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Immunization for the Elderly
MAZEN S. BADER, MD, MPH
ABSTRACT: The morbidity and mortality of vaccinepreventable diseases among older adults are high. Despite the benefits of elderly vaccination, vaccination
rates remain low and especially among some minority
groups. Specific strategies for improving the rate of
vaccination have been developed for medical offices
and clinics, hospitals, and other health care institutions.
There are vaccines that are recommended routinely for
the elderly while other vaccines are recommended in
certain circumstances. Knowing the indications, contraindications, and adverse reactions to the recommended
vaccines for the elderly is very important to the primary
care physicians. KEY INDEXING TERMS: Immunization;
Elderly; Influenza; Pneumococcal vaccine; Herpes-zoster vaccine. [Am J Med Sci 2007;334(6):481–486.]
I
number of older persons is increasing, particularly
persons ages ⬎85 years.5 Influenza-related deaths
can result from pneumonia and from exacerbations
of cardiopulmonary conditions. Influenza and its
complications can be prevented with either influenza vaccination or antiviral prophylaxis with neuroaminidase inhibitors. Prevention of influenza with
neuroaminidase inhibitors is only supportive to the
vaccine because of its lower cost-to-benefit ratio.
Immunity to the surface antigens, particularly the
hemagglutinin, by inducing specific antibody production reduces the likelihood of infection and severity of disease if infection occurs.6 The effectiveness of
inactivated influenza vaccine depends primarily on
the age and immunocompetence of the vaccine recipient, and the degree of similarity between the
viruses in the vaccine and those in circulation. Older
persons might have lower postvaccination antibody
titers than healthy young adults and can remain
susceptible to influenza virus infection and influenza-related upper respiratory tract illness.7 In the
40% to 60% of elderly patients in whom the influenza vaccine produces the desired immunity, an
effective immune response can be mounted within
10 to 14 days of vaccination.8 Prevaccination titers
and the number of previous influenza vaccinations
have been identified as factors that influence postvaccination titers. Having one or more vaccinations
over the previous 4 years confers greater reduction
in mortality than first-time immunization.9 Among
older persons who reside in nursing homes the vaccine can be 50% to 60% effective in preventing influenza-related hospitalization or pneumonia, 80%
effective in preventing influenza-related death, and
30% to 40% effective in preventing influenza illness.10 However, the effectiveness of influenza vaccine in community-dwelling elderly is modest.11
Moreover, economic studies of influenza vaccination
in persons older than 65 years conducted in the
nfectious diseases, particularly influenza and
pneumonia, are the fifth leading cause of death
among older adults.1 Immunization is one of the
most effective means of preventing disease, disability, and death from infectious diseases. By the time
most people reach old age, they have been immunized or exposed to many disorders. Nonetheless,
they still need immunizations.
Despite the benefits of elderly vaccination, vaccination rates remain low and especially among some
minority groups. Influenza vaccination coverage
among adults ages ⬎65 years is 65% which remain
below the Healthy People 2010 objective of 90%
coverage nationwide. Despite increase in the pneumococcal vaccination coverage among adults ages
ⱖ65 years from 1997 to 2005, 25% of older adults
have reported never having received pneumococcal
vaccine.2 Strategies for increasing vaccination rates
among older adults are summarized in Table 1.3
In this review we will focus on the routinely recommended vaccinations for elderly individuals (Table 2).
Influenza Vaccine
Although influenza is a very common, moderate,
and self-limited viral infection, it could be seriously
complicated in elderly. Approximately 90% of influenza-related deaths occur among adults ages ⱖ65
years.4 In the United States, the number of influenzaassociated deaths has increased in part because the
From the Division of Infectious Diseases, Memorial University
School of Medicine, St. John’s, Newfoundland, Canada.
Submitted May 18, 2007; accepted in revised form July 27,
2007.
Correspondence: Dr. Mazen S. Bader, Memorial University of
Newfoundland Health Sciences Center, 300 Prince Phillip Drive,
1J426, St. John’s, NL A1B3V6. Canada (E-mail: msbader1@
hotmail.com.).
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
481
Immunization for the Elderly
Table 1. Interventions to Increase Vaccination Rates Among
Older Adults*
Intervention
Comments
Patient reminder/recall
systems
Reminders that vaccinations are
due or late through telephone
calls, letters, or postcards
This can include free vaccination
and insurance coverage
Reducing distance from setting to
patients Expanding access
through more convenient
hoursProviding vaccination in the
inpatient settings Providing a
well-publicized day for free
influenza vaccination of all
employees at the work site
(hospital, long-term care facility)
This can include both vaccines
administration and education
Reminders to who administer
vaccinations that patients are due
or overdue through patient’s
chart, computer, and mail
This involves assessing the
performance of providers in
delivering recommended vaccines
to their patients and giving this
information to the providers
This involves administration of
vaccines to patients by
nonphysician medical personnel
through a protocol without
physician involvement at clinics,
hospitals, and nursing homes
Reducing out-of-pocket
costs
Expanding access in
medical or public
health clinical
settings
Home visits
Provider reminder
Assessment and
feedback for
vaccination providers
Standing orders
* References 3.
United States have reported overall societal cost
savings.5
There are 2 types of licensed influenza vaccines
in the United States: inactivated influenza vaccine
and live attenuated inhaled influenza vaccine. Live
attenuated inhaled influenza vaccine (FluMist) has
not been approved in persons ages 50 years and
older.5
The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and
Prevention (CDC) recommends annual influenza
vaccination for all adults ages 50 years and older
and for all residents of long-term care facilities.5
Immunization should be administered shortly before the anticipated onset of influenza season. In the
United States, this usually corresponds to mid-October through mid-November. However, health-care
providers should continue to offer influenza vaccine
during December and throughout the influenza season, even after influenza activity has been documented in the community.
The committee also recommends vaccination for
persons who could transmit influenza to elderly patients, such as healthcare personnel, employees of
long-term care facilities, providers of home care to
people at high risk, and household contacts (includ482
ing children). Vaccination of healthcare workers has
been associated with fewer deaths among nursing
home patients.12
Inactivated influenza vaccine is most commonly
associated with mild local reactions such tenderness
at vaccination site. Systemic symptoms (eg, fever,
malaise, myalgia, and headache) are rare among
vaccinated older adults. Immediate, presumably allergic, reactions (eg, hives, angioedema, allergic
asthma, and systemic anaphylaxis) rarely occur after influenza vaccination. These reactions probably
result from hypersensitivity to residual egg protein
or thimerosal, which is a mercurial antibacterial
agents acting as a preservative. The currently licensed inactivated influenza vaccine has either no or
minimal amount of thimerosal mercury, ⬍1.25 ␮h
Hg/0.5 mL dose, except the 5.0-mL multidose vial
which contains approximately 25 ␮h Hg of mercury
as a preservative.5 Persons with a history of severe
hypersensitivity, such as anaphylaxis, to eggs
should not receive influenza vaccine.5 Evidence for a
causal relation of Guillian-Barre syndrome (GBS)
with influenza vaccine is unclear. The potential benefits of influenza vaccination in preventing serious
illness, hospitalization, and death among older
adults substantially outweigh the possible risk for
experiencing vaccine-associated GBS.5
Pneumococcal Vaccine
Pneumococcal disease is a significant cause of
morbidity and mortality in the elderly. The case
fatality rate of invasive pneumococcal disease increase from 20% for those ages ⱖ65 years to 40% for
those ages ⱖ85 years.13
The currently available pneumococcal polysaccharide vaccine (PPV) includes 23 purified capsular
antigens. These serotypes in the vaccine represent
85% to 90% of serotypes that cause invasive pneumococcal disease in the United States.14 Pneumococcal capsular polysaccharide antigens induce typespecific antibodies that enhance opsonization,
phagocytosis and killing of pneumococci by leukocytes. The antibodies against pneumococcal antigens remain elevated for at least 5 years in healthy
adults.15 The vaccine protects against invasive
pneumococcal diseases such as bacteremia, pneumonia with bacteremia, and meningitis. However, it is
less effective for preventing pneumonia without bacteremia.16 The vaccine should be regarded as 23
different vaccines, rather than 1. Older persons who
fail to respond to one serotype may well be protected
against infection by the other 22 serotypes. Pneumococcal vaccination was found to cost-saving among
adults ages ⱖ65 years.17
The vaccine is administered intramuscularly, not
intradermally which can cause severe local reaction.
It can be administered with other vaccines such as
influenza vaccine, but at a separate site. ApproxiDecember 2007 Volume 334 Number 6
Bader
Table 2. Routinely Recommended Vaccines for the Elderly*
Pneumococcal
Polysaccharide
Vaccine
Inactivated Influenza
Vaccine
Type of vaccine
Killed or inactivated
virus
Indications for
vaccination
All adults ⱖ50 years
of age
Contraindication
for vaccination
Severe hypersensitivity
reaction to the
vaccine or eggs
Revaccination
schedule
Annually
Varicella-Zoster
Vaccine
Tetanus and Diphtheria
Vaccine
23-Valent purified
bacterial capsular
polysaccharides
All adults ⱖ65 years
of age
Live attenuated virus
Bacterial toxoids
All adults ⱖ60 years
of age
Severe allergic
reaction to the vaccine
All previously
unvaccinated
adults Patients with
contaminated
wound if ⬎5 years have
elapsed since last dose
Severe allergic reactions
to the vaccine
Immunocompromised adults
such as those with leukemia,
lymphoma, or generalized
malignancy and in patients
receiving chemotherapy,
radiation, and large doses of
corticosteroids. Persons with
active, untreated tuberculosis
and with anaphylactic reaction
to neomycin or gelatin
None
Every 10 years
One-time revaccination
after 5 yr for adults
ⱖ65 years of age if
first dose before age 65
Intramuscular injection Intramuscular injection
Subcutaneous injection
Route of
administration
Can be given
Yes
simultaneously
with other
vaccines
Yes
Yes
Yes
* References 4, 13, 17, 25, and 29.
mately one-third of persons who receive pneumococcal vaccine develop mild local side effects such as
erythema, pain, or swelling. These local side effects
are more common with revaccination with pneumococcal polysaccharide vaccine than with initial vaccination. Systemic reaction such as fever and myalgias are very rare.14
PPV is recommended for all persons 65 years and
older. The ACIP does not recommend routine revaccination with the vaccine every 5 years. The ACIP
recommends that persons ages 65 years and older
who were initially vaccinated before age 65 should
receive only one revaccination provided that at least
5 years have elapsed since the initial vaccination.
Furthermore, 1-time revaccination after 5 years is
recommended for older adults with chronic renal
failure or nephritic syndrome, immunosuppressive
conditions such as leukemia, lymphoma, generalized malignancy, organ or bone marrow transplantation, and multiple myeloma, or chemotherapy
with alkylating agents, antimetabolites, or highdose, long-term corticosteroids.18
The 7-valent conjugate pneumococcal vaccine is
not recommended for older adults. However, vaccination of young children with the conjugate pneumococcal vaccine has significantly reduced the inciTHE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
dence of pneumonia caused by only the 7 conjugate
vaccine serotypes among older adults.19
Herpes Zoster Vaccine
Varicella-zoster virus (VZV) causes chickenpox as
a primary infection and herpes zoster (HZ) or shingles as a reactivation form of the infection. About
25% of people develop zoster during their lifetime,
and there are about 1 million cases of shingles per
year. The risk is highest in the elderly, where more
that two-thirds of cases occur in people over the age
of 50 years.20 Postherpetic neuralgia (PHN) is the
most debilitating complication of HZ. Both the incidence and the duration of postherpetic neuralgia are
directly related to increasing age.21 This increase in
the incidence of zoster among older adults is due to
a decline in specific cell-mediated immune responses
to (CMI) VZV with advancing age. A single dose of
live attenuated zoster vaccine substantially reduced
the risk for HZ (by 51%) and PHN (by 67%) by
increasing VZV-specific CMI in older adults 60 years
of age and older over 5.5 years. The vaccine is not
100% effective in preventing HZ. However, cases of
HZ and PHN after vaccination appear to be much
milder than in those people who develop HZ in the
483
Immunization for the Elderly
absence of vaccination. The vaccine was more efficacious in preventing HZ among persons who were 60
to 69 years of age than among those who were 70
years or older. On the other hand, the vaccine prevented postherpetic neuralgia to a greater extent
among adults ages 70 or more years.22 VZV vaccination improved the quality of life among older adults
because of prevention of both acute pain associated
with HZ and postherpetic neuralgia. The cost-effectiveness of the varicella zoster vaccine varies substantially with patient age and often exceeds $100,000 per
quality-adjusted life-year saved.23
The ACIP has recommended people age 60 and
older receive zoster vaccine (Zostavax) once regardless of previous history of chickenpox or HZ.24 It is
administered subcutaneously as a single 0.65-mL
dose. It must be stored in a freezer with an average
temperature of –15°C (5°F) and should not be used if
a temperature deviation above –5°C (23°F).25,26 If
the vaccine is not used with 30 minutes after reconstitution with the supplied diluent, it should be
discarded. Although the current recommendation is
to vaccinate the elderly once with Zostavax, it is not
clear how long the boosted immunity will last and
whether an additional booster vaccination will be
required. The current vaccine resulted in increased
VZV-specific CMI for up to 5 years.27 It is contraindicated in people with active, untreated tuberculosis
and in immunocompromised adults such as those
with leukemia, lymphoma, or generalized malignancy and in patients receiving chemotherapy, radiation, and large doses of corticosteroids. The vaccine should not be administered to persons with a
history of anaphylactic reaction to gelatin, neomycin, or any other vaccine component. In general,
adverse reactions associated with Zostavax are limited to injection-site reactions, such as pain, erythema or swelling, itching, and headache. Rarely,
zosteriform rash due to preexisting wild-type virus
has been reported at the injection site within the
first 42 days after vaccination. Cardiac events occurred more often among the vaccine recipients than
among the placebo recipients.28
Tetanus Toxoid
Tetanus in the United States is most commonly
reported in older persons who are less likely to be
adequately vaccinated than younger persons. In
2004, 47% of the 34 cases reported were among
persons ⬎60 years of age. 94% of persons who contract tetanus in the United States are not up-to-date
on tetanus vaccination or have never received the
primary series.29 Tetanus toxoid consists of a formaldehyde-treated toxin. There are 2 types of toxoids
available, adsorbed toxoid and fluid toxoid and adsorbed toxoid is preferable because of higher and
longer standing antitoxin titers. Tetanus toxoid is
combined with diphtheria toxoid in the adult vac484
cine, Td, or with both reduced diphtheria toxoid and
acellular pertussis, Tdap.18,30 Tdap is not licensed
for use among adults ages ⱖ65 years. Routine boosters are recommended every 10 years for all persons,
including older adults 65 years and older, because
antitoxin titers approach the minimal protective
level by 10 years after the last dose. Although Tdap
is the recommended booster vaccine for tetanus in
adults ages 19 to 64, Td is still the recommended one
for adults 65 or older.18 In a small percentage of
individuals, antitoxin titers fall below the protective
level within 10 years of last booster. Therefore, persons who sustain a wound that is other than clean
and minor should receive a tetanus booster if more
than 5 years have elapsed since their last booster.
For individuals who were never vaccinated against
tetanus, a primary series of 3 doses is recommended
(0 month, 1 month, 6 to 12 months).18 Local adverse
reactions such as erythema and tenderness are common and often self-limited. An extensive local reaction presented 2 to 8 hours after vaccination as
extensive painful swelling of injection site is rare. It
is more common in adults who have received frequent doses of tetanus toxoid. Brachial neuritis and
Guillian-Barre syndrome, although very rare, is associated with Td vaccination. Td is contraindicated
in individuals with severe allergic reactions to the
vaccine. In these individuals tetanus immune globulin should be considered whenever an injury other
than clean minor wound is sustained.18
Other Vaccines
The vaccines that are indicated for special circumstances in older adults are summarized in Table 3.
Information for travel-related vaccination can be
accessed through CDC website at http://www.cdc.
gov/travel.
Conclusion
Vaccination appears to be safe and effective in the
elderly. It is routinely recommended for influenza
and pneumococcal pneumonia, herpes zoster, and
tetanus. Annual influenza vaccination with inactivated vaccine is recommended for all adults 50 years
and older. Live attenuated influenza vaccine is not
recommended for elderly. PPV is recommended for
all persons 65 years and older. Revaccination with
PPV every 5 years is not recommended. However,
one-time revaccination is recommended if they were
vaccinated ⱖ5 years previously and were ages ⬍65
years at the time of primary vaccination. Unless
contraindicated, all adults ages 60 and older should
receive zoster vaccine (Zostavax) once. For all older
adult who were never vaccinated against tetanus, a
primary series of 3 doses is recommended; otherwise
routine boosters are recommended every 10 years.
December 2007 Volume 334 Number 6
Bader
Table 3. Vaccines Indicated for Special Circumstances for the Elderly*
Vaccine
Indication
Comments
Hepatitis A vaccine
Persons with chronic liver disease
Persons who receive clotting factors
Men who have sex with men
Persons who use illegal drugs
Persons traveling to or working in
endemic countries for hepatitis A
Persons with end-stage renal disease,
including patients receiving
hemodialysis
Persons with chronic liver disease
Persons who receive clotting factors
Household or sexual contacts of
hepatitis B carriersHealthcare
workers or volunteers who are
exposed to blood or other potentially
infectious body fluids
Persons who have close contact
withother individuals who are at high
riskfor serious varicella complications
P⫹atients who are receiving inhaled
corticosteroids for the treatment of
pulmonary disease. International
travelers
A susceptible individual who has had
close contact with VZV
Complement-deficient and asplenic
patients
Persons who travel to areas where
meningococcal disease is
hyperendemic or epidemic and to
Mecca for the Hajj
It is a killed virus vaccine given IM in
2-dose schedule at either 0 and 6 to 12 months, or 0 and
6 to 18 months
If combined hepatitis A and B vaccine is used, 3 doses at
0, 1, and 6 months
Hepatitis B vaccine
Varicella vaccine
Meningococcal
vaccine
Recombinant hepatitis B surface antigen given IM in the
deltoid region in 3 dose-schedule at 0, 1, and 6 months
Give serologically negative adultsa 0.5-mL dose of
varicella vaccine administered subcutaneously,
followed by a second 0.5-mL dose 4 to 8 weeks later
It is contraindicated in individuals with diminished cellmediated immunity because it is alive virus vaccine
It must be given within 3 to 4 days of exposure to a
susceptible individual
It is a bacterial polysaccharides from serotypes A, C,
W-135, and Y.given once subcutaneously
The quadrivalent conjugate meningococcal vaccine is
indicated only for persons aged 11 to 55 years
* References 17.
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