The latest release丨 Expert consensus on the application of vaccines for common infectious diseases in the elderly in the community

Reprinted with the authorization of the Chinese Journal of General Practitioners, the original article was published in the Chinese Journal of General Practitioners, No. 1, 2022, pages 6-23

preface

Infectious disease (infectious disease) is a general term for diseases caused by pathogenic microorganisms, which have a high incidence and high case fatality rate in the elderly population, which seriously affect the quality of life of the elderly and cause a heavy economic burden, and have become one of the major public health problems in the world.

With the increase of age, the physiological and metabolic functions and immune functions of various tissues and organs in the elderly gradually decay, and chronic diseases such as cardiovascular and cerebrovascular diseases, respiratory diseases, diabetes, kidney diseases, and tumors often exist at the same time, and the risk of infectious diseases increases significantly [1]. In addition, once the elderly are infected, their clinical manifestations are often atypical, have many complications, and have poor treatment effects, which seriously affect the quality of life of the elderly[2], and may lead to the aggravation of the original chronic disease, the occurrence of clinical adverse health outcomes and even an increase in the risk of death [3, 4], and increase the consumption of medical resources [5].

First, the benefits of vaccination in the elderly and the guidelines recommend

Vaccination is a measure that specifically protects susceptible populations, increasing the level of specific immunity in vaccinated populations and reducing the risk of infectious diseases and associated complications [6]. Vaccination can also slow the progression of chronic diseases in older adults by preventing infection, reducing the risk of adverse outcomes due to complications of chronic diseases [7]. Studies have shown that the effectiveness of influenza vaccine in preventing influenza-like diseases in the elderly in mainland China is 53% (20% to 72%)[8]; the effectiveness of 23-valent pneumoccal polysaccharide vaccine (Pneumoccal polysaccharide vaccine 23, PPV23) against invasive pneumococcal disease (IPD) in the elderly ranges from 39% to 76% [9, 10] The protective efficacy of the shingles vaccine against people aged 60 to 69 years and ≥ 70 years is 97.4 percent and 91.3 percent, respectively [7,11]. Combined influenza and pneumococcal vaccination in ≥ 75-year-olds reduced all-cause mortality, hospitalization rates, and hospitalization costs by 26 percent, 23 percent, and 6 to 13 percent, respectively [12].

Many guidelines on the prevention and treatment of chronic diseases recommend vaccinations for common infectious diseases in the elderly, especially elderly patients with chronic diseases [13, 14, 15, 16], covering influenza, pneumococcal pneumonia, herpes zoster, meningitis, etc. In July 2019, the Healthy China Action Promotion Committee issued the Healthy China Action (2019-2030)[17], which recommended that high-risk groups such as the elderly and patients with chronic respiratory diseases take the initiative to receive influenza vaccine and pneumococcal vaccine. In 2019, the General Office of the National Health Commission issued the "Core Information on the Prevention of Disability in the Elderly", recommending that the elderly be regularly injected with pneumococcal vaccine and herpes zoster vaccine, and that influenza vaccines be given under the guidance of doctors before the influenza epidemic season [18].

Second, the current situation and influencing factors of vaccination for the elderly in the mainland

(1) The vaccination rate is low

Under the current apparent infectious disease burden, the overall vaccination rate of vaccines such as influenza vaccine, pneumococcal vaccine and shingles vaccine in mainland China is still low, despite the available evidence of the benefits of vaccination and recommended by numerous authoritative guidelines. According to the survey, influenza vaccination rates for ≥ 60-year-olds in mainland China were only 3.8% in 2014-2015[19], far below the >60% in developed countries and the 75% target set by the World Health Organization [20, 21]. Even in Shanghai, Beijing, Changsha and other places, the vaccination rate of pneumococcal vaccine for the elderly is only 1.9% to 5.8% [22, 23, 24], far lower than the 71% in the United States and 58% in Canada [25, 26].

(2) Factors affecting vaccination rates

Vaccination rates are affected by a variety of factors, such as the awareness and importance of both doctors and patients on diseases and vaccine-related knowledge, the cost of vaccination, and the accessibility and convenience of vaccination services.

There is a general lack of willingness in older people to be vaccinated against infectious diseases. According to the survey, the willingness rate of the elderly population in mainland China to vaccinate pneumococcal vaccine, influenza vaccine and shingles vaccine is only 36.0%, 46.9% and 49.6% respectively, and the factors affecting vaccination mainly include age, family income, education level, cognition of vaccines, other chronic diseases, whether there is medical insurance, etc., and the elderly with high degree of Chinese, younger age, chronic diseases, lower incomes, and medical insurance are more willing to be vaccinated [27, 28, 29].

In addition, the perception and attitude of doctors or vaccinators about diseases and vaccines can directly affect vaccination rates for infectious diseases in older adults. Health education and recommended vaccination recommendations for disease prevention in older adults have helped increase vaccination rates among older adults in the community [30]. However, at present, the awareness of medical staff about related diseases and vaccines is uneven, which is not conducive to helping the elderly establish correct cognition. Surveys have shown that vaccination vaccinators have insufficient knowledge of vaccines [31], only 59.4% of vaccinators believe that the proportion of pneumococcal pneumonia in the elderly is high, and 37.1% of vaccinators do not believe that PPV23 vaccination is effective in preventing pneumococcal pneumonia in the elderly.

The way vaccinations are paid also has an impact on the prevalence of infectious disease vaccinations in the elderly. Surveys show that in Beijing, Shenzhen and other areas that have adopted the policy of free influenza vaccination, the influenza vaccination rate of 60-year-olds in ≥ can reach 50%, but in other areas where influenza vaccines are self-funded, the influenza vaccination rate of the elderly is only 4% [32]. Since 2014, Chengdu has implemented a pneumococcal vaccination subsidy policy for the elderly aged ≥ 60 years old, and the pneumonia vaccination rate of the city's elderly population reached 42.1% in 2017 [33].

3. The background of the formulation of this Consensus and the applicable population

In view of the current widespread problem of insufficient awareness of infectious disease vaccines and low vaccination rates among the elderly in the community on the mainland, medical personnel in grass-roots medical and health institutions should focus on increasing the importance of vaccination of the elderly population, strengthen vaccination publicity and education for the public, recommend vaccination for suitable vaccinators, and actively promote the elderly to establish a correct understanding of infectious disease vaccines, so as to improve the vaccination rate of the elderly in the community, improve their quality of life, and achieve healthy aging.

In order to strengthen the scientific publicity of the knowledge of infectious disease vaccination in the elderly by medical staff in grass-roots medical and health institutions, and promote the vaccination of common infectious disease vaccines for the elderly in the community, the General Medicine Branch of the Chinese Medical Association, the Journal of the Chinese Medical Association and the Editorial Committee of the Chinese Journal of General Practitioners organized experts from professional fields such as disease prevention and control, respiratory medicine, dermatology and general medicine, based on evidence-based medical evidence of vaccination of the elderly in the community to prevent common infectious diseases. Combined with relevant guidelines or recommendations at home and abroad, the Expert Consensus on the Application of Vaccines for Common Infectious Diseases in the Elderly in the Community was jointly formulated. Given the wide spectrum of infectious diseases, this consensus is only for the current high incidence, heavy burden of disease, vaccine-related research and guidelines recommend more mature influenza vaccines, pneumococcal vaccines and shingles vaccines.

Influenza vaccine

Influenza (hereinafter referred to as influenza) is an acute respiratory infectious disease caused by influenza viruses. The elderly are at high risk of influenza virus infection and high risk of severe illness and death due to factors such as reduced immune response, decreased lung compliance, decreased respiratory muscle strength, weakened cough reflex, coexistence of multiple diseases and malnutrition, and are also at high risk of severe illness and death.

1. Influenza

(1) Influenza virus

Influenza viruses are RNA viruses belonging to the family Orthogonal viruses. Influenza viruses are classified as A, B, C, and D4 according to viral nuclear proteins and matrix proteins[34]. Influenza A virus can be divided into various subtypes according to the protein structure and genetic properties of hemagglutinin (HA) and neuraminidase (NA) on the surface of the virus. Ha and NA have been found to have 18 (H1-18) and 11 (N1-11) subtypes, respectively. The subtypes that cause seasonal influenza epidemics are the Victoria and Yamagata lines of H1N1, H3N2, and B viruses in influenza A [36]. Influenza C virus causes only sporadic cases [37]. Influenza D virus mainly infects pigs, cattle and other animals, and no cases of human infection have been detected [38, 39].

(2) Epidemiology

1. Source of infection, mode of transmission and incubation period: Influenza patients and latent infected people are the main source of influenza infection, influenza virus is mainly transmitted through droplets of its respiratory secretions (such as sneezing and coughing, etc.), and can also be transmitted through direct or indirect contact with mucous membranes such as mouth, nasal cavity, and eyes, and may also be transmitted in the form of aerosols in specific places [34]. The usual incubation period is 1 to 4 days, averaging 2 days, and it is contagious from the end of the incubation period to the acute phase of onset, and the detoxification period generally lasts 3 to 8 days [36]. Older adults have worse virus clearance and longer detoxification times [40, 41].

2. Epidemiological characteristics and seasonality: Influenza is seasonally endemic and high incidence in winter and spring every year in temperate regions [42, 43, 44]. In the tropics, particularly in Asia, the seasonality of influenza is highly diverse, ranging from semi-annual or year-round cyclical epidemics to annual cycles [43, 44, 45, 46]. Seasonal influenza epidemics usually occur in the Northern Hemisphere between October and May, peaking in January and February[47]. Influenza A shows a single annual peak in the northern provinces north of 33° north latitude of the mainland, with a single annual peak from January to February; in the southern provinces of the central latitude of the mainland, in addition to January to February, summer (June to August) can also be circulated, that is, a double-cycle peak; and the southernmost provinces south of the mainland latitude of 27° north latitude show a single annual peak epidemic from April to June each year [48]. Influenza B is high in most parts of the continent in a single winter [48]. Influenza B in mainland China is generally less prevalent than A, but higher in some regions and in some years [49].

3. Clinical features [34,36,50]: Influenza is generally acute onset, mainly with fever, headache, myalgia and general malaise, body temperature up to 39 ~ 40 °C, can have chills, chills, with fatigue, loss of appetite and other systemic symptoms, often have sore throat, cough, nasal congestion, runny nose, retrosternal discomfort, flushing of the face, conjunctival congestion and so on. Mild flu often behaves similarly to the common cold, but its fever and constitutional symptoms are more pronounced. The course of the disease in uncomplicated patients is self-limiting, and it gradually resolves after 3 to 5 days of onset, and the systemic symptoms improve, but cough and physical recovery often take a long time. Severe cases may present with extrapulmonary manifestations such as viral pneumonia, secondary bacterial pneumonia, acute respiratory distress syndrome, shock, diffuse intravascular coagulation, cardiovascular and neurological manifestations, and a variety of complications.

Diagnosis of influenza depends on laboratory tests. Pathogenic-related tests include viral antigen testing, viral nucleic acid detection, viral culture isolation, and serological testing.

2. Influenza vaccine

(1) Types and mechanisms of influenza vaccines

Influenza vaccines approved for marketing in foreign countries for the elderly include trivalent and quadrivalent standard antigen content and high antigen content inactivated vaccines, adjuvant trivalent inactivated vaccines, and recombinant vaccines. The only influenza vaccines approved for marketing in the mainland for the elderly are trivalent and quadrivalent standard antigen content inactivated vaccines cultured in chicken embryos, of which the antigen components of the trivalent vaccine contain one line (Victoria line or Yamagata line) of the A (H3N2) subtype, A (H1N1) subtype and B strain, and the antigen component of the quadrivalent vaccine contains A (H3N2) subtype, A (H1N1) subtype, and B type two lines [51]. Trivalent inactivated vaccines, including cleavage vaccines and subunit vaccines, can be given to people aged 6 months and older, with 0.25 ml of dosage form for infants and young children aged 6 to 35 months and 0.5 ml of 36 months of age and older [36]. Live trivalent attenuated vaccines are lyophilized formulations of 0.2 ml per dose for people aged 3 to 17 years [16]. Quadrivalent inactivated vaccines are lytic vaccines that can be given in people 36 months of age and older in a single dosage form of 0.5 ml [36]. For vaccinated populations, either vaccine may be given voluntarily, with no priority recommendation [36].

Influenza vaccines induce humoral and cellular immune responses in the body. Humoral immunity works primarily by inducing the body to produce antibodies to glycoproteins on the surface of influenza viruses through influenza vaccines [52]. Serum antibody levels usually peak at 2 to 4 weeks after influenza vaccination, while older adults may need at least four weeks to reach antibody peaks [53, 54]. Cellular immunity works primarily through CD8+ T lymphocytes [55], and the number of T lymphocytes in older adults decreases and their proliferative capacity decreases, resulting in a relatively low immune response in older adults [52]. Influenza vaccines with high antigen content or adjuvant containing antigens enhance the body's immune response to influenza-specific antigens and antibody responses compared to standard antigen content or antigen alone [52,56].

The protective effects of influenza vaccines last for six to eight months [57], and serum antibody levels decrease significantly after one year of vaccination [36]. Each year, the World Health Organization updates the recommended influenza vaccine components accordingly based on the predictions of influenza virus strains in the next epidemic season. Even though the influenza vaccine components are identical to the previous season, influenza vaccination is recommended before the influenza season for maximum protection, regardless of whether most vaccinated people have significantly reduced antibody titers [36].

(2) The effect of vaccination

Meta-analysis showed that influenza vaccination in older adults was 58 percent effective against influenza viruses [58]. Results from mainland studies have shown that influenza vaccines are 53% (20% to 72%) effective against influenza-like illness in ≥ 60-year-olds [8].

Influenza vaccine reduces the incidence of influenza-related complications, hospitalization and mortality for chronic diseases in older adults, and influenza-related hospitalization and mortality rates [36]. A meta-analysis of influenza vaccinations in older adults by Beyer et al. [59] showed that influenza vaccines helped prevent 28 percent of flu-related complications, 39 percent of flu-like symptoms, and 49 percent of confirmed flu in older adults.

(3) The safety of vaccination

Common adverse effects, which are local and systemic, are usually mild and resolve spontaneously within a few days, with severe adverse effects rarely occurring [36,51].

Surveillance of adverse vaccine events in the United States showed that the overall adverse response rate of trivalent inactivated influenza vaccine administered to older ≥ 65-year-olds from 1990 to 2005 was approximately 1.65 per 100,000 doses [60]. There was no significant difference in safety between trivalent and quadrivalent inactivated influenza vaccines, and no significant difference in safety between domestic and imported influenza vaccines [51]. According to a mainland study, the incidence of adverse reactions in populations receiving domestic influenza lysis vaccines and two imported influenza vaccines was 3.76%, 4.10%, and 3.54%, respectively [61]. Another study of ≥ 60-year-olds showed a 5.35 percent incidence of adverse reactions from influenza vaccination in older adults [62]. Studies in the United States have shown no statistically significant difference in the proportion of people who experienced serious adverse events with high antigen inactivated vaccines and standard antigen inactivated vaccines within 180 days of vaccination [63]. A meta-analysis showed that trivalent inactivated influenza vaccines containing MF59 adjuvants had more adverse effects than non-adjuvant vaccines, but the incidence of adverse reactions in the two vaccines was almost indistinguishable on day 3 after vaccination [64]. Another randomized controlled trial in the United States found that a small number of people with a small number of people in ≥50 years of vaccination had common serious adverse events in both the quadrivalent recombinant influenza vaccine and the quadrivalent standard antigen inactivated influenza vaccine, but none of these events were associated with the trial vaccine [65].

III. Vaccination Recommendations

(1) Inoculation targets

The Technical Guidelines for Influenza Vaccination in China issued by the Mainland over the years and the 2018 Expert Recommendations on Influenza and Streptococcus Influenza and Pneumoniae Vaccination for the Elderly recommend that ≥ 60-year-olds receive influenza vaccines every year [16,36,52]. In particular, influenza vaccination reduces the risk of severe influenza in the following subjects:elderly people at home; elderly people and employees in crowded places such as nursing homes, welfare homes, and long-term care institutions; influenza vaccination can reduce the risk of cluster outbreaks; elderly people with chronic diseases: cardiovascular disease (except for simple hypertension), chronic respiratory diseases, metabolic diseases (including diabetes), hepatic and renal insufficiency, hematologic diseases, nervous system diseases, Chronic diseases such as neuromuscular dysfunction and the elderly suffering from immunosuppressive diseases or immunocompromised diseases.

(2) Timing of vaccination

Because influenza viruses are susceptible to mutation and the titers of antibodies produced after influenza vaccination begin to decay after 6 to 8 months, influenza vaccines should be given annually. In order to obtain protection before the high incidence season of influenza, it is recommended to be vaccinated as soon as possible after the vaccine is available in that year, preferably before the end of October; those who have not been vaccinated before the end of October can be vaccinated throughout the epidemic season. During the same influenza epidemic season, people who have completed influenza vaccination do not need to be vaccinated repeatedly [36].

(3) Vaccination methods

Inactivated influenza vaccines are given using intramuscular injection (except for intradermal formulations). Adults choose to vaccinate against deltoid muscles in the upper arm. Give 1 dose of 0.5 ml each [36].

(4) Contraindications to vaccination

Vaccination is prohibited for those who are allergic to any of the ingredients contained in vaccines, including excipients, formaldehyde, cleavers, and antimicrobials [36]. Mild to moderate acute illness with or without febrile symptoms is recommended to be given after symptoms have subsided [36]. Contraindications to specific vaccine products should refer to the product manual and the doctor's recommendation.

(5) Adverse reactions

Common adverse effects of inactivated influenza vaccines include systemic reactions and local reactions at the site of vaccination, which generally disappear spontaneously 1 to 2 days after injection without the need for treatment [47]. Local reactions mainly include redness, pain, swelling, induration, and burning sensation at the inoculation site [51]. Systemic reactions include fever, dizziness, headache, drowsiness, fatigue, myalgia, general malaise, abdominal pain, diarrhea, nausea, and vomiting [51]. Serious adverse effects are rare, such as allergic rash, allergic purpura, anaphylactic shock, angioedema, convulsions, transient thrombocytopenia, meningococcal, neuralgia, neuritis, paresthesias, and Guillain-Barré syndrome [47].

(6) Matters needing attention

1. Because the incubation period of influenza is several days, influenza infection is still possible if you are exposed to the presence of influenza virus before or immediately after vaccination [52].

2. If the vaccine bottle is cracked, illlabeled or invalid, the vaccine is cloudy or foreign in appearance is prohibited [36].

3. It is forbidden to mix influenza vaccine with other vaccines in the same container, and two or more vaccines should be given at different sites at the same time [52].

4. Drugs such as epinephrine and rescue facilities are always prepared at the vaccination site to prevent severe allergic reactions after vaccination [36].

5. Fever, acute infection, and acute exacerbations of chronic diseases should be vaccinated until the symptoms have subsided [52].

6. Subjects should be observed at the vaccination site for 30 min after vaccination [36].

7. Inactivated influenza vaccines and other inactivated and live attenuated vaccines such as pneumococcal vaccine, live attenuated herpes zoster vaccine, chickenpox vaccine, measles vaccine, and DTP vaccine can be given at the same time, but after vaccination with live attenuated influenza vaccine, other live attenuated vaccines must be given at intervals of > 28 days [36]. In addition, ≥ 65-year-olds can receive both influenza and pneumococcal vaccines [36].

According to the recommendations of the Mainland's Technical Guidelines for COVID-19 Vaccination (First Edition), the interval between influenza vaccine and COVID-19 vaccination should be > 14 d[16], that is, the new crown virus vaccine can be given after 14 days of influenza vaccination, or the influenza vaccine can be given after completing the full vaccination procedure of the new crown virus vaccine for 14 days; or the influenza vaccine is given between two doses of the new crown virus vaccine, that is, the influenza vaccine is given after the first dose of the new crown virus vaccine for 14 days, and the second dose of the new crown virus vaccine is given after 14 days. Choosing between two doses of COVID-19 vaccine for influenza vaccination is subject to the requirements for the number and spacing of COVID-19 vaccinations [16]. The interval between influenza vaccine and COVID-19 vaccine must be updated in accordance with the vaccination guidelines for both vaccines.

To avoid possible drug-drug interactions, the vaccinator should be informed of any vaccines, medications, or treatments that are or have been used recently before vaccination [36]. The use of immunosuppressants may affect immune efficacy after vaccination [36]. During prophylaxis and treatment with influenza antiviral drugs, an inactivated influenza vaccine may be given [36].

Pneumococcal vaccine

Community acquired pneumonia is a common infectious disease in the elderly, of which streptococcus pneumonia, also known as pneumococcus, is a common cause of community-acquired pneumonia. At the same time, pneumococcus can also cause bacteremia, meningitis and other threats to the health of the elderly. Pneumococcal vaccine is effective in preventing pneumococcal infections and reducing the incidence of these infections. Given the heavy direct and indirect burden of disease caused by pneumococcal disease, the World Health Organization, in its classification of vaccine-preventable diseases, identified pneumococcal infection as a case requiring "very high priority" use of the vaccine [66].

1. Community-acquired pneumonia and invasive pneumococcal diseases caused by pneumococcal bacteria

(1) Streptococcus pneumoniae

Pneumococcus is a gram-positive cocci with capsular membranes, facultative anaerobic, widely distributed in nature. The pathogenic mechanisms of pneumococcal bacteria include adhesion, inflammatory response, cytotoxic effects of bacterial products, etc. Capsular polysaccharides are important pathogenic agents of pneumococcal bacteria, and according to the different antigenic properties of capsular polysaccharides, pneumococcus is divided into different serotypes, and more than 90 serotypes have been found [67]. Viability and pathogenicity vary from serotype to pneumococcal.

Pneumococcus can be inhaled by aerosols or droplets and colonizes the nasopharynx, and pneumococcal colonization occurs in 40 to 50 percent of healthy adults with pneumococcal colonization for 4 to 6 weeks, and pneumococcus is more common in smokers than in non-smokers [68]. Pneumococcus is a conditional pathogenic bacterium, colonized pneumococcus does not usually cause disease, but when the host has impaired defense function, decreased resistance, respiratory viral infection, etc., pneumococcal oropharyngeal secretions can cause pneumonia after inhalation. Pneumococcus can also be transmitted by respiratory droplets to cause infection. When pneumococcal bacteria enter the bloodstream can cause bacteremia, crossing the blood-brain barrier can cause meningitis. Pneumococcus colonizing the nasopharynx can migrate to the sinuses to cause sinusitis, or enter the middle ear through the Eustachian tube, causing otitis media.

Pneumococcal disease is a general term for infectious diseases caused by pneumococcal, which are divided into IPD and non-invasive pneumococcal disease (NIPD) according to the site of infection. IPD refers to the infection caused by the invasion of pneumococcal bacteria into the originally sterile sites and tissues, mainly including bacteremia, meningitis, bacteremia pneumonia and so on. NIPD refers to the infection of the parts of the external environment caused by pneumococcus, mainly including sinusitis, otitis media and non-bacteremia pneumonia.

Clinical judgment of pneumococcal infection often requires a comprehensive judgment based on the epidemiological findings of the pathogen composition in the region (including pathogen composition and bacterial resistance), bacterial culture results, and the clinical characteristics of the patient. Primary health facilities usually do not have the necessary conditions for pathogen isolation and culture, and can be treated empirically. The same strategy is used when the pathogen is unknown, and when the pneumococcal infection is clear, the appropriate antimicrobial agent is selected based on the results of the drug susceptibility test.

Pneumococcus was once sensitive to almost all antibacterial drugs used to treat its infections. In the late 1970s, widespread use of penicillin led to the emergence and epidemic of penicillin-resistant pneumococcal bacteria. Subsequently, the resistance spectrum and drug resistance rate of pneumococcal bacteria to antibacterial drugs have gradually increased, becoming a global public health problem of great concern. Due to the irrational use of antibacterial drugs, in recent years, the resistance of pneumococcus to commonly used antibacterial drugs has gradually increased, and the resistance to commonly used antibacterial drugs such as penicillins, macrolides, cephalosporins and sulfonamides has posed a serious challenge. At present, the mainland bacterial resistance monitoring report shows that the resistance rate of pneumococcal bacteria infected ≥ 65 years old to penicillin is 53.6%, some strains are highly resistant to penicillin, the resistance rate to cefuroxime is 46.4%, and the resistance rate to macrolides is as high as 94.2% [69].

For different degrees of pneumococcal resistance, different treatment strategies should be adopted clinically, such as increasing the dose of major antibacterial drugs such as penicillin, and selecting other antibacterial drugs (fluoroquinolones, ceftriaxone and other three-generation cephalosporins and even glycopeptide antibacterial drugs, etc.) for treatment. Infections caused by pneumococcal drug-resistant bacteria have a poor prognosis.

Vaccination against pneumococcal bacteria can reduce pneumococcal infection by blocking the colonization and spread of pneumococcal bacteria. At the same time, vaccination reduces the colonization rate of resistant strains, thereby preventing a sustained increase in bacterial resistance [70]. Therefore, pneumococcal vaccination is an important means of improving pneumococcal resistance.

1. Community-acquired pneumonia caused by pneumococcal bacteria: Community-acquired pneumonia is one of the most common and serious diseases in the clinic, and pneumococcus is an important pathogen of community-acquired pneumonia [71]. In the United States, about 650 out of every 100,000 adults are hospitalized for community-acquired pneumonia each year. The annual hospitalization rate for community-acquired pneumonia is approximately 2,000 per 100,000 in older people aged ≥65 years, approximately three times that of the general population, indicating that 2% of older adults are hospitalized for community-acquired pneumonia each year [72, 73].

According to the China Health Statistics Yearbook, the number of pneumonia discharged nationwide in 2017 was 3.592 million, and 17.2% of the elderly aged 60 ≥, and the case fatality rate was 0.49%[74].

Before the antimicrobial era, 95% of pneumonia was caused by pneumococcal infections. In recent years, the incidence of disease caused by viruses and atypical pathogenic microorganisms (mainly Mycoplasma pneumoniae and Chlamydia pneumoniae) has increased significantly, but pneumococcus remains an important pathogen of community-acquired pneumonia in all groups of outpatient, inpatient and intensive care units. Pneumococcal infections can cause serious health problems and lost productivity. According to 2010 data from the United States, among Americans aged ≥50, the direct and indirect losses caused by pneumococcal infection are US$ 3.7 billion and US$ 1.8 billion per year, respectively.

2. IPD: Regardless of whether the immune function is normal or not, pneumococcal bacteria is an important cause of bacteremia. Pneumococcal bacteremia can be accompanied by pneumonia or directly develop bacteremia without pneumonia. Pneumococcal bacteremia can cause meningitis, peritonitis, ileitis, arthritis, and/or endocarditis.

The incidence of IPD is influenced by the following factors: geographical location, season, serotype prevalence, age, comorbid disease, and vaccination status. The highest incidence of IPD is ≥ 65-year-old adults,

(3) Clinical features

1. Community-acquired pneumonia caused by pneumococcal bacteria: pneumococcal pneumonia often has a sudden onset and is manifested by fever, chills, cough and chest pain. As we age, symptoms tend to become atypical. Older patients may present with confusion or delirium at first. Signs of pulmonary consolidation may be seen on lung examination, and there may be wet rales. Most patients present with an increased white blood cell count and neutrophil ratio. "Lobular pneumonia" is seen on chest x-ray or CT, characterized by the distribution of lobes or lung segments. Common complications of pneumococcal pneumonia include bacteremia and metastatic infections such as pleural effusions and empyema.

2. IPD: The clinical manifestations of IPD depend on the primary site of infection and the presence or absence of bacteremia. Pneumococcal meningitis is the most common and serious purulent complication of pneumococcal bacteremia. Even with treatment, the case fatality rate of pneumococcal meningitis is as high as 20 to 30 percent [77]. Other manifestations of IPD include peritonitis and appendicitis. Adjunctive tests for patients with IPD are common for leukocytosis and anemia. Blood culture is an important means of diagnosing the diagnosis.

The risk of developing IPD is closely related to some serotypes and is also associated with respiratory viral infections, possibly associated with increased expression of respiratory epithelial cell pneumococcal adhesion receptors after viral infection.

2. Pneumococcal vaccine

(1) Types and mechanisms of vaccines

There are currently two kinds of pneumococcal vaccines in clinical use, namely pneumococcal polysaccharide vaccine (PPV) and pneumococcal conjugate vaccine (PCV). Both vaccines are made from the pneumococcal polysaccharide antigen, which most often causes aggressive disease, because the two types of vaccines cause different immune responses because of different methods.

1. PPV: PPV was marketed in the United States in 1977 and is made from partially purified pneumococcal capsule polysaccharides. PPV23 contains a mixture of 23 purified capsule polysaccharides for the pneumococcal serotype, which most commonly causes IPD, and is currently the most widely used dosage form. PPV23 serotypes once covered 85 to 90 percent of pneumococcal causes of disease, but current coverage is 50 to 60 percent [78]. In China, PPV23 contains 23 serotypes that cover 87 percent of the serotypes that cause IPD and 53 percent that cause NIPD [79]. Studies have shown that the PPV23-induced antibody response weakens within 5 to 10 years of vaccination and approaches preimmune levels at 10 years. Therefore, every 5 to 10 years after PPV vaccination, people at risk of infection should be re-implanted.

2. PCV: PCV by covalently binding pneumococcal capsular polysaccharides to carrier proteins, so that the pod polysaccharide antigen is transformed from a non-T cell-dependent antigen to a T cell-dependent antigen, so that infants and young children under 2 years of age can produce a good antibody response after immunization, and can produce immune memory, so PCV is suitable for infants and young children. The 13-valent pneumococcal conjugate vaccine (PCV13) contains 13 capsule types and is currently the most widely used PCV dosage form, with 12 of these 13 serotypes identical to PPV23 serotypes.

PCV also stimulates mucosal immunity, thereby eradicating pneumococcal colonization in the nasopharynx. Thus, PCV can significantly reduce pneumococcal carrying of vaccine-covered serotypes. Infants and young children are the primary hosts of pneumococcal bacteria, so the widespread use of PCV in this population can significantly reduce the incidence of disease caused by serotype coverage in adults.

(2) The effect and safety of vaccines

1. Vaccination effect: PPV23 can help 56% to 85% of adults resist IPD [80]. The widespread use of PCV has reduced associated serotype bacterial infections in children and the elderly by more than 90 percent [81]. Domestic studies have shown that the frequency of lower respiratory tract infections, antimicrobial use, and hospitalization after one year of PPV23 vaccination and follow-up decreased, with protective efficacy of 69.7%, 72.6%, and 65.9%, respectively [82]. A three-year prospective cohort study in Spain showed a 51 percent decrease in PPV23 in older adults aged ≥60 years compared with community-acquired pneumonia caused by pneumococcal bacteria in unvaccinated patients in 2008-2011 [83]. In an Israeli nested case-control study, PPV23 vaccination significantly reduced the risk of IPD by 42 percent in older adults aged ≥ 65 years and by 46 percent in older adults aged 65 to 74 years [84]. Another mainland study showed that PPV23 vaccination reduced the incidence of pneumococcal disease, including community-acquired pneumonia, IPD, and overall hospitalization rates, and was cost-effective in older adults [85].

On the mainland, PPV23 is currently the only vaccine for the prevention of pneumococcal infection in the elderly. The PCV13 vaccine is on the market but has not yet been approved for use in older adults.

2. Safety of vaccination: According to clinical trials, post-marketing observations, literature reviews, etc., the safety of PPV23 alone, simultaneous vaccination with other vaccines and re-vaccination is good. Injection site reactions are the most common adverse reactions in adults after vaccination with pneumococcal vaccine [86, 87], and common local reactions to injections are pain, redness and swelling at the vaccination site. In some cases, these symptoms can limit arm movements. Injection site reactions usually resolve spontaneously within 3 to 4 days. Nonsteroidal anti-inflammatory drugs and hot compresses help relieve pain. Systemic reactions are mainly fever and irritability in children, and in adults and the elderly, they are mainly fever, chills, muscle soreness, joint pain, etc., and the symptoms are mild and self-limiting.

From 1990 to 2013, the Vaccine Adverse Event Reporting System (VAERS) monitored PPV23 for up to 24 years after its marketing, and no serious adverse events were found. PPV23 safety was assessed, and the most common of adverse events following immunization (AEFI) was local reactions, namely redness at the site of vaccination (28 percent) and pain (25 percent) [88]. Safety data obtained from VAERS for PCV13 show that the most common adverse events after vaccination are also local reactions in adults aged 19 to 65 years, namely redness at the vaccination site and pain at the vaccination site, respectively, and redness at the vaccination site and swelling at the vaccination site in > 65 years of age [89].

From 2009 to 2010, a clinical safety observation study on the large-scale use of PPV23 in 18 provinces (autonomous regions and municipalities directly under the Central Government) in Mainland China showed a sample size of nearly 150,000 people, showing that the local reactions within 0 to 7 days included redness, swelling, induration, pain, itching and rash at the vaccination site, with an average incidence

Large-scale clinical safety observation of PPV23 Phase IV and post-marketing AEFI data monitoring in mainland China have shown that PPV23 has a good safety profile, systemic adverse reactions are mild, and possible systemic reactions include fever, headache, fatigue/drowsiness, irritability, nausea/vomiting, diarrhea, allergic rash, etc., of which the fever incidence rate is the highest, only 1.2%, and the rest are all incidence

1. Persons ≥ 65 years of age.

2. People with chronic diseases, such as chronic lung diseases, chronic cardiovascular diseases, diabetes, chronic liver diseases, etc.; there are cases of impaired immune function, such as impaired spleen function (congenital or acquired asplenia), congenital or acquired immunodeficiency, human immunodeficiency virus infection, chronic kidney failure, nephrotic syndrome, malignant tumors of the blood system, solid tumors requiring chemotherapy, organ transplanters, etc.; meningitis risk, such as cerebrospinal fluid leakage, cochlear implants, etc.; alcoholic smokers.

3. Re-vaccination: those who have previously been vaccinated with ≥ 1 dose of PPV23 and are ≥ 65 years old should be vaccinated with another dose of PPV23, at least 5 years away from the previous dose; those with spleen function impairment, cerebrospinal fluid leakage, cochlear implantation, etc., can be re-implanted every 5 to 7 years.

Vaccination is available throughout the year. Elective splenectomy should be given at least 2 weeks before surgery, preferably 1 month before surgery.

Subcutaneous or intramuscular injection is used, preferably in the upper arm deltoid muscle. 1 dose at a time.

For those who are allergic to any of the components of the vaccine; moderate or severe acute disease, whether fever or not, vaccination should be done with caution, that is, the parties weigh the pros and cons of vaccination before vaccination, and if not necessary, they can postpone the vaccination until recovery.

The main adverse reactions after PPV23 vaccination in the elderly are fever, chills, muscle soreness, joint pain and other systemic symptoms, and the symptoms are mild and self-limiting. Other systemic adverse effects include weakness, fatigue, and headache.

Some PPV23 inoculators have mild local reactions such as pain, swelling and erythema at the injection site, and the general duration is less than 48 h. If subcutaneous injection is used or if given for the second time, these local reactions are relatively common, but serious systemic adverse reactions, such as allergic reactions, are rare.

1. For those with severe cardiopulmonary diseases, especially those with impaired cardiac and/or pulmonary function, the systemic reaction during vaccination may cause life-threatening, and must be used with caution or close observation and timely treatment; after vaccination, it should be observed for at least 30 minutes.

2. For patients with decreased platelet count, coagulation dysfunction or anticoagulation therapy, intramuscular injection should be very cautious. Injection should be given after treatment has reached a safe level of coagulation, with a thin needle and compression for at least 2 min after injection.

3. In case of fever, acute infection or other acute severe diseases, acute onset of chronic diseases, etc., vaccination should be suspended.

4. It is forbidden to be vaccinated after mixing with other vaccines, if other vaccines need to be administered at the same time, different sites should be selected for injection.

5. Intravenous injection is strictly prohibited.

6. When inoculating, drugs such as epinephrine should be prepared for first aid in the event of a severe allergic reaction.

Shingles vaccine

1. Shingles

(1) Chickenpox-zoster virus

The causative agent of herpes zoster is varicella-zoster virus (VZV). VZV belongs to the human herpesvirus α family, a DNA virus that is widespread worldwide and highly contagious. The virus has neurological and skin-inducing properties, and humans are the sole hosts of VZV. VZV can be transmitted by droplets and/or contact. Initial infection with VZV is clinically presented as chickenpox or occult infection, and the virus induces the body to produce specific antibodies and T cell-mediated cellular immunity. As age increases or specific immune function is impaired, VZV-specific cellular immunity levels decrease, the risk of developing shingles increases, and viruses lurking in the body are activated, replicated, and transferred to the skin through sensory axons, causing shingles [93].

1. VZV infection: herpes zoster is caused by the reactivation of the underlying virus after primary infection with VZV or latent infection, so VZV seroepidemiological investigation can reflect the risk of developing shingles in the population. Prior to the approval of the vaccine against chickenpox in children in the United States, 95.5 percent of people aged 20 to 29 years, 98.9 percent of people aged 30 to 39 years, and more than 99.6 percent of people aged 40 years > had been infected with VZV [94]. The lifetime prevalence of shingles is estimated to be 10 to 30 percent [95]. Some provinces and cities in mainland China also carried out serological surveys of VZV, showing that 96.56% of people aged 31 to 70 years had been infected with VZV[96]; the survey results in some parts of Shanghai showed that 42.78% of the population had been infected with VZV, the infection rate of the population before the age of 7 was 45.9%, 100% of the 40-50-year-old population had been infected with VZV[97], and the survey results in Guangzhou showed that 100% of the ≥ 50-year-olds had been infected with VZV[97]; the survey results in Guangzhou showed that 100% of the 50-year-old people in the ≥ Previously infected with VZV [98].

2. Incidence of shingles: the age-adjusted incidence of shingles in different countries around the world is (3 to 5)/person-year [1000]. The incidence of shingles increases with age, from

The hospitalization rate for shingles is (2-25)/100,000 person-years, and hospitalized patients account for 29% to 42% of the total number of shingles patients [99]. The hospitalization rate of the disease rises sharply with age, and most of the hospitalization cases are middle-aged and elderly people aged ≥ 50 years. The overall recurrence rate of shingles is 1% to 6%, and the mortality rate is (0.017 to 0.465)/100,000 person-years [99]. Immunocompromised is a risk factor for recurrence of shingles, and one cohort study found that immunocompromised patients had a approximately 1.4-fold risk of recurrence of shingles in the general population [102].

3. Post herpetic neuralgia (PHN): PHN is a persistent pain syndrome that appears after the herpes zoster rash subsides, and is one of the most common complications of shingles, which can last for weeks, months or even years. At present, there is no international consensus on the definition of PHN, and the most commonly used definition abroad is pain that lasts for at least three months after the appearance of herpes zoster rash [103]. In the Chinese Expert Consensus on the Diagnosis and Treatment of Postherpetic Neuralgia in Mainland China, PHN is defined as pain that lasts for one month or more after the rash heals [104]. The incidence and prevalence of PHN increases with age, ≥ more likely to occur in patients aged 50 years [103], and in patients with herpes zoster ≥ 60 years and 75 percent at ≥70 years of age [104]. Pain persists for more than one year in 30 to 50 percent of patients, with some courses lasting 10 years or more [105]. Research data on PHN are still lacking in mainland China, and it is estimated that there are about 4 million patients with PHN in the mainland [104].

4. Incidence of shingles in patients with chronic underlying diseases: Common chronic underlying diseases are risk factors for the incidence of shingles and PHN, and the severity of chronic disease patients after suffering from shingles is higher than that of non-chronic disease patients. A meta-analysis showed that patients with diabetes had a 24 percent increased risk of developing shingles, patients with chronic obstructive pulmonary disease had a 41 percent higher risk of developing shingles, cardiovascular disease patients had a 34 percent higher risk of shingles, and patients with chronic disease had a 1.23 to 2.08-fold risk of developing shingles than in non-chronic disease patients [106]. A prospective cohort study showed that patients with underlying medical conditions (e.g., diabetes, cardiovascular, and respiratory diseases) had significantly higher pain intensities than patients without underlying medical conditions during the acute phase and within one month of onset [107]. Other studies have found that underlying disease is also an independent risk factor for the development of PHN, with people with underlying disease having a 4.3 times higher risk of developing PHN than people without underlying disease [108].

Patients with shingles often develop mild prodromal symptoms such as fever, fatigue, general malaise, regional lymphadenopathy, and burning, hypersensitivity, or nerve pain in the affected area of the skin. These symptoms may precede the shingle rash for several days, and in rare cases, only prodromal symptoms without rash, or rash without prodromal symptoms.

The eruptions tend to occur in the intercostal nerve, the cervical nerve, the cranial nerve (most commonly the trigeminal nerve is affected by a single branch), and the lumbosacral innervated area [105]. The typical rash is characterized by clusters of miliary to soybean-sized papules based on erythema, which then become blisters, with clear vesicle fluid, tight vesicle walls, and a red halo around them. The rash is often banded along the peripheral nerves, mostly unilaterally, and generally does not cross the midline. If there is no secondary infection, temporary pigmentation remains after a few days of blister drying up and scabs shedding. The course of the disease is 2 to 3 weeks in young patients and 3 to 4 weeks or more in older patients.

Neuralgia is an important feature of the disease, which can occur before or with a rash, and is usually paroxysmal, pinprick, burning, or hypersensitive. Pain is evident in older patients, often severe and unbearable, and can persist for months or longer after the rash resolves. Acute herpes zoster neuralgia and PHN can severely affect sleep and mood, disrupt normal work and daily life, and in severe cases can lead to mental disorders and depression [104, 105].

In addition to classic shingles, there are special clinical types such as ocular shingles, ear shingles, sudden and convulsive shingles, non-rash shingles, disseminated shingles, etc.; in addition, if shingles invades the nervous system, brain parenchyma, meninges, and internal organ nerve fibers, etc., it can cause corresponding clinical symptoms.

2. Shingles vaccine

(1) Vaccine types and mechanisms

There are two types of herpes zoster vaccines: live attenuated shingles vaccine and recombinant zoster vaccine (RZV), with only RZV approved for marketing in mainland China so far. RZV is a subunit vaccine containing recombinant glycoprotein E (gE) and novel adjuvant (AS01B). gE is the most abundant glycoprotein expressed on the surface of infected cells and is also the main target of cellular immunity and humoral immunity. AS01B can increase the immune response level of vaccines by enhancing the presentation of antigens by antigen-specific immune cells. Since RZV is a non-living subunit vaccine, immunocompromised people are not contraindicated to the vaccine.

1. General population: Phase III clinical trials in 18 countries and regions around the world showed that the protective efficacy of RZV was 97.2% in subjects aged ≥50 years, of which 96.6% were 50-59 years old and 97.4% in 60-69 years of age, and there was no significant difference in protective efficacy between different age groups [109]. The protective efficacy of the vaccine was 91.3% in subjects aged ≥70 years, compared with 91.3% in 70 to 79 years of age and 91.4% in ≥ 80 years of age, and the protective efficacy of RZV was slightly lower than that of ≥ 50 years of age in ≥70 years, but the difference was not statistically significant [110].

2. People with a history of shingles: Individuals who have previously suffered from shingles can prevent recurrence of shingles by vaccinating RZV. Clinical data show that individuals with a history of shingles are able to produce and maintain high immunogenicity after vaccination with RZV. After one month of two doses of the vaccine, 90.2 percent of the participants developed an immune response [111].

3. Population with underlying diseases: The Phase III clinical study included 13 881 participants with underlying diseases, and conducted a post-mortem analysis of the protective efficacy of vaccinated subjects with common underlying diseases (e.g., hypertension, dyslipidemia, diabetes, coronary heart disease, asthma, respiratory disease, kidney disease, etc.), and the results showed that the protective efficacy of RZV was 84.5% to 97.0% in patients with underlying diseases, which was consistent with the overall protective efficacy [112].

Immunocompromised populations: Clinical studies have shown that subjects with autologous hematopoietic stem cell transplantation received RZV 50 to 70 days after transplantation, and the protective efficacy of the vaccine was 68.2% [113]; subjects with hematologic malignancies receiving or having completed immunosuppressive therapy 4 to 18 months after kidney transplantation, human immunodeficiency virus infection and solid tumors who were receiving or preparing for immunosuppressive therapy all produced higher immune responses after vaccination [114, 115, 116, 117］。

5. Persistence of protective efficacy: Phase III clinical trials showed no significant decrease in vaccine efficacy for four years, with protective efficacy of 97.6%, 92.0%, 84.7%, and 87.9% in the first, second, third, and fourth years after vaccination [110]. Interim results from the extended study of key Phase III clinical trials showed an overall vaccine efficacy of 90.9% over an average of 7.1 years from vaccination to post-vaccination, and 84.0% overall protective efficacy in the 5.1 to 7.1 years after vaccination [118]. Long-term follow-up studies have shown that humoral and cellular immune response levels are 6.0 and 3.5 times higher than before inoculation 10 years after the first vaccination of RZV. Based on 10 years of immunogenicity studies, models predict that 20 years after vaccination, humoral and cellular immune responses remain above pre-vaccination levels [119].

In eight studies in 18 countries, 15,264 of whom were vaccinated with RZV, 15,264 patients were enrolled in eight studies in 18 countries, safety observations for one year after vaccination showed no significant difference in the incidence of serious adverse events, fatal serious adverse events, and potential immune-mediated diseases between the vaccination and placebo groups [120]. Phase III clinical study [109, 110] collected adverse events by filling in diary cards within 7 days after vaccination, showing that the incidence of local adverse reactions in the vaccination group and placebo group ≥ 50 years old were: pain 78% and 11%, redness 38% and 1%, swelling 26% and 1%, and the incidence of systemic adverse reactions was: fatigue 46% and 17%, myalgia 46% and 12%, headache 39% and 16%, chills 28% and 6%, fever 21% and 3%, gastrointestinal symptoms 18% And 9%, the vaccination group was higher than the placebo group. The reporting rates of tertiary adverse events in the vaccination and placebo groups were 16.5% and 3.1%, respectively, of which the reporting rates of tertiary local adverse reactions were 9.4% and 0.3%, respectively, and the reporting rates of tertiary systemic adverse reactions were 10.8% and 2.4%, respectively. In addition, multiple clinical studies have shown that immunocompromised populations have no serious adverse events associated with vaccination following RZV vaccination, and all safety outcomes are expected and acceptable [113, 114, 115, 116, 117].

Real-world data [121] show that between 13 October 2017 and 10 February 2019, an estimated 9.3 million doses of the vaccine were distributed, mostly in the United States, with a total of 15 638 reports of spontaneous adverse events involving RZV received, with 95.3% of the reports classified as minor. Analysis by age or sex showed that the incidence of adverse events was the highest at 62.1% in the ages of 50 to 69, while the proportion of adverse events in women was higher than that in men at 66.7%. The most commonly reported adverse events were consistent with known primary features of RZV responses observed in clinical trials, including inoculation site reactions, fever, chills, fatigue, and headache.

(1) Vaccination targets and timing of vaccination

1. General population: RZV is used to prevent shingles in people ≥ 50 years of age.

2. People with a history of shingles: Based on the evidence of recurrence of shingles and the immunogenicity after RZV vaccination, many countries have proposed that people who have previously suffered from shingles can be vaccinated with RZV to prevent recurrence, but the timing of vaccination is slightly different. The Advisory Committee on Immunization Practices (ACIP) states that patients with shingles should wait for the acute phase of the disease to end and symptoms to disappear before receiving RZV vaccination [122]. The National Advisory Committee on Immunization (NACI) recommends that RZV vaccination be given at least one year apart after an episode of herpes zoster [123]. The Austrian Vaccination Commission noted that RZV can be given ≥ adults aged 50 years after the first onset of shingles and after acute symptoms disappear after herpes recurrence (at least two months apart) [124]. For patients with the onset of shingles, it is recommended that RZV be administered after the acute phase of shingles has ended and the symptoms have disappeared [122].

3. People with underlying medical conditions: ACIP in the United States clearly states that basic diseases such as chronic renal failure, diabetes, rheumatoid arthritis, chronic lung disease and tumors are important risk factors for the development of shingles and PHN, so it is recommended for the elderly with underlying diseases to be vaccinated with RZV when the condition is stable [122].

4. Immunocompromised populations: Existing studies have shown that immunocompromised populations can produce higher immune responses after vaccination with RZV [113, 114, 115, 116, 117]. The US ACIP recommends receiving low-dose immunosuppressive therapy (eg, prednisone.)

(2) Vaccination methods

The site of inoculation is the deltoid muscle of the upper arm, which is injected intramuscularly. At present, the vaccine approved for marketing in China consists of 2 doses of 0.5 ml per dose, and the interval between the 2nd dose and the 1st dose is 2 months. If the immunization schedule needs to be changed, the second dose is given between two and six months after the first dose [47].

(3) Contraindications to vaccination

It is contraindicated for those who are allergic to the active ingredient of RZV or any excipient component.

(4) Adverse reactions

1. Common adverse reactions [47]: systemic reactions (such as fever, headache, chills, fatigue, gastrointestinal reactions, etc.) and local reactions at the inoculation site (such as pain, redness, swelling, etc.), are generally mild to moderate, and can be relieved by themselves within 1 to 3 days without treatment.

2. Rare adverse reactions [47]: hypersensitivity reactions such as angioedema and urticaria can be given antiallergic treatment; anaphylactic shock and laryngeal angioedema should be immediately rescued by subcutaneous or intramuscular injection of epinephrine.

(5) Matters needing attention

1. If the vaccinated person has an acute febrile illness, the vaccination time should be postponed.

2. Intravenous or intradermal injection of the vaccine is strictly prohibited.

3. It is forbidden to mix with other vaccines and then administer, if other vaccines need to be given at the same time, different parts should be selected.

4. At the vaccination site, drugs such as epinephrine and rescue facilities are always available to prepare for first aid in case of severe allergic reactions.

5. The ovulated subject should stay at the vaccination site for 30 minutes after vaccination.

Health management and health education for elderly vaccinators in the community

1. Health management

(1) Establish health records

Establish health records for the elderly and sign up for family doctor contract services. The content of the health record includes the basic information of the elderly, medical and health information, etc. and is evaluated, and the corresponding management services are provided for their main health problems, and recorded in the archives.

(2) Regular health follow-up

Assess changes in the health of the elderly; effectively combine daily medical and health services with screening of patients with target diseases, and proactively identify high-risk patients with common infectious diseases during medical treatment or physical examinations in the elderly.

(3) Evaluate whether there are contraindications to relevant vaccination

Evaluate the contraindications to vaccination in the elderly, recommend vaccination for the elderly without relevant contraindications, and explain the relevant precautions before and after vaccination, make an appointment for vaccination routes, etc.; and do a good job of education on relevant disease prevention knowledge for the elderly with contraindications.

(4) Do a good job of follow-up after vaccination

It is necessary to do a good job in monitoring adverse vaccine reaction events, giving symptomatic treatment to general vaccination reactions; giving timely treatment to suspected abnormal reactions to vaccination [126], referring them in time when necessary, and reporting to relevant departments in a timely manner, and the expert group for investigation and diagnosis of abnormal reactions to vaccination will investigate and diagnose.

2. Health education

The purpose of health education is to make the elderly in the community aware of the prevalence of influenza, community-acquired pneumonia and varicella-zoster virus infection, the severity of the disease and the effectiveness of active prevention, and to increase the willingness and vaccination rate of the elderly.

(1) Community medical personnel should carry out normalized education through health lectures, face-to-face, text messages, telephones, health management platforms, WeChat, posters and other channels to improve the awareness of the elderly on the necessity, effectiveness and safety of vaccination against related infectious diseases. An atmosphere of active vaccination and immunization should be created to raise awareness of word-of-mouth transmission among the elderly in the community and attract more candidates for vaccination.

(2) Carry out knowledge education on relevant vaccine indications, contraindications, etc., and improve the awareness of self-screening and self-protection of the elderly.

(III) Educate the relevant precautions and self-health monitoring knowledge before and after vaccination, once the patient has an adverse reaction, he should promptly call the telephone number on the informed consent form and contact the family doctor, report the adverse event and get early effective treatment.

(4) Conduct education on the epidemiological characteristics of relevant infectious diseases and protective measures. Advocate a good lifestyle, quit smoking and alcohol, it is recommended to wear a mask when going to public places during the high incidence of respiratory diseases, maintain a safe distance, pay attention to the environment and personal hygiene, wash hands frequently, open windows and ventilation regularly, try not to go to crowded places; balanced diet, strengthen nutrition; regular work and rest, appropriate scientific physical exercise, improve immunity, in order to reduce the occurrence of infectious diseases.

Expert group on the preparation of the Expert Consensus on the Application of Vaccines for Common Infectious Diseases in the Elderly in the Community:

Consultant: Chen Wang

Team Leader: Chi Chunhua Du Xueping

Deputy Team Leader: Qu Jieming, Li Ruoyu, Shao Zhujun, Wu Hao

Experts (in alphabetical order): Cai Shaoxi (Southern Hospital of Southern Medical University), Chang Jianmin (Beijing Hospital), Chen Hong (Sichuan Provincial People's Hospital), Chen Liying (Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine), Chen Yahong (Third Hospital of Peking University), Chi Chunhua (First Hospital of Peking University), Cui Yong (China-Japan Friendship Hospital), Ding Jing (Yuetan Community Health Service Center, Fuxing Hospital Affiliated to Capital Medical University), Dong Jianqin (Yuetan Community Health Service Center, Fuxing Hospital Affiliated to Capital Medical University) Du Xueping (Yuetan Community Health Service Center, Fuxing Hospital Affiliated to Capital Medical University), Du Zhaohui (Shanghai Pudong New Area Shanggang Community Health Service Center), Duan Yingwei (Shichahai Community Health Service Center, Xicheng District, Beijing), Feng Mei (Shanxi Bethune Hospital), Feng Luzhao (School of Qun Medicine and Public Health, Peking Union Medical College), Guo Yanfei (Beijing Hospital), He Hanqing (Zhejiang Provincial Center for Disease Control and Prevention), Huang Min (Suzhou Municipal Hospital), Jiang Sunfang (Zhongshan Hospital Affiliated to Fudan University) Jiang Yue (First Affiliated Hospital of Tsinghua University), Jiang Tianwu (Community Health Service Center of Wulin Subdistrict, Tianshui, Hangzhou, Zhejiang Province), Jin Zhe (Peking University First Hospital), Jin Hongzhong (Peking Union Medical College Hospital), Kong Yu (Fangzhuang Community Health Service Center, Fengtai District, Beijing), Li Bo (Beijing Hospital), Li Haichao (Peking University First Hospital), Li Houmin (Peking University People's Hospital), Li Ruoyu (Peking University First Hospital), Li Yanming (Beijing Hospital), Li Yuye (First Affiliated Hospital of Kunming Medical University) Liu Kaixiong (Ruijin Hospital Affiliated to Shanghai Jiao tong University School of Medicine); Liu Xiaoyu (Henan Provincial People's Hospital); Liu Yanmin (Chinese Center for Disease Control); Ma Li (Beijing Tiantan Hospital affiliated to Capital Medical University); Ma Yan (Beijing Panjiayuan Second Community Health Service Center), Ma Cuiling (Xijing Hospital of Air Force Military Medical University); Pan Zhigang (Zhongshan Hospital Affiliated to Fudan University); Peng Zhibin (Chinese Center for Disease Control); Qu Jieming (Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine); Sha Yue (Peking Union Medical College Hospital) Shao Zhujun (Chinese Center for Disease Control); Shi Guochao (Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine); Shi Ling (Shanghai Putuo District Health Affairs Management Center); Wang Chen (Chinese Academy of Medical Sciences and Peking Union Medical College); Wang Liuyi (Henan Provincial People's Hospital); Wang Rongying (Second Hospital of Hebei Medical University); Wang Shuang (First Affiliated Hospital of China Medical University); Wang Shangcai (Shahe Hospital, Changping District, Beijing); Wang Wei (First Affiliated Hospital of China Medical University) Wang Yongchen (Second Affiliated Hospital of Harbin Medical University), Wei Xuejuan (Fangzhuang Community Health Service Center, Fengtai District, Beijing), Hao Wu (College of General Medicine and Continuing Education, Capital Medical University), Wu Lin (Yuetan Community Health Service Center, Fuxing Hospital Affiliated to Capital Medical University), Xi Sen (Community Health Service Center of Huairou Town, Huairou District, Beijing), Xiao Xue (Affiliated Hospital of Zunyi Medical University), Yi Chuntao (Community Health Service Center of Fenglin Street, Xuhui District, Shanghai) Yin Zhaoxia (Shenzhen Luohu Hospital Group Social Management Center), Ying Kejing (Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine), Zhang Jie (Second Hospital of Jilin University), Zhang Chunlei (Peking University Third Hospital), Zhang Yuehong (Community Health Service Center of Exhibition Road, Xicheng District, Beijing), Zhu Lan (Community Health Service Center of Xietu Street, Xuhui District, Shanghai)

Writing expert (in alphabetical order): Chang Jianmin, Chen Yahong, Li Haichao, Ma Li

Reviewers (in alphabetical order): Chi Chunhua, Du Xueping, Li Ruoyu, Zhai Jieming, Shao Zhujun, Wu Hao

Author: Chinese Medical Association General Medicine Branch Chinese Medical Association Journal of Chinese Medical Association Editorial Board of Chinese Journal of General Practitioners Expert Consensus on Vaccine Application of Common Infectious Diseases in the Elderly in the Community Compilation Expert Group

This article was published in: Chinese Journal of General Practitioners 2022, 21(1): 6-23.

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