Protecting Pregnant Women and Babies During Public Health Emergencies - Transcript

Moderator: Mabel Woghiren
Presenters: Sascha Ellington, MSPH; Kara Polen, MPH
Date/Time: August 22, 2018, 1:00 – 2:00 pm ET

>> Good Afternoon. I am Mabel Wolghiren 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 by completing this webinar. Please follow the instructions linked
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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 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.

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