Maternal Child Health

Maternal Child Health ‹ Women's Health Notes ‹ October 2009

Women's Health Notes

Volume 1, No. 1, October 2009

Direct Links to Topic Content:

Featured Issue

H1N1 Influenza; Pregnancy Multiplies the Risk of Severe Disease

"Swine Flu Spreading Widely; Worry Over Pregnant Women"
"As of late August, 100 pregnant women had been hospitalized in intensive care and 28 have died"
"As of Monday, October 5th, seven pregnant women were on respirators in Arkansas hospitals"

These are all quotes from recent New York Times articles about the ongoing global pandemic of H1N1 influenza. With school back in session and cooler weather prevailing, infection rates have soared dramatically since early September. Areas that had lower infection rates in the spring outbreak are particularly hard-hit now. Although Native American-specific mortality data is not currently available, many IHS, Tribal, and Urban sites are seeing dramatic increases in patients with suspected H1N1 disease. Several Native American patients have died, including at least one maternal death.

This novel H1N1 Influenza A virus, with combined genetic elements of human, avian, and swine influenza virus, was first recognized in the spring of 2009. Worldwide dissemination quickly ensued and the World Health Organization declared a pandemic on June 11th. Unlike seasonal influenza, which is often associated with high rates of severe disease in older people, 2009 H1N1 influenza can cause especially virulent disease in children and young adults. It is believed that past exposure to similar strains of influenza may confer a degree of protection to those over 60, although serious illness in the elderly can also occur. With H1N1, people with asthma, pregnant women, and those with chronic medical conditions have been most severely affected.

Pregnant women are known to have higher rates of hospitalization and death from influenza than their non-pregnant counterparts; with H1N1 infection this increased susceptibility is especially pronounced. Jamieson, et al. reviewed hospitalization and mortality data for pregnant women in the first two months of the H1N1 outbreak. From mid-April to mid-May, 34 confirmed cases of H1N1 in pregnant women were reported to the CDC from 13 states, including one Native American woman. The estimated rate of hospitalization was 4 times higher than in non-pregnant women. Also, in the first two months of the outbreak (through mid-June), 6 of 45 deaths from H1N1 in the United States were in otherwise healthy pregnant women. All 6 women died from respiratory collapse after developing pneumonia and ARDS requiring mechanical ventilation. It is of grave concern that, in this initial period of H1N1 surveillance, 13% of reported deaths were in pregnant women (pregnant women are approximately 1% of the overall U.S. population). With additional reporting, this has decreased to an estimated 6% of H1N1 deaths occurring in pregnant women, still significantly higher than their percentage in the general population.

There are extensive resources on the CDC website for prevention and treatment of H1N1 influenza in pregnant women and this information is being updated frequently. Some highlights include:

Limiting Exposure

Although the best prevention is vaccination, additional steps can also be taken to protect pregnant women and others from H1N1 influenza. H1N1, like seasonal flu, is spread by close contact with infected individuals. Coughing, sneezing, and residual respiratory secretions (which can remain infectious for several hours on a variety of surfaces) all transmit disease. Frequent hand washing and "cough etiquette" can help limit transmission. In the healthcare setting, screening should be undertaken at the initial point of contact and patients with signs of current respiratory illness should be segregated. One model for this practice is the Winslow Indian Health Care Center in Arizona, where everyone presenting to the clinic is queried about fevers, cough, and sore throat at the clinic entrance. Those with possible influenza are given masks and instructed to "follow the blue line" to a flu clinic where they receive evaluation, education, and treatment in a separate area from a dedicated team of nursing, provider, and pharmacy staff.

Vaccination

Despite strong recommendations for vaccination, recent national data show that pregnant women have the lowest rates of coverage among all adult populations recommended to receive influenza vaccine. In this face of the H1N1 pandemic, a joint statement has been issued by ACOG, ACNM, AWHONN, AAFP, The March of Dimes Foundation, and other organizations urging vaccination with both seasonal and H1N1 vaccine for all pregnant women. Vaccination in pregnancy also confers a degree of protection to the newborn as well; this is especially important as there is no licensed influenza vaccine for those under 6 months of age. In mid-September, the FDA approved H1N1 vaccine from 4 suppliers. Traditional injectable vaccine and live attenuated influenza vaccine (LAIV) for nasal administration are both available. LAIV should not be used to vaccinate children less than 2 years old, adults more than 49 years old, PREGNANT women, people with underlying medical conditions, or children under 5 with episodes of wheezing in the past year.

Pregnant women can be vaccinated for influenza during any trimester. If not already vaccinated, the H1N1 vaccine can be given postpartum. Either IM or nasal (LAIV) vaccine can be administered prior to hospital discharge and is safe in breastfeeding mothers. Partners and other household contacts of infants should also be vaccinated. Both seasonal and H1N1 vaccine can be given on the same day, one shot in each arm. If a nasal formulation for one vaccine is used, the other must be given IM or a 4 week delay between immunizations is recommended. Q & As on H1N1 for pregnant women are available at http://www.cdc.gov/h1n1flu/pregnancy.

All health care workers are a priority for being vaccinated against H1N1, both for their own protection and to minimize disease transmission.

Treatment

Patients should be educated about flu symptoms and encouraged to seek care promptly if they have been exposed to H1N1 or become ill. In the case series reviewed by Jamieson, et al. , the following symptoms were reported: fever (97%), cough (94%) rhinorrhea (59%), sore throat (50%), headache (47%), shortness of breath (41%), myalgia (35%), vomiting (18%), diarrhea (12%) and conjunctivitis (9%), Individuals may be infected with influenza, including 2009 H1N1, and have respiratory symptoms without fever.

Early treatment (within 48 hours of the onset of symptoms, if possible) with influenza antiviral medications is recommended for pregnant women with suspected influenza illness. Clinicians should not wait for test results to initiate treatment since these medications work best if started as early as possible after illness onset. Moreover, rapid diagnostic tests for influenza have variable sensitivities for detecting the 2009 H1N1 influenza virus (10-70%). A negative rapid test does NOT exclude the possibility of infection with 2009 H1N1 influenza.

At this time, most 2009 H1N1 influenza viruses are susceptible to oseltamivir and zanamivir. However, antiviral treatment regimens might change depending on new antiviral resistance or viral surveillance information. Pregnancy should not be considered a contraindication to the use of oseltamivir or zanamivir (both "Pregnancy Category C"). Oseltamivir is currently preferred because of its systemic absorption.Treat flu exposure in pregnant women with a prophylactic course of oseltamivir (75 mg. once daily for 10 days). Treat those with flu-like symptoms with a therapeutic course of oseltamivir (75 mg twice daily for 5 days). Fever in pregnant women should be treated because of the risk that it appears to pose to the fetus. Acetaminophen appears to be the best option for treatment of fever during pregnancy.

Bacterial co-infections have also been implicated in cases of severe disease and death. Autopsy specimens from 77 patients were examined and 22 (29%) had evidence of bacterial infection in addition to H1N1 disease. The bacteria causing these infections included Streptococcus pneumoniae (pneumococcus), group A, Streptococcus, and Staphylococcus aureus, several of the leading causes of community-acquired pneumonia and other severe bacterial infections. For the prevention of pneumococcal disease, two vaccines are currently available in the U.S. All children less than 5 years of age should receive pneumococcal conjugate vaccine according to current recommendations. In addition, the 23-valent pneumococcal polysaccharide vaccine (PPSV23) should be administered to all persons 2-64 years of age with high risk conditions and everyone 65 years and older. During this influenza season, it is especially important for adults with chronic medical problems to get PPSV23. In communities where 2009 H1N1 is circulating, empiric treatment of patients with community acquired pneumonia should include both influenza antiviral agents and appropriate antibiotic therapy.

Given the threat posed to the health of pregnant women and their newborns by H1N1 (and seasonal influenza), we have clear duties as health care providers:

To educate our patients and their families so that they can reduce flu transmission and seek care promptly if they are exposed to flu or become ill.
To provide accurate information about vaccine safety and the valuable protection that H1N1 and seasonal influenza vaccine confers to pregnant women and their newborns.
To get vaccinated ourselves, so that we will not spread the disease further.
To immediately develop and maintain screening systems, at the first point of contact, to separate those with respiratory illness from non-infected patients and visitors and thus minimize transmission in our waiting areas, exam rooms, and hospitals.
To make oseltamivir available promptly to all pregnant women with recent flu exposure or symptoms of influenza. For women who become seriously ill, antibiotic coverage for possible concurrent bacterial infection should also be considered.
Wash your hands, cover your cough, get your shots; it could be a long winter

Resources

General information:
http://www.cdc.gov/flu

Pregnancy specific information:
http://www.cdc.gov/h1n1flu/guidance/obstetric.htm

Free educational materials from the CDC:
http://www.cdc.gov/h1n1flu/flyers.htm

References

Centers for Disease Control. Update on Influenza A (H1N1) 2009 Monovalent Vaccines. MMWR. October 9, 2009 / 58(39);1100-1101 http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm

Centers for Disease Control,Â Receipt of Influenza Vaccine During Pregnancy Among Women With Live Births --- Georgia and Rhode Island, 2004â€”2007. MMWR. September 11, 2009 / 58(35);972-975 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5835a2.htm?s_cid=mm5835a2_e

Centers for Disease Control. Novel Influenza A (H1N1) Virus Infections in Three Pregnant Women --- United States, April--May 2009. MMWR; May 12, 2009 / 58(Dispatch);1-3 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0512a1.htm?s_cid=mm58d0512a1_e

Centers for Disease Control. Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel. http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm

Jamieson DJ, Honein MA, Rasmussen SA, et al. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet. 2009 Aug 8;374(9688):429-30.
http://www.ncbi.nlm.nih.gov/pubmed/19643469

Phillipe M. Pandemic Influenza: What obstetricians need to know. Obstet & Gynecol 2009;114:206-8. http://www.ncbi.nlm.nih.gov/pubmed/19622977

Zaman K, Roy E, Arifeen SE, et al. Effectiveness of maternal influenza immunization in mothers and infants. N Engl J Med. 2008 Oct 9;359(15):1555-64. http://www.ncbi.nlm.nih.gov/pubmed/18799552

Free full text: http://content.nejm.org/cgi/content/full/359/15/1555

Topic Summary ‹ Previous | Next › Maternity Care

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	Maternal Child Health ‹ Women's Health Notes ‹ October 2009 Women's Health Notes Volume 1, No. 1, October 2009 Direct Links to Topic Content: Featured Issue H1N1 Influenza; Pregnancy Multiplies the Risk of Severe Disease "Swine Flu Spreading Widely; Worry Over Pregnant Women" "As of late August, 100 pregnant women had been hospitalized in intensive care and 28 have died" "As of Monday, October 5th, seven pregnant women were on respirators in Arkansas hospitals" These are all quotes from recent New York Times articles about the ongoing global pandemic of H1N1 influenza. With school back in session and cooler weather prevailing, infection rates have soared dramatically since early September. Areas that had lower infection rates in the spring outbreak are particularly hard-hit now. Although Native American-specific mortality data is not currently available, many IHS, Tribal, and Urban sites are seeing dramatic increases in patients with suspected H1N1 disease. Several Native American patients have died, including at least one maternal death. This novel H1N1 Influenza A virus, with combined genetic elements of human, avian, and swine influenza virus, was first recognized in the spring of 2009. Worldwide dissemination quickly ensued and the World Health Organization declared a pandemic on June 11th. Unlike seasonal influenza, which is often associated with high rates of severe disease in older people, 2009 H1N1 influenza can cause especially virulent disease in children and young adults. It is believed that past exposure to similar strains of influenza may confer a degree of protection to those over 60, although serious illness in the elderly can also occur. With H1N1, people with asthma, pregnant women, and those with chronic medical conditions have been most severely affected. Pregnant women are known to have higher rates of hospitalization and death from influenza than their non-pregnant counterparts; with H1N1 infection this increased susceptibility is especially pronounced. Jamieson, et al. reviewed hospitalization and mortality data for pregnant women in the first two months of the H1N1 outbreak. From mid-April to mid-May, 34 confirmed cases of H1N1 in pregnant women were reported to the CDC from 13 states, including one Native American woman. The estimated rate of hospitalization was 4 times higher than in non-pregnant women. Also, in the first two months of the outbreak (through mid-June), 6 of 45 deaths from H1N1 in the United States were in otherwise healthy pregnant women. All 6 women died from respiratory collapse after developing pneumonia and ARDS requiring mechanical ventilation. It is of grave concern that, in this initial period of H1N1 surveillance, 13% of reported deaths were in pregnant women (pregnant women are approximately 1% of the overall U.S. population). With additional reporting, this has decreased to an estimated 6% of H1N1 deaths occurring in pregnant women, still significantly higher than their percentage in the general population. There are extensive resources on the CDC website for prevention and treatment of H1N1 influenza in pregnant women and this information is being updated frequently. Some highlights include: Limiting Exposure Although the best prevention is vaccination, additional steps can also be taken to protect pregnant women and others from H1N1 influenza. H1N1, like seasonal flu, is spread by close contact with infected individuals. Coughing, sneezing, and residual respiratory secretions (which can remain infectious for several hours on a variety of surfaces) all transmit disease. Frequent hand washing and "cough etiquette" can help limit transmission. In the healthcare setting, screening should be undertaken at the initial point of contact and patients with signs of current respiratory illness should be segregated. One model for this practice is the Winslow Indian Health Care Center in Arizona, where everyone presenting to the clinic is queried about fevers, cough, and sore throat at the clinic entrance. Those with possible influenza are given masks and instructed to "follow the blue line" to a flu clinic where they receive evaluation, education, and treatment in a separate area from a dedicated team of nursing, provider, and pharmacy staff. Vaccination Despite strong recommendations for vaccination, recent national data show that pregnant women have the lowest rates of coverage among all adult populations recommended to receive influenza vaccine. In this face of the H1N1 pandemic, a joint statement has been issued by ACOG, ACNM, AWHONN, AAFP, The March of Dimes Foundation, and other organizations urging vaccination with both seasonal and H1N1 vaccine for all pregnant women. Vaccination in pregnancy also confers a degree of protection to the newborn as well; this is especially important as there is no licensed influenza vaccine for those under 6 months of age. In mid-September, the FDA approved H1N1 vaccine from 4 suppliers. Traditional injectable vaccine and live attenuated influenza vaccine (LAIV) for nasal administration are both available. LAIV should not be used to vaccinate children less than 2 years old, adults more than 49 years old, PREGNANT women, people with underlying medical conditions, or children under 5 with episodes of wheezing in the past year. Pregnant women can be vaccinated for influenza during any trimester. If not already vaccinated, the H1N1 vaccine can be given postpartum. Either IM or nasal (LAIV) vaccine can be administered prior to hospital discharge and is safe in breastfeeding mothers. Partners and other household contacts of infants should also be vaccinated. Both seasonal and H1N1 vaccine can be given on the same day, one shot in each arm. If a nasal formulation for one vaccine is used, the other must be given IM or a 4 week delay between immunizations is recommended. Q & As on H1N1 for pregnant women are available at http://www.cdc.gov/h1n1flu/pregnancy. All health care workers are a priority for being vaccinated against H1N1, both for their own protection and to minimize disease transmission. Treatment Patients should be educated about flu symptoms and encouraged to seek care promptly if they have been exposed to H1N1 or become ill. In the case series reviewed by Jamieson, et al. , the following symptoms were reported: fever (97%), cough (94%) rhinorrhea (59%), sore throat (50%), headache (47%), shortness of breath (41%), myalgia (35%), vomiting (18%), diarrhea (12%) and conjunctivitis (9%), Individuals may be infected with influenza, including 2009 H1N1, and have respiratory symptoms without fever. Early treatment (within 48 hours of the onset of symptoms, if possible) with influenza antiviral medications is recommended for pregnant women with suspected influenza illness. Clinicians should not wait for test results to initiate treatment since these medications work best if started as early as possible after illness onset. Moreover, rapid diagnostic tests for influenza have variable sensitivities for detecting the 2009 H1N1 influenza virus (10-70%). A negative rapid test does NOT exclude the possibility of infection with 2009 H1N1 influenza. At this time, most 2009 H1N1 influenza viruses are susceptible to oseltamivir and zanamivir. However, antiviral treatment regimens might change depending on new antiviral resistance or viral surveillance information. Pregnancy should not be considered a contraindication to the use of oseltamivir or zanamivir (both "Pregnancy Category C"). Oseltamivir is currently preferred because of its systemic absorption.Treat flu exposure in pregnant women with a prophylactic course of oseltamivir (75 mg. once daily for 10 days). Treat those with flu-like symptoms with a therapeutic course of oseltamivir (75 mg twice daily for 5 days). Fever in pregnant women should be treated because of the risk that it appears to pose to the fetus. Acetaminophen appears to be the best option for treatment of fever during pregnancy. Bacterial co-infections have also been implicated in cases of severe disease and death. Autopsy specimens from 77 patients were examined and 22 (29%) had evidence of bacterial infection in addition to H1N1 disease. The bacteria causing these infections included Streptococcus pneumoniae (pneumococcus), group A, Streptococcus, and Staphylococcus aureus, several of the leading causes of community-acquired pneumonia and other severe bacterial infections. For the prevention of pneumococcal disease, two vaccines are currently available in the U.S. All children less than 5 years of age should receive pneumococcal conjugate vaccine according to current recommendations. In addition, the 23-valent pneumococcal polysaccharide vaccine (PPSV23) should be administered to all persons 2-64 years of age with high risk conditions and everyone 65 years and older. During this influenza season, it is especially important for adults with chronic medical problems to get PPSV23. In communities where 2009 H1N1 is circulating, empiric treatment of patients with community acquired pneumonia should include both influenza antiviral agents and appropriate antibiotic therapy. Given the threat posed to the health of pregnant women and their newborns by H1N1 (and seasonal influenza), we have clear duties as health care providers: To educate our patients and their families so that they can reduce flu transmission and seek care promptly if they are exposed to flu or become ill. To provide accurate information about vaccine safety and the valuable protection that H1N1 and seasonal influenza vaccine confers to pregnant women and their newborns. To get vaccinated ourselves, so that we will not spread the disease further. To immediately develop and maintain screening systems, at the first point of contact, to separate those with respiratory illness from non-infected patients and visitors and thus minimize transmission in our waiting areas, exam rooms, and hospitals. To make oseltamivir available promptly to all pregnant women with recent flu exposure or symptoms of influenza. For women who become seriously ill, antibiotic coverage for possible concurrent bacterial infection should also be considered. Wash your hands, cover your cough, get your shots; it could be a long winter Resources General information: http://www.cdc.gov/flu Pregnancy specific information: http://www.cdc.gov/h1n1flu/guidance/obstetric.htm Free educational materials from the CDC: http://www.cdc.gov/h1n1flu/flyers.htm References Centers for Disease Control. Update on Influenza A (H1N1) 2009 Monovalent Vaccines. MMWR. October 9, 2009 / 58(39);1100-1101 http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm Centers for Disease Control,Â Receipt of Influenza Vaccine During Pregnancy Among Women With Live Births --- Georgia and Rhode Island, 2004â€”2007. MMWR. September 11, 2009 / 58(35);972-975 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5835a2.htm?s_cid=mm5835a2_e Centers for Disease Control. Novel Influenza A (H1N1) Virus Infections in Three Pregnant Women --- United States, April--May 2009. MMWR; May 12, 2009 / 58(Dispatch);1-3 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0512a1.htm?s_cid=mm58d0512a1_e Centers for Disease Control. Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel. http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm Jamieson DJ, Honein MA, Rasmussen SA, et al. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet. 2009 Aug 8;374(9688):429-30. http://www.ncbi.nlm.nih.gov/pubmed/19643469 Phillipe M. Pandemic Influenza: What obstetricians need to know. Obstet & Gynecol 2009;114:206-8. http://www.ncbi.nlm.nih.gov/pubmed/19622977 Zaman K, Roy E, Arifeen SE, et al. Effectiveness of maternal influenza immunization in mothers and infants. N Engl J Med. 2008 Oct 9;359(15):1555-64. http://www.ncbi.nlm.nih.gov/pubmed/18799552 Free full text: http://content.nejm.org/cgi/content/full/359/15/1555 Topic Summary ‹ Previous \| Next › Maternity Care Top of Page