CD Alert

Monthly Newsletter of National Centre for Disease Control,

Directorate General of Health Services, Government of India

February-March 2011 Vol. 14 : No. 2

ADULT IMMUNIZATION
INTRODUCTION epidemiological patterns of major infectious diseases.
Countries have found that vaccine induced immunity
Vaccination is one of the most cost effective may not have the same long term stability as disease
strategies available in public health today. In induced immunity, raising the average age of
addition to protecting the vaccinated individual from incidence for various vaccine preventable diseases.
developing a potentially serious disease, vaccines Many childhood vaccine preventable infections are
help protect the community by reducing the spread now found among adults. A massive diphtheria
of infectious diseases. It is highly fitting that one epidemic occurred in the former Soviet Union with
of the most dramatic successes in the history of more than 1,57,000 cases and 5000 deaths. A majority
public health, the eradication of small pox served of cases throughout this epidemic occurred in persons
as a definitive conclusion to the story of smallpox > 15 yrs old, and adults from 40 to 49 yrs old had
vaccination by Edward Jenner. very high incidence and death rates. Both in resource
rich and resource poor countries, outbreaks of
More than three decades have passed since India
adopted the WHO EPI schedule in January 1978. measles, mumps and rubella have caused major
India has responded with an unhesitating disruptions on college campuses, in the workplace
commitment of leadership and resources to expand and in institutions such as hospitals and prisons. An
immunization efforts. The Universal Immunization estimated 6% to 11% of young adults are unprotected
Programme (UIP) was launched in 1985 to against rubella.
progressively cover the country. The UIP aimed to
There is also a sizeable disease burden due to vaccine
reduce mortality and morbidity from the six vaccine
preventable diseases in adults. This is responsible
preventable diseases (measles vaccine was added
for large economic losses directly and indirectly.
in 1985). Vitamin A supplementation was included
Among adults, with Community-Acquired Pneumonia
in 1990. Many advances have been made in
increasing vaccine coverage amongst infants for (CAP) requiring hospital admission, S pneumoniae
the diseases covered under the EPI (tuberculosis, ranks first as a cause and accounts for most of such
tetanuns, diphtheria, pertusis. polio and measles) cases. There are 155.8 million clinical episodes of
although the coverage remains variable in different pneumonia globally, which contribute to approximately
parts of the country. 1.9 million deaths, 70% of which occur in Africa and
south-east Asia. A study from the Gambia showed
At present our public health system has reached a that mortality was 16% lower in a PCV immunized
stage where basic infrastructure for immunization group compared to placebo recipients. Similarly,
programme, system for vaccine delivery, cold chain Pneumococcal disease is also estimated to account
and vaccine production capacity are in place. A for 3,000 cases of meningitis, 50,000 cases of
potential exists where the immunization programme bacteraemia, 500,000 cases of pneumonia, and 7
can expand its immunization activities beyond million cases of otitis media each year.
infancy to accommodate newer vaccines for
adolescents and adults, depending on disease In the United States alone, 36,000 annual deaths are
burden and cost-effectiveness of the intervention. . related to influenza and the average number of
hospitalizations associated with influenza has been
REASONS FOR TARGETTING ADULTS estimated at 226,000.
Immunization for infants worldwide has led to The number of HBsAg carriers in India has been
important long term effects on the traditional estimated to be over 40 million. Annually around

1
205,286 deaths related to chronic hepatitis occur in STRATEGIES FOR REACHING OUT TO ADULTS
India. Tetanus causes nearly 309,000 deaths
worldwide annually. Surveillance of tetanus in United Increase the demand for adult vaccination by
States between 1998 -2000 showed that the majority improving provider and public awareness
of tetanus cases occurred among persons
inadequately vaccinated or with unknown vaccination Better public understanding of the seriousness of
history who sustained an acute injury. Adults aged vaccine preventable diseases and the benefits of
>60 years were at highest risk for tetanus and vaccination is essential. Studies have shown that
tetanus-related death. literacy status and socioeconomic profile is an
important determinant associated with adult
The adult age group (more than 18 years) along with immunization. (Guthmann JP, Med Mal Infect 2010)
adolescents presents an important additional target Health educational programmes can help increase
group for existing immunization programmes. public understandinig of the need for and benefits of
adult immunization.
The WHO scientific advisory group of experts (SAGE)
to Global programme for vaccines and immunization Ensure that health care system has an adequate
(GPV) has indicated the need to expand immunization capacity and strategies to deliver vaccines to
activities beyond infancy, either as part of routine adults
immunization services, or as part of disease
elimination and/ or eradication measures. Tetanus toxoid vaccine has been delivered
successfully to women of child bearing age for many
ADULT IMMUNISATION: BOTTLENECKS years as part of routine immunization services. Such
an organized approach should also be replicated for
Inspite of the heavier burden of diseases, vaccines other vaccines for adults. However, healthy adults are
recommended for adults are not widely used. There harder to reach through public health systems and
are several reasons for this such as: most vaccines recommended for adults are not part
• There is a limited perception on part of the health of the Government immunization programme. Hence
care providers and beneficiaries that adult vaccine it becomes important that physicians both general
preventable diseases are significant health as well as specialists should explore opportunities
problems. for vaccination while providing clinical care. For those
working in the organized sector, employers should
• There are doubts in the minds of some heath review the vaccination status of their employees from
care providers and public about the efficacy and time to time.
safety of several of the vaccines used for adults.
Ensure adequate financing mechanisms to
• Adult immunization is selective not universal, support the expanded delivery of vaccines to
different vaccines have different target group. adults

• Healthy adults are harder to reach through public Childhood immunization programme have received
health system and hence vaccination of this age- financial support from national as well as international
group becomes difficult. agencies like Global Alliance for Vaccine Initiative
(GAVI) and UNICEF. The Government of India currently
ADULT IMMUNISATION: CATEGORIES spends over Rs. 200 crores annually on the
procurement of the 6 UIP vaccines alone (excluding
• Boost protection acquired by immunization earlier
the Pulse Polio Immunization Programme). Til now
in life in the absence of “natural” boosting from
public health agencies have been negligibly involved
exposure to the infectious agent.
with adult immunization. Steps should be taken to
• Accelerate control or elimination efforts: Disease increase indigenous production capacity of vaccines
control initiatives frequently aim at increasing herd used for adult immunization.
immunity, interrupting transmission and covering
Ensure adequate support for research
the non-immune cohorts.
An important policy for the Government is the
• Counter specific risks such as travel, high risk
prioritization and coordination of national vaccine
behaviour and immuno-compromised state.
development needs. R&D and production in public

2
funded organizations, and PSUs must be patronized be administered, 2 doses, 1-2 months apart and a
to develop and produce affordable, safe and effective third dose after 6-12 months can be used with
vaccines that are needed for the Indian markets. Prior subsequent boosters at least 1 year apart for a total
identification of which vaccines are most suitable for of 5 appropriately spaced doses to obtain same long
the public health standpoint may be helpful for the term protection. Pertussis whole cell vaccine is not
researchers in steering their research priorities recommended for adolescents or adults.
accordingly.
Booster dose:
VACCINES
A booster dose of tetanus and diphtheria toxoid-
CHOLERA VACCINE containing vaccine should be administered to adults
who have completed a primary series and if the last
Acute diarroheal diseases continue to be a major vaccination was received >10 years previously. Tdap,
source of morbidity and mortality worldwide. 15% of Td or TT vaccine may be used, as indicated.
under five mortality worldwide is due to acute
diarroheal diseases. Cholera is an important cause Tetanus vaccination in pregnancy:
of acute infectious diarrohea and therefore vaccines
against cholera are an attractive disease prevention Since 1983 in India, the nationwide Expanded
strategy. Vaccines for cholera are available as Program on Immunization policy has been
injectable killed whole cell vaccine; and oral cholera implemented to provide 2 doses of tetanus toxoid
vaccine. The injectable killed whole cell vaccine has (TT2) to all pregnant women during each pregnancy
been found to have a poor efficacy (45%) and the (1 dose is provided if <3 years have passed since the
protection lasts for a duration of only 3 months. previous pregnancy, and this is designated as TT-B).
The policy aims at preventing neonatal and maternal
Recommendations tetanus.

Two types of oral cholera vaccines are available: (i) a HEPATITIS A

monovalent vaccine – not licensed for children < 2
The virus has a worldwide distribution and causes
years of age) and (ii) bi-valent vaccines). The
about 15 million cases of clinical hepatitis each year.
injectable vaccine prepared from phenol-inactivated
Different studies in India have shown HAV sero-
strains of V. cholerae is still manufactured in a few
prevalence to be between 38% to 92% in different
countries; the use of this vaccine is not recommended
age groups.
mainly because of its limited efficacy and short
duration of protection. Recommendations

WHO recommends that Cholera control should be a WHO considers that in countries where hepatitis A is
priority in areas where the disease is endemic. Given highly endemic, exposure to HAV is almost universal
the availability of 2 oral cholera vaccines and data on before the age of 10 years. In such countries clinical
their efficacy, field effectiveness, feasibility and hepatitis A is usually a minor public health problem,
acceptance in cholera-affected populations, and large-scale immunization efforts against this
immunization with these vaccines should be used in disease may not be undertaken. Hence, universal
conjunction with other prevention and control immunization for hepatitis A is not recommended as
strategies in areas where the disease is endemic yet. More epidemiological data is required to ascertain
and should be considered in areas at risk for the benefits of the vaccine.
outbreaks. Although all age groups are vulnerable to
Currently, four inactivated vaccines against HAV are
cholera, where resources are limited immunization
internationally available. All four vaccines are safe and
should be targeted to the high-risk age groups
effective, with long-lasting protection. None of the
(children, pregnant women, and the elderly)
vaccines are licensed for children less than one year
of age.
DIPHTHERIA, PERTUSSIS & TETANUS
The (HAV) vaccines are given parenterally, as a two-
Recommendations
dose series, 6-18 months apart. The dose of vaccine,
Primary vaccination: vaccination schedule, ages for which the vaccine is
licensed, and whether there is a paediatric and adult
For unvaccinated individuals 7 years of age and older,
formulation varies from manufacturer to manufacturer.
WHO recommends that Td combination vaccine can
3
In developed countries with low endemicity of B vaccination series should be offered the vaccine
hepatitis A and with high rates of disease in specific before leaving for endemic areas.
high-risk populations, vaccination of those populations
against hepatitis A may be recommended. The high- HUMAN PAPILLOMA VIRUS
risk groups include injection-drug users, homosexual
HPV infection is one of the most common sexually
men, persons travelling to high-risk areas, and certain transmitted infections. HPV is associated with >95%
ethnic or religious groups. However, it should be noted
cervical cancers which is the second most common
that vaccination programmes targeting specific high-
cancer among women worldwide and the commonest
risk groups may have little impact on the overall in India.
national incidence of disease.
Two vaccines are currently available. Quadrivalent
HEPATITIS B
(HPV types 6,11,16 and 18) licensed for use in females
Hepatitis B causes a spectrum of liver diseases, as young as 9 years of age to prevent cervical
including acute self limiting hepatitis, acute fulminant precancers and cancers. In addition, the quadrivalent
hepatitis and chronic HBV infection. Burden of HBV vaccine is licensed for prevention of vulvar and vaginal
infection across India varies across regions. A pre-cancers and cancers as well as of anogenital warts
systematic review of literature concluded the in females. In some countries, the vaccine is also
prevalence of Hepatitis A in India to be between 1- licensed for the prevention of anogenital warts in
2%. A recent met-analysis showed the prevalence of males. Bi-valent (HPV types 16 and 18) has been
Hepatitis A among tribal population to be 15.9% licensed for use in females as young as 10 years of
(95%CI-11.4-20.4) and amongst non tribal population age to prevent cervical pre-cancers and cancers. HPV
2.4% (95%CI- 2.2-2.7%). vaccines are designed for prophylactic use only; they
do not clear existing HPV infection or treat HPV-
Recommendations related disease. The mechanisms by which these
Hepatitis B vaccination is indicated for all vaccines induce protection have not been fully defined
unvaccinated adults at risk for HBV infection and all but seem to involve both cellular immunity and
adults seeking protection from HBV infection including neutralizing immunoglobulin G antibodies.
post-exposure prophylaxis.
The vaccine has to be delivered prior to exposure to
WHO recommends inclusion of hepatitis B vaccine the HPV virus. Therefore, the immunization must
in the routine immunization schedule. Three doses precede the sexual debut. Evidence suggests the
(for high-risk groups if not previously immunized) is age for initiation for vaccination to be 10 - 12 years.
also recommended. Screening for cervical cancer and primary prevention
should be continued in spite of HPV vaccination.
Additional target groups for vaccination include people
with risk factors for acquiring HBV infection, such as Recommendation
those who frequently require blood or blood products,
dialysis patients, recipients of solid organ - Since both vaccines are intended for females
transplantations, people interned in prisons, injecting before the onset of sexual activity, i.e. before first
drug users, household and sexual contacts of people exposure to HPV infection, a three-dose schedule
with chronic HBV infection, people with multiple is recommended. The quadrivalent is given at
sexual partners, as well as health-care workers and baseline and after 2 and 6 months. A minimum
others who may be exposed to blood and blood interval of 4 weeks between the first and second
products through their work. dose, and a minimum interval between the second
and third does of 12 weeks is recommended by
In countries with intermediate to low endemicity where the manufacturer. The bivalent vaccine is given
a relatively large part of the disease burden results at baseline and after 1 and 6 months. If flexibility
from acute HBV-related disease and is attributable in the schedule is necessary the manufacturer
to infection acquired by older children, adolescents recommends that the second dose is
and adults, catch-up strategies targeted at administered between 1 and 2.5 months after the
adolescents as a supplement to routine infant first dose.
vaccination are also recommended.
- For both vaccines, alternative schedules are being
People with risk factors for acquiring HBV infection
explored. Restarting the 3-dose series is not
and travelers who have not completed their hepatitis
necessary if interrupted, but remaining doses

4
 should be administered as close to the schedule The WHO is also currently assessing a trivalent
intervals as possible. vaccine effective against the H1N1 pandemic virus,
the seasonal H3N2 virus, and influenza B viruses,
- Currently, the manufacturers do not recommend and a bivalent seasonal vaccine, effective against
any booster dose following completion of the H3N2 and influenza B viruses, which might need to
primary series. be supplemented with a separate monovalent H1N1
pandemic vaccine. SAGE concluded that both
- Catch-up vaccination can be advised up to the
options should remain available for vaccine
age of 26 years for Gardasil® vaccine
(quadrivalent vaccine) and 45 years for Cervarix® formulations in the southern hemisphere, subject to
national needs.
vaccine (bivalent vaccine)
In terms of protective efficacy, the live influenza
- HPV vaccination of males for prevention of cervical
cancer is not recommended at this time. vaccines appear to be comparable with the TIVs
(trivalent, inactivated influenza vaccines.) However,
Vaccination strategies that achieve high coverage
CAIV-T (cold-adapted influenza vaccine) is licensed
(>70%) in the primary target population of young
adolescent girls are expected to be more cost- only for healthy people aged 5-49 years, given reports
of an increase in reactive airway disease in vaccinees
effective in reducing cervical cancer than
<5 years of age and insufficiently documented
including vaccination of males.
protective efficacy in older people.
INFLUENZA
JAPANESE ENCEPHALITIS
Influenza caused by Influenza A and Influenza B are
Japanese encephalitis (JE) is a form of viral
the most common illness experienced by otherwise
healthy adults and children and causes significant encephalitis spread by arthropod borne virus
belonging to the family Flaviviridae and genus
morbidity. Ramamurty N et al have reported a monthly
Flavivirus. It is spread by the bite of infected culicine
incidence of respiratory infections to be 23% in urban
areas and 17.7% in rural areas in Chennai among mosquito. In India, the disease is endemic in southern
India and cases occur sporadically throughout the
the peadiatric age group. Although the rates of
year, while in north India the cases occur in the form
infection are highest among children, risks for
complications, hospitalizations and deaths from of epidemics during the summer and monsoon
months. It is predominantly a disease of children living
influenza are higher among persons aged over 65
in rural areas although people residing in semi urban
years, young children and persons of any age who
have co-morbid medical conditions that place them areas may also be affected. The control measures
for JE are two pronged, namely vector control and
at increased risk for complications from influenza.
prophylactic vaccination.
Recommendations
The vaccines used for immunization against Japanese
In the absence of epidemiological surveillance encephalitis (JE) are (i) mouse brain-derived
regarding the influenza serotypes in our country, inactivated vaccine that uses the Nakayama strain
presently the use of influenza vaccine in India is not (e.g., BIKEN/JE-VAX®) and (ii) PHK cell-cultured, live-
recommended. attenuated vaccine (e.g., SA 14-14-2 vaccine). With
effect from 2007, the production of the mouse brain-
However, in response to the current influenza (H1N1) derived inactivated vaccine has been stopped at the
pandemic, the WHO strategic advisory group of Central Research Institute (CRI), Kasauli and this
experts (SAGE) have recommended the use of H1N1 vaccine is not available for use in India. The SA 14-
influenza vaccine for health-care workers as a first 14-2 live attenuated vaccine is currently in use in
priority to protect the essential health infrastructure. China, India, Korea, Sri Lanka and Nepal. It is
SAGE recommends that vaccination is also administered subcutaneously as a single 0.5 ml dose
particularly important for people who are at increased and a booster dose may be given at one year.
risk of severe outcomes if they catch pandemic
influenza, including pregnant women and people with Recommendations
underlying medical conditions. As vaccines available
The JE vaccine is primarily useful in the pediatric
throughout is initially not sufficient, a step-wise
approach to vaccinate particular groups is to be age group in JE endemic areas as JE is mainly a
disease of children. Currently, the JE vaccine is not
considered.
recommended for routine use in adults

5
 MENINGOCOCCAL MENINGITIS particularly if their contact with local
populations will be prolonged. Vaccination is
Meningococcal disease is an acute bacterial disease required by the government of Saudi Arabia for
caused by Gram negative capsular diplococcal all travellers to Mecca during the annual
bacteria, the meningococcus (Neisseria Hajj.
meningitides). At present 13 serogroups of
meningococcus are known viz. A, B, C, E, H, I, K, L, In older children and adolescents group C disease
M ,X, Y, Z, W 135. Meningococcal disease occurs may be prevented by a single dose of (group C
worldwide as endemic infections. Strains of serogroup conjugate meningococcal) vaccine. Where disease
in children above two years of age is the main
B and C cause majority of infections developed
concern, or where resources are limited, several years
countries, where as strains of serogroup A and to a
of protection may be achieved by single injection of
lesser extent serogroup C dominate in the developing
the combined groups A and C polysaccharide vaccine.
world. In India the disease is endemic in some states
like Delhi and sporadic cases are reported from other PNEUMOCOCCUS
states such as Haryana, UP, Rajasthan, Gujarat,
West Bengal and Orissa. Meningococcal disease is Lower respiratory infections including community
potentially preventable through vaccination and or acquired pneumonia (CAP) are an important cause
chemoprophylaxis in special circumstances. of morbidity and mortality worldwide. A vast majority
of the lower respiratory infections are caused by viral
Two types of vaccines are in use for meningococcal infections. However, most cases of CAP are of
meningitis (i) the polysaccharide vaccines and (ii) bacterial origin. Among the bacterial pathogens
conjugate vaccines. A third type based on outer causing CAP, S. Pneumoniae is the single most
membrane protein [OMP] has not been found to be common organism worldwide. A study conducted by
very effective and is not widely used. Internationally International Clinical Epidemiology Network (INCLEN)
marketed meningococcal polysaccharide vaccines on pneumococcal infection during 1993-97 in India
are either bivalent (groups A and C) or tetravalent showed pneumococcal pneumonia, bacteremia and
(groups A, C, Y and W135). meningitis were associated with case fatality rates
of 19%, 21% and 34% respectively. Moreover nearly
Recommendations one third (33%) of patients with proven IPD were
younger than 5 years and about 23% were older than
Routine vaccination of all adults is not
50 years.
recommended in view of low efficacy of
meningococcal vaccines in children below 2 years Currently, a 7-valent polysaccharide–protein conjugate
and the short-lived protection provided by the vaccine (PCV-7) and an unconjugated polysaccharide
currently available polysaccharide vaccines. vaccine covering 23 serotypes are marketed
internationally. A three dose regimen before one year
Vaccination of adults with meningococcal vaccine
of age along with a booster after one year is
should be done if they meet any of the following
recommended for the 7-valent polysaccharide–protein
indications and any person seeking protection from conjugate vaccine. 23-valent vaccine is primarily
hepatitis A virus (HAV) infection. designed for use in older children and adults who are
• Medical: Adults with anatomic or functional at high risk for pneumococcal disease. It is not
licensed for use in children aged <2 years.
asplenia, or persistent complement component
deficiencies. Recommendations
• Other: First-year college students living in More than 15 meta-analyses with conflicting results
dormitories; microbiologists routinely exposed have been published so far the efficacy of PPV in
to isolates of Neisseria meningitidis; military adults. Available evidence is insufficient to
recruits; and persons who travel to or live in recommend routine use of PPV in adults. Although
countries in which meningococcal disease is PPV is efficacious in preventing invasive
hyperendemic or epidemic (e.g., the pneumococcal disease among adults, routine PPV
“meningitis belt” of sub-Saharan Africa during administration to adults is not likely to be cost-
the dry season [December through June]), effective in India. Pneumococcal vaccination is

6
recommended in patients undergoing splenectomy RUBELLA
(preferably at least 2 weeks prior to splenectomy)
There are a number of rubella vaccines available, either
Currently the WHO states that in resource-limited as single antigen vaccines or combined with either
settings where there are many competing health measles vaccine (MR), mumps vaccine or measles
riorities, the evidence does not support routine and mumps vaccine (MMR). Most of the currently-
immunization of the elderly and high-risk populations licensed vaccines are based on the live, attenuated
with PPV. RA 27/3 strain of rubella virus, propagated in human
diploid cells.
RABIES
Rubella is a mild childhood disease. However
Rabies is an acute viral disease which causes infection during pregnancy may cause fetal death or
encephalomyelitis in virtually all warm blooded congenital rubella syndrome (CRS). The primary
mammals including man. Rabies virus is transmitted purpose of rubella vaccination is to prevent the
to other animals and to humans through close contact occurrence of congenital rubella infection including
with their saliva (i.e. bites, scratches, licks on broken congenital rubella syndrome (CRS), which is an
skin and mucus membrane). Rabies occurs in all important cause of deafness, blindness and mental
continents with the exception of Antarctica. Estimates retardation. Women of child bearing age should
suggest that in India, around 20,000 human deaths consider vaccination with rubella if not immunized
occur due to rabies annually which accounts for about during childhood. Rubella vaccination should be
1/3rd of total global mortality (APCRI 2004). It is avoided in pregnancy because of the theoretical, but
never demonstrated, teratogenic risk.
estimated that 17.4 million animal bites occur per
year; of these many do not seek post exposure Recommendation
prophylaxis.
For adult immunization, two doses of the vaccine are
As rabies has a long incubation period, it is possible recommended for health care workers; in the setting
to institute prophylactic post exposure vaccination. of outbreaks; recent exposure to these infections;
women who could become pregnant; and college
Recommendations students.

Currently, cell culture rabies vaccines are used for WHO recommends two approaches for rubella
rabies prophylaxis, which may be administered by vaccination. (a) prevention of CRS only, through
intramuscular or intradermal route. For post exposure immunization of adolescent girls and/or women of
prophylaxis, five doses of the vaccine are childbearing age; or (b) elimination of rubella as well
administered on days 0, 3, 7, 14, and 28 in the deltoid as CRS through universal vaccination of infants,
muscle or in the anterolateral part of the thigh. They surveillance and assuring immunity in women of
are not to be injected in the gluteal region. For childbearing age. The WHO also emphasizes the
intradermal inoculation of cell culture vaccines, need for a childhood vaccination programmes
achieving and maintaining high levels of coverage to
Updated Thai Red Cross Regimen is approved for
avoid the risk of increasing the number of susceptible
use in India. In this, 0.1 ml of vaccine, irrespective of
among adults, including women of childbearing age,
reconstituted volume, is administered at 2 sites intra-
and the possibility of increased numbers of cases of
dermally in the deltoid region on days 0, 3, 7 and 28.
CRS. On the other hand a policy of rubella vaccination
Intradermal inoculation of cell culture vaccines not
of adults is essentially free of risks of altering rubella
only makes post exposure prophylaxis economical
transmission dynamics.
but also enables wider coverage in available quantity
of vaccines. VARICELLA

Pre-exposure prophylaxis is recommended in high The currently marketed varicella vaccines are based
risk groups such as veterinary personnel, medical on the so-called Oka strain of VZV, which has been
doctors, dog catchers, postmen, wild life wardens modified through sequential propagation in different
etc. Vaccine is given intramuscularly (1ml/0.5ml) or cell culture. Following a single dose of the above-
intra-dermally (0.1ml, irrespective of reconstituted mentioned vaccines, seroconversion is seen in about
volume) on days 0, 7, 21 or 28. 95% of healthy children. From a logistic as well as

7
an epidemiological point of view, the optimal age for At the present time WHO does not recommend the
varicella vaccination is 12-24 months. inclusion of varicella vaccination into the routine
immunization programmes of developing countries.
Recommendations However, (Varicella) vaccine may be offered
in any country to individual adolescents and adults
Varicella vaccine may be used either at an individual
level to protect susceptible adolescents and adults. without a history of varicella, in particular to
those at increased risk of contracting or spreading
But will not have a significant impact on the
the infection. This use in adolescents and
epidemiology of the disease on a population basis.
Varicella in persons who have received the vaccine adults entails no risk of an epidemiological shift,
as childhood exposure to VZV remains
(“break-through varicella”) is substantially less severe
unaffected.
than the disease in unvaccinated individuals.

TREATMENT
Figure 1 Recommended adult immunization schedule, by vaccine and age group
Vaccine 19-26 yrs 27-49 yrs 50-59 yrs 60-64 yrs >=65 yrs

Tetanus, diphtheria, pertusis
(Tdap should replace one time dose of Td)
(Td
booster
every 10
yrs)

Human Pipillomavirus

(3 doses females) × × × ×

Varicella

(2 doses)

Zoster × × ×

(1 dose)

Measles, mumps, rubella

(1 or 2 doses)
(1 dose)

Influenza


(1 dose annually)

Pneumococcal
(1 or 2 doses)

(1 dose)

Hepatitis A
(2 doses)

Hepatitis B
(3 doses)

Meningococcal
(1 or more doses)

(Source: Adapted from CDC MMWR, January 2010)

For all persons in the category who meet the age requirement and who lack evidence of immunity

Recommended if some other risk factor is present (eg based on medical, occupational or other indication)
× Not recommended

...about CD Alert
CDAlert is a monthly newsletter of the National Centre for Disease Control (NCDC) (formerly known as NICD), Directorate
General of Health Services, to disseminate information on various aspects of communicable diseases to medical fraternity
and health administrators. The newsletter may be reproduced, in part or whole, for educational purposes.

Chief Editor: Dr. R. K. Srivastava

Editorial Board: Dr. L. S. Chauhan, Dr. R. L. Ichhpujani, Dr. Shashi Khare, Dr. A. K. Harit
Guest Editor (Authors): Dr Anil Kumar, Dr. Sunil Gupta, Dr. Paul Francis, Dr. Tanzin Dikid, Dr Arti Bahl
Publisher: Director, National Centre for Disease Control, 22 Shamnath Marg, Delhi 110 054
Tel: 011-23971272, 23971060 Fax : 011-23922677
E-mail: dirnicd@bol.net.in and dirnicd@gmail.com Website: www.nicd.nic.in
Acknowledgement: Financial assistance by WHO/USAID is duly acknowledged.

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