Post on 31-Jan-2021
INDIAN PEDIATRICS 785 VOLUME 51__OCTOBER 15, 2014
Indian Academy of Pediatrics (IAP) Recommended ImmunizationSchedule for Children Aged 0 through 18 years – India, 2014 and Updateson ImmunizationVIPIN M VASHISHTHA, PANNA CHOUDHURY, AJAY KALRA, ANURADHA BOSE, NAVEEN THACKER, VIJAY N YEWALE,CP BANSAL AND PRAVIN J MEHTAIndian Academy of Pediatrics, Advisory Committee on Vaccines and Immunization Practices (ACVIP)Correspondence to: Dr Vipin M Vashishtha, Convener, IAP Advisory Committee on Vaccines and Immunization Practices, ManglaHospital and Research Center, Shakti Chowk, Bijnor, Uttar Pradesh 246 701, India. vipinipsita@gmail.com
The IAP Advisory Committee on Vaccines andImmunization Practices (ACVIP) has recentlyreviewed and revised the recommendedimmunization schedule for children aged 0through 18 years to ensure that the schedule reflectsrecommendations based on recent evidences for licensedvaccines in the country. The first annual meeting of the IAPACVIP was held on 19th and 20th April 2014 in NewDelhi. IAP ACVIP members and invited experts whoattended the meeting are listed in Annexure 1. The aim ofthe meeting was to discuss and debate recentdevelopments in the field, to revise recommendations forthe IAP Immunization Timetable for the year 2014, and toissue recommendations for available licensed vaccines inthe country. Following the meeting, a draft of revisedimmunization schedule for the year 2014 was preparedand circulated among the meeting participants to arrive ata consensus.
The detailed process behind issuing IAP recommen-dations on immunization – primarily for the pediatricians
in office practice has been described earlier [1]. Theserecommendations provide guidelines to a pediatrician onhow best to utilize available licensed vaccines in theiroffice-practice settings. The members may use their owndiscretion while using them in a given situation within theframework suggested [2]. The existing Nationalimmunization schedule and government policies are alsotaken into account while drafting recommendations.
AIMS AND OBJECTIVES
To revise IAP Immunization Timetable for the year 2014,and review and issue recommendations on the availablelicensed vaccines.
RECOMMENDATIONS FOR IAP IMMUNIZATIONTIMETABLE, 2014
The IAP ACVIP has issued recommendations for the IAPImmunization Timetable (Table I and Fig. 1) for the year2014 that includes the following major changes from lastyear:
G U I D E L I N E SG U I D E L I N E SG U I D E L I N E SG U I D E L I N E SG U I D E L I N E S
Justification: There is a need to review/revise recommendationsabout existing vaccines in light of recent developments in the fieldof vaccinology.
Process: Following an IAP ACVIP meeting on April 19 and 20,2014, a draft of revised recommendations for the year 2014 andupdates on certain vaccine formulations was prepared andcirculated among the meeting participants to arrive at aconsensus.
Objectives: To review and revise recommendations for 2014Immunization timetable for pediatricians in office practice andissue statements on certain new and existing vaccineformulations.
Recommendations: The major changes in the 2014Immunization Timetable include two doses of MMR vaccine at 9and 15 months of age, single dose recommendation foradministration of live attenuated H2 strain hepatitis A vaccine,inclusion of two new situations in ‘high-risk category of children’ incontext with ‘pre-exposure prophylaxis’ of rabies, creation of a
new slot at 9-12 months of age for typhoid conjugate vaccine forprimary immunization, and recommendation of two doses ofhuman papilloma virus vaccines with a minimum interval of 6months between doses for primary schedule of adolescent/preadolescent girls aged 9-14 years. There would not be anychange to the committee’s last year’s (2013) recommendationson pertussis vaccination and administration schedule ofmonovalent human rotavirus vaccine. There is no need ofproviding additional doses of whole-cell pertussis vaccine tochildren who have earlier completed their primary schedule withacellular pertussis vaccine-containing products. A brief update onthe new Indian Rotavirus vaccine, 116E is also provided. Thecommittee has reviewed and offered its recommendations on thecurrently available pentavalent vaccine (DTwP+Hib+Hepatitis-B)combinations in Indian market. The comments and footnotes forseveral vaccines are also updated and revised.
Keywords: Immunity, Child, Guidelines, MMR Vaccine,Vaccination.
INDIAN PEDIATRICS 786 VOLUME 51__OCTOBER 15, 2014
INDIAN ACADEMY OF PEDIATRICS IMMUNIZATION SCHEDULE, 2014
TABLE I IAP IMMUNIZATION TIMETABLE 2014I. IAP recommended vaccines for routine use
Age (completed Vaccines Commentswks/mo/y)
Birth BCG Administer these vaccines to all newborns before hospital dischargeOPV 0Hep-B 1
6 weeks DTwP 1 DTP:IPV 1 • DTaP vaccine/combinations should preferably be avoided for theHep-B 2 primary seriesHib 1 • DTaP vaccine/combinations should be preferred in certain specificRotavirus 1 circumstances/conditions onlyPCV 1 • No need of repeating/giving additional doses of whole-cell pertussis (wP) vaccine
to a child who has earlier completed their primary schedule with acellular pertussis(aP) vaccine-containing products
Polio:• All doses of IPV may be replaced with OPV if administration of the former is not
feasible• Additional doses of OPV on all supplementary immunization activities (SIAs)• Two doses of IPV instead of 3 for primary series if started at 8 weeks, and 8 weeks
interval between the doses• No child should leave the facility without polio immunization (IPV or OPV), if
indicated by the scheduleRotavirus:• 2 doses of RV1 and 3 doses of RV5• RV1 should be employed in 10 and 14 week schedule, instead of 6 and 10 week• 10 and 14 week schedule of RV1 is found to be far more immunogenic than existing
6 and 10 week schedule10 weeks DTwP 2 Rotavirus:
IPV 2 • If RV1 is chosen, the first dose should be given at 10 weeksHib 2Rotavirus 2PCV 2
14 weeks DTwP 3 Rotavirus:IPV 3 • Only 2 doses of RV1 are recommended at presentHib 3 • If RV1 is chosen, the 2nd dose should be given at 14 weeksRotavirus 3PCV 3
6 months OPV 1 Hepatitis-B:Hep-B 3 • The final (third or fourth) dose in the HepB vaccine series should be administered
no earlier than age 24 weeks and at least 16 weeks after the first dose9 months OPV 2 MMR:
MMR-1 • Measles-containing vaccine ideally should not be administered before completing270 days or 9 months of life
• The 2nd dose must follow in 2nd year of life• No need to give stand-alone measles vaccineTyphoid:
9-12 months Typhoid • Currently, two typhoid conjugate vaccines, Typbar-TCV and PedaTyph available inConjugate Vaccine Indian market
• PedaTyph is not yet approved; the recommendation is applicable to Typbar-TCV only• An interval of at least 4 weeks with the MMR vaccine should be maintained while
administering this vaccine• Should follow a booster at 2 years of age
INDIAN PEDIATRICS 787 VOLUME 51__OCTOBER 15, 2014
INDIAN ACADEMY OF PEDIATRICS IMMUNIZATION SCHEDULE, 2014
12 months Hep-A 1 Hepatitis A:• Single dose for live attenuated H2-strain Hep-A vaccine• Two doses for all killed Hep-A vaccines are recommended now
15 months MMR 2 MMR:Varicella 1 • The 2nd dose must follow in 2nd year of lifePCV booster • However, it can be given at anytime 4-8 weeks after the 1st dose during 2nd year
Varicella:• The risk of breakthrough varicella is lower if given 15 months onwards
16 to 18 months DTwP B1/DTaP B1 • The first booster (4th dose) may be administered as early as age 12 months, provided atIPV B1, Hib B1 least 6 months have elapsed since the third dose.
DTP:• First and second boosters should preferably be of DTwP• Considering a higher reactogenicity of DTwP, DTaP can be considered for the boosters
18 months Hep-A 2 • 2nd dose for killed vaccines; only single dose for live attenuated H2- strain vaccine2 years Typhoid booster • Either Typbar-TCV® or Vi-polysaccharide (Vi-PS) can be employed as booster;
• Typhoid revaccination every 3 years, if Vi-polysaccharide vaccine is used• Need of revaccination following a booster of Typbar-TCV® not yet determined
4 to 6 years DTwP B2/DTaP B2 Varicella:OPV 3 Varicella 2 • 2nd dose can be given at anytime 3 months after the 1st doseTyphoid booster
10 to 12 years Tdap/Td Tdap:HPV • Tdap is preferred to Td followed by Td every 10 years
HPV:• Only 2 doses of either of the two HPV vaccines for adolescent/pre-adolescent girls aged
9-14 years• For girls 15 years and older, and immunocompromised individuals 3 doses are
recommended• For two-dose schedule, the minimum interval between doses should be 6 months.• For 3 dose schedule, the doses can be administered at 0, 1-2 (depending on brands)
and 6 months
A. Measles and MMR vaccination
Recommendation: The committee has revised itsrecommendations on Measles and MMR vaccinationschedule. The new schedule will have a dose of MMR at 9months instead of measles, and another dose (2nd) at 15months of age. The earlier recommendation of 2nd dose ofMMR at 4-6 years of age has been removed.
The need and justification: NTAGI Standing TechnicalSub-Committee (STSC) recommended two doses ofMeasles – Rubella (MR) vaccines in the Universalimmunization program (UIP) at 9 months and 16-24months at the time of 1st booster of DTP vaccine. Since theAcademy has argued very strongly in favor of MMRinstead of MR vaccine in UIP schedule, the revisedrecommendations will facilitate inclusion of Mumps
II. IAP recommended vaccines for High-risk* children (Vaccines under special circumstances)
1-Influenza Vaccine2-Meningococcal Vaccine3-Japanese Encephalitis Vaccine4-Cholera Vaccine5-Rabies Vaccine6-Yellow Fever Vaccine7-Pneumococcal Polysaccharide vaccine (PPSV 23)
* High-risk category of children: Congenital or acquired immunodeficiency (including HIV infection); Chronic cardiac, pulmonary(including asthma if treated with prolonged high-dose oral corticosteroids), hematologic, renal (including nephrotic syndrome) andliver disease; Children on long term steroids, salicylates, immunosuppressive or radiation therapy; Diabetes mellitus, Cerebrospinalfluid leak, Cochlear implant, Malignancies; Children with functional/ anatomic asplenia/ hyposplenia; During disease outbreaks;Laboratory personnel and healthcare workers; Travelers; Children having pets in home; Children perceived with higher threat of beingbitten by dogs such as hostellers, risk of stray dog menace while going outdoor.
INDIAN PEDIATRICS 788 VOLUME 51__OCTOBER 15, 2014
INDIAN ACADEMY OF PEDIATRICS IMMUNIZATION SCHEDULE, 2014
vaccine in the National immunization program in nearfuture. Furthermore, it will be more in sync with theupcoming UIP schedule. The detailed reasons arediscussed in another recent position paper from IAPpublication [3].
The evidence: There are many studies both from India andfrom other countries demonstrating efficacy and safety ofMMR vaccine given at 9 month of age [3-8].
B. Live attenuated Hepatitis A vaccine
Recommendation: The committee has revised itsrecommendations on administration schedule of liveattenuated hepatitis A vaccine, based on the viral H2 strain(Chinese vaccine). Now a single dose of this vaccine isrecommended at 12 months of age over-riding theprevious recommendation [9] of two doses of the samevaccine.
The justification and evidence: The committee reviewedboth published [11,12] and unpublished long term follow-up data on immunogenicity and safety of a single dose ofthis vaccine from trials in India. The data showed 79.3% of121 children were seroprotected (anti-HAV titers >20mIU/mL) up to 6 years follow-up in the pivotal singlecenter study, whereas 97.3% of 111 children had shownseroprotection after 5 years of follow-up period in themulti-centric group. In the multi-centric study [12], the testsubjects maintained good GMT levels even after 5 years offollow-up. The committee had earlier shown its concernon waning of seroprotection in a subgroup of individualsof original single-center study cohort [2]. However, it waslater disclosed that only ten subjects had shown thisphenomenon, and most of these subjects were ofcomparatively higher age groups than other study subjects.The decision was also facilitated by the SAGE/WHOrecommendations of single dose of live attenuatedhepatitis A vaccine [10].
C. Rotavirus Vaccines
Monovalent rotavirus vaccine, RV1
The committee reviewed new data on administrationschedule of RV1 (Rotarix) from Pakistan [13] and Ghana[14]. In both studies, the seroconversion and GMTs werehigher at delayed (10 and 14 weeks) than early (6 and 10weeks) schedule, though not statistically significant [13,14]. In Ghana study, the seroconversion and GMTs weresignificantly higher in 3-dose (6, 10 and 14 week) schedulethan 2-dose early (6 and 10 week) schedule [14]. As thesestudies are yet unpublished, full methodology and resultsare not available for scrutiny. The available results do notwarrant any change in the existing schedule of RV1vaccine that includes the first dose at 10 weeks of ageinstead of 6 weeks in order to achieve better immune
response, and the second dose at 14 weeks to fit withexisting National immunization schedule [9].
Indian rotavirus vaccine, 116 E
This vaccine developed by Bharat Biotech (Rotavac) is alive, naturally attenuated vaccine containing monovalent,bovine human reassortant strain characterized as G9 P[11], with the VP4 of bovine rotavirus origin, and all othersegments of human rotavirus origin. The vaccine strainwas isolated from asymptomatic infants with mild diarrheaby Indian researchers in 1985 at AIIMS, New Delhi.Follow up of these infants indicated that they wereprotected against severe rotavirus diarrhea for up to 2years. This strain was sent for vaccine development to theNational Institute of Health by Department ofBiotechnology, India, and later transferred to BharatBiotech International Limited in 2001 for furtherdevelopment.
In a phase II study, both low (104 ffu) and high (105ffu) dosages of 116E were found safe in infants between 8and 20 weeks of age. IgA immunogenicity rates for the 105ffu dosage were 64.7% after 1 dose, and 89.7% after 3doses. The vaccine virus was shed in about 20% of infants[15].
A randomized, double-blind, placebo-controlledphase III clinical trial [16] amongst 6,799 infants wasconducted at three sites in India. The first year efficacyagainst severe rotavirus diarrhea was 53·6% (95% CI35·0-66·9; P=0·001) with protection continuing into thesecond year of life also. The vaccine also showed 20%efficacy against all-cause severe diarrhea admission. Sixcases of intussusceptions (all occurring afteradministration of 3rd dose) were recorded in the vaccineesand two in the control group. This vaccine has alreadybeen licensed in India and would soon be available for usein Indian market.
The committee reviewed the evidence and opined it tobe a moderately effective vaccine against rotavirusdiarrhea in India. As this is the only vaccine that hasundergone large scale field- efficacy trial in India, the levelof evidence regarding its efficacy is rated higher by thecommittee. However, the committee stresses the need ofhaving large scale studies, particularly post-marketingsurveillance to monitor occurrence of acuteintussusception amongst vaccinated children. There seemsto be one excess case of intussusception for every 2000children vaccinated. Apparently, the sample size was notadequately powered to look for statistical significance[16]. Regarding use of the vaccine in office-practice, it isnot clear whether pediatricians would be able to use it incoming months since information about formulation andcommercial availability of the vaccine is not yet available.
INDIAN PEDIATRICS 789 VOLUME 51__OCTOBER 15, 2014
INDIAN ACADEMY OF PEDIATRICS IMMUNIZATION SCHEDULE, 2014
FIG
. 1 IA
P Re
com
men
ded
imm
uniz
atio
n sc
hedu
le fo
r chi
ldre
n ag
ed 0
-18
year
s (w
ith ra
nge)
, 201
4.
Ran
ge o
f rec
omm
ende
d ag
es fo
r all
child
ren
Ran
ge o
f rec
omm
ende
d ag
es fo
r cer
tain
hig
h-ris
k gr
oups
Ran
ge o
f rec
omm
ende
d ag
es fo
r cat
ch-u
p im
mun
izat
ion
Not
rout
inel
y re
com
men
ded
•Th
is sc
hedu
le in
clud
es re
com
men
datio
ns in
effe
ct as
of S
epte
mbe
r 201
4.•
Thes
e rec
omm
enda
tions
mus
t be r
ead
with
the f
ootn
otes
that
follo
w. F
or th
ose w
ho fa
ll be
hind
or s
tart
late
, pro
vide
catc
h-up
vac
cina
tion
at th
e ear
liest
opp
ortu
nity
as in
dica
ted
by th
e gre
en b
ars i
n Fi
g. 1
INDIAN PEDIATRICS 790 VOLUME 51__OCTOBER 15, 2014
INDIAN ACADEMY OF PEDIATRICS IMMUNIZATION SCHEDULE, 2014
Foot
note
s: R
ecom
men
ded
Imm
uniz
atio
n Sc
hedu
le fo
r Per
sons
Age
d 0
thro
ugh
18 Y
ears
— IA
P, 2
014
I. G
ener
al in
stru
ctio
ns:
•Va
ccin
atio
n at
bi
rth
mea
ns
as
early
as
poss
ible
with
in 2
4 to
72
hour
s af
ter
birth
or
at le
ast n
ot la
ter t
han
one
wee
k af
ter b
irth
•W
hene
ver m
ultip
le v
acci
natio
ns a
re t
o be
give
n si
mul
tane
ousl
y, th
ey s
houl
d be
giv
enw
ithin
24
ho
urs
if si
mul
tane
ous
adm
inis
tratio
n is
not
fea
sibl
e du
e to
som
ere
ason
s•
The
reco
mm
ende
d ag
e in
wee
ks/m
onth
s/ye
ars
mea
n co
mpl
eted
wee
ks/m
onth
s/ye
ars
•A
ny
dose
no
t ad
min
iste
red
at
the
reco
mm
ende
d ag
e sh
ould
be
adm
inis
tere
dat
a s
ubse
quen
t vi
sit,
whe
n in
dica
ted
and
feas
ible
.•
The
use
of a
com
bina
tion
vacc
ine
gene
rally
is p
refe
rred
ove
r se
para
te i
njec
tions
of
itseq
uiva
lent
com
pone
nt v
acci
nes
•W
hen
two
or m
ore
live
pare
nter
al/in
trana
sal
vacc
ines
are
not
adm
inis
tere
d on
the
sam
eda
y, th
ey s
houl
d be
giv
en a
t lea
st 2
8 da
ys (4
wee
ks) a
part;
this
rule
doe
s no
t app
ly to
live
oral
vac
cine
s•
Any
inte
rval
can
be
kept
bet
wee
n liv
e an
din
activ
ated
vac
cine
s.•
If gi
ven
5 da
ys b
efor
em
inim
um p
erio
d it
is c
ount
ed a
s in
valid
dose
.•
Any
num
ber o
f ant
igen
s ca
n be
giv
en o
n th
esa
me
day
•C
hang
ing
need
les
betw
een
draw
ing
vacc
ine
into
the
syrin
ge a
nd in
ject
ing
it in
to th
e ch
ildis
not
nec
essa
ry.
•D
iffer
ent
vacc
ines
sho
uld
not
be m
ixed
in
the
sam
e sy
ringe
un
less
sp
ecifi
cally
licen
sed
and
labe
led
for s
uch
use.
•P
atie
nts
shou
ld b
e ob
serv
ed fo
r an
alle
rgic
reac
tion
for 1
5 to
20
min
utes
afte
r rec
eivi
ngim
mun
izat
ion(
s).
•W
hen
nece
ssar
y, 2
vac
cine
s ca
n be
giv
en in
the
sam
e lim
b at
a s
ingl
e vi
sit.
•Th
e an
tero
late
ral a
spec
t of t
he th
igh
is th
epr
efer
red
site
fo
r 2
sim
ulta
neou
s IM
inje
ctio
ns b
ecau
se o
f its
gre
ater
mus
cle
mas
s.•
The
dist
ance
sep
arat
ing
the
2 in
ject
ions
isar
bitra
ry b
ut s
houl
d be
at l
east
1 in
ch s
o th
atlo
cal r
eact
ions
are
unl
ikel
y to
ove
rlap
•A
lthou
gh
mos
t ex
perts
re
com
men
d“a
spira
tion”
by
gent
ly p
ullin
g ba
ck o
n th
esy
ringe
bef
ore
the
inje
ctio
n is
giv
en,
ther
ear
e no
dat
a to
doc
umen
t th
e ne
cess
ity f
orth
is
proc
edur
e.
If bl
ood
appe
ars
afte
rne
gativ
e pr
essu
re,
the
need
le s
houl
d be
with
draw
n an
d an
othe
r si
te
shou
ld
bese
lect
ed u
sing
a n
ew n
eedl
e.•
A p
revi
ous
imm
uniz
atio
n w
ith a
dos
e th
at w
asle
ss
than
th
e st
anda
rd
dose
or
on
ead
min
iste
red
by a
non
-sta
ndar
d ro
ute
shou
ldno
t be
coun
ted,
and
the
pers
on s
houl
d be
re-
imm
uniz
ed a
s ap
prop
riate
for a
ge.
II. S
peci
fic in
stru
ctio
ns:
1. B
CG
Vac
cine
Rou
tine
vacc
inat
ion:
•S
houl
d be
giv
en a
t birt
h or
at f
irst c
onta
ctC
atch
up
vacc
inat
ion:
may
be
give
n up
to
5ye
ars
2. H
epat
itis
B (H
epB
) vac
cine
Rou
tine
vacc
inat
ion:
•M
inim
um a
ge: b
irth
•A
dmin
iste
r m
onov
alen
t Hep
B v
acci
ne to
all
new
born
s w
ithin
48
hour
s of
birt
h.•
Mon
oval
ent
Hep
B v
acci
ne s
houl
d be
use
dfo
r dos
es a
dmin
iste
red
befo
re a
ge 6
wee
ks.
•A
dmin
istra
tion
of a
tota
l of 4
dos
es o
f Hep
Bva
ccin
e is
per
mis
sibl
e w
hen
a co
mbi
natio
nva
ccin
e co
ntai
ning
Hep
B i
s ad
min
iste
red
afte
r the
birt
h do
se.
•In
fant
s w
ho d
id n
ot r
ecei
ve a
birt
h do
sesh
ould
re
ceiv
e 3
dose
s of
a
Hep
Bco
ntai
ning
va
ccin
e st
artin
g as
so
on
asfe
asib
le.
•Th
e id
eal m
inim
um in
terv
al b
etw
een
dose
1an
d do
se 2
is 4
wee
ks, a
nd b
etw
een
dose
2an
d 3
is 8
wee
ks. I
deal
ly, th
e fin
al (3
rd o
r 4th)
dose
in th
e H
epB
vac
cine
ser
ies
shou
ld b
ead
min
iste
red
no e
arlie
r th
an a
ge 2
4 w
eeks
and
at le
ast
16 w
eeks
afte
r th
e fir
st d
ose,
whi
chev
er is
late
r.•
Hep
B v
acci
ne m
ay a
lso
be g
iven
in a
ny o
fth
e fo
llow
ing
sche
dule
s: B
irth,
1,
& 6
mo,
Birt
h, 6
and
14
wee
ks; 6
, 10
and
14 w
eeks
;B
irth,
6 ,1
0 an
d 1
4 w
eeks
, etc
. All
sche
dule
sar
e pr
otec
tive.
Cat
ch-u
p va
ccin
atio
n:•
Adm
inis
ter
the
3-do
se s
erie
s to
tho
se n
ot
prev
ious
ly v
acci
nate
d.•
In c
atch
up
vacc
inat
ion
use
0, 1
, an
d 6
mon
ths
sche
dule
.3.
Pol
iovi
rus
vac
cine
sR
outin
e va
ccin
atio
n:•
Birt
h do
se o
f OP
V u
sual
ly d
oes
not l
ead
toVA
PP.
•O
PV
in
plac
e of
IP
V, i
f IP
V i
s un
feas
ible
,m
inim
um 3
dos
es.
•A
dditi
onal
dos
es o
f OP
V o
n al
l SIA
s.•
IPV:
Min
imum
age
- 6
wee
ks.
•IP
V: 2
inst
ead
of 3
dos
es c
an b
e al
so u
sed
ifpr
imar
y se
ries
star
ted
at 8
wee
ks a
nd t
hein
terv
al b
etw
een
the
dose
s is
kep
t 8 w
eeks
•N
o ch
ild s
houl
d le
ave
your
fac
ility
with
out
polio
im
mun
izat
ion
(IPV
or
O
PV
), if
indi
cate
d by
the
sche
dule
!!C
atch
-up
vacc
inat
ion:
•IP
V c
atch
-up
sche
dule
: 2 d
oses
at 2
mon
ths
apar
t fol
low
ed b
y a
boos
ter a
fter 6
mon
ths
ofpr
evio
us d
ose.
4.D
ipht
heria
an
d te
tanu
s to
xoid
s an
dpe
rtus
sis
(DTP
) vac
cine
.R
outin
e va
ccin
atio
n:•
Min
imum
age
: 6 w
eeks
•Th
e fir
st
boos
ter
(4thth
do
se)
may
be
adm
inis
tere
d as
ear
ly a
s ag
e 12
mon
ths,
prov
ided
at
leas
t 6
mon
ths
have
ela
psed
sinc
e th
e th
ird d
ose.
•D
TaP
vacc
ine/
com
bina
tions
sh
ould
pref
erab
ly b
e av
oide
d fo
r the
prim
ary
serie
s.•
DTa
P m
ay b
e pr
efer
red
to D
TwP
in c
hild
ren
with
his
tory
of s
ever
e ad
vers
e ef
fect
s af
ter
prev
ious
dos
e/s
of D
TwP
or
child
ren
with
neur
olog
ic d
isor
ders
.•
Firs
t an
d se
cond
boo
ster
s m
ay a
lso
be o
fD
TwP.
H
owev
er,
cons
ider
ing
a hi
gher
reac
toge
nici
ty, D
TaP
can
be
cons
ider
ed fo
rth
e bo
oste
rs.
•If
any
‘ace
llula
r per
tuss
is’ c
onta
inin
g va
ccin
eis
use
d, i
t m
ust
at l
east
hav
e 3
or m
ore
com
pone
nts
in th
e pr
oduc
t.•
No
need
of
re
peat
ing/
givi
ng
addi
tiona
ldo
ses
of w
hole
-cel
l per
tuss
is (
wP
) va
ccin
eto
a c
hild
who
has
ear
lier
com
plet
ed t
heir
prim
ary
sche
dule
with
ace
llula
r pe
rtuss
is(a
P) v
acci
ne-c
onta
inin
g pr
oduc
tsC
atch
-up
vacc
inat
ion:
•C
atch
-up
sche
dule
: The
2nd
chi
ldho
odbo
oste
r is
not r
equi
red
if th
e la
st d
ose
has
been
give
n be
yond
the
age
of 4
yea
rs•
Cat
ch u
p be
low
7 y
ears
: DTw
P/D
TaP
at 0
, 1an
d 6
mon
ths;
•C
atch
up
abov
e 7
year
s: T
dap,
Td,
and
Td
at0,
1 a
nd 6
mon
ths.
5.Te
tanu
s an
d di
phth
eria
to
xoid
s an
dac
ellu
lar p
ertu
ssis
(Tda
p) v
acci
neR
outin
e va
ccin
atio
n:•
Min
imum
ag
e:
7 ye
ars
(Ada
cel®
isap
prov
ed fo
r 11
-64
year
s by
AC
IP a
nd 4
to64
yea
r old
s by
FD
A, w
hile
Boo
strix
® fo
r 10
year
s an
d ol
der b
y A
CIP
and
4 y
ears
of a
gean
d ol
der b
y FD
A in
US
).•
Adm
inis
ter
1 do
se o
f Td
ap v
acci
ne t
o al
lad
oles
cent
s ag
ed 1
1 th
roug
h 12
yea
rs.
•Td
ap d
urin
g pr
egna
ncy:
One
dos
e of
Tda
pva
ccin
e to
pre
gnan
t m
othe
rs/a
dole
scen
tsdu
ring
each
pre
gnan
cy (p
refe
rred
dur
ing
27th
roug
h 36
wee
ks g
esta
tion)
reg
ardl
ess
ofnu
mbe
r of
yea
rs f
rom
prio
r Td
or
Tdap
vacc
inat
ion.
Cat
ch-u
p va
ccin
atio
n:•
Cat
ch u
p ab
ove
7 ye
ars:
Tda
p, T
d, T
d at
0, 1
and
6 m
onth
s.•
Per
sons
age
d 7
thro
ugh
10 y
ears
who
are
not
fully
im
mun
ized
w
ith
the
child
hood
DTw
P/D
TaP
vacc
ine
serie
s, s
houl
d re
ceiv
eTd
ap v
acci
ne a
s th
e fir
st d
ose
in th
e ca
tch-
up s
erie
s; i
f ad
ditio
nal
dose
s ar
e ne
eded
,us
e Td
va
ccin
e.
For
thes
e ch
ildre
n,
anad
oles
cent
Tda
p va
ccin
e sh
ould
no
t be
give
n.•
Per
sons
age
d 11
thro
ugh
18 y
ears
who
hav
eno
t rec
eive
d Td
ap v
acci
ne s
houl
d re
ceiv
e a
dose
fol
low
ed b
y te
tanu
s an
d di
phth
eria
toxo
ids
(Td)
boo
ster
dos
es e
very
10
year
sth
erea
fter.
•Td
ap
vacc
ine
can
be
adm
inis
tere
dre
gard
less
of
the
inte
rval
sin
ce t
he l
ast
teta
nus
and
diph
ther
ia
toxo
id–c
onta
inin
gva
ccin
e.6.
Hae
mop
hilu
s in
fluen
zae
type
b
(Hib
)co
njug
ate
vacc
ine
Rou
tine
vacc
inat
ion:
•M
inim
um a
ge: 6
wee
ks•
Prim
ary
serie
s in
clud
es
Hib
co
njug
ate
vacc
ine
at a
ges
6, 1
0, 1
4 w
eeks
with
abo
oste
r at a
ge 1
2 th
roug
h 18
mon
ths.
Cat
ch-u
p va
ccin
atio
n:•
Cat
ch-u
p is
rec
omm
ende
d til
l 5
year
s of
age.
•6-
12 m
onth
s; 2
prim
ary
dose
s 4
wee
ks a
part
and
1 bo
oste
r;•
12-1
5 m
onth
s:
1 pr
imar
y do
se
and
1bo
oste
r;•
Abo
ve 1
5 m
onth
s: s
ingl
e do
se.
INDIAN PEDIATRICS 791 VOLUME 51__OCTOBER 15, 2014
INDIAN ACADEMY OF PEDIATRICS IMMUNIZATION SCHEDULE, 2014
•If
the
first
dos
e w
as a
dmin
iste
red
at a
ge 7
thro
ugh
11 m
onth
s, a
dmin
iste
r th
e se
cond
dose
at l
east
4 w
eeks
late
r and
a fi
nal d
ose
at a
ge 1
2-18
mon
ths
at le
ast 8
wee
ks a
fter
the
seco
nd d
ose
7. P
neum
ococ
cal c
onju
gate
vac
cine
s (P
CVs
)R
outin
e va
ccin
atio
n:•
Min
imum
age
: 6 w
eeks
•B
oth
PC
V10
and
PC
V13
are
lic
ense
d fo
rch
ildre
n fro
m 6
wee
ks t
o 5
year
s of
age
(alth
ough
the
exa
ct l
abel
ing
deta
ils m
aydi
ffer
by c
ount
ry).
Add
ition
ally,
PC
V13
is
licen
sed
for t
he p
reve
ntio
n of
pne
umoc
occa
ldi
seas
es in
adu
lts >
50 y
ears
of a
ge•
Prim
ary
sche
dule
(Fo
r bo
th P
CV
10 a
ndP
CV
13):
3 p
rimar
y do
ses
at 6
, 10,
and
14
wee
ks w
ith a
boo
ster
at a
ge 1
2 th
roug
h 15
mon
ths.
Cat
ch-u
p va
ccin
atio
n:•
Adm
inis
ter 1
dos
e of
PC
V13
or P
CV
10 to
all
heal
thy
child
ren
aged
24
thro
ugh
59 m
onth
sw
ho a
re n
ot c
ompl
etel
y va
ccin
ated
for t
heir
age.
•Fo
r PC
V 13
: C
atch
up
in 6
-12
mon
ths:
2do
ses
4 w
eeks
apa
rt an
d 1
boos
ter;
12-2
3m
onth
s: 2
dos
es 8
wee
ks a
part;
24
mo
&ab
ove:
sin
gle
dose
•Fo
r PC
V10:
Cat
ch u
p in
6-1
2 m
onth
s: 2
dose
s 4
wee
ks a
part
and
1 bo
oste
r; 12
mon
ths
to 5
yea
rs: 2
dos
es 8
wee
ks a
part
•Va
ccin
atio
n of
per
sons
with
hig
h-ris
kco
nditi
ons:
oP
CV
and
pne
umoc
occa
l po
lysa
ccha
ride
vacc
ine
[PP
SV
] bo
th a
re u
sed
in c
erta
inhi
gh ri
sk g
roup
of c
hild
ren.
oFo
r chi
ldre
n ag
ed 2
4 th
roug
h 71
mon
ths
with
ce
rtain
un
derly
ing
med
ical
cond
ition
s, a
dmin
iste
r 1 d
ose
of P
CV
13 if
3 do
ses
of P
CV
wer
e re
ceiv
ed p
revi
ousl
y,or
adm
inis
ter 2
dos
es o
f PC
V13
at l
east
8w
eeks
apa
rt if
few
er th
an 3
dos
es o
f PC
Vw
ere
rece
ived
pre
viou
sly.
oA
si
ngle
do
se
of
PC
V13
m
ay
bead
min
iste
red
to p
revi
ousl
y un
vacc
inat
edch
ildre
n ag
ed 6
thr
ough
18
year
s w
hoha
ve
anat
omic
or
fu
nctio
nal
aspl
enia
(incl
udin
g si
ckle
ce
ll di
seas
e),
HIV
infe
ctio
n or
an
im
mun
ocom
prom
isin
gco
nditi
on,
coch
lear
im
plan
t or
cere
bros
pina
l flu
id le
ak.
oA
dmin
iste
r P
PS
V23
at
leas
t 8
wee
ksaf
ter
the
last
dos
e of
PC
V t
o ch
ildre
nag
ed
2 ye
ars
or
olde
r w
ith
certa
inun
derly
ing
med
ical
con
ditio
ns.
8.
Pneu
moc
occa
l po
lysa
ccha
ride
vacc
ine
(PPS
V23)
.•
Min
imum
age
: 2 y
ears
•N
ot re
com
men
ded
for r
outin
e us
e in
hea
lthy
indi
vidu
als.
R
ecom
men
ded
only
fo
r th
eva
ccin
atio
n of
per
sons
with
cer
tain
hig
h-ris
kco
nditi
ons.
•A
dmin
iste
r PP
SV
at l
east
8 w
eeks
afte
r the
last
dos
e of
PC
V to
chi
ldre
n ag
ed 2
yea
rs o
rol
der
with
ce
rtain
un
derly
ing
med
ical
cond
ition
s lik
e an
atom
ic
or
func
tiona
las
plen
ia (i
nclu
ding
sic
kle
cell
dise
ase)
, HIV
infe
ctio
n, c
ochl
ear
impl
ant o
r ce
rebr
ospi
nal
fluid
leak
.•
An
addi
tiona
l do
se o
f P
PS
V s
houl
d be
adm
inis
tere
d af
ter
5 ye
ars
to c
hild
ren
with
anat
omic
/func
tiona
l as
plen
ia
or
anim
mun
ocom
prom
isin
g co
nditi
on.
•P
PS
V
shou
ld
neve
r be
us
ed
alon
e fo
rpr
even
tion
of
pneu
moc
occa
l di
seas
esam
ongs
t hig
h–ris
k in
divi
dual
s.•
Chi
ldre
n w
ith
follo
win
g m
edic
alco
nditi
ons
for w
hich
PPS
V23
and
PCV1
3ar
e in
dica
ted
in th
e ag
e gr
oup
24 th
roug
h71
mon
ths:
oIm
mun
ocom
pete
nt c
hild
ren
with
chr
onic
hear
t di
seas
e (p
artic
ular
ly
cya-
notic
cong
enita
l he
art
dise
ase
and
card
iac
failu
re);
chro
nic
lung
dis
ease
(in
clud
ing
asth
ma
if tre
ated
w
ith
high
-dos
e or
alco
rtico
ster
oid
ther
apy)
, dia
bete
s m
ellit
us;
cere
bros
pina
l flu
id
leak
s;
or
coch
lear
impl
ant.
oC
hild
ren
with
an
atom
ic
or
func
tiona
las
plen
ia (i
nclu
ding
sic
kle
cell
dise
ase
and
othe
r he
mog
lobi
nopa
thie
s, c
onge
nita
l or
acqu
ired
aspl
enia
, or s
plen
ic d
ysfu
nctio
n);
oC
hild
ren
with
im
mun
o-co
mpr
omis
ing
cond
ition
s: H
IV i
nfec
tion,
chr
onic
ren
alfa
ilure
and
nep
hrot
ic s
yndr
ome,
dis
ease
sas
soci
ated
w
ith
treat
men
t w
ithim
mun
osup
pres
sive
dr
ugs
or
radi
atio
nth
erap
y, i
nclu
ding
mal
igna
nt n
eopl
asm
s,le
ukem
ias,
ly
mph
omas
an
d H
odgk
indi
seas
e; o
r so
lid o
rgan
tra
nspl
anta
tion,
cong
enita
l im
mun
odef
icie
ncy.
9. R
otav
irus
(RV)
vac
cine
sR
outin
e va
ccin
atio
n:•
Min
imum
ag
e:
6 w
eeks
fo
r bo
th
RV-
1[R
otar
ix] a
nd R
V-5
[Rot
aTeq
])•
Onl
y tw
o do
ses
of R
V-1
are
reco
mm
ende
dat
pre
sent
•R
V1
shou
ld p
refe
rabl
y be
em
ploy
ed i
n 10
and
14 w
eek
sche
dule
, ins
tead
of 6
and
10
wee
k; th
e fo
rmer
sch
edul
e is
foun
d to
be
far
mor
e im
mun
ogen
ic th
an th
e la
ter
•If
any
dose
in s
erie
s w
as R
V-5
or v
acci
nepr
oduc
t is
unk
now
n fo
r an
y do
se i
n th
ese
ries,
a t
otal
of
3 do
ses
of R
V v
acci
nesh
ould
be
adm
inis
tere
d.C
atch
-up
vacc
inat
ion:
•Th
e m
axim
um a
ge f
or t
he f
irst
dose
in t
hese
ries
is 1
4 w
eeks
, 6 d
ays
•Va
ccin
atio
n sh
ould
no
t be
in
itiat
ed
for
infa
nts
aged
15
wee
ks, 0
day
s or
old
er.
•Th
e m
axim
um a
ge fo
r th
e fin
al d
ose
in th
ese
ries
is 8
mon
ths,
0 d
ays.
10.
Mea
sles
, m
umps
, an
d ru
bella
(M
MR
)va
ccin
eR
outin
e va
ccin
atio
n:•
Min
imum
age
: 9
mon
ths
or 2
70 c
ompl
eted
days
.•
Adm
inis
ter t
he fi
rst d
ose
of M
MR
vac
cine
at
age
9 th
roug
h 12
mon
ths,
and
the
sec
ond
dose
at a
ge 1
5 th
roug
h 18
mon
ths.
•Th
e 2n
d do
se m
ust f
ollo
w in
2nd
yea
r of
life
.H
owev
er,
it ca
n be
giv
en a
t an
ytim
e 4-
8w
eeks
afte
r the
1st d
ose
•N
o ne
ed
to
give
st
and-
alon
e m
easl
esva
ccin
eC
atch
-up
vacc
inat
ion:
•E
nsur
e th
at a
ll sc
hool
-age
d ch
ildre
n an
dad
oles
cent
s ha
ve h
ad 2
dos
es o
f M
MR
vacc
ine;
the
min
imum
inte
rval
bet
wee
n th
e2
dose
s is
4 w
eeks
.•
One
dos
e if
prev
ious
ly v
acci
nate
d w
ith o
nedo
se•
‘Sta
nd a
lone
’ m
easl
es/m
easl
es c
onta
inin
gva
ccin
e ca
n be
adm
inis
tere
d to
infa
nts
aged
6 th
roug
h 8
mon
ths
durin
g ou
tbre
aks.
How
ever
, thi
s do
se s
houl
d no
t be
coun
ted.
11. V
aric
ella
vac
cine
Rou
tine
vacc
inat
ion:
•M
inim
um a
ge: 1
2 m
onth
s•
Adm
inis
ter
the
first
dos
e at
age
15
thro
ugh
18 m
onth
s an
d th
e se
cond
dos
e at
age
4th
roug
h 6
year
s.•
The
seco
nd
dose
m
ay
be
adm
inis
tere
dbe
fore
age
4 y
ears
, pr
ovid
ed a
t le
ast
3m
onth
s ha
ve e
laps
ed s
ince
the
first
dos
e. If
the
seco
nd d
ose
was
adm
inis
tere
d at
leas
t 4w
eeks
afte
r the
firs
t dos
e, it
can
be
acce
pted
as v
alid
.•
The
risk
of b
reak
thro
ugh
varic
ella
is lo
wer
ifgi
ven
15 m
onth
s on
war
ds.
Cat
ch-u
p va
ccin
atio
n:•
Ens
ure
that
all
pers
ons
aged
7 th
roug
h 18
year
s w
ithou
t ‘ev
iden
ce o
f im
mun
ity’ h
ave
2do
ses
of th
e va
ccin
e.•
For
child
ren
aged
12
mon
ths
thro
ugh
12ye
ars,
the
reco
mm
ende
d m
inim
um in
terv
al
betw
een
dose
s is
3 m
onth
s. H
owev
er, i
f the
seco
nd d
ose
was
adm
inis
tere
d at
lea
st 4
wee
ks a
fter t
he fi
rst d
ose,
it c
an b
e ac
cept
edas
val
id.
•Fo
r pe
rson
s ag
ed 1
3 ye
ars
and
olde
r, th
em
inim
um
inte
rval
be
twee
n do
ses
is
4w
eeks
.•
For
pers
ons
with
out
evid
ence
of
imm
unity
,ad
min
iste
r 2
dose
s if
not
prev
ious
lyva
ccin
ated
or t
he s
econ
d do
se if
onl
y 1
dose
has
been
adm
inis
tere
d.•
‘Evi
denc
e of
imm
unity
’ to
varic
ella
incl
udes
any
of th
e fo
llow
ing:
•do
cum
enta
tion
of
age-
appr
opria
teva
ccin
atio
n w
ith a
var
icel
la v
acci
ne•
labo
rato
ry
evid
ence
of
im
mun
ity
orla
bora
tory
con
firm
atio
n of
dis
ease
•di
agno
sis
or
verif
icat
ion
of
a hi
stor
y of
varic
ella
dis
ease
by
a he
alth
-car
e pr
ovid
er•
diag
nosi
s or
ve
rific
atio
n of
a
hist
ory
ofhe
rpes
zos
ter b
y a
heal
th-c
are
prov
ider
12. H
epat
itis
A (H
epA
) vac
cine
sR
outin
e va
ccin
atio
n:•
Min
imum
age
: 12
mon
ths
•K
illed
Hep
A va
ccin
e: S
tart
the
2-do
se H
epA
vacc
ine
serie
s fo
r chi
ldre
n ag
ed 1
2 th
roug
h23
mon
ths;
sep
arat
e th
e 2
dose
s by
6 to
18
mon
ths.
•Li
ve
atte
nuat
ed
H2-
stra
in
Hep
atiti
s A
vacc
ine:
Sin
gle
dose
sta
rting
at 1
2 m
onth
san
d th
roug
h 23
mon
ths
of a
geC
atch
-up
vacc
inat
ion:
•E
ither
of
the
two
vacc
ines
can
be
used
in‘c
atch
-up’
sch
edul
e be
yond
2 y
ears
of a
ge•
Adm
inis
ter 2
dos
es fo
r kill
ed v
acci
ne a
t lea
st6
mon
ths
apar
t to
unva
ccin
ated
per
sons
•O
nly
sing
le d
ose
of li
ve a
ttenu
ated
H2-
stra
inva
ccin
e•
For
catc
h up
vac
cina
tion,
pre
vac
cina
tion
scre
enin
g fo
r H
epat
itis
A an
tibod
y is
reco
mm
ende
d in
chi
ldre
n ol
der
than
10
year
s as
at
this
age
the
est
imat
ed s
ero-
posi
tive
rate
s ex
ceed
50%
.13
. Typ
hoid
vac
cine
sR
outin
e va
ccin
atio
n:•
Bot
h V
i-PS
co
njug
ate
and
Vi-P
S(p
olys
acch
arid
e) v
acci
nes
are
avai
labl
e•
Min
imum
age
s:o
Vi-P
S (T
ypba
r-TC
V®
): 6
mon
ths;
oVi
-PS
(pol
ysac
char
ide)
vac
cine
s: 2
yea
rs•
Vacc
inat
ion
sche
dule
:•
Typh
oid
conj
ugat
e va
ccin
es (V
i-PS
): S
ingl
edo
se a
t 9-
12 t
hrou
gh 2
3 m
onth
s an
d a
boos
ter d
urin
g se
cond
yea
r of l
ife•
Vi-P
S (
poly
sacc
harid
e) v
acci
nes:
S
ingl
e
INDIAN PEDIATRICS 792 VOLUME 51__OCTOBER 15, 2014
INDIAN ACADEMY OF PEDIATRICS IMMUNIZATION SCHEDULE, 2014
dose
at 2
yea
rs; r
evac
cina
tion
ever
y 3
year
s;•
Cur
rent
ly,
two
typh
oid
conj
ugat
e va
ccin
es,
Typb
ar-T
CV
® a
nd P
edaT
yph®
ava
ilabl
e in
Indi
an m
arke
t;•
Ped
aTyp
h®
is
not
yet
appr
oved
; th
ere
com
men
datio
n is
app
licab
le t
o Ty
pbar
-TC
V®
onl
y•
An
inte
rval
of a
t lea
st 4
wee
ks w
ith th
e M
MR
vacc
ine
shou
ld
be
mai
ntai
ned
whi
lead
min
iste
ring
Typb
ar-T
CV
® v
acci
ne•
Prim
ary
dose
of
conj
ugat
e va
ccin
e sh
ould
follo
w a
boo
ster
at 2
yea
rs o
f age
•E
ither
Typ
bar-
TCV
® o
r Vi
-pol
ysac
char
ide
(Vi-P
S) c
an b
e em
ploy
ed a
s bo
oste
r;•
Typh
oid
reva
ccin
atio
n ev
ery
3 ye
ars,
if V
i-po
lysa
ccha
ride
vacc
ine
is u
sed
•N
o ev
iden
ce o
f hy
po-r
espo
nsiv
enes
s on
repe
ated
re
vacc
inat
ion
of
Vi
-po
lysa
ccha
ride
vacc
ine
so fa
r•
Nee
d of
reva
ccin
atio
n fo
llow
ing
a bo
oste
r of
Typb
ar-T
CV
® n
ot y
et d
eter
min
edC
atch
-up
vacc
inat
ion:
•R
ecom
men
ded
thro
ugho
ut t
he a
dole
scen
tpe
riod,
i.e.
18
year
s14
. Inf
luen
za v
acci
neR
outin
e va
ccin
atio
n:•
Min
imum
ag
e:
6 m
onth
s fo
r tri
vale
ntin
activ
ated
influ
enza
vac
cine
(TIV
)•
Rec
omm
ende
d on
ly f
or t
he v
acci
natio
n of
pers
ons
with
cer
tain
hig
h-ris
k co
nditi
ons.
•Fi
rst t
ime
vacc
inat
ion:
6 m
onth
s to
bel
ow 9
year
s:
two
dose
s 1
mon
th a
part;
9 y
ears
and
abov
e: s
ingl
e do
se•
Ann
ual r
evac
cina
tion
with
sin
gle
dose
.•
Dos
age
(TIV
) : a
ged
6–35
mon
ths
0.25
ml;
3ye
ars
and
abov
e: 0
.5 m
l•
For c
hild
ren
aged
6 m
onth
s th
roug
h 8
year
s:A
dmin
iste
r 2 d
oses
(sep
arat
ed b
y at
leas
t 4w
eeks
) to
ch
ildre
n w
ho
are
rece
ivin
gin
fluen
za v
acci
ne fo
r the
firs
t tim
e.•
All
the
curr
ently
ava
ilabl
e TI
Vs
in th
e co
untry
cont
ain
the
‘Sw
ine
flu’ o
r ‘A
(H1N
1)’ a
ntig
en;
no n
eed
to v
acci
nate
sep
arat
ely.
•B
est t
ime
to v
acci
nate
:o
As
soon
as
the
new
vac
cine
is r
elea
sed
and
avai
labl
e in
the
mar
ket
oJu
st b
efor
e th
e on
set o
f rai
ny s
easo
n.15
.Hum
an p
apill
omav
irus
(HPV
) vac
cine
sR
outin
e va
ccin
atio
n:•
Min
imum
age
: 9 y
ears
•H
PV
4 [G
arda
sil]
and
HP
V2
[Cer
varix
] ar
elic
ense
d an
d av
aila
ble.
•O
nly
2 do
ses
of e
ither
of
the
two
HP
Vva
ccin
es (
HP
V4
& H
PV
2) f
or a
dole
scen
t/
prea
dole
scen
t girl
s ag
ed 9
-14
year
s;•
For
girls
15
ye
ars
and
olde
r, an
dim
mun
ocom
prom
ised
ind
ivid
uals
3 d
oses
are
reco
mm
ende
d•
For
two-
dose
sc
hedu
le,
the
min
imum
inte
rval
bet
wee
n do
ses
shou
ld b
e 6
mon
ths.
•E
ither
HP
V4
(0, 2
, 6 m
onth
s) o
r HP
V2
(0, 1
,6
mon
ths)
is
reco
mm
ende
d in
a 3
-dos
ese
ries
for f
emal
es a
ged
15 y
ears
and
old
er•
HP
V4
can
also
be
give
n in
a 3
-dos
e se
ries
for
mal
es a
ged
11 o
r 12
yea
rs, b
ut n
ot y
etlic
ense
d fo
r use
in m
ales
in In
dia.
•Th
e va
ccin
e se
ries
can
be s
tarte
d be
ginn
ing
at a
ge 9
yea
rs.
•Fo
r th
ree-
dose
sc
hedu
le,
adm
inis
ter
the
2nd d
ose
1 to
2 m
onth
s af
ter t
he 1
stdo
se a
ndth
e 3r
d dos
e 6
mon
ths
afte
r th
e 1s
tdos
e (a
tle
ast 2
4 w
eeks
afte
r the
firs
t dos
e).
Cat
ch-u
p va
ccin
atio
n:•
Adm
inis
ter
the
vacc
ine
serie
s to
fem
ales
(eith
er H
PV
2 or
HP
V4)
at a
ge 1
3 th
roug
h 45
year
s if
not p
revi
ousl
y va
ccin
ated
.•
Use
rec
omm
ende
d ro
utin
e do
sing
inte
rval
s(s
ee a
bove
) for
vac
cine
ser
ies
catc
h-up
.16
. Men
ingo
cocc
al v
acci
ne.
•R
ecom
men
ded
only
for
cer
tain
hig
h ris
kgr
oup
of c
hild
ren,
dur
ing
outb
reak
s, a
ndin
tern
atio
nal
trave
lers
, in
clud
ing
stud
ents
goin
g fo
r stu
dy a
broa
d an
d tra
vele
rs to
Haj
jan
d su
b-S
ahar
a A
frica
.•
Bot
h M
enin
goco
ccal
co
njug
ate
vacc
ines
(Qua
driv
alen
t M
enA
CW
Y-D
, Men
actra
® b
yS
anof
i Pas
teur
and
m
onov
alen
t g
roup
A,
PsA
–TT,
Men
Afri
Vac®
by
Ser
um In
stitu
te o
fIn
dia)
and
pol
ysac
char
ide
vacc
ines
(bi-
and
quad
rival
ent)
are
licen
sed
in In
dia.
PsA
–TT
is n
ot fr
eely
ava
ilabl
e in
mar
ket.
•C
onju
gate
va
ccin
es
are
pref
erre
d ov
erpo
lysa
ccha
ride
vacc
ines
du
e to
th
eir
pote
ntia
l fo
r he
rd
prot
ectio
n an
d th
eir
incr
ease
d im
mun
ogen
icity
, pa
rticu
larly
in
child
ren
1 ye
ar o
ld.
18. J
apan
ese
ence
phal
itis
(JE)
vac
cine
.R
outin
e va
ccin
atio
n:•
Rec
omm
ende
d on
ly fo
r in
divi
dual
s liv
ing
inen
dem
ic a
reas
•Th
e va
ccin
e sh
ould
be
of
fere
d to
th
ech
ildre
n re
sidi
ng i
n ru
ral
area
s on
ly a
ndth
ose
plan
ning
to
vi
sit
ende
mic
ar
eas
(dep
endi
ng u
pon
the
dura
tion
of s
tay)
•Th
ree
type
s of
new
gen
erat
ion
JE v
acci
nes
are
licen
sed
in In
dia
: one
, liv
e at
tenu
ated
,ce
ll cu
lture
der
ived
SA
-14-
14-2
, an
d tw
oin
activ
ated
JE
vac
cine
s, n
amel
y ‘v
ero
cell
cultu
re-d
eriv
ed S
A 1
4-14
-2 J
E va
ccin
e’(J
EEV®
by
B
E In
dia)
an
d ‘v
ero
cell
cultu
re-d
eriv
ed,
8215
64XY
, JE
vac
cine
’(J
ENVA
C®
by
Bha
rat B
iote
ch)
•Li
ve a
ttenu
ated
, cel
l cul
ture
der
ived
SA
-14
-14-
2:o
Min
imum
age
: 8
mon
ths;
oTw
o do
se s
ched
ule,
firs
t dos
e at
9 m
onth
sal
ong
with
mea
sles
vac
cine
and
sec
ond
at16
to 1
8 m
onth
s al
ong
with
DTP
boo
ster
oN
ot a
vaila
ble
in p
rivat
e m
arke
t fo
r of
fice
use
•In
activ
ated
cel
l cul
ture
der
ived
SA
-14-
14-
2 (J
EEV®
by
BE
Indi
a) :
oM
inim
um a
ge: 1
yea
r (U
S-F
DA
: 2 m
onth
s)o
Prim
ary
imm
uniz
atio
n sc
hedu
le:
2 do
ses
of
0.25
ml
each
ad
min
iste
red
intra
mus
cula
rly
on
days
0
and
28
for
child
ren
aged
≥ 1
to ≤
3 y
ears
o2
dose
s of
0.5
ml f
or c
hild
ren
>3ye
ars
and
adul
ts a
ged
≥ 18
yea
rso
Nee
d of
boo
ster
s st
ill u
ndet
erm
ined
•In
activ
ated
Ve
ro
cell
cultu
re-d
eriv
edK
olar
st
rain
, 82
1564
XY,
JE
vacc
ine
(JEN
VAC
® b
y B
hara
t Bio
tech
)o
Min
imum
age
: 1 y
ear
oP
rimar
y im
mun
izat
ion
sche
dule
: 2
dose
sof
0.
5 m
l ea
ch
adm
inis
tere
din
tram
uscu
larly
at 4
wee
ks in
terv
alo
Nee
d of
boo
ster
s st
ill u
ndet
erm
ined
.C
atch
up
vacc
inat
ion:
•A
ll su
scep
tible
chi
ldre
n up
to 1
5 yr
s sh
ould
be a
dmin
iste
red
durin
g di
seas
e ou
tbre
ak/
ahea
d of
ant
icip
ated
out
brea
k in
cam
paig
ns19
. Rab
ies
vacc
ine:
•P
ract
ical
ly
all
child
ren
need
va
ccin
atio
nag
ains
t rab
ies
•Fo
llow
ing
two
situ
atio
ns i
nclu
ded
in ‘
high
-
risk
cate
gory
of
ch
ildre
n’
for
rabi
esva
ccin
atio
n an
d sh
ould
be
offe
red
‘Pre
-ex
posu
re p
roph
ylax
is’ (
Pre
-EP
):o
Chi
ldre
n ha
ving
pet
s in
hom
e;o
Chi
ldre
n pe
rcei
ved
with
hig
her
thre
at o
fbe
ing
bitte
n by
dog
s su
ch a
s ho
stel
lers
, ris
kof
stra
y do
g m
enac
e w
hile
goi
ng o
utdo
or.
•O
nly
mod
ern
tissu
e cu
lture
va
ccin
es(M
TCV
s) a
nd I
M r
oute
s ar
e re
com
men
ded
for
both
‘pos
t-exp
osur
e’ a
nd ‘p
re-e
xpos
ure’
prop
hyla
xis
in o
ffice
pra
ctic
e•
Pos
t-exp
osur
e pr
ophy
laxi
s (P
EP
) is
reco
mm
ende
d fo
llow
ing
a si
gnifi
cant
cont
act
with
dog
s, c
ats,
cow
s, b
uffa
loes
,sh
eep,
go
ats,
pi
gs,
donk
eys,
ho
rses
,ca
mel
s,
foxe
s,
jack
als,
m
onke
ys,
mon
goos
e,
squi
rrel
, be
ars
and
othe
rs.
Dom
estic
rod
ent
(rat
) bi
tes
do n
ot r
equi
repo
st e
xpos
ure
prop
hyla
xis
in In
dia.
•P
ost-e
xpos
ure
prop
hyla
xis:
oM
TCV
s ar
e re
com
men
ded
for a
ll ca
tego
ryII
and
III b
ites.
oD
ose:
1.0
ml i
ntra
mus
cula
r (IM
) in
ante
ro-
late
ral
thig
h or
del
toid
(ne
ver
in g
lute
alre
gion
) fo
r H
uman
Dip
loid
Cel
l Va
ccin
e(H
DC
V),
Pur
ified
C
hick
E
mbr
yo
Cel
l(P
CE
C)
vacc
ine,
Pur
ified
Duc
k E
mbr
yoVa
ccin
e (P
DE
V);
0.5
ml f
or P
urifi
ed V
ero
Cel
l Va
ccin
e (P
VR
V).
Intra
derm
al
(ID)
adm
inis
tratio
n is
no
t re
com
men
ded
inin
divi
dual
pra
ctic
e.o
Sch
edul
e: 0
, 3, 7
, 14,
and
30
with
day
‘0’
bein
g th
e da
y of
co
mm
ence
men
t of
vacc
inat
ion.
A s
ixth
dos
e on
day
90
isop
tiona
l an
d m
ay b
e of
fere
d to
pat
ient
sw
ith s
ever
e de
bilit
y or
tho
se w
ho a
reim
mun
osup
pres
sed
oR
abie
s im
mun
oglo
bin
(RIG
) al
ong
with
rabi
es v
acci
nes
are
reco
mm
ende
d in
all
cate
gory
III b
ites.
oE
quin
e ra
bies
im
mun
oglo
bin
(ER
IG)
(dos
e 40
U/k
g) c
an b
e us
ed i
f hu
man
rabi
es im
mun
oglo
bin
is n
ot a
vaila
ble;
•P
re -e
xpos
ure
prop
hyla
xis:
oTh
ree
dose
s ar
e gi
ven
intra
mus
cula
rly in
delto
id/
ante
rola
tera
l th
igh
on d
ays
0, 7
and
28 (
day
21 m
ay b
e us
ed i
f tim
e is
limite
d bu
t day
28
pref
erre
d).
oFo
r re
-exp
osur
e at
any
poi
nt o
f tim
e af
ter
com
plet
ed (
and
docu
men
ted)
pre
or
post
expo
sure
pro
phyl
axis
, tw
o do
ses
are
give
non
day
s 0
and
3.o
RIG
is
not
requ
ired
durin
g re
-exp
osur
eth
erap
y.
INDIAN PEDIATRICS 793 VOLUME 51__OCTOBER 15, 2014
INDIAN ACADEMY OF PEDIATRICS IMMUNIZATION SCHEDULE, 2014
D. Pre-exposure prophylaxis for rabies
Recommendations for office practice: The committee hasnow recommended that practically all children needvaccination against rabies and following two situations tobe included in high-risk category of children for rabiesvaccination: (i) children having pets at home; and (ii)children perceived with higher threat of being bitten bydogs such as hostellers, and those with risk of stray dogbite while going outdoor. These children should be offeredpre-exposure prophylaxis (Pre-EP) against rabies. Thismust be preceded by a one-to-one discussion with theparents. The Pre-EP is not included in the IAPimmunization schedule for all children. Three doses arerecommended to be given intramuscularly on days 0, 7 and28 (day 21 may be used if time is limited, as with imminenttravel, but day 28 is preferred). The intradermal schedulehas been shown to be effective, but is not approved for thispurpose in office practice.
There are studies to show that good antibody levelspersist up to 10 years even after a 3 dose pre-exposureprophylaxis followed by a booster at one year. However,on account of the nature of the disease, for re-exposure atany point of time after completed and documented, pre-orpost-exposure prophylaxis, two doses are to be given ondays 0 and 3. Rabies immunoglobulins (RIG) are notneeded in these children. There is no change in the IAPrecommendations for post-exposure prophylaxis (PEP) ofrabies.
Public use: The committee urges the Government of India(GoI) to urgently take remedial measures to address thehuge burden of rabies in India [17]. These measuresinclude public education campaigns, need to ensure theuninterrupted availability of vaccines and anti-rabiesimmunoglobulin in primary health care facilities andtraining of primary care providers (includingpediatricians), vaccination of dogs, sterilization of straydogs, and declaration of rabies as a notifiable disease. Thecommittee reiterated its position that universal Pre-EPvaccination, especially for children, could reduce thenumber of human rabies dramatically. Use of intradermalvaccination would bring down the vaccine cost foruniversal vaccination program dramatically [2].
Justifications: The advantages of the Pre-EP includeelimination of the need for RIG, reduction in the number ofvaccine doses on exposure and provision of immunity toindividuals whose post-exposure prophylaxis is delayed.Further, the likelihood of lack of documentation of a dogbite amongst young children who may not report scratchesand small playful bites from dogs and cats are other reasonswhy Pre-EP would be useful. However, it was agreed uponthat inclusion of Pre-EP in only IAP schedule for office
practice would not serve the desired purpose since majorityof deaths occur among children belonging to lowsocioeconomic strata and those living in remote areas [17].WHO encourages the implementation of carefullydesigned studies on the feasibility, cost-effectiveness andlong-term impact of incorporating ‘Cell Culture Vaccinesand Embryonated egg-based vaccines’ (CCEEVs) into theimmunization programs of infants and children wherecanine rabies is a public health problem [18].
E. Typhoid conjugate vaccines
Recommendation for office practice
Primary schedule: The committee has now created a newslot for typhoid conjugate vaccine for primaryimmunization at 9-12 months of age in the IAPImmunization schedule. There are currently two typhoidconjugate vaccines (Typbar-TCV and PedaTyph),available and licensed in the country. However, thisrecommendation would be applicable only to the former asthe committee is awaiting more data on the latter. Only asingle dose of the vaccine is recommended for primaryseries. An interval of at least 4 weeks with the measles/MMR vaccine should be maintained since the data oninterference with the measles/MMR vaccine are not yetavailable.
Boosters: Those who received a dose of conjugate vaccineat 9-12 months can be prescribed booster of either Vi-polysaccharide (Vi-PS) or the conjugate vaccine at 2 yearsof age. Those who have received booster of Vi-PS vaccinewill need revaccination every 3 years till the intendedduration of protection. There is no evidence of hypo-responsiveness on repeated vaccination so far. The needof further boosters after conjugate vaccine is not yetdetermined since long term data are not yet available.
Catch-up schedule: Catch-up vaccination is recommendedthroughout the adolescent period, i.e. up to 18 years of age.Below 2 years, only conjugate vaccine is recommendedwhile above 2 years of age any of the two can be employed.The details about further schedule should be followed asdescribed above in the ‘boosters’ section.
Recommendations for public use
The committee strongly urges the GoI to include universaltyphoid vaccination in its UIP all over the country at theearliest.
Evidence and justification: The committee believes thatconsidering the epidemiology of typhoid in the country,there is definite need of protection against typhoid feverbelow 2 years of age. The Vi-PS vaccines are ineffectivebelow 2 years of age and provide modest and short lastingprotection. There is definite need of typhoid conjugate
INDIAN PEDIATRICS 794 VOLUME 51__OCTOBER 15, 2014
INDIAN ACADEMY OF PEDIATRICS IMMUNIZATION SCHEDULE, 2014
vaccines, effective below 2 years of age and capable ofproviding superior long-lasting protection. The committeereviewed the published [19] and unpublished data of newtyphoid conjugate vaccines, (BBIL’s Typbar-TCV,BioMed’s PedaTyph and Novartis’s Vi-CRM197). Allthese vaccines can be administered at and around 9 monthsof age. Only a single dose is sufficient for adequateseroconversion for primary immunization, and the seconddose failed to show incremental effect on antibody titers(data after 2nd dose of PedaTyph are not yet available). Inthe published trial of Novartis’s Vi-CRM197 conjugatetyphoid vaccine [19], a low response was noted to measles,hepatitis B and H influenza type b both in reference(PCV13) and test vaccine (conjugate typhoid vaccine)groups, with a non-significant reduction in the rate ofmeasles seroconversion in the test vaccine group in onecenter. The committee has thus recommended maintainingan interval of at least 4 weeks with the measles/MMRvaccine while administering this vaccine. The committeehas also asked the manufacturer to undertake a ‘measles/MMR interference study’ with vaccination at 9 months.
Regarding the need and timing of boosters, the dataprovided by the manufacturer of Typbar-TCV vaccineshow almost 100% seroprotection (>7.2 EU/mL) of testvaccine in both the cohorts (6 mo-2 years and 2-45 years)till 18 months of follow-up, although both seroconversion(>4-fold rise of antibody level) and GMT levels wanedsignificantly in both cohorts. Regarding comparison of Vi-PS non-conjugate vaccine with the Vi-PS conjugatevaccine, both fared equally well above 2 years of age as faras immediate and long-term seroconversion areconcerned, although the latter had significantly higherGMTs and slightly better seroconversion rates than theformer. The committee has thus recommended either of thevaccines as a booster at 2 years of age. The need of repeatdoses/boosters for conjugate vaccine shall only bedetermined after long-term efficacy data are available.
F. Human Papillomavirus (HPV) vaccinationschedule
Recommendations: Two doses of HPV vaccine areadvised for adolescent/pre-adolescent girls aged 9-14years; for girls 15 years and older, current 3 dose schedulewill continue. For two-dose schedule, the minimuminterval between doses should be 6 months. The intervalbetween the first and second dose may be extended upto12months, should this facilitate administration – say inschool settings. For girls, primed before the age of 15years, even if older at the time of second dose, a two-doseschedule will be applicable. However, for immuno-compromised individuals, including HIV-infected, thethree-dose schedule is recommended, irrespective of age.
Evidence and justification: IAP had recommended use ofHPV vaccine in its immunization schedule way back in2007. Though there is no coverage data on uptake of thisvaccine through private sector, the common perception isthat acceptance is poor and the coverage still remainsminiscule. The move to revise HPV vaccine immunizationschedule for adolescent girls from existing three to twodoses would not only be cost-saving, but would alsosimplify logistics like increased flexibility of the intervals,and annual doses for school-based delivery. Hence, therevised recommendations may help in improvingacceptance, facilitating delivery, and enhancing coverageof the vaccine.
The WHO’s Strategic Advisory Group of Experts(SAGE) working group (WG) on HPV has recommendedrevision of vaccination schedule for pre-adolescent andadolescent girls from three primary doses to two in itsApril 2014 meeting [20]. The committee has reviewed thebackground material and various trials conducted in thisregard so far [21]. The main source of evidence is providedby a systematic review commissioned by SAGE WG [22].The other sources include review of the data fromobservational studies on 2 versus 3 dose schedule, andproceedings of an Ad hoc Expert Consultation on HPVvaccine schedules organized in Geneva, 2013 [21]. TheEuropean Medicines Agency (EMA) has also approvedtwo doses for pre-adolescent and adolescent girls aged 9-14 years for the bivalent HPV vaccine and also offeredpositive opinion for a similar schedule for quadrivalentvaccine [23]. Many countries have either already adoptedor are planning to adopt a two-dose schedule [21]. Fewcountries like Brazil, Mexico, Columbia and BritishColumbia are running an extended schedule (2+1, i.e. 0, 6,60 months) where the last dose at 5 years depends onfollow-up assessment of the need [21]. In Costa Rica,strong 4 year protection was reported in women whoreceived just one dose of bivalent HPV vaccine [21].
The systematic review [22] has identified variousstudies that include both randomized and non-randomizedtrials of both the vaccines, bivalent and quadrivalent, fromvarious high income group countries like Canada,Australia, Sweden, Denmark, Germany, and low andmiddle income (LMI) countries like Uganda, Mexico, andIndia. In randomized comparisons of two-dose and three-dose schedules (overall 3 RCTs), seroconversion andseropositivity were non-inferior or inconclusive at all-timepoints. In non-randomized comparisons, all available datafor seroconversion and seropositivity showed non-inferiority of the 2-dose compared with the 3-doseschedule. The efficacy against virological endpoints ininitially HPV-naïve subjects who received 2 doses ofbivalent vaccine at 48th month indicates that the two-dose
INDIAN PEDIATRICS 795 VOLUME 51__OCTOBER 15, 2014
INDIAN ACADEMY OF PEDIATRICS IMMUNIZATION SCHEDULE, 2014
schedule prevents HPV-16/18 infection in subjects whodid not receive a complete 3-dose vaccination course. Thereview also compared different intervals between doses ofHPV vaccine. The 6-month interval resulted in superiorGMCs compared with the 2-month interval one monthafter the last vaccine dose in all the age groups enrolled.
The mathematical models also support the two-doseschedule for girls aged 9-14 years. In one such model itwas shown that in high-income settings (such as the UKand Canada), if it was documented that a 2-dosevaccination conferred more than 10-20 years protectionthen adding the third dose would not be cost-effective [21].The cost-effectiveness of 2-dose vs. 3-dose vaccination inlow/middle income settings still needs to be explored.
The committee’s recommendations are also facilitatedby the evidence generated by an ongoing multi-centricRCT on alternative dosing schedule of quadrivalent HPVvaccine in India [24-2