Maternal immunisation and Tdap vaccination improve survival of newborns in Malaysia

Dear Editor,

I am writing to express my support for the recent news indicating that our Ministry of Health is considering including the 3-in-1 Tetanus-diphtheria-pertussis (Tdap) vaccine in the public vaccination program for expecting mothers, especially with the latest rise in pertussis cases in Malaysia such as in Rompin and Alor Gajah.

As an advocate for maternal immunisation, I am heartened by the fact that the Ministry is looking to take proactive measures to enhance accessibility to relevant preventive measures. These efforts are crucial in reducing the risk of vaccine-preventable diseases in newborns and promoting overall child health in Malaysia.

Despite the significant global progress in reducing childhood mortality since 1990, driven by the United Nations Sustainable Development Goals (SDGs) aiming to eliminate preventable deaths of newborns and children under five by 2030, there has been a slowdown in survival gains since 2010, particularly in neonatal mortality – referring to the death of a newborn within the first 28 days of life.

Approximately 6,400 newborns lose their lives daily, nearly 47 per cent of child deaths under age 5, while in Malaysia, the neonatal mortality rate in 2021 was 4.1 per 1000 live births, slightly higher than 2020's rate of 3.9.

Improving newborn survival is essential, and prioritizing disease prevention becomes crucial when vaccine-preventable infections have been identified as significant contributors to neonatal mortality.

However, a considerable challenge arises to protect infants less than 3 months of age who are too young to be vaccinated from infectious diseases like pertussis without active vaccinations.

Why is maternal immunisation – or vaccination in pregnancy – a public health priority?

To bridge this gap, maternal immunisation emerges as one of the most effective solutions, as this approach is already widely practised in many developed countries and is a proven method to prevent illnesses and save lives.

By receiving vaccinations during pregnancy, a mother can achieve a dual advantage: boosting her own immunity and providing vital protection for her unborn child. The antibodies developed in the mother's body are transmitted to the baby through the placenta, giving essential protection at the time of birth and continuing to shield the child for several months thereafter until the baby receives their own vaccinations.

This unique phenomenon of a single intervention benefiting both the mother and her child is a noteworthy achievement in public health and empowers mothers with valuable protection at a time when she is most needed.

In Malaysia, maternal Tetanus Toxoid (TT) vaccination is included in the public program for pregnant mothers. However, we must always remain vigilant and adapt our strategies to effectively address any emerging cases of vaccine-preventable diseases.

Pertussis (Whooping Cough) – a rising concern impacting newborns and infants

The WHO's Expanded Program on Immunisation has initially reduced global pertussis cases, but the disease is now reemerging due to waning immunity and vaccine refusal or delay. South and Southeast Asia have high neonatal pertussis burdens, with cases increasing in infants under three months, leading to mortality rates of 5.6 per cent to 14.7 per cent in the region and this vulnerable age group faces a higher likelihood of severe disease and hospitalisation.

In our country, pertussis cases have risen for the last 20 years, with vaccine refusal rates escalating from 600 in 2013 to 1,600 in 2016. Authorities suspect higher actual incidence due to undetected or unreported cases.

The presentation of pertussis in adolescents and adults differs from infants, and the diagnosis is not often made. They are very infectious and can have a significant impact on infants, particularly those who are too young to be vaccinated. As of Aug 19, 2023, there have been 329 cases of pertussis with 23 deaths reported this year nationwide, with 189 (57.4 per cent) of the reported cases involving babies below 12 months. Also, a recent 12-month observation of several hospitals found that 89.3 per cent of confirmed pertussis cases occurred in infants too young to be fully vaccinated or were under-vaccinated for their age.

Such statistics indicate that childhood illnesses like pertussis remain far from eradicated. One must not forget the emotional and financial burden on the parents and families when their newest bundle of joy is severely ill. On-time infant vaccination to prevent vaccine-preventable infectious diseases must be emphasized, and maternal immunisation is an important strategy to reduce the disease burden of infections like pertussis.

Safeguarding our youngest from pertussis

Multiple studies show that passive immunity from maternal immunisation has the highest impact in preventing pertussis in newborns. Despite the potential benefits and WHO's recommendation to consider the Tdap vaccination for pregnant women, many countries in this region continue to recommend the TT vaccine for pregnant women or women of childbearing age. Our neighboring country Singapore has introduced Tdap vaccination for pregnant mothers in their health program, and we should follow a similar step.

In Malaysia, many women are missing maternal vaccinations due to factors such as low awareness, vaccine hesitancy, safety concerns, and financial constraints. The uptake of the Tdap vaccine in Malaysia is mainly in private healthcare and relies on individual doctors' recommendations. I am a strong advocate of vaccine and has incorporated Tdap vaccine for our pregnant mothers to replace the stand-alone TT vaccine since 2021 in Hospital Al-Sultan Abdullah (Hasa) Puncak Alam UiTM. We are the first public hospital that provides the Tdap vaccine on-site, given the proper counseling result in the willingness of mothers to bear the cost of the vaccine.

Vaccine confidence among healthcare providers and the ability to address issues on misinformation and availability of vaccines on-site has a significant impact on improving vaccination rates among pregnant women in Malaysia.

Thus, I urge my peers to actively engage in discussions with their patients and recommend maternal immunisation, thereby raising awareness and fostering acceptance of this life-saving practice, and I firmly appeal to the Ministry to sustain the momentum in reinforcing our maternal immunisation strategy.

By working together to prioritise newborn health, we can address the gap in protection during a baby's early months of life, ultimately moving Malaysia closer to achieving the SDG targets by 2030. It is my sincere hope that we can join forces to create a healthier future for our nation's children.

Professor Dr Jamiyah Hassan is a consultant of Fetomaternal Medicine, Department of Obstetrics and Gynaecology at Hospital Al-Sultan Abdullah UiTM Puncak Alam.

The views expressed in this article are the author's own and do not necessarily reflect those of Sinar Daily.