Chapter 4

Guidelines for vaccination in normal adults in India

The immunization of an adult depends on the previous exposure should be vaccinated if not immunized in
immunization received in childhood. Unlike the Pediatric childhood. Percutaneous or mucosal exposure can
Immunization Guidelines, given by the Indian Academy occur in intravenous drug users; household contacts of
of Pediatrics and the National Immunization Programs,[1,2] persons with chronic hepatitis B virus (HBV) infection;
the guidelines for vaccination in healthy adults vary from inmates and staff of institutions for developmentally
region to region. disabled persons in long‑term care facilities; persons at
risk for occupational exposure to HBV (such as dialysis
The major guidelines are: staff, laboratory staff dealing with blood samples, blood
• The Advisory Committee on Immunization bank staff, nurses working in intensive care units,
Practices (ACIP) guidelines from Centers for Disease operation theaters, and surgeons and other doctors at
Control and Prevention[3‑5] high‑risk); patients who are human immunodeficiency
• WHO guidelines[6] virus (HIV)‑seropositive, patients with chronic liver
• Association of Physicians of India – Expert panel disease (CLD), chronic kidney disease (CKD); and
guidelines [Tables 6 and 7].[7] diseases where blood products or multiple blood
transfusions are required such as hemophilia, aplastic
Hepatitis B vaccine anemia, leukemia, hemoglobinopathies, and patients
Vaccine awaiting major surgeries. Sexual exposure is a risk factor
Hepatitis B vaccine is a recombinant vaccine. Plasma‑ derived for HBV infection in patients presenting to sexually
vaccine is not used due to risk of transmission of infections. transmitted disease clinics, homosexuals; promiscuous
heterosexuals; commercial sex workers; and sex partners
Schedule of hepatitis B surface antigen (HBsAg)‑positive persons.
Primary immunization at birth: In normal individuals, the
dose is 10 μg in children given intramuscularly at 0, 1, and Prevaccination screening in general population has not
6 months and a booster after 5 years. In adults, the dose is 20 been found to be cost‑effective in India.
µg. Booster is not needed in immunocompetent adults.[8-11]
If the vaccination schedule is interrupted after the first
Indications of hepatitis B vaccine in Indian adults dose, the second dose should be administered as soon
Adults at high risk, e.g., patients with percutaneous or as possible and the second and third doses should be
mucosal exposure to blood and patients with sexual separated by an interval of at least 8 weeks. If only the
third dose has been delayed, it should be administered
Table 6: Vaccines recommended for all healthy adults as soon as possible.
DPT
MMR
Postexposure screening is not indicated for most adults,
Influenza (>50 years)
Pneumococcal (>65 years) except in immunocompromised persons, sex partners of
Human papillomavirus (9-26 years) HBsAg‑positive persons, and health care workers at high
Zoster (>60 years) risk for continued percutaneous or mucosal exposure
DPT: Diphtheria, pertussis, and tetanus, MMR: Measles, mumps, and rubella
to blood or body fluids. When indicated, postexposure
screening should be performed 1–2 months after
Table 7: Vaccines recommended in high‑risk individuals administration of the last dose of the vaccine series. The
Hepatitis B anti‑HBs titer should be maintained above 10 mIU/ml in
Hepatitis A
all healthy adults.
Meningococcal
Varicella
HiB Nonresponders who are HBsAg and anti‑HBc‑negative
Typhoid should receive a further full course of vaccination as
Rabies
fourth, fifth, and sixth doses. Retesting should be done
Cholera and Japanese encephalitis vaccines are routinely not
indicated due to lack of adequate evidence 1–2 months after the last dose. If there is no response,
HiB: Haemophilus influenzae b 40 µg of recombinant vaccine is administered at 0, 1,

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 Chapter 4

and 6 months. Retesting should be done 1–2 months diabetes, HIV, lupus, cancer and those on chemotherapy or
after the last dose. If the person remains a nonresponder, radiotherapy, long‑term steroid, asplenia, or splenectomy.
alternative strategies for protection must be explored.
A single dose PPSV23 is recommended in immunocompetent
Booster doses of HBV vaccine are not indicated in persons adults. In those who have received primary immunization,
with normal immune status. A booster dose may be vaccination is done with PPSV23 0.5 ml single dose IM.
administered when anti‑HBs levels decline to <10 mIU ml In those who have not received primary vaccination,
and >65 years. PCV13 can be given followed by PPSV23 after a minimum
interval of 8 weeks. If PPSV23 has been given earlier PCV
Pneumococcal vaccine can be given after 1 year.
Pneumococcal vaccine is available in two forms:
• Polysaccharide vaccine consisting of polysaccharides Revaccination can be done with PPSV23 at least 5 years
from 23 serotypes. This vaccine is less immunogenic, after the first dose. Revaccination with PPSV23 within
does not affect carrier rates, promote herd immunity, 5 years leads to hyporesponsiveness. Monitoring for
or protect from respiratory tract infections as there is seroconversion is not needed.
no mucosal immunity
• Conjugated Vaccine with 13 serotypes consists In the year 2014, ACIP recommended routine use of
of capsular polysaccharides covalently bound to PCV13 among adults aged ≥ 65 years.[15] This was based
diphtheria toxoid, which is highly immunogenic on the results of the CAPiTA trial that supported the
but nontoxic. This combination results in mucosal evidence on the efficacy of PCV13 against noninvasive
immunity and lifelong immunity.[3-5,12,13] pneumococcal pneumonia among adults. [16] As per
this recommendation, both PCV13 and PPV23 should
Table 8 summarizes the key differences between be routinely administered in series to all adults
Pneumococcal Polysaccharide Vaccine (PPSV23) and aged ≥ 65 years. ACIP recommendations for use of
Pneumococcal Conjugate Vaccine (PCV13).[14] PCV13 (high risk) in adults aged ≥ 19 years with
immunocompromising conditions, functional or anatomic
PCV13 is approved in several countries worldwide, asplenia, cerebrospinal fluid leak, or cochlear implants
including the US, EU, and India, for use in adults remain unchanged.
aged >50 years for the prevention of pneumonia
and/or invasive disease caused by Streptococcus pneumonia The recommendations for usage of both the vaccines is
serotypes included in the vaccine.[14] In immunocompetent mentioned in Table 9.[14]
adults, PPSV23 is indicated in those over the age of
65. The vaccine is also indicated for those with CKD, The ACIP recommendation was amended in 2015 to
chronic obstructive pulmonary disease (COPD), cirrhosis, simplify the spacing between PCV13 and PPSV23 in

Table 8: Key differences between pneumococcal polysaccharide vaccine23 and pneumococcal conjugate
vaccine13
Vaccine Advantages Disadvantages
PPSV23 Long experience (licensed in 1983) T‑cell‑independent immune response (IgM antibody produced,
Not expensive response declines in 3-5 years and no anamnestic response at
At present, relatively high serotype coverage for IPD revaccination)
in elderly (60-70%) Decrease in memory B cell frequency after PPV23
Considerable efficacy proven against IPD (50-70%) Weak immunogenicity in some individuals
in immunocompetent elderly Unclear (null to small) efficacy against nonbacteremic
Cost‑effective proven for elderly people even if it only pneumococcal pneumonia
prevents IPD No effect on nasopharyngeal carriage
No efficacy demonstrated in reducing nasopharyngeal carriage
No impact proven in reducing overall pneumococcal disease burden
PCV13 T cell‑dependent immune response (larger duration Short experience (approved in 2011)
and boosting effect at revaccination) Expensive
High efficacy (80-90%) against vaccine type IPD At present, relatively small serotype coverage for IPD in the
proven in children elderly (30-40%)
Significant efficacy against pneumococcal Future reduction of vaccination impact in adults/elderly (because
pneumonia (CAPiTA study) of probable indirect effects from PCV13 pediatric use)
Potential efficacy in reducing nasopharyngeal carriage
Considerable impact in reducing all pneumococcal
disease burden shown by prior PCV7
PPSV: Pneumococcal polysaccharide vaccine, PCV: Pneumococcal conjugate vaccine, IPD: Invasive pneumococcal disease

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Table 9: Advisory Committee on Immunization Practice Side effects include allergic reactions, Guillain Barre
recommendations for the use of pneumococcal syndrome. High‑risk individuals (see above) should not
conjugate vaccine 13 and pneumococcal polysaccharide receive nasal spray live flu vaccine. The vaccine provides
vaccine 23 adequate protection against HINI infection. Antibody
Indications Indications monitoring is not required.
Pneumococcal One dose PCV13 followed by a dose of
vaccine‑naïve persons PPSV23
Adults aged ≥65 years PPSV23 should be given 6-12 months Meningococcal vaccine
who have not previously after PCV13 The quadrivalent vaccines contain 50 mg of each of the
received pneumococcal If PPSV23 cannot be given during this antigens A, C, Y, and W135 whereas the bivalent vaccine
vaccine or whose time window, the dose of PPSV23
previous vaccination should be given during the next visit
has only A and C antigens. Two types of quadrivalent
history is unknown The two vaccines should not be vaccines are available. The meningococcal polysaccharide
co‑administered, and the minimum vaccine (MPSV4) does not induce herd immunity, has no
acceptable interval between PCV13 and
PPSV23 is 8 weeks
effect on nasopharyngeal carriage, and can be used only in
Previous vaccination Should receive a dose of PCV13 if they those >2 years age. The meningococcal conjugate vaccine
with PPSV23 have not yet received it (MCV4) provides herd immunity, reduces nasopharyngeal
Adults aged A dose of PCV13 should be given carriage, provides long‑lasting immunity after 28 days of
≥65 years who have ≥1 year after PPSV23
previously received For those for whom an additional dose of vaccination, but cannot be used for people >55 years.
≥1 doses of PPV23 PPSV23 is indicated, it should be given These vaccines do not protect against meningococcus
6-12 months after PCV13 and ≥5 years groups B or meningitis due to other organisms. MCV4
after the most recent dose of PPSV23
PPSV: Pneumococcal polysaccharide vaccine, PCV: Pneumococcal conjugate
(conjugated) is preferred for adults who are aged 55 years
vaccine or younger as well as for adults aged 56 years or older
who (a) are vaccinated previously with MCV4 and are
adults >65 years.[17] The old ACIP recommended that recommended for revaccination, or (b) for whom multiple
PPSV23 can be given after 6–12 months after PCV13. doses are anticipated. MPSV4 is preferred for adults aged
The new recommendation states that the recommended 56 years or older who have not received MCV4 previously
interval for adults receiving PCV13 and PPV23 to be at and who require a single dose only (e.g., travelers).[20]
least 1 year apart, regardless of sequence. In summary,
this means that PCV13 is given first followed by PPSV23 Vaccination is indicated in specific situations, such as
with spacing at least 1 year. If the adult above 65 years during an outbreak. A single dose of vaccine (A + C)
received PPSV23, he will receive PCV13 after 1 year as may be given to health care workers, laboratory
the older recommendation [Tables 10 and 11]. workers, and close contacts of cases. Vaccination may
be given to personnel living in dormitories, military
Influenza vaccine recruits, jail inmates, immunocompromised individuals,
The available vaccine in India is a killed virus vaccine such as those suffering from terminal complement
to be given intramuscularly.[18,19] Other vaccines include component deficiency, splenectomy, active and passive
nasal spray vaccines (containing live attenuated virus). smokers, systemic lupus erythematosus, HIV, and
As the influenza virus constantly mutates, a new batch multiple myeloma (2 doses separated by 2 months for
is prepared every year. The vaccine becomes effective adult <55 years).
against influenza virus 2 weeks after administration.
Since the peak influenza season begins in October and For travelers, a single dose is recommended 10‑14 days
lasts till May, October–November are the best times to before the scheduled visit depending on the prevalent
receive vaccination.[18,19] serotype in the visiting country. As a national policy, the
National Institute of Communicable Diseases, New Delhi,
A single dose of inactivated flu vaccine in dose of 0.5 ml administers quadrivalent polysaccharide vaccine to the
is given intramuscularly into the deltoid muscle. Haj pilgrims to fulfill the requirements of the Government
of Saudi Arabia.
Vaccination is indicated in high‑risk subjects, e.g., those with
COPD, CKD, cardiac or lung diseases, hepatic, metabolic Rabies vaccine
diseases (diabetes), hematological diseases, pregnancy, The sheep brain‑derived nerve tissue vaccine “semple
nursing homes, health care personnel, household contacts vaccine” is no longer used. Tissue culture vaccines (TCV)
of children <5 years or adults >50 years, diseases which such as human diploid cell vaccine, purified chicken
impair respiratory functions, and immunosuppressed embryo cell vaccine (PCECV), and newer and less
individuals. expensive vero cell‑purified rabies vaccines are now

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Table 10: Immunization for all adults with normal immune status
Immunized Not immunized Vaccine Dose and route brands
DPT Universal except if 18 to 64 years 3 doses of Td Td (one 0.5 cc IM Boostrix GSK
contraindicated booster dose of Td vaccine; 2 doses are dose can Adacel –sanofi
vaccine once every administered 4 weeks be Tdap) Triple Ag SI
10 years till the age apart 3rd dose 6 to
of 65 years 12 months after the
second dose
MMR Recommended Not indicated Single dose SC Live 0.5 cc SC Tresivac‑ SI
in adults but vaccine GSK
contraindicated
in pregnancy and
immunosuppressed
states
Influenza For all, esp high risk Every year Every year Inactivated 0.5 cc IM Fluvac
Pneumococcus For all >65 years Single dose Single dose >65 years 0.5 cc IM Pneumococal
<65 years in those >65 years polysaccharide 23
at risk Protein conjugate‑13
Varicella For all who are not For those already two doses administered attenuated 2 doses 0.5 ml Varilrix (GlaxoSmithKline
immune immunized in 4 to 8 weeks apart live VZV in deltoid area Biologicals) Okavax
childhood booster (Oka strain) SC (Pasteur Mérieux)
doses are not needed in both Varibed MSD
if titres are adequate Biovac chinese
Papilloma For young adults For adults who are In age group 9‑14 years dose is 0.5 ml GSK Cervarix‑ bivalent
already immunized, 2 doses are intramuscularly MSD Guardasil ‑4
booster dose is not recommended at an valent
needed. For non interval of 6 months.
immunized, 3 doses For 15‑26 years at 0,1
given and 6 months
Zoster in>60 years >60 years single dose >60 years single dose Live 0.65 ml
attenuated subcutaneous
in deltoid

available. TCV are used for pre‑ and post‑exposure falls below 0.5 IU/ml. The duration of immunity by two
prophylaxis. They are easy to administer, highly injection vaccination course is 2–3 years.
immunogenic, and have a good margin of safety.[7]
Postexposure prophylaxis
Pre-exposure schedule A person who is exposed and has never been vaccinated
Pre-exposure schedule for rabies vaccination is 3 doses at against rabies should get five doses of rabies vaccine at
days 0, 7, and 28 and is recommended for high‑risk groups 0, 3, 7, 14, and 28 days. They should also get human
such as veterinarians, laboratory personnel working with rabies immune globulin (20 IU/kg body weight; up to a
rabies virus, medical and paramedical personnel treating maximum of 1500 IU) at the same time as the first dose.
rabies patients, dog catchers, forest staff, zookeepers, A person who has been previously vaccinated should get
postmen, policemen, courier boys, and schoolchildren 2 doses – 1 on 0 day and another on 3rd day.
in endemic countries. The human diploid cell culture
vaccine [HDCV] and purified chick embryo cell culture When needed, the rabies immunoglobulin should be
PCECV (1 ml) or purified vero cell rabies vaccine (0.5 ml) infiltrated as much as possible into and around the wounds
are administered by intramuscular route in the deltoid and the remaining should be given intramuscularly at a site
region or the anterolateral thigh. The reconstituted tissue away from the site where vaccine has been administered.
culture vaccines (0.1 ml) can be administered by the
intradermal route over the deltoid region. Management of re-exposure
On reexposure, 2 booster doses should be administered on
Antibody titers should be monitored every 6 months days 0 and 3 irrespective of category of exposure or time
in persons working with live virus in diagnostic, that has elapsed since previous vaccination. All subjects
research, and vaccine production laboratories. In other who have received incomplete vaccination should be
professions at permanent risk of exposure to rabies, such treated as fresh cases.
as veterinarians, animal handlers, and wildlife officers,
antibody titers in the serum should be monitored annually. If rabies immunoglobulin is not available, double dose
Booster dose should be administered when the titer of the first dose of vaccination may be administered

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Table 11: Vaccination in special situation in adults

Insert vaccines Risk groups Immunized Not immunized Vaccine Dose and route Brands
Hepatitis B At high risk Not indicated 0, 1, and 6 months if not Recombinant and Single dose Shanta biotech
immunized in childhood plasma‑derived
Hepatitis A At risk Single dose if 2 doses 6 months if not Inactivated and live Inactivated single
high risk immunized in childhood antigen (HAV
antigen) vaccine,
e.g., havrix (GSK)
and vaqta (merck
and co); combination
vaccine, e.g., Twinrix
(HAV + HBV)(GSK)
Meningococcal Not Single dose 2 doses <16 years Meningococcal 0.5 cc SC
recommended >16 years single dose conjugate <55 years 2
routinely (not for<2 years or doses 1 month
High risk >55 years) apart >55 1 dose
Travelers and Meningococcal
epidemic polysaccharide
HiB At risk Single dose of Single dose of HiB in Ag is polyribose 0.5 ml IM GSK
HiB in high risk high risk phosphate or outer
membrane protein
and carrier is tetanus
toxoid conjugate or
diphtheria CRM protein
Rabies Not routine as Preexposure for Pre exposure 0, 7, and HDCS 1 ml IM
prophylaxis. high risk 28 days IM PCECV 0.1 ml ID
Only for For those Postexposure 0.3, 7, 14, Verorab (not for pre 0.5 cc IM
high‑risk groups immunized and 28 days (90 days exposure)
Indiacted 0, 3rd days no optional) with RIg
postexposure immunoglobulin ID 0, 3, 7, and 28 days
over deltoid
Cholera High‑risk patients For high risk For high risk 2 oral vaccines 2 separate doses, Dukoral (WC/rBS )
Two currently 2 separate 2 separate doses, Dukoral (WC/rBS) 1 to 6 weeks Recombinant
available doses, 1 to 1–6 weeks apart for Recombinant apart B‑subunit
vaccines are not 6 weeks apart those aged over 6 years B‑subunit 2 separate doses (Vabiotech)
recommended in for those aged given 1 week
India over 6 years apart
Typhoid High‑risk If immunized Three doses of typhoid Live oral
Travelers or booster every 21a capsules/sachets typhoid 21a
outbreak 3 years are administered on vaccine‑ suspension
alternate days or capsule (not in
Series repeated once in India)
every 3 years as booster Injectable Vi
dose polysaccharide
Vi vaccine single SC/ vaccine
IM dose of 0.5 ml. Typhoid conjugate –
Revaccination every bharat biotech
3 years
Varicella Those who For those already Two doses Attenuated live 2 doses 0.5 ml in Varilrix (GSK
did not have immunized in administered 4 to VZV (Oka strain) in deltoid area SC Biologicals) Okavax
chickenpox childhood booster 8 weeks apart both (Pasteur Mérieux)
doses are not Varibed MSD
needed if titers Biovac Chinese
are adequate
Japanese Not routine Single dose and Mouse brain‑derived 0.5 ml SC
encephalitis booster dose inactivated Booster at 1 year
may be given at vaccine (NA)
1 year cell‑culture,
live‑attenuated vaccine
Polio Adults traveling Single dose of 3 doses of IPV/OPV Oral sabin Chiron ‑ old protect
to polio infected IPV spaced by 1 month IM killed salk Sanofi ‑ immumax
countries polio
Rotavirus Not routinely Live vaccine Rotarix GSK
recommended Rotatech MSD
for adult
immunization
ID: Intradermal, IM: Intramuscular, SC: Subcutaneous, GSK: GlaxoSmithKline, IPV: Inactivated polio vaccine, OPV: Oral poliomyelitis, NA: Not available,
VZV: Varicella‑zoster virus, PCECV: Purified chicken embryo cell vaccine, HDCS: Human diploid cell strains, HiB: Haemophilus influenzae b, HAV: Hepatitis A vaccine

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in the following situations: (i) category III exposure, dose. The Tdap vaccine can substitute any one of the
(ii) patients who are malnourished and patients Td doses.
receiving corticosteroids, anticancer drugs, and
antimalarials, and (iii) patients with HIV/AIDS with For adults who have not received Tdap vaccine and are likely
CD4+ count <200/mm3. If feasible, antibody titers to come in contact with infants suffering from diphtheria
should be monitored and boosters given if titer is less or pertussis, a single dose of Tdap vaccine should be given
than 0.5 IU/ml. 2 weeks before the contact with the infant if 2 years or
more have elapsed since the last dose of Td vaccination.
Immunosuppressed patients should avoid activities Health care personnel, especially those in direct contact
for which rabies preexposure prophylaxis is indicated. with the patients, who have not received Tdap vaccine
Antibody titer is checked after immunization in an should receive a single dose of Tdap vaccine if 2 years or
immunosuppressed person. Sera should be collected more have elapsed since the last dose of Td vaccination.
around day 14 of vaccine series and at the time of Women planning pregnancy should receive one dose of
completing prophylaxis. Tdap vaccine if they did not receive it previously. Pregnant
women who have received the Td vaccination more than
Human papillomavirus vaccine 10 years ago should receive one dose of Td vaccine in the
The vaccine protects against human papillomavirus (HPV) second or third trimester of pregnancy. Pregnant women
types responsible for most cervical cancers and genital who have received Td vaccination during the preceding
warts. It is most effective when administered before onset 10 years should receive one dose of Tdap in the immediate
of sexual activity.[21] postpartum period if the last dose of Td was administered
more than 2 years ago. For pregnant women who have
It can be given to young males and females between never received previous vaccination, three doses of Td
the ages of 9 and 26 years. In age group 9‑14 years, vaccine are indicated; in the second or third trimester of
2 doses are recommended at an interval of 6 months. pregnancy, two doses are administered at least 4 weeks
For >15 years, the dose is 0.5 ml intramuscularly at 0, apart, and the third dose is given 6–12 months after the
1, and 6 months. second dose. Following minor trauma in non immunized
individual or those immunized more than 10 years if
Tetanus, diphtheria, and pertussis vaccine major wound both Td/Tdap and TIG should be given; if
Full dose diphtheria, tetanus, and pertussis are used immunized >5 years and <10 years ago only Td/Tdap is
in children (DPT). Acellular pertussis vaccine (DTaP) given and TIG is not required. Modified dose vaccine is not
should be used for older children instead of whole effective post transplant and full dose is needed.
cell vaccine (DTwP) because it is associated with less
neurological complications. Two new tetanus toxoid, Precautions
reduced diphtheria toxoid and acellular pertussis Tdap/Td vaccines are contraindicated for persons with
vaccines (Tdap) are available for use in those who are a history of anaphylaxis to any component. The Tdap
more than 10 years of age.[22,23] vaccine is contraindicated in adults with a history of
encephalopathy not attributable to an identifiable cause
The vaccination schedule varies with status of primary within 7 days of administration of a vaccine with pertussis
immunization. The dose is 0.5 ml given IM preferably component; these persons should receive Td vaccine. In
in deltoid. DTaP (acellular pertussis) or DTwP (whole adults with moderate or severe acute illness and those
cell pertussis) vaccine should be used for first booster at with unstable neurologic conditions (e.g., stroke, acute
18 months while Tdap (low dose diphtheria and acellular encephalopathies), Tdap vaccination is to be deferred
pertussis) may be used for the second booster at 5 years until the acute illness resolves. In adults with a history
and 10–15 years. of Arthus reaction with the previous dose of tetanus/
diphtheria containing vaccine, Tdap/Td is administered
For adults between 18 and 64 years who have completed only after 10 years since the last dose.
their primary vaccination schedule, a booster dose of Td
vaccine is indicated once every 10 years till the age of Haemophilus influenzae
65; one dose of Tdap vaccine may be administered in The vaccine antigen is polyribose phosphate or outer
place of Td vaccine. For adults >18 years who have not membrane protein (OMP), and carrier is tetanus toxoid
received prior vaccination against diphtheria, pertussis conjugate or diphtheria CRM protein.[7]
and tetanus, three doses of Td vaccine are indicated;
two doses are administered at least 4 weeks apart, and Vaccination is a part of primary immunization. Adults at
the third dose is given 6–12 months after the second high risk such as patients with asplenia, HIV, hematological

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malignancies, corticosteroid use, CSF leak, trauma, is same as for normal population. Live oral typhoid is
diabetes, pregnancy, alcoholism, immunosuppression due contraindicated in transplant recipient.
to bone marrow or kidney transplant, cancer, radiation,
or chemotherapy should be vaccinated. Cholera
Vaccines for cholera are available as injectable killed
A single 0.5 ml dose of haemophilus influenza b (HiB) whole cell vaccine; and oral cholera vaccine. The
conjugate vaccine is administered intramuscularly.[7] injectable killed whole cell vaccine has a poor efficacy
with short‑lasting protection and is not recommended.
Hepatitis A
Vaccines against hepatitis A virus (HAV) include Among the oral cholera vaccines, Dukoral (WC/rBS) is
inactivated vaccines as single antigen (HAV antigen) approved for use in persons aged over 2 years. Dukoral
vaccines or combined with HBV antigens. is administered in three separate doses, 1–6 weeks apart
for 2–6‑year‑old children and as two separate doses,
Universal immunization for hepatitis A is not recommended. 1–6 weeks apart for those aged over 6 years. It confers
The following groups of adults are considered at high risk 85–90% protection for 6 months among all age groups
for acquiring hepatitis A: persons who use illicit drugs; which declines over 6 months to 2 years.[7]
persons who work with HAV‑infected primates or with
HAV in a laboratory; people who receive clotting factor Japanese encephalitis
concentrates; persons infected with other hepatitis The vaccines used for immunization against Japanese
viruses; persons with CLD who are not already immune encephalitis (JE) are mouse brain‑derived inactivated
to HAV; persons who have received, or are awaiting a liver vaccine and cell‑cultured, live‑attenuated vaccine.
With effect from 2007, the production of the mouse
transplant; food handlers; and men who have sex with
brain‑derived inactivated vaccine has been stopped. The
men. Hepatitis A vaccine is indicated for all transplant
live attenuated vaccine is currently in use in India. It is
candidates with CLD or those patients of end‑stage renal
administered subcutaneously as a single 0.5 ml dose, with
disease (ESRD) who have chronic hepatitis B or C because
a booster dose at 1 year.[7]
of increased risk of fulminant hepatic failure.[9,10]
The JE vaccine is primarily useful in the pediatric age. The
Typhoid vaccine
issue of adult immunization against JE in case of major
The available vaccines for typhoid fever include
outbreaks needs to be reviewed.
inactivated whole cell vaccine, live oral Ty21a vaccine,
injectable Vi polysaccharide vaccine, and Vi‑rEPA
Varicella vaccine
vaccine. The lyophilized oral Ty21a vaccine is available Two vaccines, both containing an attenuated live VZV are
in two formulations: A liquid suspension (in sachets) or currently available in India.[20]
enteric coated capsules. The Vi polysaccharide vaccine
is a subunit vaccine composed of purified Vi capsular All adults who have never had chickenpox should receive 2
polysaccharide.[7] doses 0.5 ml in deltoid area subcutaneously. For <13 years
of age, the first dose is administered at 12–15 months
Three doses of Ty21a capsules/sachets are administered and the second dose at age 4–6 years. For people older
on alternate days. This series should be repeated once in than 13 years, the two doses are administered 4–8 weeks
every 3 years as a booster dose. The capsule formulation apart. For those already immunized, booster doses are not
should be taken orally with safe water. The sachet should needed if titers are adequate. In resource‑limited countries
be given with 100 ml of safe water with buffer to protect at least the females in reproductive age group, people at
the B‑subunit against gastric acidity. The Vi vaccine is high risk for exposure to varicella, i.e., health care workers,
given as a single subcutaneous or intramuscular dose household contacts, etc., should be vaccinated.[20]
of 0.5 ml, with revaccination every 3 years. Typbar
conjugate vaccine is now recommended between 9 and Varicella vaccines should not be administered to persons
12 months. receiving HD systemic immunosuppressive therapy,
including oral corticosteroids >2 mg/kg of body weight
Entire community at risk should be vaccinated during or a total of more than 20 mg/day of prednisone or
an outbreak. If immunization of the entire community its equivalent for persons who weigh >10 kg, when
is not possible, individuals aged 2–19 years should be administered for >2 weeks; HIV‑seropositive adult
specifically targeted. Ty21a should not be used during or adolescent with CD4 + T‑lymphocytes count
pregnancy. Vaccination policy for renal disease patients <200 cells/μL; persons with a family history of

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congenital or hereditary immunodeficiency in first‑degree December, 2012.

relatives (e.g. parents, siblings). It is also contraindicated 9. Guidelines for the Management of CKD. Indian J Nephrol 2005;15
Suppl 1:S72-4.
in those with gelatin allergy, neomycin allergy, people 10. Danzinger‑Isakov L, Kumar D; AST Infectious Diseases
on radiotherapy or chemotherapy, people who have Community of Practice. Guidelines for vaccination of solid
received blood products or transfusions during past organ transplant candidates and recipients. Am J Transplant
5 months. Varicella vaccination has been shown to be 2009;9 Suppl 4:S258‑62.
11. Kidney Disease: Improving Global Outcomes (KDIGO) CKD
effective in patients with nephrotic syndrome and should Work Group. KDIGO 2012 Clinical Practice Guideline for the
be given to all patients with negative varicella titers. It is Evaluation and Management of Chronic Kidney Disease. Kidney
ideally administered when in remission or on low‑dose Inter 2013;Suppl 3:1-150.
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S14 Supplement 1 - 2016 - Volume 26 Indian Journal of Nephrology