Prenatal Immunization Status (PRS-E)

The percentage of deliveries in the measurement period in which pregnant persons received influenza and tetanus, diphtheria and acellular pertussis (Tdap) vaccinations.

Why it Matters

This measure focuses on improving immunization rates for vaccines that pregnant persons should receive to protect themselves and their infants from serious illness and death. This measure is based on the best available evidence which recommends vaccination against influenza and

Studies have found that about half of pregnant persons do not receive the influenza vaccine and/or the Tdap vaccine during pregnancy. A survey conducted by the CDC found that only 47% of persons who were pregnant any time between October 2023 and January 2024 reported receiving the influenza vaccine before or during their pregnancy, while 22% reported not receiving a provider recommendation for the vaccine [8]. In the same survey, almost 60% of persons with a recent live birth reported receiving the Tdap vaccine during pregnancy, and similarly to influenza, 20% of the persons surveyed did not receive a provider recommendation for the vaccine. These rates vary based on race, ethnicity, age, insurance status and adequacy of prenatal care [8].

Note:

Influenza is a serious disease that is characterized by a variety of symptoms related to the nose, throat and lungs that can range in severity and lead to hospitalization and death [9, 10]. Pregnant persons are at higher risk from influenza because changes in physiology and immune function predispose them to severe disease and worse outcomes from infections [11]. A study conducted between 2010 and 2016 revealed that of pregnant persons in the cohort, 10% had a hospitalization that included a diagnosis for pneumonia, 5% had an intensive care unit admission, 2% had a hospitalization that included a diagnosis of sepsis and less than 1% resulted in respiratory failure [12]. During the 2009 Influenza A (H1N1) outbreak, pregnant persons composed 1 percent of the U.S. population but accounted for 5 percent of all Influenza A-related deaths [13]. Pregnant persons have consistently higher rates of hospital admission than nonpregnant women due to serious respiratory illness during influenza season with studies showing approximately 2-4 times higher hospitalization rates among pregnant persons compared with nonpregnant women of reproductive age [14,15]. Infants are also highly susceptible to influenza and as there are no influenza vaccines currently licensed for infants under 6 months of age, the transfer of antibodies from an immunized pregnant person to the fetus is the primary means of protecting infants after birth [16]. If unprotected, infected newborns face a higher risk of developing severe influenza symptoms and complications, including sinus infections, ear infections, pneumococcal disease, myocarditis, encephalitis, sepsis, respiratory failure, kidney failure and death [9, 17]. This risk increases for children with comorbid asthma, neurologic diseases, obesity and cardiovascular disease.

An influenza vaccine during pregnancy significantly reduces the risk of contracting influenza for both mother and the infant following birth [18]. Routine prenatal immunization schedules recommend one annual dose of influenza vaccination for all pregnant individuals [1, 2, 3, 4, 6, 7]. The influenza vaccine is associated with reductions in influenza cases, flu-associated health care utilization, flu-related deaths and missed school and workdays [17]. A 2023 study estimated that the incremental cost-effectiveness ratio of the influenza vaccine was approximately $95,000 per quality-adjusted life year (QALY) for all age and risk groups except for non-high-risk adults 18–49 [19]. A large and growing body of evidence indicates that influenza vaccination during pregnancy is safe, with no increased risk of serious adverse maternal or infant outcomes, including preterm birth, spontaneous abortion, stillbirth or congenital anomalies [20, 21, 22].

Tetanus. The resulting muscle spasms can cause fractures, difficulty breathing, arrhythmia and death [23]. Without intensive care, almost all cases of tetanus are fatal [24]. Diphtheria can present as a respiratory or cutaneous disease [25, 26]. Complications include myocarditis, which can lead to heart failure, and neuritis, which may temporarily paralyze motor nerves. Death occurs in 5%–10% of cases, with a higher mortality rate in young children [26]. Acellular pertussis, also known as whooping cough, is a highly communicable respiratory infection characterized by a prolonged cough [27]. While pertussis is usually mild in children, adolescents and adults, infected infants are more likely to experience severe complications, including apnea, pneumonia, pulmonary hypertension and death. Unvaccinated infants under 6 months account for most pertussis-related hospitalizations and mortality [28].

While there are three combination vaccines (DTaP, Td and Tdap) that offer protection against tetanus, diphtheria and acellular pertussis, only the Tdap vaccine series is recommended for pregnant individuals[1, 2, 3, 4, 6, 7]. The Tdap vaccine is recommended for pregnant individuals because pertussis poses a high risk of serious illness and death to the infants of unvaccinated birthing parents [4]. No Tdap vaccines are currently licensed for infants under 2 months of age; therefore, the transfer of placental pertussis antibodies from an immunized mother to fetus provides short-term protection for the infant until old enough to be immunized [29]. Studies on the prenatal Tdap vaccine indicate that immunizations are between 70 and 90% effective in preventing pertussis in infants [30,31,32]. Related studies conclude that prenatal immunization is more effective than postpartum immunization [33, 34].

This measure was developed with support from the Department of Health and Human Services (DHHS), Office of the Assistant Secretary for Health (OASH), National Vaccine Program Office (NVPO).

Historical Results – National Averages

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References

  1. American Academy of Family Physicians. 2026a. Recommended Adult Immunization Schedule for Ages 19 Years or Older, United States 2026. Immunization Schedule. American Academy of Family Physicians, March 1. https://www.aafp.org/assets/image/upload/v1777392265/nyme0soclvvfkutpwgvh.pdf.
  2. American College of Obstetricians & Gynecologists. 2026. 2026 Maternal Immunization Schedule. Immunization Schedule. American College of Obstetricians & Gynecologists, June 10. https://www.acog.org/-/media/project/acog/acogorg/files/pdfs/programs/immunization/maternal-immunization-schedule.pdf?rev=4b52fc2cc3444d03a9964ab67aa5a7b0&hash=751F4499B1D7C4954A5995052DED3C21.
  3. American Academy of Family Physicians. 2026b. Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger, United States 2026. Immunization Schedule. American Academy of Family Physicians, March 1. https://www.aafp.org/assets/image/upload/v1774979609/bhmf8pcgmuhzn7jcekdd.pdf.
  4. Havers, Fiona P., Pedro L. Moro, Paul Hunter, Susan Hariri, and Henry Bernstein. 2020. “Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines: Updated Recommendations of the Advisory Committee on Immunization Practices — United States, 2019.” MMWR 69 (3): 77–83. https://doi.org/10.15585/mmwr.mm6903a5.
  5. Grohskopf, Lisa A. 2025. “Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2025–26 Influenza Season.” MMWR. Morbidity and Mortality Weekly Report 74. https://doi.org/10.15585/mmwr.mm7432a2.
  6. Issa, Anindita N., Patricia A. Wodi, Charlotte A. Moser, and Sybil Cineas. 2025. “Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger — United States, 2025.” Morbidity and Mortality Weekly Report 74 (2): 26–29. https://doi.org/10.15585/mmwr.mm7402a2.
  7. Wodi, A. Patricia, Anindita N. Issa, Charlotte A. Moser, and Sybil Cineas. 2025. “Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older — United States, 2025.” Morbidity and Mortality Weekly Report 74 (2): 30–33. https://doi.org/10.15585/mmwr.mm7402a3
  8. Kahn, Katherine E., Emma Garacci, Hilda Razzaghi, et al. 2024. “Flu, Tdap, and COVID-19 Vaccination Coverage Among Pregnant Women – United States, April 2024.” FluVaxView, U.S.
  9. S. Centers for Disease Control and Prevention. 2024d. “Signs and Symptoms of Flu.” Influenza (Flu), U.S. Centers for Disease Control and Prevention, August 26. https://www.cdc.gov/flu/signs-symptoms/index.html
  10. S. Centers for Disease Control and Prevention. 2025j. “Key Facts About Seasonal Flu Vaccine.” Influenza (Flu), U.S. Centers for Disease Control and Prevention, September 3. https://www.cdc.gov/flu/vaccines/keyfacts.html.
  11. 2026b. “Recommendations for Obstetric Health Care Providers Related to Use of Antiviral Medications for the Treatment and Prevention of Influenza.” Influenza (Flu), March 23. https://www.cdc.gov/flu/hcp/antivirals/treatment_obstetric.html.
  12. Dawood, Fatimah S., Shikha Garg, Rebecca V. Fink, et al. 2020. “Epidemiology and Clinical Outcomes of Hospitalizations for Acute Respiratory or Febrile Illness and Laboratory-Confirmed Influenza Among Pregnant Women During Six Influenza Seasons, 2010–2016.” The Journal of Infectious Diseases 221 (10): 1703–12. https://doi.org/10.1093/infdis/jiz670.
  13. Siston, Alicia M., Sonja A. Rasmussen, Margaret A. Honein, et al. 2010. “Pandemic 2009 Influenza A(H1N1) Virus Illness Among Pregnant Women in the United States.” JAMA 303 (15): 1517–25. https://doi.org/10.1001/jama.2010.479.
  14. Mertz, Dominik, Johanna Geraci, Judi Winkup, Justin Ortiz, and Mark Loeb. 2015. “Pregnancy as a Risk Factor for Severe Outcomes From Influenza Virus Infection: A Systematic Review and Meta-Analysis of Observational Studies.” Open Forum Infectious Diseases 2 (suppl_1): 1153. https://doi.org/10.1093/ofid/ofv133.865.
  15. Prasad, Namrata, Q. Sue Huang, Tim Wood, et al. 2019. “Influenza-Associated Outcomes Among Pregnant, Postpartum, and Nonpregnant Women of Reproductive Age.” The Journal of Infectious Diseases 219 (12): 1893–903. https://doi.org/10.1093/infdis/jiz035.
  16. Zhong, Z., M. Haltalli, B. Holder, et al. 2018. “The Impact of Timing of Maternal Influenza Immunization on Infant Antibody Levels at Birth.” Clinical & Experimental Immunology 195 (2): 139–52. https://doi.org/10.1111/cei.13234.
  17. S. Centers for Disease Control and Prevention. 2026l. “Flu and Children.” Influenza (Flu), U.S. Centers for Disease Control and Prevention, June 29. https://www.cdc.gov/flu/highrisk/children.html.
  18. Lindley, Megan C., Katherine E. Kahn, Barbara H. Bardenheier, et al. 2019. “Vital Signs: Burden and Prevention of Influenza and Pertussis Among Pregnant Women and Infants — United States.” Morbidity and Mortality Weekly Report 68 (40): 885–92. https://doi.org/10.15585/mmwr.mm6840e1.
  19. Kim DeLuca, Ellen, Acham Gebremariam, Angela Rose, Matthew Biggerstaff, Martin I. Meltzer, and Lisa A. Prosser. 2023. “Cost-Effectiveness of Routine Annual Influenza Vaccination by Age and Risk Status.” Vaccine 41 (29): 4239–48. https://doi.org/10.1016/j.vaccine.2023.04.069.
  20. S. Centers for Disease Control and Prevention. 2024a. “Flu Vaccine Safety and Pregnancy.” Influenza (Flu), U.S. Centers for Disease Control and Prevention, September 17. https://www.cdc.gov/flu/vaccine-safety/vaccine-pregnant.html.
  21. Siu, Winnie, Angela Sinilaite, and Jesse Papenburg. 2024. “Summary of the National Advisory Committee on Immunization (NACI) Updated Guidance on Influenza Vaccination During Pregnancy.” Canada Communicable Disease Report 50 (3/4): 86–92. https://doi.org/10.14745/ccdr.v50i34a01.
  22. Wolfe, Dianna M., Deshayne Fell, Chantelle Garritty, et al. 2023. “Safety of Influenza Vaccination during Pregnancy: A Systematic Review.” BMJ Open 13 (9): e066182. https://doi.org/10.1136/bmjopen-2022-066182.
  23. Hughes, Michelle M. 2024. “Chapter 16: Tetanus.” Manual for the Surveillance of Vaccine-Preventable Diseases, U.S. Centers for Disease Control and Prevention, October 22. https://www.cdc.gov/surv-manual/php/table-of-contents/chapter-16-tetanus.html.
  24. S. Centers for Disease Control and Prevention. 2025e. “Fast Facts: Global Tetanus Vaccination.” Global Tetanus Vaccination, U.S. Centers for Disease Control and Prevention, November 17. https://www.cdc.gov/global-tetanus-vaccination/data-research/index.html.
  25. Pan American Health Organization. 2026. “Diphtheria.” World Health Organization Americas Region, June 15. https://www.paho.org/en/topics/diphtheria
  26. S. Centers for Disease Control and Prevention. 2025c. “Clinical Features of Diphtheria.” Diphtheria, U.S. Centers for Disease Control and Prevention, May 12. https://www.cdc.gov/diphtheria/hcp/clinical-signs/index.html
  27. S. Centers for Disease Control and Prevention. 2026d. “About Whooping Cough.” Whooping Cough (Pertussis), U.S. Centers for Disease Control and Prevention, June 24. https://www.cdc.gov/pertussis/about/index.html.
  28. Vijayan, Vini, and Sharon F. Daley. 2026. “Pertussis.” In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK519008/.
  29. S. Centers for Disease Control and Prevention. 2025l. “Tdap Vaccination for Pregnant Women.” Whooping Cough, U.S. Centers for Disease Control and Prevention, December 2. https://www.cdc.gov/pertussis/vaccines/tdap-vaccination-during-pregnancy.html.
  30. Shi, Qianqian, Jun Li, Quanman Hu, et al. 2025. “Efficacy, Immunogenicity, and Safety of Pertussis Vaccine During Pregnancy: A Meta-Analysis.” Vaccines 13 (7): 666. https://doi.org/10.3390/vaccines13070666.
  31. Regan, Annette K., Hannah C. Moore, Michael J. Binks, et al. 2023. “Maternal Pertussis Vaccination, Infant Immunization, and Risk of Pertussis.” Pediatrics 152 (5): e2023062664. https://doi.org/10.1542/peds.2023-062664.
  32. Kandeil, Walid, Caroline van den Ende, Eveline M. Bunge, Victoria A. Jenkins, Maria Angeles Ceregido, and Adrienne Guignard. 2020. “A Systematic Review of the Burden of Pertussis Disease in Infants and the Effectiveness of Maternal Immunization Against Pertussis.” Expert Review of Vaccines 19 (7): 621–38. https://doi.org/10.1080/14760584.2020.1791092.
  33. S. Centers for Disease Control and Prevention. 2025m. “Vaccinating Pregnant Patients.” Whooping Cough, U.S. Centers for Disease Control and Prevention, December 2. https://www.cdc.gov/pertussis/hcp/vaccine-recommendations/vaccinating-pregnant-patients.html.
  34. Winter, Kathleen, James D. Cherry, and Kathleen Harriman. 2017. “Effectiveness of Prenatal Tetanus, Diphtheria, and Acellular Pertussis Vaccination on Pertussis Severity in Infants.” Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America 64 (1): 9–14. https://doi.org/10.1093/cid/ciw633.

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