ACIP is Recommending Tdap for Every Pregnancy

During its late October meeting in Atlanta, the CDC's Advisory Committee on Immunization Practices (ACIP) made a provisional recommendation that will further alter the way family physicians approach tetanus, diphtheria and acellular pertussis (Tdap) vaccination for pregnant women.

According to Jamie Loehr, M.D., of Ithaca, N.Y., the AAFP's liaison to the ACIP, the committee voted 14-0, with one abstention, to recommend that providers of prenatal care implement a Tdap immunization program for all pregnant women, administering a dose during each pregnancy irrespective of immunization history. If not administered during pregnancy, Tdap should be administered immediately postpartum.

"The recommendation is that all pregnant women should receive the Tdap (vaccine) during the late-second or third trimester, regardless of whether or not they've had the Tdap before," Loehr told AAFP News Now. "It is a huge change. In the past, it was recommended that pregnant women get the Tdap during that time period, but (the ACIP) never talked about subsequent pregnancies. Now they are saying you can get pregnant two times in a year and get two Tdaps."

Loehr said the data show that when the Tdap vaccine is given to an expectant mother, she produces antibodies, which then are passed on to the fetus. These antibodies protect the baby in the first couple of months of life before the diphtheria and tetanus toxoids and acellular pertussis adsorbed (DTaP) vaccine is administered to the child. Because Tdap protection has been shown to decrease over time and because pertussis epidemics across the United States have already claimed the lives of 16 children in 2012, the ACIP passed the recommendation in spite of a paucity of evidence regarding efficacy and outcomes.

"We know the protection wanes, so it might not be there for the next pregnancy, and so we will give them another shot so that the protection will be there at the end of the subsequent pregnancy," said Loehr. "But there is limited data on repeat Tdap (vaccinations) with non-pregnant women. As a practicing FP, I'm going to follow the recommendations, because in general I believe in the process, even when I think the process is not as rigorous as I would like."

ACIP recommendations are considered provisional until they have been approved by the CDC director and HHS and published in Morbidity and Mortality Weekly Report. Only after the provisional recommendation has been posted to the ACIP site will it be formally reviewed by the AAFP Commission on Health of the Public and Science's Subcommittee on Clinical Preventive Services.

The ACIP also voted to recommend that infants at increased risk for meningococcal disease should be vaccinated with four doses of the Haemophilus influenzae type B–Neisseria meningitidis serogroups C and Y–tetanus toxoid (HibMenCY) vaccine at ages 2, 4 and 6 months, as well as 12 through 15 months.

"These include infants with recognized persistent complement pathway deficiencies and infants who have anatomic or functional asplenia, including sickle cell disease," the CDC said in a media advisory. "HibMenCY can be used in infants ages 2 through 18 months who are in communities with serogroup C and Y meningococcal disease outbreaks."

Loehr said the affected subset of infants is very small.

"There was a movement to try and recommend it for all infants … but the burden of disease in the United States for infants was so low that the working group and the ACIP couldn't bring themselves to vote for it," he said.

Loehr noted that the ACIP also heard information on two other issues: the availability of Merck and Co.'s combination measles, mumps, rubella and varicella (MMRV) vaccine (ProQuad) and the status of both the inhalable and injectable versions of the quadrivalent influenza vaccine.

"ProQuad is back on the market and available now," said Loehr. "There will also be an influenza quadrivalent on the market for the 2013-2014 flu season, with a small caveat," he noted. "There will be a large supply of quadrivalent nasal vaccine, but the injectable quadrivalent (vaccine) still needs FDA approval, which will likely happen in the next several months. So while the injectable version will technically be available, the trivalent will be the predominant injectable vaccine offered in 2013-2014 because it is likely the FDA will not yet have given its approval by the time we start ordering vaccines."