OBJECTIVE: We examined practices of obstetrician-gynecologists regarding nonvaccine-related public health recommendations during the 2009 H1N1 influenza pandemic.STUDY DESIGN: From February to May 2010, a survey was sent to a random sample of members of the American College of Obstetricians and Gynecologists involved in obstetric care.RESULTS: Obstetrician-gynecologists varied in their adherence to 2009 H1N1 influenza public health recommendations. Nearly all reported prescribing antiviral medications to pregnant women with suspected influenza. Most obstetrician-gynecologists reported using preventive practices in the outpatient setting to reduce exposure of well patients to ill ones. A wide range of responses was provided regarding postpartum infection control practices, suggesting lack of awareness of, disagreement with, or difficulty adhering to these recommendations.CONCLUSION: Obstetrician-gynecologists reported that they adhered to some recommendations related to 2009 H1N1 influenza, but not to others. These data provide insight into strategies for development and dissemination of recommendations in a future pandemic.

Objectives To understand pharmacists' knowledge, attitudes, and practices regarding vaccination and treatment of pregnant women for seasonal influenza and pandemic 2009 influenza A (H1N1). Design Descriptive, exploratory, nonexperimental study. Setting United States between January 21, 2010, and February 9, 2010. Participants 606 pharmacists who participated in the American Pharmacists Association (APhA) Immunization Certificate Training Program and practice in chain, supermarket, mass merchandise, and independent pharmacies. Intervention Electronic survey sent by APhA to 7,356 pharmacists who had participated in its Immunization Certificate Training Program. Main outcome measures Pharmacists' knowledge, attitudes, and practices regarding vaccination and antiviral treatment of pregnant women for seasonal and H1N1 influenza. Results Respondents were more likely to recognize that pregnant women are at an increased risk associated with H1N1 influenza (85%) than to recognize the increased risk associated with seasonal influenza (78%). However, respondents were less likely to believe that they have an important role in vaccinating pregnant women compared with the general public (82% vs. 97%) and less likely to agree that 2009 H1N1 vaccine was safe during pregnancy compared with the seasonal influenza vaccine (78% vs. 87%). Pharmacists who had been vaccinated themselves were more likely to recommend vaccination for pregnant patients. Only 38% believed that antiviral medications such as oseltamivir can be given during pregnancy because the benefits outweigh the risks. However, in response to case studies of pregnant women who were candidates for antiviral medications, respondents indicated that they would take extraordinary steps to ensure that pregnant women were either referred for medical assessment or for assistance in obtaining prescribed antiviral medications. Conclusion Education efforts that focus on the effectiveness and safety of influenza vaccination during pregnancy and the benefits of treating pregnant women with confirmed or suspected influenza with antiviral medications may be useful in improving pharmacists' support of pharmaceutical interventions to reduce the impact of influenza in pregnant women. Pharmacists' personal decisions regarding vaccination may be a marker for their overall assessment of risks and benefits and may influence their recommendations for pregnant patients.

ABSTRACTDuring the 2009 influenza A (H1N1) pandemic, many pregnant women experienced severe illness and some gave birth while ill with suspected or confirmed pandemic (H1N1) 2009 influenza. Because of concerns about possible transmission of this novel virus to immunologically naïve newborns, and the absence of definitive studies regarding this risk, the Centers for Disease Control and Prevention (CDC) reviewed relevant literature to understand the potential burden of disease and routes of transmission affecting newborns. This report describes the issues considered during the 2009 H1N1 pandemic as CDC developed guidance to protect newborns in hospital settings. Also presented is a framework of protection efforts to prevent novel influenza infection in fetuses/newborns before birth and in hospital settings. Although developed specifically for the pandemic, the framework may be useful during future novel influenza outbreaks.(Disaster Med Public Health Preparedness. 2012;6:97-103)

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Pregnant women and their newborn infants are at increased risk for influenza-associated complications, based on data from seasonal influenza and influenza pandemics. The Centers for Disease Control and Prevention (CDC) developed public health recommendations for these populations in response to the 2009 H1N1 pandemic. A review of these recommendations and information that was collected during the pandemic is needed to prepare for future influenza seasons and pandemics. The CDC convened a meeting entitled "Pandemic Influenza Revisited: Special Considerations for Pregnant Women and Newborns" on August 12-13, 2010, to gain input from experts and key partners on 4 main topics: antiviral prophylaxis and therapy, vaccine use, intrapartum/newborn (including infection control) issues, and nonpharmaceutical interventions and health care planning. Challenges to communicating recommendations regarding influenza to pregnant women and their health care providers were also discussed. After careful consideration of the available information and individual expert input, the CDC updated its recommendations for these populations for future influenza seasons and pandemics.

OBJECTIVE: To assess knowledge, attitudes, and practices of obstetrician-gynecologists (ob-gyns) regarding vaccination of pregnant women during the 2009 H1N1 pandemic.METHODS: From February to July 2010, a self-administered mail survey was conducted among a random sample of American College of Obstetricians and Gynecologists (the College) members involved in obstetric care. To assess predictors of routinely offering influenza vaccination, adjusted prevalence ratios and 95% confidence intervals (CIs) were calculated from survey data.RESULTS: Among 3,096 survey recipients, 1,310 (42.3%) responded to the survey, of whom 873 were eligible for participation. The majority of ob-gyns reported routinely offering both seasonal and 2009 H1N1 influenza vaccination to their pregnant patients (77.6% and 85.6%, respectively) during the 2009-2010 season; 21.1% and 13.3% referred patients to other specialists. Reported reasons for not offering vaccination included inadequate reimbursement, storage limitations, or belief that vaccine should be administered by another provider. Seasonal and 2009 H1N1 influenza vaccination during the first trimester was not recommended by 10.6% and 9.6% of ob-gyns, respectively. Predictors of routinely offering 2009 H1N1 influenza vaccine included: considering primary care and preventive medicine a very important part of practice (adjusted prevalence ratio 1.2, CI 1.01-1.4); observing serious conditions attributed to influenza-like illness (adjusted prevalence ratio 1.1, CI 1.02-1.1); personally receiving 2009 H1N1 influenza vaccination (adjusted prevalence ratio 1.2, CI 1.1-1.4); and practicing in multispecialty group (adjusted prevalence ratio 1.1, CI 1.1-1.2). Physicians in solo practice were less likely to routinely offer influenza vaccine (adjusted prevalence ratio 0.8, CI 0.7-0.9).CONCLUSION: Although most ob-gyns routinely offered influenza vaccination to pregnant patients, vaccination coverage rates may be improved by addressing logistic and financial challenges of vaccine providers. LEVEL OF EVIDENCE: III (Obstet Gynecol 2011;118:1074-80) DOI: 10.1097/AOG.0b013e3182329681

We describe the efforts of the Maternal Health Team, which was formed to address the needs of pregnant and breastfeeding women during the Centers for Disease Control and Prevention's (CDC's) 2009 pandemic influenza A (2009 H1N1) emergency response. We examined the team's activities, constructed a timeline of key pandemic events, and analyzed the Maternal Health 2009 H1N1 inquiry database. During the pandemic response, 9 guidance documents that addressed the needs of pregnant and breastfeeding women and their providers were developed by the Maternal Health Team. The Team received 4661 maternal health-related inquiries that came primarily from the public (75.5%) and were vaccine related (69.3%). Peak inquiry volume coincided with peak hospitalizations (October-November 2009). The Maternal Health 2009 H1N1 inquiry database proved useful to identify information needs of the public and health care providers during the pandemic.

CDC first identified cases of respiratory infection with a novel influenza A (H1N1) virus in the United States on April 15 and 17, 2009. During seasonal influenza epidemics and previous pandemics, pregnant women have been at increased risk for complications related to influenza infection. In addition, maternal influenza virus infection and accompanying hyperthermia place fetuses at risk for complications such as birth defects and preterm birth. As part of surveillance for infection with the novel influenza A (H1N1) virus, CDC initiated surveillance for pregnant women who were infected with the novel virus. As of May 10, a total of 20 cases of novel influenza A (H1N1) virus infection had been reported among pregnant women in the United States, including 15 confirmed cases and five probable cases. Among the 13 women from seven states for whom data are available, the median age was 26 years (range: 15-39 years); three women were hospitalized, one of whom died. This report provides preliminary details of three cases of novel influenza A (H1N1) virus infection in pregnant women. Pregnant women with confirmed, probable, or suspected novel influenza A (H1N1) virus infection should receive antiviral treatment for 5 days. Oseltamivir is the preferred treatment for pregnant women, and the drug regimen should be initiated within 48 hours of symptom onset, if possible. Pregnant women who are in close contact with a person with confirmed, probable, or suspected novel influenza A (H1N1) infection should receive a 10-day course of chemoprophylaxis with zanamivir or oseltamivir.

Pandemic Influenza: Special Considerations for Pregnant Women was a meeting convened by the Centers for Disease Control and Prevention in 2008 to obtain input from experts and key partners regarding clinical management of pregnant women and related public health actions to be taken during a pandemic. Meeting goals were to discuss issues specific to pregnant women, identify gaps in knowledge, and develop a public health approach for pregnant women in the event of a pandemic. The meeting focused on 4 main topics: prophylaxis and treatment with influenza antiviral and other medications, vaccine use, nonpharmaceutical interventions and health care planning, and communications. Participants reviewed the available evidence to guide action in each of these areas and identified areas of critical needs for future research.

We agree with Roberto Burioni and colleagues that novel treatment approaches for influenza virus infection such as use of anti-influenza monoclonal antibodies might hold promise and are certainly worth pursuing. However, most investigations have used animals, and treatment in human beings has mainly focused on the most severe cases. Treatment with anti-influenza virus antibodies has not yet been shown safe and effective for use in non-pregnant people.1Beigel J Bray M Current and future antiviral therapy of severe seasonal and avian influenza.Antiviral Res. 2008; 78: 91-102Crossref PubMed Scopus (217) Google Scholar It will probably be even longer before such treatment options would be considered for pregnant women since additional safety studies would need to be done, and pregnant women and their health-care providers might be reluctant to use new treatments, even if proven safe and effective. Therefore, it is important to promote a strategy of vaccination and basic hygienic prevention, and prompt antiviral treatment of pregnant women who develop influenza illness. Frequent hand washing, covering mouth and nose when coughing or sneezing, staying home and away from others when sick, and avoiding contact with people sick with influenza-like illness are basic steps that can help decrease the likelihood of influenza and other respiratory illnesses. Owing to the increased risk of severe disease and death, once influenza is suspected in a pregnant woman, appropriate antiviral therapy should be started promptly, ideally within 48 h when the benefit is expected to be the greatest. Although there are known side-effects of antiviral therapy, as pointed out by Burioni and colleagues, the benefits of antiviral therapy outweigh potential risks for pregnant women. We were pleased to learn of the experience in Singapore as reported by Lin Lin Su and colleagues. Singapore should be applauded for its remarkable achievement in providing antivirals to 28 pregnant women promptly, with a median of 2 days from symptom onset to receipt of antiviral drugs. We agree that experience with managing pregnant women during the outbreak of severe acute respiratory syndrome probably helped prepare them and others for this current influenza pandemic2Jamieson DJ Ellis JE Jernigan DB Treadwell TA Emerging infectious disease outbreaks: old lessons and new challenges for obstetrician-gynecologists.Am J Obstet Gynecol. 2006; 194: 1546-1555Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar and that there is much for us to learn from the experiences and successes of others. Finally, the very promising news about the 2009 pandemic influenza A (H1N1) monovalent vaccine3Clark TW Pareek M Hoschler K et al.Trial of influenza A (H1N1) 2009 monovalent MF59-adjuvanted vaccine—preliminary report.N Engl J Med. 2009; (published online Sept 10.)https://doi.org/10.1056/NEJMoa0907650Crossref Scopus (413) Google Scholar, 4Greenberg ME Lai MH Hartel GF et al.Response after one dose of a monovalent influenza A (H1N1) 2009 vaccine—preliminary report.N Engl J Med. 2009; (published online Sept 10.)https://doi.org/10.1056/NEJMoa0907413Crossref Scopus (452) Google Scholar highlights the potential role that vaccination efforts can have in preventing morbidity and mortality. It is essential that all pregnant women are encouraged to be vaccinated, as reflected in current US guidance that places pregnant women in a high-priority group for vaccination with 2009 H1N1 vaccine.5Centers for Disease Control and PreventionUse of influenza A (H1N1) 2009 monovalent vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009.MMWR Recomm Rep. 2009; 58: 1-8Google Scholar The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. We declare that we have no conflicts of interest. Pregnancy and H1N1 infectionDenise Jamieson and colleagues (Aug 8, p 451)1 highlight the risk of infection with pandemic influenza A virus (H1N1) in pregnant women, documenting high rates of hospital admission and complications. Notably, six deaths in H1N1-infected pregnant women were reported between April 15 and June 16, 2009, in the USA. Full-Text PDF Pregnancy and H1N1 infectionDenise Jamieson and colleagues1 highlight high morbidity and mortality rates in pregnant women infected with the H1N1 influenza virus. Admission rates were 41% and the median time from symptom onset to receipt of antiviral therapy was 9 days. Could earlier initiation of antiviral treatment have resulted in a better outcome? Full-Text PDF

Background Pandemic HlN1 2009 influenza virus has been identified as the cause of a widespread outbreak of febrile respiratory infection in the USA and worldwide. We summarised cases of infection with pandemic H1N1 virus in pregnant women identified in the USA during the first month of the present outbreak, and deaths associated with this virus during the first 2 months of the outbreak.Methods After initial reports of infection in pregnant women, the US Centers for Disease Control and Prevention (CDC) began systematically collecting additional information about cases and deaths in pregnant women in the USA with pandemic H1N1 virus infection as part of enhanced surveillance. A confirmed case was defined as an acute respiratory illness with laboratory-confirmed pandemic H1N1 virus infection by real-time reverse-transcriptase PCR or viral culture; a probable case was defined as a person with an acute febrile respiratory illness who was positive for influenza A, but negative for H1 and H3. We used population estimates derived from the 2007 census data to calculate rates of admission to hospital and illness.Findings From April 15 to May 18, 2009, 34 confirmed or probable cases of pandemic H1N1 in pregnant women were reported to CDC from 13 states. 11 (32%) women were admitted to hospital. The estimated rate of admission for pandemic H1N1 influenza virus infection in pregnant women during the first month of the outbreak was higher than it was in the general population (0.32 per 100000 pregnant women, 95% CI 0.13-0.52 vs 0.076 per 100 000 population at risk, 95% CI 0.07-0.09). Between April 15 and June 16, 2009, six deaths in pregnant women were reported to the CDC; all were in women who had developed pneumonia and subsequent acute respiratory distress syndrome requiring mechanical ventilation.Interpretation Pregnant women might be at increased risk for complications from pandemic H1N1 virus infection. These data lend support to the present recommendation to promptly treat pregnant women with H1N1 influenza virus infection with anti-influenza drugs.Funding US CDC.

Background Pandemic H1N1 2009 infl uenza virus has been identifi ed as the cause of a widespread outbreak of febrile respiratory infection in the USA and worldwide. We summarised cases of infection with pandemic H1N1 virus in pregnant women identifi ed in the USA during the fi rst month of the present outbreak, and deaths associated with this virus during the fi rst 2 months of the outbreak. Methods After initial reports of infection in pregnant women, the US Centers for Disease Control and Prevention (CDC) began systematically collecting additional information about cases and deaths in pregnant women in the USA with pandemic H1N1 virus infection as part of enhanced surveillance. A confi rmed case was defi ned as an acute respiratory illness with laboratory-confi rmed pandemic H1N1 virus infection by real-time reverse-transcriptase PCR or viral culture; a probable case was defi ned as a person with an acute febrile respiratory illness who was positive for infl uenza A, but negative for H1 and H3. We used population estimates derived from the 2007 census data to calculate rates of admission to hospital and illness.