Assessing the relationship between operationally defined zero-dose communities and access to selected primary healthcare services for children and pregnant women in emergency settings.

In this study the authors examine the relationship between "zero-dose" communities and access to healthcare services. This was done by first ensuring the first dose of the Diphtheria Tetanus and Pertussis vaccine was a better measure of zero-dose communities than the measles-containing vaccine. Once ensured, it was used to examine the association with access to primary healthcare services for children and pregnant women in the Democratic Republic of Congo, Afghanistan, and Bangladesh. These services were divided into: a) unscheduled healthcare services such as birth assistance as well as seeking care and treatment for diarrheal diseases and cough/fever episodes and b) other scheduled health services such as antenatal care visits and vitamin A supplementation. Using recent Demographic Health Survey data (2014: Democratic Republic of Congo, 2015: Afghanistan, 2018: Bangladesh), data was analyzed via Chi Squared analysis or Fischer's Exact Test. If significant, a linear regression analysis was performed to examine if the association was linear. While the linear relationship observed between children who had received the first dose of the Diphtheria Tetanus and Pertussis vaccine (the reverse to zero-dose communities) and coverage of other vaccines was expected, the results of the regression analysis depicted an unexpected split in behavior. For scheduled and birth assistance health services, a linear relationship was generally observed. For unscheduled services associated with illness treatments, this was not the case. While it does not appear that the first dose of the Diphtheria Tetanus and Pertussis vaccine can be used to predict (at least in a linear manner) access to some primary (particularly illness treatment) healthcare services in emergency/ humanitarian settings, it can serve as an indirect measure of health services not associated with the treatment of childhood infections such as antenatal care, skilled birth assistance, and to a lesser degree even vitamin A supplementation.

Knowledge, Perceptions, Attitudes and Practices of Midwives Regarding Maternal Influenza and Pertussis Vaccination: A Qualitative Study.

The coverage of maternal vaccination against pertussis and, particularly, influenza is lower than expected. The lack of recommendation from healthcare providers conditions non-vaccination in pregnant women. The purpose was to determine the knowledge, perceptions, attitudes and practices of midwives regarding maternal influenza and pertussis vaccination. A qualitative descriptive study based on semi-structured, face-to-face interviews with seventeen midwives was conducted, including purposive sampling and thematic analyses. Midwives had disparate knowledge and perceptions about the severity of influenza and pertussis in pregnant women, and influenza was not considered very serious. The vaccines were generally considered safe. However, because midwives did not have enough information about the safety of the influenza vaccine, there was a tendency not to recommend it. While most midwives had a positive attitude toward vaccination, their advocation for vaccination against influenza was not as clear as it was for pertussis. Not wanting to influence the decision and assuming an informative-facilitating role also led providers to recommend the influenza vaccine less frequently. Midwives are among the main sources of professional advice for pregnant women. Addressing their understanding and professional practices regarding maternal vaccination is key to change the attitude of pregnant women and thus increase vaccine uptake among them, particularly for influenza.

Understanding factors that influence the decision to be vaccinated against influenza and pertussis in pregnancy: A qualitative study.

AIMS AND OBJECTIVES: To identify how pregnant women perceive pertussis and influenza and the factors that influence their decision to be vaccinated. BACKGROUND: Suffering from influenza during pregnancy increases complications in the pregnant woman, foetus and newborn. Pertussis in children under six months of age causes severe complications. Maternal vaccination against influenza and pertussis is effective and safe. However, vaccination rates are insufficient. DESIGN: We conducted a qualitative descriptive study, using semi-structured interviews. This research adheres to the COREQ guidelines and checklist. METHODS: We carried out 18 semi-structured face-to-face interviews with pregnant women, using intentional sampling and thematic analysis. RESULTS: We identified an overarching theme, 'factors that influenced participants' decision to be vaccinated or not', which was composed of four subthemes that were in turn made up of 12 categories. The factors that influenced participants' decision to be vaccinated against influenza and pertussis were related to their knowledge of and their perception of risk for these diseases. Participants perceived the risk of pertussis to be greater, and they focused their concern on the newborn. The recommendations and convictions of nurse-midwives were the most important factors encouraging vaccination. Participants trusted their nurse-midwives and most reported that they would have been vaccinated if their midwife had recommended it. Other factors were linked to lack of information, fear and concerns about economic interests. CONCLUSIONS: The convictions and actions of the nurse-midwife in recommending vaccination to pregnant women are decisive. Strategies to improve vaccination rates should be directed to helping health professionals understand how their practice affects the final decision of pregnant women. RELEVANCE TO CLINICAL PRACTICE: Understanding the factors that limit vaccination rates among pregnant women provides valuable information to nurse-midwives that can help to improve vaccination strategies and practices. Increased maternal vaccination rates would reduce morbidity and mortality among pregnant women and newborns.

Pharmacotherapy for Bordetella pertussis infection. II. A synthesis of clinical sciences.

Despite the plethora of studies that have examined laboratory susceptibility testing for Bordetella pertussis, assessments of treatment have lagged far behind both in quality and quantity. Macrolides and trimethoprim/sulfamethoxazole historically served the needs of both treatment and prevention, albeit there is still controversy about the degree of protection measured both bacteriologically and clinically. As high-level macrolide resistance has emerged in some geographic regions and since macrolides have been the mainstay of therapy, alternative antibiotics need to be defined for pertussis. In vitro susceptibility testing suggests the potential for several alternatives to macrolides, including trimethoprim/sulfamethoxazole, specific ß-lactam agents, chloramphenicol, some quinolones and possibly some tetracyclines. For the latter antibiotics, more clinical studies for treatment and prophylaxis are required in to order to establish bacteriological-clinical correlates for outcome. In the interim, if the clinical circumstances mandate the use of proposed interim alternatives to macrolides, outcomes should be assessed with test of cure by culture, since genetic amplification technologies do not discriminate bacterial viability. Whereas there may be debate in regard to using placebo or macrolides as the controls for alternative antibiotic therapy in geographies where most B. pertussis isolates are antibiotic-susceptible, both placebo and macrolide controls should be assessed along with alternative antibiotics in well-designed controlled studies in regions pressured by macrolide resistance. Outcomes of clinical response and epidemiological patterns of disease should continue to be monitored given the degree of macrolide resistance that is emerging.

The global prevalence ptxP3 lineage of Bordetella pertussis was rare in young children with the co-purified aPV vaccination: a 5 years retrospective study.

BACKGROUND: The global prevalent ptxP3 strains varies from about 10% to about 50% of circulating B. pertussis population in different areas of China. METHODS: To investigate the difference of vaccination status between different genotypes in the circulating B. pertussis after 10 years of acellular pertussis vaccine (aPV) used in China. The nasopharyngeal swabs and isolates of B. pertussis from these patients were used to perform genotyping of antigen genes. We use antibiotic susceptibility test against erythromycin and sequencing methods for site 2047 of 23S rRNA to determine the resistance status. RESULTS: The ptxP1 allele with erythromycin resistant (ER) B. pertussis infection (total of 449 subjects) consisted of 84.70 to 96.70% from 2012 to 2016 in this study. Vaccinated with co-purified aPV was found in 133(133/403,33.0%), 1(1/9,11.1%) and 2(2/21,9.5%) in ptxP1/fhaB3-ER, ptxP1/fhaB2-ES and ptxP3/fhaB2-ES B. pertussis infected children each, which showed a significant difference (χ2 = 6.87, P = 0.032). CONCLUSIONS: The ptxP3-ES B. pertussis was rare while the ptxP1-ER B. pertussis was steadily increased in Xi'an, China from 2012 to 2016, where co-purified aPV was prevalent used. This pose a hypothesis that the co-purified aPV might protect against ptxP3 strains more efficient, which generated a rare chance for ptxP3 strains to be under the antibiotic pressure and further developed to be erythromycin resistance. A further cohort study and the mechanisms of the additional antigen proteins of co-purified aPV protected against B. pertussis should be consideration.

Maternity staff immunization coverage against pertussis and maternal vaccination practices: Results of a 2017 cross-sectional survey in five public maternity hospitals.

OBJECTIVES: To conduct an audit of vaccination practices against pertussis in maternity wards to assess immunization practices targeting women, knowledge and awareness among health professionals and their involvement in the vaccination process, and to estimate their vaccine coverage. MATERIALS AND METHODS: 2017 cross-sectional descriptive survey using a data collection sheet of immunization practices targeting women and an anonymous questionnaire for health professionals whose vaccine coverage had been documented by the occupational health service. RESULTS: Five public maternity wards participated: one had a vaccination policy for women; 426 of 822 health professionals completed the questionnaire, 76% (from 50% of all residents to 83% of nurses) declared their vaccination status as up to date. Staff files in occupational health services showed that 69% of 822 health professionals received at least one vaccine booster during adulthood (57% less than 10 years before the survey); documented vaccination coverage rates ranged from 75% for residents to 91% for senior physicians. Occupational physicians and family physicians respectively performed 41% and 34% of vaccinations. While knowledge regarding vaccines was good, only 47% of health professionals declared prescribing them and 18% declared administering the anti-pertussis vaccine "often" or "very often". CONCLUSIONS: Updated data is needed to confirm the reported increase as participating centers are not representative of all birth centers. The active role of health professionals in vaccination-based pertussis prevention needs to be reinforced.

Acceptance of pregnant women's vaccination against pertussis among French women and health professionals: PREVACOQ-1 and -2 studies.

OBJECTIVES: Protection of French young infants against pertussis only relies on their relatives' vaccination. The alternative is vaccination of pregnant women against pertussis (cocooning strategy), but this strategy is not yet recommended in France. We assessed the acceptance of this strategy among French postpartum women and health professionals. PATIENTS AND METHODS: We performed a multicenter survey in 2016 among postpartum women and health professionals (family physicians, obstetricians-gynecologists, midwives, and medical students) to determine the acceptance of anti-pertussis vaccination. We evaluated knowledge, perception, and attitude towards vaccination to identify factors associated with acceptance. RESULTS: Questionnaires were completed by 52% (1208/2337) of women and 40% (694/1754) of health professionals. Seventy-seven per cent of women (95% CI: 74-79) and 93% of health professionals (95% CI: 91-95) were favorable to anti-pertussis vaccination of pregnant women. Thirty-three per cent (227/687) of health professionals believed that pertussis induced life-long immunity and 20% (136/687) of them were not aware of the cocooning strategy. In multivariate analysis, factors associated with acceptance among women were younger age, higher knowledge, having received advice during pregnancy, being vaccinated against influenza, and having never refused any vaccine; among health professionals, factors associated with acceptance were belief that inactivated vaccines are obstetrically safe, regular practice of influenza vaccination in pregnant women, pertussis cocooning strategy, and never prescribing preventive homeopathy for influenza. CONCLUSION: Vaccination of pregnant women against pertussis should be well-accepted by informed mothers and health professionals. If this strategy were to be implemented in France, efforts should be made towards adequate information.

Potential use of Western Australia's mandatory Midwives Notification System for routinely monitoring antenatal vaccine coverage

Background: Despite the maternal and infant health benefits of antenatal vaccines and availability of government-funded vaccination programs, Australia does not have a national system for routinely monitoring antenatal vaccination coverage. We evaluated the potential use of Western Australia's mandatory Midwives Notification System (MNS) as a tool for routinely monitoring antenatal vaccination coverage. Methods: Two hundred and sixty-eight women who gave birth to a live infant between August and October 2016 participated in a telephone survey of vaccines received in their most recent pregnancy. For women who reported receiving influenza and/or pertussis vaccine and whose vaccination status was documented by their vaccine provider, MNS vaccination data were compared with the vaccine provider's record as the 'gold standard.' For women who reported receiving no vaccines, MNS vaccination data were compared with self-reported information. Results: Influenza and pertussis vaccination status was complete (i.e. documented as either vaccinated or not vaccinated) for 66% and 63% of women, respectively. Sensitivity of MNS influenza vaccination data was 65.7% (95% CI 56.0-74.2%) and specificity was 53.0% (95% CI 42.4-63.4%). Sensitivity of MNS pertussis vaccination data was 62.5% (95% CI 53.3-70.9%) and specificity was 40.4% (95% CI 27.6-54.7%). There was no difference between vaccinated and unvaccinated women in the proportion of MNS records with missing or unknown vaccination information. When considering only MNS records with complete vaccination information, the sensitivity of the MNS influenza vaccination field was 91.8% (95% CI 83.0-96.9%) and the sensitivity of the MNS pertussis vaccination field was 88.0% (95% CI 76.7-95.5%). Conclusion: Due to the high proportion of records with missing or unknown vaccination status, we observed low sensitivity and specificity of antenatal vaccination data in the MNS. However, given we did not observe differential ascertainment by vaccination status, MNS records with complete information may be reliable data source for routinely monitoring antenatal vaccine coverage.

PERISCOPE: road towards effective control of pertussis.

The resurgence and changing epidemiology of pertussis in high-income countries, the high infant mortality caused by pertussis in low-income countries, and the increasing morbidity in all age groups worldwide call for a concerted effort to both improve the current vaccines and develop new vaccines and vaccination strategies against pertussis. In this Personal View, we identify several key obstacles on the path to developing a durable solution for global control of pertussis. To systematically address these obstacles, the PERtussIS Correlates Of Protection Europe (PERISCOPE) Consortium was established in March, 2016. The objectives of this consortium are to increase scientific understanding of immunity to pertussis in humans induced by vaccines and infections, to identify biomarkers of protective immunity, and to generate technologies and infrastructure for the future development of improved pertussis vaccines. By working towards the accelerated licensure and implementation of novel, well tolerated, and effective pertussis vaccines, we hope to strengthen and stimulate further collaboration and transparency between the key stakeholders, including the public, the scientific community, public health institutes, regulatory authorities, and vaccine manufacturers.

Vaccination against pertussis and influenza in pregnancy: a qualitative study of barriers and facilitators.

OBJECTIVES: Influenza and pertussis vaccination programmes have been in place for pregnant women in the UK since 2009 and 2012, respectively. In 2015, vaccine uptake rates were 55% for influenza and 63% for pertussis in Northern Ireland. We conducted a qualitative study with the aim of learning about the views of pregnant women and identifying potential barriers to vaccination in pregnancy. STUDY DESIGN: Qualitative study using focus groups and in-depth interviews. METHODS: We conducted focus group discussions and interviews on vaccination in pregnancy using a discussion guide developed in consultation with stakeholders and service users. Pregnant women were recruited on-street. We performed inductive coding of transcripts and thematic analysis, using a phenomenological approach. RESULTS: Sixteen pregnant women participated. We identified six key themes. Information and knowledge: Vaccinated and unvaccinated women demonstrated similar levels of knowledge and desire for information, preferring direct communication with healthcare professionals. The influence of others: Some vaccinated participants reported firm endorsements of vaccination by healthcare professionals including midwives, while some unvaccinated women recalled neutral or reticent staff. Acceptance and trust: Most women expressed trust of health professionals. Fear and distrust: Vaccinated individuals expressed concerns about side-effects more than unvaccinated women. A few unvaccinated women expressed distrust of vaccines and healthcare systems. Responsibility for the baby: Both groups prioritised protecting the baby but unvaccinated participants were concerned about vaccine-related harm. Accessing vaccination: Multiple appointments, lack of childcare, time off work and having responsibility to organise vaccination hindered some participants from getting immunised. Some women were willing to be vaccinated but did not recall being offered vaccination or were not sufficiently motivated to make arrangements themselves. CONCLUSION: Healthcare professionals appear to have a vital influential role in pregnant women's decisions about vaccination. Involving midwives and improving convenience of vaccination access may increase uptake. Strategies to develop interventions should address the aforementioned barriers to meet the pregnant women's needs.

Strategies for increasing uptake of vaccination in pregnancy in high-income countries: A systematic review.

INTRODUCTION: Vaccination in pregnancy is an effective method to protect against disease for the pregnant woman, foetus and new born infant. In England, it is recommended that pregnant women are vaccinated against pertussis and influenza. Improvement in the uptake of both pertussis and influenza vaccination among pregnant women is needed to prevent morbidity and mortality for both the pregnant women and unborn child. AIM: To identify effective strategies in increasing the uptake of vaccination in pregnancy in high-income countries and to make recommendations for England. METHODS: A systematic review of peer reviewed literature was conducted using a keyword search strategy applied across six databases (Medline, Embase, PsychInfo, PubMed, CINAHL and Web of Science). Articles were screened against an inclusion and exclusion criteria and papers included within the review were quality assessed. RESULTS AND CONCLUSIONS: Twenty-two articles were included in the review. The majority of the papers included were conducted in the USA and looked at strategies to increase influenza vaccination in pregnancy. There is limited high quality evidence for strategies in high-income countries to increase coverage of pertussis and influenza vaccination in pregnancy. A number of strategies have been found to be effective; reminders about vaccination on antenatal healthcare records, midwives providing vaccination, and education and information provision for healthcare staff and patients. Future interventions to increase vaccination in pregnancy should be evaluated to ensure efficacy and to contribute to the evidence base.

Pertussis vaccination uptake in pregnancy: lessons to be learned from an integrated healthcare approach.

AIM: To determine the proportion of pregnant women vaccinated with the pertussis booster in the third trimester of their pregnancy, and explore factors influencing coverage. METHODS: A clinical audit was undertaken at Rotorua hospital using electronic databases to determine pertussis immunisation among women who birthed from 25 March to 25 April, 2017 (n=111). Lead maternity carers (LMCs) were surveyed to assess knowledge of the vaccine and explore suggestions to increase vaccination coverage. RESULTS: Only 44% (n=49) of women were vaccinated in 2017. Women 25 years and under, and women from Rotorua were less likely to be vaccinated. A woman not being recalled to the GP for vaccination was the biggest reason for not being vaccinated (n=27). Every woman in Taupo/Turangi was recalled in pregnancy, leading to greater vaccine uptake compared to women in Rotorua. CONCLUSION: Overall, the proportion of pregnant women vaccinated for pertussis continue to be low with coverage being disproportionally lower for younger women. The integrated healthcare approach in Taupo/Turangi has resulted in improved vaccine uptake. Interventions that allow general practitioners, LMCs and primary health organisations to work together can improve vaccination rates of pregnant mothers in New Zealand.

The Adjuvant Bordetella Colonization Factor A Attenuates Alum-Induced Th2 Responses and Enhances Bordetella pertussis Clearance from Mouse Lungs.

The reemergence of pertussis or whooping cough in several countries highlights the need for better vaccines. Acellular pertussis vaccines (aPV) contain alum as the adjuvant and elicit Th2-biased immune responses that are less effective in protecting against infection than the reactogenic whole-cell pertussis vaccines (wPV), which elicit primarily a Th1/Th17 response. An important goal for the field is to devise aPV that will induce immune responses similar to those of wPV. We show that Bordetella colonization factor A (BcfA), an outer membrane protein from Bordetella bronchiseptica, has strong adjuvant function and elicits cellular and humoral immune responses to heterologous and Bordetella pertussis antigens. Addition of BcfA to a commercial aPV resulted in greater reduction of B. pertussis numbers from the lungs than that elicited by aPV alone. The more-efficient pathogen clearance was accompanied by increased interleukin-17 (IL-17) and reduced IL-5 and an increased ratio of IgG2/IgG1 antibodies. Thus, our results suggest that BcfA improves aPV-induced responses by modifying the alum-induced Th2-biased aPV response toward Th1/Th17. A redesigned aPV containing BcfA may allow better control of pertussis reemergence by reshaping immune responses to resemble those elicited by wPV immunization.

Assessment of Tdap Vaccination Effectiveness in Adolescents in Integrated Health-Care Systems.

PURPOSE: Despite high national vaccination coverage with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines among U.S. adolescents, rates of adolescent pertussis disease are increasing. We estimated the duration of protection after Tdap vaccination and the possible effects of the change from whole-cell to acellular childhood pertussis vaccines in the United States during the 1990s. METHODS: We conducted a retrospective cohort analysis among 11- to 18-year-olds enrolled in two integrated health-care delivery systems during 2005-2012. Cases met the Council of State and Territorial Epidemiologists' confirmed or probable definition or a polymerase chain reaction-positive suspect definition. We estimated vaccine effectiveness (VE) overall and by time since Tdap receipt. We stratified VE estimates by primary series pertussis vaccine received (based on birth year): mixed-vaccine cohort (1987-1997) and acellular vaccine cohort (1998-2001). RESULTS: The overall Tdap VE was 57% (95% confidence interval [CI]: 42%-68%); the VE in the mixed-vaccine and acellular cohorts was 65% (95% CI: 44%-78%) and 52% (95% CI: 30%-68%), respectively. Tdap VE within <2 years post vaccination (69%, 95% CI: 54%-79%) was significantly different from VE ≥2 years post vaccination (34%, 95% CI: 1%-55%, p value < .01). VE was significantly higher <2 years post vaccination compared with ≥2 years post vaccination in both mixed-vaccine (87%, 95% CI: 58%-96%, and 52%, 95% CI: 13%-73%; p value = .04) and acellular cohorts (62%, 95% CI: 41%-76%, and 21%, 95% CI: -30% to 52%; p value = .01). CONCLUSIONS: Although Tdap vaccination remains the best pertussis prevention method for adolescents, protection wanes within 2 years regardless of the type of childhood primary vaccine. Vaccines with longer duration of protection could decrease pertussis burden.

The importance of involving midwives before and during the implementation of an antenatal pertussis vaccination program in New South Wales, Australia.

PROBLEM: Typically there is limited opportunity for stakeholder engagement to determine service delivery gaps when implementing an outbreak or supplementary vaccination program. BACKGROUND: In response to increasing pertussis notifications in NSW, Australia, an antenatal pertussis vaccination program was introduced offering pertussis containing vaccine to all pregnant women in the third trimester. AIM: To explore the effectiveness of consulting with midwives prior to and during a new state-wide vaccination program. METHODS: A pre-program needs analysis was conducted through an online audit of the NSW Clinical Midwifery Consultants followed by a post-implementation audit at 18 months. FINDINGS: Information received from the midwives was utilised during program planning which facilitated program implementation without any major issues in all Local Health Districts. The post-implementation audit provided feedback to program planners that that implementation was continuing consistently and Midwives were found to be very supportive and engaged. DISCUSSION: Education and support of clinicians is vital for high vaccine uptake in new vaccination programs which can be enabled through appropriate educational packages and program resources. CONCLUSION: Consulting with the midwives in advance of a new vaccination program was a new initiative and highly recommended as it was time well spent gaining essential information on program resourcing and operational needs. Conducting a post-implementation audit is also strongly recommended as a check-point for issues and recommendations, to empower frontline staff and support consistent program implementation. Frontline staff engagement before and during implementation of a new vaccination program is a powerful mechanism for effective, efficient and consistent program delivery.

Maternal Care Providers' Barriers Regarding Influenza and Pertussis Vaccination During Pregnancy in Catalonia, Spain.

Objective Maternal care providers (MCPs), obstetrician-gynaecologists and midwives are uniquely placed to increase maternal vaccination acceptance. We aimed to assess their knowledge, attitudes and practices regarding influenza and pertussis vaccination during pregnancy. Methods We conducted an online survey among MCPs working at "Attention to Sexual and Reproductive Health" (ASSIR) Units in Catalonia region. The survey included questions about current recommendations of influenza and pertussis immunization during pregnancy, reasons for not routinely recommending vaccination and several strategies to increase vaccination uptake. Results A total of 194 MCPs completed the survey, 178 (91.8%) were female and 145 (70%) were midwives. Only 61 (31.4%) stated they vaccinated themselves annually against influenza with a significant lower uptake among midwives (26.9%) than obstetrician-gynaecologists (44.9%) (p = 0.03). Overall, 53.6% of MCPs knew influenza vaccine was indicated during first trimester but only 43.3% stated they prescribed it. Almost all MCPs (98.5%) knew pertussis vaccine was recommended and 97.4% stated they prescribed it. The most important vaccination barrier found was the concern related to vaccine adverse events (25.9%) and more midwives than obstetrician-gynaecologists expressed this concern (30.8 vs. 10%) (p = 0.02). The most popular strategies were: including vaccine recommendations in the pregnancy booklet (93.8%) and receiving vaccination training (92.3%). In the adjusted analysis, the only factor significantly associated with MCPs' prescription of influenza vaccine during second/third trimester was having been vaccinated themselves (odds ratio 3.70, 95% confidence interval 1.3-13.2). Conclusions for Practice Implementation of practical tools, continuous training and clear definition of responsibilities regarding vaccination among MCPs may have a significant impact on maternal vaccination coverage.

Vaccination in pregnancy: Attitudes of nurses, midwives and health visitors in England.

OBJECTIVE: To examine amongst healthcare professionals in England; knowledge of vaccinations in pregnancy, their perceived roles in these programmes and whether they recommend scheduled vaccines to pregnant women. DESIGN: Cross sectional survey (online questionnaire) Setting: Healthcare workers in contact with pregnant women in England. PARTICIPANTS: The survey analysis included 3441 healthcare workers who had been surveyed during May to August 2015. The participants were midwives, practice nurses and health visitors, working in England who were members of the Royal College of Midwives, Royal College of Nursing and the Institute of Health Visiting. RESULTS: We found that knowledge of vaccination in pregnancy was high in all professional groups. Seventy three percent of all respondents would recommend the influenza vaccine and 74% would recommend the pertussis vaccine to pregnant women. They were more likely to recommend vaccination in pregnancy if they would personally have the influenza and pertussis vaccines themselves and/or if they had the influenza vaccine as a healthcare worker. Practice nurses were significantly more likely to recommend the pertussis and influenza vaccines to pregnant women than midwives and health visitors. Health professionals who had received immunisation training were more confident in giving advice to pregnant women. CONCLUSION: Immunisation training is essential if healthcare workers are to be informed and confident in effectively delivering the maternal immunisation programme and thus improving uptake of vaccines in pregnancy. These findings are important in tailoring educational programmes and addressing the training needs of different healthcare professional groups.

Association of BCG, DTP, and measles containing vaccines with childhood mortality: systematic review.

OBJECTIVES:  To evaluate the effects on non-specific and all cause mortality, in children under 5, of Bacillus Calmette-Guérin (BCG), diphtheria-tetanus-pertussis (DTP), and standard titre measles containing vaccines (MCV); to examine internal validity of the studies; and to examine any modifying effects of sex, age, vaccine sequence, and co-administration of vitamin A. DESIGN:  Systematic review, including assessment of risk of bias, and meta-analyses of similar studies. STUDY ELIGIBILITY CRITERIA:  Clinical trials, cohort studies, and case-control studies of the effects on mortality of BCG, whole cell DTP, and standard titre MCV in children under 5. DATA SOURCES:  Searches of Medline, Embase, Global Index Medicus, and the WHO International Clinical Trials Registry Platform, supplemented by contact with experts in the field. To avoid overlap in children studied across the included articles, findings from non-overlapping birth cohorts were identified. RESULTS:  Results from 34 birth cohorts were identified. Most evidence was from observational studies, with some from short term clinical trials. Most studies reported on all cause (rather than non-specific) mortality. Receipt of BCG vaccine was associated with a reduction in all cause mortality: the average relative risks were 0.70 (95% confidence interval 0.49 to 1.01) from five clinical trials and 0.47 (0.32 to 0.69) from nine observational studies at high risk of bias. Receipt of DTP (almost always with oral polio vaccine) was associated with a possible increase in all cause mortality on average (relative risk 1.38, 0.92 to 2.08) from 10 studies at high risk of bias; this effect seemed stronger in girls than in boys. Receipt of standard titre MCV was associated with a reduction in all cause mortality (relative risks 0.74 (0.51 to 1.07) from four clinical trials and 0.51 (0.42 to 0.63) from 18 observational studies at high risk of bias); this effect seemed stronger in girls than in boys. Seven observational studies, assessed as being at high risk of bias, have compared sequences of vaccines; results of a subset of these suggest that administering DTP with or after MCV may be associated with higher mortality than administering it before MCV. CONCLUSIONS:  Evidence suggests that receipt of BCG and MCV reduce overall mortality by more than would be expected through their effects on the diseases they prevent, and receipt of DTP may be associated with an increase in all cause mortality. Although efforts should be made to ensure that all children are immunised on schedule with BCG, DTP, and MCV, randomised trials are needed to compare the effects of different sequences.

Respiratory Conditions Update: Chronic Obstructive Pulmonary Disease.

Chronic obstructive pulmonary disease (COPD) is defined as persistent airflow limitation due to irritant-induced chronic inflammation. A postbronchodilator forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) ratio of 0.7 or less is diagnostic in a patient with dyspnea, chronic cough or sputum production, and a history of irritant exposure. Tobacco smoking is the most significant etiology, and smoking cessation is the only intervention shown to slow disease progression. Long-acting beta2-agonists and long-acting muscarinic antagonists are first-line treatments for patients with persistently symptomatic COPD with an FEV1 of 80% or less of predicted. When COPD is uncontrolled with a long-acting bronchodilator, combination therapy with a long-acting muscarinic antagonist-long-acting beta2-agonist or long-acting beta2-agonist-inhaled corticosteroid should be prescribed. Patients with COPD and reduced exercise tolerance should undergo pulmonary rehabilitation and be evaluated for supplemental oxygen therapy. Other treatment options for persistently symptomatic COPD include inhaler triple therapy (ie, long-acting muscarinic antagonist, long-acting beta2-agonist, inhaled corticosteroid), phosphodiesterase type 4 inhibitors, oxygen, and surgical interventions.

Intention to Accept Pertussis Vaccination for Cocooning: A Qualitative Study of the Determinants.

CONTEXT: Several countries have reported a resurgence of pertussis in the last decades. This puts infants (especially <6 months) at risk of severe complications, because they are too young to be fully protected by vaccination. The global pertussis initiative has proposed pertussis vaccination of young infants' close contacts, in order to reduce pertussis transmission and the burden of the disease on infants. Our aim is to explore the perceived determinants (barriers and facilitators) of intention to accept vaccination among the possible target groups of pertussis vaccination for cocooning. Consideration of these determinants is necessary to optimise the uptake of the vaccination. METHODS: We conducted 13 focus groups and six individual semi-structured interviews with members of possible target groups for pertussis cocooning (i.e. parents, maternity assistants, midwives, and paediatric nurses) in the Netherlands. Here, both maternal pertussis vaccination as well as pertussis cocooning has not been implemented. The topic list was based on a literature review and a barrier framework. All interviews were transcribed verbatim and two researchers performed thematic content analysis. FINDINGS: The participants' risk perception, outcome expectations, general vaccination beliefs, moral norms, opinion of others, perceived autonomy, anticipated regret, decisional uncertainty, and perceived organisational barriers were all factors that influenced the intention to accept pertussis vaccination for cocooning. DISCUSSION: This study has identified nine perceived determinants that influence the intention to accept pertussis cocooning vaccination. We add the following determinants to the literature: perceived cost-effectiveness (as a concept of outcome expectations), justice (as a concept of moral norms), anticipated regret, and decisional uncertainty. We recommend considering these determinants in vaccination programmes for pertussis cocooning vaccination. Experience, information and trust emerged as predominant themes within these determinants. These themes require particular attention in future research on vaccination acceptance, especially with regard to their role in use and implementation in policy and practice.