Abstract
Vaccination 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 vaccination are needed to reduce the health consequences of vaccine-preventable diseases 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 periodically 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 immediate 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 sensitize the health planners as well as health care providers regarding this pertinent issue.
Keywords: Communicable diseases, morbidity, mortality, disability, vaccination
Vaccinations are recommended throughout life to prevent infectious diseases and their sequelae. Vaccines of adults is very important given that >25% of 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 disability among adults particularly due to communicable 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, communicable diseases contribute to a large burden morbidity, mortality, and disability.2
Substantial improvements in adult vaccination are needed to reduce the health consequences of vaccine-preventable diseases. Although adults have less chance of getting infection, the emergence of HIV and re-emergence of disease like malaria and tuberculosis worldwide have complicated 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 opportunities 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 coverage in India is negligible; even in a developed country like US, the coverage is only 2% of the adult population. The economically productive adult populations have been denied the full benefit of personal protection owing to either non-availability of vaccines or those receiving vaccines not being protected to the fullest extent due to incomplete effectiveness of available vaccines. Protecting adults by vaccination has never been considered in India a preventive strategy likely to have a great impact on population health. This is true even in developed countries, although efforts have been made in this regard in US and Europe.7
A recently published ‘National Vaccine Policy – 2011’ by the India Ministry of Health and Family Welfare, Government8 gives guidelines to policy makers and program managers regarding various strategies for strengthening the ‘Universal Immunisation Programme’, but the main focus is on children not adults. The Expert Group on Immunization explored this; in India there is paucity of epidemiological reliable data regarding the burden of communicable diseases. This group also observed that few published data are available from India regarding efficacy and safety of vaccines in adult immunization strategies. Because of scarcity data on communicable diseases and adequacy of immunization (e.g., optimal antibody titers in adults for preventing various diseases), the Expert Group realized that there is an urgent need for collecting reliable epidemiological data in India on infectious diseases, efficacy, and safety data regarding various adult immunization strategies, and data regarding the adequacy of immunization in adults.9
The Expert Group recommended that data on infectious diseases in India should be updated, refined, and reviewed periodically and published regularly. This group suggested that the consensus guidelines about adult immunization should be reviewed every 3 y to incorporate new strategies from emerging research in India. The Expert Group reviewed the available data from India and other countries and extrapolated to conditions in India, keeping in view the cost-effectiveness of adult immunization in a huge-population country like India with limited resources. Various issues were discussed by the ‘Expert Group Meeting for evolving Consensus Recommendations on Adult Immunization in India’, which was jointly organized on December 6–7, 2008 by the Association of Physicians of India and the Department of Medicine, All India Institute of Medical Sciences, New Delhi (Table 1).
Table 1.
Recommended adult vaccination schedule by Advisory Committee on Immunization Practices (ACIP)
| Adult vaccines | Schedule |
|---|---|
| Tdap (tetanus toxoid, diphtheria toxoid & 0.5 mL, intramuscular (IM) acellular pertussis)10 | 0.5 mL, intramuscular (IM) Primary: 3 doses; 0, 1, 6–12 mo Booster: Once every 10 y |
| Hepatitis A virus (HAV)9 | |
| Inactivated vaccine | 1 mL (>18 y) IM (deltoid) |
| Combination vaccine: HAV and Hepatitis B virus (HBV) |
1 mL (>18 y) 0, 1, 6 mo IM (deltoid) |
| HBC Vaccine11 | 1 mL 0, 1, 6 mo IM (deltoid) For Chronic Kidney Disease and other immunosuppressed patients, 2 mL at 0, 1, 6 mo. Boosters not recommended except in immuno-compromised patients |
| Human papilloma virus (HPV)10 | |
| HPV4 for types 6,11,16 and 18 HPV2 for types 16 and 18 |
0.5 mL 0, 1, 6 mo IM (deltoid) |
| Japanese encephalitis12 | |
| Primary hamster kidney (PHK) cell-cultured, live attenuated vaccine (e.g., SA 14–14–2 vaccine) |
0.5 mL, Subcutaneous (SC) Booster after 1 y |
| Measles, Mumps and Rubella11 | |
| Live attenuated vaccine | 0.5ml 0, 1 mo SC (at deltoid) |
| Meningococcal meningitis ploysaccharide9 | |
| Bivalent (A and C) | 0.5ml SC at deltoid 1 dose |
| Quadrivalent (A, C, Y, W-135/MPSV4) | 0.5ml SC at deltoid 2 doses (0, 2 mo) for asplenia |
| Pneumococcal13 | |
| Polysaccharide – 23-valent | 0.5 mL (SC), 1 dose |
| Conjugate – heptavalent | 0.5 mL (IM) 2 doses |
| Typhoid14 | |
| Vi polysaccharide | 0.5 mL SC/IM Booster every 3 y |
| Live oral Ty21a: Liquid suspension/ enteric- coated capsule | 3 doses on alternate days Booster: every 3 y, Liquid recommended over live oral |
| Influenza15 | |
| Trivalent inactivated (TIV) | 0.5mL IM / Intradermal annual |
| Live attenuated influenza vaccine | Intranasal annual |
| Varicella (Chickenpox)16 | |
| Live attenuated (Oka strain) | 0.5 mL 2 doses, 4–8 wk apart SC (over deltoid) |
| Cholera17 | |
| Oral (monovalent inactivated killed whole cells plus recombinant CTB) | 2 doses: 0, 6 wk |
The following adult vaccination schedule was recommended by the Expert Group Meeting and the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (CDC ACIP) guidelines 2012.9
In summary, India needs to immediately 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 policies must be framed by the India Ministry 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.
References
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