Influenza vaccination in pregnancy: practices among obstetrician-gynecologists--United States, 2003-04 influenza season

Women infected with influenza virus during pregnancy are at increased risk for serious complications and hospitalization. During 1997-2003, the Advisory Committee on Immunization Practices (ACIP) included healthy pregnant women who would be in their second or third trimester of pregnancy during the influenza season among those persons at high risk for whom influenza vaccination was indicated. Also included were women at any stage of pregnancy with certain chronic medical conditions, such as asthma, diabetes mellitus, or heart disease. ACIP emphasized that the influenza vaccine was safe for breastfeeding mothers and their infants and that household contacts of children aged <2 years also should be vaccinated. However, despite these recommendations, only 13% of pregnant women received influenza vaccination in 2003. To assess understanding of the ACIP recommendations among obstetrician-gynecologists (OB/GYNs), the American College of Obstetricians and Gynecologists (ACOG), with support from CDC, surveyed a national sample of OB/GYNs in May 2004. This report describes the results of that survey, which indicated that 52% of OB/GYNs surveyed would recommend influenza vaccination for a healthy woman in the first trimester of pregnancy, 95% would recommend the vaccine for a healthy pregnant woman beyond the first trimester, and 63% would recommend vaccination for a woman with a medical condition in the first trimester. However, of the physicians who would recommend vaccination, 36%-38% reported that influenza vaccination was not offered in their practices. Increased efforts are needed to improve vaccine availability and to educate OB/GYNs regarding the updated ACIP recommendations on the use of influenza vaccine in the first trimester for both healthy pregnant women and pregnant women at high risk.     

Physician knowledge levels and barriers to coronary risk prevention in women: survey results from the Women and Heart Disease Physician Education Initiative.

BACKGROUND: Few studies have examined whether physician knowledge, attitudes, or practice patterns might contribute to gender disparities in the primary prevention of coronary heart disease (CHD), including among physicians caring for the largest number of reproductive-age women, obstetricians and gynecologists (OB/GYNs). We sought to identify barriers affecting the provision of recommended coronary risk factor therapies in women. METHODS: We surveyed internists and OB/GYNs who attended Grand Rounds presentations developed for the New York State Women and Heart Disease Physician Education Initiative. This program was designed to improve screening and management of coronary risk factors in women. Attendees were asked to complete a 7-minute questionnaire. RESULTS: The mean age of the 529 respondents was 40.3 years (standard deviation = 12.3), 75.1% were internists (n=378), and 42.7% (n=226) were women. Physicians correctly responded to 71.5% of the 13 questions assessing knowledge of coronary risk prevention (range, 4-13). Almost one third of internists and half of the OB/GYNs did not know that tobacco use was the leading cause of myocardial infarction in young women. For patients who smoked tobacco, only two thirds of internists and 55.4% of OB/GYNs reported suggesting a quit date (p=.007). After controlling for covariates, physicians who did not perceive time as a barrier were more likely to discuss smoking cessation (odds ratio=1.7 [1.1-2.7]). CONCLUSIONS: Among the internists and OB/GYNs surveyed, time was perceived as a barrier to implementing risk prevention. These physicians also underestimated the impact of tobacco use as a risk factor for CHD in young women. To lessen gender disparities in CHD prevention, both specialties need time-efficient educational programs that reflect specialty differences.     

Missed Opportunities: A National Survey of Obstetricians About Attitudes on Maternal and Infant Immunization

The recent reoccurrence of several vaccine-preventable diseases demonstrates the need for new techniques to promote childhood vaccination. Many mothers make decisions regarding vaccination of their children during pregnancy. As a result, obstetricians have a unique opportunity to influence maternal decisions on this crucial component of child health. Our objective was to understand OB/GYNs?? attitudes, beliefs, and current practices toward providing vaccinations to pregnant patients and providing information about routine childhood immunizations during standard prenatal care. We surveyed OB/GYNs in the United States about their vaccination practices and perceptions during the 2009 H1N1 outbreak. Most (84%) respondents indicated their practice would be administering H1N1 vaccines to pregnant patients. While a majority (98%) of responding providers felt childhood vaccination is important, relatively few (47%) felt that they could influence mothers?? vaccination choices for their children. Discussion of routine childhood immunization between obstetricians and their patients is an area for future improvements in childhood vaccination.     

Improving Care for Women with a History of Gestational Diabetes: A Provider Perspective

To identify perceived roles with regard to care for women with gestational diabetes mellitus (GDM) history and resources for improving care among women with a history of GDM from the perspective of obstetrician/gynecologists (OB/GYNs), certified nurse midwives (CNM), family practitioners, and internists. In 2010, a survey was sent to a random sample of OB/GYNs, CNM, family practitioners, and internists (n = 2,375) in Ohio to assess knowledge, attitudes, and postpartum practices regarding diabetes prevention for women with a history of GDM. A total of 904 practitioners completed the survey (46 %). Over 70 % of CNMs strongly agreed it is part of their job to help women with GDM history improve diet and increase exercise, compared with 60 % of family practitioners/internists and 55 % of OB/GYNs (p < 0.001). More OB/GYNs and CNMs identified a need for more local nutrition specialists and patient education materials, compared with family practitioners/ internists. Between 60 and 70 % of OB/GYNs and CNMs reported lifestyle modification programs and corresponding reimbursement would better support them to provide improved care. Health care providers giving care to women with GDM history have varying perceptions of their roles, however, there was agreement on resources needed to improve care.     

US Provider-Reported Diet and Physical Activity Counseling to Pregnant and Non-pregnant Women of Childbearing Age During Preventive Care Visits

Healthy diet, physical activity and appropriate weight gain during pregnancy contribute to healthy birth outcomes. The Institute of Medicine recommends that women receive counseling about diet and exercise during preconception, pregnancy and postpartum periods. We sought to determine how often healthcare providers report counseling women of childbearing age about diet or exercise and if such rates vary by pregnancy, overweight/obesity status or physician specialty. We combined the 2005–2010 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to obtain nationally representative estimates of outpatient preventive care visits for women of child-bearing age (15–44 years). Accounting for survey design, we compared proportions of preventive visits that included diet/exercise counseling for pregnant women versus non-pregnant women and performed multivariable logistic regression models to estimate odds ratios. Providers reported counseling pregnant women about diet/exercise during 17.9 % of preventive care visits compared to 22.6 % of visits for non-pregnant women (P < 0.01, adj. OR 0.8, 95 % CI 0.7, 1.0). Overweight/obese pregnant (vs. non-pregnant) women were significantly less likely to receive diet/exercise counseling (adj. OR 0.7, CI 0.5, 0.9) as were women seen by OB/GYNs versus non-OB/GYNs (adj. OR 0.4, CI 0.3, 0.5). Our findings suggest that provider-reported diet/exercise counseling rates during preventive care visits for women of childbearing age vary by overweight/obesity and pregnancy statuses, as well as by provider specialty. Our data suggest that there may be missed opportunities to provide diet/exercise counseling and that increasing rates of counseling could result in improved maternal and infant health outcomes.     

Modestly protective cytomegalovirus vaccination of young children effectively prevents congenital infection at the population level

A vaccine to prevent congenital cytomegalovirus infection (cCMV) is a public health priority. cCMV results from maternal primary or non-primary CMV infection (reinfection, or reactivation of chronic infection) during pregnancy. Young children are a major source of transmission to pregnant women because they shed CMV at high viral loads for prolonged periods. CMV vaccines evaluated in clinical trials so far have demonstrated only approximately 50% efficacy against maternal primary infection. None of these have been approved, as higher levels of vaccine efficacy are assumed to be required to substantially reduce cCMV prevalence. Here, we designed a mathematical model to capture the relationship between viral shedding by young children and maternal CMV infections during pregnancy. Using this model, we were able to quantify the impact of CMV post-infection immunity on protecting against reinfection and viral shedding. There was a 36% reduction in the risk of infection to a seropositive person with post-infection immunity (reinfection) versus a seronegative person without this immunity (primary infection), given the same exposure. Viral shedding following reinfection was only 34% the quantity of that following primary infection. Our model also predicted that a vaccine that confers the equivalent of post-infection immunity, when given to young children, would markedly reduce both CMV transmission to pregnant women and the prevalence of cCMV. Thus, we predict that existing vaccine candidates that have been shown to be only modestly protective may in fact be highly effective at preventing cCMV by interrupting child-to-mother transmission.     

Medicaid patients' access to office-based obstetricians

Recent expansion of the eligibility of low-income pregnant women for Medicaid-funded prenatal care may be jeopardized by undersupplies of obstetricians and gynecologists (OB/GYNs) in rural and urban low-income areas and by widely reported declines in the number of OB/GYNs willing to accept Medicaid patients. This paper examines the availability of office-based obstetric care to Medicaid patients in Illinois. We present and test a model of the determinants of Medicaid participation by private, office-based OB/GYNs that highlights the role of residential segregation and practice economics. We find that a large growth in demand for obstetrical care or the enhancement of Medicaid fees is unlikely to have a major effect on OB/GYN participation in Medicaid. We conclude that improving access will require expanding the supply of providers in underserved areas.     

From the Centers for Disease Control and Prevention. Progress toward elimination of perinatal HIV infection--Michigan, 1993-2000

In 1994, the U.S. Public Health Service (PHS) issued guidelines for maternal and neonatal zidovudine (ZDV) use to reduce perinatal human immunodeficiency virus (HIV) transmission. These guidelines recommend maternal ZDV use during the second and third trimesters of pregnancy and during labor and delivery (L&D) and administration of ZDV to the neonate for the first 6 weeks of life. In 2001, PHS updated 1995 guidelines for routine HIV counseling and voluntary testing of pregnant women. The Michigan Department of Community Health (MDCH) requires reporting of all children who are perinatally exposed to HIV and follows up these children to monitor their infection status and record demographic, clinical, and laboratory characteristics of infected children. The reporting of perinatally HIV-exposed children enables MDCH to monitor the effectiveness of public health efforts to prevent perinatal HIV transmission and assists the targeting of prevention programs and activities. This report summarizes surveillance data collected through December 31, 2001, on children born to HIV-infected women in Michigan during 1993-2000. The report highlights rapid adoption of PHS guidelines that resulted in the reduction of perinatally acquired HIV infection to historically low levels in Michigan. Improving levels of prenatal care (PNC) for HIV-infected pregnant women, especially substance users, and routine HIV counseling and voluntary testing for all pregnant women are needed to further reduce perinatal HIV infection.     

Awareness of and behaviors related to child-to-mother transmission of cytomegalovirus

Objective

Congenital cytomegalovirus (CMV) infection is a common cause of hearing loss and intellectual disability. We assessed CMV knowledge and the frequency of women's behaviors that may enable CMV transmission to inform strategies for communicating prevention messages to women.

Methods

We analyzed survey responses from 4184 participants (2181 women, 2003 men) in the 2010 HealthStyles survey, a national mail survey designed to be similar to the United States population.

Results

Only 7% of men and 13% of women had heard of congenital CMV. Women with children under age 19 (n = 918) practiced the following risk behaviors at least once per week while their youngest child was still in diapers: kissing on the lips (69%), sharing utensils (42%), sharing cups (37%), and sharing food (62%). Women practiced protective, hand cleansing behaviors most of the time or always after: changing a dirty diaper (95%), changing a wet diaper (85%), or wiping the child's nose (65%), but less commonly after handling the child's toys (26%).

Conclusions

Few women are aware of CMV and most regularly practice behaviors that may place them at risk when interacting with young children. Women should be informed of practices that can reduce their risk of CMV infection during pregnancy.     

HTLV-3 infection and AIDS: risk of spread by heterosexual contact

This article reviews current research evidence on the natural history, epidemiology, and clinical features of acquired immunodeficiency disease (AIDS) and presents guidelines for controlling the sexual transmission of human lymphotropic virus type III (HTLV-III) infection. The rapid spread of HTLV-III infection through homosexual communities in the US and Europe and its association with promiscuity initially obscured the fact that heterosexual transmission is also a significant risk factor for infection. Public health workers and epidemiologists are examining which sexual practices are most associated with the transmission of HTLV-III infection. Case-control studies in homosexuals have suggested that promiscuity, passive anal intercourse, and other sexual practices associated with rectal trauma and bleeding correlate with infection. Similar studies involving heterosexuals have not been conducted. However, the following guidelines have been proposed for couples where 1 partner has been found to be positive for HTLV-III antibodies: 1) sexual partners should be confined to established relationships; 2) anal intercourse should be avoided, even if the male uses a condom; 3) no oral contact with semen should occur; 4) if vaginal intercourse is practiced, the use of condom is essential; and 5) the only practices that are free from risk of infection are mutual masturbation and hand caresses. Since a high proportion of children of women with HTLV-III develop severe immunodeficiency, it is undesirable for women who are HTLV-III antibody positive to become pregnant. Furthermore, there is evidence that women who are HTLV-III antibody positive are more likely to develop AIDS if they become pregnant. A reliable method of permanent or reversible contraception is recommended for these women. Finally, men who are antibody positive should not donate sperm to a sperm bank.     

Use of contraceptive methods and contraceptive recommendations among health care providers actively involved in contraceptive counseling — results of an international survey in 10 countries

BackgroundThis study was conducted to determine the personal choices of contraceptive methods among an international sample of contraception health care professionals (HCPs) and to determine if these choices are concordant with their recommendations to women.Study DesignIn an anonymous online survey, 1001 HCPs actively involved in contraceptive counseling [obstetrician/gynecologists (OB/GYNs), general practitioners (GPs) and midwives (only in Sweden)] from 10 countries (Australia, Brazil, Canada, France, Germany, Korea, Mexico, Spain, Sweden and the United Kingdom) were asked about their personal use of contraceptive methods and their recommendations to women in two different clinical scenarios: for spacing between children (Group A) and after completion of the family (Group B).ResultsThe largest HCP group was OB/GYNs (67.1%), followed by GPs (31.4%) and midwives (1.5%). A total of 42.7% of respondents were male, and 57.3% were female. The majority of respondents were aged 36–45 years (38.9%) or 46–55 years (42.8%), 79.7% had children, and 53.9% were currently using contraception (by themselves or by their partners). Among 540 contraceptive users, the three most common methods were the levonorgestrel-releasing intrauterine system (LNG-IUS; 29.3%), combined oral contraceptives (COCs; 20.0%) and condoms (17.0%). OB/GYNs were more likely to be using the LNG-IUS than GPs (p=.014). Gender did not seem to influence contraceptive preference. Reasons for these choices were largely influenced by family situation and high contraceptive efficacy (for the LNG-IUS) or side effects caused by other methods (for condoms). The top contraceptive recommendation was COCs for Group A and the LNG-IUS for Group B. HCPs currently using COCs and the LNG-IUS were more likely to recommend these methods than other contraceptive methods for Group A and Group B, respectively.ConclusionsThe most popular contraceptive method in this sample of HCPs was the LNG-IUS. Choice of contraceptive method was driven by family situation, age and profession. It appears that, in this sample, personal contraceptive use influences contraceptive recommendations.     

Obstetric Providers’ Knowledge, Awareness, and Use of CDC’s HIV Testing Recommendations and One Test. Two Lives.™

This study examined the impact of the Centers for Disease Control and Prevention’s (CDC’s) One Test. Two Lives.? (OTTL) campaign on key outcomes related to CDC’s revised HIV testing recommendations and the use of the campaign materials. Data from three cross-sectional surveys were used to assess the effect of OTTL on Obstetricians/Gynecologists’ (OB/GYN) HIV knowledge and practice. A 2-year combined sample of 500 OB/GYNs completed DocStyles, a Web-based survey for physicians, and 575 American College of Obstetricians and Gynecologists (ACOG) Fellows completed an ACOG survey. The surveys were similar in focus but did not contain the same items. Data were analyzed using cross-tabulations, χ² analyses, and logistic regression. There was a 20% recall of exposure to OTTL with DocStyles and 25% with ACOG. DocStyles respondents reporting having seen OTTL materials were significantly more likely to report awareness of CDC’s recommendations [χ²(1) = 25.43, P < .001] and include HIV testing as a regular screening test for all patients [χ²(1) = 4.98, P < .05]. ACOG respondents not using the materials indicated high levels of willingness to use the materials—63.0 to 71.5%, depending on the material. Of the ACOG sample, 68.1% correctly answered the knowledge items regarding the recommendations. However, a significant relationship between correct knowledge and campaign exposure was not found. Overall, results suggest that OTTL is instrumental in raising awareness and implementation of the testing recommendations and plays an important role in facilitating HIV testing practices with obstetric providers and their patients.     

天津市2011年度预防艾滋病、梅毒和乙肝母婴传播年度数据分析与工作进展报告

为提高人群对预防艾滋病、梅毒和乙肝母婴传播的认识,为孕产妇提供预防艾滋病、梅毒和乙肝母婴传播的综合防治服务,最大限度地减少因艾滋病、梅毒和乙肝母婴传播造成的儿童感染,改善妇女、儿童的生活质量及健康水平,天津市卫生局在2011年下发了《天津市预防艾滋病、梅毒和乙肝母婴传播工作实施方案》,明确了各级职能,加强了管理培训和质控督导,增加了政府的经费支持,以期扩大对艾滋病、梅毒、乙肝感染孕产妇的干预治疗覆盖面,提高救治水平,降低新发感染,减少母婴传播。     

妊娠早期巨细胞病毒活动性感染患者可溶性白细胞介素-2受体水平与病毒宫内感染的关系

目的: 探讨巨细胞病毒活动性感染的早期妊娠妇女外周血可溶性白细胞介素 -2受体 (SolubleInterleukin-2Receptor, sIL-2R) 水平与巨细胞病毒 (cytomegalovirus, CMV) 宫内感染的相关性。方法: 应用酶联免疫吸附试验和逆转录聚合酶链反应方法筛查出巨细胞病毒活动性感染孕妇 134例, 测定其外周血中sIL-2R水平, 并通过超声影像动态观察其子代生长发育情况直至终止妊娠, 流产、引产或分娩后检测子代标本确定有无宫内感染。结果: 134例研究对象中, 足月分娩者 77例,妊娠结局不良者 10例, 获得子代标本者 64例, 其中 21例CMVDNA阳性, 其母体外周血sIL-2R平均水平 258 41±15 44U/ml, 43例无宫内传播者母体外周血sIL-2R平均水平 188 41±21 35U/ml, 两者差异具有统计学意义 (t=2 52, p=0 02)。10例妊娠结局不良者孕妇外周血sIL-2R平均水平 (223 66±25 15U/ml) 高于 77例足月分娩孕妇 (166 67±18 17U/ml)。结论: 巨细胞病毒活动性感染的早期妊娠妇女外周血中sIL-2R水平与病毒宫内传播有一定相关性, 出现流产、死胎等异常妊娠结局者外周血sIL-2R水平具有升高趋势。     

Educating women about congenital cytomegalovirus: assessment of health education materials through a web-based survey

Background

Congenital cytomegalovirus (CMV) is the most common congenital infection in the U.S. and can result in permanent disabilities, such as hearing and vision loss, intellectual disability, and psychomotor and language impairments. Women can adopt prevention behaviors in an attempt to reduce their exposure to CMV. Currently, few women are familiar with CMV. To increase awareness of CMV, the Centers for Disease Control and Prevention (CDC) developed draft health education materials. The purpose of this study was to pilot test two health education materials to gauge their appeal and to determine if they increase knowledge about CMV and motivate audiences to seek additional information on CMV and adopt CMV prevention behaviors.

Methods

African-American (n?=?404) and Caucasian women (n?=?405), who had a young child and were either pregnant or planning a pregnancy, were recruited to participate in a 15-minute web survey. Participants were randomly assigned to view one of two CMV health education materials, either a factsheet or video. Pre and post survey measures were used to assess changes in knowledge of CMV and motivation to adopt prevention behaviors. We also examined audience preferences regarding materials and motivation.

Results

CMV knowledge score increased significantly after presentation of either the video or factsheet (from 3.7 out of 10 to 9.1 out of 10, p <0.001). The average materials appeal score was high, with a mean of 3.6 on a four-point scale, indicating women responded very positively to both materials. Regression analyses indicated that appeal, message involvement (e.g., information seeking, discussing with others), post materials knowledge score, and viewing the video (vs. factsheet) were significantly positively associated with increased support for CMV prevention behaviors.

Conclusions

Overall, we found that the health education materials improved women’s knowledge of CMV and encouraged them to adopt prevention behaviors. Given the low awareness levels among women currently, these findings suggest that appropriate education materials have the potential to greatly increase knowledge of CMV.As women become more knowledgeable about CMV and transmission routes, we expect they will be more likely to adopt prevention behaviors, thereby reducing their risk of CMV infection.

     

秦巴山区孕期巨细胞病毒感染状况分析

目的 研究弱智高发区巨细胞病毒(CMV)感染流行病学状况。方法 用ELISA和PCR方法对弱智高发区的367例孕妇进行监测及问卷调查，并监测63例孕期CMV感染2两周内母体乳汁CMV—DNA。结果 弱智高发区孕期CMV活动性感染率19．62％，宫内传播率33．33％，产后乳汁排泄率39．02％；孕期CMV感染与年龄、化程度、经济状况、胎次及病理性生产史有关，与孕周无关。结论 提示在弱智高发区也应重视CMV的监测，化程度低、经济状况差、胎次及有病理性生产史，应视为孕期CMV感染的高危因素。     

孕产妇艾滋病知识、态度和感染情况调查

[目的]了解孕产妇对艾滋病传播和预防知识知晓率水平、对感染人类免疫缺陷病毒(HIV)感染者的态度、高危行为以及艾滋病病毒(HIV)感染状况,为制订本地区母婴阻断艾滋病干预措施提供科学依据。[方法]采用现况调查方式了解辖区内孕产妇对艾滋病知识掌握情况、所持态度及其吸毒、有偿供血、外出打工、性病感染情况等高危行为和干预措施进行分析,并采集静脉血进行HIV抗体检测。[结果]在本次监测的454名孕产妇中,孕产妇HIV感染率为0.22%;对传播途径等8个核心指标知晓率为47.58%;64.1%不愿意与HIV感染者交往;0.44%丈夫有吸毒史;30.40%丈夫去外地打工或经商;17.10%接受过安全套发放服务;84.36%艾滋病知识信息来源于电视。[结论]该地区孕产妇HIV感染率高于本地区全人群感染率,艾滋病知识知晓率低,对HIV感染者存在恐惧和歧视,安全套发放、知识宣传这些干预工作开展力度和普及面尚不能满足目前艾滋病防治工作的需要。应充分关注本地区孕产妇的艾滋病预防工作,并采取更为有效的艾滋病健康促进干预措施。建议开展产前门诊常规HIV检测,提高孕妇HIV自愿咨询检测率。