Immunizations for the older adult
Robert D. Kennedy
WHY: Vaccination rates for influenza and pneumococcal disease in the United States approach only 60% in spite of aggressive vaccination program efforts. However, these preventable illnesses cause substantial morbidity and mortality in older patients, who tend to have more medical co-morbidities and are at higher risk for complications. In the USA, influenza causes 36,000 annual deaths, 90% of which are people beyond the age of 65. Pneumonia, most often due to pneumococcus, has a mortality rate of up to 40%. In the elderly, tetanus, while not as common as the flu or pneumonia, involves people aged 60 or older more than 60% of the time with the highest mortality rate in this age group.
* Adults above age 50 (for annual influenza vaccination) and above age 65 (for one-time pneumococcal vaccination) and above age 50 (for every ten-yearly tetanus-diphtheria toxoid booster) who are either healthy or have medical conditions including chronic medical conditions such as: heart disease, pulmonary disease, diabetes mellitus, liver disease, renal failure, alcoholism, immunosuppresed states such as HIV and congenital immunodeficiency, anatomic or functional asplenia (sickle cell disease, splenectomy), malignancies (lymphoma, leukemia, solid tumors) receiving immunosuppressive therapy including steroids and bone marrow- and organ-transplant recipients. (Younger adults with these medical conditions should also receive immunizations.)
* Residents of nursing homes and other long-term care facilities.
* Health care workers such as hospital staff, nursing home staff and home care givers.
BEST PRACTICES: It is imperative to screen for immunization histories during patient office visits, as well as hospital admissions, and offer vaccination as indicated. It is vital to screen health care staff on a pre-employment basis, and keep them informed and immunized at regular intervals.
STRENGTH AND LIMITATIONS: Vaccines for influenza, pneumonia (excluding viral), and tetanus have preventive efficacy rates approaching 90%. Such vaccines are relatively safe, with very few contraindications and a low rate of adverse reactions. Most non-vaccinated individuals either are not offered vaccination, do not know that such vaccines are available or have refused vaccination, due in part to misinformation. Furthermore, only one out of every three health care workers are immunized against influenza. This means two out of every three health care workers can transmit a potentially lethal illness to the very population being cared for.
ADMINISTRATION OF VACCINES: All vaccines are administered intramuscularly in the deltoid muscle. Pneumococcal vaccine and influenza vaccine may be administered at the same time, (by separate injection in the other arm) without an increase in side effects or decreased antibody response to either vaccine. Tetanus-diphtheria toxoid booster also may be administered concurrently with other vaccines.
For the Older Adult Patient
1. Always attempt to obtain patient’s immunization history. Ask family for assistance if patient cannot provide reliable information. Old medical records or computer records may indicate prior vaccinations. Pay attention to any history of neurological or hypersensitivity reactions.
2. Educate the patient on vaccine-preventable diseases and the importance of vaccination. Patients and patient’s families oftentimes have misconceptions or lack of information regarding immunization. Offer vaccination as indicated.
3. Provide clear documentation of vaccination provided to minimize risk of unnecessary duplication.
4. Follow the following guidelines recommended by the Department of Health and Human Services:
* Provide influenza vaccine annually, starting October and ending February.
* Provide pneumococcal vaccine once after the age of 65 with a revaccination after 5 years if diseases such as chronic renal failure, chronic immunosuppression, malignancies, and functional or anatomic asplenia are present.
* Provide Tetanus-diphtheria toxoid (Td) as a booster shot every ten years to those who have either completed the immunization series during childhood or teen years and have not received a booster dose in the last 10 years. If the patient ahs never been vaccinated, administer 0.5 mg. intramuscularly twice with a 1-2 month interval and an additional dose 6-12 months later. Again, previous neurologic or hypersensitivity reactions are an absolute contraindication.
Hospital Immunization Protocols
Work with hospital administration to develop a system that:
1. Screens for immunization, upon admission, of the older adult.
2. Educates new admissions about immunization.
3. Incorporates immunization history and standing physician orders into the electronic medical record.
4. Tracks healthcare staff immunizations and ensures adequate compliance.
5. Provides immunization education and screening to the community at large.
6. Provides personal immunization records for older adult patients.
MORE ON THE TOPIC:
Department of Health and Human Services (DHHS). Recommended Adult Immunization Schedule by Age Group and Medical Condition. Summary of Recommendations published by the Advisory Committee on Immunization Practices, 2003-2004.
Gosney, M. (2000). Factors affecting influenza vaccination rates in older people admitted to hospital with acute medical problems. Journal of Advanced Nursing. 32(4), 892-897.
Resnick, B. (2002). Health promotion practices of the older adult. Public Health Nursing. 17(3), 160-168.
Santibanez, T. A., Nowalk, M. P., Zimmerman, R. K., Jewell, I. K., Bardella, I. J., Wilson, S. A., & Terry, M. A. (2002). Knowledge and Beliefs About Influenza, Pneumococcal Disease, and Immunizations Among Older People. Journal of American Geriatrics Society, 50(10), 1711-1716.
Wexler, D. L. et. al. (2004). Vaccinate Adults! A Bulletin for Adult Medicine Specialists from the Immunization Action Coalition, 8(2).
Robert D. Kennedy MD and Kurt Cullamar MD
COPYRIGHT 2006 Jannetti Publications, Inc.
COPYRIGHT 2007 Gale Group