Before the COVID-19 pandemic , most people linked and associated vaccination with children only. The fact is that vaccines — ever since the first vaccine against smallpox became available in 1798 — had always been for a far wider age group, including for adults. However, soon after smallpox eradication and the launch of the Expanded Programme on Immunisation (EPI) across the world in the 1970s — and in India in 1978 — there were concerted efforts to increase vaccine use and coverage in children. Scientifically, the benefit of most vaccines are greater if administered earlier in life — infancy and childhood — a reason children are usually prioritised and vaccines recommended for every child. For the remaining age groups including adults, vaccines are recommended for specific sub-groups such as older people or those with specific health conditions.
The COVID-19 vaccines are exceptions in some sense. These are the first vaccines which have been recommended for all adults, who have been given priority over children. In fact, the jury is still out on whether, which age sub-group and when children should receive COVID-19 vaccines.
The importance of vaccines, which are considered to be among the most cost-effective public health interventions, has been recognised globally. Yet, the full benefits of vaccines do not reach all children and other age groups. There are wide inequities in vaccine coverage in children by geography, gender, parent’s education and family’s socio-economic status, and other stratifiers. The coverage of most available vaccines in adults in India is sub-optimal. The COVID-19 vaccination drive is an opportunity to take stock of the status of adult immunisation and the future ahead.
Need for adult vaccination
Following the outbreaks of Japanese Encephalitis (JE) in 2005-06 — in the years that followed — India had conducted mass scale JE vaccination in the endemic districts, which included the adult age group. Then, there had been a limited use of Swine Flu vaccines for health workers during the H1N1 (2009) pandemic in 2009-10. Other than that, there has been limited focus on the systematic efforts for adult vaccination in India. The first and only national vaccine policy of India, released in 2011, had no mention of adult vaccination. The National Technical Advisory Group on Immunisation (NTAGI) in India, on a few occasions, discussed adult immunisation but stayed away from any recommendation for the general population except for the vaccination of health workers as high-risk groups, for hepatitis B vaccine, etc.
Outside the Government, professional groups such as the Association of Physicians of India and the Indian Society of Nephrology have released guidelines on adult vaccination; however, as these are voluntary and the private sector share in vaccination in India is very small, understandably, the impact remains unknown and is likely to be low.
There is very limited data on the burden of vaccine preventable diseases (VPDs) in adult age groups — in most settings including India. Lately, review of available data has pointed that the increased childhood vaccination coverage has resulted in proportionately higher cases of VPDs in the older age groups. It is known that the burden of VPDs in adults (in comparison to children) is relatively low; the larger adult population renders a greater social impact in terms of absenteeism from work (due to illnesses) and the associated costs of health care seeking and hospitalisation.
There is emerging scientific evidence on waning immunity and the need of booster doses in the adult age group for the vaccines administered in childhood. The vaccines which have become available in the last two decades (which adults had not received as children), have potential to be beneficial. As an example, there are more deaths due to pneumonia in adults than in children. A proportion of those illnesses, hospitalisations and deaths — in all age groups — can be prevented by increasing coverage of currently licensed vaccines which prevents pneumonia and related complications. Fortunately, these vaccines have become part of childhood vaccination programmes; however, the coverage and benefits need to be expanded to the identified high-risk adult population. The available evidence has resulted in the global stakeholders agreeing to ‘the Immunization Agenda 2030’ (https://bit.ly/3qlKnH1) which has emphasised that countries should consider extending the benefit of vaccines to all age groups.
An opportunity in hand
The COVID-19 vaccination drive has drawn our attention to the possibilities of adult vaccination, which should be used effectively.
The initiatives should be taken to educate public, health-care providers and members of professional associations about currently available vaccines for adult age groups. This can help people to make an informed choice and healthcare providers to share information with citizens. Various training programmes and graduate and postgraduate teaching curricula should be revised to have content on adult vaccination.
The current discourse should be used to plan and develop a national adult vaccination strategy and road map for India. It can be done through a few coordinated efforts.
The steps to take
First, the mandate of NTAGI needs to be expanded to adult vaccination. NTAGI may start with a review of available scientific evidence and providing recommendations on adult vaccination in India. These recommendations can be regularly revisited and revised once additional data become available. A NTAGI sub-group on adult vaccination can also be constituted to facilitate the process.
Second, the VPD surveillance system and the capacity to record, report and analyse data on the disease burden and immunisation coverage need to be strengthened. The focus has to be on analysing immunisation coverage and VPD surveillance data by age and other related stratifiers.
Third, the capacity of research and academic institutions to conduct operational research including the cost benefit analysis and to guide evidence-informed decisions needs to be boosted. Such analysis and evidence can be used by NTAGI in decision making processes.
Fourth, the process for developing and drafting a road map, possibly India’s national adult vaccination policy and strategy should be initiated. Any such policy should factor-in the learnings and lessons from the ongoing COVID-19 vaccination drive as well. In fact, policy questions in need of the answers should be identified now, and the process to generate evidence started. Otherwise, we may be at risk of asking policy questions 10 years down the line which can be answered in a few years from now.
Fifth, on a more operational level, the shortage of life-saving rabies vaccine in India in 2019 is a reminder of the risk and vulnerability in vaccine supply. To ensure vaccine security and be future ready for adult vaccination, the existing public sector vaccine manufacturing units in India should be revived and more need to be set up.
Vaccination policy for adults
The childhood vaccination programme is amongst the best performing government health programmes in India. In COVID-19 vaccination, it was the government facilities which have delivered 93%- 95% of total vaccine shots. The COVID-19 vaccination is a reminder that the benefits of already licensed vaccines are yet to reach the adult population. It is an opportunity for health policy makers in India to institutionalise mechanisms to examine the need, take policy decisions on adult vaccination and empower adult citizens to make informed choices on whether they wish to get currently available vaccines. It is time to plan for and expand the benefits of vaccines, for all age groups as part of the Universal Immunization Programme Plus in India. Drafting and developing a national adult vaccination policy and strategy for India could be one such concrete step in this direction.
Chandrakant Lahariya, a physician-epidemiologist, is a vaccines and health systems specialist. His forthcoming book is The Lighthouse of Peeragarhi: What We Need To Prevent Diseases And Protect Health
Published - November 10, 2021 12:02 am IST
