should be administered as close to the schedule intervals as possible :

- Currently, the manufacturers do not recommend any booster dose following

completion of the primary series.
- Catch-up vaccination can be advised up to the age of 26 years for Gardasil
vaccine (quadrivalent vaccine) and 45 years for Cervarix vaccine (bivalent vaccine)
- HPV vaccination of males for prevention of cervical cancer is not recommended at
this time.Vaccination strategies that achieve high coverage(>70%) in the primary
target population of young adolescent girls are expected to be more costeffective in
reducing cervical cancer than including vaccination of males.

INFLUENZA
Influenza caused by Influenza A and Influenza B are the most common illness
experienced by otherwise healthy adults and children and causes significant
morbidity. Ramamurty N et al have reported a monthly incidence of respiratory
infections to be 23% in urban areas and 17.7% in rural areas in Chennai among the
peadiatric age group. Although the rates of infection are highest among children,
risks for complications, hospitalizations and deaths from influenza are higher among
persons aged over 65 years, young children and persons of any age who have co-
morbid medical conditions that place them at increased risk for complications from
influenza.

Recommendations
In the absence of epidemiological surveillance regarding the influenza serotypes in
our country, presently the use of influenza vaccine in India is not recommended.
However, in response to the current influenza (H1N1) pandemic, the WHO strategic
advisory group of experts (SAGE) have recommended the use of H1N1 influenza
vaccine for health-care workers as a first priority to protect the essential health
infrastructure. SAGE recommends that vaccination is also particularly important for
people who are at increased risk of severe outcomes if they catch pandemic
influenza, including pregnant women and people with underlying medical conditions.
As vaccines available throughout is initially not sufficient, a step-wise approach to
vaccinate particular groups is to be
considered. The WHO is also currently assessing a trivalent vaccine effective against
the H1N1 pandemic virus, the seasonal H3N2 virus, and influenza B viruses, and a
bivalent seasonal vaccine, effective against H3N2 and influenza B viruses, which
might need to be supplemented with a separate monovalent H1N1 pandemic
vaccine. SAGE concluded that both options should remain available for vaccine
formulations in the southern hemisphere, subject to national needs. In terms of
protective efficacy, the live influenza vaccines appear to be comparable with the TIVs
(trivalent, inactivated influenza vaccines.) However, CAIV-T (cold-adapted influenza
vaccine) is licensed
only for healthy people aged 5-49 years, given reports of an increase in reactive
airway disease in vaccinees <5 years of age and insufficiently documented
protective efficacy in older people.

JAPANESE ENCEPHALITIS
Japanese encephalitis (JE) is a form of viral encephalitis spread by arthropod borne
virusbelonging to the family Flaviviridae and genus Flavivirus. It is spread by the bite
of infected culicine mosquito. In India, the disease is endemic in southern India and
cases occur sporadically throughout the year, while in north India the cases occur in
the form of epidemics during the summer and monsoon months. It is predominantly a
disease of children livingin rural areas although people residing in semi urban areas
may also be affected. The control measures for JE are two pronged, namely vector
control and prophylactic vaccination. The vaccines used for immunization against
Japanese encephalitis (JE) are (i) mous brain-derived inactivated vaccine that uses
the Nakayama strain
(e.g., BIKEN/JE-VAX) and (ii) PHK cell-cultured, liveattenuated vaccine (e.g., SA
14-14-2 vaccine). With effect from 2007, the production of the mouse brainderived
inactivated vaccine has been stopped at the Central Research Institute (CRI), Kasuli
and this vaccine is not available for use in India. The SA 14- 14-2 live attenuated
vaccine is currently in use in China, India, Korea, Sri Lanka and Nepal. It is
administered subcutaneously as a single 0.5 ml dose and a booster dose may be
given at one year.

Recommendations
The JE vaccine is primarily useful in the pediatric age group in JE endemic areas as
JE is mainly a disease of children. Currently, the JE vaccine is not recommended for
routine use in adults

MENINGOCOCCAL MENINGITIS

Meningococcal disease is an acute bacterial disease caused by Gram negative

capsular diplococcal bacteria, the meningococcus (Neisseria meningitides). At
present 13 serogroups of meningococcus are known viz. A, B, C, E, H, I, K, L, M ,X,
Y, Z, W 135. Meningococcal disease occurs worldwide as endemic infections.
Strains of serogroup B and C cause majority of infections developed countries,
where as strains of serogroup A and to a lesser extent serogroup C dominate in the
developing world. In India the disease is endemic in some states like Delhi and
sporadic cases are reported from other states such as Haryana, UP, Rajasthan,
Gujarat, West Bengal and Orissa. Meningococcal disease is potentially preventable
through vaccination and or chemoprophylaxis in special circumstances. Two types of
vaccines are in use for meningococcal meningitis (i) the polysaccharide vaccines
and (ii)
conjugate vaccines. A third type based on outer membrane protein [OMP] has not
been found to be very effective and is not widely used. Internationally marketed
meningococcal polysaccharide vaccines are either bivalent (groups A and C) or
tetravalent (groups A, C, Y and W135).

Recommendations
Routine vaccination of all adults is not recommended in view of low efficacy of
meningococcal vaccines in children below 2 years and the short-lived protection
provided by the currently available polysaccharide vaccines. Vaccination of adults
with meningococcal vaccine should be done if they meet any of the following
indications and any person seeking protection from hepatitis A virus (HAV) infection.

- Other: First-year college students living in dormitories; microbiologists

routinely exposed to isolates of Neisseria meningitidis; military recruits; and
persons who travel to or live in countries in which meningococcal disease is
 hyperendemic or epidemic (e.g., the meningitis belt of sub-Saharan Africa
during the dry season [December through June]), particularly if their contact
with local populations will be prolonged. Vaccination is required by the
government of Saudi Arabia for all travellers to Mecca during the annual Hajj.
- Medical: Adults with anatomic or functional asplenia, or persistent
complement component deficiencies.

In older children and adolescents group C disease may be prevented by a single

dose of (group C conjugate meningococcal) vaccine. Where disease in children
above two years of age is the main concern, or where resources are limited, several
years of protection may be achieved by single injection of the combined groups A
and C polysaccharide vaccine.

PNEUMOCOCCUS

Lower respiratory infections including community acquired pneumonia (CAP) are an

important cause of morbidity and mortality worldwide. A vast majority of the lower
respiratory infections are caused by viral infections. However, most cases of CAP
are of bacterial origin. Among the bacterial pathogens causing CAP, S. Pneumoniae
is the single most common organism worldwide. A study conducted by International
Clinical Epidemiology Network (INCLEN) on pneumococcal infection during 1993-97
in India showed pneumococcal pneumonia, bacteremia and meningitis were
associated with case fatality rates of 19%, 21% and 34% respectively. Moreover
nearly one third (33%) of patients with proven IPD were younger than 5 years and
about 23% were older than 50 years. Currently, a 7-valent polysaccharideprotein
conjugate vaccine (PCV-7) and an unconjugated polysaccharide vaccine covering 23
serotypes are marketed internationally. A three dose regimen before one year of age
along with a booster after one year is recommended for the 7-valent polysaccharide
protein conjugate vaccine. 23-valent vaccine is primarily designed for use in older
children and adults who are at high risk for pneumococcal disease. It is not licensed
for use in children aged <2 years.

Recommendations
More than 15 meta-analyses with conflicting results have been published so far the
efficacy of PPV in adults. Available evidence is insufficient to recommend routine use
of PPV in adults. Although PPV is efficacious in preventing invasive pneumococcal
disease among adults, routine PPV administration to adults is not likely to be
costeffective in India. Pneumococcal vaccination is recommended in patients
undergoing splenectomy (preferably at least 2 weeks prior to splenectomy) Currently
the WHO states that in resource-limited settings where there are many competing
health riorities, the evidence does not support routine immunization of the elderly
and high-risk populations with PPV.
RABIES

Rabies is an acute viral disease which causes encephalomyelitis in virtually all warm
blooded mammals including man. Rabies virus is transmitted to other animals and to
humans through close contact with their saliva (i.e. bites, scratches, licks on broken
skin and mucus membrane). Rabies occurs in all continents with the exception of
Antarctica. Estimates suggest that in India, around 20,000 human deaths occur due
to rabies annually which accounts for about 1/3rd of total global mortality (APCRI
2004). It is estimated that 17.4 million animal bites occur per year; of these many do
not seek post exposure prophylaxis. As rabies has a long incubation period, it is
possible to institute prophylactic post exposure vaccination.

Recommendations
Currently, cell culture rabies vaccines are used for rabies prophylaxis, which may be
administered by intramuscular or intradermal route. For post exposure prophylaxis,
five doses of the vaccine are administered on days 0, 3, 7, 14, and 28 in the deltoid
muscle or in the anterolateral part of the thigh. They are not to be injected in the
gluteal region. For intradermal inoculation of cell culture vaccines, Updated Thai Red
Cross Regimen is approved for use in India. In this, 0.1 ml of vaccine, irrespective of
reconstituted volume, is administered at 2 sites intradermally in the deltoid region on
days 0, 3, 7 and 28. Intradermal inoculation of cell culture vaccines not only makes
post exposure prophylaxis economical but also enables wider coverage in available
quantity of vaccines. Pre-exposure prophylaxis is recommended in high risk groups
such as veterinary personnel, medical doctors, dog catchers, postmen, wild life
wardens etc. Vaccine is given intramuscularly (1ml/0.5ml) or intra-dermally (0.1ml,
irrespective of reconstituted volume) on days 0, 7, 21 or 28.

RUBELLA

There are a number of rubella vaccines available, eitheras single antigen vaccines or
combined with either measles vaccine (MR), mumps vaccine or measles and mumps
vaccine (MMR). Most of the currently licensed vaccines are based on the live,
attenuated RA 27/3 strain of rubella virus, propagated in human diploid cells. Rubella
is a mild childhood disease. However infection during pregnancy may cause fetal
death or congenital rubella syndrome (CRS). The primary purpose of rubella
vaccination is to prevent the occurrence of congenital rubella infection including
congenital rubella syndrome (CRS), which is an important cause of deafness,
blindness and mental retardation. Women of child bearing age should consider
vaccination with rubella if not immunized during childhood. Rubella vaccination
should be avoided in pregnancy because of the theoretical, but never demonstrated,
teratogenic risk.

Recommendation
For adult immunization, two doses of the vaccine are recommended for health care
workers; in the setting of outbreaks; recent exposure to these infections; women who
could become pregnant; and college students. WHO recommends two approaches
for rubella vaccination. (a) prevention of CRS only, through immunization of
adolescent girls and/or women of childbearing age; or (b) elimination of rubella as
well as CRS through universal vaccination of infants, surveillance and assuring
immunity in women of childbearing age. The WHO also emphasizes the need for a
childhood vaccination programmes achieving and maintaining high levels of
coverage to avoid the risk of increasing the number of susceptible among adults,
including women of childbearing age, and the possibility of increased numbers of
cases of CRS. On the other hand a policy of rubella vaccination of adults is
essentially free of risks of altering rubella transmission dynamics.

VARICELLA
The currently marketed varicella vaccines are based on the so-called Oka strain of
VZV, which has been modified through sequential propagation in different cell
culture. Following a single dose of the abovementioned vaccines, seroconversion is
seen in about 95% of healthy children. From a logistic as well as an epidemiological
point of view, the optimal age for varicella vaccination is 12-24 months.

Recommendations
Varicella vaccine may be used either at an individual level to protect susceptible
adolescents and adults. But will not have a significant impact on the epidemiology of
the disease on a population basis. Varicella in persons who have received the
vaccine (break-through varicella) is substantially less severe than the disease in
unvaccinated individuals

TREATMENT

At the present time WHO does not recommend the inclusion of varicella vaccination
into the routine immunization programmes of developing countries. However,
(Varicella) vaccine may be offered in any country to individual adolescents and adults
without a history of varicella, in particular to those at increased risk of contracting or
spreading the infection. This use in adolescents and adults entails no risk of an
epidemiological shift, as childhood exposure to VZV remains unaffected.