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Adult Vaccination

Dr.Shobhana Mohandas.

 


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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. 

Tetanus Toxoid.

This is the commonest vaccination given in India, and is prescribed after a cut or a wound, beside pregnant women.

Dosage: 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 pertussis (Tdap) vaccine

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.

Indications:  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 vaccine.

Dose:  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.

Cholera

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, insufficient data.

Hepatitis A vaccine

Indication:  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.

Dose:   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 6-18months later. 

Hepatitis B vaccine

Indication:  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.

Dose:   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  observed 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 arm.

Varicella vaccine:

Indications: 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  strongly 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. 

Dose:   Two 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. 

Influenza vaccine

Indication: 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.

Dose: Trivalent inactivated influenza vaccine (TIV) and live attenuated influenza vaccine (LAIV) are available for use in adults.    In India it will cost around 1350R. The TIV is administered by an annual, single intramuscular dose of 0.5 ml.for all agegroups.  

Measles Mumps rubella vaccine

Indications:  A 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 pregnancy. 

Dose: For adult immunization, two doses of the vaccine are recommended 4-6 weeks apart. 

 

Meningococcal vaccine:

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.

Dose: In India bivalent (A+C) and quadrivalent (A,C, Y, W 135) polysaccharide meningococcal vaccines are marketed by few multinational companies.

 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 five years.

 

 

Pneumococcal Polysacharide vaccine (PPSV)

Indications:  Although PPV is efficacious in preventing invasive pneumococcal disease among adults, routine PPV administration to adults is not likely to be cost-effective in India.    

Dose:  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.  

Dose:  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

Indications: Rabies vaccine is indicated, in two categories of people with exposure.

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 management.

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.

Dose: 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 recently.

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 manufacturer’s guidelines. 

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 sites.  Travelers should be vaccinated at least 10 days before arrival in a risk zone.

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 encephalitis.

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.

 

Conclusion: 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.

References:

1.      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.

2.      Recommended Adult Immunization Schedule: United States, 2012; Clinical Guideline:  Annals of Internal Medicine Volume 156 • Number 3 :211.

             

3.      John Hornberger,, and Katherine Robertus,: Cost-Effectiveness of a Vaccine To Prevent Herpes Zoster and Postherpetic Neuralgia in Older Adults: Ann Intern Med. 2006;145:317-325. www.annals.org.

4.      Nayer Khazeni,;David W. et al: Effectiveness and Cost-Effectiveness of Expanded Antiviral Prophylaxis

  and Adjuvanted Vaccination Strategies for an Influenza A (H5N1) Pandemic: Ann Intern Med. 2009;151:840-853.

 www.annals.org.

 

5.Brian S. Schwartz, MD,Regina C. LaRocque et al: In the clinic travel medicine: Annals of Internal Medicine 5 June  

  2012.

      6. Col SP Gorthi: Meningococcal Vaccine: Which, When and for Whom?: MJAFI 2010; 66 : 2-3.