Boosting uptake of flu vaccination in pregnant women

Last year, only a quarter of pregnant women were vaccinated against flu, prompting the Department of Health to ask practices to focus on this group in the current seasonal flu vaccination campaign. But how can practice nurses improve uptake?

There has been an influenza immunisation programme in the UK since the late 1960s, with the aim of protecting those at increased risk of serious morbidity and mortality.¹

WHY VACCINATE PREGNANT WOMEN?

Pregnant women with an existing health condition are at increased risk of severe disease or complications requiring hospital admission for intensive care, and nine deaths attributable to influenza have occurred in pregnant women.³ This risk increases during the third trimester (6 - 9 months of pregnancy) when women are at five times greater risk of a stillbirth than non-infected pregnant women.³ Approximately 80% of babies of vaccinated women developed a passive immune response to A/H1N1v, compared with 25 - 30% of babies of unvaccinated mothers.⁴

UPTAKE RATES

Recent uptake of flu vaccination in pregnant women in England is shown in Table 1. 5

Why is uptake low?

Early uptake of H1N1 vaccine by pregnant women was extremely poor due to healthcare providers either not offering, or actually advising against, vaccination, and also to many women's concerns over vaccine safety. Rates in 2010-2011 were 36.6%, still far below recommended levels of 60%.⁶ Hence, there is still a clear need to promote the benefits of seasonal flu vaccine, not only to the women themselves, but also to healthcare professionals.⁴

Research commissioned by the Department of Health, undertaken by Sheffield University, documented the factors that improved flu vaccination uptake, including:

Perception that

• Influenza is a serious illness, and
• Vaccination is an effective preventative strategy

is associated with higher uptake of flu vaccination. People who are given this information from professional health sources, especially from GPs or nurses in primary care, are more likely to accept vaccination.

Conversely, and really importantly, a lack of recommendation from the GP was the main reason in one large study for not getting vaccinated.⁴

Anecdotal evidence suggests reasons for the lack of uptake of the flu vaccination by pregnant women include:

• Attitudes of clinicians/health professionals and past practice
• Attitudes of pregnant women, partners, family and friends
• Impracticalities of identifying pregnant women (as pregnancy is not a static condition) during the flu season

COLLABORATIVE STRATEGIES

Improving uptake of flu vaccination in pregnant women is not an issue confined to general practice. It is essential that it is managed in a collaborative manner, involving not only GPs and practice nurses, but also all practice staff, midwives, obstetricians, health visitors, school nurses, pharmacists and social workers.

Multidisciplinary/professional training and education to emphasise the importance of protecting pregnant women through the influenza vaccination programme is essential.

A study among pharmacists in the US found that educational efforts that focused on the effectiveness and safety of influenza vaccination could improve the support given by pharmacists to pregnant women, reducing the impact of flu on this group.⁷

Public health information and education also needs to target the pregnant woman, using a variety of media and resources to raise awareness of the risks of flu and benefits of vaccination. This might include anything from posters in GP surgeries and antenatal clinics to story lines in TV soaps.

The Sheffield study identified seven key steps that would have a real impact on flu vaccination uptake rates in general practice.⁴

Practices should

• Identify a lead staff member with responsibility for running the flu vaccination campaign.
• Identify a lead staff member with responsibility for the identification of eligible patients
• Be able to modify searches of the practice's IT system to improve accuracy if necessary
• Send personal invitations to all eligible patients
• Collaborate with local midwives to offer and provide vaccination to pregnant women
• Only stop offering vaccinations once they have achieved the highest targets in both QOF and non-QOF qualifying patients
• Document uptake rates in a report to be circulated to all practice staff, especially those involved in the delivery of the vaccination campaign

Involving community midwives in providing vaccine to pregnant patients has the potential to increase uptake in this group by a further 4%.⁴

ADDITIONAL HINTS TO INCREASE UPTAKE

• Plan clinic times to make it easier for women to attend - e.g. late morning slots allowing for the school drop, early after before school pick up time, evening and Saturday appointments for working mothers
• All general practice staff should be reminded regarding this risk group at the start of the flu season (and as appropriate during this period) who can encourage the woman to book a flu vaccination.
• Perform initial search for eligible women before campaign starts (e.g. 1 October) and perform further searches on a regular basis, perhaps weekly, to identify women who become pregnant at any point during the seasonal flu period.
• Telephone, text (if practice mobile) or write to the woman advising of the need for influenza vaccination and to make an appointment, documenting invitation and method of communication
• Tag other communications with pregnant women, e.g. prescriptions, letters etc.
• Ensure access to vaccines in each of the consultation/treatment rooms, (observing cold chain storage requirements)
• Set up an alert on the patient record system to prompt clinicians to offer/administer flu vaccination opportunistically to pregnant women (can be vaccinated at any stage of their pregnancy during the flu season).
• If flu vaccination has been declined, check the woman's understanding, clarify any misconceptions, offer literature to support your advice, but tactfully offer vaccination on each encounter with her - people do change their minds. An audit trail of basic questions as to why the woman declined could help to understand any common themes so that, if possible, they can be addressed for future flu campaigns.
• When vaccination is administered, ensure it is clearly and appropriately documented, both in the woman's hand held maternity records, and electronically under appropriate READ code
• Prompt updating of GP electronic clinical records following birth or loss of pregnancy
• Electronic antenatal templates should include influenza vaccination status (only during seasonal flu session)
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CONCLUSION

A safe and effective inactivated vaccine is produced ahead of each flu season, based on strain recommendations provided by the WHO, and offered to at risk groups. Flu vaccination has been recommended for pregnant women since the initial 2009 H1N1 pandemic, which resulted in increased numbers of severe illnesses and deaths in this group. However, despite the benefits to both mother and baby of maternal vaccination during pregnancy, uptake remains comparatively low. The single most effective measure to improve uptake in pregnant women is likely to be collaboration with local midwives, to ensure that vaccination is offered and its benefits conveyed. Lack of recommendation by a healthcare professional is one of the key reasons for women not to have the vaccination.

REFERENCES

1. Department of Health Immunisation against infectious disease accessed via https://www.wp.dh.gov.uk/immunisation/files/2012/07/Green-Book-Chapter-19-v4_71.pdf 31/8/12
2. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/SeasonalInfluenza/InformationForThePublic/influsw15vaccinationandpregnancyFAQ/ 31/8/12
3. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1287142522535 4. Understanding seasonal influenza vaccination practice in primary care and identifying the correlates of higher influenza vaccination rates
http://www.sheffield.ac.uk/polopoly_fs/1.180289!/file/III-FullReportt.pdf 5. Seasonal influenza vaccine uptake amongst GP patient groups in England Winter season 2011/12
https://www.wp.dh.gov.uk/immunisation/files/2012/06/Flu-vaccine-uptake-GP-patients-2011.12.pdf
6. CMO, CNO, CPO. Seasonal Flu Immunisation Programme 2011/12. Department of Health, 2011.
7. Pharmacists' knowledge, attitudes and practices regarding influenza vaccination and treatment of pregnant women.
http://www.nelm.nhs.uk/en/NeLM-Area/Evidence/Medicines-Management/References/2012---January/20/Pharmacists-knowledge-attitudes-and-practices-regarding-influenza-vaccination-and-treatment-of-pregnant-women/?id=767127