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Preparing for influenza after 2009 H1N1: special considerations for pregnant women and newborns

https://doi.org/10.1016/j.ajog.2011.01.048Get rights and content

Pregnant women and their newborn infants are at increased risk for influenza-associated complications, based on data from seasonal influenza and influenza pandemics. The Centers for Disease Control and Prevention (CDC) developed public health recommendations for these populations in response to the 2009 H1N1 pandemic. A review of these recommendations and information that was collected during the pandemic is needed to prepare for future influenza seasons and pandemics. The CDC convened a meeting entitled “Pandemic Influenza Revisited: Special Considerations for Pregnant Women and Newborns” on August 12-13, 2010, to gain input from experts and key partners on 4 main topics: antiviral prophylaxis and therapy, vaccine use, intrapartum/newborn (including infection control) issues, and nonpharmaceutical interventions and health care planning. Challenges to communicating recommendations regarding influenza to pregnant women and their health care providers were also discussed. After careful consideration of the available information and individual expert input, the CDC updated its recommendations for these populations for future influenza seasons and pandemics.

Section snippets

Antiviral treatment and chemoprophylaxis

Issues related to influenza treatment were considered, including the severity of disease in pregnant women and benefits and risks of treatment to the mother and fetus. Consistent with data from previous influenza pandemics and seasonal influenza,2 pregnant women were at increased risk for 2009 H1N1-associated morbidity and death; pregnant women had a 4-fold increased risk of hospitalization4 and accounted for a disproportionate number of deaths.3 During the 2009-2010 season, the CDC recommended

Vaccination

The Advisory Committee on Immunization Practices and the American College of Obstetricians and Gynecologists recommend the administration of inactivated influenza vaccine for all women who are pregnant during the influenza season, regardless of pregnancy trimester.30, 31 In influenza pandemic situations and periods of vaccine shortage, pregnant women are included in the highest priority group for influenza vaccination because of their increased risk for influenza-associated morbidity and death.

Intrapartum and newborn infant (including infection control) issues

Issues that are related to vertical transmission, hospital infection control, discharge advice, and use of antiviral medications while breastfeeding were discussed. Data are limited on vertical transmission of seasonal or pandemic influenza viruses; vertical transmission has been suggested to occur with maternal illness (usually severe), although it appears to be rare.75, 76, 77, 78 Asymptomatic newborn infants who are born to mothers who are symptomatic or who have recovered from suspected or

Nonpharmaceutical interventions and health care planning during a pandemic

Before the 2009 H1N1 pandemic, the CDC, in collaboration with other federal agencies and public health partners, developed interim guidance on the use of nonpharmaceutical interventions in the event of a pandemic.83 This guidance was designed to mitigate an influenza pandemic and included measures (eg, school dismissals, social distancing) other than vaccination and antiviral treatment. During the 2009 H1N1 pandemic, CDC-issued guidance on prevention emphasized universal adherence to good

Communication

Despite the efforts of public health agencies and professional organizations to promote and communicate information about influenza, influenza vaccination coverage among pregnant women has historically been low,33 and many pregnant women with suspected 2009 H1N1 did not receive recommended antiviral treatment in a timely manner.3, 4 Improved outreach, education, and communication efforts are needed, including tailored strategies for different population subgroups of pregnant women.

Comment

Pregnant women and their newborn infants are at increased risk of severe influenza illness. Although the 2009 H1N1 pandemic emphasized the importance of special considerations for these populations in a pandemic situation, these populations are also at increased risk for severe complications with seasonal influenza. Regardless of influenza vaccination status, women who are pregnant or <2 weeks after delivery with suspected influenza should receive early antiviral treatment. Treatment of fever

Acknowledgments

Members of the Pandemic Influenza and Pregnancy Working Group include Sharon Alexander, Robert Wood Johnson University Hospital, New Brunswick, NJ; Kevin Ault, Emory University, Atlanta, GA; Hilary Babcock, Washington University School of Medicine, St. Louis, MO; Carol Baker, Baylor College of Medicine, Houston, TX; Niranjan Bhat, Johns Hopkins Children's Center, Baltimore, MD; Carolyn Bridges, National Center for Immunization and Respiratory Diseases (NCIRD), Centers for Disease Control and

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    Authorship and contribution to the article is limited to the authors indicated. There was no outside funding or technical assistance with the production of this article.

    Conflict of Interest: none.

    The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

    Publication of this article was supported by the Centers for Disease Control and Prevention and the Association of Maternal and Child Health Programs.

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