1. Adult Immunization
Dr Abhay Dhanorkar
2/15/2013 1

2. Scope
• Definition
• Introduction
• Rationale for Adult Immunization (AI)
• Disease burden of VPD in USA & Scenario in India
• Recommendations for Adult Immunization in USA & India
• Adult Immunization monograph by API – 2008
• Recommended Vaccines in India
• Challenges in adult immunization
• Standards for Adult Immunization Practices
• Recommendations by CDC
• References
2/15/2013 2

3. When meditating over a disease,
I never think of finding a remedy for it,
but, instead, a means of preventing it.
Louis Pasteur
(1822-1895)
2/15/2013 3

4. Definition
• Immunization refers to the artificial
induction of immunity. It can be by
Active Immunization: the use of live
attenuated infectious agents or
inactivated toxins, or antigens obtained
by genetic recombination OR
Passive Immunization: temporary
immunity obtained by the administration
of immunoglobulins or antitoxins.
2/15/2013 Source : Dictionary of Public Health, J Kishore - 2007 4

5. What is Immunization?
Administration of all or part of micro
organism or modified product resulting in
protection against the disease.
2/15/2013 5

6. Introduction
• Certain vaccines are routinely
recommended for all infants and
children in India.
• These include BCG, Diphtheria, Pertussis
and Tetanus vaccine (DPT), Oral Polio
Vaccine (OPV),HBV, Measles .
• Vaccine against H.Influenza
(Hib), JE, Chickenpox, herpes
Zoster, Human Papilloma Virus
, Rotavirus diarrhea etc. are optional.
2/15/2013 6

7. Vaccine-preventable infectious agents or diseases
Draft - Global vaccine action plan May 2012 - WHO
2/15/2013 7

8. Introduction cont…
• Smallpox eradicated in 1978 from
India
• On the verge of polio eradication.
• Infant/Childhood immunization –
one of the top public health success
stories of the 20th century
• The prevalence of
Diphtheria, Pertussis, tetanus, measl
es, mumps, rubella, poliomyelitis are
reduced.
2/15/2013 8

9. Rationale for Adult
Immunization
• Build on success of infant/childhood, adolescent
immunization program.
• Not vaccinated earlier, booster.
• New vaccines targeted at adults.
• Ageing : more susceptible.
• Increasing Antimicrobial Resistance.
• Recognition of the burden of adult vaccine-
preventable disease.
• No equivalent “Vaccines for Adults” program.
• Few settings in which vaccination is “required.”
2/15/2013 9

10. Disease BurDen of vpD’s in usa
• Influenza
>200,000 hospitalizations per year
36,000 deaths
>90% in persons 65 years and older
with comorbid conditions
• Invasive Pneumococcal Disease
Cases: 42,000 (14.0/100,000)
Deaths: 4,500 (1.5/100,000)
Rates higher in elderly
http://www.cdc.gov/ncidod/dbmd/abcs/survreports.spneu.
2/15/2013 10
pdf

11. Disease BurDen usa cont…
• Hepatitis B
51,000 new infections/yr; 95% in adults
2,000 – 3,000 deaths/yr
 ~1.25 million with chronic HBV infection
• Human Papillomavirus (HPV)
At least 70% of sexually active persons
acquire genital HPV infection at some
point in their lives
~20 million currently infected
6.2 million new infections/year
~ >11,000 new cervical cancer cases/year
2/15/2013 11

12. Disease BurDen usa cont…
• Herpes Zoster (Shingles)
Reactivation of varicella zoster virus
Associated with normal aging and reduced
immunocompetence
Lifetime risk of 20%
~ 1 million cases/yr
• Pertussis
Of >25,000 cases reported in 2009, >7,000
were in adults
Source of infant infection often an older
child or adult
• 71% household contact
2/15/2013 12

13. scenario of vpD’s in india
Diphtheria
• Overall cases of Diphtheria reduces
• 1980 – 39231
• 2005 – 10231
• 2009 – 3480
• Study in Hyderabad shows that annual incidence
increases from 11 to 23/lakh from 2003 to 2006 in 5 –
19 years.
• Study for Protective levels of antibodies in Delhi shows
 121 pregnant women – 94% have protective Ab titer
(>0.125U/ml)
 574 adults – 87% have protective Ab titer
2/15/2013 13

14. VPD’s in India cont…
Tetanus
• Total cases in India
 1980 – 45948 cases
 2007 – 7005 cases
• Study in Pondicherry for protective level of
Tetanus Ab (> 0.15U/ml)
 21 - 30 years – 50.4% (105/208)
 31 – 40 years – 29.4%(58/198)
 > 41 years – 2.2% (5/224)
Pertusss
 1987 -163000 cases
 2009 – 55074 cases
Meningococcal Meningitis cases (2009) in 9 states
 Cases – 6386
 Deaths – 460
2/15/2013 14

15. VPD’s in India cont…
Hepatitis – A
• Study by Mall in 5 cities (Kolkota,
Cochin, Indore, Jaipur & Patna) shows
adult population was at risk of HAV as low
level of anti HAV antibodies
• Study by Dhawan et al – seroprevalance
for protective anti HAV antibodies
High socioeconomic class – 54.5%
Low socioeconomic class – 85%
• Study by Jindal in Medicos at Delhi – 66%
with low anti HAV antibodies
2/15/2013 15

16. VPD’s in India cont…
Hepatitis – B
• Hepatitis – B prevalence in India - 1-2%
(Lodha et al)
• Study by Murhekar in 2001 at Andaman in
healthy people
 HBsAg +ve – 1.6% &
 Anti HBs +ve – 18%
• Overall chronic HBsAg +ve rate in India is
4.7%
• Meta-analysis by Biswas D et al. shows
prevalence of Hep – B in
 Non tribal – 2.4%
 Tribal – 15.9%
2/15/2013 16

17. VPD’s in India cont…
Human Papilloma Virus (HPV) Infection
• Nearly 80% of sexually active women & men are
infected with HPV.
World – 5,00,000 new cases/year. (CaCx)
India – 1,32,000 new cases & 74,000 deaths per year
Pneumococcal
• Study by International Clinical Epidemiology
Network (INCLEN) shows case fatality rate in
south India due to
Pneumococcal Pneumonia – 19%
Pneumococcal bacterimia – 21%
Pneumococcal meningitis – 34%
• 23% of IPD patients were > 50 years
2/15/2013 17

18. 2012 ACIP Adult Immunization Schedule, Age-Based Recommendations - USA
2/15/2013 18

19. 2012 ACIP Adult Immunization Schedule- Medical/Occupational
and Behavior-Based Recommendations (USA)
Pregn Immunoco HIV & Men Heart Aspleni Chro Diabete Health
having disease, c a Kidney
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sex hronic includi
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conditions with diseases,
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2/15/2013 19

20. ACIP Adult Immunization Schedule, Age-Based
Recommendations, INDIA
Vaccine / Age group 19-26 yrs 27-49 yrs 50-59 yrs 60-64 yrs > 65 yrs
Substitude one time dose of Tdap with Td, Td booster
Tetanus, Diptheria, Pertussis (Tdap) every 10 yrs
then booster with Td every 10 years
Human Pappiloma Vaccine 3 doses
Varicella 2 doses
Zoster 1 dose
Measles, Mumps, Rubella 1 or 2 doses 1 dose
Influenza 1 dose annually
Pnemococcal (Polysaccharide) 1 or 2 doses 1 dose
Hepatitis A 2 doses
Hepatitis B 3 doses
Meninngicoccal 1 or more doses
Recommended if some risk factor is present
All persons who meet the age criteria
2/15/2013 20
No recommendation

21. Adult Immunization based on medical and other indications (INDIA)
Immunoco Diabetes, Kidney
HIV infection heart Asplenia
mpromise failure, end Health
Indications with CD4 (excluding Chronic
d disease, stage renal care
Pregnancy count elective liver
conditions chronic disease, on professi
splenectomy disease
(Excluding <200 >200
lung hemodialysi onals
Vaccine )
HIV) cells/ µl cells/ µl disease s
Tetanus, Diptheria, Substitute one time dose of Tdap with Td, then booster with Td every 10
Td years
Pertussis (Tdap)
Human Pappiloma
3 doses for females through age 26 years
Vaccine
Varicella Contraindication 2 doses
Zoster Contraindication 1 dose
Measles, Mumps, Rubella Contraindication 1 or 2 doses
1 dose TIV
Influenza 1 dose TIV annually or LAIV
Pnemococcal
(Polysaccharide)
1 or 2 doses
Hepatitis A 2 doses
Hepatitis B 3 doses
Meninngicoccal 1 or more doses
Recommended if some risk factor is present
All persons who meet the age criteria
2/15/2013 21
Contraindication

22. Adult Immunization recommended in india
Tdap MMR
Influenza Pneumococcal
Hepatitis B Hepatitis A
Varicella HPV (cervical cancer)
Meningococcal Herpes Zoster
2/15/2013 22

23. Diphtheria, Tetanus, Pertussis
Vaccines
• Two Tdap Vaccines are available for use in those
who are more than 10 years of age.
 [i] Adacel contains tetanus toxoid, diphtheria
toxoid, and five pertussis antigens;
 [ii] Boostrix contains tetanus toxoid, diphtheria
toxoid, and three pertussis antigens.
• Efficacy of Tdap vaccine - 92% in a recent RCT.
Recommendations
• For adults in the age group of 18 to 64 years
 Three dose series if never vaccinated at 0 and 4
weeks, the third 6-12 months after second
 One dose booster of Tdap every 10 years
2/15/2013 23

24. Tdap cont…
• 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 had not
received it previously.
2/15/2013 24

25. Tdap cont…
• For Pregnant Women
Last dose Recommendation
> 10 Years 1 dose in 2nd or 3rd trimester
2-10 years 1 dose immediate postpartum
Never 3 doses 0, 1, 6 months
• During outbreak if previous unimmunized or
Td before 2 years give 1 dose of Tdap
2/15/2013 25

26. Tdap cont…
Contraindications
• History of anaphylaxis to any component.
• History of encephalopathy within 7 days of
previous vaccination of Tdap.
• Moderate or severe acute illness, and those
with unstable neurologic conditions (e.g.,
stroke, acute encephalopathies)
• Tdap vaccination is to be deferred until the
acute illness resolves.
2/15/2013 26

27. Measles, Mumps And Rubella
Vaccines
• In India the measles, mumps, rubella (MMR) live
attenuated vaccine is manufactured using the following
strains:
 Edmonston Zagreb - Measles,
 L-Zagreb - Mumps
 Wistar RA27/3 strain - Rubella.
• The measles and the rubella components are produced
using human diploid cells while the mumps component
is produced from chick embryo.
• The MMR vaccine should be administered
subcutaneously into the upper arm.
2/15/2013 28

28. MMR cont…
MMR cont…
• Adults who are > 18yrs of age should
receive at least one dose of MMR if
there is no serologic proof of immunity
or documentation of a dose given on or
after the first birthday.
• Adults in high-risk groups, such as health
care workers and international
travelers, should receive two doses.
• All women of childbearing age who do
not have acceptable evidence of rubella
immunity or vaccination.
2/15/2013 29

29. MMR cont…
MMR cont…
Schedule
• One or two doses are needed 4 wks
apart.
• If a pregnant woman is found to be
rubella susceptible, administer MMR
postpartum.
2/15/2013 30

30. MMR cont…
MMR cont…
Contraindications
• Previous anaphylactic reaction to this vaccine,
or to any of its components.
• Pregnancy or possibility of pregnancy within 4
weeks (use contraception).
• Persons immunocompromised due to cancer,
leukemia, lymphoma, immunosuppressive
drug therapy, including high-dose steroids or
radiation therapy.
2/15/2013 31

31. Influenza
Vaccines
 Trivalent inactivated influenza vaccine (TIV) and
 Live attenuated influenza vaccine (LAIV)
• The TIV contains
 A/17/California/2009/38(H1N1),
 A/Brisbane/ 10/2007 (H3N2), and
 B/Brisbane/60/2008 strains.
• Live attenuated influenza vaccine (LAIV) –
Nasovac contains
 A/17/California/2009/38 like strain
• Schedule
 The TIV - annual, single dose of 0.5 ml IM.
 The LAIV – 0.5 ml intranasal (spray 0.25 ml per
nostril)
2/15/2013 32

32. Influenza cont…
Recommendations
• People aged > 50 years
• Chronic obstructive pulmonary
disease (COPD).
• Cardiac diseases
• Diabetes Mellitus, Cancer
• Immunodeficiency, Renal Disease
• Hemoglobinopathies
• Pregnant Women
• Health Care Providers
• Adult household contacts
• Travelers to endemic area
2/15/2013 33

33. Influenza cont…
• August - September is the optimal time to receive an
annual flu shot to maximize protection.
• Influenza vaccine may be given at any time during the
influenza season (typically October to March) or at
other times when the risk of influenza exists.
• May give with all other vaccines but as a separate
injection.
Contraindications
• Previous anaphylactic reaction to this vaccine, to any of
its components, or to eggs.
• Moderate or severe acute illness.
2/15/2013 34

34. Pneumococcal Infection
Vaccines
• The pneumococcal polysaccharide
vaccine (PPV), contains 25 μg each of purified
capsular polysaccharide from 23 serotypes of
Streptococcus pneumoniae.
Schedule
A single standard dose (0.5 ml) is
administered by the intramuscular or
subcutaneous route.
This vaccine can be co-administered with live
vaccines such as the influenza vaccine.
2/15/2013 35

35. PPV cont…
• Adults who are 65yrs of age or older.
High risk people
• Anatomic asplenia • Chronic renal failure
• Sickle cell disease • Nephrotic syndrome
• Immunocompromised • Chemotherapy &
persons including HIV corticosteroids)
• Leukemia, Lymphoma • Organ or bone marrow
• Hodgkin’s disease transplant.
• Multiple myeloma • Pregnant women with
• Generalized malignancy high-risk conditions
2/15/2013 36

36. PPV cont…
• One-time revaccination is recommended 5yrs
later for people with
Rapid antibody loss (e.g., renal disease)
People >65yrs of age if the 1st dose was
given prior to age 65 and > 5yrs have
elapsed since previous dose.
2/15/2013 37

37. Hepatitis B
Vaccines
• For immunocompetent adults, 1ml (20 μg) of
recombinant vaccine is administered at 0, 1, and 6
months as an intramuscular.
• Protection (anti-HBs antibody titer of 10mIU/ml or
higher) after recombinant vaccine
 After first dose - 20% to 30%
 After second dose - 75% to 80%
 After third doses - 90% to 95%
Recommendations
• All unvaccinated adult risk for HBV infection and
• All adults seeking protection from HBV infection
including post-exposure prophylaxis.
2/15/2013 38

38. HBV cont…
Prevaccination screening
• Prevaccination screening in general population has not been
found to be cost effective in India.
• Prevaccination screening may be cost-effective in adult
populations with a prevalence of HBV infection of >20% such
as
 Household or sexual contacts of HBsAg-positive persons;
 HIV infected persons
 Injection drug users
 Men who have sex with men
 Patients with chronic liver disease (CLD)
 End-stage renal disease (ESRD).
2/15/2013 39

39. HBV cont…
2/15/2013 40

40. HBV cont…
• Booster doses of HBV vaccine are not indicated
in persons with normal immune status .
• For CKD patients, the need for booster doses
should be assessed by annual anti-HBs antibody
titre testing.
• A booster dose should be administered when
anti-HBs levels decline to less than 10 mIU/ml &
<100 mIU/ml in patients on dialysis.
Contraindications
• Previous anaphylactic reaction to this vaccine or
to any of its components.
• Moderate or severe acute illness.
2/15/2013 41

41. Hepatitis A
Vaccines
• Inactivated-single antigen (HAV antigen) vaccines,
 Havrix (GlaxoSmithKline) and
 Vaqta (Merck & Co)
• Combination vaccine
 Twinrix ( HAV + HBV antigens GlaxoSmithKline).
Schedule
• Two doses of 1ml at 6 month interval.
• Immune status for hepatitis A should be checked
2/15/2013 42

42. Hepatitis A cont…
Recommendations
• The Expert Group felt that universal immunization
for hepatitis A is not recommended as yet.
• Not only is the vaccine costly, more epidemiological
data are required to ascertain its benefits.
• Adults at risk for acquiring hepatitis A, and adults
who are negative for anti-HAV antibodies are likely
to benefit most in view of changing epidemiology.
2/15/2013 43

43. Hepatitis A cont…
Adults high risk for acquiring hepatitis A:
People who travel to endemic area of Hep A
Persons who work with HAV-infected
primates or with HAV in a laboratory
Who receive clotting factor concentrates
Persons infected with other hepatitis viruses
Chronic liver disease not immune to HAV
Received, or are awaiting a liver transplant
Men who have sex with men
2/15/2013 44

44. Hepatitis A cont…
Vaccination schedule for hepatitis A
2/15/2013 45

45. Hepatitis A cont…
Contraindications
• Previous anaphylactic reaction to this vaccine
or to any of its components.
• Moderate or severe acute illness.
• Safety during pregnancy has not been
determined, so benefits must be weighed
against potential risk.
2/15/2013 46

46. Varicella (Var) (Chickenpox)
Vaccines
• Two Live attenuated VZV (Oka strain)
vaccines for varicella virus are currently
available in India.
– Varilrix (GlaxoSmithKline, Belgium) and
– Okavax (Pasteur Mérieux, France).
Schedule
– < 13 years - 1 dose - 0.5ml SC
– > 13 years - 2 doses are recommended.
– Interval between 2 doses should be 4–
8wks.
2/15/2013 47

47. Varicella cont…
Recommendations
• All susceptible adults and adolescents should
be vaccinated.
• It is especially important to susceptible
persons
– Health care workers
– Family contacts of immunocompromised persons
– High risk of exposure (e.g., teachers, day care
employees, military personnel, and international
travelers).
2/15/2013 48

48. Varicella cont…
• People with reliable histories of chickenpox
(such as self or parental report of disease) can
be assumed to be immune.
• For adults who have no reliable
history, serologic testing may be cost effective
since most adults with a negative or uncertain
history of varicella are immune.
2/15/2013 49

49. Varicella cont…
Contraindications
• Previous anaphylactic reaction to this vaccine or to any
of its components.
• Pregnancy, or possibility of pregnancy within 1 month.
• Immunocompromised persons due to malignancies and
primary or acquired cellular immunodeficiency including
HIV/AIDS.
• Salicylates to be avoided for 6wks after receiving
varicella vaccine because of a risk of Reye’s syndrome.
2/15/2013 50

50. Human Papilloma Virus
• Papilloma virus infection is precursor to cervical
cancer
 Types 16, 18 account for 70% of cervical
cancers
Vaccines
• Two types HPV vaccines are available.
 Gardasil (Merck, USA), a quadrivalent vaccine
containing HPV virus L1 protein like particles of
HPV 6,11,16, and 18
 Cervarix (GlaxoSmithKline, Belgium) is a
bivalent vaccine containing L1 VLPs of HPV
16,18.
2/15/2013 51

51. HPV cont…
Schedule
• Gardasil vaccine, 3 doses- 0.5ml IM at
0, 2, and 6 months.
• Cervarix vaccine, 3 doses - 0.5 ml IM at 0, 1
and 6 months
2/15/2013 52

52. HPV cont…
Recommendations
• The vaccine has to be delivered prior to
exposure to the HPV virus. Therefore, the
immunization must precede the sexual debut.
• Age for initiation for vaccination 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.
2/15/2013 53

53. HPV cont…
Contraindications
• Pregnancy
• Patients with hypersensitivity to any of the
vaccine components.
Special situations
• The HPV vaccine is not contraindicated during
lactation.
• The vaccine can be administered to
immunosuppressed individuals.
2/15/2013 54

54. HPV cont…
• Several mild self limiting problems may
occur with HPV vaccine:
Pain at the injection site ( 8 people in 10)
Redness or swelling at the injection site
(1 in 4)
Mild fever (100 oF) (1 in 10)
Itching at the injection site (1in 30)
Moderate fever (102 oF) (1 in 65)
2/15/2013 55

55. HPV cont…
Natural History of HPV Infection and
Potential Progression to Cervical Cancer
0–1 Year 0–5 Years 1–20 Years
Continuing CIN Invasive
Infection 2/3 Cervical
Cancer
Initial
HPV
Infection
CIN 1
Cleared HPV Infection (~80%)
2/15/2013 AP, Crum CP. Clin Obstet Gynecol. 2000;43:352–362.
1. Pinto 56

56. Meningococcal Meningitis
Vaccines
• Types
Polysaccharide vaccines
• Bivalent (A&C)
• Quadrivalent (A,C,Y & W135)
Conjugate vaccines.
• The vaccine does not induce herd immunity
and has no effect on nasopharyngeal
carriage.
• Containing 50 μg of polysaccharide per dose.
• After reconstitution use within 8-12 hours.
2/15/2013 57

57. Meningococcal cont…
Schedule
• A single dose of 0.5 ml SC in deltoid region.
• In children between 3 months and 2 years of
age, two doses at an interval of 3 months are
indicated.
2/15/2013 58

58. Meningococcal cont…
Recommendations
• The meningococcal vaccine can be used in
selected populations in certain
situations, such as
During an outbreak (HCW, Lab.
worker, Close contacts )
During inter-epidemic period
To travelers, pilgrims(Quadrivalent), people
attending fairs and festivals(bivalent 10-14
days prior).
2/15/2013 59

59. Meningococcal cont…
• Mass vaccination may be considered
depending on the age-specific attack rate,
geographical distribution of cases, and the
availability of vaccine.
• During the inter-epidemic period, to
personnel living in dormitories; military
recruits; jail inmates; immunocompromised
individuals.
• Adults with anatomic or functional asplenia,
or terminal complement component
deficiencies.
2/15/2013 60

60. Herpes zoster (shingles)
• Shingles is caused by a reawakening
of the chickenpox virus
• Symptoms – rash usually along
nerve pathways
• Very painful and debilitating
• 20-30 % people can expect to get
shingles in their lifetime
2/15/2013 61

61. Herpes Zoster cont…
Vaccines
• Zostavax - lyophilized preparation of the Oka
strain of live, attenuated varicella zoster virus
(VZV).
Schedule
• Single 0.65 ml dose subcutaneously in the upper
arm.
• Each 0.65 ml dose contains a minimum of 19,400
plaque-forming units [PFU].
• The vaccine must be used within 30 minutes after
reconstitution.
2/15/2013 62

62. Herpes Zoster cont…
Recommendations
• Recommended for persons > 60 years.
• High risk for developing recurrent herpes
zoster, such as
Patients with chronic medical conditions
(CKD, diabetes mellitus, rheumatoid arthritis, and
chronic pulmonary disease);
Persons who are likely to have severe
immunosuppression in near future.
2/15/2013 63

63. Recommended Vaccines for Healthcare
Workers
• Healthcare workers should maintain an
immunization history for:
Hepatitis B
Influenza *
MMR
Varicella (chickenpox)
Tetanus, diphtheria, pertussis
Meningococcal**
* Receive annually
** For specific healthcare personnel
2/15/2013 64

64. Recommended vaccines for travelers to
India
CDC recommends the vaccines according
to duration of stay in India.
• Tetanus-Diphtheria
• Hepatitis A
• Yellow Fever < 1 month
• Polio
• Japanese Encephalitis
• Rabies 1- 5 month
• Typhoid
• Hepatitis B
• Tuberculosis > 6 month
• Meningitis
2/15/2013 65
Source : CDC

65. Adult Immunization Challenges
• Inadequate funding for vaccines and
administration in public programs
• Lack of knowledge – both patients
and providers
• Poor public health and private
infrastructure for vaccine delivery.
• Lack of availability of vaccine.
• High cost of vaccine.
2/15/2013 66

66. Reasons -Aware but not receiving vaccine
Source: Johnson et al, Barriers to Adult Immunization, The American Journal of
2/15/2013 67
Medicine, Vol 121, No 7B, July 2008

67. Reasons -Aware but not receiving vaccine
Source: Johnson et al, Barriers to Adult Immunization, The American Journal of
2/15/2013 68
Medicine, Vol 121, No 7B, July 2008

68. Reasons -Aware but not receiving vaccine
Source: Johnson et al, Barriers to Adult Immunization, The American Journal of Medicine,
2/15/2013 69
Vol 121, No 7B, July 2008

69. Screening Patients for Vaccines
• Screen every patient regardless of reason for
visit
• Utilize screening tools; H-A-L-O
Health condition
Age
Lifestyle
Occupation
2/15/2013 70

70. Documentation
• Provide copy of Vaccine
Information Statement (VIS)to
patient
• Documents to be maintained
Date vaccination & next dose
Vaccine manufacturer
Lot number
Dose & site of vaccine
Vaccinator’s initials
2/15/2013 71

71. Vaccine Administration
• Health care personnel should get proper
training before administrating vaccine.
• Always prepare and check the following for
every vaccination you give:
Right Patient
Right Drug (vaccine)
Right Dose
Right Route (intramuscular, SC,intradermal)
Right Time (is scheduling correct)
2/15/2013 72

72. Standards for Adult Immunization
Practices
• Make immunizations available
 Adult immunization services are readily available
 Barriers to receiving vaccines are identified and minimized
 Patient “out-of-pocket” immunization costs are minimized
• Assess patients’ immunization status
 Health care professionals routinely review the
immunization status of patients
 Health care professionals assess for valid contraindications
• Communicate effectively with patients
 Patients are educated about risks and benefits of
immunization in easy-to-understand language
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73. Standards for AI cont….
• Administer and document immunizations properly
 Persons who administer vaccines are properly trained
 Simultaneous administration of indicated vaccine doses
 Immunization records for patients should be accurate
 All personnel who have contact with patients are
appropriately vaccinated
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74. Standards for AI cont….
• Implement strategies to improve immunization rates.
 Systems are developed and used to remind patients and
health care professionals when immunizations are due and
to re-call patients who are overdue
 Standing orders for immunizations are employed
 Regular assessments of immunization coverage levels are
conducted in a provider’s practice
• Patient oriented and community based
Source : Poland GA, Shefer AM, McCauley M, et al. Standards for adult
immunization practices. Am J Prev Med 2003
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75. Recommendations (CDC)
Finances
Research on barriers
Public and Provider Education
Standards of Care
Improved vaccines (immunogenicity, safety)
Supply of Vaccines
Support for programs and partners
Legislative and regulatory strategies
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76. References
• Centers for Disease Control and Prevention (CDC). Recommended
adult immunization schedule—United States, 2012. MMWR Morb
Mortal Wkly Rep Feb 2012.
• Poland GA, Shefer AM, McCauley M, et al. Standards for adult
immunization practices. Am J Prev Med 2003;25:144–50.
• Guthrie S. Birkhead & Julie Morita, NY, A Pathway to Leadership for
Adult Immunization: Recommendations of the National Vaccine
Advisory Committee, on June 14, 2011.
• World Health Organization (WHO)/UNICEF global estimates for
Immunization 2010, May 2012.
• K.Park-Park’s Textbook of Preventive and Social Medicine,21st
edition, Banarsidas Bhanot Publishers,Jabalpur,India.
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77. References
• Draft global vaccine action plan for 2010 -2020 by the Secretariat, 65th
World Health Assembly ,11 May 2012.
• Progress Toward Interruption of Wild Poliovirus Transmission —
, Morbidity and Mortality Weekly Report Weekly by CDC / Vol. 61 / No. 19
May 18, 2012.
• Fiore AE, Uyeki TM, Broder K et al. Prevention and control of influenza
with vaccines: recommendations of the Advisory Committee on
Immunization Practices (ACIP), 2010. MMWR Recomm Rep. 2010; 59(RR-
8):1-62.
• Sharma SK, Singhal RK, Agarwal AK,Adult Immunization (Monograph),Vol.
1, March 2009.Indian Association of Physicians.
• www.who.int/topics/immunization.com
• www.cdc.gov/vaccines.com.
• www.google.co.in/vaccines/images/index.id
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