Immunisation of pregnant women and newborn infants Maternal

Immunisation of pregnant women and new-born infants Maternal vaccination 4: vaccines for pre or post natal vaccination

Using this training resource • This slideset has been developed to support the delivery of immunisation training to health care workers providing or advising on immunisation of pregnant women • Trainers may opt to use this slideset alone or in combination with any of the other slidesets listed on slide 6 to deliver a comprehensive immunisation update • When delivering immunisation updates, trainers should consider the audience background, role, specific needs and the planned duration of the training event 2

Learning outcomes After completing this immunisation training, Health Care Professionals working with pregnant women will: • Understand their role in raising the issue of vaccination with all pregnant women during the pre, ante and post natal periods and in providing women with evidence based information about MMR vaccine, rash illness in pregnancy and inadvertent vaccination during pregnancy • Be able to describe the aetiology and epidemiology of rubella and other rash illness • Understand how rubella is transmitted and the consequences of infection during pregnancy • Be able to discuss the important role of vaccination before, during and after pregnancy • Be aware of sources of additional information 3

Key messages for pregnant women • Infectious diseases in pregnancy can have an increased risk of death and long term complications for both the mother and her unborn baby • These risks include perinatal mortality, prematurity, smaller neonatal size, lower birth weight and increased risk of complications for the mother (influenza); increased risk of death in neonates too young to have their own vaccines (pertussis and influenza); congenital rubella syndrome, and future risk of cirrhosis and liver cancer for the infant (Hepatitis B) • Women should be protected against rubella before pregnancy and all pregnant women should be offered pertussis containing vaccines during each pregnancy and influenza vaccine if pregnant during flu season • The Antenatal Screening Programme offers screening for hepatitis B during pregnancy • At birth, babies identified as being at risk of Hepatitis B infection should be vaccinated and arrangements made for completion of the course of vaccines and blood test at twelve months of age (to test for infection) 4

Key messages for health care workers • Vaccination is one of the most effective interventions midwives and other healthcare workers can provide to reduce harm from vaccine preventable diseases such as influenza, rubella and pertussis for both mother and baby • Midwives and other health care professionals should ensure that they are fully vaccinated to protects themselves and to reduce the risk of spreading diseases to their patients, service users, colleagues and family members 5

6 Contents Immunisation of pregnant women and newborn infants is a training resource consisting of five slidesets. These cover: 1. Maternal vaccination: Background, history and attitudes towards maternal vaccination 2. Vaccine recommendations for pregnant women: Influenza and pertussis vaccines 3. Selective vaccination programmes for neonates 4. Vaccine for pre or post natal vaccination 5. Governance considerations, challenges to achieving high vaccine coverage, horizon scanning and resources

Session 4: vaccines for pre or post natal vaccination Objectives: 1. To provide an overview of the role of MMR vaccination before and after pregnancy, 2. To describe the assessment process for pregnant women presenting with a rash in pregnancy 3. To review the risks of vaccination during pregnancy and the recommended actions to take when vaccines not routinely recommended for pregnant women are administered during pregnancy 7

MMR vaccine and protection against congenital rubella syndrome (CRS)

9 Rubella infection and vaccination • Rubella is usually a mild infection, but if a pregnant woman is infected during the first 12 weeks of pregnancy, the unborn baby has around a 9 in 10 chance of permanent health problems including heart defects, cataracts and deafness. • The risk is much lower if infection occurs in later pregnancy. • When first introduced in 1970, rubella vaccine was only given to teenage girls and women of child-bearing age, i. e. offered only direct protection to immunised individuals • This was supplemented with a screening programme for pregnant women to identify those susceptible to rubella • Rubella vaccine was offered post-natally to those identified as susceptible to protect future pregnancies

Cessation of antenatal rubella susceptibility screening • Rubella susceptibility screening in pregnancy is no longer making a useful contribution to the control of rubella and ceased for women booking for antenatal care on 1 st April 2016 in England on 1 st October 2016 in Wales. • The MMR vaccination programme was introduced in 1988, for both males and females, and has led to the UK becoming free from endemic rubella through both direct and indirect effects • Cases of congenital rubella infection are now very rare, mainly occurring in women who did not grow up in the UK and have missed MMR immunisation • Between January 2015 and March 2016, three cases of CRS were reported to PHE. • Two of these cases acquired the infection abroad, 1 acquired the infection from a male relative with recent travel abroad. None of the women were vaccinated and all were in their first pregnancies • There have been no cases of rubella reported in Wales for 10 years • It remains important that all young people and adults who do not have two recorded doses of MMR vaccine are offered it. • Postnatal women without two recorded doses of MMR should be offered the vaccine after delivery at their 6 week maternal check with their GP 10

Rash illness in pregnancy

12 Viral rash in pregnancy Rash illness with fever during pregnancy may indicate infection with a viral illness that could potentially cause harm to the unborn baby. Pregnant women in contact with another person with a rash illness or who develop a rash with fever should be advised: • to inform their midwife, GP or obstetrician immediately • To avoid any antenatal clinic or maternity setting until they have been assessed, • To avoid contact with other pregnant women. Delay in seeking advice could affect treatment options

13 Assessment of rash illness or contact in pregnant woman Assessment should include: • Confirmation of stage of pregnancy • Dates of contact with the person with a rash illness • The date that fever or rash first appeared • An assessment of the rash (papular, petechial, vesicles) • History of previous viral infections eg chicken pox, measles • Vaccination history and dates of vaccination Management guidelines for viral rash in pregnancy are available and should be followed Further advice can be obtained : http: //www. antenatalscreening. wales. nhs. uk/sitesplus/documents/989/V 3 a. Final%20 Infections%20 in%20 Pregnancy%20 August%202017. pdf

ADDITIONAL INFORMATION Further information on rash illness in pregnancy can be found at http: //www. antenatalscreening. wales. nhs. uk/sitesplus/documents/989/V 3 a. Final%20 Infections%20 in%20 Pregnancy%20 August%202017. pdf 14

Inadvertent vaccination in pregnancy

Are there any risks when vaccinating in pregnancy? There are no known risks for women who are vaccinated against measles, mumps, rubella, chickenpox, shingles or HPV during any stage of pregnancy or shortly before conception. 16

When to vaccinate in pregnancy 1. Non-live vaccines • Flu vaccination and pertussis vaccination are recommended in pregnancy with good evidence of safety and effectiveness. • Inactivated vaccines cannot replicate and so cannot cause infection in either the mother or the foetus. • There is no evidence of risk from vaccinating pregnant women or those who are breast-feeding with other inactivated virus or bacterial vaccines or toxoids. • However, inactivated vaccines (other than those specifically recommended) should be administered to pregnant women only if protection is required without delay to avoid a link being made between vaccination and any adverse pregnancy outcome. Breast-feeding or being breast-fed are not contraindications to vaccination. 17

2. Live vaccines • There is a theoretical concern that vaccinating pregnant women with live vaccines may infect the foetus. • There is no evidence that any live vaccine (including MMR) causes birth defects. • However, since theoretical possibility of foetal infection exists, live vaccines should generally be delayed until after delivery. • Termination of pregnancy following inadvertent immunisation is not recommended as there is no evidence that these women or their babies are at higher risk than other pregnant women. • Breast-feeding or being breast-fed are not contraindications to live vaccines 18

Vaccination in pregnancy surveillance The Immunisation department at Public Health England (PHE) follows up women who have been given certain vaccines in or just before pregnancy This enables PHE to better inform: • pregnant women who are inadvertently immunised • their families • health professionals who are responsible for their care Vaccination follow up by PHE • MMR vaccine: immunisation from 30 days before last menstrual period to anytime during pregnancy • Varicella (chickenpox) or shingles vaccine : immunisation from 90 days before last menstrual period to anytime during pregnancy • Human papilloma virus (HPV) vaccine: immunisation from 60 days before last menstrual period to anytime during pregnancy 19

Patient consent • The Health Service Regulation 2002 stipulates that confidential patient information may be processed with a view to monitor and manage the delivery, efficacy and safety of immunisation campaigns, so individual consent is not required. • However, it is recommended that details of this surveillance are discussed with the pregnant woman by any health professional reporting a case in one of their patients. • Initial reports will be followed up with the GP for more detailed information. The outcome of the pregnancy is followed at 10 weeks post EDD and again when the child is a year of age. • PHE does not contact the pregnant women herself unless this is requested for further discussion/ reassurance. 20

Chickenpox vaccine (Varilrix® and Varivax®) and shingles vaccine (Zostavax®) • Both are live vaccines that contain varicella-zoster virus that has been carefully weakened to safely protect against disease. (shingles vaccine has a higher dose) • No specific risk has been associated with the weakened varicella-zoster virus used in these vaccines and pregnancy. • If women are immune when they receive either vaccine their existing antibodies against varicella zoster virus will simply be boosted, as it would if they came across the natural diseases. • Most women in the UK will already be immune to varicella-zoster virus because they have had chicken pox disease. 21

Advice after chickenpox vaccine has been given in pregnancy There is no specific safety concern, either for the mother or the baby, when chickenpox vaccine is given in, or shortly before, pregnancy and no cases of congenital varicella syndrome have been causally linked to chickenpox vaccine. Women who have been immunised with chickenpox vaccine in pregnancy can therefore be immediately reassured. 22

Advice after shingles vaccine has been given in pregnancy Establish as soon as possible whether the woman who received shingles vaccine was already immune. She can be reassured that she is protected from infection if she has: • a past history of chickenpox or shingles, or 2 doses of a varicella containing vaccine and • is not immunosuppressed If immunity is uncertain, she should be offered testing to establish her immunity as early as possible. 23

Advice after shingles vaccine has been given in pregnancy • If she is found to be immune to chickenpox on testing she can be reassured that the shingles vaccine will boost her existing antibodies and there is no reason for any further action. • If a woman with an uncertain or negative history of chickenpox is found susceptible (VZV Ig. G negative) check whether she meets the criteria for VZIG as defined in the guidance for issuing varicella zoster immunoglobulin document • https: //www. gov. uk/government/uploads/system/uploads/attachment_dat a/file/559469/VZIG_Chicken. Pox_v 4. pdf • If VZIG is indicated, contact Public Health England Colindale (tel: 020 8200 4400) • Any treatment (VZIG) should ideally be given within 7 days, but can be given up to 10 days after vaccination, for it to be of any potential benefit. 24

MMR vaccination in pregnancy • Immunisation with rubella-containing vaccine (currently MMR vaccine in the UK) in pregnancy or shortly before becoming pregnant has no known specific risk to the woman or her baby. • https: //www. gov. uk/government/publications/vaccine-in-pregnancy-advice-forpregnant-women/mmr-measles-mumps-rubella-vaccine-advice-for-pregnantwomen • MMR vaccine is not recommended in pregnancy due to theoretical risk which may occur from the use of a live vaccine containing a weakened strain of measles and rubella virus. • There are good data to support the safety of rubella-containing vaccines in pregnancy. Women who have been immunised with MMR vaccine in pregnancy should immediately reassured. 25

Notify PHE • If you have patients who have had MMR, chickenpox, shingles or HPV vaccine administered during their pregnancy or shortly before conception, please visit the vaccination during pregnancy webpage and complete a notification form • https: //www. gov. uk/guidance/vaccination-in-pregnancy-vip#vaccinationduring-pregnancy • The completed form should be submitted as detailed on the form • If further discussion is required, please contact the local health protection teams Public Health Wales • PHE run UK wide surveillance on the safety of vaccine given in pregnancy • Information sheets are available on the PHE webpages to share with pregnant women. 26

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