Adult vaccination is one of the most neglected areas of preventive care in India. Childhood immunisation is well understood, and then the subject disappears until something goes wrong.
Several adult vaccines prevent serious illness, particularly in people with chronic conditions who are least likely to have been offered them.
Influenza Vaccine
Influenza is treated as a minor illness and causes serious complications in specific groups.
The vaccine is recommended annually because circulating strains change and immunity wanes. In India, timing before the monsoon is generally advised, since influenza activity peaks during and after it.
Particularly recommended for: adults over sixty five, anyone with diabetes, heart disease, chronic lung disease, kidney disease or immunosuppression, pregnant women at any stage, healthcare workers, and carers of vulnerable people.
Vaccination during pregnancy protects both the mother and the newborn for the first months of life, when the baby is too young to be vaccinated. This is under used and worth requesting.
Pneumococcal Vaccine
Pneumococcal bacteria cause pneumonia, meningitis and bloodstream infection, and the burden falls heavily on older adults and those with chronic conditions.
Recommended for: adults over sixty five, and younger adults with diabetes, chronic heart, lung, liver or kidney disease, immunosuppression, absent or non functioning spleen, cochlear implants, or a history of smoking.
Two types exist, conjugate and polysaccharide, and the recommended sequence and interval depends on age and condition. Ask specifically which you need rather than assuming a single dose covers you.
People without a functioning spleen are at particular risk of overwhelming pneumococcal infection and need this vaccine along with meningococcal and Hib vaccination.
Hepatitis B
Hepatitis B is common in India and is preventable with a highly effective vaccine, yet a large proportion of adults have never been vaccinated.
Recommended for: all healthcare workers, household and sexual contacts of infected people, dialysis patients, people with diabetes, people with chronic liver disease, those receiving frequent blood products, and anyone previously unvaccinated who wishes to be protected.
The schedule is three doses over six months. Antibody testing after completion is advised for healthcare workers and dialysis patients to confirm response.
Hepatitis A vaccination is also worth considering for adults with chronic liver disease and for travellers to areas with poor sanitation.
Tetanus and Diphtheria
Tetanus is rightly associated with wounds, and adult boosters are widely misunderstood.
A booster is recommended every ten years, and many adults have not had one since childhood.
The Tdap version, which includes pertussis, is particularly important in pregnancy. Given between twenty seven and thirty six weeks, it transfers antibodies to the baby and protects them against whooping cough during the vulnerable first months. This is one of the most valuable and least administered adult vaccines in India.
Family members and carers of newborns should also be up to date, since adults are the usual source of whooping cough in infants.
HPV Vaccine
Best given at nine to fourteen years, before exposure, but catch up vaccination remains useful in adults.
It is recommended up to twenty six years and can be considered up to forty five after discussion, with benefit depending on prior exposure.
It prevents cervical cancer, and also several other cancers and genital warts. Boys and men benefit too, both directly and by reducing transmission.
Vaccination does not remove the need for cervical screening, since the vaccine does not cover every high risk strain. Both are needed. Our gynaecology department provides HPV vaccination and screening.
Shingles and Other Considerations
Shingles is a reactivation of the chickenpox virus, causing a painful rash and sometimes persistent nerve pain that can last months or years.
Risk rises with age and immunosuppression. Vaccination is recommended for older adults where available, and it substantially reduces both shingles and the persistent nerve pain that follows it.
Varicella vaccination is also worth considering for adults who have never had chickenpox, since chickenpox in adulthood is considerably more severe than in childhood, and particularly for women planning pregnancy.
Typhoid vaccination is worth considering given local prevalence, and for travellers.
Vaccines for Specific Situations
Some vaccines are indicated by circumstance rather than age.
- Pregnancy: influenza at any stage, and Tdap in the third trimester. Live vaccines are avoided
- Diabetes: influenza, pneumococcal and hepatitis B
- Before splenectomy: pneumococcal, meningococcal and Hib, ideally two weeks before
- Chronic liver disease: hepatitis A and B, influenza, pneumococcal
- Before immunosuppressive treatment: live vaccines must be given beforehand, as they cannot be given during
- Travel: depends on destination, with yellow fever required for some countries
- Animal bite: rabies post exposure treatment, which is urgent
The point about immunosuppression matters. Anyone about to start biologic therapy, chemotherapy or transplant medication should have their vaccination status reviewed in advance, since the window closes once treatment starts.
Practical Points
A few things make adult vaccination easier to keep track of.
- Keep a record. Adults rarely have a vaccination card, and reconstructing history is difficult
- Multiple vaccines can usually be given at the same visit in different sites
- Mild fever and arm soreness are normal and indicate an immune response
- A cold is not a reason to postpone. Moderate or severe illness with fever is
- Tell the clinician about allergies, immunosuppression, pregnancy and recent blood products
- Ask about vaccination at your annual health check, since it is rarely raised otherwise
Adding a vaccination review to the annual health check is the simplest way to ensure this does not get overlooked for another decade.
Adult vaccination is worth raising at your next appointment, particularly if you have diabetes, heart, lung, liver or kidney disease. Influenza annually, pneumococcal in the right groups, hepatitis B if unvaccinated, and Tdap in pregnancy are the ones most often missed.
Our general medicine department at T. Nagar reviews adult immunisation as part of preventive care.
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