© JAPI • APRIL 2009 • VOL. 57 345 Introduction C onsiderable controversy exists regarding adult immunization especially in developing countries, such as India. Even among the published guidelines from international organizations, like the World Health Organization (WHO) and other professional associations from the developed countries, there is a lack of consensus regarding the optimal strategy for adult immunization. Moreover, these guidelines do not address the issue of adult immunization in developing countries like India. 1-6 On the other hand, pediatric immunization programs have been one of the most successful public health interventions in India also. Therefore, the Association of Physicians of India (API) decided to fill this void regarding technical guidance for adult immunization strategies in India. To address the issue, an Expert Group Meeting for evolving Consensus Recommendations on Adult Immunization in India was jointly organized by the Association of Physicians of India and the Department of Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, at the AIIMS on December 6-7, 2008. Epidemiology, Vaccine Efcacy and Safety The Expert Group observed that reliable epidemiological data regarding the burden of infectious diseases (also true for non-infectious diseases) from India were lacking. The Expert Group felt that sparse published data are available from India regarding the efcacy and safety of various adult immunization strategies. Furthermore, the issue of paucity of data regarding objective monitoring of the adequacy of immunization (e.g., optimal antibody titre) against various infectious diseases was also discussed. The Expert Group, therefore, felt that there is an urgent need for collecting and periodically updating reliable epidemiological data; generating efcacy and safety data regarding various adult immunization strategies; and documenting the adequacy of immunization from India. The Expert Group was of the opinion that these recommendations should be periodically reviewed, updated, refined and reissued as and when new data become available. The Expert Group proposes that the Consensus Guidelines should be reviewed every 3 years to incorporate modifcations of any emerging research from our country. It was sincerely hoped by the Expert Group that health care professionals should sensitize themselves regarding operational research as a part of their professional duty so that more indigenous evidence-based interventions can be generated for the beneft of our population. However, the Expert Group fully appreciates the limitations faced by the health care professionals working in resource constrained settings in India. The current consensus guidelines of the Expert Group are an amalgamation of the available data from our country as well as other countries extrapolated to Indian conditions, keeping in view the cost-effectiveness of immunization in adults in a vast country like India with limited resources. Depending on the available published data, the different levels of evidence and recommendations cited in these adult immunization guidelines have been given a grading as shown in Table 1. This document can serve as a template to guide national API Guidelines Members of the Advisory Board on Adult Immunization: S.K. Sharma (Chief, Division of Pulmonary, Critical Care, and Sleep Medicine, Professor and Head, Department of Medicine, All India Institute of Medical Sciences, New Delhi), Y.P. Munjal (Editor-in-Chief, API Textbook of Medicine, Past-President Association of Physicians of India and Past-Dean Indian College of Physicians), A.K. Agarwal (President, Association of Physicians of India), Chief Consultant in Medicine, Professor and Head, PGIMER, Dr. RML Hospital, New Delhi; and R.K. Singal (Past-President, Association of Physicians of India) Senior Consultant Medicine, BLK Memorial Hospital, New Delhi. Executive Summary The Association of Physicians of India Evidence-Based Clinical Practice Guidelines on Adult Immunization Expert Group of the Association of Physicians of India on Adult Immunization in India Table 1 : Diferent levels of evidence Grading of evidence Ia: systematic review or meta-analysis of randomized controlled trials Ib: at least one randomized controlled trial lIa: at least one well-designed controlled study without randomization IIb: at least one well-designed quasi-experimental study, such as a cohort study III: well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, case-control studies, and case series IV: expert committee reports, opinions, and/or clinical experience of respected authorities Grading of recommendations A: based on hierarchy I evidence B: based on hierarchy II evidence or extrapolated from hierarchy I evidence C: based on hierarchy III evidence or extrapolated from hierarchy I or II evidence D: directly based on hierarchy IV evidence or extrapolated from hierarchy I, II, or III evidence