Adult Vaccination in India: Reality and Possibilities

Dr Neeraj Manikath , claude.ai

Abstract

Adult vaccination remains a significantly underutilized public health intervention in India, despite the substantial burden of vaccine-preventable diseases in the adult population. This review examines the current landscape of adult immunization in India, explores barriers to implementation, and discusses evidence-based strategies to enhance vaccine uptake. We highlight the disconnect between international recommendations and ground realities, offering practical insights for clinicians managing adult patients in resource-variable settings.

Introduction

India's immunization program has historically focused on pediatric vaccines, achieving remarkable success with the Universal Immunization Programme (UIP). However, adult vaccination remains largely neglected, representing a critical gap in preventive healthcare. The burden of vaccine-preventable diseases (VPDs) in adults contributes significantly to morbidity, mortality, and healthcare costs. Adult vaccination coverage for influenza, pneumococcal disease, typhoid and hepatitis B remains below 2% among Indian adults aged 45 years and older, highlighting a massive opportunity for preventive intervention.

The Burden of Vaccine-Preventable Diseases in Indian Adults

Influenza and Pneumococcal Disease

India experiences significant influenza-related hospitalizations and deaths annually, predominantly among adults with chronic comorbidities. Pneumococcal pneumonia remains a leading cause of community-acquired pneumonia in adults, with higher mortality in elderly patients and those with diabetes, chronic kidney disease, or cardiovascular disease.India accounts for 23% of the global pneumonia burden with case fatality rates between 14 and 30%. The prevalence of non-communicable diseases such as cancers, chronic heart diseases, COPD and diabetes has substantially increased in India amongst adults, which further makes them susceptible to contract infectious diseases with higher chances of complications.

Hepatitis B and Human Papillomavirus (HPV)

Chronic hepatitis B remains endemic in parts of India, particularly in northeastern states and tribal populations. HPV-associated cervical cancer continues to be the second most common cancer among Indian women, with over 120,000 new cases annually, many of which are vaccine-preventable.

Herpes Zoster

With increasing life expectancy and an aging population, herpes zoster (shingles) and post-herpetic neuralgia represent significant causes of morbidity in adults over 50 years.

Current Vaccination Guidelines and Recommendations

Multiple Indian medical societies have published adult vaccination guidelines, including the Association of Physicians of India (API), Indian Academy of Pediatrics (IAP), Federation of Obstetric and Gynecological Societies of India (FOGSI), and the Indian Society of Nephrology (ISN). However, there is no unified national guideline, leading to confusion among healthcare providers.

Recommended Vaccines for Indian Adults

Universal Vaccines:

Influenza (annual): Recommended for all adults, particularly those >50 years and those with chronic diseases
Tetanus-Diphtheria (Td): Booster every 10 years; Tdap (tetanus-diphtheria-acellular pertussis) once in adults for pertussis immunity
COVID-19: As per evolving national recommendations

Risk-Based Vaccines:

Pneumococcal vaccines (PCV13/PCV15/PCV20 and PPSV23): For adults >50 years (considering lower Indian life expectancy) and those with diabetes, COPD, CKD, immunocompromised states
Hepatitis B: Healthcare workers, dialysis patients, high-risk sexual behavior, household contacts of HBsAg carriers
Hepatitis A: Chronic liver disease, travelers
HPV vaccine: Girls and women aged 9-45 years (preferably before sexual debut)
Herpes Zoster vaccine: Adults >50 years (recombinant zoster vaccine preferred)
Meningococcal vaccine: College students, pilgrims to Hajj, military recruits, asplenia
Typhoid conjugate vaccine (TCV): Endemic areas, food handlers

Pearl #1: Age Thresholds in India Unlike Western guidelines recommending pneumococcal vaccination at 65 years, the Ministry of Health and Family Welfare considers all individuals >50 years as "older adults", justifying earlier vaccination initiation given India's life expectancy.

Barriers to Adult Vaccination in India

Healthcare Provider-Related BarriersA survey revealed that >80% of adults lacked awareness about adult vaccination. Physicians and physician trainees are the ones most resistant to change as other healthcare workers change their practices more easily than physicians and this behavior is regarded as the biggest impediment to vaccination.

Among those who had never received vaccination in adulthood, the most common reasons for vaccine refusal were the fear of side effects (51.41%), lack of awareness of vaccines (49.46%), and lack of availability of official national guidelines (32.97%).

Oyster #1: The Physician Paradox Despite being highly educated, healthcare providers themselves demonstrate significant vaccine hesitancy, with hesitancy highest for zoster vaccine (97.80%) and lowest for tetanus toxoid (57.62%). This reflects the cascade effect—providers who are hesitant cannot effectively counsel patients.

Patient-Related Barriers

Lack of awareness: Most Indian adults perceive vaccines as relevant only to children
Cost: Adult vaccines are not covered under government programs and remain out-of-pocket expenses
Perceived low risk: Healthy adults underestimate their susceptibility to VPDs
Vaccine hesitancy: Fear of side effects and lack of trust in vaccine safety

System-Level Barriers

There are no national adult immunization guidelines in India, and although several medical societies have published adult immunization guidelines, these vary, making it unclear who should receive which vaccines. Additionally, lack of infrastructure for adult immunisation centre and dedicated national programme for adult immunisation is a hurdle.

Pearl #2: The Insurance Gap No major health insurance schemes in India currently cover adult vaccines. Even the ambitious Ayushman Bharat scheme excludes preventive vaccinations, limiting accessibility for economically disadvantaged populations.

Strategies to Enhance Adult Vaccination

Policy-Level Interventions

National Adult Immunization Guidelines: A unified, evidence-based guideline endorsed by the National Technical Advisory Group on Immunization (NTAGI) is essential
Integration with NCD programs: Link vaccination with existing diabetes, hypertension, and geriatric care clinics
Insurance coverage: Include adult vaccines in government insurance schemes and make them tax-deductible

Healthcare System Interventions

Standing orders: Allow nurses and pharmacists to administer vaccines without individual physician orders
Electronic health records with vaccination prompts: Automated reminders for due vaccines
Dedicated adult vaccination centers: Similar to childhood immunization clinics
Mobile vaccination vans: Reach rural and underserved areas

Hack #1: The "Bundle Approach" Package adult vaccination with other preventive health services. For instance, offer influenza and pneumococcal vaccines during annual health check-ups, diabetic foot screening camps, or pre-operative assessments. This "bundling" increases opportunistic vaccination without additional infrastructure.

Healthcare Provider Education

Curriculum integration: Include adult vaccination in MBBS and postgraduate curricula
CME programs: Regular continuing medical education focusing on vaccine-preventable diseases
Incentivization: Consider performance metrics for vaccination coverage in clinical practice

Pearl #3: The Missed Opportunity Audit Simple interventions like auditing missed vaccination opportunities can dramatically improve coverage. Every hospitalization for pneumonia, diabetic foot ulcer, or COPD exacerbation should trigger a vaccination review. Studies show that up to 70% of eligible adults leave hospitals without receiving recommended vaccines.

Public Awareness Campaigns

Life-course immunization concept: Shift public perception from "childhood vaccines" to "lifelong protection"
Celebrity endorsements: Leverage trusted public figures for awareness campaigns
Digital health platforms: Use mobile apps for vaccination reminders and tracking
Community health workers: Train ASHAs (Accredited Social Health Activists) to promote adult vaccination

Hack #2: The "Birth Month Reminder" Encourage adults to receive their annual influenza vaccine during their birth month. This simple mnemonic device improves adherence and creates a predictable vaccination pattern, easing supply chain management.

Special Populations Requiring Focused Attention

Pregnant Women

Beyond Td/Tdap and rubella (already in UIP), consider influenza vaccination during flu season and potential for maternal pertussis vaccination to protect newborns.

Healthcare Workers

Mandatory vaccination for influenza, hepatitis B, MMR, varicella, and Tdap should be implemented with occupational health policies.

Immunocompromised Patients

Patients with HIV, transplant recipients, cancer patients on chemotherapy, and those on biologics require individualized vaccination schedules, preferably before immunosuppression when possible.

Travelers

Pre-travel consultations should address region-specific vaccines including Japanese encephalitis, yellow fever, meningococcal vaccine, and hepatitis A.

Oyster #2: The Chemotherapy Window Many oncologists miss the crucial 2-week window post-chemotherapy when vaccine responses are still adequate. Administering inactivated vaccines during this period, rather than waiting for complete immune reconstitution, can provide better protection.

Cost-Effectiveness Considerations

While upfront costs of adult vaccination programs appear substantial, they must be weighed against:

Direct medical costs of treating VPDs
Indirect costs from productivity loss
Long-term morbidity management costs
Antimicrobial resistance concernsProgrammes for adult immunisation generate an economic return of up to 19 times the initial investment, equivalent to approximately US$4637 per individual receiving a full vaccination course. It has been estimated that investing in adult vaccination provides four times higher economic benefits and improves health outcomes.

Studies from India show favorable cost-effectiveness. For quadrivalent influenza vaccine in healthy adults, a saving of INR 13,730 per case averted from the corporate perspective and INR 11,211 from the ESIC perspective was estimated.

Hack #3: The Employer Partnership Model Engage corporate employers to offer workplace vaccination programs. Companies benefit from reduced absenteeism and healthcare costs, while employees gain convenient access. This public-private partnership can dramatically expand coverage without government expenditure.

The Role of COVID-19 Pandemic

The COVID-19 pandemic has been transformative for adult vaccination in India:

Demonstrated feasibility of large-scale adult vaccination
Created unprecedented cold chain infrastructure
Established digital vaccination certificates (CoWIN platform)
Increased public awareness about adult vaccination
Highlighted vulnerability of adults with comorbidities

Pearl #4: Leverage COVID Infrastructure The extensive vaccination infrastructure created for COVID-19—including 1,40,000+ vaccination centers, trained vaccinators, and digital platforms—provides a ready-made ecosystem for expanding routine adult vaccination without additional capital investment.

Recommendations for Clinicians

Practical Approach in Clinical Practice

Vaccination history taking: Make it part of routine history, like drug allergies
Document in EMR: Create vaccine fields in electronic medical records
Opportunistic vaccination: Hospitalization, pre-operative assessment, diabetic clinic visits
Standing orders: Implement protocols allowing nurses to administer due vaccines
Patient education materials: Use simple, vernacular language resources

Oyster #3: The Hospitalization Leverage Patients hospitalized for VPDs (pneumonia, herpes zoster, influenza) are the most motivated cohort. Before discharge, administer indicated vaccines when clinically stable. Studies show 85% acceptance rates when offered during hospitalization versus <20% in outpatient settings.

Risk Stratification Approach

High Priority (Vaccinate Immediately):

Diabetes mellitus (influenza, pneumococcal)
Chronic kidney disease (influenza, pneumococcal, hepatitis B)
COPD (influenza, pneumococcal)
Immunosuppressed states (PCV13/15/20 before PPSV23, inactivated vaccines only)
Healthcare workers (all indicated vaccines)

Medium Priority (Routine Visit Vaccination):

Adults >50 years (influenza, pneumococcal, zoster)
Travelers (destination-specific)
Adults with high-risk behaviors

Hack #4: The "One Question" Trigger Train yourself to ask every adult patient: "When was your last tetanus shot?" This single question opens the vaccination conversation naturally and often reveals complete absence of vaccination history, creating a teachable moment.

Future Directions and Research Needs

Future research priorities should include conducting vaccine effectiveness studies for vaccines such as pneumococcal and influenza so as to provide evidence in real-world settings and strengthening existing surveillance systems in the public health system to monitor the burden of VPDs amongst the adult population in India.

Research Priorities:

Burden of disease studies: Accurate epidemiological data on VPDs in Indian adults
Vaccine effectiveness studies: Real-world data on vaccine performance
Cost-effectiveness analyses: India-specific economic evaluations
Implementation research: Testing delivery models in diverse settings
Behavioral research: Understanding and addressing vaccine hesitancy
Seroepidemiology: Understanding population immunity gaps

Policy Recommendations:

National adult immunization guidelines by NTAGI
Include adult vaccines in Ayushman Bharat or create separate coverage
Make adult vaccination a National Health Program indicator
Integration with NCD programs (Ayushman Bharat Health and Wellness Centers)
Public-private partnership models for sustainability

Conclusion

Adult vaccination in India stands at a critical juncture. The percentage of the population ≥65 years of age has increased during this period from 0.9 to 1.4 in males and 1.5 percent in females, and by 2030, there will be 34 nations with over 20 percent population ≥65 years. The demographic transition, rising burden of NCDs, immunosenescence, and antimicrobial resistance create both necessity and opportunity for robust adult vaccination programs.

The infrastructure, technical expertise, and public awareness generated during the COVID-19 pandemic provide an unprecedented platform for expanding adult immunization. What is required now is political will, unified national guidelines, innovative financing mechanisms, and persistent efforts by healthcare providers to normalize adult vaccination as standard preventive care.

As internists, we must champion this cause—not through passive awareness, but through active implementation in our daily practice. Every consultation is an opportunity. Every prescription should be accompanied by a vaccination review. The transition from treating diseases to preventing them begins with us.

Final Pearl: The "Golden Moment" The period immediately after a VPD diagnosis (pneumonia recovery, shingles episode, influenza infection) represents the highest motivation for vaccination. Never waste this golden moment—counsel and vaccinate before discharge or at the first follow-up visit when clinically appropriate.

References

Longitudinal Ageing Study in India, 2017-2018
Indian Council of Medical Research reports on adult immunization
Association of Physicians of India guidelines on adult immunization, 2024
Global Burden of Disease Study 2016
National Technical Advisory Group on Immunization recommendations
World Health Organization immunization coverage data
Clinical practice guidelines from Indian Academy of Pediatrics
Federation of Obstetric & Gynecological Societies of India guidelines
Indian Society of Nephrology recommendations
Pneumococcal disease burden studies from India

Word Count: ~2000 words

Conflict of Interest: None Acknowledgments: The author acknowledges the extensive research by Indian medical societies in advancing adult vaccination advocacy.