Vaccine Communication for the ob/gyn - Immunization for Women

Vaccine Communication for the ob/gyn - Immunization for Women

UW MEDICINE ACOG WEBINAR Integrating Immunizations into Ob-gyn Practice: Practical Tips and Resources Office Administration strategies Communication strategies Vaccine information LINDA O ECKERT, MD PROFESSOR, OBSTETRICS & GYNECOLOGY ADJUNCT PROFESSOR GLOBAL HEALTH UNIVERSITY OF WASHINGTON ACCME Accreditation The American College of Obstetricians and Gynecologists is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

AMA PRA Category 1 Credit(s) The American College of Obstetricians and Gynecologists designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit Physicians should claim only the credit commensurate with the extent of their participation in the activity. College Cognate Credit(s) The American College of Obstetricians and Gynecologists designates this enduring material for a maximum of 1 Category 1 College Cognate Credit. The College has a reciprocity agreement with the AMA that allows AMA PRA Category 1 Credits to be equivalent to College Cognate Credits. Disclosure of Faculty and Industry Relationships In accordance with the College policy, all faculty and planning committee members have signed a conflict of interest statement in which they have disclosed any financial interests or other relationships with industry relative to topics they will discuss at this program. At the beginning of the program, faculty members are expected to disclose any such information to participants. Such disclosure allows you to evaluate better the objectivity of the information presented in lectures. Please report on your evaluation form any undisclosed conflict of interest you perceive.

Thank you! This project was made possible by the Cooperative Agreement Number, 1H23IP000981, funded by the Centers for Disease Control and Prevention. Views expressed in written materials do not necessarily reflect the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services nor does the mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. Our recommended software and hardware configuration is the following: Windows Macintosh Processor: 850MHz or faster processor (or above) Operating System: Windows XP/2000/98 Memory: 512MB of RAM (or above)

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ACOG PRACTICE ACTIVITIES IMMUNIZATION PROGRAM Integrating Immunizations into Ob-gyn Practice: Practical Tips and Resources September 27, 2016 CONFLICT OF INTEREST DISCLOSURE: FACULTY/PLANNING COMMITTEE/REVIEWER/STAFF All faculty, planning committee members, reviewers and staff have no conflicts of interest to disclose relative to the content of the presentation. Course Faculty Linda Eckert, MD, is a Professor in the Department of Obstetrics & Gynecology and Adjunct Professor in the Department of Global Health at the University of Washington in Seattle, Washington. Dr. Eckert

completed a Fellowship in Infectious Diseases and has expertise in immunization and policy development. She has worked at the World Health Organization in the Department of Immunizations and continues to serve as a consultant to WHO concentrating on the intersection of immunizations and reproductive health. She serves on the ACOG Immunization Expert Work Group and on the ACIP workgroup for HPV vaccine. Learning Objectives By the end of the webinar participants will be able to : Address the most common concerns and misconceptions around vaccines Integrate immunizations into routine practice and increase

immunization rates among ob-gyn patients Identify and locate resources for themselves and for patients regarding immunizations Describe and appropriately provide recommendations for Flu, Hep B, Tdap, Pneumococcal, Zoster Overview Office Administration-Tips and Tools Communication Strategies Vaccine Highlights Pneumo, Zoster, Hep B, Flu, Tdap Case Presentations Provider Roles: Creating Culture of

Immunization Educate nursing/MA/front desk staff If use interpreters, or case workers, educate them also. Use Electronic prompts/sticky notes in chart to help remember Provider Roles: Creating Culture of Immunization (cont.) Patient vaccine records are kept up to date Use Standing Orders Tie Immunization to a Routine glucola and Tdap on same visit Set up a Vaccine Champion in the office

Provider Roles: Creating Culture of Immunization (cont.) Vaccinate Office Staff Place signs at the front desk during Flu season about immunization, and also about Tdap being given to all pregnant women Empower MAs, Nurses, front desk to advocate for vaccines Provider Roles: Creating Culture of Immunization (cont.) If you do not have the immunization in your office, know where she can get it Consider having a written list with addresses/names of local pharmacies

Ask patient to bring documentation of immunization so you can put it in her chart Consider starting to deliver the vaccine especially the common ones can positively showcase your practice Provider Roles: Creating Culture of Immunization (cont.) Provide VIS (Vaccine Information Statement) forms for each vaccine administered Available at: http://www.cdc.gov/v

accines/hcp/vis/curren t-vis.html ACOG Committee Opinion 661: Integrating Immunizations Into Practice Immunization against vaccine-preventable diseases is an essential component of womens primary and preventive health care Ob-gyns should talk with each patient directly and strongly recommend indicated immunizations. Many studies have shown that a recommendation from an obstetrician gynecologist or other health care provider for an immunization is one of the strongest influences

on patient acceptance. http://www.acog.org/Resources-And-Publications/Committee -Opinions/Committee-on-Gynecologic-Practice/Integrating-Im munizations-Into-Practice Business Practice: Office Delivery How Tos Information about Practice Management can be found at Immunizationforwomen.org Tdap and Flu Toolkits including: Coding Information on Tdap

Immunization and Flu Immunization How to Have the Conversation How to Have the Conversation DO IT Strength of Recommendation G N

O R T S BE Style of Recommendation ASSU E C N TA P E

C C A E M WHAT leads to Perceived NEED of Vaccination Perceived risk of illness Likelihood of illness Effectiveness of Intervention Anticipating the MOST frequent concerns SAFETY SAFETY SAFETY

especially in pregnancy Flu, Tdap WHY does she need it? DATA Number of cases of pertussis in your last year Number of deaths from flu last year in region county your Creating the Atmosphere Listened to as an individual

Questions Information that would be helpful What have you heard? Embed into routine procedures Help with the Script Help with the Script Available at Immunizationforwomen.org: Provider scripts for Tdap, Flu and HPV FAQs for Providers

FAQs for Patients Review of Vaccines Three Lesser Known Treasures Pneumococcus Zoster Hepatitis B Flu Vaccine Tdap Case Presentations Pneumococcus Streptococcus pneumoniae A Leading Cause of infectious serious illness [Invasive

Pneumococcal Disease (IPD)] among older adults > 65 yo 13-valent conjugate vaccine (PCV13[Prevnar]) 20-25% of IPD cases and 10% Comm-acquired pneumonia PCV13 serotypes 23-valent pneumococcal polysaccharide vaccine (PPSV23[Pneumovax 23]) in 2013, 38% of IPD serovar types unique to PPSV23 So, BOTH vaccines are useful and recommended

Pneumococcus Pneumococcus Sequential administration for PCV 13 and PPSV23 Pneumococcus Pneumococcus Sequential administration for PCV 13 and PPSV23 Pneumococcus Pneumococcus Sequential administration for PCV 13 and PPSV23

Pneumococcus Pneumococcus KEY POINTS Both PCV13 and PPSV23 should be given to all adults > 65 yo Pneumo. vaccine nave individuals should receive PCV 13 followed with PPSV 23 in 6-12 mo. If previously received PPSV23 at > 65, should receive PCV 13 If received PPSV 23 at <65, and now are > 65, give

PPV 13, then redose with PPSV 23 in 6-12 months. MMWR Morb Mortal Wkly Rep 2015;64:944-7 Pneumococcus Vaccine in Pregnancy PPSV is Recommended in Adults <65, including Pregnant Women if: Chronic Illness: Lung, heart, liver or kidney disease; asthma; diabetes; alcoholism Conditions that weaken the immune system: HIV/AIDS, cancer, damaged/absent spleen . Living in nursing homes or other long-term care facilities Those with cochlear implants or cerebrospinal fluid (CSF) leaks Smokers http://www.cdc.gov/pneumococcal/index HerpesZoster ZosterVaccine Vaccine Herpes Zoster: IS BAD!!!!!

Reactivation of latent VZV virus 1 in 3 people develop Zoster in their lifetime (1 million episodes in US annually) Zoster increases with age steep increase after 50 As age increases, risk of post shingles complications increases Post Herpetic Neuralgia (PHN) (debilitating nerve pain lasts months to years) Eye complications, non pain complications, hospitalizations Herpes Zoster Vaccine

Herpes Zoster Vaccine Zostavax [Merck] single dose > 60 Given in deltoid region Can give it if person has had shingles Decreases risk of shingles by half (51%) Decreases risk of PHN by 2/3s (67%) Protection lasts about 5 years, so that is why recommendation is for 60.

If get it earlier, may not be well protected at age of greatest risk MMWR 2014;63:729-31; http://www.cdc.gov/vaccines/vpd-vac/shingles/vacc-needknow.htm#protection Hepatitis B Vaccine Three dose series (0, 1, 6 months) Recommended for all < 18 yo, >18 if risk factor for Hep B Started for some children 1982, all children 1991

Hep B decreased by > 95% in children/adolescents, 75% decrease other age groups Usually life long immunity, but is correlate of protection If anti-HBs is at least 10 mIU/mL (positive), the vaccinee is immune. No further serologic testing or vaccination is recommended.

http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.html Hepatitis B Vaccine Hepatitis B Vaccine Risk Factors = indications to vaccinate > 18 yos sex partners of people infected with hepatitis B, men who have sex with men,

people who inject street drugs, people with more than one sex partner, people with chronic liver or kidney disease, people under 60 years of age with diabetes, people with jobs that expose them to human blood or other body fluids, household contacts of people infected with hepatitis B http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.html Hepatitis Vaccine Hepatitis B Vaccine Risk Factors = indications to vaccinate > 18 yos (continued) residents and staff in institutions for the

developmentally disabled, kidney dialysis patients, people who travel to countries where hepatitis B is common, people with HIV infection. Pregnant women who are at risk for one of the reasons stated above should be vaccinated. Other pregnant women who want protection may be vaccinated. http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.html CONCEPT OF MATERNAL IMMUNIZATION Concept of Maternal Immunization Boosts

maternal levels of pathogenspecific antibodies Provides newborn and infant with sufficient concentration of antibodies to protect against infections until able to adequately respond to active

immunization or infectious challenge MATERNAL-INFANT ANTIBODIES Maternal-Infant Antibodies Closing the window of vulnerability NARROWED window of vulnerability Infant Ab Antibody c Level

c Level Antibody Window of vulnerability Maternal Ab 22 28 32 36 Weeks Gestation cc Birth

2 4 6 8 Age (Months) 22 28 32 36 Weeks Gestation cc Birth 2

4 6 8 Age (Months) Influenza Vaccine Influenza Vaccine Everyone 6 months and older Many approved vaccines-most important factor is to get a vaccine Think of it in pregnancy, but also should mention to all, and for their kids. Table of influenza vaccine products licensed and available in the

US is provided by the CDC at: http://www.cdc.gov/mmwr/volumes/65/rr/rr6505a1.htm#T1_d own RECOMMENDATIONS Recommendations Influenza Immunization INFLUENZA IMMUNIZATION IN PREGNANCY in Pregnancy Inactivated influenza vaccine* recommended for women who will be pregnant during influenza season 1950-1994: Pregnant women at high risk 1997: All women during 2nd and 3rd trimester 2004: All women, any trimester 2005: WHO adopted US recommendations

2012: SAGE / WHO priority worldwide Postpartum vaccination, if not vaccinated during pregnancy Breastfeeding not a contraindication ACOG, AAP, AAFP support these recommendations ACOG: Influenza vaccination essential element of prenatal care *Live influenza vaccine contraindicated during pregnancy MMWR, July 2010

ACOG Committee Opinion 608: Influenza Vaccination During Pregnancy Influenza vaccination is an essential part of prenatal and pre-conception care Pregnant women have increased morbidity and mortality from influenza Neonates also have increased morbidity and mortality from influenza and cannot be vaccinated until 6 months Keeping mom healthy during pregnancy protects fetus from early delivery http://www.acog.org/Resources-And-Publications/Committee-Opinions/C INACTIVATED INFLUENZA VACCINE:

Inactivated Influenza Vaccine: EFFECTIVENESS IN MOTHER AND CHILD Effectiveness in Mother and Child Infants Maternal influenza vaccine reduced proven influenza illness in infants by 65% 29% reduction in any respiratory illness 42% reduction in clinic visits Mothers

Maternal influenza vaccine reduced respiratory illness with fever by 36% Fewer clinic visits Zaman. NEJM, 2008. INFLUENZA VACCINATION COVERAGE AMONG PREGNANT WOMEN, 2013-14 FLU SEASON Influenza Vaccination Coverage among Pregnant Women, 2013-14 Flu Season Clinician Recommended

and Offered Recommended with NO Offer NO Recommendation or Offer % Recommended & Offered Vaccine Coverage 65% 70.5% N = 1,619

surveyed 15.1% 32% 19.8% 9.7% MMWR Sept 19, 2014;63(37):816821. ACOG Committee Opinion 566: Update on Immunization and Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination A dose of Tdap vaccine should

be given to all pregnant women preferably between 27-36 weeks gestation during every pregnancy. Co-administration of indicated inactivated vaccines during pregnancy (ie, Tdap and influenza) is also acceptable, safe, and may optimize effectiveness of immunization efforts http://www.acog.org/Resources-And-Publications/Committee-Opinions

/Committee-on-Obstetric-Practice/Update-on-Immunization-and-Pregn ancy-Tetanus-Diphtheria-and-Pertussis-Vaccination Timing of Maternal Tdap & CORD Ab Levels 250 200 150 27-30 wk 100 50 0

cord PT IgG (n-21) cord FHA IgG (n=30) Cord PRN (n=7) CONCLUSIONS Immunization of pregnant women with Tdap between 2730+6 wks associated with highest umbilical cord GMCs of IgG to PT and FHA, compared with immunization beyond 31 wks Abu Raya, Srugo, Kessel et al. Vaccine 2014;132:5787. Case 1 Case 1:

A 31 yo patient at 8 weeks gestation comes to your clinic for a new OB visit. It is November, and the flu vaccine is available so you offer it to her. She states I have never had the flu, so I am not sure why I need that. And, I hate shots. What will you say to her? Now this same patient presents in March. She wonders if she should get the vaccine since flu season is almost over. What do you say? When September comes, and the new flu shot arrives, would you give her another influenza vaccine this pregnancy? Case 2

Case 2: You have a 26 yo G3 P2002 patient who is now 28 weeks pregnant. When you mention her Tdap to her, she is concerned that she had a Tdap with her last pregnancy, and it made her arm sore. She is reticent to accept another Tdap. How would you counsel her? Case 3 Case 3: Your 63 yo post menopausal woman says she had a neighbor develop shingles, and she clearly knows she would not want shingles. She has heard there is a shingles vaccine.

What would you say to her? Case 4 Case 4: You have a 30 yo pregnant patient who has asthma. What vaccines would you recommend for her? What would you say to her? Immunizationforwomen.org Find all the Immunization Resources you need in one spot at ACOGs Immunization for Women website: Up to date immunization

recommendations Specific immunization information for pregnant and breastfeeding women Information on how to set up and expand an office-based immunization program Latest immunization news and updates Features separate provider and patient sections ACOG Immunization Coding Resources Immunization Coding for ObstetricianGynecologists 2016 Available electronically on the Immunization

for Women website at http://immunizationforwomen.org/providers/re sources/acog-resources/coding-resources.ph p Coding Section of Immunizationforwomen.org ACOG Fellows and their staff are able to submit specific OB/GYN coding questions to ACOG Coding Assistance by registering for our New Ticket Database at https://acogcoding.freshdesk.com. Registration is free, quick and easy! Read the announcement for more details. Immunization Toolkits

Available at Immunizationforwomen.org/toolkits CDC Recourses CDC vaccine resources for providers and patients can be found at www.cdc.gov/vaccines You can also refer women to CDCs new website about pregnancy and vaccination, www.cdc.gov/vaccines/pregnancy Features a new quiz on Vaccines for Pregnant Women CDC Vaccines during Pregnancy Resources Available at: http://www.cdc.gov/pertussis/downloads/fs-hcp-tdap-vaccine-referral.pdf and http://www.cdc.gov/pertussis/downloads/fs-hcp-provide-prenatal-care.pdf

Conclusions Adults need vaccines too and Ob-Gyns have an opportunity to educate and vaccinate their patients Influenza, Tdap, Pneumococcal, Hepatitis B, and Herpes Zoster vaccines are safe and effective Ob-gyns should integrate immunizations into their routine assessment and practice with both pregnant and non-pregnant patients Immunization Resources can be found at cdc.gov/ vaccines and Immunizationforwomen.org ACOGs Immunization Department Contact Information Immunization Program:

[email protected] Debra Hawks, MPH, Senior Director Practice Activities, Obstetrics, & Immunization [email protected] Sarah Carroll, MPH, Immunization Director [email protected] Amy Feinberg, Immunization Program Coordinator [email protected] Valerie Echeveste, Immunization Program Specialist [email protected]

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