VACCINATION IN

ELDERLY
Putrawan I.B.Putu
Divisi Geriatri, Bag/SMF Ilmu Penyakit Dalam
RSUP Sanglah – FK UNUD
When meditating over a disease,
I never think of finding a remedy for it,
but, instead, a means of preventing it.

Louis Pasteur
(1822-1895)
 Introduction

 Vaccination:

 A cost-effective and efficient way to protect people from morbidity

and mortality due to infections

 Reduces hospitalizations

 The economic cost of lost productivity

 As we age, changes occur in both the innate and adaptive immune

compartments  immunosenescence

Whitney et al., 2003; Jefferson et al., 2005

 Immunosenescence

 Immunosenescence is defined as age-associated changes in the

immune response
 Immunosenescence (“senescent immune remodeling”)
• Aging of the immune system begins at the level of the
hematopoietic stem cell (HSC) ==> increased susceptibility
to infectious disease and decreased efficacy of vaccination in
the elderly.

Frontiers in Immunology | Immunotherapies and Vaccines, June 2013 | Volume 4 |

Article 171 |
Vaccines for Older Adults

Influenza
Pneumococcal
Zoster
 Influenza

 Severe influenza virus infections are very common in the elderly and
are often accompanied by fatal secondary bacterial infections.
 5th leading cause of death in people over 50
 A number of meta-analyses: a reduction in influenza-specific
hospitalizations by 27–45% and death by up to 50%, compared to 70–
90% efficacy in healthy, young adults.*

(Gross et al., 1995; Jefferson et al., 2005; Manzoli et al., 2012)*.

 Influenza

 Multiple vaccine products available

 CDC does not recommend one vaccine over another
– Flumist® (live attenuated influenza virus (LAIV)
• 2-49 years old, non-pregnant, healthy
– Trivalent inactivated influenza (TIV)
• 6 months and older
– Fluzone High Dose® (TIV)
• For those age 65 and older
– Fluzone Intradermal® (TIV)
• New for 2011! For those 18-64 year old
• Uses a smaller needle and is injected into the skin
 Influenza Vaccines
Live Attenuated Influenza Vaccine (LAIV)

LAIV Indications  LAIV Contraindications

– Healthy – Egg allergy
– 2-49 year olds – Chronic medical problems
– Asthma/wheezing
– History of Guillain-Barre (GBS)
– Immunocompromise
 LAIV Precautions – Pregnancy
– Resolving moderate or severe acute – Acute moderate or severe illness
illness w/ or w/out fever – Age 50 and older
– Getting antivirals (i.e., amantadine,
rimantadine, zanamivir or
oseltamivir)
48 hours before vaccination (Also
avoid for 14 days after vaccination)
– Close contact with an
immunosuppressed person
 Influenza Vaccines
Trivalent Inactivated Virus (TIV)

Indications
– Age 6 months to 64 years dependent on specific
vaccine
– Long-term care facility residents
– Pregnancy
– Any contraindication to LAIV
– Chronic medical problems
• Pulmonary (asthma, COPD)
• Cardiovascular (CHF)
• Metabolic disorders (Diabetes)
• Renal disease
• Hemoglobinopathy (Sickle Cell disease)
• Immunosuppression (HIV, chemotherapy, steroid use)
• Any condition that compromises respiratory function
 Influenza Vaccines
Trivalent Inactivated Virus (TIV)

TIV vaccine contraindications

– Severe egg allergy!
– History of severe allergic reaction
to prior vaccine
– Acute moderate or severe illness
TIV vaccine precautions
– Improving moderate or severe acute illness
with or without fever
– History of GBS within 6 weeks of previous
influenza vaccine
 Pneumococal
Vaccine

Year Vaccine
1977 14-valent polysaccharide vaccine licensed
(no longer in U.S.)
1983 23-valent polysaccharide vaccine licensed
(PPSV23)
2000 7-valent polysaccharide conjugate vaccine
licensed (PCV7)
2010 13-valent PCV Adult
licensed (PCV13)
Immunizations
Pneumococcal Vaccine
(PPSV 23)

Different than the pediatric pneumococcal

vaccine
23 valent polysaccharide vaccine
Indications:
– Children age 2 and older with co-morbidities
– Adults with health conditions
– All adults age 65 and older
Pneumococcal Vaccine
Adult Indications
• Age 65 and older
• COPD
• Asthma
• Smokers age 19-64
• CV disease
• Liver disease/cirrhosis
• Chronic alcoholism
• CKD/nephrotic syndrome
• Residents of long-term
care facility
• HIV
• 2 weeks before
elective splenectomy
• Immunosuppression
• Diabetes Mellitus
• CSF leaks
Adult Immunizations
Pneumococcal Vaccine
Contraindications
– Severe allergic reaction (e.g., anaphylaxis)
after a previous vaccine dose or to a vaccine
component
Precautions
– Moderate or severe acute illness with or
without fever
Pneumococcal Vaccine
(PPSV23)

Revaccinate once after 5 years only if

– Sickle cell disease
– Functional or anatomic asplenia
– Immunosuppressed
– Chronic renal failure
– Nephrotic syndrome
– Age 65 or older and 1st vaccine given when
<65 years old
Pneumococcal Schedule for Adults >65 years +

Adults:

• PCV13 (for PCV13 naïve adults) and PPSV23 are

routinely administered to adults 65 years of age and
older

• PCV13 should be administered first

• PPSV23 should be administered 1 year after

PCV13
PCV13 & PPSV23 Spacing for Adults >65 years +

Notes: "For immunocompetent adults

who previously received PPSV23
when aged <65 years and for whom
an additional dose of PPSV23 is
indicated when aged ≥65 years, this
subsequent PPSV23 dose should be
given ≥1 year after PCV13 and ≥5
years after the most recent dose of
PPSV23. For adults aged ≥65 years
with immunocompromising conditions,
functional or anatomic asplenia,
cerebrospinal fluid leaks, or cochlear
implants, the recommended interval
between PCV13 followed by PPSV23
is ≥8 weeks."
Please refer to the footnotes in the
respective schedules for further
details about pneumococcal
vaccination.
Herpes Zoster (Shingles)

Herpes Zoster Opthalmica

Adult Immunizations
Age Most Important Zoster
Risk Factor
• Risk increases when
>50 years old
• 50% of people living
to age 85 will get
Zoster
• 50% of post-herpetic
neuralgia (PHN)
cases occur in adults
age >85

Adult Immunizations
 How Effective is
the Zoster Vaccine?

In adults 60 years of age or older

– Reduced incidence of shingles 51%
– Reduced post-herpetic neuralgia by 67%
Most effective 60-69 years
– Vaccine efficacy 64% versus 38% if
>70 years old
 Zoster Vaccine
Live attenuated vaccine
One dose indicated for adults 60 or older
Contraindications
– Pregnancy
– Immunocompromised
– Severe allergic reaction (anaphylaxis) to neomycin,
gelatin, or varicella vaccine
– Tuberculosis –active untreated
Precautions
– Moderate or severe illness with/without fever
– Antivirals 24 hours before vaccination
NOVEL APPROACHES TO VACCINATION IN THE ELDERLY
 HERD IMMUNITY

 Herd immunity occurs when the percentage of

individuals vaccinated is high enough that the rate
of disease decreases to the point where the
probability of unvaccinated individuals contracting
disease is minimal.

In essence, the pathogen is kept at a

subclinical level in the population as a whole
protecting those who are at risk of infection.

Kim et al., 2011; Thomas et al., 2010

 Summary

 Immune changes in older adults makes them more susceptible to infection

 Contributes to death and catastrophic disability

 Vaccines less effective in older population – innovative mechanisms to

address this:

 Adjuvants, high dose, viral vectors,…Etc

 Waiting till > 65 years to begin “elderly vaccination” may be too late -- start
erlier while immune sistem still viable

 Need policy

 Adults over 65 years need Influenza, Pneumococcal, and Zoster vaccine

 TERIMA KASIH
MATUR SUKSME