Vaccinating Women of Reproductive Age Recommendations and Guidelines
Introduction
The New York State Department of Health Immunization Program developed these guidelines using the current recommendations from the Centers for Disease Control and Prevention, the Advisory Committee on Immunization Practices and the American College of Obstetricians and Gynecologists. This document serves to guide best practices. However, guidelines never replace the need to evaluate each patient individually and utilize sound clinical judgment. These guidelines are based on the best available evidence and will provide a foundation from which women's health care providers can achieve optimal quality in patient care.
Immunizations in the Preconception and Interconception Period
Ideally, all women should be up-to-date with their vaccinations before they become pregnant. It is known that approximately 50 percent of all pregnancies are unplanned1; therefore, it is important to keep women of reproductive age current with immunizations, regardless of whether they are actively trying to conceive.
The following immunizations are strongly recommended:
- Influenza - Women who want to reduce their chances of developing influenza or who have other medical or occupational indications should receive an annual dose of influenza vaccine. Healthy, non-pregnant women under the age of 50 without high-risk medical conditions and who are not close contacts of severely immunocompromised persons can receive live attenuated influenza vaccine (LAIV) or trivalent inactivated vaccine (TIV)2.
- Td/Tdap - Women who have completed a primary series of diphtheria- and tetanus toxoid-containing vaccine should receive a booster dose of tetanus and diphtheria vaccine (Td) every ten years. One dose of tetanus, diphtheria and acellular pertussis vaccine (Tdap) should be substituted for the Td booster in women who have not previously received Tdap3. Ensuring that women are current with their Td/Tdap boosters helps protect newborns from neonatal tetanus and pertussis.
The following immunizations are recommended for women at risk for these diseases and who do not have a history of immunity, or for anyone who would like to receive the vaccine:
- Hepatitis A - Women at risk for hepatitis A virus (HAV) infection or anyone who requests the vaccine should receive a two-dose single antigen series at zero and six months or the three-dose combination hepatitis A and hepatitis B vaccine, Twinrix, at zero, one and six months.4
- Hepatitis B - Women at risk for hepatitis B virus (HBV) infection or anyone who requests the vaccine should receive the three-dose primary series at zero, one to two and four to six months.4 Infants who acquire HBV perinatally are at very high risk of developing chronic HBV which can lead to chronic liver disease, cirrhosis and primary hepatocellular carcinoma in early adulthood.
- Human papillomavirus (HPV) - Women ages nine through 26 years should receive three doses of HPV vaccine at zero, two and six months. Genital HPV is the most common sexually transmitted infection in the United States. The currently available quadrivalent HPV vaccine, Gardasil, protects against HPV serotypes 6, 11, 16 and 18. Protection against these four HPV serotypes can prevent the occurrence of up to 90 percent of genital warts and 70 percent of cervical cancers in women.5
- Measles, mumps and rubella (MMR) - Women who have no history of previous immunization or lack laboratory evidence of rubella immunity should receive at least one dose of MMR vaccine. In addition to protecting individual women, MMR vaccine helps to prevent the occurrence of congenital rubella syndrome in newborns.9 As it is a live virus vaccine, women should be counseled to avoid pregnancy for four weeks after receiving the MMR vaccine.4
- Meningococcal - Women at risk for meningococcal infection, due to occupational or medical risk factors, should receive one dose of meningococcal conjugate vaccine (MCV4). Medical indications include anatomic or functional asplenia or terminal complement component deficiencies. Those with occupational indications include military recruits, first-year college students living in dormitories, microbiologists who are exposed to N. meningitidis and persons who live in or travel to countries where meningococcal disease is widespread.6
- Pneumococcal - Women with certain high-risk medical indications should receive one dose of pneumococcal polysaccharide vaccine (PPV23). These high-risk medical indications include smoking (if ≥19 years of age), chronic pulmonary disease (including asthma), chronic cardiovascular disease, diabetes, chronic liver disease, chronic alcoholism, chronic renal failure, nephrotic syndrome, functional or anatomic asplenia, HIV infection, immunosuppressive conditions, cochlear implants and cerebrospinal fluid leaks. A second dose should be repeated five years later for those with chronic renal failure, nephrotic syndrome, functional or anatomic asplenia or immunosuppressive conditions.6
- Varicella (chickenpox) - Women who have previously been immunized with one dose of varicella vaccine should receive a second dose at least four weeks after the first dose. Women without a history of varicella infection should receive a total of two doses of varicella vaccine, four to eight weeks apart. Infants of women without a history of immunity may be at risk for congenital varicella syndrome and neonatal varicella infection. Pregnant women infected with varicella may also be at higher risk of developing a severe case of varicella pneumonia. As it is a live virus vaccine, women should be counseled to avoid pregnancy for four weeks after receiving the varicella vaccine.78
Immunizations in the Prenatal Period
Pregnancy is not an absolute contraindication to any vaccination. On the contrary, some vaccines are strongly recommended for pregnant women during the prenatal period. Therefore, the prenatal visit is an ideal time to assess a woman's need for vaccines.
All pregnant women should be evaluated for serologic evidence of immunity to rubella at their first prenatal visit, unless known to be immune by a previous test.8,8 Varicella immunity should also be assessed by either a reliable history of disease, laboratory evidence of previous disease or documented receipt of two doses of vaccine.8 Birth before 1980 is not considered evidence for varicella immunity.7 In addition, New York State Public Health Law 2500-e requires that every pregnant woman be tested for the presence of hepatitis B surface antigen (HBsAg) and that the test result and date are documented in the prenatal record.
The following immunization is strongly recommended for all pregnant women:
- Influenza - Due to the increased risk of influenza-related complications among pregnant women, TIV is recommended for all women who are or will be pregnant during the flu season (September through March). TIV can be given during any trimester. As it is a live virus vaccine, LAIV is contraindicated for use in pregnant women.2
- Tdap/Td - In order to protect newborns against pertussis, all pregnant women should be administered a single dose of Tdap vaccine during the third trimester of each pregnancy, irrespective of her history of receiving Tdap prior to the current pregnancy. Tdap is safe during pregnancy and provides protection against pertussis both to the pregnant woman and to her infant. There is no minimum interval between doses of Tdap or between Tdap and the last Td booster. To maximize the maternal antibody response and passive antibody transfer to the infant, optimal timing for Tdap administration is between 27 and 36 weeks gestation.11 To ensure protection against maternal and neonatal tetanus, pregnant women who have never been vaccinated against tetanus should receive three vaccinations containing tetanus and reduced diphtheria toxoids. The recommended schedule is 0, 4 weeks, and 6 to 12 months. Tdap should replace 1 dose of Td, during the third trimester of pregnancy.
The following immunizations are recommended for women at risk for these diseases and who do not have a history of immunity or for anyone who would like to receive the vaccine:
- Hepatitis B - A woman's risk of acquiring HBV should be assessed along with her risk of acquiring other sexually transmitted infections. Pregnant women who have been identified as being at risk for HBV infection should be vaccinated. Pregnancy is not a contraindication for HBV vaccination, and limited evidence does not suggest any fetal harm from the HBV vaccine.
Pregnancy is considered a precaution for most other inactivated vaccines, including HAV, PPV23 and MCV4. Immunization with these vaccines should only occur if the benefits of vaccination outweigh the risks of not vaccinating. The only inactivated vaccine that should not be given during pregnancy is HPV vaccine due to a lack of safety and efficacy data in pregnant women. If a woman starts the HPV vaccine series then becomes pregnant, the remainder of the series should be postponed until after delivery and administration during pregnancy should be reported to the manufacturer's pregnancy registry.5
All live attenuated vaccines are contraindicated in pregnancy due to a theoretical risk to the fetus, although no evidence of any harm from live vaccines has been documented. The one exception is vaccinia vaccine which has a small but documented risk to the fetus if given during pregnancy.10
The following live virus vaccines should not be given during pregnancy:
- LAIV
- MMR
- Varicella
- Zoster (shingles)
- Vaccinia (smallpox)
If a woman is vaccinated with a live virus vaccine then discovers that she might have been pregnant at the time or within four weeks after vaccination, she should be counseled about the theoretical risk to her fetus. Because no evidence exists of any harm to fetuses that have been exposed to live virus vaccines during this period, she should not be advised to terminate her pregnancy. There is a small, but documented risk from vaccinia vaccination during pregnancy; however, it is still not considered a reason to terminate the pregnancy if exposure has occurred.
Immunizations in the Postpartum Period
The period after delivery and before discharge from the hospital is an ideal time to administer both live and inactivated vaccines. It ensures that both the woman and her child will be protected from preventable diseases after leaving the birthing facility, when they are especially vulnerable. Women who plan to breastfeed can and should receive vaccinations as no evidence exists of any risk to a mother or her infant if she is vaccinated while breastfeeding. Breastfeeding is not a contraindication to any vaccination, with the exception of vaccinia vaccine. 4
The following vaccinations are recommended for women at risk for these diseases or for those who do not have a history of immunity:
- Influenza - Women should receive an annual dose of influenza vaccine, either TIV or LAIV, if they have not already been immunized during their pregnancy. Influenza vaccine should be given before leaving the hospital.
- Rubella (MMR) - Women born on or after January 1, 1957, without evidence of immunity to rubella should be vaccinated with one dose of the MMR vaccine before leaving the hospital. Single antigen rubella vaccine should not be used.
- Tdap - Women who have not previously received one dose of Tdap should receive Tdap before leaving the hospital. There is no minimum interval between receipt of Tdap and of the last Td booster. Immunizing the mother with Tdap will help protect the newborn during their first few months of life when they are most vulnerable to pertussis.
- Varicella - Women without evidence of immunity to varicella should be vaccinated with the first dose of varicella vaccine before leaving the hospital. The second dose should be given at the postpartum visit, six to eight weeks after delivery. As it is a live virus vaccine, women should be counseled to avoid pregnancy for four weeks after receiving the varicella vaccine.7
- HPV - Women ages nine through 26 years who have not completed a primary series should receive three doses of HPV vaccine at zero, two and six months. If the HPV series was started prior to pregnancy, the series can be completed postpartum without repeating the initial dose(s).5
Immunization of Close Contacts of Pregnant Women
Vaccines should not be withheld from household or close contacts of pregnant women. Rather, ensuring that close contacts are up-to-date with their immunizations can help protect the health of the mother and her fetus. It is especially important that household contacts be current with their influenza and Tdap vaccines. The only vaccine that should not be given to close contacts of pregnant women is vaccinia vaccine due to the small but serious risk of fetal vaccinia.4
Special Situations
Certain medical situations may arise during or after a pregnancy that have implications for the receipt of certain vaccines.
- Anti-Rho(D) immune globulin administration - Postpartum vaccination should not be delayed because of anti-Rho(D) immune globulin receipt. Live virus vaccines, such as MMR and varicella, should be administered simultaneously with anti-Rho(D) immune globulin in the immediate postpartum period. Women who have received both MMR vaccine and anti-Rho(D) immune globulin should be serologically tested 3 months after vaccination to ensure that immunity has developed to rubella and measles, if appropriate.4,12
- Vaccine-preventable disease exposure
- Passive immunization - Any pregnant woman who is exposed to a vaccine-preventable disease to which they have no immunity should consult their provider about passive immunization. For example, in the event a pregnant woman is exposed to varicella disease and does not have evidence of immunity, varicella zoster immune globulin can be given.
- Rabies exposure - Due to the severe course of rabies infection, pregnancy is not a contraindication to post-exposure prophylaxis of rabies. No data exists that suggests any harm from rabies vaccination. For women who are pregnant and at high risk of exposure to rabies, pre-exposure prophylaxis to rabies may be warranted.13
Immunizations Prior to International Travel
Pregnant women planning to travel to areas where other diseases are endemic may need certain vaccines. Pregnant women who are immunized with these vaccines should be counseled about potential risk to the fetus, as often there is little or no data on the safety of these vaccines in pregnancy.
The following vaccines are recommended for pregnant women planning to travel to endemic areas where there is a high risk of exposure: 10
- Anthrax
- Inactivated polio
- Japanese encephalitis
- Meningococcal conjugate
- Typhoid
- Yellow fever
The following vaccines are not recommended for pregnant women planning to travel: 10
- Bacille Calmette-Guérin (BCG) - tuberculosis
- Vaccinia (smallpox)
Pregnancy Vaccine Registries
Several registries have been established by vaccine manufacturers for women who have received certain vaccines during pregnancy. Providers should contact the appropriate registry if their patients have been exposed to the following vaccines during any trimester:
- HPV
- Gardasil (Merck): (800) 986-8999
- Tdap
- Boostrix (GlaxoSmithKline): (888) 825-5249
- Adacel (sanofi pasteur): (800) 822-2463
- Varicella
- Varivax (Merck): (800) 986-8999 - Exposure to Varivax during pregnancy, as well as three months prior to becoming pregnant, should be reported to the Varivax Pregnancy Registry.7
- Smallpox
- National Smallpox Vaccine in Pregnancy Registry14
- Civilian and military cases - Department of Defense: (619) 553-9255
Tdap and Flu Vaccination Poster
Pregnant? Protect yourself and your baby.
Additional Information
Additional information on immunizations can be found at the following websites:
- New York State Department of Health Immunization Program: http://www.health.ny.gov/prevention/immunization
- CDC's National Center for Immunization and Respiratory Diseases (NCIRD) http://www.cdc.gov/vaccines/parents/pregnant.html
- The American College of Obstetricians and Gynecologists (ACOG): http://www.acog.org
- Immunization Action Coalition: http://www.immunize.org/pregnancy/
References
1Williams L., Morrow B., Shulman H., Stephens R., D'Angelo D., & Fowler C.I. (2006). PRAMS 2002 Surveillance Report. Atlanta, GA: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.
2Centers for Disease Control and Prevention. Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007. MMWR 2007; 56(RR-6): 1-54.
3Centers for Disease Control and Prevention. Preventing Tetanus, Diphtheria, and Pertussis Among Adults: Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and Recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for Use of Tdap Among Health-Care Personnel. MMWR 2006; 55(RR-17): 1-37
4Centers for Disease Control and Prevention. General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2006; 55(RR-15): 1-48.
5Centers for Disease Control and Prevention. Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory Committee on Immunization Practices. MMWR 2007; 56(RR-2): 1-23.
6Centers for Disease Control and Prevention. Recommended Adult Immunization Schedule - United States, October 2007 - September 2008. MMWR 2007; 56(41): Q1-Q4.
7Centers for Disease Control and Prevention. Prevention of Varicella: Recommendations of the Advisory Committee on Immunization Practices. MMWR 2007; 56(RR-4): 24-28.
8American Academy of Pediatrics & the American College of Obstetricians and Gynecologists (2007). Chapter 9: Perinatal Infections. In Lemnos, J.A. & Lockwood, C.J. (Eds.), Guidelines for Perinatal Care, Sixth Edition (pp. 303-348). Washington, DC: American Academy of Pediatrics & the American College of Obstetricians and Gynecologists.
9Centers for Disease Control and Prevention. Measles, Mumps, and Rubella - Vaccine Use and Strategies for Elimination of Measles, Rubella, and Congenital Rubella Syndrome and Control of Mumps: Recommnedations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998; 47(RR-8): 18.
10Centers for Disease Control and Prevention (2007). Guidelines for Vaccinating Pregnant Women: from Recommendations of the Advisory Committee on Immunization Practices. Retrieved June 12, 2008 from http://www.cdc.gov/vaccines/pubs/preg-guide.htm.
11Centers for Disease Control and Prevention (2012). ACIP Provisional Updated Recommendations on the Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine (Tdap) for Pregnant Women. Retrieved December 27, 2012 from http://www.cdc.gov/vaccines/recs/provisional/downloads/Tdap-pregnant-Oct-2012.pdf.
12American Academy of Pediatrics (2006). Rubella. In Pickering, L.K., Baker, C.J., Long, S.S., & McMillan, J.A. (Eds.), Red Book: 2006 Report of the Committee on Infectious Disease, 27th ed. (pp. 574-579). Elk Grove Village, IL: American Academy of Pediatrics.
13Centers for Disease Control and Prevention. Human Rabies Prevention - United States, 2008. Recommendations of the Advisory Committee on Immunization Practices. MMWR 2008; 57(RR-3): 20-21.
14Centers for Disease Control and Prevention. Women with Smallpox Vaccine Exposure During Pregnancy Reported to the National Smallpox Vaccine in Pregnancy Registry -United States, 2003. MMWR 2003; 52(17): 386-388.