Elsevier

Vaccine

Volume 33, Issue 38, 11 September 2015, Pages 4983-4987
Vaccine

Tetanus and diphtheria toxoids and acellular pertussis vaccine uptake during pregnancy in a metropolitan tertiary care center

https://doi.org/10.1016/j.vaccine.2015.07.018Get rights and content

Highlights

  • Improving provider education resulted in sustained increases in antenatal Tdap uptake rates.

  • Pregnant women received Tdap at gestations optimal for placental transfer of maternal antibodies.

  • This suggests provider recommendation is key to increasing vaccine uptake during pregnancy.

  • Further increases in vaccine uptake may require system changes such as best practice alerts.

Abstract

Objectives

Tetanus, diphtheria and acellular pertussis (Tdap) vaccine is recommended during each pregnancy, but national uptake is poor. We assessed Tdap uptake in a tertiary referral hospital served by university-affiliated and private obstetrical offices.

Methods

Review of women delivering at Texas Children's Hospital Pavilion for Women, Houston, Texas, during April 2013–June 2014.

Results

6577 deliveries occurred during the study period. Mean maternal age was 29.8 years (range 13–49); race/ethnicity was 43.6% White, 27% Hispanic, 21% Black, 7.1% Asian, and 1.3% other. 252 were multiple gestations; 229 sets of twins, 21 triplets and 2 quadruplets. 3678 (56%) women received Tdap during pregnancy, 249 (3.8%) postpartum and 100 (1.5%) received Tdap pre-conception only. Tdap uptake during pregnancy increased from 36% in April 2013 to a sustained uptake of greater than 61% since November 2013, with increases noted coincidental with presentations highlighting Tdap maternal immunization recommendations at faculty and staff meetings, and the release of the ACOG “toolkit”. When antenatal Tdap vaccine was administered, mean gestation at receipt of Tdap was 31.4 weeks and 95% of vaccinated women received Tdap at the recommended gestation interval of 27–36 weeks, 71.6% during the 28–32 week window believed optimal for placental transport and 98.5% at least 7 days before delivery. Of 19 women with two pregnancies during the study period, four (21%) had Tdap during both. Black women were less likely to receive antenatal Tdap than women of other race/ethnicity (41% versus 60%; P < 0.001).

Conclusions

Sustained antenatal Tdap uptake rates exceeding 61% were achieved after strategies to increase awareness of recommendations were introduced and 95% of women were immunized at a gestation optimal for efficient maternal antibody placental transport. Further increases in uptake will require system changes such as best practice alerts in electronic medical records.

Introduction

Pertussis incidence, morbidity and mortality rates are highest in infants too young to have completed their primary immunization series with diphtheria, tetanus and acellular pertussis (DTaP) vaccine. Furthermore, pertussis-related deaths occur almost exclusively in infants under three months of age in resource-rich countries [1], [2], [3], [4]. Pertussis immunization strategies in the United States (US) and other resource-rich countries focus on preventing young infant pertussis-associated morbidity and mortality.

In 2006, the Advisory Committee on Immunization Practices (ACIP) to the Centers for Disease Control and Prevention (CDC) recommended targeted immunization of postpartum women and contacts of infants with tetanus, diphtheria and acellular pertussis (Tdap) vaccine (cocooning) [5]. Although immunization of pregnant women was offered as an option, this was not presented as the preferred option. Logistical and financial barriers limited implementation of cocooning at a national level, and outcome studies in the US and Australia demonstrated little or modest effectiveness in preventing infant pertussis, thus limiting cocooning as a stand-alone pertussis prevention strategy [6], [7], [8]. In 2011, ACIP recommended that pregnant women who had not previously received it routinely receive Tdap vaccine after week 20 of pregnancy [9], and in 2013, ACIP revised this recommendation stating that Tdap should be given in the third trimester of every pregnancy, regardless of history of previous Tdap receipt [1]. This recommendation was based on continued pertussis-associated morbidity and mortality in young infants and data indicating that pertussis antibody levels in newborn infants whose mothers had received Tdap within the prior two years were likely insufficient for protection [1], [10]. The 2013 recommendation was endorsed by the American College of Obstetricians and Gynecologists (ACOG) [11]. Despite studies from the US and United Kingdom (UK) demonstrating the safety [12], [13] and effectiveness of maternal immunization in preventing infant pertussis infection and deaths [14], limited US data reveal that only approximately 16% of pregnant women from 2010 to April, 2013 received Tdap vaccine [15], [16]. We assessed Tdap vaccine uptake during pregnancy in women receiving prenatal care in practices affiliated with a metropolitan tertiary referral hospital in Houston, Texas.

Section snippets

Methods

The Pavilion for Women at Texas Children's Hospital (PFW) in Houston, Texas is a 15-story facility that delivers obstetrical and gynecological care to women. This facility is a tertiary referral center for obstetrics, and has approximately 5000 deliveries annually which include both low and high risk pregnancies, and women whose infants are likely to require Level IV neonatal intensive care at the adjoining pediatric hospital. Approximately 70% of women have private insurance with the remainder

Results

During the 15-month study period, there were 6584 deliveries. Seven deliveries occurred before 20 weeks’ gestation, leaving 6577 meeting criteria for analysis. Mean maternal age at delivery was 29.8 years (range 13–49). Maternal self-reported race and ethnicity was 43.6% White, non-Hispanic or Latino; 27% White, Hispanic or Latino; 21% Black or Africa-American; 7.1% Asian; 0.5% Native American and 0.8% other or did not disclose. Two hundred fifty two (3.8%) of deliveries were multiple

Discussion

This study demonstrating that multiple interventions that aimed to improve provider awareness of recommendations to immunize pregnant women appeared to coincide with increased Tdap vaccine uptake is the first, to our knowledge, to demonstrate that these improvements can be sustained over time in the setting of a tertiary referral center serving academic-affiliated and private obstetric practices. This was achieved in a setting where the ability to deliver vaccines on-site was not available to

Conflict of interest

Dr. Healy has received research grants from Sanofi Pasteur and Novartis Vaccines and has participated in Advisory Boards for Novartis Vaccines and Pfizer Inc. All authors have approved the final article.

Contributors

Dr. Healy participated in the concept and design of the study, the analysis and interpretation of the data, and the drafting and revision of the manuscript.

Ms. Ng participated in data collection and revision of the manuscript.

Mr Taylor assisted in data collection and revision of the manuscript.

Ms. Rench assisted study design and revision of the manuscript.

Dr. Swaim assisted in the interpretation of the data, and revision of the manuscript.

Source of support

This publication was made possible by award number CDC-CI10-101203PPHF12 from the Centers for Disease Control and Prevention (CDC) through the Houston Department of Health and Human Services (HDHHS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or HDHHS.

Acknowledgements

We thank Houston Department of Health and Human Services, Texas for their aid in performing this study. We thank Robin Schroeder (Baylor College of Medicine) for her assistance in manuscript preparation and Carol J. Baker, MD (Baylor College of Medicine) for her thoughtful review and critique of the manuscript.

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