Background. Pertussis booster vaccine (Tdap) recommendations assume that pertussis-specific antibodies in women immunized preconception, during, or after previous pregnancies persist at sufficient ...levels to protect newborn infants. Methods. Pertussis-specific immunoglobulin G (IgG) was measured by IgG-specific enzyme-linked immunosorbent assay (ELISA) in maternal—umbilical cord serum pairs where mothers received Tdap during the prior 2 years. Geometric mean concentrations (GMCs) of pertussis antibodies and cord-maternal GMC ratios were calculated. Results. One hundred five mothers (mean age, 25.3 years range, 15.3–38.4 years; mean gestation, 39 weeks range, 37–43 weeks) immunized with Tdap vaccine a mean of 13.7 months (range, 2.3–23.9 months) previously were included; 72 (69%) had received Tdap postpartum, 31 at a routine healthcare visit and 2 as contacts of another newborn. There was no difference in GMCs for pertussis-specific IgG in maternal delivery or infant cord sera for women immunized before (n = 86) or during (n = 19) early pregnancy. Placental transport of antibodies was 121%–186% from mothers immunized before and during pregnancy, respectively. Estimated GMC of IgG to pertussis toxin was <5 ELISA units (EU)/mL at infant age 2 months (start of infant immunization series). More infants of mothers immunized during pregnancy had pertussis toxin levels estimated to be higher than the lower limit of quantitation of the assay (4 EU/mL) through age 2 months (52% vs 38%; P = .34). Conclusions. Infants of mothers immunized preconception or in early pregnancy have insufficient pertussis-specific antibodies to protect against infection. Maternal immunization during the third trimester, immunization of other infant contacts, and reimmunization during subsequent pregnancies may be necessary.
Highlights • Pregnant women will accept vaccination during pregnancy if recommended by their physician. • Safety for baby and mother, and adequate discussion are factors critical to vaccination ...decisions. • Providers underestimated amount of trust placed in physicians by pregnant women. • A strong physician recommendation is essential to optimizing uptake of vaccines during pregnancy.
Background. In 2006, the Advisory Committee on Immunization Practices recommended tetanus, diphtheria, acellular pertussis (Tdap) vaccination of all caregivers of infants aged <1 year ("cocooning") ...to prevent pertussis-related complications and deaths. We implemented cocooning in a predominantly Hispanic, medically underserved, uninsured population at a Houston hospital. Phase 1 (January 2008–January 2010) provided maternal postpartum Tdap vaccine; Phase 2 (June 2009–January 2010) also vaccinated infant contacts on-site. Methods. Pertussis education was provided to health care personnel and mothers. Standing orders for maternal postpartum Tdap vaccination were initiated. Mothers were interviewed to ascertain the number of additional infant contacts eligible to receive Tdap vaccine. Consenting eligible contacts received Tdap vaccine as soon as possible after delivery. Results. From 7 January 2008 through 31 January 2010, 8334 (75%) of 11,174 postpartum women received Tdap vaccine. During Phase 2, 2969 (86%) of 3455 postpartum women were vaccinated; another 197 (6%) had previously received Tdap vaccine. Mothers were Hispanic (91.4%), black (5.4%), white (0.8%), Asian (1.4%) and other (1.0%). A median of 3 (range, 1–11) other Tdap-eligible contacts per infant were identified, and a median of 2 (range, 0–10) contacts per infant received Tdap vaccine. Of 1860 contacts vaccinated, 1813 (98%) anticipated daily infant contact. A total of 1697 (91%) received Tdap vaccine before infant hospital discharge, and 144 (8%) received Tdap vaccine within 7 days after hospital discharge. Barriers to full cocooning included the need for extended vaccination hours, visiting restrictions because of pandemic H1N1 influenza, and inaccurate recall of vaccination history. Conclusion. Although practical and logistical barriers exist, Tdap cocooning was well accepted by and successfully implemented in a high-risk population by using standing orders and providing vaccinations on-site.
Group B Streptococcus (GBS) is the leading cause of meningitis in young infants. We evaluated long-term outcomes among GBS meningitis survivors. We hypothesized that despite reduced mortality, GBS ...meningitis would remain a significant cause of morbidity among GBS survivors.
Ninety term and near-term infants diagnosed with GBS meningitis from 1998 through 2006 were identified from 2 children's hospitals. Five died acutely, and 5 died at 6 months to 3 years of age. Forty-three survivors (54%; mean age 6.8, range 3-12 years) were consented for evaluation and underwent physical and neurologic examinations, hearing and vision screening, and standardized developmental assessments. Associations among presenting features, laboratory parameters, neurologic status at hospital discharge, and later developmental outcomes were explored by using descriptive statistics and logistic regression.
Twenty-four of 43 (56%) children evaluated demonstrated age-appropriate development, 11 (25%) had mild-to-moderate impairment, and 8 (19%) had severe impairment. Admission features associated with death after hospital discharge or severe impairment included lethargy (P = .003), respiratory distress (P = .022), coma or semicoma (P = .022), seizures (P = .015), bulging fontanel (P = .034), leukopenia (P = .026), acidosis (P = .024), cerebrospinal fluid protein >300 mg/dL (P = .006), cerebrospinal fluid glucose <20 mg/dL (P = .026), and need for ventilator (P = .002) or pressor support (P < .001). Features at discharge associated with late death or severe impairment included failed hearing screen (P = .004), abnormal neurologic examination (P < .001), and abnormal end of therapy brain imaging (P = .038).
Survivors of GBS meningitis continue to have substantial long-term morbidity, highlighting the need for ongoing developmental follow-up and prevention strategies such as maternal immunization.
Background. Further reduction in the group B streptococcal (GBS) disease burden in neonates in the United States awaits an additional prevention strategy, such as maternal immunization. Methods. We ...performed a prospective, multicenter, case-control study of 33 mothers delivering neonates with early onset GBS infection (cases), and 99 age- and ethnicity-matched mothers colonized with the same capsular polysaccharide (CPS) types delivering healthy neonates (controls). Relative risk and absolute risk were calculated for early onset disease associated with concentrations of type Ia, III, or V CPS-specific antibody in maternal serum. Results. For GBS types Ia and III, maternal CPS-specific antibody concentrations of ≥0.5 μg/mL were associated with a relative risk of approximately 0.1 (95% confidence intervals CIs, .01-.74 and 0-. 72, respectively; P = .02 for each), corresponding to a 90% risk reduction (by logistic regression). For type V, the relative risk was 0.3 (95% CI, .01-3.1), corresponding to a 70% risk reduction. By Bayesian modeling, the risk of early onset disease would decrease by 70% if maternal CPS-specific antibody concentrations for these 3 GBS types were ≥1 μg/mL. Conclusions. Maternal CPS-specific antibody serum concentrations of ≥1 μg/mL at the time of delivery appear to protect most neonates from early onset GBS type Ia and III disease.
The goal was to assess the effectiveness of complete (3-dose) or partial (1- or 2-dose) immunization with pentavalent rotavirus vaccine (RV5) against rotavirus acute gastroenteritis (AGE) in US ...clinical practice.
A case-control evaluation was conducted in February through June 2008 at an emergency department in Houston, Texas. Case patients with rotavirus AGE (N = 90) were identified through testing for rotavirus in fecal specimens obtained from 205 children 15 days through 23 months of age presenting with AGE. Control groups included rotavirus-negative AGE patients (N = 115), concurrently enrolled patients with acute respiratory infection (ARI) (N = 228), and up to 10 age- and zip code-matched children sampled from the Houston-Harris County Immunization Registry (HHCIR) for each case patient >8 months of age. Immunization data were obtained from parent records, health care providers, and/or the HHCIR. Vaccine effectiveness was calculated as 1 minus odds of RV5 vaccination for case patients versus control patients, after adjustment for age at presentation and birth date.
The vaccine effectiveness of a complete RV5 series was 89% (95% confidence interval CI: 70%-96%) and 85% (95% CI: 55%-95%) with rotavirus-negative AGE and ARI control patients, respectively. Immunization data were available for 44% of case patients (n = 40) from the HHCIR; the estimated 3-dose vaccine effectiveness with these HHCIR control patients was 82% (95% CI: 19%-96%). A complete RV5 series conferred 100% protection (95% CI: 71%-100%) against severe rotavirus disease requiring hospitalization and 96% protection (95% CI: 72%-99%) against disease requiring intravenous hydration. Vaccine effectiveness of 1 and 2 doses against hospitalization and emergency department visits was 69% (95% CI: 13%-89%) and 81% (95% CI: 13%-96%), respectively, using rotavirus-negative AGE and ARI control groups combined.
In this setting, a complete series of RV5 was highly effective against severe rotavirus AGE. Partial immunization also conferred substantial protection.
Tetanus, diphtheria and acellular pertussis immunization of infant contacts (cocooning) is recommended by the Centers for Disease Control and Prevention to prevent infant pertussis. We determined ...whether implementing a cocooning program at Ben Taub General Hospital, Houston, reduced severe pertussis in young infants.
Infants ≤6 months of age, diagnosed with pertussis (determined by International Classification of Diseases, Ninth Revision codes and microbiology records) at 4 hospitals, and born at times when only postpartum women (January 2008 through May 2009) and all infant contacts (June 2009 through August 2011) were offered tetanus, diphtheria and acellular pertussis vaccine at Ben Taub General Hospital were compared with infants born preintervention (May 2004 through December 2007).
One hundred ninety-six (49%) infants with pertussis were born preintervention, 140 (35%) during maternal postpartum (PP) and 64 (16%) during cocooning (C) periods. Infants were similar in age at diagnosis (81.2 vs. 71.3 PP vs. 72.5 C days; P 0.07), sex (male 59% vs. 51% PP vs. 48% C; P 0.17), hospitalization (68% vs. 71% PP vs. 78% C; P 0.27) and outcome (2 deaths in the PP period; P 0.15), but more were admitted to intensive care units during cocooning (24% vs. 35% PP vs. 68% C; P < 0.001). Similar proportions of infants were born at Ben Taub General Hospital throughout the study (8% vs. 9% PP vs. 5% C; P 0.53).
Postpartum immunization and cocooning did not reduce pertussis illness in infants ≤6 months of age. Efforts should be directed toward increasing tetanus, diphtheria and acellular pertussis immunization during pregnancy, combined with cocooning, to reduce life-threatening young infant pertussis.
Immunization with tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is recommended in the United States during weeks 27 through 36 of pregnancy to prevent life-threatening infant pertussis. ...The optimal gestation for immunization to maximize concentrations of neonatal pertussis toxin antibodies is unknown.
To determine pertussis toxin antibody concentrations in cord blood from neonates born to women immunized and unimmunized with Tdap vaccine in pregnancy and optimal gestational age for immunization to maximize concentrations of neonatal antibodies.
Prospective, observational, cohort study of term neonates in Houston, Texas (December 2013-March 2014).
Tdap immunization during weeks 27 through 36 of pregnancy or no Tdap immunization.
Primary outcome was geometric mean concentrations (GMCs) of pertussis toxin antibodies in cord blood of Tdap-exposed and Tdap-unexposed neonates and proportions of Tdap-exposed and Tdap-unexposed neonates with pertussis toxin antibody concentrations of 15 IU/mL or higher, 30 IU/mL or higher, and 40 IU/mL or higher, cutoffs representing quantifiable antibodies or levels that may be protective until the infant immunization series begins. Secondary outcome was the optimal gestation for immunization to achieve maximum pertussis toxin antibodies.
Six hundred twenty-six pregnancies (mean maternal age, 29.7 years; 41% white, 27% Hispanic, 26% black, 5% Asian, 1% other; mean gestation, 39.4 weeks) were included. Three hundred twelve women received Tdap vaccine at a mean gestation of 31.2 weeks (range, 27.3-36.4); 314 were unimmunized. GMC of neonatal cord pertussis toxin antibodies from the Tdap-exposed group was 47.3 IU/mL (95% CI, 42.1-53.2) compared with 12.9 IU/mL (95% CI, 11.7-14.3) in the Tdap-unexposed group, for a GMC ratio of 3.6 (95% CI, 3.1-4.2; P < .001). More Tdap-exposed than Tdap-unexposed neonates had pertussis toxin antibody concentrations of 15 IU/mL or higher (86% vs 37%; difference, 49% 95% CI, 42%-55%), 30 IU/mL or higher (72% vs 17%; difference, 55% 95% CI, 49%-61%), and 40 IU/mL or higher (59% vs 12%; difference, 47% 95% CI, 41%-54%); P < .001 for each analysis. GMCs of pertussis toxin antibodies were highest when Tdap vaccine was administered during weeks 27 through 30 and declined thereafter, reaching a peak at week 30 (57.3 IU/mL 95% CI, 44.0-74.6).
Immunization with Tdap vaccine during the third trimester of pregnancy, compared with no immunization, was associated with higher neonatal concentrations of pertussis toxin antibodies. Immunization early in the third trimester was associated with the highest concentrations.
Background. Group A rotaviruses (RVA) are a significant cause of pediatric gastroenteritis worldwide. The New Vaccine Surveillance Network (NVSN) has conducted active surveillance for RVA at ...pediatrie hospitals and emergency departments at 3-7 geographically diverse sites in the United States since 2006. Methods. Over 6 consecutive years, from 2008 to 2013, 1523 samples from NVSN sites that were tested positive by a Rotaclone enzyme immunoassay were submitted to the Centers for Disease Control and Prevention for genotyping. Results. In the 2009, 2010, and 2011 seasons, genotype G3P8 was the predominant genotype throughout the network, with a 46%-84% prevalence. In the 2012 season, G12P8 replaced G3P8 as the most common genotype, with a 70% prevalence, and this trend persisted in 2013 (68.0% prevalence). Vaccine (RotaTeq; Rotarix) strains were detected in 0.6%-3.4% of genotyped samples each season. Uncommon and unusual strains (eg, G8P4, G3P24, G2P8, G3P4, G3P6, G24P14, G4P6, and G9P4) were detected sporadically over the study period. Year, study site, and race were found to be significant predictors of genotype. Conclusions. Continued active surveillance is needed to monitor RVA genotypes in the United States and to detect potential changes since vaccine licensure.
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