What vaccine recommendations are suggested for adults over 70, including frequency and dosage, such as one-time or annual vaccinations for influenza, pneumococcal disease, shingles, tetanus, diphtheria, and pertussis (Tdap), and hepatitis B?

Vaccine Recommendations for Adults Over 70

Adults over 70 should receive annual influenza vaccination, a one-time 2-dose recombinant zoster vaccine series, pneumococcal vaccines (both PCV13 and PPSV23), and a Td or Tdap booster every 10 years, with additional vaccines based on specific risk factors. 1

Annual Vaccinations

Influenza Vaccine

• All adults aged ≥65 years should receive influenza vaccination every year without exception. 1
• Adults ≥65 years should preferentially receive high-dose inactivated influenza vaccine, recombinant influenza vaccine, or adjuvanted inactivated influenza vaccine for enhanced protection compared to standard-dose formulations. 1
• This is an annual requirement that must be repeated every fall/winter season. 2, 1

One-Time or Limited Series Vaccinations

Shingles (Herpes Zoster) Vaccine

• All adults ≥50 years should receive a 2-dose series of recombinant zoster vaccine (RZV, brand name Shingrix), which is the preferred formulation. 1
• This is a one-time 2-dose series (not annual), with doses separated by 2-6 months. 1
• The older live zoster vaccine (Zostavax) mentioned in earlier guidelines 2 has been superseded by RZV, which provides superior protection. 1

Pneumococcal Vaccines

• All adults ≥65 years should receive PPSV23 (pneumococcal polysaccharide vaccine). 1
• PCV13 (pneumococcal conjugate vaccine) may be given based on shared clinical decision-making, and if given, should be administered at least 1 year before PPSV23. 1
• This is typically a one-time vaccination, though one-time revaccination with PPSV23 may be indicated 5 years after the initial dose for those who received it before age 65. 2, 3

Tetanus, Diphtheria, and Pertussis (Tdap/Td)

• Adults should receive one dose of Tdap if they have never received it, followed by Td or Tdap boosters every 10 years. 1
• For adults ≥65 years, Tdap can be administered regardless of the interval since the last tetanus-containing vaccine. 2, 4
• This is a recurring vaccination every 10 years, not annual. 2, 1
• A critical pitfall: Do not administer tetanus boosters more frequently than every 10 years for routine immunization, as this can cause severe local hypersensitivity reactions (Arthus reactions). 4

Risk-Based Vaccinations

Hepatitis B

• Hepatitis B vaccination is recommended for adults with specific risk factors including chronic liver disease, end-stage renal disease, HIV infection, healthcare workers, injection drug users, and those with multiple sexual partners. 1
• This is a one-time 2-3 dose series (depending on the vaccine formulation used), not annual. 1

Hepatitis A

• Recommended for adults with risk factors such as chronic liver disease, men who have sex with men, injection drug users, and travelers to endemic areas. 1
• This is a one-time 2-3 dose series, not annual. 1

Meningococcal Vaccines

• Indicated for adults with asplenia, complement deficiencies, HIV infection, or specific occupational exposures (e.g., microbiologists). 1
• Typically a one-time 2-dose series for high-risk individuals, not annual. 2, 1

Practical Implementation for Adults Over 70

Multiple vaccines can be safely administered during the same visit. 5, 4

Typical Initial Visit Strategy:

• Administer influenza vaccine (annual), Tdap (if never received), and initiate pneumococcal series at separate anatomic sites (preferably different deltoid muscles). 4
• If zoster vaccine series has not been completed, initiate or continue the 2-dose RZV series. 1

Key Clinical Pitfalls to Avoid:

• Do not assume immunity to vaccine-preventable diseases based on age alone—adults over 70 still need documentation of vaccination or serologic evidence of immunity. 1
• Do not restart vaccine series if doses are delayed—continue where the patient left off regardless of time elapsed between doses. 2, 1
• Do not use live vaccines in immunocompromised patients—this includes live attenuated influenza vaccine and the older live zoster vaccine (Zostavax). 1

Special Considerations for Immunocompromised Adults Over 70

• Pneumococcal vaccination is strongly recommended with both PCV13 and PPSV23 for immunocompromised individuals. 1
• Live vaccines are generally contraindicated in immunocompromised states. 1
• Inactivated vaccines (pneumococcal, meningococcal, inactivated influenza) are generally acceptable and should be prioritized. 2

Summary Algorithm

For a typical healthy adult over 70:

1. Annual: Influenza vaccine (preferably high-dose or adjuvanted formulation)
2. Every 10 years: Td or Tdap booster
3. One-time series: Pneumococcal vaccines (PPSV23 required; PCV13 based on shared decision-making)
4. One-time 2-dose series: Recombinant zoster vaccine (if not previously completed)
5. Risk-based: Hepatitis A, Hepatitis B, Meningococcal vaccines as indicated by specific risk factors

1, 6, 3