Original Research

Association of a Best-Practice Alert and

Prenatal Administration With Tetanus Toxoid,

Reduced Diphtheria Toxoid, and Acellular

Pertussis Vaccination Rates

Jamie L. Morgan, MD, Sangameshwar R. Baggari, MBA, Wendy Chung, MD, Julia Ritch, BS,

Donald D. McIntire, PhD, and Jeanne S. Sheffield, MD

OBJECTIVE: To evaluate how implementation of a bestpractice alert, a reminder of clinical guidelines within the

electronic medical record, in combination with the

recommended change in immunization timing from

postpartum to antepartum, affected tetanus toxoid,

reduced diphtheria toxoid and acellular pertussis (Tdap)

rates, and to examine the association of vaccination with

local pertussis attack rates.

METHODS: A Tdap best-practice alert was introduced

into the electronic prenatal charting system in June 2013.

The best-practice alert was designed to appear starting at

32 weeks of gestation and to reappear at every subsequent encounter until vaccine acceptance was recorded or delivery occurred. The overall acceptance

rate was then compared with postpartum vaccination

rates at our institution from the previous year. Records of

pertussis cases in children younger than 2 years of age

diagnosed since 2012 in Dallas County were also reviewed to correlate local trends with vaccination efforts.

RESULTS: Of the 10,201 women offered Tdap during

prenatal care, 9,879 (96.8%) ultimately accepted. This is

compared with a 48% (5,064 of 10,600) Tdap postpartum

immunization rate in the year prior, before introduction

of the best-practice alert. The incidence of pertussis

From the Department of Obstetrics and Gynecology, University of Texas

Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital

System, Dallas, Texas; and Dallas County Department of Health and Human

Services, Dallas, Texas.

Corresponding author: Jamie L. Morgan, MD, Department of Obstetrics and

Gynecology, University of Texas Southwestern Medical Center, 5323 Harry

Hines Boulevard, Dallas, TX 75390-9032; e-mail: jamie.morgan@

utsouthwestern.edu.

Financial Disclosure

The authors did not report any potential conflicts of interest.

© 2015 by The American College of Obstetricians and Gynecologists. Published

by Wolters Kluwer Health, Inc. All rights reserved.

ISSN: 0029-7844/15

among neonates born to mothers who received prenatal

care at Parkland Hospital showed a nonsignificant decline

from 13 cases per 10,000 deliveries (19 of 14,834, 95%

confidence interval [CI] 7–19) between January 2012 and

May 2013 to seven per 10,000 deliveries during the study

period (eight of 11,788, 95% CI 2–11, P5.174).

CONCLUSION: The use of a best-practice alert, in

concert with the recommended change in timing of

maternal vaccination from postpartum to antepartum,

was associated with an increase in the Tdap immunization rate to 97%.

(Obstet Gynecol 2015;126:333–7)

DOI: 10.1097/AOG.0000000000000975

LEVEL OF EVIDENCE: II

Pertussis or whooping cough, a highly communicable upper respiratory disease, was a common

childhood illness and a significant cause of mortality

in the United States until the introduction of the first

whole cell vaccine in the mid-1940s.1 However, epidemiologic trends in Bordetella pertussis infection have

demonstrated alarming increases since the 1980s with

a steady rise in reported cases as well as associated

morbidity and mortality. This pertussis resurgence

has disproportionately affected infants, particularly

those younger than 3 months of age, who are too

young for vaccination and account for the majority

of hospitalization and deaths.2

Studies examining the contact source for infants

hospitalized with severe pertussis have consistently

documented the mother to be the most common

vector, because adult pertussis cases frequently go

undiagnosed as such.3,4 This recognition led the Advisory Committee on Immunization Practices to implement serial alterations to the tetanus toxoid, reduced

VOL. 126, NO. 2, AUGUST 2015 OBSTETRICS & GYNECOLOGY 333

Copyright a by The American College of Obstetricians
 

and Gynecologists. Published by Wolters Kluwer Health, Inc.

Unauthorized reproduction of this article is prohibited.
 
diphtheria toxoid, and acellular pertussis (Tdap) recommendations centered around pregnancy with the

goal of reducing disease transmission to vulnerable

infants. In February of 2013, the Advisory Committee

on Immunization Practices published the most recent

Tdap immunization guidelines, which recommend

routine antepartum Tdap administration between 27

and 36 weeks of gestation in each pregnancy, regardless of vaccination history.5

Although the recommendation for antepartum

Tdap is relatively recent and uptake data are still

forthcoming, pregnant women historically have poor

vaccination rates, ranging from 13% to 34% nationally, according to the Centers for Disease Control and

Prevention.6,7 In an effort to boost these dismal immunization compliance rates during pregnancy, several

strategies have been suggested, including the use of an

electronic reminder of clinical guidelines within the

medical record.8 Our objective was to evaluate the

association of Tdap rates during pregnancy with

a best-practice alert installation within the electronic

medical record and the 2012 recommended change to

prenatal administration. Additionally, we sought to

analyze whether our hypothesized increase in Tdap

rates translated into a decline in infant pertussis cases

reported in Dallas County.

MATERIALS AND METHODS

Beginning in June 2013, Parkland Hospital began

offering routine antepartum Tdap to all pregnant

women seen in our prenatal care system, in accordance

with the 2012 Advisory Committee on Immunization

Practices recommendations. A best-practice alert within

the electronic charting system, which appeared starting

at or after 32 weeks of gestation, prompted health care

providers to offer Tdap. Each patient’s response to the

best-practice alert was recorded in the electronic medical record along with date and time of vaccine administration. If a patient declined Tdap vaccine in response

to the best-practice alert, additional electronic reminders

continued at each prenatal visit thereafter, either until

vaccine acceptance was documented or until delivery

occurred. These repeated prompts served as an opportunity for the health care provider to address patient

concerns regarding vaccination and supply additional

vaccine information. Before implementation of the

best-practice alert in June 2013, women were routinely

offered Tdap immunization only during the postpartum

period.

The current quality assessment project was

approved by the University of Texas Southwestern

Medical School institutional review board. Best-practice

alert responses and Tdap vaccine administration dates

were extracted from the electronic medical record

between June 2013 and July 2014 (epoch 2). For

women who ultimately delivered at our institution,

demographic information and maternal medical complications were abstracted from a prospectively maintained departmental database and compared with that

of women who did and did not receive antepartum

Tdap. Additionally, the overall acceptance rates with

the use of the Tdap best-practice alert were compared

with postpartum vaccination rates from the year

directly preceding best-practice alert installation.

Records of pertussis cases reported in children

younger than 2 years of age diagnosed between

January 2012 and September 2014 were obtained

from the Dallas County Health Department so

pertussis rates could be compared between the

study period (epoch 2) and the preceding 17 months

(epoch 1). The historical comparator (epoch 1517

months) and intervention (epoch 2513 months) timeframes were chosen based on the availability of complete pertussis ascertainment data from the Dallas

County Health Department as well as the timing

of best-practice alert implementation. If the affected

child’s mother delivered at our institution, her Tdap

immunization status was reviewed to establish

whether maternal vaccination occurred during the

course of care at Parkland Hospital and, if so,

whether the vaccine was administered antepartum

or postpartum.

Statistical analyses were performed using Fisher’s

exact test for categorical data and Student’s t test

for continuous data. P values ,.05 were considered

significant.

RESULTS

Over a 13-month period (epoch 2), we identified

10,201 women who were offered the Tdap vaccine

during prenatal care, of whom 9,879 (96.8%) ultimately accepted antenatal Tdap immunization. Of the

7,378 women who ultimately delivered at Parkland

Hospital, the acceptance rate was similar: 7,152

accepted (97%) and 226 declined (3%). In comparison,

48% (5,064 of 10,600) of women who delivered at

Parkland in the year before the best-practice alert’s

introduction received the Tdap vaccine postpartum.

In the cohort of women delivering at Parkland

Hospital, the mean gestational age of vaccine administration was 34.362.4 weeks. On average, patients

delivered 35.3617.3 days after antenatal Tdap immunization. As reported in our previous article on pregnancy outcomes after Tdap, there was no significant

difference in maternal age, nulliparity, or body mass

index between women who accepted vaccination and

334 Morgan et al Best-Practice Alert for Antenatal Tdap Vaccination OBSTETRICS & GYNECOLOGY

Copyright a by The American College of Obstetricians
 

and Gynecologists. Published by Wolters Kluwer Health, Inc.
 

Unauthorized reproduction of this article is prohibited.
 
those who declined.9 However, women who declined

vaccination were more likely to be black or white,

enroll later in prenatal care, and necessitate referral

to our high-risk obstetric clinic.

According to Dallas County Health Department

records, 61 cases of pertussis in children younger than

2 years of age were reported between January 2012

and May 2013 (epoch 1). Over the course of our study

from June 2013 to July 2014 (epoch 2), 22 cases of

pertussis were reported in this same cohort. The

incidence of pertussis among neonates born to mothers who delivered at Parkland Hospital declined from

13 cases per 10,000 deliveries (19 of 14,834, 95%

confidence interval [CI] 7–19) during the first epoch

from the beginning of 2012 to mid-2013 to seven per

10,000 deliveries during the second epoch (eight of

11,788, 95% CI 2–11, P5.174). Interestingly, all

women who delivered a neonate subsequently diagnosed with pertussis during the second epoch (n58)

were vaccinated (seven antepartum, one postpartum)

reflecting the known incomplete Tdap vaccine effectiveness (estimated to be 70% by the Centers for Disease Control and Prevention).10 Six of the eight cases

were diagnosed within 90 days of birth and all eight

cases occurred within the infant’s first 4 months of life.

DISCUSSION

We found that implementation of a best-practice alert

in the electronic medical record, in combination with

a switch from postpartum to antepartum administration, was associated with an increase in the rate of

Tdap to 97% compared with a 48% postpartum

acceptance rate at our institution in the year before

the best-practice alert introduction. This high acceptance level is particularly notable in our county

hospital-based prenatal care setting where the majority of pregnant patients are indigent, medically

underserved, and receive Medicaid benefits.

The effect of the Advisory Committee on Immunization Practices change in Tdap timing recommendations from postpartum to antepartum on maternal

acceptance rates is yet uncertain. Generally speaking,

the Advisory Committee on Immunization Practices’

expanded recommendations for Tdap administration,

both in pregnant and nonpregnant individuals, have

led to modest increases in Tdap uptake over the past 5

years,11 although actual immunization rates still vary

widely. A 2011–2012 survey of 1,231 recently postpartum women noted a 2.6% Tdap rate during their

antecedent pregnancy (Liang J. Considerations for

recommendation of Tdap for every pregnancy. Presented to the Advisory Committee on Immunization

Practices; Atlanta, Georgia; October 24, 2012), raising

significant concerns about adherence to antepartum

vaccination guidelines. Such concerns were affirmed

by a 2011–2013 report on Tdap uptake in Michigan

Medicaid recipients, which again documented a low

antepartum Tdap rate of 14.3%.12 However, a comparatively high uptake rate of 81.6% was reported by

Goldfarb et al13 in a cohort of 1,467 women receiving coordinated prenatal care with targeted health

care provider and patient education at Massachusetts

General Hospital. These reports are consistent with

trends described for the previous postpartum

“cocooning” strategy, which demonstrated significant improvement after health care provider education, streamlining of processes, and implementation

of standing orders.14–16

The use of the electronic medical record to

improve adherence to national recommendations

such as immunization schedules is, however, in its

infancy. Although electronic charting systems boast

the potential to improve health care quality, safety,

and efficacy based on improved legibility, comprehensiveness, streamlined communication, and employment of clinical reminders, such improvements in

quality and outcomes have been difficult to document.17–19 A recent systematic review of eHealth systems published in 2011 concluded that the evidence

base in support of such technologies is “weak and

inconsistent.particularly in relation to patient-level

benefits.”19

The use of the electronic medical record has

been shown to be associated with increased influenza

vaccination rates in several high-risk groups.20–22

Klatt and Hopp recently examined the association

of a best-practice alert implementation and pregnant

women’s acceptance of the influenza vaccine. They

noted a significant increase in influenza immunization rates, from 42% to 61% after the best-practice

alert was instituted.22 Using a best-practice alert, like

other successful vaccine coverage strategies used to

promote immunizations, targets underlying issues

identified as vaccination barriers, namely deficits in

health care provider vaccine awareness, patient and

health care provider knowledge gaps, and a lack

of health care provider–patient communication

regarding the importance of preventive care measures.23,24 By installing an automated clinical

reminder within the electronic medical record, our

health care providers were prompted to discuss the

importance of Tdap in a timely manner, educate

patients on vaccine benefits, and address any

underlying patient concerns about immunization,

all of which have been shown to be associated

with increased vaccine acceptance.23 Multiple studies

VOL. 126, NO. 2, AUGUST 2015 Morgan et al Best-Practice Alert for Antenatal Tdap Vaccination 335

Copyright a by The American College of Obstetricians
 

and Gynecologists. Published by Wolters Kluwer Health, Inc.
 

Unauthorized reproduction of this article is prohibited.
 
have shown that vaccine recommendation by health

care providers governs parental decisions about

immunization.24–27 In our study, the consistent, programmed best-practice alert reminding our health

care providers to make this highly valued recommendation, along with streamlined processes for

ordering and administering the vaccine, may account

for the success of our Tdap program.

This study has several limitations, the most

significant of which is our inability to distinguish

how the temporal shift in Tdap administration from

postpartum to antepartum, which occurred concurrently with best-practice alert implementation, may

have positively contributed to our increased Tdap

uptake. Additionally, our institution, although large,

boasts a well-coordinated network of prenatal clinics

that practices relatively homogenized and regimented

care. Therefore, a best-practice alert was easily

instituted and health care provider compliance was

high, which may not be the case in all health care

settings. Unfortunately, the design of our best-practice

alert did not allow us to further analyze what

additional barriers prevented the remaining 3% of

women from accepting Tdap. Although the health

care provider was prompted to cite a reason for

patient vaccine refusal within the best-practice alert

platform, the overwhelming majority utilized either

the “patient declines” or “other” options, and no further explanation was requested or required, thus providing no additional information for targeted vaccine

education. We are, however, able to identify specific

clinics and health care providers with lower than average vaccination rates to target health care provider

education.

Implementation of the Tdap vaccine best-practice

alert within the electronic medical record, in combination with a switch from postpartum to antepartum

administration, was associated with a high vaccination

rate of 97% at our institution, representing a doubling

from our postpartum immunization rate in the previous

year. By serving as a timely reminder to health care

providers, this relatively simple, inexpensive, and

easily reproducible strategy has the potential to significantly improve national vaccine coverage during

pregnancy, ultimately with the goal of decreasing

maternal and pediatric infectious morbidity.

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