Introduction:

We (geriatrician / Geriatric Physicians ) have been working in a era where a programme in the name “Decade of Healthy Aging” from 2021-2030, has been launched and under implementation by WHO, as a programme of United Nations. WHO defines Healthy Ageing “as the process of developing and maintaining the functional ability that enables wellbeing in older age”. Healthy lifestyle includes nutritious diet, work, appropriate physical exercise, strategy for preventive healthcare , the interaction with the environment, and social connectivity ; therefore healthy life style practices in senior citizen plays crucial role in their healthy living .(1) Vaccination against preventable diseases is an important part of healthy life style practice. Human body has armamentarium to fight against foreign body / invaders ,but without passing through a process called immunization by introducing vaccines, protection against specific disease is not achievable. There are many (about 20) diseases those are vaccine preventable . We have experienced success of immunization programme in children in terms of morbidity and mortality . Now, vaccination is not limited to children, it has turned to life course vaccination that also include geriatric vaccination . Through vaccinating geriatric people we can protect elderly from diseases like pneumonia, influenza, tetanus, herpes zoster; thereby reducing morbidity and mortality and improving quality of life in geriatric population .

Indian Guideline for Vaccination in older adults (2)

• Pneumococcal
• Influenza
• Tetanus
• Herpes Zoster

PNEUMOCOCCAL VACCINE :

Types of vaccines –

(1)Pneumococcal Polysaccharide Vaccine (PPSV23)

(2) Pneumococcal Conjugate vaccine (PCV 13)

• Both the vaccines are indicated in all adults above the age of 50 years.
• Help in preventing Invasive Pneumococcal Diseases.

PCV 13 (Prevnar 13)

Pneumococcal 13-valent Conjugate Vaccine is a sterile solutions of Saccharides of capsular antigens of Streptococcus Pneumoniae serotypes conjugated by reductive amination to nontoxic Diphtheria CRM 197 protein.

PCV 13 confers T cell immunity.

PPSV 23(Pulmovax)

A 23-valent formulation of polysaccharide pneumococcal vaccine (PPSV23) , containing long chains of polysaccharide molecules that make up surface capsule of 23 types(Streptococcus pneumoniae are lancet-shaped, gram-positive, facultative anaerobic bacteria with more than 100 known serotypes).

PPSV confers B cell Immunity.

Doses Schedule : .5ml given IM PCV 13 to be given before giving PPSV 23.(3) PPSV 23 .5ml IM usually given 1 year after PCV 13 (minimum gap is 08 weeks ). PPSV 2 can be given as booster dose 5 years after the first dose.

INFLUENZA:

Facts about Influenza Vaccines :

• Vaccinated annually . Before the monsoon season(June-September) in South India or before the winter season(December-February) in Northern India
• Dose: .5 ml IM yearly(INFLUVAC TETRA)
• Contraindicated in persons allergic to egg.

• Influenza vaccine may be egg based , cell culture based or recombinant vaccines
• For quadrivalent egg- or cell culture-based or recombinant vaccines for use in the 2023-2024 northern hemisphere influenza season, the WHO recommends inclusion of the B/Yamagata lineage component in addition to other components for Trivalent egg based vaccines.
• ** Flublok quadrivalent is cell based and egg free

1. Diphtheria,Pertussis&Tetanus (Tdap - BOOSTRIX)

Recommendation:

For individuals without prior tetanus, diphtheria, or pertussis vaccination:

• 1 dose Tdap, then 1 dose Td or Tdap 4 weeks later, and a third dose of Td or Tdap 6–12 months later (Tdap preferred as first dose),
• Td or Tdap every 10 years thereafter.

For previously vaccinated individuals :

Td/Tdap vaccine at every 10 years in previously vaccinated persons. (4)

Wound management:

• Previously vaccinated with tetanus-toxoid vaccine,

Tdap/Td if >10 years since last dose for clean/minor wounds, >5 years for other wounds.

• Tdap preferred for those without previous Tdap history.

Precaution:

• Guillain-barr’e Syndrome(GBS) within 6 weeks after a previous dose of TT containing vaccine.
• History of arthus reaction with previous dose of TT containing vaccine , including MCV4**; defer vaccination until 10 years have elapsed since the last dose.
• Pregnancy

ZOSTER(SHINGLES)

Vaccine Type :Recombinant Zoster Vaccine.(SHINGRIX)

Doses : 02 doses(.5 ml) I/M, Deltoid or Anterolateral thigh ; 0,2-6 month.(5)

• SHINGRIX does not contain gelatin or neomycin.

Contraindications:

• Pregnancy
• Known severe immunodeficiency
• H/O immediate hypersensitivity reaction to Any ingredient of the vaccine.

Rabies Vaccine : According to doses schedule.

Hepatitis B vaccine :

Normal healthy Person : 0,1 & 06 month ; 20mcg /ml per dose.

For Weak Immune System Geriatric Patient –

Four Doses : 0,1, 2 & 06 month & Double the normal dose (i.e. 40mcg each dose)

For Travellers-

• Hepatitis A : To be given IM two to four week before travel (First dose), 2nd dose after 6 To 12 month.
• Japanese encephalitis : Completed one week before travel,if stay is longer than a month. Two doses 4 weeks apart ,.5ml IM.(Widespread in India), JENVAC-Brand.
• Yellow fever : 10 (TEN) days before travel, single dose subcutaneous .5ml. STAMARIL (17D Vaccine)- Yellow fever occurs in Africa and South America
• Meningococcal: MPSV (Menactra available), .5ml subcutaneously, to all Haj Pillgrims.(N.B- some vaccines are available in Govt. Vaccination centres only)

MenFive-First conjugate vaccine (in collaboration with Serum Institue); 7-10days prior to travel.

• Typhoid : Typbar TCV Vaccine(Vi conjugate vaccine, typhoid capsular polysaccharide conjugated with Tetanus toxoid) .5ml given in deltoid, 02 weeks prior to travel.Offers protection for 03 years.

Organizing a Geriatric Vaccination Clinic-

Requirements(check list ):

• Placement of Clinic
• Rooms(one for resuscitation)
• Refrigerator with thermometer with generator backup
• Cold Chain Facility
• Selection of vaccines to be kept /arranged for vaccination
• Proper handling of vaccine after receiving.
• Storing and documentation
• Proper dispensing under the guidance of expert(Geriatrician)
• Readiness of medicines for managing anaphylaxis , injury etc.
• Equipment including oxygen full O2 cylinder and Ambu bag.
• Trained Nurse and trained Geriatric Social worker.

Drawbacks of Geriatric Vaccination:

• Immunosenescence- The antibody formation is less.
• Response –Less and fades away faster.
• Every strain not covered
• Mutation
• The Cost.
• Yearly / Repetitive.
• The schedule has to be followed.
• Ignorance –Lay public ,Planners ,Medical community.

Way Forward:

There should be easy availability of vaccines and reimbursement from Govt. PSU’s, Insurance providers, should be there.

Mass public awareness regarding use of vaccine in geriatric population need to be enhanced . Geriatric vaccination need to be included in National Policy.

References:

1.https://www.who.int

2.https://www.geriatricindia.com

3. Indian consensus -guideline for adult vaccination.

4.https://www.cdc.gov>vaccines>adult

5.shirinrix.com.