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British Geriatrics Society
Best Practice Guide
Vaccination programmes in Older People
January 2011
1. Executive Summary
Infectious diseases account for a significant proportion of hospital admissions and
deaths in the elderly. Influenza and pneumonia are of particular importance, and
effective vaccines exist which are recommended for people aged over 65 years.
Unfortunately the immunological response to vaccines in older individuals is less than
that in younger adults, and there is limited evidence of benefit of the influenza
vaccine in the over-65s from Randomised Controlled Trials (RCTs). However, cohort
studies suggest that those who are vaccinated do seem to fare better in terms of
reduced hospital admissions and total mortality, The evidence for benefit is
sufficiently strong that influenza vaccine is recommended throughout Europe. A lifecourse vaccination programme can promote healthy ageing and reduce the burden of
preventable disease [1].
2. Introduction
Infectious diseases including pneumonia remain a big killer in old age, in spite of
modern antibiotics. Influenza and pneumonia are responsible for around 8% of all
deaths in old people, this being the 4th commonest cause of death after cancer, heart
disease and stroke. Each year there is a peak incidence of deaths that coincides with
the peak in influenza rates in the community. There have been influenza epidemics
every 3 years or so for 400 years. Highest death rates are in the very old, the frail,
those with chronic respiratory disease, and those in longstay care.
3. Influenza vaccination
It is difficult to diagnose influenza clinically as symptoms are a poor guide, and there
are many asymptomatic infected carriers who can pass the virus on to others.
Laboratory diagnosis on naso-pharyngeal swabs is specific but insensitive as well.
The influenza vaccine can be inactivated, live attenuated, purified protein or DNA, but
the inactivated vaccine is most common. Around 5% of subjects will have an adverse
reaction to the vaccine, with upper respiratory symptoms.
The success of the vaccine depends upon seroconversion in the individual, and then
the extent to which the strain in the vaccine matches the circulating viral strain.
Seroconversion after vaccination occurs in 70-90% of young subjects, 60% of
community-dwelling subjects around 60 years (the rate seen with the recent “swine
flu” vaccine), 30% in 70-80’s, and 12% in those over 80[2]. In one study in Care
Homes, seroconversion rate was 11% [3]. This reduced ability to seroconvert is
attributed to immunosenescence. This has multiple elements and is difficult to
measure. It includes T cell reduction from thymic involution, less effective antigen
presentation through monocytes, and reduced killer cell toxicity. There are currently
no reliable ways of improving responsiveness to vaccines, although higher vaccine
doses and improving nutrition may be of benefit.
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There is some evidence from observational studies that vaccination reduces the
number of hospitalisations and deaths due to respiratory disease, in the influenza
seasons [4]. In the elderly, protection against infection may be less, but immunisation
has been shown to reduce the incidence of bronchopneumonia, with a 27% reduction
in hospital admissions, and 47% reduction in overall mortality [5], after adjusting for
confounders in the observational studies. Confusingly, mortality from respiratory
disease was unaffected, which must question the mechanism of effect. Benefits are
more consistent in the 65-74 years age group, while no mortality benefit is seen in
the age group above 85 years [6]. There is only one RCT of influenza vaccination in
3,000 subjects, and a recent Cochrane review concluded that it impossible to state
whether the vaccine is effective in older people [7].
4. Other vaccines
a. Pneumococcal vaccine
Streptococcus pneumoniae remains the most common pathogen causing
pneumonia. The 23-valent Pneumococcal polysaccharide vaccine is used in most
European countries for adults aged over 60 yrs and for younger at-risk adult
populations (asplenia, immunocompromised adults, chronic cardiac, renal,
pulmonary or liver disease, and recipients of organ transplants). Meta-analysis has
shown a 36% reduction in pneumococcal pneumonia, but no overall effect on
pneumonia mortality [8]. The efficacy varies with the age of the population studied
and the endpoint used: in adults aged 65-74 years, the vaccine is 70-80% effective,
falling to 53-67% in 75-84 yr olds, and even further to 0-22% in the group aged 85 yrs
and above [9]. However, a recent RCT from Japan showed a significant reduction in
pneumonia with nursing home residents (2.8% vs 7.3% over 2 years), and
pneumonia mortality rate (20.6% vs 25%) [10].
Antibody levels fall after about 5 years, and a repeated vaccine leads to a further
(weaker) rise in antibody. There is no data on whether repeated vaccination confers
benefit in older people.
b. Herpes Zoster
Herpes zoster (or shingles) affects approximately 30% of the population at some
point in their life. The risk of disease rises after 50 yrs, with zoster 8-10 times more
likely to affect people aged 60 yrs or older (compared to younger people)[11]. About
70% of cases occur after the age of 70. It also occurs with more frequency in
immunocompromised patients. Post herpetic neuralgia is the most challenging and
debilitating complication, and occurs in around 20% of those between 60 and 80, and
around 50% of those above 80.
A vaccine for herpes zoster was licensed in 2006 in Europe for immunocompetent
adults aged 60 or over, and recommendations amended to include adults over 50 yrs
in 2007.The use of herpes zoster vaccine reduced the incidence by 51 percent,
incidence of post-herpetic neuralgia by 66 percent, and the overall burden of illness
due to zoster by 61 percent [12]. The vaccine has uncertain duration of benefit, and
the severity of post-herpetic neuralgia is greater above 70 years.
5. Immunisation and Care Homes
Influenza and pneumococcal pneumonia both take a heavy toll in Care Home
residents, especially during the winter and influenza epidemics. As described above,
there is limited evidence that influenza vaccination is successful in Care Homes. One
study found only an 11% antibody response to a combination vaccine of influenza A
and B [3]. Frailty and poor nutrition as well as extreme old age diminish the ability to
respond to the vaccine. Nevertheless vaccination is generally recommended [5][13],
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but probably should not be given to resistive patients, or without patient consent
given the equivocal benefit, or to patients with very limited life expectancy.
An alternative approach is to offer vaccination to the staff in care homes to provide
herd immunity to the patients. There is RCT evidence that during an epidemic year of
influenza, this approach is effective in reducing resident mortality. There is the added
benefit that sick leave in the staff is likely to be reduced. This strategy appears to rely
on staff uptake of the vaccine of at least 50% [14][15]. However this evidence has
been criticised as a concommitant reduction in circulating influenza has not been
demonstrated after staff vaccination [16].
6. Health Policy
Trivalent (inactivated) Influenza Vaccine (serotypes H3N2, H1N1 and B) Trivalent
influenza vaccine is recommended for adults aged 60 yrs and older in most
European countries. The WHO has set coverage target rates of 75% or over for
influenza vaccine for persons aged 60 and over, and this is also adapted by the
European Parliament. The Department of Health policy on immunisation is covered
by the “Green Book”, last updated in 2010 [13]. The Joint Vaccine Working Group of
the European Union Geriatric Medicine Society and the International Association of
Gerontology and Geriatrics (European Region) recently published recommendations
for people over the age of 60 [1]. A summary of their recommendations are shown in
the table appendixed below. They recommend universal coverage for those over 60
years for the annual influenza vaccine, and the pneumococcal vaccine to be given
every 5 years.
The UK Joint Committee on Vaccines and Immunisation (JCVI) recommended in
March 2010 [17] that a universal herpes zoster vaccination programme for adults
aged 70 up to and including 79 years should be introduced provided that a licensed
vaccine is available at a cost effective price.
7. Recommendations
The annual influenza campaign is one of the United Kingdom’s most successfully
implemented public health programmes—uptake in those over 70 is estimated at
78%, the highest in Europe [18]. This combined with pneumococccal vaccination are
important contributions to maintaining health and prolonging life, especially in “early”
old age. The introduction of a shingles vaccine could also make a significant
reduction in morbidity from post-herpetic neuralgia.
Unfortunately the body’s ability to respond effectively to vaccines diminishes with
age, and this does compromise the value of immunisation in frail subjects and above
the age of 80. Resources therefore need to be targeted at additional approaches.
These include developing more effective vaccines and better forms of delivery for the
elderly (for example, adjuvants and intradermal injections), and ensuring that more
healthcare workers and carers who come into contact with vulnerable elderly people
are vaccinated against influenza.
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8. References
1.
2.
3.
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5.
6.
7.
8.
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10.
11.
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13.
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16.
17.
18.
Michel J-P et al., Advocating vaccination of adults aged 60 years and older in Western
Europe – Rejuvenation Research 2009;12(2):127-136.
Goodwin K et al Antibody response to influenza vaccination in the elderly: a
quantitative review. Vaccine 2006;24:1159-69.
Potter JM, O’Donnel B Serological response to influenza vaccination and nutritional
and functional status of patients in geriatric longterm care. Age Ageing 1999;28:141-5.
Mangtani P, Cumberland P, Hodgson CR, et al. A cohort study of the effectiveness of
influenza vaccine in older people, performed using the United Kingdom general
practice research database. J Infect Dis 2004;190:1–10.
Jefferson T, Rivetti D, Rivetti A et al. Efficacy and effectiveness of influenza vaccines in
elderly people: a systematic review. Lancet 2005;366:1165-74.
Nichol KL, Nordin JD, Nelson DB et al. Effectiveness of influenza vaccine in the
community-dwelling elderly. N Engl J Med 2007;357:1373-81
Jefferson T Cochrane Acute Respiratory Infections Group Issue 2 2010
http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004876/pdf_standard_fs.h
tml
Huss A, Scott P, Stuck A et al Efficacy of pneumococcal vaccination in adults: a metaanalysis, Can Med J, 2009;180:1503.
High K. Immunizations in older adults. Clin Geriatr Med 2007;23:669–685.
Maruyama T et al Efficacy of 23-valent pneumococcal vaccine in preventing pneumonia
and improving survival in nursing home residents: double blind, randomised and
placebo controlled trial. BMJ 2010;340:1004.
Kimberlin DW, Whitley RJ. Varicella-zoster vaccine for the
prevention of herpes zoster. N Engl J Med 2007;356:1338–1343
Oxman MN, Levin MJ, Johnson GR et al. A vaccine to prevent
herpes zoster and postherpetic neuralgia in olderadults. N Engl J Med 2005;352:2271–
2284
Dept of Health, ‘The Green Book’: 2006, updated Nov 2010
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/
digitalasset/dh_121552.pdf.
Carman WF et al. Effects of influenza vaccination of health-care workers on mortality of
elderly people in long-term care: a randomised controlled trial. Lancet 2000;355:93-8.
Hayward AC et al. Effectiveness of an influenza vaccine programme for care home
staff to prevent death, morbidity, and health service use among residents: cluster
randomised controlled trial. BMJ 2006;333:1241.
Thomas RE Influenza vaccination for healthcare workers who work with the elderly.
Cochrane Acute Respiratory Infections Group Issue 9 2010.
http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD005187/frame.html
accessed 8.12.2010.
Joint Committee for Vaccination and Immunisation. Statement on Varicella and Herpes
Zoster vaccinations March 2010.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/
digitalasset/dh_114908.pdf
Jordan RE Influenza vaccine in the over 65’s. BMJ 2008;337:2545.
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9. Appendix
Authors: Dr Taj Hasan and Dr Ian Donald
January 2011