Immunity Protection of Pregnant Employees Working in the Healthcare Sector

Abstract

Background

Infectious diseases during pregnancy can pose a serious health risk for mother and child. Employees with an occupational risk of infection are especially at risk. We investigated the immune status of pregnant employees working in the health service to determine the percentage of women who were adequately protected during pregnancy and the percentage of cases with a pregnancy-relevant risk.

Methods

This retrospective data collection was done using the standard records of the Occupational Health Department (Betriebsärztliche Dienststelle) of Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany. The data of employees with a pregnancy reported between 1 May 2018 and 31 May 2020 were collected. This resulted in a total study population of 406 cases. We collected data on the respective occupational groups, occupational risk profile, employment bans for expectant mothers, occupational-medical consultations, and immunity status with regards to measles, mumps, rubella, varicella zoster virus, parvovirus B19, CMV, hepatitis A and B, tetanus, diphtheria, pertussis, and poliomyelitis.

Results

The investigated employees had attended a mean of three previous occupational-medical consultations; 45.8% had received advice about maternity protection from the occupational physician’s office. The immunity rates of the total study population at the time of their last medical consultation prior to their due date varied, depending on the respective disease, from 77.3% (mumps) to 90.9% (varicella zoster virus). 182 cases (44.8%) were prohibited from working during their further pregnancy.

Conclusion

Medical advice on infection risks and immunization combined with the offer of vaccinations are decisive in determining the immune status and ensure that immunizations can be carried out in good time. To achieve full immunization before becoming pregnant, girls and women should be advised early on about preventive maternity protection measures.

Keywords

pregnancy - infections - immunity - occupational medicine - health service - employment ban

Introduction

In the second half of the 20th century, widespread vaccinations led to a decline or even the elimination of many diseases, for example, poliomyelitis, measles, rubella and diphtheria [1] [2] [3] [4]. The legal basis for vaccinations in Germany is set out in the Infection Protection Act. The Standing Committee on Vaccination (STIKO) at the Robert Koch Institute (RKI) issues evidence-based recommendations on vaccinations for the total population and for especially at-risk groups of people and reports on occupationally recommended vaccinations, for example, for the health care sector.

Compared to the general population, medical staff are exposed to higher risks of infection [5] [6] [7]. Therefore, according to the German Ordinance on Preventive Occupational Health Care (Arbeitsmedizinische Vorsorgeverordnung, ArbMedVV), employers are responsible for ensuring that staff working in the health care sector have regular occupational-medical consultations. Attending these medical consultations is an employment requirement for employees working in the health care sector [8]. Employees working in medical facilities where the risk of infection is higher must be sufficiently protected against influenza, measles, mumps, rubella, pertussis, varicella zoster virus, hepatitis A and B and poliomyelitis by having up-to-date vaccinations [9]. In reality, the limited immunity of medical staff against diseases which can be prevented by vaccination does not match the recommendations [10]. Although vaccination coverage against hepatitis B was found to be quite high, coverage against other infections, especially against pertussis and influenza, is inadequate [11]. In Germany, the only currently compulsory vaccination for employees working in the health care sector is against measles (since the Measles Protection Act came into effect in March 2020) [12].

Special protective measures are indispensable to protect mother and child against infections and their possible consequences during the vulnerable stage of a pregnancy. An infection with measles, mumps or the varicella zoster virus during pregnancy can have serious complications or result in the death of the fetus [13]. Especially women working in the health care sector should be vaccinated against these infectious diseases before they become pregnant. As vaccinations against measles, mumps, rubella and the varicella zoster virus are carried out using live vaccines, they are contraindicated during pregnancy [1] [14] [15]. This means that immunity gaps cannot be closed during pregnancy and the consequence of this is that the mother and unborn child are at risk throughout the entire pregnancy.

Our study therefore aimed to record the immunity status of pregnant women working in the health care sector with regards to measles, mumps, rubella, chicken pox, and other preventable infectious diseases. This should allow estimates to be made about how many women could be induced to have vaccinations to close their immunity gaps in good time before the start of any pregnancy by proffering advice and the opportunity to be vaccinated and whether more intensive measures to provide information on infectious diseases and vaccinations against these diseases are needed for women working in the health care sector.

Methods

Study population

This study investigated women working at the university hospital in Erlangen (Universitätsklinikum Erlangen) and Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg for whom a pregnancy was reported to the Section for Occupational Safety of the FAU in the period from 1 May 2018 to 31 May 2020. Only employees who had contacted the Occupational Health Department of FAU Erlangen-Nürnberg at least once in accordance with the ArbMedVV [8] prior to the time of our data collection (08.09.2020–07.10.2020) were included in our study. This resulted in a total study population of 406 cases. 401 women were employed by Universitätsklinikum Erlangen and five by FAU Erlangen-Nürnberg. The majority of the women in our study population worked in health care and nursing (33.5%) and 19.7% were physicians. A further 16.3% were medical assistants (e.g., medical-technical assistants) and 9.1% were academic staff. 7.4% worked as other types of medical professionals (e.g., midwives, physiotherapy); 14.0% were employed as non-medical staff (e.g., social education workers, office clerks). The mean age of the women at their due date was 32.5 years (median age: 32 years, range: 22–44 years; n = 382).

Data collection and analysis

The study is based on information obtained from the Section for Occupational Safety about reported pregnancies and maternity protection in the above-mentioned period and records in the respective personnel files of employees held by the Occupational Health Department. The collected data included age, occupational group, workplace, occupational risk profile, employment bans, previous occupational-medical consultations, and immunity status with regards to measles, mumps, rubella, varicella zoster virus, parvovirus B19, cytomegalovirus (CMV), hepatitis A and B and tetanus, diphtheria, pertussis and poliomyelitis.

The IBM software SPSS Statistics (Statistical Package for the Social Sciences, IBM, Version 28.0.1.0 [142]) was used for data collection and statistical analysis.

The study was approved by the Ethics Commission of FAU Erlangen-Nürnberg (application no. 230_20 Bc).

Occupational-medical consultations

The date and reasons for the first and last (most recent) occupational-medical consultation prior to the due date [8] were determined using the records of the Occupational Health Department, and the interval between the respective medical consultation and the due date was calculated.

The number of medical consultations and number of contacts with the Occupational Health Department in general were also recorded in this context. The number of contacts included appointments which were not consultations, for example, subsequent appointments for vaccinations. Additional recorded data included whether and at which point during the pregnancy the employee attended an advisory appointment about maternity protection in the Occupational Health Department and whether the employer had already been informed about the pregnancy.

Occupational risk profile

The risk of exposure to pregnancy-relevant infectious diseases while at work was also recorded using the records of the Occupational Health Department. Criteria for an increased professional risk of infection included contacts to patients, working in the operating theater or in direct contact with patients during dental work, working in anesthetics or in an intensive care unit, and being in regular contact with children. Three groups were defined in terms of their contacts to children: contacts with children below the age of three, contacts with children of preschool age (between three and six years of age) and contacts with school-age children above the age of six.

Employment ban

Whether it was necessary to impose an employment ban was taken from the records of the Section for Occupational Safety and the Occupational Health Department. We differentiated between fixed-term and indefinite occupational work bans. Fixed-term work bans imposed because of the COVID-19 pandemic were considered separately from March 2020. In addition, medical (individual) work bans, parental leave, and incapacity to work during pregnancy were recorded separately. Retrospectively, it was not possible to determine in individual cases whether an employment ban was (only) imposed because of the risk of infection or whether the ban was (also) necessary because of other hazards in the workplace of the pregnant woman.

Occupational work bans are imposed by the employer and, in accordance with the Maternity Protection Act [16], are always necessary if the occupational activity is judged to constitute an unjustifiable risk for the mother or the unborn child which cannot be eliminated by other protective measures. Medical employment bans are issued by physicians; in addition to the occupational activity, they also take the individual health condition of the pregnant woman into account.

[Table 1] summarizes the different types of exemption from work during pregnancy, lists who is responsible for signing the employee off from work, and what needs to be considered in each case.

Table 1 Exemption from work during pregnancy.

Type of exemption from work	Reasons	Issued by	Examples	Considerations
* Caution: There is a certain scope for interpretation here. According to § 9 (1) of the Maternity Protection Act, “Disadvantages arising from pregnancy […]” must be “avoided or offset”. Accordingly, complaints due to pregnancy would always require a medical employment ban because, if the pregnant woman is deemed to be unable to work, after 6 weeks she will only receive sickness benefits and would therefore be experiencing a financial disadvantage because of her pregnancy.
Occupational employment ban	There is a general risk for all pregnant women at the workplace which cannot be removed by suitable protective measures.	Employer	Unavoidable risk of infection Exposure to ionizing radiation Activities during which lead may be absorbed into the body	A medical evaluation is not required.
Medical (individual) employment ban	There are individual factors affecting the pregnant woman which mean that certain activities in her specific case would result in the health of mother or child being at risk.	Any physician (usually the treating physician, e.g., the pregnant woman’s gynecologist or general practitioner)	Certain smells in the workplace cause vomiting in a pregnant woman who does not otherwise suffer much from morning sickness; High-risk pregnancy with a prior history of several miscarriages	The type, extent, and duration of the restrictions on activities must be clearly recorded. Both complete and partial employment bans are possible (e.g., only for certain activities or time periods). Must be carefully differentiated from an inability to work*
Temporary medical employment ban	From a medical perspective, certain risks for pregnant women may be present at her workplace; however, the employer has not (yet) carried out a risk assessment.	Any physician	Workplace with an occupational risk of infection (e.g., child care, care of patients) and the pregnant woman lacks immune protection (e.g., against rubella, chickenpox, parvovirus B19). Basically, no workplace can completely exclude risks if no risk assessment has been carried out recently by the employer.	Ban is limited until the employer has carried out a risk assessment and implemented the required protective measures (e.g., limited to a period of 2 weeks). The physician must inform the regulatory authorities.
Inability to work	The pregnant woman is suffering from an illness or accident which prevents her from performing her current activities any longer.	Treating physician	Hyperemesis gravidarum* Hypertensive diseases of pregnancy* Acute infections (e.g., influenza, rhinovirus)	Complaints with or without reference to the pregnancy which are illness-related. Must be carefully differentiated from a medical employment ban*

Immunity

The first step taken to evaluate immunity according to the specifications of the STIKO was to look at vaccination passports. If immunity against specific risks was lacking or unclear, assessment of IgG antibody titers was carried out (where appropriate). The assessment criteria for immunity are shown in detail in [Table 2].

Table 2 Assessment criteria of the Occupational Health Department at the IPASUM for an assumption of immune protection.

	Immune protection is present if one of the following criteria has been met:
Measles	2 vaccinations Serological proof of immunity (measles IgG positive) If at least two vaccinations have been reliably recorded, immunity is assumed even if the IgG titer is borderline or negative.
Rubella	2 vaccinations Serological proof of immunity (rubella IgG positive) If at least two vaccinations have been reliably recorded, immunity is assumed even if the IgG titer is borderline or negative.
Varicella zoster virus	2 vaccinations Serological proof of immunity (VZV IgG positive) In accordance with the version of the S2k guideline “Laboratory Diagnostics of Pregnancy-relevant Virus Infections” (issued 03/2014) valid at the time when the study was carried out, a positive history of chicken pox was assessed to be proof of immune protection. The guideline has since been updated (10/2021), and now determination of VZV IgG is recommended as proof of immune protection for all women of child-bearing age who have not been vaccinated twice against VZV [13].
Hepatitis A	2 vaccinations or 3 combination vaccinations Prior history of disease with serological proof of immunity
Hepatitis B	Basic immunization followed by anti-HBs titer > 100 IU/L
Pertussis	1 vaccination within the last 10 years
Mumps	2 vaccinations During the study period, the Occupational Health Department also accepted a positive mumps IgG antibody titer as proof of immunity. This is not in accordance with the current scientific consensus, as there is no cut-off value for mumps IgG which reliably correlates with immune protection [17]. The determination of mumps IgG is therefore not recommended to evaluate immunity to mumps. Since the publication of the updated S2k-guideline “Laboratory Diagnostics of Pregnancy-relevant Virus Infections” (10/2021), mumps is no longer listed as a disease with special relevance for pregnancy [13].

Results

Occupational-medical consultations

Between 1 and 9 occupational-medical consultations were recorded by the Occupational Health Department for evaluated employees, with a mean and a median of 3 visits per pregnant woman. 340 women (84%) had attended occupational-medical consultations at least twice.

On average, the studied employees had attended an occupational checkup appointment at the Occupational Health Department for the first time 7.8 years prior to their due date (median: 7 years, range: 1–22 years; n = 369). For 404/406 employees (99.5%), the first checkup visit was a mandatory occupational-medical consultation carried out in accordance with the German Ordinance on Preventive Occupational Health Care (ArbMedVV) [8]. The two remaining women (0.5%) had had received a mandatory offer of an occupational-medical consultation. On average, the interval between the last occupational checkup at the Occupational Health Department and the respective due date was 2.1 years (median: 2 years, range: 0–13 years; n = 381).

186 of the 406 women (45.8%) with a reported pregnancy in the period under analysis had voluntary counselling on maternity protection provided by the Occupational Health Department. On average, the pregnant women presented to the Department in the 12th week of gestation (range: 5–33; n = 180). 71% of the employees had already informed their employer that they were pregnant, the remaining 29% had not yet informed their employer at the time of counselling (n = 162).

Occupational risk profile

324 of 406 women (79.8%) reported that their work activities included contacts to patients. 39 women (9.6%) worked in the operating room or provided dental services with contacts to patients. 17 (4.2%) worked in anesthesia and 46 (11.3%) in the intensive care unit. 63 (15.5%) had contacts to children under the age of three years, 46 (11.3%) had contacts to preschool age children, and 62 (15.3%) had contacts to school-age children above the age of six.

Employment bans

Based on the analyzed data, no employment ban during pregnancy was recorded for 53.7% of the studied employees. 119 employees (29.3%) were issued an indefinite occupational employment ban. A fixed-term occupational employment ban was issued for 9 (2.2%) employees and 47 (11.6%) were issued a fixed-term occupational employment ban due to the SARS-CoV-2 pandemic. Seven of the studied employees (1.7%) were issued with a medical employment ban during their pregnancy. [Fig. 1] provides an overview of the number of occupational and medical employment bans for different occupational groups.

Fig. 1 Number of occupational and medical employment bans for different occupational groups. In the case of one pregnant woman listed under “other medical staff” it was not possible to find out retrospectively whether she had been issued with an employment ban.

Five women (1.2%) were on parental leave during the time of their pregnancy covered by our study. One of them was recorded as being unable to work during her pregnancy and there was no data on any employment bans for another woman in the group.

Immunity

The immunity rates of the total study population at the time of the last consultation before the due date varied, depending on the disease, between 77.3% (mumps) and 90.9% (varicella zoster virus). A separate analysis of the subgroup with contacts to patients (n = 324, 79.8% of the study population) showed higher immunity rates than for the total study population (see [Table 3]).

Table 3 Overview of immunity rates of the total study population and the subgroup with contacts to patients at the time of their last medical checkup prior to their due date.

	Total study population (n = 406)	Subgroup with contacts to patients (n = 324)
Varicella zoster virus (VZV)	369 (90.9%)	315 (97.2%)
Measles	333 (82.0%)	289 (89.2%)
Mumps	314 (77.3%)	273 (84.3%)
Rubella	369 (90.9%)	313 (96.6%)
Hepatitis A	358 (88.2%)	295 (91.0%)
Hepatitis B	353 (86.9%)	290 (89.5%)
Cytomegalovirus (CMV)	70 (40.9%); n = 171 (tested persons)	66 (41.5%); n = 159 (tested persons)
Parvovirus B19	134 (72.4%); n = 185 (tested persons)	129 (73.3%); n = 176 (tested persons)

For the subgroup of women who attended occupational-medical consultations at least twice (n = 340), clarification of the immune status by the time of their last appointment before their due date was achieved in 86% (mumps) to 95% (rubella) of cases. The rise in immunity rates by the last antenatal appointment can be attributed, to a relevant extent, to more women having (confirmed) complete vaccination protection, some of whom were vaccinated in the Occupational Health Department (see [Fig. 2]). Between the first and the most recent occupational medical checkup, 31 women in this subgroup received a measles-mumps-rubella vaccination (MMR vaccination) and six women received two MMR vaccinations in the Occupational Health Department. Three women received one or two vaccinations against the varicella zoster virus. For one woman, the use of live vaccines was contraindicated. Nevertheless, even at the last checkup attended before their due date, some employees (between 5% [rubella] and 16% [mumps]) still had no immune protection or their immune status was unclear.

Fig. 2 Comparison of immune status between the first and the last occupational-medical consultation before the due date in the subgroup of women who attended at least two occupational-medical consultations in the Occupational Health Department (n = 340).

At the time of the last checkup before the due date, 238 women in the total study population had been vaccinated at least three times with a vaccine specifically targeting hepatitis B and 159 women had been vaccinated at least twice with a vaccine specifically targeting hepatitis A (by the Occupational Health Department or an external provider). 151 women had been vaccinated at least three times with a combination vaccine against hepatitis A and B (Twinrix). In the subgroup with contacts to patients, the majority had been immunized against hepatitis A and B (see [Fig. 3]).

Fig. 3 Number of women with immunity protection against hepatitis A and hepatitis B in the subgroup with contacts to patients (n = 324).

At the time of their most recent checkup, 90.9% of the women met the STIKO criteria for assumed immunity against pertussis. 85.2% had been vaccinated against polio in the last 10 years, 91.3% against tetanus and 91.8% against diphtheria.

Some of the women also lacked immunity protection against non-vaccine-preventable infections which are a potential risk during pregnancy. Only 40.9% of all tested women in the total study population had been immunized against cytomegalovirus (CMV), whereas it was safely assumed that 72.4% of all tested women in the total study population had immunity protection against parvovirus B19.

Discussion

Our study showed that immune status was determined in most subjects for all investigated diseases and that immunity rates increased between the first and the last occupational-medical consultation. The improvement in immunity rates was also due to increased vaccine immunity. Some vaccinations were carried out by the Occupational Health Department; in the remaining cases, it was not possible to determine retrospectively whether the confirmed complete vaccination protection was the result of vaccinations carried out by an external facility or may (only) have been due to presentation of vaccine records which had been forgotten at the first appointment. In their study of employees working in preschool childcare facilities, Görtz et al. also reported an increase in vaccination immunity at follow-up checkups. When they compared the vaccination rates of their study population at the first medical checkup and at subsequent follow-up medical checkups, they found that the vaccination gap with regards to measles, rubella and the varicella zoster virus decreased [18]. It must be assumed that repeated information and advice on the risk of infection and vaccination protection contributed to a greater awareness of risk in affected women and may simultaneously have reduced existing uncertainties with regards to vaccination, thereby increasing the willingness to be vaccinated. This was combined with an offer of direct vaccination at the medical checkup, meaning that vaccinations could be administered immediately during the checkup appointment, which increased the vaccination protection rates. The fact that the subgroup of women with contacts to patients consistently had higher immunization rates also suggests that risk awareness and objective information play an important role with regards to vaccination coverage rates. It can be assumed that the women with contacts to patients have medical training, which is likely to have positively influenced their understanding and attitude towards vaccinations. But a study by Schmid et al. also showed that medical training alone is clearly not enough to prompt someone to review their own vaccination status and optimize it. The publication from 2008 shows that even among medical students, vaccination rates increased significantly after they attended an individual occupational medical checkup [19].

With regards to measles, mumps, rubella and the varicella zoster virus, there was no difference in the vaccination advice provided by the Occupational Health Department to employees with or those without contacts to patients as, in addition to the occupational recommendations for vaccination against these virus infections, a general vaccination recommendation has been issued by the STIKO. It is possible, however, that if a vaccination was not occupationally indicated, women were not directly offered the option of vaccination during their occupational-medical consultation but only received a general recommendation to get vaccinated, for example, by their GP. Not offering a vaccination immediately following occupational medical counselling could be an obstacle which contributed to the lower immunity rates in the group without contacts to patients.

The German Measles Protection Act came into effect on 1 March 2020 [9]. This new law, coupled with changes to the STIKO recommendations [20] [21] in 2020, means that a general change in the measles immunity rates among employees working in sectors with an occupational risk of infection is expected. But this is not relevant for our study population because the new STIKO guidelines on occupationally indicated vaccinations to protect against measles (two measles vaccinations are required in adulthood instead of just one vaccination as before) had already been implemented by the Occupational Health Department of Universitätsklinikum Erlangen during the entire period covered by our study.

In addition to the very good immunity protection rates against hepatitis A and B in the subgroup with contacts to patients, the employees in our study had the highest immunity rates against the varicella zoster virus (VZV) and the rubella virus. In the case of rubella, immunity in a large percentage of the women was achieved through complete vaccination in accordance with the STIKO guidelines. The percentage of women whose immune status was unknown at the time of their first occupational-medical consultation was significantly lower for rubella than for other investigated diseases. This could be because the rubella-related risk for any pregnancy is well known by large parts of the population and in medical circles. Out of the list of vaccine-preventable virus infections reviewed in this study, rubella is the only disease where, up to and including 2020, the maternity passport explicitly asked into the immunity status of the expectant mother [22] [23]. It must be assumed that this is why more preventive medical measures to ensure immunity protection against rubella are carried out prior to pregnancy than for other diseases.

This is in contrast to the immunity rates against the varicella zoster virus. The very high immunity rates for the years 2018 to 2020 in our studied population were not based on complete vaccination of the women but on proof of a positive IgG antibody titer or previous positive medical history of infection with the varicella zoster virus and therefore on a high natural prevalence of this endemic disease in the studied age groups [24] [25]. This poses a problem which should not be underestimated. With regards to the varicella zoster virus, the recommendation since 2004 has been to administer a standard vaccination in childhood. Since 2009, the recommendation has been to administer two doses of the vaccination [26]. Vaccine protection has increased without achieving complete vaccination coverage (the current vaccination rate is 85.1% for two vaccinations at the time of the school entry checkup) [27]. But because natural infection rates from circulating viruses are now lower, this may result in a shift in the usual age of infection, with infection occurring at an older age [24] [28] [29]. This means that, in the future, the number of infected cases could increase in the age group in which the majority of pregnancies occurs. It is therefore important to take countermeasures early on through the provision of increased information and advice to prevent additional cases of disease in pregnant women.

As mentioned at the outset, the vaccinations against measles, mumps, rubella, and the varicella zoster virus use live vaccines and are therefore contraindicated in pregnancy. Immunity gaps which are present at the start of pregnancy cannot be closed during pregnancy and represent a potential risk throughout the entire pregnancy. This is particularly important if the pregnant woman has an occupational risk of infection. Although the Maternity Protection Act mandates that employers must carry out a risk assessment and implement adequate protective measures [16], that is only possible after the woman knows that she is pregnant and has also reported her pregnancy to her employer. In the period between conception and notification of the pregnancy (a very vulnerable developmental stage for the unborn child), the woman is not protected by special measures at her workplace and is therefore at greater risk.

Workplace-related risks are present for a relevant percentage of employees working in the health care sector. This is demonstrated by the fact that an occupational employment ban (excluding employment bans for SARS-CoV-2) was recorded for just under one third of the pregnant women in our study population. The relative frequency of occupational employment bans (excluding employment bans for SARS-CoV-2) differed considerably between different occupational groups. While the rate of occupational employment bans among the academic staff was only around 11%, a fixed-term or indefinite occupational employment ban was issued for more than 50% of women working in health care and nursing. This was followed by medical assistants, of whom just under 35% were issued with occupational employment bans, and physicians with just under 23% issued with an employment ban.

The observed differences between groups can very likely be ascribed to the different activity and risk profiles of the different occupational groups. Overall, academic staff only had contacts to patients in exceptional cases, whereas contacts to patients are the norm for health care and nursing staff and physicians. Contacts to preschool-age children were also much less common among the academic staff compared to most other occupational groups. This results in relevant differences with regards to the occupational risk of infection. The high percentage of occupational employment bans among the staff working in health care and nursing compared to physicians can be partly explained by the fact that nursing is inevitably associated with closer contacts to patients and the physical burden on nursing staff is usually considerably heavier than that on physicians. This needs to be taken into account when carrying out a maternity protection risk assessment. If the risk assessment shows that a current activity should no longer be carried out, it is presumably easier to find alternative activities for physicians which correspond to their qualifications and avoid having to ban them from working than for nursing staff.

A further aspect which may also have an impact and should not be underestimated is the motivation for pregnant women to continue working during pregnancy. From a legal standpoint, the wish of a pregnant woman to work or not to work should not play a decisive role in the employer’s risk assessment. But practical experience has taught us that for employers, issuing an occupational employment ban often seems to be an easier solution and entails less organizational work, and this approach is therefore sometimes preferred, in consultation with the pregnant woman, over more complicated protective measures or staff restructuring. This does not correspond to the sense and purpose of the Maternity Protection Act, which was intended to make risk-free continued employment possible during pregnancy. But the battle waged by many pregnant physicians to be allowed to continue working or operating, which has led to the compilation of lists of approved activities during pregnancy by various medical professional societies, shows that consistent implementation of risk assessments and protective measures is still far from reality in many places.

The commitment of pregnant physicians is almost certainly also based on the fact that specialist medical training also includes meeting specific targets with regards to times and treatment numbers and an occupational employment ban constitutes an enormous loss of time during advanced medical training. This could also be partly responsible for the fact that in our study population, the rate of occupational employment bans issued for physicians was significantly lower than that for nursing staff. Whether the self-motivation of pregnant women in our study population affected the issuing of occupational work bans cannot be determined from the retrospective data available to us. But the Maternity Protection Act sets clear limits with regards to the self-motivated wishes of pregnant women. As soon as the assessment carried out by the employer concludes that the risk is unjustifiable and cannot be eliminated by protective measures, then the employer may no longer permit the pregnant woman to perform the specific activity [16].

Unjustifiable risks can also include an occupational risk of infection. The analysis of the data of the last occupational-medical consultation before or during pregnancy provides a good picture of the probable immune status of the women in our study population with an occupational risk of infection at the start of their pregnancy.

Our study also has some limitations. Not all the women included in our study presented to the Occupational Health Department during their pregnancy. This means that those women whose last occupational-medical consultation was before the start of their pregnancy may have taken the opportunity to complete their missing vaccinations outside the Occupational Health Department. This means that our study may have even underestimated the immunity rates in our study population. Moreover, it is also possible that their first occupational-medical consultation in the Occupational Health Department was not necessarily their first occupational-medical consultation overall. Some of the women in our study population may have previously worked for another employer and already had an occupational-medical consultation there, where they were made aware of their occupational risk of infection.

Conclusion

Based on the results of our study, we would like to make a plea for expanding and intensifying the counselling on preventive maternity protection offered to girls and women, especially with regards to possible (later) risks of infection in both a private and an occupational context. Girls and women should be informed as early as possible about the importance of vaccinations and be offered vaccinations which would ideally ensure that their vaccination protection would already be complete by the time they decide they wish to have children. This is the only way to ensure that expectant mothers and their unborn children are also protected during the vulnerable phase at the start of pregnancy when often not even the women themselves are aware of the pregnancy. Our study shows that repeated counselling by physicians is very important to determine immune status and complete vaccination protection. In view of the current changes in immunity rates and levels of endemic infection, emphasis should also be placed on ensuring protection against the varicella zoster virus.

Note

The present work was carried out by Marie Seidling in fulfillment of the requirements for obtaining the degree of a Doctor of Medicine.

Conflict of Interest

The authors declare that they have no conflict of interest.

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• 13 AWMF. Labordiagnostik schwangerschaftsrelevanter Virusinfektionen. Zugriff am 12. Juli 2024 unter: https://register.awmf.org/assets/guidelines/093-001l_S2k_Labordiagnostik-schwangerschaftsrelevanter-Virusinfektionen_2022-02.pdf
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• 15 Bundesinstitut für Arzneimittel und Medizinprodukte, Paul-Ehrlich-Institut. Bulletin zur Arzneimittelsicherheit, Ausgabe 4, Dezember 2014. Zugriff am 12. Juli 2024 unter: https://www.bfarm.de/SharedDocs/Downloads/DE/Arzneimittel/Pharmakovigilanz/Bulletin/2014/4-2014.html
• 16 Bundesrepublik Deutschland. Gesetz zum Schutz von Müttern bei der Arbeit, in der Ausbildung und im Studium (Mutterschutzgesetz – MuSchG) vom 23.05.2017. Zugriff am 12. Juli 2024 unter: https://www.gesetze-im-internet.de/muschg_2018/BJNR122810017.html
• 17 Robert Koch-Institut. RKI – Impfungen A–Z – Schutzimpfung gegen Mumps: Häufig gestellte Fragen und Antworten. Zugriff am 20. September 2024 unter: https://www.rki.de/SharedDocs/FAQ/Impfen/MMR/FAQ-Liste_Mumps_Impfung.html
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• 22 Gemeinsamer Bundesausschuss. Richtlinien des Gemeinsamen Bundesausschusses über die ärztliche Betreuung während der Schwangerschaft und nach der Entbindung („Mutterschafts-Richtlinien“), in der Fassung vom 10. Dezember 1985 (veröffentlicht im Bundesanzeiger Nr. 60 a vom 27. März 1986), zuletzt geändert am 16. September 2021, veröffentlicht im Bundesanzeiger AT 26.11.2021 B4, in Kraft getreten am 1. Januar 2022. Zugriff am 12. Juli 2024 unter: https://www.g-ba.de/downloads/62-492-2676/Mu-RL_2021-09-16_iK-2022-01-01.pdf
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• 24 Ständige Impfkommission. Stellungnahme der Ständigen Impfkommission (STIKO) am Robert Koch-Institut: Evaluation der Varizellen-Impfempfehlung durch die STIKO. Epid Bull 2013; 1: 1-8
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• 26 Ständige Impfkommission. Evaluation der Varizellen-Impfempfehlung durch die STIKO, 2019. Epid Bull 2020; 3: 3-15
• 27 Rieck T, Feig M, Siedler A. Impfquoten von Kinderschutzimpfungen in Deutschland – aktuelle Ergebnisse aus der RKI-Impfsurveillance. Epid Bull 2022; 48: 3-25
• 28 Siedler A, Hecht J, Rieck T. et al. Die Varizellenimpfung in Deutsch-land. Eine Zwischenbilanz mit Blick auf die Masern-Mumps-Röteln-(MMR)-Impfung. Bundesgesundheitsbl 2013; 56: 1313-1320
• 29 Hecht J, Siedler A. Die Epidemiologie der Varizellen in Deutschland unter Einfluss der Varizellen-Impfempfehlung. Auswertung der Sentinel- und Meldepflichtdaten 2002–2014. Bundesgesundheitsbl 2017; 60: 118-126

Publikationsverlauf

Eingereicht: 04. August 2024

Angenommen nach Revision: 05. November 2024

Artikel online veröffentlicht:
06. Februar 2025