COMMENTARY

Human Vaccines & Immunotherapeutics 11:9, 2180--2182; September 2015; © 2015 Taylor & Francis Group, LLC

Adult immunization in India: Importance and recommendations

Ramesh Verma1,*, Pardeep Khanna1, and Suraj Chawla2
1
Department of Community Medicine; Pt. B.D. Sharma PGIMS; Rohtak (Haryana), India; 2Department of Community Medicine; SHKM Govt. Medical College;
Nalhar (Mewat), Haryana, India

is very important given that >25% of

Keywords: Communicable diseases, mor-
bidity, mortality, disability, vaccination
*Correspondence to: Ramesh Verma;
dr.rameshverma@yahoo.co.in
Submitted: 05/12/2014
Accepted: 05/23/2014
http://dx.doi.org/10.4161/21645515.2014.975011
V accination is recommended
throughout life to prevent infectious
diseases and their sequelae. Vaccines are
crucial to prevent mortality in that
>25% of deaths are due to infections.
Vaccines are recommended for adults on
the basis of a range of factors. Substantial
improvement and increases in adult vac-
cination are needed to reduce the health
consequences of vaccine-preventable dis-
eases among adults. Incomplete and
inadequate immunization in India
against these communicable diseases
results in substantial and unnecessary
costs both in terms of hospitalization and
treatment. The government of India as
well as the World Health Organization
(WHO) consider childhood vaccination
as the first priority, but there is not yet
focus on adult immunization. Adult
immunization in India is the most
ignored part of heath care services. The
Expert Group recommended that data on
infectious diseases in India should be
updated, refined, and reviewed periodi-
cally and published regularly. This group
suggested that the consensus guidelines
about adult immunization should be
reviewed every 3 years to incorporate
new strategies from any emerging
research from India. There is an immedi-
ate need to address the problem of adult
immunization in India. Although many
issues revolving around efficacy, safety,
and cost of introducing vaccines for
adults at the national level are yet to be
resolved, there is an urgent need to sensi-
tize the health planners as well as health
care providers regarding this pertinent
Email:
issue.
Vaccinations are recommended
throughout life to prevent infectious dis-
eases and their sequelae. Vaccines of adults
mortality are due to infectious diseases.
Vaccines are recommended for adults on
the basis of age, prior vaccinations, health
conditions, lifestyle, occupation, and
travel.1 There have been significant efforts
to curb morbidity, mortality, and disabil-
ity among adults particularly due to com-
municable diseases such as tetanus,
diphtheria, pertussis, hepatitis A, hepatitis
B, human papilloma virus, Japanese
encephalitis, measles, mumps, rubella,
meningococcus, pneumococcus, typhoid,
influenza, and chickenpox. Nevertheless,
in a developing country like India, com-
municable diseases contribute to a large
burden morbidity, mortality, and
disability.2
Substantial improvements in adult vac-
cination are needed to reduce the health
consequences of vaccine-preventable dis-
eases. Although adults have less chance of
getting infection, the emergence of HIV
and re-emergence of disease like malaria
and tuberculosis worldwide have compli-
cated prevailing fragile healthcare scenarios.
Incomplete and inadequate immunization
in India against these diseases results in
costs for hospitalization and treatment.
The adult population has increased oppor-
tunities of getting communicable diseases
owing to urbanization, globalization, and
increasing international travel.3
The government of India as well as the
WHO consider childhood vaccination as
the leading priority. However, there is no
focus on adult immunization,4-6 which
also is the most ignored part of healthcare
services in India. Adult vaccination cover-
age in India is negligible; even in a devel-
oped country like US, the coverage is only
2% of the adult population. The econom-
ically productive adult populations have
been denied the full benefit of personal

2180 Human Vaccines & Immunotherapeutics Volume 11 Issue 9

Table 1. Recommended adult vaccination schedule by Advisory Committee on Immunization Practices protection owing to either non-availability
(ACIP) of vaccines or those receiving vaccines not
Adult vaccines Schedule being protected to the fullest extent due to
incomplete effectiveness of available vac-
Tdap (tetanus toxoid, diphtheria toxoid & 0.5 mL, 0.5 mL, intramuscular (IM)
cines. Protecting adults by vaccination has
intramuscular (IM) acellular pertussis)10 Primary: 3 doses; 0, 1, 6–12 mo
Booster: Once every 10 y never been considered in India a preven-
Hepatitis A virus (HAV)9 tive strategy likely to have a great impact
Inactivated vaccine 1 mL (>18 y) IM (deltoid) on population health. This is true even in
Combination vaccine: 1 mL (>18 y) developed countries, although efforts have
HAV and Hepatitis B virus (HBV) 0, 1, 6 mo
been made in this regard in US and
IM (deltoid)
Europe.7
HBC Vaccine11 1 mL A recently published ‘National Vaccine
0, 1, 6 mo Policy – 2011’ by the India Ministry of
IM (deltoid) Health and Family Welfare, Government8
For Chronic Kidney Disease and other
gives guidelines to policy makers and pro-
immunosuppressed patients, 2 mL at 0, 1, 6 mo.
Boosters not recommended except in immuno- gram managers regarding various strategies
compromised patients for strengthening the ‘Universal Immuni-
sation Programme’, but the main focus is
Human papilloma virus (HPV)10 on children not adults. The Expert Group
HPV4 for types 6,11,16 and 18 0.5 mL
on Immunization explored this; in India
HPV2 for types 16 and 18 0, 1, 6 mo
IM (deltoid) there is paucity of epidemiological reliable
Japanese encephalitis12 data regarding the burden of communica-
Primary hamster kidney (PHK) 0.5 mL, ble diseases. This group also observed that
cell-cultured, live attenuated vaccine Subcutaneous (SC) few published data are available from India
(e.g., SA 14–14–2 vaccine) Booster after 1 y
regarding efficacy and safety of vaccines in
Measles, Mumps and Rubella11
Live attenuated vaccine 0.5ml adult immunization strategies. Because of
0, 1 mo scarcity data on communicable diseases
SC (at deltoid) and adequacy of immunization (e.g., opti-
mal antibody titers in adults for preventing
Meningococcal meningitis ploysaccharide9
various diseases), the Expert Group real-
Bivalent (A and C) 0.5ml SC at deltoid
1 dose ized that there is an urgent need for collect-
ing reliable epidemiological data in India
Quadrivalent (A, C, Y, W-135/MPSV4) 0.5ml SC at deltoid on infectious diseases, efficacy, and safety
2 doses (0, 2 mo) for asplenia data regarding various adult immunization
Pneumococcal13
strategies, and data regarding the adequacy
Polysaccharide – 23-valent 0.5 mL (SC), 1 dose
Conjugate – heptavalent 0.5 mL (IM) 2 doses of immunization in adults.9
Typhoid14 The Expert Group recommended that
Vi polysaccharide 0.5 mL data on infectious diseases in India should
SC/IM be updated, refined, and reviewed periodi-
Booster every 3 y
cally and published regularly. This group
Live oral Ty21a: Liquid suspension/ enteric- coated 3 doses on alternate days
capsule Booster: every 3 y, suggested that the consensus guidelines
Liquid recommended over live oral about adult immunization should be
Influenza15 reviewed every 3 y to incorporate new strat-
Trivalent inactivated (TIV) 0.5mL egies from emerging research in India. The
IM / Intradermal annual
Expert Group reviewed the available data
Live attenuated influenza vaccine Intranasal annual
from India and other countries and extrap-
Varicella (Chickenpox)16 olated to conditions in India, keeping in
Live attenuated (Oka strain) 0.5 mL view the cost-effectiveness of adult immu-
2 doses, 4–8 wk apart nization in a huge-population country like
SC (over deltoid)
India with limited resources. Various issues
Cholera17
Oral (monovalent inactivated killed whole cells 2 doses: 0, 6 wk were discussed by the ‘Expert Group Meet-
plus recombinant CTB) ing for evolving Consensus Recommenda-
tions on Adult Immunization in India’,
The following adult vaccination schedule was recommended by the Expert Group Meeting and the which was jointly organized on December
Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (CDC 6–7, 2008 by the Association of Physicians
ACIP) guidelines 2012.9
of India and the Department of Medicine,

www.tandfonline.com Human Vaccines & Immunotherapeutics 2181

All India Institute of Medical Sciences,
New Delhi (Table 1).
In summary, India needs to immedi-
ately address the challenge of adult
immunization. Although many issues
revolving around efficacy, safety and cost
of introducing vaccines for adults at the
national level are yet to be resolved,
there is an urgent need to sensitize
health planners as well as health care
providers regarding this pertinent issue.
Adult immunization practices and poli-
cies must be framed by the India Minis-
try of Health and Family Welfare, and
there need to be intensive efforts for the
provision of vaccines in the national
immunization schedule that could help
mitigate adult suffering from infectious
diseases. Adult vaccination must become
part of routine immunization because
these vaccines can save millions of lives
in India alone.
Disclosure of Potential Conflicts of Interest
No potential conflicts of interest were
disclosed.
2182
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