Preparing for influenza after 2009 H1N1: special considerations for pregnant women and newborns

ppes

www.AJOG.org

Preparing for influenza after 2009 H1N1: specialconsiderations for pregnant women and newbornsSonja A. Rasmussen, MD, MS; Dmitry M. Kissin, MD, MPH; Lorraine F. Yeung, MD, MPH; Kitty MacFarlane, MN, MPH;Susan Y. Chu, PhD, MSPH; Reina M. Turcios-Ruiz, MD; Elizabeth W. Mitchell, PhD; Jennifer Williams, MSN, MPH;Alicia M. Fry, MD, MPH; Jeffrey Hageman, MHS; Timothy M. Uyeki, MD, MPH, MPP; Denise J. Jamieson, MD, MPH;
and the Pandemic Influenza and Pregnancy Working Group
tdnw1APmvnGtetnppp

fkw

rflbitfadflmbgta

The year 2009 brought the world’s firstinfluenza pandemic in�40 years.1 As

redicted on the basis of the experience inrevious pandemics and seasonal influ-nza,2 pregnant women were among thoseeverely affected.3,4 As part of the response

to the 2009 pandemic influenza A (2009H1N1) pandemic, public health recom-

From the Division of Birth Defects andDevelopmental Disabilities, National Centeron Birth Defects and DevelopmentalDisabilities (Drs Rasmussen, Yeung, andMitchell, and Ms Williams), Centers forDisease Control and Prevention; theDivision of Reproductive Health, NationalCenter for Chronic Disease Prevention andHealth Promotion (Drs Kissin, Chu,Turcios-Ruiz, and Jamieson and MsMacFarlane), Centers for Disease Controland Prevention; the Influenza Division,National Center for Immunization andRespiratory Diseases (Drs Fry and Uyeki),Centers for Disease Control and Prevention;and the Division of Healthcare QualityPromotion, National Center for Emerging andZoonotic Infectious Diseases (Mr Hageman),Centers for Disease Control and Prevention,Atlanta, GA.

Received Nov. 15, 2010; revised Jan. 18,2011; accepted Jan. 21, 2011.

Reprints not available from the authors.

Authorship and contribution to the article islimited to the authors indicated. There was nooutside funding or technical assistance with theproduction of this article.

Conflict of Interest: none.

The findings and conclusions in this report arethose of the authors and do not necessarilyrepresent the official position of the Centers forDisease Control and Prevention.

Publication of this article was supported by theCenters for Disease Control and Preventionand the Association of Maternal and ChildHealth Programs.

0002-9378/$36.00Published by Mosby, Inc.

rdoi: 10.1016/j.ajog.2011.01.048

mendations that are specific to pregnantwomen and newborn infants were devel-oped.5-7 Much of the evidence on whichthese recommendations were based hadbeen reviewed with outside experts andpartners at a meeting that had been con-vened by the Centers for Disease Controland Prevention (CDC) in April 2008 inpreparation for a future pandemic.8 Sincehat meeting, many studies have been con-ucted to describe the experience of preg-ant women and their newborn infantsith 2009 H1N1 influenza. On August 12-3, 2010, the CDC, in partnership with thessociation of Maternal and Child Healthrograms and the March of Dimes, held aeeting entitled “Pandemic Influenza Re-

isited: Special Considerations for Preg-ant Women and Newborns” in Atlanta,A. This meeting was designed to review

he public health recommendations citedarlier and to consider new informationhat was available on pregnant women andewborn infants from the 2009 H1N1andemic with experts and partners torepare for future influenza seasons andandemics. Experts who covered a broad

Pregnant women and their newborn infantscomplications, based on data from seasoCenters for Disease Control and Preventiontions for these populations in response torecommendations and information that waprepare for future influenza seasons andentitled “Pandemic Influenza Revisited: SpeNewborns” on August 12-13, 2010, to gaintopics: antiviral prophylaxis and therapy,infection control) issues, and nonpharmaceChallenges to communicating recommendaand their health care providers were alsoavailable information and individual expertfor these populations for future influenza se

Key words: 2009 H1N1, influenza, pandem

ange of relevant areas and representatives

Supplement to JUNE 2011 Am

rom organizations that were identified asey partners during the pandemic (Table)ere invited to participate in the meeting.Four main topics were discussed: antivi-

al treatment and chemoprophylaxis, in-uenza vaccine use, intrapartum and new-orn infant (including infection control)

ssues, and nonpharmaceutical interven-ions and health care planning. After care-ul consideration of available informationnd individual expert input, the CDC up-ated its recommendations for future in-uenza seasons and pandemics. Recom-endations for influenza will continue to

e updated as new information (eg, re-arding circulating viruses that include an-iviral resistance patterns) becomes avail-ble (see www.cdc.gov/flu for updated

information). Throughout this article, dis-cussions relate to seasonal influenza, un-less specifically noted to apply to a futurepandemic.

Antiviral treatment andchemoprophylaxisIssues related to influenza treatmentwere considered, including the severity

at increased risk for influenza-associatedinfluenza and influenza pandemics. TheC) developed public health recommenda-2009 H1N1 pandemic. A review of thesellected during the pandemic is needed tondemics. The CDC convened a meetingl Considerations for Pregnant Women andut from experts and key partners on 4 maincine use, intrapartum/newborn (includingal interventions and health care planning.

ns regarding influenza to pregnant womencussed. After careful consideration of theut, the CDC updated its recommendationsons and pandemics.

pregnancy, seasonal

arenal(CD

thes copaciainpvacutictiodisinpas

ic,

of disease in pregnant women and ben-

erican Journal of Obstetrics & Gynecology S13

http://www.cdc.gov/flu

J O

Supplement www.AJOG.org

efits and risks of treatment to themother and fetus. Consistent with datafrom previous influenza pandemicsand seasonal influenza,2 pregnantwomen were at increased risk for 2009H1N1-associated morbidity and death;pregnant women had a 4-fold in-creased risk of hospitalization4 and ac-counted for a disproportionate num-ber of deaths.3 During the 2009-2010season, the CDC recommended thatpregnant women with confirmed orsuspected 2009 H1N1 receive promptempiric antiviral treatment with osel-tamivir.6 Subsequent studies showedthat early (�2 days after symptom on-set) treatment of pregnant women with2009 H1N1 was associated with fewerintensive care unit admissions and

TABLEAreas of expertise andorganizations that wererepresented at the “PandemicInfluenza Revisited: SpecialConsiderations for PregnantWomen and Newborns”meeting in Atlanta, GA,on August 12-13, 2010

Areas of expertise...........................................................................................................

Communications..................................................................................................

Emergency response..................................................................................................

Family medicine..................................................................................................

Health education..................................................................................................

Infection control..................................................................................................

Infectious diseases..................................................................................................

Influenza..................................................................................................

Lactation and infant feeding..................................................................................................

Maternal-fetal medicine..................................................................................................

Midwifery..................................................................................................

Obstetrics..................................................................................................

Pediatrics..................................................................................................

Pharmacy..................................................................................................

Preventive medicine..................................................................................................

Public health..................................................................................................

Teratology..................................................................................................

Vaccines...........................................................................................................

Rasmussen. Preparing for Influenza after 2009H1N1. Am J Obstet Gynecol 2011. (continued )

fewer deaths, when compared with late

S14 American Journal of Obstetrics & Gynecology

(�4 days after symptom onset)treatment.3,9

During the 2009-2010 influenza sea-son, 99% of influenza viruses that wereidentified in the United States were 2009

TABLEAreas of expertise and organizationthe “Pandemic Influenza Revisitedfor Pregnant Women and Newbornon August 12-13, 2010 (continued)

Organizations...................................................................................................................

Academy of Breastfeeding Medicine..........................................................................................................

Advisory Committee on Immunization Prac..........................................................................................................

American Academy of Family Physicians..........................................................................................................

American Academy of Pediatrics..........................................................................................................

American College of Nurse Midwives..........................................................................................................

American College of Obstetricians and Gyn..........................................................................................................

American Medical Association..........................................................................................................

American Nurses Association..........................................................................................................

American Pharmacists Association..........................................................................................................

Association for Professionals in Infection C..........................................................................................................

Association of Maternal and Child Health P..........................................................................................................

Association of Women’s Health, Obstetric..........................................................................................................

California Department of Public Health..........................................................................................................

Centers for Disease Control and Preventio..........................................................................................................

Centers for Medicare & Medicaid Services..........................................................................................................

Food and Drug Administration..........................................................................................................

Georgia Division of Public Health..........................................................................................................

Indian Health Service..........................................................................................................

International Lactation Consultant Associa..........................................................................................................

March of Dimes..........................................................................................................

Memphis County (TN) Health Department..........................................................................................................

National Association of County and City He..........................................................................................................

National Institutes of Health..........................................................................................................

National Medical Association..........................................................................................................

National Vaccine Program Office..........................................................................................................

New York City Department of Health and M..........................................................................................................

New York State Department of Health..........................................................................................................

Nurses for Newborns Foundation..........................................................................................................

Organization of Teratology Information Spe..........................................................................................................

Shelby County (TN) Health Department..........................................................................................................

Society for Healthcare Epidemiology of Am..........................................................................................................

World Health Organization...................................................................................................................

Rasmussen. Preparing for Influenza after 2009 H1N1. Am

H1N1, essentially all of which were resis-

Supplement to JUNE 2011

tant to adamantanes (amantadine andrimantadine). However, nearly all influ-enza A (2009 H1N1 and H3N2) and Bvirus strains that were tested were sus-ceptible to neuraminidase inhibitors

that were represented atecial Considerations

meeting in Atlanta, GA,

..................................................................................................................

..................................................................................................................

s..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

logists..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

rol and Epidemiology..................................................................................................................

rams..................................................................................................................

Neonatal Nurses..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

Officials..................................................................................................................

..................................................................................................................

..................................................................................................................

..................................................................................................................

tal Hygiene..................................................................................................................

..................................................................................................................

..................................................................................................................

lists..................................................................................................................

..................................................................................................................

a..................................................................................................................

..................................................................................................................

bstet Gynecol 2011.

s: Sps”

.........

.........

tice.........

.........

.........

.........

eco.........

.........

.........

.........

ont.........

rog.........

and.........

.........

n.........

.........

.........

.........

.........

tion.........

.........

.........

alth.........

.........

.........

.........

en.........

.........

.........

cia.........

.........

eric.........

.........

(oseltamivir and zanamivir).10 Among

dnbt

rtfltaptirwsistmrtrpvnsvada

iotatr

mtwr(co

pasttswflo

tHtnztama

cpb

fliaparrvw

stk

wtbi

mtwotstpci

www.AJOG.org Supplement

patients with infection with an oseltami-vir-resistant 2009 H1N1 virus, �90%had received oseltamivir for either treat-ment or prophylaxis before specimencollection.11,12

Information on the effects of influenzaantiviral medications on the fetus is lim-ited. Data had been reviewed previouslyregarding infant outcomes after the use ofantiviral medications during pregnancy;no evidence was available to suggest thatany of the 4 available influenza antiviralmedications had adverse effects on infantoutcomes.8 Since that review, 2 more stud-ies on oseltamivir use during pregnancyhave been published.13,14 Neither study

emonstrated increased fetal risk after pre-atal oseltamivir exposure, but the num-ers of women who were exposed duringhe first trimester were small.

Based on available data to evaluate theisk vs the benefit, the CDC recommendshat pregnant women with suspected in-uenza receive prompt early empiric

reatment with appropriate influenzantiviral medications. Oseltamivir isreferred over zanamivir, assuming thathe prevalence of oseltamivir resistances low among circulating influenza vi-uses (for updated information, seeww.cdc.gov/flu). Health care providers

hould educate pregnant women aboutnfluenza symptoms and of the need toeek treatment promptly so that antiviralreatment can be initiated in a timely

anner. Antiviral chemoprophylaxisecommendations should be the same ashose for other groups that are at highisk for complications from seasonal andandemic influenza. Because influenzaaccines are not 100% effective, preg-ant women with suspected influenzahould be treated, regardless of influenzaaccination status. Because currentlyvailable rapid influenza diagnostic testso not have sufficient sensitivity to reli-bly rule out influenza virus infection,15

clinical decisions to initiate antiviraltreatment should be based on clinicalsuspicion of influenza. Recommenda-tions for influenza testing of pregnantwomen should be consistent with thosefor other high-risk patients.

Although the impact of influenza virusinfection in postpartum women is not
well understood, it seems likely that m
changes during pregnancy that placewomen at increased risk might extendinto the postpartum period. Surveillancedata on postpartum women from Cali-fornia support this increased risk; fromApril-December 2009, 9 women (�6months after delivery) with 2009 H1N1were admitted to the intensive care unit,3 of whom died.16 Eight of these women,ncluding all 3 who died, had symptomnset at �8 days after delivery. Based onhese limited data and what is knownbout the timing of physiologic changeshat occur during the postpartum pe-iod,16 recommendations for antiviral

treatment and chemoprophylaxis ofpregnant women apply to women for atleast 2 weeks after the end of pregnancy,regardless of pregnancy duration.

Fever during pregnancy has been asso-ciated with an increased risk for certainbirth defects and other adverse out-comes,17-19 and antipyretic medications

ight attenuate these risks.8,18 Data onhe effects of antipyretic medicationshen used during pregnancy have been

eviewed.8 Given that other antipyreticseg, aspirin, ibuprofen) have been asso-iated with adverse pregnancy and infantutcomes,20-22 acetaminophen was se-

lected as the best option for treatment ofinfluenza-associated fever during preg-nancy.8 Subsequently, 2 additional stud-ies have shown no increased risk of birthdefects associated with acetaminophenuse during pregnancy.23,24 Although

renatal use of acetaminophen has beenssociated with asthma in infants inome studies,25-27 at this time, no consis-ent evidence supports an association be-ween acetaminophen and asthma in off-pring. Treatment of fever in pregnantomen with suspected or confirmed in-uenza is recommended, and acetamin-phen appears to be the best option.During the 2009-2010 season, some pa-

ients who were severely ill with 20091N1 (including pregnant women) were

reated with experimental intravenouseuraminidase inhibitors (ie, peramivir,anamivir).28 No data on the effects ofhese medications on the fetus are avail-ble. It should be noted that the oral for-ulation of oseltamivir appears to be

bsorbed adequately after nasogastric ad-
inistration.29 Antiviral treatment for

ritically ill pregnant women with sus-ected or confirmed influenza should note withheld based on pregnancy status.Further research on fetal safety of in-

uenza antiviral medications is a prior-ty, given the limitations of data in thisrea. Additional studies on the patho-hysiologic condition and optimal man-gement of influenza in pregnancy andesearch to understand factors that affecteceipt and compliance with empiric anti-iral treatment among pregnant womenith influenza are needed.

VaccinationThe Advisory Committee on Immuniza-tion Practices and the American Collegeof Obstetricians and Gynecologists rec-ommend the administration of inacti-vated influenza vaccine for all womenwho are pregnant during the influenzaseason, regardless of pregnancy trimes-ter.30,31 In influenza pandemic situationsand periods of vaccine shortage, preg-nant women are included in the highestpriority group for influenza vaccinationbecause of their increased risk for influ-enza-associated morbidity and death.32

However, influenza vaccination cover-age among pregnant women historicallyhas been low,33 although preliminarydata suggest higher coverage during the2009-2010 season.34 For future influenzaeasons, attaining high influenza vaccina-ion coverage among pregnant women is aey public health priority.Influenza vaccination of pregnantomen induces protective concentra-

ions of hemagglutinin inhibition anti-odies and effectively prevents influenza

llness.35-39 In addition to the protectionthat is provided to pregnant women, in-fluenza vaccination in pregnancy pro-vides benefits to their infants.39,40 Im-

unogenicity studies consistently showhat influenza vaccination of pregnantomen results in transplacental transferf hemagglutinin inhibition antibodieso the fetus.35,38,40-43 In prospectivetudies that included a randomized con-rolled trial, influenza vaccination ofregnant women reduced laboratory-onfirmed influenza illness by 41-63% innfants who were �6 months old,39,40

which is a critical group for protection
because they are at increased risk for se-

http://www.cdc.gov/flu

bbcoo

mfst

ewvrotw

etsttoanren

tthfiflhttcgpltafralsasvbpoaa

hvuf


vere influenza illness and have high ratesof hospitalization and death but are un-able to mount an adequate immune re-sponse after influenza vaccination andare ineligible for any of the influenza vac-cines that are licensed in the UnitedStates.31,44,45 An additional way to protectthese infants who are �6 months old is to

uild a protective “cocoon” of immunityy vaccinating all household contacts,aretakers, and other close contacts, as rec-mmended by the Advisory Committeen Immunization Practices.31

Trivalent inactivated influenza vaccinehas been administered to pregnant womensince the late 1950s and has been recom-mended for pregnant women in all trimes-ters since 2004. Although prospectivelycollected data that include women whohad been vaccinated in the first trimester ofpregnancy are lacking, safety research andmonitoring have not demonstrated in-creased risks of maternal, fetal, or infantcomplications after inactivated influenzavaccination during pregnancy.36-39,41,46-54

Safety of the monovalent 2009 H1N1 vac-cine was monitored carefully during the2009-2010 pandemic, and based on pre-liminary data, no concerns for pregnantwomen, their fetuses, or their infants havebeen identified.55,56

Despite recommendations and evi-dence of the benefits and safety of influ-enza vaccination during pregnancy, in-fluenza vaccination coverage of pregnantwomen before the 2009-2010 pandemicremained �15% for most years.31,33 Sev-eral barriers have been identified in sur-veys of health care personnel who typi-cally vaccinate pregnant women, whichincludes financial disincentives relatedto inadequate reimbursement, logisticalbarriers, concerns about liability, lack ofknowledge about the risk of influenza topregnant women or about influenza vac-cine benefit, and concerns about vaccinesafety.57-64 Several approaches (eg, re-

inder systems, provider assessment/eedback, standing orders) have beenhown to improve provider participa-ion in influenza vaccination.57,61,65-68

Greater implementation of these strate-gies in settings in which pregnantwomen receive care would likely im-
prove vaccine coverage.

Low influenza vaccination coverage isalso related to the acceptability and up-take of the vaccine by pregnant women.Based on data from recent surveys andfocus groups of pregnant women,69 keybarriers were concerns about influenzavaccine safety (including thimerosalcontent) and a lack of awareness aboutthe increased risk of influenza-associatedcomplications during pregnancy or thebenefits of vaccination for themselvesand their infants. A provider recommen-dation, which can encourage vaccinationand address concerns, is one of the stron-gest predictors of influenza vaccinationamong pregnant women.48,70-72 Influ-nza vaccination uptake by pregnantomen would be expected to improve ifaccine administration were incorpo-ated into routine prenatal care and ifther effective strategies to improve up-ake, such as patient reminder systems,ere used more widely.66,73,74

Several knowledge gaps and priority ar-eas for future research were identified dur-ing the meeting. Priorities for future re-search include greater understanding ofthe barriers that affect the uptake of influ-enza vaccine among pregnant women, es-pecially among minority and other under-served populations, and the development,implementation, and evaluation of novelstrategies that improve vaccination cov-rage among pregnant women. In addi-ion, greater knowledge regarding theafety of influenza vaccination in the firstrimester of pregnancy is needed. Al-hough available evidence does not dem-nstrate an increased risk of adverse eventsfter receipt of inactivated influenza vacci-ation during pregnancy, vaccine safetyesearch and careful monitoring of adversevents after influenza vaccination in preg-ant women should be continued.

Intrapartum and newborn infant(including infection control) issuesIssues that are related to vertical transmis-sion, hospital infection control, dischargeadvice, and use of antiviral medicationswhile breastfeeding were discussed. Dataare limited on vertical transmission of sea-sonal or pandemic influenza viruses; verti-cal transmission has been suggested to oc-cur with maternal illness (usually severe),
although it appears to be rare.75-78 Asymp- c

omatic newborn infants who are borno mothers who are symptomatic or whoave recovered from suspected or con-rmed influenza illness do not need in-uenza testing as part of routine care;owever, newborn infants who are borno mothers who are symptomatic at theime of delivery should be monitoredlosely for clinical illness that might sug-est influenza virus infection. If theregnancy results in fetal death, the col-

ection of fetal tissues (including respira-ory tract, umbilical cord, and placenta)nd respiratory and serum specimensrom the mother for influenza testing byeal-time reverse transcriptase-polymer-se chain reaction, viral culture, and mo-ecular and serologic assays can be con-idered. For research purposes, thessessment of whether vertical transmis-ion of influenza virus occurs from a se-erely ill mother to newborn infant cane done on a case-by-case basis when ap-ropriately timed specimens (eg, infantropharyngeal swabs, paired maternalnd cord sera, placental tissue) arevailable.

Measures that should be applied in allealth care settings to prevent influenzairus transmission are outlined in CDC’spdated infection control guidance in-

ormation.79 Influenza vaccination ofhealth care providers is an importantcomponent of the prevention of trans-mission of influenza in the health caresetting. Other measures include ensur-ing adherence to recommended infec-tion control precautions for influenzaprevention for all patient care, includingcare of women and newborn infantswithin the labor, delivery, recovery, andpostpartum settings. While in the healthcare setting, ill pregnant and postpartumwomen with suspected or confirmed in-fluenza should be placed on “DropletPrecautions”79 and isolated in separaterooms whenever possible. Droplet Pre-cautions should be implemented for 7days after illness onset or until 24 hoursafter the resolution of fever and respira-tory symptoms, whichever is longer,while the woman is in a health care facil-ity. Health care personnel who enter theroom should adhere to Standard andDroplet Precautions.79 Pregnant health
are personnel should adhere strictly to

fattmirBlbsfimumtwwrmPtaamfltnatptaerpbfta

uiltie�efmftrhpr

ihenwn

wpsotdtgaoufmfdt

ciceatlt


general infection prevention measuresfor health care personnel. They maybe offered work accommodations (eg,avoiding involvement with aerosol-gen-erating procedures on patients with sus-pected or confirmed influenza) to avoidpotentially high-risk exposure scenarios.Pregnant workers in school and child-care settings or who have direct contactwith groups of children should followthe same guidance as other workers.

Although it is recognized that the idealsetting for care of a healthy term new-born infant while in the hospital is withina healthy mother’s room,80 newborn in-ants who are infected with influenza aret increased risk for severe complica-ions. To reduce the risk of influenza inhe newborn infant, the CDC recom-

ends that facilities consider temporar-ly separating a mother with influenza vi-us infection from her newborn infant.ecause of the paucity of evidence, the

ength of temporary separation has noteen established and will need to be as-essed on a case-by-case basis after manyactors are considered. Guidelines dur-ng the 2009 H1N1 pandemic recom-

ended that separation should continuentil all of the following criteria wereet: the mother had received antiviral

reatment for �48 hours, was afebrileithout antipyretics for �24 hours, andas able to control her cough and respi-

atory secretions. Once contact betweenother and infant is resumed, Droplet

recautions for influenza should con-inue to be observed until at least 7 daysfter maternal illness onset. Asymptom-tic newborn infants who are born toothers with suspected or confirmed in-

uenza should be cared for accordingo Standard Precautions in the well-ewborn nursery by healthy caregiversnd closely observed for signs of infec-ion. Droplet Precautions should be im-lemented if symptoms develop. Symp-omatic persons, including the mothernd visitors, should not enter the nurs-ry. Throughout the course of tempo-ary separation, all feedings should berovided by a healthy caregiver if possi-le, and mothers who intend to breast-eed should be encouraged to expressheir milk. If co-location of an ill mother
nd her asymptomatic newborn infant is
navoidable because of a hospital’s phys-cal configuration, nursery constraints,ack of isolation rooms, or other reasons,he use of engineering controls like phys-cal barriers to reduce influenza-virusxposure, keeping the newborn infant6 feet away from the ill mother, and

nsuring a healthy adult is present to careor the infant must be considered. The

other and other visitors should be in-ormed of the risks of influenza virusransmission and instructed to adhere toespiratory hygiene and cough etiquette,and hygiene, and the use of personalrotective equipment, according to cur-ent facility policy.

Before the newborn infant is discharged,nfluenza vaccination status of all house-old contacts �6 months old and caregiv-rs of the infant should be assessed. Vacci-ation should be strongly encouraged and,hen possible, provided for any unvacci-ated contact, including the mother.81 On

discharge, good hygiene practices in thehome should be emphasized. The familyshould be advised to contact their healthcare provider promptly if the mother orinfant becomes ill or has symptoms thatsuggest influenza virus infection and toisolate any individuals in the home whobecome ill to minimize exposure of thenewborn infant and mother. Dischargeadvice for mothers with suspected or con-firmed influenza should be largely thesame as that given to healthy mothers andbe consistent with advice for persons whoare at high risk for influenza complica-tions. The family should be educated onsigns of worsening disease for the motherand infant, and vaccinated adults who arenot ill should provide care to the infant athome, if possible, until the mother’s illnessresolves. If the mother initiated breastfeed-ing inthehospital, sheshouldbe instructedto follow respiratory hygiene and cough et-iquette (eg, to perform hand hygiene be-fore contact with the infant and to coverher nose and mouth when coughing) whilecontinuing to breastfeed at home.

Although data on levels of oseltamivirand zanamivir in breast milk amonglactating women are very limited,82

available data suggest that oseltamiviradministration to lactating mothers atrecommended doses poses no harm to
breastfeeding infants. Therefore, if clini-

cally indicated, oseltamivir can be pre-scribed to breastfeeding women withinfluenza. Lactating women who take os-eltamivir should be encouraged to con-tinue breastfeeding when possible, whilefollowing recommended infection con-trol practices to reduce influenza virustransmission to the infant.

Nonpharmaceutical interventionsand health care planningduring a pandemicBefore the 2009 H1N1 pandemic, theCDC, in collaboration with other federalagencies and public health partners, de-veloped interim guidance on the use ofnonpharmaceutical interventions in theevent of a pandemic.83 This guidance

as designed to mitigate an influenzaandemic and included measures (eg,chool dismissals, social distancing)ther than vaccination and antiviralreatment. During the 2009 H1N1 pan-emic, CDC-issued guidance on preven-ion emphasized universal adherence toood respiratory and hygiene practicesnd encouraged persons with suspectedr confirmed influenza to stay at homentil 24 hours after becoming afebrile. In

uture pandemics, the role of nonphar-aceutical interventions will depend on

actors such as pandemic severity, pan-emic strain virulence, antiviral suscep-ibility, and vaccine availability.

Although pregnant women are at in-reased risk of influenza complications,t is not clear whether they are more sus-eptible to influenza virus infection. Novidence of increased susceptibilitymong pregnant women was observed inhe 2009-2010 season; however, onlyimited data were available to evaluatehis question.4 Given the lack of evidence

to support increased susceptibility to in-fluenza among pregnant women, duringfuture pandemics, pregnant and post-partum women generally should followthe same guidance as nonpregnant per-sons regarding nonpharmaceutical mea-sures. Furthermore, children of preg-nant women should follow the sameguidance as other children regardingmeasures to mitigate the spread of pan-demic influenza, including following lo-cal and state public health recommenda-
tions (such as school dismissals), if

ndtpmtt

Cpiewnamrthpbtsmtild


recommended. Pregnant women shouldnot be advised to avoid crowds unless thegeneral population is also advised todo so. However, given that pregnantwomen are at higher risk for severe influ-enza, during a pandemic, individual andclinical judgment is warranted.

Visitor policies for pregnant womenshould be consistent with general visitorpolicies in health care facilities. How-ever, during a pandemic, considerationshould be given to limiting visitors tohealthy adults and prohibiting childrenfrom visiting obstetric units because ofthe major role that children play inspreading influenza viruses.84 In a pan-demic, recommendations for routinepregnancy care may be altered (eg, tele-phone triage capabilities may be en-hanced, and outpatient visit schedulesmay be modified to avoid exposure ofwell patients to ill ones).

In a pandemic and during typical in-fluenza seasons, hospitals should plan todeliver babies of both well and illwomen. Ideally, in a pandemic, separatehospitals could be designated for in-fected and uninfected patients. Whennot feasible, separate labor and deliveryand postpartum care areas for infectedand uninfected women within the samehospital might be more practical. Hospi-tals should incorporate obstetric andnewborn infant care into pandemicplans. Accommodations should be madeto care for ill and well infants appropri-ately. Because of the potential for in-creases in preterm delivery rates during apandemic,8,85 increased demands forneonatal intensive care should beanticipated.

CommunicationDespite the efforts of public health agen-cies and professional organizations topromote and communicate informationabout influenza, influenza vaccinationcoverage among pregnant women hashistorically been low,33 and many preg-

ant women with suspected 2009 H1N1id not receive recommended antiviralreatment in a timely manner.3,4 Im-roved outreach, education, and com-unication efforts are needed, including

ailored strategies for different popula-
ion subgroups of pregnant women.

ommunication must be culturally ap-ropriate and accessible and presented

n a unified voice, when possible, by fed-ral agencies and their partners, whichould include community-based orga-izations that specifically reach minoritynd underserved populations. Researchust explore best practices that are al-

eady in use and develop new strategieso improve knowledge, attitudes, and be-aviors with regard to influenza and itsrevention and treatment among child-earing-aged women. Additional forma-ive research is needed to increase under-tanding of the barriers, concerns, and

otivators for use of antiviral medica-ions during pregnancy. Messages thatncorporate information that has beenearned from formative research must beeveloped and tested.

CommentPregnant women and their newborn in-fants are at increased risk of severe influ-enza illness. Although the 2009 H1N1pandemic emphasized the importance ofspecial considerations for these popula-tions in a pandemic situation, thesepopulations are also at increased risk forsevere complications with seasonal in-fluenza. Regardless of influenza vaccina-tion status, women who are pregnant or�2 weeks after delivery with suspectedinfluenza should receive early antiviraltreatment. Treatment of fever in preg-nant women with influenza is recom-mended; acetaminophen appears to bethe best option. Vaccination with inacti-vated influenza vaccine during preg-nancy is the best way to protect themother from influenza and its complica-tions; however, uptake among pregnantwomen has been low. In addition, influ-enza vaccination of pregnant womenand of household contacts and caregiv-ers of infants who are �6 months old canhelp prevent influenza in these infantsfor whom vaccination is not recom-mended. Understanding barriers to andincentives for early empiric antiviraltreatment and influenza vaccinationamong pregnant women and their healthcare providers is essential to the develop-ment of strong communications materi-als that are tailored to various groups.
Continued surveillance and research to

address gaps in the understanding ofinfluenza and its treatment and pre-vention among pregnant women andways to best communicate publichealth messages to pregnant womenand their health care providers are crit-ically needed. f

AcknowledgmentsMembers of the Pandemic Influenza andPregnancy Working Group include Sha-ron Alexander, Robert Wood JohnsonUniversity Hospital, New Brunswick,NJ; Kevin Ault, Emory University, At-lanta, GA; Hilary Babcock, WashingtonUniversity School of Medicine, St. Louis,MO; Carol Baker, Baylor College ofMedicine, Houston, TX; Niranjan Bhat,Johns Hopkins Children’s Center, Balti-more, MD; Carolyn Bridges, NationalCenter for Immunization and Respira-tory Diseases (NCIRD), Centers for Dis-ease Control and Prevention (CDC);Kimberly Brinker, Emory University,Atlanta; Karen Broder, Division ofHealthcare Quality Promotion (DHQP),CDC; William Callaghan, Division ofReproductive Health (DRH), CDC;Christina Chambers, University of Cali-fornia, San Diego; JoAnna Cheatham,ORISE Fellow, National Center on BirthDefects and Developmental Disabilities(NCBDDD), CDC; Janet Cragan, NCB-DDD, CDC; Michael Fraser, Associationof Maternal and Child Health Programs(AMCHP), Washington, DC; Jan Fried-man, University of British Columbia,Vancouver; Melody Gilbert, AMCHP,Washington, DC; Susan Hocevar,DHQP, CDC; Martha Iwamoto,DHQP, CDC; Treana Johnson-James,Corporate Temps, Atlanta, GA; Mari-lyn Kacica, New York State Depart-ment of Health, Albany, NY; RobertLawrence, Shands Children’s Hospital,University of Florida, Gainesville, FL;Diamond Marks, ORISE Fellow, NCB-DDD, CDC; Patricia Mersereau, Sci-Metrika, Atlanta, GA; Allen Mitchell,Boston University, Boston, MA; PedroMoro, DHQP, CDC; Laura Mosby,Emory University, Atlanta, GA; FlorMunoz, Baylor College of Medicine,Houston, TX; Kim Newsome, Sci-Metrika, Atlanta, GA; Christine K. Ol-
son, National Center for Emerging


and Zoonotic Infectious Diseases(NCEZID), CDC; Saad B. Omer, Em-ory University, Atlanta, GA; GeorginaPeacock, NCBDDD, CDC; DeWaynePursley, Beth Israel Deaconess MedicalCenter, Boston, MA; Natalya Revzina,Empowered Global Solutions, Inc,Englewood, CO; Laura E. Riley, Mas-sachusetts General Hospital, Boston,MA; Catherine Ruhl, Association ofWomen’s Health, Obstetric and Neo-natal Nurses (AWHONN), Washing-ton, DC; Katherine Shealy, NationalCenter for Chronic Disease Preventionand Health Promotion (NCCDPHP),CDC; Jeanne Sheffield, University ofTexas Southwestern Medical Center,Dallas, TX; Dixie Snider, Office of theDirector, CDC; Naomi Tepper, DRH,CDC; Shannon Hebert Way, Sci-Metrika, Atlanta, GA; Cindy Wein-baum, NCIRD, CDC; Marianne Zotti,NCCDPHP, CDC.

REFERENCES1. Dawood FS, Jain S, Finelli L, et al. Emer-gence of a novel swine-origin influenza A(H1N1) virus in humans. N Engl J Med 2009;360:2605-15.2. Rasmussen SA, Jamieson DJ, Bresee JS.Pandemic influenza and pregnant women.Emerg Infect Dis 2008;14:95-100.3. Siston AM, Rasmussen SA, Honein MA, et al.Pandemic 2009 influenza A(H1N1) virus illnessamong pregnant women in the United States.JAMA 2010;303:1517-25.4. Jamieson DJ, Honein MA, Rasmussen SA, etal. H1N1 2009 influenza virus infection duringpregnancy in the USA. Lancet 2009;374:451-8.5. Centers for Disease Control. Interim guid-ance: considerations regarding 2009 H1N1 in-fluenza in intrapartum and postpartum hospi-tal settings. Available at: http://www.cdc.gov/h1n1flu/guidance/obstetric.htm. Accessed Aug.24, 2010.6. Centers for Disease Control. Updated interimrecommendations for obstetric health care pro-viders related to use of antiviral medications inthe treatment and prevention of influenza for the2009-2010 season. Available at: http://www.cdc.gov/h1n1flu/pregnancy/antiviral_messages.htm. Accessed Aug. 23, 2010.7. Centers for Disease Control. Use of influenzaA (H1N1) 2009 monovalent vaccine: recom-mendations of the Advisory Committee on Im-munization Practices (ACIP), 2009. MMWR Re-comm Rep 2009;58:1-8.8. Rasmussen SA, Jamieson DJ, MacFarlaneK, et al. Pandemic influenza and pregnantwomen: Summary of a meeting of experts.
Am J Public Health 2009;99 S248-54.
9. Louie JK, Acosta M, Jamieson DJ, HoneinMA. Severe 2009 H1N1 influenza in pregnantand postpartum women in California. N EnglJ Med 2010;362:27-35.10. Centers for Disease Control. FluView: aweekly influenza surveillance report preparedby the Influenza Division. Available at: http://www.cdc.gov/flu/weekly/. Accessed Aug. 24,2010.11. Nguyen HT, Sheu TG, Mishin VP, Klimov AI,Gubareva LV. Assessment of pandemic andseasonal influenza A (H1N1) virus susceptibilityto neuraminidase inhibitors in three enzyme ac-tivity inhibition assays. Antimicrob Agents Che-mother 2010;54:3671-7.12. Gubareva L, Trujillo A, Okomo-AdhiamboM, et al. Comprehensive assessment of 2009influenza A (H1N1) virus drug susceptibility invitro. Antivir Ther 2010;15:1151-9.13. Greer LG, Sheffield JS, Rogers VL, RobertsSW, McIntire DD, Wendel GD Jr. Maternal andneonatal outcomes after antepartum treatmentof influenza with antiviral medications. ObstetGynecol 2010;115:711-6.14. Tanaka T, Nakajima K, Murashima A, Gar-cia-Bournissen F, Koren G, Ito S. Safety of neur-aminidase inhibitors against novel influenza A(H1N1) in pregnant and breastfeeding women.CMAJ 2009;181:55-8.15. Centers for Disease Control. Evaluation ofrapid influenza diagnostic tests for detection ofnovel influenza A (H1N1) Virus: United States,2009. MMWR Morb Mortal Wkly Rep 2009;58:826-9.16. Louie JK, Jamieson DJ, Rasmussen SA.2009 pandemic influenza A (H1N1) virus infec-tion in postpartum women in California. Am JObstet Gynecol 2010. Epub ahead of print.17. Edwards MJ. Review: hyperthermia and fe-ver during pregnancy. Birth Defects Res A ClinMol Teratol 2006;76:507-16.18. Moretti ME, Bar-Oz B, Fried S, Koren G.Maternal hyperthermia and the risk for neuraltube defects in offspring: systematic review andmeta-analysis. Epidemiology 2005;16:216-9.19. Petrova A, Demissie K, Rhoads GG, Smu-lian JC, Marcella S, Ananth CV. Association ofmaternal fever during labor with neonatal andinfant morbidity and mortality. Obstet Gynecol2001;98:20-7.20. James AH, Brancazio LR, Price T. Aspirinand reproductive outcomes. Obstet GynecolSurv 2008;63:49-57.21. TERIS, The Teratogen Information System[internet database]. Seattle, WA: University ofWashington, 2008. Available at: http://depts.washington.edu/terisweb/teris/. AccessedOct. 29, 2010.22. Rasmussen SA, Frias JL. Non-genetic riskfactors for gastroschisis. Am J Med Genet CSemin Med Genet 2008;148C:199-212.23. Rebordosa C, Kogevinas M, Horvath-PuhoE, et al. Acetaminophen use during pregnancy:effects on risk for congenital abnormalities.Am J Obstet Gynecol 2008;198:178.e1-7.24. Feldkamp ML, Meyer RE, Krikov S, Botto
LD. Acetaminophen use in pregnancy and risk

of birth defects: findings from the National BirthDefects Prevention Study. Obstet Gynecol2010;115:109-15.25. Kang EM, Lundsberg LS, Illuzzi JL, BrackenMB. Prenatal exposure to acetaminophen andasthma in children. Obstet Gynecol 2009;114:1295-306.26. Rebordosa C, Kogevinas M, Sorensen HT,Olsen J. Pre-natal exposure to paracetamol andrisk of wheezing and asthma in children: a birthcohort study. Int J Epidemiol 2008;37:583-90.27. Lowe AJ, Carlin JB, Bennett CM, et al.Paracetamol use in early life and asthma: pro-spective birth cohort study. BMJ 2010;341:c4616.28. Boltz DA, Aldridge JR Jr, Webster RG, Go-vorkova EA. Drugs in development for influenza.Drugs;70:1349-62.29. Ariano RE, Sitar DS, Zelenitsky SA, et al.Enteric absorption and pharmacokinetics of os-eltamivir in critically ill patients with pandemic(H1N1) influenza. CMAJ 2010;182:357-63.30. American College of Obstetricians and Gy-necologists. ACOG committee opinion no. 468:influenza vaccination during pregnancy. ObstetGynecol 2010;116:1006-7.31. Fiore AE, Uyeki TM, Broder K, et al. Preven-tion and control of influenza with vaccines: rec-ommendations of the Advisory Committee onImmunization Practices (ACIP), 2010. MMWRRecomm Rep 2010;59:1-62.32. US Department of Health and Human Ser-vices and the US Department of Homeland Se-curity. Guidance on allocating and targetingpandemic influenza vaccine. Available at: http://www.pandemicflu.gov/vaccine/allocationguidance.pdf. Accessed Aug. 22, 2008.33. Lu P, Bridges CB, Euler GL, Singleton JA.Influenza vaccination of recommended adultpopulations, US, 1989-2005. Vaccine 2008;26:1786-93.34. Centers for Disease Control. Interim results:influenza A (H1N1) 2009 monovalent vaccina-tion coverage: United States, October-Decem-ber 2009. MMWR Morb Mortal Wkly Rep2010;59:44-8.35. Steinhoff MC, Omer SB, Roy E, et al. Influ-enza immunization in pregnancy: antibody re-sponses in mothers and infants. N Engl J Med2010;362:1644-6.36. Hulka JF. Effectiveness of polyvalent influ-enza vaccine in pregnancy: report of a con-trolled study during an outbreak of Asian influ-enza. Obstet Gynecol 1964;23:830-7.37. Murray DL, Imagawa DT, Okada DM, StGeme JW Jr. Antibody response to monovalentA/New Jersey/8/76 influenza vaccine in preg-nant women. J Clin Microbiol 1979;10:184-7.38. Sumaya CV, Gibbs RS. Immunization ofpregnant women with influenza A/New Jer-sey/76 virus vaccine: reactogenicity and immu-nogenicity in mother and infant. J Infect Dis1979;140:141-6.39. Zaman K, Roy E, Arifeen SE, et al. Effective-ness of maternal influenza immunization inmothers and infants. N Engl J Med 2008;359:
1555-64.

http://www.cdc.gov/h1n1flu/guidance/obstetric.htm

http://www.cdc.gov/h1n1flu/guidance/obstetric.htm

http://www.cdc.gov/h1n1flu/pregnancy/antiviral_messages.htm



http://www.cdc.gov/flu/weekly/

http://www.cdc.gov/flu/weekly/

http://www.depts.washington.edu/terisweb/teris/

http://www.depts.washington.edu/terisweb/teris/

http://www.pandemicflu.gov/vaccine/allocationguidance.pdf




40. Eick AA, Uyeki TM, Klimov A, et al. Maternalinfluenza vaccination and impact upon influenzavirus infection among young infants. Arch Pedi-atr Adolesc Med 2011;165:104-11.41. Englund JA, Mbawuike IN, Hammill H, Hol-leman MC, Baxter BD, Glezen WP. Maternalimmunization with influenza or tetanus toxoidvaccine for passive antibody protection inyoung infants. J Infect Dis 1993;168:647-56.42. Puck JM, Glezen WP, Frank AL, Six HR.Protection of infants from infection with influ-enza A virus by transplacentally acquired anti-body. J Infect Dis 1980;142:844-9.43. Reuman PD, Ayoub EM, Small PA. Effect ofpassive maternal antibody on influenza illness inchildren: a prospective study of influenza A inmother-infant pairs. Pediatr Infect Dis J 1987;6:398-403.44. Bhat N, Wright JG, Broder KR, et al. Influ-enza-associated deaths among children in theUnited States, 2003-2004. N Engl J Med 2005;353:2559-67.45. Dawood FS, Fiore A, Kamimoto L, et al.Burden of seasonal influenza hospitalization inchildren, United States, 2003 to 2008. J Pediatr2010;157:808-14.46. Heinonen OP, Shapiro S, Monson RR,Hartz SC, Rosenberg L, Slone D. Immunizationduring pregnancy against poliomyelitis and in-fluenza in relation to childhood malignancy. Int JEpidemiol 1973;2:229-35.47. Deinard AS, Ogburn P Jr. A/NJ/8/76 influ-enza vaccination program: effects on maternalhealth and pregnancy outcome. Am J ObstetGynecol 1981;140:240-5.48. Yeager DP, Toy EC, Baker B 3rd. Influenzavaccination in pregnancy. Am J Perinatol 1999;16:283-6.49. Black SB, Shinefield HR, France EK, Fire-man BH, Platt ST, Shay D. Effectiveness of in-fluenza vaccine during pregnancy in preventinghospitalizations and outpatient visits for respira-tory illness in pregnant women and their infants.Am J Perinatol 2004;21:333-9.50. Munoz FM, Greisinger AJ, Wehmanen OA,et al. Safety of influenza vaccination duringpregnancy. Am J Obstet Gynecol 2005;192:1098-106.51. France EK, Smith-Ray R, McClure D, et al.Impact of maternal influenza vaccination duringpregnancy on the incidence of acute respiratoryillness visits among infants. Arch Pediatr Ado-lesc Med 2006;160:1277-83.52. Pool V, Iskander J. Safety of influenza vac-cination during pregnancy. Am J Obstet Gyne-col 2006;194:1200-1.53. Tamma PD, Ault KA, Del Rio C, SteinhoffMC, Halsey NA, Omer SB. Safety of influenzavaccination during pregnancy. Am J Obstet Gy-necol 2009;201:547-52.54. Moro PL, Broder K, Zheteyeva Y, et al. Ad-verse events in pregnant women following ad-ministration of trivalent inactivated influenzavaccine and live attenuated influenza vaccine inthe Vaccine Adverse Event Reporting System,1990-2009. Am J Obstet Gynecol 2011;
204:146.e1-7.

55. US Department of Health and Human Ser-vices; National Vaccine Advisory Committee.Report on 2009 H1N1 Vaccine Safety Risk As-sessment. Available at: http://www.hhs.gov/nvpo/nvac/reports/index.html. Accessed Aug.26, 2010.56. Moro PL, Broder K, Zheteyeva N, et al.Safety of influenza A (H1N1) 2009 monovalentvaccine in pregnant women in the Vaccine Ad-verse Event Reporting System (VAERS) (ab-stract). In: Thirteenth Annual Conference onVaccine Research; 2010 April 26-28; Bethesda,MD; 2010.57. Panda B, Stiller R, Panda A. Influenza vac-cination during pregnancy and factors for lack-ing compliance with current CDC guidelines. JMatern Fetal Neonatal Med 2011;24:402-6.58. Gonik B, Jones T, Contreras D, Fasano N,Roberts C. The obstetrician-gynecologist’s rolein vaccine-preventable diseases and immuniza-tion. Obstet Gynecol 2000;96:81-4.59. Schrag SJ, Fiore AE, Gonik B, et al. Vacci-nation and perinatal infection prevention prac-tices among obstetrician-gynecologists. ObstetGynecol 2003;101:704-10.60. Wallis DH, Chin JL, Sur DK. Influenza vac-cination in pregnancy: current practices in asuburban community. J Am Board Fam Pract2004;17:287-91.61. Naleway AL, Smith WJ, Mullooly JP. Deliv-ering influenza vaccine to pregnant women.Epidemiol Rev 2006;28:47-53.62. Wu P, Griffin MR, Richardson A, Gabbe SG,Gambrell MA, Hartert TV. Influenza vaccinationduring pregnancy: opinions and practices ofobstetricians in an urban community. SouthMed J 2006;99:823-8.63. Broughton DE, Beigi RH, Switzer GE, RakerCA, Anderson BL. Obstetric health care work-ers’ attitudes and beliefs regarding influenzavaccination in pregnancy. Obstet Gynecol2009;114:981-7.64. Power ML, Leddy MA, Anderson BL, GallSA, Gonik B, Schulkin J. Obstetrician-gynecol-ogists’ practices and perceived knowledge re-garding immunization. Am J Prev Med 2009;37:231-4.65. Mouzoon ME, Munoz FM, Greisinger AJ, etal. Improving influenza immunization in preg-nant women and healthcare workers. Am JManag Care 2010;16:209-16.66. Ndiaye SM, Hopkins DP, Shefer AM, et al.Interventions to improve influenza, pneumococ-cal polysaccharide, and hepatitis B vaccinationcoverage among high-risk adults: a systematicreview. Am J Prev Med 2005;28:248-79.67. Wallis DH, Chin JL, Sur DK, Lee MY. In-creasing rates of influenza vaccination duringpregnancy: a multisite interventional study.J Am Board Fam Med 2006;19:345-9.68. Ogburn T, Espey EL, Contreras V, Arroyo P.Impact of clinic interventions on the rate of in-fluenza vaccination in pregnant women. J Re-prod Med 2007;52:753-6.69. SteelFisher GK, Blendon RJ, Bekheit MM,et al. Novel pandemic A (H1N1) influenza vac-
cination among pregnant women: motivators

and barriers. Am J Obstet Gynecol 2011;204:S116-23.70. Yudin MH, Salripour M, Sgro MD. Impact ofpatient education on knowledge of influenzaand vaccine recommendations among preg-nant women. J Obstet Gynaecol Can 2010;32:232-7.71. Silverman NS, Greif A. Influenza vaccinationduring pregnancy: patients’ and physicians’ at-titudes. J Reprod Med 2001;46:989-94.72. Ahluwalia IB, Jamieson DJ, Rasmussen SA,D’Angelo D, Goodman D, Kim H. Correlates ofseasonal influenza vaccine coverage amongpregnant women in Georgia and Rhode Island.Obstet Gynecol 2010;116:949-55.73. Jacobson VJ, Szilagyi P. Patient reminderand patient recall systems to improve immuni-zation rates. Cochrane Database Syst Rev2005:CD003941.74. Walsh JM, McPhee SJ. A systems model ofclinical preventive care: an analysis of factorsinfluencing patient and physician. Health EducQ 1992;19:157-75.75. Irving WL, James DK, Stephenson T, et al.Influenza virus infection in the second and thirdtrimesters of pregnancy: a clinical and seroepi-demiological study. BJOG 2000;107:1282-9.76. Dulyachai W, Makkoch J, Rianthavorn P, etal. Perinatal pandemic (H1N1) 2009 infection,Thailand. Emerg Infect Dis 2010;16:343-4.77. Gu J, Xie Z, Gao Z, et al. H5N1 infection ofthe respiratory tract and beyond: a molecularpathology study. Lancet 2007;370:1137-45.78. Lieberman RW, Bagdasarian N, Thomas D,Van De Ven C. Seasonal influenza A (H1N1)infection in early pregnancy and second trimes-ter fetal demise. Emerg Infect Dis 2011;17:107-9.79. Centers for Disease Control. Preventionstrategies for seasonal influenza in healthcaresettings. Available at: http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm. Accessed Sept. 22, 2010.80. Kennell JH, Klaus MH. Pediatric support forparents. In: Hoekelman RA, Adam HM, NelsonNM, Weitzman ML, Wilson ME, eds. Primarypediatric care, 4th ed. St. Louis: Mosby Year-book; 2001:566-74.81. Walter EB, Allred NJ, Swamy GK, HellkampAS, Dolor RJ. Influenza vaccination of house-hold contacts of newborns: a hospital-basedstrategy to increase vaccination rates. InfectControl Hosp Epidemiol 2010;31:1070-3.82. Wentges-van Holthe N, van Eijkeren M, vander Laan JW. Oseltamivir and breastfeeding. IntJ Infect Dis 2008;12:451.83. Community strategy for pandemic influenzamitigation. Available at: http://pandemicflu.gov/professional/community/commitigation.html#I.Accessed Sept. 22, 2010.84. Viboud C, Boelle PY, Cauchemez S, et al.Risk factors of influenza transmission in house-holds. Br J Gen Pract 2004;54:684-9.85. Beigi RH. Pandemic influenza and preg-nancy: a call for preparedness planning. Obstet
Gynecol 2007;109:1193-6.
http://www.hhs.gov/nvpo/nvac/reports/index.html

http://www.hhs.gov/nvpo/nvac/reports/index.html

http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm



http://pandemicflu.gov/professional/community/commitigation.html%23I

http://pandemicflu.gov/professional/community/commitigation.html%23I

Documents

Preparing for influenza after 2009 H1N1: special considerations for pregnant women and newborns