Use of

Flu vaccine

in Pregnancy : An OverviewDr. Sharda Jain Founder & Chairman

Dr. Jyoti Agarwal

Dr. Jyoti Bhaskar

Dr. Jyoti Agarwal

Dr. Jyoti Bhaskar

• Group photo

Our TeamOur Team

Presented in Delhi Gynaecology forum June 2015 at J.P ResortPresented in Delhi Gynaecology forum June 2015 at J.P Resort

Aim • Infection and

PREGNANCY increased susceptibility or severity in pregnancy

• INFLUENZA & its vaccination

Pregnant women more SEVERELY affected by infections with some organisms

INFECTION INCREASED SUSCEPTIBILITY

INCREASED SEVERITY

PREVENTION STRATEGIES

INFLUENZA No YES Influenza vaccination ; antiviral prophylactic medication for selected patients

HEPATITIS E No YES Sanitation programs

HERPES SIMPLEX No YES Protection from S.T.D transmitted during pregnancy

MALARIA \

(Mainly due to plasmodium falciparum)

No YES Insecticide – treated bad nets (for areas where malaria is endemic appropriate prophylaxis (for travelers)

STRONG EVIDENCE STRONG EVIDENCE

Infection IncreasedSusceptibility

IncreasedSeverity

Prevention strategies

Measles No Yes Vaccinations

Smallpox No Yes Vaccination

Varicella No Yes Vaccination

HIVType - 1

Yes No Consistent andCorrect condom use:Protection from S.T.DDuring pregnancy

Pregnant women more SEVERELY affected by infections with some organisms (cont.)

MORE LIMITED EVIDENCEMORE LIMITED EVIDENCE

Influenz&

Vaccine

Influenza• Influenza is a highly contagious

acute respiratory illness caused by infection with influenza viruses

• Affects the upper and lower respiratory tracts

• Produces systemic signs and symptoms– Fever (abrupt onset), Myalgia– Sore throat, Cough

(nonproductive), Headache – Weakness

Infection Process and Transmission

• Virus attaches to and penetrates respiratory epithelial cells in trachea and bronchi

• Virus replicates and destroys host cell (4-6hr)• Incubation period: 1 to 4 days• Symptoms occur but viremia absent• Virus shed in respiratory secretions for 5-10

days, runs course in 2 weeks• Person-to-person (aerosols from cough or

sneeze), or surface transmission

Clinical presentation• Headache,fever, myalgia,malaise, • within 1 to 2 days after infection may reveal basilar

rales.• Bilateral interstitial infitrates –seen in lungs.• Gram stains of sputum - bacteria and mononuclear cells.• Virus within exfoliated epithelial cells • Culture -- Nasopharyngeal washings, nasal swabs, and

throat swabs.• Serum antibody is detectable 2 to 3 weeks after

infection . Paired specimens are needed

Often misunderstood and underestimated, Influenza is not just

“a bad cold”!

JAMA 2000; 284 (13): 1740

Often misunderstood and underestimated, Influenza is not just “a Bad Cold”!

Complications Of Influenza

PULMONARY: Primary influenza viral

pneumonia Secondary bacterial

pneumonia Asthma, COPD,

bronchitis, cystic fibrosis exacerbation

Exacerbation of other chronic medical conditions

NON-PULMONARY:MyositisCardiac complicationsToxic shock syndromeGuillian-Barré syndromeTransverse myelitisEncephalitisReye’s syndrome

Betts RF. Chapter 141: Influenza virus. In: Principles and Practice of Infectious Diseases, 4th ed. Editors: Mandell GL, et al. Churchill Livingstone, New York, 1995, 1556-58

High risk conditionsRespiratory disease• Asthma• Chronic bronchitis and

emphysema• Other pulmonary diseasesCardiac disease• Atherosclerotic heart disease• Cardiomyopathy/CCF• Congenital heart diseaseNeurodevelopmental disorders• Cerebral palsy• Musculodystrophy• Cognitive disordersMetabolic disorders• Diabetes Haematological diseases• Sickle cell anaemia• Thalassemia major

Immunocompetency disorders•HIV/AIDS•Chemotherapy•Transplant pts on immunosuppressants•Chronic corticosteroid therapy

Chronic renal insufficiency on dialysisChronic liver disease, esp. with cirrhosisMorbid obesity

Pregnancy Background Paper on Influenza Vaccines and Immunization. SAGE Working Group: April 2012

PROGNOSIS

Influenza generally is a self-limited disease,

but serious morbidity and mortality do occur.

Influenza in Pregnancy

Mother • Pregnant women are a HIGH-RISK group

during influenza epidemics.• Increased mortality is caused by viral

pneumonia itself and by superimposed staphylococcal and gram-negative enteric pneumonias.

• Rates of spontaneous abortion are as high as 25% to 50 %.

Fetus • Influenza virus can be transmitted

transplacentally to the fetus.• Many studies of large number of

patients have failed to link influenza and congenital malformations.

• However, serious maternal illness with hypoxia can cause premature labor and abortion.

Disease burden: epidemic influenza

• Virus is not a new virus• Belongs to the family Orthomyxoviridae• Three types determined by nuclear material

– Influenza A, B and C

• Influenza A subtypes are further described based

on H and N surface glycoproteins• Virus appears in groups or clusters • Vaccine usually available• Post exposure prophylaxis available

Seasonal Epidemics• 5 to 10 % of the world’s population catches influenza

i.e., 500 million people• Including 3 to 5 million I million = 10 lac

• And 2,50,000 to 5,00,000 deaths each year• 15 - 45% of children are infected with an influenza

virus each year• Certain groups are at high risk for complications

(pregnancy & old people)

WHO Public Research Agenda for Influenza 2009. www.who.int/csr/disease/influenza

serious casesserious cases

PANDEMIC Influenza(World – Wide Outbreak)

• Occurs when:–new influenza type A virus emerges

(antigenic shift)–no immunity in population–virus spreads efficiently between humans

Pandemic History (120 years)

2014 – 2015

H1N1

2014 – 2015

H1N1

Estimated global mortality association with the first 12 months of 2009 pandemic

Influnza A H1N1 virus

•18,500 lab-confirmed deaths reported worldwide between April 2009 and August 2010

• Authors estimate 2,01,200 respiratory deaths and 83,300 cardiovascular deaths due to H1N1

15 times higher than reported lab-confirmed deaths15 15 timestimes

Fatimah S Dawood, A Danielle luliano carrireed, mortin I meltzer, David K shay, Po-yung cheng, Don Bandaranayake, robert F breiman lancet (online)june 26,2012

Fatimah S Dawood, A Danielle luliano carrireed, mortin I meltzer, David K shay, Po-yung cheng, Don Bandaranayake, robert F breiman lancet (online)june 26,2012

2014 - 2015Toll on deaths was less

2014 - 2015Toll on deaths was less

Treatment • Hospitalzation if FEBRILE or Pulmonary symptoms

due to high rates of pneumonia especially in the third trimester.

• Antiviral prophylaxis should be initiated as soon as possible

• OSELTAMIVIR is generally preferred : 75 mg two times per day for 5 days.

• Bacterial superinfection should be treated empirically on the basis of presumed pathogens (third – generation cephalosporin or gentamicin )

The CDC recommends

that all pregnant women receive flu vaccine regardless of

Gestational age.

Influenza (inactivated)• Because vaccinating against influenza before

the season begins is critical, and because predicting exactly when the season will begin is impossible, routine influenza vaccination is recommended for all women who are or will be pregnant (in any trimester) during influenza season

• Protection to infant lasts for 6 months

Influenza Vaccine• Lack of awareness of benefits and concerns

about vaccine safety in pregnancy are the common barriers to vaccination

• Pregnant women whose provider recommended and offered influenza vaccine were 5 times more likely to be vaccinated than those who were not offered

Vaccines recommended for all pregnant women

• In the United States, vaccines recommended in pregnancy include the seasonal influenza vaccine, tetanus toxoid, and the pertussis vaccine as a combined tetanus-diphtheria toxoid and acellular pertussis vaccine (Tdap).

• Influenza vaccination recommended in the USA for all pregnant women regardless of trimester since 2004

Munoz FM. Maternal Immunization: An Update for Pediatricians. Pediatric Annals 2013; 42(8): e163-e168Munoz FM. Maternal Immunization: An Update for Pediatricians. Pediatric Annals 2013; 42(8): e163-e168

Advocacy on influenza vaccine

Association of Physicians of India

• Women in 2nd and 3rd trimester at increased risk for influenza requiring hospitalization

• Vaccination before flu season is critical• Routine influenza vaccination recommended

for all women who are/will be pregnant in any trimester just before start of influenza season

Sharma RK, Ruhela V. Immunization in pregnant women. In: Muruganathan A et al. API. Adult immunization 2014. 2nd Ed. Jaypee Brothers, 2014.pp.120-27

FOGSI (Nov 2014)

• All pregnant women should receive influenza

vaccination at 26 weeks of pregnancy or later. Vaccination can be done earlier in case of a pandemic.

• All non-immunized postnatal mothers should receive the influenza vaccine.

• In addition, annual influenza vaccination can be offered to all adults and elderly women.

Other bodies recommending Influenza vaccination in pregnancy

• American College of Obstetricians and Gynaecologists (ACOG)

• Indian Academy of Pediatrics (IAP)• Advisory Committee on Immunization

Practices (ACIP)• American Academy of Pediatrics (AAP)

Advisory Committee on Immunization Practices (ACIP)

Routine Recommendation in pregnancy

20112011

Vaccine Before pregnancy Type of vaccine

HEPATITIS A Yes, if at risk Inactivated

HEPATITIS B Yes, if at risk Inactivated

HPV Yes Inactivated

INFLUENZA TIV Yes Inactivated

INFLUENZA LAIV Yes, avoid conception for 4 weeks Live

MMR Yes, avoid conception for 4 weeks Live

MENINGOCOCCAL If indicated Inactivated

PNEUMOCOCCAL If indicated Inactivated

TETANUS/ DIPHTHERIA TD

Yes, Tdap preferred Toxoid

TDAP Yes, preferred Toxoid/ inactivated

VARICELLA Yes, avoid conception for 4 weeks Live

Vaccine During pregnancy

Hepatitis A Yes, if at risk

Hepatitis B Yes, if at risk

HPV No

Influenza TIV trivalent inj. Vaccine

Yes

Influenza LAIV live alternative inj. Vaccine

No

MMR No

Meningococcal If indicated

Pneumococcal If indicated

Tetanus/ diphtheria Td>2 only

Yes, Tdap preferred if >20 weeks gestationTdap preference

Varicella No

Vaccine After Pregnancy

HEPATITIS A YES, IF AT RISK

HEPATITIS B YES, IF AT RISK

HPV YES

INFLUENZA TIV YES

INFLUENZA LAIV YES

MMR YES, GIVE IMMEDIATELY POSTPARTUM IF SUSCEPTIBLE TO RUBELLA

MENINGOCOCCAL IF INDICATED

PNEUMOCOCCAL IF INDICATED

TETANUS/ DIPHTHERIA TD

YES, TDAP PREFERRED

TDAP YES, PREFERRED

VARICELLA YES, GIVE IMMEDIATELY POSTPARTUM IF SUSCEPTIBLE

Cherish by following best practices in Medicare

Take Home Message

•It is good practice that medical fraternity takes flu vaccine in January every year

All pregnant women should also be Vaccinated for flu at 26 weeks

• With the exception of clean drinking water , vaccines are most effective intervention to reduce and prevent an infectious disease

• Today 28 diseases are vaccine preventable

• Let us add Flu Vaccine to this list

Has started routine influenza vaccination in pregnancy 2014 oct

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Influenza in Pregnancy

• Flu is more likely to cause severe illness in pregnant women

• Women in the second and third trimesters of pregnancy are at increased risk for hospitalization, severe illness and even death from influenza

• Higher risk of preterm labor