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 ≥ 4 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: Rachael McGuire (MVEC Education Nurse Coordinator)

Date: May 31, 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.