Immunization of adults is as important as that for children.
More than 25% of adult deaths are due to infections
preventable by vaccination. It is a vast neglected field in
India. Vaccines are recommended for adults on the basis of
age, prior vaccinations, health conditions, lifestyle,
occupation, and travel. Even in developed countries the
vaccination coverage of adult population is negligible [1].
The Centres for Disease Control and Preventions (CDCs)
Advisory Committee on Immunization Practices (ACIP) annually
reviews the recommended adult immunization schedule to ensure
that the schedule reflects current recommendations for the
licensed vaccine. Vaccines are recommended for adults on the
basis of their age, prior vaccinations, health conditions,
lifestyle, occupation, and travel [2].
The vaccines recommended for all adults are:
DPT
MMR
Influenza > 50yrs
Pneumococcal > 65yrs
Human papilloma virus 9 - 26 years
Zoster > 60yrs
Pneumococcal vaccine
The primary cause of vaccine preventable death in all age
groups is pneumococcal infection. The incidence of
pneumococcal infection increases according to the presence of
co morbid conditions like diabetes mellitus, alcoholism,
chronic liver disease, kidney disease etc. Pneumococcal
vaccination was also associated with a decrease of more than
50% in the rate myocardial infarction 2 years after exposure.
If confirmed, this association should generate interest in
exploring the putative mechanisms and may offer another reason
to promote pneumococcal vaccination.
Pneumococcal vaccine is available in two forms:
Polysaccharide vaccine, consisting of
polysaccharides from 23 serotypes (PPSV23). This vaccine is
less immunogenic, does not affect carrier rates, promote
herd immunity, or protect from respiratory tract infections
as there is no mucosal immunity.
Conjugated Vaccine with 13 serotypes consists of capsular
polysaccharides covalently bound to diphtheria toxoid, which
is highly immunogenic but nontoxic (PCV13). This combination
results in mucosal immunity and lifelong immunity.
Between age 19-64 years PPSV23 can be given to all those
having co morbid conditions like diabetes, chronic liver lung
or heart disease, alcoholics and smokers. Immunocompetent
elderly population (age > 64yrs) single shot of PCV
13 followed 1 yr later by PPSV23 can be given in younger
adults having severe immunosuppressive disorders like
malignancies, nephritic syndrome, retroviral infections etc.
One dose of PCV13 followed 8 weeks later by PPSV23 and repeat
at 5 yrs. Revaccination can be done with PPSV23 after at least
5 yrs. The ACIP recommendation was amended in 2015 to simplify
the spacing between PCV13 and PPSV23 in adults >65 years.
The old ACIP recommended that PPSV23 can be given after 6-12
months after PCV13. The new recommendation states that the
recommended interval for adults receiving PCV13 and PPV23 to
be at least 1 year apart, regardless of sequence. In summary,
this means that PCV13 is given first followed by PPSV23 with
spacing at least 1 year. If the adult above 65 years received
PPSV23, he will receive PCV13 after 1 year as the older
recommendation. Revaccination with PPSV23 within 5 years leads
to hypo responsiveness [3].
Influenza vaccine
The available vaccine in India is a killed virus vaccine to be
given intramuscularly. In June 2018, the ACIP updated
recommendations on the use of live attenuated influenza
vaccine (LAIV) after 2 influenza seasons (20162017 and
20172018) during which use of LAIV was not recommended in the
United States [4].
Indications of LAIV: For adults through age 49
years, except for those who have immunocompromising
conditions, including HIV infection; have anatomical or
functional asplenia; are pregnant; have close contact with or
are caregivers of severely immunocompromised persons in a
protected environment; have received influenza antiviral
medications in the previous 48 hours; or have cerebrospinal
fluid leak or a cochlear implant.
Those with a history of Guillain-Barre syndrome within 6 weeks
of a previous dose of influenza vaccine generally should not
be vaccinated. As the influenza virus constantly mutates, a
new batch is prepared every year. The vaccine becomes
effective against influenza virus 2 weeks after
administration. Since the peak influenza season begins in
October and lasts till May, October-November are the best
times to receive vaccination.
Indications for killed vaccine: Chronic
obstructive pulmonary disease, chronic kidney disease, cardiac
or lung diseases, hepatic, metabolic diseases (diabetes),
haematological diseases, pregnancy, nursing homes, health care
personnel, household contacts of children <5 years or
adults >50 years, diseases which impair respiratory
functions, and immunosuppressed individuals [5].
Tetanus diphtheria pertussis
For adults between 18 and 64 years who have completed their
primary vaccination schedule, a booster dose of Td vaccine is
indicated once every 10 years till the age of 65.
For adults who are more than 18 yrs but have not completed
the primary vaccination schedule two doses are administered at
least 4 weeks apart, and the third dose is given 6-12 months
after the second dose.
Health care personnel, especially those in direct contact
with the patients, who have not received Tdap vaccine, should
receive a single dose of Tdap vaccine if 2 years or more have
elapsed since the last dose of Td vaccination.
Women planning pregnancy should receive one dose of Tdap
vaccine if they did not receive it previously.
Pregnant women who have received the Td vaccination more
than 10 years ago should receive one dose of Td vaccine in the
second or third trimester of pregnancy.
For pregnant women who have not received any previous
vaccination 3 doses of Td vaccine are indicated; in the second
or third trimester of pregnancy, two doses are administered at
least 4 weeks apart, and the third dose is given 6-12 months
after the second dose.
Following minor trauma in non immunized individual or those
immunized more than 10 years if major wound both Td/Tdap and
TIG should be given.
If immunized <10 years ago only Td/Tdap is given and TIG
is not required [6].
Human papilloma virus
The vaccine protects against human papillomavirus (HPV) types
responsible for most cervical cancers and genital warts. It is
most effective when administered before onset of sexual
activity
It can be given to young males and females between the ages
of 9 and 26 years. In age group 9-14 years, 2 doses are
recommended at an interval of 6 months.
Immunocompromising conditions (including HIV infection)
through age 26 years: 3-dose series HPV vaccine at 0, 12, 6
months.
Men who have sex with men and transgender persons through
age 26 years: 2- or 3-dose series HPV vaccine.
Pregnancy through age 26 years: HPV vaccination not
recommended until after pregnancy [7].
MMR (Measles Mumps Rubella vaccine)
All adults should receive two doses of MMR vaccine or one dose
of measles followed by a dose of MMR, administered at least 4
weeks after the first dose. Since it is a live vaccine, it is
contraindicated in pregnant women and the immunosuppressed
[8].
Hepatitis B vaccine
It is not indicated to all adults [9].
Indications:
Patients with percutaneous or mucosal exposure to blood and
patients with sexual exposure should be vaccinated if not
immunized in childhood.
Persons at risk for occupational exposure to hepatitis B.
Patients who are human immunodeficiency virus (HIV)
seropositive.
Patients with chronic liver disease (CLD), chronic kidney
disease (CKD), and diseases where blood products or multiple
blood and patients awaiting major surgeries.
Dose: In adults, the dose is 20 μg. Booster is not
needed in immunocompetent adults. If the vaccination schedule
is interrupted after the first dose, the second dose should be
administered as soon as possible and the second and third
doses should be separated by an interval of at least 8 weeks.
Non-responders who are HBsAg and anti-HBc negative should
receive a further full course of vaccination as fourth, fifth,
and sixth doses. Booster doses of HBV vaccine are not
indicated in persons with normal immune status. A booster dose
may be administered when anti-HBs levels decline to < 10
mIU ml and > 65 years.
Hepatitis A vaccine
Vaccines against hepatitis A virus (HAV) include inactivated
vaccines as single antigen (HAV antigen) vaccines or combined
with HBV antigens.
Indications: Adults at high risk for acquiring
and transmitting HAV infection like food handlers, persons
infected with other hepatitis viruses, persons who have
received, or are awaiting a liver transplant.
Hepatitis A vaccine is indicated for all transplant candidates
with CLD or those patients of end-stage renal disease (ESRD)
who have chronic hepatitis B or C because of increased risk of
fulminant hepatic failure [10].
Typhoid vaccine
The available vaccines are inactivated whole cell vaccine,
live oral Ty21a vaccine, injectable Vi polysaccharide vaccine,
Vi- rEPA vaccine.
Three doses of Ty21a capsules/sachets are administered on
alternate days. This series should be repeated once in every 3
years as a booster dose. Ty21a should not be used during
pregnancy.
The Vi vaccine is given as a single subcutaneous or
intramuscular dose of 0.5 ml, with revaccination every 3
years.
Vaccination policy for renal disease patients is same as for
normal population. Live oral typhoid is contraindicated in
transplant recipient [11].
Meningococcal vaccine
The quadrivalent vaccines contain 50 μg of each of the
antigens A, C, Y, and W135.
Two types of quadrivalent vaccines are available. The
meningococcal polysaccharide vaccine (MPSV4) does not induce
herd immunity, has no effect on nasopharyngeal carriage, and
can be used only in those >2 years age.
Vaccination may be given to personnel living in dormitories,
military recruits, jail inmates, immunocompromised
individuals, such as those suffering from terminal complement
deficiency, splenectomy, active and passive smokers, systemic
lupus erythematosus, HIV, and multiple myeloma (2 doses
separated by 2 months for adult < 55 years).
For travellers, a single dose is recommended 10-14 days
before the scheduled visit depending on the prevalent serotype
in the visiting country.
The meningococcal conjugate vaccine (MCV4) provides herd
immunity, reduces nasopharyngeal carriage, provides
long-lasting immunity after 28 days of vaccination, but cannot
be used for people >55 years. MCV4 (conjugated) is
preferred for:
Adults who are aged 55 years or younger
Adults aged 56 years or older who (a) are vaccinated
previously with MCV4 and are recommended for revaccination, or
(b) for whom multiple doses are anticipated.
Adults aged 56 years or older who have not received MCV4
previously and who require a single dose only (e.g.,
travelers) [12].
Haemophilus influenzae vaccination
It is a part of primary immunization. Adults at high risk such
as patients with asplenia, HIV, hematological malignancies,
corticosteroid use, CSF leak, trauma, diabetes, pregnancy,
alcoholism, immunosuppression due to bone marrow or kidney
transplant, cancer, radiation, or chemotherapy should be
vaccinated [13].
Varicella vaccine
Two vaccines, both containing an attenuated live VZV are
currently available in India. All adults who have never had
chickenpox should receive 2 doses 0.5 ml in deltoid area
subcutaneously. For <13 years of age, the first dose is
administered at 12-15 months and the second dose at age 4-6
years. For people older than 13 years, the two doses are
administered 4-8 weeks apart [14].
References
1. National Vaccine Policy. Ministry of Health and Family
Welfare. Government of India. April 2011. Available
from:
http://mohfw.nic.in/WriteReadData/l892s/1084811197NATIONAL%20VACCINE%20POLICY%20BOOK.pdf.
2. Centers for Disease Control and Prevention 2012.
Recommended adult immunization schedule-United States 2012.
3. Ramesh V, Pardeep K. Pneumococcal conjugate vaccine: A
newer vaccine available in India. Hum Vaccin Immunother 2012;
28:1-4
4. Beyer WE, Versluis DJ, Kramer P, Diderich PP, Weimar W,
Masurel N. Trivalent influenza vaccine in patients on
haemodialysis: Impaired seroresponse with differences for
A-H3N2 and A-H1N1 vaccine components. Vaccine. 1987;5:438.
5. Guidelines API. Executive Summary The Association of
Physicians of India Evidence-Based Clinical Practice
Guidelines on Adult Immunization. Expert Group of the
Association of Physicians of India on dult ImmunizCenters for
Disease Control and Prevention 2012.
6. Recommended adult immunization scheduleUnited States
2012. [online] CDC website. Available from
www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule.pdf.
7. Markowitz LE, Hariri S, Lin C, Dunne EF, Steinau M,
McQuillan G, et al. Reduction in human papillomavirus (HPV)
prevalence among young women following HPV vaccine
introduction in the United States, National Health and
Nutrition Examination Surveys, 20032010. J Infect Dis
2013;208:38593.
8. Vashishtha VM, Choudhury P, Kalra A, Bose A, Thacker N,
Yewale VN, et al. Indian Academy of Pediatrics (IAP)
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Pediatr. 2014;51:785800.
9. Muruganathan A, Mathai D, Sharma SK, editors. Adult
Immunization. J Assoc Physicians India. 2014:1270.
10. Doshani M , Weng,M Moore KL et al
Recommendations of the advisory committee on immunization
practices for use of hepatitis A vaccine for persons
experiencing homelessness. MMWR Morb Mortal Wkly Rep
2019:68:153 -6.
11. Verma R, Bairwa M, Chawla S, Prinja S, Rajput M. New
generation typhoid vaccines: an effective preventive strategy
to control typhoid fever in developing countries. Hum Vaccin
2011; 7:883-5.
12. Centers for Disease Control and Prevention. Charter of the
Advisory Committee on Immunization Practices. Updated 1 April
2018. Accessed at
www.cdc.gov/vaccines/acip/committee/acip-charter.pdf on 6
September 2019.
13. Schuchat A, Jackson LA. Immunization principles and
vaccine use. In: Longo DL, editor; , Fauci AS, editor, Kasper
DL, editor; , Hauser SL, editor; Jameson JL, editor; Loscalzo
J, editor, Eds. Harrison's Principles of Internal Medicine.
New York, USA:McGraw-Hill publisher; 2011; 1031-41.
14. Dinesh K, Bhavana L, Zorawar S. Immunization Facts: Adult
Need Their Shots. JK science. 2009; 11(1):49-50.