Young adult immunization initiative (YUVA/YAII): A policy framework for India’s life-course vaccination strategy

The epidemiological case for young adult immunization

HPV prevalence among women aged 18-25 yr reached 19 per cent, with over 65 per cent carrying high-risk types such as HPV 16 in a 2012 survey of tribal women.⁶ Urban studies report prevalence around 13 per cent in women aged 16-26 yr, and acquisition rates remain high among sexually active young women^9,10. Cervical cancer caused ∼77,000 deaths annually in the year and contributed to anal, penile, and oropharyngeal cancers in men¹¹. The disease burden exceeds 1.5 million disability-adjusted life years (DALYs) annually as of year 2025, with 10 per cent of cases diagnosed under the age of 35 yr, underscoring early infection risk and the need for timely prevention¹².

HBV also imposes a significant burden. India harbours an estimated 37-40 million carriers¹¹ and studies show high HBsAg prevalence in the 21-40 yr age group¹³. Despite routine childhood vaccination, coverage gaps persist - only 22.7 per cent of surveyed adults reportedly completing the HBV series, leaving young adults vulnerable to acute infection and long-term complications such as cirrhosis and liver cancer¹⁴. Low awareness and incomplete coverage heighten HBV risk, with liver disease costing India tens of billions annually in treatment and lost productivity¹⁵.

Hepatitis A virus (HAV), once a childhood infection, now increasingly affects adolescents and young adults, causing more severe illness and economic disruption¹⁶. HPV, HBV, and HAV remain key burdens, while outbreaks of measles, varicella, influenza, typhoid, and JE underscore the need for a bundled approach. These preventable infections drive cancer, liver disease, and acute hepatitis in India’s most productive age group, making young adult immunization a public health and economic priority.

Social and economic rationale

India’s demographic dividend depends on young adults, whose health is vital for sustaining productivity and resilience. Cervical cancer treatment costs reportedly range from INR 19,494 to INR 41,388 per patient, with catastrophic health expenditure affecting over 60 per cent of households as of yr 2020¹⁷, while HBV-related liver disease imposes a substantial national economic burden. Cost-effectiveness modeling from Tamil Nadu demonstrates that early HBV diagnosis and vaccination can save approximately INR 180,000 per 1,000 population and gain 505 quality-adjusted life years (QALYs)¹⁸ as of yr 2020. Preventing HPV-related cancers and hepatitis-driven liver disease can avert catastrophic costs, safeguard earning potential, and ease long-term pressure on insurance systems. Chronic illness also drives productivity losses: 6.9 per cent of adults aged 45-64 report completely stopping work, while 22.7 per cent report limiting paid work due to health problems¹⁹ as of yr 2017-2018, underscoring the economic imperative for preventive immunization.

Adult immunization is concentrated in private urban markets, rationed by ability to pay, leaving rural and marginalised groups excluded. Expanding publicly financed, accessible vaccination for young adults is both an equity obligation and an economic efficiency measure that aligns household welfare with national growth.

Policy gaps and missed opportunities

India lacks a coherent framework for young adult immunization; programmes end at adolescence with no mechanism to provide catch-up or vaccines relevant to sexually active and mobile populations. The 2024 Routine Immunization Manual (MoHFW) focuses on childhood immunization and provides no framework for adults²⁰. Previously published reports, noting the policy vacuum, have called for a structured approach to adult immunization^7,21.

Western models highlight contrasts: the UK achieves high HPV coverage through school programmes at ages 12–13 yr²², while the USA enforces college-entry vaccine mandates and workplace flu campaigns²³, relying on compliance and insurance incentives absent in India. School-based delivery is impractical for India’s 18-35 yr age group due to high dropout rates (14% at secondary, retention to higher secondary ∼45%)²⁴, low tertiary enrolment (GER ∼28%)²⁵, and youth mobility (migration rate ∼29%, ∼5% employment-related)²⁶. Instead, feasible platforms include colleges, workplaces, PHCs, and harm-reduction hubs, supported by Covid Vaccine Intelligence Network (CoWIN) and Ayushman Bharat Digital Mission (ABDM) for portability and equity dashboards. Rather than replicating Western mandates, India can adapt their intent - routine access and cohort reach, through opt-in consent, public financing, and interoperable registries.

Regulatory and ethical considerations are critical in these settings. Informed consent must be voluntary, informed, and documented, with disclosure of benefits, risks, and alternatives. Digital platforms can operationalize consent management through secure, opt-in mechanisms, ensuring privacy and compliance with India’s Health Data Management Policy. These safeguards are essential to maintain trust and uphold ethical standards.

Stigma and misinformation deepen these gaps: HPV is miscast as a “girls’ vaccine,” and hepatitis vaccines are poorly understood. Overcoming these barriers is vital for equitable uptake and a stronger young adult immunization framework. This paper envisions a mission-driven policy framework for the young adult populations of India (Box).

Integration with Harm Reduction

A distinctive feature of YUVA is its integration with harm-reduction services. According to the 2019 ‘Magnitude of Substance Use in India’ report, ⁓2.8 per cent of Indians aged 10-75 yr were cannabis users while 2.1 per cent used opioids and an estimated 850,000 people were injecting drug users (PWIDs)²⁷. NACO through NACP-V (2021–2026)²⁸, designates NSPs and OST as core prevention services for PWIDs. Operational guidelines for bridging populations²⁹ and the Link Worker Scheme 2.0³⁰ emphasize community-based outreach and referral pathways, creating a strong foundation for embedding vaccination within these hubs.

Financing and affordability

The economic burden of HPV-related cancers, hepatitis-driven liver disease, and STI complications far exceeds prevention costs, positioning immunization as an investment. YUVA is feasible due to low-cost indigenous vaccines, minimal marginal costs through existing infrastructure, and blended financing via NHM, CSR, and philanthropy, aligning with SDG 17’s shared-responsibility framework.

Risks and mitigation

YUVA faces predictable challenges, including HPV vaccine hesitancy if framed as gender-specific, mitigated through gender-neutral messaging, youth-led campaigns, and routine adult health delivery. Supply and logistics risks including cold-chain gaps beyond paediatric systems are addressed through phased rollout and indigenous production. Digital exclusion is mitigated via dual paper-digital records. Political contestation and programme fatigue are reduced by aligning YUVA with national missions, piloting through state programmes, integrating delivery into colleges, workplaces, and harm-reduction clinics, and sustaining transparency through external evaluations and public dashboards.

Overall, young adult immunization is a critical but overlooked component of India’s life-course vaccination strategy. The YUVA framework offers a pathway to close this gap by leveraging existing infrastructure, digital platforms, and youth-centred delivery points. The benefits are clear: protecting young adults against HPV-related cancers, hepatitis-driven liver disease, and other vaccine-preventable infections can reduce catastrophic health costs and strengthen workforce productivity. Pilot implementation in two to three states, supported by cost-effectiveness modelling and stakeholder consultation, is essential for policy translation. Investing in young adult immunisation is a strategic choice for equity, economic resilience, and future vaccine preparedness. YUVA represents India’s first integrated immunization platform for young adults. Implemented effectively, it can protect the demographic dividend and strengthen public health resilience over the coming decades.