PICOT Clinical Question
In pregnant women, how does receiving the Tdap vaccine compared to not receiving the Tdap vaccine reduce the risk of developing pertussis in infants under two months?
Systematic Review and Error Analysis
Systematic Review and Database Used
The systemic review of using the Tdap vaccine to vaccinate pregnant women against pertussis was implemented to determine the clinical and immunological benefits of immunization against bacterial infection. The databases used included Expert Review of Vaccines, Journal of Emergencies, Trauma, and Shock, Infectious Diseases and Therapy, and Annals of Medicine. The current guidelines on the administration of the pertussis vaccine do not focus on the immunological response of pregnant women and, thus, the outcome of the immunization on the infant. However, the results of the systematic review concluded that maternal pertussis immunization with Tdap during pregnancy was safe and that the vaccination led to sufficient transfer of antibodies, which protected the infants aged below 2 to 3 months (Martinón-Torres et al., 2018).
The benefits if pertussis immunization included reduced hospital admissions and improved lung function among infants. The conclusion made in these systematic reviews was as a result of the integration of data from sources obtained in the aforementioned databases.
Error Analysis
The evidence from the research that was drawn to a conclusion indicated a significant likelihood of incorrect analysis. Seven randomized controlled trials (RCTs) were included in the maternal immunization systematic review in 2000, which had a sample size of 665 patients and a P-value of 0.05 (Kandeil et al., 2020). The maternal immunization systematic review from 2014 had a sample size of 2313, was based on fourteen double-blind RCTs, and had a P-value of 0.18 (Martinón-Torres et al., 2018). In 2016, the pregnant women immunization comprehensive review included five RCTs with a total sample size of 182 children and a P-value of 0.14 (Kandeil et al., 2020). More data are required to assess whether intravenous magnesium is lessening the requirement for intubation due to the high P-values in the last two systemic evaluations.
Evidence-Based Quantitative Article Selection
Switzer, C., D’Heilly, C., & Macina, D. (2019). Immunological and clinical benefits of maternal immunization against pertussis: a systematic review. Infectious Diseases and Therapy, 8(4), 499–541. Web.
Summary of the Case Study
Especially during the first few months following birth, infants must be protected from whooping cough. In some nations, the vaccination of pregnant women is advised to protect the unborn child against the disease by passing on the mother’s defense mechanisms. This article examined the scientific research on the clinical and immunological advantages of the whooping cough vaccine in pregnant women (Switzer et al., 2019).
Pregnant women who received the whooping cough vaccine experienced strong maternal immune responses and high antibody levels passed on to the fetus. In the first several months after birth, babies born to moms who received the whooping cough vaccination during pregnancy were better protected against the disease than babies whose mothers did not receive the shot. Pregnant women should receive their vaccinations in the late second or early third trimester (Switzer et al., 2019). Although the basic immune responses of infants delivered to mothers who received vaccinations during pregnancy were diminished, this did not impair the efficacy of the vaccine. This review supports the idea that whooping cough vaccination during pregnancy shields children from contracting the illness.
Study Approach, Sample Size and Population Studied
Study Approach
This article used the systematic review methodology approach to review scientific literature. The approach followed the PRISMA framework to identify, filter and include study articles in the review. The search strategy reviewed articles published in English on the immunogenicity and efficacy of pertussis vaccination (Tdap) among pregnant mothers to protect the mother and the infant from contracting whooping cough within four months after their birth. The articles involved in the study were limited to articles published between January 1995 to June 2016. However, the authors updated the literature search to articles published between July 2016 to October 2018.
All articles used in the study were obtained from PubMed, MEDLINE, EMBASE, Scopus, Cochrane systematic review documents, ProQuest, and Science Direct. The keywords used in the search strategy include “pertussis OR whooping cough” AND “vaccine OR Tdap OR immunization” AND “pregnancy OR pregnant OR pre-partum OR gestation OR maternal” AND “immunogenicity OR immunity OR immune response OR antibody OR antibodies OR effectiveness OR efficacy.”
Sample Size
This systematic review used 43 relevant articles in the study to evaluate the efficacy of the Tdap vaccine to combat pertussis epidemiology in infants under two months by vaccinating pregnant mothers. However, the article found 288 articles from the databases and five additional records identified through other sources. The articles were filtered to remove 72 duplicate articles obtained from the seven databases.
Two hundred sixteen articles remained, and they were further screened on the exclusion criterion of irrelevant results, where 172 articles were excluded involving 162 articles with irrelevant information and 11 with duplicate and repetitive information. Based on the full-text criterion, the articles were screened for eligibility. However, no articles were excluded from this criterion, and 43 articles were found relevant to include in the systematic review. This sample was representative of the efficacy of the Tdap vaccine in combating pertussis around the globe, as the studies were not limited to any country or continent.
Population Studied
The population studied in this study included infants below two months, pregnant mothers, older siblings, and adults. The study was not limited to any ethnic group, race, or country. The study evaluated the potential risk factors of pertussis among infants below two months. It argued that older siblings and adults in close contact with infants are the main risk factors. This is because these individuals can reserve the pertussis pathogen and wait to transmit it to the newborns. However, the study has identified that vaccinating pregnant mothers can be an important intervention to combat the epidemiology of whooping cough among infants below two months. Since the Tdap vaccine of DPT vaccines is immunized at six, ten, and fourteen weeks, this intervention would efficiently combat this illness. Therefore, the main study population of the article is infants below the age of two months, as they are at risk of contracting pertussis before their right age of vaccination, 6 weeks.
Application of this Evidence to My Practice Overview
Tdap vaccine, which protects against diphtheria, tetanus, and whooping cough, is indicated after the 20th week of gestation to protect mainly the newborn. A recent study by the US Centers for Disease Control and Prevention, published in Clinical Infectious Disease, proves that the Tdap vaccine, when given in the third trimester of pregnancy, dramatically reduces the risk of developing whooping cough in newborn babies (Switzer et al., 2019).
The researchers reviewed three-year data from six US states to reach that conclusion. My study found that vaccinating pregnant women between the 27th and 36th week of gestation was 78% effective in preventing whooping cough in babies under eight weeks of age when they are too young to receive the first dose of vaccine. The study shows that the vaccine works because it exposes the mother to the disease, causing her to produce antibodies and pass them on to the child during pregnancy and, later, during breastfeeding. In this way, the vaccine in the last trimester of pregnancy raises antibodies the mother can transmit to the child.
The introduction of the Tdap vaccine resulted in a recession in the number of pertussis cases. In the United States, before the creation of the vaccine for children, the number of pertussis cases exceeded 200,000 a year, but after immunization, this figure dropped to just over 10,000 (Kandeil et al., 2020). The Tdap vaccine for pregnant women should be part of the essential vaccination schedule in my practice. According to Kandeil et al. (2020), the number of pertussis cases has shown a significant drop for the past few years, especially among children under one year of age, since pregnant mothers were vaccinated between the 27th and 36th weeks of pregnancy. In my practice, I would involve the Tdap vaccine among the three vaccines allowed in pregnancy. However, I would make vaccines mandatory even though they are not recommended. Vaccines are against hepatitis B, flu and diphtheria, tetanus, and whooping cough, the Triple Adult Bacterial (Tdap). In my practice as a doctor or nurse, I would explain the purpose of these immunizers is to protect the mother and, especially, the child since the antibodies are passed during pregnancy.
To prevent pertussis-related infant mortality, I would involve and recommend Tdap vaccination in the clinical attendance of pregnant mothers. As with measles, whooping cough returned because, as the disease had been eliminated, people began to take care of themselves less and were not vaccinated (Kandeil et al., 2020). In my practice, I would explain the big problem of whooping cough in newborns to health stakeholders to convince them with an expert argument. This is because infants below two months can only receive the first dose of this vaccine at two months. Therefore, the newborn is most at risk of contracting the disease (Kandeil et al., 2020).
A technique called’ cocoon’ would be used to protect the newborn from this global health epidemic. This technique would be borrowed from the research article evaluated in this study which stated that vaccinating people around the mother and infant would reduce the risk. Therefore, the mother, father, and older siblings must be vaccinated when a woman is pregnant.
In my practice, I would ensure that children are vaccinated at the right time by issuing health education to the stakeholders on the importance of this practice. Tdap is administered at two, four and six months of age. At fifteen months, a booster dose is required. The child should receive another dose at age 10 with the dual adult vaccine (diphtheria and tetanus) (Vojtek et al., 2018). Even if the woman has already taken this vaccine, this dose during pregnancy serves as a booster to stimulate antibodies. The pregnant woman who does not take this vaccine will be putting the baby at risk (Vojtek et al., 2018).
Whooping cough is an infectious disease that compromises the respiratory system. It presents in the most serious form in children under six months and can lead to death. The main symptom is the attack of dry cough. It is transmitted by an infected person coughing, sneezing, or talking. According to Vojtek et al. (2018), diphtheria, on the other hand, is considered a controlled disease in the United States and tetanus is practically impossible to contract during childbirth in maternity hospitals.
Outcome Evaluation
The evaluation of the article and other relevant studies have to yield evidence-based techniques to combat pertussis among infants below two months. First, to receive the Tdap vaccine, the pregnant woman does not need a medical prescription. The evidence in the article has provided that the health professionals attending the pregnant mothers in the antenatal clinic should just look for one of the 36,000 vaccination rooms spread across the United States, present the Pregnancy Book, and get vaccinated for free (Switzer et al., 2019).
Moreover, the evidence from the article provides that from the 20th week, the earlier the pregnant woman takes the vaccine, the more she has a chance of creating more antibodies. In the case of pregnant women who, for some reason, did not take Tdap during prenatal care, the WHO recommendation is to receive the vaccine during the postpartum period – from 0 to 45 days after the baby’s birth. However, in these cases, the vaccine will only protect the mother and prevent her from passing the disease on to the newborn. But the baby will not be able to produce antibodies until the vaccination at two months.
Validity and Reliability of Outcomes
Validity
The validity of the results is based on the scientific evidence surrounding the transfer of antibodies by transplacental means. According to the study, antibodies induced by the pertussis vaccine were transferred from the mother to the fetus, which conferred immunity to the infant against the bacteria after birth. The same success was achieved against neonatal tetanus. Additionally, the antibodies were found to be transferred through breast milk, showing that the findings of the study were valid to this consistency. The protection is essential in the first months of a child’s life, as the immune system is still developing and strengthening.
Reliability
The evidence from the article is reliable to answer the research question of this paper as it upholds that the ideal time is to vaccinate Tdap during pregnancy. Tdap Immunization is just as effective in pregnant women as in those who are not. Vaccines made with the live virus, for example, the rubella vaccine and the chickenpox vaccine, are not given to women who are or may be pregnant (Switzer et al., 2019). Other vaccines are given to pregnant women only if there is a significant risk of her getting that infection and if the risk of the vaccine against cause side effects is low. However, all pregnant women in the second or third trimester should receive the Tdap vaccine when the pertussis is at its peak. Therefore, this evidence has answered the research question that the Tdap vaccine during pregnancy is the most efficient intervention to prevent the prevalence of pertussis among infants under the age of 2 months.
Possible Bias
The article is unlikely to have biasness in the systematic review methodology to evaluate the efficacy of the Tdap vaccine during pregnancy to control pertussis among infants. The study was not biased to race, gender, ethnic group, country, or continent. The biases likely involved in the study would come from the primary article in the systematic review. The studies might have involved biases in data collection and analysis, which would affect the validity and reliability of the results of the evaluation of this paper. However, there are a few biases that can be identified from the literature search of the study. The literature search was limited to the PRISMA strategy, which would be biased to provide reliable data sources. Therefore, the authors decided to update their search by involving five articles outside the research strategy. Furthermore, the authors used research articles from other studies done in the following two years to lessen the biases of the initial review.
However, the study has the possibility of being biased in the number of articles it obtained from all the databases identified in the PRISMA search strategy. This is because the authors did not involve the number of articles found from each database which would Bias the information involved in the study (Martinón-Torres et al., 2018). Regarding this criterion, the authors would have proved that the results presented came from all the databases because these studies can come from only one database. For future research studies, this paper would recommend that if such articles or when a researcher would conduct a systematic review, they should provide the number of studies obtained from all the databases during the primary search using the keywords. Additionally, the other possible biases would have come from the limitation of the English articles. The reason is that some countries do not use English, and they might have presented information on the efficacy of the Tdap vaccine.
Level of Evidence
The level of evidence presented in the article would be rated to provide 80% of important information regarding the research question of this study. The article’s evidence would be anticipated to cover 80% of the countries in the world as it did not evaluate non-English articles. Therefore, the evidence presented partially represents the effectiveness of the Tdap vaccine in combating pertussis among infants below the age of two months globally. However, the article presented results that can serve as important evidence-based knowledge in nursing to combat the epidemiology of pertussis among infants below two months.
The guidelines provided by the reviewed article can be important evidence for nursing practice. According to the reviewed article, maternal pertussis immunization during pregnancy results in strong and long-lasting immune reactions to all vaccine antigens comparable to those seen in non-pregnant women.
Furthermore, greater antibody GMCs in cord blood than maternal blood show that maternal immunization causes effective transplacental transfer of anti-pertussis antibodies to the fetus. Before childhood pertussis vaccination, the infant’s pertussis-specific antibodies persisted and lowered the chance of illness. However, it appears that a minimum of two weeks must pass between the administration of the maternal vaccine and delivery, longer gaps. This includes vaccination in the second or early third trimester, which results in higher antibody concentrations in newborn infants and allows the immune system to mature, improving the quality (i.e., avidity) of antibodies transferred to the fetus.
To enhance the results of the research presented by the reviewed article would be enhanced by reviewing studies concerning other pertussis vaccines. Finally, the impact of the vaccines on the maternal and infant immunity of the other vaccines should be evaluated. This research would complement the findings of the reviewed article and provide reliable and valid evidence-based approaches to combat the prevalence of pertussis among infants below two months.
References
Kandeil, W., van den Ende, C., Bunge, E. M., Jenkins, V. A., Ceregido, M. A., & Guignard, A. (2020). A systematic review of the burden of pertussis disease in infants and the effectiveness of maternal immunization against pertussis. Expert Review of Vaccines, 19(7), 621-638. Web.
Martinón-Torres, F., Heininger, U., Thomson, A., & Wirsing von König, C. H. (2018). Controlling pertussis: how can we do it? A focus on immunization. Journal of Emergencies, Trauma, and Shock 17(4), 289-297. Web.
Vojtek, I., Dieussaert, I., Doherty, T. M., Franck, V., Hanssens, L., Miller, J., & Vyse, A. (2018). Maternal immunization: Where are we now and how to move forward? Annals of Medicine, 50(3), 193-208. Web.