The document provides guidelines on immunization for Indian adolescents. It discusses how immunization is important not just for infants and children, but adolescents as well. It recommends vaccines for different age groups, including Tdap, HPV, meningococcal, and annual influenza vaccines for ages 11-12. The guidelines emphasize delivering immunization services to adolescents to protect their health and future. Barriers to adolescent immunization rates are also addressed, along with ways providers can improve communication and access to help more adolescents get recommended vaccines.

1. D.G.F. Guidelines on
Immunization
for
Dr. Jyoti Agarwal
Dr. Sharda Jain …Caring hearts, healing hands
Indian Adolescents Girls

2. WELCOME TO

4. Immunization
is not just for infants
& children under five any more

5. How Quickly We Forget
• 1920s : 13,000 died yearly from diphtheria
• 1940s : 8,000 died yearly from pertussis
• 1952 : polio paralyzed 21,000
• 1963 : 3 million cases of measles and 500 died
• 1964-65 : 12.5 million cases of rubella; 20,000
infants were born with congenital rubella
• 1985: 12,000 meningitis cases from H.
influenza type B

6. Vaccines are 85-100% effective in
preventing diseases
Biggest question ??
If vaccines prevent hundreds of thousands of
diseases and thousands of death yearly, then
why aren’t all children /adolescents/Adults are
immunized ?

7. Why Target Adolescent ??
• Adolescent are an important group of any
country and their health care is of utmost
importance. Somehow. This group is totally
neglected.
• There are 225 million adolescents that include
12% in the 10 – 14 years and
10% in the 15 -19 age group (census 2001]

8. Why Target Adolescent ??
• Immune protection provided by childhood vaccinations may
not cover adolescent period
• This may happen because the effect of vaccination
wanes off
• May be the initial vaccination in childhood was not given or
was given in inadequate doses
• Underlying chronic diseases in adolescents or certain high
risk groups also demand vaccination for their protection

9. The youth of INDIA is Nation’s
FUTURE
• Physical, psychological changes occurring at this time and our social
scenario prevents adolescents to access a health care facility on their own
• Ministry of Health recognize the impact of the growing number of teenage
pregnancy contributing to high MMR, IMR and LBW babies
• There is also concern about the high incidence of HIV and STDs and nutritional
deficiencies: specially anemia in adolescent girls (70% )
• Hence, delivery of services related to Adolescent reproductive and Sexual Health
(ARSH) is a priority and has been included in the RCH II program
• It is for us as gynecologists, paediatricians, teachers and parents to see
that they are cared for and vaccinated from dreaded diseases.

10. United States in the only country
with well updated yearly program
for adolescents
…Caring hearts, healing hands

11. Recommended Adolescent
Vaccines
…Caring hearts, healing hands

12. CDC Guidelines 2016
Advisory Committee on Immunization Practices
by
• Centers for Disease Control and Prevention (CDC),
• American academy of Pediatrics (AAP),
• American Academy of Family Physicians (AAFS), &
• American College of Obstetricians and Gynecologists
(ACOG)
released the 2016 recommended childhood and
adolescent immunization schedule

13. CDC Vaccination Schedule for
Adolescents

14. USA

15. Recommended Adolescent
Immunizations in INDIA
11-12 Years
Tdap
HPV
Meningococcal
(MCV4)
Annual influenza
High Risk
PCV 13
PPSV 23Catch-Up
High Risk
Hepatitis
BMMR
Varicella
Hepatitis A

16. Four Vaccines Are
Recommended for ALL
Preteens at age 11 or 12
years
…Caring hearts, healing hands

17. Four Vaccines Are Recommended for
ALL Preteens at age 11 or 12 years
• Tetanus-Diphtheria-acellular Pertussis
vaccine (Tdap)
• Meningococcal conjugate vaccine
(MCV4)
• Human papilloma virus vaccine (HPV)
• Influenza (flu) vaccine
…Caring hearts, healing hands

18. Indian Academy of Pediatrics ( IAP )
recommended vaccination for adolescents
Recommended Vaccination Schedule (2016)
Vaccine
Tadp/Td
Schedule
10 years
9 to 14 years
15 years & olderor immunocompromiesd
• Adolescent & preadolescent girls of 9 -10 years of age only 2 doses
needed
• Either of the two vaccines can be given with minimum interval
between doses to be 6 months
• Females 15 years or older or immunocompromised adolescents,
three doses at 0, 1 or 2 and 6 months to be given

19. Why do Adolescents need
Pertussis Vaccine?
• Pertussis is endemic
• Outbreaks are still occurring
• Adolescents are responsible for spread of pertussis in the
community
• Immunity to pertussis may last 3-10 years
• Both humoral and cellular immunity wanes
• Vaccination of adolescents prevents spread of disease and
increases herd immunity
• so adolescents need Tdap as a booster hence
• Tdap
– Developed to address outbreaks of pertussis

20. Tdap Recommendations for
Adolescents
• Tdap is preferred over Td, followed by
repeat Td every 10 years
• Tdap to be used only once

21. TdapRecommendations for
Adolescents
• Tdap should be administered regardless of interval
since the last tetanus or diphtheria toxoid-
containing vaccine
• Tdap vaccine can be administered at the same time
as other adolescent vaccines
• Adverse reactions:
– Fainting
– Pain, redness, swelling at the injection site
– Fever, chills
– Headache, tiredness, nausea

22. HPV vaccination
…Caring hearts, healing hands

23. HPV vaccination
• Human papilloma virus infection is the most
common sexually transmitted infection
• It is transmitted early in adolescence when
sexual activity begins
• It is associated with anogenital and
oropharyngeal cancers
• High risk subtypes of HPV are responsible for
these type of cancers

24. HPV vaccination
• Two vaccines HPV 4 (Gardasil ) and HPV 2 (Cervarix )
are licensed & available in India
• Bivalent vaccine is against HPV types 16 and 18
• Quadrivalent vaccine against HPV 6, 11 , 16 & 18
& protects against warts also
• Both vaccines are safe and efficacious against
precancerous lesions due to types 16 and 18
• It is generally agreed that HPV vaccines should be
administrated to adolescents before they start to
engage in sexual activity as antibodies produced are
highest between the ages of 9-15 years

25. Routine HPV Immunization
• Minimum Age: 9 years.
• Either HPV4 at 0, 2, 6 months or HPV2 at 0, 1, 6
months is recommended in a 3-dose series
• HPV4 can also be given to boys aged 11 or 12
years, but not yet licensed for use in males in
India.
• For adolescent and preadolescent girls aged 9 –
14 years only 2 doses of either of the two HPV
vaccines is recommended with minimum
interval of 6 months between the two doses

26. WHO
Two Vaccine are only
needed
0 & 6 if given
Between 9- 14 years

27. Catch – up HPV immunization
Administer the vaccine series to
females either HPV2 or HPV4 at
any age till 45 years if not
previously vaccinated
…Caring hearts, healing hands

28. HPV Vaccination after 14 years
• HPV vaccines administered in 3 doses
• Use the same brand of HPV vaccine for the
entire series
• Vaccine can still be given, even if
– History of genital warts
– History of abnormal Pap test result
– Patient is immunocompromised
…Caring hearts, healing hands

29. 9vHPV
The most recent recommendation in the USA
considers that adolescents of both sexes should
be vaccinated at the age of 11-12 years by
Bivalent or Quadrivalent vaccine or
Nanovalent vaccine.
In Australia too both sexes Adolescents are
given HPV vaccine
In Europe and many countries including India,
HPV vaccine is only recommended for girls.

30. IAP Recommendation for
Catch Up Immunization
for adolescent
…Caring hearts, healing hands

31. Catch-Up Vaccines
• All adolescents should be screened to make
sure they have had
– MMR (2 doses): 4 weeks apart
– Varicella (2 doses):
• Age > 13: 4 weeks apart, Age < 13: 12 weeks apart
– Hepatitis B (3 doses): 0, 1-2 months, 6 months
– Hepatitis A (2 doses): 6 months apart
– Typhoid
…Caring hearts, healing hands

32. IAP Recommendation for Catch Up
Immunization for adolescent
Vaccine Schedule
MMR 2 doses at 4 - 8 weeks interval I@
HepatitisB # 3 doses at 0, 1 and 6 months
Hepatitis A 2 doses at 0,6 months (prior check for
## anti – HAV IgG may be cost
effective)
Typhoid 1 dose every 3 years**
Varicella 2 doses at 4 – 8 weeks interval
@ one dose if previously vaccinated with one dose
#, ## Combination of hepatitis B and A may be use in 0, 1, 6 schedule
**A minimum interval of 3 years should be observed between 2 doses of
typhoid vaccine

33. Measles Mumps & Rubella (MMR)
• It should be ensured that all school - aged children
and adolescent should have had 2 doses of MMR
vaccine
• Minimum interval between 2 doses should be 4
weeks
• Only One dose should be given if previously
vaccinated with one dose
• ‘Stand Alone’ measles/measles containing
vaccine can be given to infants aged 6 through 8
months during outbreaks. However, this dose should
not be counted.

34. IAP Recommendations
for adolescent
Immunization in Special
Circumstances
…Caring hearts, healing hands

35. IAP Recommendations for adolescent
Immunization in Special Circumstances
Vaccine Age recommended
Influenza One dose every year
Japanese encephalitis vaccine Catch up to 15 years @
PPSV23 (Pneumococcal)
vaccine
2 doses 5 years apart*
Rabies vaccine 0, 3, 7, 14, 28
day
As soon as possible after
exposure
@ Only in endemic area as catch up;
* Maximum number of doses - Two

36. Pneumococcal Vaccines
Two types available
• Pneumococcal conjugate vaccine [PCV]
• Pneumococcal polysaccharide vaccine [PPSV ]
A single dose of PCV may be administered to children
aged 6 through 18 years in high risk group
…Caring hearts, healing hands

37. Pneumococcal Vaccine
• If not received previously: PCV13 and PPSV23 (2 doses
five years apart) for adolescents with:
– Cerebrospinal fluid leak / cochlear implants
– Sickle cell disease / other hemoglobinopathies
– Anatomic or functional asplenia
– Immunodeficiencies / malignancies / transplant
– Immunosuppressive drugs or radiation treatment
– HIV
– Chronic renal failure / nephrotic syndrome
• Give PCV13 first and the PPSV23, eight weeks later
• Give PCV13 first and MCV4 four weeks later (NOT
simultaneously)
• Adverse reactions: pain, swelling, redness

38. Pneumococcal (PPSV23) Vaccine
PPSV23 single dose only for adolescents with
– Chronic heart disease
– Chronic lung disease (including asthma treated with high-dose
steroids)
– Diabetes
– Alcoholism
– Chronic liver disease
…Caring hearts, healing hands

39. Meningococcal conjugate vaccine
(MCV4)
• Two doses of MCV4 are recommended for
adolescents aged 11 to 18 years
– First dose at age 11 - 12 years
– Booster dose at 16 years
• Adolescents who receive their first dose at
or after 16 years of age do not need a
booster dose
…Caring hearts, healing hands

40. Meningococcal conjugate
vaccine
• Adverse Reactions
– Fainting
– Pain, redness, swelling at the injection site
• 2 doses for adolescents at risk:
– HIV
– Asplenia
– Complement component deficiency
Should be given to unprotected children who travel to
countries in the African meningitis belt or the Hajj
…Caring hearts, healing hands

41. What about Influenza (flu)
Vaccine?
• Flu can be serious, even for healthy
adolescents
• Adolescents with high-risk conditions more
likely to suffer flu complications
• Flu seasons are unpredictable and can be
severe
…Caring hearts, healing hands

42. Influenza Vaccine
Recommendations
• Adolescents should receive a single dose of
influenza vaccine every year
• Two types of flu vaccine available
 Injection: Trivalent Inactivated Influenza Vaccine (TIV)
 Intranasal: Live, Attenuated Influenza Vaccine (LAIV)
• Be aware of vaccine precautions and contraindications
An egg-free vaccine is also now available
…Caring hearts, healing hands

43. TAKE HOME MESSAGES …..
• All 11 - 12 year should receive a single dose of Tdap vaccine
if they have completed the recommended childhood
DTP/DTaP vaccination series and have not received Tdap
• All 11 - 12 year should receive a single dose of
meningococcal vaccine, booster dose at age of 16 years
• All girls 09 - 1 4years old should get 2 doses of either HPV
vaccine 6 months apart to protect against genital warts and
anal cancer
• All adolescent should receive a single dose of influenza
vaccine every year

44. RECOMMENDED IMMUNIZATIONS
BIRTH TO AGE 18

45. Improving Immunization Rates
in Adolescents:
What Should We Do ?
…Caring hearts, healing hands

46. Barriers to Adolescent
Immunization
Parent barriers
– Low health literacy
– Not understanding vaccine
safety and efficacy
– Cost / lack of insurance
coverage
– Avoidance of multiple
vaccines
Doctors barriers
– Provider knowledge and
attitude
– Lack of standing orders
– Not stocking all vaccines or
problems with storage
– Cost, time, and
reimbursement
Supply of vaccine

47. Improving Immunization
RatesTake advantage of all opportunities
Routine visits
Sports physicals
Health problems
Nurse visits
86% of children 6-17 years and 76% of adolescents and
young adults age 18-24 years reported at least one visit to a
doctor’s office, emergency department, or home visit in last
1 year
Provider recommendation is strongest predictor of vaccination
…Caring hearts, healing hands

48. Improving Immunization Rates
Improve communication
– Take time to listen
– Solicit and welcome questions
– Keep the conversation going
• 84 % of parents indicated that a doctor was their main
source of information about vaccines
Education regarding vaccination is more important
than education regarding the disease

49. Improving Immunization Rates
• Use multiple injections
– There is no evidence that giving multiple immunizations:
A. Decreases the efficacy
B. Imposes any increased risk of complications
• Recall / Reminder systems and registries
• Community activism
• Make it more difficult for parents to refuse
immunizations
…Caring hearts, healing hands

50. Adopt a Process
1. Assess immunization history at every visit
2. Check the recommended immunization
schedule
3. Screen for contraindications and precautions
4. Educate the patient and the parent(s)
5. Administer all vaccines
6. Document administration of vaccines
7. Inform parent and patient when next vaccines
are due

51. Physicians Can Change
Minds
Journal of Pediatrics, October 2008

52. LEGENDS NEVER DIE………
When meditating over a disease,
I never think of finding a remedy for it,
but, instead, a means of preventing it.
Louis Pasteur
(1822-1895)

53. Stay Up to Date
• Visit accurate websites:
– CDC www.cdc.gov/vaccines
– American Academy of Pediatrics
www.aap.org and www.2.aap.org/immunization
– American Academy of Family Physicians www.aafp.org
– Immunization Action Coalition www.immunize.org
– Vaccine Safety www.cdc.gov/vaccinesafety
…Caring hearts, healing hands

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