Vaccine-Preventable Diseases in Older Adults
In this podcast, William Schaffner, MD, answers our questions about herpes zoster, pneumococcal disease, and COVID-19 vaccinations for adults aged 50 years or older.
- Schaffner W. William Schaffner, MD, on the ACIP’s pneumococcal recommendations. Consultant360. Published online August 27, 2019. https://www.consultant360.com/podcast/infectious-diseases/vaccines/william-schaffner-md-acips-pneumococcal-recommendations
- Frequently asked questions about COVID-19 vaccines. National Foundation for Infectious Diseases. Updated February 2021. Accessed February 24, 2021. https://www.nfid.org/infectious-diseases/frequently-asked-questions-about-covid-19-vaccines/
- Pneumococcal disease. National Foundation for Infectious Diseases. Reviewed September 2020. Accessed February 24, 2021. https://www.nfid.org/infectious-diseases/pneumococcal/
- Shingles (herpes zoster). National Foundation for Infectious Diseases. Accessed February 24, 2020. https://www.nfid.org/infectious-diseases/shingles/
William Schaffner, MD, is the medical director of the National Foundation for Infectious Diseases (NFID) and is a professor of preventive medicine in the Department of Health Policy and a professor of medicine in the Division of Infectious Diseases at Vanderbilt University School of Medicine in Nashville, Tennessee.
Jessica Bard: Hello, everyone, and welcome to another installment of Podcast 360, your go to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network.
According to the CDC, vaccines have prevented countless cases of disease and have saved millions of lives. People need different vaccinations depending on their age, location, lifestyle, and health conditions.
Our expert today on vaccine preventable diseases in older adults is Dr. William Schaffner. Dr. Schaffner is the medical director of the National Foundation for Infectious Diseases and a professor of infectious diseases at Vanderbilt University Medical Center in Nashville, Tennessee.
Thank you for joining us today Dr Schaffner. To start, can you give us an overview of the recommended vaccines for adults age 50 years or older?
Dr William Schaffner: Vaccines are not just for children anymore. Over the years, a number of vaccines have been developed and now recommended for the adult population and particularly the middle age and older population, aged 50 and older.
Let's do a quick rundown of those. The first I always start with is influenza. It's easy. It's straightforward. Everybody should get influenza vaccine. That's the CDC's annual recommendation, and that applies to everyone, everyone age 50 and older.
For people age 65 and older, there are actually two especially formulated and licensed vaccines, a high dose vaccine and an adjuvanted vaccine. Both of them are about 20, 25 percent better in preventing influenza in the older population, aged 65 and older, and yes, Medicare will pay for it. That's something to keep in mind.
To emphasize this, people age 50 and older begin to accumulate chronic underlying illnesses [laughs] of one kind or another. We know that– heart disease, lung disease, diabetes, and the like.
All the more important, make sure we vaccinate absolutely everyone in that age group, because clearly influenza has its worst effect. It has its greatest morbidity. It's going to put more people in the hospital and, I'm afraid, will kill more people of that age group. The older you are, the greater your risk is, so let's vaccinate everybody against flu.
While we're talking about respiratory infections, we have to mention pneumococcal vaccine, or pneumococcal vaccines. The first one that we'll talk about is the conjugate vaccine, PCV13, PREVNAR13. That's the vaccine that should be given to everyone aged 65 and older.
According to the current recommendations, there are certain people with underlying illnesses and who are immunocompromised who also, a year later, should get the pneumococcal polysaccharide vaccine. There are complicated recommendations for people who are younger than age 65. I refer you to the nfid.org website or to the CDC website to give you those details.
What's next? Shingles vaccine. Shingles vaccine is now recommended for every person, every person aged 50 and older who's not immunocompromised. Recommendations for immunocompromised people are coming. They're not here yet. For everyone else, they should get the second generation shingles vaccine, that two dose recombinant vaccine. Very important to get that.
Now, a little bit about compensation under Medicare. Virtually all private insurance companies will cover shingles vaccine aged 50 to 65, but after age 65, it's not first dollar coverage. It's covered under Part D. That's the prescription drug benefit, and not every patient has that.
Under certain Part D plans the patients have to lay out money in advance, etc. It's more complicated, so vaccinate everybody before [laughs] they get to age 65. It'll be covered for the patient, and there will be compensation for the practitioner.
The next vaccine I would like to mention is the successor to simple TD, tetanus, diphtheria. It's now tetanus, diphtheria, acellular pertussis– whooping cough. That's the standard vaccine we should be using for our 10 year boosters is Tdap, tetanus, diphtheria, acellular pertussis. Every patient, every 10 years.
We'll then mention, also, Hepatitis B vaccine. We all know that that's recommended for people in certain risk groups, health care providers, people who use IV drugs. You can also acquire this infection through sexual transmission.
What most practitioners don't recognize, it hasn't been presented as intensely as I would like, is the recommendation from the CDC that everyone who is diabetic should receive a course of Hepatitis B vaccination as soon as the diagnosis is made.
That's a lot of people in the United States who have not yet been vaccinated. Over aged 60, its physician's option. I would encourage you to do that, because there have been outbreaks of Hepatitis B associated with blood glucose monitoring in populations, and we'd sure like to avoid that. Think about Hepatitis B vaccine for people aged 50 and older, particularly if they have diabetes.
The last vaccine I'll mention, of course, is COVID vaccine. We all know that gradually, as the priorities work down the age range, we will be trying to give COVID vaccine to everybody aged 50 and older.
Jessica: That was a thorough list. We appreciate that. You had mentioned shingles. What are the major complications of herpes zoster?
Dr Schaffner: So good you ask. I would mention too, first, with acute shingles, most shingles outbreaks occur on the thorax or on the back, on the body, but it can occur on the face. If it involves the face, it can threaten vision and that's very, very ominous. In addition to the pain and the disfigurement, it's the threatening of the vision that's important in the eye that can be affected.
Then there's post herpetic neuralgia, post shingles pain, which can be the bane of many people's existence. It can go on for months. It can be life changing. It can distress some people to the point and, I do not exaggerate, they consider ending their life.
Please, vaccinate everybody 50 years of age and older who's not immunocompromised with the shingles vaccine. It's an extraordinarily effective vaccine, over 90 percent effective even in people of advanced age.
If you're lucky enough to reach age 80, somewhere between a third and a half of the entire population will experience at least 1 episode of shingles. If you've ever known anybody with shingles, you don't want to have it, and you don't want any of your patients to have it.
Jessica: In your list before, you mention pneumococcal disease. Pneumococcal disease is another vaccine preventable illness that's common among older adults. We recorded a podcast with you about the ACIP's recommendation for pneumococcal vaccination last year. How have those updated recommendations affected the pneumococcal vaccination rate in the United States?
Dr Schaffner: People like age based vaccination recommendations. Physicians are doing a reasonable, but not perfect, job in vaccinating people age 65 and older. I think we're up to about 65 to 70 percent of people of that age range, 65 and older, who are now vaccinated with at least 1 of the 2 usually conjugate pneumococcal vaccine.
We don't do nearly as well with the risk based recommendations of patients younger than age 65. There may be a little light at the end of the tunnel. There are two new pneumococcal vaccines that are in the later stages of getting licensed.
We may hear more about them, and we're certain we'll hear about new recommendations from the Advisory Committee on Immunization Practices of the CDC. They're not here yet, but stay tuned. During the next couple of years, I'm sure the pneumococcal vaccination recommendations will be updated.
Jessica: Again, you mentioned COVID 19 vaccines in older adults. Could you elaborate for us a little more on that? Are there any contraindications?
Dr Schaffner: The great thing about the COVID vaccines is, at least the Pfizer and the Moderna vaccines that are currently licensed, is that they're remarkably safe and they're remarkably effective, 95 percent, even in older persons. There are no explicit exceptions to that.
Obviously, if your patient is immunocompromised, they may not achieve the 95 percent protection rate that everybody else does. We understand. That's true of everybody who's immunocompromised. We'll take what we can get, so we'll vaccinate those folks anyway.
The one group where we have a yellow caution light is for people who previously have had a serious allergic reaction to any medication, or any substance, any vaccine. By serious I mean anaphylaxis, or any reaction that involves difficulty breathing, because we know both of these vaccines have a very low rate, it's about five per million doses, of a serious anaphylactic reaction.
Those persons, you should have a discussion with them, counsel with them. They are eligible for the vaccine. When they receive it, they will be watched for a half hour instead of the standard 15 minutes to make sure that they don't have a reaction.
Frankly, if I were they, I would take my EpiPen along to the vaccination site, and I would prefer to get vaccinated at a location that's close to sophisticated medical care. If I were one of these people, I wouldn't do it in a drive through vaccination site. I would do it where medical care is ready to hand.
I hasten to add that everyone who's had one of these serious reactions has done well after they have received appropriate medical care. We just want to be cautious with those folks.
Jessica: What else, Dr. Schaffner, do you believe that health care providers should know about vaccinations for older adults?
Dr Schaffner: We have important means of preventing illnesses in older adults through vaccination. It takes a little study. It takes a little acquaintance. We do a great service to our patients if we vaccinate them with the array of vaccines for which they are eligible.
We as internists are not the professional vaccinators that our friends, the pediatricians and the family docs are, because they take care of kids.
I will tell you, looking to the future, here we are in the 21st century, more vaccines directed at specific subpopulations of adults are at various stages in the research pipeline. We are well advised to acquaint ourselves with the current vaccines, become vaccinators, and do provide that great preventive benefit to our patients.
Jessica: Thank you so much, Dr Schaffner, for speaking with us. I really enjoyed hearing your perspective and I learned a lot, too.
Dr Schaffner: My pleasure. As I always like to say, "Disease bad, vaccines good. Vaccines never prevented disease, but vaccination does. Let's do it."