Recently the CDC updated its recommendations for immunization for the H1N1 influenza virus. Here are the latest updates on these issues. We invite you to discuss with your colleagues and all our members any suggestions or concerns you may have. This segment was adapted from the ACOG and the Pennsylvania Medical Society sites.

Thanks

Albert

---

H1N1 Vaccines En Route to Pennsylvania (from the PMS site)

H1N1 influenza vaccines are on their way to Pennsylvania. The Pennsylvania Department of Health (DOH) reported that it placed orders for the vaccine on Wednesday, Sept. 30.

First to arrive in early October will be live attenuated influenza vaccine (LAIV), a nasal spray vaccine that retails under the name FluMist.

Since this vaccine cannot be given to everyone at high-risk of complications from influenza, DOH will first target school children 5 to 9 years old and, to a lesser degree, college students. The DOH reported that 70 percent of illness in the state has been seen in children and young adults ages 5 to 24.

The initial rounds of vaccine will be channeled to the areas of the state with the highest rate of disease: the southwest, southeast, and north central.

Injectable, inactivated vaccines will follow later in October. Physicians should target those groups recommended by the Advisory Committee on Immunization Practices.

“We need your cooperation in assuring the vaccine reaches individuals in the prioritized groups, especially early in the process, as this makes the greatest impact on reducing disease transmission and protecting individuals at higher risk of influenza complications,” said Stephen Ostroff, MD, the state’s acting Physician General.

Physicians who wish to distribute the H1N1 vaccine must register with the DOH.

Adapted form ACOG site

• Pregnant women are at increased risk for severe complications and death from the 2009 H1N1 influenza virus (formerly called “novel H1N1 flu” or “swine flu”).

• Early treatment (i.e., within 48 hours of illness onset) with influenza antiviral medications is recommended for pregnant women with suspected influenza illness. Clinicians should not wait for test results to initiate treatment since these medications work best if started as early as possible after illness onset http://www.cdc.gov/H1N1flu/pregnancy/antiviral_messages.htm. Moreover, rapid diagnostic tests for influenza have variable sensitivities for detecting the 2009 H1N1 influenza virus (10-70%). A negative rapid test does NOT exclude the possibility of infection with 2009 H1N1 influenza http://www.cdc.gov/h1n1flu/guidance/diagnostic_tests.htm.

• Pregnancy has been identified as a co-morbid condition needing contact with a health care provider. CDC states that all pregnant women should be counseled about the early signs and symptoms of influenza infection and advised to immediately call for evaluation if clinical signs or symptoms develop. Since rapid access to antiviral medications is essential, health care providers who care for pregnant women should develop methods to ensure that treatment can be started quickly after symptom onset. This includes ensuring rapid access to telephone consultation and clinical evaluation for pregnant women. Also, consider empiric treatment of pregnant women based on telephone contact if hospitalization is not indicated and if this will substantially reduce delay before treatment is initiated.

• The Centers for Disease Control and Prevention (CDC) and ACOG recommend that pregnant women be vaccinated for both the 2009 H1N1 influenza virus and the seasonal flu [http://www.acog.org/publications/pdfs/co305.pdf]. Pregnant women can be vaccinated for influenza during any trimester. The H1N1 vaccine can be given postpartum, providing indirect protection for infants less than 6 months old, and to breastfeeding women. Q & As on H1N1 for pregnant women are available at http://www.cdc.gov/h1n1flu/pregnancy.

• Some pregnant women are concerned about mercury (thimerosal) in vaccines as a risk for being vaccinated. However, there is no evidence that thimerosal (used as a preservative in vaccine packaged in multi-dose vials) is harmful to pregnant women or the fetus. Because of their concern, however, there will be preservative-free seasonal and H1N1 vaccine available in single dose syringes for pregnant women and young children. See CDC’s Q & A on thimerosal and pregnant women at http://www.cdc.gov/h1n1flu/vaccination/pregnant_qa.htm.

• The H1N1 vaccine is expected to be available in October, initially in a nasal spray and then in vials for injection. The seasonal flu vaccine that is currently available in most areas is also available in a nasal spray. However, the nasal spray is a live attenuated virus and should NOT be used in pregnant women. Pregnant women should get the “flu shot” for both H1N1 and seasonal flu. See CDC’s guidelines at http://www.cdc.gov/h1n1flu/pregnancy.

• As health care workers, obstetrician-gynecologists and their staff are as much a priority for being vaccinated against H1N1 as are pregnant women http://www.cdc.gov/h1n1flu/vaccination/acip.htm.

• The government is providing the H1N1vaccine and administration supplies for free so providers cannot charge for that but can charge for administering the vaccine. AMA just issued new CPT codes specific to the H1N1 vaccine product that are effective immediately www.ama-assn.org/go/h1n1. The new codes are: ??90470 — H1N1 immunization administration (intramuscular, intranasal), including counseling when performed ?90663 — Influenza virus vaccine, pandemic formulation, H1N1

• CDC’s National Ob Grand Rounds on H1N1 influenza and pregnancy address many key treatment, testing and vaccination issues. Continuing education credit hours are provided with the archive of the September 29 Grand Rounds conference call at http://emergency.cdc.gov/coca/updates/2009/2009sep28.asp.

• On September 23 ACOG, SMFM, AAP, ACNM and other health and education organizations released [http://www.marchofdimes.com/aboutus/49267_61364.asp] a joint information message for pregnant women about H1N1 and influenza [http://www.acog.org/departments/dept_notice.cfm?recno=20&bulletin=4913].

ACOG’s web site is frequently updated as new H1N1 guidance and other resources are released, so ob-gyns should bookmark it and check back often. ACOG’s home page features late-breaking information on H1N1 [http://www.acog.org] and links to ACOG’s H1N1 page that includes pertinent guidelines, resources and updates for ob-gyns and pregnant women [http://www.acog.org/departments/dept_notice.cfm?recno=20&bulletin=4866].