When mediating over a disease,

I never think of nding a remedy for it,

But instead , a means of preventing it.
LOUIS PASTEUR
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ADULT IMMUNISATION
DR.RAJESH KUMAR .R
UNIT 4- GENERAL MEDICINE
PROF. DR. RAMESH SIR UNIT

Immunisation refers to arti cial induction of immunity . It can be

ACTIVE Immunisation - achieved by use of live attenuated infectious

agents or inactivated toxins or antigens obtained by genetic
recombination

PASSIVE Immunisation - temporary immunity achieved by use of

immunoglobulins or antitoxins
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 Why adult immunisation?

Immunosenescence- immunity conferred by childhood vaccines wanes

off by age

In the late 20th century, massive diphtheria outbreak occurred in

Russia spanning more than 157,000 cases and 5000 deaths which
occurred mostly in adults more than 45 years' age group This may be
attributed to the fact that immunity against pertussis following
primary booster wanes after 10 years.
Over 2 lakh babies are born with birth defects because of
Rubella infection during pregnancy in the India.

Around 132,000 women in India each year are detected with

cervical cancer, and 74,000 of them die of its complications.

Each year, 300,000 new hepatitis cases occur in India and over
40 million HBsAg carriers
Increased incidence of symptomatic hepatitis A among adults is
being reported among patients with acute viral hepatitis
 Annually around 205,286 deaths related to chronic hepatitis occur.

In uenza has a global annual attack rate of 5%–10% in adults and

20%–30% in children.In India, around 40,000 deaths occur due to
in uenza annually.

Numerous meningococcal outbreaks have been reported in temperate

northern regions of India, especially in and around Delhi, Meghalaya,
and Tripura

In India, more than 30% of the adolescent and adult population

above 15 years of age are susceptible to varicella]
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Nowadays, due to increasing incidence of HIV and other immunocompromised states such as
diabetes, herpes is being evidently seen in the younger adult population too.

Community-acquired pneumonia is the second-most common reason of death from infectious

diseases in the Indian subcontinent.

Only 47% of adults over the age of 20 years were found to have protective antibodies to
tetanus and diphtheria. Between 2001 and 2016, the Centers for Disease Control and
Prevention (CDC) – US Department of Health and Human Services – reported 1261 cases
including 16 neonatal cases. Thirteen cases of respiratory diphtheria were reported to the CDC
from 1996 to 2016.

A major outbreak of measles was noted in Kerala, with a large number of students in the age
group of 13–19 years being involved.
 Recommendations available

Advisory committee on immune practices (AICP) guidelines from

CDC

WHO guidelines

API expert panel guidelines 2008

 AICP Guidelines ,CDC 2022

Recommends adult immunisation schedule for ages 19 yrs and

older

Recommends vaccines based on age , medical conditions and other

indications.
 Vaccines Available
Hepatitis A vaccine

Hepatitis B vaccine

Hepatitis A & B vaccine

Hemophilus in uenza type B vaccine

Human papilloma virus vaccine

In uenza vaccine - live attenuated , inactivated & recombinant .

Measles , mumps and rubella vaccine

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Meningococcal vaccine (serogrp B & serogrp AWCY vaccine)

Pneumococcal vaccine - conjugate (PCV 15, PCV 20) &

polysaccharide vaccine (PPSV 23)

Tetanus , diphtheria , pertussis vaccines - Td(tetanus &diptheria

toxoid) and Tdap(tetanus &diptheria toxoids plus acellular pertussis
vaccine)

Varicella vaccine

Zoster vaccine - recombinant

 Haemophilus influenza B Vaccine
H.In uenza B is the most common cause of bacterial meningitis and other invasive diseases
such as epiglottitis, pneumonia, septic arthritis, and bacteremia.

In a randomized control trial, it was noted that H.In uenza B conjugate vaccines prevented
more than 95% of invasive HiB disease.

Dose

This vaccine is administered as a single 0.5 ml dose of HiB conjugate vaccine intramuscularly.
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Anatomical or functional asplenia (including sickle cell disease):
1 dose if previously did not receive Hib; if elective splenectomy, 1
dose, preferably at least 14 days before splenectomy

Hematopoietic stem cell transplant (HSCT): 3-dose series 4 weeks

apart starting 6–12 months after successful transplant, regardless of
Hib vaccination history
 Hepatitis A Vaccine
Hepatitis A, spread by close contact with affected individuals, mainly via fecal-oral route, is highly
endemic in the Indian subcontinent.

Vaccine type
1) Live attenuated hepatitis A vaccine is available in India which is well-tolerated and is highly
immunogenic.
2) A combination inactivated vaccine which contains hepatitis A (Havrix) and hepatitis B
(Engerix-B).

Dose
1)Two-dose series Hep A (Havrix 6–12 months apart or Vaqta 6–18 months apart [minimum
interval: 6 months])
2)Three-dose series Hep A-Hep B (Twinrix at 0, 1, 6 months [minimum interval: 4 weeks between
doses 1 and 2 and 5 months between doses 2 and 3]).
1)Chronic liver disease (e.g., persons with hepatitis B, hepatitis C, cirrhosis, fatty liver
disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase [ALT] or
aspartate aminotransferase [AST] level greater than twice the upper limit of normal)

2)HIV infection
3)Men who have sex with men
4)Injection or noninjection drug use )
5)Persons experiencing homelessness
6)Work with hepatitis A virus in research laboratory or with nonhuman primates with
hepatitis A virus infection

7)Travel in countries with high or intermediate endemic hepatitis A (HepA-HepB [Twinrix]

may be administered on an accelerated schedule of 3 doses at 0, 7, and 21–30 days, followed
by a booster dose at 12 months)

8)Pregnancy if at risk for infection or severe outcome from infection during pregnancy








 Hepatitis B Vaccine
Hepatitis B is a major public health problem in India, especially among health-care workers and other high-risk groups.

Vaccine types
Hepatitis B vaccine is available as recombinant vaccine
Heplisav-B, Engerix-B, and Recombivax-HB are the three recombinant vaccines available. Heplisav-B combines hepatitis B
surface antigen with Dynavax's proprietary toll-like receptor agonist to enhance the immune response, while Engerix-B
does not contain any adjuvant.

Dose and schedule

Heplisav-B - Two doses -atleast 4 weeks apart
Engerix-B or Recombivax-HB - 3 doses-at 0, 1, and 6 months .A minimum interval of 4 weeks between the rst two
doses, an interval of 8 weeks between second and third doses, and an interval of 16 weeks between doses rst and
third dose are recommended.

In adults, the dose is 20 mcg, and in those on hemodialysis, the dose is 40 mcg. Booster may be administered when
anti-HB level decline to <10 mIU/ml and more than 65 years.

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Routine vaccination

Age 19 through 59 years: complete a 2- or 3-, or 4-dose series

-2-dose series only applies when 2 doses of Heplisav-B* are used at least 4 weeks apart

- 3-dose series Engerix-B or Recombivax HB at 0, 1, 6 months [minimum intervals: dose 1 to

dose 2: 4 weeks / dose 2 to dose 3: 8 weeks / dose 1 to dose 3: 16 weeks])

- 3-dose series HepA-HepB (Twinrix at 0, 1, 6 months [minimum intervals: dose 1 to dose 2: 4

weeks / dose 2 to dose 3: 5 months])

- 4-dose series HepA-HepB (Twinrix) accelerated schedule of 3 doses at 0, 7, and 21–30 days,
followed by a booster dose at 12 months

- 4-dose series Engerix-B at 0, 1, 2, and 6 months for persons on adult hemodialysis (note: each
dosage is double that of normal adult dose, i.e., 2 mL instead of 1 mL)

*Note: Heplisav-B not recommended in pregnancy due to lack of safety data in pregnant women
Special situations

Age 60 years or older* and at risk for hepatitis B virus infection:

- Chronic liver disease (e.g., persons with hepatitis C, cirrhosis, fatty liver disease, alcoholic liver disease,
autoimmune hepatitis, alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater
than twice upper limit of normal)

- HIV infection
- Sexual exposure risk

- Current or recent injection drug use

- Percutaneous or mucosal risk for exposure to blood (e.g., household contacts of HBsAg-positive
persons; residents and staff of facilities for developmentally disabled persons; health care and public safety
personnel with reasonably anticipated risk for exposure to blood or blood-contaminated body uids;
hemodialysis, peritoneal dialysis, home dialysis, and predialysis patients; patients with diabetes)
- Travel in countries with high or intermediate endemic hepatitis B

*Note: Anyone age 60 years or older who does not meet risk-based recommendations may still receive
Hepatitis B vaccination.




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 Human papilloma virus vaccine
Human papillomavirus (HPV) is a sexually transmitted pathogen. Persistent infection
with high-risk genotypes such as 16 and 18 causes 70% of all cancers of the cervix.

Strains 6 and 11 are known to cause genital warts; hence, the quadrivalent vaccine is
preferred in males.

Vaccine types

A quadrivalent HPV4 vaccine containing L1 protein-like particles of HPV6, HPV11,

HPV16, and HPV18 marketed as Gardasil

Dose

Three doses of 0.5 ml intramuscular in deltoid at 0, 2, and 6 months are administered.

 HPV vaccination recommended for all persons unto age 26 years:

2- or 3-dose series depends on age at initial vaccination or condition:

- Age 15 years or older at initial vaccination: 3-dose series at 0, 2 months, 6 months

-Age 9–14 years at initial vaccination and received 1 dose or 2 doses less than 5 months
apart: 1 additional dose

-Age 9–14 years at initial vaccination and received 2 doses at least 5 months apart: HPV
vaccination series complete, no additional dose needed

Special situations
- Immunocompromising conditions, including HIV infection: 3-dose series, even for those who
initiate vaccination at age 9 through 14 years.
- Pregnancy: Pregnancy testing is not needed before vaccination; HPV vaccination is not
recommended until after pregnancy; no intervention needed if inadvertently vaccinated while
pregnant






 In uenza vaccine
In tropics and subtropics like India, complexities of in uenza such as multiple peaks and year-round activity
are noted among the elderly, especially the geriatric age group.

Vaccine type

The available vaccines in India are quadrivalent inactivated and live attenuated vaccine

Quadrivalent in uenza vaccine contains two in uenza A strains and two in uenza B strains.

Dose

A single dose of 0.5 ml intramuscular injection to deltoid containing 45 mcg of hemagglutinin in uenza antigen
inoculation or live attenuated in uenza vaccine (LAIV) as 0.5 ml intranasal spray (0.25 ml/nostril) is currently
recommended. The vaccine is only effective 2 weeks after administration.

Optimal schedule

September is considered to be optimal time to receive the vaccine. It has been noted that the annual dose of
vaccine reduced the mortality by 41%, while complications and the length of hospital stay have been reduced
by 75% in those vaccinated previously
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All persons aged ≥6 months who do not have contraindications should be vaccinated annually.

However, vaccination to prevent in uenza is particularly important for persons who are at increased risk for
severe illness and complications from in uenza

• All children aged 6 through 59 months.

• All persons aged ≥50 years.

• Adults and children who have chronic pulmonary (including asthma), cardiovascular (excluding isolated
hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus).

• Persons who are immunocompromised due to any cause (including but not limited to immunosuppression
caused by medications or HIV infection).

• Persons who are or will be pregnant during the in uenza season

• Residents of nursing homes and other long-term care facilitieS

• Persons who are extremely obese (body mass index ≥40 for adults)
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 Measles, mumps and rubella vaccine
Measles is a major killer of children, mainly in developing countries.

Complications from measles affect every organ, and adults are likely to suffer encephalitis, hepatitis,
hypocalcemia, and pancreatitis.

Although Mumps manifests as a mild disease in adults but still 10% of individuals who are affected by the disease
have been noted to develop complications.

Dose and schedule

All adults born in 1957 or later without acceptable level of immunity to measles, mumps, and rubella (MMR) and
nonpregnant women of childbearing age without evidence of rubella immunity with focus on reducing congenital
rubella syndrome should be given one dose of MMR vaccine, 0.5 ml, subcutaneous in outer aspects of triceps.

Two-dose MMR vaccine is recommended in health-care workers, students planning to travel, and adults with HIV
with CD4 more than 200 cells for at least 6–12 months

In outbreak scenario, two doses separated by 28 days are to be administered with the rst dose 72 h after the
initial exposure.

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Special situations

1) Pregnancy with no evidence of immunity to rubella: MMR contraindicated during pregnancy; after
pregnancy (before discharge from health care facility), 1 dose

Nonpregnant women of childbearing age with no evidence of immunity to rubella: 1 dose

2) HIV infection with CD4 percentages ≥15% and CD4 count ≥200 cells/mm3 for at least 6
months and no evidence of immunity to measles, mumps, or rubella: 2-dose series at least 4 weeks
apart; MMR contraindicated for HIV infection with CD4 percentage <15% or CD4 count <200 cells/mm3

3 )Severe immunocompromising conditions: MMR contraindicated

4) Students in postsecondary educational institutions, international travelers, and household or

close, personal contacts of immunocompromised persons with no evidence of immunity to measles,
mumps, or rubella: 2-dose series at least 4 weeks apart if previously did not receive any doses of
MMR or 1 dose if previously received 1 dose MMR

5) Health care personnel: with no evidence of immunity to measles, mumps and rubella
2-dose series at least 4 weeks apart for measles or mumps or at least 1 dose for rubella



 MMR vaccine contd.

Evidence of immunity:

Born before 1957 , documentation of receipt of MMR vaccine,

laboratory evidence of immunity or disease (diagnosis of disease
without laboratory con rmation is not evidence of immunity
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 Meningococcal vaccine
Meningococcal meningitis, caused by Neisseria meningitidis, is one of the most
devastating infections and tends to strike young individuals which can
progress over hours to death.

It is an inactivated vaccine - 2 types

1)Quadrivalent meningococcal vaccine, which contains 50 mcg of each of the

capsular polysaccharide antigens from serogroups A, C, Y, and W135
conjugated to diphtheria toxoid.[59]

2)Monovalent meningococcal vaccine, which is not available in India.

Special situations for MenACWY

Anatomical or functional asplenia (including sickle

cell disease), HIV infection, persistent complement component de ciency,
complement inhibitor (e.g., eculizumab, ravulizumab) use: 2-dose series -at
least 8 weeks apart and revaccinate every 5 years if risk remains

Travel in countries with hyperendemic or epidemic meningococcal disease, or

microbiologists routinely exposed to Neisseria meningitidis: 1 dose MenACWY
and revaccinate every 5 years if risk remains

3)First-year college students who live in residential housing (if not previously
vaccinated at age 16 years or older) or military recruits: 1 dose MenACWY



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 Pneumococcal vaccine
Pneumococcal infection caused by Streptococcus pneumoniae is the leading bacterial
cause of pneumonia, otitis media, sinusitis, and bronchitis and leads to invasive
pneumococcal disease.

In adults, serotypes 1, 3, 6, 7, 9, 14, 19, and 23 are most prevalent. The most common
serotype-1 accounts for one-fourth of invasive infections in the Indian population, while
in the Indian population, serotype-6 accounts for 11.5% of invasive infections.

Vaccine type

Pneumococcal polysaccharide vaccine (PPSV) and pneumococcal conjugate vaccine (PCV)

are the two kinds of pneumococcal vaccine available for clinical use.

The current PPSV23 provides protection against 80%–90% of the pneumococcal capsular
serotypes causing disease.
 CDC recommends vaccination for :
•
 Adults 65 years old and older
• Adults 19 through 64 years old with certain underlying medical
conditions or other risk factors:
– Alcoholism
– Cerebrospinal uid leak
– Chronic heart/liver/lung disease – Chronic renal failure*
– Cigarette smoking
– Cochlear implant
– Congenital or acquired asplenia*
– Congenital or acquired immunode ciencies*
– Diabetes
– Generalized malignancy*
– HIV infection*
– Hodgkin disease*
– Iatrogenic immunosuppression*
– Leukemia*
– Lymphoma*
– Multiple myeloma*
– Nephrotic syndrome*
– Sickle cell disease or other hemoglobinopathies* – Solid organ transplants*
* Considered an immunocompromising condition
•








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 In India PCV15 and PCV 20 are not available

Dose and optimal schedule in India

In adults more than 65 years of age, a single dose 0.5 ml

intramuscular to deltoid of PCV13 followed by PPSV23 after 1 year
is recommended,

whereas in immunocompromised individuals, PCV13 followed by

PPSV23 after 8 weeks with PPSV23 booster after 5 years is advised.
The two vaccines must not be co-administered and the minimum
acceptable interval between the two is 8 weeks.
 Tetanus , diphtheria and pertussis vaccine
Routine vaccination
Previously did not receive Tdap at or after age 11 years: 1 dose Tdap, then Td or Tdap every 10 years

Special situations
Previously did not receive primary vaccination series for tetanus, diphtheria, or pertussis: 1 dose Tdap
followed by 1 dose Td or Tdap at least 4 weeks after Tdap and another dose Td or Tdap 6–12 months after last Td
or Tdap (Tdap can be substituted for any Td dose, but preferred as rst dose), Td or Tdap every 10 years
thereafter

Pregnancy: 1 dose Tdap during each pregnancy, preferably in early part of gestational weeks 27–36

Wound management: Persons with 3 or more doses of tetanus-toxoid-containing vaccine: For clean and minor
wounds, administer Tdap or Td if more than 10 years since last dose of tetanus-toxoid-containing vaccine; for all
other wounds, administer Tdap or Td if more than 5 years since last dose of tetanus-toxoid-containing vaccine. Tdap
is preferred for persons who have not previously received Tdap or whose Tdap history is unknown. If a tetanus-
toxoid- containing vaccine is indicated for a pregnant woman, use Tdap.
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 Varicella vaccine

Varicella can cause signi cant complications such as soft-tissue infection,

pneumonia, hepatitis, and encephalitis in adults, pregnant women, and
immunocompromised hosts.

Vaccine type-Live attenuated vaccine

All adults who have never had chickenpox are recommended to receive two
doses of 0.5 ml in the deltoid area subcutaneously.
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 Special situations

Pregnancy with no evidence of immunity to varicella: VAR contraindicated during

pregnancy; after pregnancy , 1 dose if previously received 1 dose varicella-containing
vaccine
or dose 1 of 2-dose series (dose 2: 4–8 weeks later) if previously did not receive any
varicella-containing vaccine,

Health care personnel with no evidence of immunity

to varicella: 1 dose if previously received 1 dose varicella- containing vaccine; 2-dose
series 4–8 weeks apart if previously did not receive any varicella-containing vaccine

HIV infection with CD4 percentages ≥15% and CD4 count ≥200 cells/mm3 with no
evidence of immunity: Vaccination may be considered (2 doses 3 months apart); VAR
contraindicated for HIV infection with CD4 percentage <15% or CD4 count <200 cells/mm3

Severe immunocompromising conditions: VAR contraindicated





 Zoster Vaccine
Herpes zoster/shingles is a neurocutaneous disease that occurs due to reactivation of varicella-zoster virus.

Vaccine types and schedule

Recombinant zoster vaccine(Shingrix) separated by 2–6 months, are preferred over live zoster due to better
immunogenicity. [31]

All adults more than 50 years are advised to take zoster vaccination.

Special situations

Pregnancy: There is currently no ACIP recommendation for RZV use in pregnancy. Consider delaying RZV
until after pregnancy.

Immunocompromising conditions (including HIV): RZV recommended for use in persons age 19 years or
older
who are or will be immunode cient or immunosuppressed because of disease or therapy


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 Vaccines for diabetics

Annual u vaccine

Pneumococcal

Hepatitis B

Zoster

Tdap
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 Vaccines for lung diseases inc asthma
And heart diseases

In uenza

Pneumococcal

Zoster

Tdap
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 Vaccines in liver diseases
Hepatitis A

Hepatitis B

In uenza

Zoster

Pneumococcal

Hpv

Varicella

MMR

Tdap
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 Vaccines in renal disease
In uenza

Tdap

pneumococcal

Hepatitis b

Zoster

Hpv

MMR

Varicella
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 Vaccines in pregnancy

Tdap

In uenza

Covid

Avoid live vaccines

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 Vaccines for HCWs
Annual in uenza

Hepatitis B

Varicella vaccine

MMR

Tdap

Meningococcal - microbiologist
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 Vaccines in elderly

Annual in uenza

Pneumococcal

Zoster

Tdap
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 Vaccines in HIV

Irrespective of CD count - annual in uenza , Tdap, hepatitis B ,

Pneumococcal, meningococcal,

CD count > 200- MMR , Varicella HPBV

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Thank you