Seasonal influenza vaccine coverage among pregnant women: pregnancy risk assessment monitoring system.
ABSTRACT Since 2004, the American College of Obstetricians and Gynecologists (ACOG) and the Advisory Committee on Immunization Practices (ACIP) have recommended that pregnant women receive the seasonal influenza vaccine, regardless of pregnancy trimester, because of their increased risk for severe complications from influenza. However, the uptake of the influenza vaccine by pregnant women has been low. During the 2009-2010 influenza season, pregnant women were identified as a priority population to receive the influenza A (H1N1) 2009 (2009 H1N1) monovalent vaccine in addition to the seasonal influenza vaccine. In this issue, we highlight information from the 10 states that collected data using the survey administered by the Pregnancy Risk Assessment and Monitoring System (PRAMS) about seasonal vaccine coverage among women with recent live births and reasons for those who chose not to get vaccinated. The combined estimates from PRAMS of influenza vaccination coverage for the 2009-2010 season, which included data from October 2009 to March 2010, from 10 states were 50.7% for seasonal and 46.6% for 2009 H1N1 vaccine among women with recent live births. Among women who did not get vaccinated, reasons varied from worries about the safety of the vaccines for self and baby to not normally getting the vaccination. Further evaluation is needed on ways to increase influenza vaccination among pregnant women, effectively communicate the risk of influenza illness during pregnancy, and address women's concerns about influenza vaccination safety during pregnancy.
- SourceAvailable from: Paula M Frew[Show abstract] [Hide abstract]
ABSTRACT: Objective: We examined pregnant women's intention to obtain the seasonal influenza vaccine via a randomized controlled study examining the effects of immunization history, message exposure, and sociodemographic correlates. Methods: Pregnant women ages 18-50 participated in a randomized message framing study from September 2011 through May 2012. Venue-based sampling was used to recruit racial and ethnic minority women throughout Atlanta, Georgia. Key outcomes were evaluated using bivariate and multivariate analyses. Results: History of influenza immunization was positively associated with intent to immunize during pregnancy [OR = 2.31, 90%CI: (1.06, 5.00)]. Significant correlates of intention to immunize included perceived susceptibility to influenza during pregnancy [OR = 3.8, 90% CI: (1.75, 8.36)] and vaccine efficacy [OR = 10.53, 90% CI: (4.34, 25.50)]. Single message exposure did not influence a woman's intent to vaccinate. Conclusions: Prior immunization, perceived flu susceptibility and perceived vaccine effectiveness promoted immunization intent among this population of pregnant minority women. Vaccine efficacy and disease susceptibility are critical to promoting immunization among women with no history of seasonal influenza immunization, while those who received the vaccine are likely to do so again. These findings provide evidence for the promotion of repeated exposure to vaccine messages emphasizing vaccine efficacy, normative support, and susceptibility to influenza.Human Vaccines and Therapeutics 09/2014; · 3.64 Impact Factor
Article: Maternal immunization.[Show abstract] [Hide abstract]
ABSTRACT: Maternal immunization holds tremendous promise to improve maternal and neonatal health for a number of infectious conditions. The unique susceptibilities of pregnant women to infectious conditions, as well as the ability of maternally-derived antibody to offer vital neonatal protection (via placental transfer), together have produced the recent increased attention on maternal immunization. The Advisory Committee on Immunization Practices (ACIP) currently recommends 2 immunizations for all pregnant women lacking contraindication, inactivated Influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap). Given ongoing research the number of vaccines recommended during pregnancy is likely to increase. Thus, achieving high vaccination coverage of pregnant women for all recommended immunizations is a key public health enterprise. This review will focus on the present state of vaccine acceptance in pregnancy, with attention to currently identified barriers and determinants of vaccine acceptance. Additionally, opportunities for improvement will be considered.Human Vaccines and Therapeutics 06/2014; · 3.64 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Pregnant women and infants are at high risk for complications, hospitalization, and death due to influenza. It is well-established that influenza vaccination during pregnancy reduces rates and severity of illness in women overall. Maternal vaccination also confers antibody protection to infants via both transplacental transfer and breast milk. However, as in the general population, a relatively high proportion of pregnant women and their infants do not achieve protective antibody levels against influenza virus following maternal vaccination. Behavioral factors, particularly maternal weight and stress exposure, may affect initial maternal antibody responses, maintenance of antibody levels over time (i.e., across pregnancy), as well as the efficiency of transplacental antibody transfer to the fetus. Conversely, behavioral interventions including acute exercise and stress reduction can enhance immune protection following vaccination. Such behavioral interventions are particularly appealing in pregnancy because they are safe and non-invasive. The identification of individual risk factors for poor responses to vaccines and the application of appropriate interventions represent important steps towards personalized health care.Vaccine 04/2014; · 3.49 Impact Factor
Report from the CDC
Seasonal Influenza Vaccine Coverage
Among Pregnant Women:
Pregnancy Risk Assessment Monitoring System
Indu B. Ahluwalia, M.P.H., Ph.D., James A. Singleton, M.S., Denise J. Jamieson, M.D.,
Sonja A. Rasmussen, M.D., M.S., and Leslie Harrison, M.P.H.
Since 2004, the American College of Obstetricians and Gynecologists (ACOG) and the Advisory Committee on
Immunization Practices (ACIP) have recommended that pregnant women receive the seasonal influenza vaccine,
regardless of pregnancy trimester, because of their increased risk for severe complications from influenza.
However, the uptake of the influenza vaccine by pregnant women has been low. During the 2009–2010 influenza
season, pregnant women were identified as a priority population to receive the influenza A (H1N1) 2009 (2009
H1N1) monovalent vaccine in addition to the seasonal influenza vaccine. In this issue, we highlight information
from the 10 states that collected data using the survey administered by the Pregnancy Risk Assessment and
Monitoring System (PRAMS) about seasonal vaccine coverage among women with recent live births and reasons
for those who chose not to get vaccinated. The combined estimates from PRAMS of influenza vaccination
coverage for the 2009–2010 season, which included data from October 2009 to March 2010, from 10 states were
50.7% for seasonal and 46.6% for 2009 H1N1 vaccine among women with recent live births. Among women who
did not get vaccinated, reasons varied from worries about the safety of the vaccines for self and baby to not
normally getting the vaccination. Further evaluation is needed on ways to increase influenza vaccination among
pregnant women, effectively communicate the risk of influenza illness during pregnancy, and address women’s
concerns about influenza vaccination safety during pregnancy.
on Immunization Practices (ACIP) have recommended sea-
sonal influenza vaccination for pregnant women, regardless
of trimester,1,2because of their increased risk for serious
complications from influenza.3,4Despite the long-standing
recommendations for pregnant women to get the seasonal
influenza vaccine,1,2the literature on vaccine safety,5–7and
the demonstrated risk of severe influenza-associated compli-
cations for women and their babies,8–12vaccination rates
among pregnant women have remained low and historically
have been lowest among adults recommended to receive the
influenza vaccine.13In 2009, a novel strain of influenza A
(2009 H1N1) virus was identified,14and as with seasonal in-
fluenza, pregnant women were found to be at increased risk
for influenza-related complications from this new virus.15,16
ince 2004, the American College of Obstetricians
and Gynecologists (ACOG) and the Advisory Committee
As a result, during the 2009–2010 influenza season, two sep-
arate influenza vaccines were recommended for pregnant
women: the trivalent inactivated seasonal vaccine and influ-
enza A (H1N1) 2009 monovalent vaccine.17
Previously, limited data were available about pregnant
women’s perceptions of influenza vaccine and about factors
that affect their decision to get the seasonal vaccine.18–21
(PRAMS) data have provided important insights into influ-
enza vaccine uptake among pregnant women, the influence
providers have on a woman’s decision to get the vac-
cine, and reasons among those who decided not to get
vaccinated.21,22The purpose of this article is to highlight the
role that PRAMS data have played in understanding influ-
enza vaccine uptake among pregnant women. Under-
standing barriers and motivators for receipt of influenza
vaccine during pregnancy is a critical step in improving
vaccine use during pregnancy.
Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.
JOURNAL OF WOMEN’S HEALTH
Volume 20, Number 5, 2011
ª Mary Ann Liebert, Inc.
PRAMS is an important source of data on maternal and
child health (MCH) since 1987. PRAMS is an ongoing,
population-based surveillance system that collects data on a
wide range of maternal behaviors and experiences before,
during, and after pregnancy among women who deliver a
live-born infant. PRAMS surveys are currently administered
by 37 states, New York City, and a South Dakota tribal-state
project in collaboration with the U.S. Centers for Disease
Control and Prevention (CDC). The PRAMS surveillance
system uses a standardized mail and telephone methodology
for data collection. Each month, the participating state selects
a stratified random sample of 100–300 women with recent
live-born deliveries from the birth certificate of the child.
A questionnaire is mailed to the selected mothers approxi-
mately 2–6 months after delivery. The primary mode of data
collection is the mail survey, and nonrespondents are con-
tacted by telephone. All states using the PRAMS data collec-
additional questions added to the core to ensure that emerg-
ing issues at the state level are assessed and monitored over
time. Selected information from the birth certificate is in-
season, a supplement tothe PRAMS questionnaire was added
by 30 states/localities to collect information about women’s
experiences with the seasonal and 2009 H1N1 vaccinations.
PRAMS data are weighted to represent the population of a
state or other entity collecting data using the PRAMS meth-
odology. More information about PRAMS is available
at www.cdc.gov/prams/methodology.htm. We examined
PRAMS data to characterize the population of women who
received the seasonal and 2009 H1N1 influenza vaccinations
and to examine the reasons given by those who did not re-
ceive vaccine.22Prior to the 2009–2010 influenza season, only
two PRAMS states collected influenza vaccination data on
women with live births. However, beginning with the 2009–
2010 season, a majority (30 of 37) of PRAMS jurisdictions
began collecting surveillance data on pregnant women and
from 10 states (October 2009 to March 2010) who met the
inclusion criteria of ‡65% response rate and were included in
the analysis that was published in early December 2010.22In
the PRAMS seasonal influenza supplement, the participants
were asked: At any time during your most recent pregnancy,
did a doctor, nurse, or other healthcare worker offer you a
seasonal flu shot or tell you to get one? Since September 2009,
did you get a seasonal flu shot? Questions related to the 2009
H1N1 were: At any time during your most recent pregnancy,
did a doctor, nurse, or other healthcare worker offer you an
H1N1 flu shot or tell you to get one? During your most recent
pregnancy, did you get an H1N1 flu shot? For each vaccina-
tion, seasonal and 2009 H1N1, those who did not get vacci-
nated were asked for their reasons for not getting vaccinated.
The data were weighted to adjust for complex survey design
prevalence of influenza vaccination coverage for the 2009–
2010 season was 50.7% for seasonal (state median 50.7%,
range 36.6%–68.3%) and 46.6%% (state median 45.5%, range
26.9%–72.4%) for 2009 H1N1 vaccination during pregnancy
among women with recent live births.22Among 2994 re-
spondents who did not receive the seasonal influenza vacci-
nation, the most common reasons for not receiving the
vaccination were that they do not normally get flu vaccina-
tions (72.1%), safety concerns for their baby (47.7%), and
safety concerns for themselves (45.2%). Among 2602 who did
not receive the 2009 H1N1 vaccination, the most common
reasons were safety concerns for their baby (63.6%), safety
concerns for themselves (61.4%), and that they normally do
not get seasonal flu vaccinations (57.6%) (Fig. 1).
What Have We Learned?
ACOG and ACIP recommend that all pregnant women be
given seasonal influenza vaccine during any trimester of
pregnancy. Despite this recommendation, historically, vacci-
nation coverage for pregnant women has been low, only
24.2% during the 2007–2008 influenza season and 11.3%
during the 2008–2009 season, according to data from the
National Health Interview Survey (NHIS).2During the 2009–
2010 influenza season, combined data from 10 states collect-
ing data through PRAMS suggested that seasonal influenza
vaccination coverage among pregnant women was higher
than it has been in past seasons.22Among those who did not
report getting the vaccination, there were multiple concerns
about vaccine safety; therefore, continued efforts to educate
the public and healthcare providers about the available data
on safety of influenza vaccination for pregnant women and
their newborns are necessary to increase influenza vaccina-
tion coverage among pregnant women during future influ-
conducted to identify existing gaps in knowledge and vaccine
uptakes and to evaluate the potential impact of programs to
increase immunization coverage, as states may have used
different ways to promote adult vaccinations.21PRAMS data
could be an important and useful source of state-specific data
to address many of these issues and to provide data to help
achieve the Healthy People 2020 objective of 80% coverage
for pregnant women with seasonal influenza vaccination
cination, 2009–2010 season, among women with live-born
infants, 10 states (Illinois, Maryland, Massachusetts, Mis-
sissippi, Missouri, New Jersey, Rhode Island, Utah, Wa-
shington, and West Virginia). Pregnancy Risk Assessment
and Monitoring System (PRAMS).
Reasons for not getting the seasonal or H1N1 vac-
650AHLUWALIA ET AL.
What Can You Do?
uptake of seasonal influenza vaccine among pregnant wom-
en.21–24Data show a strong relationship between healthcare
provider advice or offer of vaccine and vaccine uptake by
pregnant women.21,22Providers can take an active role in
women’s decision to get the seasonal influenza vaccination by
discussing the recommendations with them, educating preg-
nant women about the available data on safety of the vaccine,
and offering influenza vaccines in their offices. Resources to
learn more about the seasonal influenza vaccine and to com-
municate appropriate information to pregnant women are
available at www.cdc.gov/Features/Pregnancyandflu/. In
addition, a free fact sheet is available at www.cdc.gov/flu/
and resources that providers can use as aids in educating
and communicating with pregnant women and other persons
are available online at www.cdc.gov/flu/freeresources/
The findings and conclusions in this report are those of the
author(s) and do not necessarily represent the official position
of the Centers for Disease Control and Prevention.
The authors have no conflicts of interest to report.
1. American College of Obstetricians and Gynecologists.
Committee on Obstetric Practice. ACOG committee opinion
number 305, November 2004. Influenza vaccination and
treatment during pregnancy. Obstet Gynecol 2004;104:1125–
2. Fiore AE, et al. Prevention and control of influenza with
vaccines: Recommendations of the Advisory Committee on
Immunization Practices (ACIP), 2010. MMWR 2010:59;1–62.
3. Dodd L, MCNeil SA, Fell DB, et al. Impact of influenza ex-
posure on rates of hospital admission and physician visits
because of respiratory illness among pregnant women. Can
Med Assoc J 2007;176:463–468.
4. Neuzil KM, Reed GW, Mitchel EF, et al. Impact of influenza
on acute cardiopulmonary hospitalization in pregnant wo-
men. Am J Epidemiol 1998;148:1094–1102.
5. Tamma PD, Ault KA, del Rio C, et al. Safety of influenza
vaccination during pregnancy. Obstet Gynecol 2009;34:547–
6. Yudin MH, Salaripour M, Sgro MD. Pregnant women’s
knowledge of influenza and the use and safety of the in-
fluenza vaccine during pregnancy. J Obstet Gynaecol Can
7. Munoz FM, Greisinger AJ, Wehmanen OA, et al. Safety of
influenza vaccination during pregnancy. Obstet Gynecol
8. Benowitz I, Esposito DB, Gracey KD, Shapiro ED, Vazquez
M. Influenza vaccine given to pregnant women reduces
hospitalizations due to influenza in their infants. Clin Infect
9. Eick A, Uyeki TM, Kilmov A, et al. Maternal influenza
vaccination and effect on influenza virus infection in young
infants. Arch Pediatr Adolesc Med 2011;165:104–111.
10. Zaman K, Roy E, Arifeen SE, et al. Effectiveness of maternal
influenza immunization in mothers and infants. N Engl J
11. Black SB, Shinefield HR, France EK, et al. Effectiveness of
influenza vaccine during pregnancy in preventing hospital-
izations and outpatient visits for respiratory illness in
pregnant women and their infants. Am J Perinatol 2004;21:
12. France EK, Smith-Ray R, McClure D, et al. Impact of ma-
ternal influenza vaccination during pregnancy on the inci-
dence of acute respiratory visits among infants. Arch Pediatr
Adolesc Med 2006;160:1277–1283.
13. Lu P, Briges CB, Euler GL, Singleton JA. Influenza vaccina-
tion of recommended adult population, US, 1989–2005.
14. Novel Swine-Origin Influenza A (H1N1) Virus Investigation
Team. Emergence of a novel swine-origin influenza A
(H1N1) virus in humans. N Engl J Med 2009;360:2605–2615
15. Jamieson DJ, Honein MA, Rasmussen SA, et al. H1N1 2009
influenza virus infection during pregnancy in the USA.
16. Siston AM, Rasmussen SA, Honein MA, et al. Pandemic
H1N1 Influenza in Pregnancy Working Group. Pandemic
2009 influenza A (H1N1) virus illness among pregnant
women in the United States. JAMA 2010;303:1517–1525.
17. Use of influenza A (H1N1) 2009 monovalent vaccine: Re-
commendations of the Advisory Committee on Immuniza-
tion Practices (ACIP), 2009. MMWR Recommendations Rep.
18. Brownsyne M, Tucker E, Coleman J, et al. Risk perceptions,
worry, or distrust: What drives pregnant women’s decisions
to accept the H1N1 vaccine? Matern Child Health J October
9, 2010 [Epub ahead of print]
19. Beigi RH, Switzer G, Meyn LA. Acceptance of a pandemic
avian influenza vaccine in pregnancy. J Reprod Med 2009;
20. Harris KM, Maurer J, Kellerman AL. Influenza vaccine—
Safe, effective, and mistrusted. N Engl J Med 2010;263:2183–
21. Ahluwalia IB, Jamieson DJ, Rasmussen SA, et al. Correlates
of seasonal influenza vaccine among pregnant women in
Georgia and Rhode Island. Obstet Gynecol 2010;116:949–
22. Ahluwalia IB, Jamieson DJ, D’Angelo D, et al. Seasonal in-
fluenza and 2009 H1N1 influenza vaccination coverage
among pregnant women—10 states, 2009–10 influenza sea-
son. MMWR 2010;59:1541–1545.
23. Broughton D, Beigi RH, Switzer GE, et al. Obstetric health
care workers’ attitudes and beliefs regarding influenza
vaccination in pregnancy. Obstet Gynecol 2009;114:981–987.
24. Power ML, Leddy M, Anderson BL, et al. Obstetrician-gy-
necologists’ practices and perceived knowledge regarding
immunization. Am J Prev Med 2009;37:231–234.
Address correspondence to:
Indu B. Ahluwalia, M.P.H., Ph.D.
Division of Reproductive Health
Centers for Disease Control and Prevention
4770 Buford Highway, NE
Mail Stop K-22
Atlanta, GA 30341-3724
INFLUENZA VACCINATION UPTAKE BY PREGNANT WOMEN 651