The value of vaccination in preventing ill health globally is widely acknowledged (Figure 77.1). The vaccination schedule in the UK now includes vaccines to protect against over 20 infections (see links to resources in Box 77.1). The schedule changes as new vaccines are developed and understanding increases on how they can impact on the burden of disease to people at different stages in their lives.
Midwives are in an ideal position to discuss and promote immunisation with women and families at various stages during the antenatal period and postnatally. They need to make sure they know where to access the most recent schedule and how to get the most up to date advice on new vaccines (Box 77.2). The on-line version of the Green Book Immunisation Against Infectious Diseases (PHE 2016), contains all the up to date information with the rationale for each vaccine schedule.
There have been significant changes over the last few years in the way vaccines and immunisation advice in pregnancy is seen, and immunisation checks are part of the antenatal screening process (PHE/NHS 2016). Using the opportunities during pregnancy to make sure women get the best advice and to provide information for the future health of their baby has always been important (Figure 77.2). Box 77.2 emphasises making every contact count.
Midwives may have anxieties about actively immunising during pregnancy due to concerns about the potential teratogenic effects of vaccines to the fetus. The World Health Organization, Global Advisory Committee for Vaccine Safety (2014) have reviewed and evaluated the evidence on vaccines given in pregnancy, both intended and inadvertent use. The review showed no evidence of adverse pregnancy outcomes from vaccination with inactivated vaccines, therefore where it is appropriate vaccination should be available in pregnancy. They also concluded that although there is a theoretical risk to the fetus in using live vaccines there is a substantial body of literature describing their safety.
Some infections are known to cause complications to both the mother and fetus. Infants also benefit from the passive immunity acquired from giving the mother vaccines in pregnancy and boosting the antibodies. This provides protection in the first few months of life.
Influenza vaccination: Influenza is more likely to cause severe illness in pregnant women than those who are not pregnant. The reason for this is thought to be due to the normal physiological changes that occur during pregnancy, altered heat rate, oxygen consumption and immune response. The vaccine is offered during the flu season (October to February) to help protect the woman from infection. It can be given at any stage of pregnancy. The vaccine helps protect against influenza and its complications, including maternal pneumonia, premature birth, low birth weight and in rare cases maternal mortality. Influenza can also be serious for neonates and passive immunity from vaccinating women also protects the infant.
Pertussis vaccination: There has been an increase in pertussis infections in many countries. Waning immunity from the vaccine and natural infection mean that boosting of immunity is required for lasting protection. The disease can be fatal, particularly in babies too young to be protected by the primary immunisation schedule. Maternal vaccination boosts the maternal antibodies, which cross the placenta and provide protection to the baby for the first few months. The vaccine is offered in the second trimester from 16 weeks of pregnancy. In practice, the fetal anomaly scan, at 20 weeks provides an ideal opportunity although the vaccine can be given after this and midwives should always check the vaccine has been offered.
MMR status: The measles mumps and rubella vaccine was introduced into the UK in 1988. Rubella is normally a mild illness but can cause serious complications such as terminations and congenital rubella syndrome (CRS) if women contract the disease in the early stages of pregnancy. The vaccine is very effective with one dose providing protection in 95–100% of cases. Infections in the UK are now very rare since the introduction of universal vaccination. Those most at risk are women born overseas and particularly those from rubella endemic countries. Ideally, women should be asked about their vaccination history to check they have had the recommended two doses of vaccine preconception. MMR is a live vaccine and is not recommended during pregnancy; however, women should be reminded to go to their GP surgery postpartum and have missing doses to protect them in future pregnancies from rubella.
Hepatitis screening: Antenatal screening includes screening women for the presence of hepatitis B infection. The infants of infectious women are at risk of acquiring infection at the time of delivery and should be commenced on a course of hepatitis B vaccine at birth. Vaccinating susceptible infants can protect them from contracting chronic hepatitis B in 90% of cases. Midwives are in an ideal position to make sure that the importance of this vaccine is explained to the woman and her family and that this information is passed on the GP surgery and Health Visiting teams to make sure the course is completed.
The offer of vaccination in pregnancy will continue to evolve. New vaccines in development for group B streptococcus and respiratory syncytial virus (RSV) will help to prevent these neonatal infections in the future (Oxford Vaccine Group 2016).