Years later, as a teratogen information specialist for MotherToBaby, I realized some of the best gifts for a healthy pregnancy didn’t come with ribbons and bows, but from awareness and education! For example, did you know the holiday buffet table could include foods that could potentially cause harm to a developing baby? Or, if not careful, decorating could put a pregnant person in a dangerous situation? Today I encourage pregnant people to master must-know safety tips long before putting together must-have gift lists this season. Here are a few of my tips:

Tip 1. Importance of Getting Vaccinated

It is recommended that pregnant people have a flu vaccine in every pregnancy and be current on Tdap vaccine and Covid 19 vaccines.  People who are 32-36 weeks pregnant are currently eligible for the RSV vaccine https://mothertobaby.org/fact-sheets/rsv-vaccine/. This vaccine can pass protection to the developing baby, helping lower the chance of severe RSV infection once the baby is born.  

Not only should a pregnant person be up-to-date on vaccines, but  anyone older than 6 months of age who will be around a newborn should be vaccinated.

Tip 2. Choose Wisely at the Buffet Table

Drinks like eggnog and spiced cider may contain alcohol https://mothertobaby.org/fact-sheets/alcohol-pregnancy. If you’re not sure what’s s in a beverage, ask the host. Also, avoid soft cheeses made from unpasteurized milk, as they may contain bacteria that can cause a serious illness for a developing baby called Listeria https://mothertobaby.org/fact-sheets/listeriosis-pregnancy, as well as increased risk of miscarriage, uterine infection, or premature labor. Meats like cocktail franks and pâté can also contain bacteria. Meats need to be thoroughly cooked so that bacteria are killed.

Tip 3. CMV (cytomegalovirus) May Be Lurking

CMV is a common virus that often has no symptoms. If a pregnant person gets CMV https://mothertobaby.org/fact-sheets/cytomegalovirus-cmv-pregnancy, the baby could be at increased risk for hearing loss, developmental delays, or birth defects. To prevent infection, pregnant people should wash hands after changing diapers, feeding children, wiping children’s noses, or handling children’s toys. Also, avoid sharing food, eating utensils, toothbrushes, and pacifiers with children.

Tip 4. Holiday Decoration Safety

Some artificial trees, strings of lights, and ornaments may contain lead. Use gloves or wash hands after handling decorations to reduce exposure. Because of changes in their center of gravity, pregnant people should stay off ladders and let others decorate the hard-to-reach places.

Tip 5. Manage Anxiety and Depression

Having a ‘happy holiday’ can mean lots of stress, especially when pregnant.  Anxiety https://mothertobaby.org/fact-sheets/anxiety-fact to have that perfect holiday is real. Depression https://mothertobaby.org/fact-sheets/depression-pregnancy can be triggered this time of year as well.  Don’t hesitate to ask for help if you are feeling overwhelmed with all the gift giving and holiday activities.  Stay in-touch with your healthcare providers because…. help is available!

I hope these tips are helpful. While my son did end up turning out to be just fine, I think I would have caused myself less stress and worry had I known these tips during my pregnancy. If you have questions, don’t hesitate to reach out to MotherToBaby by phone, text, chat or email.

On behalf of all of us at MotherToBaby, here’s to wishing you a happy and healthy holiday!

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Melissa is not alone. Many people contact MotherToBaby to find the most up-to-date information about vaccines during pregnancy. Protecting yourself from circulating viruses can also help protect your developing baby. Infections such as influenza, pertussis, rubella, chicken pox, and COVID-19 can cause serious problems in both a pregnant person and their developing baby.  In light of August being National Immunization Awareness Month (NAIM), let’s navigate through the current recommendations.

Plan to Receive Some Vaccines Prior to Pregnancy

You may have heard there are some vaccines you should not receive during pregnancy. These “live” vaccines are avoided as they are made from viruses or bacteria that have been weakened, but not killed. Due to the small chance that a live vaccine might cause the disease itself, live vaccines are not routinely given to pregnant people.

So how can you protect yourself and your developing baby from viruses like measles, mumps, rubella and chicken pox (varicella) if it is not recommended (also known as contraindicated) to receive the vaccine during pregnancy? Your healthcare provider can take your titers (lab test that measures the antibody levels in the blood) before pregnancy to make sure you have enough antibodies to help protect yourself from these infections during pregnancy. Low titer levels? You can safely receive the necessary live vaccines needed before that positive pregnancy test! Out of an abundance of caution (small possibility of that infection) it is advised to wait at least one month before becoming pregnant after these vaccines. This is just one reason why it is beneficial to have a pre-pregnancy health checkup and to discuss any future conception plans with your provider!

Keep Up with Recommended Vaccines During Pregnancy and Encourage Others to Do So, Too

So, which vaccines should you receive during pregnancy?

The Centers for Disease Control and Prevention (CDC) recommend all people who are pregnant receive the influenza vaccine each year and a Tdap (tetanus diphtheria pertussis) vaccine for each pregnancy, and the most up-to-date COVID vaccine when you are due. These vaccines are not live vaccines and have not been associated with an increased chance for birth defects or pregnancy complications. An exception would be the live attenuated Influenza vaccine which is intranasal (given through the nose).

The flu vaccine usually becomes available in September and is offered throughout flu season. CDC recommends getting a flu vaccine by the end of October despite flu seasons varying in their timing from season to season. This timing helps protect a pregnant woman before flu activity begins to increase. Protection begins about two weeks after you get the flu shot and lasts at least six to eight months. It is necessary to receive the seasonal flu shot each year to be protected in the current flu season. Getting vaccinated during your pregnancy may also help protect your baby from getting sick during the first 6 months of life! This is especially important because infants less than 6 months of age cannot receive the flu vaccine.

“I just had a Tdap vaccine a couple years ago – so I don’t need another one, right?” Melissa asked a very common question we receive regarding the Tdap vaccine during pregnancy. Although this vaccine is recommended for adults every 10 years, for people who are pregnant, receiving the shot in the 3^rd trimester (specifically 27-36 weeks gestation) can help the baby get as many of the mother’s antibodies as possible. After delivery, these antibodies provide some protection against pertussis (a very contagious respiratory infection) until the baby can receive his/her own dTAP vaccine (at 2 months of age). Additionally, if everyone who lives with you and any caregivers get the vaccine, it can lower the chance for the baby to get pertussis.

It is well known that pregnant people are more likely to get very sick from COVID-19 compared to those who are not pregnant. This is why is so important to receive your COVID-19 vaccinations when you are due, anytime during pregnancy, for the best protection against severe illness. CDC recommends one updated (no longer called “booster”) Pfizer-BioNTech or Moderna COVID-19 vaccine to be up-to-date:  https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html.

Pregnant people who receive vaccines can also share their experiences with maternal health researchers, like MotherToBaby. Our studies are published in medical journals and product labels, and can help others like you when navigating vaccine decisions in pregnancy.

There are no Vaccines to Prevent Some Infections

Many people are packing their bags for a getaway during these summer months. If you are considering an upcoming vacation or babymoon, it’s important to protect yourself from viruses and infections with the appropriate vaccines for that area. Where are you headed? Check with your healthcare provider regarding any specific travel vaccines you might need. CDC recommends discussing any travel plans with your provider 4-6 weeks before your trip. Contact MotherToBaby to check the information on any vaccines your healthcare provider recommends.

Zika is a virus that is usually spread by mosquitos. Being infected with the Zika virus during pregnancy is known to increase the risk for serious and lifelong problems for the baby. While there are no current outbreaks of the Zika virus, it can still be circulating in some levels in many countries and there is no vaccine or treatment currently for Zika! The safest approach during pregnancy would be to not travel to areas with any possible level of risk; should you choose to travel, it’s important to protect yourself using the recommended insect repellents among other ways to help reduce risk.

Although masks are no longer required in most public areas, this is still a great way to reduce the risk for infections and illness while around others! Good hand washing, good ventilation, air conditioning, staying outdoors as much as possible, etc. can also be considered.

After chatting with Melissa, she decided to make her appointment for her COVID-19 and Tdap vaccines (you can get them at the same time!) and will go in ASAP when the flu vaccine for this season is available. She felt reassured knowing she had decided to give herself and her developing baby the best protection from these illnesses as possible.  “Thank you for all this info! I just want to make the best choice for me and my baby – I feel so much better.”

Do you have questions about vaccines during pregnancy? Call, chat, text, or email MotherToBaby!

References:

https://mothertobaby.org/fact-sheets/vaccines-pregnancy/

https://mothertobaby.org/pregnancy-studies/

https://www.cdc.gov/vaccines/parents/by-age/pregnancy.html

https://www.cdc.gov/vaccinesafety/concerns/vaccines-during-pregnancy.html

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“I am 20 weeks pregnant…when is it safe to get my flu shot?” The texted question came in to the MotherToBaby texting helpline, and the answer that I texted back was simple – “As soon as possible…it’s safe at any time in pregnancy and really important for you and your baby!”

Once we are into influenza (flu) season (November to March), pregnant women are strongly recommended to get immunized (vaccinated), regardless of how far along they are in their pregnancy. Yet many women delay, and in the end only about 50 percent of pregnant women get their flu shot.

The flu can cause severe illness and even death in pregnant and postpartum women. The flu shot contains an inactivated virus that won’t make you or your baby sick. It is the most effective way to prevent the flu or help you have less severe symptoms if you do get the flu. Currently the nasal-spray flu vaccination is NOT recommended for pregnant women because it contains live attenuated (weakened) virus.

As if the benefits to you from the flu shot aren’t enough, here’s another one: getting vaccinated while you are pregnant can protect your baby from getting the flu after birth! This is because the antibodies that you develop when you get the flu shot get passed to your developing baby during pregnancy and help protect your newborn for the first few months of life.

Here’s another common question that I get about vaccines during pregnancy.

“I received my diphtheria/pertussis/tetanus (Tdap) shot last year. Since I am already immune, why do I have to get it again in my third trimester of pregnancy?”

The third trimester Tdap booster is to help your baby, not you. Diseases like pertussis (whooping cough) can cause serious life-threatening illness in newborns. When a pregnant woman gets a Tdap booster in her third trimester, she mounts a strong antibody response which is passed on to her baby and helps protect the newborn until the baby starts a vaccination series at 2 months of age.

Some pregnant women are worried about whether immunizations will harm their baby. The scares about vaccines being associated with problems like autism have been debunked. Most vaccines are safe for pregnant and breastfeeding women. A few, such as the measles, mumps and rubella (MMR) and chicken pox vaccinations, contain live attenuated virus and are best given when you are not pregnant. The benefits of protection against disease strongly outweigh any potential risk. That’s why Birth Defects Prevention Month’s Tip ❸ is a really important one: Become up-to-date with all vaccines, including the flu shot. Better yet…if you are thinking about getting pregnant, it’s an excellent time to speak with your health care provider to make sure you are current on all of your recommended vaccinations. Remember, a healthy mother is more likely to have a healthy baby!

Are you interested in learning more about vaccinations in pregnancy or while breastfeeding?

Visit the Mother to Baby website and read all of our vaccine-related fact sheets. There is a general fact sheet on all vaccines, and then specific fact sheets on the influenza vaccine and Tdap vaccine (of course!) but also many others like the Measles, Mumps, and Rubella (MMR), HPV, hepatitis A, and chicken pox vaccinations.

Beth Conover, APRN, CGC, is a genetic counselor and pediatric nurse practitioner. She established the Nebraska Teratogen Information Service in 1986, also known as MotherToBaby Nebraska. She was also a founding board member of the Organization of Teratology Information Specialists (OTIS). In her clinical practice, Beth sees patients in General Genetics Clinic, Prenatal Clinic, and the Fetal Alcohol Syndrome Clinic at the University of Nebraska Medical Center. Beth has provided consultation to the FDA and CDC.

About MotherToBaby

MotherToBaby is a service of the Organization of Teratology Information Specialists (OTIS), suggested resources by many agencies including the Centers for Disease Control and Prevention (CDC). If you have questions about exposures during pregnancy and breastfeeding, please call MotherToBaby toll-FREE at 866-626-6847 or try out MotherToBaby’s new text information service by texting questions to (855) 999-3525. You can also visit MotherToBaby.org to browse a library of fact sheets about dozens of viruses, medications, vaccines, alcohol, diseases, or other exposures during pregnancy and breastfeeding or connect with all of our resources by downloading the new MotherToBaby free app, available on Android and iOS markets.

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Reviewed by Elizabeth Salas, MPH

Are you currently pregnant? Are you aware of the risk of pertussis to your baby?

Pertussis, also known as whooping cough, is a serious problem throughout California. Public health officials confirm our state is currently experiencing a pertussis epidemic. In 2010, there were more pertussis cases in California than had been reported in over 60 years with approximately 9,000 cases including 10 infant deaths. In 2014 10,831 cases were reported. The California Department of Public Health (CDPH) January 7, 2015 Pertussis Report states that of the 376 cases requiring hospitalization, 227 (60%) were babies less than 4 months of age. The two deaths reported in 2014 were babies less than 6 weeks of age. Unfortunately, babies are among the most vulnerable, but there are things you can do to protect your baby.

What Every Pregnant Woman Should Know About Pertussis

What is Pertussis?

Pertussis is a bacterial infection caused by the bacterium bordetella pertussis. This germ can be transferred from an infected person to an uninfected person through coughing, sneezing, or having close contact with someone infected. Pertussis is very contagious and can cause serious illness. It can affect any person at any age, but is more commonly reported in infants and the elderly.

At first pertussis may resemble a cold, but the symptoms change over time. Within 1-3 weeks after being infected, the person will have a rapid cough leading to difficulties in breathing. After coughing for seconds to minutes, they will make a “whooping” sound as they try to catch their breath. It can take weeks or even months before a person recovers from this infection. However, this infection may be prevented by vaccinating.

Why is pertussis a concern for newborns?

Newborns are at a higher risk of getting pertussis because their immune systems are weaker and not as capable of fighting off infections. In addition, they cannot receive their first pertussis vaccine until they are at least 6 weeks of age. Newborns infected with pertussis are at risk of being hospitalized, depending on the severity of the illness and can experience life-threatening symptoms. According to the CDC, in babies who are hospitalized for pertussis, studies suggest that 1 in 4 of these babies get pneumonia, 2 in 3 will experience apnea (slowed or stopped breathing), 1-2 per 100 will have convulsions, 1 in 300 experience encephalopathy (disease of the brain), and 1-2 per 100 babies hospitalized will die.

What can a pregnant woman do to protect her newborn?

Vaccinating during pregnancy is the best tool we have to protect moms and babies against pertussis. When mom receives the vaccine during pregnancy, it provides protection for the newborn. Mom can transfer protective antibodies (proteins that protect against pertussis) to the baby during pregnancy, which helps protect the newborn in the first 6-8 weeks when they are too young to get vaccinated. This vaccine will also help the mother by keeping her healthy and decreasing the chances of her spreading pertussis to her infant. It is important to get vaccinated during every pregnancy because over time levels of antibodies will start to decrease. In order to transfer the highest levels of antibodies to your baby, vaccination late in pregnancy is ideal.

It is also very important that new moms vaccinate their newborns against pertussis at 6-8 weeks rather than delaying vaccination. The longer mom waits to vaccinate, the longer her baby is vulnerable.

Is this vaccine safe during pregnancy?

The Tdap vaccine is an inactivated vaccine. This means the vaccine is made of particles of killed bacteria. It does not contain a live virus. There is no risk of contracting the infection from the vaccine, unlike vaccines that contain live viruses or bacteria. Currently the published information on vaccination against pertussis in pregnancy has not found an increased risk for problems in pregnancy or for the newborn. In every pregnancy, there is a 3-5% chance of having a baby with a birth defect regardless of exposures in pregnancy. This is known as the background risk. Vaccination against pertussis during pregnancy has not been shown to increase the risk of birth defects above the background risk that already exists in every pregnancy.

In 2011, the Centers for Disease Control and Prevention recommended the pertussis vaccine for pregnant women. The update in October of 2012, recommended that pregnant women, regardless of vaccination history, should receive the Tdap vaccine in every pregnancy. The optimal time to administer the vaccine is between 27-36 weeks gestation to maximize benefits to mom and baby. The American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice also supports the recommendations.

What can family and friends do to help protect a newborn?

Staying up to date with pertussis vaccination is important, especially since adults may not know they are infected or may confuse pertussis with a common cold. “Cocooning” is a strategy recommended to protect the newborn. “Cocooning” refers to the vaccination of those who will be in close contact with the baby (dad, siblings, grandparents, and caretakers) in order to reduce the chance baby will be exposed to pertussis. Newborns are more likely to get pertussis from a family member or by having close contact with an infected person, especially when that person has not been vaccinated. Anyone not up to date with pertussis vaccines should be vaccinated at least 2 weeks before coming in contact with the infant to ensure their bodies have had enough time to develop immunity.

The Bottom Line for Expecting Moms and Their Families

Getting the vaccine does not necessarily mean that you or your baby are not at risk of being infected. While adults, who have been vaccinated, can still get pertussis, the infection is usually less severe. Vaccinating can reduce the chances you and your baby will get pertussis. Contact your doctor for more information about getting vaccinated. According to the Immunization Branch of the CDPH, even a single dose of the DTaPvaccine may provide some protection against severe pertussis disease in babies.

Elizabeth Salas is the Lead Teratology Information Specialist for MotherToBaby California, a non-profit that provides information to healthcare providers and the general public about medications and more during pregnancy and breastfeeding. She is based at the University of California, San Diego, and is passionate about the work MotherToBaby is doing to promote healthy moms, healthy pregnancies and healthy babies.

Download the Tetanus, diphtheria and pertussis and Tdap Vaccine and Pregnancy fact sheet and other fact sheets by MotherToBaby (also available in Spanish) at

http://www.mothertobabyca.org/resources/fact-sheets/

For the latest information on pertussis in California, visit the California Department of Public Health Pertussis Summary Reports at http://www.cdph.ca.gov/programs/immunize/Pages/PertussisSummaryReports.aspx

Additional information about pertussis is available at the following Centers for Disease Control and Prevention link at http://www.cdc.gov/pertussis/materials/pregnant.html

References:

1. Committee Opinion Number 566 June 2013, The American College of Obstetricians and Gynecologists, Committee on Obstetric Practice. Web. 21 January 2015. <http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Update-on-Immunization-and-Pregnancy-Tetanus-Diphtheria-and-Pertussis-Vaccination>
2. “Pertussis Summary Report 2015-1-7.” California Department of Public Health, Pertussis Summary Reports, 7 January 2015. Web. 21 January 2015. <http://www.cdph.ca.gov/programs/immunize/Pages/PertussisSummaryReports.aspx>
3. “Pertussis (Whooping Cough).” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 15 Jan. 2013. Web. 04 June 2014. <http://www.cdc.gov/pertussis/about/complications.html>.
4. “Prevention.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 13 Feb. 2014. Web. 04 June 2014. <http://www.cdc.gov/pertussis/about/prevention/index.html>.
5. “Protect Babies from Whooping Cough (Pertussis).” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 10 Feb. 2014. Web. 04 June 2014. <http://www.cdc.gov/features/pertussis>.

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“I’m very confused” said the pregnant caller. “I’ve heard different things about whether I should get the vaccine against whooping cough now or after I deliver. Maybe I should just wait?” As a teratogen information specialist who talks to women and health professionals daily regarding the recommended vaccines for pregnancy, it concerns me that pregnant women are not receiving a clear message about the recommendations for vaccination against pertussis during pregnancy. How can pregnant women make informed decisions when they are not getting the correct information?

When it comes to understanding and preventing illness and injury to their children, a parent’s job starts before they hold the baby in their arms and continues for many years afterward. Before birth, parents research toys, car seats, bedding, and a number of other potential threats. High on the radar should also be preventable diseases such as pertussis, which we are hearing about much more frequently these days.

Pertussis, commonly known as “whooping cough,” is a disease caused by a bacteria, bordetella pertussis, that can spread easily through the air in infectious droplets, for example from a cough or sneeze. Although pertussis is not something that most Americans of childbearing age remember from their own childhood, pertussis harmed many children in the years before a vaccine was discovered. In the early 1900’s, 1 out of 10 children with pertussis died. When pertussis became a reportable disease in 1922, more than 100,000 cases of pertussis were reported each year.

Introduced in the late 1940’s, the pertussis vaccine has improved the health of children tremendously. The wide distribution of the vaccine since first developed meant that the numbers of infections (and deaths) from pertussis dropped dramatically. By the 1970’s, vaccination programs had been so successful that U.S. cases totaled only about 1,000 per year. Unfortunately, those historic declines have been reversed and in the past 20 years, we have seen an increase in cases rather than a decline. In 2012, over 48,000 cases of pertussis infection were reported in the U.S. which was a 60-year record high. Experts are trying to understand why the numbers of reported cases have increased. Is it due to a decrease in vaccination of children, or another reason?

Currently the pertussis vaccine comes in two forms – DTaP (Diphtheria Tetanus and Pertussis), which is the vaccine that is given in five doses to infants and children, and Tdap (Tetanus, Diphtheria and Pertussis), which is a vaccine that acts as a booster for adults and pregnant women. DTaP and Tdap are inactive vaccines and there is no chance of “catching” pertussis from the vaccination since neither contains live bacteria. While the earliest pertussis vaccines developed in the 1940’s had risks of injection site reactions such as redness and swelling, the newer forms in use today are purified (acellular) and have fewer reported side effects.

The most successful strategy for preventing pertussis in infants and children is consistent and timely vaccination of all children and adults. The Centers for Disease Control has added to this strategy by recommending that all pregnant women be vaccinated in their third trimester of pregnancy, between 27 and 36 weeks of pregnancy. Studies have shown that when women receive Tdap vaccination during the recommended time period in pregnancy, the newborn baby develops immunity through the mom’s vaccination that lasts for about two months after birth. Newborn infants are particularly vulnerable to pertussis, therefore smart vaccination interventions are needed to curb the risk to the baby.

Results of a randomized, double-blind, placebo controlled clinical trial were published in May of 2014 by Munoz, et al. The trial included 48 pregnant women who received the Tdap vaccine (33) or a placebo (15). All women received either shot at 30-32 weeks of pregnancy. The goal was to evaluate the safety of Tdap for the woman and her pregnancy as well as to determine if the vaccine would interfere with the infant’s response to the DTaP when given later in infancy. The authors found no Tdap related side effects and no other complications for mother or baby during pregnancy. Infants in both groups had similar growth and development, and reassuringly, being exposed to Tdap prior to birth did not interfere with the baby’s immune response to the DTaP series.

August is National Immunization Awareness Month and although immunizations take place daily across the country, having a specific month dedicated to vaccines gives all of us a reason to educate ourselves and others about the importance of timely vaccination and the work that is being done to understand the health benefits and any potential risks from vaccination of any group, including pregnant women. The research published to date on vaccination of pregnant women with Tdap and other vaccines including the flu shot has been reassuring and no adverse effects have been identified for either mom or the baby. Additional studies can contribute to the pool of information that is already available. MotherToBaby is conducting such a study to further understand the effects of Tdap on pregnancy. Click here to learn more.

Preventing pertussis through vaccination is similar to adding safety equipment to a pool that your own children use – as well as any neighbor children that visit. Vaccination with Tdap, particularly if you are pregnant or will be around any children, is key to preventing the damage done by this potentially fatal disease. So, just as you would talk about swimming safety with others, don’t hold your breath about pertussis. It’s air well spent to help us all breathe a bit easier!

Sonia Alvarado is a bilingual (Spanish/English) Senior Teratogen Information Specialist with MotherToBaby California, a non-profit that aims to educate women about medications and more during pregnancy and breastfeeding. Along with answering women’s and health professionals’ questions regarding exposures during pregnancy/breastfeeding via MotherToBaby’s toll-free hotline, email and private chat counseling service, she’s provided educational talks regarding pregnancy health in community clinics and high schools over the past decade.

MotherToBaby is a service of the international Organization of Teratology Information Specialists (OTIS), a suggested resource by many agencies including the Centers for Disease Control and Prevention (CDC). If you have questions about medications, vaccines, beauty products, or other exposures, call MotherToBaby toll-FREE at 866-626-6847 or visit MotherToBaby.org to browse a library of fact sheets and find your nearest affiliate.

References

Clark, Thomas A. (2014). Changing Pertussis Epidemiology: Everything Old is New Again. Journal of Infectious Diseases, 209;978-981. doi:10.1093/infdis/jiu001

Munoz M. Flor, MD, Bond Nanette H. PAC, Maccato Maurizio, MD, et al (2014). Safety and Immunogenity of Tetanus Diphtheria and acellular Pertussis (Tdap) Immunization during pregnancy in Mothers and Infants. JAMA, 311(17), 1760-1769. doi:10.1001/jama.2014.3633

Hirtle, P. B. (2008, July-August). Copyright renewal, copyright restoration, and the difficulty of determining copyright status. D-Lib Magazine, 14(7/8). doi:10.1045/july2008-hirtle

Centers for Disease Control and Prevention, Pertussis (Whooping Cough) http://www.cdc.gov/pertussis/about/index.html

The History of Vaccines, A Project of The College of Physicians of Philadelphia. http://www.historyofvaccines.org/content/articles/pertussis-whooping-cough

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