Feature Article — Adult Vaccine Recommendations? What Should I Know?

Adult vaccine needs do not get nearly the attention that childhood vaccines do. In part this is because children have regularly scheduled healthcare visits during which vaccines are discussed and administered, and in part, it is because vaccines are often required to attend daycare or school. Vaccine requirements play an important role in stemming the spread of infectious diseases in schools and by extension, homes and communities. Unfortunately, the focus on vaccine requirements (“What vaccines are needed for my child to attend school?”) diminishes attention to the more important “R word” when it comes to vaccines — recommendations.

Vaccine recommendations are the guidance related to who should get a vaccine, when and how many doses. These are used to create the vaccine schedule, but just because a vaccine is on the schedule does not mean it is required. States decide requirements, whereas recommendations are made at the federal level. Unfortunately, when vaccines are recommended but not required, they often do not get the same attention from healthcare providers or patients. If requirements are viewed as “must haves,” recommendations tend to be treated as “nice to haves.” But that is not the best way of looking at recommendations because the reality is that if a person gets all the required vaccines, they will have some protection. If they get all the recommended vaccines, they will have better protection. When my children were young, I didn’t even think about requirements. If a vaccine was recommended, I wanted my kids to have it. Why leave protection on the table?

When it comes to adult vaccines, requirements are few and far between. Since most adult vaccines are recommended and few are required, many adults put themselves at unnecessary risk. They may not even realize they are doing so, especially since adults are particularly bad at getting themselves to the doctor unless they are ill, and vaccine conversations do not often make the cut during provider-patient discussions.

Recently, recommendations have changed for several adult vaccines, so we thought it would be a good time to describe these changes and remind adults of other recommended vaccines.

Recent adult vaccine changes

• Hepatitis B is a virus that can cause liver cancer or cirrhosis. The virus has traditionally been considered a sexually transmitted disease (STD), and while it is frequently spread in this manner, it is not only spread that way. Because large quantities of the virus are present in the blood of an infected person, the virus can be spread via exposure to quantities of infected blood that are too small to see. Further complicating this is the fact that many people do not realize they are infected until years later when they develop cancer or liver disease. As such, they can unwittingly spread the virus for decades before realizing they are doing so.
  
  Historically, high-risk groups of people were recommended to get vaccinated against hepatitis B. However, in 2022, the recommendations were changed to include all adults between 19 and 59 years of age. Those 60 years and older are recommended to get the vaccine if they have risk factors and were not previously vaccinated, but any adult 60 and older can get the vaccine if they so choose.
• Tdap – Tdap vaccine protects against three diseases: tetanus, diphtheria and pertussis. Adults are used to getting “a tetanus booster” when injured or every ten years, whichever comes first. Historically, that vaccine was Td, meaning it protected against tetanus and diphtheria, but not pertussis. When the Tdap vaccine became available, adults were recommended to get it the next time they were due for a tetanus booster or if they were going to be around new babies, and then to return to getting Td. The recommendation related to newborns was meant to protect the babies by decreasing their chance of being exposed to pertussis before they were old enough to be vaccinated against it (called “cocooning”). However, the recommendations have changed again. Specifically, adults can get Tdap in place of Td at every booster opportunity, and they do not need to get Tdap if they are going to be around newborns. Pregnant women, however, should now get a dose of Tdap during a specific period of each pregnancy (27- to 36-weeks gestation). The reason for the changes related to newborns and pregnancy was because cocooning was not as effective as hoped, but maternal antibodies passed to the baby through the placenta before birth were found to protect more babies during the period before they could get their own vaccines.
• Influenza – While most adults are aware of the annual influenza vaccine recommendation, two recent changes are worth noting. First, adults 65 years and older and pregnant women in their first or second trimester should not be vaccinated earlier than September. This is to ensure higher levels of circulating antibodies during the most likely period of exposure, particularly since both groups are at increased risk of complications from influenza infection. In the case of pregnant women, the antibodies also serve to protect the baby before it can get the influenza vaccine. The second change relates to which vaccine adults 65 years and older should receive. Specifically, those 65 years and older should get a “high-dose” or “adjuvanted” version of influenza vaccine if it is available, so they generate a better immune response; however, if those versions are not available, they should get one that is available so they do not remain unvaccinated longer than necessary.
• Pneumococcus – Adults 65 years and older as well as several high-risk groups of younger adults are recommended to be vaccinated against this infection. A newer version of pneumococcal conjugate vaccine (PCV20) protects against 20 of the most common types of pneumococcus. A previous version (PCV15) protects against 15 types of the bacteria, and a non-conjugated (polysaccharide) version, called PPSV23, protects against 23 types. The conjugated vaccines include a “helper protein” that is attached to the sugar coating of the bacteria, resulting in a better immune response than the polysaccharide version generates. Adults who were not previously vaccinated against pneumococcus can either get one dose of PCV20 or get the other two vaccines separated by a year (PCV15 then PPSV23). Adults who were previously vaccinated against pneumococcus should talk to their healthcare provider to determine if they need another dose of pneumococcal vaccine and if so, which one.
• Human papillomavirus (HPV) – Adults up to 26 years of age who did not receive or complete this vaccine series are recommended to do so. Those 27 to 45 years of age can talk with their healthcare provider about whether they could benefit from receiving this vaccine. On one hand, the immune response to the vaccine decreases as people get older. On the other hand, most people have not been exposed to all nine types of HPV that the vaccine protects against, so it is worth a discussion with your healthcare provider if you want to be protected against HPV.
• Adults born after 1980 who were not diagnosed with chickenpox and did not receive two doses of the chickenpox vaccine should get this vaccine, particular since infections tend to be worse in adults.
• Adults who have not received the COVID-19 vaccine are recommended to do so. At this point, most of the hospitalizations and deaths are occurring in previously unvaccinated, or partially vaccinated, individuals.

Other adult vaccine considerations

Adults are also recommended to be protected against several other infectious diseases, including shingles, hepatitis A, measles, mumps, rubella and meningococcus. The recommendations for each of these vaccines vary, so talk to your healthcare provider if you are uncertain of your vaccine status.

If traveling internationally, additional vaccines may be of benefit. Likewise, certain subgroups of adults have more specific recommendations based on their health status (e.g., chronic conditions), job, or a temporary status, such as during pregnancy or before receiving chemotherapy or an organ transplant.

For more detailed information, check out the VEC’s recently updated booklet, “Vaccines and Adults: A Lifetime of Health.” The booklet is also available in Spanish.

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