BERNALILLO, N.M. – A personal one-on-one recommendation from a woman’s obstetrician is what’s most likely to convince a woman to get flu and Tdap shots during pregnancy, according to an e-mail survey of 274 women from nine private obstetrics practices in Colorado.
Women were almost four times more likely to get Tdap during pregnancy and have at least one close contact get the shot – a practice known as cocooning – if their obstetricians recommended it (adjusted odds ratio [aOR], 3.67), and almost twice as likely to cocoon with the flu shot (aOR, 1.89). Recommendations from office staff, written material, and other sources didn’t work.
Dr. Meghan Donnelly
And yet only about half of the respondents said that their obstetrician recommended the flu vaccine, and that about two-thirds recommended Tdap vaccine; the survey was done after Tdap was recommended for all pregnant women in the fall of 2012. "The practice may have provided written material or the nurse may have said [something], but their [obstetrician] didn’t sit down with them and recommend it. We are not doing a great job of recommending cocooning for our patients," said Dr. Meghan Donnelly, an ob.gyn. specializing in maternal and fetal medicine at the University of Colorado Hospital in Aurora.
"You can’t just be lazy and put the ACOG [American College of Obstetricians and Gynecologists] pamphlet in your office," she said.
Just 61% of women reported cocooning for Tdap or flu vaccines. Perceived benefit – gauged by questions such as "getting myself vaccinated will help keep my baby from getting pertussis" – and perceived susceptibility to infection also made cocooning more likely; negative beliefs about vaccines made it less likely. Hispanic women also were less likely to get the shots than white women (aOR, 0.26).
In addition to patient education, the solution is "to educate providers" that they need "to mention [the shots] specifically in the office visit" and that it’s possible to give the shots without slowing down their practices or losing money, Dr. Donnelly said at the Infectious Diseases Society for Obstetrics and Gynecology annual meeting.
She and her colleagues are working to get the word out; the survey was part of an ongoing, randomized Centers for Disease Control and Prevention–funded trial to compare vaccine uptake rates between practices that are taught those things and those that are not.
Vaccine supply specialists are meeting with offices in the intervention group to teach them how to predict the needs of their patients, and effectively order, properly store, and bill for vaccines so they don’t lose money.
"We are [also] helping them create a vaccine champion program so that there’s one person who takes ownership of the [issue]. We are providing education to every level of staff about the importance of this, how to record a vaccination history, and how you identify who you need to talk to about vaccination, because it’s not every person and you don’t need to ask every time. We are [also] creating flow maps of practices to come up with the most efficient way to increase vaccine uptake [without] taking more time per patient," she said.
"In some practices, we created a standing order set where a nurse could identify who needs the flu vaccine and administer it without a doctor seeing the patient or writing a separate order. In some clinics, nurses did not feel comfortable with that approach, whereas other clinics thought it was a really great idea and embraced it enthusiastically," Dr. Donnelly said.
"It is harder to do interventions in some practices than others, mainly if their medical record system isn’t electronic. We’ve had to adjust interventions differently for each practice," she said.
Dr. Donnelly said she had no relevant financial disclosures.