Adult Vaccination_Dr Animesh Jain IMA KSB 16 March 2022
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This slideset was a part of a webinar talk by Dr Animesh Jain in a programme hosted by IMA Karnataka State Academic Subcommittee on 16th March 2022. This brief presentation was an attempt to sensitize the audience regarding adult vaccination.
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Adult Vaccination_Dr Animesh Jain IMA KSB 16 March 2022
- 1. Adult Vaccination Dr. Animesh Jain Member, Medical Education Sub-Committee, IMA KSB Professor of Community Medicine Kasturba Medical College, Mangalore Disclaimer: The views and ideas expressed in this session are that of the speaker and do not represent any organization or official view of the institution that the speaker is affiliated with or is/was a part of.
- 2. Adult Immunization - Dr Animesh Jain 2
- 3. Outline of presentation • Vaccination & Immunization • Need for vaccinating adults • Vaccines routinely encountered for adults in primary care practice • Vaccine schedule for adults • Vaccines for travelers • Vaccination for healthcare providers • Summary and Q&A Adult Immunization - Dr Animesh Jain 3
- 4. Vaccination & Immunization • Vaccination – process of administering a vaccine • Immunization – antibody response mounted against a disease post vaccination Adult Immunization - Dr Animesh Jain 4
- 5. Type of vaccines • Live attenuated • Inactivated or killed • Toxoid • Polysaccharide vaccines • Conjugate vaccines • Subunit vaccine • Recombinant DNA vaccines • Combined vaccines • Tissue culture vaccines Adult Immunization - Dr Animesh Jain 5
- 6. India – Brief health profile • People >15 yrs account for 72% of India’s population • 42% health insurance claims – 26-55 yrs + infectious disease category • India ranks 158/195 in terms of expected human capital • India ranks below all countries in South Asian region in terms of functional health Adult Immunization - Dr Animesh Jain 6
- 7. India - Vaccine preventable diseases (VPDs) in various age groups Tetanus HiB Rotavirus Pneumococcus Mumps Varicella Pertussis Adolescents HPV Hepatitis A Epidemiological transition of VPD of childhood Elderly Zoster Influenza Pneumococcus VPD risk due to chronic diseases Children TB Hepatitis B Polio JE Measles Rubella Diphtheria Adult Immunization - Dr Animesh Jain 7
- 8. Source : WHO/UNICEF 2018. Challenges in Universal immunization coverage Adult Immunization - Dr Animesh Jain 8
- 9. Why do we need to vaccinate adults? • Waning immunity to childhood vaccines in adulthood • Poor vaccination coverage in children • Epidemiological transition of disease burden • Age related immunosenescence reduces resistance to infections • Chronic diseases increases susceptibility to infections Adult Immunization - Dr Animesh Jain 9
- 10. Why do we need to vaccinate adults? • Proportion of adults dying of VPDs = 350 fold higher than children • Overemphasis on curative medical care Vs preventive health care • No free adult vaccines in national immunization program • No advocacy based on epidemiological data • Adult vaccination coverage – Low for most vaccines • High probability of exposure to infectious agents – Increased manifold, owing to globalization and increasing travel opportunities both within and across the countries. Adult Immunization - Dr Animesh Jain 10
- 11. VPD burden in India Sl no Disease Incidence/Prevalence (all age groups) 1. Influenza 127000 cases, 8000 deaths (last 5 years) 2. Pneumococcal 39% Pneumonia, 25% Meningitis 3. Hepatitis A 7% 4. Hepatitis B > 37 million HBV carriers 5. Measles 55399 6. Rubella 1066 7. HPV 12% 8. Typhoid 120/100000 adults Adult Immunization - Dr Animesh Jain 11
- 12. VPD burden in India • In 2017 - India had high burden share of global VPD cases – Diphtheria (60% ), JE (44%) and Tetanus (40%), Pertussis (17%), Measles (7%), Rubella (17%), Congenital rubella syndrome (9%) • In first 2 months of 2018 - 50% outbreaks in India were due to Measles and Varicella Adult Immunization - Dr Animesh Jain 12
- 13. Co-morbidities and VPDs Co-morbidity/ Disease Acute event Risk Diabetes Influenza Hospitalization risk – 3 to 6 fold ICU admission - 4 fold Influenza IHD 6 times higher risk Diabetes Pneumococcal 51.4/100000 Chronic lung disease Pneumococcal 62.9/100000 IHD Pneumococcal 93.7/100000 VS 8/100000 normal adult risk CKD Pneumonia 4-10 fold Adult Immunization - Dr Animesh Jain 13
- 14. Adult Vaccination in Primary Care • Tetanus • Rabies • Hepatitis B Adult Immunization - Dr Animesh Jain 14
- 15. Tetanus History of TT doses Clean minor wounds All other wounds TT/Td TIG TT/Td TIG Unknown, ≤3 doses, immunodeficient YES No YES YES ≥3 doses No** No No*** No ** Yes, if >10 years since last dose ***Yes, if >5 years since last dose Adult Immunization - Dr Animesh Jain 15
- 16. Tetanus toxoid in other wounds • High risk wounds – contact with soil, manure, compost • Puncture type wound • Infected wound • Compound fracture • Large amount of devitalized tissue • Animal or human bite Adult Immunization - Dr Animesh Jain 16
- 17. Rabies • Pre exposure – 3 doses. 0-7-28 • Post exposure: IM – 0-3-7-14-28, ID- 2doses 0.1 ml at 2 sites (deltoid) on days 0, 3, 7, 28. • Re exposure – within 3 months – no vaccines > 3 months – 2 doses, 0-3 • Late presentation – Vaccines need to be administered, with risk communication Adult Immunization - Dr Animesh Jain 17
- 18. Hepatitis B • 3 doses – 0 – 1 – 6 months • Antibody titre - >10mIU protective (mandatory for health professionals) • Non-responders – Repeat 3 more • Titre estimation - 6 to 12 weeks after last dose Adult Immunization - Dr Animesh Jain 18
- 19. Adult vaccination schedule • WHO guidelines • Geriatric society of India guidelines • Advisory Committee on Immunization Practices guidelines from CDC • Association of Physicians of India – Expert panel guidelines • Research Society for Study of Diabetes in India guidelines • Indian Society of Nephrology guidelines • Indian Medical Association guidelines • FOGSI Adult Immunization - Dr Animesh Jain 19
- 20. Adult Immunization - Dr Animesh Jain 20
- 21. Adult Immunization - Dr Animesh Jain 21
- 22. Adult Immunization - Dr Animesh Jain 22
- 23. • HPV – 15-45 yrs (IAOH), 9-26 yrs (ISN, FOGSI, WHO,API & CDC), 9-45 yrs (IMA). • Influenza - > 19 yrs onwards • DPT – 19 yrs onwards • MMR – 19-60 yrs • Pneumococcal - > 50 yrs (PCV-13, PPSV-23) (IAOH), > 65 yrs (API,CDC & ISN) • Herpes Zoster - > 60 yrs Adult Immunization - Dr Animesh Jain 23
- 24. Vaccine / Age group 19-26 yrs 27-49 yrs 50-59 yrs 60-64 yrs > 65 yrs Tetanus, Diptheria, Pertussis (Tdap) Substitute one time dose of Tdap with Td, then booster with Td every 10 years Td booster every 10 yrs Human Papilloma Vaccine 3 doses Varicella 2 doses Zoster 1 dose Measles, Mumps, Rubella 1 or 2 doses 1 dose Influenza 1 dose annually Pneumococcal 1 or 2 doses 1 dose Hepatitis A 2 doses Hepatitis B 3 doses Meningococcal 1 or more doses ACIP Adult Immunization Schedule, Age-Based Recommendations, India Recommended if some risk factor is present All persons who meet the age criteria No recommendation Adult Immunization - Dr Animesh Jain 24
- 25. Vaccine / Age group 19-26 yrs 27-49 yrs 50-59 yrs 60-64 yrs > 65 yrs Tetanus, Diptheria, Pertussis (Tdap) Substitute one time dose of Tdap with Td, then booster with Td every 10 years Td booster every 10 yrs Human Papilloma Vaccine* 3 doses Varicella * 2 doses Zoster 1 dose Measles, Mumps, Rubella * 1 or 2 doses Influenza * 1 dose annually Pneumococcal Special situations 1 dose PCV 13 followed by PPSV 23 Hepatitis A 2 doses Hepatitis B 3 doses Meningococcal 1 or more doses IAOH vaccination recommendations for working adults, India Adult Immunization - Dr Animesh Jain 25
- 26. Adult Immunization based on medical and other indications (INDIA) Indications Pregnancy Immunoco mpromise d conditions (Excluding HIV) HIV infection with CD4 count Diabetes, heart disease, chronic lung disease Asplenia (excluding elective splenectomy ) Chronic liver disease Kidney failure, end stage renal disease, on hemodialysi s Health care professi onals Vaccine <200 cells/ µl >200 cells/ µl Tetanus, Diphtheria, Pertussis (Tdap) Td Substitute one time dose of Tdap with Td, then booster with Td every 10 years Human Papilloma Vaccine 3 doses for females through age 26 years Varicella Contraindication 2 doses Zoster Contraindication 1 dose Measles, Mumps, Rubella Contraindication 1 or 2 doses Influenza 1 dose annually Pneumococcal 1 or 2 doses Hepatitis A 2 doses Hepatitis B 3 doses Meningococcal 1 or more doses Recommended if some risk factor is present All persons who meet the age criteria Contraindication Adult Immunization - Dr Animesh Jain 26
- 27. Recommended vaccines for patients with respiratory disease Adult Immunization - Dr Animesh Jain 27
- 28. Vaccination for travellers Adult Immunization - Dr Animesh Jain 28
- 29. • Immunization for travelers depends on the place of travel, staying conditions, activities at the place of visit, and other risk behaviors. • Administer recommended vaccines if vaccination history is incomplete or unknown. Adult Immunization - Dr Animesh Jain 29
- 30. Adult Immunization - Dr Animesh Jain 30
- 31. Categories of Travel Vaccine Adult Immunization - Dr Animesh Jain 31
- 32. Vaccination for Hajj Pilgrims Adult Immunization - Dr Animesh Jain 32
- 33. Vaccination for Kumbh Mela Adult Immunization - Dr Animesh Jain 33
- 34. Yellow fever vaccination • Public health institutes run by state governments – subsidized rate • Karnataka – Public health institute, Bangalore 080-22210248 • Wednesdays - (next working day if holiday) • Appointment 2 days in advance, for availability • 10 dose vial – for a group of 10 • Carry Original passport copy – passport number will be entered in yellow card and register • Validity – 10 days after vaccination. Lasts lifelong. Adult Immunization - Dr Animesh Jain 34
- 35. Influenza • Vaccines available – Trivalent inactivated, Quadrivalent inactivated and Live attenuated nasal spray • Inactivated vaccines - 0.5 ml IM every year • Live attenuated – sprayed into each nostril Adult Immunization - Dr Animesh Jain 35
- 36. Influenza (contd)… • Vaccines becomes effective 2 weeks after administration • October – November best time to take • Quadrivalent vaccine since 2019 – 2 strains of Influenza A and B respectively • 0.5 ml IM • Live influenza vaccines as nasal spray are contraindicated for Health care workers Adult Immunization - Dr Animesh Jain 36
- 37. Pneumococcal • Common serotypes in India – 1,3,4,5,6B,8,14,19A,19F,23F • 2 vaccines available – PPSV23, PCV13 • Initial PCV13 enhances response to subsequent PPSV23 rather than PCV13 alone Adult Immunization - Dr Animesh Jain 37
- 38. MMR • Vaccines • Measles (MCV); • Measles & Rubella (MR); • Mumps , Measles and Rubella (MMR); • Mumps , Measles, Rubella and Varicella (MMRV) • Adults - 2 doses MMR vaccine at 4-8 weeks intervals • Dose & route: 0.5ml SC Adult Immunization - Dr Animesh Jain 38
- 39. Tdap/Td • Till 7 yrs - DPT • > 10 yrs – Tdap one dose followed by Td once every 10 yrs till 64 yrs • Booster dose of Tdap may be used instead of Td if Tdap was never received • Unimmunized adults – 3 doses of Td (0, 4 to 8 wks, 6-12 months) • Dose & route: 0.5 ml IM Adult Immunization - Dr Animesh Jain 39
- 40. Typhoid • Vaccines • Vi Capsular polysaccharide • Typhoid Conjugate vaccine • 0.5 ml IM • Single dose for TCV • Every 3 yrs for polysaccharide Adult Immunization - Dr Animesh Jain 40
- 41. HPV • Bivalent and quadrivalent • 9- 12 yrs • 0.5 ml 3 doses – 0, 2, 6 months • Catch up – 13 to 26 yrs Adult Immunization - Dr Animesh Jain 41
- 42. Vaccination for healthcare personnel Adult Immunization - Dr Animesh Jain 42
- 43. Vaccination and healthcare personnel • Healthcare workers have the ethical responsibility to protect their patients by reducing the risk of transmission of vaccine preventable diseases within the context of clinical care, in accordance with the ‘do not harm’ Hippocrates principle. • Any transmissible vaccine-preventable disease poses a risk to both HCP and their patients Adult Immunization - Dr Animesh Jain 43
- 44. Why should HCPs be vaccinated? • Risk of acquiring vaccine-preventable diseases is higher for susceptible healthcare personnel • Increased risk of acquisition has been described for diseases like pertussis, measles and influenza • HCP may be a source of transmission of vaccine preventable diseases to patients Adult Immunization - Dr Animesh Jain 44
- 45. Why should HCPs be vaccinated? • Protect the individual (HCP) and their family • Protect patients and service users, including vulnerable patients • Protect other healthcare and laboratory staff • Allow for the efficient functioning of services Adult Immunization - Dr Animesh Jain 45
- 46. HCPs have been identified as a source of several healthcare associated outbreaks including Adult Immunization - Dr Animesh Jain 46
- 47. Immunization Action Coalition HCPs Vaccination Recommendation Adult Immunization - Dr Animesh Jain 47
- 48. Vaccination for HCPs • Hepatitis B • If unvaccinated for hepatitis, give intramuscular 3-dose series (0, 1 and 6 months) • For HCP performing procedures that may involve exposure to blood or bloody fluids, do anti-HBs testing 1–2 months after dose 3 Adult Immunization - Dr Animesh Jain 48
- 49. Vaccination for HCPs • Influenza • Give 1 dose of influenza vaccine annually • MMR • For those born in 1957 or later without evidence of immunity or vaccination, give 2 subcutaneous doses of MMR, 4 weeks apart • Varicella • For HCP without proof of immunity, vaccination, or history of varicella or zoster, give 2 doses of varicella vaccine, 4 weeks apart Adult Immunization - Dr Animesh Jain 49
- 50. Vaccination for HCPs • Tdap • Give 1 dose of Tdap to all HCP who have not received it previously, and give Td boosters every 10 years thereafter • Meningococcal • Give MenACWY and MenB vaccine intramuscularly to microbiologists routinely exposed to N. meningitidis and boost every 5 years with MenACWY if risk continues Adult Immunization - Dr Animesh Jain 50
- 51. Vaccination recommendation for Health care workers (ACIP) Vaccine Doses Schedule Hepatitis B 3 0-1-6 months Hepatitis A 2 or 1 0-6 (Killed) single dose (live) Tdap 1 1 dose every 10 yrs Varicella 2 4-8 week interval IPV 1 or 2 If previously unimmunized 2 doses (0-4 to 8 wks) Influenza 1 1 dose every year Pneumococcal PCV-13 PPSV-23 1 2 Single dose - > 50 yrs 2 doses 5 yrs apart in high risk Typhoid (TCV) 1 Single, every 3 yrs for polysacharide MMR 2 2 doses 4 to 8 weeks apart Meningococcal 1 1 dose (repeat after 3-5 yrs if at risk) Rabies 3 Pre exposure (0,7,28 days) Adult Immunization - Dr Animesh Jain 51
- 52. Reasons for HCPs not getting vaccinated • Information specific to influenza 1 and hepatitis 2 vaccination • 1. Douville LE, et al. Arch Pediatr Adolesc Med 2010;164:33–7; • 2. FitzSimons D, et al. Vaccine 2014:32;4849–54 Adult Immunization - Dr Animesh Jain 52
- 53. Acknowledgement: • Dr Sudhir Prabhu • IMA Hqtrs • Academic Sub-Committee, IMA KSB 2021-22 Adult Immunization - Dr Animesh Jain 53
- 54. Q & A Adult Immunization - Dr Animesh Jain 54
Editor's Notes
- Overemphasis on curative medical care Vs preventive health care is more cost effective Which vaccines against what diseases and which risk groups – elderly, pregnant women, health care professionals, patients with chronic co-morbidities.