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Table of Contents
GUEST EDITORIAL
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 68-70

Adult immunization in India: Time to move from negligence to a new beginning


Department of Community Medicine, JSS Academy of Higher Education and Research, Mysore, Karnataka, India

Date of Submission28-Mar-2021
Date of Decision29-Mar-2021
Date of Acceptance29-Mar-2021
Date of Web Publication21-Apr-2021

Correspondence Address:
Dr. Praveen Kulkarni
Department of Community Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysore - 570 015, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajim.ajim_41_21

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How to cite this article:
Kulkarni P. Adult immunization in India: Time to move from negligence to a new beginning. APIK J Int Med 2021;9:68-70

How to cite this URL:
Kulkarni P. Adult immunization in India: Time to move from negligence to a new beginning. APIK J Int Med [serial online] 2021 [cited 2021 May 14];9:68-70. Available from: https://www.ajim.in/text.asp?2021/9/2/68/314196



India is the second most populous country in the world comprising nearly 1.5 billion people accounting nearly to 18% of world population. Infectious diseases contribute to the larger proportion of morbidity and mortality among both adults and children. Risk of acquiring the infectious diseases has drastically increased in the current century due to increasing incidence of antibiotic resistance, higher frequency of mutations, globalization, trade, and transport.[1]

According to the World Health Organization (WHO) statistics on the selected vaccine-preventable diseases (VPDs) in India and other countries in 2018, there is a dramatic drop in the number of reported cases of most, though not all, VPDs in India.[2] This may be likely due to successful implementation of universal immunization program (UIP), introduction of newer immune biologicals into the program, and higher level of political commitment and encouragement for innovations in cold chain management as well as vaccination policies.[3] However, India had a disproportionately high share of the globally reported cases of diphtheria (60%), Japanese encephalitis (44%), and tetanus (40%) in 2017, given that it is home to around 18% of the world's population per million population; the magnitude of diphtheria, Japanese encephalitis, and tetanus in India was 2.2–3.4-fold that of the world as a whole.[2]

Immunization is one of the most popular modes of intervention to prevent the infectious diseases worldwide. In addition to protecting individuals from VPDs, the vaccination can confer community-wide protection by reducing the incidence of disease and the likelihood of transmission to those who are unvaccinated.[4],[5] Considering the importance of vaccination as an important public health investment, India launched Expanded Programme on Immunization in 1978, which was rechristened as UIP in 1985. Over the last four decades after launch of this program, there has been significant reduction in childhood morbidity and mortality due to VPDs and the substantial increase in the number of lives saved and sufferings averted.[6] According to the National Family Health Survey-4, overall childhood vaccination coverage among children between 12 and 23 months of age in India is to the extent of 62.0%.[3] The two major milestones of UIP have been the elimination of polio in 2014 and maternal and neonatal tetanus elimination in 2015.[6]

Widespread coverage of vaccination against infectious diseases has led to the important long-term effects on the pattern of these diseases. Studies have found that vaccine-induced immunity may not have the same long-term stability as disease-induced immunity, raising the average age of incidence for various VPDs. Many childhood vaccine-preventable infections are now found among adults. Both in resource-rich and resource-poor countries, outbreaks of measles, mumps, and rubella have caused major disruptions on college campuses, workplace, and institutions such as hospitals and prisons.[4] There are four main reasons why adults might be susceptible to outbreaks of VP: (1) lack of adult immunization; (2) waning immunity; (3) age-related factors (including immunosenescence); and (4) epidemiological shift. Thus, there is a wider consensus among public health experts that the vaccination should be a strategy across all the stages of life.[1]

Childhood vaccination is a major area of focus for both the Government of India and the WHO with no or negligible emphasis on adult immunization.[7] National Vaccine Policy 2011 does not provide any strategy to introduce or enhance adult vaccination in the country.[8] This implies that the economically productive adult populations have been denied the full benefit of personal protection owing to either nonavailability of vaccines or those receiving vaccines not being protected to the fullest extent due to incomplete effectiveness of available vaccines. Protecting adults by vaccination has never been considered in India a preventive strategy likely to have a great impact on population health.[9] Even in countries where adult vaccines are nationally recommended, uptake remains suboptimal. In the US, various age-specific vaccinations are recommended for adults. However, survey data from 2015 indicate that uptake in the US only ranged from 23% (for tetanus + pertussis; previous 10 years) to 64% (for pneumococcal disease; ever; among those aged ≥65 years).[1]

Common vaccines, that can be offered to the adults are against, pneumococcus, measles, pertussis, rubella, H influenza, tetanus, typhoid, human papillomavirus, cholera, hepatitis A, hepatitis B, yellow fever, herpes zoster, seasonal influenza, H1N1, COVID 19, Japanese encephalitis, meningococcus, rabies etc. Additionally BCG is offered to the adults and elderly for prophylactic and therapeutic purposes. Various Indian societies and associations have published vaccination guidelines for all adults and for women specifically.[10] In this issue of our journal, Kamath V et al. has made an attempt to provide detailed updates on the various aspects of adult vaccination.

The Government of India has incorporated vaccination against JE among adults in the routine immunization program in endemic districts. Rabies vaccine is made available at all the levels of health care for the animal bite victims. Antirabies clinics are established at tertiary health-care centers, to offer antirabies vaccines and immunoglobulins. Tetanus toxoid is administered to all the pregnant women as a part of antenatal service package. This intervention has brought down the incidence of postpartum and neonatal tetanus to the significant extent. An attempt is being made by private organizations and health-care institutions to vaccinate their employees and students against hepatitis B and seasonal influenza.[11]

Barriers for adult vaccination in India are as follows:

  1. Lack of adequate and authentic data on the burden of VPDs among adults
  2. Poorer political and administrative commitment toward adult vaccination
  3. Nonavailability of nationwide, uniform guidelines for adult vaccination
  4. Vaccine hesitancy among adults – wider preference toward taking the treatment on illness over prevention through vaccination
  5. Lack of knowledge on availability, safety, efficacy, and benefits of vaccination among adults
  6. Lack of coordinated adult vaccination program in the country
  7. Cultural and religious factors.


Dash R et al. put the barriers for adult vaccination as 4C model. These include complacency (lack of perceived need), convenience (lack of accessibility or affordability), confidence (lack of trust), and the cultural acceptance.[1]


  Way forward Top


The lessons learned from the successful implementation of childhood vaccination program should facilitate the policy makers in the country to establish a coordinated adult vaccination strategy. The following measures can be taken up to facilitate designing and implementing nationwide adult vaccination program.

  1. Establishing a strong surveillance system on the VPDs among adults. This will facilitate the understanding of burden and consequences of VPDs among adults
  2. Setting up a national level taskforce to lay down guidelines and plan for the implementation of adult vaccination program
  3. Align the adult vaccination with existing UIP for children and providing the services through the well-established primary health-care system
  4. Government should come out with a comprehensive national vaccine policy by including the strategies for implementation of successful vaccination program for both children and adults
  5. Facilitating research and innovation in development vaccines, cold chain management, implementation, monitoring, and evaluation of vaccination program for adults
  6. Understanding the best practices related to successful implementation of adult vaccination program elsewhere in the world. For example, life course immunization' strategy is adapted by many countries, which focuses on the extension of vaccination from birth through childhood, adolescence, adulthood, and into older age
  7. Intersectoral collaboration between government, NGOs, medical colleges, professional bodies/organizations, private practitioners, and vaccine manufacturers for the successful implementation of the adult vaccination strategy
  8. Spreading awareness on importance of adult vaccination at individual and community level by involving various stakeholders. Medical fraternity should also receive regular training and updates on adult vaccination guidelines. Incentivizing adult vaccination can be thought as a short-term strategy to popularize the program
  9. Establishing dedicated adult immunization clinics at health centers and medical college hospitals with adequate infrastructure facilities.


COVID-19 pandemic has made us clearly understand the loopholes in our public health system at various levels. On the other hand, this has also taught us the importance of adult vaccination in prevention of disease and promotion of healthy lifestyle. The most significant and unprecedented effort by the government in the present century is emergency vaccination of health-care workers, elderly, and adults above the age of 45 years with comorbidities against COVID-19 disease. This effort is widely appreciated by people of the country and the policy makers globally. This program has brought in a sort of awareness and seriousness among general public on the matter that even adults can be vaccinated. Public health experts and policy makers should this as a starting point to promote and popularize adult vaccination in the country.

To conclude, introducing a comprehensive immunization program including both children and adults as beneficiaries is a need of the hour. Revising the decade old national vaccine policy, drafting the updated guidelines on adult vaccination, empowering the stakeholders including the general public on importance of adult vaccination, promoting research and innovation in vaccine development and distribution, establishing dedicated adult vaccination clinics at health centers, and following life course immunization strategy to cover all the age groups for vaccination can help in reducing the sufferings due to VPDs in adults.



 
  References Top

1.
Dash R, Agrawal A, Nagvekar V, Lele J, Pasquale AD, Kolhapure S, et al. Towards adult vaccination in India: A narrative literature review. Hum Vaccin Immunother 2020;16:991-1001.  Back to cited text no. 1
    
2.
World Health Organization (WHO). Data, Statistics and Graphics. Available from: https://www.who.int/immunization/monitoring_surveillance/data/en/. [Last accessed on 2021Mar 20].  Back to cited text no. 2
    
3.
Ministry of Health and Family Welfare India. National Family Health Survey (NFHS-4). 2015-16. Available from: http://rchiips.org/nfhs/NFHS-4Reports/India.pdf. [Last accessed on 2021 Mar 21].  Back to cited text no. 3
    
4.
Weiser T, Bacon A, Corum B, Van Lew H, Groom A. Evaluation of an adult immunization composite measure in the Indian Health Service. Vaccine 2018;36:4952-7.  Back to cited text no. 4
    
5.
Director, National Centre for Disease Control New Delhi. CD Alert. Adult Immunization, Monthly Newsletter of National Centre for Disease Control, Directorate General of Health Services, Government of India 2011;14:1-8. URL Available from: https://ncdc.gov.in/WriteReadData/linkimages/February_Final_020862513827. pdf downloaded on 20 Mar 2021.  Back to cited text no. 5
    
6.
Lahariya C, Bhardwaj P. Adult vaccination in India: Status and the way forward. Hum Vaccin Immunother 2020;16:1508-10.  Back to cited text no. 6
    
7.
Verma R, Khanna P, Chawla S. Adult immunization in India: Importance and recommendations. Hum Vaccin Immunother 2015;11:2180-2.  Back to cited text no. 7
    
8.
Ministry of Health and Family Welfare, Government of India. National Vaccine Policy 2011. Available from: https://main.mohfw.gov.in/sites/default/files/108481119000.pdf. [Last accessed on 2021 March 20].  Back to cited text no. 8
    
9.
Chakravarthi PS, Ganta A, Kattimani VS, Tiwari RV. Adult immunization – Need of the hour. J Int Soc Prevent Communit Dent 2016;6:272-7.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Guidelines API. Executive Summary the Association of Physicians of India Evidence-Based Clinical Practice Guidelines on Adult Immunization. Expert Group of the Association of Physicians of India on Adult Immunization in India. JAPI 2009;57:345-56.  Back to cited text no. 10
    
11.
National Health Mission. Ministry of Health and Family Welfare, Government of India. Immunization. Available from: https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=824&lid=220. [Last accessed on 2021 Mar 26].  Back to cited text no. 11
    




 

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