From pregnancy to protection: advancing the intersection between antenatal care and immunization

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By: Cyril Engmann, member of AMI’s Strategic Leadership Team and Program Lead for Maternal, Newborn, Child Health, and Nutrition at PATH; Jessica Fleming, Director of AMI and Maternal Immunization Delivery Lead for PATH


RSV maternal immunization, if successful, could empower women to protect themselves and their babies from a common cause of lower respiratory infection. PHOTO: PATH/Cuong Nguyen Phu

Every mother has the right see her baby survive and thrive, but infant health and survival has been slower to improve than for older age groups. Projections indicate that, of the estimated 60 million child deaths before age five between 2017 and 2030, the majority will be clustered in sub-Saharan Africa and South Asia and will occur in the first year of life—mostly due to preventable causes[1]. Among these causes are diseases that strike fiercely in early infancy, including a widespread, but often under-recognized, cause of severe infant respiratory infections called respiratory syncytial virus (RSV). Too often, threats like these go unchecked. But, what if moms could wield a powerful tool to stop these foes before they strike?

This is possible for some diseases through maternal immunization (MI). By getting vaccinated in pregnancy, mothers can safeguard themselves and their infants in those first, most vulnerable months of life. It is used safely and effectively against tetanus, influenza, and pertussis, but delivery challenges and information gaps prevent MI from being widely available in low- and middle-income countries (LMICs) beyond the success of tetanus prevention. The looming question is how LMICs can improve maternal, newborn, and child health (MNCH) by applying MI more broadly while also adding value—not burden—to antenatal care (ANC) and immunization programs.

A maternal RSV vaccine, which is quickly advancing through clinical trials and could be available as early as 2021, is a natural opportunity for MNCH and immunization programs to come together like never before to answer this question. As a resource, a new RSV MI roadmap published by the Advancing Maternal Immunization (AMI) collaboration convened by PATH and the World Health Organization is now available. It is designed to help researchers, policymakers, funders, health practitioners, advocates, and others gauge when and where to direct their efforts for addressing obstacles inherent to MI introduction in LMICs.

Navigating a way forward against a dangerous, largely unrecognized, disease

 A common and widespread infection, RSV occurs in almost every child by the age of two and leads to more than 30 million childhood infections worldwide every year.[2] In older children and adults, it’s mild,  can be easily confused with the common cold,  and often goes away on its own. However, for infants, early RSV infections combined with tiny airways can lead to deadly complications like lung infection (pneumonia) and inflamed airways (bronchiolitis) that make breathing difficult and potentially deadly. RSV is responsible for at least 1.4 million infant hospitalizations and 120,000 deaths among children under five every year, with nearly all deaths occurring in LMICs and mostly before six months of age. Options for RSV treatment are limited, and caring for infants sick with RSV, whether in the hospital or at home, puts further burden on family livelihoods.

To combat this threat, the AMI RSV MI roadmap (based on a gap analysis published in early 2018) outlines the activities needed to fill critical information gaps for decision-making and move RSV MI from development to delivery in LMICs. The most urgent activities center on assessing RSV MI’s potential health impact and return on investment; supporting vaccine development and licensure; preparing for post-introduction monitoring; developing communications strategies to support awareness and uptake; and ensuring that countries are equipped to deliver the vaccine routinely, efficiently, and equitably once it is available. Linked to the former, perhaps the biggest emphasis overall is on the need to collaborate across maternal health services, particularly ANC and vaccine programs, to determine how delivery could work in different country and service delivery contexts, and even strengthen maternal health and vaccine services overall.

Learning from the past to improve the future

Beyond preventing a dangerous respiratory infection for infants, figuring out how to efficiently, equitably, and reliably deliver RSV MI could strengthen overall healthcare provisions for moms and their infants and lay a foundation for delivering existing and future maternal vaccines (such as for Group B Streptococcus, which is currently in development). Benefits could include leveraging resources to improve ANC and immunization service delivery; encouraging pregnant women to attend more well-care visits; and protecting two populations often underserved in current immunization programs from diseases—pregnant women and young infants. Further, the same surveillance systems for tracking maternal vaccine performance could be leveraged to better monitor pregnancy and other MNCH outcomes.

Despite these possibilities, the road ahead requires venturing into uncharted territory to address remaining questions and challenges. Current maternal and neonatal tetanus elimination efforts have paved part of the way by reaching pregnant women in LMICs through vaccination campaigns and supplementary immunization activities. We must learn from this experience as we explore what adaptions may be necessary to incorporate RSV and other maternal vaccines into routine healthcare.

To give maternal RSV vaccine a chance to pave the way for broader MI, we need to act on the roadmap now to ensure that such a vaccine can be used to the greatest benefit once available. Check out the report to see how you can contribute to advancing the scientific, policy, economic, regulatory, communications, and programmatic activities needed to lay the foundation for RSV MI and other maternal vaccines to come. Working together, we can chart a new course to offer mothers and their babies a better shot at good health.

[1] UNICEF. Progress for Every Child in the SDG Era. New York City: UNICEF; 2018. Available at

[2] Lancet. Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in young children in 2015: a systematic review and modelling study. 2017, Sep 2; 390 (10098):946-958.