Pregnant People - Key Activity 16

KEY ACTIVITY #16:

Vaccines

 

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.

 

Overview

Immunization is a core part of primary preventive care for adolescents and adults; pregnant people are no exception. Several vaccinations are recommended during pregnancy and lactation[1]; this section will focus on two key vaccines of importance during pregnancy: influenza (“flu”) and tetanus, diphtheria, acellular pertussis (“Tdap”).

While this section focuses on flu and Tdap, there are additional new vaccine recommendations during pregnancy. If your practice already has high rates of patient receipt of flu/Tdap, you could consider implementing a project to improve uptake of vaccines against COVID-19[2] with seasonal or annual administration or respiratory syncytial virus (RSV) with administration once between 32 and 36 weeks of gestation.[3]

The flu and Tdap vaccines have well established health benefits for both pregnant individuals and their newborn infants. Pregnant individuals are at increased risk of severe illness from influenza as compared to the general adult population. Seasonal vaccination during pregnancy at any gestational age can prevent hospitalization and other severe complications of flu. Tdap vaccination during pregnancy, ideally between 27 and 36 weeks of gestation, has health benefits for newborns, who receive passive immunity to protect them from whooping cough until they can begin pediatric immunizations against these infections at two months of life.

The receipt of flu and Tdap vaccines among pregnant patients is also of growing interest as a care quality measure. Both are recognized by the National Committee for Quality Assurance (NCQA)[4] [5] as key adult preventive care quality measures. Immunizations are also a good focus for quality improvement projects; the intervention is rapid and measurable with a clear eligible population. Improvement projects in this area are recommended by the Centers for Disease Control and Prevention (CDC) and others.

Disparities in vaccine uptake can magnify existing inequitable health outcomes seen in the perinatal population. A prime example of this relationship was seen during the COVID-19 pandemic. Rates of vaccine uptake were lowest in those groups[6] – racial and ethnic, income-level, employment type – who were also at greatest risk of severe COVID-19 disease or death in pregnancy.[7] While the disparities in maternal and infant health outcomes seen in California are multifactorial, immunization equity can play a role in improvement.

A quality improvement project focused on certain subgroups less likely to be offered or accept the flu and/or Tdap vaccines during pregnancy could also mitigate inequities in your patient population. Studies[8] [9] have demonstrated racial disparities in flu/Tdap immunization uptake during pregnancy; some of these studies show that a provider recommendation can promote vaccine receipt in these groups.

While patient-level hesitancy may be one factor playing into an individual’s decision to accept a recommended immunization, a variety of health-related social needs can combine to play an even greater part in this choice.

Measures of economic and social deprivation are known to be linked with rates of vaccine coverage among adults and children. Addressing health-related social needs in your practice can improve vaccination rates – a lesson learned during the COVID-19 pandemic).[10] For example, providing transportation resources, extended appointment hours (to account for inflexible jobs and school), walk-in vaccine clinics, and educational materials that are literacy level and language appropriate may have a positive impact.

Using data on the needs of your patient communities may help you focus your immunization improvement project on a population that could use more support. The California Healthy Places Index[11] may provide you with relevant information to guide project development.

Action steps and roles

1. Evaluate vaccine uptake data.

Suggested team member(s) responsible: Clinical lead and data lead.

Perform a chart review to identify rates of uptake of flu and Tdap vaccine during the appropriate prenatal windows. You can also leverage external validated sources of immunization data (e.g., California’s state registry). Linking your EHR to state registry data will allow your staff access to a patient’s full immunization record. In addition, you can leverage this data to get an accurate picture of your quality performance.

Beginning to analyze these data will allow you to answer important questions to design your improvement project. Is performance better in one vaccine than the other? Are certain patient subpopulations less likely to be vaccinated (use REAL/SOGI data)? Knowing what your baseline data look like will also help you to set performance improvement goals.

 

2. Assess practice infrastructure to support vaccine administration.

Suggested team member(s) responsible: Operations lead and clinical support staff.

While providing onsite immunizations may be standard practice in a pediatrics office, it may not be an existing perinatal care service in your office. Ensure that you have the correct procedures in place to provide vaccines at the point of care (associated with higher levels of acceptance). This may include: cold storage and monitoring, ordering and forecasting demand, supply chain development, and training on new staff policies and procedures.

 

3. Billing for vaccine administration (adults).

Suggested team member(s) responsible: Operations lead, finance lead, providers.

If providing onsite vaccinations is new to your perinatal practice, ensure that the appropriate billing and coding procedures are in place. This may help you track improvement data and will support the financial sustainability of your new service.

 

4. Engage the whole practice team in promoting vaccine uptake.

Suggested team member(s) responsible: Entire practice team.

Your practice’s administrative staff and clinicians should all share the same positive message about vaccine uptake during pregnancy. Ensure all members of the team have accurate information to share with patients regarding the benefits of vaccine administration on patient and newborn health. Your nonclinical partners (CHWs, doulas, peer support persons), ECM or complex care management (CCM), and transitional care services care managers may be particularly effective trusted messengers on vaccine benefits to your patient community.

 

5. Create educational materials to support informed decision-making regarding vaccines.

Suggested team member(s) responsible: Clinical lead, nonclinician partners, community-based organization partners, patients.
Educational materials for patients on the benefits and risks of accepting the flu and Tdap vaccines during pregnancy can support informed decision-making about this preventive service. Clinical team members can be sure the information provided is accurate; materials should be translated into relevant languages and written at an appropriate reading level. Nonclinician partners, community organizations and patients can review materials to ensure they speak to true patient concerns.

 

6. Think creatively about addressing health-related social needs that are barriers to vaccine acceptance.

Suggested team member(s) responsible: Entire team, nonclinician partners, community partners, patients.

Look to your community partners and patients for suggestions on what some nonmedical barriers might be. Should your practice arrange transportation vouchers for immunization appointments? Could you put on a mobile vaccine event (e.g., seasonal flu) in community spaces where pregnant patients already gather?

Implementation tips

These resources may help you in designing and implementing your practice’s immunization improvement activities.

Endnotes

  1. Pregnancy Guidelines and Recommendations by Vaccine [Internet]. 2020. Available from: https://www.cdc.gov/vaccines/pregnancy/hcp-toolkit/guidelines.html 
  2. ACOG Practice Advisory: “COVID-19 Vaccination Considerations for Obstetric-Gynecologic Care” (2020) 
  3. ACOG Practice Advisory: “Maternal Respiratory Syncytial Virus Vaccination” (2023) 
  4. Adult Immunization Status [Internet]. NCQA. Available from: https://www.ncqa.org/hedis/measures/adult-immunization-status/ 
  5. Adult Immunization Status [Internet]. NCQA. Available from: https://www.ncqa.org/hedis/measures/adult-immunization-status/ 
  6. 2023. COVID-19 Cases, Deaths, and Vaccinations by Race/Ethnicity as of Winter 2022 [Internet]. KFF. 2023. Available from: https://www.kff.org/coronavirus-covid-19/issue-brief/covid-19-cases-deaths-and-vaccinations-by-race-ethnicity-as-of-winter-2022/ 
  7. Office USGA. Maternal Health: Outcomes Worsened and Disparities Persisted During the Pandemic [Internet]. www.gao.gov. 2022. Available from: https://www.gao.gov/products/gao-23-105871 
  8. Ghaswalla P, Poirrier JEM, Packnett ER, Irwin DE, Gray SR, Buck PO. Maternal Immunization in the U.S.: A Nationwide Retrospective Cohort Study. American Journal of Preventive Medicine. 2019 Sep;57(3):e87–93. 
  9. Flu, Tdap, and COVID-19 Vaccination Coverage Among Pregnant Women – United States, April 2022 | FluVaxView | Seasonal Influenza (Flu) | CDC [Internet]. www.cdc.gov. 2022. Available from: https://www.cdc.gov/flu/fluvaxview/pregnant-women-apr2022.htm 
  10. Lacy L, Solosi I. Addressing the Social Determinants of Health May Help Increase COVID-19 Vaccine Uptake [Internet]. Urban Institute. 2022. Available from: https://www.urban.org/urban-wire/addressing-social-determinants-health-may-help-increase-covid-19-vaccine-uptake 
  11. Business - Webflow HTML website template [Internet]. www.healthyplacesindex.org. Available from: https://www.healthyplacesindex.org/