immunisation schedule for various diseases in adults for developing countries

1. Dr. A.P.NAveeN KumAr
Chief sPeCiAlist (GeN. meD. )
visAKhA steel GeNerAl
hosPitAl
visAKhAPAtNAm steel PlANt

2. Considerable controversy exists exists
regarding Adult Immunisation especially in
developing countries,such as India
Lack of consensus regarding the optimal
strategy
VSGH
01/09/14

3. Benefits include protection from





symptomatic illness
improved quality of life and productivity and
prevention of death.
Social benefits include creation and
maintenance of herd immunity against
communicable disease
prevention of disease outbreaks and
reduction in health care related costs.
VSGH
01/09/14

4. 
Benefits and risks are associated with using all
immunobiologics (i.e. an antigenic substance or
antibody containing preparation).

No vaccine is completely safe or effective.

Benefits of vaccine include partial or complete
protection against infection for the vaccinated
person and overall benefit to society as a
whole.
VSGH
01/09/14

5. 
Routine vaccines for all adults

Vaccines for high-risk exposure group ( healthcare
workers,prisoners,students,military
personnel,travelers,injection drug users,MSM )

Vaccines for persons at high risk for severe
outcomes of infection (pregnant,elderly, chronic
diseases )

Vaccines for household contacts of group 3 persons
VSGH
01/09/14

6. 
The international guidelines do not address the issue of
adult immunization in developing countries like India, unlike
the most successful pediatric immunization.

In India lack of reliable data regarding epidemiology
(burden of infectious diseases),

sparse published data regarding efficacy and safety of
various immunization strategies and

data regarding objective monitoring of adequacy of
immunization i.e. optimal antibody titers makes it difficult to
come to any strong recommendations
VSGH
01/09/14

7. 
Since 2005 two new tetanus toxoid, reduced
diphtheria and acellular pertussis vaccines (Tdap)
are available, 0.5 ml is administered IM in the
deltoid.

Tdap vaccine was shown to be 92% efficacy in a
recent RCT (Grade 1 b)
VSGH
01/09/14

8. 
Whole cell pertussis vaccine is not used in adults because of its
adverse effects and contraindicated in > 7 yrs.

Acellular pertussis vaccines are effective and less reactogenic

Two component Ap is more effective than monocomponent

Addition of pertactin and fimbria further increases efficacy

Recommended in adolescents and adults as a combination
vaccine
VSGH
01/09/14

9. 
Adult primary series: 3 doses of Td,
Tdap can substitute one of the doses
◦ 3 doses: 0, +4 weeks, +6-12 months

Booster with either Td or Tdap
For adults in the age group 18 to 64 years
a booster of Td vaccine - every 10 years till the age of 65 ,
one dose of Tdap vaccine - in place of Td vaccine.
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01/09/14

10. Tdap 1 dose 2 weeks prior to contact
 HCP - 1 dose of Tdap

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01/09/14

11. 
Planning pregnancy – 1 dose of Tdap

Pregnant
Already immunised – 1 dose of Td in 2 or 3
trimester if > 10 yrs immunised
Td received within 10 yrs – Tdap in
postpartum

No h/o immunisation
3 doses – 0,1& 6 months Td starting in 2 or 3
trimester
VSGH
01/09/14

12. 
H/o of TT doses
wound

Not known

3 or > doses
Minor wound
Tdap / Td
Tdap /Td if
> 10 yrs
Major
Tdap/Td/TIG
Tdap /Td if
> 5 yrs
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01/09/14

13. Tdap vaccination deferred
in moderate and severe infections
Unstable neurologic conditions
ADACEL
BOOSTRIX
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01/09/14

14. 
95% of adults develop protective antibody in 4
weeks

100% seroconvert after two doses

Indicated for:
• Travelers to areas of high hepatitis A endemicity
• Men who have Sex with Men (MSM) & IV Drug
abusers
• Patients with chronic liver disease
• Patients who receive clotting factors

Administer:
◦ 2 dose schedule: 0 & +6-18 months
VSGH 01/09/14
◦ Single dose provides ~ 1 year immunity

15. 
Universal immunization for hepatitis is not recommended as
yet.


There are single antigen ,HAV antigen vaccine and
combination vaccines - HAV and HBV antigens

Adults at risk of developing hepatitis A and are negatives for
anti HAV antibodies are likely to benefit most.


HAV immunoglobulin (0.02 ml/mg) seems more efficacious
than vaccine in post exposure prophylaxis - especially in
adults

Combine vaccine 4 dose schedule 0, 7, 21-30 days and
booster at 12 months allows greater protection to travelers to
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depart in less than 1 month .

16. Vaqta ( Merck )
 Havrix ( GlaxoSmithKline )
 Twinvix (GSK )

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01/09/14

17. 

On demand
All adults at risk:
• People who work or live in areas with high endemicity for
Hepatitis B-Health-care workers
• Occupational & recreational blood exposure
• Travellers to areas of high hepatitis B endemicity
• Sexual exposure: sex partner of hepatitis B patient,
promiscuous sex (STD clinic patients), & MSM ,IV Drug
abusers
• ESRD on HD ,HIV infection & Chronic Liver Disease
• Persons with Diabetes < 60 yrs.
• Household contacts and sex partners of HbS Ag carrier
VSGH
01/09/14

18. 
HBV vaccine is available as a recombinant vaccine for
immunocompetent adult

20mcg is administered at 0, 1 and 6 months as an intramuscular
injection in the deltoid using a 24 – 38 mm needle (level A).

Antibody titres rise 20 to 30% after the first dose, 75 to 80% after 2 nd
dose and 90 to 95% after 3 rd dose.

Booster dose not routinely recommended.

CKD patient with declining antibody titers < 10 mIU/ml , < 100 Miu / ml
in patients on dialysis a booster dose is recommended.

For patients of CKD and immunocompromised patients 2 doses of 20
mgs/ml at 0,1,2 and 6 months
VSGH
01/09/14

19. VSGH
01/09/14

20. 
Further 3 doses

Retest after 2 months

40 mg at 0,1 &6

GM-CSF (150-300 MGS sc ) -24 hrs. later
with 40 mgs
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01/09/14

21. 
Live, attenuated, virus vaccine
◦ Contraindicated in pregnancy &

For children (>12 months) & adults, particularly adult:
•
•
•
•
•
•
•

immunocompromised
Health care workers
Primary school teachers & day care workers
Institutional residents and employees
College students
Military personnel
Non-pregnant women of child bearing age
International travelers
2 dose adult schedule: 0 & 4-8 weeks – No booster
VSGH
01/09/14

22. 
Documentation of vaccination

h/o of varicella based on diagnosis

h/o of herpes zoster

Laboratory

Pregnant women- first dose in postpartum period
or before discharge and second dose 4-8 weeks
later

Avoid conception for 1 month after each dose
e/o immunity
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01/09/14

23. 
2 Vaccines are available containing attenuated
like V2V (Oka Strain).

Varicella zoster immune globulin(V214) can be
given to prevent Varicella in non immune,
healthy individuals within 72 hours of exposure
-125 units / 10 kg of body weight upto max.625

Vaccine is 2 doses 4 to 8 weeks apart.

All adults without e/o immunity – 2 doses

Second dose if 1 dose is recieved
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01/09/14

24. 
Vaccine within 3 days

VZIG
Immunocompromised persons
Pregnant
HIV CD4 <200
High dose steroids
Neoplastic diseases

Varicella vaccine is delayed by 5 months after
VZIG administration
VSGH
01/09/14

25. 
Herpes zoster vaccine is being advocated to adults aged
60 years and above

Who are at risk for developing recurrent herpes zoster,
such as patient with CKD, diabetes mellitus, rheumatoid
arthritis and COPD

SINGLE DOSE IS ADVOCATED
VSGH
01/09/14

26. 
MMR vaccine includes live, attenuated measles,
mumps, and rubella virus

Contraindicated for immunosuppressed:
◦ Symptomatic HIV+ (asymptomatic OK)
◦ Steroids (>20 mg/day)
◦ Congenital immune deficiencies
◦ Leukemia, lymphoma, advanced malignancy
◦ Chemotherapy & radiation therapy
VSGH
01/09/14

27. 


Born prior to 1957 considered measles & mumps immune
Adults born since 1956 should have at least one dose of the
two dose series
One dose for women with either none or uncertain immunity
◦ Do not vaccinate pregnant women or women who might
become pregnant within 4 weeks of vaccination
Pregnant women with no e/o immunity – MMR after completion
or termination of pregnancy and before discharge

Two doses indicated for:
◦ Adults exposed to measles
◦ Adults vaccinated with killed measles vaccine
◦ Adult students
◦ Health care workers without measles or mumps immunity
◦ International travelers

No booster after 2 doses
Single dose only is advocated if h/o vaccination +
VSGH 01/09/14


28. Double stranded DNA virus – more than 100 types


60 types  cutaneous infection  skin warts
40 types  mucosal & genital infection
 Type 16 causes 50%;
Types 16 + 18 cause 70%
 Type 16 causes
10% of HPV genital infection in ♀s
◦ Causes squamous cell & adenocarcinoma
◦ Types 6 & 11  90% of anogenital warts
◦ 70% of cervical cancers, 80% of anal cancers,
◦ 60% of vaginal cancers, and 40% of vulvar cancers
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01/09/14

29. 
Two vaccines are available -0.5 ml IM injection at 0, 2 and 6 months.

Gardasil (HPV),[3] specifically HPV types 6, 11, 16 and 18.

Cervarix - infection from HPV types 16 and 18

The vaccine has to be delivered prior to exposure to the HPV.

Therefore the immunization must precede the sexual debut

The HPV vaccine can be given simultaneously with other vaccines eg.,
Hepatitis B, Tdap.


Contraindicated in those who are hypersensitivity and pregnancy.
No contraindication during lactation and immunocompromised.
VSGH
01/09/14

30. 
Quadrivalent (HPV4 ) or bivalent ( HPV2 ) recommended for
females 11 or 12 yrs. And catchup vaccination from 13-26
Yrs.

Sexually active females not infected with any of the 4 types
(6,11,16 &18) or 2 types ( 16 &18 ) receive full benefit of
vaccination.

Less beneficial for females infected with one or more of
vaccine types

Can be administered to persons with genital warts,PAP
positive or positive HPV DNA test

In males 9-26 yrs. to reduce genital warts

DOSAGE SCHEDULE 0 , 1-2 & 6 MONTHS
VSGH
01/09/14

31. 
Not recommended in pregnant women

Pregnancy testing not necessary before vaccination

Found pregnant during vaccination series no intervention is
needed

Remainder of series is given after completion of pregnancy

Not specifically recommended for HCP

HCP should receive as recommended
VSGH
01/09/14

32. Recorded Influenza Pandemics
VSGH
01/09/14

33. When the antigenic match between vaccine
and circulating virus is close, prevents
 <65: prevents 70-90%
 >65: prevents only 30-40% of clinical
illness
But:
◦ Prevents hospitalization in 50-60%
◦ Prevents death in 80%
VSGH
01/09/14

34. 
Trivalent inactivated influenza vaccine (TIV) and
live attenuated influenza vaccine (LAIV) are
available in India. TIV is annual, single IM dose of
0.5 ml.

LAIV is administered by the intranasal route is
approved for use in adults upto 50 years of age.
Evidence recommends people at high risk for
influenza related complication.
VSGH
01/09/14

35. 
Annual vaccination for all persons > 6 months

Healthy, nonpregnant adults < 50 yrs without
medical complications – live or inactivated

Others should receive inactivated

Adults >65 –receive standard vaccine or high
dose influenza vaccine ( Fluzone )
VSGH
01/09/14

36. 
Two types (1) polysaccharide vaccines and (ii) conjugate
vaccine are available.

Single dose 0.5 ml of reconstituted vaccine is administered
subcutaneously in the deltoid region.

Useful in (a) during an outbreak
b) during inter epidemic period and
c) to travelers, pilgrims and people attending
fairs and festivals
d)incoming freshmen who live in dormitories
e) asplenia ,splenectomy and sickle cell anemia patients

Ineffective in children < 2 yrs.
Protection for 5 yrs.
VSGH
01/09/14

37. 
2 doses recommended for adults with anatomic or
functional asplenia or persistent complement component
deficiency

Dosage 0 and 2 months

HIV -2 doses

Meningococcal conjugate vaccine ,quadrivalent (MCV4 )
55 yrs. and younger

Meningococcal polysaccharide vaccine (MPSV4 ) 56 yrs.
and older

Revaccination with MCV4 every 5 yrs. For adults at
increased risk of infection
VSGH
01/09/14

38. 
Not routinely recommended

Quadrivalent polysaccharide vaccine to Haj pilgrims

For travellers going to endemic countries > 2 yrs. - A single
dose

On demand for high risk personnel
VSGH
01/09/14

39. 
The polysaccharide vaccine most commonly used today -purified
polysaccharides from 23 serotypes (1, 2, 3, 4, 5, 6b, 7F, 8,9N, 9V,
10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F and
33F).

This immune response is less robust than response by conj.
vaccines

The vaccine is ineffective in children < 2 yrs. old, presumably

Non-responders are also common amongst older adults.

Immunization is not lifelong, so individuals must be re-vaccinated
every 5–6 years.

Since no mucosal immunity is provoked, the vaccine does not
affect carrier rates, promote herd immunity, or protect from upper
or lower respiratory tract infections
VSGH 01/09/14

40. 
The conjugated vaccine consists of capsular polysaccharides
covalently bound to the diphtheria toxoid CRM197, which is highly
immunogenic but non-toxic. [

This combination provokes a significantly more robust immune
response

This results in mucosal immunity and eventual establishment of
lifelong immunity after several exposures. [
The main drawbacks to conjugated vaccines are that they only
provide protection against a subset of the serotypes covered by
the polysaccharide vaccines.



The normal 4-dose series is given at 2, 4, 6 & 12–14 months of
age.
VSGH
01/09/14

41.  Active against 88% of bacteremic pneumococcal pneumonia
 Cross-reactive for an additional 8% of bacteremic disease
 Prevents 60-70% of invasive disease
 Does not prevent pneumococcal pneumonia
Not effective in children < 2 y/o-does not respond to
polysaccharide so a heptavalent protein conjugate vaccine
is developed
VSGH
01/09/14

42. 










All >64 y/o
Chronic pulmonary disease (except asthma)
Chronic cardiovascular disease
Diabetes mellitus
Chronic liver disease
Chronic renal failure & nephrotic syndrome
Asplenia – functional or anatomical (pre-surgery)
Immunosuppression & HIV
Neoplasia: leukemia, lymphoma, multiple
myeloma
Cochlear implants (pre-placement)
Special populations: Native Americans & longterm-care-facility residents
VSGH
01/09/14

43. 
After 5 years for :
◦
◦
◦
◦

Chronic renal failure & nephrotic syndrome
Asplenia – functional or anatomical
Immunosuppression & HIV
Neoplasia: leukemia, lymphoma, multiple myeloma
For >65 y/o if:
◦ Vaccinated >5 years ago &
◦ <65 when first vaccinated
VSGH
01/09/14

44. 1 dose should be considered for persons who
have sickle cell disease , leukemia or HIV
infection or who had a splenectomy if they have
not received the Hib vaccine previously
VSGH
01/09/14

45. 
Is recommended as part of routine immunization
in adolescents (Grade A).

Either the orals Ty21a vaccine or inject able VI
polysacchride may be used.
Entire community at risk during an outbreak
should be vaccinated
or
at least individual aged 2 – 19yrs should be
specifically given.

VSGH
01/09/14

46. 
No recommendation for routine vaccination of adults

Pregnancy – not safe

Injectable Vi
– HIV <200

Both Ty21a &Vi
- HIV >200
VSGH
01/09/14

47. 
Intra dermal two sites dose 0.1 ml day 0,
3, 7,14 & 28.

Passive immunization is carried out with
human rabies immunoglobulin (HRIG) 10 20 IU/ug infiltrate the site of bite then rest
is given IM.
VSGH
01/09/14

48. 
The two currently available oral cholera vaccine are not
recommended for routine adult immunization (grade C).

Ongoing Randomized control trial in Kolkata
modify this recommendation.

Basic measures of safe drinking water, food hygiene and
health education are key factors essential for control of
cholera.
VSGH
may
01/09/14

49. 
Routine immunisation better avoided

Tetanus toxoid must

Diphtheria toxoid safe

Live viruses contraindicated

If risk of exposure is great other vaccines like
polio,yellow fever,hep B, influenza,pneumococcal can
be given in 2 or 3 trimester
VSGH
01/09/14

50. 
Yellow fever and killed cholera vaccine

Routine immunization to polio,measles,DPT

Hep A ,meningococcal,rabies,Japanese B
encephalitis,Plague for certain regions
VSGH
01/09/14

51. 
Measles -0.25-0.50 ml /kg or 40-80 mg of IgG/kg
active immunisation after 3-6 months

Rubella – 0.55 ml/kg or 90 mg of IgG /kg im

Tetanus – human tetanus immunoglobulin 10-20
mg
of IgG /Kg IM

Rabies – human rabies immunoglobulin 20 IU/Kg

Hepatitis A – Immune serum globulin 0.02-0.04
ml/kg every 5 months
VSGH
01/09/14

52. For Healthy Adults:
Vaccine
19-49
50-64
>65
q 10 yrs
Td
HPV
3 doses, ♀
MMR
1 or 2 doses
Varicella
2 doses
Influenza
1 dose
q year
Pneumococcal
1 dose
Hepatitis A
Hepatitis B
Meningococcal
VSGH
01/09/14

53. For Adults with Health Problems:
Vaccine
19-49
50-64
>65
Td
HPV
1 dose
MMR
Varicella
Influenza
Pneumococcal
2 doses
q year
1-2 doses
Hepatitis A
2 doses
Hepatitis B
3 doses
Meningococcal
1 or more doses
VSGH
01/09/14

54. 
Off schedule? – Do not restart series, just pick-up
where left off and continue

Multiple vaccines? – Can usually co-administer vaccines,
such as: Pneumococcal and influenza & travel vaccines
Exceptions:
◦ Live virus vaccines: delay one for a month to avoid
possible impaired immune response to either agent
◦ Immune globulins should not be given with live virus
vaccines (exceptions: inactivated virus vaccines, oral
polio, and yellow fever)
VSGH
01/09/14

55. Vaccine Administration


Ensure you are properly trained
Always prepare and check the following for every
injection or medication you give:
−
−
−
−
−
Right Patient
Right Drug (vaccine)
Right Dose
Right Route (intramuscular, intradermal)
Right Time (is scheduling correct)
VSGH
01/09/14

56. API GUIDELINES JAPI APRIL
-2009.VOL-57
'Vaccine Information.org 'Vaccine Information
for the Public and Health Professionals'
http://www.sh.lsuhsc.edu/IntraGrad/micro/OLD
-Micro289/2003/289%20PID
%2003%20Vaccines%20.DOC
http://www.bio.davidson.edu/Courses/Molbio/
MolStudents/01teparakh/Methods.htm
http://web.uct.ac.za/depts/mmi/jmoodie/vacc2.
html
www.ImmunizeTexas.com
www.immunize.org/catg.d/p2011.pdf*
Department of health and human services
Centers for Disease Control and Prevention
VSGH
01/09/14