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ACOG Committee Opinion No. 772: Immunization Implementation Strategies for Obstetrician–Gynecologists

doi: 10.1097/AOG.0000000000003130
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ABSTRACT: Immunization against vaccine-preventable diseases is an essential component of women’s primary and preventive health care. Many studies have shown that a recommendation from an obstetrician–gynecologist or other health care provider for a vaccine is one of the strongest influences on patient acceptance. Obstetrician–gynecologists and other health care providers should develop a standard process for assessing and documenting the vaccination status of patients and for recommending and administering vaccines. If allowed by state law, obstetrician–gynecologists and other health care providers are encouraged to institute standing orders for indicated immunizations. Obstetrician–gynecologists and other health care providers are encouraged to stock and, ideally, administer commonly recommended vaccines in their offices. Studies show that immunization rates are higher when a health care provider can offer and administer the vaccine during the same visit, as opposed to recommending vaccination and referring the patient elsewhere to receive the vaccine. Given the demonstrated efficacy and safety of vaccines and the large potential for prevention of many infectious diseases that affect adolescents, adults, pregnant women, and newborns, obstetrician–gynecologists should include immunizations as an integral part of their practice. This Committee Opinion has been revised to incorporate additional strategies for obstetrician–gynecologists to consider implementing to enhance their immunization programs.

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center.

While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

All ACOG committee members and authors have submitted a conflict of interest disclosure statement related to this published product. Any potential conflicts have been considered and managed in accordance with ACOG’s Conflict of Interest Disclosure Policy. The ACOG policies can be found on acog.org. For products jointly developed with other organizations, conflict of interest disclosures by representatives of the other organizations are addressed by those organizations. The American College of Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the development of the content of this published product.

Number 772 (Replaces Committee Opinion Number 661, April 2016)

Immunization, Infectious Disease, and Public Health Preparedness Expert Work Group

This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Immunization, Infectious Disease, and Public Health Preparedness Expert Work Group, in collaboration with members Howard Minkoff, MD and J. Martin Tucker, MD.

Published online on February 21, 2019.

Copyright 2019 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

Requests for authorization to make photocopies should be directed to Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400.

American College of Obstetricians and Gynecologists 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920

Immunization implementation strategies for obstetrician–gynecologists. ACOG Committee Opinion No. 772. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e254–59.

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Recommendations

The American College of Obstetricians and Gynecologists offers the following recommendations:

  • Given the demonstrated efficacy and safety of vaccines and the large potential for prevention of many infectious diseases that affect adolescents, adults, pregnant women, and newborns, obstetrician–gynecologists should include immunizations as an integral part of their practice.
  • Obstetrician–gynecologists and other health care providers should talk with each patient directly and strongly recommend indicated immunizations.
  • Obstetrician–gynecologists and other health care providers should routinely discuss and, ideally, administer recommended vaccines, which at a minimum include influenza; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap); and human papillomavirus (HPV).
  • After educating the patient and recommending a vaccine, the obstetrician–gynecologist or other health care provider should document that the vaccine has been offered and that the patient accepted, declined, or obtained her immunization at an outside facility.
  • Obstetrician–gynecologists and other health care providers should develop a standard process for assessing and documenting the vaccination status of patients and for recommending and administering vaccines.
  • The obstetrician–gynecologist or other health care provider should document when a patient declines an immunization, including the discussion and her decision. The obstetrician–gynecologist or other health care provider should inquire about her reasons for declining and reintroduce the discussion and offer the immunization at the next office visit.
  • Obstetrician–gynecologists and other health care providers are encouraged to create a culture of immunization by educating and involving all staff in immunization processes. Delegate the responsibilities of maintaining and championing an immunization program to a team of staff, as appropriate for your practice structure.
  • Obstetrician–gynecologists and other health care providers are encouraged to use existing systems and resources to conduct periodic assessments of immunization rates among patients to determine if and where progress is needed.

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Introduction

Immunization against vaccine-preventable diseases is an essential component of women’s primary and preventive health care. Despite the importance of vaccination and clear guidance from public health agencies, adult vaccination rates lag behind national goals (1). Obstetrician–gynecologists can play a major role in improving vaccination coverage and reducing morbidity and mortality from vaccine-preventable diseases, including pertussis, influenza, HPV, and hepatitis. Given the demonstrated efficacy and safety of vaccines and the large potential for prevention of many infectious diseases that affect adolescents, adults, pregnant women, and newborns, obstetrician–gynecologists should include immunizations as an integral part of their practice.

The annual health assessment should include immunization assessment and recommendations based on age and risk factors (2). This document will outline how immunization advocacy and provision can be integrated into office practice. Immunization recommendations, safety and efficacy data, as well as talking points for health care providers for specific vaccines and populations are addressed in separate ACOG Committee Opinions (3–6). This Committee Opinion has been revised to incorporate additional strategies for obstetrician–gynecologists to consider implementing to enhance their immunization programs.

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Tips for Office Immunization Program Success

Many reports have addressed successful implementation strategies that are relevant to immunizations indicated for obstetric patients and gynecologic patients (7–9). The techniques discussed in the following sections have been successful in promoting immunization in office settings.

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Integrate Immunizations and Practice Management Strategies

Advocate

Obstetrician–gynecologists and other health care providers should talk with each patient directly and strongly recommend indicated immunizations. Obstetrician–gynecologists and other health care providers should routinely discuss and, ideally, administer recommended vaccines, which at a minimum include influenza, Tdap, and HPV. Many studies have shown that a recommendation from an obstetrician–gynecologist or other health care provider for a vaccine is one of the strongest influences on patient acceptance (10, 11). Obstetrician–gynecologists and other health care providers should counsel their pregnant and nonpregnant patients about immunizations in an evidence-based manner that allows patients to make an informed decision (12). Obstetrician–gynecologists and other health care providers can share tailored reasons why immunizations are beneficial for a patient’s family, highlight the risks of not immunizing, address patient questions and concerns, and remind patients that immunizations are the best protection against many common and serious diseases.

After educating the patient and recommending a vaccine, the obstetrician–gynecologist or other health care provider should document that the vaccine has been offered and that the patient accepted, declined, or obtained her immunization at an outside facility. The obstetrician–gynecologist or other health care provider should document when a patient declines an immunization, including the discussion and her decision. The obstetrician–gynecologist or other health care provider should inquire about her reasons for declining and reintroduce the discussion and offer the immunization at the next office visit.

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Immunization Culture

Obstetrician–gynecologists and other health care providers are encouraged to create a culture of immunization by educating and involving all staff in immunization processes. Delegate the responsibilities of maintaining and championing an immunization program to a team of staff, as appropriate for your practice structure. If feasible within your practice setting, designate an immunization champion or team in the office. If you have a single champion, identify and train a backup person in case the designated champion is absent. Among other duties, the immunization champion or team orders the vaccines, receives vaccine deliveries, ensures the vaccines are stored properly, and serves as a resource for clinicians and staff in the practice. All state health departments have an immunization department with an immunization program manager who is able to help practices. Someone on your staff should know whom to contact at the local, regional, or national level for answers to clinical or logistical immunization questions (see the For More Information section to access a complete list of state immunization program managers).

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Assess

A key component of a successful immunization program is the ability to routinely assess every patient’s immunization status at each visit. Obstetrician–gynecologists and other health care providers should develop a standard process for assessing and documenting the vaccination status of patients and for recommending and administering vaccines. The Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists recommend the use of prompts—paper or electronic—to remind physicians and staff which patients need to be immunized. Many electronic medical record systems have these prompts available. Electronic medical records that use reminder systems can highlight opportunities to immunize when patients are in the office for regularly scheduled appointments (9). Immunization Information Systems are also useful tools to assess and document a patient’s immunization history. All states have an existing immunization registry or a registry in development. Each state has unique functionality, age requirements, and limitations (13, 14). The obstetrician–gynecologist or other health care provider should document vaccine administration in the patient’s chart. To further ensure complete documentation, obstetrician–gynecologists or other health care providers are encouraged to document vaccination in their state’s immunization registry when feasible (see the For More Information section for information on how to access your state’s registry).

Finally, obstetrician–gynecologists and other health care providers are encouraged to use existing systems and resources to conduct periodic assessments of immunization rates among patients to determine if and where progress is needed.

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Standing Orders

As mentioned previously, obstetrician–gynecologists and other health care providers should develop a standard immunization process for assessing and documenting the vaccination status of patients and recommending and administering vaccines. If allowed by state law, obstetrician–gynecologists and other health care providers are encouraged to institute standing orders for indicated immunizations. Standing orders allow administration of vaccines to appropriate patients without an individual physician order (see the For More Information section for additional resources on standing orders). However, obstetrician–gynecologists and other health care providers should familiarize themselves with local statutory requirements before standing order protocols are established. Standing orders can be an effective way to integrate immunizations into practice flow (15, 16).

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Vaccine Reactions and Emergency Management

Side effects from vaccines are usually mild (eg, injection site reactions [pain, swelling, and redness], mild fever, shivering, fatigue, headache, and muscle and joint pain) and serious adverse events are rare (eg, anaphylaxis rates are approximately 1 per million) (17). Mild side effects usually respond to simple interventions such as ice packs and antiinflammatories. Obstetrician–gynecologists and other health care providers should be able to identify the signs of immediate allergic reactions, have supplies on hand to address these events, and be prepared to call emergency medical services in the event of a severe reaction (18). For more information on the management and reporting of adverse events after vaccine administration, see the Centers for Disease Control and Prevention’s General Best Practice Guidelines for Immunization (18).

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Educate

Educate office staff about the recommendations, safety, and efficacy of immunizations. Office personnel may express their own uncertainty or lack of knowledge to patients. This can have a detrimental effect on a patient’s willingness to receive an immunization. In contrast, educational efforts for all office staff can markedly increase patient immunization rates (19, 20).

Immunize office health care providers and staff as recommended. Maintaining expectations for the vaccination of office health care providers and staff serves to meet quality criteria for practices. Additionally, clinicians have ethical obligations to decrease vaccine-preventable diseases for health care providers and staff, provide leadership through example, develop an immunization culture in the office, and, importantly, avoid being the source of infection among their patients (12).

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Legal Considerations

Federal law (National Childhood Vaccine Injury Act of 1986) mandates that all health care providers who administer vaccines must give patients or their parents or legal representatives the appropriate vaccine information statement before administration of each dose of a vaccine. Vaccine information statements are official documents and are not the same as vaccine fact sheets. The appropriate vaccine information statement can be used to educate patients about the vaccine an obstetrician–gynecologist administers or recommends (see the For More Information section for additional resources on vaccine information statements and patient education materials). Additionally, obstetrician–gynecologists and other health care providers should be aware of the National Vaccine Injury Compensation Program. The National Vaccine Injury Compensation Program is a no-fault system for resolving vaccine injury claims. If a patient believes that she or her fetus has been harmed by a vaccine covered by this program, she can file a claim with the U.S. Court of Federal Claims (21) (see the For More Information section for additional information on the National Vaccine Injury Compensation Program).

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Vaccine Purchasing

Obstetrician–gynecologists and other health care providers are encouraged to stock and, ideally, administer commonly recommended vaccines in their offices. Studies show that immunization rates are higher when a health care provider can offer and administer the vaccine during the same visit, as opposed to recommending vaccination and referring the patient elsewhere to receive the vaccine (11).

Obstetrician–gynecologists and other health care providers may wish to research vaccine manufacturers for available special pricing offers to ensure the practice is securing the best price per vaccine. The purchase price of a given vaccine may vary by the vendor, and certain discounts may be available based on when and how the practice orders and pays (eg, discounts for advanced ordering and large quantities). Obstetrician–gynecologists and other health care providers also can explore group purchasing organizations or develop partnerships with nearby clinics and pharmacies to collectively make larger orders that result in discounted purchase rates (see the For More Information section for additional resources on vaccine purchasing). These responsibilities can be delegated to the immunization champion or team in the practice. Health care providers should consult their legal counsel regarding discounts and group purchasing organizations because certain restrictions may apply.

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Coding and Reimbursement

Many obstetrician–gynecologists perceive a lack of reimbursement as a major barrier to including immunization services in their practices (22). However, with proper documentation and coding, these services can be reported to third-party payers and reimbursement can be received.

The practice should adhere to basic coding principles when billing for immunization services. In general, the appropriate vaccine product code should always be reported along with the appropriate Current Procedural Terminology (CPT) vaccine administration code. These codes should be linked to the appropriate International Classification of Diseases, 10th Revision, Clinical Modification code to support the medical necessity for the service(s). The inherent components of a vaccine administration code include making an appointment for the patient, pulling the chart or accessing the electronic record, and billing the service. Clinical services such as greeting the patient, taking vital signs, reviewing the immunization history and allergies, and charting the immunization administration also are considered inherent components of this service.

The CPT guidelines state that vaccination services should be reported separately from a standard preventive medicine service or wellness visit. In addition, immunization services are not part of the global obstetric package and should be reported separately as well. If a significant, separately identifiable, problem-oriented evaluation and management service is performed, the appropriate CPT Evaluation and Management code should be reported in addition to the immunization codes.

It is important for a practice to track reimbursement for immunization services. Explanation of benefits should be examined at periodic intervals to ensure that reimbursement covers the costs of the vaccine product. With diligent oversight, immunization services will be sustainable for most practices.

The American College of Obstetricians and Gynecologists provides several resources to help physicians and their staff with coding, purchasing, and reimbursement issues related to immunization services. See the For More Information section for additional resources about the implementation of an immunization program in your office, including vaccine purchasing, storage and handling, and safety.

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Conclusion

Obstetrician–gynecologists have a unique opportunity to reduce the frequency of vaccine-preventable diseases. To accomplish that goal, obstetrician–gynecologists must be aware of current vaccine recommendations, educate patients about vaccination, encourage patients to be vaccinated, and institute systems in the office to integrate vaccination into the routine running of their practice.

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For More Information

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/ImmunizationsinPractice.

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s website, or the content of the resource. The resources may change without notice.

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References

1. Williams WW, Lu PJ, O'Halloran A, Kim DK, Grohskopf LA, Pilishvili T, et al. Surveillance of vaccination coverage among adult populations—United States, 2015. MMWR Surveill Summ 2017;66(SS-11):1–28.
2. Well-woman visit. ACOG Committee Opinion No. 755. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e181–6.
3. Human papillomavirus vaccination. Committee Opinion No. 704. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e173–8.
4. Influenza vaccination during pregnancy. ACOG Committee Opinion No. 732. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e109–14.
5. Update on immunization and pregnancy: tetanus, diphtheria, and pertussis vaccination. Committee Opinion No. 718. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e153–7.
6. Maternal immunization. ACOG Committee Opinion No. 741. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e214–7.
7. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Task Force on Community Preventive Services. Am J Prev Med 2000;18:92–6.
8. Recommendations from the National Vaccine Advisory committee: standards for adult immunization practice. National Vaccine Advisory Committee. Public Health Rep 2014;129:115–23.
9. The Community Guide. Vaccination programs: provider reminders. Atlanta (GA): Centers for Disease Control and Prevention; 2015. Available at: https://www.thecommunityguide.org/findings/vaccination-programs-provider-reminders. Retrieved October 2, 2018.
10. Influenza vaccination coverage among pregnant women: 2011-12 influenza season, United States. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep 2012;61:758–63.
11. Ding H, Black CL, Ball S, Fink RV, Williams WW, Fiebelkorn AP, et al. Influenza vaccination coverage among pregnant women—United States, 2016-17 influenza season. MMWR Morb Mortal Wkly Rep 2017;66:1016–22.
12. Ethical issues with vaccination for the obstetrician–gynecologist. Committee Opinion No. 564. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:1144–50.
13. Centers for Disease Control and Prevention. About immunization information systems. Atlanta (GA): CDC; 2012. Available at: https://www.cdc.gov/vaccines/programs/iis/about.html. Retrieved October 2, 2018.
14. Recommendation for use of immunization information systems to increase vaccination rates. J Public Health Manag Pract 2015;21:249–52.
15. McKibben LJ, Stange PV, Sneller VP, Strikas RA, Rodewald LE. Use of standing orders programs to increase adult vaccination rates. Advisory Committee on Immunization Practices. MMWR Recomm Rep 2000;49:15–6.
16. Barnard JG, Dempsey AF, Brewer SE, Pyrzanowski J, Mazzoni SE, O'Leary ST. Facilitators and barriers to the use of standing orders for vaccination in obstetrics and gynecology settings. Am J Obstet Gynecol 2017;216:69.e1–7.
17. McNeil MM, Weintraub ES, Duffy J, Sukumaran L, Jacobsen SJ, Klein NP, et al. Risk of anaphylaxis after vaccination in children and adults. J Allergy Clin Immunol 2016;137:868–78.
18. Kroger AT, Duchin J, Vázquez M. General best practice guidelines for immunization. Best practices guidance of the Advisory Committee on Immunization Practices (ACIP). Atlanta (GA): Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html. Retrieved October 17, 2018.
19. Hoppe KK, Eckert LO. Achieving high coverage of H1N1 influenza vaccine in an ethnically diverse obstetric population: success of a multifaceted approach. Infect Dis Obstet Gynecol 2011;2011:746214.
20. Broughton DE, Beigi RH, Switzer GE, Raker CA, Anderson BL. Obstetric health care workers' attitudes and beliefs regarding influenza vaccination in pregnancy. Obstet Gynecol 2009;114:981–7.
21. Health Resources and Services Administration. What you need to know about the National Vaccine Injury Compensation Program (VICP). Rockville (MD): HRSA; 2016. Available at: https://www.hrsa.gov/sites/default/files/vaccinecompensation/resources/84521booklet.pdf. Retrieved October 2, 2018.
22. Leddy MA, Anderson BL, Power ML, Gall S, Gonik B, Schulkin J. Changes in and current status of obstetrician-gynecologists' knowledge, attitudes, and practice regarding immunization. Obstet Gynecol Surv 2009;64:823–9.
© 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.