Vaccinations for the Older Adult

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Key points

  • Influenza vaccines reduce clinical influenza in outpatient elderly adults, more so after vaccination with the high-dose vaccine.

  • Standard-dose vaccines that are well matched to circulating influenza also reduce hospitalization risk in older adults compared with those who are not vaccinated.

  • The 13-valent pneumococcal conjugate vaccine reduces both vaccine-specific invasive disease and pneumonia in older adults as well as nasal colonization and, hence, reduced transmissibility.

  • The increase in

Influenza Epidemiology

Influenza and pneumonia remain the leading cause of infectious morbidity and mortality for older adults. Influenza accounts for more than three-quarters of incident vaccine-preventable disease in people 65 years of age and older, some 4 million cases each year in the United States.4 It also is responsible for half the health care costs for vaccine-preventable disease (see Table 1). More than 90% of influenza deaths occur in patients 65 years of age and older,5 and the likelihood of dying

Influenza vaccines and vaccine administration

Over the last few years, the FDA approved several new influenza vaccines for use in the United States. These vaccines include a recombinant egg-free manufacturing process for one of the influenza vaccines, so an egg allergy need no longer be a concern for those receiving the influenza vaccine; quadrivalent influenza vaccines, which are replacing trivalent vaccines and include an additional influenza B virus antigen; cell-culture-based influenza vaccine; high-dose influenza vaccine; and

Influenza vaccination of health care workers

A separate issue of note to health care personnel (HCP) is that they themselves should receive the annual influenza vaccine. All paid and unpaid individuals working in a health care setting who have the potential for exposure to patients should be considered HCP. For HCP younger than 65 years of age, there are more vaccine options available, including both an intranasal and intradermal quadrivalent vaccine.24 HCP immunization is recommended to prevent the spread of infection, especially to

Epidemiology of Pneumococcal Disease

Pneumococcal pneumonia, which may occur after influenza, has a mortality rate higher than any other vaccine-preventable disease, with an estimated 40,000 deaths annually.31 Although pneumococcal pneumonia is the most common clinical presentation of pneumococcal disease in adults, serious complications, such as meningitis and bacteremia, are more likely in older adults, children, and those living with chronic diseases.5 Further, antibiotic resistance is a continuing problem worldwide and

Polysaccharide pneumococcal vaccine

The 23 antigens in PPSV-23 represent the strains most commonly associated with both noninvasive and invasive pneumococcal disease. The vaccine seems to reduce vaccine-strain bacteremia, but its effectiveness has been less adequate for other types of pneumococcal disease. This ineffectiveness led to the development of a new-generation conjugate vaccine (PCV)5 and to dual recommendations for immunization with the new PCV-13 as well as PPSV-23 to maximize coverage across strains and immunity.

Conjugated pneumococcal vaccines

In 2000, the PCV with 7 antigens (PCV-7) was licensed for use in children. It was shown to generate a memory response by both B and T cells. Immunization of children with the conjugate vaccine induces antibodies that clear nasopharyngeal carriage, and this presumably has led to clearance of localized and nonbacteremic infections like otitis media by strains included in the vaccine.37

PCV-7 reduces IPD by 97%; it also reduces episodes of radiograph-confirmed pneumonia, acute otitis media,

Pneumococcal vaccine administration recommendations

One dose of PCV-13 vaccine is recommended for all adults 65 years of age and older who have not previously received a pneumococcal vaccine. A dose of PPSV-23 is recommended 6 to 12 months later. People who have already received PPSV-23 vaccine before reaching their 65th birthday should receive one dose of PCV-13 at least 1 year after receiving their most recent PPSV-23. After at least a 6-month interval following PCV-13 and at least after 5 years after the first dose of PPSV-23 vaccine, another

Individuals with chronic disease and immunocompromised states

The recommendation for those with chronic conditions (heart disease except hypertension, lung disease including asthma, liver disease including cirrhosis, diabetes, and alcoholism) and residents of long-term care facilities mirror those of older adults, with the age restriction starting at 19 years of age.24

For people with immunocompromised states (including human immunodeficiency virus infection), chronic renal failure, nephritic syndrome, or asplenia, a PCV-13 vaccine followed at an 8-week

Tetanus

Although tetanus incidence remains low in the United States, it continues to cause serious health problems, principally for older adults. Caused by the toxin produced by Clostridium tetani spores, tetanus occurs almost exclusively in people with no or little antibody to tetanus toxin. Clinical manifestations follow inoculation via puncture or laceration. Classic signs include prolonged spasms of the flexor and extensor muscle groups. Progression to generalized flexion contractures and masseter

Diphtheria

Diphtheria is caused by Corynebacterium diphtheriae. Although diphtheria still occurs around the world, it is rare in the United States, with only a few cases reported per year. Widespread use of diphtheria toxoid limits annual incidence, with most cases occurring in unimmunized or inadequately immunized individuals.5 Vaccination remains an effective strategy to limit the incidence of diphtheria.

Pertussis

Pertussis, or whooping cough, is caused by the bacterium Bordetella pertussis. It can cause uncontrollable, violent coughing that makes it hard to breath and is often accompanied by the need to take deep breaths resulting in the characteristic whooping sound. Pertussis can be contracted by persons of all ages but is especially serious for infants. It is a disease that only occurs in people who serve as the reservoir for the bacteria. The introduction of pertussis vaccine first for children, and

Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccination

Tetanus-diphtheria toxoids and acellular pertussis are among the most immunogenic vaccines approved for older adults. They are considered 100% effective for immunocompetent persons with up-to-date vaccination status. Natural immunity to tetanus does not occur, and natural immunity to diphtheria and pertussis occurs in only a subset of cases. Primary vaccination with tetanus toxoid provides 10 or more years of protection. Reemergence of pertussis in the United States and of diphtheria in Sweden

Summary

The number and variety of vaccines available and recommended for older adults is increasing, as are the vaccination schedules, creating a challenge for providers to keep their patients up to date with the correct dosing and schedule (Table 4). In general, intramuscular vaccines cause local reactions, including mild local pain and erythema, usually lasting only a few days. Typically, the more immunogenic vaccines have slightly more local reactogenicity; but severe reactions are equally uncommon

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  • Cited by (12)

    • The public health value of vaccination for seniors in Europe

      2018, Vaccine
      Citation Excerpt :

      A similar trend was observed in most EU countries [9]. Data from the United States (US) show that influenza accounts for more than three-quarters of incident vaccine-preventable diseases in senior, and for half of the healthcare costs for vaccine-preventable disease [10]. Pneumococcal diseases are caused by Streptococcus pneumoniae bacteria, sometimes referred to as pneumococcus.

    View all citing articles on Scopus

    Funding source: Grant support from Sanofi Pasteur (G. Gnanasekaran, H.E. Davidson, S. Gravenstein); no funding (R. Biedenbender).

    Conflict of interest: No disclosures (G. Gnanasekaran, R. Biedenbender); grant support from Sanofi Pasteur (H.E. Davidson); consultant or speakers bureau for Merck, Novartis, Novavax, Pfizer, Sanofi Pasteur in the last year. Grant support from Sanofi Pasteur (S. Gravenstein).

    View full text