Better Health While Aging

Practical information for aging health & family caregivers

COVID Vaccination for Aging Adults:
What to Know & Do

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As everyone knows, the COVID-19 pandemic has caused a public health — and societal — crisis of epic proportions. The impact has been especially severe on older adults, who are more likely to be severely affected by COVID, and who represent a distressingly high proportion of the U.S.’s COVID deaths.

But, in an amazing feat of scientific achievement, COVID vaccines were developed in truly record time, and in 2021, a large-scale vaccination campaign has been rolled out in the U.S.

This doesn’t mean everything will be back to normal very soon. But vaccination is key to reducing the dangers of COVID, because to date, the Pfizer and Moderna vaccines have proven to be extremely effective in preventing hospitalizations and deaths due to COVID. They have also been shown to be safe.

Although it’s exciting that we benefit from the significant protection of COVID vaccines, these vaccines have also raised a lot of questions for people. This article summarizes what I think is most important for older adults and families to know about coronavirus vaccination.

In particular, I want to offer science-based information to help with common questions, such as “Which COVID vaccine is better for seniors?” or “Which COVID vaccine for a 90-year-old?”

I’ll also cover vaccine safety, and what we know so far about how effective these COVID vaccines are in older adults. And in 2021, I am adding information related to the Delta variant and boosters.

Latest Updates:

Starting from 2022, I’ll be posting updates to a new page, which is here:  COVID & Aging Adults: 2023 & 2022 Updates

Here is my most recent video update, from August 14, 2023:

In this update, I discuss the latest COVID news for August 2023, including the recent rise in COVID cases, whether to get boosted again now or later, what we know about the upcoming fall COVID vaccine, and more. 

In this episode:

  • What to know about the new COVID wave
  • Update on the EG.5 subvariant
  • Whether vaccines work against the newest variants
  • Update on the upcoming 2023 COVID vaccine booster
  • Answers to FAQs
    • Should you get boosted again now or wait?
  • Symptoms of COVID & what to do if you catch it
  • What will really help us live with COVID

Note: For the masks I recommend, you can get the 3M V-flex here https://amzn.to/3OxrsRY, and the Powecom KN95 here https://amzn.to/3W9frXf

These are Amazon affiliate links, so any purchases will help support Better Health While Aging, thank you!

For all links and resources mentioned in the update, see the related podcast page here.


Here is the last 2021 video update, from Dec 16, 2021:

This video update covers Omicron, COVID boosters, plus how to search the CDC data to see just how well vaccines have worked, even in older adults. I also show the data demonstrating that vaccinated people age 80+ are still at higher risk of serious COVID than unvaccinated people under age 50; this is why fully vaccinated older adults should take precautions during the current surge!

The update addresses these FAQs:

  • What do we know about Omicron so far, and will the vaccines remain protective
  • Should I get vaccinated against COVID?
  • Should my 90-year-old mother get the COVID vaccine?
  • How well does the vaccine work in older adults? How well does it work over time, and against Delta?
  • Should I worry that the vaccine might harm me (or my frail older parent)?
  • Who should get a COVID booster and why?
  • How to stay safer during the holidays.

For related links specific to this update, see the related podcast show notes page.

What’s Most Important to Know About COVID Vaccination

As of December 17, 2021, what is most important to know is:

  • There is currently a COVID surge in the US, involving both Delta and the newer Omicron variant. Very high case numbers are expected. Unvaccinated older adults are at quite high risk of hospitalization or death due to COVID (as explained in 12/16/21 video update). Even vaccinated older adults are at some risk, and should take extra precautions during the surge, to avoid being exposed to COVID.
  • The COVID vaccines are safe and remain very effective at preventing hospitalization or death from COVID (especially the mRNA vaccines from Pfizer and Moderna). Even after 5-6 months, the vaccines continue to provide excellent protection against hospitalization and death due to COVID, even in older age groups.
  • After several months, the vaccines do become less effective at preventing mild COVID infections and breakthrough infections can happen. These are unlikely to become serious.
    • The small number of breakthrough infections that become very serious are mostly in people who are older or have serious chronic medical conditions. (Note: General Colin Powell, who died of a breakthrough COVID infection, was 84 and had a very serious blood cancer.)
  • The Omicron variant is very contagious and its mutations enable it to cause breakthrough infections in people who are vaccinated or have previously had COVID. Vaccination is expected to continue providing good protection against hospitalization and severe COVID.
  • Both Omicron and Delta are causing symptoms and (usually) mild COVID illness in fully vaccinated people. There is also evidence that fully vaccinated people can transmit the Omicron and Delta COVID variants to others. Many COVID cases in vaccinated people are asymptomatic, as well.
    • This means you should not assume that you can’t get COVID from a fully vaccinated person.
    • If you are vaccinated, you should be careful about the possibility you could transmit COVID to another vulnerable person, such as an unvaccinated child or frail older person.
  • Getting vaccinated is safe, will protect you personally from serious illness due to COVID, and helps reduce the impact of COVID in our communities. I recommend vaccination for all adults. I have personally vaccinated my own children (ages 13 and 11), to reduce risk to our family members who are in their 90s.
  • I also recommend resuming wearing masks indoors and taking COVID exposure precautions (ventilation, minimize time indoors with people outside your household), at least until COVID case rates decline.
  • Getting a booster dose of the vaccine does seem to reduce the risk of a vaccinated person getting a breakthrough infection.  I recommend getting a COVID booster.

What COVID vaccines are currently available?

You can see which COVID vaccines have been approved for use in the U.S. on the FDA’s COVID-19 Vaccines page: FDA COVID-19 Vaccines.

As of December, 2021, in the U.S., three COVID-19 vaccines are in use: Pfizer, Moderna, and Janssen (which is the pharmaceutical branch of Johnson & Johnson).

On December 11, 2020, the FDA granted an emergency use authorization (EUA) to Pfizer’s COVID-19 vaccine. Moderna was granted a similar EUA on December 18, 2020.

On February 27, 2021, the FDA granted emergency use authorization to Johnson & Johnson’s COVID vaccine. Unlike the Pfizer and Moderna vaccines, which require two injections spaced about a month apart, the J&J vaccine only requires one injection.

On August 21, 2021, the FDA authorized an additional dose of COVID vaccine for people who are moderately to severely immunocompromised.

On August 23, 2021, the FDA granted full authorization to Pfizer’s vaccine.

On Sept 22, 2021, the FDA authorized a single booster dose for Pfizer COVID vaccine recipients who are age 65 or older, plus for a few other select groups.

On October 20, 2021, the FDA authorized a booster dose for older Moderna COVID vaccine recipients (plus for a few other at-risk groups) and for Johnson & Johnson vaccine recipients (all).

On December 16, 2021, following a review of the effectiveness and safety of the Johnson & Johnson vaccine, the CDC announced that it’s preferred that adults receive one of the mRNA vaccines (Moderna or Pfizer).

Many other vaccines have been approved in other countries, such as the Oxford AstraZeneca vaccine in the U.K. You can see a list of COVID vaccines on the NYTimes Coronavirus Vaccine Tracker page, which also includes a helpful summary of the vaccine approval process.

Vaccines were initially prioritized for frontline health workers and nursing home residents, and then were prioritized in most areas for older adults. As of May 2021, vaccinations are available in most parts of the US to all adults who wish to be vaccinated.

The Pfizer vaccine received emergency approval for children ages 12 and older in May 2021, and a pediatric dose for children ages 5-11 received approval in November 2021.

About the mRNA COVID Vaccines (Pfizer and Moderna)

How the Pfizer and Moderna COVID vaccines work

The Pfizer and Moderna vaccines use a new approach for vaccination: messenger RNA (“mRNA”). This technology had never before been used in a licensed vaccine. But it was under development at the NIH about 10 years prior to the pandemic, and it offers several advantages over pre-existing vaccine technology.

Whereas most vaccines work by injecting a person with a killed virus or portion of virus, mRNA vaccines use a totally different approach: they contain limited instructions that prompt the body’s cells to create copies of the COVID spike protein component (but not the whole virus).

The body’s immune system then recognizes the COVID spike protein as foreign, and builds up immunity. This means that when the body later encounters the complete COVID virus during an infection, it can ramp up quickly and defeat the virus before the person feels ill, or becomes seriously ill.

So, it’s impossible to get COVID from the mRNA COVID vaccines, because they don’t inject killed or weakened COVID, and the injected instructions cannot cause the body to create complete functioning COVID virus.

Another advantage of the new mRNA technology is that vaccine doses can be manufactured much more quickly.

You can learn more about these mRNA vaccines here: CDC: Understanding mRNA COVID-19 Vaccines

Unfortunately, there has been a lot of misinformation spread about the mRNA COVID vaccines. An excellent article debunking the false claims is here: Irish Professor Makes Unfounded Claims About Long-Term Effects of mRNA Vaccines

For the Pfizer and Moderna vaccines, two doses are required (3 and 4 weeks apart, respectively).

mRNA COVID Vaccine Efficacy in Older Adults: What we know so far

What we know about how well these vaccines work is based on two types of information: randomized trial data submitted to the FDA to get emergency use authorization, and then observational analyses conducted over the past several months.

CDC data indicate that since vaccination began, COVID case rates and death rates have fallen dramatically in nursing home residents and among people aged 85+. A UK study also noted a significant drop in COVID hospitalizations among older adults after their vaccine rollout. (See the video here for an explanation of where to find this data.)

Also, in May 2021, researchers published an updated study of the Pfizer vaccine efficacy in Israel. This found a real-world overall vaccine efficacy of 94% (93% in over 65 age group). Table 3 of this study report also reported vaccine efficacy in 3 older age groups (over 65, over 75, and over 85). (I explain this data in my COVID update video from 5/14/21.)

This data found that vaccine efficacy dropped in the older age groups for asymptomatic infection (83% in people over age 85) but remained around 97% for symptomatic COVID and severe COVID, with no drop seen in the older age groups. This suggests that although the risk of passing on COVID or having a breakthrough infection may go up as people get older, even those over age 85 should expect to get excellent vaccine protection from serious COVID illness.

A CDC report published in early May of 2021 found that getting either the Pfizer or Moderna vaccine was 94% effective against COVID-19 hospitalization among fully vaccinated adults aged 65 and older.

At this time, research and observational data overall supports the efficacy of the mRNA vaccines, even in the very old. The main group that seems to be an exception is those with significant immunocompromise, such as those taking certain immune medications, those who’ve had transplants, and those with a history of hematological malignancies (“blood cancers”) or other conditions affecting their B cells and T cells. For more on this, see Researchers Tie Severe Immunosuppression to Chronic COVID-19 and Virus Variants.

The CDC recently began reporting COVID cases and deaths based on vaccination status. This NY Times article includes graphics based on the CDC data, showing how vaccination reduces cases (and deaths) for every age group: Who Had Covid-19 Vaccine Breakthrough Cases?

For these reasons, I highly encourage COVID vaccination for adults of all ages, and especially for older adults.

What we know about COVID vaccine protection weakening over time

Several observational studies indicate that the three COVID vaccines become less good at preventing mild infection after a few months. However, so far they have continued to provide excellent protection against hospitalization, especially in people under age 65.

Most studies show that after several months, Moderna remains more effective than Pfizer, and both are more effective than Johnson and Johnson.

For this reason, COVID boosters are now being recommended for all adults, and especially for older adults or those at risk of severe COVID. For more on COVID boosters:  CDC: COVID-19 Vaccine Booster Shots

For data on how boosters increase antibody levels, see  Heterologous SARS-CoV-2 Booster Vaccinations – Preliminary Report.

Note: A COVID vaccine booster is not technically the same as getting a “third dose,” which was approved by the FDA on 8/21/21 for certain people who are immunocompromised and unlikely to mount sufficient response to the usual COVID vaccine schedule. For more on who qualifies for this type of extra dose, see CDC: COVID-19 Vaccines for Moderately to Severely Immunocompromised People.

What we know from the COVID trial data submitted to the FDA

The Pfizer phase 3 trial data was published in the New England Journal of Medicine (NEJM) on December 10, 2020, and the Moderna phase 3 trial data was published on December 30, 2020.

The Pfizer trial included about 43000 participants, who were randomized to get the Pfizer COVID vaccine or a placebo injection. During a follow-up period of a few months, there were 8 cases of Covid-19 among vaccine recipients and 162 cases among placebo recipients. The authors concluded that the vaccine was 95% effective in preventing Covid-19.

But before you assume that you — or your aging parent — will be 95% protected by vaccine trial data: it’s extremely important to take a good look at the study data, to find out: how many people like you were studied, and what were the results in that group?

Being a geriatrician, I always want to know how many older adults were included in a study, what was the age breakdown of older participants (because the average 65-year-old is medically fairly different from the average 85-year-old), and what happened with those participants.

Here is the short video presentation I recorded in December 2020, about how I assess whether the COVID vaccine (or other treatment) is effective in older adults, especially those over age 85 and those in nursing homes. I also have summarized some key vaccine information below.

In this video, I review the data for Pfizer’s vaccine, and I show you how you can assess the data on older adults when the data for upcoming vaccines is released.

(For a short tutorial on how to slow down the video or search the transcript, see here.)

Here’s what I found out, for the Pfizer trial:

  • The median age of participants was 52 years, and 42% of participants were older than 55 years of age. The age range of participants was 16-91.
  • COVID cases and vaccine efficacy results are reported for four age ranges (see Table 3):
    • 16-55 years (19852 people) –> 5 cases (vaccine) vs 114 cases (placebo) –> 95.6% efficacy (statistically likely range: 89.4–98.6%)
    • >55 years (15043 people) –> 3 cases (vaccine) vs 48 (placebo) –> 93.7% (statistically likely range: 80.6–98.8%)
    • >65 years (7728 people) –> 1 case (vaccine) vs 19 (placebo) –> 94.7% efficacy (statistically likely range: 66.7–99.9)
    • >75 years (1559 people) –> zero cases (vaccine) vs 5 cases (placebo) –> 100.0% efficacy (statistically significant range: −13.1–100.0%)

Please note that it’s not a typo: for participants aged 75 years or older, the initial Pfizer trial data reported a statistically likely efficacy range of negative 13% to 100%. (!)

Why is this? In practical terms, they didn’t have enough people aged 75+ catch COVID during the study period. (This may be because everyone in this age group was being careful to minimize their COVID exposure.)

In short, when Pfizer’s vaccine was authorized, it wasn’t clear just how effective it was in older adults aged 75+, much less those aged 85-90+. They also didn’t report just how many people aged 85+ were in the study, but probably it was a small number.

As a geriatrician, this concerned me. Most vaccines, such as the influenza vaccine, tend to work less well in older adults because of an aging immune system. (This is why vaccine makers have designed flu vaccines specifically for older adults.)

That said, in February 2021, researchers published a study of the Pfizer vaccine efficacy under real-world conditions in Israel, which noted a real-world vaccine efficacy of over 90%. The study did exclude nursing home residents from the study, and did not specify effectiveness in people over age 80. But it was excellent to see the vaccine demonstrating such good results overall.

Also, as noted earlier in this article, in May 2021, researchers published an updated study of the Pfizer vaccine efficacy in Israel, which reported vaccine efficacy in 3 older age groups (over 65, over 75, and over 85).

This data found that vaccine efficacy dropped in the older age groups for asymptomatic infection (83% in people over age 85) but remained around 97% for symptomatic COVID and severe COVID, with no drop seen in the older age groups. This suggests that although the risk of passing on COVID or having a breakthrough infection may go up as people get older, even those over age 85 should expect to get excellent vaccine protection from serious COVID illness.

For the most recent information on what data from Israel shows (including why they decided to give boosters), see my latest video update.

What about the efficacy of the Moderna vaccine?

The Moderna phase 3 trial data was overall similar to the Pfizer data. They also had a limited number of participants over age 75, and so could not draw statistically significant conclusions regarding the efficacy of the vaccine in people over age 75.  The peer-reviewed Moderna vaccine study results published in the New England Journal are here.

The data that Moderna submitted to the FDA when requesting emergency approval can be viewed here.

  • In Table 17 (page 29), you can see that in people aged 65+, the point estimate for vaccine efficacy was 86.4% (95% likely range of 61.4 – 95.5%), compared to an efficacy of 95.6% (range 90.6%, 97.9%) in people age 18 to under 65.
    • This is overall excellent vaccine efficacy.
  • You can see the number of participants aged 75+ and the vaccine efficacy results in Table 10 (page 24).
    • The number of people over age 75 was quite small (about 1300 overall) and there were only 3 COVID cases in the vaccinated group.
    • So the posted efficacy rate of 100% is not statistically significant (which is why they don’t provide a range).

Needless to say, the participants in the vaccine trials who were aged 75+ are overall much younger and healthier than people in nursing homes, and should be assumed to have a better immune system response to vaccines than even a healthy 90 year old will have.

If you are wondering why there weren’t more people aged 75+ in the trials, see this interview with geriatrician Dr. Sharon Inouye, of Harvard: Why Aren’t Highest-Risk People Better Represented in COVID Vaccine Trials?

When the Pfizer and Moderna vaccine were released, my concern was that the biggest risk in vaccinating frail older adults is that people may overestimate the associated protection and then take fewer precautions around these older adults. So even if all residents of a nursing home are vaccinated, it’s important for staff to be vaccinated as well, and that everyone continues to take precautions until the levels of COVID community transmission finally drop down.

For the latest information on the efficacy of the Moderna vaccine (which in many studies appears to be more effective than the Pfizer vaccine), see my latest video update above.

Do the Pfizer and Moderna vaccines protect against the new variants of COVID?

The CDC is monitoring several COVID variants, some of which appear to be more contagious than usual. These seem to have originated overseas but appear to be circulating in the United States. The variants include:

  • Alpha, (B.1.1.7, first identified in the U.K.)
  • Beta (B.1.351, first identified in South Africa)
  • Gamma (P.1., first identified in Brazil)
  • Delta (B.1.617, first identified in India) — As of October, 2021, this has proven to be extremely transmissible . It was implicated in a breakthrough cluster of cases among vaccinated airport workers in Singapore and has become the dominant COVID variant in many parts of the world.
  • Omicron (B.1.1.529, first identified in South Africa) — This one has an exceptional number of mutations and as of Dec 2021, seems to be rapidly spreading.

The vaccine makers are actively studying how well their vaccines protect again these variants. In July 2021, a study published in the New England Journal of Medicine concluded that the Pfizer vaccine and AstraZeneca vaccines were effective against the Delta variant, provided two doses were administered.

To date, no COVID boosters have been designed specifically for any COVID variants, but it is possible that this will be developed in the future.

To find out if the COVID variants are causing cases near you, see this CDC page: US COVID-19 Cases Caused by Variants.

Are the Pfizer and Moderna COVID vaccines safe?

In general, they appear to be quite safe and there were very few true severe problems noted in the study.

As of March 26, 2021, over 130 million doses of these vaccines have been administered. To date, the primary safety issue that has emerged is the possibility of severe allergic reactions. However, these are uncommon and only affect a handful of people per every million doses administered. For more on this, see this CDC page.

Now, it’s important to note that it was quite common for vaccine recipients to feel unwell after vaccination, especially after the second dose. The most common symptoms were fatigue and headache, and some people experienced fever, as well.

These are signs that the immune system is responding to the vaccine! (Which is why they occurred less often in older participants than younger ones.) So these should not be taken as a sign that the vaccine is dangerous, or not worthwhile.

About the Johnson & Johnson COVID Vaccine

The Johnson & Johnson vaccine requires only a single injection. A good summary of the J&J vaccine, including how it’s different from the Pfizer and Moderna vaccines, is here: How does the Johnson & Johnson vaccine work? When is it available? What to know about the new shot.

Reviewing the J&J vaccine data is more complicated in that the Phase 3 trial was conducted in three regions (the US, South Africa, and 6 Latin American countries), and also took place in the winter of 2020-2021, when some areas had COVID variants spreading.

The trial data submitted to the FDA can be viewed here:  FDA Briefing Document: Janssen Ad26.COV2.S Vaccine for the Prevention of COVID-19.

In reviewing the J&J data, I noted:

  • Vaccine effectiveness (VE) overall, by region was:
    • US: 72% (95% confidence interval 58-82%)
    • Latin America 61% (95% confidence interval 47-72%)
    • South Africa 64% (95% confidence interval 41-79%)
  • 35% of participants were over age 60
    • 3.7% over age 75
  • VE after 28 days against moderate-severe COVID:
    • Age 18-59: 66% (95% CI 53-76%); 64% if comorbidities
    • Age 60+: 66% (95% CI 37-83%); 42% if comorbidities
  • VE after 28 days against hospitalization/ICU/death
    • No cases were noted among vaccine recipients; VE 100% (31-100%)

The bottom line is that although the posted overall efficacy rate appears to be lower (72% in the US) than that of the mRNA vaccines, the J&J vaccine is still quite effective overall and after 28 days, it had good efficacy (83%; see table 16) in preventing severe/critical COVID.

It is perhaps a little bit concerning that it was less effective among older adults with comorbidities, but it is still better than being unvaccinated.

There was no very detailed data on the vaccine efficacy in people over age 75; they are mentioned in some results tables (e.g. table 12) but there does not seem to be enough data to draw an efficacy conclusion.

The vaccine also appeared to be safe overall. Similar to the previously approved COVID vaccines, many vaccine recipients did experience side effects such as headache, fatigue, and body aches, and these were more common in younger recipients.

There has been some concern about a rare but serious side effect involving clots: as of December 17, 2021, 57 people have experienced clots associated with the J&J vaccine. These all occurred in people under the age of 59. Given 16 million doses have been administered, this appears to be a very rare side-effect.

Although it is better to be vaccinated with J&J than to be unvaccinated, as of December 2021, it has become clear that the Pfizer and Moderna vaccines are more effective, and potentially safer. For these reasons, on December 16, the CDC announced that the mRNA vaccines are now preferred over J&J.

COVID Vaccination and Nursing Homes:

CDC data indicates that since vaccinations began in nursing homes in December 2020, COVID case rates and death rates have fallen dramatically in nursing home residents and among people aged 85+. A UK study also noted a significant drop in COVID hospitalizations after their vaccine rollout.

You can view current counts for COVID cases and COVID deaths in nursing homes here:
CDC: Nursing Home Covid-19 Data Dashboard

The numbers have improved a lot since the winter of 2020-2021. However, in December 2021, there were still 4000 cases per week in nursing homes nationwide, along with nearly 400 deaths per week.

Past investigations suggest that some nursing homes are experiencing outbreaks related to unvaccinated staff members, and “breakthrough” COVID cases in vaccinated residents are occurring. Most of these breakthrough cases are mild or asymptomatic, fortunately.

To date, vaccination rates are much higher among nursing home residents than among the staff who work in the facilities.

The CDC’s Advisory Committee on Immunization Practices (ACIP) reviewed COVID vaccine safety data in a meeting on January 27, 2021.  You can view the meeting slides and safety data here. This meeting included data on the immunization of nursing home residents (slides 39-41). These vaccinations used Pfizer and Moderna vaccines.

The safety data, for nursing home residents, were reassuring. As the slides explained, after the vaccination campaign in nursing homes, there was no sign that people were more likely to die within after vaccination, compared to nursing home residents who are not vaccinated.

Especially given the risk of COVID exposure due to those staff members who have chosen to not be vaccinated, I highly recommend COVID vaccination for all nursing home residents. I also recommend vaccination for visiting family members, as this helps protect nursing home residents, who may be more vulnerable to breakthrough COVID cases after vaccination.

I also recommend a booster dose for older adults and especially for nursing home residents, since recently published CDC data finds that the mRNA vaccines efficacy against COVID infection has dropped over the past few months:
Effectiveness of Pfizer-BioNTech and Moderna Vaccines in Preventing SARS-CoV-2 Infection Among Nursing Home Residents Before and During Widespread Circulation of the SARS-CoV-2 B.1.617.2 (Delta) Variant — National Healthcare Safety Network, March 1–August 1, 2021.

Who shouldn’t be vaccinated against COVID?

At this time, there are not many specifics on who should not be vaccinated, provided a vaccine is approved for your age group. (None of the available vaccines have an emergency authorization for children under the age of 5.)

As of December 2021, there have been a relatively small number of severe allergic reactions, which the FDA is investigating. So people with a history of anaphylactic allergic reactions should probably check with their health providers before pursuing vaccination. There have also been some very rare cases (28 out of 9 million doses given) of serious clots in people who receive the Johnson and Johnson vaccine, as noted above.

That said, with millions of vaccine doses being distributed over the next several months, guidelines are likely to rapidly evolve, regarding who should not be vaccinated, or who should be vaccinated with caution. For accurate information on this topic, I recommend reputable information sources, such as the FDA and the CDC’s COVID information pages. (See Resources, below.)

My current recommendation for COVID vaccination

As of December 17, 2021, I am urging all adults to get vaccinated for COVID, unless your own health provider advises you otherwise. Although any vaccine is better than no vaccine, the mRNA vaccines have proven to be more effective than Johnson & Johnson, so I would recommend one of those. There is also evidence that the Moderna vaccine is a little “stronger” and more effective, which can be good for aging immune systems.

I recommend vaccination against COVID because:

  • The Pfizer and Moderna vaccines appear to be quite effective in preventing hospitalization, even in older adults.
    • See my December 2021 video update in which I walk through the CDC data showing how COVID cases, hospitalization, and deaths are much higher in unvaccinated people, especially in older age groups
    • Data from Israel suggests good effectiveness in people over age 85, as well. Although there does seem to be some recent waning of vaccine protection against breakthrough infections (esp in older adults), vaccine protection against hospitalization remains quite good.
  • Even though it’s unclear exactly how effective these vaccines are in people over age 75, COVID case numbers and deaths in this age group have fallen as older adults have been vaccinated.
  • So far there is no reason to believe these vaccines are unsafe or likely to cause lasting harm.
  • Until COVID rates drop way, way, down, the risks of catching and transmitting COVID should vastly outweigh the potential discomfort of vaccination or very small risk of an adverse reaction.

I also recommend that previously vaccinated older adults get a booster COVID vaccine dose. Younger adults should get a booster as well, as it’s now recommended for all adults and helps reduce transmission to older adults and other vulnerable people.

What is an older person’s risk of dying from COVID?

To get an estimated answer to this question, in March 2021, queried the CDC’s COVID-19 Case Surveillance Public Use Data set, which is available online.

In reviewing available data for COVID cases from 9/1/20 to 3/25/21, I calculated the following:

  • For people aged 80+
    • 16.4% mortality overall
    • 43% mortality if hospitalized
    • 67% mortality if admitted to the ICU
  • For ages 70-79
    • 6% mortality
  • For ages 60-69
    • 2% mortality

Note that these figures are pre-Delta. The Delta variant does seem to cause more severe illness, so the risk of serious COVID illness in the unvaccinated is probably higher now.

For a more recent estimate of COVID mortality, see this part of my December 2021 COVID update.

What to remember if you — or your loved one — is over age 75:

I strongly urge you to get vaccinated! Moderna is likely better for older adults, but Pfizer is good too. Studies are finding that both mRNA vaccines offer superior protection compared to the Johnson & Johnson vaccine, and so I would recommend getting an mRNA two-dose vaccine if at all possible.

I also recommend that previously vaccinated older adults get a booster COVID vaccine dose. This will hopefully help reduce the chance of catching Omicron.

Please note that vaccination will make you much safer from COVID, but it often does not make you 95% safer and I especially urge caution for those who are frail, immuno-compromised, or over age 85.

Although most breakthough COVID infections in older adults are not severe, some are. Most deaths due to breakthrough COVID infections have been in people over age 65. It is hoped that boosters will reduce serious COVID breakthroughs in older adults.

There continues to be relatively little research published on vaccine efficacy in people over 85, which makes it challenging to know just how effective these vaccines are for our most vulnerable older adults. That said, the nursing home outbreaks we’ve had since residents were vaccinated show that although breakthrough infections can definitely happen, vaccinated nursing home residents are MUCH less likely to die of COVID.

COVID is also mutating and although so far the current vaccines appear protective against variants, that could change.

So I recommend erring on the side of taking precautions, such as being careful about crowded indoor spaces, especially if COVID cases are going up in your community.

Outdoor activity is in general low-risk for COVID exposure and transmission, and I believe that in most cases, it shouldn’t be necessary to wear a mask while outdoors.

You can find the CDC latest recommendations for fully vaccinated people here: CDC: When You’ve Been Fully Vaccinated

We can also protect nursing home residents and other vulnerable older adults by encouraging all younger adults around them to accept vaccination.

Please take care, stay safe, and I hope you’ll get vaccinated once it’s available to you! 

And if it’s been more than six months since you were vaccinated please get a COVID booster soon!

You can view my past COVID vaccine video updates here: Oct 2021, Sept 2021, July 2021, May 2021, March 2021, Dec 2020.

For 2022, I’ll be posting updates to a new page, which is here:  COVID & Aging Adults: 2022 Updates

Resources:

This article was first published on Dec 18, 2020, and was last updated by Dr. Kernisan on December 17, 2021.

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  1. I agree that this article was extremely informative which has now stimulated more questions. What’s being shared on the news is the overall efficacy of the vaccines, not what was discussed in this article. As a result, people who do receive the vaccine feel they are fully protected and are totally unaware they may have minimal or reduced protection if they are older. The CDC just issued initial guidelines for vaccinated people. Should the older population follow these guidelines given the lack of knowledge surrounding the actual efficacy of this group? My parents are 99 and 105 and have received both doses of Moderna and did well with the vaccine (my Dad was tired the second day). They live in a senior community with my brother who is their caregiver. I’m around them 4 days a week. We’ve been keeping them isolated in their apartment except when they are at my home twice a week. We have not had them around their grandchildren (late thirties) and their great-grandchildren (8 and under). Do we continue with what we are doing or should we feel more comfortable having them around the rest of the family? Should they wear masks or follow the new CDC guidelines that they may see families at low risk for severe infection indoors without a mask? Can we sit outside at a restaurant not knowing who may be at the next table? Since I am around my parents, should I feel comfortable seeing vaccinated friends and my family indoors following the new CDC guidelines or should I continue doing what I’ve been doing for another couple of months? Do we wait to see how the new variants affect our numbers and the spread of the virus? (My husband, 78, and I, 71, have both been vaccinated.) Part of me wonders if the new CDC guidelines are to just to give people reasons to get vaccinated. If there are no “benefits” to getting vaccinated (ie seeing family and socializing again), why get vaccinated? Are these guidelines truly safe and reasonable especially for the elderly population? Any feedback would be greatly appreciated. Thank you.

    • Those are all great questions and I’m not sure we have all the answers. There’s no question that the vaccine will confer some immunity from contracting COVID, even in the very elderly, and will also reduce the risk of getting extremely ill even if a COVID infection happens, so I think it’s reasonable to relax some of the physical distancing we’ve all been practicing.

      Nothing will reduce the risk to zero, and every decision involves some trade offs and compromises. If you’re able to ask your parents what they prefer, then follow their lead. They may be willing to accept some (reduced, now that they’re vaccinated) risk in order to return to a more family-filled lifestyle.

      • I am 75 and have had the two doses of the Moderna vaccine. Four weeks after the second dose, I had an antibody test, and it was negative. I am a blood cancer patient on a clinical trial of a bispecific antibody drug and reached remission recently. Like most blood cancer patients, I have somewhat suppressed immune response, but it is not drastic, and I am not neutropenic. Are the results of the antibody test reliable? Is there any additional step I should take? Meanwhile, I am following all recommended precautions, but I fear I will never see my grandchildren again since they live 3000 miles away.

        • I’m so glad you had your vaccine.

          Antibody tests may not be useful in determining if your vaccine has been effective. Even in those who’ve had COVID, an antibody test may be falsely negative if it’s done before or after the antibody levels have risen. Also, remember that your immune system has other responses than just forming antibodies, that an antibody test won’t reveal.

          I wouldn’t wait for a positive antibody test result before doing the activities that you planned to do when you were “immune”, but I would continue to use sensible precautions when you’re out and about. I hope you get to see your grandchildren soon.

  2. Terrific article, best I’ve seen out there on possible studies for advanced aged. We are in Dallas, still unsure whether it’s in best interest of a homebound and home-based 95 year old mother with heart issues and on max. blood pressure meds—to receive vaccine. thanks thanks for any additional info you might receive since Jan 2021—–concerning frail, heart issues, over 90 year olds. thanks thanks

    • Thanks for your kind comment and I hope you’re safe and well in Dallas. I am fielding a lot of questions about COVID vaccine safety for older adults, and you can hear what I surmised from the data we have so far in this video.

      Officially, there’s no absolute reason to avoid the vaccine unless a person has had a severe allergic reaction to a an immunization in the past, and frail older individuals seem to be at higher risk for complications of COVID compared to younger adults. So it’s a balance between the risk of a vaccine versus the risk of getting ill with COVID. IT also seems that older adults have milder or fewer side effects after vaccination compared to younger folks. I’m tending to lean towards vaccination for my frail patients in almost all cases.

      I understand being worried and I am advising individuals in your situation to have a chat with their PCP to help make this tough decision.

  3. I just got my first shot of Moderna and am 70 years old. I’m reading that the antibodies drop off for people 65 and older between 50 and 75 percent after 3 months and am now wishing I had waited for a Pfizer vaccine. Will I be able to get booster shots after 3 months? How often will I need them? and can I change vaccines to one that will provide longer efficacy?

    • Hi Teresa and I’m glad to hear you got your first vaccination. I’m not sure what source you are reading to get those stats about the “antibodies dropping off”, but right now, there is no need for a booster (except for your second shot in about 28 days ). From what I have read about the vaccines, the efficacy is similar, so waiting for a particular brand (Pfizer or Moderna) is not advisable. Right now, it’s not clear that getting 2 different brands of vaccine would be as effective as getting the same one, so I would think that getting a second dose of the Moderna would be the way to go if one has already received the first dose with that brand.

      I’m glad you got your vaccine and I would encourage you to keep up your good infection control practices and get that second shot when you can!

  4. Great article.

    My father is 97, lives at home, and had his first Moderna vaccine a month ago. He is scheduled to get his second shot this Friday, but our other sibling says he should not get it because she is panicking he will get so weak and die from the second vaccine. He did fine with the first vaccine with no reactions or side effects.

    Our questions are: How safe is the second Moderna vaccine for a relatively healthy 97 year-old,and will it make him so weak, he won’t even be able to walk?

    What data do you have on the second Moderna shot for people in their 90’s? Has anyone this age group not in a nursing home had severe after effects?

    How long will the first vaccine be effective to protect him? How long can we wait to get a second vaccine if she refuses to take him To get it?

    Thank you

    • Hi Kathy, those are all reasonable questions about the vaccine. We have very limited data on how the Moderna (or Pfizer) vaccine works in adults over age 90, and unfortunately, that’s not likely to change in the short term.

      I can tell you that from what I have seen on the CDC and Health Canada websites, most reactions (whether local or systemic) are happening in those under 65. In those over 65, milder adverse reactions are common, and less than one tenth of one percent of those vaccinated got ill enough after the second vaccine dose to seek help in a hospital or emergency room.

      Having said that, it appears that about 70% of individuals got some kind of reactions, such as fever, chills, body aches, fatigue or nausea (compared to 30% of those in the placebo group).

      As far as I know, one dose of COVID-19 vaccine is not enough to confer any protection. Current recommendations are that the second dose should be given within 42 days of the first, and that immunity might occur about 2 weeks after that second dose.

      Many are asking me whether the vaccine id right for their older relative, and in general, the only reason to not vaccinate is if the person has had an anaphylactic (severely allergic) reaction to a vaccine in the past. If a family member is worried about how their relative will be able to tolerate the vaccine, I would suggest they talk to their doctor or primary care provider about it.

    • I completely agree with Dr. Didyk’s comments above. There is basically no published data on vaccine efficacy or side-effect on 97 year olds who are outside the long-term care system, as your father is.

      The CDC is collecting COVID vaccine safety data through vsafe.cdc.gov (an optional smartphone-based program) and also their usual vaccine surveillance systems, but I don’t believe that data is easily accessible to the public.

      We also don’t know how much protection is conferred by a single Moderna dose in someone your father’s age. There is some evidence suggesting that a single dose of Pfizer or Moderna provides some protection from COVID, but no one knows for how long, and most of that evidence is in people much younger than your father.

      We do know how vaccines work in general: they need to stimulate the immune system, and the immune system ages and gets harder to stimulate as people get older. So for the influenza vaccine, we have developed “stronger” vaccines for older adults: they either have more antigen, or include an extra substance (an “adjuvant”) meant to goose the immune system.

      Because of what we know about vaccines in older adults, I think that the older people get, the more likely it is that they really need that second dose, to get whatever protection is possible from the vaccine. Multi-dose vaccines in general work under the premise that you get better (meaning stronger and/or more durable immunity) when you give the immune system more than one exposure to the antigen.

      With millions of people getting vaccinated, there will surely be someone somewhere in their late 90s who has a reaction or health crisis after their second vaccination. It will be hard to say whether it’s likely due to the vaccine or just random (very old people are prone to health crises in general).

      I would reassure your sister that because of your father’s age and the fact that he did fine after the first vaccine dose, it’s very unlikely that the second Moderna dose would cause a serious health crisis in him. He is overall at higher risk of harm from COVID. So I hope he’ll get his second dose…even if the vaccine is only 50% effective in him rather than 95%, that’s much better than not being vaccinated at all.

      Oh and, no one knows how long he can wait…it has not been studied…and of course no one knows yet just what is happening in the immune systems of 97 year olds in regards to this vaccine.

      Sorry we don’t have better answers for you! We are all in uncharted waters, especially when it comes to people 85+.

      • This relates to my questions. I have a 97 year old healthy mother who lives by herself in her own home. Takes no medicines. Exercises daily. The challenge is we are in Texas which is hell bent on opening up March 10th even though we are 48th out of 50 states in terms of vaccination rate. Right now, it’s just about impossible to get her an appointment, has been for two months, and it anytime appointments become available, thousands (ten times the number of available appointments) jump in line and they never tell you the time the appointments go live beforehand. On top of that there is a fight in the family between those who want her to get it pronto and those who don’t want her to get it (yes, basically we have some in the family that believe the conspiracy theories and think the vaccine is unsafe and will kill her, they have heard stories from their “doctor” that two unrelated otherwise healthy 90+ year old mothers of his patients had heart attacks and died within days of getting the first shot. I have to wonder why that medical professional is spreading stories he has heard from his other patients, but it certainly is causing conflict in our family). So given the sketchiness of the data for those over 90. Given she can isolate in her home, and wear masks on once a week grocery shopping and that the local store has promised to still require masks. How hard to push to try to find a vaccine appointment? Is it irresponsible to take a wait and see attitude, look for more data to come in ? She decided to stop driving herself this past year, so there is logistics problems as any of these appointments are more than 30-40 miles away and someone will need to drive her, most likely me and I live hours away, not in the same city.

        • Hi Gary and thanks for sharing your story which I am sure is a common one! Even after vaccination, I think it’s a good idea to use precautions like mask wearing, handwashing and avoiding crowds until this pandemic is truly over. I wish it were easier to get a vaccine in your area and I understand your frustration. I would make a reasonable effort to get an appointment and I hope they get easier to obtain as more people have their dose. I don’t think we need more data to tell us that the vaccines we have available will provide some protection, even in those over 90, but every family has to make a decision about how much risk is worth the benefit.

        • My uncle is 95. We were banned from their house (my cousin is a doctor) up until he got the vaccine. Believe it or not, someone was with him when he got his second dose. We all felt he was going to get one or all the symptoms the second dose brings. WRONG!!!, he was well all the time…He had none of the symptoms all of us have. Is this an everyday fact? I am a MPH and believes there should be more studies regarding this fact…

          • I agree that we would benefit from more studies, Maria-Luisa! You can watch my video about that here:https://youtu.be/2G5LZDYiiCs It does seem that, in general, older adults have fewer vaccine side effects from the COVID shots than younger ones. This may be related to the dampened response of the aging immune system, but doesn’t necessarily mean that the vaccine will not be effective. I’m so glad your uncle got his immunization!

          • Hello Patti and I completely understand how you’re feeling. We’ve been making sacrifices for the sake of our health for over a year and it’s frightening to think about what happens now. Not having side effects after a vaccine doesn’t necessarily mean it’s not working, and I don’t recommend an antibody test (see my answer to previous comments).

            Vaccines reduce our risk of getting very ill with COVID, but no vaccine is 100% effective. There’s no way to tell how “immune” a person is after getting immunized, but almost certainly, they will be much safer if they happen to get in contact with someone with COVID.

            On the other hand, continuing to avoid social contact could have serious health consequences for many. I am advising my patients to be sensible with handwashing, masking in public and staying home if they’re ill, and to move towards a more relaxed way of moving around as they feel comfortable. I hope you get back to seeing your grandchildren very soon!

  6. Thank you for this summary, it was very helpful. Do you believe I should get the Pfizer or Moderna vaccine for my 87 and 88 years old Dad based the information that we have so far. I have heard that the Moderna say offer more efficacy after just one dose of the Pfizer vaccine. I want the best efficacy is the long run, but also would like to get them some protection between the doses at this point?

    • I’m glad you’re getting informed about the vaccine and plan to get your dad immunized.

      Well, I don’t know if we will ever be in a position to choose which vaccine we prefer, given the current challenges with vaccine supply, but the evidence we have is that there is not a major difference between these two compounds. It takes 2 shots for full efficacy and I would encourage everyone to continue to use good infection control practices even after the first and second shot.

  8. I had an anaphylaxis reaction years ago with non-ionic iodine injected for a radiological test. As you probably know, non-ionic is supposed to be very safe, only containing 5% iodine, yet my reaction was rather severe. Does this qualify for concern with the new CDC guidelines? It doesn’t seem like a reason to avoid the vaccination but I wondered your thoughts? Thanks.

  9. My mom is 99 years old. She has COPD, congestive heart failure, Asthma and diabetes. We have questions about whether she should get the vaccine. In light of these underlying conditions and her age what are the risks in her receiving the vaccine.

  10. Your thoughtful analysis of how much we can rely on the test results from the Pfizer data is extremely helpful in putting things into context. Thank you.

    Now that the Moderna vaccine is out, what do we know about it’s efficacy in older adults? The headline is that the test results show it’s only 86% effective in those over 65. But your analysis shows how difficult it is to actually get statistically significant results given the size of the test groups.

    Can you please analyze the Moderna results the same way you’ve analyzed the Pfizer data?

    • Thanks for your comments and I’m glad the article was helpful. Based on my quick review, it looks like the Moderna vaccine, also an mRNA vaccine had a similar
      lack of older adults in its trials. But their report on a small group of about 40 individuals over the age of 56 seemed to have immune responses similar to younger adults so that bodes well. It will probably be about the same as the Pfizer vaccine. Let’s all just get one when we can!

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