Current guidelines and status of vaccination in older persons, with recent evidence

Vaccination is the single most cost-effective primary preventive measure in geriatrics. Pathy's advises tailoring it to the patient's functional category and probable life expectancy.

Immunosenescence and inflammaging reduce vaccine response. Pathy's notes that frailty impairs vaccine-induced antibody response and increases post-vaccination influenza infection in community-dwelling elders — hence adjuvanted and high-antigen preparations are preferred.

Influenza vaccine — yearly, in all categories. Over 90% of pneumonia and influenza deaths in epidemics occur in those ≥65. It reduces influenza risk by ~50% and influenza mortality by ~70%.

In nursing homes, efficacy against clinical illness is only ~40%, but protection against pneumonia, hospitalisation and death is much better; vaccinating >80% of residents prevents outbreaks.

Vaccinate healthcare staff, relatives and regular visitors — reduces respiratory infection and mortality in residents. Pathy's states this explicitly.

Pneumococcal vaccine — textbook schedule is PCV13 followed by PPSV23 one year later after 65; PPSV23 alone is the practice in the UK, USA, Germany, Canada, Australia and Japan. CAPITA showed PCV13 cut vaccine-type pneumococcal pneumonia by 45%; a Japanese nursing-home RCT showed PPSV23 reduced pneumonia and mortality.

Tetanus — Td booster every 10 years (5 years for a tetanus-prone wound); >50% of tetanus cases occur in people ≥60; at least one booster should be Tdap.

Herpes zoster — Shingrix ~90% protective versus Zostavax ~30%; two doses for all ≥50 regardless of chickenpox history. Essentials records for the live vaccine: HZ HR 0.45, ophthalmic HZ HR 0.37, HZ hospitalisation HR 0.35.

Essentials (Nichol 2007): influenza vaccination in community-dwelling elders gave HR 0.75 for pneumonia/influenza hospitalisation and HR 0.52 for death. The textbook also records the counter-argument (Simonsen) that hospitalisation rates rose despite rising coverage, and the ongoing debate on pneumococcal cost-effectiveness.

Both textbooks predate — and therefore do not cover — RSV vaccines, PCV20/PCV21, preferential high-dose influenza vaccine, off-target effects of zoster vaccine, and Indian adult immunization guidelines.

Influenza — annual for all older adults. For age ≥65, HD-IIV3, RIV3 or aIIV3 is preferred; if none is available, any age-appropriate vaccine may be used. All formulations are now trivalent (B/Yamagata removed).

Pneumococcal — the sequential schedule is obsolete. On 23 October 2024 ACIP recommended a single dose of PCV for all PCV-naïve adults aged ≥50 years, using PCV20 or PCV21 alone, or PCV15 in series with PPSV23. The age threshold was formally lowered from 65 to 50 years.

RSV — now a core elderly vaccine. First approved May 2023 for adults ≥60. Current position: universally recommended at ≥75 years, risk-based at 60–74 years, extended in April 2025 to risk-based 50–59. A single dose only.

Herpes zoster — RZV two doses for all ≥50 years, now emphasised also for immunocompromised adults ≥18 years, given 2–6 months apart.

COVID-19 — policy has narrowed. For 2025–26, ACIP moved from a universal recommendation to shared clinical decision-making.

Td/Tdap unchanged — booster every 10 years, with at least one lifetime Tdap.

Individualisation is the new theme. The AGS position (JAGS, 2025) is that guidelines list recommendations by chronological age, but biological sex, frailty, functional status and multimorbidity modify vaccine responses and outcomes, and clinicians must increasingly account for this heterogeneity — as well as overcome barriers to uptake in long-term care.

There is no unified national guideline for geriatric immunization in India; society recommendations are heterogeneous and evidence-limited. Coverage among Indian older adults is <3% for most vaccines, with barriers including absent national guidelines, poor awareness, cost, accessibility and ageism (Indian Academy of Geriatrics position statement, 2026).

LASI Wave 1 (2017–18, n = 31,464 aged ≥60) coverage figures — high-yield numbers: diphtheria–tetanus 2.75%, typhoid 1.84%, hepatitis B 1.82%, influenza 1.59%, pneumococcal 0.74%; coverage was highest in the most affluent groups. Male sex, urban residence, wealthier household, more schooling and existing medical conditions predicted uptake.

Guideline development in India is now rapid: API issued the first exhaustive Indian Consensus Guideline on Adult Immunization in 2024. The 2026 Update involves 23 associations and adopts a life-course immunization framework, with PCV20 preferred, RZV for all ≥50, annual influenza ≥50, and standardised adult immunization cards. The Indian Academy of Geriatrics published a dedicated position statement on vaccination for older adults ≥60 years in 2026.

Programmatic gap: adult vaccines are not included in the Universal Immunization Programme or NPHCE, so they remain out-of-pocket — the main reason for low uptake.

RSV vaccine efficacy and durability. AReSVi-006 showed 82.6% efficacy against RSV lower respiratory tract disease in adults ≥60, and 94.6% in those with at least one underlying condition. Cumulative efficacy over three seasons was 62.9%, with 67.4% against severe RSV-LRTD, falling to 48% in the third season. The authors conclude protection lasts at least three RSV seasons despite waning, and that the optimal revaccination strategy is still undefined (Lancet Respiratory Medicine, 2025). For RSVpreF (Abrysvo), the RENOIR trial has reported efficacy across two seasons (NEJM, 2023).

DANFLU-2 — the largest randomised influenza vaccine trial ever conducted. In 332,438 adults ≥65 randomised to high-dose versus standard-dose vaccine, high-dose did not significantly reduce hospitalisation for influenza or pneumonia — a neutral primary endpoint (NEJM, December 2025). In a prespecified secondary analysis, cardiorespiratory hospitalisation was 2.25% vs 2.38%, driven mainly by fewer cardiovascular hospitalisations (1.30% vs 1.40%), described as exploratory in a neutral trial (JAMA Cardiology, 2025). A further analysis found fewer cardiorespiratory, cardiovascular and influenza hospitalisations with high-dose vaccine regardless of diabetes status (JAMA Internal Medicine, 2026).

Zoster vaccine and dementia — the most discussed geriatric vaccine finding of the decade. Using the Welsh date-of-birth eligibility cut-off (born before versus after 2 September 1933, with vaccine uptake jumping from 0.01% to 47.2% across one week), live zoster vaccination reduced new dementia diagnoses by about one-fifth over 7 years (Nature, 2025). A 2025 extension found HZ vaccination also reduced mild cognitive impairment diagnoses and, among people already living with dementia, deaths due to dementia, with effects not confined to one dementia subtype (Cell, 2025). In 436,788 propensity-matched individuals, AS01-adjuvanted shingles and RSV vaccines were associated with lower 18-month dementia risk (npj Vaccines, 2025). Zoster vaccination has also been linked to a 23% lower risk of cardiovascular events (European Heart Journal, 2025).

Pneumococcal — simplification plus wider serotype coverage. The ACIP expansion to adults ≥50 was formally published in MMWR 2025;74(1):1–8. Supporting data include the STRIDE-8 trial of PCV21 in high-risk adults, with immunogenicity comparable to PCV15 and PPSV23.

India-specific evidence base. An Indian Journal of Medical Research rapid review (2024) documented influenza vaccine uptake of ≤2% in adults ≥45 years and hepatitis B uptake of only 55–64% even among healthcare workers in Delhi and Mumbai. Indian advocacy documents highlight two influenza peaks (monsoon and winter) creating year-round exposure, a case-fatality rate of 20–25% for invasive pneumococcal disease in ≥65 years versus 5–10% in younger adults, and a lifetime herpes zoster risk of ~30%, rising to ~50% by age ≥85.