4,6-8

1Gonik et al, 2000. 2Wallis et al, 2004. 3Naleway et al, 2006. 4Panda et al, 2010. 5Power et al, 2009. 6Schrag et al, 2003. 7Wu et al, 2006. 8Dolan et al, unpublished.

Barriers for obstetricians and other providers to vaccinate pregnant

women - continued KNOWLEDGE: Uncertainty about

recommendations, lack of knowledge about increased morbidity of pregnant women from influenza, lack of knowledge about conferring passive immunity to infant, lack of data on effectiveness1-5

ATTITUDES/PRACTICES: patient demand low or patient unwillingness, not being vaccinated themselves2-6

SAFETY: Concerns about safety for pregnant women and fetus, concern about preservatives, concerns about vaccination during the first trimester2-7

1Gonik et al, 2000. 2Naleway et al, 2006. 3Power et al, 2009. 4Schrag et al 2003. 5Wu et al, 2006. 6Panda et al, 2010. 7Dolan et al, unpublished.

Provider/system- based and access-enhancing interventions to

increase vaccination during pregnancy Provider reminder systems: chart prompts, printing

vac. record Provider assessment and feedback: monitoring and

reporting vaccination rates Standing orders: vaccination by healthcare personnel

without direct physician involvement, encouraged by ACIP Provider education: active education, promotion

activities, vaccination training, communication with ob providers through letters and calls from ACOG, AMA leadership*

Enhancing access to vaccinations: providing vaccine directly to ob providers (2009-10), vaccination clinics for pregnant women and their partners*

Sources: CDC, MMWR 2000. Naleway et al, 2006. Ndiaye et al, 2005. Mouzoon et al, 2010. Ogburn et al, 2007. Panda et al, 2010. Wallis et al, 2006. Mills, Maine Dept of Health, personal communication, 2010. Koelemay, Seattle King County Health Dept, personal communication, 2010.*Interventions not formally evaluated