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Abstract

To audit the uptake of pandemic (H1N1) 2009 influenza vaccine in pregnant women entering the 2010 influenza season in Western Australia, and to identify why some women did not receive the vaccine. Cross-sectional study of consecutive patients attending the Joondalup Health Campus public antenatal clinics in WA in January 2010. Audit of uptake of the H1N1-specific vaccine. Rate of H1N1-specific vaccination, and reasons for not being the vaccinated. 479 of 541 women who attended the clinics (88.5%) were included in the audit. Three women had been infected with pandemic influenza in the preceding influenza season, leaving 476 women who were eligible for vaccination in pregnancy. Of these 476 women, only 33(6.9%) had been vaccinated. Of the remaining 443 women who were eligible to receive the vaccine but had not been vaccinated, 63.9% had not been offered vaccination despite multiple visits to their general practitioners during pregnancy, 19.6% had been advised by their GPs against vaccination in pregnancy, and 61.6% stated that they would decline vaccination if offered because of safety concerns. Uptake of H1N1-specific influenza vaccine in pregnant women was poor. Reasons for this relate both to vaccination not being offered to or actively sought by the women, as well as concerns - of both the women and their GPs - about vaccine safety in pregnancy. Uptake in this setting may improve if vaccination is offered through public antenatal clinics with concurrent safety education for obstetricians and vaccination providers.
MJA Volume 193 Number 7 4 October 2010 405
PANDEMIC (H1N1) 2009
The Medical Journal of Australia ISSN:
0025-729X 4 October 2010 193 7 405-
407
©The Medical Journal of Australia 2010
www.mja.com.au
Pandemic (H1N1) 2009
regnancy has been identified as a risk
factor for severe pandemic (H1N1)
2009 influenza.1-3 Pregnant women
were identified early in the pandemic as
“vulnerable” and therefore candidates for
heightened alertness to the disease. Once
the H1N1-specific vaccine (CSL Limited,
Melbourne, VIC) was available and judged
by the Therapeutic Goods Administration as
safe and effective, pregnant women were
atop the list of recommended recipients in
the first rollout of the vaccination program
in September 2009.4 Indeed, pregnancy has
been recommended as an indication for
seasonal influenza vaccination since this cat-
egory of vaccination was included in the
Australian immunisation handbook in 2008.5
The Australian Chief Medical Officer wrote
to general practitioners in November 2009
emphasising the increased risk to pregnant
women of severe pandemic influenza and
the suitability of the H1N1-specific vaccine
for use in pregnancy.6
A widespread public education campaign
was undertaken to alert those at increased
risk of severe pandemic influenza to the
recommendation for vaccination. In metro-
politan Western Australia, individuals were
directed to traditional immunisation provid-
ers such as their GPs or Aboriginal medical
services.7
Vaccination against pandemic influenza
for pregnant women has been advocated by
the Australian Technical Advisory Group on
Immunisation, the World Health Organiza-
tion,8 and the United States Centers for
Disease Control and Prevention,9 on the
basis that the theoretical risks associated
with the vaccine are outweighed by the
potential benefits to the pregnant woman
and her fetus. After birth, immunity of the
mother also reduces the risk of transmission
to the infant who is too young to be vacci-
nated.
On informal questioning of patients at the
public antenatal clinics at Joondalup Health
Campus — a secondary hospital in WA —
we found that uptake of H1N1-specific vac-
cination among pregnant patients had been
low. Therefore, we audited the uptake of
H1N1-specific vaccination among pregnant
patients, with the aim of identifying reasons
for not receiving the vaccine.
METHODS
The study sample consisted of consecutive
patients attending the Joondalup Health
Campus public antenatal clinics over a 4-
week period in January 2010. Joondalup
Health Campus services a metropolitan–
rural population mix (about two-thirds met-
ropolitan).
During antenatal clinic consultations,
patients were asked by their attending doc-
tors whether they had received the “swine
flu” (H1N1-specific) vaccine as prophylaxis
against the pandemic influenza. If patients
answered “no” to this question, they were
asked why they had not been vaccinated.
Patients could list multiple reasons. Immu-
nisation outcomes for each patient — vacci-
nation status (yes, no, previous infection)
and, where applicable, response to the
query as to why they had not received the
vaccine — were entered into the medical
record results summary page which was part
of the patient’s hospital medical record.
Patients’ immunisation outcomes were also
recorded on a data sheet. Data sheets were
collected by one of us (JA Q) at the end of
each clinic session and were secured in a
locked office within the Department of
Obstetrics and Gynaecology.
After the first week, verbatim answers
were evaluated using qualitative analytical
methods10 and content analysis was under-
taken independently by two of us (J A Q and
R W P). This revealed three GP-related and
two patient-related reasons for not receiving
the vaccine. Both independent reviewers
generated the same broad (GP and patient)
categories and subcategories, meaning that
there was high inter-rater reliability.
In the remaining 3 weeks of the audit,
answers were coded to one of the subcatego-
ries determined by the qualitative analysis of
the pilot data. In cases where patients were
not able to articulate a reason for failure to
accept vaccination, the responses were
coded as “insufficient data to code”.
The audit met the National Health and
Medical Research Council (NHMRC) criteria
Pandemic (H1N1) 2009 influenza vaccine uptake in pregnant
women entering the 2010 influenza season in Western Australia
Scott W White, Rodney W Petersen and Julie A Quinlivan
ABSTRACT
Objective: To audit the uptake of pandemic (H1N1) 2009 influenza vaccine in pregnant
women entering the 2010 influenza season in Western Australia, and to identify why
some women did not receive the vaccine.
Design, setting and participants: Cross-sectional study of consecutive patients
attending the Joondalup Health Campus public antenatal clinics in WA in January 2010.
Intervention: Audit of uptake of the H1N1-specific vaccine.
Main outcome measures: Rate of H1N1-specific vaccination, and reasons for not being
the vaccinated.
Results: 479 of 541 women who attended the clinics (88.5%) were included in the audit.
Three women had been infected with pandemic influenza in the preceding influenza
season, leaving 476 women who were eligible for vaccination in pregnancy. Of these 476
women, only 33 (6.9%) had been vaccinated. Of the remaining 443 women who were
eligible to receive the vaccine but had not been vaccinated, 63.9% had not been offered
vaccination despite multiple visits to their general practitioners during pregnancy, 19.6%
had been advised by their GPs against vaccination in pregnancy, and 61.6% stated that
they would decline vaccination if offered because of safety concerns.
Conclusions: Uptake of H1N1-specific influenza vaccine in pregnant women was poor.
Reasons for this relate both to vaccination not being offered to or actively sought by the
women, as well as concerns — of both the women and their GPs — about vaccine safety
in pregnancy. Uptake in this setting may improve if vaccination is offered through public
antenatal clinics with concurrent safety education for obstetricians and vaccination
MJA 2010; 193: 405–407
providers.
eMJA Rapid Online Publication 6 September 2010
P
406 MJA Volume 193 Number 7 4 October 2010
PANDEMIC (H1N1) 2009
for a negligible-risk project. The Joondalup
Health Campus Human Research Ethics
Committee exempts negligible-risk projects
that meet the criteria outlined in section
5.1.22 of the NHMRC National statement on
ethical conduct in human research from formal
ethics approval processes.11
RESULTS
Of 564 patient bookings for the 4-week audit
period, 23 were for patients who attended the
antenatal clinics on a second occasion. This
meant that 541 patients attended on at least
one occasion, of whom 479 (88.5%) were
included in the audit. The remaining 62
patients were missed as the attending doctor
forgot to ask and record responses to the
audit questions. Similar numbers of patients
were missed by each of the seven doctors
who collected data during the audit.
Three patients included in the audit
stated that they had been infected with
“swine flu” in the preceding influenza sea-
son. Two of these cases had been confirmed
by laboratory testing, and the other was
presumptive — the patient developed
symptoms after a family member had been
microbiologically confirmed. This left 476
women who were eligible for vaccination in
pregnancy. Of the 476 eligible women, only
33 women (6.9%) had been vaccinated
against pandemic influenza. The remaining
443 women were eligible to receive the
vaccine but stated that they had not been
vaccinated and, to the best of their knowl-
edge, had not been infected in the preceding
influenza season.
Qualitative and quantitative analysis iden-
tified five reasons why vaccination had not
occurred: three related to the GP and two
related to the patient (Box). The most com-
mon GP-related reason was that the GP had
not raised or discussed the matter with the
woman despite more than one visit during
pregnancy (63.9%). The most common
patient-related reason was concern regard-
ing safety of the vaccination in pregnancy
(61.6%). Of note, 19.6% of the women
stated that their GPs had actively advised
against vaccination.
DISCUSSION
This study showed poor uptake of H1N1-
specific vaccine (6.9%) within a population
of pregnant women in WA and identified
several GP-related and patient-related rea-
sons that influenced the poor uptake. This is
despite previous findings reporting willing-
ness to accept vaccination of 62.3% in Aus-
tralian women and 64.6% in Australians
aged 20–40 years.12
Our findings highlight a suboptimal
response to the education campaign on pan-
demic influenza: 41.5% of women had not
thought about and sought vaccination, and
63.9% of women reported that their GPs
had not raised the issue despite several
consultations during pregnancy. Of more
concern is that, even with specific commu-
nication from the Chief Medical Officer
regarding the benefits and safety of vaccina-
tion in pregnancy,6 19.6% of women
reported active discouragement of vaccina-
tion by their GPs. Given the large number
GPs who refer to the antenatal clinics at
Joondalup Health Campus, it is likely this
represents a number of different practices in
the region. Also of note is that 61.6% of
women expressed concern regarding the
safety of the vaccine in pregnancy and stated
that they would decline vaccination if
offered. We wonder whether some of those
women who expressed concern over safety
may have been reassured by more effective
education, including education of the GPs in
the community who were advising against
vaccination in pregnancy. GPs may feel more
confident about offering H1N1-specific vac-
cination when it appears as a recommenda-
tion in literature from their local maternity
hospital and is incorporated into the routine
care plans for women, and especially when
it is included in consensus statements for
shared maternity care. Such strategies have
been associated with high levels of support
for and compliance with hepatitis B and
anti-D vaccination.
This study has a number of limitations.
First, demographic details were not col-
lected, which makes generalisation of results
difficult. However, the mean age at time of
birth and proportion of primiparous women
in the hospital population were similar to
those reported for the wider Australian pop-
ulation — 30.4 years and 39%, respectively,
for the hospital population (Ms Wendy
Candy, Deputy Director of Nursing [Mid-
wifery], Joondalup Health Campus, per-
sonal communication, April 2010) v 29.9
years and 41.6%, respectively, for the Aus-
tralian population.13 The study design also
meant that we were not able to determine
how many women who were not offered
vaccination by their GPs would have
accepted vaccination had this occurred. In
addition, some women who were eligible for
inclusion in the audit were missed as their
attending doctors forgot to ask and record
responses to the audit questions, reflecting
the busy nature of the clinic. Nonetheless,
88.5% of eligible patients were included,
hence the results are representative of the
antenatal clinic population.
Vaccination rates might be improved by
shifting the provision of antepartum vacci-
nation into antenatal clinics. Antenatal clin-
ics are currently able to provide antenatal
vaccination as prophylaxis against rhesus
disease — this involves offering routine anti-D
vaccination at 28 and 34 weeks’ gestation to
all rhesus-negative women. Maternity hospi-
tals also provide routine vaccination against
hepatitis B and rubella where indicated.
Thus most hospital-based antenatal clinics
should be able to initiate a suitable program
Reasons for not receiving the pandemic influenza vaccine, as given by pregnant
women who were eligible to receive the vaccine (n= 443)*
* Women could provide more tha n one reason for their answer.
Number (%)
General practitioner-related reasons
Despite more than one visit to GP during pregnancy, GP has not
suggested the vaccination to me
283 (63.9%)
Visited GP once only during pregnancy (to confirm diagnosis
and be referred to hospital for care) and the vaccination was not
discussed during that visit
88 (19.9%)
GP discussed the vaccination with me but advised against it
during pregnancy
87 (19.6%)
Insufficient data to code 21 (4.7%)
Patient-related reasons
Personal safety concern, would decline the vaccination if offered 273 (61.6%)
Did not think about the vaccination or raise the issue with my GP 184 (41.5%)
Insufficient data to code 22 (5.0%)
MJA Volume 193 Number 7 4 October 2010 407
PANDEMIC (H1N1) 2009
to address pandemic influenza vaccination.
It is possible that, in smaller clinics, patients
could be vaccinated either in the clinic or
referred to another vaccination provider if
patient numbers are not sufficient to sustain
an ongoing clinic-based program. This
approach may also overcome difficulties
experienced by obstetricians in private prac-
tice who may not be equipped to provide
vaccination due to storage and cold-chain
issues. Nevertheless, obstetricians are well
suited to providing relevant education and
could refer their patients to vaccination pro-
viders at other services.
Reasons for the poor uptake of H1N1-
specific influenza vaccine by pregnant
patients at Joondalup Health Campus were
related to GP and patient factors, including
concerns regarding safety of vaccination in
pregnancy. We believe that offering vaccina-
tion in antenatal clinics and improving
safety education for obstetricians and vacci-
nation providers could increase pandemic
influenza vaccination rates.
ACKNOWLEDGEMENTS
We thank the staff in the antenatal clinics at Joon-
dalup Health Campus for their assistance in data
collection and the patients who contributed their
information.
COMPETING INTERESTS
None identified.
AUTHOR DETAILS
Scott W White, MB BS, Obstetrics and
Gynaecology Registrar1
Rodney W Petersen, MB BS, MBA,
FRANZCOG, Director of Obstetrics and
Gynaecology,1 and Associate Professor2
Julie A Quinlivan, MB BS, PhD, FRANZCOG,
Pro Vice Chancellor and Executive Dean of
Medicine3
1 Joondalup Health Campus, Joondalup, WA.
2 Edith Cowan University, Joondalup, WA.
3 University of Notre Dame Australia,
Fremantle, WA.
Correspondence: juliequinlivan@nd.edu.au
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... Previous studies generally focused on understanding the impact of knowledge level on vaccine uptake rates [5,[14][15][16]. However, it has not been clarified whether women still may avoid the influenza vaccine even after understanding the vaccine's positive effect on pregnancy outcomes. ...
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Purpose Most societies recommend routine influenza vaccine to all pregnant women. In Turkey, the Ministry of Health provides the influenza vaccine free of charge to pregnant women during the second and third trimesters. Pregnant women may not be willing to accept vaccination despite their knowledge and attitudes. We aimed to investigate the rate and determining factors of influenza vaccine acceptance after receipt of face-to-face information. Methods Pregnant women were informed about the benefits of the influenza vaccine and asked if they would get the vaccine. Results A total of 353 Turkish women were involved, and 191 (54.1%) accepted influenza vaccination. There was no statistically significant difference in terms of maternal age, body mass index, gravida, number of children, socioeconomic status, smoking and occupation between groups. Women in the third trimester had lower vaccination rates compared to first- and second-trimester pregnancies (35.7% vs. 67.7–64.2%). Women with at least a university degree also had lower vaccine uptake rates (58.1% vs. 59.5–36.8%). While 82.2% of women who accepted vaccination believed the benefit of the vaccine to the baby, the rate was 54.9% in the non-vaccinated group. The most common reason for refusal was the belief that influenza was not a serious disease. Vaccination uptake was higher especially for women who understood the benefits of the influenza vaccine for the baby (OR=3.79, 95%Cl=2.34–6.14). Conclusion Women who had enough information, who had a lower education level, who had a previous history of influenza infection, and who had decided to have their babies vaccinated were more likely to accept influenza vaccine.
... This can be attributed to both the absence of an accurate data identification method by the Australian Immunization Register (Australian Government Department of Human Services, 2019) and to the absence of immunization data recorded in the Perinatal Outcomes Information (South Australia) (SA Health, 2016). For this reason the numbers of pregnant women receiving the influenza immunization is currently unknown despite estimates of around 40% (O'Grady et al., 2015;White, Petersen, & Quinlivan, 2010). One recent publication was able to lift that number to 76% with the aid of a midwifery led immunization program however, it is not yet known if this was a sustained increase in immunization levels (Mohammed et al., 2018). ...
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To investigate the Australian public's expectations, concerns and willingness to accept vaccination with the pandemic (H1N1) 2009 influenza vaccine. A computer-assisted telephone interview survey was conducted between 20 August and 11 September 2009 by trained professional interviewers to study issues relating to vaccine uptake and perceived safety. The sample comprised 1155 randomly selected representative adults who had participated in a 2007 national study exploring knowledge and perceptions of pandemic influenza. Likely acceptance of pandemic (H1N1) 2009 vaccination, factors associated with acceptance, and respondents' willingness to share Australian vaccine with neighbouring developing countries. Of 1155 possible participants, 830 (72%) were successfully interviewed. Twenty per cent of the study group (169/830) reported that they had developed influenza-like symptoms during the 2009 pandemic period. Most respondents (645/830, 78%) considered pandemic (H1N1) 2009 to be a mild disease, and 211/830 (25%) regarded themselves as being at increased risk of infection. Willingness to accept pandemic (H1N1) 2009 vaccination was high (556/830, 67%) but was significantly lower than when pandemic vaccination uptake was investigated in 2007 (88%; P < 0.0001). Respondents who had already been vaccinated against seasonal influenza and those who perceived pandemic (H1N1) 2009 to be severe were significantly more willing to accept vaccination. Most respondents (793/822, 96%) were willing to share surplus vaccine with developing countries in our region. Although two-thirds of Australian adults surveyed were willing to accept pandemic (H1N1) 2009 vaccination, and most supported sharing vaccine with developing countries, there is a need for accessible information on vaccine safety for those who are undecided about vaccination.
Article
Pandemic H1N1 2009 influenza virus has been identified as the cause of a widespread outbreak of febrile respiratory infection in the USA and worldwide. We summarised cases of infection with pandemic H1N1 virus in pregnant women identified in the USA during the first month of the present outbreak, and deaths associated with this virus during the first 2 months of the outbreak. After initial reports of infection in pregnant women, the US Centers for Disease Control and Prevention (CDC) began systematically collecting additional information about cases and deaths in pregnant women in the USA with pandemic H1N1 virus infection as part of enhanced surveillance. A confirmed case was defined as an acute respiratory illness with laboratory-confirmed pandemic H1N1 virus infection by real-time reverse-transcriptase PCR or viral culture; a probable case was defined as a person with an acute febrile respiratory illness who was positive for influenza A, but negative for H1 and H3. We used population estimates derived from the 2007 census data to calculate rates of admission to hospital and illness. From April 15 to May 18, 2009, 34 confirmed or probable cases of pandemic H1N1 in pregnant women were reported to CDC from 13 states. 11 (32%) women were admitted to hospital. The estimated rate of admission for pandemic H1N1 influenza virus infection in pregnant women during the first month of the outbreak was higher than it was in the general population (0.32 per 100 000 pregnant women, 95% CI 0.13-0.52 vs 0.076 per 100 000 population at risk, 95% CI 0.07-0.09). Between April 15 and June 16, 2009, six deaths in pregnant women were reported to the CDC; all were in women who had developed pneumonia and subsequent acute respiratory distress syndrome requiring mechanical ventilation. Pregnant women might be at increased risk for complications from pandemic H1N1 virus infection. These data lend support to the present recommendation to promptly treat pregnant women with H1N1 influenza virus infection with anti-influenza drugs. US CDC.
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