Halpern2017 2
Halpern2017 2
Halpern2017 2
a, b
Leslie R. Halpern, DDS, MD, PhD, MPH *, Charles Mouton, MD, MS
KEYWORDS
Vaccine-preventable diseases Vaccine effectiveness Active
Passive immunization Vaccine Adverse Event Reporting System (VAERS)
CDC Standard precautions
KEY POINTS
The pervasive increase in transmissible vectors of infectious diseases has created great
concern in the health of populations globally.
Oral health care professionals are especially at risk for the transmission of significant mi-
croorganisms, both bacterial and viral.
The provider needs to be knowledgeable about the exposure/transmission of life-
threatening infections in their daily practice, as well as options for prevention.
This article is designed to increase the oral health care provider’s awareness of vaccine-
preventable diseases that pose a high risk in the dental health care setting.
Specific dosing strategies are suggested for the prevention of infections caused by
several bacterial and viral microorganisms based on available evidence and the epidemi-
ologic changes described recently.
INTRODUCTION
a
Residency Program, Oral and Maxillofacial Surgery, Meharry Medical College, 1005 DB Todd
Junior Boulevard, Nashville, TN 37208, USA; b Department of Family and Community Medicine,
Meharry Medical College, School of Medicine, Nashville, TN 37208, USA
* Corresponding author.
E-mail address: [email protected]
been a global public health concern since the 1980s, when the human immunodefi-
ciency virus (HIV) epidemic came to light. Risk factor identification revealed the high
risk of contact between dentists and their patients serving as a vector for transmis-
sion.5,6 Furthermore, dentists experience puncture wounds by needles more than
any other health care specialist.4–7 As such, oral health care professionals are espe-
cially at greatest risk for the transmission of significant microorganisms, both bacterial
and viral (Table 1). There are numerous reports across the globe that document sig-
nificant cases where dentists still do not engage in safe practices with regard to barrier
protection; that is, gloves, eye glasses, facemasks, and other protective shields.3,4,6
In the 1980s, viral hepatitis, that is, hepatitis B virus (HBV) infection, was 4 times
greater among oral health care workers, which has declined significantly owing to
high compliance with HBV immunizations of the dental staff, as well as infection con-
trol practices referred to as universal precautions.8,9 The Centers for Disease Control
and Prevention (CDC) in 1996 expanded the “concept” of universal precautions to
Table 1
Representative infectious diseases in dentistry
Adapted from Molinari JA. Infection control: its evolution to the current standard precautions. J
Am Dent Assoc 2003;134(5):570; with permission.
Immunizations 403
standard precautions and in 2003 updated Guidelines for Infection Control in the
Dental Health-care Setting.8,9 In 2016, the CDC reissued a “Summary of Infection Pre-
vention Practices in Dental Settings: Basic Expectations for Safe Care.”8–10 Because
of the significant risk of exposure to BBPs, such as HBV, the oral health care provider
continues to be at high risk for not only viral infections, but also numerous bacterial
infections that are now increasing nationally and globally.
Although the immunization protocols for HBV are well-followed in the dental profes-
sion, few infection control guidelines have applied immunization paradigms against
other bacterial and viral diseases that pose a true risk for infection in dental health
personnel and their patients, including measles, rubella, tuberculosis (TB), and diph-
theria.3,4,11,12 Another caveat to this dilemma is assessing the state of vaccine confi-
dence in the United States based on the incidence and risk for these diseases.
Vaccine confidence defines the trust that health care providers and patients have
with respect to vaccine administration and recommended immunization sched-
ules.11–13 There is judicious monitoring of adverse effects of vaccine administration
by the Vaccine Adverse Event Reporting system, who are in turn monitored by the
US Food and Drug Administration and the CDC.13 This is further discussed elsewhere
in this article.
This article is designed to increase the oral health care provider’s awareness of the
latest assessment of vaccine and immunization prevention for vaccine-preventable dis-
eases that pose a high risk in the dental health care setting. Basic principles of immu-
nology and immunization and vaccination are described, followed by recommendations
for the prevention and control of infectious diseases that can affect dental health care
personnel and their patients. Specific dosing strategies are suggested for the prevention
of infections caused by several bacterial and viral microorganisms based on available ev-
idence and the epidemiologic changes in diseases described in recent years to provide a
clear understanding of risks and benefits of vaccine-preventable diseases that pose a
public health consequence in the oral health care setting.
Active immunization
Active immunization is acquired through an induction of immunity after exposure to an
antigen. The antibody response is elicited by a vaccine or toxoid and the humoral im-
munity of the host is relative to the specific pathogen of interest. The response can
take several days to weeks and can last a lifetime. An example is the hepatitis A vac-
cine (see elsewhere in this article for specific immunization).
Passive immunization
Passive immunization, often thought of as acquired, is a process of providing IgG an-
tibodies to protect against infections; it is immediate and can be short lived. An
example is the transfer of maternal tetanus antibodies across the placenta to the un-
born child. Acquired passive immunity is through serum from immune individuals to a
susceptible donor.15
Vaccines
Vaccines are biologic preparations that provide active acquired immunity against a
specific infectious disease. Vaccinations can be separated into 2 types: inactivated
or attenuated. Inactivated forms are derived from previously virulent microbes that
Immunizations 405
Box 1
Building blocks for immunization and vaccination
Immunobiologic
Antigenic substance or antibody containing preparation used to induce immunity and
prevent infectious diseases.
Active immunization
Use of an antigenic substance to induce immunity by stimulating an immune response.
Vaccine
A suspension of live (usually attenuated) or inactivated microorganisms, or fractions thereof.
1. Monovalent
A vaccine consisting of a single strain or type of organism.
2. Trivalent
A vaccine consisting of 3 types of strains of a single organism (influenza vaccine), or
3 different organisms (diphtheria, pertussis, tetanus vaccine).
3. Polyvalent
Multiple strains or types of organisms in the vaccine (23-valent pneumococcal vaccine).
Toxoid
A modified (nontoxic) bacterial toxin that is capable of stimulating antitoxin formation.
Passive immunization
Use of an antibody containing preparation to enhance or restore immunity. Immune
globulin: A sterile solution containing antibodies from human blood.
Antitoxin
A solution of antibodies derived from the serum of animals immunized with specific
antigens.
From Quaranta P. Immunizations and oral health care providers. Dent Clin North Am
2003;47(4):644; with permission.
are killed by biologic agents, heat, or radiation. Examples are the influenza, polio,
and hepatitis A vaccines.4,12 Attenuated forms contain live microbes, most
which are viruses that are cultured to become disabled. Examples are measles, yel-
low fever, rubella, and mumps. Bacteria such as Mycobacterium tuberculin and
typhoid are made noncontagious and used as an antigen to provide active immu-
nity. An example is the Bacillus of Calmette and Guerin (BCG) vaccine. It must be
remembered that these strains must not be administered to medically compro-
mised and immunocompromised patients because they can mutate and cause
disease.16
Toxoid vaccines are produced from inactivated toxic compounds of the microbes
such as tetanus and diphtheria that serve as a modified (nontoxic) bacterial toxin
capable of stimulating antitoxin antibody formation (the reader is referred to Quaranta4
for further examples of vaccines types).
The CDC estimates that 40 to 50,000 vaccine-preventable deaths occur every year
in the United States and estimates the health care burden of vaccine-preventable
diseases are at $10 billion.8–10 As such, maintenance of immunity is an important
part of disease prevention and the use of vaccines safeguard the health of various
types of oral health care providers, their staff, and their patients. Within the last
2 decades the Advisory Committee on Immunization Practices (ACIP) advocated
for infection control guidelines with respect to immunoprophylaxis of dentists
406 Halpern & Mouton
against the BBP HBV and standard precautions against hepatitis C virus (HCV),
for which there is no vaccine (reviewed elsewhere in this article).10 All healthy adults
within the United States are encouraged to be vaccinated for measles, mumps,
rubella (MMR) and pneumococcal diseases. Recommendations for all health
care workers including dentists according to the CDC are described in Box 2.
Despite these recommendations, many practices have not implemented these
precautions.
Dentists are at greater risk for infections caused by bacteria and viruses owing to
numerous encounters with the use of sharps and must be judicious with respect to
his/her awareness of preventive measures against vaccine-preventable diseases
within their clinical practice.2–4,9 Studies have shown a low level of awareness to-
ward vaccine-preventable diseases within the oral health care setting. Petti and col-
leagues3 applied a survey questionnaire to 379 dental practitioners to evaluate their
awareness toward vaccine-preventable diseases. The results concluded that prac-
titioners had a low awareness of vaccine-preventable diseases, and the authors sug-
gested a need for greater attention to immunization focusing on vaccine-preventable
diseases that poses a significant risk to both the clinician and patients they serve.
The survey evidence obtained with this dental population can be used as a founda-
tion for designing immunization programs tailored specifically for the oral health care
setting.3,16
Box 2
Health care personnel vaccination recommendations
Influenza
Vaccination is by 1 dose of influenza annually. The inactivated formula is given IM, except when
using the intradermal influenza vaccine. LAIV is administered intranasally. All HCP must receive
vaccinations annually and LAIV administered only to nonpregnant HCP ages 49 or younger.
Inactivated injectable vaccines are preferred when HCPs are caring for immunocompromised
patients, especially those in isolation.
MMR
HCPs born in 1957 or after without titer measurements or prior vaccination should receive 2
doses of MMR, 4 weeks apart. HCPs born before 1957 should have been exposed but if not
then should be administered 2 doses of MMR or subcutaneously. One dose of MMR is consid-
ered for an HCP with no evidence of disease of immunity to rubella. In this group 2 doses of
MMR are required if there is an outbreak of measles or mumps; 1 dose for an outbreak of
rubella.
Immunizations 407
Meningococcal
Vaccinations are required for HCPs exposed on a routine basis to isolates of Neisseria meningi-
tis. MenACWY and MenB strains are used with a booster every 5 years if risk of exposure con-
tinues. Each vaccination is given at a separate site on the body. Subcutaneous can be used in the
form of MPSV4 if necessary.
Varicella (Chickenpox)
All HCPs are strongly recommended to receive immunity against varicella zoster, whether or
not they were exposed either to Chickenpox or Shingles. Two doses of vaccines are given
28 days apart and tested for degree of immunity.
Abbreviations: Hbs, hepatitis B surface; HBSAg, hepatitis B surface antigen; HCP, health care
provider; IM, intramuscularly; LAIV, live attenuated influenza vaccine; MenACWY, meningo-
coccal A, C, and Y diseases; MenB, meningococcal B disease; MMR, measles, mumps, rubella;
MPSV4, meningococcal vaccine; Tdap, tetanus toxoid, acellular pertussis and reduced diph-
theria toxoid.
Adapted from Immunization action coalition, healthcare personnel vaccination recommen-
dations. 2016. Available at: www.immunize.org/catg.d/p2017.pdf. Accessed December 2, 2016.
The following vaccine-preventable diseases that require awareness by the oral health
care provider to avoid transmission within their practice setting and patient population
are presented in this section.
Hepatitis A Virus
Hepatitis A virus (HAV) infection arises from an RNA virus and transmitted through a
fecal–oral route. It can elicit symptoms or may be asymptomatic. Although self-
limiting, this virus can cause significant morbidity.11,12,16 HAV exposure has been un-
der control since 1995, when two forms of inactivated vaccine were developed: Hav-
rix, given to ages 18 or greater in two doses 6 to 12 months apart and Vaqta given to
patients 17 or older in two doses; 6 months apart.12,16–18 Since 2006, the ACIP has
recommended vaccination of children 1 year and older. It is also available in combi-
nation with the HBV vaccine (Twinrix). Immunogenicity studies indicate a 95% to
100% seroconversion when the vaccine is given and immunogenicity can remain
active for 20 to 30 years.4,11,12 The ACIP recommends HAV vaccination in travelers
and at-risk populations, namely, intravenous drug users, men who have sex with
men, those who are previously exposed to HAV, patients receiving clotting factors,
and those who travel to areas that are endemic to the viral infection.11,12,16 Adverse
effects include anorexia, headaches, and malaise. HAV exposure without vaccina-
tion can be treated with either immunoglobulin or a single dose of the vaccine.
The CDC recommends vaccinations to people exposed to anyone who they are in
personal contact with, such as adoptee children from other countries.11,12 HAV is
recommended for oral health care providers that work in special needs facilities as
well as penal institutions.4
408 Halpern & Mouton
Hepatitis B Virus
HBV infection is a global public health problem and is 1 of 2 forms of chronic hepatitis
worldwide.1 More than 240 million people are chronically infected, with more than
300,000 fatalities owing to cirrhosis and more than 340,000 owing to hepatocellular car-
cinoma.1,3,4 There are at least 10 separate genotypes that are geographically separated,
with genotype A in Europe and North America, genotypes B and C in Asia, genotype D in
the Mediterranean, genotype E in Africa, genotype F in Central America, and so on.6,19
Age of infection varies and will determine the chronicity of infection; that is, 90% of ba-
bies born to hepatitis B e antigen–positive mothers may be at risk and regions that are
highly endemic for HBV have acquired the infection at birth or early childhood.1 Infec-
tivity within Western Europe is markedly lower with HBs-Ag positive individuals who
have acquired HBV via sexual contact, intravenous drug use, or parenteral exposure
of the BBPs by splashing or spillage.1,4,10,12 With respect to spillage, HBV can survive
at room temperature on surfaces for 1 week.1 Within the United States, unprotected
sexual contact as well as intravenous drug use is the major risk factors. Blood donor
screening has been successful in reducing exposure of HBV to 1 to 4 cases per
1,000,000 in areas of low prevalence and 1 per 20,000 in areas of high prevalence.1,3,12
Studies on HBV infection in health care workers vary throughout the globe and
range from 0.1% (in the United States) up to 73% (in Africa), depending on country
of origin.1,3,6,12 Vectors of transmission include blood via stick or aerosol, saliva,
and nasopharyngeal secretions transmitted through male sex, older age, dental treat-
ment, blood transfusion, and working in a health care setting.1,9,10 Serum HBV has an
incubation period of 50 to 100 days. A recent 2016 update examined the transmission
of BBPs in the US dental health care setting (Cleveland and colleagues9) indicated that
transmission of BBPs in the dental setting was rare since 2003, that is, 3 events re-
ported. Failure to adhere to CDC guidelines resulted in these adverse events.10
HBV infection is the most significant occupational hazard in the oral health care
arena, with a significantly higher incidence in dental staff, as well as oral surgeons,
periodontists, and endodontists.3,4,10 Patients with periodontal disease demonstrate
increased HBV surface antigens, anti–hepatitis B core, and anti-HCV in saliva than
comparable control patients.6,19 To decrease the burden of HBV in the dental care
setting, all doctors and staff should receive vaccinations (discussed elsewhere in
this article) as well as using other standard procedures; that is, gloves, gowns, protec-
tive equipment. It is mandatory within the United States to be vaccinated against HBV
before admission into dental schools and colleges.9,10 In a literature review by
Cleveland and colleagues,9 from 2010 to 2015 there have been only 3 reports of trans-
mission of HBV and HCV in the dental care setting. The rare occurrence of transmis-
sion was owing to failure of sterilization of instruments, a lack of training of staff on
BBPs, and the use of multidose vials inappropriately. The 2016 CDC prevention rec-
ommendations are in place to be implemented as standard precautions to be applied
by all oral health care providers in their practice settings (Table 2).9,10 The 2016 update
by the CDC’s guidelines for infection control in dental health care settings emphasizes
the elements of standard precautions and basic prevention of infection in the dental
clinic setting in the form of a checklist that can be designed based on the specific
needs of the practice. Dental staff can apply their checklist to daily procedures and
how well they adhere to the guidelines that provide a safe environment from HBV
transmission.10 Table 2 depicts examples of methods and their evaluation.
Table 2
Guidelines for providing a safe environment for infection prevention
Abbreviations: CDC, Centers for Disease Control and Prevention; CE, continuing education; DHCP,
dental health care provider; EPA, Environmental Protection Agency.
Adapted from Centers for Disease Control and Prevention (CDC). Guidelines for infection control
in dental health-care settings — 2003. MMWR Morb Mortal Wkly Rep 2003;52:1–61.
diabetes is diagnosed.11 Studies have shown an increased risk for HBV infection in di-
abetics that are in facilities where their blood glucose is being monitored constantly.11
Testing for circulating antibodies is also recommended for clinicians older than age 30
because advancing age is correlated with lower seroconversion rates; 42% serocon-
version for those older than age 60 compared with 83.3% of those younger than age
50.4,22 Oral health care workers who suffer from immunocompromised diseases
should not be exposed to live vaccines if they are receiving chemotherapy and/or ra-
diation. The time between ending therapy and getting vaccinated is 3 months and the
CDC has outlined specifics for HIV-infected health care providers.4,9,10
Hepatitis C Virus
HCV was first identified as the causative vector in 95% of cases of non-A non-B hep-
atitis during the 1980s.6 The incubation period can vary from 3 to 20 weeks and can
present in an asymptomatic fashion, because exposure is associated with a tran-
sient increase in liver alanine transferase of up to 10-fold before symptoms pre-
sent.6,23 HCV infection progresses to chronicity and is a major health problem that
leads to cirrhosis and hepatocellular carcinoma.4,6,23 The World Health Organization
reports that 130 to 150 million people are infected and HCV exposure is regionally
variable, with high prevalence rates in the Middle East and Northern Africa and
low rates in North American and Western Europe.24 Seven strains of HCV have
been recorded and HVC genotype 1 is the most prevalent worldwide followed by
HCV 3. The transmission of infection was through infected blood products until
1989, and routine screening for antibodies to HCV occurred in the 1990s, which
has reduced transmission significantly. More recent risk for HCV exposure has
been through acupuncture, body piercing, tattooing, nail scissors, hair clippers,
and needle stick injury to health care workers.25 HCV and HBV have never been in-
fectious with exposure to vomit, urine, sweat, or tears.6 HCV transmission occurs in
10% of health care workers after parenteral exposure from percutaneous and
mucosal blood of an HCV RNA-positive patient.1,6
Cleveland and colleagues10 reported a study within the oral health care setting of an
oral surgery office that a patient became infected with HCV from another patient owing
to multiple lapses of infection prevention and control. Dental assistants in this setting
were administering medications without appropriate training and exposed a patient to
HCV. The use of multidose vials for more than 1 patient and a lack of autoclave moni-
toring resulted in transmission of HCV.10 Other studies related to infectivity have iden-
tified that HCV can survive in the environment for up to 6 weeks on a dry surface.10
Whether or not this can act as a route remains to be determined because only a percu-
taneous path has been identified as the source of contact. The prevalence of HCV an-
tibodies in US dentists who participated in the American Dental Association health
screens are well below that of the population at large (0.5% vs 1.6%) suggesting a
very low risk for occupational exposure as compared with studies worldwide that
show greater anti-HCV positivity in health care providers.9,10
HCV vaccine
A report by the Committee on a National Strategy for the Elimination of Hepatitis B and
C, Board on Population Health and Public Health Practice (Health and Medicine Divi-
sion; National Academies of Sciences, Engineering, and Medicine; Buckley GJ, Strom
BL, editors) is examining the feasibility of hepatitis B and C elimination in the United
States. Although there is no vaccine for HCV, new direct-acting antivirals may cure
95% of chronic infections, although these drugs are unlikely to reach all chronically
infected people anytime soon. As such, per the CDC guidelines, all oral health care
Immunizations 411
Influenza
Over the past 5 years, the CDC and the ACIP have strongly recommended that all
health care workers, as well as all patients including children be immunized against
influenza.4,11,12 The epidemiology, morbidity, and mortality of influenza have
described and the rates of serious illness and death among patients age 65 and older
is approximately 36,000 deaths in the 1990s.31 Influenza is a strongly infectious path-
ogen causing a severe respiratory illness with concomitant fever, headaches, coryza,
vomiting, and diarrhea. Transmission is via respiratory droplets. Influenza A and B
cause epidemic disease outbreaks worldwide.12,31 Type A is broken down further
into subtypes based on surface antigens (neuraminidase and hemagglutinin). Anti-
genic shifts can result in serious pandemics based on mutational changes within
the antigen structure.11,12,31
Influenza vaccines
Randomized clinical trials have looked at the efficacy of vaccine-preventable disease
and health care worker absenteeism.12 Results suggest an increased cost effective-
ness in the immunization of all health care workers during the flu season.32 There
are 2 types of influenza vaccine for adults: the trivalent inactivated form (TIV) and
the attenuated form influenza vaccine (live attenuated influenza vaccine).12,31 The
latter is administered nasally.33 The attenuated form is sensitive to temperature and
cannot replicate within the human core range. These are adapted to cold and require
Immunizations 413
coolness for activation of immunity protection. The live attenuated influenza vaccine is
more effective in children and is not approved in ages for those 50 years of age and
older, in pregnant women, in immunocompromised patients (ie, HIV), chronic obstruc-
tive pulmonary disease, renal disease, hepatic dysfunction, or metabolic sequelae of
diabetes. There is a new trivalent vaccine (TIVI) given intradermally to ages those 18 to
64 in the deltoid muscle. Adverse reactions include pain erythema, induration, and
pruritus. The TIVHD is an alternative to TIV if the patient is older than 65 years of
age. Both the live attenuated influenza vaccine and TIV are equivalent to influenza A
subtype H3N2, H1N1, and 1 influenza B virus.12,32 With reference to allergic reactions,
the ACIP recommended in 2011 to revise the egg allergy contraindication to a precau-
tion strategy if there is no history to anaphylaxis and egg exposure. The issue of the
older patient relates to their immune system undergoing an “immunosenescence”
and, therefore, higher doses of vaccine may be warranted. This hypothesis is still un-
der investigation.33
Streptococcus pneumoniae
S pneumoniae is a gram-positive anaerobic bacteria inhabiting the respiratory tract
and seen in 70% of healthy subjects. The vector is via respiratory droplets and results
in serious exacerbations of pneumonia, meningitis, and septic bacteremia. Epidemio-
logic evidence indicates up to 40,000 cases in the United States and 1.6 million deaths
of pneumococcal disease worldwide in the elderly and children.12,34 As such, there
has been a global public health effort to decrease the death rate from septicemia
through the use of immunization against pneumococcal disease.
Tetanus
Clostridium tetani is a gram-positive anaerobic organism whose exotoxins prevent the
release of neurotransmitters leading to uncontrolled muscle spasms and trismus. They
enter via an open wound and can exacerbate/prevent swallowing and breathing lead-
ing to death. During the 1940s, tetanus toxoid was introduced as part of the routine
immunization package in children consisting of 3 spaced doses with a recurrent
414 Halpern & Mouton
booster every 10 years except if there is an exposure such as stepping on a rusty nail
or open wounds in soil.11,12 C tetani produces a toxin that destroys tissue on any mu-
cous membrane but most often on the tonsils and pharyngeal tissue. These locations
of injury can cause respiratory obstruction and death.
Pertussis
Among the 3 diseases, pertussis remains an endemic health problem with between
800,000 and 3.3 million cases in the United States annually.12 Bordetella pertussis is
a gram-negative coccobacillus that attacks the respiratory epithelium. There are 3
phases of the disease process:
1. Catarrhal consisting of coryza, coughing, and sneezing;
2. Paroxysmal stage with continued coughing, followed by a long inspiration and a
whooping for 4 to 6 weeks; and
3. A convalescent stage, where the coughing decreases.
Older individuals are often vectors for transmission to young children. The latter is
on the rise owing to the debate about vaccine effectiveness (discussed elsewhere
in this article).13,37
Diphtheria
Corynebacterium diphtheria is an aerobic gram-positive bacteria producing a toxin
that acts to destroy tissue within the mucous membranes. Diphtheria was a
significant cause of mortality in children during the 1940s, but with toxoid immuniza-
tion this disease has been eradicated with only 5 cases reported within the last
15 years.12
Tetanus-Diphtheria-Pertussis Vaccine
Within the United States, there are 2 preparations of vaccines—Adacel and Boos-
trix—each containing tetanus toxoid, acellular pertussis and reduced diphtheria
toxoid (Tdap).11,12,38 One dose of Tdap is as efficacious as 3 doses of diphtheria
toxoid, acellular pertussis, and tetanus toxoid with respect to the antibody
response. Boostrix is available for those ages 10 to 64 years and Adacel is
approved for those ages 11 to 64 years.11,12 The ACIP suggest that Tdap can be
administered to those greater than 65 years of age if the patients are in contact
with young children because morbidity and mortality are greatest in children.12,38
Furthermore, if parents are immunized their young children are protected more
than 50% of the time they are exposed. The ACIP has structured a vaccination pro-
tocol for Tdap (see Box 2).38
Human Papillomavirus
HPV is a double-stranded DNA virus that infects basal epithelium. HPV type 16 and 18
are responsible for the majority of cervical dysplasia seen, as well as 40% of penile
cancers seen in the United States and worldwide.11,12,39,40 It is the most common
sexually transmitted disease and out of 80% of females who are sexually active,
41% can be exposed to HPV type 16 by age 50.41 HPV can cause skin warts and cer-
vical dysplasia that can mature into squamous cell carcinoma in the vagina, anus,
vulva, and oral cavity.40,41 Pregnant women can transmit the virus to their newborn
at the time of birth. Other risk factors are numerous sex partners and a partner’s
sex history. HPV 16 is especially responsible for more than 85% of head and neck
squamous cell cancers.12,39,40 The progression of HPV infection from precancerous
to cancer can occur over a period of 10 years. Most HPV infections, however, can
clear over 8 months to 2 years.11,12,40
Immunizations 415
for careful selection of food and water; the protection of the vaccine can be overcome
by large inoculates of S typhi. With respect to oral health care, this vector of infection
is not routinely listed as one that necessitates a vaccine-preventable disease
strategy.46,47
Box 3
Characteristics and strategies for vaccine-preventable disease in primary, secondary and
immune regulatory abnormalities
PID
Increase susceptibility to infection, autoimmune and inflammatory sequelae
Diagnosis requires thorough evaluation of T-cell, B-cell, and innate immunity
Antibody deficiency often cause of PID
Inactivated vaccines recommended
Attenuated vaccines; that is, MMR, VAR, rotavirus, live influenza, oral polio contraindicated
SID/IRA
Usually owing to consequences of immunosuppression and/or modulatory treatment
Human immunodeficiency virus infection, hematologic malignancies, tumors, solid organ
transplant recipients, multiple sclerosis, inflammatory bowel disease, autoimmune/
inflammatory diseases, chronic diabetes, heart, lung disease and complement deficiencies.
Immune impairment may be may be a combination of B- and T-cell deficiencies.
Yearly vaccination of inactivated PCV and pneumococcal polysaccharide vaccine 23 highly
recommended, as well as quadrivalent meningococcal vaccines and hepatitis B.
Live vaccines administration is predicated upon severity of immune state with need for risk to
benefit decisions by an immunologist.
SID/IRA patients require higher dosing and more frequent immunizations.
Abbreviations: IRA, immune-regulatory abnormalities; MMR, measles, mumps, rubella; PID, pri-
mary immune deficiency; SID, secondary immune deficiency; VAR, varicella.
Adapted from Eibl MM, Wolf HM. Vaccination in patients with primary immune deficiency,
secondary immune deficiency and autoimmunity with immune regulatory abnormalities.
Immunotherapy 2015;7(12):1286.
Immunizations 417
until 3 months after steroid therapy that exceeds 2 week duration. It is most important
to weigh the risk to benefit ratio with the provider’s physician of record. Evaluation and
monitoring within this population would define and improve treatment decisions for
greater cost effectiveness, reduction of complications owing to their disease state,
and a better health-related quality of life.
The US population generally has great confidence in the efficacy and reliability of the
vaccine program and the latest measles cases provided yet another reminder of the
importance of vaccines and timely vaccination.13 Although the source case traced
to the tourist destination is not known, the first identified case of measles stemmed
from an individual who had not been vaccinated against the disease and most of
the subsequent infections involved people who were unvaccinated. Unfortunately,
in many cases, the unvaccinated children were likely unvaccinated by choice.13 The
recommended measles vaccination must have been delayed or declined, a choice
that left them vulnerable and the rest of the unvaccinated population susceptible to
measles. These cases are a lesson to health providers who chose not to be vaccinated
and lack immunity to vaccine-preventable infectious diseases.49
Immunity is often silent or invisible until it is tested—and measles is one of the most
sensitive “stress tests” we have. The need to maintain the high immunization rates,
particularly in health workers, along with evidence that more parents are hesitating
or delaying when it comes to following vaccination recommendations, prompted the
Assistant Secretary for Health of the Department of Health and Human Services to
ask the National Vaccine Advisory Committee to assess how confidence in vaccines
affects vaccination in the United States.13,49,50
Vaccines are one of the most effective and successful public health tools to prevent
disease, illness, and premature death from preventable infectious diseases. and there
is much good news in the United States when it comes to recommended vaccines and
vaccinations.13,51 When there are high levels of immunity in a community induced by
vaccination, a transmitting case is unlikely to encounter a susceptible host, thus ter-
minating transmission and preventing exposure of others in the community who are
either not protected by vaccination (no vaccine is 100% effective5), cannot be vacci-
nated (ie, have a legitimate contraindication to vaccination), or who are not eligible for
vaccination (eg, children too young for some recommended vaccines).50,51 Thus, what
makes vaccines unique is that with high levels of vaccination both the individual and
the community are protected, a phenomenon, characterized often as “herd immunity.”
However, high vaccination coverage rates are required for community protection. In
the United States, high vaccination rates have been reached for many recommended
vaccines, leading to the near elimination of the corresponding vaccine-preventable
diseases and 99% to 100% reductions in mortality from vaccine-preventable dis-
eases, leading to thousands of lives saved each year.13,51 Not all recommended vac-
cinations have reached high coverage rates and there are places in the country where
coverage is not high enough to achieve population protection, leaving the people,
including young children and health professionals, vulnerable to vaccine-
preventable diseases, especially in the event of a disease outbreak. Vaccination rates
among children are high and, for most parents, following the recommended schedule
is the norm. Health care providers are highly supportive of vaccines and immunization
recommendations and, for most parents, are a trusted source of information and guid-
ance. When it comes to vaccine confidence, trust in health care providers, health care
provider communication and endorsement, social norms, and communication play
418 Halpern & Mouton
central roles in instilling, maintaining, and fostering vaccine confidence. Health care
providers can also demonstrate this trust by being fully immunized against vaccine-
preventable disease.13,49,50
The Working Group recognized several challenges that threaten successful utiliza-
tion of recommended vaccines. There are communities and places (eg, schools)
where vaccination levels are below and sometimes far below the levels needed to pro-
tect those who are unvaccinated. There are also parents whose reluctance, hesitation,
concerns, or lack of confidence has caused them to question or forego recommended
vaccines. In some cases, the children are vaccinated, but vaccinations are delayed
beyond recommended ages, alternative schedules are used, or vaccines are totally
declined, health workers are declining vaccination, and others fail to recognize their
lack of immunogenicity. In these cases, the individual is left susceptible to the disease
and, if infected, can transmit it to others.13,49–51
PUBLIC CONFIDENCE
As the World Health Organization’s Strategic Advisory Group of Experts’ vaccine hes-
itancy efforts illustrate, building and fostering vaccine confidence and acceptance is
not just a problem in the United States, but an issue of urgent importance in global
health.52 More efforts are needed to identify, develop, and evaluate strategies and ap-
proaches to find the ones that facilitate or instill confidence, and the resources and
systems need to be in place to share lessons learned and effective practices. Along
these lines, it is also the case that vaccine confidence and acceptance efforts need
to encompass health care providers.13,52 Not only is it imperative that they have
high confidence in recommended vaccines and vaccinations, they must have the re-
sources, capacities and capabilities needed to effectively educate and address indi-
viduals’ questions and concerns. In most cases, it is health care providers who
directly affect workers’ confidence and acceptance of recommended vaccines and
vaccinations.
Vaccination in accordance with the CDC’s ACIP recommended immunization
schedule continues to be the social norm in the United States and high vaccination
coverage has been achieved for most recommended vaccines on the recommended
childhood immunization schedule.13,51 For infant and early childhood immunizations,
rates have been high and stable for the past several decades, namely, at or above the
80% to 90% range for nearly all ACIP recommended childhood vaccinations. Simi-
larly, recent reports suggest that a majority of parents have favorable beliefs or per-
ceptions with regard to recommended childhood vaccines. A 2009 Health Styles
survey of parents of children 6 years old and younger, for instance, found 79%
were “confident” or “very confident” in the safety of routine childhood vaccines.13,53
A 2010 Health Styles survey found 72% of parents were confident in the safety of vac-
cines, with slightly more parents expressing confidence in the effectiveness of vac-
cines (78%) and the benefits of vaccines (77%).13,53 Further analyses of these data
showed that 2 factors—confidence in vaccine safety and confidence in vaccine effec-
tiveness—were a major source of influence on parents’ self-reported vaccination
behavior.9 Overall, however, these studies also suggested that about 1 in 5 parents
were not fully confident in the safety or importance of recommended vaccinations.
The Cultural Cognition Project at the Yale Law School has collected data involving
or related to confidence.54 They also found that about 27% of adults strongly to
slightly disagreed with the statement, “I am confident in the judgment of public health
officials who are responsible for identifying generally recommended childhood vacci-
nations.” About 62% had moderately or extremely high confidence in “the judgment of
Immunizations 419
the American Academy of Pediatrics that vaccines are a safe and effective way to pre-
vent serious disease,” but about 20% had relatively low confidence.13,54
It is clear from published studies that health care providers—the frontline people who
interact with parents and who administer vaccines—are critically important when it
comes to vaccine confidence.13,51 Studies consistently find that the vast majority of
parents (80% or more) look to their child’s health care provider for information and
advice on vaccine-preventable diseases, vaccines, and the recommended immuniza-
tion schedule.55 When providers are able to communicate effectively with parents
about vaccine benefits and risks, the value and need for vaccinations, and vaccine
safety, parents are more confident in their decision to adhere to the recommended
schedule. In a study involving both parents and health care providers, Mergler and col-
leagues56 found a strong association between parental and provider vaccine-related
attitudes and beliefs. For example, parents had a 45 times higher odds of agreeing
that the community benefits from having children fully vaccinated if their provider
agree, compared with parents whose provider did not agree. They also noted that
some parents likely chose providers who are similar vaccine beliefs as their own—
and, as such, providers with doubts about recommended vaccinations can foster or
support hesitancy.57 Finally, it has also been found that reliance on vaccine informa-
tion sources other than providers is associated with exemptions from school entry re-
quirements. Rosenstock,13,58 for instance, found that parents who sought vaccine
information on the Internet were more likely to have lower perceptions of vaccine
safety, vaccine effectiveness, and disease susceptibility and were more likely to
have a child with a nonmedical exemption. From the perspective of vaccine confi-
dence, it is thus important to recognize that health care providers are key players
when it comes to establishing, maintaining, and building parent confidence in vac-
cines. Thus, health care providers need to demonstrate vaccine confidence by
becoming fully vaccinated.13,57,58
In many instances, however, health care providers have not met their responsibility
to be fully immunized against vaccine-preventable disease.3,4,9,13 They continue to put
themselves and the public at risk. For influenza, vaccination coverage among physi-
cians and dentists (84.2%) was similar to coverage among nurse practitioners and
physician assistants (82.6%), and was significantly higher than for those working in
all other occupational groups. Coverage also was significantly higher among health
care providers aged 60 years or greater (74.2%), compared with those aged 18 to
29 years (56.4%) and those 30 to 44 years (57.8%).13 An in-depth literature review
describing universal influenza vaccination attitudes in hospital-based health care pro-
vider identified a number of reasons commonly cited for not receiving the vaccine. In
21 studies in 9 countries, the authors reported that the 5 most frequently reported cat-
egories for vaccine refusal included:
1. Fear of adverse reactions;
2. Lack of concern (ie, perception that influenza does not pose a serious public health
risk);
3. Inconvenient delivery;
4. Lack of perception of own risk; and
5. Doubts regarding vaccine efficacy.
These studies also found that health care providers are more likely to be vaccinated
to protect themselves against influenza than to be vaccinated for the protection of
420 Halpern & Mouton
patients. Similarly, a recent CDC report found that the prevalence of beliefs regarding
influenza and influenza vaccination differ between vaccinated and unvaccinated
health care provider. This study found that 92.7% of vaccinated health care provider
believed getting vaccinated could protect them from influenza infection, whereas only
54.2% of those who were unvaccinated shared that belief. Notably, the CDC study
also indicated that 55.4% of unvaccinated health care provider do not believe that
vaccination better protects those around them from influenza infection. The most
important factor facilitating vaccine acceptance was a desire for self-protection, pre-
vious receipt of influenza vaccine, perceived effectiveness of vaccine, and older age.
These studies highlight the importance of educating health care providers on the seri-
ousness of influenza and vaccine-preventable disease as a public health threat.13
Fig. 1. Vaccine-preventable diseases in oral health care. HIV, human immunodeficiency vi-
rus; Strep/Staph, Streptococcus; Staphylococcus; TB, tuberculosis.
Immunizations 421
awareness and decrease the transmission of infectious diseases within the oral health
practice setting.
REFERENCES
19. Mealy BL, Klokkevold PR, Corgel CO. Periodontal treatment of medically compro-
mised patients. Carranza’s Clinical Periodontology. 10th edition. Amsterdam
(Netherlands): Elsevier Publication; 2010.
20. Center for Disease Control, Prevention. A comprehensive immunization strategy
to eliminate transmission of Hepatitis B virus infection in the United States. Rec-
ommendations of the Advisory Committee on Immunization Practices (ACIP). Part
II: vaccination in adults. MMWR Recomm Rep 2006;55(RR16):1–33.
21. Immunization safety review: hepatitis B vaccine and demyelinating neurological
disorders overview of the Institute of Medicine (IOM) report. CDC web site.
2002. Available at: http://www.cdc.gov/nip/news/iom-hepb-5-2002/iom.htm. Ac-
cessed June 2, 2010.
22. Guss P, Havlichek D, Rosenman K, et al. Age-related Hepatitis B seroconversion
rates in healthcare workers. Am J Infect Control 1997;25(5):418–20.
23. Abeulhassan W. Hepatitis C virus infection in 2012 and beyond. South Afr J Epi-
demiol Infec 2012;27:93–7.
24. WHO guidelines Approved By the Guidelines Review Committee. Guidelines for
the screening, care and treatment of persons with hepatitis C infection. Geneva
(Switzerland): World Health Organization; 2014. Available at: http://apps.who.
int/medicinedocs/documents/s22180en/s22180en.pdf.
25. Mass S, Berg T, Rosktroth J, et al. Hepatology. 6th edition. Flying Publishers;
2015.
26. Centers for Disease Control. Prevention. In: Atkinson W, Wolfe S, Hamborsky J,
editors. Mumps. Epidemiology and prevention of vaccine-preventable diseases.
12th edition. Washington, DC: Public Health Foundation; 2011. p. 205–14.
27. Rubella Vaccines: WHO position paper. Wkly Epidemiol Rec 2011;86(29):301–16.
28. Centers for Disease Control. Notice to readers: revised ACIP recommendation for
avoiding pregnancy after receiving a rubella-containing vaccine. MMWR Morb
Mortal Wkly Rep 2001;50(49):1117.
29. Tseng H, Harpaz R, Bialek S. Herpes zoster vaccine in older adults and the risk of
subsequent herpes zoster disease. JAMA 2011;302(2):160–6.
30. Atkinson W, Wolfe S, Hamborsky J, et al, editors. Varicella. Epidemiology and pre-
vention of vaccine preventable diseases. Washington, DC: Public Health Founda-
tion; 2009. p. 283–304.
31. Atkinson W, Wolfe S, Hamborsky J, et al, editors. Influenza. Epidemiology and
prevention of vaccine preventable diseases. Washington, DC: Public Health
Foundation; 2009. p. 135–56.
32. Centers for Disease Control. Prevention. Prevention and control of Influenza with
Vaccines. Recommendations of the Advisory Committee on Immunization Prac-
tices (ACIP). MMWR Recomm Rep 2010;59:1–63.
33. Muszkat M, Greenbaum E, Ben-Yehudah A, et al. Local and systemic immune
response in nursing-home elderly following intranasal or intramuscular immuniza-
tion with inactivated influenza vaccine. Vaccine 2003;21(11–12):1180–6.
34. Healthy People 2020, US Department of Health and Human Services. Available
at: http://www.healthypeople.gov/2020/default/aspx. Accessed June 26, 2013.
35. Talbot TR, Herbert TV, Mitchel E, et al. Asthma as a risk factor for invasive pneu-
mococcal disease. N Engl J Med 2005;352(20):2082–90.
36. Centers for Disease Control, Prevention. Updated recommendations for preven-
tion of invasive pneumococcal disease among adults using the 23-valent pneu-
mococcal polysaccharide vaccine (PPSV23). MMWR Morb Mortal Wkly Rep
2010;59:1102–6.
Immunizations 423
37. Pickering LK, Baker CJ, Freed GL, et al. Immunization programs for infants, chil-
dren, adolescents, and adults: clinical practice guidelines by the Infectious Dis-
eases Society of America. Clin Infect Dis 2009;49:817–40.
38. Centers for Disease Control and Prevention (CDC). Updated recommendations
for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vac-
cine (Tdap) in pregnant women and persons who have or anticipate having close
contact with an infant aged <12 months-Advisory Committee on Immunization
Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep 2011;60:1424–6.
39. Parkin DM, Breay F. Chapter 2: The burden of HPV-related cancers. Vaccine
2006;24(Suppl 3):S11–25.
40. Weinstein LC, Buchanan EM, Hillson C, et al. Screening and prevention: cervical
cancer. Prim Care 2009;36(3):559–74.
41. Markowitz LE, Dunne EF, Saraiya M, et al. Quadrivalent human papillomavirus
vaccine: recommendations of the Advisory Committee on Immunization Practices
(ACIP). MMWR Recomm Rep 2007;56(RR-2):1–24.
42. Center for Disease Control and Prevention. FDA licensure of bivalent human
papillomavirus (HPV2, Cervarix) for use in females and updated HPVC vaccina-
tion recommendations from the Advisory Committee on immunization Practices
(ACIP). MMWR Morb Mortal Wkly Rep 2010;59:626–9.
43. International tuberculosis incidence rates. Internet web page. 2011. World
Health Organization. Available at: http://www.who.int/immunization_monitoring/
diseases/en/. Accessed July 9, 2016.
44. Lalvani A. Diagnosing tuberculosis infection in the 21st century: new tools to
tackle an old enemy. Chest 2007;131(6):1898–906.
45. CDC. Development of new vaccines for tuberculosis: recommendations of the
Advisory Council for the elimination of Tuberculosis (ACET). MMWR Recomm
Rep 1998;47(RR13):1–6.
46. Shepherd SM, Shoff WH. Immunization in travel medicine. Prim Care 2011;38:
643–79.
47. Emmett GA, Schneider M. Office immunization. Prim Care 2011;38:729–45.
48. Eibl MM, Wolf HM. Vaccination in patients with primary immune deficiency, sec-
ondary immune deficiency and autoimmunity with immune regulatory abnormal-
ities. Immunotherapy 2015;7(12):1273–92.
49. Omer SB, Enger KS, Moulton LH, et al. Geographic clustering of nonmedical ex-
ceptions in school immunization requirements and associations with geographic
clustering of pertussis. Am J Epidemiol 2008;168:1389–96.
50. Lieu TA, Ray GT, Klein NP, et al. Geographic clusters in under immunization and
vaccine refusal. Pediatrics 2015;135:280–9.
51. Centers for Disease Control and Prevention (CDC) (US). National Immunization
Survey. Available at: http://www.cdc.gov/nchs/nis.htm. Accessed July 28, 2015.
52. World Health Organization. Report of the SAGE working group on Vaccine Hes-
itancy: 2014. Available at: http://www.who.int/immunization/sage/meetings/2014/
october/1_report_working_group_vaccine_hesitence_final.pdf. Accessed August
1, 2016.
53. Nowak GJ, LaVail K, Kennedy A, et al. Insights from public health; a framework
for understanding and fostering vaccine acceptance. In: Chattergee A, editor.
Vaccinophobia and vaccine controversies of the 21st century. New York:
Springer; 2013. p. 459–79.
54. Kahan DM. Vaccine risk perceptions and ad hoc risk communication: an empir-
ical assessment. 2014. Available at: http://papers.ssrn.com/so13/papers.cfm?
abstract_id52386034. Accessed August 10, 2016.
424 Halpern & Mouton
55. Kennedy A, LaVail K, Nowak G, et al. Confidence about vaccines in the United
States; understanding parents’ perceptions. Health Aff (Millwood) 2011;30:
1151–9.
56. Mergler MJ, Omer SB, Pan WK, et al. Association of vaccine-related attitudes and
beliefs between parents and healthcare providers. Vaccine 2013;31:4591–5.
57. Gargano LM, Weiss P, Underwood NL, et al. School-located vaccination clinics
for adolescents: correlates of acceptance among parents. J Community Health
2015;40:660–9.
58. Rosenstock I. Historical origins of the Health Belief Model. Health Educ Behav
1974;2:328–35.