Transcript Title of Presentation Myriad Pro, Bold, Shadow, 28pt

Anthrax: Special Considerations for
Pregnant and Postpartum Women
Communication and Training Workgroup
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.
Workgroup Members

Renee Brown-Bryant

Jacqueline Grant

Juliette Kendrick

Catherine Ruhl

Laura Ann Smith

Etobssie Wako

Linda West

Marianne Zotti
Questions

What are the primary concerns of pregnant/postpartum
women related to vaccinations and treatment?

What did the Pandemic H1N1 Influenza (pH1N1) response
reveal about factors that may influence health care
providers to support vaccination and treatment
recommendations for pregnant/postpartum women?

What factors may affect adherence to antimicrobial
inhalational anthrax prophylaxis among anthrax exposed
populations?

What factors do we need to consider for training health care
providers regarding anthrax and pregnant/postpartum
women?

What should the priorities be for future research in this
area?
QUESTION 1: WHAT ARE THE
PRIMARY CONCERNS OF
PREGNANT/POSTPARTUM
WOMEN RELATED TO
VACCINATIONS AND
TREATMENT?
 Focus is on pregnant and
postpartum women
 Focus is not specific to anthrax
 Much of this background is from
pH1N1 response
Issues to Consider

Issues specific to pregnant and postpartum women

Critical message components associated with influenza
vaccinations among pregnant/postpartum women

Influence of Obstetric (OB) providers on behavior of
pregnant women
Issues specific to pregnant and postpartum women

Pregnant women are an at-risk population that needs preevent planning to facilitate good health outcomes 1,2

Pregnancy is a teachable moment due to the pregnant
woman’s strong motivation to protect the fetus3

High risk pregnant and postpartum women reported
caregiving responsibilities for immediate and extended
family members after Hurricane Katrina4

High risk pregnant and postpartum women tended to trust
information related to Hurricane Katrina from influential
community and/or family members, churches or shelters
more than other sources4
1Callaghan
2008
et al, 2007; 2 Pandemic & All-Hazards Preparedness Act, 2006; 3 McBride, Emmons & Lipkus, 2003; 4DRH Topline Report,
Issues specific to pregnant and postpartum women

Pregnant women were more likely to obtain the influenza
vaccine if they believed that
 it was very safe or benefits the infant 1,2,3
 pregnant women get sicker than other women 1,2,3
 Pandemic H1N1 Influenza (pH1N1) would adversely affect her
pregnancy1
1Fridman
et al, 2011; 2Goldfarb et al, 2011; 3SteelFisher et al, 2011
Critical message components associated with influenza
vaccinations among pregnant and postpartum women

Communication to pregnant women needs to include1
 detailed descriptions of the vaccine’s or medication’s benefits or lack
of risk to the fetus
 risks associated with breastfeeding
 clear rationale about why a medicine or vaccine is necessary

Barriers to receiving the Influenza vaccine included
 concerns about fetal and maternal health2,3,4
 inadequate knowledge about the importance of the vaccine2
 not knowing where to get the vaccine2
 fear of side-effects3
1Lynch
et al, 2011; 2Fisher et al, 2011; 3Fridman et al, 2011; 4Goldfarb et al, 2011
Influence of OB providers on behavior of
pregnant women

Health care providers were identified by pregnant women as
their major source of information about what they should or
should not do during pregnancy1

The pregnant woman’s health care provider was a trusted
source of information about the 2009 pH1N12

Recommendations to receive pH1N1 and seasonal influenza
immunizations from health care providers were associated
with pregnant women being vaccinated3,4,5
1Aaronson,
Mural & Pfoutz, 1988; 2Lynch et al, 2011; 3Ahluwalia, et al, 2010; 4Ding, et al, 2011; 5Tong, et al, 2008
Workgroup Recommendations

Pilot test all communication materials and messages for
both pregnant and postpartum women

Ensure that messages address pregnant and postpartum
women’s primary concerns
 Benefits or lack of risk to the fetus
 Clear rationale about why a medicine or vaccine is necessary
 Implications for breastfeeding among postpartum women with
anthrax or who receive antibiotics and/or vaccines
 Risks to other family members
QUESTION 2: WHAT DID THE
pH1N1 RESPONSE REVEAL
ABOUT FACTORS THAT MAY
INFLUENCE HEALTH CARE
PROVIDERS TO SUPPORT
VACCINATION AND TREATMENT
RECOMMENDATIONS FOR
PREGNANT/POSTPARTUM
WOMEN?
 Focus is on health care
providers and pH1N1
response
Issues to Consider

Provider knowledge, attitudes, and behavior

Public health support for local physicians pertaining to CDC
pH1N1guidance

Public health support to local communities pertaining to
CDC pH1N1guidance
Provider knowledge, attitudes, and behavior

From focus groups of obstetricians/gynecologists, family
physicians, certified nurse midwives and nurse practitioners
regarding pH1N1:1
 Most were aware of the CDC guidance
 There were mixed perceptions of pH1N1 as a severe threat among
pregnant women
 Some providers expressed confusion about vaccination schedules
and vaccine safety during the first trimester
 Some expressed concern about presumptive treatment of sick
pregnant women
 Primary trusted sources of information were CDC, professional
organizations, and state and local public health
1Mersereau
et al, 2012
Public health support for local physicians
pertaining to CDC pH1N1guidance

Local public health and medical care providers gave
suggestions below to facilitate use of CDC pH1N1guidance: 1
 The CDC website has been a tremendous resource to clinicians,
particularly the “information box” with dates and times that notifies
readers of updated information or changes in guidance.
 OB/GYNs are very concerned about adverse effects to their pregnant
patients from vaccination.
 The CDC website should link to websites of professional societies to
provide reliable information on locations where pregnant patients
can be vaccinated.
1Meeting
notes, “Considerations for Pregnant Women, Newborns and Children in an Anthrax Response: Medical/Public Health
Collaboration,” September 7, 2011, Atlanta, Georgia
Public health support for local communities
pertaining to CDC pH1N1guidance

GA Public Health Districts (examples of activities):
 Fact sheets with summaries of CDC changes for primary care and OB
providers
 Vaccine distribution to physician offices, colleges, others such as Job
Corps
 Distribution of antivirals to hospitals
 Distribution of antivirals to hospital ERs and pharmacies for
vulnerable populations
 Local school-based vaccination clinics and drive through vaccination
sites
 Fact sheets for patients (English and Spanish)
 Letters to schools and camps
 Call lines with triage messages
Workgroup Recommendations

Pilot test all communication materials and messages for OB
professionals (including physicians, nurse midwives, nurse
practitioners, physician assistants, and registered nurses)

Develop strategies for communication with OB professionals
that include CDC, professional organizations, and state and
local public health
QUESTION 3: WHAT FACTORS MAY AFFECT
ADHERENCE TO ANTIMICROBIAL INHALATIONAL
ANTHRAX PROPHYLAXIS AMONG ANTHRAX
EXPOSED POPULATIONS?
 Focus is not on pregnant and postpartum women
Issues to Consider

2001 response: Public health communication issues

2001 response: Health care provider communication with
exposed populations

2001 response: Other influences on adherence behavior

Priority issues identified by local providers in 2011
2001 response: Public health
communication issues

Initially both Senate and postal workers relied on public
health for information and guidance1,2

Repeated visits by public health staff to worksites promoted
adherence among postal workers3

Postal workers reported that they wanted public health
information in a variety of formats, both written and orally, as
well as information from the media3,4

Trust in information from public health eroded due to
confusion, unclear or inaccurate messages, disorganization,
inability or perceived unwillingness of public health staff to
answer questions, and a perception of unfair treatment
among postal workers1,2,3,4
1Blanchard et
al, 2005; 2Stein et al, 2004; 3Jefferds et al, 2002; 4Quinn et al, 2005
2001 response: Public health
communication issues

Perceived lack of empathy in officials contributed to
diminished trust1

Communication lessons learned included a need to: 1,2
 identify priority audiences and how to reach them
 use local communication channels
 explain contradictions and mistakes
1Quinn
et al, 2005; 2Chess, Calia & O’Neill, 2004
2001 response: Health care provider
communication with exposed populations

Less than half the Senate and postal workers reported that
their physicians supported recommendations by public
health1

Private physician advice to take their medications appeared
to positively influence adherence1,2

Conversely, private physician recommendations to not take
their medications negatively affected adherence1,2
1Stein
et al, 2004; 2Blanchard et al, 2005
2001 response: Other influences on
adherence behavior

Both Senate and postal workers experienced difficulty in judging
their risk1

Adherence was positively affected by coworkers, friends, and
family members who encouraged workers to begin antibiotics
and to continue taking them1

Among postal workers, perceived increased risk for developing
the disease and >5 physical signs of stress were associated with
adherence2

Among postal workers, adherence was negatively affected by2
 perceptions of adverse drug effects, potential long-term adverse
effects, and low risk for developing anthrax
 difficulties in remembering to take medications
 age <45 years
1Stein
et al, 2004; 2Jefferds et al, 2002
Priority issues identified by local providers
in 2011

Local medical care providers identified priority issues to promote
use of CDC guidance pertaining to anthrax and pregnant and
postpartum women:1
 CDC should strongly emphasize and communicate valid information
to clinicians about the severity of their pregnant patients not
receiving treatment during an event. This approach will be critical to
obtaining clinician support and endorsement. For example, CDC’s
emphasis on the 60% mortality rate from anthrax would be a strong
motivator.
 CDC should provide the evidence base for guidance or clearly
articulate the rationale for the absence of supporting data for its
recommendations to assure transparency.
 Regardless of the communication channel, clinicians will need rapid
answers to many questions regarding exposure (e.g., Is it better to
over-treat or under-treat pregnant women initially?)
Meeting notes, “Considerations for Pregnant Women, Newborns and Children in an Anthrax Response: Medical/Public Health
Collaboration,” September 7, 2011, Atlanta, Georgia
Workgroup Recommendations

Develop critical background documents needed to guide
communication
 Scientific guidance regarding anthrax treatment and prevention
 Talking points for both the exposed and the worried well
populations
 Strategies to promote long-term drug adherence among pregnant
and postpartum women
 A resource describing antibiotic use during pregnancy
 The pregnancy estimation document to help to determine the
number of pregnant women to reach in a geographic area
 Any surveillance data about pregnant women and anthrax
Workgroup Recommendations

Identify priority audiences who may influence the behaviors
of pregnant and postpartum women

Develop a broad-based strategy that includes messages to
pregnant and postpartum women, their health care
providers, local and state public health, and a variety of other
partners

Develop short, concise, and flexible communication
materials because guidelines are likely to change during an
event
Workgroup Recommendations

Leverage DRH and other CDC partnerships with
professional and nonprofit organizations and state and local
public health

Develop pre-event training for OB professionals regarding
anthrax in pregnant and postpartum women and
prevention and treatment recommendations
QUESTION 4: WHAT
FACTORS DO WE NEED TO
CONSIDER FOR TRAINING
HEALTH CARE PROVIDERS
REGARDING ANTHRAX
AND PREGNANT AND
POSTPARTUM WOMEN?
Issues to Consider

Bioterrorism and emergency preparedness are priority
topics for most medical specialties

Health care providers may need an incentive to seek training
related to anthrax

Health care providers have limited time for training
Bioterrorism and emergency preparedness are
priority topics for most medical specialties

A study revealed that bioterrorism and emergency
preparedness are priority topics for most medical
specialties1

Following bioterrorism preparedness training of 578
physicians, residents, and third and fourth year medical
students, 94% agreed that the training increased their
understanding of bioterrorism, but only 42% stated that
they were prepared to respond2

ACOG issued a Committee on Obstetric Practice Opinion on
Management of Asymptomatic Pregnant or Lactating
Women Exposed to Anthrax in 2002 and reaffirmed it in
2009
1Lane
et al, 2012; 2Switala et al, 2011;
Bioterrorism and emergency preparedness
are priority topics for most medical specialties

The American Medical Association convened organizational
leaders from medical specialties, nursing, public health,
physician emergency medical services, and the Uniformed
Services University to develop a new educational framework
for disaster medicine and public health preparedness1
 7 core learning domains,
 19 core competencies
 73 specific competencies
 All above targeted at 3 broad health personnel categories

Emergency preparedness and disaster response core
competencies have been identified for perinatal and
neonatal nurses2
1Subbarao
et al, 2008; 2Jorgensen et al, 2010
Health care providers may need an incentive
to seek training related to anthrax

Local public health and medical care providers gave the
suggestions pertaining to motivating clinicians:1
 Specific actions should be taken to motivate clinicians in various
MCH fields (e.g., OB/ GYNs, neonatologists and pediatricians) to
attend pre-event training and receive education on anthrax as an
actual threat. For example, existing preparedness activities at the
local level should be expanded to include pre-event training for
clinicians.
 The ACOG Educational Committee should be extensively involved in
creating new emergency preparedness and response requirements
for clinicians.
1Meeting
notes, “Considerations for Pregnant Women, Newborns and Children in an Anthrax Response: Medical/Public Health
Collaboration,” September 7, 2011, Atlanta, Georgia
Health care providers have limited
time for training

Local public health and medical care providers gave the
suggestions for training busy clinicians:1
 Continuing medical education (CME) should be offered through
professional societies for clinicians to complete a preparedness
course. Hospital medical staff meetings should be utilized as a forum
to disseminate EPR information. An emergency preparedness and
response video for clinicians should be developed and widely
disseminated.
 Professional associations (e.g., AAP, ACOG and ACP) should be
encouraged to disseminate basic pre-event training materials to
their members to guide discussions with their patients.
 Pre-event training should clarify whether clinicians or public health
will be expected to handle MCH patients during an event.
1Meeting
notes, “Considerations for Pregnant Women, Newborns and Children in an Anthrax Response: Medical/Public Health
Collaboration,” September 7, 2011, Atlanta, Georgia
Workgroup Recommendations

Develop a ‘public health communication 101’ course to
guide OB professionals’ understanding of risk
communication

Leverage existing mechanisms for providing CMEs and CEUs
pertaining to anthrax
 Work with professional organizations to insert preparedness articles
within existing training/certification (board) processes
 Publish preparedness articles in journals that promote CMEs and
CEUs
 Develop online training modules for CMEs and CEUs that can be
distributed through channels such as WebMD and Medscape
Workgroup Recommendations

Plan and develop rapid or ‘just-in-time’ training pertaining to
anthrax and pregnant and postpartum women that
includes:
 A team who is responsible for daily content updates
 Easily modifiable slide presentations for the public and for OB
professionals
 Talking points that are time sensitive
 Is adaptable for a variety of training modalities
QUESTION 5: WHAT
SHOULD THE
PRIORITIES BE FOR
FUTURE RESEARCH
IN THIS AREA?
Need for More Data

Little known data exists about knowledge of anthrax or
attitudes towards medications or vaccines among pregnant
and postpartum women

Data concerning provider knowledge and support of public
health recommendations in 2001 event were reported by
exposed populations, not the health care providers

Little known data exists about OB professionals’ knowledge
of anthrax or attitudes towards anthrax medications or
vaccines for pregnant and postpartum women
Workgroup Recommendations

Conduct qualitative and/or quantitative research to assess
knowledge about inhalational anthrax and attitudes toward
vaccines, antibiotics and other treatments
 Among pregnant/postpartum women, their families and community
leaders
 Among OB professionals