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Indian J Nephrol. 2016 Apr; 26(Suppl 1): S7–S14. PMCID: PMC4928530

Guidelines for vaccination in normal adults in India

The immunization of an adult depends on the previous immunization received in childhood.

Unlike the Pediatric Immunization Guidelines, given by the Indian Academy of Pediatrics and
the National Immunization Programs,[1,2] the guidelines for vaccination in healthy adults vary
from region to region.

The major guidelines are:

The Advisory Committee on Immunization Practices (ACIP) guidelines from Centers for
Disease Control and Prevention[3,4,5]
WHO guidelines[6]
Association of Physicians of India – Expert panel guidelines [Tables ​6 and ​7].[7]

Table 6

Vaccines recommended for all healthy adults

 Table 7

Vaccines recommended in high-risk individuals

Hepatitis B vaccine

Vaccine

Hepatitis B vaccine is a recombinant vaccine. Plasma- derived vaccine is not used due to risk of
transmission of infections.

Schedule

Primary immunization at birth: In normal individuals, the dose is 10 μg in children given intra‐
muscularly at 0, 1, and 6 months and a booster after 5 years. In adults, the dose is 20 μg.
Booster is not needed in immunocompetent adults.[8,9,10,11]

Indications of hepatitis B vaccine in Indian adults

Adults at high risk, e.g., patients with percutaneous or mucosal exposure to blood and patients
with sexual exposure should be vaccinated if not immunized in childhood. Percutaneous or
mucosal exposure can occur in intravenous drug users; household contacts of persons with
chronic hepatitis B virus (HBV) infection; inmates and staff of institutions for developmentally
disabled persons in long-term care facilities; persons at risk for occupational exposure to HBV
(such as dialysis staff, laboratory staff dealing with blood samples, blood bank staff, nurses
working in intensive care units, operation theaters, and surgeons and other doctors at high-
risk); patients who are human immunodeficiency virus (HIV)-seropositive, patients with
chronic liver disease (CLD), chronic kidney disease (CKD); and diseases where blood products
or multiple blood transfusions are required such as hemophilia, aplastic anemia, leukemia,
hemoglobinopathies, and patients awaiting major surgeries. Sexual exposure is a risk factor for
HBV infection in patients presenting to sexually transmitted disease clinics, homosexuals; pro‐
miscuous heterosexuals; commercial sex workers; and sex partners of hepatitis B surface anti‐
gen (HBsAg)-positive persons.

Prevaccination screening in general population has not been found to be cost-effective in India.
If the vaccination schedule is interrupted after the first dose, the second dose should be admin‐
istered as soon as possible and the second and third doses should be separated by an interval
of at least 8 weeks. If only the third dose has been delayed, it should be administered as soon
as possible.

Postexposure screening is not indicated for most adults, except in immunocompromised per‐
sons, sex partners of HBsAg-positive persons, and health care workers at high risk for contin‐
ued percutaneous or mucosal exposure to blood or body fluids. When indicated, postexposure
screening should be performed 1–2 months after administration of the last dose of the vaccine
series. The anti-HBs titer should be maintained above 10 mIU/ml in all healthy adults.

Nonresponders who are HBsAg and anti-HBc-negative should receive a further full course of
vaccination as fourth, fifth, and sixth doses. Retesting should be done 1–2 months after the last
dose. If there is no response, 40 μg of recombinant vaccine is administered at 0, 1, and 6
months. Retesting should be done 1–2 months after the last dose. If the person remains a non‐
responder, alternative strategies for protection must be explored.

Booster doses of HBV vaccine are not indicated in persons with normal immune status. A
booster dose may be administered when anti-HBs levels decline to <10 mIU ml and >65 years.

Pneumococcal vaccine

Pneumococcal vaccine is available in two forms:

Polysaccharide vaccine consisting of polysaccharides from 23 serotypes. This vaccine is less

immunogenic, does not affect carrier rates, promote herd immunity, or protect from
respiratory tract infections as there is no mucosal immunity
Conjugated Vaccine with 13 serotypes consists of capsular polysaccharides covalently
bound to diphtheria toxoid, which is highly immunogenic but nontoxic. This combination
results in mucosal immunity and lifelong immunity.[3,4,5,12,13]

Table 8 summarizes the key differences between Pneumococcal Polysaccharide Vaccine

(PPSV23) and Pneumococcal Conjugate Vaccine (PCV13).[14]
 Table 8

Key differences between pneumococcal polysaccharide vaccine23 and pneumococcal conjugate vaccine13

PCV13 is approved in several countries worldwide, including the US, EU, and India, for use in
adults aged >50 years for the prevention of pneumonia and/or invasive disease caused by
Streptococcus pneumonia serotypes included in the vaccine.[14] In immunocompetent adults,
PPSV23 is indicated in those over the age of 65. The vaccine is also indicated for those with
CKD, chronic obstructive pulmonary disease (COPD), cirrhosis, diabetes, HIV, lupus, cancer and
those on chemotherapy or radiotherapy, long-term steroid, asplenia, or splenectomy.

A single dose PPSV23 is recommended in immunocompetent adults. In those who have re‐
ceived primary immunization, vaccination is done with PPSV23 0.5 ml single dose IM. In those
who have not received primary vaccination, PCV13 can be given followed by PPSV23 after a
minimum interval of 8 weeks. If PPSV23 has been given earlier PCV can be given after 1 year.

Revaccination can be done with PPSV23 at least 5 years after the first dose. Revaccination with
PPSV23 within 5 years leads to hyporesponsiveness. Monitoring for seroconversion is not
needed.

In the year 2014, ACIP recommended routine use of PCV13 among adults aged ≥ 65 years.[15]
This was based on the results of the CAPiTA trial that supported the evidence on the efficacy of
PCV13 against noninvasive pneumococcal pneumonia among adults.[16] As per this recom‐
mendation, both PCV13 and PPV23 should be routinely administered in series to all adults
aged ≥ 65 years. ACIP recommendations for use of PCV13 (high risk) in adults aged ≥ 19 years
with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid
leak, or cochlear implants remain unchanged.

The recommendations for usage of both the vaccines is mentioned in Table 9.[14]
 Table 9

Advisory Committee on Immunization Practice recommendations for the use of pneumococcal conjugate vac‐
cine 13 and pneumococcal polysaccharide vaccine 23

The ACIP recommendation was amended in 2015 to simplify the spacing between PCV13 and
PPSV23 in adults >65 years.[17] The old ACIP recommended that PPSV23 can be given after 6-
12 months after PCV13. The new recommendation states that the recommended interval for
adults receiving PCV13 and PPV23 to be at least 1 year apart, regardless of sequence. In sum‐
mary, this means that PCV13 is given first followed by PPSV23 with spacing at least 1 year. If
the adult above 65 years received PPSV23, he will receive PCV13 after 1 year as the older rec‐
ommendation [Tables ​10 and ​11].
Table 10

Immunization for all adults with normal immune status

 Table 11

Vaccination in special situation in adults

Influenza vaccine

The available vaccine in India is a killed virus vaccine to be given intramuscularly.[18,19] Other
vaccines include nasal spray vaccines (containing live attenuated virus). As the influenza virus
constantly mutates, a new batch is prepared every year. The vaccine becomes effective against
influenza virus 2 weeks after administration. Since the peak influenza season begins in October
and lasts till May, October-November are the best times to receive vaccination.[18,19]

A single dose of inactivated flu vaccine in dose of 0.5 ml is given intramuscularly into the del‐
toid muscle.

Vaccination is indicated in high-risk subjects, e.g., those with COPD, CKD, cardiac or lung dis‐
eases, hepatic, metabolic diseases (diabetes), hematological diseases, pregnancy, nursing
homes, health care personnel, household contacts of children <5 years or adults >50 years,
diseases which impair respiratory functions, and immunosuppressed individuals.
Side effects include allergic reactions, Guillain Barre syndrome. High-risk individuals (see
above) should not receive nasal spray live flu vaccine. The vaccine provides adequate protec‐
tion against HINI infection. Antibody monitoring is not required.

Meningococcal vaccine

The quadrivalent vaccines contain 50 μg of each of the antigens A, C, Y, and W135 whereas the
bivalent vaccine has only A and C antigens. Two types of quadrivalent vaccines are available.
The meningococcal polysaccharide vaccine (MPSV4) does not induce herd immunity, has no ef‐
fect on nasopharyngeal carriage, and can be used only in those >2 years age. The meningococ‐
cal conjugate vaccine (MCV4) provides herd immunity, reduces nasopharyngeal carriage, pro‐
vides long-lasting immunity after 28 days of vaccination, but cannot be used for people >55
years. These vaccines do not protect against meningococcus groups B or meningitis due to
other organisms. MCV4 (conjugated) is preferred for adults who are aged 55 years or younger
as well as for adults aged 56 years or older who (a) are vaccinated previously with MCV4 and
are recommended for revaccination, or (b) for whom multiple doses are anticipated. MPSV4 is
preferred for adults aged 56 years or older who have not received MCV4 previously and who
require a single dose only (e.g., travelers).[20]

Vaccination is indicated in specific situations, such as during an outbreak. A single dose of vac‐
cine (A + C) may be given to health care workers, laboratory workers, and close contacts of
cases. Vaccination may be given to personnel living in dormitories, military recruits, jail in‐
mates, immunocompromised individuals, such as those suffering from terminal complement
component deficiency, splenectomy, active and passive smokers, systemic lupus erythematosus,
HIV, and multiple myeloma (2 doses separated by 2 months for adult <55 years).

For travelers, a single dose is recommended 10-14 days before the scheduled visit depending
on the prevalent serotype in the visiting country. As a national policy, the National Institute of
Communicable Diseases, New Delhi, administers quadrivalent polysaccharide vaccine to the Haj
pilgrims to fulfill the requirements of the Government of Saudi Arabia.

Rabies vaccine

The sheep brain-derived nerve tissue vaccine “semple vaccine” is no longer used. Tissue cul‐
ture vaccines (TCV) such as human diploid cell vaccine, purified chicken embryo cell vaccine
(PCECV), and newer and less expensive vero cell-purified rabies vaccines are now available.
TCV are used for pre- and post-exposure prophylaxis. They are easy to administer, highly im‐
munogenic, and have a good margin of safety.[7]

Pre-exposure schedule

Pre-exposure schedule for rabies vaccination is 3 doses at days 0, 7, and 28 and is recom‐
mended for high-risk groups such as veterinarians, laboratory personnel working with rabies
virus, medical and paramedical personnel treating rabies patients, dog catchers, forest staff,
zookeepers, postmen, policemen, courier boys, and schoolchildren in endemic countries. The
human diploid cell culture vaccine [HDCV] and purified chick embryo cell culture PCECV (1 ml)
or purified vero cell rabies vaccine (0.5 ml) are administered by intramuscular route in the del‐
toid region or the anterolateral thigh. The reconstituted tissue culture vaccines (0.1 ml) can be
administered by the intradermal route over the deltoid region.

Antibody titers should be monitored every 6 months in persons working with live virus in diag‐
nostic, research, and vaccine production laboratories. In other professions at permanent risk
of exposure to rabies, such as veterinarians, animal handlers, and wildlife officers, antibody
titers in the serum should be monitored annually. Booster dose should be administered when
the titer falls below 0.5 IU/ml. The duration of immunity by two injection vaccination course is
2-3 years.

Postexposure prophylaxis

A person who is exposed and has never been vaccinated against rabies should get five doses of
rabies vaccine at 0, 3, 7, 14, and 28 days. They should also 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. A per‐
son who has been previously vaccinated should get 2 doses – 1 on 0 day and another on 3rd
day.

When needed, the rabies immunoglobulin should be infiltrated as much as possible into and
around the wounds and the remaining should be given intramuscularly at a site away from the
site where vaccine has been administered.

Management of re-exposure

On reexposure, 2 booster doses should be administered on days 0 and 3 irrespective of cate‐

gory of exposure or time that has elapsed since previous vaccination. All subjects who have re‐
ceived incomplete vaccination should be treated as fresh cases.

If rabies immunoglobulin is not available, double dose of the first dose of vaccination may be
administered in the following situations: (i) category III exposure, (ii) patients who are mal‐
nourished and patients receiving corticosteroids, anticancer drugs, and antimalarials, and (iii)
patients with HIV/AIDS with CD4+ count <200/mm3. If feasible, antibody titers should be mon‐
itored and boosters given if titer is less than 0.5 IU/ml.

Immunosuppressed patients should avoid activities for which rabies preexposure prophylaxis
is indicated. Antibody titer is checked after immunization in an immunosuppressed person.
Sera should be collected around day 14 of vaccine series and at the time of completing
prophylaxis.

Human papillomavirus vaccine

The vaccine protects against human papillomavirus (HPV) types responsible for most cervical
cancers and genital warts. It is most effective when administered before onset of sexual activity.
[21]
It can be given to young males and females between the ages of 9 and 26 years. In age group 9-
14 years, 2 doses are recommended at an interval of 6 months. For >15 years, the dose is 0.5
ml intramuscularly at 0, 1, and 6 months.

Tetanus, diphtheria, and pertussis vaccine

Full dose diphtheria, tetanus, and pertussis are used in children (DPT). Acellular pertussis vac‐
cine (DTaP) should be used for older children instead of whole cell vaccine (DTwP) because it
is associated with less neurological complications. Two new tetanus toxoid, reduced diphtheria
toxoid and acellular pertussis vaccines (Tdap) are available for use in those who are more than
10 years of age.[22,23]

The vaccination schedule varies with status of primary immunization. The dose is 0.5 ml given
IM preferably in deltoid. DTaP (acellular pertussis) or DTwP (whole cell pertussis) vaccine
should be used for 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 once every 10 years till the age of 65; one dose of Tdap
vaccine may be administered in place of Td vaccine. For adults >18 years who have not re‐
ceived 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. The Tdap vaccine can substitute any one of the Td doses.

For adults who have not received Tdap vaccine and are likely to come in contact with infants
suffering from diphtheria or pertussis, a single dose of Tdap vaccine should be given 2 weeks
before the contact with the infant if 2 years or more have elapsed since the last dose of Td vac‐
cination. Health care personnel, especially those in direct contact with the patients, who have
not received Tdap vaccine should receive a single dose of Tdap vaccine if 2 years or more have
elapsed since the last dose of Td vaccination. Women planning pregnancy should receive one
dose of Tdap vaccine if they did not receive it previously. Pregnant women who have received
the Td vaccination more than 10 years ago should receive one dose of Td vaccine in the second
or third trimester of pregnancy. Pregnant women who have received Td vaccination during the
preceding 10 years should receive one dose of Tdap in the immediate postpartum period if the
last dose of Td was administered more than 2 years ago. For pregnant women who have never
received previous vaccination, three doses of Td vaccine are indicated; in the second or third
trimester of pregnancy, two doses are administered at least 4 weeks apart, and the third dose
is given 6-12 months after the second dose. Following minor trauma in non immunized individ‐
ual or those immunized more than 10 years if major wound both Td/Tdap and TIG should be
given; if immunized >5 years and <10 years ago only Td/Tdap is given and TIG is not required.
Modified dose vaccine is not effective post transplant and full dose is needed.

Precautions

Tdap/Td vaccines are contraindicated for persons with a history of anaphylaxis to any compo‐
nent. The Tdap vaccine is contraindicated in adults with a history of encephalopathy not attrib‐
utable to an identifiable cause within 7 days of administration of a vaccine with pertussis com‐
ponent; these persons should receive Td vaccine. In adults with moderate or severe acute ill‐
ness and those with unstable neurologic conditions (e.g., stroke, acute encephalopathies), Tdap
vaccination is to be deferred until the acute illness resolves. In adults with a history of Arthus
reaction with the previous dose of tetanus/diphtheria containing vaccine, Tdap/Td is adminis‐
tered only after 10 years since the last dose.

Haemophilus influenzae

The vaccine antigen is polyribose phosphate or outer membrane protein (OMP), and carrier is
tetanus toxoid conjugate or diphtheria CRM protein.[7]

Vaccination is a part of primary immunization. Adults at high risk such as patients with asple‐
nia, HIV, hematological malignancies, corticosteroid use, CSF leak, trauma, diabetes, pregnancy,
alcoholism, immunosuppression due to bone marrow or kidney transplant, cancer, radiation,
or chemotherapy should be vaccinated.

A single 0.5 ml dose of haemophilus influenza b (HiB) conjugate vaccine is administered intra‐
muscularly.[7]

Hepatitis A

Vaccines against hepatitis A virus (HAV) include inactivated vaccines as single antigen (HAV
antigen) vaccines or combined with HBV antigens.

Universal immunization for hepatitis A is not recommended. The following groups of adults are
considered at high risk for acquiring hepatitis A: persons who use illicit drugs; persons who
work with HAV-infected primates or with HAV in a laboratory; people who receive clotting fac‐
tor concentrates; persons infected with other hepatitis viruses; persons with CLD who are not
already immune to HAV; persons who have received, or are awaiting a liver transplant; food
handlers; and men who have sex with men. Hepatitis A vaccine is indicated for all transplant
candidates with CLD or those patients of end-stage renal disease (ESRD) who have chronic
hepatitis B or C because of increased risk of fulminant hepatic failure.[9,10]

Typhoid vaccine

The available vaccines for typhoid fever include inactivated whole cell vaccine, live oral Ty21a
vaccine, injectable Vi polysaccharide vaccine, and Vi-rEPA vaccine. The lyophilized oral Ty21a
vaccine is available in two formulations: A liquid suspension (in sachets) or enteric coated cap‐
sules. The Vi polysaccharide vaccine is a subunit vaccine composed of purified Vi capsular
polysaccharide.[7]

Three doses of Ty21a capsules/sachets are administered on alternate days. This series should
be repeated once in every 3 years as a booster dose. The capsule formulation should be taken
orally with safe water. The sachet should be given with 100 ml of safe water with buffer to pro‐
tect the B-subunit against gastric acidity. The Vi vaccine is given as a single subcutaneous or in‐
tramuscular dose of 0.5 ml, with revaccination every 3 years. Typbar conjugate vaccine is now
recommended between 9 and 12 months.
Entire community at risk should be vaccinated during an outbreak. If immunization of the en‐
tire community is not possible, individuals aged 2-19 years should be specifically targeted.
Ty21a should not be used during pregnancy. Vaccination policy for renal disease patients is
same as for normal population. Live oral typhoid is contraindicated in transplant recipient.

Cholera

Vaccines for cholera are available as injectable killed whole cell vaccine; and oral cholera vac‐
cine. The injectable killed whole cell vaccine has a poor efficacy with short-lasting protection
and is not recommended.

Among the oral cholera vaccines, Dukoral (WC/rBS) is approved for use in persons aged over
2 years. Dukoral is administered in three separate doses, 1–6 weeks apart for 2–6-year-old
children and as two separate doses, 1–6 weeks apart for those aged over 6 years. It confers
85–90% protection for 6 months among all age groups which declines over 6 months to 2
years.[7]

Japanese encephalitis

The vaccines used for immunization against Japanese encephalitis (JE) are mouse brain-de‐
rived inactivated vaccine and cell-cultured, live-attenuated vaccine. With effect from 2007, the
production of the mouse brain-derived inactivated vaccine has been stopped. The live attenu‐
ated vaccine is currently in use in India. It is administered subcutaneously as a single 0.5 ml
dose, with a booster dose at 1 year.[7]

The JE vaccine is primarily useful in the pediatric age. The issue of adult immunization against
JE in case of major outbreaks needs to be reviewed.

Varicella vaccine

Two vaccines, both containing an attenuated live VZV are currently available in India.[20]

All adults who have never had chickenpox should receive 2 doses 0.5 ml in deltoid area subcu‐
taneously. For <13 years of age, the first dose is administered at 12-15 months and the second
dose at age 4-6 years. For people older than 13 years, the two doses are administered 4-8
weeks apart. For those already immunized, booster doses are not needed if titers are adequate.
In resource-limited countries at least the females in reproductive age group, people at high risk
for exposure to varicella, i.e., health care workers, household contacts, etc., should be vacci‐
nated.[20]

Varicella vaccines should not be administered to persons receiving HD systemic immunosup‐

pressive therapy, including oral corticosteroids >2 mg/kg of body weight or a total of more
than 20 mg/day of prednisone or its equivalent for persons who weigh >10 kg, when adminis‐
tered for >2 weeks; HIV-seropositive adult or adolescent with CD4 + T-lymphocytes count <200
cells/μL; persons with a family history of congenital or hereditary immunodeficiency in first-
degree relatives (e.g. parents, siblings). It is also contraindicated in those with gelatin allergy,
neomycin allergy, people on radiotherapy or chemotherapy, people who have received blood
products or transfusions during past 5 months. Varicella vaccination has been shown to be ef‐
fective in patients with nephrotic syndrome and should be given to all patients with negative
varicella titers. It is ideally administered when in remission or on low-dose alternative days or
off corticosteroid therapy. It is recommended for all CKD patients and those on dialysis.

Patient groups at risk for severe disease and complications from varicella can receive varicella
zoster immunoglobulin (VZIG). These include those with immune-deficiency disorders; neo‐
plastic diseases; on immunosuppressive treatment and pregnant women. VZIG should be ad‐
ministered within 96 h of the exposure at a dose of 125 units/10 kg body weight, up to a maxi‐
mum of 625 units. Patients should be monitored for varicella for 28 days after exposure as
VZIG prolongs incubation period.[24]

Rotavirus

The vaccine can be given after the age of 6 weeks- 2 doses at 10 weeks and 14 weeks. It is not
routinely recommended for adult immunization. The vaccine is recommended for pediatric
solid organ transplant candidates before transplantation.[1,2,3]

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