This document provides guidelines on adult immunization for Indian women. It summarizes the key adult vaccines recommended in India including tetanus, diphtheria, pertussis (Tdap), human papillomavirus (HPV), influenza, measles, mumps, rubella (MMR), and varicella. For each vaccine, it outlines the target populations, dosing regimens, contraindications and precautions. The guidelines aim to promote awareness of the importance of adult immunization for preventing disease and maintaining health.

1. D.G.F. Guidelines on
Adult Immunization for
Indian Women
Dr. SHARDA JAIN
Dr. Jyoti Agarwal / Dr. Jyoti Bhasker
…Caring hearts, healing hands

2. WELCOME TO

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)

4. Immunization
is not just for infants
& children under five any more

5. Today
Vaccination
is just not
for Kids
But
Adolescents
&Adults
Too

6. What is IMMUNIZATION?
• 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.
6Source : Dictionary of Public Health, J Kishore - 2007

7. WHY ADULT
IMMUNIZATION?
•“Disease-free young and older adults can remain
active, healthy participants in society / contribute a lot
in NATION building and more fully generating money..
• Researchers strongly feel… this create a Win- win
situation for all individuals in the society.
• Health costs for curing will be contained, and
economic productivity will go up.

8. WHY NO ONE IS TALKING ABOUT
ADULT IMMUNIZATION ?
In INDIA, there is often lack of resources, political will and
awareness on immunization and the impact on health
among DOCTORS & POLICY MAKERS, it takes years to
build system & evolve.
•As we have seen with childhood vaccinations access. …
raising awareness and understanding of how vaccines can
improve health and economies has taken so long. Still we
are far away from 100% immunisation Goal
It takes decades for new public health interventions
to reach those most in need

9. • Adult immunizations have:
• Lack of clear vaccination recommendations
among national and global bodies except USA
• Complex vaccination schedules
• Inadequate physician and patient knowledge
• Patients have limited awareness of the benefits
of vaccinations for themselves and their families
WHY NO ONE IS TALKING ABOUT
ADULT IMMUNIZATION ?

10. ADULT IMMUNIZATION SHOULD BE A
MAJOR POLICY PRIORITY FOR
POLICYMAKERS AND OTHER
STAKEHOLDERS IN INDIA
This is also how childhood immunizations
were developed, and the model & motivation
behind success should be brought to
innovations in adult vaccines too
Now is the time to create similar levels of attention
on the critical value of adolescent & adult
vaccines as is done western countries

11. WHY ADULT VACCINATION ?
• Immunity wanes over time
• As we age, we become more susceptible to serious
diseases caused by common infections, such as
shingles, flu & pneumonia. This results in otherwise
preventable morbidity & mortality.
• Considerable vaccine – preventable morbidity
* Excess Hospitalization
* Diminished quality of life (Post – herpetic neuralgia)
* Missed work
* Medical Complications

12. CDC GUIDELINES on
ADULT VACCINATION
IN U.S.A.

13. ACIP Adult Immunization Schedule, Age-Based Recommendations - USA

14. ACIP Adult Immunization Schedule- Medical/Occupational and Behavior-Based
Recommendations (USA)
12/15/2016 14
Pregn
ancy
Immunoco
mpromisin
g
conditions
excluding
HIV
HIV &
CD4
Count
<200
cell/
µl
>200
cell/
µl
Men
having
sex
with
men
(MSM)
Heart
disease,
chronic
lung
diseases,
chronic
alcoholic
Aspleni
a
includi
ng
elective
Splenec
tomy
Chro
nic
liver
dise
ases
Diabete
Kidney
failure,
ESRD,
on
hemodi
lysis
Health
-Care
perso
nnel

15. Vaccine / Age group 19-26 yrs 27-49 yrs 50-59 yrs 60-64 yrs > 65 yrs
Tetanus, Diptheria, Pertussis (Tdap)
Substitude one time dose of Tdap with Td,
then booster with Td every 10 years
Td booster
every 10 yrs
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
ACIP Adult Immunization Schedule, Age-Based Recommendations, INDIA
Recommended if some risk factor is present
All persons who meet the age criteria
No recommendation

16. 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, Diptheria,
Pertussis (Tdap)
Td
Substitute one time dose of Tdap with Td, then booster with Td every 10
years
Human Pappiloma
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 TIV annually 1 dose TIV
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
Contraindication

17. ADULT Immunization
recommended in India
Tdap MMR
Influenza Pneumococcal
Hepatitis B Hepatitis A
Varicella HPV (cervical cancer)
Meningococcal Herpes Zoster

19. HPV VACCINATION

20. HUMAN PAPILLOMA VIRUS
infection is the most common
sexually transmitted infection. It is
transmitted early in adolescence
when sexual oro pharyngeal cancer.
The high risk subtypes of HPV are
responsible for these cancers.

21. YOU DON’T NEED TO CURE
IF YOU CAN PREVENT IT
CANCER

22. India ~1,22,844
Total world ~ 5,27,624
India ~23% of new
Cervical Cancer cases in world
India ~ 67,477
Total world ~ 2,65,653
India ~23%
Rest of World - 77%
India ~25% of deaths
due to Cervical Cancer in world
Rest of World - 73%
India - 27%
2013
Cervical Cancer Disease Burden INDIA
Incidence Mortality
India ~25%
Rest of World - 75%
2. Bruni L, Barrionuevo-Rosas L, Serrano B, Brotons M, Cosano R, Muñoz J, Bosch FX, de Sanjosé S, Castellsagué X. ICO Information Centre on HPV and
Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in India. Summary Report 2014-01-31. [Accessed on 11th Feb 14]

23. HPV 16
HPV 18
HPV 6
HPV 11
Cancer causing Types
High risk group-16,18,
31,33,45,52,58
Non-cancer causing types
Low risk group- 6,11.
• >75% of Cervical Cancer5,6
• >50% of Vaginal & Vulvar Cancer5
90% of Anogenital warts5
HPV is a necessary cause of cervical cancer – 99.7%4
HPV
1.Schiffman M, Castle PE. Arch Pathol Lab Med. 2003;127:930–934. 2. Wiley DJ, Douglas J, Beutner K, et al. Clin Infect Dis. 2002;35(suppl 2):S210–S224. 3. Muñoz N, Bosch FX, Castellsagué X, et al. Int J
Cancer. 2004;111:278–285. Reprinted from J Virol. 1994;68:4503–4505 with permission from the American Society for Microbiology Journals Department. 4. Walboomers JM, Jacobs MV, Manos MM, et al. J
Pathol. 1999;189:12–19. 5. X. Castellsagué, S. de Sanjose, T. Aguado, K. S. Louie, L. Bruni, J.Muñoz, M. Diaz, K. Irwin, M. Gacic, O. Beauvais, G. Albero, E. Ferrer, S. Byrne,F. X. Bosch. HPV and Cervical
Cancer in the World. 2007 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre6. Bhatla N et al.Vaccine (2008;26; 2811-17
HUMAN PAPILLOMAVIRUS (HPV)
Need for multivalent HPV vaccine for broader HPV protection

24. RATIONALE FOR VACCINATION
Natural Infection – Weak AB response
Vaccination - High AB Response
Higher AB level at
cervical epithelium
prevents HPV infection

25. 3 HPV Vaccine
available in the World
Gardasil 0 2 6 (MSD)
Cevarix 0 1 6 (GSK)
Nano valent vaccine (MSD)
(3 doses in six months)
Target Population 9 to 45 years

26. WHO
Two Vaccine are only
needed
0 & 6 if given
Between 9- 14 years

27. TARGET POPULATION - HPV
• HPV vaccination can also be given with the
following special situations: abnormal
Papanicolau (Pap) smear,
• History of genital warts,
• Breastfeeding
• Immunocompromised.
Papsmear and HPV infection status
is not a prerequisite for HPV vaccination.

28. 9vHPV VACCINATION
The most recent recommendation in the USA considers
that adolescents of both sexes should be vaccinated at
the age of 11-12 years with 9vHPV vaccination .
However , bivalent or quadrivalent vaccine may be used
for females, but boys can have only quadrivalent vaccine
or 9vHPV vaccination .
In Europe and many countries including
India, HPV vaccine is only
recommended for girls.

29. TETANUS, DIPTHERIA,
PERTUSSIS

30. TARGET POPULATION - TDAP
• Pregnant women with no previous
tetanus immunization or unknown
tetanus immunization history
should receive three doses of Td
vaccine to be given on month apart,
starting the second trimester. The
third dose can be given postpartum
as Tdap.

31. TDaP
• Pregnant women whose last
Td/ Tdap vaccination was more
than ten years ago should receive Td
booster in the second or third
trimester of pregnancy.

32. DOSE REGIMEN OF TDAP
• The primary tetanus immunization series
consists of 3 Td injections given
intramuscularly. The first two doses are given
one month apart, and the third dose is given 6-
12 months after the second dose. The third
dose may be given as Tdap.
• Tdap dose is 0.5 mL administered IM,
preferably into the deltoid muscle.

33. CONTRAINDICATION - TDAP
• Severe allergic reaction
(e.g. anaphylaxis) after a previous
dose or to a vaccine component.

34. PRECAUTION - TDAP
• History of hypersensitivity reactions
following a previous dose of TT-
containing vaccine – defer
vaccination until at least 10 years
have lapsed since the last TT-
containing vaccine.

35. ADVERSE EVENTS - TDAP
• Pain
• Redness or swelling
• Fever
• Headache or tiredness

36. AVAILABLE PREPARATIONS
Vaccine Formulation
Tetanus toxoid 0.5 ml/ampule
Tdap absorbed 0.5 ml/ampule
Tetanus-Diphtheria 0.5 ml/ampule

37. INFLUENZA

38. TARGET POPULATION – INFLUENZA VIRUS
• All pregnant and breastfeeding women
should receive the inactivated flu vaccine
• Individuals belonging to the following risk
groups
– All children aged 6 months to 18 years
– All persons aged ≥ 50 years
– Other persons at risk for medical complications
from influenza
– All healthcare professionals

39. DOSING REGIMEN – INFLUENZA VIRUS
• Infants, children and adolescents aged 6
months to 18 years.
• Women ≥ 19 years: given
intramuscularly, every year, as soon as
the newest/current WHO-recommended
vaccine strains become available.

40. CONTRAINDICATIONS –
INFLUENZA VIRUS
Severe allergic reactions
(e.g. anaphylaxis) after a previous dose
or to a vaccine component, including
egg protein

41. PRECAUTIONS – INFLUENZA VIRUS
• Guillaine Barre Syndrome within 6
weeks of previous dose of influenza
vaccine
• Moderate or severe acute illness with
or without fever.

42. Available Preparations –
Influenza Virus
Vaccine Formulation
Inactivated Split-Influenza
Virus Vaccine
0.5 mL prefilled
syringe
Inactivated Influenza Virus
Vaccine
0.25 mL and 0.5 mL
prefilled syringe

43. MUMPS, MEASLES,
RUBELLA

44. TARGET POPULATION - MMR
• All non-pregnant women of
childbearing age must be offered
measles, mumps and rubella (MMR)
vaccination if not had vaccination in
childhood.

45. TARGET POPULATION - MMR
• Upon completion or termination of
pregnancy, women who do not have
serologic evidence of rubella immunity
or documentation of rubella vaccination
should be vaccinated with MMR before
discharge from the hospital or birthing
centre.

46. TARGET POPULATION - MMR
• Routine prenatal serologic testing
for rubella on all pregnant women
to test rubella immunity should be
done.

47. DOSE REGIMEN - MMR
• 0.5 mL, administered subcutaneously, 1-
2 doses.
• Second dose of MMR vaccine,
administered 4 weeks after the first dose
is recommended for adults

48. CONTRAINDICATIONS - MMR
• Severe allergic reaction after a
previous dose of the vaccine.
• Pregnancy
• Severely immunocompromised
patients

49. PRECAUTIONS - MMR
• Women administered the
MMR vaccine should be
advised not to get pregnant
during the next 4 weeks post-
vaccine.

50. PRECAUTIONS - MMR
• History of thrombocytopenia or
thrombocytopenic purpura
• Need for tuberculin skin testing
• Moderate or severe acute illness
with or without fever

51. AVAILABLE PREPARATION - MMR
Vaccine Formulation
Measles, Mumps, Rubella Virus
Vaccine, live-attenuated
0.5 mL

52. VARICELLA

53. TARGET POPULATION - VARICELLA
• Persons aged >13 years
• School-aged children,
• college students, and students in other post-
secondary educational institutions
• Other healthy adults

54. POSTPARTUM VACCINATION - VARICELLA
• Women who do not have evidence of
varicella immunity should receive the first
dose of vaccine before discharge from the
health-care facility. The second dose should
be administered 4-8 weeks later.
• Women should be counselled to avoid
conception 1 month after each dose of
varicella vaccine.

55. DOSE REGIMEN - VARICELLA
• Eligible recipients should receive two
0.5 mL doses of single-antigen
varicella vaccine administered
subcutaneously, 4-8 weeks apart. If
>8 weeks elapsed after the first
dose, the second dose may be
administered without restarting the
schedule.

56. CONTRAINDICATIONS - VARICELLA
• Persons with history of anaphylactic
reaction to any component of the vaccine,
to neomycin.
• Persons with malignant condition
• Family history of congenital or hereditary
immunodeficiency

57. CONTRAINDICATIONS - VARICELLA
• Persons receiving high-dose systemic
immunosuppressive therapy.
• Pregnant women

58. PRECAUTIONS - VARICELLA
• Vaccination of persons who have acute severe
illness, including untreated, active
tuberculosis, should be postponed until
recovery.
• Varicella vaccines should not be administered
for the same intervals as measles vaccine, after
administration of blood, plasma or
immunoglobulin.

59. AVAILABLE PREPARATION - VARICELLA
Vaccine Formulation
Varicella Virus Vaccine, live-
attenuated, freeze-dried with
separate diluent, to be
reconstituted right before
administration
0.5 mL

60. HEPATITIS - A

61. TARGET POPULATION - HEPATITIS A
• Women, 18 years old and above, who have
close contact with persons with hepatitis A,
must be vaccinated.
• Women travelling to or working in countries
with high or intermediate prevalence of
hepatitis A should be vaccinated.

62. TARGET POPULATION - HEPATITIS A
• Women who use street drugs are
candidates for vaccination.
• Women with chronic liver disease
(including hepatitis B and C) should
receive hepatitis A vaccination.

63. TARGET POPULATION - HEPATITIS A
• Women previously treated with clotting
factor concentrates should avail of
hepatitis A vaccination.
• Women with occupational risk including
laboratory staff should be vaccinated.

64. POST-EXPOSURE PROPHYLAXIS -
HEPATITIS A
• For susceptible healthy women up to age 40
years, single-antigen hepatitis A vaccine should
be administered as soon as possible after
exposure.
• Beyond 40 years, immune globulin (Ig) is
preferred. Vaccine can be used if Ig cannot be
obtained.

65. DOSE REGIMEN - HEPATITIS A
• Hepatitis A vaccine should be
administered by intramuscular route
for 2 doses, 6-12 months apart, for
lasting protection.

66. CONTRAINDICATIONS/PRECAUTIO
NS /ADVERSE EVENTS -
HEPATITIS A
• Severe or life-threatening allergic reaction to a
previous dose of hepatitis A vaccine is an
absolute contraindication.
• Severe or life-threatening allergic reaction to
any vaccine component contraindicates the
administration of hepatitis A vaccine.

67. CONTRAINDICATIONS/PRECAUTIONS
/ADVERSE EVENTS - HEPATITIS A
• Moderate or severe ilnnes at the time of
vaccination may defer the scheduled
administration.
• Safety of the hepatitis A vaccine for pregnant
women has not been determined.

68. CONTRAINDICATIONS/PRECAUTIO
NS /ADVERSE EVENTS -
HEPATITIS A
• The most commonly reported adverse
reaction following hepatitis A
vaccination is local reaction at the site
of injection.

69. AVAILABLE PREPARATIONS -
HEPATITIS A
Vaccine Formulation
Inactivated hepatitis A vaccine 1 ml/vial
Combined inactivated
hepatitis A and B vaccine
1 mL prefilled
syringe

70. HEPATITIS - B

71. TARGET POPULATION - HEPATITIS B
• Women 18 years old and above who belong to
the high risk groups:
– Healthcare and public safety and security workers
who may have exposure to blood in the workplace
– Persons in training for allied health professions
– Hemodialysis patients and those receiving blood
and blood products including transplant
candidates

72. TARGET POPULATION - HEPATITIS B
• Women 18 years old and above who
belong to the high risk groups:
–Patients in early course of chronic liver
diseases
–Sexually transmitted disease (STD) clinic
clients
–Multiple sexual partners or prior STD
–Inmates of correctional facilities

73. TARGET POPULATION - HEPATITIS B
• Women 18 years old and above who belong to
the high risk groups:
– Clients and staff of institutions for development
disability.
– Travellers to high endemicity areas
– Overseas foreign workers
– Injection drug users
– Household contacts and sexual partners of
hepatitis B virus carriers

74. TARGET POPULATION - HEPATITIS B
• Hepatitis B vaccine may be administered to a
pregnant woman who is otherwise eligible for
it.
• All HBsAg-negative pregnant women seeking
STD treatment who have not been previously
vaccinated should receive hepatitis B
vaccination.

75. DOSE REGIMEN - HEPATITIS B
• Hepatitis B vaccine is administered
intramuscularly in 3 doses at 0, 1, 6-12 months.
• The accelerated schedule should be
given in 4 doses at 0, 1, 2, 12 months.
• The rapid schedule should be given in
4 doses at 0, 7, 21 days and 12 months.

76. CONTRAINDICATIONS/
PRECAUTIONS/ADVERSE EVENTS -
HEPATITIS B
• A severe allergic reaction to vaccine
component or to a prior dose of hepatitis B
vaccine is a contraindication to further doses of
the vaccine.
• Persons with moderate or severe acute illness
should not be vaccinated until their condition
improves.

77. CONTRAINDICATIONS/
PRECAUTIONS/ADVERSE EVENTS -
HEPATITIS B
• Minor illnesses like upper respiratory
tract infection is not a
contraindication to vaccination.

78. AVAILABLE PREPARATION -
HEPATITIS B
Vaccine Formulation
Recombinant hepatitis B virus
vaccine
20 mcg/mL
5 mL

79. HERPES ZOSTER (SHINGLES)
for old adults

80. 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

81. 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.
Herpes Zoster

82. 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.
HERPES ZOSTER

83. PNEUMOCOCCAL
Vaccination
for old adults

84. PNEUMOCOCCAL Vaccination
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.

85. • Adults who are 65yrs of age or older.
HIGH RISK PEOPLE
• Anatomic asplenia
• Sickle cell disease
• Immunocompromised
persons including HIV
• Leukemia, Lymphoma
• Hodgkin’s disease
• Multiple myeloma
• Generalized malignancy
• Chronic renal failure
• Nephrotic syndrome
• Chemotherapy &
corticosteroids)
• Organ or bone marrow
transplant.
• Pregnant women with
high-risk conditions
PNEUMOCOCCAL Vaccination

86. • 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.
PNEUMOCOCCAL Vaccination

87. MENINGOCOCCAL
MENINGITIS

88. 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.

89. 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.
Meningococcal Vaccination

90. 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).
Meningococcal Vaccination

91. • 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.
Meningococcal Vaccination

92. 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

93. RECOMMENDED VACCINES FOR
TRAVELERS TO INDIA
CDC recommends the vaccines according
to duration of stay in India.
• Tetanus-Diphtheria
• Hepatitis A
• Yellow Fever
• Polio
• Japanese Encephalitis
• Rabies
• Typhoid
• Hepatitis B
• Tuberculosis
• Meningitis
< 1 month
1- 5 month
> 6 month

94. TAKE HOME MESSAGE
Adult women are an important group of
any country & their health care is utmost
important. Our social scenario prevent
them to access a health care facility on
their own …it is for us as gynaecologists,
Paediatricians, general practitioners to
see that they are cared & needed
vaccination are given in time

95. REMEMBER..ADULT Immunization
recommended in India for WOMEN
Tdap MMR
Influenza Pneumococcal
Hepatitis B Hepatitis A
Varicella HPV (cervical cancer)
Meningococcal Herpes Zoster

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LIFECARE CENTRE IS THE STAR
TRAINING CENTRE OF D.G.F
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