Clinical Review Recommended Immunizations for Older Adults: A Primer for Pharmacists

Key Words: Efficacy, Immunization, Influenza, Older adult,

Safety, Vaccines. Abbreviations: ACIP = Advisory Committee on Immunization

Chad M. Harte, Patricia W. Slattum Objective: To assess the effectiveness and safety of currently

recommended vaccines in older adults. Data Sources: PubMed was used to search for relevant articles. Key words searched included: immunosenescence, influenza vaccine efficacy, influenza vaccine safety, Tdap safety and efficacy elderly, Td safety and efficacy elderly, pneumococcal vaccine safety and efficacy elderly, pneumococcal vaccine efficacy, Recombivax safety and efficacy elderly, Zostavax safety and efficacy, influenza vaccine timing, frailty and immunosenescence. Study Selection/Data Extraction: Articles were reviewed and selected considering relevance to the subject. Selected articles were written in the English language, conducted mainly in humans, and published from 2008 to 2014, if it was a review article. Articles were then determined to be relevant or irrelevant based on their abstracts. Data Synthesis: Immunizations are a major means of preventing diseases, and pharmacists are a frontline health professional, with significant interactions with the older population. There are no recent published reviews that compile the efficacy and safety evidence for recommended immunizations in older people. Pharmacists are often asked questions about the efficacy and safety of these immunizations. Conclusion: Overall, efficacy and safety profiles of currently recommended vaccines are positive in the older population. The least-effective vaccine currently recommended is the varicellazoster vaccine, with a 50% efficacy. The vaccine with the highest rates of adverse events is the tetanus booster, with local pain and swelling at the injection site.

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Practices, CDC = Centers for Disease Control and Prevention, Ig = Immunoglobulin, IM = Intramuscular, PCV13 = 13-Valent pneumococcal conjugate vaccine, PPSV23 = 23-Valent pneumococcal polysaccharide vaccine, SC = Subcutaneous, Td = Tetanus-diphtheria, Tdap = Tetanus, diphtheria, and pertussis. Consult Pharm 2015;30:210-20.

Introduction Currently, the Advisory Committee on Immunization Practices (ACIP) and the Centers for Disease Control and Prevention (CDC) recommend that all individuals 65 years of age and older receive four vaccines.1 These vaccines include: • An influenza vaccine, annually • A 23-valent pneumococcal polysaccharide vaccine (PPSV23), once after the age of 65, and at least five years following the previous dose (if applicable) • A tetanus, diphtheria, and pertussis (Tdap) (or tetanus and diphtheria [Td]) booster every 10 years • A one-time dose of the varicella-zoster vaccine1 A summary of recommended vaccines for all individuals 65 years of age and older can be found in Table 1. The 13-valent pneumococcal conjugate vaccine (PCV13) has been increasingly considered for older adults in those not previously vaccinated with the PCV13, particularly with certain comorbidities. Hepatitis B vaccines are also increasingly recommended for this population because of an increase in the incidence of hepatitis B in older adults. This correlates with the increased incidence of diabetes mellitus, requiring glucose monitoring in long-term care facilities, as well as the increased incidence of hepatic and renal disease in older adults.1 Though literature regarding the safety and efficacy for vaccines in older adults is limited, it is expected that immune response to these vaccines may be decreased because of a naturally occurring process associated with aging commonly referred to as immunosenescence.

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Table 1. Recommended Vaccines for Adults 65 Years of Age or Older Vaccine

Dose

Route

Frequency

Influenza Pneumococcal (PPSV23)

0.5 mL 0.5 mL

IM IM/SC

(PCV13)**

0.5 mL

IM

Tetanus, Diphtheria, Pertussis (Td or Tdap) Varicella-Zoster Hepatitis B**

0.5 mL

IM

Yearly Once after the age of 65 and 5 years after previous dose (if necessary)* Once either 1 year after PPSV23 vaccine or 6-12 months before PPSV23 if not previously administered Every 10 years

0.65 mL 1 mL

SC IM

Once after the age of 60 One at 0, 1, and 6 months

* Several disease states suggest a dose of PPSV23 before 65 years of age. If an individual receives the pneumococcal vaccine before age 65, the second dose should be five years after the first dose. ** Not currently one of the four vaccines recommended by CDC for all people 65 years of age and older. Abbreviations: CDC = Centers for Disease Control and Prevention, IM = Intramuscular, PCV13 = 13-Valent pneumococcal conjugate vaccine, PPSV23 = 23-Valent pneumococcal polysaccharide vaccine, SC = Subcutaneous. Source: Reference 1.

Immunosenescence Immunosenescence is characterized by a decline in immune function with increasing age. Older adults experience a compromise in function of both divisions of the immune system, adaptive and innate, compared with the younger population. The adaptive immune system is responsible for responding to specific antigens within the body and comprises B- and T-cells. The innate immune system is nonspecific in nature, and comprises barriers (physical and chemical), neutrophils, and macrophages. The adaptive immune system can be further categorized into cellular and humoral immunity. Cellular immunity encompasses the actions of T-cells or T-lymphocytes, and its immunity is responsible for inducing the death of cells infected by antigens. Overall, T-cell numbers typically do not decline with increasing age because of an increase in memory T-cells; however, immature or naive T-cell numbers decline significantly with advancing age. This lower naive T-cell count can be attributed to involution of the thymus gland.2-4 Thymic involution decreases the ability of the thymus to store these naive T-cells and begins at an

early age, often around the first year of life. Naive T-cells are typically stored and differentiated within the thymus. There is also a decline in T-cell activity, characterized by reduced response to antigens and decreased development of specific T-cells.2 Signaling of T-cells is also compromised with increasing age as a result of a decline in the number of T-cell receptors as well as reduced functionality. This is compounded by increases in prostaglandin E2, which is thought to decrease the activation of T-cells.2 Humoral immunity encompasses the actions of B-cells or B-lymphocytes. Humoral immunity recognizes antigens in bodily fluids and is responsible for producing antibodies essential for an adequate immune response to vaccines. As with T-cell numbers, B-cell numbers typically remain constant throughout life, with an increase in the numbers of memory B-cells and a decrease in the numbers of naive B-cells.3,4 Naive B-cells are primarily responsible for recognizing novel pathogens and producing antibodies specific to that antigen. Decreases in naive B-cell numbers can impair the body’s ability to mount an effective immune response and provide adequate

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Clinical Review immunity following vaccination. There is a transition in the production of immunoglobulins from predominantly immunoglobulin (Ig) G to IgM antibodies with increasing age, which decreases the effects of B-cell function.3 B-cells are also dependent on other cell lines for proper activation, specifically dendritic cells from the innate immune system. The interaction between dendritic and B-cells significantly decreases with increasing age.3 A summary of age-related changes to the adaptive immune system can be found in Table 2. Frailty is a condition that can affect people with increasing age, and it has been shown to decrease physiologic reserve as well as the ability of a person’s body to mount an immunological response to vaccines.5 The innate immune system is nonspecific and comprises barriers (skin, stomach acid), neutrophils, natural killer cells, macrophages, and dendritic cells. Barriers can become impaired with increasing age, related to alterations in skin and mucosal integrity and increasing pH of the stomach, which can be further compounded by use of proton-pump inhibitors, histamine-2 receptor blockers, and antacids. With increasing age, production of neutrophils does not decrease because hematopoietic stem cells tend to preferentially produce myeloid (white blood cells, red blood cells, and platelets) compared with lymphoid (T- and B-cells) precursors.3,4,6 However, neutrophil activity and functionality decrease, and the time required for adequate neutrophil aggregation at infection sites increases. Natural

killer cells function by causing cell death of virally infected and malignant cells; these cell lines increase in number with advancing age, but overall effectiveness of each cell decreases. Macrophage function is also compromised with decreasing phagocytic activity and signaling to T-cells with increasing age.3,4,6 Macrophages are also responsible for the increased secretion of prostaglandin E2, which can result in decreased T-cell activation.4 Dendritic cells are a critical link between the innate and adaptive immune systems because they are major antigen-presenting cells and significantly aid in inducing immune responses.3,4 The number and function of dendritic cells decrease with advancing age, leading to an impaired immune response.4,6 A summary of age-related changes to the innate immune system can be found in Table 3. Because the efficacy of vaccines is dependent on mounting an adequate immune response, immunosenescence may adversely affect the success of vaccinations in older adults. Vaccines elicit a response from both the adaptive and innate immune systems. Within the innate immune system, there is a decrease in the numbers of dendritic cells, which act as antigen, presenting cells to activate the adaptive immune system in response to vaccinations.7 Within the adaptive immune system, naive B-cells recognize antigens present on dendritic cells and produce antibodies specific to the antigen.7 Dendritic cells also activate naive T-cells to mount a response against

Table 2. Summary of Changes to the Adaptive Immune System with Aging Cellular Immunity

Decreased numbers of naive T-cells Decreased T-cell activation related to increased prostaglandin E2 Decreased T-cell signaling resulting from decreased T-cell receptors and functionality Involution of the thymus Reduced response to novel antigens

Humoral Immunity

Decreased numbers of naive B-cells Decreased B-cell activation because of impaired interaction with dendritic cells Shift from IgG to IgM antibodies, resulting in decreased effectiveness of antibodies produced later in life

Abbreviations: IgG = Immunoglobulin G, IgM = Immunoglobulin M. Source: References 2–4.

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Table 3. Summary of Changes to the Innate Immune System with Aging Barriers (Physical and Chemical)

Decreased integrity of the skin and mucosal membranes, leading to increased risk of antigen penetration Increased pH of gastric fluids (can be compounded by the use of proton pump inhibitors, histamine-2 receptor blockers, and antacids)

Neutrophils

Decreased aggregation time Decreased functionality and activity

Natural Killer Cells

Increased absolute number, but decreased effectiveness per cell

Macrophages

Decreased phagocytic activity Decreased signaling to T-cells Increased secretion of prostaglandin E, leading to decreased T-cell activation

Dendritic cells

Decreased numbers, correlating with decreased activation of the cellular immune response

Source: References 3-6.

cells that are already infected by the antigen.7 After a successful immune response, memory B- and T-cells are responsible for long-term immunity and suppression of successive infections. If these cell lines are depleted, such as in immunosenescence, long-term immunity may become compromised. This may lead to an increase in the incidence of infections by antigens, against which older persons were previously vaccinated.

Influenza Vaccine Vaccine Significance According to the World Health Organization, the incidence of hospitalizations of older people was six times higher for the 2012-2013 influenza season (190.5/100,000 people) than the previous season (30.3/100,000).8 These hospitalizations can be further compounded by comorbid conditions. A recent study showed that 47% of hospitalizations as a result of influenza infection were compounded by comorbidities, particularly diabetes mellitus, chronic obstructive pulmonary disease, asthma, and

cardiovascular disease.9 Those with comorbid conditions were also at an increased risk of developing secondary bacterial infections such as pneumonia.9 Healthy People 2020, a national health promotion and disease prevention initiative, has set the goal immunization rate for influenza in older people at 90%, the same goal as was set forth in Healthy People 2010.10 CDC estimated that vaccination rates in the older population was 66.2% for the 2012-2013 influenza season, which was slightly higher than during the 2011-2012 influenza season (64.9%).11,12 The importance of increasing vaccination rates for the older population can be demonstrated by looking at the incidence of influenza-related hospitalizations and deaths. Those older than 65 years of age account for 60% of influenza cases requiring hospitalization and 90% of deaths related to influenza.13

Vaccine Efficacy Currently, there are several available types of influenza vaccines; however, only two are approved for use in older people. The first was the inactivated trivalent or

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Clinical Review quadravalent influenza vaccine, which is approved for all individuals six months or older and is administered intramuscularly. The most recent clinical trial looking at the efficacy of the inactivated influenza vaccine compared with placebo in the elderly population was in 1994 by Govaert et al. This trial showed that the efficacy of this vaccine—defined as achieving adequate titers on serological tests and decreased diagnosis of influenza by family physicians—was estimated to be 50%. Those who received the vaccine in the previous year experienced an increase in efficacy with the present year’s vaccine.14 A diagnosis of influenza was based on viral culture or serological testing, indicating an infection, as well as clinical presentation. The study focused on people older than 60 years of age; further analysis showed that the efficacy of the vaccination was greatest in those 60 to 69 years of age and was not as significant for those 70 years of age or older.15 It also showed that analysis of influenza antibody titers did not correlate with clinical presentation of influenza.14 A high-dose influenza vaccine was developed specifically for older adults and was first licensed for use in the United States in December 2009. It contains four times more antigen than the standard vaccine, which increases the production of antibodies, providing a theoretical increased efficacy. Currently, this vaccine is only approved for those 65 years of age and older in the United States. In an initial study of the efficacy and safety of the high-dose influenza vaccine compared with the standard-dose influenza vaccine, there was not a significant increase in efficacy with the high-dose vaccine. This was because no subjects in the trial receiving either vaccine tested positive for the strains of influenza that were contained in the vaccine.13 In 2014, DiazGrandos et al. published a study looking at the safety and efficacy of the high-dose vaccine compared with the standarddose vaccine, specifically in older adults. The study showed a relative efficacy for the high-dose influenza vaccine of 24.2% for any influenza viral type and 35.4% for those types included in the vaccine, compared with the standard dose vaccine in laboratory-confirmed influenza.16 Efficacy of the high-dose vaccine was

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evaluated by comparing the incidence of influenza confirmed by a laboratory in the high-dose group versus the standard-dose group. DiazGrandos et al. also examined immunogenicity in the study. The study showed that the high-dose vaccine elicited a higher immune response than the standard-dose vaccine.16

Vaccine Safety In 2010, a Cochrane review was published that discussed the safety of the influenza vaccine in the older population. This review revealed there was a significant increase in the incidence of local injection site-reactions (tenderness and soreness at the injection site).17 There was also a reported increase in systemic effects (fatigue, fever, headache, and nausea), which was not statistically significant.17 A study comparing the standard-dose influenza vaccine with the high-dose influenza vaccine showed both doses of vaccine had comparable adverse-event profiles. There were similar percentages of adverse and serious adverse events for each arm of the study.13 In the phase III trial of the high-dose vaccine, it had a statistically significant increase in the incidence of injection-site reactions compared with the standard dose (36%, compared with 24%, respectively), and there was also a slightly increased incidence of systemic reactions, which was not reported as statistically significant.18 The study published by DiazGrandos et al. showed similar rates of adverse events, with significantly fewer serious adverse events in the high-dose group compared with the standard dose, which was different from previous studies.16 Other Considerations Most influenza vaccines are made in eggs, and those with a significant egg allergy should not receive these vaccines because of the possibility of anaphylactic reactions. Currently, there is an influenza vaccine available that is not produced in eggs, Flublok, that would be more appropriate for these individuals. There is an alternate parenteral vaccine available called Fluzone intradermal. A study in 2008 looked at the immunogenicity and safety of an intradermal influenza vaccine compared with the traditional intramuscular

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(IM) influenza vaccine in older adults. In this study, two concentrations of intradermal vaccine were compared with the standard IM vaccine in 2005.19 This study found both doses of the intradermal influenza vaccine to be superior in immune response compared with the IM vaccine among older adults.19 With regard to safety, there was no difference in adverse events three days after injection; however, there was an increased incidence of pruritus, erythema, swelling, and induration seven days after injection, with similar rates of systemic reactions.19 Timing of vaccination administration has also been considered for the influenza vaccine. Lee et al. looked at peak influenza cases from the 2000-2001 through the 2007-2008 influenza seasons, showing that most cases of influenza occur in the months of January through March, though the 2000-2001 and 2003-2004 seasons had earlier onsets.20 The study stated that optimal administration of the influenza vaccine was in October; however, September did not have any disadvantages as far as cost and efficacy compared with October.20 Therefore, it can be inferred that optimal timing of the administration of the influenza vaccine is in either September or October, which coincides with the CDC’s recommendation of receiving the influenza vaccine by October. However, vaccination remains appropriate throughout the influenza season for those having not received the vaccine without a contraindication. 23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23)/13-Valent Pneumococcal Conjugate Vaccine (PCV13)

Vaccine Significance Recent estimates from CDC indicate that influenza and pneumonia ranked ninth in the United States in causing mortality in 2010, and accounted for 556.5 deaths per 100,000 population in those older than 65 years of age.21 Currently, CDC recommends that all adults older than age 65 should receive a one-time dose of PPSV23 unless the person was previously vaccinated. If a person has previously been vaccinated prior to age 65, a second vaccination should be administered five years after the first. ACIP and CDC also recommend that all adults 65 years of age

or older previously unvaccinated with the PCV13 receive the vaccine, followed by the PPSV23 6 to 12 months later, particularly if there are other compelling indications.22 If a person has already received a dose of the PPSV23, but was not previously vaccinated with the PCV13, a dose of the PCV13 should be administered no sooner than one year after the most recent PPSV23.22 Healthy People 2020 has set the goal immunization rate for the pneumococcal vaccine for older adults at 90%.10 Based on the 2011 National Health Interview Survey, CDC estimated that 62.3% of community-dwelling older people had received the pneumococcal vaccine, a 42.4% increase from 1997.23 This most recent figure leaves 37.3% of older adults unvaccinated. There are several risk factors in older individuals that increase the incidence of pneumonia, particularly the following chronic conditions: pulmonary diseases, cardiopathy, smoking, alcoholism, liver disease, nephropathy, diabetes mellitus, and any condition that impairs the immune system.24

Vaccine Efficacy The current PPSV23 covers the 23 most prevalent bacterial strains from the Streptococcus pneumoniae species, which are responsible for a majority of pneumonia cases. This vaccine was released for use in the United States in the mid-1980s. Since its release, the efficacy of the vaccine has been surrounded by controversy, with some studies showing positive results, while others were inconclusive. In early 2009, a study evaluated the efficacy of the PPSV23 in middle-aged and older adults, with an average age of 73 years.25 This study showed the effectiveness of the vaccine, evaluated by comparing incidence of pneumonia in vaccinated and unvaccinated adults, to be 46% in overall pneumonia and 76% effective against pneumonia caused by bacteria, against which the vaccine was targeted.25 A 2009 double-blind, randomized, and placebo-controlled trial on PPSV23 efficacy in nursing facility residents from Japan revealed that the vaccine reduced the overall incidence of pneumonia by 44.8% and decreased the incidence of pneumococcal pneumonia by 63.8%.26 The average age of individuals in this study was 84 years, and those included in this study were closely linked to the health

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Clinical Review care system because they resided in nursing facilities. This study also showed a decrease in mortality associated with pneumonia when PPSV23 was administered compared with placebo.26 Because the efficacy of the vaccine has not been conclusively established over time, a recent study looked at the immune response of older people to this vaccine. The results showed that older adults generated the same amount of antibodies as younger individuals; however, the activity of those antibodies was significantly reduced in older adults compared with younger adults.27 Studies have also shown that because there is no T-cell response elicited by the vaccine, the long-term immunity may be compromised in older adults with PPSV23.24 In comparison to the PPSV23, the PCV13 elicits a T-cell response and may offer more of a long-term immune response.28 Jackson et al. compared the safety and immune response of the PCV13 with the PPSV23 in pneumococcal vaccine-naive adults.28 They measured the immune response elicited by both vaccines in adults aged 50 years and older, and further divided the groups into those 50 to 59 years of age and those 60 to 64 years of age. The results of their study showed a noninferior immune response of the PCV13 compared with the PPSV23, with a significant increase in 8 of the 12 serotypes in those vaccinated with the PCV13 one month after vaccination.28

Vaccine Safety Safety reporting on the vaccine has been limited. A recent study compared the safety profile of PPSV23 to PCV13.28 This study showed that PPSV23 administration resulted in local reactions of pain, swelling, and redness at the injection site, and that there were also some associated systemic reactions (fatigue, chills, headache), which were similar to the PCV13 injection.28 Another study looked at adverse events in people requiring a second administration of PPSV23 compared with the primary administration.29 This analysis revealed that there was an increased incidence of local injection site reactions and self-reported fever, joint pain, fatigue, and headache on the second administration compared with the first.29

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Other Considerations The pneumococcal vaccine is typically administered intramuscularly; however, it can also be administered subcutaneously. In 2007, Cook et al. published a study comparing the efficacy and safety of both injection routes.30 They concluded that there was no significant difference in the immunogenicity attained postvaccination regardless of route.30 Subcutaneous injections resulted in significantly more local injection site reactions than the IM route, but with similar systemic reactions.30

Tetanus and Diphtheria/Tetanus, Diphtheria, and Pertussis Vaccine (Td/Tdap) Vaccine Significance Vaccines intended to prevent tetanus have decreased the incidence of tetanus by 95% and mortality associated with tetanus by 99% since 1947.31 From 2001 to 2008, the average number of tetanus cases in the United States was 29 per year.31 The number of doses a person receives of tetanus boosters and the time since the most recent vaccination appear to affect the incidence of tetanus; the increased numbers of doses, and having received the vaccine within the 10-year limit, resulted in decreased tetanus incidence.31 Risk of mortality from tetanus is highest among those 65 years of age or older compared with those younger than 65 years of age.31 The incidence of diphtheria has decreased to a point where only case studies are reported and none since 2003.32 Pertussis cases have become more prevalent in older adults in recent years. From 2000 to 2010, the average number of pertussis cases in the United States among people older than 65 years of age was 318 cases per year, which may be underreported because of the difficulty in diagnosis.33 Before 2005, after the initial DTaP (diphtheria, tetanus, and pertussis) vaccine received as a child, it was recommended that adults receive the Td booster every 10 years, which contains only tetanus and diphtheria antigens. Since 2005, however, CDC recommends a one-time substitution of Tdap, which contains pertussis antigens in addition to tetanus and diphtheria for the Td booster, because of the increased incidence of pertussis in the last decade.

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Vaccine Efficacy In 2010, Choi et al. looked at the immunogenicity of the Td booster among those older than 40 years of age. They found that age did not significantly affect the titers of antidiphtheria and antitetanus antibodies after successive immunizations.34 A recent randomized, double-blind, noninferiority trial showed similar post-vaccination response rates when comparing Td to Tdap vaccinations, with increased protection against pertussis in Tdap compared with Td.35 However, this trial evaluated only those younger than 55 years of age.35 A recent review reported that there was similar immunogenicity when receiving the Tdap across all age groups; 87% of those 65 years of age and older had protective levels of antidiphtheria antibodies, and 98% had protective levels of antitetanus antibodies, measured approximately one month after vaccination.36 Vaccine Safety In their study, Choi et al. found significant local injectionsite reactions, particularly pain at the injection site, but there were fewer systemic adverse events, malaise being the most prevalent of these.34 In a trial comparing Td with TdaP vaccinations, there appeared to be a not statistically significant increased incidence of injection-site reactions with Td compared with TdaP, with similar rates of systemic reactions.35

Varicella-Zoster (Shingles) Vaccine Vaccine Significance The varicella-zoster virus, which causes shingles, is the same virus that causes chicken pox in children. When the virus is reactivated and shingles manifests, there is significant pain and itching along nerve branches. The outcome of shingles could be long-term neuropathies that may result in blindness, if the face is involved, or postherpetic neuralgia, which is characterized by nerve pain lasting after the rash is gone. Shingles typically affects people as they age, and older adults are at an increased risk of developing shingles. It is estimated that shingles affects approximately one million individuals per year in the United States.37 Currently, CDC recommends all adults

older than 60 years of age receive a one-time dose of varicella-zoster vaccine.1 The Food and Drug Administration, however, recommends and has approved the vaccine for all adults older than 50 years of age. Healthy People 2020 has established a goal of 30% for shingles vaccination rates among those 60 years of age and older.10 In 2011, CDC estimated that 15.8% of adults 60 years or older had received the varicella-zoster vaccination.37

Vaccine Efficacy Recently, it has been estimated that the efficacy of the varicella-zoster vaccine in decreasing the incidence of shingles is 48%, and the effectiveness in preventing postherpetic neuralgia was estimated to be 59%.38 A recent Cochrane review, however, found there was no evidence to support a statistically significant efficacy of the vaccine in reducing postherpetic neuralgia aside from decreasing the overall incidence of shingles.39 When analyzing immune response to the vaccine, Levin et al. found a significant increase in varicella-zoster antibodies after immunization. However, the response was diminished with age when compared with those 60 to 69 years of age and those 70 years of age and older; this decrease was found to be 1% per year.40 They also found that three years after vaccination, antibody levels began to decrease.40 Vaccine Safety Major adverse events associated with the varicella-zoster vaccine are local injection-site reactions, particularly erythema, pain, and swelling.41 Systemic reactions were minimal, with headache being the most common.41 The vaccine formulation does contain gelatin, and those who have an allergy to gelatin should not receive this vaccine because of the possibility of anaphylactic reactions. Other Considerations Because this vaccine is a live vaccine, people taking antiviral medications should wait to receive the vaccine because antivirals may decrease the efficacy of the vaccine. Also, those who are immunocompromised should not receive the vaccine. It is recommended that the varicella-zoster vaccine should not be administered at the same time as or

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Clinical Review within four weeks of the pneumococcal vaccine because of the possible decreased immune response to the varicellazoster vaccine with concurrent administration.

Hepatitis B Vaccine Vaccine Significance The incidence of hepatitis B has been increasing in the older population, partly because of the increased incidence of diabetes mellitus, which requires monitoring in the long-term care facility.1 Blood glucose monitoring increases the opportunity for blood exposure when testing equipment is shared among individuals. For these reasons, vaccination has been increasingly recommended in the older population. CDC recommends the administration of the hepatitis B vaccine to adults 60 years of age or older, at the discretion of the physician, based on the risk of becoming infected with hepatitis B. CDC also recommends the vaccine for people with end-stage renal disease and chronic liver disease.1 CDC estimated that 12.4% of people 60 years of age or older with diabetes mellitus had received the hepatitis B vaccination series.38 Currently, there are two hepatitis B vaccines available in the United States: Recombivax HB and Engerix-B. Vaccine Efficacy Because the hepatitis B vaccination is only recommended in high-risk older adults, there has not been significant investigation into its efficacy in the elderly. A recent study looked at the efficacy and safety of each hepatitis B vaccine, comparing them in adults 50 years of age or older, those 50 to 64 years of age, and those older than age 65.42 It found Engerix-B to be more effective at eliciting an adequate immune response than Recombivax HB (67.7% compared with 34.4%, respectively).42 Vaccine Safety As with the efficacy of hepatitis B vaccination, evidence for the safety in older adults is lacking. Gilbert et al. looked at the safety profiles of both Energix-B and Recombivax-HB in their study. They found that there were similar rates of

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local injection-site reactions between the two vaccines, with pain and erythema being the most common reactions.42

Other Considerations Hepatitis B vaccination requires a three-shot series, with the second injection administered one month after the first, and the third administered five months after the second (or one administration at 0, 1, and 6 months).

Summary According to the 2013 ACIP/CDC vaccination guidelines, individuals 65 years of age and older should receive four vaccinations. These vaccinations are an annual influenza vaccine, a one-time dose of pneumococcal vaccine, a one-time dose of varicella-zoster vaccine, and a tetanus booster once every 10 years. The hepatitis B vaccination series also is increasingly indicated for this population. Of these vaccines, only the varicella-zoster vaccine is a “live” vaccine, so all vaccines can be administered in one session, if desired. However, it is recommended that there be at least a four-week separation between administering the Pneumovax-23 and the Zostavax vaccines because of the decreased immune response to the varicella-zoster vaccine when these two vaccines are administered concomitantly. Pharmacists are in a unique position as health care providers with regards to vaccine administration and advocacy. Often, people do not need to make appointments to see a pharmacist to receive vaccines, nor is a prescription needed for a pharmacist to administer these vaccines to individuals older than 65 years of age, if consistent with state law. Pharmacists frequently see consumers every month when filling maintenance medications and therefore have the opportunity to talk to and counsel these individuals. With increasing roles of technology in pharmacy, pharmacists can document when vaccines have been administered and can track when vaccines should be administered to their customers. Vaccination coverage by Medicare can vary by the types of Medicare each person has. Medicare Part B covers all influenza, pneumococcal, and hepatitis B vaccinations, and Medicare Part D covers all vaccines not covered by Part B, including tetanus boosters and varicella-zoster

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vaccines.43,44 Therefore, all vaccinations are covered by Medicare; however, what each person will pay will vary based on what type of coverage he or she has.

Chad M. Harte, PharmD, is a pharmacist, Riverside Health System, Shore Memorial Hospital, Nassawadox, Virginia. Patricia W. Slattum, PharmD, PhD, is professor, and director, Geriatric Pharmacotherapy Program, Department of Pharmacotherapy & Outcomes Sciences, Virginia Commonwealth University. For correspondence: Patricia W. Slattum, PharmD, PhD, Virginia Commonwealth University, 410 N. 12th Street, Rm 656A, Box 980533, Richmond, VA 23298-0533; Phone: 804-828-6355; Fax: 804-828-0343; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2015 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2015.210.

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Recommended immunizations for older adults: a primer for pharmacists.

To assess the effectiveness and safety of currently recommended vaccines in older adults...
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