Protecting Pregnant Women and Babies During Public Health Emergencies

>>Good Afternoon. I am Madel [phonetic] Woolgaren [phonetic]
from CDC Office of Public Health and Response, a Division of Emergency Operations. Thank you for joining us today’s emergency
partners information connection webinar [inaudible] protecting pregnant women and
babies during public health emergencies. Today we will hear from CDC’s
Sascha Ellington and Kara Polen. If you do not wish for your [inaudible]
to recognized, please exit at this time. You can end comminuting education
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-0-8-2-2 with all letters capitalized. To repeat the cost access code to receive
continuing education is in caps E-P-I-C-0-8-2-2. Today’s webinar is interactive. To make a comment click the chat button
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use the Q and A button. The Q and A session will begin after
both presenters have presented. We will now transition to our presenters
Sascha Ellington and Kara Polen. Sascha Ellington has been an
epidemiologist at CC since 2006. Primarily working in areas of
infections during pregnancy and emergency preparedness and response. Ms. Ellington led the maternal health
helping for CDC’s 2014 Ebola’s response. And subsequently led the emergency
preparedness and response activity in CDC’s division of reproductive heath. She sat on the pregnancy and birth defects
task force for CDC’s 2016 Zika response — Zika virus response and led the, and led the
domestic, and led the domestic Zika pregnancy and infants research [inaudible]
in the division of congenital and developmental disorders until May 2018. Ms. Ellington recently started as the
emergency preparedness and response team lead in the division of, in the
division of reproductive health. Thanks for joining us Sascha. Kara Polen has been an epidemiologist and health
communicator with CDC’s division of congenital and developmental disorders since 2008. From 2016 to 2017 she sat as the
communications lead for the pregnancy and birth defects task force
for CDC’s Zika virus response. In this role she led efforts to translate
complex scientific guidance into resources and information for healthcare providers. Pregnant women and families. Prior to that Ms. Polen deployed to Sierra
Leone to support communication activities for the Ebola prevention vaccine trial strive. Thank you for joining us today. Thank you Sascha. And thank you Kara for joining us today. You may begin.>>Thank you for that introduction
and good afternoon everybody. Here’s an outline of today’s presentation. We will discuss the impact that
public health emergencies have had on pregnant women and infants. Then we will highlight two public
health emergencies the H1N1 pandemic and the Zika virus outbreak and how they
uniquely affected pregnant women and infants. Lastly we will provide some tips and resources
for ensuring the needs of pregnant woman and infants are addressed during
public health emergencies. Next slide. First we are going to discuss the impact of public health emergencies
on pregnant women and infants. Next slide please. I want to be sure we’re all on the same page
first when we discuss public health emergencies. During today’s presentation when we refer to a public health emergency this can
include large scale natural disasters, man-made disasters, and significant
infectious disease outbreaks. Natural disasters include
hurricanes, earth quakes, wild fires, and even events like Fukushima. Man-made disasters maybe intentional like
September 11th and the 2001 anthrax attacks. Or an unintentional like the Flint water crisis. Recent significant infectious disease
outbreaks include the 2009 H1N1 pandemic, the Ebola outbreak in West Africa
and the Zika virus outbreak. Next slide please. Pregnant women are sited as populations
with special clinical needs or at risk in the 2013 Pandemic and All-Hazards
Preparedness Reauthorization Act or PAHPRA. So what makes pregnant women at risk? Well we know that for some infectious diseases
there’s a disproportionate burden among pregnant women. For example pregnant women may be at increased
susceptibility compared to non-pregnant women for diseases such as Malaria, Listeria, and HIV. Pregnant women maybe at increased
risk for severity of disease once infected such
as influenza and measles. Additionally some infections in pregnant women
may increase risk for adverse pregnancy outcomes such as Zika virus infection during pregnancy. We know less about the effects of disaster on
pregnant women and reproductive health outcomes. Of the studies that have been conducted
findings have been consistent — have been inconsistent and
methodologies have varied widely. However studies suggest that
disaster exposure maybe associated with poor reproductive health
outcomes including preterm birth or low birth weight infants
increases in pregnancy complications, increase is psychological stress, separation
from family and other support systems, possible exposure to contaminates and loss
of access to health care and medications. We lack surveillance on pregnant
women affected by disasters. This is partly due to pregnant women
comprising about 1% of the general population at any given time in the United
States which makes it difficult to collect meaningful information about them using traditional population
based post disaster sampling strategies. Next slide. While out focus today is on pregnant women
and infants I’d like to briefly mention that postpartum women are also uniquely
affected by public health emergencies. Though, though the literature is even
more scant then for pregnant women. During a public health emergency
there may be reduced access to reproductive healthcare including
contraception for women of reproductive age. And this may be particularly important
for women who have recently given birth as was noted after hurricane Katrina. Other factors that have been noted include
lack of access to well child and acute care, effects on infant feeding for both
breast feeding and formula feeding, a loss of infant care supplies, and
increase in psychological stress, and separation from family and support systems. I’ll now turn it over to Kara to talk about
exposures during pregnancies and experiences and recent public health emergencies.>>Sorry. Thanks Sascha. As Sascha mentioned emergencies present
unique challenges to pregnant women and potential exposures to the developing
baby during pregnancy can impact infants and children as they grow. Oh next slide please. Listed here are some of the possible
impacts of exposures during pregnancy. Some exposures during pregnancy like Zika virus
infection can cause birth defects in infants. Other possible impacts of public health
emergencies during pregnancy include small for gestational age and low birth
weight, neonatal complications, prolonged hospital stay,
and morbidity and mortality. For more — for many exposures during
pregnancy we don’t know the longer term impacts, but possible outcomes include cognitive
impairment, motor delay, behavioral issues and education attainment in childhood. Next slide. Next we’ll cover some of our experiences
from recent public health emergencies and what we’ve learned particularly regarding
impacts to pregnant women and infants. Next slide. On this slide is a depiction of CDC’s
emergency response activation levels. From level three the lowest level of activation
to level on the highest level of activation. The EOC has only operated at a level
one response for four emergencies, hurricane Katrina in 2005, H1N1 pandemic flue
in 2009, Ebola in 2014 and Zika virus in 2016. I want to draw your attention to two of these
public health emergencies H1N1 and Zika. We will be discussing these examples
in more detail in the next few sides because of their impacts to
pregnant women and infants. For example H1N1 was the first time
a maternal health desk was activated to respond to issues facing pregnant women. And similarly the Zika response set up
the pregnancy and birth defects task force to respond to these vulnerable populations. Next slide. So what did we learn from these emergencies? From H1N1 to Ebola to Zika the public
health and medical community faced a series of complex and unpredictable outbreaks. The recent Zika outbreak served as a reminder
of the vulnerability of pregnant women and babies to emerging infectious diseases. In each of these emergencies it
was critical to provide guidance to frontline health care providers
caring for these vulnerable populations. And these emergencies also highlighted the need to rapidly collect data to
inform response efforts. Now I’m going to turn it back over
to Sascha to talk about 2009 H1N1. Next slide.>>Thanks Kara. Now I will talk a little
bit about pandemic influence and specifically the 2009 H1N1 pandemic
and how it affected pregnant women. Next slide. In 2008 CDC convened a meeting entitled
Pandemic Influenza Special Considerations for Pregnant Women to obtain input from experts and key partners develop public heath
recommendations for pregnant women in the event of an influenza pandemic. Meeting goals were to discuss issues specific
to pregnant women, identify gaps and knowledge and develop a public health approach for
pregnant women in the event of a pandemic. The meeting focused on four main topics
prophylaxis and treatment with antivirals, vaccine use, non-pharmaceutical interventions
and health care planning and communications. As you may recall one year later the first
case of the pandemic H1N1 were reported. Next slide. On April 22nd 2009 CDC’s emergency
operation center was activated for H1N1. Less than a week later the
maternal health desk staffed by the maternal health team was activated. It became very quickly that pregnant women
were disproportionately affected by H1N1. The second documented death in the U.S. from H1N1 was a healthy pregnant
women at 35 weeks gestation. She presented with symptoms to her
obstetrician on April 15th, 2009. Then on April 19th she presented to the
emergency room with worsening symptoms. And an emergency cesarean
delivery was performed. On April 21st, she developed acute
respiratory distress syndrome or ARDS. She began receiving Oseltimivir on
April 29th and she dies on May 4th. The H1N1 pandemic was the first time
a maternal health desk was established at CDC for a public health response. Next slide please. An early report summarizing cases of H1N1 and
pregnant women in the U.S. from the first month of the outbreak found that the admission rate for pregnant women was 4.3 times
that of the general population. The same report also described the six
deaths, deaths among pregnant women in the first two months of the outbreak. All were in women who had developed
pneumonia and subsequent ARDS. This highlighted the need to promptly treat
pregnant women with H1N1 with antivirals. Next slide please. In a subsequent publication
of data through December 2009, it was reported that 280
pregnant women with H1 in the — H1N1 in the U.S. has been
admitted to an insensive — intensive care unit and 56 pregnant women died. 5% of all reported H1N1 deaths
were among pregnant women. This is compared to pregnant women making up
approximately 1% of the general population in the U.S. Only one of those 56
deaths occurred in a pregnant patient who received treatment within two symptom onset. Next slide. During the 2009 H1N1 pandemic, CDC
established the pregnancy flu line. This was the first national influenza
surveillance system among pregnant women. It was a shot term targeted program to
monitor pandemic and seasonal influenza in pregnant and postpartum women. The pregnancy flue line consisted of a
24-hour consultation phone line for clinicians and heal departments and it enhanced passive
surveillance system for severe influenza in pregnant and postpartum women. It was operational for two years from
October 2009 through September 23011. Next Slide. Many lessons were learned about influenza
and pregnancy following the H1N1 pandemic. It provided clear and consistent evidence
documenting the importance of treatment with influenza antiviral medications in
pregnancy and justification for treatment of postpartum women for up to
two weeks following delivery. It also increased influenza vaccination rates
among pregnant women which served as a model for other vaccines during pregnancy. It renewed scientific interest
and focus in a wide variety of pregnancy and preparedness issues. Kara will now talk about the 2016 Zika outbreak. Next slide please.>>Thanks Sascha. Now I’ll discuss the 2016 Zika virus response. Similar to the maternal health desk
for H1N1, we set up the pregnancy and birth defects task force because of the
severe outcomes observed during Zika virus infection during pregnancy. The pregnancy and birth defects task
force aimed to reduce the risk and impact of Zika virus infection in
pregnant women, infants, and children through the
activities mentioned here. So just collecting critical information about
the impacts of infection during pregnancy, providing technical assistance, assisting
local partners, educating various audiences about Zika prevention, providing
assistance to clinicians specifically around Zika virus testing and more. Next slide. With Zika we started some knowledge of the
infection but very little understanding of the consequences to pregnant
women and infants. Therefore very early in the response we
recognized the need to collect information about the effects of the Zika
virus infection during pregnancy. About two months into the response,
we started building the framework for the U.S. Zika pregnancy registry which
collected information about pregnant women with any laboratory evidence of
possible Zika virus infection in the United States regardless
of whether there were symptoms. In Porto Rico we set u a
similar pregnancy registry which was tailored to the needs in Porto Rico. Enhanced surveillance was
also set up in Columbia. We also expanded birth effects
surveillance to collect information on birth defects potentially related to Zika which complimented the data
collected through the registry. The information collected through these
systems helped direct public health efforts to mitigate the impact of Zika and guide
recommendations for the monitoring , evaluation and management of women infected
with Zika during pregnancy. Next Slide. So briefly here are the two data collection
systems for Zika in the United States and how they complement each other. The U.S. Zika pregnancy and infant registry
collected information on pregnant women with lab evidence of possible
Zika infection in their infants and follows them for up to — sorry. Follows them to assess the impact of
infant infection during pregnancy. Zika birth defect surveillance
collected information on al infants with birth defects potentially related
to Zika regardless of congenital exposure and helped refer these families
to services in their communities. Next slide. So what have we learned so far? Since the Zika virus outbreak
began CDC established that Zika is a cause of serious
brain abnormalities. Microcephaly potentially other birth defects. We recognize a pattern of birth defects
associated with Zika virus infection which is called congenital Zika syndrome. We provided clues toward the level of
risk from congenital Zika virus infection, level of risk of birth defects, and we identified that Zika infections
during any trimester has been associated with birth defects in the infant. Next slide. The data we collected help inform
updates to CDC’s clinical guidance. For example CDC updated the recommended
testing algorithm for pregnant women to reflect accumulating data on fetal
abnormalities that might be consistent with Zika virus disease including microcephaly, intracranial classifications
and brain and eye abnormalities. Next slide. The Zika response demonstrated
the need to rapidly collect data for action as shown in this model. Collaboratively with our state, local and territorial health departments
we consistently collected information about Zika’s impact on pregnancy and use
the data to update clinical guidance. The data was essential to protect
this medically vulnerable population. And these lessons can be applied
to other known or emerging threats. In the case of Zika, the
threat was an infectious agent, but the same approach can be used to monitor any
exposure as it relates to mothers and babies, whether it’s a medication
during pregnancy or vaccine or another remerging infection
or public health emergency. Next slide. Now we’ll discuss some of the tips and resources
if you’re working with these populations. Next slide. We’ll start with some strategies to reach
these target audiences and then discuss some of the emergency preparedness and
response tools that are available. They include the post disaster indicators for
pregnant and postpartum women and infants. The pregnancy estimation tool and,
and online training on the affects of disasters on reproductive health. Next slide. So typically during a public health emergency,
we need to get information out fast in order to protect your market population. Now this sounds really intuitive but
it’s important to remember to consider who you’re trying to reach and tailor
your messages to your audience. Also try to focus your dissemination where
you, you might find your target audience. So I’m going to use Zika as an example here. Our target audience is of pregnant women,
families and health care providers. For pregnant women we really
want to push the Zika prevention and how they could protect themselves. For families we wanted to make
sure they were aware of medical and social services to help children. And for health care providers we wanted to make
sure they could educate their patient’s on how to prevent infection and
that they knew the tests and recommendations and clinical
care guidelines. Next slide. Here’s some ideas for how
to reach pregnant women. You can share information at events where you
think they may be present such as health fairs, local food banks, women shelters
WIC or home visiting services. You can also provide communication materials to
healthcare providers caring for pregnant women. Shown here are some of the materials and
information we had available for Zika. So all the way to the left
you can see a Zika fact sheet. We had a You Tube video on ways
pregnant women can protect themselves such as wearing EPA registered insect repellant. We had social media messages going
out through the CDC channels. We also worked with Text For Baby which is a
text — texting service that sends health alerts and reminders to women during pregnancy. And mother to baby which is an organization
who helps respond to pregnant women when they are concerned about a
particular exposure during pregnancy. Next slide. Similarly for healthcare providers we
disseminated health alerts or advisories. We worked with national local
chapters, professional organizations such as the American College of Obstetrics
and Gynecology and The American Academy of Pediatrics, to help disseminate
messages to their membership. And we used tools to help with
implementation of the guidance. So as shown here we have a testing algorithm. We also have a web based app that
we developed that tailors next steps for testing pregnant women based
on a few questions in the app. And then sometimes just face to face
outreach and education is what’s needed, but having tools at hand can
help get the message across. Now I’m going to turn it over to Sascha to talk
about some of the other tools that we have.>>Thanks. Moving on I’ll talk about a few
additional tools that we have. First I’d like to discuss
our post disaster indicators for pregnant, postpartum women and infants. This is a list of common epidemiologic
indicators for pregnant and postpartum women and infants affected by disaster. These were developed for a twelve months period in which we convened a nationwide
group consisting of 23 federal, state, academic and other key maternal
child health partners to identify or develop the epidemiologic post
disaster reproductive health indicators. The indicators are primarily to
guide assessment and surveillance and effect public health interventions
for disaster effected pregnant and postpartum women and infants. And it’s whenever possible the
focus is on actionable items where the public health programs interventions and policy would be used
or adapted to meet needs. The final overall post list contains 25
indicators and, the 90 measures for pregnant and postpartum women and infants. And their accompanying set of questions. Al, all are available online at the DRH emergency preparedness
web page noted on the slide. We do not envision that all indicators or
questions should be used in every assessment or surveillance tool but the user can select
what indicators are important and what aspects of the indicator need to be
measured in their setting. We encourage our partners to sue
these indicators and measures and share their experience with us. Next slide please. Additionally when conducting other post disaster
morbidity surveillance you can use the post disaster health indicators to
collect supplemental information on pregnant and postpartum women. We have a sample protocol on our web
page which shows how this can be done. So if you’d like more information you
should see the link on this slide. Next slide please. I’d also like to take the opportunity to let
you know about our pregnancy estimator tool. This is a tool — this tool is for
estimating the number of pregnant women in a geographic are when there’s an emergency. It can be used as a preparedness tool
as well as for whenever response occurs. The tool has been a valuable
resource for us in many settings. IT is also available on our web page. There’s also an Excel link where
you can plug in the numbers to calculate the number of
women in your area as well. And it calculates the number of
pregnant women at any point in time. Next slide please. So I’d like to briefly discuss how CDC’s
pregnancy risk assessment monitoring system or PRAMS has been used to collect
preparedness and response data. PRAMS is a population based surveillance system
of women who recently delivered a live infant. There are currently 51 sites
representing 83% of all U.S. live births. Since 2009 PRAMS has been used
to collect data from new mothers on emergency preparedness in several states. Additionally PRAMS has been used post disaster
to collect much needed vital information on maternal behaviors and knowledge. FO instance there were supplemental
questionnaires implemented to collect data on H1N1 and Zika. And PRAMS is currently collecting data to
assess the impact of the 2017 hurricane season in areas that were heavily impacted. Next slide please. Additionally the infrastructure built
during the Zika first response can be used for future public health emergencies as well. First the vantage point of maternal exposure
we can prospectively collect information about women with a potential
exposure during pregnancy such as in the U.S. Zika pregnancy and infant registry. From the vantage point of infant outcomes we
can leverage birth defect surveillance to focus on rapidly identifying fetuses and infants
with potential exposures during pregnancy. The third component used during
Zika that can be leveraged for future public health responses was
search capacity for local health departments in the form of public health professionals. This component was a way to get boots on
the ground and provide additional support to local health departments that were
heavily impacted by the Zika virus outbreak. Some states are already leveraging this
infrastructure to address the opioid crisis and the effects of nonessential
exposure to opioids during pregnancy. Next slide please. We also have a web based training. It’s titled Reproductive Health and
Emergency Preparedness and Response. After completing this course learners should
be able to identify ways to effectively respond to the needs of women of reproductive
age during and after a disaster. The target audience for the course is healthcare
professionals, state and local epidemiologists, emergency preparedness personnel, and
other public health staff interested in reproductive health and emergency response. Next slide. It’s a web based training. It’s divided into several sections, with supplemental learning materials
provided throughout the course. There’s a lot of helpful links and items
you can download during the course. IT takes about an hour to complete. It’s offered through CDC train a comprehensive
catalogue of public health learning products. It can be found at the web
address provided on this slide. And there’s also a link to
it through the Division of Reproductive Health Emergency
Preparedness and Response web page. And continuing education
credits are offered for it. Next slide please. So to summarize we know that
emergencies are unpredictable and the spread of disease can happen quickly. Pregnant women and babies are uniquely
susceptible and preparedness related to thee populations should be a priority. Next slide. Thank you and we’ll take questions now.>>Thank you so much Sascha and Kara
for that beautiful presentation. We will be taking questions right now.>>So our first question is from Beth and she says [inaudible] measures be
used In massive wild fire situations?>>Yes. If there — if post
disaster surveillance or even current you know currently
disaster surveillance is going on, the reproductive health indicators could be
used to collect information on pregnant women and postpartum women and women
with infants during wild fires. So they could be a leveraged fro that
if — probably best if there is on, ongoing surveillance if it could be
integrated into ongoing surveillance efforts to identify the needs of the women in that area.>>Thank you very much Sascha. And we have another question from Brad and he
ways if there expectation for jurisdictions to use the pregnancy estimator during disasters?>>No there’s no expectation that
jurisdictions would need to use this. This would be specifically if you
are trying to estimate the number of pregnant women in your jurisdiction. There may be several reasons
why you want to estimate that ad know you know during the Zika response
some jurisdictions developed Zika prevention kits for pregnant women. So that could be a use on why
you would want o know how many or estimate how many pregnant women
are in your specific geographic area. If you’re trying to get a
denominator for risk estimates, you may get that using the,
the estimator as well.>>Thank you Sascha. And he’s also asking he says
also after prior to disasters, to specifically response
planning, can that be used?>>Yes. Yes. IT can be used for any reason why would
need to know how many pregnant women or estimate how many pregnant
women are in your area. So it could be you know for
non response setting as well if that’s information that
you’re trying to ascertain. And it could be used primarily by
getting information from census data and you plug those parameters
in and you get an estimate. And when you if you can’t find the specific
parameters, there are some guidelines on general ones that may be
appropriate for the U.S. at large.>>Okay. Thank you. So there’s another question from doctor,
doctor Rahood [phonetic] Rahoodid [phonetic]. He says he would like to ask how it can be
integrated with surveillance at the airport and the border quarantine centers as this
may also require restraining prior to travel. So that intervention or prevention
steps can be adapted.>>That, that’s a good question. I think it can be im — you could integrate
aspects of this into border quarantine centers. A lot of and surveillance of the airports. I believe — there, there was a lot of
communication materials specifically targeted for these populations during Zika. Ebola there — during the Ebola
outbreak there was also a lot of surveillance being conducted
at the airport as well. So the information was needed there too. Kara did you want to add anything to this?>>Yeah I was going to chime in on the — what
you mentioned about communication materials. I know they had a lot of
communication materials at the airports and at the border quarantine centers to advise
people traveling or to areas of risk of Zika and things they could do to
protect themselves while traveling or if they were planning to
become pregnant afterwards. We were hoping to reach pregnant
before they were thinking about travel because we you know the recommendation was that
they avoid travel to areas with risk of Zika. So hopefully they weren’t traveling to these
areas but for everyone else we did have a lot of communication materials to, to let
them know how to protect themselves, and protect people once they,
they returned as well.>>Thank you very much Kara. We don’t have any more questions right now. We’re just going to give you some time to ask
you know — send any questions that you have. So I’m going to read just one more. It says in the event of a large disaster
with emergency shelters in place, does the CDC have a stance on mother or
mother sharing of breast milk in shelters, especially if in the event formula
may not be available or is emitted?>>I do not believe we have
any policy specific to that, just that we would recommend
safe feeding for the infant.>>Yeah I’m not aware of a CDC policy
but we can definitely follow-up.>>Okay. Thank you very much Sascha and
Kara for this beautiful presentation. We have just one more question
from Brant that’s just coming in. Could you possible demonstrate
the pregnancy estimator?>>I think it would be a little
difficult to, to demo right here. But we’ll say if you go to the link
that was provided on that slide, it walks you through an example
of how to calculi it. So in that there’s a pdf
document that you can walk through that example of a, a fictional area. And then you could also open up and
download the Excel spreadsheet that’s on the web page a swell. And you can play with that
and put numbers in there. And then if you have questions you know
you can feel free to contact us as well.>>Okay thank you very much Sascha. So we have another one saying — asking has
there been any research on the long-term effects of H1N1 immunization that was
given almost 10 years ago?>>I’m not aware of any specific
research related to that.>>I’m not either.>>Okay. Thank you. Thank you again for joining
us for today’s webinar. If you have additional questions if you
have additional questions you may email them to [email protected] As a reminder today’s presentation
has been recorded and you can end continuing
education for you participation. Please follow the instructions linked
in the invitation you received. The cost access code E-P-I-C-0-8-2-2
with all letters capitalized. Thank you again. Goodbye.

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