AT THE NATIONAL IMMUNIZATION CONFERENCE
ATLANTA (FRONTLINE MEDICAL NEWS) – Both the influenza and the tetanus-diphtheria-acellular pertussis (Tdap) vaccines have been recommended during pregnancy for years, but uptake remains low.
The most recent national data from the Centers for Disease Control and Prevention show that the Tdap vaccination rate is about 14% before pregnancy and 10% during pregnancy. For influenza , the vaccination rate among pregnant women is about 50%, with 14% of women being vaccinated in the 6 months before pregnancy and 36% during pregnancy.
“For many ob.gyn. offices, vaccination is a relatively new paradigm,” Sean O’Leary, MD, of the department of pediatrics, section of infectious diseases, at the University of Colorado, Denver, said at the conference sponsored by the CDC. “They didn’t really get on board with vaccination until maybe the 2009 [H1N1] pandemic, and we know little about the vaccination practices in the ob.gyn. practices nationally.”
To get a handle on how ob.gyn. practices approach vaccination, Dr. O’Leary and his colleagues sent out a mail and Internet survey to 482 physicians from June through September 2015 and analyzed 353 responses.
Among the responders, 92% routinely assessed whether their pregnant patients had received the Tdap vaccine, and 98% routinely assessed whether pregnant patients had received the influenza vaccine. But only about half of the physicians (51%) assessed Tdap vaccination in nonpregnant patients, and 82% assessed influenza vaccine status in nonpregnant patients.
For the human papillomavirus (HPV) vaccine, ob.gyns. were more likely to ask their nonpregnant patients about the vaccine. A total of 46% of providers routinely assessed whether their pregnant patients had received it, while 92% assessed whether their nonpregnant patients needed or had received the HPV vaccine.
The numbers were lower when it came to actually administering the vaccines. Just over three-quarters of providers routinely administered the Tdap vaccine, and 85% routinely administered the influenza vaccine to their pregnant patients.
For their nonpregnant patients, 55% routinely administered Tdap, 70% routinely administered the flu vaccine, and 82% routinely administered the HPV vaccine.
Ob.gyns. were most likely to have standing orders in place for influenza vaccine for their pregnant patients, with 66% of providers reporting that they had these orders in place, compared with 51% for nonpregnant patients. Standing orders were less likely for Tdap vaccine administration (39% for pregnant patients and 37% for nonpregnant patients).
Barriers
Reimbursement-related issues topped the reasons that ob.gyns. found it burdensome to stock and administer vaccines. The most commonly reported barrier – cited by 54% of the respondents – was lack of adequate reimbursement for purchasing vaccines, and 30% of physicians cited this as a major barrier. Similarly, lack of adequate reimbursement for administration of the vaccine was listed as a major barrier for a quarter of the respondents and a moderate barrier by 21% of the respondents.
A quarter of physicians also cited difficulty determining if a patient’s insurance would reimburse for a vaccine as a major barrier.
Other barriers included having too little time for vaccination during visits when other preventive services took precedence, having patients who refused vaccines because of safety concerns, the burden of storing, ordering, and tracking vaccines, and difficulty determining whether a patient had already received a particular vaccine.
Fewer than 2% of ob.gyns., however, reported uncertainty about a particular vaccine’s effectiveness or safety in pregnant women as a barrier.
“Physician attitudinal barriers are nonexistent,” Dr. O’Leary said. “The perceived barriers were primarily financial, but logistical and patient attitudinal barriers were also important.”
Testing interventions
While the barriers to routine vaccine administration are clear, the solutions are less obvious. A recently reported intensive intervention to increase the uptake of maternal vaccines in ob.gyn. practices had only modest success in increasing Tdap vaccination and no significant impact on administration of the influenza vaccine.
“Immunization delivery in the ob.gyn. setting may present different challenges than more traditional settings for adult vaccination, such as family medicine or internal medicine offices,” Dr. O’Leary said.
The study involved eight ob.gyn. practices in Colorado and ran from August 2011 through March 2014, a period during which the Advisory Committee for Immunization Practices recommended that Tdap vaccination be given in every pregnancy.
Four ob.gyn. practices – one rural and three urban – were randomly assigned to usual care while the other four – two rural and two urban – were randomly assigned to the intervention. The practices were balanced in terms of their number of providers, the proportion of Medicaid patients they served, the number of deliveries per month, and an immunization delivery score at baseline.
The researchers assessed receipt of influenza vaccines among women pregnant during the previous influenza season and receipt of the Tdap vaccine among women at at least 34 weeks’ gestation. There were 13,324 patients in the control arm and 12,103 patients in the intervention arm.
The multimodal intervention involved seven components:
1. Designating immunization champions at each practice.
2. Assisting with vaccine purchasing and management.
3. Historical vaccination documentation training.
4. Implementing standing orders for both vaccines.
5. Chart review and feedback.
6. Patient/staff education materials and training.
7. Frequent contact with the project team, at least once a month during the study period.
At baseline, the rate of Tdap vaccination among pregnant women was 3% in the intervention clinics and 11% in the control clinics. During year 2, following the intervention, 38% of women at the intervention clinics and 34% of the women at the control clinics had received the Tdap vaccine. Those increases translated to a four times greater likelihood of getting the Tdap vaccine among women at clinics who underwent the intervention (risk ratio, 3.9; 95% confidence interval, 1.1-13.3).
Influenza vaccine uptake also increased collectively at the clinics, from 19% at intervention clinics and 18% at control clinics at baseline, to 21% at intervention clinics and 25% at control clinics a year later. But there was no significant difference in uptake between the intervention and control clinics.
An additional qualitative component of the study involved hour-long interviews with staff members from six of the clinics to assess specific components of the intervention, such as implementing standing orders for each vaccine.
“Prior to establishing standing orders at practices, the responsibility for assessing immunization history and eligibility had fallen to the medical providers,” Dr. O’Leary said. “By establishing standing orders for immunizations, providers and staff reported overall improved immunization delivery to their patient population.”
But barriers existed for standing orders as well, including patient reluctance to receive the vaccine without first discussing it with her physician.
The qualitative interviews also revealed that some nurses may have felt anxious about administering vaccines to pregnant women until they received vaccine education. Overall, staff education and implementation of standing orders were well received at the intervention practices.
“Adding immunization questions to standard intake forms was an efficient and effective method to collect immunization history that fit into already established patient check-in processes,” Dr. O’Leary said.
Standing order templates could also be customized to each practice’s processes, and the process of the staff reviewing these templates often led to consensus about how to integrate the orders into routine care, according to Dr. O’Leary.
“To increase the uptake of vaccinations in pregnancy, all ob.gyns. need to stock and administer influenza and Tdap vaccines,” Dr. O’Leary said. “And if ob.gyns. are to play a significant role as vaccinators of nonpregnant women, a paradigm shift is required.”
Both studies were funded by the CDC. Dr. O’Leary reported having no relevant financial disclosures, but one of the coinvestigators in the intervention study reported financial relationships with Merck and Pfizer.
