Vaccination in the adult could pave way for prevention of
many infective pathologies, which were hitherto bereft of
solutions other than antibiotics, to which organisms are
increasingly becoming resistant. Vaccination in the
adult, has, however, taken a backseat in India. The nation
has, as yet, not completed immunizing the paediatric
population fully against all preventable infective diseases,
and so the onus of immunizing the adult population has as
yet not received any impetus in the country. However , it
is useful to know the adult vaccinations currently available
and the possible populations in whom they could be useful.
This is the commonest vaccination given in India, and is
prescribed after a cut or a wound, beside pregnant women.
The full basic course of immunisation against tetanus toxiod
consists of three primary doses of 0.5ml at least four weeks
apart, deep intramuscularly, followed by booster doses at 18
months, 5 years, 10 years and 16 years and then every 10
years. Where the immunization history is inadequate 1500
IU tetanus antiserum and 0.5ml Tetanus toxoid should be
injected, with separate syringes, to different body sites.
(If available, 250 units of tetanus immune globulin (human
origin) can be substituted for the tetanus antiserum).
A second 0.5ml dose of toxoid is recommended after 2 weeks
and a third dose after a further 1 month.
Tetanus, diphtheria, acellular
Tdap/DTaP vaccines which are now
available in India are a newer version of DTP vaccine.
Tdap/DTaP vaccine which contains acellular pertusis vaccine
is safer as it causes lesser adverse reactions than the
older DTP vaccine.
Expert Group of the Association of Physicians of
India on Adult Immunization in India recommends routine Tdap
vaccination for all adults not immunized earlier. For adults
in the age group of 18 to 64 years who have completed their
childhood vaccination schedule, a booster dose of Td vaccine
is indicated once every 10 years till the age of 65 years;
one dose of Tdap vaccine may be administered in place of Td
For unvaccinated adults, administer the first 2 doses at
least 4 weeks apart and the third dose 6–12 months after the
second. If incompletely vaccinated (i.e., less than 3
doses), administer remaining doses.
Assossiation of Physicians of India (API) expert group does
not recommend the available oral vaccines for routine adult
immunization. Some of them have waning efficacy and some,
Hepatitis A vaccine
At present there is lack of evidence for recommending
universal vaccination against hepatitis A in India. close
personal contacts; child-care center staff, attendees, and
household members of the attendees and persons exposed to a
common source, such as infected food handlers need
protection after exposure to hepatitis A. Immune status for
hepatitis A should be checked prior to vaccination.
In healthy persons aged between 1 and 40 years, a
single-antigen hepatitis A vaccine is preferred. However,
after 40 years, the manifestations of hepatitis A are more
severe. For them, administration of anti-HAV immunoglobulin
(0.02 ml/kg, intramuscularly) as soon as possible, within
two weeks following exposure is preferred since little
information is available regarding the performance of the
vaccine in this age group. If the anti-HAV immunoglobulin is
not available, the vaccine can be used.
Glaxo's HAV costs Rs 1,000 per dose.` Primary vaccination
protects the person for up to one year and a booster dose
administered after six months provides protection for 20
years. Thus it should be administered as
2 doses 6- 12 months apart 1 ml IM . Merck’s Vaqta can
alternately be used, in dose of 1ml in 2 doses, second dose
Hepatitis B vaccine
Hepatitis B vaccination is indicated for all unvaccinated
adults at risk for HBV infection and all adults seeking
protection from HBV infection including post-exposure
prophylaxis. They include patients with sexual exposure.
injection-drug users; household contacts of persons with
chronic HBV infection; inmates and staff of institutions for
developmentally disabled persons in long-term care
facilities; dialysis staff, laboratory staff dealing with
blood samples, blood bank staff, nurses working in intensive
care units, operation theaters and surgeons and other
doctors at high-risk ; patients who are HIV-seropositive,
patients with CLD, chronic kidney disease (CKD); diseases
where blood products or multiple blood transfusions are
required such as hemophilia, aplastic anemia, leukemia,
hemoglobinopathies, and patients awaiting major surgeries.
homosexuals; promiscuous heterosexuals; commercial sex
workers; and sex partners of HBsAg-positive persons.
For immunocompetent adults, 20 µg of recombinant vaccine is
administered at 0, 1, and 6 months .
If the combined hepatitis A and hepatitis B vaccine
(Twinrix) is used, give 3 doses at 0, 1, and 6 months;
alternatively, a 4-dose Twinrix schedule, administered on
days 0, 7, and 21–30 followed by a booster dose at month 12
may be used.
Herpes Zoster vaccination
Indications:The expert group from API
that presently herpes zoster vaccine is not recommended for
use in adult population, with or without comorbid conditions
as reliable epidemiological data are not available from
India regarding the burden of herpes zoster.
Dose: Herpes zoster vaccine is administered as a single 0.65
ml dose subcutaneously in the deltoid region of the upper
Varicella vaccine is recommended for post-exposure
administration for unvaccinated persons without other
evidence of immunity against varicella. It should preferably
be given within 3 days of exposure to varicella rash and can
be given up to 5 days of exposure to rash . In case of an
outbreak, it can be used to control the outbreak by
vaccinating unaffected people. It is also
recommended in adults at increased risk for exposure of
varicella such as health care personnel, household contacts
of immunocompromised persons, non-pregnant women of
childbearing age, persons who live or work in environments
in which transmission of VZV is likely (e.g., teachers,
day-care employees, residents and staff in institutional
settings), persons who live or work in environments in which
transmission has been reported (e.g., college students,
inmates and staff members of correctional institutions, and
military personnel), adolescents and adults living in
households with children, and international travelers.
vaccines for varicella virus are currently available in
India. These are Varilrix and Okavax . Two doses (0.5 ml
each) of varicella vaccine subcutaneously over the deltoid
region. Minimum interval between first and the second doses
should be 4 weeks. If more than 8 weeks elapse after the
first dose, the second dose may be administered without
restarting the schedule. Those who have received one dose of
vaccine in childhood are advised to get their second dose.
Varicella zoster immune globulin (vzig) is at present not
available in India.
In the absence of epidemiological surveillance regarding the
influenza serotypes in our country, the Expert Group of API
observed that presently the use of influenza vaccine in
India is not recommended.
Trivalent inactivated influenza vaccine (TIV) and live
attenuated influenza vaccine (LAIV) are available for use in
In India it will cost
The TIV is administered by an annual, single intramuscular
dose of 0.5 ml.for all agegroups.
Measles Mumps rubella vaccine
ll adults (except those who have medically documented
history of having suffered from all the three disease; those
who have received two doses of MMR vaccine in the childhood;
and those with any contraindications for receiving this
vaccine), should receive one dose of the MMR vaccine.
Hospital employees, particularly those working in the O and
G Department are at risk. At the start of their employment,
the health care workers should be vaccinated. Provision of
this vaccine to both medical and nursing students before
they enter the hospital environment (ie pre-clinical phase)
would help prevent the hospital-based outbreaks and would
protect the female health personnel before their first
For adult immunization, two doses of the vaccine are
recommended 4-6 weeks apart.
Indication: Routine vaccination of all adults is not
recommended in view of the short lived protection provided
by the currently available polysaccharide vaccines. The
meningococcal vaccine can be used in selected populations in
certain situations such as during an outbreak, during inter
epidemic periods to persons living in dormitories and
immunocompromised individuals, to travellers, pilgrims,
people attending fairs and festivals in large numbers.
In India bivalent (A+C) and quadrivalent (A,C, Y, W 135)
polysaccharide meningococcal vaccines are marketed by few
A single dose of 0.5 ml of reconstituted vaccine is
administered subcutaneously in the deltoid region for
adults. Immunity is conferred for a period of only three to
Pneumococcal Polysacharide vaccine (PPSV)
Although PPV is efficacious in preventing invasive
pneumococcal disease among adults, routine PPV
administration to adults is not likely to be cost-effective
Single dose vaccination. cost: around Rs. 4,500.
Human Papilloma Virus Vaccines
Two HPV vaccines are commercially available. These include
Gardasil, a quadrivalent vaccine containing the HPV virus L1
protein like particles of HPV 6,11,16, and 18; Cervarix is a
bivalent vaccine containing L1 VLPs of HPV 16,18.
For the Gardasil vaccine, 3 doses are administered as 0.5 ml
intramuscular injection at 0, 2, and 6 months. The minimum
interval between the 1st and 2nd doses and the 2nd and 3rd
doses should be 4 weeks and 12 weeks respectively. For the
Cervarix vaccine, 3 doses are administered as 0.5 ml
intramuscular injection at 0, 1 and 6 months.
Immunization must precede the sexual debut. initiation for
vaccination is recommended to be 10 - 12 years . Catch-up
vaccination can be advised up to the age of 26 years for
Gardasil vaccine and 45 years for Cervarix vaccine .
The HPV vaccine is contraindicated during pregnancy and in
patients with hypersensitivity to any of the vaccine
components. In case a patient becomes pregnant during the
course of vaccination, the subsequent doses should be
delayed till delivery, but, should be completed within 1
year. Screening for cervical cancer should be continued in
spite of HPV vaccination.
Rabies vaccine is indicated, in two categories of people
Category III: Single or multiple transdermal bites,
scratches or contamination of mucous membrane with salinva (i.e.licks),
exposure to bats: In these cases, vaccination and the use
of rabies immunoglobulin is indicated in addition to wound
Category II: If there are only minor scratches or abrasions
without bleeding or licks on broken skin and nibbling of
uncovered skin, use of vaccine alone is sufficient.
Category I: In case of just touching, feeding of animals or
licks on intact skin, no prophylaxis is needed.
The tissue culture rabies vaccines are administered in the
deltoid muscle or in the anterolateral part of the thigh.
They are not to be injected in the gluteal region. Five
doses of the vaccine are administered on days 0, 3, 7, 14,
and 28. Optionally on day 90 a sixth dose may be given.
Following exposure, there is no need to wait for laboratory
confirmation of diagnosis to start treatment. Immediately
after exposure, wound care is started, and the degree of
exposure is classified and the post-exposure treatment is
started. The animal is to be observed for 10 days.
Post-exposure vaccination can be discontinued if the animal
is healthy after 10 days. Persons who present for evaluation
and prophylaxis even months after having been bitten should
be dealt with in the same manner as if the contact occurred
Passive immunization is carried out with human rabies
immunoglobulin (HRIG) (20 IU/kg body weight; up to a maximum
of 1500 IU or equine rabies immunoglobulin (ERIG) (40 IU/kg
body weight; maximum of 3000 IU). The ERIG must be given
only after administering the test dose as per the
Re exposure: On re-exposure following a full course of
either pre-or post-exposure vaccination, 2 booster doses are
to be administered intramuscularly or intradermally on days
0 and 3 irrespective of category of exposure or time that
has elapsed since previous vaccination. Rabies
immunoglobulin is not indicated in this scenario. All
subjects who have received incomplete vaccination should be
treated as fresh cases.
Yellow fever vaccine.
Indication: for travelers to African continent.
The vaccine may only be administered through clinics and
sites registered as yellow fever vaccine distribution
should be vaccinated at least 10 days before arrival in a
The vaccine is generally safe. It is associated with a risk
for vaccine-associated neurologic disease and viscerotropic
disease, the latter of which may be fatal. Risk increases
with age, and
the risk for either approximates 1 in25 000 among recipients
older than 70 years.
Japanese encephalitisis a mosquito-borne viral infection in
Asia. It is a tissue-culture– derived vaccine administered
as 2 doses (day 0 and 28) and is currently approved for use
in travelers 17 years of age and older.
The middleclass in India is becoming stronger, and there is
a sizeable upper class population. At least in this
population should be sensitized about adult immunization in
selected groups. Once a start is made, these vaccines will
be available more freely, bringing down the cost, leading to
more universal acceptance in the future.
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 Adult Immunization in India; API guidelines:
April 2009 : Volume 57.
Recommended Adult Immunization Schedule: United States, 2012;
Clinical Guideline: Annals of Internal Medicine Volume 156
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