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podcast

Immunization Recommendations for Older Adults

04/06/2023

In this podcast, William Schaffner, MD, discusses recent updates to the Advisory Committee on Immunization Practices’ (ACIP) immunization recommendations in adults aged 65 or older, including pneumococcal, zoster, Hepatitis B, COVID-19, influenza, and tetanus, diphtheria, and pertussis vaccines.

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William Schaffner, MD, is the medical director of the National Foundation for Infectious Diseases (NFID), 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 (Nashville, TN).

 

TRANSCRIPTION:

Jessica Bard:

What are the current recommendations for pneumococcal vaccine, and were there any recent changes to those recommendations?

Dr William Schaffner:

Well, there were changes. And actually, Jessica, you've given me the hardest question first. So let us just say that the previous recommendations were fairly complex and the new ones, although they tried to simplify them, are still somewhat complex. Let me just outline them. Part of the complexity is that there are two new pneumococcal conjugate vaccines that have been licensed. Until this time we've had pneumococcal conjugate vaccine 13, PCV13. Well, we have two new ones. One is PCV15 and the other is PCV20. And of course, we all know those numbers are determined by the number of pneumococcal serotypes that are encompassed in each vaccine. And in addition to these new two vaccines, PCV15 and PCV20, we continue to have, on the scene, that traditional vaccine that goes way back to the 1980s pneumococcal polysaccharide vaccine 23. Now for people aged 65 and older, if you've not had pneumococcal vaccine in the past, you should be vaccinated with pneumococcal vaccine.

There are two options. The first, very simple, is that you could receive pneumococcal conjugate vaccine 20, PCV20, very simple. If you choose option B and use PCV15, you should also wait one year and then get polysaccharide vaccine 23. So two options, PCV20 for everyone age 65 or older who hasn't had the vaccine in the past, and the other option is PCV15, followed a year later by polysaccharide vaccine 23. That's simple enough, choose one or the other. However, you will actually have people age 65 and older, some of whom may have had polysaccharide vaccine in the past, some of whom may have had PCV13 in the past, or both. So what do you do now? And by the way, although we're emphasizing people age 65 and older, there are adults younger than age 65 who are also in this mix. Without going into all the details, the CDC actually has a very nice graphic that you can look at on their website that helps you negotiate this.

And I can just tell you that it's a very nice graphic that'll help give you a sense of which vaccine is indicated. The ACIP does not make a preferential recommendation whether you should, at age 65, receive PCV20 or the PCV15 followed by polysaccharide vaccine schedule. And of course, neither does the National Foundation for Infectious Diseases. But if you're interested in what the internists in my neck of the woods are starting to do, this is not official, but I've asked several of them and they're opting for the PCV20 option simply because it's simpler.

Jessica Bard:

Now, moving on to zoster vaccine, what are the current recommendations, and were there any changes made to the zoster vaccine recommendation?

Dr William Schaffner:

The zoster vaccine recommendation remains very firm. Everyone aged 50 or older should receive the recombinant zoster vaccine. In fact, that's the only one available in the United States at the present time. It's remarkably effective in preventing zoster. There are no recommendations for boosters, at least at the present time, but let's focus. If your patient arrives in your office at age 65 or older and has not received zoster vaccine, give them recombinant zoster vaccine. And if they arrive having received the previous version of zoster vaccine Zostavax, please re-vaccinate them with the current recombinant vaccine, Shingrix. That's the clear recommendation.

Jessica Bard:

And now moving on, Tdap. I know that was one that you wanted to talk about too. What are the current recommendations for Tdap.

Dr William Schaffner:

Tdap. Tetanus-diptheria-acellular pertussis vaccine. It continues to be driven, in its frequency, by the tetanus component. Remember, we were all taught in medical school that you should get a tetanus booster every 10 years. That remains the recommendation with Tdap. So, every 10 years, your patient should receive a Tdap immunization. I think that's pretty straightforward and useful.

Jessica Bard:

Now, rounding out the list here, hepatitis B vaccine.

Dr William Schaffner:

Ah, hepatitis B vaccine. There is something new here in a relatively new recommendation. Well, let's step back a moment. We know that hepatitis B vaccine has been recommended for a long time for people with risk factors for hepatitis B. If you are a drug user, etc. Also, it's been recommended for everyone with diabetes in the United States up to age 60 and that recommendation has been in place for some time and many practitioners are not aware of it.

The recommendation has been expanded even beyond that for up to age 60–the recommendation is now universal vaccination against hepatitis B, every adult not previously vaccinated against hepatitis B, and if you haven't had hepatitis B, every adult in your practice up to age 60 is recommended for hepatitis B. Beyond age 60, it's shared clinical decision-making. So, what ought to persuade someone to recommend the hepatitis B vaccine for people aged 60 or older? Clearly, if they have diabetes, particularly if they use a glucometer and particularly so if they live or spend a lot of time in a congregate setting where they might potentially share a glucometer. And I mentioned this because sharing a glucometer among patients who have diabetes has been a means of transmission of the hepatitis B virus.

Jessica Bard:

And now COVID-19 vaccine. What are the current recommendations for the COVID-19 vaccine?

Dr William Schaffner:

Well, the current recommendations apply to all adults. In fact, most children also– namely get your COVID-19 vaccine bivalent updated booster. It's the only booster available out there now. It's in essentially every pharmacy, and many doctors' offices, and regardless of your previous COVID-19 vaccination history, please get the updated booster. You should be at least two months beyond your last vaccination. And if you've had COVID-19 itself, you should let three months elapse before you get that booster.

Now that's a clear and very simple recommendation. The question I've been asked the most is, "Well, I've already received that bivalent booster and that was four months ago. Should I get another one of those by bivalent boosters? Because I'm older and I have underlying illnesses and I'm worried about waning immunity." At the moment, hang tight, please, because there are no recommendations for a second bivalent booster at this time. You may have heard news reports. The Food and Drug Administration advisory committee, looking ahead, down the road is thinking about updating the vaccine on an annual basis, very similar to the way we update influenza vaccine. And it might be, the recommendation's not there yet, but we seem to be headed in this direction, it might be that we will be recommending on an annual basis to get an updated booster. That's kind of a preview of coming attractions for this fall, this coming September and October. But stay tuned. Those recommendations are not out there yet.

Jessica Bard:

That's a great transition. Looking ahead to this fall, would you like to talk about influenza vaccine?

Dr William Schaffner:

Oh, always. Influenza vaccine, people aged 65 or older. The answer is yes, with two exclamation points! Please [get an annual influenza vaccine]. I'm always saddened that we vaccinate two-thirds of people aged 65 or older. I guess I shouldn't say I'm saddened. I'm glad about that. I'm saddened by the fact that one-third of the population, aged 65 or older, does not avail themselves of influenza vaccine. Influenza causes hospitalizations, illness, intensive care unit admissions, and deaths disproportionately in that population, age 65 and older. Is influenza vaccine perfect? No, but each year it prevents many, many hospitalizations and deaths. And even if you get vaccinated and still get influenza, remember you are here to complain because you didn't die. Influenza vaccine, along with COVID-19 vaccine, they do best in preventing severe disease and in keeping you out of the hospital. They're not as good at preventing milder infection. But if you got influenza despite getting the vaccine, you likely had some protection from requiring hospitalization.

So, we should all get influenza vaccine [every year]. And the final point is that the Advisory Committee on Immunization Practices (ACIP) has now made a preferential recommendation. Of the influenza vaccines available out there, the ones that are preferred for people aged 65 or older are, number one, the high-dose vaccine. Number two, the vaccine with an adjuvant, and three is the vaccine that we call the recombinant vaccine. So, there are three vaccines available, particularly formulated for people age 65 and older. They do a better job of preventing influenza in the older population, so they are now preferred. And indeed, of people age 65 or older who already receive the influenza vaccine, over 60% already receive one of these three vaccines. And so your provider, likely going forward this fall, will be giving you, offering you one of those vaccines.

Jessica Bard:

Did we miss any? Is there anything else that you would like to add?

Dr William Schaffner:

I think we've done a comprehensive job, but if we are doing previews of coming attractions, there may be another vaccine on the horizon, and who knows, it may already be available this fall. There are three major winter respiratory viruses that are particularly ominous for people aged 65 or older. We've just talked about influenza, so we know about that bad guy. We've mentioned COVID-19. Oh yes, we know that that's nasty for people aged 65 or older. But there's the other virus, RSV, respiratory syncytial virus. We all used to think that this was, oh, a pediatric virus, causing bronchiolitis in infants and young children. True. But what we have learned is that RSV can cause as much medical illness and hospitalization as influenza in people age 65 and older, particularly those with chronic lung disease and underlying heart disease. We don't have a vaccine against RSV yet, but it's getting close and there's an RSV vaccine or vaccines in the research pipeline. And who knows that RSV vaccine may be ready this fall. Wait and see.

Jessica Bard:

We'll certainly stay tuned and keep our eyes out for that. Well, Dr. Schaffner, thank you so much for joining us on the podcast today. We really appreciate your time.

Dr William Schaffner:

Jessica, it's always good to be with you. And remember, disease bad, vaccines good. When in doubt, vaccinate.