To lessen the burden of influenza in pregnancy: Nonpharmaceutical interventions
Influenza threatens the lives of thousands each year, and pregnant women are particularly susceptible to its consequences. The rates of hospitalization, intensive care unit admission, and death are all elevated. Vaccine hesitancy is an obstacle for pregnant women in obtaining the influenza vaccine, and insufficient provision of the vaccines in physicians' offices may be a contributing factor. Even among women who do get vaccinated, the efficacy of the "flu shot" is well below that seen with COVID-19 vaccines. Although antivirals can be helpful to those who become infected, they may be employed too long after the first symptoms to be helpful, and even when used appropriately, they are not always successful. There is a clear need for additional interventions to mitigate the acquisition and the consequences of influenza in pregnant women.
The potential utility of nonpharmaceutical interventions was convincingly demonstrated in the 2020 influenza season.
Current strategies for the prevention and treatment of influenza are imperfect and insufficient. The data demonstrating the potential utility of masks and social distancing in reducing the acquisition of influenza make a discussion about nonpharmaceutical interventions in pregnancy worth having. It should be acknowledged that the dramatic decline in influenza in 2020 was unique to an event that is unprecedented and unlikely to be replicated simply by masking. During the COVID19 pandemic, not only did individuals at risk wear masks, but almost everyone else with whom that person came in contact did so.
The Centers for Disease Control and Prevention (CDC) has advocated the use of nonpharmaceutical interventions to blunt pandemics in the past. Nonpharmaceutical interventions have been defined as "actions that persons and communities can take to help slow the spread of respiratory virus infections, including seasonal and pandemic influenza viruses." The categories of nonpharmaceutical interventions include personal protective measures for influenza pandemics, environmental measures, and measures at a community level. However, they have not focused particularly on pregnant women, and the degree to which physicians have been champions of this approach is unclear.
The American College of Obstetricians and Gynecologists has been an unflagging champion of activities that mitigate the harms of influenza in pregnancy. There is no doubt that an even greater societal benefit, vis-Ã -vis reductions in respiratory infections, would be obtained if the shutdowns that marked 2020 were implemented annually during the influenza season. However, the tremendous societal and economic cost of that approach would make it virtually impossible. Yet, voluntary programs could have salutary benefits for many vulnerable segments of society.
Currently, masks are provided freely to anyone in need within these spaces and in municipal areas where masking is mandated, such as subways or buses. It is worth noting, however, that these customs are temporary, and the cost of mask wearing may one day be borne by individuals. Although one should normalize staying at home when having symptoms of influenza-like illness and masking when going out if symptomatic, the costs should be considered, and ways to allow indigent women to benefit from these interventions should be developed. These minor changes, if broadly adopted, might help to mitigate the rates of disease overall and the consequences for those most at risk in particular. As discussed above, pregnant women fall into the latter category.
So what to suggest as standards for obstetricians? In the first instance, they must be aware of the extent of influenza outbreaks in their communities; the CDC and local departments of public health can provide guidance.
Obstetricians should counsel their patients about the appropriate steps to mitigate risks as part of standard care during yearly influenza seasons. They should routinely recommend the influenza vaccine for all of their patients and provide guidance regarding the use of antivirals for treatment and postexposure prophylaxis.
When the community spread of influenza is high, obstetricians should discuss the risks and benefits of avoiding crowds, allowing them to consider the economic burden on the one hand and any particular comorbidity on the other.
They should be informed about the option of masking.
It is also important that providers and governing bodies maintain uniform guidelines and consistent patient advice with regard to the modes of transmission and the individual risk for influenza. In doing so, it will be easier to foster a sense of trust in the general population and avoid the level of panic seen at the onset of the current pandemic.
The CDC has recommended masking for people who are ill during the influenza season even before the COVID-19 pandemic. They were more reticent to recommend masking for prevention, noting in the past that, "little evidence supports the use of face masks by well persons in community settings." They did note, however, that, "during a severe pandemic, pregnant women and other persons at high risk for influenza complications might use face masks if unable to avoid crowded settings" Since the time of that writing, the COVID-19 pandemic taught several painful public health lessons, making it reasonable to move from "might use" to "should use," particularly if the woman has frequent contact with the public.
The CDC has also suggested that to increase social distancing, it would be reasonable to offer telecommuting and replace inperson meetings with virtual. Again, the COVID-19 pandemic demonstrated the acceptability of that approach for both employees and businesses. All members of the healthcare team should be reminded about respiratory etiquette and hand hygiene, and pregnant women should utilize frequent environmental surface cleaning measures. However, authors acknowledge that there exist a large number of workers who are unable to work remotely, and the ability to implement nonpharmaceutical interventions is a luxury that many essential workers cannot afford.
Obstetricians play an essential role in public health, because they have contact with a population that can suffer disproportionately from infections that are more benign within the general population. Increasing demands on obstetricians make the dissemination of public health information a challenge. It is imperative that we promote discourse regarding infection prevention and common-sense information about risk. They can use patient interactions to educate our patients about how respiratory droplets spread while reassuring patients that things such as grocery shopping and public transportation are safe. As the prospect of a postCOVID world beckons, the medical community and society at large are poised to take hard-learned lessons and consider how one can be more proactive about contagion in the future.
Although physicians may feel more comfortable wielding a scalpel or a prescription pad than advocating behavioral interventions, the experience with COVID-19 demonstrated that behavioral change can be a potent public health weapon. Accordingly, obstetricians should employ those tools during future flu seasons to promote the health interests of their patients
Source: Laura C. Gilroy, MD; Howard L. Minkoff, MD; American Journal of Obstetrics & Gynecology JUNE 2022
