How to Give a Strong Recommendation to Adult Patients Who Require Vaccination

Mary C. Anderson, MD; Marie T. Brown, MD; Marie-Michele Léger, MPH, PA-C; Aparna Ramakrishnan, MA, MSW

Disclosures

April 16, 2015

Case Presentation: The Pregnant Patient

Maya is a 33-year-old woman who is 3 months pregnant. When she comes in to visit you in October, you recommend that she receive the influenza vaccine now and let her know that she will need to get the Tdap vaccine in her third trimester.

She asks, "Is it safe to get the flu vaccine while I'm pregnant? Is it worth the risk of side effects given that the vaccine isn't always a good match to strains that are spreading?"

Vaccine safety is a common and understandable concern for pregnant women, many of whom have heightened fears about health risks and wish to avoid taking unnecessary medications. Addressing these questions with clear and simple facts about safety and side effects, while reminding them that vaccination can protect them and their baby from serious illness, can help patients understand the real risks and benefits so that they can make an informed decision.

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Influenza in Pregnancy

Changes in the immune system, heart, and lungs during pregnancy make pregnant and postpartum women more prone to severe illness from influenza than women who are not pregnant. Risk for premature labor and delivery is increased in pregnant women with influenza. Vaccination during pregnancy has been shown to protect both the mother and her baby (up to 6 months old) from influenza-related illness and hospitalizations. The influenza vaccine can be given to pregnant women in any trimester. Pregnant women should receive IIV, not LAIV. The most recent recommendations for influenza vaccine are available on the CDC website.

Maya then asks, "Why do I need the Tdap vaccine? I got a tetanus shot just last year when I accidentally stepped on a rusty nail."

Patients are more likely to be vaccinated if they understand why they need the vaccine and how it can benefit them. Reminding patients that vaccines protect them and their loved ones from common and serious diseases can help motivate them to be vaccinated.

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Vaccinating Pregnant Women

Women should receive one dose of Tdap during each pregnancy, irrespective of the patient's history of receiving the Tdap (or Td) vaccine. To maximize the maternal antibody response and passive antibody transfer to the infant, optimal timing for Tdap administration is between 27 and 36 weeks gestation. This recommendation is supported by the American College of Obstetricians and Gynecologists[4] and the American College of Nurse-Midwives.[5]

The level of pertussis antibodies decreases over time, so Tdap vaccine should be administered during every pregnancy so that each infant receives high levels of protective antibodies. Postpartum Tdap vaccination of the mother is not adequate because it does not provide direct protection to the infant. To date, no safety signals have been found in pregnant women who received Tdap or in their infants. Most side effects from Tdap vaccination are mild or moderate and short-lived.

Pertussis and influenza vaccines can safely be administered at the same time to pregnant women. Pregnant women should receive the flu vaccine as early as possible in the flu season, during any trimester, whereas the pertussis vaccine should be administered between 27 and 36 weeks gestation. See ACIP Guidelines for Vaccinating Pregnant Women.[6]

If you do not stock pertussis or influenza vaccines, make a strong recommendation and referral to help ensure that your patients receive these vaccines elsewhere. You should provide information on where patients can get the vaccine(s) that you recommend and write a patient-specific prescription to help your patients obtain the vaccine(s) at another location that may require a prescription.

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