Paper IV — Immunisation and screening

Immunization — Numbers to Quote Item Figure Influenza deaths >90% occur in adults ≥65 Influenza vaccine ↓ influenza risk ~50%; ↓ influenza mortality ~70%; only ~40% effective vs clinical illness in nursing homes Herd protection Vaccinating >80% of nursing-home residents prevents outbreaks Nichol 2007 (Essentials) HR 0.75 for pneumonia/influenza hospitalisation; HR 0.52 for death CAPITA PCV13 ↓ vaccine-type pneumococcal pneumonia by 45% Zoster vaccines Zostavax 30% protective; Shingrix ~90% protective Post-herpetic neuralgia >40% of those over 60; zoster in up to 50% by age 85 Tetanus >50% of cases occur in people ≥60 AReSVi-006 (RSV) 82.6% season 1; 94.6% with comorbidity; 62.9% cumulative over 3 seasons; 48% in season 3 DANFLU-2 332,438 adults ≥65; primary endpoint neutral; cardiorespiratory hospitalisation 2.25% vs 2.38% Zoster & dementia (Wales) ~20% reduction in new dementia diagnoses over 7 years; uptake jump 0.01% → 47.2% Zoster & cardiovascular 23% lower risk of cardiovascular events PCV21 Covers ~85% of IPD in ≥50s vs ~59% for PCV20; lacks serotype 4 PCV20 real-world VE IPD 25.6% overall (35.4% at 65–74; 24.0% at 75–84; 16.6% at ≥85); all-cause pneumonia 15.2% 2. Immunization — Age Thresholds (Current)

Travel Vaccination — Key Facts Item Figure / rule Pre-travel consult 4–6 weeks before departure YF certificate Valid 10 days after vaccination; now valid for life; India — 6 days' quarantine if absent YF and age ≥60 Precaution, not contraindication YEL-AND 0.8/100,000 doses overall; 2.2/100,000 at ≥60 YEL-AVD Multi-organ failure, ~48% mortality; 6× higher in the elderly Serious AEs in elderly 3× higher overall; 5× higher above 70 Hajj / Umrah Meningococcal ACWY required, ≥10 days before arrival, valid 3–5 years Rabies PrEP 2 doses — day 0 and day 7 Japanese encephalitis Stay ≥1 month in rural endemic area; age itself is a risk factor for severe JE Hepatitis A in India Check anti-HAV IgG first — most older Indians already immune 4. Cancer Screening — Age Cut-offs Cancer Pathy's / textbook Current (USPSTF) Breast Mammography 1–2 yearly: Robust to 80, Frail to Biennial 40–74 (B); ≥75 insufficient (I)

Cancer Screening — Trials and Numbers Trial / source Result NordICC (NEJM 2022) 10 y: CRC 0.98% vs 1.20% = 18% ↓ incidence; no mortality benefit; uptake 42%; per-protocol 31% / 50% NordICC (Lancet 2026) 13 y: incidence reduced, mortality still not; 30% of endoscopists below ADR of 25% ECLIPSE / Shield 83% sensitivity for CRC; 90% specificity; only 13.2% for advanced adenoma; FDA approved 29 July 2024 FOBT (Pathy's) Sensitivity 82% MASAI (Lancet 2026) 105,934 women; +29% detection, −44% workload, −12% interval cancers; sensitivity 80.5% vs 73.8% at specificity 98.5% Mammography ≥70 meta- 28% ↓ breast cancer mortality (RR 0.72); overdiagnosis ~19% analysis ERSPC (NEJM 2025) 162,236 men aged 55–69; 23 y: 13% relative, 0.22% absolute ↓ prostate cancer mortality ERSPC Rotterdam (2023) 21 y: RR 0.73; NNI 246, NND 14 CAP overdiagnosis analysis Overdiagnosis 16% at 50 → 32% at 70 → 58% at 80 ProtecT (NEJM 2023) 15 y: ~3% prostate cancer mortality in all three arms (monitoring, surgery, radiotherapy) PROSA (Eur Urol 2025) MRI-first detected csPCa 4.6% vs 1.8%, no rise in GG1 disease PRECISION (2018) 28% avoided biopsy; 12% more clinically significant cancers detected TRANSFORM >250,000 men; £42 million; results not before 2028 LDCT ↓ lung cancer mortality ~20% vs chest X-ray

Indian Data — Must-Quote Figures Item Figure LASI Wave 1 (n = 31,464, ≥60) DT 2.75%; typhoid 1.84%; hepatitis B 1.82%; influenza 1.59%; pneumococcal 0.74% Adult vaccine coverage overall <3% for most vaccines in older adults Influenza uptake ≥45 y ≤2% (IJMR rapid review, 2024) Hepatitis B in healthcare workers Only 55–64% (Delhi, Mumbai) Invasive pneumococcal disease CFR 20–25% at ≥65 vs 5–10% in younger adults Herpes zoster lifetime risk ~30%, rising to ~50% by age ≥85 Cancer burden Breast + cervix + oral ≈ 34% of all cancers in India NP-NCD screening Oral, breast, cervical — free at AAMs, ages 30–65 only; VIA-based Cervical screening coverage 10.18 crore of 25.42 crore eligible women screened (July 2025); but <2% of women 30–49 screened at NFHS 2019–21 National Cancer Grid VIA 1–3× lifetime (low resource); HPV q10y (enhanced); HPV q5y at 25–65 (high resource) ICMR breast screening Clinical breast examination every 1–3 years Programme gaps Adult vaccines outside UIP and NPHCE; no CRC or prostate screening programme; no cancer screening at all above 65 The Five Sentences That Carry This Whole Topic

In geriatrics, prevention is governed by life expectancy versus lag time to benefit, not by chronological age.

Immunosenescence means older adults need higher-antigen, adjuvanted or recombinant vaccines — and paradoxically the frailest gain most from preventing hospitalisation while responding least immunologically.

The global immunization framework has moved from age-based schedules to life-course, risk-profile immunization; age thresholds for pneumococcal, zoster and RSV have all fallen to 50.

Cancer screening in the old is limited less by the test's accuracy — which often improves with age — than by competing mortality and overdiagnosis.

In India the limiting factor is not the guideline but the programme: adult vaccines lie outside the UIP and NPHCE, and organised cancer screening stops at 65.