Protecting Pregnant Moms and Babies this Flu Season

MODERATOR: On November 20, 2013, CDC hosted a webinar briefing focused on the importance of flu vaccination for pregnant women and young children. Speakers included Julie Moise, a board member with Families Fighting Flu, Dr. Georgina Peacock, Medical Officer and developmental-behavioral pediatrician with the Division on Birth Defects and Developmental Disabilities at CDC, Dr. Siobhan Dolan, Medical Advisor to March of Dimes, Professor of Clinical Obstetrics & Gynecology and Women's Health at the Albert Einstein College of Medicine, and an attending physician in the Division of Reproductive Genetics at Montefiore Medical Center, the University Hospital for Einstein, and Amy Pirretti, Clinical Quality Director for Text4Baby, a program of the National Healthy Mothers, Healthy Babies Coalition. The recording that follows begins as Julie Moise is sharing her story. Julie is a board member of Families Fighting Flu, a nonprofit, volunteer-based advocacy organization. Its members include parents whose children have suffered serious medical complications or sadly, have died from influenza, as well as health care practitioners and advocates committed to flu prevention. As a mother who lost a child to influenza, Julie knows personally how important it is to vaccinate children against influenza. She has dedicated herself to educating others about the seriousness of the disease and the importance of annual vaccination, particularly in children. In December of 2003, her 6-month-old son, Ian, died from the flu less than 30 hours after his first symptom appeared. Though Ian received his immunizations at his six-month well baby appointment, including the first of two doses of flu vaccine required for his age, he was not protected from the flu because he hadn't received his second dose. (Two doses spaced 28 days apart, are needed for those 6 months through 8 years old who are being vaccinated for the first time). Less than two weeks after his well baby appointment, he began to run a fever and show signs of flu illness. Julie called the doctor's office to ask a question about his symptoms but initially did not plan to take Ian in. About an hour later, though, she decided to schedule an appointment. The following recording picks up at this point in Julie's presentation. JULIE: We were seen around five o'clock that evening and Ian's temperature had risen to 102 degrees. He had also started panting a little. Our doctor examined Ian and concluded that he had the flu. We were told to treat the symptoms and keep Ian hydrated. We were also told if we didn't see improvement to take Ian back in to be seen. We left the office feeling somewhat confident in what we had heard. As the evening wore on Ian's panting did not improve even when his fever would go down. My husband Glen and I were still concerned about his breathing so I called a nurse hotline. We were told that the panting is normal with a fever. This did not calm our fears, so next we called our pediatrician's office. The doctor on call suggested we have Ian looked at again. By this time it was about 10:30 at night and I quickly loaded Ian into the car and I hurried into a children's pediatric urgent care center. Ian's fever was now over 104 degrees. The doctor ordered the nasal swab to test for RSV and influenza. The test came back that Ian did not have RSV, but he did test positive for influenza. When the doctor told me the test result I said well, good, it's just the flu, we can handle that. We'd been through flu seasons before with our other two boys. I'm a mother of three; I know how to handle the flu. I once again asked about Ian's breathing. I was once again told that it was normal with the fever. I asked about his temperature. I was reassured not to worry unless it reached 105 degrees. The doctor told me to take Ian home, keep him hydrated and treat his symptoms. Little did we know that just the flu was going to change our lives forever. That night Ian did not want to lie in his crib to sleep. I held him in my arms so he could rest. Around two in the morning I started feeling achy. I also started to run a fever. In the morning my husband Glen helped our other two boys get ready for school. By this time I was feeling terrible. Glen told me to get some rest and he would stay with Ian. Ian's fever went down during this time. We thought he was getting better. After my nap, Glen left for work, we thought our beautiful baby boy was on the road to recovery. Ian's temperature was now down to less than 100 degrees. His panting had turned into a sigh but he wasn't taking his bottle very well and I was worried about him getting dehydrated, so I called our doctor's office again and left a message on the triage line. I started giving water and Pedia-lite with a medicine syringe. I called the nurse hotline to make sure it was okay to be doing this. I was reassured it was fine. Meanwhile I was feeling worse. My fever was up to 103 degrees and I called Glen crying and asked if he would please come home so that I could crawl into bed. He said he would. I laid on the floor and I placed Ian in a bouncy seat next to me, even though he was so big, he was more comfortable sitting up and I was afraid I would fall asleep holding him. He napped a little and would sigh and I kept patting him and telling him I know Sweetie, Mommy doesn't feel good either. After about 45 minutes Glen got home. He went over to Ian in the bouncer and said hey, little buddy, Ian opened his eyes and looked at his daddy. He also grabbed Glen's thumbs. It was a game that they played. Ian's grip was weak. About this time the phone rang and it was the doctor's office calling back. Glen picked Ian up and said he didn't like the way he looked. He said he wanted to take him to the hospital. I told the nurse on the phone that we were going to take Ian to the hospital to get him looked at. Glen then noticed that Ian's fingertips were turning blue. As soon as he said this, Ian stopped breathing. I hung up on the nurse and dialed 911. Glen said let's go, we're not waiting. We live only a few miles from the hospital, so we jumped into our truck and began giving Ian rescue breathing. Ian wasn't responding. I told Glen to stop at the fire station that is only a few blocks away. Thankfully the firefighters were in and they immediately began CPR. The ambulance met us at the fire station in less than five minutes. The paramedics started to work on Ian. He was just lying there so small and still on the table. After several minutes they carried Ian to the ambulance. It seemed like an eternity before they left for the hospital. They would not let Glen or I ride with them. I knew that this was not a good sign. I called my sister while we were on our way to the hospital. Once we arrived at the hospital I jumped out of the truck and ran to the emergency room. Glen and I were not allowed to go into the room with Ian. They brought us two chairs and asked us to sit outside the trauma room. They closed the curtains so that we could not see what they were doing. I noticed everyone's feet standing around the gurney. I asked why the staff wasn't moving. When we watch the television show ER everyone was always running and Ian's doctors and nurses were all just standing there. I could also see the firemen; they were in the trauma room with Ian. They all looked so sad. Why? Ian was going to be fine. He just had the flu. My sister arrived at the hospital. Now the three of us sat outside Ian's room, waiting, just waiting. What was taking so long? Ian just had the flu. When the doctor walked out he did not even have to say a word, it was in his eyes. I knew Ian was gone. I fell to my knees, how, he just had the flu? I ran into the room, the nurse pulled me out, how could this be, he just had the flu? Our pastor arrived with many members of our family and we all had to say good bye to this beautiful baby who just had the flu. We thought Ian must have had some underlying medical condition. We thought healthy children just don't die from the flu. We were wrong. Unfortunately we were not aware how serious the flu is. About seven years ago I had some friends call me to tell me about an organization that they had seen on Good Morning America and CNN. It was called Families Fighting Flu. I tuned into CNN and I saw the story. I immediately went to the website and could not believe what I was reading, there were these beautiful little faces and they had all died of the flu. I knew I wanted to get involved with this group. I wanted people to know that there is no reason for healthy children to die from the flu. Both Families Fighting Flu and I strongly support the CDCs recommendation that everyone six months and older get vaccinated against the flu every year. Children are at a high risk for the flu-related complications. However the flu vaccine is not approved for use in children less than six months of age. Therefore it is critically important for pregnant women to also get vaccinated to help protect themselves and their baby for the first six months of his or her life. I was not vaccinated against the flu while I was pregnant with Ian. Had I been perhaps my story might have a happier ending. It's also important to vaccinate other family members and people in contact with their children to help stop the spread of the flu virus to vulnerable people like our kids. Because Ian was six months old he did receive his first of two flu vaccines. However he died before he could get his second dose, which would have provided him full immunity. Our other two sons Sean and Ryan also received their flu vaccines. But they had been vaccinated in previous seasons and only needed one vaccine that year. We were lucky, neither of them got sick. However, my husband and I were not so lucky, the same day that Ian died I tested positive for influenza. Two days later my husband got sick. In fact, we were at the cemetery picking out our baby's grave site, when my husband got the news that he too had tested positive for the flu. Neither one of us had gotten vaccinated that year. I have a story, its not a happy story, so my message to you today is if you are pregnant, get vaccinated. If you have children six months or older, get them vaccinated. And get yourself vaccinated too and encourage everyone around you to do the same. It's not too late. I want your story to end happier than mine did. Thank you. MODERATOR: Thank you, Julie. What an incredibly powerful story that drives home the importance of understanding more about flu vaccination, pregnancy and young children. So thank you for sharing that. Dr. Peacock, before I turn it over to you, I'll share a bit more about your background. Dr. Peacock is a medical officer and developmental behavioral pediatrician with the Division on Birth Defects and Developmental Disabilities at CDC. She's currently on detail working with CDC's Office of Public Health Preparedness and Response on an initiative to enhance CDC's public health disaster preparedness and response for children. She's continued to work and publish on influenza, particularly with regard to children with neurologic conditions and other special health care needs. Dr. Peacock continues to see patients in a developmental clinic at the Good Samaritan Health Center and is an Adjunct Professor with the Georgia State Center for Leadership in Disability in Georgia State Lend Program. Dr. Peacock thanks for being here. DR. PEACOCK: Thank you. I wanted to echo, thank you Julie for telling your story and so I think all I'm going to do is sort of underline the detailed recommendations from the CDC for flu vaccination. But your story is I think what should drive us all to make sure that that doesn't happen again to children who can be protected and families that can be protected through flu vaccination. So the CDC's recommendation for flu vaccination as Julie mentioned to us is that everyone six months or older needs an annual flu vaccination. This is especially important for people who are at high risk for flu complications. As we've heard pregnant women, children younger than five, but especially those younger than two, adults 65 years and older and people with chronic conditions like asthma, diabetes and neurologic conditions. It's also important that those who live with or care for those at high risk are, including health care workers, are vaccinated. And there are many hospitals now that have a mandatory vaccination recommendation. And then parents and caregivers of children younger than six months of age because as we've heard those children under six months of age can't get the vaccination themselves, so we need to make sure that those around them have been vaccinated. There are a number of different options for flu vaccination available in this 2013-2014 flu season. There are what we call trivalent vaccines. This is the traditional vaccine that's been available that protects against three flu viruses. And it's available in a number of different forms. It's available in the standard flu shot for people six months or older. There's also an egg free flu shot, so usually the flu vaccine is grown in eggs and so those that are allergic to eggs can't use this, but there is an egg free flu shot for people. It's approved 18 years to 49 years. Then there's a high dose flu shot now available for people that are 65 and older. And this is felt that because this group is highly impacted by flu disease and may not respond as well to the flu vaccine that's why there's this high dose flu shot available for people over 65. And then there's another way this shot can be given now, which is called an intradermal flu shot. So this flu shot instead of going into the muscle is a smaller needle and it goes more into the skin. And that's also available for adults, 18 to 64 years old. In addition to that vaccine that has the three strains in it, there is also now what we call quadrivalent vaccine. Maybe if you can go back to the slide before. Thank you. And this has four flu viruses in it. And it's got the same three viruses that are in that first vaccine and then there's an additional one and so the idea is that this may give broader protection. However, CDC right now is not recommending one vaccine over the other; they're recommending that everyone get a flu vaccine. And you know there's different variability of what's available in your community. The most important thing is that you get vaccinated against the flu. So if we can go to the next slide now. I think that I can't underline the message any more eloquently than we already heard, but influenza is not just the flu, influenza can be very serious. And flu vaccination is the first and best way to protect yourself and others against the flu. The timing of when flu happens is unpredictable. Flu seasons can begin as early as October, and I know I have been hearing already in our community that there are children in our elementary schools that have flu. And so we are certainly seeing flu already. But it can last as late as May and it usually peaks sometime in January or after. So really the best time to get vaccinated against the flu is now, is to get vaccinated right away, because we do know that it takes two weeks after vaccination for that protection to be there, and so the earlier the better. And we know that flu vaccination can reduce flu illness. It also can reduce flu visits, missed work due to flu as well as hospitalizations and deaths that are associated with flu illness. You can go to the next, so just talking about some of these special groups and the vaccine messages for these different groups. Pregnant women are recommended to get the flu vaccine. We know that flu is more likely to cause severe illness in pregnant women than women who are not pregnant. And we know also that the flu shot has been given to millions of pregnant women over many years and it's a safe way to protect both the mom and her unborn child from serious illness and complications of flu. We know that giving that flu shot in pregnancy likely as heard can protect the mother, but also her baby up to six months of age. And just a reminder the nasal spray vaccine shouldn't be given to women that are pregnant. The next slide. And in thinking about children who are under six months of age they are not able to get the flu vaccine so it's very important that those caregivers around them and those close contacts around them, I think it's important to make sure that childcare centers and childcare providers have a flu vaccination policy and that childcare providers also get vaccinated. So in essence we need to just make sure that all of those people around that child, that infant are also vaccinated to protect them. And then finally caregivers and parents of young children, so this is the message that children six months to five years of age are at higher risk also for flu complications as well as these other groups we've been talking about. And it's especially important that these children get a yearly flu vaccination. If a child is six months to eight years old and they're being vaccinated for the first time they will need two doses. And these doses need to be 28 days apart. There is not a lot of protection from that first vaccination when the children need the two doses, so it's very important that they get that second dose and that it's 28 days after the first dose because the first dose is what we call, it primes the immune system, it gets that immune system ready and then that second dose is what is actually providing that protection. So it's very important that those children six months to eight years get the two doses. And then all other children should be getting that one dose of the flu vaccine every year. So if we move to the next slide. This is just a reminder for everybody that while we are pushing flu vaccination now and we'll continue to throughout the influenza season there is a national influenza vaccination week or NIVW and that will be December 8th through the 14th. And this is to continue to promote vaccination in the flu season, like I said it's never too late to get the flu vaccine, but get it now. So this helps. This campaign really helps to keep promoting vaccination through flu season. And you'll see a link to some specific tools that have been created that encourage flu vaccination during this week and you can also see sort of what activities are going out throughout the United States about this campaign. So if you have any questions you can direct them to the flu inbox at CDC.gov and we are happy to answer those questions. It may be me, it may be another flu expert here at CDC. And I encourage you also to go to the CDC website, www.cdc.gov/flu. And also follow us on Twitter @ CDC flu. And we'll continue to promote flu vaccination and give information about flu through those different venues. So thank you for having me today and thanks once again Julie for sharing your story because I think what you're doing is so important and we want to make sure that it doesn't happen. Thank you. MODERATOR: Thank you, Dr. Peacock. And just as a reminder to our attendees today these slides will be available after our briefing, so if you didn't get any of the contact information down you'll have that accessible to you in a PDF this afternoon. So our next speaker is Dr. Siobhan Dolan. She's Professor of Clinical Obstetrics and Gynecology at Women's Health at the Albert Einstein College of Medicine and an Attending Physician in the Division of Reproductive Genetics at Montefiore Medical Center, the University Hospital for Einstein in New York City. Trained as an obstetrician gynecologist and clinical geneticist Dr. Dolan also serves as a medical advisor to March of Dimes. She's also on the faculty of the Human Genetics Program at Sarah Lawrence College in Bronxville, New York, and maintains her clinical practice serving women and families in the Bronx. Her research interests focus on the integration of genetics into maternal child health, specifically looking at ways to apply advances in genetics and genomics to prevent birth defects and preterm birth. Dr. Dolan thanks for being here. DR. DOLAN: Thank you so much for having me, I'm delighted to be with this esteemed panel today. And what I'd like to do in the next few minutes I think is revisit some topics that were raised but just get into a little more detail with a little more data to try to flesh out these issues. And again I'm happy to then answer questions at the question and answer period. The first issue I wanted to raise is the question of risks and benefits of flu itself, getting the flu versus getting the flu vaccine and sort of what a challenging issue that has been for pregnant women and even the clinicians and the public at large. And I think what we have seen over the past even five years is a change in perception, a very good change in perception with a better understanding of the data and the previous sort of misinformed thinking was that somehow vaccination during pregnancy was risky and really there is no data to support that, but I think that perception was out there and that somehow getting the flu was sort of not such a big deal. And I again want to thank Julie for sharing her story and I think sort of Julie's perception of that this was just the flu kind of echoes that sentiment that's really out there in the public that the flu is something, it comes, it goes, it's not a big deal. So we had this situation where people thought wow, getting vaccinated while you're pregnant is risky and getting the flu is not such a big deal. Well, I think the data you know very clearly and quite definitively shows just the opposite. And I think that's one thing that a lot of the activities around the 2009 H1N1 influenza epidemic really gave folks the opportunity with leadership from CDC and many of those on this call the opportunity arose to really look at the data. And what the data showed us is that you know what being pregnant and getting the flu was quite a risky situation. And what we learned from that 2009 H1N1 reporting was that pregnant women were more than four times as likely to be hospitalized from influenza as compared to their non-pregnant colleagues. In addition in that season five percent of flu related deaths reported to the CDC were among pregnant women, even though this age group were only about one percent of the general population. And so what we really learned was that you know what during pregnancy your heart's already working harder to pump the blood volume around, your lungs are working harder to keep your body oxygenated and your immune system has some changes that are adaptive to carrying a pregnancy. But in that setting flu is a very serious illness and it can lead to hospitalization, intensive care unit admission and death. And so the awareness of the risks of flu during pregnancy became very real to folks. And I think at the same time what we became aware of is that women did not suffer adverse consequences from getting the flu vaccine and in fact the flu vaccine is safe and effective. And so I think the good news in 2013, and I'm delighted to be part of sharing it, is that the risk benefit equation looks quite different, and there's a very strong push from all the organizations that pregnant women should be vaccinated. And I think that messages like today's broadcast give us the opportunity to present that data and the data behind the message. Next slide, please. Another issue that we learned and this picture shows it, is that the flu vaccine is not just a good idea for mom, because mom will not be as likely to get the flu, but also it's a way to give immunity to the newborn so that the newborn who during the first six months of life is too young to be vaccinated, but yet is susceptible to flu. It's actually, vaccinating a pregnant mom is a way to get passive immunity to the baby in utero, so that when the baby is born in that first six month window it can benefit, the child can benefit from the immunity of their mother. So this is really interesting data that came out of a study in Bangladesh and it showed about a one-third reduction in respiratory illness with fever among infants whose mom had been vaccinated while they're pregnant and then also a reduction in confirmed cases of influenza. And so this strategy that we're helping not just mom but baby as well is really been effective and has actually been carried over into some other conditions like pertussis and places where we're trying to figure out how to protect newborns, those precious newborns. Next slide. Thank You. So here is a recommendation from the American Congress of Obstetricians and Gynecologists with a little script of what can be said. And I think we have to realize that in changing public awareness we have to educate moms, educate the public and educate clinicians. And so we want to give clinicians the data and then a way to present this to their patients. So here's the script and I'll just read it briefly. I strongly recommend you get the flu shot today. And actually lots of studies show that a physician's recommendation makes a big difference for moms in terms of following health care recommendations. So a very straightforward recommendation is an important way to start the conversation. You could go onto say as a clinician I offer the influenza vaccine to all of my pregnant patients and to women considering becoming pregnant. The vaccine is safe and effective for pregnant women. And again a very clear message and I think that's important. Then to go on with some of the supporting data, which I just illustrated, the risks of getting sick with the flu are far greater for a pregnant woman and her baby than the possibility of having a complication from the vaccine. The flu shot will protect you, as well as your baby in the first six months of life from getting the flu. Your family members who have contact with your newborn should also be vaccinated. Next slide. So this is just a very, very clear cut message to reassure women that the flu shot is safe and effective. Now I just want to reiterate one point that one of my colleagues raised, but just to point out again that the inactivated influenza vaccine, the shot, quote unquote, is what is recommended for pregnant women. The nasal spray is a live attenuated influenza vaccine and while it has not been demonstrated to have huge risks there's theoretic risks and so as a result because it's a live attenuated vaccine it is not recommended for pregnant women. So pregnant women are advised to get the shot and that's a safe way to go. The other issue I just wanted to raise in the last minute or two is the importance of early treatment of pregnant women with influenza like illness. And there are medications available at this time of year in particular, which is important to have early identification of women that are ill with the flu especially pregnant women, and then assessment, triage and early treatment to improve their outcomes. So again we're educating clinicians about an algorithm for triage, assessment and treatment of pregnant women. But the message is identify early and treat, because certainly pregnancies will be better off if moms are healthy. Next slide. Thank you and I'm happy to answer any questions at the question and answer session. MODERATOR: Thank you Dr. Dolan. Amy Pirretti is our final speaker today. Amy has over a decade of experience directing large scale multisite and stakeholder federal agreements related to maternal and child health. Currently she works with leading experts on maternal and child mobile health and serves as the Clinical Quality Director for Text4Baby. The National Healthy Mothers Healthy Babies Coalition is a programmatic host of Text4Baby. Healthy Mothers, Healthy Babies expertise was particularly helpful in the development of accurate and relevant content for the Text4Baby messages, which are designed to help pregnant women and new moms. Amy is considered an expert in pediatric preventative healthcare and regularly publishes with the nation's top pediatric experts. She is a doctoral candidate in human development and family studies at Penn State where she previously directed a multistate project looking at how developmental trajectories influence school readiness. So Amy thanks for joining. AMY PIRRETTI: Thank you. So again I'd like to echo my fellow panelists sentiments that Julie your story was highly motivating and I think we have taken both the words of mothers as well as some of my additional esteemed colleagues on this panel. And our view within Text4Baby is really trying to operationalize these to our mothers enrolled in our program. So Text4Baby is a free mobile health information service directly aimed at pregnant women and mothers of infants up to age one. Just a little bit of background on the program. It is housed within the National Healthy Mothers Healthy Babies Coalition and women sign up for Text4Baby by texting baby or bebe to 511411. When they do this they receive three personalized text messages every Monday, Wednesday and Friday at noon and that's timed to their due date and then to their baby's birthdate up until their baby turns age one. Text4Baby provides personalized messages and we also have a host of interactive features of which one I will highlight today related to influenza. And these cover everything from prenatal visits to developmental milestones, immunization, oral health and more. Today Text4Baby is the largest mobile health initiative in the nation and we have reached over 644,000 moms since our launch in February of 2010. We wouldn't be able to do it without this massive public/private partnership of which everyone on the phone is actually involved with. But the programmatic host is the National Healthy Mothers Healthy Babies Coalition. Voxiva provides all of the technology and platform. Our founding sponsor is Johnson and Johnson. And the Wireless Foundation have pulled together all the leading mobile operators to provide the service to mothers for free. So this is an important point that this programmatic effort is actually free to the mothers in that there are no text messages charged from any of their data plans and that is actually possible because of the Wireless Foundation and their advocacy. And then the Department of Health and Human Services, CDC has been a fantastic partner and continues to be a fantastic partner along with the March of Dimes and other leading medical organizations to make sure that our content is up to date and can help as many mothers as possible. And then we have over 1,000 outreach partners at the state and local level that range anywhere from health plans to local fire departments. Next slide, please. So today I really want to talk a little bit about how we've operationalized some of the information that's been in recommendations set forth from the CDC, the American Congress of Obstetricians and Gynecologists, certainly reinforced by the March of Dimes and the American Academy of Pediatrics and have really conceptualized that into a mobile health intervention directed at mothers and then has pregnant mothers and then has also as you'll see across time reached out to mothers with infants over the age of six months. So what I'll be presenting is a little bit of our iterative history of how we have done our flu module and how we have conceptualized it and how and where our messaging has evolved to. So in 2011 that was our first initiation of the Text4Baby Flu Module. We were really testing out the mobile health capacity and interactivity of text reminders to make an influence in a flu shot initiation within our users. So we wanted to gather insights about barriers that our pregnant moms perceived related to obtaining flu shots, test their openness to text reminders and then just determine the self-reported influence of coverage among our Text4Baby users. So what we found were a couple of things. One, mobile health we can ask a question as you see here on this little phone right here, flu season is here, are you planning to get your flu shot? Within I'd say about six hours we were able to send this out to 96,000 users and we had a 30 percent response rate right away. So both the service, this shows us that the service, that our moms are interested and that in answering questions like this that are primed around flu season and we can reach a large number of women during that time. We did obviously go ahead and provide some education if they stated they were not interested in receiving the flu shot, and I'll go through that a little bit more in depth in some future slides. And then we asked a follow up survey after that education if they did end up getting the flu shots and 14 percent said that they did end up getting that flu shot. Now obviously there is no causality determined; I am just presenting these results in a descriptive format. Next slide, please. So in 2012 our flu module goals became a little bit more evolved. We wanted to roll this out to all of our Text4Baby users. We wanted to see how useful the tool was to increase flu vaccination rates, again to look at the intention of vaccination during the flu season and to address some specific barriers. We built out the reminder functionality a little bit more to address the forgetting and the getting busy that can certainly happen during pregnancy and infancy. We address specific cost based issues and health concerns such as the safety and efficacy of the vaccination that Dr. Dolan highlighted so well previously. So in the next slide you'll see the specific pathways that a mom entered within our mobile health intervention. So how this works is that on a specific date and we do it May to October, so typically on or around October 15th we send out a message that says flu season is here and we're checking in with moms. Are you planning on getting the flu shot this year? If they are, we obviously encourage them to keep that up. And you know we do provide some additional information about reminders and how to utilize our reminder function. They can opt in for a general reminder, which is just that we will prompt them and send a text message back in two weeks or four weeks to remind them to get the flu shot. Or they can actually enter any specific reminder which is I'm seeing Dr. Dolan on October 31st at two pm. So we also ask within that many women have got the shot. And that's what you're seeing in the blue bar across there. And then for those folks that were not planning on getting the shot, we provide some additional tailored education and intervention. So they were able to, the responses could be I think it may give me the flu, the cost issues are there for me and my family, I don't think it's safe and I do not need a shot. And so we provide that tailor education and then again they move through the reminder protocol. What you're seeing in the light purple is that we actually had a control group that we initiated within this. And so that is our flu model kind of responsivity and the pathways for our module. Currently the 2012 results analyses are complete and we're moving it towards publication. So I can't share the in-depth results at this time. But they are very favorable. So moving into 2013, our goals here were again to send some timely messages and reminders that have been proven effective during previous flue seasons, specifically the reminder functionality as well as moving forward with addressing the cost barriers. To address this fully we partnered with Rite Aid who generously offered to give our Text4Baby users in Rite Aid localities up to 10,000 free flu shots. So this is a new addition in 2013 to also understand via mobile health how effective coupon codes can be for providing and motivating pregnant women and mothers with infants to get the free flu shots. We also built the module so that the timing works to get flu shot prevalence data for our mothers that is analogous to CDC's November and April data collection. And then we also plan to get consent around qualitative feedback for why moms are not getting the flu shots, so we can inform our additional modules. So some general results; this is the flow I should say for 2013. Again it's just we are now to the point where we're again reminding everyone six months and older to get the flu shot. We're also providing information this year on the coupon codes. Rite Aid agrees that both pregnant women and women of infants could utilize the coupon codes for the free flu shot and we also have specific messaging going out, related to infants around the flu shots. And again we have built in general reminders as well as specific reminders and added in the prevalence data checking into see who did actually get the flu shot both in November and April related to the overarching timing that the CDC has set forth for data collection around this. So the next slide provides a little bit more information about our partnership with Rite Aid. And so on October 15th again in the localities where Rite Aid is present we sent the information out to moms where they specifically had to request a coupon code. And what we've seen within the first two weeks with that almost 1,400 women had redeemed their codes for a free flu shot. So we're seeing, it's roughly about ten working days, 1,371 moms had redeemed their codes. We also have additional messaging going out this season. The prevalence questions actually are going out right now for that initial prevalence question and we plan on December 9th again sending out more coupon codes. The way that it works within our mobile health intervention is that month by month as new users enroll we send out that flu messaging protocol that you've seen here today. So what that essentially means is that we send out about 632 messages over the course of flu season to moms that are broken down into about I want say anywhere from 1,000 to 2,000 kind of increments. So we continue to do this throughout flu season and as you can see here I've just provided a couple of illustrative quotes here directly from our mothers on the importance of this year's partnership around providing free coupon codes and how that has motivated them. So with that said, I'll pause there and I'm absolutely available for any additional questions. MODERATOR: Fantastic, thank you Amy and thank you to all four of our speakers. Now I'd like to open it up to questions from our attendees. One question that I often hear is, and this might be a question for Dr. Peacock and Dr. Dolan is you know there a better time of year to get the flu shot than another? And Dr. Peacock I think you touched on this, but if you want to elaborate how to answer that question best, I'd love to hear more. DR. PEACOCK: I think as soon as the flu vaccine is available in your community, which starts happening sort of around September is a fine time to get the flu vaccine and then you know they continue to be available throughout the flu season. But again there is no need to wait, so going ahead and getting that early is important just because when flu peaks and when we see flu in communities can be very variable, so it's important to get it as soon as it's available. MODERATOR:Thanks. We have another question coming in from one of our attendees for you Dr. Peacock. Do we have any data or idea how well matched the flu vaccine is to the flu strains in the community this season? DR. PEACOCK: It's probably too early to tell yet, but so far it looks like the match is quite good. One way to monitor that sort of on a weekly basis is to go to the flu website, so it's www.cdc.gov/flu. And there is something called flu view and you can see where you're seeing more flu in communities. And you can also see the strains that are being tested and which strains are predominant. I actually went on it just before this talk and saw that in the flu positive tests that are coming in right now to the CDC the predominant strain is the H1N1. Though that can change obviously throughout the season, but right now a lot of it is that Influenza A H1N1. MODERATOR: Great. And another question for any of our speakers, likely Dr. Peacock or Dr. Dolan, is it safe for pregnant women to get their flu shot at any point of pregnancy? DR. DOLAN: Yes, the recommendation is during any trimester of pregnancy there is a sort of general principle in obstetrics and prevention of birth defects that the first trimester when organs are forming in a fetus we try to limit any kind of exposure, so that's a general principle. But with that said there is no demonstrated data that the flu vaccine causes any birth defects. So that idea of a first trimester window is not an issue in flu vaccine and any trimester any pregnant woman should get the flu vaccine. MODERATOR: Great. Thank you. Do our attendees have any other questions at this time or our speakers questions for each other? DR. DOLAN: This is Siobhan Dolan. I had a question regarding the coupons. Do you think there was real financial barriers for women or do you know it just sort of gave them the extra motivation, the coupon code? Because the coupons were a great idea, I wonder what was really behind why they were so successful. AMY PIRRETTI: So for our particular population which is definitely underserved, so it's roughly 50 percent Medicaid cost is the most commonly cited barrier for our particular population. Now with that being said, there are certainly a lot of programs at the local level that we would have thought would have cut through some of those issues. However, the perception is still there. So again that was one of the reasons why we wanted to test this out in 2013 was to see if that was helpful. DR. DOLAN: That's great. Thank you. AMY PIRRETTI: No problem. MODERATOR: Great. Well, let me pull up this slide and if there are any other questions while I'm wrapping up here, feel free to jump in. But I just wanted to reiterate one last time that we will be sharing the slides and bios of our speakers this afternoon. If you weren't contacted by myself or my colleague Adam Finch, feel free to email me directly or the person that you have been in contact with to ensure that you do get the follow up information. Likewise feel free to email me directly. My email is at the top of the screen there Julieyeagan@westat.com if you have any follow up questions and I'll be sure to get your question in front of the right speaker. I did just notice one other question come in for Amy. The Text4Baby program sounds amazing, I write the cold and flu site for about.com, this is from Kristina Duda, and would love to feature it there. Do you have any restrictions currently for enrolling in the program? AMY PIRRETTI: Restrictions for enrollment into Text4Baby? MODERATOR: Correct. AMY PIRRETTI: No, actually anyone can enroll in Text4Baby. The three kind of data points that we collect are if you're a mother, if you're an observer or if you're a grandparent or father/partner, the zip code that you're located within and if you want free messaging around pregnancy or infancy. So there are no restrictions and those are the data points that we collect just to track over time. So I'm happy to link you with our communications person and we would love to be featured. MODERATOR: Fantastic. Kristina we'll make sure that you get the contact information that you need in case you have follow up questions about that. So thank you to all of our speakers and to the attendees for joining today's flu briefing. We hope that you heard valuable information that you can use on your website, blog, website, newsletters, social media channel, etc. just to help us spread the word about the importance of flu vaccination. So again any questions feel free to reach out and thanks again for your time. MODERATOR: This concludes the November 20, 2013 webinar briefing recording on Protecting Pregnant Women and Young Children from Influenza. For more information, visit www.cdc.gov/flu or one of CDC's pages dedicated to pregnant women, family members, and children shown here on the screen. For questions related to this recording, please email fluinbox@cdc.gov.