Varicella zoster virus (VZV)
Given the significant risk of maternal and fetal harm with primary VZV infection during pregnancy, assessing a woman’s VZV immunity preconception will allow you to provide her with varicella vaccine if she is not immune. A history of chicken pox infection, evidence of VZV vaccination, or positive VZV serologies are all acceptable means to assess immunity. For a woman without proof of immunity, a preconception VZV vaccine can protect her from life-threatening pneumonia and her fetus from congenital varicella syndrome. Because the vaccine for VZV is live attenuated, vaccination should be performed, at least 4 weeks prior to attempted conception given the theoretical concern for causing birth defects.12
Other vaccines may be indicated, particularly in women who have medical illnesses that put them at high risk for
vaccine-preventable illnesses. Obtaining a thorough preconception immunization history as part of routine care also may uncover adult women who have missed prior vaccination opportunities.
Hepatitis B (HPV) and hepatitis A (HAV)
HAB and HAV immunity is particularly important for women planning pregnancy who are at high risk for these infections (Table 2). HBV vaccine is administered in a three-dose series (0, 1, and 4 months apart). The vaccine for HAV is inactivated and can be given pre-exposure as a two-dose series (6 to 18 months apart), or as post-exposure prophylaxis. These vaccines are recombinant and have not been associated with adverse fetal outcomes. Therefore, no waiting period is required after administration in the preconception period and they can be administered during pregnancy if needed or if the three-dose series has not been completed.13
The pneumococcal vaccine is indicated for adult women who are at high risk for serious complications from pneumococcus, such as individuals who smoke or who have asthma or diabetes. Additional indications are summarized in Table 2.14-17 There are two pneumococcal vaccines. For adults with risk factors, the CDC recommends administering one dose of PCV13 followed by the PPSV23 dose at least 8 weeks later without a delay in conception.16-18
Human papillomavirus (HPV)
Vaccination against HPV is recommended to prevent new HPV infections and HPV-associated diseases, including cervical cancer. While this vaccine remains targeted to young adolescents, the Advisory Committee on Immunization Practices (ACIP) now endorses catch-up HPV vaccination for all individuals through age 26 years. Adults who have previously been infected with one or more HPV types can still benefit from protection for other types available in the vaccine. For adults aged 27 through 45 years, and at risk for new HPV infection, decisions around vaccination should be made using a shared clinical decision-making model.19,20 HPV vaccination for patients older than age 15 should follow a three-dose regimen (0, 1 to 2 and 6 months). Counseling and guidance about the benefits of HPV vaccination are ideal for preconception women who plan for pregnancy in greater than 6 months. While the HPV vaccine is not recommended during pregnancy, inadvertent HPV vaccination during pregnancy is not associated with adverse events for a woman or her fetus.19
- Finney Rutten LJ, St Sauver JL, Beebe TJ, et al. Association of both consistency and strength of self-reported clinician recommendation for HPV vaccination and HPV vaccine uptake among 11- to 12-year-old children. Vaccine. 2017;35(45):6122-6128.
- Rutten LJF, St Sauver JL, Beebe TJ, et al. Clinician knowledge, clinician barriers, and perceived parental barriers regarding human papillomavirus vaccination: Association with initiation and completion rates. Vaccine. 2017;35(1):164-169.
- Martinello RA, Jones L, Topal JE. Correlation between healthcare workers’ knowledge of influenza vaccine and vaccine receipt. Infect Control Hosp Epidemiol. 2003;24(11):845-847.
- Shavell VI, Moniz MH, Gonik B, Beigi RH. Influenza immunization in pregnancy: overcoming patient and health care provider barriers. Am J Obstet Gynecol. 2012;207(3 Suppl):S67-S74.
- Goldfarb I, Panda B, Wylie B, Riley L. Uptake of influenza vaccine in pregnant women during the 2009 H1N1 influenza pandemic. Am J Obstet Gynecol. 2011;204(6 Suppl 1):S112-S115.
- ACOG Committee Opinion No. 732: Influenza Vaccination During Pregnancy. Obstet Gynecol. 2018;131(4):e109-e114.
- Mølgaard-Nielsen D, Fischer TK, Krause TG, Hviid A. Effectiveness of maternal immunization with trivalent inactivated influenza vaccine in pregnant women and their infants. J Intern Med. July 2019.
- Grohskopf LA, Alyanak E, Broder, KR et al . Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2019–20 Influenza Season. MMWR Recomm Rep. 2019;68(3); 1-21.
- Measles & the MMR Vaccine: Recommendations Around Pregnancy, Including the Periconception and Postpartum Periods - UW Medicine Provider Resource. http://providerresource.uwmedicine.org/flexpaper/measles-and-the-mmr-vaccine-recommendations-around-pregnancy-including-the-periconception-and-postpartum-periods. Accessed September 25, 2019.
- Centers for Disease Control and Prevention. Measles: Evidence of Immunity. https://www.cdc.gov/measles/hcp/index.html#immunity.
- McLean HQ, Fiebelkorn AP, Temte JL, et al. Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62(RR-04):1-34.
- Marin M, Güris D, Chaves SS, S et al. Centers for Disease Control and Prevention (CDC). Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56(RR-4):1-40.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 86: Viral hepatitis in pregnancy. Obstet Gynecol. 2007;110(4):941-956.
- Mast EE, Weinbaum CM, Fiore AE, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults. MMWR Recomm Rep. 2006;55(RR-16):1-33; quiz CE1-CE4.
- Fiore AE, Wasley A, Bell BP. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(RR-7):1-23.
- Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61(40):816-819.
- Centers for Disease Control and Prevention (CDC), Advisory Committee on Immunization Practices. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR Morb Mortal Wkly Rep. 2010;59(34):1102-1106.
- Pneumococcal Vaccination Summary | Who and When to Vaccinate | For Providers | CDC. https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html. Published June 20, 2019. Accessed September 25, 2019.
- HPV Vaccine Recommendations | Human Papillomavirus | CDC. https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html. Published June 27, 2019. Accessed September 25, 2019.
- Committee Opinion No. 704 Summary: Human Papillomavirus Vaccination. Obstet Gynecol. 2017;129(6):1155-1156.
- Use of Standing Orders Programs to Increase Adult Vaccination Rates: Recommendations of the Advisory Committee on Immunization Practices. https://www.cdc.gov/mmwr/PDF/rr/rr4901.pdf.
- Committee on Obstetric Practice, Immunization and Emerging Infections Expert Work Group. Committee Opinion No. 718: Update on Immunization and Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination. Obstet Gynecol. 2017;130(3):e153-e157.
- ACOG Committee Opinion No. 741: Maternal Immunization. Obstet Gynecol. 2018;131(6):e214-e217.