An Overview of Adult Immunizations for Ob-Gyn Providers

About the Webinar

This webinar identifies vaccines recommended for routine use in their adult patients, effectively describes and communicates the burden of vaccine preventable disease in adult patients, incorporates immunizations into routine ob-gyn practice, and identifies, locates, and provides patient resources to address adult immunizations with patients.

Learning Objectives

Upon completion of the presentation, the participants will be able to:

• Identify vaccines recommended for routine use in their adult patients
• Effectively describe and communicate the burden of vaccine preventable disease in adult patients
• Incorporate immunizations into routine ob-gyn practice
• Identify, locate, and provide patient resources to address adult immunizations with patients

This webinar is supported by the Cooperative Agreement Number, 5 NH23IP000981-03-00, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.

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Video Transcript

Moderator: Hello and thank you for joining us today. This is Don from Blue Sky. Today's collaborative webcast from the American College of Obstetricians and Gynecologists, ACOG Foundation, and the Centers for Disease Control and Prevention is entitled An Overview of Adult Immunizations for Ob/Gyn Providers. This webcast will discuss vaccines recommended for routine use in adult ob/gyn patients and the burden of vaccine of preventable disease as well as review strategies and resources ob/gyns can utilize as they incorporate immunizations into their practice. This webinar offers one continuing medical education credit, and there's some information here on the slide for you. We'll allow you a moment or two to take a look at that.

This webinar is supported by a cooperative agreement funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of ACOG and do not necessarily represent the official views of CDC.

The Faculty and Planning Committee wish to disclose the information displayed on this slide. Please note and be aware of that the use of trade names is for identification purposes only and does not imply endorsement.

And now, please let me introduce our faculty for today's event. Amy Parker Fiebelkorn is a senior epidemiologist in the Immunization Services Division and is a Pandemic Influenza Vaccine Response Program deputy for the Vaccine Task Force at the Centers for Disease Control and Prevention. She's the CDC technical lead of two contracts focused on adult immunizations and leads a $10 million cooperative agreement focused on implementing the standards for adult immunization practice. She's the lead of the Influenza Working Group for the National Adult and Influenza Immunization Summit and a captain in the US Public Health Service.

Prior to joining the Immunization Services Division in 2015, she was a subject matter expert in measles, mumps, rubella, and polio in CDC's Division of Viral Diseases for 10 years. She joined CDC as Epidemic Intelligence Service Officer in 2005 and obtained her Master's degree in Nursing and Public Health from Emory University.

Amy Parker Fiebelkorn: All right. Thank you very much for that introduction and good afternoon, everyone. So vaccine-preventable diseases cause substantial morbidity and mortality among adults. Although vaccinations have decreased the burden of illness in adults, the vaccine effectiveness varies by vaccine type, the disease outcome being measured, and the age or health of the person vaccinated.

I will now discuss the burden of disease and impact of vaccination on the most common vaccine-preventable diseases in adults. We'll start with the burden of disease for hepatitis B, a liver infection caused by the hepatitis B virus. Hepatitis B is transmitted when blood, semen, or another body fluid from a person infected with the virus enters the body of someone who is not infected. Approximately 3,200 cases of acute hepatitis B were reported in the U.S. in 2016, but after adjusting for under-reporting, its actually closer to an estimated 20,900 acute Hepatitis B cases. Approximately 95% of new hepatitis B virus infections occur among adults, and persons with diabetes are at twice the risk of being infected with hepatitis B. This figure shows reported acute hepatitis B incidents by age groups in the United States between 2000 and 2015. Highest incidences in yellow and green are among adults 30-39 years and 40-49 years.

This past February, ACIP recommended a new hepatitis B vaccine with a novel adjuvant called Heplisav B, which requires two doses separated by one month. 90 to 100% of subjects who received two doses of Heplisav B demonstrated seroprotection compared with 71 to 90% of subjects who received three doses in the comparison group. The graph on the right shows data from one of the studies with Heplisav B in blue and the comparator in orange with weeks on the X axis and seroprotection rate on the Y axis. At week 4, when the second dose was given, the seroprotection rate for Heplisav B increased dramatically compared with Engerix. And even when a third dose of Engerix was given at week 24, the seroprotection rate was far below the Heplisav B group, which did not receive a third dose. The newer vaccine has also shown to offer better protection for patients with type 2 diabetes and chronic kidney disease.

Next, we'll discuss herpes zoster, or shingles, a painful rash that develops on one side of the face or body. About one million cases of herpes zoster occur annually in the U.S. Ten to eleven cases occur per 1000 population per year in persons 60 years of age or older. There is a lifetime risk of shingles of 32%. Thoracic, cervical, and ophthalmic involvement are most common. Approximately 10 to 25% of cases have complication of the eye.

In October of 2017, ACIP gave a preferential recommendation for a new recombinant zoster vaccine, or RZV. Whereas the older zoster vaccine live was only 51% effective against shingles and 66% effective against post-hepatic neuralgia with considerable waning over a five-year period, the new recombinant vaccine has demonstrated a much higher efficacy, up to 96% for 50 to 70 year olds and 90% for adults 70 and older. RZV's immunogenicity has shown to persist to nine years post-vaccination.

This figure shows the results of the shingles prevention study, Short-Term Persistence Study and Long-Term Persistence Study which measured ZVL immunogenicity in the same population over time in blue as well as the ZOE 70 results in red, which was a two-part, phase three, randomized control trial of RUV with over 30,000 subjects age 70 years or older. Years are on the X axis, and vaccine effectiveness is on the Y axis.

Now I'll discuss Human Papilloma Virus, or HPV. Approximately 14 million people become infected with HPV each year. The symptoms resolve without intervention in 9 of 10 people within two years. However, HPV infections can last longer and can cause certain cancers. HPV causes 30,700 cancers in men and women annually. However, within six years of vaccine introduction, there was a 64% decrease in prevalence of four HPV types among females age 14 to 19 years and a 34% decrease among those age 20 to 24 years. This finding extends previous observations of population impact in the United States and demonstrates the first national evidence of impact among females in their 20s.

Now I'll discuss influenza, a contagious respiratory illness that can cause mild to severe illness. Influenza disease burdens vary year to year. Millions of cases, and an average of 226,000 hospitalizations, occur annually with 75% among adults. And between 3,000 and 49,000 deaths occur annually, with more than 90% occurring among adults. The direct medical costs in the United States are approximately $10.4 billion, and when we add in the loss of work and life, that increases to about $87 billion.

Influenza can be severe in pregnant women. During seasonal influenza, from about 19.5 to 33.5% of lab-confirmed influenza hospitalizations among women 15 to 45 years of age are pregnant. And during the 2009 H1N1 pandemic, 6% of all influenza related hospitalizations, 5.9% of ICU admissions, and 5.7% of deaths were among pregnant women. In contrast, only 1% of the U.S. population is pregnant at any given time. The risk of influenza-related hospitalization increases with trimesters. There is a five-fold difference from the first to third trimester.

Influenza vaccine effectiveness varies annually based on antigenic match and also age and health of the person being vaccinated. There is about a 60 to 70% vaccine effectiveness in younger adults and about 30% effectiveness in adults 65 years and older against medically attended, laboratory-confirmed influenza when there is a good match. Vaccination reduces antibiotic use, medical visits, and loss of work days. The 2017-2018 interim seasonal influenza vaccine effectiveness estimate showed a 36% overall effectiveness against medically attended, laboratory-confirmed influenza.

This figure shows the impact of influenza vaccination by influenza season on the X axis. In 2015-2016 alone, when the overall vaccine effectiveness was 48%, there were over 5 million cases prevented because of vaccination, as shown in orange, and 70,000 hospitalizations prevented, as shown in blue.

Influenza vaccine has also shown impact for persons with high-risk medical conditions, with a 78% reduction in death attributable to any cause and an 87% reduction in hospitalization attributable to acute respiratory or cardiovascular disease. For persons with diabetes, influenza vaccination has resulted in a 56% reduction in any complication, a 54% reduction in hospitalizations, and 58% reduction in death. And for persons with chronic obstructive lung disease, influenza vaccination has resulted in reduced COPD exacerbation.

Next I'll discuss Staphylococcus pneumonia or pneumococcal disease, which can cause pneumonia, ear infections, sinus infections, and invasive pneumococcal disease, or IPD, including meningitis and bacteremia. Adults at increased risk for pneumococcal disease include adults age 65 or older and certain adults age 19 to 64 years including adults with chronic illnesses such as chronic heart, liver, kidney, or lung disease; diabetes or alcoholism; as well as adults with conditions that weaken the immune system, such as persons with HIV-AIDS, cancer, or those with a damaged or absent spleen; adults with cochlear implants or cerebral spinal fluid leaks; and adults who smoke cigarettes. There were 24 cases of invasive pneumococcal disease per 100,000 people in 2016 among adults age 65 and older, and there were eight cases of invasive pneumococcal disease per 100,000 people in 2016 among all adults age 19 to 64 years.

Amy Parker Fiebelkorn: So PCD-13, our pneumococcal conjugate vaccine, is 45% effective against vaccine type pneumococcal pneumonia and 75% effective against vaccine type invasive pneumococcal disease among adults age 65 years and older. PPSV23, or pneumococcal polysaccharide, is 74% effective in the meta-analysis against invasive pneumococcal disease, but it's not effective against non-invasive pneumococcal disease pneumonia.

Next I'll discuss tetanus, diphtheria, and acellular pertussis. Tetanus and diphtheria are rare in the U.S. For pertussis, there were 15,800 provisional cases reported in 2017, and approximately 3,400 of these cases were among adults. The burden in older adults is unknown. It is an under-recognized cause of a cough illness. It has an atypical clinical presentation in adults, and it has a low suspicion by providers. Also of note, maternal Tdap vaccinations during pregnancy has a high level of effectiveness of 88% in preventing pertussis in infants before their first dose of DTaP.

Tdap is approximately 70% effective against pertussis in the first year after vaccination, but its effectiveness decreases each year. Four years post-vaccination, its effectiveness is 30 to 40%. However, vaccinated persons who are infected with pertussis are less likely to have a serious infection.

So now that I've discussed the burden of these diseases and the impact of vaccinations, I'll next describe updates to the adult immunization schedule. You are hopefully all familiar with this, which shows the 2018 adult immunization schedule by vaccine type on the left and age group on the top row. This slide shows the adult immunization schedule by medical conditions and other indications.

As I mentioned earlier, a new Hepatitis B vaccine was licensed and approved called Heplisav-B for all HBV subtypes for adults age 18 and older. It's the fifth inactivated HepB vaccine in the U.S. and contains a yeast-derived recombinant HepB surface antigen with cytosine-phosphate-guanine as an adjuvant. The big change with this vaccine is that it is given in two doses one month apart. There is no preferential recommendation for this vaccine over other HepB vaccines. Also of note, this vaccine may be used in the HepB alone series, but three doses of HepB are needed unless two doses of Heplisav-B are administered one month apart.

So there was also a new vaccine liked and approved for zoster. However, unlike for hep B, the new vaccine, recombinant zoster vaccine, or RZV, was given a preferential recommendation by ACIP. A few of the differences between RZV and ZVL are highlighted here. RZV is stored in the refrigerator versus the freezer. It's not a live vaccine. It's given intramuscularly rather than subcu, and it's in a two-dose series two to six months apart instead of the one dose of ZVL. I want to highlight that RZV should be given even when adults have a history of herpes zoster and to adults who previously received ZVL. Also of note, RZV is recommended for immunocompetent adults age 50 and over versus 60 and over for ZVL. RZV can be administered to age-eligible adults with chronic health conditions including diabetes, chronic heart, lung, liver and kidney disease, asplenia, and complement deficiencies. However, RZV is pending considerations on use for persons with immunocompromising conditions including HIV infection. Also, there are no data on pregnant women, so providers should consider delay in this population.

And finally, I wanted to touch on the side effects. One in six people who received RZV recorded grade 3 side effects compared with less than 1% who received ZVL.

Changes were also made to the HPV recommendations in recent years. Information was modified based on the new recommendation for a two-dose HPV vaccine schedule. Adult females through age 26, and adult males through age 21, and eligible males age 22 through 26 who initiated HPV vaccination series before age 15 and received two doses at least five months apart, are considered adequately vaccinated and do not need an additional dose of HPV vaccine. Whereas those who received only one dose or two doses less than five months apart are not considered adequately vaccinated and should receive one additional dose of HPV vaccine.

Next I will discuss updated influenza vaccination recommendations. An annual influenza vaccination is recommended for persons six months of age and older. Options for adults include high-dose inactivated influenza vaccines for adults 65 years and older; adjuvanted inactivated influenza vaccine, or IIV; for adults 65 and older; intradermal IIV for adults 18 to 64 years; cell culture-based IIV for adults 18 and over; recombinant influenza vaccine, or RIV, for adults 18 and over; and now live attenuated influenza vaccine, or LAIV, for adults 49 and younger. The updated ACIP recommendation for 2018 to 2019 season was to reinstitute the use of LAIV which contains a new H1N1 strain, A/Slovenia. If you recall, LAIV was not recommended for the previous two seasons due to low effectiveness against H1N1, pdm09 in the U.S. during the 2013-14 and 2015-16 seasons.

So, additionally, a few other modifications were made to the influenza vaccination recommendations. They now state that providers should offer vaccination by the end of October if possible. Previously, the recommendation stated by October. Changes were also made to the egg allergy recommendation. If a person has previously reacted to influenza vaccination with hives only, they can use any licensed, age-appropriate influenza vaccine. If their reaction was anything other than hives, they may use any age-appropriate vaccine in a medical setting.

Now on to recent Tdap updates, where the timing of the dose was updated for pregnant women. Pregnant women should receive one dose of Tdap during each pregnancy, preferably during the early part of gestational weeks 27 through 36, regardless of prior history of receiving Tdap.

In efforts to improve the use of the adult immunization schedule, health care providers want to see immunization recommendations from their professional organizations. I want to highlight here that ACOG developed the Maternal Immunization Committee Opinion 741, a summary of maternal immunization recommendations. It is a useful table describing the vaccinations recommended during pregnancy and the ones that are contraindicated or that should only be given in certain situations.

Unfortunately, many health care providers treating adults in general are not using the adult immunization schedule. Providers often mistakenly think that the EHR will automatically prompt them when a vaccination is needed. Unfortunately, although prompts for age-based recommendations are built into many EHRs, there are no prompts built in for risk-based recommendations. This, along with many other factors, such as the fact that adult immunization recommendations are complicated, providers have concerns about reimbursements, and there's a lack of coordinated care with adult patients seeking treatment from multiple providers, has resulted in adult immunization coverage rates that are persistently low.

This figure shows the proportion of adults, age 19 and over, who received selected vaccines by age group and increased risk status in the United States from 2010 to 2015. There's a lot to look at on this figure, but the main message is that although small increases in coverage in the United States occurred for some vaccines from 2010 to 2015, overall coverage levels remain low for all the routinely recommended vaccines for adults. The highest coverage levels for adults are for TB or Tdap for adults age 19 years or older in the red line and for adults age 65 years or older for pneumococcal vaccine in the light blue dashed line, but levels are much lower for other adult vaccines.

I also wanted to highlight influenza vaccination coverage among pregnant women, which was up to 53.7% for the 2016-2017 influenza season. When looking at vaccination coverage among older adults, there are considerable differences by race/ethnicity. For instance, in the second column, which shows pneumococcal vaccinations in adults age 65 and older, 68% of whites were vaccinated, compared with 50% of blacks and 42% of Hispanics.

Health insurance status also affects vaccination coverage among adults. 87% of adults recorded some type of health insurance, either private or public. Vaccination coverage was two to five times higher for adults with health insurance for influenza, Tdap, zoster, and HPV vaccinations. And among insured persons with 10 or more physician contacts in the past 12 months, 24 to 89% were missing at least one recommended vaccine. 65% of adults with diabetes are missing the hepatitis B vaccination, and 61% of adults age 19 to 64 years were at high risk for missing pneumococcal vaccinations.

So how can we improve adult vaccination coverage rates? Successful vaccination programs use a combination of approaches. Evidence-based strategies that have been shown to improve coverage are use of standing orders and the reminder-recall systems; efforts to remove administrative barriers; provider and practice assessment of vaccination and feedback; use of immunization registries; and education of both providers and the public as a component of any of the other strategies.

A meta-analysis with interventions to increase adult vaccine updates showed that organizational change such as implementing standing orders was by far the most effective intervention. In 1990, the National Coalition for Adult Immunization developed the Standards for Adult Immunization Practice, which I'll refer to as the Standard going forward. And they outlined basic strategies to improve vaccine delivery to adults. The Standards were updated in 2014 by the National Vaccine Advisory Committee to account for changes in the vaccine environment, including more vaccinators and vaccination locations such as in pharmacies, work places, and in ob/gyn practices; increased use of electronic health records and immunization registries; and even the use and popularity of social media; as well as changes that were occurring in the healthcare system in 2014 such as the implementation of the Affordable Care Act.

The standards were revised to emphasize the responsibility of all health care personnel who treat adults to conduct routine assessments of a patient's vaccination needs during every clinical encounter, strongly recommend vaccinations that patients need, administer needed vaccines or refer patients for vaccinations, and document administered vaccinations in the IIS or the state vaccine registry.

This figure shows reported implementation of the Standards among health care personnel by provider specialty in the U.S. in 2016. The data are from an opt-in internet panel survey. The middle of the figure shows results from ob/gyns. 84% of ob/gyns in blue reported that they routinely conduct vaccine assessments. 95% in green routinely recommend needed vaccines, and 87% in red and yellow reported that they routinely administered vaccines or referred patients to providers who could vaccinate. And 39% in purple document vaccines administered into the registry.

In contrast, this figure shows the percentage of patients who reported receiving the Standards by provider type. 30% of patients reported receiving a vaccine assessment by their OB/GYN at their most recent visit. 6% report receiving a vaccine recommendation, and 3% reported receiving a vaccine offer, and 2% reported receiving a vaccine referral. Granted, these results are not a direct comparison with the previous findings, since these patients likely saw different providers than those who were surveyed as part of the health care provider panel, and these findings reflect the patient's most recent visit rather than what providers report they routinely do. However, it is striking that there is such vastly different perceptions between providers and patients on implementation of the Standards.

So what tools are available to help providers incorporate the Standards into their routine practices? This link directs you to one-page handouts that describe each step of the Standards in more detail. There are numerous resources for vaccine assessment, which is the first component of the Standards, including a patient check-in vaccine questionnaire; a patient online quiz, which directs patients to complete the quiz before coming to their appointment, and it gives them and you a starting point for talking about which vaccines they might need; and a CDC Adult Vaccine Schedule app.

Another example of a vaccine assessment tool is this form, which focuses on the acronym HALO to remind providers to consider health, age, lifestyle, and occupation or other factors when conducting vaccination assessments.

Strong recommendations are a critical factor in whether your patients get the vaccines they need. However, oftentimes providers think they're making a recommendation, but the patient does not perceive it that way. To make strong, effective recommendations, this Medscape module has useful case presentations and videos that include examples of evidence-based strategies and tips on how to improve the vaccine recommendations that are made.

Vaccine administration is important because this step is when the vaccine actually enters the patient's arm. These links point to helpful vaccine administration resources, such as CDC's general immunization training and an immunization skills self-assessment.

For providers who do not stock vaccines or for situations where the patient prefers to be vaccinated elsewhere, such as with their primary care provider, there are also many vaccine referral options, including local pharmacies, health departments, and travel clinics. There is even a health map vaccine finder. The health map vaccine finder is a free online service where users can search by zip code for providers who offer vaccines in their area.

For documentation, which is the final component of the Standards, there are many benefits to using the registry, also called the Immunization Information System, or IIS. The IIS consolidates vaccination records for patients. It helps assess patients' immunizations status; it ensures that patients have completed their necessary vaccine series; it reduces chances for unnecessary doses of vaccine or missed opportunities to provide vaccines; it facilitates the use of reminder and recall notifications to send to patients; and it makes calculation of immunization coverage rates easier.

However, this figure shows that the percentage of adults participating in an IIS is very low. Only one state, Minnesota, in yellow, has 95% of adults participating. In five states, in dark blue, has 75 to 94% of adults participating. However, adult participation just means that an adult has one or more adult vaccines recorded in the IIS, so these states are not necessarily capturing the full vaccination histories of adults in their IIS.

Another way of looking at these data is from a national level rather than by state. This figure shows that only 39% of adults in the U.S. had one or more vaccinations recorded in an IIS in 2015. That's despite all of the advantages an IIS can provide. We have very incomplete vaccination data on adults in our state immunization registries.

So the big question is what can be done. Next steps to help improve adult immunization rates and improve the current situation are improving providers' ability to see their own vaccination performance data; also increasing the use of IIS and IIS/EMR interoperability; developing new and utilizing existing quality measures as a motivator for system change; addressing billing and reimbursement issues is important to consider; and also addressing state-level policies in some states that result in barriers for some providers, especially for pharmacies.

And ACOG has many resources as well aimed at assisting ob/gyns and their staff in improving immunization rates among their patients. The ACOG app for use of Android and Apple devices includes an interactive immunization tool to help guide decision making. And at ACOG’s Immunization for Women website, you can find up-to-date immunization recommendations, ACOG clinical guidance, frequently asked questions documents for patients, practice management resources, and tip sheets for providers and more. Additionally, the site is set up with separate provider and patient sections, with the patient sections serving as an excellent resource to feature on your own practice or organization website.

So below is contact information for your ACOG representatives and for me, and I'm happy now to take questions. Thank you. And I do see a few questions that have come in.

Moderator: Yeah. We'll give you a moment to take a look at those, Amy, while I remind our audience that to submit a question, please use the question block on the right-hand side of your screen and then click send or enter. And we thank you, Amy, for the excellent presentation, and we'll jump into those questions.

Amy Parker Fiebelkorn: All right. Thank you. So someone asked about why RZV was preferred or given a preferential recommendation by ACIP and specifically because of the fact that RZV has higher grade 3 side effects profile. And there was quite a bit of the deliberation by ACIP. It was an extremely close vote. And as the committee was weighing the options, people brought up really solid points against giving a preferential recommendation. Once a preferential recommendation is made, considering the fact that RZV has shown such higher efficacy, it was feared that the manufacturer of ZVL would stop producing the vaccine. But even when all of that evidence was weighed, the committee in the end just felt like despite the fact that there are more side effects with RZV, that it is so much more effective, and it doesn't wane as quickly as ZVL. And I think ultimately they felt like it was a better approach to give a preferential recommendation for RZV, knowing that the consequences could be that if people stop using RZV because of increased reports of side effects that ZVL down the line might no longer be manufactured. So then we would be stuck. But I think they just felt like the evidence that we had on hand was strong enough to give it a preferential recommendation. But it was an extremely close and contentious discussion that day at ACIP.

Okay. So one question that came in, it says, "In most practices, how are immunizations added to the IIS direct from EMR, staff, and providers?" And that really depends. It depends on the interoperability of your EMR. So wherever you practice, you would need to find out if your EMR talks with your IIS, so to speak, and if it goes directly. And if not, then that has to be entered separately.

Someone asked about ... "So the new hep B vaccine is not recommended above the old one, and that's correct. So for the new Heplisav-B vaccine, there was not a preferential recommendation given. And even with the higher efficacy, again, with ACIP discussions, oftentimes it can really swing either way. And for this vaccine, they decided not to give a preferential recommendation. And sometimes the decisions don't always seem to be consistent, but after weighing the evidence, I think they just wanted to leave both vaccines on the table.

Someone asked about, "What are the most common side effects of the RZV vaccine?" These can be anything from myalgia, fatigue, headache, shivering, fever, GI illness. There've been reactions that have prevented regular activities. I think one thing to remember is to remind patients that even though the reactions can be severe—they can have a grade 3 reaction—these side effects generally only last two to three days. And on the contrary, for patients that end up with shingles, shingles pain can last a lifetime if they end up with postherpetic neuralgia. And so I think it is worth having those discussions with your patients and making sure they understand that in the long run, the shorter-term side effects are a better situation than ending up with shingles and postherpetic neuralgia in the long run.

Someone asked about, "Can we expect the 2018 influenza vaccines to be more effective than the 2017 vaccine? And also can you clarify the recommendation for women who have an egg allergy?" Certainly. No one can predict whether or not we'll have a better VE this coming flu season then we had last flu season. I think the important thing to remember is even when we have seasons like we just did, where we had a 36% overall vaccine effectiveness, even with such a low overall vaccine effectiveness, we still prevented deaths and hospitalizations from having the vaccine coverage that we did and having even such a low, in relative terms, vaccine effectiveness. So even though we can't predict how this next flu vac season will turn out, it's still important to recommend that all of our adult patients receive flu vaccines.

And as far as egg allergies, the second component of your question, so people who have egg allergies are recommended to receive the flu vaccine, and they can now receive any recommended flu vaccine that would ordinarily be recommended for their age group. The only thing to take into consideration is if the person had a reaction that was anything other than hives. They just ask that the vaccine be given in a medical setting so that there’s more resources around.

One of the questions says, "With mosquito and insect vectors on the rise, are there any plans for dengue vaccine or Zika vaccine in the U.S.?" I know they're working on Zika vaccines. There's quite a few vaccines coming down the pike in various stages of development, but for right now, for Zika, we're not at that point. Good question, though.

Other questions. I think going back, just because I think you might get a lot of questions about RZV and their reactogenicity, it is important to remember that reactions to the first dose do not strongly predict reactions to the second dose. And I also did find percentages here on reactogenicity, so it looks like 78% of people reported pain after being vaccinated with RZV. 45% reported myalgia, and 45% reported fatigue. But again, vaccine recipients should be encouraged to complete the series even if they experienced grade 1 to 3 reaction.

Regarding the safety of flu vaccines, someone's asking about whether it is safe to give flu vaccine in any trimester. And some of you may be aware of that Donahue study that came out of Marshfield. And that was a CDC-funded study that found that women vaccinated early in pregnancy with a flu vaccine containing pandemic H1N1 component and who had also been vaccinated the prior season with an H1N1 pdm09-containing flu vaccine had an increased risk of spontaneous abortion or miscarriage in the 28 days after vaccination. I think the main thing to take into consideration with that is that was a case controlled study, and they estimated an odds ratio of vaccination among women who had a miscarriage compared to those who did not. But the study did not estimate risk of miscarriage after influence vaccination. So the findings cannot be used to estimate the probability of miscarriages for pregnant women who receive an H1N1-containing flu vaccine two years in a row. So ACIP, as it currently stands, still recommends that pregnant women receive flu vaccine in any trimester. We know that flu vaccines can be given safely during pregnancy, and millions of flu doses have been given for decades to pregnant women with a very strong and good safety record. And regarding trying to understand those results of that specific study, they are doing an ongoing investigation to study the issue further, and they are anticipating results either later this year or early next year.

Someone is asking about if a patient has documented receipt of MMR or varicella vaccines, but if they're all negative, do they need to be re-vaccinated? And the answer is no. You have evidence of immunity if you have two documented doses of MMR vaccine, and that supersedes any serological testing that might have been done. So as long as the doses that you have are documented, you're good to go.

And I don't know if we have time for any more questions or not. I see we're at the top of the hour.

Moderator: Sure, we can take a couple more if you would like.

Amy Parker Fieberlkorn: Okay. I think I've-

Moderator: If there's any you think you haven't responded to.

Amy Parker Fieberlkorn: Okay.

Moderator: And then, Amy, once you've determined you've handled all the questions, we can move on to your closing thoughts.

Amy Parker Fiebelkorn: All right. I think I've hit most of these questions, Don.

Moderator: All right. Excellent. Anything else you'd like to add before we wrap things up?

Amy Parker Fiebelkorn: If there's questions as we go back, I see that I haven't gotten to them all, I'm happy to send an email to Sarah at ACOG. If anyone has any follow-up questions or additional questions, I'm happy to take those later, and send those to Sarah at ACOG, and she can send those out.

Moderator: All right. Excellent. Thank you very much, Amy, for the great presentation and for our attendees' time with us today. As a reminder, you will shortly be automatically redirected to the post-event evaluation upon the conclusion of this webcast. If you have any outstanding questions that were not answered, as Amy graciously agreed to follow up, please contact ACOG's Immunization, Infectious Disease, and Public Health Preparedness Department at [email protected]. That's [email protected]. That will conclude today's program. We thank you for joining us, and we hope that we see you next time.