Antenatal influenza vaccination: engaging clinicians for increasing coverage

Background: Influenza is a highly contagious acute respiratory illness and occurs in two epidemiological forms in humans − epidemic and pandemic influenza. Epidemic influenza is mostly characterized by seasonal outbreaks and more localized in certain areas. According to the World Health Organization (WHO) estimates, influenza seasonal epidemics are estimated to account for approximately 3 to 5 million cases of severe illness, and about 290,000 to 650,000 respiratory-related deaths worldwide annually. Pregnant women are vulnerable to influenza-associated complications because of their physiological changes in cardiopulmonary mechanics and the immune system. A review of eight studies in India reported that Influenza A (pH1N1) was associated with relative increases in maternal mortality by 25 to75% and in fetal mortality by 5.5 to 33%. A retrospective analysis conducted by a group of experts on communicable diseases prevention and control in Maharashtra, India, indicated that, between 2009 and 2015, 9.8% (214 out of 2175) of all influenza-related deaths occurred among pregnant women.
Research has shown that maternal influenza vaccination can prevent laboratory-confirmed influenza in pregnant women and their newborns (age less than 6 months). Importantly, vaccines are widely considered safe and effective for preventing influenza in pregnant women. The WHO recommends antenatal influenza vaccination (AIV) for pregnant women at any stage of pregnancy because of the high risk of serious consequences. AIV is the most effective intervention for protecting pregnant women and their newborns against influenza. Although the WHO recommends AIV at any stage of pregnancy, it is rarely provided in low- and middle-income countries (LMICs), including India. Research suggests that inappropriate antenatal care (ANC) provider practices explain much of this limited coverage.
Goals and objectives: The overarching goal of this thesis was to engage clinicians and survey community members to understand the factors influencing seasonal influenza vaccine acceptance in a LMIC setting, with the aim of improving vaccine uptake. This PhD thesis examined the feasibility of a two-stage clinician-engagement strategy to reduce missed opportunities for AIV in urban private-practice ANC clinics. Simultaneously, this thesis also assessed and analyzed fundamental aspects of AIV acceptance and demand among key stakeholders in urban Pune, India. Research findings were intended to contribute to state-level and national-level policies in India toward improving seasonal influenza control in pregnant women.
Methods: 30 clinicians were randomized to an intervention and a control arm in slum and middle-class study sites of Pune. The 16 intervention-group clinicians (active clinicians) were assessed on vaccination-related views and practices, and were presented with authoritative AIV recommendations from global, academic and professional medical organizations. In a second meeting, which took place about three months later, the clinicians were provided with the findings from a community survey regarding vaccination-related views and experiences among women in childbearing age and their spouses. This survey was conducted in the communities of the clinicians’ practices contemporaneously with the first survey among the clinicians. Community vaccination views were not provided to the 14 control-group clinicians. Both groups-maintained logs of vaccination status among pregnant women across all of their ANC clinic visits throughout the 11-month study period (July 2015 to May 2016) to enable identification of missed and taken opportunities for vaccination. Analyses were restricted to visits of women in their third trimester without previous AIV in the current pregnancy.
For rapid ethnographic assessment of AIV-related awareness, priorities and practices, semi-structured interviews were used to study clinicians and their communities of practice. A qualitative survey was conducted among the 16 active clinicians in slum and middle-class areas of Pune to ascertain their baseline views and associated practices regarding AIV acceptance and demand. On completion of the survey, they were informed about AIV recommendations of WHO and the Federation of Obstetric and Gynaecological Societies of India (FOGSI). A community survey was also conducted among 60 women of reproductive age and 30 spouses from the slum and middle-class areas in which the clinicians hat their practices. A second clinician survey was conducted three months after the first one to assess changes in clinicians’ awareness, priority and practice. On completion of this follow-up interview, they were also informed of the community survey findings.
Results: The two-stage interaction with clinicians reduced missed opportunities for AIV in urban middle-class settings of Pune. After the first and second interactions, active clinicians in middle-class communities vaccinated at 12.2% and 37.8%, respectively while middle-class control clinicians vaccinated at <0.2% throughout the study. This difference in AIV taken opportunities between middle-class active and control clinics was statistically significant (p <0.05) in both periods following each interaction. In slum-community sites, active clinicians’ AIV activity was minimal throughout. The absence of any intervention effect in slum-based clinics likely reflects critical limitations of vaccine access.
Most community respondents were unaware of AIV, in contrast to the well-known and widely used antenatal tetanus vaccination. They expressed general confidence in vaccines and trust in the clinicians. Clinicians’ advice was reportedly the most important determinant of community vaccine acceptance. Community respondents indicated high confidence in vaccines during pregnancy, considering them safe and beneficial for pregnant women and especially their newborns. Thesis findings indicate that there would be sufficient acceptance for AIV in the community if it were advised by clinicians. Clinicians were confident of the safety of AIV and endorsed AIV implementation. They anticipated that patients would accept AIV if it were recommended to them. The second clinician interview showed increased awareness of AIV policies, but clinicians were more sceptical about the severity of maternal influenza in their practice. Findings thus also indicate the need for providing more detailed information on the influenza-related risks for pregnant mothers and their newborns to ANC clinicians.
Conclusions/Significance: This thesis, based on a study conducted in urban areas of Pune, India, presents a two-stage strategy for engaging clinicians toward the objective of improving AIV uptake. In a first stage, clinicians were provided with authoritative professional evidence recommending the use of AIV and, in the second stage, they were informed about community views on vaccination-related issues in their areas of practice. The thesis also clarified awareness, priorities and practices regarding AIV among key stakeholders, namely, women of reproductive age and their spouses, and private ANC providers in urban communities of Pune, India. Based on this initial experience, a further strengthening of the approach is warranted. Moreover, efforts to apply the clinician engagement strategy in government healthcare settings and in rural areas would hold promise for improving vaccination coverage among pregnant women against influenza and potentially other diseases. In conclusion, this work contributes to the global advances in the study of vaccine acceptance and demand and its determinants and underpins the value of the stakeholder framework.