Immunizations

CME credit available from Harvard Medical School through January 2023.

Published Materials

• Summary Brochure
• Evidence Document
• Reference Card

The 2020 Centers for Disease Control and Prevention adult immunization guidelines recommend influenza, pneumococcus, zoster, and tetanus vaccination.¹  This module summarizes the current recommendations on immunizations for older adults.

Recent changes to the adult immunization guidelines

1. Prevnar (pneumococcal conjugate vaccine, PCV 13) is no longer recommended in all adults age 65 and over.
2. New quadrivalent flu vaccines—high-dose (Fluzone), adjuvanted (Fluad), and recombinant (Flublok)—are now available for adults 65 and over.
3. The live zoster vaccine (Zostavax) has been discontinued and replaced with the recombinant product Shingrix.
4. For tetanus booster, either Tdap (tetanus, diphtheria, pertussis) or Td (tetanus, diphtheria) is recommended; Td is no longer preferred over Tdap.

Summary table for 2020 CDC recommendations for immunocompetent older adults*

Influenza

In the 2019-2020 flu season, 38 million people had flu illness, 400,000 patients were hospitalized and 22,000 deaths.² The vast majority of patients who die from flu are age 60 and over.³

Flu vaccine can prevent the flu. Despite this annual preventative, more than half of American adults do not receive a flu shot.⁴

For older adults, a high-dose quadrivalent vaccine can improve the immune response and decrease flu risk compared to standard vaccines.⁵

The most important decision is to ensure that a patient gets an annual flu shot, even if the ideal formulation isn’t available at the time of vaccination.

During the Covid-19 pandemic, influenza immunization is especially important to avoid the need for hospitalization and prevent resource scarcity.

Pneumococcal pneumonia

Two vaccines can protect against various strains of pneumococcal pneumonia. Pneumovax (PPSV 23) is a polysaccharide vaccine; Prevnar (PCV 13) is a conjugate vaccine. Adding PCV 13 is no longer routinely recommended for all adults over 65 because the strains it covers have been markedly reduced by childhood immunizations.⁶

Recommendations for pneumococcal vaccination based on age and patient factors^6,7

For more information and detail about patients who may benefit from Prevnar (PCV 13), see the summary brochure or evidence document above.

Shingles

Shingrix is now the only available immunization for herpes zoster. It is a two-dose series, separated by at least 2 months. Patients who received the live vaccine (Zostavax) should receive Shingrix as efficacy of Zostavax wanes over time.⁸

Tetanus and pertussis

Current guidelines recommend a tetanus booster every 10 years. Either Tdap (tetanus, diphtheria, pertussis) or Td (tetanus toxoid) may be given. All patients at or after age 11 should receive at least one dose of Tdap, so if immunization history is unknown, Tdap is preferred.⁹

Resources for Providers

• CDC adult immunization schedule
• CDC influenza updates
• Immunization Action Coalition

Resources for Patients

• Flu Shot for older adults
• Pneumococcal pneumonia vaccine
• Shingles vaccine

Information current at time of publication, December 2020.

The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating clinician based on the individual patient’s clinical condition.

References

1. Centers for Disease Control and Prevention. Recommended Adult Immunization Schedule for ages 19 years or older, United States, 2020. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#table-age. Published February 3, 2020. Accessed October 20, 2020.
2. Centers for Disease Control and Prevention. Estimated Influenza Illnesses, Medical visits, Hospitalizations, and Deaths in the United States — 2019–2020 Influenza Season. https://www.cdc.gov/flu/about/burden/2019-2020.html. Published October 6, 2020. Accessed October 20, 2020.
3. Czaja CA, Miller L, Alden N, et al. Age-Related Differences in Hospitalization Rates, Clinical Presentation, and Outcomes Among Older Adults Hospitalized With Influenza—U.S. Influenza Hospitalization Surveillance Network (FluSurv-NET). Open Forum Infectious Diseases. 2019;6(7).
4. Centers for Disease Control and Prevention. Estimates of Influenza Vaccination Coverage among Adults—United States, 2017–18 Flu Season. https://www.cdc.gov/flu/fluvaxview/coverage-1718estimates.htm. Published November 5, 2018. Accessed October 20, 2020.
5. DiazGranados CA, Dunning AJ, Kimmel M, et al. Efficacy of high-dose versus standard-dose influenza vaccine in older adults. N Engl J Med. 2014;371(7):635-645.
6. Matanock A, Lee G, Gierke R, Kobayashi M, Leidner A, Pilishvili T. Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ≥65 Years: Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019;68(46):1069-1075.
7. Shah AA, Wallace MR, Fields H. Shared Decision-Making for Administering PCV13 in Older Adults. Am Fam Physician. 2020;101(3):134-135.
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.
9. Havers FP, Moro PL, Hunter P, Hariri S, Bernstein H. Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines: Updated Recommendations of the Advisory Committee on Immunization Practices – United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(3):77-83.