Elderly population: immunisation recommendations

There are a variety of factors that need to be considered in relation to the vaccination of the older population. A gradual decline of the immune system occurs as people age (known as immunosenescence), impacting how the immune system responds to new infections, as well as the effectiveness of long-term immune memory. It is for this reason that some vaccines are specifically designed for the older population and aim to enhance the immune response by using higher immunogenicity formulations or by containing adjuvants. Providing optimal protection can also be complicated due to the increasing prevalence of multiple co-morbidities in the ageing population. Specific medical conditions or targeted therapies (eg. chronic renal conditions, chemotherapy for cancers etc) can also cause older adults to be more vulnerable to infections and their complications. Further to this, relying on patient recall, as well as a lack of awareness for the recommended vaccines for the older population, can result in either missed vaccines or additional unnecessary doses being administered.

There are multiple vaccines recommended for the older population as outlined below.

Herpes zoster (Shingles) vaccines

Shingles is caused by a reactivation of the varicella virus and will occur in approximately 20-30% of people in their lifetime. Older people (> 70 years of age) are more likely to suffer post-herpetic neuralgia (PHN) following a shingles infection than younger people. PHN is a chronic neuropathic pain which can affect 1 in 4 cases of shingles diagnosed in those > 80 years. It can persist for months to years with pain control being difficult to manage, impacting quality of life.

There are currently 2 vaccines available in Australia for the prevention of shingles:

  • Zostavax®- a live-attenuated vaccine
  • Shingrix®- an adjuvanted recombinant varicella zoster virus glycoprotein E (gE) subunit (non-live) vaccine

Zostavax®

Zostavax® has been shown to reduce the incidence of developing shingles by up to 50%, as well as the incidence of PHN in those ≥ 60 years of age by 66%. It is currently funded under the National Immunisation Program (NIP) for persons aged 70 years, with a catch-up program for those aged 71–79 years also funded (until October 2023). As it is a live-attenuated vaccine, it is contraindicated for use in those who are immunosuppressed, or on immunosuppressive medications (eg; Rituximab, Azathioprine, Prednisolone, chemotherapy etc). Prior to administering Zostavax® it is important to take a thorough patient history to determine suitability for immunisation.

Shingrix®

Shingrix® is preferred over Zostavax® for the prevention of shingles due to a higher efficacy, particularly in the older population. In those aged ≥ 50 years, Shingrix® provided 97% protection against shingles in immunocompetent individuals and 91% protection in those aged > 70 years. Clinical trials have demonstrated high efficacy up to 4 years following vaccination with immunogenicity data indicating this is likely to persist beyond 10 years.

Shingrix® is registered for use in adults aged ≥ 50 years. It is only available through private prescription and supplies are currently limited. It is a non-live vaccine and as such can safely be administered to immunocompromised individuals. ATAGI recommends a 7 day interval between the administration of COVID-19 vaccines and Shingrix®, and prefers that FluadQuad and Shingrix® are not co-administered on the same day.

Further guidance can be provided by reviewing the Australian Immunisation Handbook: Table. Live shingles vaccine (Zostavax) screening for contraindications or by contacting SAEFVIC prior to immunisation.

Pneumococcal vaccines

Invasive pneumococcal disease (IPD) can manifest as meningitis, pneumonia and bacteremia, with severe disease requiring hospitalisation, causing significant morbidity and even death. The elderly (along with infants) are at the highest risk of developing IPD. Recommendations for pneumococcal vaccines in adults vary according to age and medical condition [refer to ATAGI clinical advice on vaccination recommendations for people with risk conditions from 1 July 2020]. Pneumococcal vaccines are currently provided for free on the NIP for the following people:

  • Aboriginal and Torres Strait Islander adults with NO risk condition – 1 dose of Prevenar 13® at 50 years of age, followed 8 weeks later by 2 doses of Pneumovax® 23, given 5 years apart
  • Non-indigenous adults with NO risk condition – 1 dose of Prevenar 13® at >70 years
  • Non-indigenous adolescents/adults diagnosed with a risk condition – 1 dose of Prevenar 13® at diagnosis, followed by 2 doses of Pneumovax® 23, given 5 years apart

In adults, injection site reactions may occur > 3 days following the Prevenar 13® dose given at > 70 years, particularly in those who have previously received Pneumovax®23. A history of large local injection site reactions following previous pneumococcal vaccines is not a contraindication to further doses.

Refer to MVEC: Pneumococcal for more information.

Influenza vaccines

For older adults, and those with certain medical conditions (eg. chronic lung disease, cardiac disease, immunosuppression), influenza disease can cause serious morbidity and mortality. Annual influenza vaccination is strongly encouraged and it is available for free on the NIP for those ≥ 65 years of age and/or adults with certain medical conditions. Due to a reduced immune response to routine influenza vaccines, those aged ≥ 65 years should receive higher-immunogenicity influenza vaccines.

Refer to MVEC: Influenza for specific information on brands and dosing.

COVID-19 vaccines

Older people and those with comorbidities (eg. hypertension, diabetes, chronic lung disease etc) are much more likely to suffer from severe COVID-19 disease if infected. Of those who are > 80 years of age and have COVID-19 disease, approximately 1 in 3 will die from it.

COVID-19 vaccination requires a 2-dose primary course for immunocompetent individuals, or a 3 -dose primary course for those with immunocompromise. A primary course shoulod be followed by a booster dose ≥ 3 months later, and a further “winter booster” dose ≥ 3 months after that for select individuals.

For more information on COVID-19 vaccination for older people please refer to COVID-19 vaccination – COVID-19 vaccination decision guide for frail older people, including those in residential aged care facilities.

Considerations for residents of residential aged care facilities (RACF)

Whilst every effort should be made to immunise residents of RACF at risk of vaccine preventable diseases like COVID-19 and influenza, it is important to monitor for adverse events following immunisation (AEFIs). Due to a high incidence of cognitive impairment, elderly residents may not have capacity to self-report any side effects. Any AEFIs experienced within 5 days of vaccination should be reported to SAEFVIC. It is important to monitor for non-specific symptoms seen in the elderly population when unwell such as falls, delirium, functional decline, decrease/loss of appetite or changes in mood/behaviour.

For further information on additional cares that may be required and management of symptoms following vaccination in residents of RACF refer to Guidance for vaccination care of residents of Victorian Residential Aged Care Facilities.

Reporting to the Australian Immunisation Register (AIR)

The AIR provides a record of all vaccine doses given, the date of administration as well as the specific brands used. Since 2016 vaccines administered to Australians of any age have been recorded onto the AIR. Patient recall, particularly in the older population, is not reliable and as such it important that immunisation records are accurately maintained and reviewed regularly.

From March 2021, new legislation came into effect making reporting vaccines to AIR mandatory. This includes all COVID-19 vaccines, influenza vaccines and all National Immunisation Program vaccines.

Resources

Authors: Daryl Cheng (Paediatrician, The Royal Children’s Hospital), Francesca Machingaifa (MVEC Education Nurse Coordinator) and Rachael McGuire (MVEC Education Nurse Coordinator)

Reviewed by: Francesca Machingaifa (MVEC Education Nurse Coordinator)

Date: August 5, 2022

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


Eczema and immunisations

Background

Eczema, or atopic dermatitis, is a skin condition affecting many people of all ages but is most common in infants and young children. It affects approximately 40% of babies and children worldwide and often appears in the first year of life. Many children grow out of eczema around the age of 5 years however, there are some individuals who will have eczema throughout their life.

Eczema, along with asthma, allergy and allergic rhinitis are more formally known as atopic conditions. Of those children with moderate to severe eczema, a small number will go on to develop food allergy, asthma of childhood and/or allergic rhinitis.

It is not well understood why some individuals develop eczema or other atopic conditions however, there is research and clinical trials currently underway looking into possible genetic, immunological and environmental causes for eczema.

Immunisation implications

Although there is no causal relationship between vaccines and eczema identified in the literature it is recognised that a flare of eczema may occur following immunisation.

Parents of infants and children with eczema can be confident that vaccines do not cause atopic disease, and should be reassured that while children may experience a flare of eczema in the days following their vaccines, this is not considered a contraindication to immunisation.  It is important that eczema management continues, including the use of moisturisers, topical steroids and barrier creams in order to treat any symptoms that may occur. Families should seek medical advice from their local GP or eczema specialist if they are concerned.

It is important to also note that the use of topical steroids to treat active eczema is not a contraindication to any vaccination. If there is active eczema present, an alternate injection site could be considered to reduce the risk of infection (or abscess) at the injection site. If no other site is deemed suitable, cleaning the site with an alcohol based wash/single use alcohol swab and allowing the site to dry completely before injecting could be considered. BCG vaccination should be deferred if there is active eczema at the injection site.

Resources

Authors: Mel Addison (SAEFVIC Research Nurse, Murdoch Children’s Research Institute)

Date: July 2020

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


Epilepsy

One in 20 children will have at least one seizure during their childhood. A single seizure does not mean a child has epilepsy. Febrile convulsions are not considered epilepsy. Epilepsy is a disorder of the brain that leads to a person having repeated unprovoked seizures. About one in 200 children has epilepsy.

Vaccine-proximate seizures

Seizures occurring within 14 days of a vaccine are defined as vaccine-proximate (VPS). Most children with epilepsy do not have a high risk of VPS. However, there are some genetic epilepsies with a strong association with VPS. These include Dravet syndrome and genetic epilepsy with febrile seizures plus (GEFS+).

Dravet syndrome

Dravet syndrome is a rare and severe form of infantile onset epilepsy with a prevalence of 1 in 15,500 – 40,000 children. Children with Dravet syndrome classically present in the first year of life with prolonged febrile seizures. These seizures can be hemiclonic (one-sided) or generalised tonic-clonic seizures and sustained such as in status epilepticus (SES). Their first seizure may be associated with their primary series of immunisation, often their 4 or 6 month vaccines. They then develop refractory (uncontrolled) afebrile seizures, particularly myoclonic seizures, and a plateau or regression in their development. A genetic mutation, usually as a one-off (de novo) change in the sodium channel gene SCN1A is found in approximately 80% of children with Dravet syndrome. VPS in infants, particularly if prolonged or SES, should raise suspicion of Dravet syndrome.  The first seizure is vaccine-proximate in approximately 30% of children with Dravet syndrome. Immunisation can lead to an earlier age of seizure onset in children with Dravet syndrome. However there is no difference in developmental or seizure outcomes in children who had a first seizure proximate to immunisation compared to children with seizures unrelated to immunisation.

Genetic epilepsy with febrile seizures (GEFS+)

Genetic epilepsy with febrile seizures plus (GEFS+) is a spectrum of seizure disorders of varying severity. A diagnosis of GEFS+ is usually made in individuals whose family members have febrile seizures with or without recurrent afebrile seizures (epilepsy).  Some children with GEFS+ have VPS.

Immunisations in Dravet syndrome and other children at risk of vaccine-proximate seizures

There is a well-reported association between febrile seizures/SES and immunisations in children with Dravet syndrome and some other genetic epilepsies, especially within the first 48 hours following an inactivated vaccine. Live-attenuated vaccines may also cause seizures 5-10 days post vaccination, often post the measles-mumps-rubella (MMR) vaccine given at 12 months.

The decision to immunise children with Dravet syndrome or other children with VPS requires a comprehensive discussion between the patient’s family and the treating medical teams, usually both immunisation experts and neurologists. Immunisations provide protection from common, and sometimes devastating, childhood vaccine preventable diseases, such as influenza, which can cause significant harm as well as also triggering febrile seizures/SES. Thus, it is in the child’s best interests to be fully vaccinated with a clear plan by the medical team to ensure safe re-vaccination under careful medical supervision if possible.

Prevention of vaccine-proximate seizures

There is no published data evaluating prophylactic measures to prevent seizures in children with Dravet syndrome undergoing immunisations. There is anecdotal evidence and experience that prophylactically administering antipyretics and benzodiazepines to children with Dravet syndrome prior to and after immunisation can reduce the rate of immunisation-related seizures and SES.

Management

If your child/patient has a diagnosis, or suspected diagnosis, of Dravet syndrome or other genetic epilepsy, they should be referred to a Specialist Immunisation Clinic for review as well as being seen by a neurologist. A clear plan for re-vaccination can be discussed, including consideration for admission to hospital under the Protocol for immunisation of children with Dravet syndrome or other vaccine-proximate seizures.

Children with epilepsy who have not had previous VPS and whose type of epilepsy is not strongly associated with VPS generally do not require prophylactic treatment around the time of vaccination. However, where there are questions or concerns about safety of vaccination in an individual child, referral to a Specialist Immunisation Clinic could be considered.

Key message

Protection from vaccine preventable diseases is important in children with epilepsy and a clear plan should be discussed and developed with the medical team and parents to ensure that the child’s routine immunisations are completed if possible. In children who have had previous vaccine-proximate SES or those with a high risk of having vaccine-proximate SES (e.g. Dravet syndrome), strong consideration should be given to performing future vaccinations under careful medical supervision in a hospital, in close collaboration with the treating neurologists.

Resources:

Authors: Georgina Lewis (Clinical Manager, SAEFVIC, Murdoch Children’s Research Institute), Nigel Crawford (Director, SAEFVIC, Murdoch Children’s Research Institute), Margie Danchin (Paediatrician, Murdoch Children’s Research Institute and Royal Children’s Hospital) and Gabriel Dabscheck and Katherine Howell (Royal Children’s Hospital neurologists)

Date: March 2020

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.