Routine childhood immunization has had a substantial impact on pediatric morbidity and mortality globally. However, owing to suboptimal immune responses to vaccines in very young infants, immunization schedules do not begin until infants are at least two months of age (six weeks of age in countries following the World Health Organization’s (WHO) Expanded Program on Immunization [EPI] schedule). Thus, the youngest infants are unable to benefit from the protective effects of routine vaccines. These infants are also the most vulnerable to complications and death due to many vaccine-preventable diseases. Immunization in pregnancy, often referred to as maternal immunization, has emerged as a promising strategy to address this gap. This immunization strategy takes advantage of the normal transplacental transfer of antibodies from mother to fetus during pregnancy (as well as to the infant through breast milk in the postpartum period) to confer passive immunity to young infants through maternally derived vaccine-induced antibodies. In addition, because pregnant women are at higher risk of complications due to certain infectious diseases that are or may be vaccine-preventable, maternal immunization is increasingly recognized as an essential component of routine antenatal care. Widespread programmatic use of immunization in pregnancy began with the inclusion of maternal tetanus toxoid vaccination in the WHO’s Expanded Program on Immunization in the 1970s. Since then, immunization of pregnant women against influenza and pertussis has now also become routine in many countries, and vaccines against other important pathogens in infancy (e.g., respiratory syncytial virus and group B Streptococcus) that may be prioritized for use in pregnancy are in development. Indeed, with increased recognition of the substantial burden of potentially vaccine-preventable diseases in pregnant women and infants, the potential public health benefits of maternal immunization could be enormous. Maternal immunization has thus grown into a field at the leading edge of vaccinology. This article highlights research that has examined a broad range of questions pertaining to immunization in pregnancy, including the immunology of pregnancy; the epidemiology of vaccine-preventable diseases in pregnant women and young infants; the clinical efficacy and safety of vaccines currently used in pregnancy; issues related to vaccine acceptance, policy, and implementation; and maternal vaccines on the horizon.
There have been a number of recent reviews of immunization in pregnancy. Omer and Jamieson 2018, published in the latest edition of (now Plotkin’s) Vaccines (edited by Stanley Plotkin, Walt Orenstein, Paul Offit, and Kathryn Edwards), is a new comprehensive overview of the ascendant field of maternal immunization. Vermillion and Klein 2018 reviews vaccine strategies from the perspective of disease pathogenesis in pregnancy. Several reviews (Beigi, et al. 2014; Faucette, et al. 2015) have systematically reviewed the existing data to identify knowledge gaps and formulate a research agenda. More recent reviews (Omer 2017; Abu Raya, et al. 2017) summarize recent clinical data specifically for maternal influenza and pertussis immunization, and also highlighted gaps in trial data relevant to the entire field. In a report from a Bill and Melinda Gates Foundation (BMGF) convening, Sobanjo-Ter Meulen, et al. 2015 describes investment and policy considerations for implementation of maternal immunization as a strategy in low-income countries. Finally, Centers for Disease Control and Prevention 2016 provides guidance for the use of existing vaccines in pregnant women.
Abu Raya, B., K. M. Edwards, D. W. Scheifele, and S. A. Halperin. 2017. Pertussis and influenza immunisation during pregnancy: A landscape review. Lancet Infectious Diseases 17.7: e209–e222.
Reviews the existing evidence for maternal influenza and pertussis immunization, focusing on knowledge gaps that are applicable to the broader field of maternal immunization.
Beigi, R. H., K. B. Fortner, F. M. Munoz, et al. 2014. Maternal immunization: Opportunities for scientific advancement. Clinical Infectious Diseases 59 (Suppl. 7): S408–S414.
Reports the conclusions of a meeting of stakeholders at the US National Institutes of Health to identify barriers to implementation and opportunities for scientific advancement in the nascent field of maternal immunization.
Centers for Disease Control and Prevention. 2016. Guidelines for vaccinating pregnant women. Atlanta: Centers for Disease Control and Prevention, August 2016.
Presents guidance from the US Centers for Disease Control and Prevention (CDC) for health-care providers who care for pregnant women, including details on indications for existing vaccines and contraindicated vaccines. Also includes educational material for educating pregnant women.
Faucette, A. N., B. L. Unger, B. Gonik, and K. Chen. 2015. Maternal vaccination: Moving the science forward. Human Reproduction Update 21.1: 119–135.
Presents the results of a systematic literature search focusing on all aspects of the field of maternal immunization, highlighting the existing evidence as well as key knowledge gaps that should guide future research priorities.
Omer, S. B. 2017. Maternal immunization. New England Journal of Medicine 376.13: 1256–1267.
Discusses immunological aspects of pregnancy as a prelude to an overview of four high-priority vaccines for pregnant women, including two existing vaccines (influenza and tetanus, diphtheria and pertussis vaccine) and two vaccines on the horizon (against respiratory syncytial virus and group B Streptococcus).
Omer, Saad B., and D. J. Jamieson. 2018. Maternal immunization. In Plotkin’s vaccines. Edited by Stanley A. Plotkin, Walt A. Orenstein, Paul A. Offit, and Kathryn M. Edwards, 567–578. Philadelphia, PA: Elsevier.
The first chapter dedicated to maternal immunization in a standard reference text in vaccinology. Discusses immunological aspects of pregnancy and their impact on vaccination, the rationale for maternal immunization in both pregnant women and infants, clinical and safety data for existing vaccines, and future research considerations.
Sobanjo-Ter Meulen, A., J. Abramson, E. Mason, et al. 2015. Path to impact: A report from the Bill and Melinda Gates Foundation convening on maternal immunization in resource-limited settings; Berlin—January 29–30, 2015. Vaccine 33.47: 6388–6395.
Reports the findings and discussion from a Bill and Melinda Gates Foundation 2015 convening focusing on implementation of maternal immunization in resource-limited settings. Provides an overview of clinical data, as well as the investment and policy considerations relevant to deploying this strategy globally.
Vermillion, M. S., and S. L. Klein. 2018. Pregnancy and infection: Using disease pathogenesis to inform vaccine strategy. NPJ Vaccines 3:6.
Describes infectious diseases that may affect pregnancy as falling into three categories, based on pathogenesis and outcome: maternal infections (affecting primarily the pregnant women), congenital infections (affecting primarily the fetus), and neonatal infections (affecting primary the infant). Discusses immunization strategies from the perspective of targeting each of these at-risk groups.
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