Assessment and Diagnosis · 4 min read
Influenza and Adult Immunizations
Why Immunization Matters in Older Adults
Immunosenescence, the gradual decline of immune function with age, blunts both the response to infection and the response to vaccines. Adults aged 65 and older account for most influenza-related hospitalizations and deaths, and pneumonia, shingles and respiratory syncytial virus (RSV) infection carry far higher complication rates in this age group. Infection in an older adult often triggers functional decline, delirium, falls and exacerbation of heart failure or COPD.
Influenza Vaccine Recommendations
The CDC and its Advisory Committee on Immunization Practices (ACIP) recommend annual influenza vaccination for everyone 6 months and older, including all adults 65 and older. Vaccinate before influenza activity begins, ideally by the end of October, but keep offering the vaccine as long as the virus circulates. Protection begins about 2 weeks after vaccination.
| Vaccine type | Key feature | Nursing note |
|---|---|---|
| High-dose inactivated | Four times the antigen of standard dose | Preferentially recommended for age 65+ |
| Adjuvanted inactivated | MF59 adjuvant boosts immune response | Preferentially recommended for age 65+ |
| Recombinant | Egg-free; three times the antigen | Preferentially recommended for age 65+ |
| Standard-dose inactivated | Usual antigen content | Give if no preferred vaccine is available; do not delay |
U.S. influenza vaccines are now trivalent (two influenza A strains and one B strain). If none of the three preferred vaccines is available at the visit, give any age-appropriate vaccine rather than miss the opportunity.
Contraindications and Precautions
| Category | Examples | Action |
|---|---|---|
| Contraindication | Severe allergic reaction (anaphylaxis) to a previous dose or a vaccine component | Do not give that vaccine |
| Precaution | Guillain-Barré syndrome within 6 weeks of a previous influenza vaccine | Weigh risks and benefits with the provider |
| Precaution | Moderate or severe acute illness, with or without fever | Defer until improved |
| Not a contraindication | Egg allergy of any severity, mild illness, current antibiotic use | Vaccinate; no extra precautions beyond those for any vaccine |
Administration and Adverse Effects
- Give 0.5 mL intramuscularly in the deltoid; a 1-inch needle suits most adults (consider 1.5 inches for larger arms)
- Document vaccine name, manufacturer, lot number, expiration date, dose, route, site, date, administrator, and the Vaccine Information Statement given; report to the state immunization registry
- Expect injection-site pain, redness or swelling and, occasionally, low-grade fever, malaise or myalgia for 1–2 days
- Inactivated and recombinant vaccines cannot cause influenza; illness soon after vaccination reflects exposure before immunity developed or another virus
Other Recommended Adult Vaccines
Review the whole immunization record at every comprehensive assessment and follow the current CDC adult schedule, which is updated regularly.
| Vaccine | Who | Schedule highlights |
|---|---|---|
| Pneumococcal (PCV20 or PCV21; or PCV15 then PPSV23) | All adults 50 and older | Usually one conjugate dose; PPSV23 follows PCV15 after at least 1 year |
| Recombinant zoster (RZV) | Adults 50 and older, regardless of prior shingles or live zoster vaccine | 2 doses, 2–6 months apart |
| RSV | All adults 75+; adults 50–74 at increased risk (e.g., chronic heart or lung disease, nursing-home residence) | Single lifetime dose; best given late summer to early fall |
| Tdap / Td | All adults | Tdap once if never received, then Td or Tdap every 10 years; wound management as needed |
| COVID-19 | Adults 65 and older | Per the current CDC schedule |
Patient Education and Vaccine Hesitancy
Older adults may decline vaccines because of misconceptions ("the flu shot gave me the flu"), fear of side effects, or a past bad experience. A strong, presumptive recommendation from the nurse is one of the most effective ways to raise uptake.
- Annual influenza vaccine for every older adult; high-dose, adjuvanted or recombinant vaccine is preferred at 65+
- Egg allergy is not a reason to withhold influenza vaccine
- Severe allergy to a prior dose is the main true contraindication; GBS within 6 weeks of a prior dose is a precaution
- Review pneumococcal, zoster, RSV, Tdap/Td and COVID-19 status at the same visit
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