Administration Of Tdap Vaccine Research Articles

Increasing antepartum Tdap vaccine administration: A quality improvement initiative

The Centers for Disease Control and Prevention (CDC) recommends antepartum Tdap vaccination for women with each pregnancy to protect themselves and their vulnerable infants through transplacental transfer of maternal antibodies. Our aim was to increase the rate of antepartum Tdap vaccine administration by 20%. Obstetricians were surveyed to identify their present approaches and barriers to antepartum Tdap vaccine administration to help guide the development of our intervention. Limited staff training, lack of vaccine on site, and cost were the most commonly identified barriers. Using these survey responses, existing literature, and brainstorming conversations with colleagues, an interdisciplinary workgroup then created a fishbone analysis and developed a 5-step intervention to address these barriers: (1) educate providers and patients on Tdap and pertussis; (2) increase Tdap availability to all pregnant women; (3) remind staff of the established Tdap standing order to facilitate administration; (4) encourage obstetricians to offer Tdap; (5) transfer documentation of Tdap administration from office to hospital. To monitor changes in the process over 15 months of pre- and post-intervention, data were collected from monthly chart audits and a two-phase control chart was created. The main outcome measure was proportion of eligible women who received Tdap during current pregnancy. In the pre-intervention period, 362 of 636 eligible women (56.9%) received Tdap during their current pregnancy; in the post-intervention period, 457 of 708 eligible women (64.5%) received Tdap during their current pregnancy. This absolute difference of 7.6% (64.5% vs. 56.9%, p < 0.01) represents a 13.4% relative increase (64.5%/56.9%) in the proportion of clinically eligible pregnant women who received Tdap. This represents a clinically and statistically significant increase in the rate of antepartum Tdap immunization. More research is needed to further understand obstetric barriers and maternal refusal of antepartum Tdap administration.

Trends in Tdap vaccination among privately insured pregnant women in the United States, 2009–2016

BackgroundInfants younger than 6 months are at increased risk of complications and mortality from pertussis infection. In October 2012, the Advisory Committee on Immunization Practices revised its recommendation to include a Tdap dose during each pregnancy, ideally between 27 and 36 weeks gestation. ObjectiveAssess trends in Tdap vaccination coverage among privately insured pregnant women from 2009 to 2016 including timing of Tdap vaccination (before, during, or after pregnancy), trimester of vaccination for women vaccinated during pregnancy, and missed vaccination opportunities for unvaccinated women. Identify factors associated with vaccination during the optimal period of 27–36 weeks gestation. Study designRetrospective analysis of privately insured women 15–49 years who delivered live births during 2009–2016 conducted using 2009–2016 MarketScan data. Tdap vaccination coverage and the timing of Tdap vaccine administration were assessed for women continuously enrolled from 6 months before pregnancy to 1 month after delivery. Multivariable logistic regression was performed to identify factors independently associated with receipt of Tdap vaccine at 27–36 weeks gestation. ResultsTdap vaccination coverage during pregnancy increased from 0.4% in 2009 to 6.2% in 2012 and to 53.2% in 2016. The proportion of vaccinated women receiving Tdap at 27–36 weeks gestation increased from <10% in 2009 to nearly 90% in 2016, with most vaccination occurring at 27–32 weeks gestation. Women of older age, residing in a metropolitan statistical area, residing outside the South, and having a capitated health insurance plan were more likely to receive Tdap at 27–36 weeks gestation than their counterparts. Among women not vaccinated during pregnancy, 77.7% had a pregnancy-related medical claim between 27 and 36 weeks gestation. ConclusionTdap vaccination coverage during pregnancy increased significantly from 2009 to 2016, with the greatest increase occurring after the revised Advisory Committee on Immunization Practices recommendation. Most women who did not receive Tdap vaccine had a missed vaccination opportunity during pregnancy, indicating potential for much higher vaccination coverage and consequent infant protection against pertussis.

Provider insight on surmounting specialty practice challenges to improve Tdap immunization rates among pregnant women

BackgroundPertussis, or “whooping cough,” is an acute, contagious pulmonary disease that, despite being vaccine-preventable, has become an increasingly widespread problem in the United States. As a result, the Advisory Committee on Immunization Practices and American College of Obstetricians and Gynecologists updated recommendations stating clinicians should give a Tdap dose during every pregnancy, preferably at 27–36 weeks. Despite this recommendation, reported Tdap vaccine receipt rates during pregnancy vary from 16–61%, and previous studies have shown that clinician recommendation and vaccine administration are strongly associated with vaccine uptake among pregnant women. MethodsOur aim was to inform new strategies to increase uptake of the Tdap vaccine among pregnant women and, ultimately, reduce pertussis-related morbidity and mortality in infants. We conducted interviews with a sample of 24 ob-gyns. We subsequently performed grounded theory analyses of transcripts using deductive and inductive coding strategies followed by intercoder reliability assessment. ResultsAll physicians interviewed were familiar with the most recent recommendation of giving the Tdap vaccine during the third trimester of every pregnancy, and the majority of physicians stated that they felt that the vaccine was important and effective due to the transfer of pertussis antibodies from the mother to the fetus. Most physicians indicated that they recommended the vaccine to patients during pregnancy, but not all reported administering it on site because it was not stocked at their practice. Implementation challenges for physicians included insurance reimbursement and other challenges (i.e., patient refusal). Tdap vaccination during pregnancy was a lower clinical priority for some physicians. Physicians recognized the benefits associated with Tdap vaccination during pregnancy. ConclusionsFindings indicate while most ob-gyns recognize the benefits of Tdap and recommend vaccination during pregnancy, barriers such as insurance reimbursement and financial concerns for the practice can outweigh the perceived benefits. This resulted in some ob-gyns reporting choosing not to stock and administer the vaccine in their practice. Recommendations to address these concerns include 1) structural support for Tdap vaccine administration in ob-gyns practices; 2) Continuing medical education-equivalent educational interventions that address management techniques, vaccine coding, and other relevant information; and 3) interventions to assist physicians in communicating the importance of Tdap vaccination during pregnancy.

Association between microcephaly, Zika virus infection, and other risk factors in Brazil: final report of a case-control study

A Zika virus epidemic emerged in northeast Brazil in 2015 and was followed by a striking increase in congenital microcephaly cases, triggering a declaration of an international public health emergency. This is the final report of the first case-control study evaluating the potential causes of microcephaly: congenital Zika virus infection, vaccines, and larvicides. The published preliminary report suggested a strong association between microcephaly and congenital Zika virus infection. We did a case-control study in eight public maternity hospitals in Recife, Brazil. Cases were neonates born with microcephaly, defined as a head circumference of 2 SD below the mean. Two controls without microcephaly were matched to each case by expected date of delivery and area of residence. We tested the serum of cases and controls and the CSF of cases for detection of Zika virus genomes with quantitative RT-PCR and for detection of IgM antibodies with capture-IgM ELISA. We also tested maternal serum with plaque reduction neutralisation assays for Zika and dengue viruses. We estimated matched crude and adjusted odds ratios with exact conditional logistic regression to determine the association between microcephaly and Zika virus infection. We screened neonates born between Jan 15 and Nov 30, 2016, and prospectively recruited 91 cases and 173 controls. In 32 (35%) cases, congenital Zika virus infection was confirmed by laboratory tests and no controls had confirmed Zika virus infections. 69 (83%) of 83 cases with known birthweight were small for gestational age, compared with eight (5%) of 173 controls. The overall matched odds ratio was 73·1 (95% CI 13·0-∞) for microcephaly and Zika virus infection after adjustments. Neither vaccination during pregnancy or use of the larvicide pyriproxyfen was associated with microcephaly. Results of laboratory tests for Zika virus and brain imaging results were available for 79 (87%) cases; within these cases, ten were positive for Zika virus and had cerebral abnormalities, 13 were positive for Zika infection but had no cerebral abnormalities, and 11 were negative for Zika virus but had cerebral abnormalities. The association between microcephaly and congenital Zika virus infection was confirmed. We provide evidence of the absence of an effect of other potential factors, such as exposure to pyriproxyfen or vaccines (tetanus, diphtheria, and acellular pertussis, measles and rubella, or measles, mumps, and rubella) during pregnancy, confirming the findings of an ecological study of pyriproxyfen in Pernambuco and previous studies on the safety of Tdap vaccine administration during pregnancy. Brazilian Ministry of Health, Pan American Health Organization, and Enhancing Research Activity in Epidemic Situations.

Tdap in Pregnancy: A Quality Improvement Project [2C

INTRODUCTION: Current recommendations are for Tdap vaccination during each pregnancy to induce immunity in the neonate. Administration rates were low at a prenatal clinic in Tampa, Florida and so a quality improvement project was undertaken to improve coverage. We sought to evaluate the effectiveness of a protocol to improve the rates of prenatal Tdap vaccine administration. METHODS: This project was implemented at a single publicly funded obstetric clinic and its affiliated academic hospital. Women receiving care at the clinic are predominately underserved minorities and working poor. The clinic's providers include physicians, nurses, midwives, and nurse practitioners. The intervention had several components: In February 2016, clinic providers received education about current recommendations regarding Tdap vaccination in pregnancy. Posters were placed throughout the clinic to motivate the patients. Finally, the hospital's administration agreed to redirect money previously used for inpatient postpartum vaccinations to instead cover the cost of vaccination for uninsured patients during prenatal visits, when the vaccine is most effective. Vaccination rates were then compared between the four months before and after implementation. RESULTS: In the four months preceding the project, a total of 273 prenatal Tdap vaccines were given at the clinic; in the four months after, 380 were given. When divided by the total number of clinic patients delivered during these time frames, rates of vaccination improved from 40% to 63% (p &lt; 0.001), respectively. CONCLUSION: Education, awareness, and financial assistance resulted in a significant increase in the Tdap vaccination rate at the clinic. Further Plan-Do-Study-Act cycles are planned to further improve vaccination rates.

Infant outcomes after exposure to Tdap vaccine in pregnancy: an observational study

ObjectivePertussis vaccination during pregnancy has recently been recommended in both the USA and UK to prevent pertussis infection in infants. While there are no apparent safety concerns about the administration...

Pertussis Vaccination of Health Care Workers

Pertussis Vaccination of Health Care Workers

Assessment of Tdap Administration Rates from 2009 to 2012 at a Large Urban Nonteaching Hospital

Due to the significant rise in pertussis cases reported in 2012, these authors investigated the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine administration at our institution from 2009 to 2012 to determine if changes in prescribing practices reflected published updates from the Advisory Committee on Immunization Practices (ACIP). A single large, urban, private, non-teaching hospital. Documented Tdap vaccines administered from January 2009 through December 2012 were retrieved using an electronic data pull. The incidence of Tdap vaccine administration was reported as number of events per 1,000 patient visits. This data pull served to provide the longitudinal context to prescribing pattern changes at our facility, which were then compared to ACIP vaccination recommendation changes. Tdap administrations increased from 1,365 vaccinations in 2009 to 3,048 vaccinations in 2012. Tdap vaccine administration increased significantly each successive year from 2009 to 2012 from 23.96±1.25 to 47.15±1.63 vaccines per 1,000 patient visits to the facility. Confidence intervals did not overlap for consecutive years representing statistically significant differences between vaccination rates from year to year. Review of Tdap administrations demonstrates a clear and significant increase over consecutive years from 2009 to 2012. Over this time period there were no institutional initiatives aimed at increasing appropriate Tdap use at our institution. This study suggests a correlation between ACIP vaccination recommendations and provider prescribing of Tdap, although no definitive association can be made.

50 Years Ago in The Journal of Pediatrics: Current Immunization Problems

Gaisford W, Feldman GV, Perkins FT. J Pediatr 1960;56:319-30Vaccinologists from Manchester and London provide primary data and much insight surrounding problems of providing protection for infants against major pathogens of 1960. They ask the same questions of each vaccine—questions that we ask today. Is an effective vaccine antigen available? Is protection important? Can the vaccine be given at the age when protection is most needed? Is it safe?With these questions in mind, the authors focus on 4 vaccines—Bacillus-Calmette Guerin (BCG), diphtheria and tetanus toxoids, and whole-cell pertussis vaccines—as well as possibilities and overarching problems of vaccinating in the neonatal period. The full article is worth reading. A few facts that stand out to this reader follow.Efficacy of BCG against severe pulmonary or central nervous system tuberculosis is not questioned, because “most paediatricians. . . have watched infants grow up in homes where there are contact patients, and have compared the mortality and morbidity from tuberculosis in vaccinated and unvaccinated infants and children.” Currently we recognize remarkable variability in effectiveness of BCG vaccines across countries (from 2% to >80%). But we forget that primary outcomes for efficacy of BCG were prevention of morbid and fatal tuberculosis, not M. tuberculosis infection.Combining these toxoids in balanced proportions enhances their immunizing potential, especially for the diphtheria component. The major advance in preventing neonatal tetanus, however, followed immunization of mothers whose infants are protected by transplacental antibody. Active infant vaccination can be deferred until 1 to 2 months of age.To enhance antigenicity of the pertussis component of DPT, an adjuvant such as aluminum hydroxide or phosphate is necessary. In 1960, in Great Britain, the concern of adjuvant-associated “provoked paralysis” following natural acquisition of poliomyelitis was relevant, leading to the recommendation of maternal immunization with inactivated poliovirus vaccine during pregnancy to protect the infant against this potential collateral effect of DPT.Although some 1960 risks for neonates (diphtheria, tetanus, tuberculosis, poliomyelitis) have been eliminated by public health measures and immunization in many countries, the problem of neonatal pertussis persists. The problems and possibilities of neonatal protection in 1960 live on—with the cocooning strategy of administration of Tdap vaccine after delivery to all contacts of neonates (so-called cocoon strategy) difficult to implement, and immunization of mothers during pregnancy to afford passive protection currently under study for its potential blunting effect on active immunization of the infant. Gaisford W, Feldman GV, Perkins FT. J Pediatr 1960;56:319-30 Vaccinologists from Manchester and London provide primary data and much insight surrounding problems of providing protection for infants against major pathogens of 1960. They ask the same questions of each vaccine—questions that we ask today. Is an effective vaccine antigen available? Is protection important? Can the vaccine be given at the age when protection is most needed? Is it safe? With these questions in mind, the authors focus on 4 vaccines—Bacillus-Calmette Guerin (BCG), diphtheria and tetanus toxoids, and whole-cell pertussis vaccines—as well as possibilities and overarching problems of vaccinating in the neonatal period. The full article is worth reading. A few facts that stand out to this reader follow. Efficacy of BCG against severe pulmonary or central nervous system tuberculosis is not questioned, because “most paediatricians. . . have watched infants grow up in homes where there are contact patients, and have compared the mortality and morbidity from tuberculosis in vaccinated and unvaccinated infants and children.” Currently we recognize remarkable variability in effectiveness of BCG vaccines across countries (from 2% to >80%). But we forget that primary outcomes for efficacy of BCG were prevention of morbid and fatal tuberculosis, not M. tuberculosis infection. Combining these toxoids in balanced proportions enhances their immunizing potential, especially for the diphtheria component. The major advance in preventing neonatal tetanus, however, followed immunization of mothers whose infants are protected by transplacental antibody. Active infant vaccination can be deferred until 1 to 2 months of age. To enhance antigenicity of the pertussis component of DPT, an adjuvant such as aluminum hydroxide or phosphate is necessary. In 1960, in Great Britain, the concern of adjuvant-associated “provoked paralysis” following natural acquisition of poliomyelitis was relevant, leading to the recommendation of maternal immunization with inactivated poliovirus vaccine during pregnancy to protect the infant against this potential collateral effect of DPT. Although some 1960 risks for neonates (diphtheria, tetanus, tuberculosis, poliomyelitis) have been eliminated by public health measures and immunization in many countries, the problem of neonatal pertussis persists. The problems and possibilities of neonatal protection in 1960 live on—with the cocooning strategy of administration of Tdap vaccine after delivery to all contacts of neonates (so-called cocoon strategy) difficult to implement, and immunization of mothers during pregnancy to afford passive protection currently under study for its potential blunting effect on active immunization of the infant.