An evaluation of strategies to achieve greater than 90% coverage of maternal influenza and pertussis vaccines including an economic evaluation

Background Maternal immunisation is an essential public health intervention aimed at improving the health outcomes for pregnant women and providing protection to the newborn. Despite international recommendations, safety and efficacy data for the intervention, and often a fully funded program, uptake of vaccines in pregnancy remain suboptimal. One possible explanation for this includes limited access to vaccination services at the point of antenatal care. The aim of this study is to evaluate the change in vaccine coverage among pregnant women following implementation of a modified model of delivery aimed at improving access at the point of antenatal care, including an economic evaluation. Methods This prospective multi-centre study, using action research design, across six maternity services in Victoria, Australia, evaluated the implementation of a co-designed vaccine delivery model (either a pharmacy led model, midwife led model or primary care led model) supported by provider education. The main outcome measure was influenza and pertussis vaccine uptake during pregnancy and the incremental cost of the new model (compared to existing models) and the cost-effectiveness of the new model at each participating health service. Results Influenza vaccine coverage in 2019 increased between 50 and 196% from baseline. All services reduced their average cost per immunisation under the new platforms due to efficiencies achieved in the delivery of maternal immunisations. This cost saving ranged from $9 to $71. Conclusion Our study demonstrated that there is no ‘one size fits all’ model of vaccine delivery. Future successful strategies to improve maternal vaccine coverage at other maternity services should be site specific, multifaceted, targeted at the existing barriers to maternal vaccine uptake, and heavily involve local stakeholders in the design and implementation of these strategies. The cost-effectiveness analysis indicates that an increase in maternal influenza immunisation uptake can be achieved at a relatively modest cost through amendment of maternal immunisation platforms.

Vaccines and pregnancy

The development of vaccines has been one of the major interventions in global health. Since they were first developed over two centuries ago, vaccines have played a prominent role in reducing morbidity and mortality from infectious diseases, including in pregnant women. The development of the coronavirus disease 2019 (COVID-19) vaccines has brought with it the possibility of reducing the high morbidity and mortality caused by this virus. This article focuses on the use of vaccines in pregnancy and discusses the benefits of maternal immunisation, recommended vaccines in pregnancy, the factors affecting uptake of vaccines, and COVID-19 vaccination in pregnancy.

Pertussis seroprevalence in mother–infant pairs from India: role of maternal immunisation

ObjectiveTo evaluate pertussis antibody status of pregnant women and their newborns, and the impact of antenatal immunisation.DesignObservational study.SettingHospitals in urban western India.ParticipantsPregnant women and their newborns.MethodsPertussis antibody titres in mothers and their newborns were determined. Vaccinated and unvaccinated mothers and their newborns were compared for baseline characteristics, geometric mean titres (GMTs) and placental transfer ratio of antibodies. Multivariate logistic regression was performed to understand the influence of different factors on protective antibody titres.ResultsOf 284 mother–infant pairs, 75 mothers and 73 of their newborns were seropositive for anti-pertussis toxin (PT) IgG antibodies. 94 women were vaccinated in pregnancy; 51 (54.3%) of these mothers and newborns were PT IgG positive, compared with 24 (12.3%) of the women (and 22 newborns) not vaccinated in pregnancy. Women vaccinated in pregnancy and their newborns had higher GMT (30.88 and 32.54 IU/mL), compared with women who were not vaccinated (12.63%, 2.24 IU/mL) and their newborns (11.58%, 2.53 IU/mL). Placental transfer ratios in newborns of mothers vaccinated in pregnancy and those who had childhood immunisation or natural immunity were similar (1.05 and 1.12, respectively). Protective titres of antibodies at birth (>20 IU/mL) were observed in 72.3% vs 21% of newborns of vaccinated and unvaccinated pregnant women, respectively; influenced by mother’s vaccination status and seropositivity.ConclusionProtection against pertussis is low in newborns of mothers who are only immunised during childhood. Vaccination early in pregnancy boosts maternal and neonatal immunity.

‘‘Those who do not vaccinate don’t love themselves, or anyone else’’: a qualitative study of views and attitudes of urban pregnant women towards maternal immunisation in Panama

ObjectivesTo identify pregnant women’s views and attitudes towards maternal immunisation in Panama based on in-depth interviews and focus groups.SettingTwo main urban centres in Panama (San Miguelito and Panama City).ParticipantsFifty-six pregnant women from Panama City (n=29) and San Miguelito (n=27).MethodsIn-depth interviews and focus groups were conducted, audio-recorded, transcribed verbatim and analysed using a deductive-inductive approach.ResultsOur findings suggest that this population perceives vaccination as a key component of maternal healthcare, not an elective part of it. The pregnant women interviewed disclosed a heightened perception of vulnerability to infectious diseases. For this reason, safety and effectiveness of maternal vaccines were closely associated for many participants (a vaccine was perceived as safe if it was effective against disease). Refusal of maternal vaccination was strongly associated with parental negligence. Participants reported the participation of husbands and partners in the decision-making around their health. Most participants reported high information-seeking behaviour, particularly online; many interviewees confirmed any information obtained online with their healthcare professionals (HCPs). Vaccine recommendations from HCPs appeared to be one of the main predictors of maternal immunisations among the sample interviewed. While acceptability of maternal vaccines was high in this sample, some pregnant women expressed concerns and doubts (e.g., that maternal vaccines could cause miscarriages) which require attention. Finally, many participants reported difficulties in accessing maternal vaccination, pointing to financial and physical barriers.ConclusionsThe acceptability of maternal immunisation was high among the interviewed women. The pregnant women’s receptiveness to maternal vaccinations, even when information provided was limited, is suggestive of high levels of trust in HCPs. Even so, HCPs and health officials should remain alert to apprehensions expressed by pregnant women. Many participants reported struggles in accessing maternal vaccination, pointing to issues that merit further examination.

Maternal Vaccination in Uganda: Exploring Pregnant Women, Community Leaders and Healthcare Workers’ Perceptions

Background: We investigated pregnant women, community leaders, healthcare workers (HCWs) and programme managers’ perceptions of maternal vaccination in Kampala, Uganda. Methods: We conducted focus group discussions, key informant interviews and in-depth discussions with HCWs (3), community leaders (3), pregnant women (8) and programme managers (10) between November 2019 and October 2020. Data were analysed thematically. Results: Pregnant women, community leaders and some HCWs had limited maternal immunisation knowledge. There was confusion over what constitutes a vaccine. Pregnant women may not receive vaccines because of mistrust of government; use of expired vaccines; reliance on traditional medicine; religious beliefs; fear of side effects; HCWs attitudes; and logistical issues. The key facilitators of maternal vaccination were a desire to prevent diseases, positive influences from HCWs and information about vaccine side effects. Community leaders and some pregnant women highlighted that pregnant women do not make decisions about maternal vaccination independently and are influenced by different individuals, including other pregnant women, older people, partners, relatives (parents), community leaders, HCWs and the government. Conclusions: Our results indicate that public health messaging should target all community members, including partners and parents of pregnant women as well as HCWs, to improve knowledge of and confidence in maternal vaccines.

Effects of maternal exposure to a bacterial antigen and altered post-hatching rearing conditions on avian offspring behaviour

The early-life environment plays a crucial role in shaping morphological, physiological, and behavioural traits, with potential long-term consequences for fitness. Indeed, a set of factors experienced by offspring during prenatal and early post-natal development has been recognised to affect behavioural trait expression in later life. Several studies have shown that in birds, nutritional and social rearing conditions and maternal and/or neonatal immunisations may profoundly determine the development and establishment of behaviour in offspring. To our knowledge, no research has examined whether and how the interaction between immune-mediated maternal effects and post-hatching rearing conditions affects offspring behaviour. Here, we studied the effects of maternal exposure to a bacterial antigen and altered brood size on docility, breathing rate, and aggression in the offspring of great tit, Parus major. We used a 2 × 2 design to investigate the interactive effects of maternal immunisation and brood size manipulation on offspring behavioural development. We found no such interactive effect on offspring behaviour, although we observed it regarding to offspring body mass and tarsus length. Maternal immunisation itself did not affect offspring behaviour. However, we demonstrated that the offspring breathing rate and level of aggression were affected by brood size manipulation. Both breathing rate and aggression in offspring reared in enlarged broods were lower than those in offspring reared in non-manipulated broods. Our study did not confirm earlier reports that immune-mediated maternal effects modulate offspring behavioural development, but we showed that brood size during rearing might indeed be a factor that affects offspring behaviour. Significance statement The early environment experienced by offspring constitutes a significant source of developmental plasticity, which may profoundly affect the establishment of their behavioural traits. Food availability, social conditions, and maternal or offspring infection are crucial factors shaping various behavioural traits in birds. However, there remains a lack of studies emphasising the potential interactive effects of early-life conditions on behavioural trait development in natural bird populations. Here, to our knowledge for the first time, we experimentally examined how maternal immunisation and altered post-hatching rearing conditions interact to determine the behaviour of fledged offspring. We found that maternal treatment and brood size manipulation interactively affected offspring body mass and tarsus length, but this interaction had no effect on offspring behaviour. Our findings suggest that different mechanisms may underlie the development of morphological and behavioural traits.