Knocked up....now what? Vaccinations - Whooping Cough

Things are getting serious now, I'm 19 weeks pregnant and last week my Doc dropped into conversation that she should give me a vaccination next month. This would be mostly to help prevent whooping cough, and also diphtheria and something else beginning with P that I couldn't quite catch. 



I remembered how adamant my best friend was/is about vaccination programmes (she's a paediatric nurse) and so I innocently, and defiantly, said "oh yes, I am all for any vaccinations, I believe they are very important" but in all honestly I know nothing about them, what they vaccinate against, when they vaccinate, if it is safe and what is available and/or different in Thailand.

Cue some frantic research, which started by watching the "Vaxxed" documentary. For those of you out there wondering where to start with research I might recommend reading the NHS website first or something mild like that and work your way up to Vaxxed which is the extreme end of opinions and likely to send you into a spin.

I am writing this post before I have spoken to my Doctor at Bumrungrad (Dr Somsri) so this post is currently about researching what the Western world does, before I confirm what is available in the Eastern world.

So, starting from the beginning....the NHS website says:

"There's a lot of whooping cough (pertussis) around at the moment and babies who are too young to start their vaccinations are at greatest risk. Young babies with whooping cough are often very unwell and most will be admitted to hospital because of their illness. When whooping cough is particularly severe, they can die. Pregnant women can help protect their babies by getting vaccinated – ideally from 20 weeks, after the foetal scan, up to 32 weeks pregnant. If for any reason you miss having the vaccine, you can still have it up until you go into labour."

So, it seemed pretty clear from that I should take this seriously. But is there a high probability of Whooping Cough in Thailand or, even worse, is it higher risk here? On 31 May 2016 Lord Ara Darzi reported on the BBC:

"To ensure protection for newborns via their mothers, all pregnant women in the UK have been offered the pertussis vaccine in the third trimester of pregnancy since 2012, but many resist because of misplaced fears about its safety. Today, it is combined with vaccines against polio, diphtheria and tetanus - diseases that have been virtually eliminated from the UK but could make a comeback. The combined vaccine, called Boostrix IPV, had a take up rate in England of 62% in 2014. The vital contribution of maternal vaccination is seen more dramatically elsewhere around the globe. In 2008, there were an estimated 16 million cases of pertussis worldwide and 195,000 deaths. In those countries where maternal vaccination programmes have been introduced, deaths have dropped sharply."

I googled "whooping cough thailand" and the second link I see says "Adult pertussis is unrecognized public health problem in Thailand" and is dated in January 2016. Cue frantic reading...the conclusion at the bottom of this short extract says:

"CONCLUSION: Pertussis is being increasingly recognized as a cause of prolonged, distressing cough among adults in Thailand. This result addresses the need of pertussis vaccination in Thai adults for preventing transmission to a high risk group such as newborn infants."

So, its easy to make the decision to vaccinate if one is living in Thailand. Time to get researching.

I found a link to the UK Government Advice Page where it explains:

"The pertussis in pregnancy programme was introduced in 2012 as the UK reported the largest increase in pertussis activity in over two decades. At that time, the greatest numbers of cases were in adolescents and young adults but the highest rates of morbidity and mortality occurred in infants too young to be protected through routine vaccination. In England and Wales, a total of 14 infant deaths were reported in 2012.  

In 2014, the Joint Committee on Vaccination and Immunisation recommended that the temporary pertussis vaccination programme for pregnant women be continued for at least a further 5 years. This decision was made in light of the success of the vaccination programme in saving infant lives and against the continued increase in pertussis incidence. Babies born to vaccinated mothers are 90% less likely to get disease than babies whose mothers were unvaccinated.  

What is the purpose of the programme?  

The purpose of this programme is to protect infants by boosting pertussis immunity in pregnant women. Although most women will have been vaccinated or exposed to natural whooping cough in childhood, if they are given pertussis containing vaccine from week 16 of pregnancy, the vaccine will temporarily boost their antibody levels. This enables the mother to transfer a high level of pertussis antibodies across the placenta to her unborn child which should passively protect her infant against pertussis until he/she is due the first dose of primary immunisations at two months of age. 

Why has the recommendation for the timing for when the vaccine should be offered been changed?  

• During 2012, it was recommended that pregnant women should be vaccinated from weeks 28 to 38 of their pregnancy, with the optimum time for transfer of maternal antibodies being between weeks 28 and 32  
• A recent study however, showed that reasonable levels of pertussis antibodies were demonstrated in neonates through transplacental transfer from mothers vaccinated earlier in pregnancy (Eberhardt C, Maternal Immunization earlier in pregnancy maximises antibody transfer and epected infant seropositivity against pertussis, Clinical Infectious Diseases, Volume 62, Issue 7, p829-836, 20 January 2016)  
• As a result of this study, JCVI has recommended that women should be offered pertussis-containing vaccine between gestational weeks 16 and 32 to maximise the likelihood that the baby will be protected from birth  
• Offering the vaccine from week 16 of pregnancy gives pregnant women greater opportunity to take up the offer of vaccination and will offer some protection to infants born prematurely who may be particularly vulnerable to complications from pertussis  
• For operational reasons, vaccination is probably best offered on or after the foetal anomaly scan at around 18- 20 weeks. Offering at this time will also avoid any associations with unrelated adverse events identified up to or at the routine anomaly antenatal scan being made.  
• Women may still be immunised after week 32 of pregnancy until delivery but this may not offer as high a level of passive protection to the baby.  

 What is the recommended vaccine for the programme and why?  

Since 1 July 2014, the recommended vaccine for the programme has been Boostrix IPV® (which contains diphtheria, tetanus, acellular pertussis and inactivated polio antigens – dTaP/IPV). Boostrix-IPV® is licensed as a booster from four years of age and contains low dose diphtheria suitable for adults. Boostrix-IPV® is not licensed for use in children under four years of age and should not be used for the pre-school booster.  

Is the vaccine safe to administer in pregnancy?  

There are no concerns about the safety of pertussis-containing inactivated vaccine at any stage in pregnancy. Inactivated vaccines are routinely used in other countries and in last few years, pertussis-containing vaccines have been given in pertussis vaccine in pregnancy programmes in countries such as USA, New Zealand and Australia. 

Inactivated vaccines contain no live organisms, cannot replicate and therefore cannot cause infection in either the mother or the foetus. 

Since the introduction of the pertussis vaccine in pregnancy programme in October 2012, the Medicines and Healthcare products Regulatory Agency (MHRA) has continually monitored the frequency and type of adverse events using the Yellow Card Scheme and the Clinical Practice Research Datalink to follow pregnancy outcomes following vaccination. 

The MHRA has found no safety concerns relating to pertussis vaccination in pregnancy based on a large observational cohort study (Donegan K, Safety of pertussis vaccination in pregnant women in UK: observational study, BMJ, 2014;349:g4219) of 18,000 vaccinated women with similar rates of normal, healthy births in vaccinated and in unvaccinated women. The study found no evidence of an increased risk of stillbirth in the 14 days immediately after vaccination or later in pregnancy and found no evidence of an increased risk of any of an extensive predefined list of adverse events related to pregnancy.  

As a result of this study, and in light of the success of the temporary programme in saving infant lives, in 2014, the JCVI recommended the programme be extended for at least the next 5 years (until 2019), at which point it will be reviewed again.  

Can the vaccine be offered to women who are more than 32 weeks pregnant?  

Yes, the vaccine can be offered to pregnant women up until they go into labour. However this is not the optimal time for immunisation since antibody levels in adults peak about two weeks after a pertussis booster. So a vaccine administered shortly before labour may mean that there is insufficient time for the mother to make a good response and have antibodies to pass across the placenta.  

Administering the vaccine between weeks 16 and 32 of pregnancy is likely to ensure sufficient levels of pertussis antibodies are transferred across the placenta, thereby providing passive immunity to the unborn child. 

If the woman reaches 38 weeks of pregnancy and has still not received the vaccine, it should still be offered. Although immunisation after week 38 of pregnancy may not provide passive protection to the infant, it would potentially protect the mother from pertussis infection and thereby reduce the risk of her becoming a source of infection to her infant.  

Can you give Repevax® (dTaP/IPV) vaccine if there is no Boostrix-IPV® (dTaP/IPV) available?  

From 1 July 2014, Boostrix-IPV® replaced Repevax® (dTaP/IPV) as the recommended vaccine for this programme and this vaccine can be ordered via Immform. Boostrix- IPV® (dTaP/IPV) should be reserved for pregnant women and Repevax® (dTaP/IPV) and Infanrix IPV® (DTaP/IPV) should be used for the pre-school booster vaccine.  

However, in those exceptional circumstances where there is no Boostrix-IPV® (dTaP/IPV) vaccine when a woman attends for vaccination and it is very unlikely that she will present again, it would be preferable to give Repevax® (dTaP/IPV).  

Boostrix-IPV® is not licensed for use in children under four years of age and should not be used for the pre-school booster.  

If a pregnant women has recently received a Td/IPV (Revaxis®) vaccine, when should Boostrix-IPV® be administered?  

A four week minimum interval period is normally observed between a course of successive vaccines to ensure an adequate response. There is good evidence to suggest that dTaP/IPV may be administered to adults as soon as one month after Td/IPV (Revaxis®) without significantly increasing the frequency or severity of side effects.  

What should you do if Boostrix-IPV® (dTaP/IPV) is given to a pregnant woman before 16 weeks in error?  

If the dose was given before 16 weeks of pregnancy, it should be repeated once the woman reaches 16 weeks of pregnancy or around the time of her fetal anomaly scan. 

A minimum interval of four weeks between doses should be observed to reduce the risk of a local reaction. Repeating the dose will ensure that the unborn baby benefits from optimal transfer of maternal antibodies.  

What should you do if you inadvertently administer Revaxis® (Td/IPV) vaccine to a pregnant women when Boostrix-IPV® should have been given?  

As Revaxis does not protect against pertussis, a dose of Boostrix-IPV® (dTaP/IPV) should be given as soon as possible after the error is realised..... 

What should you do if you inadvertently administer Menitorix® (Hib/MenC) vaccine to a pregnant women when Boostrix-IPV® should have been given?  

Due to the packaging similarities between Boostrix-IPV® and Menitorix®, healthcare professionals are encouraged to familiarise themselves with the two vaccines so that vaccine errors do not occur. Please see page 8 of Vaccine Update April 2014  

Women who have inadvertently received Menitorix® instead of the recommended Boostrix-IPV® should be reassured that there is no known risk as this is an inactivated vaccine, which means that it doesn't contain any live organisms. Since inactivated vaccines cannot replicate, they cannot cause infection in either the mother or her baby. 

There is no known risk associated with giving inactivated vaccines at any stage of pregnancy. As Menitorix® (Hib/Men C) does not protect against pertussis, a dose of Boostrix-IPV® should be administered as soon as possible after the error is realised.... 

What should you do if you inadvertently administer Repevax® (dTaP/IPV) or Pediacel® (DTaP/IPV/Hib) vaccine to a pregnant women when Boostrix- IPV® should have been given?  

Until 1 July 2014, Repevax® (dTaP/IPV) was the recommended vaccine for the pertussis vaccination in pregnancy programme. Therefore, women who have inadvertently received Repevax® instead of the recommended Boostrix-IPV® should be reassured that no further action is required.  

Women who have inadvertently received Pediacel® (DTaP/IPV/Hib) instead of the recommended Boostrix-IPV® should be reassured that Pediacel® does offer protection against pertussis and that no further action is required. Such women should also be advised that Pediacel® contains a high dose of diphtheria that is not normally given to adults because it is more likely to cause a localised reaction. Women who have inadvertently received Pediacel® should be informed of the higher risk of localised reactions.... 

A worried parent wants to know how to protect her baby who is too young for routine immunisations. Can the first dose of primary immunisation be offered before two months of age?  

Infants may receive their first dose of primary immunisations from 6 weeks of age in exceptional circumstances eg pre-travel but it is not routinely recommended to offer infants vaccine before two months of age. The schedule has been designed to provide optimum protection for infants at the earliest opportunity. Administering vaccines early may have a negative impact on the immune response that the infant makes.  

The best way to protect newborn babies from pertussis is to ensure that the baby has benefited from the transfer of maternal antibodies before it was born. When a pregnant woman has pertussis containing vaccine at the recommended time during her pregnancy, the unborn baby will receive some of those anitbodies and will be protected during their first few weeks of life, until they are old enough to make a good response to their own vaccines.  

Once a baby starts their routine vaccinations chedule, it is important that they have all their vaccines at the recommended time."

Having tried to digest all of the above I was now concerned about what form of the vaccine would, or would not, be available in Thailand.

According to the above I can see the following likely possibilities, but what are they and what do they do?

Boostrix-IPV® (dTaP/IPV)

"Indicated for the active immunisation of women from 20 weeks of pregnancy and for the prevention of pertussis by passive immunity in the neonate in accordance with the national immunisation programme, as recommended by the Joint Committee of Vaccination and Immunisation (JCVI) and Public Health England (see JCVI minutes from February 2016) and subsequent updates to Chapter 24 of Immunisation Against Infectious Disease: “The Green Book”." https://www.gov.uk/government/publications/pertussis-vaccination-in-pregnancy-dtapipv-boosterix-or-repevax-pgd-template

Repevax® (dTaP/IPV)

"Indicated for the active immunisation of women from 20 weeks of pregnancy and for the prevention of pertussis by passive immunity in the neonate in accordance with the national immunisation programme, as recommended by the Joint Committee of Vaccination and Immunisation (JCVI) and Public Health England (see JCVI minutes from February 2016) and subsequent updates to Chapter 24 of Immunisation Against Infectious Disease: “The Green Book”." https://www.gov.uk/government/publications/pertussis-vaccination-in-pregnancy-dtapipv-boosterix-or-repevax-pgd-template

"Indicated for the active immunisation of individuals from 3 years 4 months to under 10 years of age for the prevention of diphtheria, tetanus, pertussis and poliomyelitis, in accordance with the national immunisation programme and recommendations given in Chapter 15, Chapter 24, Chapter 26 and Chapter 30 of Immunisation Against Infectious Disease: “The Green Book”." https://www.gov.uk/government/publications/dtapipv-infanrix-ipv-or-repevax-pgd-template 

Td/IPV (Revaxis®)

"Indicated for the active immunisation of individuals from 10 years of age for the prevention of diphtheria, tetanus and poliomyelitis, in accordance with the national immunisation programme and recommendations given in Chapter 15, Chapter 26 and Chapter 30 of Immunisation Against Infectious Disease: “The Green Book”." https://www.gov.uk/government/publications/diphtheria-tetanus-and-inactivated-poliomyelitis-vaccine-tdipv-revaxis-patient-group-direction-pgd-template 

Menitorix® (Hib/MenC)

"The Hib/Men C vaccine is a single injection given to one-year-old babies to boost their protection against Haemophilus influenzae type b (Hib) and meningitis C." http://www.nhs.uk/Conditions/vaccinations/Pages/hib-men-C-booster-vaccine.aspx

Pediacel® (DTaP/IPV/Hib) (also known as the 5 in 1 baby vaccine)

"Preventing diphtheria, tetanus, whooping cough, polio and infection with Haemophilus influenzae type B bacteria (Hib) in babies. Hib can cause serious diseases such as meningitis, pneumonia and septicaemia (blood poisoning). The vaccine is given to babies at two, three and four months of age, as part of the childhood immunisation schedule. There are two brands of this vaccine available, Pediacel and Infanrix-IPV+Hib. Either may be used to vaccinate your baby." http://www.netdoctor.co.uk/medicines/infections/a8592/5-in-1-baby-vaccine/

It seems that (according to the UK) there are two options for immunisation against Whooping Cough in pregnancy Boostrix-IPV® or Repevax®, and call me sinister but it seems that the government in the UK made the decision to switch from Repevax® to Boostrix-IPV® in 2014 because it was easier (and probably cheaper) to order.

So can I conclude that if Dr Somsri offers me either of these vaccinations I have no reason to worry.?

The University of Oxford Vaccine Group says this:

"There are no safety concerns about the use of the vaccine in pregnancy, and there is considerable experience of its use both in the UK and the United States. The vaccine offered to pregnant women (Boostrix-IPV) is also used as a pre-school booster vaccine, and protects against diphtheria, tetanus and polio as well as pertussis. Boostrix-IPV has been used extensively in Australia, New Zealand and other countries. These combination vaccines are being used because a single pertussis vaccine is not available. Many millions of doses have been given to children in recent years without any concerns about harm. Boostrix-IPV contains low-dose diphtheria and tetanus, which means that the rate of side effects is lower than with the 5-in-1 vaccine, for example. 

A large safety study involving over 20,000 vaccinated pregnant women , undertaken by the UK's Medicines and Healthcare products Regulatory Agency (MHRA), has found no risks in pregnancy from Repevax, which was the vaccine used for this programme until summer 2014. Repevax is one of the two pre-school booster vaccinesused in the UK, and is very similar to Boostrix-IPV but made by a different manufacturer. Similar vaccines have also routinely been given to pregnant women in the USA over the last few years without concerns (see information from the US Centers for Disease Control and Prevention ). Although there is so much experience of the use of the vaccine, it was not studied as part of a clinical trial in pregnancy. This is why the manufacturer’s information leaflets for both Repevax  and Boostrix-IPV  state that the vaccine is 'not recommended for use in pregnancy' or 'should be used during pregnancy only when clearly needed'."

CONCLUSION: I am hoping that Bumrungrad will offer  Boostrix-IPV (or Boostrix, which is the same but without the Polio element), or worst case Repevax, because otherwise all of this googling has been in vain and I have to go back to frantic searching again.

I will post after my next appointment (9th Jan 2017) and update accordingly.

NB: In writing this post I also discovered that Infanrix-IPV+Hib is available as an alternative to Pediacel for childhood immunisation, but I will google that closer to the time

Update @ 9th Jan 2017 - Dr Somsri has said that I can have a DT vaccination now for myself for diptheria and tetanus (no benefit to the baby) and a Tdap (Tetanus, Diphtheria, Pertussis vaccine) at 28 weeks, this will give the baby some protection for whooping cough. She didn't know the brand though. I questioned whether we could have the Tdap before 28 weeks, but Thailand has not caught up yet with the UK advice. Given that the UK advice now is to  vaccinate for whooping cough at between 20 and 32 weeks, I am comfortable to have at 28 weeks per Dr Somsri's advice. But I am still researching brands available.

Update @ 9th Feb 2017 - I was given the Tdap vaccination today. They used the brand name Adacel [Generic Name: tetanus, diphtheria, acellular pertussis vaccine / Brand Names: Adacel (Tdap), Boostrix (Tdap)] See this link for more information www.drugs.com/adacel Essentially I am very happy to have managed to get this at 27 weeks pregnant, one week before Dr Somsri recommended, but a good compromise between Thailand and NHS guidelines. It isn't the IPV version though, so no additional Polio, but I'm not worried about that for now.