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Adult Vaccination In India: Addressing Practice Perspectives
In India, less than 2% of adults receive routine vaccinations for diseases like influenza, pneumococcal diseases, typhoid, and hepatitis B, which represent a significant public health burden. As a result, infectious and vaccine-preventable diseases (VPDs) continue to heavily affect adult health, contributing to high rates of morbidity, mortality, and health-economic burden.1
Dr. Indranil Halder, a veteran physician from Kolkata with a specialization in Pulmonary Medicine discusses the need and importance of adult vaccination in India, in an exclusive interview with Medical Dialogues.
The larger perception of Vaccines sync with their applicability in the pediatric population. Why do you think that adults too, require vaccines?
Pediatric vaccination is well-established and widely endorsed by the government of India. Public health authorities such as the World Health Organization (WHO), play a significant role in managing effective universal implementation. However, even in adults, increasing age leads to immunosenescence which becomes a significant concern, as it diminishes the immune function and heightens susceptibility to infections.
For instance, the clinical presentation of pneumonia differs significantly between a 25-year-old and a 65-year-old, with the latter suffering increased morbidity and mortality, as distinctly evidenced during the COVID-19 pandemic. Consequently, addressing these issues through targeted vaccination strategies in adults is imperative to prevent VPDs and mitigate age-related health risks.
Is the incidence of Vaccine-Preventable Diseases (VPDs) shifting to younger age groups in India?
Vaccinations were initially recommended for patients aged 65 years and above, which left patients above 50 years of age vulnerable to the sequels of complications associated with infections. However, we are now observing that respiratory diseases like influenza and pneumococcal pneumonia, are not only affecting the elderly; they are also seen in individuals in their 40s and 50s. As per the Longitudinal Ageing Study in India (LASI) study, non-communicable diseases (NCDs) often start a decade earlier, particularly between ages 45-55 than the developed countries. In fact, 26% of older adults aged 45 years and above have a single morbidity condition, while 18% have multimorbidity. This growing evidence in India suggests vaccinating the vulnerable younger age group as well.2
Why is it important to vaccinate at the age of 50 years for pneumococcal disease?
In developed nations like United States, under their national immunization program PCV13 is being administered to all children since 2010. This robust program has thus led to the development of herd immunity in adults for the 13 serotypes that are covered in PCV13. In India, PCV has been very recently added in the national immunization program, leading to incomplete population coverage and insufficient herd immunity for adults. With the pneumococcal incidence rate of 22.7% in adults between 44-60 years, it is crucial to enhance awareness and adherence to vaccination guidelines, which recommend pneumococcal vaccination, PCV13 followed by PPSV23 (1 year later) in individuals aged 50 years and above.3
Are the younger adults too at risk for pneumococcal disease?
Yes, pneumococcal vaccination is essential in India due to contemporary gaps in pediatric vaccination coverage and lack of herd immunity. Lifestyle habits such as Smoking, alcohol consumption, obesity have led to an increase in underlying medical conditions resulting in compromised immunity in younger adults. This shortfall contributes to the persistence of infections such as Chronic Obstructive Pulmonary Disease (COPD), tuberculosis, viral infections, and severe COVID-19 infections. This makes it clinically and medically justified to extend the benefit of pneumococcal vaccination to adults aged 18-50 years to prevent both non-invasive and invasive pneumococcal diseases.
What are the recommendations for pneumococcal vaccination in adults above 18 years?
Indian Consensus Guidelines on Adult Immunization is a collective initiative of Association of Physicians of India (API) along with 13 diverse medical societies including ICS (Indian Chest Society), to address a crucial aspect of Adult Immunization by bridging the existing gaps in adult vaccine understanding and implementation. The guidelines support the use of pneumococcal vaccines in adults aged 18-49 with underlying medical conditions (such as diabetes, Chronic lung, liver, kidney disease) and all adults aged 50 years and above. Pneumococcal conjugate vaccine, PCV 13 should be administered first followed by PPSV23, 1 year later (at risk conditions) or 8 weeks later (high risk conditions). (4)
Any final remarks for all healthcare stakeholders you may like to put forward?
Better awareness of the effectiveness and benefits of vaccination emphasized by clinicians to their patients is very critical. All patients having chronic diseases including respiratory, cardiac, diabetic, or malignancy should be advised for vaccination. Government and private agencies such as insurance companies need to collaborate to educate and implement action plans to mitigate the vaccine inertia among eligible adults for VPDs. Vaccination is safe and usually well-tolerated when appropriately used as per clinical guideline recommendations.
References:
1. Rizvi, Ali Abbas, and Abhishek Singh. "Vaccination coverage among older adults: a population-based study in India." Bulletin of the World Health Organization vol. 100,6 (2022): 375-384. Doi:10.2471/BLT.21.287390
2. The Longitudinal Ageing Study in India (LASI) 2020. Retrieved on 16th August 2024 from https://www.Iipsindia.Ac.In/sites/default/files/LASI_India_Report_2020_compressed.Pdf
3. Dhar, Raja et al. "Clinical practice guidelines 2019: Indian consensus-based recommendations on pneumococcal vaccination for adults." Lung India : official organ of Indian Chest Society vol. 37,Supplement (2020): S19-S29. Doi:10.4103/lungindia.Lungindia_272_20
4. Association of Physicians of India. The New Indian Consensus Guideline on Adult Immunization. 2024 Retrieved on 16 August 2024 from https://apiindia.Org/reader/immunization
The New COVID Vaccine Is Out. Why You Might Not Want To Rush To Get It
This is a KFF Health News story.
The U.S. Food and Drug Administration has approved an updated COVID-19 shot for everyone 6 months old and up, which renews a now-annual quandary for Americans: Get the shot now, with the latest COVID outbreak sweeping the country, or hold it in reserve for the winter wave?
The new vaccine should provide some protection to everyone. But many healthy people who have already been vaccinated or have immunity because they've been exposed to COVID enough times may want to wait a few months.
COVID has become commonplace. For some, it's a minor illness with few symptoms. Others are laid up with fever, cough, and fatigue for days or weeks. A much smaller group -- mostly older or chronically ill people -- suffer hospitalization or death.
MORE: Free at-home COVID testing program restarting as officials prepare for fall, winter seasonIt's important for those in high-risk groups to get vaccinated, but vaccine protection wanes after a few months. Those who run to get the new vaccine may be more likely to fall ill this winter when the next wave hits, said William Schaffner, an infectious disease professor at Vanderbilt University School of Medicine and a spokesperson for the National Foundation for Infectious Diseases.
On the other hand, by late fall the major variants may have changed, rendering the vaccine less effective, said Peter Marks, the FDA's top vaccine official, at a briefing Aug. 23. He urged everyone eligible to get immunized, noting that the risk of long covid is greater in the un- and undervaccinated.
Of course, if last year's COVID vaccine rollout is any guide, few Americans will heed his advice, even though this summer's surge has been unusually intense, with levels of the COVID virus in wastewater suggesting infections are as widespread as they were in the winter.
A pharmacist prepares to administer COVID-19 vaccine booster shots during an event hosted by the Chicago Department of Public Health at the Southwest Senior Center on Sept. 9, 2022 in Chicago.
Scott Olson/Getty Images, FILE
The Centers for Disease Control and Prevention now looks to wastewater as fewer people are reporting test results to health authorities. The wastewater data shows the epidemic is worst in Western and Southern states. In New York, for example, levels are considered "high" compared with "very high" in Georgia.
Hospitalizations and deaths due to COVID have trended up, too. But unlike infections, these rates are nowhere near those seen in winter surges, or in summers past. More than 2,000 people died of COVID in July -- a high number but a small fraction of the at least 25,700 COVID deaths in July 2020.
Partial immunity built up through vaccines and prior infections deserves credit for this relief. A new study suggests that current variants may be less virulent -- in the study, one of the recent variants did not kill mice exposed to it, unlike most earlier COVID variants.
Public health officials note that even with more cases this summer, people seem to be managing their sickness at home. "We did see a little rise in the number of cases, but it didn't have a significant impact in terms of hospitalizations and emergency room visits," said Manisha Juthani, public health commissioner of Connecticut, at a news briefing Aug. 21.
Unlike influenza or traditional cold viruses, CIVUD seems to thrive outside the cold months, when germy schoolkids, dry air, and indoor activities are thought to enable the spread of air- and saliva-borne viruses. No one is exactly sure why.
"COVID is still very transmissible, very new, and people congregate inside in air-conditioned rooms during the summer," said John Moore, a virologist and professor at Cornell University's Weill Cornell Medicine College.
Or "maybe COVID is more tolerant of humidity or other environmental conditions in the summer," said Caitlin Rivers, an epidemiologist at Johns Hopkins University.
MORE: What to know about the updated COVID vaccines coming this fallBecause viruses evolve as they infect people, the CDC has recommended updated COVID vaccines each year. Last fall's booster was designed to target the omicron variant circulating in 2023. This year, mRNA vaccines made by Moderna and Pfizer and the protein-based vaccine from Novavax -- which has yet to be approved by the FDA -- target a more recent omicron variant, JN.1.
The FDA determined that the mRNA vaccines strongly protected people from severe disease and death -- and would do so even though earlier variants of JN.1 are now being overtaken by others.
Public interest in COVID vaccines has waned, with only one in five adults getting vaccinated since last September, compared with about 80% who got the first dose. New Yorkers have been slightly above the national vaccination rate, while in Georgia only about 17% got the latest shot.
Vaccine uptake is lower in states where the majority voted for Donald Trump in 2020 and among those who have less money and education, less health care access, or less time off from work. These groups are also more likely to be hospitalized or die of the disease, according to a 2023 study in The Lancet.
While the newly formulated vaccines are better targeted at the circulating COVID variants, uninsured and underinsured Americans may have to rush if they hope to get one for free. A CDC program that provided boosters to 1.5 million people over the last year ran out of money and is ending Aug. 31.
The agency drummed up $62 million in unspent funds to pay state and local health departments to provide the new shots to those not covered by insurance. But "that may not go very far" if the vaccine costs the agency around $86 a dose, as it did last year, said Kelly Moore, CEO of Immunize.Org, which advocates for vaccination.
In this Jan. 25, 2022 file photo pre-loaded syringes of the COVID-19 vaccine are ready for use in New Orleans.
Ted Jackson/AP, FILE
People who pay out-of-pocket at pharmacies face higher prices: CVS plans to sell the updated vaccine for $201.99, said Amy Thibault, a spokesperson for the company.
"Price can be a barrier, access can be a barrier" to vaccination, said David Scales, an assistant professor of medicine at Weill Cornell Medical College.
Without an access program that provides vaccines to uninsured adults, "we'll see disparities in health outcomes and disproportionate outbreaks in the working poor, who can ill afford to take off work," Kelly Moore said.
New York state has about $1 million to fill the gaps when the CDC's program ends, said Danielle De Souza, a spokesperson for the New York State Department of Health. That will buy around 12,500 doses for uninsured and underinsured adults, she said. There are roughly one million uninsured people in the state.
CDC and FDA experts last year decided to promote annual fall vaccination against COVID and influenza along with a one-time respiratory syncytial virus shot for some groups.
It would be impractical for the vaccine-makers to change the COVID vaccine's recipe twice every year, and offering the three vaccines during one or two health care visits appears to be the best way to increase uptake of all of them, said Schaffner, who consults for the CDC's policy-setting Advisory Committee on Immunization Practices.
At its next meeting, in October, the committee is likely to urge vulnerable people to get a second dose of the same COVID vaccine in the spring, for protection against the next summer wave, he said.
If you're in a vulnerable population and waiting to get vaccinated until closer to the holiday season, Schaffner said, it makes sense to wear a mask and avoid big crowds, and to get a test if you think you have COVID. If positive, people in these groups should seek medical attention since the antiviral pill Paxlovid might ameliorate their symptoms and keep them out of the hospital.
MORE: As students head back to class, are schools ready to handle COVID-19?As for conscientious others who feel they may be sick and don't want to spread the COVID virus, the best advice is to get a single test and, if positive, try to isolate for a few days and then wear a mask for several days while avoiding crowded rooms. Repeat testing after a positive result is pointless, since viral particles in the nose may remain for days without signifying a risk of infecting others, Schaffner said.
The Health and Human Services Department is making four free COVID tests available to anyone who requests them starting in late September through covidtest.Gov, said Dawn O'Connell, assistant secretary for preparedness and response, at the Aug. 23 briefing.
The government is focusing its fall vaccine advocacy campaign, which it's calling "Risk less, live more," on older people and nursing home residents, said HHS spokesperson Jeff Nesbit.
Not everyone may really need a fall COVID booster, but "it's not wrong to give people options," John Moore said. "The 20-year-old athlete is less at risk than the 70-year-old overweight dude. It's as simple as that."
KFF Health News correspondent Amy Maxmen contributed to this report.
FDA OK's New COVID Vaccine Shots For Fall 2024 From Pfizer And Moderna
The Food and Drug Administration announced Thursday it has greenlighted updated COVID-19 vaccines from Pfizer and Moderna for the 2024 fall season. The decision clears the way for distribution to begin for the latest version of the shots earlier this year than last year.
Moderna and Pfizer's shots were revised this year to target the KP.2 variant of SARS-CoV-2, the virus that causes COVID-19, as part of a now-annual process undertaken by the FDA and health authorities around the world to update the vaccines to protect against newer strains of the virus.
"Given waning immunity of the population from previous exposure to the virus and from prior vaccination, we strongly encourage those who are eligible to consider receiving an updated COVID-19 vaccine to provide better protection against currently circulating variants," said Dr. Peter Marks, Director of the FDA's Center for Biologics Evaluation and Research.
Similar to previous seasons, the Centers for Disease Control and Prevention is recommending that all Americans ages 6 months and older get a shot of the "updated 2024-2025 COVID-19 vaccine" to protect against another expected surge of the virus this fall and winter.
In a presentation to the American Medical Association earlier this month, CDC Director Dr. Mandy Cohen recommended starting to administer COVID-19 shots this year as soon they are available.
"Then the administration should continue through September, October, November, those are the months you really want to be paying attention to," she said.
Both Moderna and Pfizer say they expect the first shots from their vaccines to become available in the coming days around the country. Another updated vaccine from Novavax is also expected to get the FDA's authorization this year.
Packages of new COVID-19 vaccines from Pfizer and Moderna for fall 2024. Pfizer / Moderna "FDA has committed to moving swiftly on regulatory authorization. We expect to have authorization in time for peak vaccination season," Novavax said in a statement.
Why are updated COVID-19 vaccines rolling out now?Since this past winter, health authorities have been working to accelerate this year's rollout of COVID-19 vaccines.
Last year's late-September rollout of the shots led to a number of fumbles that likely depressed vaccination rates, CDC officials said in February, like confusing messaging and struggles for patients to access the shots.
Instead, COVID-19 vaccines this year will become available around the same time that deliveries of flu shots are arriving in clinics. That is the result of an earlier CDC vote to recommend the shots over the summer and an earlier FDA selection of the strain to be targeted by the shots, moving it closer to the annual process to update the seasonal flu vaccine.
For most people, the CDC recommends getting a flu shot in September or October each year, which can be given at the same time as the COVID-19 vaccines.
"If you have someone in front of you, and the option is, this is my chance to give them vaccines, co-administration is a best practice. So we encourage it," the CDC's Dr. Demetre Daskalakis said at the AMA event.
Health officials have long acknowledged that the rollout of this year's new COVID-19 vaccines would likely arrive too late for many Americans infected by this summer's wave of the virus.
"It's very difficult to try to time COVID vaccine before an oncoming surge. And so I think what we're left with is trying to time it with the respiratory virus season, and think about uptake at the same time as folks are getting their flu vaccines," the CDC's Dr. Ruth Link-Gelles told a panel of the FDA's advisers in June.
Why do the shots target the KP.2 variant?The new shots from Moderna and Pfizer target the KP.2 variant, which is a descendant of the JN.1 strain that drove part of last winter's surge of infections.
This decision to target KP.2 is different from what the World Health Organization and some other countries had recommended, calling for shots aimed at the JN.1 variant.
Pfizer and Moderna presented early data on shots targeted at KP.2 as well as JN.1 to a panel of the FDA's outside vaccine advisers in June, as the companies prepared to ramp up production.
While the FDA's advisers called for the agency to target JN.1, the agency cited the "recent rise in" cases to reject the committee's advice and aim the shots at KP.2 instead in order to "more closely match" the latest strains.
But KP.2 has been declining as a share of infections for months. Another strain called KP.3.1.1 has rapidly grown amid this summer's wave. More than a third of cases are now from KP.3.1.1, the CDC estimates.
While the difference between the strains might have some impact on how effective the shots are this fall and winter, scientists have said the gap between these different variants is still relatively small compared to previous jumps in the virus.
"All of these viruses that are circulating currently, even though they have very different names are very, very similar to each other. So it is just a nomenclature issue, why you have these different sounding names," the CDC's Natalie Thornburg said Monday, in a call with testing labs.
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