What are the mandatory vaccines for the elderly?

Recommended Vaccines for Elderly Adults

All adults aged 65 years and older should receive annual influenza vaccination, pneumococcal vaccination (preferably a single dose of PCV20 or PCV15 followed by PPSV23), and the recombinant zoster vaccine (RZV) in a 2-dose series, along with tetanus-diphtheria-pertussis (Tdap/Td) boosters every 10 years. 1, 2, 3

Core Vaccinations for Adults ≥65 Years

Influenza Vaccine

• Annual vaccination is mandatory for all persons aged 6 months or older, including all elderly adults 1
• High-dose influenza vaccine is preferred for adults aged ≥65 years due to increased immunogenicity in this age group 3
• Any influenza vaccine appropriate for age and health status should be administered annually 1

Pneumococcal Vaccination

The CDC now recommends a single dose of PCV20 as the preferred option for adults aged ≥65 years 2

Alternative approach: A single dose of PCV15 followed by PPSV23 at least 1 year later 2, 3

Important sequencing considerations:

• If both PCV13 (or newer conjugate vaccines) and PPSV23 are to be administered, the conjugate vaccine must be given first 1
• PCV13 and PPSV23 should be administered at least 1 year apart and should not be given during the same visit 1
• Research demonstrates that giving PPSV23 before PCV13 significantly impairs subsequent immune responses to PCV13, and this impairment persists for at least 1 year 4, 5

For previously vaccinated elderly:

• If previously received PPSV23 only: administer PCV20 at least 1 year after the last PPSV23 dose 2
• If previously received PCV13 only: administer PCV20 at least 1 year after the PCV13 dose 2
• If previously received both PCV13 and PPSV23: no additional pneumococcal vaccination is needed until age 65 years 2

Clinical evidence: Sequential PCV13/PPSV23 vaccination showed the highest effectiveness of 80.3% against pneumococcal pneumonia in adults aged 65-74 years, compared to single-dose vaccines 6

Zoster (Shingles) Vaccination

Recombinant zoster vaccine (RZV/Shingrix) is strongly recommended for all adults aged 50 years or older 1

Dosing schedule:

• 2-dose series administered 2-6 months apart (minimum interval: 4 weeks) 1
• If dose is administered too soon, repeat the dose 1
• RZV is preferred over the live zoster vaccine (ZVL/Zostavax) 1

For previously vaccinated individuals:

• Administer RZV regardless of previous herpes zoster history 1
• If previously received ZVL, administer RZV at least 2 months after ZVL 1

Tetanus-Diphtheria-Pertussis (Tdap/Td)

• One dose of Tdap, then Td or Tdap booster every 10 years 1
• This applies to all adults who have completed the primary series 7

Special Situations and High-Risk Conditions

Immunocompromised Elderly

For adults aged 19-64 years with immunocompromising conditions (also applicable to elderly with these conditions):

• Administer a single dose of PCV20 as the preferred option, or PCV15 followed by PPSV23 at least 8 weeks later (not 1 year as in immunocompetent adults) 2
• Immunocompromising conditions include: chronic renal failure, nephrotic syndrome, functional or anatomic asplenia, cerebrospinal fluid leaks, cochlear implants, HIV infection, leukemia, lymphoma, solid organ transplant, and iatrogenic immunosuppression 1

Chronic Medical Conditions

Adults with chronic conditions require PPSV23 even before age 65:

• Chronic lung disease (COPD, emphysema, asthma), chronic cardiovascular disease, diabetes mellitus, chronic liver disease, alcoholism, or cigarette smoking 1
• These individuals should receive PPSV23 before age 65, then follow standard elderly vaccination schedules at age 65 1

Residents of Long-Term Care Facilities

• All residents of nursing homes or long-term care facilities should receive pneumococcal vaccination 1
• These individuals may be at increased risk for PCV13-type disease and should be considered for PCV13 vaccination based on shared clinical decision-making 1

Critical Timing Considerations

Common pitfall to avoid: Never administer PPSV23 before a conjugate vaccine (PCV13, PCV15, or PCV20), as this significantly diminishes the immune response to subsequent conjugate vaccination 4, 5

For elective procedures:

• Pneumococcal vaccines should be administered at least 2 weeks before elective splenectomy or initiation of immunosuppressive therapy 2

Additional Vaccines Based on Risk Factors

Hepatitis A

• Recommended for adults with chronic liver disease, men who have sex with men, injection drug users, and travelers to endemic areas 1, 2
• Standard schedule: 2 doses administered 6-12 months apart (Havrix) or 6-18 months apart (Vaqta) 2

Measles-Mumps-Rubella (MMR)

• Generally not required for adults born before 1957 unless they are healthcare personnel 1
• Healthcare personnel born before 1957 without laboratory evidence of immunity should receive 2 doses of MMR 1

Varicella

• Not routinely required for adults born before 1980 unless they are healthcare personnel or lack evidence of immunity 1

Medicare Coverage

• Influenza and pneumococcal vaccines are covered under Medicare Part B 7
• Zoster vaccine is covered under Medicare Part D 7