A Critical Precaution — Immunizations in Reproductive Health

Rita Buckley

doi:10.1177/155989771112016

Summary

Vaccination is one of the most efficient and cost-effective ways to prevent maternal and neonatal morbidity and mortality. For women in their reproductive years, it serves two roles—primary prevention of disease and protection for infants. This article discusses vaccines and their recommended use in reproductive-age women.

Vaccinations
Viral Infections
Reproductive Cancers
Screening & Prevention

Vaccination is one of the most efficient and cost-effective ways to prevent maternal and neonatal morbidity and mortality. For women in their reproductive years, it serves two roles—primary prevention of disease and protection for infants. Linda O. Eckert, MD, University of Washington School of Medicine, Seattle, Washington, USA, discussed vaccines and their recommended use in reproductive-age women.

In the late 1980s, tetanus caused approximately 800,000 neonatal and 30,000 maternal deaths per year. Since the launch of a renewed global maternal-neonatal tetanus elimination program in 2000, there has been a 92% reduction in neonatal tetanus deaths between 1992 and 1998 (Figure 1).

Figure 1.

Outcomes From a Global Campaign to Eliminate Neonatal Tetanus.

Reproduced with permission from L. Eckert, MD.

Pertussis cases in the United States (US) jumped from under 10,000 in 2000 to over 25,000 in 2003 [MMWR 2004 53:19]. Adults, including grandparent caretakers, were the suspected source of 56% of infant pertussis cases [Bisgard K et al. Pediatr Infect Dis J 2004]. The tetanus, diphtheria, pertussis (Tdap) vaccine is now licensed for use in adults aged 65 years and older and is also recommended, rather than tetanus, diphtheria (Td), for use in pregnant women, for those who are health care or child care providers, and in cases of high community incidence or wound prophylaxis [MMWR 2011;60(41):1424–1426].

The United States Advisory Committee on Immunization Practices (ACIP) currently recommends that women who will be pregnant during the influenza season receive inactivated influenza vaccine to reduce excess maternal mortality during influenza pandemics, offset physiological changes during pregnancy that may increase the morbidity of influenza infections, and reduce the risk of cardiopulmonary hospitalizations during the influenza season.

Influenza vaccine that is given to pregnant women is 91.5% effective in preventing hospitalization of their infants for influenza in the first 6 months of life [Benowitz I et al. Clin Infect Dis 2010].

Rubella continues to be a significant disease burden. The goal of rubella vaccination is to prevent congenital rubella syndrome (CRS). According to Dr. Eckert, The Americas 2003–2008 campaign to eliminate CRS led to the vaccination of 250,000,000 adolescents and adults in 32 countries and reduced CRS cases by 98%—from 135,947 cases in 1998 to 2998 cases in 2006 [Castillo-Solórzano C et al. JAMA 2009].

In the US, 10 women die of cervical cancer every day. However, worldwide, it is the second most common cause of cancer mortality, accounting for 240,000 deaths per year. Most victims are relatively young and poor women, often with dependent children. At least 15 types of human papillomavirus (HPV) have been associated with cervical cancer. Current vaccines confer type-specific immunity to HPV types 16 and 18, which account for 71% of cases of cervical cancer (Figure 2). In contrast, a vaccine that contains the seven most common HPV types would prevent about 87% of cervical cancers [Munoz N et al. Int J Cancer 2004]. ACIP recommendations for females aged 9 to 26 years call for immunization with quadrivalent or bivalent vaccine. The former protects against types 6, 11, 16, and 18, and in Phase 3 trials (n=17,622), it had 100% (95% CI, 75 to 100) efficacy [FUTURE II Study Group. J Infect Dis 2007]. The latter protects against types 16 and 18. In a Phase 3 trial (n=16,126), it had 92.9% efficacy (95% CI, 80 to 99) [Paavonen J et al. Lancet 2009].