Dear Colleague:

The information is important and may save a patient's life. Contained in this letter is material you need to know today concerning influenza and pregnant women. Please take measures to prepare your practice immediately.

It is expected that cases of H1N1 influenza will rapidly multiply in the U.S. during the fall months. Unlike seasonal flu, the infected people experiencing the highest morbidity and mortality with H1N1 flu are children and young adults. Pregnant women (particularly those in the third trimester) and infants are at very high risk of influenza related complications. A recent report noted that 1/3 of pregnant women with confirmed cases of pandemic H1N1 were hospitalized (mostly with severe respiratory distress) and deaths of otherwise healthy pregnant women are being reported.[i] Additionally, it is quite possible for an individual to experience both seasonal influenza and H1N1 influenza simultaneously or in tandem with serious results. As people gather together for school and other fall activities the likelihood of influenza transmission will increase.

The American College of Obstetricians and Gynecologists has joined with a coalition of prenatal and pediatric health care provider organizations to urge pregnant women to take steps to prevent influenza and to seek early treatment. There are very important steps you should take in your practice.

What can you do?

• Educate and inform your patients.
  • Instruct all pregnant women to report the symptoms of influenza or close exposure to persons with influenza to you immediately.
  • Instruct in the use of antipyretics.
  • Caution all pregnant women to use frequent hand washing and to avoid contact with sick individuals.
  • If a family member has flu-like symptoms, instruct pregnant women to try and arrange for another person to care for those who are sick.

  
  

• The CDC advises that you do not need to confirm influenza to initiate treatment. If H1N1 is prevalent in your community consider all pregnant women with flu-like symptoms as having H1N1.

  
  

• Treat flu exposure with a prophylactic course of oseltamivir (75 mg. once daily. for 10 days). Treat those with flu-like symptoms with a therapeutic course of oseltamivir (75 mg twice daily for 5 days). Limited data suggest that oseltamivir is not a major human teratogen and it is currently effective for both prevention of H1N1 influenza and the reduction of flu severity if started within 48 hours of the initial symptoms.[ii]

  
  

• The Immunization for seasonal flu is available NOW and the Immunization for H1N1 will be available in mid-October. We urge you to make provisions for all pregnant women to receive both the H1N1 immunization AND immunization for seasonal flu, and to strongly encourage ALL pregnant women to be immunized for both. This may require your counseling on the safety of immunization during pregnancy.[iii]

  
  

• The Advisory Committee on Immunization Practices and ACOG recommend inactivated flu vaccine for all pregnant women in every trimester.[iv] Please consider immunizing your patients in your office. If you have not already done so, please immediately order your seasonal flu vaccine from an IVATS distributors. IVATS was developed to enable healthcare providers to find influenza vaccine to purchase, especially during the critical vaccination period. (http://www.preventinfluenza.org/ivats)

  
  

• Contact your health department immediately to obtain the H1N1 vaccine . The H1N1 vaccine is free, however you are able to bill for vaccine administration. Up-to-date CDC guidance on the H1N1 flu vaccines can be found at http://www.cdc.gov/h1n1flu/vaccination.

  
  

• Make a plan in your office for how you will inform your pregnant patients, respond to their calls concerning influenza symptoms and exposures, isolate sick women, monitor those you treat, and cover for sick staff.

  
  

• Follow the CDC's H1N1 influenza during pregnancy web site (http://www.cdc.gov/h1n1flu/guidance/obstetric.htm) and the ACOG web site for up-to-date information

  
  

• If you have pregnant health care workers on staff, please also follow CDC guidance at http://www.cdc.gov/h1n1flu/pregnancy and limit their exposure to situations of influenza exposure.

The ACOG Workgroup on Immunization will be mailing you the Immunization Coding Guide for Obstetricians and Gynecologists. This coding guide will serve as a ready reference for your practice. It addresses reimbursement for vaccinations, coding for vaccinations, coding examples and other coding resources. Also enclosed in that mailing are two pocket guides on seasonal influenza vaccine developed by the National Influenza Vaccine Summit. For more information or to request additional pocket guides, please visit, http://www.immunize.org

The virulence, mutation and distribution patterns of the H1N1 virus are likely to change over time. It is essential that you stay current with this information

YOUR ACTION TO PREVENT AND TREAT INFLUENZA IN YOUR PREGNANT PATIENTS IS OF CRITICAL IMPORTANCE.

Sincerely,

Gerald F. Joseph, Jr., MD, FACOG
President

1. Jamieson DJ, Honein MA, Rasmussen SA, Williams JL, Swerdlow DL, Biggerstaff MS, et al. H1N1 2009 influenza virus infection during pregnancy in the USA. Novel Influenza A (H1N1) Pregnancy Working Group. Lancet 2009;374:451-8. Abstract available at:

   http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61304-0/fulltext. Retrieved August 27, 2009. 

2. Tanaka T, Nakajima K, Murashima A, Garcia-Bournissen F, Koren G, Ito S. Safety of neuraminidase inhibitors against novel influenza A (H1N1) in pregnant and breastfeeding women. CMAJ 2009;181:55-8.

3. Phillippe M. Pandemic influenza: what obstetricians need to know. Obstet Gynecol 2009;114:206-8.

4. Influenza vaccination and treatment during pregnancy. ACOG Committee Opinion No. 305. American College of Obstetricians and Gynecologists. Obstet Gynecol 2004;104:1125-6.

jm/mash

8/27/2009