Video

PUPC Recap—Up to Date: What's New in Immunizations for Primary Care in 2026

William Schaffner, MD


Key Highlights

  • Adult vaccination recommendations are increasingly moving from risk-based criteria toward universal age-based approaches.
  • Influenza vaccination remains broadly recommended, with enhanced vaccines preferred for adults aged 65 years and older.
  • COVID-19 and RSV vaccination recommendations emphasize older adults and patients with chronic conditions or immunocompromised.
  • Pneumococcal, shingles, and hepatitis B vaccines are key preventive tools for adults aged 50 years and older.

In this interview, William Schaffner, MD, professor of preventive medicine and infectious diseases at Vanderbilt Health, discusses the evolving landscape of adult vaccination. He highlights the shift from primarily risk-based recommendations to broader, more universal guidance for vaccines against influenza, COVID-19, RSV, pneumococcal disease, shingles, and hepatitis B, emphasizing the clinician’s role in making strong vaccine recommendations to help prevent serious illness.

Additional Resource: https://www.hmpglobalevents.com/pupc 

Transcript

Hello everyone. This is Dr. Bill Schaffner. I am a professor of preventive medicine and infectious diseases here at the Vanderbilt University Medical Center, now known as Vanderbilt Health. We're going to be talking about adult vaccination today, very briefly.

I've got 2 themes for you. The first is vaccinations: not just for kids anymore. Over the past 10 or 15 years, a number of vaccines have been developed and recommended for adults. We'll talk about some of those today. The other theme is that originally, adult vaccination was focused almost exclusively as a risk-based vaccination recommendation, namely, your patients had to qualify, as it were, for the vaccines. We're moving away from that, and, as you will see in my comments, we're going from a risk-based to a more universal vaccination set of recommendations. Several of the recommendations are still a bit of a hybrid, a little bit risk, a little bit universal, but nonetheless, we're moving into a universal recommendation framework. So, let's talk about some of the vaccines.

This is the end of the winter. So, let's start with 3 big respiratory viruses. You know all about flu. There the recommendation is universal. Actually, it starts at 6 months of age, and everybody else, unless you have a medical contraindication, and they're pretty rare, so everyone in your practice should be vaccinated, essentially, against influenza. And apropos of people aged 65 and older, you know that there are 3 enhanced, so-called vaccines that are specifically preferred for people aged 65 and older: the high-dose vaccine, the adjuvanted influenza vaccine, and the recombinant vaccine. They all perform better in preventing serious influenza, that is, influenza that will take you to the hospital, in that population, the population of ages 65 and older.

We should also pause for a moment to recognize that these 3 respiratory vaccines are all good, but not perfect, vaccines. They work better in preventing serious disease rather than milder disease. They're really designed to keep your patient out of the hospital, out of the intensive care unit, and out of the cemetery. So, you have to tell your patients what to expect. Flu vaccine, for example, will not prevent every case of influenza, but it'll keep you out of the hospital in the event that you do get the flu. So much for flu; that's easy; that's universal.

Then we come to the big conundrum: COVID-19. Now, COVID-19 vaccines have been in a state of flux and a bit of confusion because, as you know, the previous Advisory Committee on Immunization Practices had all of its memberships, all of its members, fired. A new committee was reconstituted. It made some recommendations. Those recommendations had been put aside by a judge that declared that membership to be inappropriate. So, what do we have now?

We have now what we're doing in practice and what's generally supported by a lot of scientific and professional societies, namely, a big emphasis on those at highest risk. Now, 65 and older, that's pretty universal. Then, for those younger than age 65, if you have an underlying chronic medical condition—heart disease, any kind of lung disease, diabetes, for example, if your patient is obese, any kind of chronic underlying illness—give them the COVID-19 vaccine or recommend that they get it at a pharmacy. Likewise, any of your patients who are immunocompromised, whether because of their illness or their anti-immunotherapy, one of these biologic immune modifiers, should get it, as should every woman who's pregnant. So, there's a hybrid recommendation: everybody aged 65 and older, and those who are younger, who have a risk-based indication.

COVID-19 hasn't gone away. This past season, the people who were hospitalized at my medical center fit the description I've just given you, and they had 1 other almost universal characteristic: they were not up to date with their vaccinations. So, vaccination against COVID-19 continues to be important, which brings us to the third vaccine-preventable winter respiratory virus: RSV, respiratory syncytial virus.

We have now learned that RSV in the winter in adults actually often causes as much morbidity and hospitalization as does influenza. So, we now have RSV vaccines that we can use. They also have a hybrid recommendation: everyone age 75 and older, there's your universal recommendation, and for those 50 through 74 who have a chronic medical condition, who are at increased risk, should be vaccinated. Please recall that at the moment, the RSV vaccine is a one-shot deal. There are currently no recommendations for revaccination. So, if you vaccinated your patient 2 years ago with the RSV vaccine, there is still no recommendation for revaccination. Stay tuned. That ought to be coming in subsequent seasons. So those are the 3 respiratory viruses.

Let's say a quick word about another respiratory pathogen: the pneumococcus. Pneumococcal vaccines have been changing. Now, for adults, there are really 2 major vaccines: the pneumococcal conjugate vaccine 20, which covers 20 serotypes, and the pneumococcal conjugate vaccine 21, PCV-21. Now, please understand, this is a little nerdy. Twenty-one is not just 20 plus 1. No. Twenty-one was designed to prevent the most common serotypes that are still causing disease in adults. So, they removed 9 serotypes from 20 and replaced them with 10 different ones for 21. They focused more on the serotypes that are causing disease in adults. Both are good vaccines. Choose 1; use it. What are the recommendations? The recommendations, once again, are a bit hybrid: everyone, all of your patients, aged 50 and older. There's the universal part: 50 and older. If they are younger than 50, 19-49, once again, it's risk-based.

A few words about a couple of other vaccines for adults. You all know about the shingles vaccine—there's the recommendation for everyone, aged 50 and older. You can see we're increasingly making recommendations universally, for those 50 and older, and for those aged 19-49 who are immune-compromised or are going to become immune-compromised through the use of 1 therapy or another.

 An important payment issue: I know that many of you don't stock the shingles vaccine in your office because you know that for individuals aged 65 and older, the payment for the shingles vaccine is under Part D of Medicare. That's really the prescription drug benefit and works better in pharmacies than it does in many physicians’ offices. I'd like to reorient your thinking: think 50-64. They are the vaccines paid for by medical insurance, and you're then giving your patients the benefit of even longer protection. So, start at age 50.

Okay, 1 more. This one's close to my heart because I've been interested in preventing hepatitis B for a long time. It used to be risk-based. We had a long list of risk indications. Ladies and gentlemen, it's so much easier now: it's universal for every adult aged 19-59. For those above 59, it's optional. Every adult should receive the hepatitis B vaccine between the ages of 19 and 59. So, think universally in many instances. As I like to say, if your patient is 50 or older and hasn't been fully vaccinated, they shouldn't leave your office without having received the pneumococcal, shingles, and hepatitis B vaccines. That applies to every one of your patients who is 50 and older in your practice.

A couple of last thoughts: The first is, remember, your strong recommendation is still the most persuasive in getting your patients vaccinated. In that regard, recall that the prevention of disease is medicine's most noble and highest goal. Like you, I'm sure I was attracted to medicine because I wanted to lay on hands and cure the sick, alleviate the suffering, and help parents and patients cope with illness. I wanted to make them better. Treatment is still absolutely important and the essence of day-to-day practice, but the more I practiced, the more I learned that prevention beats treatment hands down. When it comes to vaccines, that's absolutely the best way to prevent disease. Just remember an adage of Bill Schaffner's, namely, disease bad, vaccines good. When in doubt, vaccinate. Go forth and vaccinate.

 

This transcript was edited for clarity.

 

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