Immunizations for Older Adults Are Vital - Contemporary Clinic

Jennifer L. Hofmann, MS, PA-C

Monday June 24, 2019

Immunizations are an important part of preventive care for adults 65 and older.
Specific recommendations from the Advisory Committee on Immunization Practices (ACIP) and CDC include the following vaccinations; herpes zoster; influenza; pneumococcal; and tetanus or pertussis with tetanus.¹

Tetanus, Diphtheria and Pertussis (Tdap)

Clinical tetanus is rare but is more common in older adults who are not vaccinated. Adults can serve as a reservoir to transmit pertussis to unvaccinated infants and young children. Older adults are less likely to have received vaccinations for or may have diminished immunity to tetanus, diphtheria, and pertussis.² Vaccination against pertussis is important for close contacts of infants less than 1 year, such as caregivers or grandparents. Although the efficacy of a complete series of diphtheria toxoid and tetanus toxoid vaccines is excellent, acellular pertussis does not offer as effective long-term immunity. The only available adult vaccine against pertussis is the Tdap vaccine. The ACIP recommends a single dose of a vaccine containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap; Adacel or Boostrix) 0.5 mL intramuscularly for all adults 19 years and older who have not received Tdap previously.³ The most common adverse reactions with both tetanus and diphtheria and Tdap vaccines were injection site redness, pain, and erythema, with less common systemic reactions, such as fever and myalgias.⁴  
                                                              
Influenza
Older adults experience significantly increased mortality and morbidity from influenza illness. Annual influenza vaccination is recommended for all adults. There are 2 types of influenza vaccine are available: inactivated influenza vaccines (IIVs) and a live attenuated vaccine. Two vaccines specifically approved for adults 65 and older are the high-dose inactivated influenza virus (60 mcg hemagglutinin per strain) vaccine and the adjuvanted (standard dose of 15 mcg of hemagglutinin per strain) trivalent IIV. Both are administered intramuscularly on an annual basis, ideally before the onset of influenza season. High-dose IIV is more effective and immunogenic than standard-dose IIV and may confer a mortality benefit.⁵ Adverse effects of the influenza vaccines are generally localized, mild, and most commonly arm soreness at the injection site. The high0dose flu vaccine is associated with more local reactions and possibly increased vomiting.  The IIVs are contraindicated in patients who have had a severe allergic reaction (eg, anaphylaxis) to any influenza vaccine. 

Pneumococcal
Pneumococcal diseases, such as bacteremia, meningitis, and pneumonia, cause significant morbidity and mortality in older adults. Two types of pneumococcal vaccines are approved for use: the 23-valent polysaccharide vaccine (PPSV23) and the 13-valent pneumococcal conjugate vaccine (PCV13). The ACIP recommends both pneumococcal vaccines for adults 65 and older. The PCV13 should be given first, followed by the PPSV23, given at least 1 year later. Both vaccines are administered intramuscularly and can be given concomitantly with other vaccines in different anatomic sites. Extensive data supports the effectiveness of PPSV in preventing invasive pneumococcal disease.^6,7 The most common adverse effects of both pneumococcal vaccines were local redness, pain, and swelling at the injection site and less commonly fever and myalgias. Contraindication to vaccination is any allergy to any component of either vaccine. 

Herpes Zoster
Herpes zoster vaccination is  recommended to prevent herpes zoster or shingles, which is caused by the reactivation of the latent varicella zoster virus. Older people are more likely to experience sequelae of herpes zoster, such as encephalitis, post-herpetic neuralgia, and nerve palsies. All individuals 50 years and older should receive the herpes zoster vaccination. There are 2 types of zoster vaccines: live attenuated zoster vaccine live (ZVL), sold as Zostavax, and non-live recombinant zoster vaccine (RZV), sold as Shingrix. Data suggest that RZV has greater efficacy and prolonged immunity and is preferable in most cases to ZVL.⁸ RZV is administered intramuscularly in 2 doses, with the second dose 2 to 6 months after the first. RZV can be administered with other vaccines at a different anatomic site. Adverse effects are more common with RZV then ZVL and include injection site reactions (78%) and systemic reactions, including fatigue, fever, headache, and myalgia, (ranging from about 20% to 45%). Reactions that prevented normal activities were also more common with RZV but only lasted 1 to 3 days.⁹ Contraindication to RZV administration is allergy to any vaccine component. ZVL is administered as 1 subcutaneous dose. ZVL is well tolerated with fewer adverse effects than RZV. The most common adverse effects were injection site reactions. Contraindications to ZVL include allergy to vaccine components, immunocompromise, and pregnancy. Rare cases of eye disorders including acute retinal necrosis have been reported in associated with ZVL.¹⁰  
Routine preventive care for older adults includes appropriate immunizations, according to updated ACIP and CDC guidelines. Herpes zoster, influenza, pneumococcal, and Tdap vaccines are safe and generally effective in older adults. 
 
References

1. CDC. Immunization schedules. cdc.gov/vaccines/schedules/hcp/imz/adult.html. Updated February 5, 2019. Accessed March 25, 2019.
2. CDC. Tetanus surveillance --- United States, 2001-2008. MMWR Morb Mortal Wkly Rep. 2011;60(12):365-369.
3. Kim DK, Hunter P, Advisory Committee on Immunization Practices. Recommended Adult Immunization Schedule, United States, 2019. Ann Intern Med. 2019;170(3):182-192. doi: 10.7326/M18-3600.
4. CDC. About diphtheria, tetanus, and pertussis vaccines. cdc.gov/vaccines/vpd/dtap-tdap-td/hcp/about-vaccine.html. Updated December 17, 2018. Accessed May 7, 2019.           
5. CDC. People 65 years and older & influenza. cdc.gov/flu/about/disease/65over.htm.  Updated February 12, 2019. Accessed March 21, 2019.
6. Moberley S, Holden J, Tatham DP, Andrews RM. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Syst Rev. 2013;(1):CD000422. doi: 10.1002/14651858.CD000422.pub3.
7. Bonten MJ, Huijts SM, Bolkenbaas M, et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N Engl J Med. 2015;372(12):1114-1125. doi: 10.1056/NEJMoa1408544.
8. Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep. 2018;67(3):103-108. doi: 10.15585/mmwr.mm6703a5.
9. Cunningham AL, Lal H, Kovac M, et al. Efficacy of the herpes zoster subunit vaccine in adults 70 years of age or older. N Engl J Med. 2016;375(11):1019-1032. doi: 10.1056/NEJMoa1603800.
10. Charkoudian LD, Kaiser GM, Steinmetz RL, Srivastava SK. Acute retinal necrosis after herpes zoster vaccination. Arch Ophthalmol. 2011;129(11):1495-1497. doi: 10.1001/archophthalmol.2011.320.

Jennifer L. Hofmann, MS, PA-C, is a clinical associate professor and full-time faculty and pharmacology courses instructor at Pace University-Lenox Hill Hospital PA Program in New York, New York. She is also a PA Program adjunct professor for the Touro College School of Health Sciences in Bayshore, New York, and Nassau University Medical Center in East Meadow, New York. In addition, she is a Stony Brook University PA Program postprofessional clinical pharmacology seminar adjunct professor in New York.

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