Immunizations for Older Adults

By: Sherry A. Greenberg, PhD(c), MSN, GNP-BC, Hartford Institute for Geriatric Nursing, New York University College of Nursing

WHY: Older adults are at increased risk for many vaccine-preventable diseases. Preventable illnesses cause substantial morbidity and mortality in older patients, who tend to have more medical co-morbidities and are at higher risk for complications. Acute respiratory infections, including pneumonia and influenza, are the 8th leading cause of death in the United States, accounting for 56,000 deaths annually. On average, influenza leads to more than 200,000 hospitalizations and 36,000 deaths each year (DHHS, Healthy People 2020).

Each year in the United States about nine out of 10 flu-related deaths and more than six out of 10 flu-related hospital stays occur in people over the age of 65 (NCA, 2012). Nonetheless, vaccination rates in the United States do not meet targets. In the United States, the majority of deaths from influenza occur among those over 65, yet only 65% of older adults were immunized against the flu during the 2008-2009 season, short of the Healthy People 2010 target of 90% (Moyer, 2010; DHHS, CDC, NHIS, 2009). Only 60.6% of Americans 65 and older were immunized against pneumococcal pneumonia (DHHS, CDC, NHIS, 2009).  Additionally, the herpes zoster vaccine, recommended for all Americans 60 and older, had the lowest adult immunization rate at 10% (Moyer, 2010).

BEST PRACTICES: Screen for patient’s immunization histories during office visits and hospital admissions and offer vaccination as indicated. Health care personnel should be screened pre-employment and kept up to date with immunizations during yearly visits.

TARGET POPULATION:

• Adults above age 50 (for annual influenza vaccination) and above age 65 (for one-time pneumococcal vaccination) and above age 50 (for every ten-yearly tetanus-diphtheria toxoid booster) who are either healthy OR have medical conditions such as: heart disease, pulmonary disease, diabetes mellitus, liver disease, renal failure, alcoholism, immune suppression such as Human Immunodeficiency Virus (HIV), anatomic or functional asplenia (sickle cell disease, splenectomy), malignancies (lymphoma, leukemia, solid tumors), patients receiving immunosuppressants including steroids, bone marrow- and organ transplant recipients. (Younger adults with these medical conditions should also be immunized).

• Patients with chronic debilitating conditions which increase risk for aspiration should also be vaccinated against influenza.

• Residents of assisted living, rehabilitation, and long-term care facilities.

• Healthcare workers such as hospital staff, assisted living staff, nursing home staff and home care givers.

STRENGTH AND LIMITATIONS: Vaccines for influenza, pneumococcal pneumonia, and tetanus have preventive efficacy rates approaching 90%. Such vaccines are relatively safe, with very few contraindications and a low rate of adverse reactions. Most non-vaccinated individuals either are not offered vaccination, do not know that such vaccines are available or have refused vaccination. Health care workers must be immunized to prevent transmission of a potentially lethal illness to the population they are caring for.

ADMINISTRATION OF VACCINES: All vaccines are administered intramuscularly in the deltoid muscle. Pneumococcal vaccine and influenza vaccine may be administered at the same time, (by separate injection in the other arm) without an increase in side effects or decreased antibody response to either vaccine. Tetanus-diphtheria toxoid (Td) or Tetanus, diphtheria, pertussis (Tdap) booster also may be administered concurrently with other vaccines.

RECOMMENDED IMMUNIZATION PRACTICES:

For the Older Adult Patient

1. Try to obtain patient’s immunization history. Check medical records to verify prior vaccinations. Note any history of neurological or hypersensitivity reactions.

2. Educate the patient on vaccine-preventable diseases and the importance of vaccination. Offer vaccination as indicated. Patients and their families often have misconceptions regarding immunization.

3. Provide clear documentation of vaccination provided to minimize risk of unnecessary duplication.

4. Follow the following guidelines recommended by the Department of Health and Human Services (DHHS), Centers for Disease Control (CDC):

• Give influenza vaccine annually, starting October and ending February. This refers to the intramuscular trivalent inactivated virus standard or high-dose vaccine. The live, intranasal flu vaccine is indicated only for persons ages 5-49 and is contraindicated in the geriatric population. Consult with an allergist if the patient has an egg allergy.

• Give pneumococcal vaccine once after the age of 65 with a revaccination after 5 years if diseases such as chronic renal failure, chronic immunosuppression, malignancies, and functional or anatomic asplenia are present. Give one-time revaccination for patients older than 65 years old if they were previously vaccinated more than 5 years previously and were aged less than 65 years at the time of initial vaccination.

• Provide Tetanus-diphtheria toxoid (Td) as a booster shot every ten years to those who have either completed the immunization series during childhood or teen years and have not received a booster dose in the last 10 years. If the patient has never been vaccinated, administer 0.5 mg intramuscularly twice with a 1-2 month interval and an additional dose 6-12 months later. If the patient is in contact with a child less than 12 months, then Tetanus, diphtheria, pertussis (Tdap) is recommended over Td.

5. In selected patients aged 60 years or more, vaccination against herpes zoster (shingles) has decreased the incidence of herpes zoster and postherpetic neuralgia by 51% and 67% respectively.

6. Certain subsets of the geriatric population may require vaccinations for Hepatitis A, Hepatitis B, meningococcal disease, varicella and for measles, mumps, rubella (MMR), due to certain health problems, occupations or risks posed by lifestyles. Furthermore, if such patients travel, it would be advisable to offer relevant vaccines such as yellow fever vaccine.

HOSPITAL IMMUNIZATION PROTOCOLS: Work with hospital administration to develop a system that:

1. Obtains immunization history upon admission of older adults.

2. Educates new admissions about immunization.

3. Incorporates immunization history and standing orders into the electronic medical record.

4. Tracks healthcare staff immunizations and ensures adequate compliance.

5. Updates and maintains immunization records for older adults.

6. Provides immunication education and screening to the community at large.

MORE ON THE TOPIC:

Best practice information on care of older adults: www.ConsultGeriRN.org.

Department of Health and Human Services (DHHS). Centers for Disease Control (CDC). Vaccines and Immunizations website: http://www.cdc.gov/vaccines/.

Department of Health and Human Services (DHHS). Centers for Disease Control (CDC). Adult Immunization Schedule: Details for health care professionals. Retrieved June 28, 2012, from http://www.cdc.gov/vaccines/schedules/hcp/adult.html.

Department of Health and Human Services (DHHS). Centers for Disease Control and Prevention. Recommended adult immunization schedule—United States, 2012. Morbidity and Mortality Weekly Report, 61(4), 1-7. http://www.cdc.gov/vaccines/schedules/downloads/adult/mmwr-adult-schedul....

Department of Health and Human Services (DHHS). Centers for Disease Control and Prevention. Statistics and Surveillance: 2009 Adult Vaccination Coverage, NHIS.

Moyer, C.S. (Nov 29, 2010 online). Vaccination rates for adults continue to drop below optimal levels. American Medical News. Retrieved June 28, 2012 from http://www.ama-assn.org/amednews/2010/11/29/prsa1129.htm.

Gosney, M. (2000). Factors affecting influenza vaccination rates in older people admitted to hospital with acute medical problems. Journal of Advanced Nursing, 32(4), 892-897.

National Council on Aging (NCA). Flu+You. Retrieved June 28, 2012, from http://www.ncoa.org/improve-health/community-education/flu--you/.

Stefanacci, R.G. (2012). To the point: Meeting vaccination quality measures for older adults. Annals of Long-Term Care, 20(1), 28-31.

U.S. Department of Health and Human Services. Healthy People 2020: Immunization and Infectious Disease. Retrieved June 28, 2012, from http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicId=23.