Influenza and Pregnancy

Influenza affects different population groups disproportionately with pregnant women, the very young, the very old and people with certain health conditions at highest risk of serious complications.

Two important groups at high risk of disease and serious complications have been recognised since the 1918 influenza pandemic, they are pregnant women and their babies (up to 6 months of age).

Influenza vaccination of pregnant women during any stage of pregnancy has been found to be highly effective in preventing influenza and its complications in the woman and her baby, during pregnancy and for up to six months after birth by the passive protection passed on to the baby in utero, through the placenta.

The World Health Organization recommends influenza vaccination of pregnant women at any stage of pregnancy, and that they are given the highest priority. Influenza vaccination has been recommended and funded in New Zealand for pregnant women since 2010.

Inactivated influenza vaccine is used in New Zealand. There are no concerns about the safety of influenza vaccination during any trimester of pregnancy.

The funded influenza vaccine is usually available from March until 31 December.

Pregnancy

It is well established that some of the physiological changes that occur during pregnancy leave pregnant women and their growing baby at greater risk of serious influenza complications.

Influenza infection during pregnancy can have catastrophic consequences for both mother and baby including premature birth, stillbirth, small for gestational age and perinatal death.

Physiological changes during pregnancy that can lead to complications from influenza include the following:

• Immune system: While humoral (antibody mediated) immunity appears to be enhanced, the cellular arm of the immune system is temporarily suppressed. This is to prevent harmful immune responses being directed at the growing baby, which is genetically foreign to the mother. These changes can leave a pregnant woman more vulnerable to some intracellular pathogens including viral infections
• Physical changes: Changes in the pelvic region, abdominal and thoracic cavities place pressure on surrounding organs. Lung capacity is decreased and oxygen consumption increased. Blood volume, heart rate and the amount of blood pumped per contraction (stroke volume) are increased

Risk for the women

Data from the Southern Hemisphere Influenza and Vaccine Effectiveness Research and Surveillance (SHIVERS) hospital based surveillance for severe acute respiratory infections in Auckland during 2012–2014 identified that pregnant women with influenza were five times more likely to be hospitalised than non-pregnant women. A normally healthy woman who is pregnant has a similar risk for complications from influenza as non-pregnant women who have co-morbidities. This risk increases with gestation. When pre-existing medical conditions are superimposed on pregnancy the risks become even higher.

Evidence suggests that pregnant women are even more vulnerable during pandemics.

Risk for the growing baby

Direct vertical transmission of the influenza virus to the growing baby is thought to be extremely rare. The adverse effects observed on the baby in mothers who have influenza are likely to be indirect, i.e. as a result of the mother’s response to the virus. Maternal influenza infection can be associated with congenital abnormalities caused by fever. Overall there is an increase of general pregnancy complications in women who have influenza.

Historical studies proposed a possible link between maternal influenza infection during pregnancy and an increased risk of cancer in infants and children, such as leukaemia, brain tumours or neuroblastomas. The increased risk of cancer in a child born to a mother who had influenza during pregnancy was extremely low as these are rare cancers.

Risk for young babies

Babies aged under 6 months have a higher risk of being hospitalised with influenza than other age groups. Influenza-related complications can include fever-related convulsions, vomiting and diarrhoea, pneumonia and occasionally brain inflammation.

In Auckland during 2017, infants aged under 1 year had the second highest rate of hospitalisation with a severe acute influenza respiratory infection compared with other age groups, 145 cases per 100,000 people compared with 283/100,000 for adults aged 80 years or older, 97/100,000 for adults aged 65–79 years and 17/100,000 for midlife adults.

Influenza survivor Kim Neho – Influenza and Pregnant Women

Kim Neho watches her seven-month-old twins rolling around the floor trying to sit upright in their Kaitaia home and, as she does every day, counts her lucky stars she is still around to witness these milestone moments.

Rewind seven months and she was lying in a coma at death’s door, her body ravaged by influenza and a range of other complications, surrounded by her husband, three kids and, nuzzling into their mother, her newborn twins, who she was yet to meet http://youtu.be/mM_t23Rn7ig (Courtesy of the Northland District Health Board - Media Release)

Questions and answers for pregnant women

Is INFLUVAC® TETRA the funded influenza vaccine for pregnant women?
Yes. One dose of the inactivated quadrivalent influenza
vaccine is recommended each influenza season/year that a
woman is pregnant. A woman who is pregnant across two
influenza seasons would receive two influenza vaccinations
during her pregnancy.

Is there a minimum interval between receiving an influenza vaccination at the end of 2017 and receiving one in 2018?
No. The 2018 influenza vaccination can be given as soon as the vaccine is available. No minimum time is required between an influenza vaccination in 2017 and one in 2018.

Why is an influenza vaccination recommended every year?
Yearly vaccination is recommended for two reasons: first, because protection from the previous vaccination lessens over time; and second, because the circulating influenza viruses can change and the strains in the vaccine usually change each year in response to the changing virus pattern. 

Women who are pregnant across two influenza seasons are recommended to have an influenza vaccination in both of the seasons. In addition to the reasons explained above, a pregnant woman’s risk from influenza also increases with increasing gestation.

When is the best time to be vaccinated?
Influenza vaccination can be given at any time during pregnancy. It is preferable to vaccinate as soon as the vaccine is available (usually from March), well before the start of winter. The funded vaccine is available through to 31 December.

Can influenza and whooping cough booster vaccinations be given at the same visit?
If the woman is between 28–38 weeks of pregnancy (in their third trimester) the influenza vaccine and whooping cough booster vaccine (Tdap) can be administered at the same visit. Both vaccines are funded for pregnant women.

Can women with a history of miscarriage receive an influenza vaccination?
Yes. Influenza vaccination does not increase the risk of miscarriage. However, catching influenza can increase the risk.

Can a post-partum woman receive an influenza vaccination? Will it protect her baby if she is breastfeeding?
It is safe for a breastfeeding woman to have the influenza vaccination. Breastfeeding may offer some initial influenza protection to her baby. However, babies will have more protection if their mother is vaccinated during pregnancy.

Is the influenza vaccine a live vaccine?
No. The influenza vaccine used in New Zealand does not contain any live viruses; the influenza viruses are completely inactivated and cannot cause influenza.

Are there any preservatives in the influenza vaccine, e.g. thiomersal?
No. The vaccine used in New Zealand is preservative free. 

Should pregnant women who work with children receive an influenza vaccination?
Yes. Influenza infection rates are generally highest in children, and they are a major source of the spread of influenza. The influenza virus may be found in respiratory secretions (breathing, coughing and sneezing) for two weeks or longer in children. The risk of exposure to the influenza virus is higher and, for pregnant women, so is their risk of influenza disease and serious complications.

It is also important for all people working with children, and especially young babies, to be vaccinated against influenza to reduce the risk of passing influenza onto them.

Vaccination and breastfeeding

The influenza vaccine can be given to a breastfeeding woman. Protecting the mother can help prevent her becoming infected and transmitting influenza to her baby. Breastfeeding may offer some protection against influenza.