Towards adult vaccination in India: a narrative literature review

Review of the unmet medical need for vaccination in adults with immunocompromising conditions: An Indian perspective

Immunocompromised (IC) populations are at increased risk of vaccine-preventable diseases (VPDs). In India, the concern of VPDs in IC populations is particularly acute due to the prevalence of crowded living situations, poor sanitation and variable access to healthcare services. We present a narrative review of IC-related disease and economic burden, risk of VPDs and vaccination guidelines, based on global and India-specific literature (2000-2022). IC conditions considered were cancer, diabetes mellitus, chronic kidney disease, respiratory disorders, disorders treated with immunosuppressive therapy, and human immune deficiency virus (HIV). The burden of IC populations in India is comparable to the global population, except for cancer and HIV, which have lower prevalence compared with the global average. Regional and socioeconomic inequalities exist in IC prevalence; VPDs add to the burden of IC conditions, especially in lower income strata. Adult vaccination programs could improve health and reduce the economic impact of VPDs in IC populations.

Double Jab: Survey Evidence on Vaccine Hesitancy, Beliefs, and Attitudes in India

India witnessed a large surge in COVID-19 cases in April 2021, a second wave of nearly 350,000 daily new infections across the country. As of December 2021, cases have reduced drastically, in part due to greater vaccine coverage across the country. This study reports results on vaccine hesitancy, attitudes, and behaviors from an online survey conducted between February and March 2021 in nine Indian cities (N = 518). We find that vaccine hesitancy negatively predicts willingness to take the vaccine, and beliefs about vaccine effectiveness supersede hesitancy in explaining vaccine uptake. Furthermore, we find that mask-wearing and handwashing beliefs, information sources related to COVID-19, and past COVID-19 infection and testing status are all strongly associated with the hypothetical choice of vaccine. We discuss these findings in the context of behavioral theories as well as outline implications for vaccine-related health communication in India.

Addressing Unmet Needs in Vaccination for Older Adults in the Asia Pacific: Insights from the COVID-19 Pandemic

The impact of vaccinating the older population against vaccine-preventable diseases in terms of health, social and economic benefits has been increasingly recognised. However, there is a gap in the utilisation of vaccines worldwide. The population is ageing at an unprecedented pace in the Asia-Pacific (APAC) region, with the number of persons older than 65 years set to double by 2050 to around 1.3 billion. More than 18% of the population in Japan, Hong Kong, and China is over the age of 65 years. This highlights the importance of prioritising resources to address societal obligations toward the needs of the ageing generation. This review provides an overview of the challenges to adult vaccination in APAC, drivers to increase vaccination coverage, vaccination insights gained through the COVID-19 pandemic, and potential measures to increase the uptake of adult vaccines in the region.

Disparities in Coverage of Adult Immunization among Older Adults in India

A lack of a universal adult immunization scheme in India poses a challenge to achieve universal health coverage. Healthcare disparity is one of the biggest challenges in low- and middle-income countries such as India. We aimed to estimate the disparities in coverage of various adult vaccines among older adults in India using nationally representative data. An observational analysis among 31,464 participants aged ≥60 years from the Longitudinal Ageing Study in India, 2017-2018, was conducted. Vaccination coverage across wealth quintiles and selected non-communicable diseases were reported as frequencies and weighted proportions along with their 95% confidence intervals as a measure of uncertainty. The highest coverage was of the diphtheria and tetanus vaccine (2.75%) followed by typhoid (1.84%), hepatitis B (1.82%), influenza (1.59%), and pneumococcal (0.74%). The most affluent groups had a higher coverage of all vaccines. Participants having high cholesterol, psychiatric conditions, and cancer had the highest coverage of all vaccines. Overall, a very low coverage of all vaccines was observed. The coverage was influenced by social determinants of health, depicting a disparity in accessing immunization. Hence, at-risk groups such as the deprived and multimorbid patients need to be covered under the ambit of free immunization to achieve universal health coverage.

The need for vaccination in adults with chronic (noncommunicable) diseases in India - lessons from around the world

Worldwide, chronic diseases (noncommunicable diseases [NCDs]) cause 41 million (71%) deaths annually. They are the leading cause of mortality in India, contributing to 60% of total deaths each year. Individuals with these diseases are more susceptible to vaccine-preventable diseases (VPDs) and have an increased risk of associated disease severity and complications. This poses a substantial burden on healthcare systems and economies, exemplified by the COVID-19 pandemic. Vaccines are an effective strategy to combat these challenges; however, utilization rates are inadequate. With India running one of the world’s largest COVID-19 vaccination programs, this presents an opportunity to improve vaccination coverage for all VPDs. Here we discuss the burden of VPDs in those with NCDs, the benefit of vaccinations, current challenges and possible strategies that may facilitate implementation and accessibility of vaccination programs. Effective vaccination will have a significant impact on the disease burden of both VPDs and NCDs and beyond.

What is already known on this topic?

Annually, chronic or noncommunicable diseases (NCDs) cause >40 million deaths worldwide and 60% of all deaths in India

Adults with these diseases are more susceptible to vaccine-preventable diseases (VPDs); however, vaccine utilization is inadequate in this population

What is added by this report?

We highlight the benefits of vaccination in adults with NCDs that extend beyond disease prevention

We discuss key challenges in implementing adult vaccination programs and provide practical solutions

What are the implications for public health practice?

Raising awareness about the benefits of vaccinations, particularly for those with NCDs, and providing national guidelines with recommendations from medical societies, will increase vaccine acceptance

Adequate vaccine acceptance will reduce the VPD burden in this vulnerable population

Creation, dissemination, and evaluation of videos to promote COVID-19 vaccination in India: A research protocol

Background: Vaccine hesitancy is one of the greatest challenges to the success of coronavirus disease 2019 (COVID-19) vaccination campaigns. Videos promoting vaccines have a narrow scope focusing solely on facts, and less on the emotional and narrative elements of communication that can be equally persuasive. The role of humor, for example, has remained largely unexplored.   Objective: This study investigates whether theory-based videos can change people's attitudes, beliefs, and intentions to receive the second COVID-19 vaccine. Our primary research question is: How do collectivistic and individualistic appeals, humor, and protagonist gender individually and jointly affect vaccination attitudes, beliefs, and intentions?   Methods: This project tapped into the underutilized Indian film industry-the world's largest film producer-to promote vaccination messaging through short videos. Feedback from a community advisory board was utilized to inform the video scripts that were then shot by a production team. Eight videos were filmed and shared by adopting a 2 (appeal: individualistic or collectivistic) x 2 (tone: humor or non-humor) x 2 (protagonist gender: male or female) between-subjects design approach. Our sample includes Odia-speaking participants aged between 18 - 35 years old randomly assigned to watch one of the eight study videos. An online survey questionnaire, social media network analysis, and small group qualitative interviews will be utilized to explore how the entertainment-education videos can be used to reduce vaccine hesitancy.  Discussion: Vaccine messages do not fall into a cultural or cognitive vacuum. People process and make sense of information based on their prior experience, properties of the message, and their social environment. Yet, these considerations have taken secondary importance in vaccine communications. This research shows that it is possible to deliver high-caliber videos created in accordance with the audience's cultural and cognitive background.   Conclusions: This study will inform future health promotion messaging through brief videos on the internet.

Willingness to pay for a COVID-19 vaccine for oneself and one's child among individuals attending a tertiary care centre in West Bengal, India

BACKGROUND

The free-of-cost supply could not meet the demand for coronavirus disease-2019 (COVID-19) vaccines in India, so the government approved an injection option with a price. We aimed to determine how much money an individual would be willing to pay for a COVID-19 vaccine for themselves and their children and assess the factors determining it.

METHODS

We conducted a study among all adults visiting the outpatient department of a government tertiary care hospital in West Bengal, India, in August 2021. Trained nursing officers combined bidding game and open-ended question methods during personal interviews to estimate the willingness-to-pay (WTP) values.

RESULTS

The mean (standard deviation) age of 1565 participants was 40.8 (12.2) years with 46.5% (n = 727) males, 70.4% (n = 1102) parents, 50.0% (n = 783) educated upto class 12 and 30.9% (n = 483) belonging to upper-middle socio-economic scale (SES). The median (inter-quartile range [IQR]) WTP amount for the first dose and the subsequent/booster dose among the unvaccinated (50.2%, n = 785) and vaccinated (49.8%, n = 780) participants were ₹0 (0-100) and ₹0 (0-200), respectively. The median (IQR) WTP for inoculating children with any COVID-19 vaccine was ₹50 (0-300) in both groups. Significant differences were found in the WTP prices for adult vaccines in both groups concerning age category (P = 0.02), education (P < 0.01) and SES (P < 0.01).

CONCLUSION

Although more than half of the respondents were unwilling to pay for themselves, WTP for COVID-19 vaccination was higher for their children. Policy-makers should consider income, education and age to cap the private sector vaccination price.

Vaccine hesitancy towards COVID vaccine among unvaccinated frontline health care workers working in a designated COVID care center: A cross-sectional study

Background

Frontline health care workers (FLHCW) like doctors and nurses are bound to treat COVID patients being themselves not immune to disease are at a greater risk of COVID infection than the general population. The study was started with objectives to find out the vaccine hesitancy towards the COVID vaccine and to find out the factors associated with vaccine hesitancy among FLHCW working in a designated COVID care center.

Materials and Methods

The present study was a cross-sectional study carried out for a period of 6 months from Jan 2021 to June 2021 at a designated COVID care center. FLHCWs who were part of treating COVID patients were our study participants. Among them, FLHCWs who had not received even one dose of COVID vaccine (Covishield) were included in the study. FLHCWs who had been part of the COVID vaccine trial were excluded from the study. The sample size calculated based on a previous study found to be 240. The data collected were entered into a Microsoft office excel sheet, analyzed using SPSS v 22(IBM Corp). Descriptive statistics were applied, and parametric tests were used to compare among the groups with statistically significant P value lesser than 0.05.

Results

A total of 121 (52.6%) of FLHCWs were aged more than 30 years, 118 (51.5%) were male participants, 100 (43.5%) were paramedics by occupation, 51 (22.1%) had contracted COVID infection, 202 (87.8%) had received information, education, and communication (IEC) regarding COVID vaccine. FLHCWs more than 30 years, male participants, currently not working in COVIDward, FLHCWs who had not received IEC about COVIDvaccination and paramedics had higher scores of Vaccine hesitancy, and the difference was statistically significant indicating vaccine hesitancy.

Conclusion

Vaccine hesitancy remains a persistent global threat. Awareness campaigns can be tailored to specific locales to address identified concerns regarding vaccines.

Awareness, Attitude, and Current Practices Toward Influenza Vaccination Among Physicians in India: A Multicenter, Cross-Sectional Study

Background: Although annual influenza vaccination is recommended for healthcare providers (HCPs), vaccination rate among HCPs in India is generally low. This cross-sectional survey was conducted to evaluate physicians' awareness, attitude, and current practices toward influenza vaccination in high-risk groups in India.

Methods: The survey was performed in June–July 2020, wherein consulting physicians, pulmonologists, diabetologists, obstetricians/gynecologists, or cardiologists across 14 cities completed a 39-item questionnaire consisting of 3 sections, one each on awareness, attitude, and practice patterns. Descriptive statistics were used to summarize the study results. Statistical analysis was performed for comparison of subgroups by physician specialty, city of practice (metro/non-metro), and zone of practice (north/south/east/west). Level of statistical significance was set at p < 0.05.

Results: In all, 780 physicians completed the survey. Of these, 3.97, 53.08, and 42.95% had high, medium, and low level of awareness about influenza/influenza vaccination, respectively. Statistically significant (p < 0.05) between-group differences were found by physician specialty and zone of practice. In terms of attitude toward vaccination of high-risk group subjects, only 0.9% physicians were “extremely concerned,” while the majority (92.56%) were “quite concerned” and 6.54% were a “little concerned,” with no reported significant differences between different subgroups. With regard to practice patterns, 82.82% of physicians offered influenza vaccines to their patients, 32.69% vaccinated 10–25% of patients per month, and 38.85% required and offered the vaccine to their office staff. Physicians' reasons for not prescribing influenza vaccines to patients included fear of side effects (16.54%), cost (15.64%), lack of awareness about availability (15.38%), absence of belief that it is beneficial (14.36%), history of side effects (13.46%), and patients' fear of needles (11.28%).

Conclusion: These findings suggest the need to implement educational strategies among physicians to enhance their awareness about influenza vaccination and improve their attitudes and current practices toward influenza vaccination especially in high-risk groups in India.

Mass gatherings: a review of the scope for meningococcal vaccination in the Indian context

The risk of meningococcal transmission is increased with crowding and prolonged close proximity between people. There have been numerous invasive meningococcal disease (IMD) outbreaks associated with mass gatherings and other overcrowded situations, including cramped accommodation, such as student and military housing, and refugee camps. In these conditions, IMD outbreaks predominantly affect adolescents and young adults. In this narrative review, we examine the situation in India, where the burden of IMD-related complications is significant but the reported background incidence of IMD is low. However, active surveillance for meningococcal disease is suboptimal and laboratory confirmation of meningococcal strain is near absent, especially in non-outbreak periods. IMD risk factors are prevalent, including frequent mass gatherings and overcrowding combined with a demographically young population. Since overcrowded situations are generally unavoidable, the way forward relies on preventive measures. More widespread meningococcal vaccination and strengthened disease surveillance are likely to be key to this approach.

Vaccination in Older Adults: An Underutilized Opportunity to Promote Healthy Aging in India

Over the last 50 years, the Indian population aged 50 years and above (older adults) has quadrupled and is expected to comprise 404 million people in 2036, representing 27% of the country's projected population. Consequently, the contribution of chronic disease to older adults' total burden of diseases in India is likely to escalate. Disease burden is notably amplified by immunosenescence, a deterioration of the immune system that develops with age, leading to increasing susceptibility to infectious diseases and other comorbidities. Older adults with infectious diseases have a higher incidence and likelihood of life-threatening comorbidities such as coronary artery disease, arrhythmia, stroke, myocardial infarction, hypertension, dyslipidemia, and diabetes mellitus. Therefore, immunization of older adults through vaccination might greatly reduce the burden imposed by vaccine preventable infectious diseases in this population. Here, we review evidence relevant to the disease burden among adults aged ≥ 50 years in India, and existing vaccination recommendations. Furthermore, we suggest a set of routine vaccinations for healthy older adults in India. There is a clear mandate to recognize the contributions of older adults to society and embrace strategies promoting healthy aging, which is described by the World Health Organization as the process of developing and maintaining functional ability and well-being in older age. Increasing vaccination awareness and coverage among older adults is an important step in that direction for India.

Endemicity change of hepatitis A infection necessitates vaccination in food handlers: An Indian perspective

In the last two decades, outbreaks due to the foodborne hepatitis A virus (HAV) have been frequently reported in India, with adolescents and adults primarily affected. In India, most food handlers are adolescents and young adults who might be exposed to unsatisfactory environmental conditions and poor water quality. This increases the risk of HAV infection and consequently compounds the risk of HAV transmission from food handlers to susceptible populations. Given the shift in hepatitis A endemicity from high to intermediate levels in India, implementing the vaccination of food handlers has become important as it can also contribute to the elimination of hepatitis A in India. This narrative review makes a case for hepatitis A immunization of food handlers in India considering the growing food industry, evolving food culture, and the substantial burden caused by hepatitis A outbreaks.

What is the context?

Hepatitis A disease is a common form of viral hepatitis and is transmitted through contaminated food and water or through close contact with an infected person. The virus with stands high temperature and can survive on surfaces for long periods of time.

In India, the burden of hepatitis A has shifted from children to adolescents and adults who are more culnerable to infection. They present a high risk of complications, often requiring hopitalization.

The prevention of the disease has often bee neglected, inadequate safety measures for the preparation of food (via food handlers) is a known risk factor for the transmission of hepatitis A.

What is new?

Our review highlights the relationship between food handling and hepatitis A infection among adolescents and adults in Inida.

The lack of knowledge of food safety regulations and hygiene measures among food handlers and the organizations that guide them may contribute to the spread of hepatitis A.

What is the impact?

Sanitation efforts, awareness and educational programs for food are needed to help reduce the transmission of hepatitis A virus and disease, yet these measures alone may not be sufficient.

Vaccination among high-risk populations such as food handlers can prevent hepatitis A infection and its complications as well as transmission.

Associations between private vaccine and antimicrobial consumption across Indian states, 2009-2017

Vaccines can reduce antibiotic use and, consequently, antimicrobial resistance by averting vaccine-preventable and secondary infections. We estimated the associations between private vaccine and antibiotic consumption across Indian states during 2009-2017 using monthly and annual consumption data from IQVIA and employed fixed-effects regression and the Arellano-Bond Generalized Method of Moments (GMM) model for panel data regression, which controlled for income and public sector vaccine use indicators obtained from other sources. In the annual data fixed-effects model, a 1% increase in private vaccine consumption per 1000 under-5 children was associated with a 0.22% increase in antibiotic consumption per 1000 people (P < 0.001). In the annual data GMM model, a 1% increase in private vaccine consumption per 1000 under-5 children was associated with a 0.2% increase in private antibiotic consumption (P < 0.001). In the monthly data GMM model, private vaccine consumption was negatively associated with antibiotic consumption when 32, 34, 35, and 44-47 months had elapsed after vaccine consumption, with a positive association with lags of fewer than 18 months. These results indicate vaccine-induced longer-term reductions in antibiotic use in India, similar to findings of studies from other low- and middle-income countries.

Modelling the global burden of drug-resistant tuberculosis avertable by a post-exposure vaccine

There have been notable advances in the development of vaccines against active tuberculosis (TB) disease for adults and adolescents. Using mathematical models, we seek to estimate the potential impact of a post-exposure TB vaccine, having 50% efficacy in reducing active disease, on global rifampicin-resistant (RR-) TB burden. In 30 countries that together accounted for 90% of global RR-TB incidence in 2018, a future TB vaccine could avert 10% (95% credible interval: 9.7-11%) of RR-TB cases and 7.3% (6.6-8.1%) of deaths over 2020-2035, with India, China, Indonesia, Pakistan, and the Russian Federation having the greatest contribution. This impact would increase to 14% (12-16%) and 31% (29-33%) respectively, when combined with improvements in RR-TB diagnosis and treatment relative to a scenario of no vaccine and no such improvements. A future TB vaccine could have important implications for the global control of RR-TB, especially if implemented alongside enhancements in management of drug resistance.

Adult vaccination in India: status and the way forward

In the last two decades, the childhood vaccination coverage in most low and middle-income countries including India has increased. Additional vaccines are being offered through national immunization programs as well as through private sector and the benefits of vaccination are reaching to more children than ever. This has resulted in major decrease in vaccine preventable diseases and contributed to decline in the morbidity and mortality rates. This development is expected to result in epidemiological transition (which is already happening) and mandates for policies and strategies to extend the benefit of available vaccines and vaccination beyond traditionally target age groups to include the adults, elderly and the at-risk populations. This article reviews the present status of adult vaccination in India and proposes a few approaches to move towards life course vaccination.