Vaccinations in elderly patients

Rationale. Immunosenescence — thymic involution, reduction in naive T cells, impaired B-cell affinity maturation and class switching — together with inflammaging, both increases susceptibility to infection and blunts the response to vaccines, which is why older adults need higher-potency formulations. Vaccine-preventable infection in older adults causes hospitalisation, delirium, functional decline and death, and drives a large share of antibiotic use, so vaccination is also an antimicrobial stewardship intervention. Vaccination status should be recorded and reviewed at every comprehensive geriatric assessment.

Influenza. Annually for everyone aged 65 and over, and for residents and staff of long-term care facilities. High-dose, adjuvanted or recombinant formulations are preferred over standard-dose from age 65. The live attenuated nasal vaccine is contraindicated in this group.

Pneumococcal. A single dose of a pneumococcal conjugate vaccine — PCV20 or PCV21 — for all PCV-naïve adults. If PCV15 is used it must be followed by PPSV23 at least one year later (or after 8 weeks if the patient is immunocompromised, or has a cerebrospinal fluid leak or a cochlear implant). Pathy's states that all adults aged 65 and over should be vaccinated, and that adults with asplenia, CSF leak, cochlear implants or immunosuppressing conditions should also be vaccinated regardless of age.

Herpes zoster. Two doses of the recombinant zoster vaccine (RZV, Shingrix), 2–6 months apart, from age 50, including in the immunocompromised — it is non-live, with efficacy above 90%. It has replaced the live Zostavax, which was recommended from age 60 and reduced herpes zoster by 51% and post-herpetic neuralgia by 66%.

Tetanus, diphtheria and pertussis. Td booster every 10 years, and every 5 years for a tetanus-prone wound, with one dose given as Tdap to cover pertussis, since pertussis immunity wanes. Kane's makes the important point that many older people never received primary vaccination and therefore require tetanus toxoid plus 250–500 units of tetanus immune globulin, with the series completed by a second injection at 4–6 weeks and a third at 6–12 months.

COVID-19, RSV and situational vaccines. An updated COVID-19 vaccine for adults aged 65 and over, now through individual/shared clinical decision-making. RSV vaccine — a single dose for all adults aged 75 and over, and for those aged 50–74 with high-risk conditions, frailty, or residence in a long-term care facility; it is currently a one-time dose, not annual. Situational: hepatitis B in diabetes and dialysis; rabies post-exposure prophylaxis; typhoid, hepatitis A and yellow fever for travel; and meningococcal vaccine for Hajj and Umrah pilgrims — a common and examinable Indian indication. Live vaccines are contraindicated in significant immunosuppression.

Three changes dominate current adult immunisation practice. (i) ACIP lowered the age-based pneumococcal conjugate recommendation from 65 to 50 years (October 2024, effective January 2025), and added PCV21 (CAPVAXIVE) alongside PCV20, PCV21 offering broader serotype coverage and superior immunogenicity for 10 of its 11 unique serotypes. (ii) ACIP lowered the risk-based RSV vaccination age from 60 to 50 years (April 2025), retaining the universal recommendation at 75. (iii) COVID-19 vaccination for those aged 65 and over moved from a universal recommendation to individual-based (shared clinical) decision-making for the 2025–26 season. In addition, evidence that recombinant zoster vaccination is associated with roughly a 20% lower incidence of dementia (Nature, 2025) provides a powerful further argument for uptake in this population.