Adult Vaccination Part II. Older Adults

[[{"type":"media","view_mode":"media_crop","fid":"52922","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4729309483844","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6579","media_crop_rotate":"0","media_crop_scale_h":"257","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; float: right; height: 214px; width: 125px;","title":" ","typeof":"foaf:Image"}}]]It’s true - we are living longer and many of us are staying healthier into later stages of life than our parents did. Older 21st century adults, however, are not necessarily less vulnerable to the opportunistic diseases that swiftly compromise an aging immune system. In this section are several questions on two VPD that hit older adults hard when they strike. Although shingles can strike anyone, it tends to be a geriatric disease. The cost of treating post-herpetic neuralgia as a consequence of shingles can be prohibitive in this group.The pain may be severe enough that opioids are prescribed in a population already plagued by polypharmacy and at high risk of falls. “Pneumonia is the old man’s friend,” once noted the venerable William Osler. Well, today we beg to differ. Baby Boomers live active productive lives and should be protected against pneumococcus and zoster with appropriate vaccines. Find out what you know about both.

ANSWER AND DISCUSSION »

Answer: D

Without zoster vaccination, 50% of individuals who reach age 85 years will experience shingles. Although wild community shingles increases immunity, that immunity wanes after 3 years so vaccination should take place after.^1-3

The decrease in the incidence of zoster with vaccination is approximately 50%, but incidence of post-herpetic neuralgia decreases as much as 67%.^1-3 The duration and severity of pain are less in individuals who were vaccinated.^1-3

Caution: Administering the zoster vaccine simultaneously with the 23-valent pneumococcal vaccine blocks the immune responsiveness to the zoster portion.⁴

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ANSWER AND DISCUSSION »

Answer: A, B, and D

Patients infected with HIV who have a CD4 count of ≤200 cells/µL should not be given live zoster vaccine.⁵ The group in option C would be eligible for the immunization.

ANSWER AND DISCUSSION »

Answer: C

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ACIP guidelines for administration in this specific demographic are as above: The 13-valent vaccine followed one year later by the 23-valent if the vaccines are routine, that is, the recipient does not have other indications for “dual” vaccines. However, if a patient in the target demographic already has received the 23-valent-but not the 13-valent-the latter should be administered a year later.⁶

ANSWER AND DISCUSSION »

Answer: B. False

If a dose of PPSV23 is inadvertently given earlier than the recommended interval, the dose need not be repeated.⁶

A final note here on this population: In line with statistics noted in the Introduction to this Special Report that suggest underuse of tetanus boosters, geriatric patients are an important demographic in the caveats regarding lapsed vaccination maintenance. The recommended every-10-year booster doses with tetanus/diphtheria was amended by the ACIP in 2010 for seniors aged 65 years or older who are exposed to children younger than 1 year of age. This specific geriatric population should be boosted with Tdap to ensure coverage against pertussis, thereby protecting baby and grandparents.

FOR PART III »

For Part I: Adult Vaccination Part 1: Patients with Diabetes Mellitus

References:

1. Cohen JI. Herpes zoster. N. Engl. J. Med. 2013; 369:255-263.

2. Kimberlin DW, Whitley RJ. Varicella-zoster vaccine for the prevention of herpes zoster. N. Engl. J. Med. 2007; 356:1338-1343.

3. Hales CM, Harpaz R, Ortega-Sanchez I, et al. Update on recommendations for use of herpes zoster vaccine. MMWR 2014; 63:729-731.

4. Hata A, Inoue F, Hamamoto Y, et al. Efficacy and safety of live varicella zoster vaccine in diabetes: a randomized, double-blind, placebo-controlled trial. Diabet. Med. 2015; Nov. 25. Doi: 10.111/dme. 13038.

5. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin. Inf. Dis. 2014; 58:e44.

6. Kobayashi M, Bennett NM, Gierke R, et al. Intervals between PCV13 and PPSV23 vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb. Mortal. Wkly. Rep. 2015; 64:944.