Journal of International Society of Preventive and Community Dentistry

: 2018  |  Volume : 8  |  Issue : 6  |  Page : 475--481

Adult immunization – Need of the hour

Abhishek Jairaj1, P Shirisha2, Muqthadir Siddiqui Mohammad Abdul3, Urooj Fatima4, Rahul Vinay Chandra Tiwari5, Muhamood Moothedath6,  
1 Faculty of Dentistry, AIMST University, Bedong, Malaysia
2 Department of Humanities and Social Sciences, IIT Madras, Chennai, Tamil Nadu, India
3 Department of Paediatric Dentistry, Ministry of Health, King Khaled Hospital, Riyadh, Saudi Arabia
4 Skin and Laser Care Centre, Dr. Sulaiman Al Habib Hospital, Riyadh, Saudi Arabia
5 Department of Oral and Maxillofacial Surgery and Dentistry, Jubilee Mission Medical College Hospital and Research Center, Thrissur, Kerala, India
6 Department of Public Health Dentistry, College of Applied Health Sciences in Ar Rass, Qassim University, Buraydah, Saudi Arabia

Correspondence Address:
Dr. Rahul Vinay Chandra Tiwari
Department of Oral and Maxillofacial Surgery and Dentistry, Jubilee Mission Medical College Hospital and Research Center, Thrissur - 680 005, Kerala


Immunization is the process of making individuals immune. Childhood immunization is a common process for various aliments, but adult immunization in the Indian scenario is obscure. Officially, India has been declared polio-free, which is an achievement despite cultural, political, economic, geographic, and so many other factors. The changing demographics of adult, geriatric population and growing cost of health-care maintenance are a concern in developing countries like India. Thus, promoting healthy lifestyle needs prevention, early detection, and management of various diseases and disorders. Certainly, prevention in adults is yet to be tapped completely, so that goal of 100% prevention can be achieved. Various fraternities of medical association have come up with guidelines for adult immunization schedules in India. The present paper reviews infectious diseases such as anthrax, chikungunya, cholera, dengue, influenza, and malaria in this section of the review. We humbly request all health-care professionals and educators to educate the mass for adult immunization. So that, cost involved for treatment and workforce for the management of diseases can be better utilized in some other needed areas.

How to cite this article:
Jairaj A, Shirisha P, Abdul MS, Fatima U, Tiwari RV, Moothedath M. Adult immunization – Need of the hour.J Int Soc Prevent Communit Dent 2018;8:475-481

How to cite this URL:
Jairaj A, Shirisha P, Abdul MS, Fatima U, Tiwari RV, Moothedath M. Adult immunization – Need of the hour. J Int Soc Prevent Communit Dent [serial online] 2018 [cited 2018 Dec 13 ];8:475-481
Available from:

Full Text


In our previous review, adult immunization for HIV and hepatitis C virus was discussed thoroughly.[1] In continuation, efforts have been made to give a comprehensive review on new guidelines and prevention of infectious and contagious diseases. In rural India, every household has animals and pets as a part of their routine daily life activities. Many of the diseases dealt in this section are zoonotic and transmitted through vectors.[2] Therefore, it is important to understand the concept of spread, prevention, and treatment. The review enlightens very briefly about disease entity, but more on prevention and vaccination aspects, along with recent trends and developments.


Anthrax was known as Egyptian Plague caused by Bacillus anthracis. Anthrax estimated to occur worldwide and incidence reaches between 20,000 and 100,000 cases annually.[2],[3] Anthrax has gained its importance because of biological warfare.[4],[5] Transmission of anthrax is animal-soil-animal transmission.[6] Usually, prevalence among Asian countries is much higher.[6] Anthrax is a disease of animals, both domestic and wild. Transmission of infection will be through direct inoculation of spores in skin breach, inhalation of spores, and ingestion of contaminated food.[2],[6] Inoculation through contact occurs mainly among veterinary doctors, zookeepers, and butchers. Clinical features will be seen after 2–3 days of incubation.[6],[7] Patients will show small papules in the skin, vesicle around the central lesions. By the 3rd day, considerable local edema will be seen with lymphadenopathy. Lesions will resolve spontaneously in 80%–90% of the patients slowly over a period of 2–6 weeks.[8] Usually, inhalation of contaminated spores from hides lead to disease. The risk is more in wool makers – shepherds; so, is called as a wool-sorter's disease. Soon after a short incubation, patient will suffer with fever, chills, and feel short of breath and has higher mortality (95%). Prompt antibiotic therapy makes survival of patient possible.[8],[9],[10] In African countries because of contaminated meat consumption, intestinal anthrax may develop; which is rare, elsewhere in the world.[7] Many patients may present nonspecifically with diarrhea, vomiting, and fever but recover spontaneously.[2],[3] Sometimes, lesions occur in the oropharynx because of contaminated meat ingestion which causes severe, life-threatening edema and bacteriemia.[6]

 Diagnosis of Anthrax

It can be carried out through bacteriological (Sheep blood agar culture), serological, and immunological tests (titers of antibody to protective antigen and capsular components). New molecular diagnostic techniques use polymerized chain reaction specific to beta-anthraces.[7] Markers such as VrrA and Ba813 have been studied extensively for the diagnosis.[11]


Penicillin remains proven drug; early antibiotic administration is essential in survivors. The antibiotic should be prolonged because nongerminated spores remain in alveoli for weeks. The regimen for postexposure and active disease can be read elsewhere.[8]

 Global Scenario of Vaccination for Prevention

In 1881, Louis Pasteur successfully developed anthrax vaccine. Later in 1935, Max Stern developed attenuated live vaccine, which is used in livestock; but it is not safe for human use because of virulence.[12],[13] At present, Advisory Committee on Immunization Practices recommends five doses of AVA (anthrax vaccine adsorbed) developed by Americans.[10] Primary dose of 0.5 ml intramuscular (IM) at 0, 4 weeks and later 6, 12, and 18 months (preexposure prophylaxis) followed by annual booster dose. This vaccine is recommended for unvaccinated people, but those exposed to anthrax should be given three subcutaneous doses.[8],[10] First one as soon as possible, second and third doses at 2nd and 4th week after the first dose. In pregnant women, the timeline will be same with subcutaneous administration.[9]


It is remerging viral disease (caused by Chikungunya [CHIK] RNA virus belongs to family Togaviridae, genus Alphavirus) with abrupt fever, arthralgia followed by a rash.[14],[15],[16] The name derives from Makonde (means “which bends up”) results of arthritic symptoms; even though it is self-limiting, but rarely fatal. Patients affected show abrupt and sudden onset of high degree fever and chills, severe myalgia, arthralgia, and skin rash for 1–7 days,[17],[18],[19],[20],[21],[22] the incubation period is usually 2–3 days with a range of 1–12 days; temperature will remit for 1–2 days after a gap of 4–10 days.[14],[15],[16] Swollen joints and tender crippling arthritis are evident, involving more than 10 joint groups and usually radiological findings are normal.[22],[23] Pregnant patients if affected may abort during the first trimester and transmission to child may happen during term.[24],[25],[26] Cardinal features such as encephalitis, neuropathy myoclonic seizures, acute flaccid paralysis multiorgan involvement, and ocular involvement were reported.[17],[18],[19],[20],[21] In some cases, sensorineural hearing loss hypokalemic periodic paralysis and hemorrhagic manifestations were documented.[14],[15],[16],[17] It may unmask rheumatoid arthritis, CHIK virus (CHIKV) infection thought to confer lifelong immunity.[22],[23] It is mostly transmitted through a bite of infected mosquito Ades genus. In the recent past in India, 2008–2009, there was an outbreak.[24],[27]

 Management Challenges

The specific antiviral drug is available for management. Many times dengue and CHIK fever occur frequently, which needs to be distinguished from diseases such as other viral fevers and malaria. The gold standard for diagnosis is viral culture,[14],[15],[16],[17] but facilities are not widely available in India. Reverse transcriptase polymerized chain reaction is a useful molecular tool for rapid diagnosis.[28],[29] More frequently, ELISA and indirect immune fluorescent heme agglutination inhibition techniques are used.

 Treatment Challenges

It is symptomatic and supportive only.[30] Adequate fluid intake should be ensured. nonsteroidal anti-inflammatory drugs may be used and antirheumatic drugs also shown effective in the treatment of chronic arthritis.[31] There is a need for CHIK vaccine as the burden of disease is tremendous and infection rates are significant in developing countries.[32],[33],[34] As of now, no commercial vaccines are available to prevent the occurrence of infection. Many vaccines have tried in preclinical and Phase-I, II trial; like inactivated live-attenuated genetically engineered DNA, virus-like particles vaccine are under trial.[31],[32],[33],[34],[35],[36] CHIKV is an old virus, but now it has become a global disease.[36] This leads to socioeconomic impact, so there is an urgent need of safe and effective CHIK vaccine.[36]


Cholera is caused by Vibrio cholerae leading to acute enteric infection. Route of transmission is feco-oral contamination or ingestion of contaminated food and water. It is characterized by dehydration due to a rigorous form of acute, severe watery diarrhea, which may lead patients to deathbed.[37] Two-third of the patients will be asymptomatic, but 80%–90% of symptomatic patients develop acute-onset diarrhea. If it is untreated, the fatality may raise up to 40%.[37],[38] Recently, massive outbreaks of cholera, killed more than one lakh people.[37] Diagnosis depends on the isolation of Vibrio cholerae from feces.

According to WHO, the patient aged 5 or more and develops severe dehydration or watery diarrhea or vomiting in the cholera epidemic area should suspect infection.[37] The majority of patients may be treated for dehydration. Antibiotic therapy for 3–5 days will suffice. The single dose of tetracycline, doxycycline, or ciprofloxacin has been shown effective in reducing duration and volume of diarrhea.[38] Cholera vaccine first developed in 1980 as an injectable, later as oral form. Injectable vaccines are effective in cholera endemic areas.[39],[40],[41],[42],[43] It offers protection up to 2 years after single-dose administration. In addition, 3–4 years with annual booster dose, this will reduce 50% of the risk of death. Because of low efficacy and severe adverse reactions, the WHO never recommended the use of this vaccine, accept some specific epidemiological sequences like Kumbhmela.[44]

Currently, whole-cell-cholera toxin recombinant B subunit vaccine and bivalent killed whole-cell vaccine are available with trade names Dukoral, Shanchol, and Morcvax.[37] In the global scenario, the WHO recommends available cholera vaccine can be considered at risk areas for outbreaks and should be utilized as compliments to traditional control and preventive measures.[38],[39] Vietnam has incorporated cholera vaccine in public health program. However, an oral cholera vaccine does not provide 100% immunity from disease.

 Present Status of Vaccines

Dukoral™ approved for the age group of more than 2 years (2–6 years); administered in three doses 1–6 weeks apart; and two doses for the age group of more than 6 years, 1–6 weeks apart. Each dose of vaccine should be administered in 150 ml of water. The protection starts approximately 1 week after ingestion of the second dose and gives protection of 85%–90% at 6 months. However, Dukoral should be stored 2°–8° and will be stable for 1 month at 37°. The volume of a single dose is 15 times the volume of other vaccine.[43],[44]

Shancol™ is the second type of vaccine licensed in India in 2009; it is administered in two doses between a minimum of 1 and maximum of 6 weeks apart. In the Indian scenario, drinking water sanitation is an important cornerstone to improve the situation.[40] Two-dose product should be immunized cost effectively for the target population, for example, Kumbh Mela pilgrims. The cost involved with Shancol is approximately Rs. 12 whereas Dukoral is Rs. 300–600.[43],[44]


Dengue is an important arthropod-borne viral disease. Around 40% of population in the world is at risk of dengue transmission. It is endemic in at least 100 countries.[45],[46],[47],[48] The WHO estimates 50–100 million infections, including 5 lakh dengue hemorrhagic fever and 22,000 deaths happen among children. Dengue fever is caused by four viral serotypes, den V1–V2.[47] Dengue is transmitted by vector mosquitos Aedes aegypti, and Aedes albopictus. Symptoms will begin 3–7 days after the bite and last for typically 3–10 days. The transmission occurs if mosquito fed with an infected person during a 5-day period of viremia.[46] Sometimes, the patient may not be symptomatic but can infect mosquito after entry into the blood meal.[48] It requires 8–10 days for transmission to another host.[49] In rare cases, it can be transmitted by organ transplant or blood transfusion and vertical transmission.

In tropic and subtropic, it is endemic, often when the rainfall is optimum for breeding. Severe disease is common in babies and young children.[46] Other risk factors include female gender, high body mass index, and viral load.[47] It can be life-threatening with chronic disease.[49] The person infected with one serotype may have lifelong immunity to that particular serotype. But develop only short-term immunity against other serotypes. Clinical manifestation will have 3–14 days incubation and will experience prodrome of chills, erythematous mottling and facial flushing which may last for 2–3 days.[45],[46] Classic dengue fever begins with sudden-onset fever, chills, and severe aching of the head and back extremities. The fever lasts for 2–7 days may reach 41°C.[47] The rash typically begins on the 3rd day and persists 2–3 days. Sometimes, 2nd rash may occur within 1–2 days of defervescence lasting for 1–5 days. It is morbilliform and maculopopular, occasionally desquamates.[47] Recovery is slow but complete.[50],[51] Convalescent phase may last for 2 weeks. It has become the leading cause of morbidity and mortality, which requires vaccine against such a life-threatening virus.[52]

 Present Status of Dengue Vaccine

Even though the dengue virus was isolated in 1945 in Calcutta. However, no vaccine is available yet in the market.[52],[53],[54],[55] At present, live attenuated chimeric yellow fever, dengue virus tetravalent dengue vaccine (CYTDV) has progressed to Phase III. Whereas the live attenuated vaccine has reached up to Phase II clinical trials.[56] Chimeric dengue vaccine has shown to be genetically and phenotypically stable and immunogenic.[57] CYTDV Phase III studies are underway in 10 countries of Asia and Latin America.[58] In India, at the International Center for Genetic Engineering and Biotechnology supported by Government of India has developed a noninfectious dengue vaccine from yeast Pichiapastoris. Preliminary animal trail in mice has yielded good results. In conclusion, CYTDV remains a public health value, which needs further studies for licensing by national regulatory agencies.[58]


Influenza commonly referred as flue; caused by Orthomyxoviridae. Influenza A and B are two common types of virus.[59],[60],[61] Further, Influenza A classified based on two surface antigens as hemagglutinin (H) and neuraminidase (N). Most infections globally caused by influenza A H1N1, H3N2, and influenza B. Antigenic drift results in seasonal epidemics due to point mutations that occur during viral replication.[62],[63] Globally, 5%–10% and 20%–30% attack rate is estimated among adult and children, respectively.[60],[61] The incidence of respiratory infections in urban area is 23% and 17.7% in a rural area per month.[61],[64] Respiratory syncytial virus, Influenza A, and Para A influenza virus are the most common causes leading to acute respiratory tract infections among children in rural India.[60] The mortality rate is more in aged patients (65 years and above).[59],[61] The most effective prevention is annual vaccination, which can be routinely done in certain groups with associated risks.[65],[66] In addition, improvement of respiratory hygiene is economic strategies to reduce respiratory diseases.[65]

 Influenza Vaccine Current Scenario

It offers an important preventive tool to prevent death and substantially reduces health-care expenses. Immunization can be carried out using trivalent inactivated influenza vaccine (IIV) or live attenuated influenza vaccine (LAIV).[67],[68] Present Quadrivalent IIV approved along with LAIV.[69] A trivalent cell culture based on activated influenza vaccine and trivalent recombinant influenza vaccine (RIV). Annual vaccination is recommended for adults who want to reduce the risk of transmission and becoming ill.[70]

Center for disease control advisory committee (USA) on immunization practices indicates vaccination for women of childbearing age during influenza season,[71] patients with systemic illness including chorionic villus sampling, renal, hepatic, hematologic metabolic and chronic pulmonary disorders;[72] persons above the age group of 50 years and with immune suppressions, and conditions that may compromise respiratory function should be considered for immunization.[73],[74],[75] Residents of nursing homes, health-care personnel, and caregivers should undergo vaccination regime.[76],[77] LAIV given intensely for 2–49 years age group. Trivalent influenza vaccine and IIV can be given IM with persons aged more than 6 months, up till more than 65 years and older.[78] In India, LAIV and RIV3 vaccines free from egg are not yet available. Indian studies are needed to assess the cost-effectiveness of the vaccine among children, adults, and aged.[79] Antiviral drugs used for chemoprophylaxis are to treat influenza can be used as adjuncts, but not substitute for animal vaccination.[80]

 Avian or Swine Influenza

Swine or Avian influenza is fatal infection. H5N1 is highly pathogenic virus seen in Asia, Africa, Europe and Middle East. It will be contracted through direct contact with sick or dead birds.[70] Associated with H5N1 is panziotic among birds. H5N1 circulating among poultry caused outbreaks of Avian Influenza. Occasionally, infected humans are potential to recombine with human Influenza A virus.[60],[61] In recent years (in 2006) outbreak of H5N1 occurred in Nandurbar, Jalgaon District of Maharashtra, Gujarat, and Madhya Pradesh.[81] National Institute of Virology suggested the introduction of viruses might be due to migratory birds.[81],[82] However, reducing seasonal influenza risk through vaccination might reduce risk of recombination of animal origin virus and human virus theoretically.[83]


Malaria is mosquito-borne parasitic disease.[84] Clinical features, diagnosis, and treatment can be read elsewhere in medical literature.[85] Development of a vaccine is a complex affair because complex cycle of parasite in human and mosquito as well as antigenic diversity.[86],[87],[88],[89] Currently, no malaria vaccine is commercially available. But during the last decade in the global scenario, they developed first-generation malaria vaccine by GlaxoSmithKline.[90] Few Phase I and Phase II trials have been carried out in Tanzania which prevented quarter of Malaria cases in the study population.[91] American Biotec Company (Sanaria) developed PfSPZ vaccine, which contains weakened live form parasite of Plasmodium falciparum.[92] The vaccine safety has been tested in Phase III trial in 2011 African Sub-Saharan countries.[90],[91] Indian Institute of Malaria Vaccine targeted both P. falciparum and Plasmodium vivax. International Centre for Genetic Engineering and Biotechnology developed JAIVAC-1 first Indian Malaria vaccine underwent trail in humans.[91],[93] Efficacy was evaluated in Papua New Guinea, but in India, efficacy is still not clear as of now and it is difficult to comment on the cost-effectiveness because no commercially available vaccine is present.[93]


Many of these infections encountered during traveling. Few of the diseases can be prevented because of childhood vaccination. However, the adults often neglect the recommendations of booster dose. In addition, some adults have never been vaccinated at all. To prevent burden of disease and treatment cost; it is essential to have knowledge of adult immunization. Adult immunization makes difference for developing countries to combat infectious diseases epidemics. Due to emerging and remerging infectious diseases worldwide, everyone should have booster doses of vaccination, along with scheduled vaccination. Travelers are at risk of acquiring travel-associated infections, and they may transmit the same to their home country after return. Hence, it is necessary to have travel vaccine list with booster doses to prevent disease epidemic and pandemic.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Chakravarthi PS, Ganta A, Kattimani VS, Tiwari RV. Adult immunization-need of the hour. J Int Soc Prev Community Dent 2016;6:272-7.
2Lalitha M, Kumar A. Anthrax: A continuing problem in Southern India. Indian J Med Microbiol 1996;14:63-72.
3Doganay M, Demiraslan H. Human anthrax as a re-emerging disease. Recent Pat Antiinfect Drug Discov 2015;10:10-29.
4Banerjee D, Chakraborty B, Chakraborty B. Anthrax: Where margins are merging between emerging threats and bioterrorism. Indian J Dermatol 2017;62:456-8.
5D'Amelio E, Gentile B, Lista F, D'Amelio R. Historical evolution of human anthrax from occupational disease to potentially global threat as bioweapon. Environ Int 2015;85:133-46.
6Moayeri M, Leppla SH, Vrentas C, Pomerantsev AP, Liu S. Anthrax pathogenesis. Annu Rev Microbiol 2015;69:185-208.
7Dixon TC, Meselson M, Guillemin J, Hanna PC. Anthrax. N Engl J Med 1999;341:815-26.
8Hendricks KA, Wright ME, Shadomy SV, Bradley JS, Morrow MG, Pavia AT, et al. Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014. doi: 10.3201/eid2002.130687.
9Meaney-Delman D, Rasmussen SA, Beigi RH, Zotti ME, Hutchings Y, Bower WA, et al. Prophylaxis and treatment of anthrax in pregnant women. Obstet Gynecol 2013;122:885-900.
10Wright JG, Quinn CP, Shadomy S, Messonnier N; Centers for Disease Control and Prevention. Use of anthrax vaccine in the United States: Recommendations of the advisory committee on immunization practices (ACIP), 2009. MMWR Recomm Rep 2010;59:1-30.
11Kim J, Gedi V, Lee SC, Cho JH, Moon JY, Yoon MY, et al. Advances in anthrax detection: Overview of bioprobes and biosensors. Appl Biochem Biotechnol 2015;176:957-77.
12Belton FC, Darlow HM, Henderson DW. The use of anthrax antigen to immunise man and monkey. Lancet 1956;271:476-9.
13Henderson DW, Peacock S, Belton FC. Observations on the prophylaxis of experimental pulmonary anthrax in the monkey. J Hyg (Lond) 1956;54:28-36.
14Moizéis RN, Fernandes TA, Guedes PM, Pereira HW, Lanza DC, Azevedo JW, et al. Chikungunya fever: A threat to global public health. Pathog Glob Health 2018;112:182-94.
15Weaver SC, Lecuit M. Chikungunya virus and the global spread of a mosquito-borne disease. N Engl J Med 2015;372:1231-9.
16Erasmus JH, Rossi SL, Weaver SC. Development of vaccines for chikungunya fever. J Infect Dis 2016;214:S488-96.
17Silva JV Jr., Ludwig-Begall LF, Oliveira-Filho EF, Oliveira RA, Durães-Carvalho R, Lopes TR, et al. Ascoping review of chikungunya virus infection: Epidemiology, clinical characteristics, viral co-circulation complications, and control. Acta Trop 2018;188:213-24.
18Ganesan VK, Duan B, Reid SP. Chikungunya virus: Pathophysiology, mechanism, and modeling. Viruses 2017;9. pii: E368.
19Silva LA, Dermody TS. Chikungunya virus: Epidemiology, replication, disease mechanisms, and prospective intervention strategies. J Clin Invest 2017;127:737-49.
20Jain J, Nayak K, Tanwar N, Gaind R, Gupta B, Shastri JS, et al. Clinical, serological, and virological analysis of 572 chikungunya patients from 2010 to 2013 in India. Clin Infect Dis 2017;65:133-40.
21Corrin T, Waddell L, Greig J, Young I, Hierlihy C, Mascarenhas M, et al. Risk perceptions, attitudes, and knowledge of chikungunya among the public and health professionals: A systematic review. Trop Med Health 2017;45:21.
22Runowska M, Majewski D, Niklas K, Puszczewicz M. Chikungunya virus: A rheumatologist's perspective. Clin Exp Rheumatol 2018;36:494-501.
23Monge P, Vega JM, Sapag AM, Moreno I, Montúfar R, Khoury V, et al. Pan-American league of associations for rheumatology-central American, Caribbean and Andean Rheumatology Association Consensus-Conference endorsements and recommendations on the diagnosis and treatment of chikungunya-related inflammatory arthropathies in Latin America. J Clin Rheumatol 2018. doi: 10.1097/RHU.0000000000000868. [Epub ahead of print].
24Dutta SK, Bhattacharya T, Tripathi A. Chikungunya virus: Genomic microevolution in eastern India and its in silico epitope prediction 3 Biotech 2018;8:318.
25Powers AM. Vaccine and therapeutic options to control chikungunya virus. Clin Microbiol Rev 2018;31. pii: e00104-16.
26Abdelnabi R, Neyts J, Delang L. Chikungunya virus infections: Time to act, time to treat. Curr Opin Virol 2017;24:25-30.
27Subudhi BB, Chattopadhyay S, Mishra P, Kumar A. Current strategies for inhibition of chikungunya infection. Viruses 2018;10. pii: E235.
28Tharmarajah K, Mahalingam S, Zaid A. Chikungunya: Vaccines and therapeutics. F1000Res 2017;6:2114.
29Jain J, Pai S, Sunil S. Standardization of in vitro assays to evaluate the activity of polyherbal siddha formulations against chikungunya virus infection. Virus disease 2018;29:32-9.
30Chattopadhyay A, Aguilar PV, Bopp NE, Yarovinsky TO, Weaver SC, Rose JK, et al. Arecombinant virus vaccine that protects against both chikungunya and zika virus infections. Vaccine 2018;36:3894-900.
31Jain J, Kumari A, Somvanshi P, Grover A, Pai S, Sunil S, et al. In silico analysis of natural compounds targeting structural and nonstructural proteins of chikungunya virus. F1000Res 2017;6:1601.
32Paixão ES, Teixeira MG, Rodrigues LC. Zika, chikungunya and dengue: The causes and threats of new and re-emerging arboviral diseases. BMJ Glob Health 2018;3:e000530.
33Aggarwal A, Garg N. Newer vaccines against mosquito-borne diseases. Indian J Pediatr 2018;85:117-23.
34Yang S, Fink D, Hulse A, Pratt RD. Regulatory considerations in development of vaccines to prevent disease caused by chikungunya virus. Vaccine 2017;35:4851-8.
35Lyon J. Chikungunya vaccine trials begin. JAMA 2017;318:322.
36Rezza G. Do we need a vaccine against chikungunya? Pathog Glob Health 2015;109:170-3.
37Schwerdtle P, Onekon CK, Recoche K. A quantitative systematic review and meta-analysis of the effectiveness of oral cholera vaccine as a reactive measure in cholera outbreaks. Prehosp Disaster Med 2018;33:2-6.
38Blok L, Sondorp E. Cholera treatment. Lancet 1994;344:1022-3.
39Bi Q, Ferreras E, Pezzoli L, Legros D, Ivers LC, Date K, et al. Protection against cholera from killed whole-cell oral cholera vaccines: A systematic review and meta-analysis. Lancet Infect Dis 2017;17:1080-8.
40Butler T. Treatment of severe cholera: A review of strategies to reduce stool output and volumes of rehydration fluid. Trans R Soc Trop Med Hyg 2017;111:204-10.
41Cabrera A, Lepage JE, Sullivan KM, Seed SM. Vaxchora: A Single-dose oral cholera vaccine. Ann Pharmacother 2017;51:584-9.
42Levine MM, Chen WH, Kaper JB, Lock M, Danzig L, Gurwith M, et al. PaxVax CVD 103-hgR single-dose live oral cholera vaccine. Expert Rev Vaccines 2017;16:197-213.
43Mogasale V, Ramani E, Wee H, Kim JH. Oral cholera vaccination delivery cost in low- and middle-income countries: An analysis based on systematic review. PLoS Negl Trop Dis 2016;10:e0005124.
44Saha A, Rosewell A, Hayen A, MacIntyre CR, Qadri F. Improving immunization approaches to cholera. Expert Rev Vaccines 2017;16:235-48.
45Lee TH, Lee LK, Lye DC, Leo YS. Current management of severe dengue infection. Expert Rev Anti Infect Ther 2017;15:67-78.
46Carabali M, Hernandez LM, Arauz MJ, Villar LA, Ridde V. Why are people with dengue dying? A scoping review of determinants for dengue mortality. BMC Infect Dis 2015;15:301.
47Khetarpal N, Khanna I. Dengue fever: Causes, complications, and vaccine strategies. J Immunol Res 2016;2016:6803098.
48Horstick O, Tozan Y, Wilder-Smith A. Reviewing dengue: Still a neglected tropical disease? PLoS Negl Trop Dis 2015;9:e0003632.
49Ghosh A, Dar L. Dengue vaccines: Challenges, development, current status and prospects. Indian J Med Microbiol 2015;33:3-15.
50Ramakrishnan L, Pillai MR, Nair RR. Dengue vaccine development: Strategies and challenges. Viral Immunol 2015;28:76-84.
51Nedjadi T, El-Kafrawy S, Sohrab SS, Desprès P, Damanhouri G, Azhar E, et al. Tackling dengue fever: Current status and challenges. Virol J 2015;12:212.
52Lam JH, Ong LC, Alonso S. Key concepts, strategies, and challenges in dengue vaccine development: An opportunity for sub-unit candidates? Expert Rev Vaccines 2016;15:483-95.
53Precioso AR, Palacios R, Thomé B, Mondini G, Braga P, Kalil J, et al. Clinical evaluation strategies for a live attenuated tetravalent dengue vaccine. Vaccine 2015;33:7121-5.
54Shepard DS, Undurraga EA, Betancourt-Cravioto M, Guzmán MG, Halstead SB, Harris E, et al. Approaches to refining estimates of global burden and economics of dengue. PLoS Negl Trop Dis 2014;8:e3306.
55da Costa VG, Marques-Silva AC, Floriano VG, Moreli ML. Safety, immunogenicity and efficacy of a recombinant tetravalent dengue vaccine: A meta-analysis of randomized trials. Vaccine 2014;32:4885-92.
56Agarwal R, Wahid MH, Yausep OE, Angel SH, Lokeswara AW. The immunogenicity and safety of CYD-tetravalent dengue vaccine (CYD-TDV) in children and adolescents: A systematic review. Acta Med Indones 2017;49:24-33.
57Torresi J, Ebert G, Pellegrini M. Vaccines licensed and in clinical trials for the prevention of dengue. Hum Vaccin Immunother 2017;13:1059-72.
58Godói IP, Lemos LL, de Araújo VE, Bonoto BC, Godman B, Guerra Júnior AA, et al. CYD-TDV dengue vaccine: Systematic review and meta-analysis of efficacy, immunogenicity and safety. J Comp Eff Res 2017;6:165-80.
59Talbot HK. Influenza in older adults. Infect Dis Clin North Am 2017;31:757-66.
60Kumar V. Influenza in children. Indian J Pediatr 2017;84:139-43.
61Rotrosen ET, Neuzil KM. Influenza: A Global perspective. Pediatr Clin North Am 2017;64:911-36.
62Koutsakos M, Nguyen TH, Barclay WS, Kedzierska K. Knowns and unknowns of influenza B viruses. Future Microbiol 2016;11:119-35.
63Shim JM, Kim J, Tenson T, Min JY, Kainov DE. Influenza virus infection, interferon response, viral counter-response, and apoptosis. Viruses 2017;9. pii: E223.
64Tsang TK, Lau LL, Cauchemez S, Cowling BJ. Household transmission of influenza virus. Trends Microbiol 2016;24:123-33.
65Sooryanarain H, Elankumaran S. Environmental role in influenza virus outbreaks. Annu Rev Anim Biosci 2015;3:347-73.
66Lam W, Dawson A, Fowler C. Health promotion interventions to prevent early childhood human influenza at the household level: A realist review to identify implications for programmes in Hong Kong. J Clin Nurs 2015;24:891-905.
67Tyrrell BE, Sayce AC, Warfield KL, Miller JL, Zitzmann N. Iminosugars: Promising therapeutics for influenza infection. Crit Rev Microbiol 2017;43:521-45.
68Amarelle L, Lecuona E, Sznajder JI. Anti-influenza treatment: Drugs currently used and under development. Arch Bronconeumol 2017;53:19-26.
69Haugh M, Gresset-Bourgeois V, Macabeo B, Woods A, Samson SI. A trivalent, inactivated influenza vaccine (Vaxigrip®): Summary of almost 50 years of experience and more than 1.8 billion doses distributed in over 120 countries. Expert Rev Vaccines 2017;16:545-64.
70Bui C, Bethmont A, Chughtai AA, Gardner L, Sarkar S, Hassan S, et al. Asystematic review of the comparative epidemiology of avian and human influenza A H5N1 and H7N9 – Lessons and unanswered questions. Transbound Emerg Dis 2016;63:602-20.
71Mertz D, Geraci J, Winkup J, Gessner BD, Ortiz JR, Loeb M, et al. Pregnancy as a risk factor for severe outcomes from influenza virus infection: A systematic review and meta-analysis of observational studies. Vaccine 2017;35:521-8.
72Hampson A, Barr I, Cox N, Donis RO, Siddhivinayak H, Jernigan D, et al. Improving the selection and development of influenza vaccine viruses – Report of a WHO informal consultation on improving influenza vaccine virus selection, Hong Kong SAR, China, 18-20 November 2015. Vaccine 2017;35:1104-9.
73Hirve S, Lambach P, Paget J, Vandemaele K, Fitzner J, Zhang W, et al. Seasonal influenza vaccine policy, use and effectiveness in the tropics and subtropics – A systematic literature review. Influenza Other Respir Viruses 2016;10:254-67.
74Thomas RE. Are influenza-associated morbidity and mortality estimates for those ≥65 in statistical databases accurate, and an appropriate test of influenza vaccine effectiveness? Vaccine 2014;32:6884-901.
75Young B, Zhao X, Cook AR, Parry CM, Wilder-Smith A, I-Cheng MC, et al. Do antibody responses to the influenza vaccine persist year-round in the elderly? A systematic review and meta-analysis. Vaccine 2017;35:212-21.
76Koszalka P, Tilmanis D, Hurt AC. Influenza antivirals currently in late-phase clinical trial. Influenza Other Respir Viruses 2017;11:240-6.
77de Boer PT, van Maanen BM, Damm O, Ultsch B, Dolk FC, Crépey P, et al. Asystematic review of the health economic consequences of quadrivalent influenza vaccination. Expert Rev Pharmacoecon Outcomes Res 2017;17:249-65.
78Sano K, Ainai A, Suzuki T, Hasegawa H. The road to a more effective influenza vaccine: Up to date studies and future prospects. Vaccine 2017;35:5388-95.
79Pasquini-Descomps H, Brender N, Maradan D. Value for money in H1N1 influenza: A Systematic review of the cost-effectiveness of pandemic interventions. Value Health 2017;20:819-27.
80Ramsay LC, Buchan SA, Stirling RG, Cowling BJ, Feng S, Kwong JC, et al. The impact of repeated vaccination on influenza vaccine effectiveness: A systematic review and meta-analysis. BMC Med 2017;15:159.
81Purohit V, Kudale A, Sundaram N, Joseph S, Schaetti C, Weiss MG, et al. Public health policy and experience of the 2009 H1N1 influenza pandemic in Pune, India. Int J Health Policy Manag 2017;7:154-66.
82Rewar S, Mirdha D, Rewar P. Treatment and prevention of pandemic H1N1 influenza. Ann Glob Health 2015;81:645-53.
83D'Silva J. Swine flu: How well did India respond? BMJ 2015;350:h2286.
84Ouattara A, Laurens MB. Vaccines against malaria. Clin Infect Dis 2015;60:930-6.
85Oyo-Ita A, Wiysonge CS, Oringanje C, Nwachukwu CE, Oduwole O, Meremikwu MM, et al. Interventions for improving coverage of childhood immunisation in low- and middle-income countries. Cochrane Database Syst Rev 2016;7:CD008145.
86Mueller I, Shakri AR, Chitnis CE. Development of vaccines for Plasmodium vivax malaria. Vaccine 2015;33:7489-95.
87Kumar S, Kumari R, Pandey R. New insight-guided approaches to detect, cure, prevent and eliminate malaria. Protoplasma 2015;252:717-53.
88Singh K, Mehta S. The clinical development process for a novel preventive vaccine: An overview. J Postgrad Med 2016;62:4-11.
89Hollingdale MR, Sedegah M, Limbach K. Development of replication-deficient adenovirus malaria vaccines. Expert Rev Vaccines 2017;16:261-71.
90Aide P, Aponte JJ, Renom M, Nhampossa T, Sacarlal J, Mandomando I, et al. Safety, immunogenicity and duration of protection of the RTS, S/AS02(D) malaria vaccine: One year follow-up of a randomized controlled phase I/IIb trial. PLoS One 2010;5:e13838.
91Abdulla S, Salim N, Machera F, Kamata R, Juma O, Shomari M, et al. Randomized, controlled trial of the long term safety, immunogenicity and efficacy of RTS, S/AS02(D) malaria vaccine in infants living in a malaria-endemic region. Malar J 2013;12:11.
92Seder RA, Chang LJ, Enama ME, Zephir KL, Sarwar UN, Gordon IJ, et al. Protection against malaria by intravenous immunization with a nonreplicating sporozoite vaccine. Science 2013;341:1359-65.
93Mwangoka G, Ogutu B, Msambichaka B, Mzee T, Salim N, Kafuruki S, et al. Experience and challenges from clinical trials with malaria vaccines in Africa. Malar J 2013;12:86.