Towards adult vaccination in India: a narrative literature review

Figures & data

Figure 1. Plain language summary.

Table 1. Reported cases of selected VPDs.¹⁷

	India			Cases per million population^b (2017)			Vaccine coverage by dose in children (India)
VPD	Earliest (year)	2017 (% of world cases)^a	Highest among other countries (2017)	India	Highest among other countries	World^c	NFHS (2015–2016)^Citation18	WHO (2017)^Citation17
Polio	18,975 (1980)	0 (0%)	74 (Syrian Arab Republic)	0	4.05 (Syrian Arab Republic)	0.01	Birth dose: 79%; doses 1–3: 91%, 86%, 73%	Dose 3: 89%
Diphtheria	39,231 (1980)	5,293 (60%)	954 (Indonesia)	3.95	24.8 (Nepal)	1.17	Doses 1–3: 90%, 86%, 78%	Pregnancy TT: 82%; doses 1, 3, 4: 92%, 89%, 81%
Neonatal tetanus	11,849 (1988)	295 (13%)	478 (Pakistan)	0.22	22.5 (Central African Republic)	0.30
Total tetanus	45,948 (1980)	4,946 (40%)	1,057 (Philippines)	3.69	30.0 (Nepal)	1.65
Pertussis	320,109 (1980)	23,766 (17%)	16,183 (Germany)	17.7	1,031 (Switzerland)	19.1
Measles	114,036 (1980)	12,032 (7%)	45,107 (Democratic Republic of the Congo)	8.98	1,563 (Somalia)	23.0	Dose 1: 81%	Doses 1, 2: 90%, 80%
Rubella	1,232 (2012)	2,748 (17%)	2,111 (Philippines)	2.05	81.5 (Eritrea)	2.17	NR	Dose 1: 65%
CRS	25 (2016)	76 (9%)	532 (Indonesia)	0.06	2.02 (Indonesia)	0.11
JE	4,017 (2007)	2,043 (44%)	1,147 (China)	1.53	8.28 (Myanmar)	0.62	NR	Dose 1: 88%

CRS, congenital rubella syndrome; JE, Japanese encephalitis; NFHS, National Family Health Survey; NR, not reported; TT, tetanus toxoid; US, United States; VPD, vaccine-preventable disease; WHO, World Health Organization.

^aIndia is home to 18% of the world’s population.¹

^bCalculated based on reported cases¹⁷ and reported populations.¹

^cVPD cases data were not available for some countries, but the whole world population was used, so the world values are likely underestimated relative to the single country values.

Table 2. A selection of studies reporting outbreaks that predominantly affected adults in India.

Author	Period	VPD	Setting	State/Union territory	Adults/total
Nair et al.^Citation24	Apr 2005 to Mar 2006	Meningococcal disease	Tertiary care hospital	Delhi	34^a/55
Patel et al.^Citation25	Feb to Aug 2009	Hepatitis B	Town	Gujarat	550^b/664
Biswas et al.^Citation26	Jul to Aug 2010	Influenza A(H1N1)	City	West Bengal	104^a/129
Peter et al.^Citation27	Jun to Jul 2011	Influenza A(H3N2)	District	Kerala	54^a/96
Gurav et al.^Citation28	Feb to Apr 2012	Influenza A(H1N1)pdm09	Community	Maharashtra	30^c/59
Rathi et al.^Citation29	Nov 2013 to Jan 2014	Measles	University	Karnataka	20^d/20
Gurav et al.^Citation30	July 2014	JE	Region	West Bengal	106^c/134
Agrawal et al.^Citation31	Jan to Mar 2015	Influenza A(H1N1)pdm09	Tertiary care center	Rajasthan	44 pregnant or puerperal women
Das et al.^Citation33	Sep 2015 to Jan 2016	Diphtheria	District	Assam	5^e or 7^a/10
Meyers et al.^Citation34	Feb 2016 to Jan 2017	Varicella	University	Tamil Nadu	77 students (≥17 years)
Rakesh et al.^Citation32	Nov to Dec 2016	Hepatitis A	District	Kerala	201^d/223
Vaidya et al.^Citation35	Dec 2016 to Feb 2017	Varicella	Villages	Dadra and Nagar Haveli	91^a/149 suspected; 19^a/31 confirmed^f

^aAdults defined as ≥15 years old.

^bAdults defined as ≥21 years old.

^cAdults defined as ≥20 years old.

^dAdults defined as ≥16 years old.

^eAdults defined as ≥18 years old.

^fOnly 37/149 suspected cases were tested, of which 31 (84%) were confirmed varicella.

JE, Japanese encephalitis; VPD, vaccine-preventable disease.

Table 3. Summary of adult vaccination recommendations in India.

Guidelines	Based on API^Citation42 and CDC^Citation45	ISN^Citation40	IMA^Citation41	FOGSI^Citation43,Citation44
Diphtheria/tetanus/pertussis	Tdap once then Td 10-yearly; Tdap during each pregnancy	Td 10-yearly to 65 years; 3 doses if not immunized	Tdap 10–18 years (1 dose); Td 10-yearly; TT/Td early during pregnancy (2 doses); Tdap during third trimester of pregnancy (1 dose)	TT/Td 10-yearly; TT/Td or Tdap during pregnancy; Tdap if age ≥65 years, unvaccinated, and close contact with infant
MMR	19–59 years (1 or 2 doses)^a	Unimmunized (1 dose)	Adults (1 or 2 doses)^a	MMR for routine preconceptional/postnatal (pregnancy should be deferred for 3 months)
Influenza	Yearly (1 dose); during pregnancy (1 dose)	At risk, including during pregnancy (1 dose)^b	Yearly (1 dose); including pregnancy	Yearly; also during pregnancy
Pneumococcal	≥65 years (1 dose); at risk^b (1 or 2 doses)	≥65 years (1 dose); at risk^b	At risk^b (2 doses)	–
HPV	Women ≤26 years (3 doses); men ≤21 years^c (3 doses)	9–26 years (2 or 3 doses)	Females 9–14 years: 2 doses; 15–45 years: 3 doses	9–26 years; next dose(s) should be deferred in case of pregnancy
Varicella	2 doses if no evidence of immunity (contraindicated during pregnancy)	Nonimmune (2 doses)	Adults (2 doses)^a	Preconception/postnatal
Herpes zoster	≥50 years (1 or 2 dose based on type of vaccine)^d	>60 years (1 dose)	–	–
Hepatitis A	At risk^b (2 or 3 doses)	At risk^b (2 doses)	Adults (1 dose of live or 2 doses of inactivated)	–
Hepatitis B	At risk^b (3 doses)	At risk^b (3 doses)	Adults (3 doses)	Preconception^e or at high risk during pregnancy
Meningococcal	At risk^b (1 to 3 doses)	At risk^b (1 or 2 doses)	Adults (1 dose); At risk^b (2 doses)	–
Hib	At risk^b (1 or 3 doses)	At risk^b (1 dose)	At risk^b (1 or 3 dose)	–
Typhoid	1 dose PSV repeat 2 yearly	Outbreak or high-risk travelers (3 doses, repeat 3-yearly)	≤18 years: TCV 1 dose; >18 years: PSV 3 yearly	–
Rabies	At risk^b (3 or 4 doses)^b	At risk^b (3 doses)	At risk^b (3 or 4 doses)	–
Cholera	18–65 years (1 dose if traveling to endemic region)	At risk^b (2 doses)	At risk^b (2 doses)	–
JE	2 doses; booster (in reexposure) if primary given >1 year ago	No	≤18 years (1 dose)	–
Yellow fever	1 or 2 doses based on immune status	–	At risk^b	–
Polio	1 to 3 doses^a	Travel to polio endemic countries (1 or 3 doses)	2 doses of IPV^a	–
Rotavirus	–	No	–	–

^aBased on vaccination history.

^bThe definitions of “at risk” vary by guideline and by vaccine, but include factors such as chronic health conditions, age, occupations (e.g. healthcare workers, veterinarians), lifestyles (e.g. illicit drug users, men who have sex with men), after exposure, times of epidemic, and lack of prior vaccination.

^c ≤ 26 years if they have sex with men.

^dCDC does not recommend the use of Zostavax among those aged 50–59 years.

^eSchedule completed before conception, usually 3 months prior to conception.

API, Association of Physicians of India; CDC, Centers for Disease Control and Prevention; FOGSI, Federation of Obstetric & Gynecological Societies of India; Hib, Haemophilus influenzae b; HPV, human papillomavirus; IMA, Indian Medical Association; ISN, Indian Society of Nephrology; JE, Japanese encephalitis; MMR, measles, mumps, rubella; PSV, Polysaccharride vaccine; TCV, Typhoid conjugate vaccine; Td, tetanus, diphtheria; Tdap, tetanus, diphtheria, acellular pertussis; TT, tetanus toxoid; US, United States.

Figure 2. Barriers to adult vaccination (red) and next steps (green).

Figure 3. How immune competence, risk of infectious disease, immunization programs, vaccine awareness, and vaccine coverage vary with age.

Table 4. Summary of adult vaccination recommendations in the United States (US) by indication. Adapted from the Advisory Committee on Immunization Practices, with permission.⁸⁷

^aPrecaution for LAIV does not apply to alcoholism.

^bSee notes on Centers for Disease Control and Prevention website for influenza, hepatitis B, MMR, and varicella.⁸⁷

CD4, cluster of differentiation 4-presenting immune cells; Hib, Haemophilus influenzae b; HIV, human immunodeficiency virus; HPV, human papillomavirus; HSCT, hematopoietic stem cell transplantation; IIV, inactivated influenza vaccine; LAIV, live attenuated influenza vaccine; MenACWY, meningococcal A, C, W, Y; Men B, meningococcal B; MMR, measles, mumps, rubella; PCV13, 13-valent pneumococcal conjugate vaccine; PPSV23, 23-valent pneumococcal polysaccharide vaccine; RIV, recombinant influenza vaccine; RZV, recombinant zoster vaccine; Td, tetanus, diphtheria; Tdap, tetanus, diphtheria, acellular pertussis; US, United States; y, years; ZVL, zoster vaccine live.

^cImmunocompromized.

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