The document outlines the importance of immunization for Indian adolescents, emphasizing the need for vaccines beyond early childhood due to waning immunity and the neglect of this age group. It provides a schedule of recommended vaccinations for adolescents aged 10-19 years, highlighting critical vaccines such as Tdap, HPV, and influenza, and underscores the collective responsibility of caregivers to ensure adequate vaccination coverage. The document also addresses the ongoing risks of infectious diseases and advocates for increased funding and awareness for adolescent health immunization.

1. Immunization for INDIAN
Adolescents
…Caring hearts, healing hands
Dr. Jyoti Agarwal
Dr. Sharda Jain
Dr. Jyoti Bhaskar

2. LEGENDS NEVER DIE………
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)

3. Vaccinations are among the greatest
public health achievements of the
20th century
• First recorded in 1890-95
• Imminization is the action of making a person immune
to infection, typically by inoculation
• Immunization prevents disability & death from
infectious diseases
• It also helps control the spread of infections within
communities

4. Immunization
‘Is not just for infants & children
under five any more'

5. Vaccination
important &
must for
Adolescents
& Adults
Too

6. How Quickly We Forget
(Human Catastrophe From Infective Diseases )
• 1920s : 13,000 died yearly from diphtheria
• 1940s : 8,000 died yearly from pertussis
• 1952 : polio paralyzed 21,000
• 1963 : 3 million cases of measles and 500 died
• 1964-65 : 12.5 million cases of rubella; 20,000 infants
were born with congenital rubella
• 1985: 12,000 meningitis cases by H. influenza type B
All this could have been prevented
If they were vaccinated

7. Protect the YOUTH
‘Nation’s Future’
• Every fifth person in India
is an adolescent (10-19 yrs)
Every third – a young person
(10-24 yrs)
• They are our biggest competitive advantage,so their
health care is of utmost importance. Somehow this
group is totally neglected
30%
Investing in Adolescent Health is a
Win – Win situation for any society

8. Why Target Adolescents ??
• Immune protection provided by childhood vaccinations may not
cover adolescent period
• This may happen because the effect of vaccination wanes off
• May be the initial vaccination in childhood was not given or was
given in inadequate doses
• Underlying chronic diseases in adolescents or certain high risk
groups also demand vaccination for their protection
It is collective responsibility as gynecologists,
paediatricians, teachers and parents to ENSURE
that they are cared for and adequately
vaccinated

9. Vaccination Coverage Is Around 65 %

11. Recommended Adolescent
Vaccines

12. Age
►
Vaccine ▼
Birth
– 2
weeks
6 wk 10 wk 14 wk 18 wk 6 mo 9 mo 12 mo 1
5
m
o
18 mo 19-23
mo
2-3 Yr 4-6
Yr
7-
10Yr
11-12 Yr 13-18Yr
BCG BCG
Hep B Hep
B1
Hep B2 Hep B3
Polio
OPV 0 IPV1 IPV2 IPV3
OPV
1
OPV2 IPV B1
OP
V3
DTP
DTP
1
DTP 2 DTP 3 DTP B1
DT
P
B2
Tdap Tdap
Hib Hib 1 Hib 2 Hib 3 Hib-booster
Pneumococca
l
PCV
1
PCV 2 PCV 3
PCV -
booster
PCV
PPSV23 PPSV
Rotavirus RV 1 RV 2 RV 3
MMR
MMR 1 MMR 2
MM
R 3
Varicella
VAR 1
VA
R 2
Hep A Hep A1 & Hep A2
Typhoid
Typhoid CV (TCV)
Booste
r
Influenza Influenza (yearly)
HPV HPV
Meningococc
al
Meningococcal
Cholera Cholera 1 & 2
JE
Japanese Encephalitis
Rabies
IAP Recommended immunization schedule for children aged 0-18 years 2016

13. Recommended Adolescent
Immunizations in INDIA (2016)
11-12 Years
Tdap
HPV
Annual influenza
Catch-Up
MMR
Hepatitis B
Typhoid
Varicella
Hepatitis A
High Risk
Pneumococcal
Meningococcal
JE
Cholera
Rabies
Yellow fever

14. Vaccines Recommended
for All adolescents at age
11 to 12 years

15. Tdap vaccine
 Diphtheria - a purely vaccine-preventable disease
 It used to be a disease of children 5-7 years, but now a
shift to right in epidemiology
 A huge resurgence in last few years
 Cases in India far out number those of any other country
in the world according to WHO.
 3343 and 4233 in 2010 &2011 respectively incidence
increasing [DGHS]
India contributes 86.66% of the
diphtheria cases reported globally

16. Why do Adolescents need
Pertussis Vaccine?
• Pertussis is endemic
• Outbreaks are still occurring the general trend has
been upward
• Adolescents are responsible for spread of pertussis in
the community
• Immunity to pertussis last 3-10 years
India contributes > 43 % of
pertussis cases reported globally

17. International Consensus Group On Pertussis &
Global Pertussis Initiative Recommendation
• There is a need to vaccinate ALL adolescents
at 11 – 12 yrs of age against pertussis
• Vaccination ensures an increase in herd
immunity

18. Tdap vaccine
• Administer 1 dose of Tdap vaccine to ALL adolescents
aged 11 through 12 years
• Or at any greater age if it has not been given earlier
• Boosters after that are Td given every 10 years
• Can be administered at the same time as other adolescent
vaccines
Efficacy of Tdap vaccine - 92%

19. HPV vaccination
• Every woman is at risk of Cervical Cancer
• 1 out of 4 women who die due to Cervical
Cancer in the world is an Indian

20. Risk of cervical cancer is strongly related
to the age at first intercourse
1
2
3
4
5
6
7
CIN Invasive Cervical Cancer
RelativeRiskEstimatesa
≤17
18–22
aMantle-Haenszel estimates adjusted for age only.
1. La Vecchia C et al. Cancer. 1986;58:935–941.
Relative risks for CIN and invasive cancer increase
with decreasing age of first sexual intercourse.
Age at First Intercourse (Years)
(n=206) (n=327)
Reference Population:
First intercourse
23 years of age or never

21. Evidence and justification
• IAP had recommended use of HPV vaccine in
its immunization schedule way back in 2007
• There is NO coverage data on uptake of this
vaccine
• Common perception is that acceptance is poor
and the coverage still remains miniscule

22. In India, both IAP and FOGSI
recommend the HPV vaccine
• Minimum age: 9 years
• For girls aged 9-14 yrs only
2 doses of either of the
two HPV vaccines
• For 2 dose schedule, the
minimum interval between
doses should be 6 months
• Catch up vaccination is
permitted up to the age of
45 years
• For girls 15 years and older,
and immunocompromised
3 doses are recommended
• For 3 dose schedule, administer
the 2nd dose 1 to 2 months after
the 1st dose and the 3rd dose 6
months after the 1st dose
Use The Same Brand of Vaccine For The Entire Series

23. The WHO’s Strategic Advisory Group of Experts
(SAGE)
has recommended revision of HPV vaccination schedule
for pre-adolescent girls from three primary doses to two
April 2014
‘The move to revise HPV vaccine
immunization schedule from three to
two doses would not only be cost-
saving, but would also help in
improving acceptance, and
enhancing coverage of the vaccine’

24. Genital Warts
Vulvar/ Vaginal Precancers
(Grade 1- 3)
Cervical Cancer &
Precancers (Grade 2/ 3)
99%
98%
100%
HPV induced lesions Protection
1. The Future II Study Group. Lancet 2007; 369: 1861–68 2.Garland SM et al. New Engl J Med. 2007;356:1928–1943.
Efficacy of Quadrivalent HPV Vaccine

25. Influenza Vaccine

26. What about Influenza (flu) Vaccine
• Flu can be serious, even
for healthy adolescents
• Adolescents with high-
risk conditions more likely
to suffer flu complications
• Flu seasons are
unpredictable and can be
severe
• There are 2 influenza
viruses, types A and B
• Type A :subtypes based
on two surface antigens
Hemagglutinin (H)
Neuraminidase (N)
eg H1N1
• Influenza type B is not
categorized into subtypes

27. Influenza vaccine
Two types of flu vaccine available
• Injection: Trivalent Inactivated killed Influenza Vaccine (TIV)
• Intranasal: Live, Attenuated Influenza Vaccine (LAIV)
• Both vaccines are made from viruses grown in eggs
• Avoid in allergy to chicken or egg protein
• An egg-free vaccine is also now available
Both vaccines includes Two type A strains
(H3N2 and H1N1) & One type B strain

28. Influenza Vaccine Recommendations
Adolescents
should receive a
single dose of
influenza vaccine
Every Year
Best time to vaccinate
As soon as the new
vaccine is released and
available in the market
or Just before the onset
of rainy season
Recommended strains may change annually so in
view of changing strains the antigens configuration
for Influenza need a new model vaccine every year
Influenza – Needs very frequent updating

29. IAP Recommendation for
Catch Up Immunization
for adolescent
For those who fall behind or start late,
provide catch-up vaccination at the earliest
opportunity

30. IAP Recommendation for Catch Up
Immunization for adolescent
Vaccine Schedule
MMR 2 doses at 4 - 8 weeks interval I@
HepatitisB # 3 doses at 0, 1 and 6 months
Hepatitis A 2 doses at 0,6 months (prior check for
## anti – HAV IgG may be cost
effective)
Typhoid 1 dose every 3 years**
Varicella 2 doses at 4 – 8 weeks interval
@ one dose if previously vaccinated with one dose
#, ## Combination of hepatitis B and A may be use in 0, 1, 6 schedule
**A minimum interval of 3 years should be observed between 2 doses of
typhoid vaccine

31. MMR vaccine
• All school-going children and adolescents should
have at least 2 doses of MMR vaccine
• one dose if previously vaccinated with one dose
• Minimum interval between the 2 doses is 4 wks
“Stand Alone” vaccine given to infants during
outbreaks, should not be counted

32. Chicken pox (CDC 2007)
Most cases are mild but adolescents and
adults are at risk for severe disease
Prior to vaccination
– 4 million cases annually
– 10,600 hospitalization
– 100 – 150 deaths
Since vaccination
– 88% decrease in cases
– 88% decrease hospitalization
– 90% decrease deaths

33. Varicella vaccine -Catch-up vaccination
• Ensure that all adolescents aged 7 through 18 years
should have 2 doses of the vaccine
• For children till 12 years, the recommended
minimum interval between doses is 3 months
• For children 13 years and older, the minimum
interval between doses is 4 weeks

34. The Expert Group for Hepatitis A
• Universal
immunization for
hepatitis A is not
recommended as yet
• Sero-positive rates
exceed 50%
• Prior check for
Hepatitis A antibody
titre IgG is cost
effective &
recommended

35. Hepatitis – A vaccine , 2 types
• Live attenuated H2 strain hepatitis A vaccine
• Killed inactivated Hep A vaccine
• Either of the two vaccines can be used
• Administer 2 doses of inactivated vaccine 6
months apart
• Only single dose of live attenuated H2-strain
vaccine
Highly immunogenic & Highly efficacious
Essentially 100% have protective levels of antibody after second dose

36. Hepatitis – B prevalence in India
• 1 - 2% (Lodha et al)
• Overall chronic HBsAg
+ve rate in India is
4.7%
• Catch-up vaccination
• Recombinant hepatitis B
virus vaccine
• 90% successful
3-doses to be given to those previously
not vaccinated at 0 – 1 – 6 months
Combination of Hepatitis B & Hepatitis A may
be used at 0 – 1 – 6 months

37. Typhoid Vaccination
The committee strongly urges the GOI to
include universal typhoid vaccination in its UIP
all over the country at the earliest

38. Typhoid vaccine catch-up vaccination
• Recommended throughout the adolescent period, i.e. up to
18 years of age
• Vi conjugate typhoid vaccine should be preferred over Vi-PS
vaccine wherever feasible
• The need and exact timing of the booster doses are not yet
determined
• Typhoid revaccination every 3 years, if Vi-polysaccharide
vaccine is used
• An interval of at least 4 weeks with the MMR vaccine should
be maintained while administering Typhoid vaccine

39. IAP Recommendations
for adolescent
Immunization in High
Risk Cases

40. High-risk category of children
• Congenital or acquired immunodeficiency (including HIV
infection)
• Chronic cardiac ,pulmonary (including asthma if treated with
prolonged high-dose oral corticosteroids),renal (including
nephrotic syndrome) liver disease;
• hematologic
• Children on long term steroids, salicylates, immunosuppressive
or radiation therapy
• Diabetes mellitus,
• Cerebrospinal fluid leak
• Cochlear implant
• Malignancies
• Children with functional/ anatomic asplenia/ hyposplenia;
• Travelers
• Children having pets in home

41. IAP Recommendations for adolescent
Immunization in Special Circumstances
Vaccine Age recommended
Meningococcal vaccine 2 doses
Japanese encephalitis vaccine Catch up to 15 years @
PPSV23 (Pneumococcal)
vaccine
2 doses 5 years apart*
Rabies vaccine 0, 3, 7, 14, 28
day
As soon as possible after
exposure
Cholera & yellow fever
@ Only in endemic area as catch up
* Maximum number of doses – Two

42. Meningococcal Meningitis
• Epidemics – 20 year cycles previously, now increasing
frequency
• Annual incidence of 3000 cases
• 10% of these cases will die , high Case Fatality Rate
• 20 % of those who survive suffer serious long term
disability , hearing loss , organ failure & limb
amputation
• Often misdiagnosed as something less serious like
“ flu”
• Spreads rapidly , often within hours of first symptoms

43. MENINGOCOCCAL MENINGITIS
2 Types
Polysaccharide vaccines
• Bivalent (A&C)
• Quadrivalent (A,C,Y & W135)
Conjugate vaccines
Quadrivalent
Monovalent
Conjugate vaccines are preferred over polysaccharide vaccines
due to their potential for herd protection and their
increased immunogenicity

44. Meningococcal Conjugate Vaccine
• Two doses of MCV4 are recommended for
adolescents aged 11 to 18 years
First dose at age 11 - 12 years
Booster dose at 16 years
• Adolescents who receive their first dose at
or after 16 years of age do not need a
booster dose

45. Pneumococcal Vaccines
Two types available
• Pneumococcal conjugate vaccine
(PCV 10 , PCV 13)
• Pneumococcal polysaccharide vaccine
(PPSV 23 )
• Risk of serious Pneumococcal disease is relatively low
• Not recommended for routine use in healthy individuals
• Recommended only in high risk group of children

46. Pneumococcal Vaccines
• A single dose of PCV13 is given to previously unvaccinated
children who have anatomic or functional asplenia (including
sickle cell disease), HIV infection , immunocompromised, cochlear
implant or cerebrospinal fluid leak
• Administer PPSV23 at least 8 weeks after the last dose of PCV
• An additional dose of PPSV should be given after 5 years to
children with anatomic/functional asplenia or if immunocompromised
• PPSV should never be used alone (Maximum number of doses – 2 )
• Give PCV13 first and MCV4 four weeks later (NOT simultaneously)
• Can be co-administered with live vaccines such as the influenza vaccine

47. Cholera Vaccine
• Available as inactivated whole cell Vibrio cholera vaccine
• Not recommended for routine use in healthy individuals
• Recommended only adolescents residing in highly
endemic areas and traveling to areas where risk of
transmission is very high like Kumbh mela
• Two doses are given 2 weeks apart

48. Japanese Encephalitis Vaccines
• Recommended only for
individuals living in or
planning to visit
endemic areas till 18
years of age
• All susceptible children up
to 15 yrs should be
administered during disease
outbreak , ahead of
anticipated outbreak in
campaigns
• Live attenuated, cell culture
derived SA-14-14-2 NA
• Inactivated cell culture
derived SA-14-14-2
2 doses , 4 wks apart I/M
Need of boosters still
undetermined
• Inactivated Vero cell
culture-derived Kolar
strain, 821564XY
2 doses I/M at 4 wks interval
Need of boosters still
undetermined

49. Rabies is one of the oldest
and most feared diseases
reported in medical text
•Pre exposure prophylaxis
•Post exposure prophylaxis

50. Rabies vaccine
• Practically ALL children need
vaccination against rabies
‘High-risk’ category for
Pre-exposure prophylaxis
• Children having pets at home
• Children with higher threat of
being bitten by dogs such as
hostellers,
• Risk of stray dog menace while going
outdoor

51. WHO Approved Vaccines
• Purified chick embryo cell vaccine
(PCECV) Rabipur (novartis) (1.0 ml)
• Human diploid cell vaccine (HDCV)
Rabivac (serum institute) (1.0)
• Purified vero cell vaccine (PVCV)
Verorab (sonofi pasteur) (0.5 ml)
Only Modern Tissue Culture Vaccines (MTCVs) and
I/M routes are recommended for both
‘Post-exposure' and ‘Pre-exposure' Prophylaxis

52. Pre -Exposure Prophylaxis For Rabies
• 3 doses are given intramuscularly in deltoid/
anterolateral thigh on days 0 – 7 – 28
(day 21 if time is limited but day 28 preferred)
• First booster dose at 1 year and thereafter every 5 years
• For re-exposure at any point of time after completed and
documented pre or post exposure prophylaxis, only
2 doses are given on days 0 and 3
• Rabies immunoglobulin is not required during re-exposure
therapy

53. Post-exposure prophylaxis should be
started as soon as possible after
exposure (5 day schedule )
• Schedule: 0 – 3 – 7 – 14 – 30 with day '0'
being the day of commencement of
vaccination
• A sixth dose on day 90 is optional and may be
offered to patients with severe debility or
those who are immunosuppressed