|Year : 2021 | Volume
| Issue : 2 | Page : 71-77
An update on adult immunization
Vasantha Kamath, Kushal Markanday, B Nivea
Department of Medicine, MVJMC and RH, Bengaluru Rural, Karnataka, India
|Date of Submission||28-Jun-2020|
|Date of Decision||13-Aug-2020|
|Date of Acceptance||15-Aug-2020|
|Date of Web Publication||21-Apr-2021|
Dr. Vasantha Kamath
Department of Medicine, MVJMC and RH, Hoskote, Bengaluru Rural, Karnataka
Source of Support: None, Conflict of Interest: None
Childhood immunization is recommended and publicized globally, whereas the adult population, which comprises more than 60% of the total population, still suffers from vaccine-preventable diseases due to factors ranging from personal neglect to immunosenescence. This burden is vastly seen in developing nations like India where adults constitute a large chunk of economic productivity. This article highlights the current scenario and recommendations for adult immunization globally taking into account special conditions such as immunization in the geriatric population, pregnant women, and in travelers.
Keywords: Adult immunization, current scenario, neglect
|How to cite this article:|
Kamath V, Markanday K, Nivea B. An update on adult immunization. APIK J Int Med 2021;9:71-7
| Introduction|| |
Immunization is a process by which immune system is made to generate a response against pathogens by inoculating certain agents. The process of inoculation is called vaccination which protects the vaccinated individuals from developing potentially serious complications.
Immunity conferred by childhood vaccines wanes off with age, i.e., immunosenescence associated with increased production of pro-inflammatory cytokines and neutrophilic dysfunction.
Many childhood vaccine-preventable diseases are found in adults. In the late 20th century, massive diphtheria outbreak occurred in Russia spanning more than 157,000 cases and 5000 deaths which occurred mostly in adults more than 45 years' age group. This may be attributed to the fact that immunity against pertussis following primary booster wanes after 10 years.
Over 2 lakh babies are born with birth defects because of Rubella infection during pregnancy in the Indian subcontinent. Around 132,000 women in India each year are detected with cervical cancer, and 74,000 of them die of its complications. Each year, 300,000 new hepatitis cases occur in India with hepatitis B surface antigen carriers estimated to be over 40 million. Increased incidence of symptomatic hepatitis A among adults (3.4%–12.3%) is being reported among patients with acute viral hepatitis.
Annually around 205,286 deaths related to chronic hepatitis occur. Influenza has a global annual attack rate of 5%–10% in adults and 20%–30% in children. In India, around 40,000 deaths occur due to influenza annually.
Numerous meningococcal outbreaks have been reported in temperate northern regions of India, especially in and around Delhi, Meghalaya, and Tripura., In India, although more than 30% of the adolescent and adult population above 15 years of age are susceptible to varicella, varicella-zoster vaccine is still not a part of the Universal Immunization Program.
Nowadays, due to increasing incidence of HIV and other immunocompromised states such as diabetes, herpes is being evidently seen in the younger adult population too. Globally, the incidence ranges from 1.2 to 1.4 cases/1000 healthy persons per year over the age of 65 years.
Consecutive WHO reports and numerous studies have revealed that community-acquired pneumonia is the second-most common reason of death from infectious diseases in the Indian subcontinent.
Only 47% of adults over the age of 20 years were found to have protective antibodies to tetanus and diphtheria. Between 2001 and 2016, the Centers for Disease Control and Prevention (CDC) – US Department of Health and Human Services – reported 1261 cases including 16 neonatal cases. Thirteen cases of respiratory diphtheria were reported to the CDC from 1996 to 2016.
A major outbreak of measles was noted in Kerala, with a large number of students in the age group of 13–19 years being involved.
The Advisory Committee on Immune Practices guidelines from CDC, WHO guidelines, and API expert panel guidelines (2008) are the major guidelines for adult immunization.
Vaccines such as hepatitis B, hepatitis A, meningococcal infection, varicella, Haemophilus influenzae infection, typhoid, and rabies are being recommended for high-risk groups.
| Vaccine-Preventable Diseases|| |
In tropics and subtropics like India, complexities of influenza such as multiple peaks and year-round activity are noted among the elderly, especially the geriatric age group.
The available vaccines in India are trivalent inactivated or killed influenza vaccine and live attenuated vaccine
Trivalent vaccine contains two influenza A strains and one influenza B strain, while quadrivalent influenza vaccine contains two influenza A strains and two influenza B strains.
A single dose of 0.5 ml intramuscular injection to deltoid containing 45 mcg of hemagglutinin influenza antigen inoculation or live attenuated influenza vaccine (LAIV) as 0.5 ml intranasal spray (0.25 ml/nostril) is currently recommended. The vaccine is only effective 2 weeks after administration.
September is considered to be optimal time to receive the vaccine. It has been noted that the annual dose of vaccine reduced the mortality by 41%, while complications and the length of hospital stay have been reduced by 75% in those vaccinated previously.
Vaccine is indicated in all adults aged more than 50 years of age.
All persons who have allergy to egg protein, immunocompromised patients like HIV, pregnant women, and individuals who have taken influenza antiviral medication in previous 48 h.
Pneumococcal infection caused by Streptococcus pneumoniae is the leading bacterial cause of pneumonia, otitis media, sinusitis, and bronchitis and leads to invasive pneumococcal disease.
In adults, serotypes 1, 3, 6, 7, 9, 14, 19, and 23 are most prevalent. The most common serotype-1 accounts for one-fourth of invasive infections in the Indian population, while in the Indian population, serotype-6 accounts for 11.5% of invasive infections.
Pneumococcal polysaccharide vaccine (PPSV) and pneumococcal conjugate vaccine (PCV) are the two kinds of pneumococcal vaccine available for clinical use. The current PPSV23 provides protection against 80%–90% of the pneumococcal capsular serotypes causing disease.
Dose and optimal schedule
In adults more than 65 years of age, a single dose 0.5 ml intramuscular to deltoid of PCV13 followed by PPSV23 after 1 year is recommended, whereas in immunocompromised individuals, PCV13 followed by PPSV23 after 8 weeks with PPSV23 booster after 5 years is advised. The two vaccines must not be co-administered and the minimum acceptable interval between the two is 8 weeks.
Pneumococcal vaccine is indicated among all individuals who are 65 years and older. Due to increased vulnerability of pilgrims, it is also recommended for use in mass gatherings.
Injection site reactions are the most common adverse effects. Systemic symptoms such as fever, chills, fatigue, headache, myalgia, and arthralgia occur in <5% of individuals receiving the vaccine.
Human papillomavirus (HPV) is a sexually transmitted pathogen. Persistent infection with high-risk genotypes such as 16 and 18 causes 70% of all cancers of the cervix. Strains 6 and 11 are known to cause genital warts; hence, the quadrivalent vaccine is preferred in males.
A quadrivalent HPV4 vaccine containing L1 protein-like particles of HPV6, HPV11, HPV16, and HPV18 marketed as Gardasil and a bivalent HPV2 vaccine containing L1 protein-like particles of HPV16 and HPV18 branded as Cervarix are the two varieties of HPV vaccines which are commercially available.
Three doses of 0.5 ml intramuscular in deltoid at 0, 2, and 6 months are administered.
The age group of 11–26 years in females and 13–21 years in males and may be offered for females up to 45 years. However, the vaccination is considered less beneficial if an individual is already sexually active.
Considerations and contraindications
HPV vaccine is not recommended in pregnancy and individuals with a history of hypersensitivity to vaccine components such as yeast.
Herpes zoster/shingles is a neurocutaneous disease that occurs due to reactivation of varicella-zoster virus.
Vaccine types and schedule
Live attenuated vaccine, branded as Zostavax, is a lyophilized preparation of Oka strain of live attenuated varicella-zoster virus. However, two doses of recombinant glycoprotein vaccine, separated by 2–6 months, are preferred over live zoster due to better immunogenicity.
Indications and contraindications
All adults more than 60 years are advised to take zoster vaccination. Only contraindication is for the women of childbearing age group, pregnancy, and immunocompromised state, as it is a live vaccine.
Injection site reactions such as pain, redness, swelling, and itching are commonly seen. Fever is also often reported. Acute retinal necrosis is seen in 12% and occurs usually within 6 days to 2 months. Vaccination associated zoster can occur in immunocompromised individuals.
DTap vaccine is routinely recommended in children, with a single booster dose at 11–12 years followed by TD at 10-year intervals throughout life. However, due to immunosenescence, there is a rise in incidence of diphtheria and tetanus among adults.
Acellular pertussis vaccine (DTaP) should be used for older children instead of whole-cell vaccine (DTwP) because it is associated with less neurological complications.
The dose is 0.5 ml given intramuscularly preferably in deltoid. DTaP or DTwP vaccine should be used for the first booster at 18 months, while Tdap (low-dose diphtheria and acellular pertussis) may be used for the second booster at 5 years and 10–15 years.
For adults between 18 and 64 years who have completed their primary vaccination schedule, a booster dose of Td vaccine is indicated every 10 years till the age of 65 years. One dose Tdap vaccine may be administered in place of Td vaccine. For adults more than 18 years who have not received prior vaccination against diphtheria, pertussis, and tetanus, three doses of Td vaccine are indicated; two doses are administered at least 4 weeks apart, and the third dose is given 6–12 months after the second dose.
Pregnant women should receive one dose of Tdap during each pregnancy, around 27–36 weeks of gestation, regardless of prior history of receiving Tdap.
Anaphylaxis after a previous dose is an absolute contraindication.
Human tetanus immune globulin (3000–5000 IU IM) is indicated in those who have sustained a severe wound which is contaminated. It is also recommended for HIV patients and immunocompromised patients with concerning wounds, regardless of their tetanus immunization.
Measles, mumps, and rubella
Measles is a major killer of children, mainly in developing countries, accounting for 875,000 deaths each year around the world. Complications from measles affect every organ, and adults are likely to suffer encephalitis, hepatitis, hypocalcemia, and pancreatitis. Although Mumps manifests as a mild disease in adults but still 10% of individuals who are affected by the disease have been noted to develop complications.
Dose and schedule
All adults born in 1957 or later without acceptable level of immunity to measles, mumps, and rubella (MMR) and nonpregnant women of childbearing age without evidence of rubella immunity with focus on reducing congenital rubella syndrome should be given one dose of MMR vaccine, 0.5 ml, subcutaneous in outer aspects of triceps.
Two-dose MMR vaccine is recommended in health-care workers, students planning to travel, and adults with HIV with CD4 more than 200 cells for at least 6–12 months.
In outbreak scenario, two doses separated by 28 days are to be administered with the first dose 72 h after the initial exposure.
It is absolutely contraindicated in patients with allergy to neomycin, pregnancy, and immunodeficiency (CD count <200)
Fever, rash, lymphadenopathy, joint pain, and rarely thrombocytopenia are seen. Febrile seizures are also rarely reported. Hypersensitivity reactions are also sometimes seen.
Hepatitis A, spread by close contact with affected individuals, mainly via fecal-oral route, is highly endemic in the Indian subcontinent.
Live attenuated hepatitis A vaccine branded as Biovac-A is available in India which is well-tolerated and is highly immunogenic. A combination inactivated vaccine, TWINRIX, is also licensed in India which contains hepatitis A (Havrix) and hepatitis B (Engerix-B). The seroconversion rate, defined as an antibody concentration of more than 20 MU/mL following primary vaccination series, approximates 100% in healthy adults and children.
Two-dose series Hep A (Havrix 6–12 months apart or Vaqta 6–18 months apart [minimum interval: 6 months]) whereas three-dose series Hep A-Hep B (Twinrix at 0, 1, 6 months [minimum interval: 4 weeks between doses 1 and 2 and 5 months between doses 2 and 3]).
Patients of chronic liver disease, HIV infection, bisexuals, homosexuals, injection or noninjection drug use, and travel in countries with high or intermediate endemic hepatitis A and pregnancy.
HAV vaccine is contraindicated if a patient has a history of anaphylaxis.
Sixteen percent of individuals receiving HAV vaccine develop fever, injection-site reaction, and rash. Rare serious events can include Guillain–Barre syndrome, transaminitis, or immune thrombocytopenia. Safety of hepatitis A vaccination during pregnancy is also limited and hence warranted only for those undergoing international travel.
Hepatitis B vaccine
Hepatitis B is a major public health problem in India, especially among health-care workers and other high-risk groups.
Hepatitis B vaccine is available both as a yeast, mammalian, or plasma cell-derived single-antigen vaccine and recombinant vaccine. Plasma-derived vaccine is not used nowadays due to risk of transmission of infections.
Heplisav-B, Engerix-B, and Recombivax-HB are the three recombinant vaccines available. Heplisav-B combines hepatitis B surface antigen with Dynavax's proprietary toll-like receptor agonist to enhance the immune response, while Engerix-B does not contain any adjuvant.
Dose and schedule
Two doses of Heplisav-B at least 4 weeks apart or three-dose series of Engerix-B or Recombivax-HB at 0, 1, and 6 months are advised. A minimum interval of 4 weeks between the first two doses, an interval of 8 weeks between second and third doses, and an interval of 16 weeks between doses first and third dose are recommended.
In adults, the dose is 20 mcg, and in those on hemodialysis, the dose is 40 mcg. Booster may be administered when anti-HB level decline to <10 mIU/ml and more than 65 years.
Protection after vaccination is noted at 20%–30% after the first dose, 75%–80% after the second dose, and 90%–95% after the third dose. For three-dose series, the second and third doses should be separated by at least 2 months.
Individuals with chronic liver disease/chronic kidney disease, HIV infection, sexual exposure risk/current or recent injection drug use, percutaneous or mucosal risk for exposure to blood products, health-care workers, and travel in countries with high or intermediate endemic hepatitis B and pregnancy.
Pain over injection site, fever, headache, joint pain, and myalgia are seen in few individuals. A series of reports showed an association between hepatitis B vaccination and multiple sclerosis in 1998.
Varicella can cause significant complications such as soft-tissue infection, pneumonia, hepatitis, and encephalitis in adults, pregnant women, and immunocompromised hosts.
Single-antigen varicella vaccine (1350 [PFU] of Oka strain) for healthy individuals of 12 months of age and older and a combination of MMR and varicella vaccine (with 9772 PFU) for 12 months to 12 years of age are the two live attenuated vaccines currently available in India.
More than 40 studies done showed that a single dose of varicella vaccine had an approximate effectiveness of 80% in preventing varicella disease, 95%–98% in preventing moderate (50–500 lesions), or severe disease (more than 500 lesions).
Dose and recommendations
All adults who have never had chickenpox are recommended to receive two doses of 0.5 ml in the deltoid area subcutaneously. Health-care personnel with no evidence of immunity to varicella and individuals with HIV infection with CD4 count more than 200 cells/μL with no evidence of immunity are also recommended to get varicella vaccine.
Immunocompromised conditions like HIV when CD4 <200 cells/μL are absolute contraindications for varicella vaccine.
Injection site reaction, febrile seizures, and rarely meningitis are noted. Vaccine-associated zoster has also been reported to occur rarely within 3 months of vaccination.
Enteric fever caused by salmonella typhi is transmitted by fecal-oral route and is a systemic illness characterized by fever, abdominal pain, vomiting, loose stools, etc.
Vaccine types, doses, and schedules
In endemic areas, four types of vaccine are available for clinical use. Vi conjugate vaccines are preferred because of long-lasting immunogenicity and safety in infants and young children up to 15 years old. It consists of Vi polysaccharide antigen of Salmonella enterica serovar Typhi linked to tetanus toxoid carrier protein, which is administered as a single IM dose.
PedaTyph is a Vi-TT conjugate typhoid vaccine available in India. Vi polysaccharide vaccine consists of Vi polysaccharide antigen, administered as a single 0.5 ml IM dose. If continued protection is needed, revaccination is recommended every 2–3 years.
Ty21a vaccine is an oral live attenuated vaccine, available as capsules/sachets, administered in three to four doses on alternate days. It is indicated only after the age of 6 years. If continuation protection is needed, revaccination every 3–5 years is recommended. This vaccine is contraindicated in immunodeficiency states, acute febrile illness, and acute gastrointestinal illness.
Typhoid vaccine is recommended in travelers to endemic areas, close contacts with typhoid, and also laboratory workers working with S. typhi.
Haemophilus influenzae vaccine
H. influenzae is the most common cause of bacterial meningitis and other invasive diseases such as epiglottitis, pneumonia, septic arthritis, and bacteremia.
In a randomized control trial, it was noted that H. influenzae B (HiB) conjugate vaccines prevented more than 95% of invasive HiB disease.
This vaccine is administered as a single 0.5 ml dose of HiB conjugate vaccine intramuscularly.
In special conditions such as anatomical or functional asplenia (including sickle cell disease), one dose is recommended if previously did not receive HiB. In case of elective splenectomy, one dose is indicated preferably at least 14 days before splenectomy. In hematopoietic stem cell transplant, a three-dose series is recommended 4 weeks apart starting from 6 to 12 months after successful transplant, regardless of HiB vaccination history.
Meningococcal meningitis, caused by Neisseria meningitidis, is one of the most devastating infections and tends to strike young individuals which can progress over hours to death.
It is an inactivated vaccine and is available in two formulations, first being quadrivalent meningococcal vaccine, which contains 50 mcg of each of the capsular polysaccharide antigens from serogroups A, C, Y, and W135 conjugated to diphtheria toxoid. Another is monovalent meningococcal vaccine, which is not available in India. The vaccine used in outbreak is serogroup vaccine, and high-risk individuals include travelers to regions in which meningococcal disease is hyperendemic or epidemic, military recruits, and microbiologists exposed to N. meningitidis.
Rabies is a fatal neurological disease. Tissue culture vaccines (TCV), purified chick embryo cell vaccine, and Vero cell-purified rabies vaccines are used. TCV are used for pre- and postexposure prophylaxis as they are easy to administer, highly immunogenic, and have a good margin of safety.
Schedule preexposure prophylaxis
For high-risk groups like veterinarians, laboratory personnel, medical and paramedical, dog catchers, forest staff, etc., three doses at days 0, 7, and 28 as a preexposure prophylaxis are recommended.
The HDCV and PCEV (1ML) or purified Vero cell rabies vaccine (0.5 ml) are administered by intramuscular route in the deltoid region or the anterolateral thigh. Booster dose should is recommended when the titer falls below 0.5 IU/ml.
Schedule postexposure prophylaxis
Five doses of rabies vaccine at 0, 3, 7, 14, and 28 days, respectively, as a postexposure prophylaxis are recommended. They also should get human rabies immune globulin (20 IU/kg body weight; up to a maximum of 1500 IU) at the same time as the first dose, whereas a person who has been previously vaccinated should get two doses – first on day 0 and another on the 3rd day.
| Immunization in Elderly|| |
Vaccine-preventable diseases contribute significantly to morbidity and mortality among the elderly. [Table 1] mentions the vaccines currently recommended worldwide in this age group.
Vaccines such as varicella – 2 doses, PCV13 – 1 dose, hepatitis A – 2 or 3 doses depending on vaccine, hepatitis B – 2 or 3 doses depending on vaccine, meningococcal A, C, W, and Y – 1 or 2 doses depending on indication, meningococcal B – 2 or 3 doses depending on vaccine and indication and H. influenzae type b – 1 or 3 doses depending on indication are recommended vaccination for elderly with an additional risk factor or another indication.
Vaccines such as MMR, LAIV, and HPV are not recommended for the elder age group.
| Immunization in HIV|| |
Vaccines tend to be less immunogenic, and antibody responses are shorter lived in the setting of HIV infection, but adequate responses can be achieved when given early. [Table 2] mentions all inactivated vaccines, vaccines indicated in HIV and vaccines meant for special situations.
| Immunization in Pregnancy|| |
Maternal immunization protects both the mother and fetus and provides passive protection against vaccine-preventable infections. Transplacental passage of antibodies depends on maternal concentration, antibody type (only IgG is transported), and gestational age. Maternal IgG levels reach peak at about 4 weeks after immunization, and hence, ideal time is in the early third trimester to achieve maximum maternal antibody levels and antibody transfer before delivery.
Vaccines routinely recommended in pregnancy are influenza inactivated vaccine, Tdap, Td, hepatitis A, and hepatitis B, while those contraindicated in pregnancy are HPV, varicella, MMR vaccine, LAIV, tuberculosis, and zoster.
| Immunization in Lung Diseases|| |
Adults with chronic obstructive pulmonary disease or asthma are highly susceptible to lung infections majorly due to impaired mucociliary clearance. Influenza vaccine, pneumococcal vaccine, Tdap vaccine, and zoster vaccine are currently widely being recommended by CDC.
| Vaccines for Travelers|| |
According to the WHO guidelines, routine vaccination for diphtheria, tetanus, and pertussis, hepatitis B, H. influenzae type b, HPV, influenza, measles, mumps, and rubella, pneumococcal diseases, poliomyelitis, rotavirus, and varicella is recommended for travelers.
Vaccines for cholera, hepatitis A, Japanese encephalitis, meningococcal diseases, rabies, tick-borne encephalitis, typhoid fever, and yellow fever are recommended for selective use by travelers.
| Conclusion|| |
Vaccination of adults is very important given that more than 25% of mortality is due to infectious diseases in our country.
Although many issues revolving around efficacy, safety, and cost of introducing vaccines for adults at the national level are yet to be resolved, there is an urgent need to sensitize the health planners as well as health-care providers regarding this pertinent issue.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]