The woman was sixty-eight years old and had come in for something routine. A minor procedure, the kind that should have kept her overnight and sent her home the next morning with a folder of printed instructions. What kept her three weeks was shingles.

It started the second night: a rash across her left ribcage, burning. By morning it was blistering. By afternoon she was on IV pain medication and the medical team was explaining postherpetic neuralgia, the nerve pain that can follow a shingles outbreak for months, sometimes years, sometimes the rest of your life. I was eight years into nursing at that point. I had seen shingles before. I had not watched it arrive on top of an already compromised immune system and settle in quite like that. She went home eventually. Her daughter called me two months later. She still couldn’t wear anything that pressed against her torso.

That was 2001. Shingrix didn’t exist yet. Now it does, and it works, and a lot of people over sixty still haven’t gotten it. That’s the kind of gap that keeps me writing.

October is a reasonable time to take stock of which vaccines you actually need. Flu season is arriving. The pharmacy signs are up. And a handful of other vaccines that protect adults past sixty are worth thinking through while you’re already in that frame of mind. Let me go through what the current guidance actually says.

The flu shot: why the standard formulation isn’t the right call at sixty-five

The CDC recommends a flu shot every year for everyone six months and older. That part hasn’t changed. What changes at sixty-five is which formulation to ask for.

The immune system’s antibody response to standard-dose flu vaccines weakens with age. The protective response isn’t as strong, which is exactly the wrong direction when you’re in the age group that flu hospitalizes most. To compensate, three formulations are specifically designed for adults sixty-five and older. Fluzone High-Dose contains four times the antigen of a standard flu shot. Fluad adds an adjuvant, an ingredient that amplifies the immune response. Flublok is a recombinant vaccine grown without eggs and also formulated for higher immune response. The CDC’s advisory committee expresses a preference for any of these three over standard-dose vaccines for adults sixty-five and older.

If you’re sixty-four, a standard formulation is appropriate. If you’re sixty-five or older and your pharmacy has only the standard dose, don’t skip the vaccine to go looking for a preferred product. Protection matters more than formulation. But if you have a choice, ask.

Timing: flu vaccine immunity peaks several weeks after the shot. For older adults, getting vaccinated in July or August provides coverage that can start to wane by February, when the season often runs hardest. The CDC advisory panel considers September through October the better window for adults sixty-five and older. If you’ve missed that, getting vaccinated later in the season still helps. Better late than absent.

There’s also an mRNA flu vaccine approved for adults fifty and older if you’re interested in the newer technology. The high-dose/adjuvanted/recombinant preference still applies at sixty-five, but the mRNA option is available.

COVID: an honest account of where the guidance actually stands this fall

This one requires some candor, because the official picture is less clean than it’s been.

The CDC has not issued a new blanket recommendation for this season the way it does for flu. Its current guidance for adults sixty-five and older describes getting an updated COVID vaccine as a matter of individual decision-making in consultation with a healthcare provider. That’s the official position.

The major medical societies, including the American Academy of Family Physicians, have gone further on their own. They recommend an updated vaccine for all adults, and a second dose six months after the first for adults sixty-five and older.

What I’d say about that gap: COVID can still put people in the hospital. Adults sixty-five and older remain at significantly higher risk for severe illness than younger adults. An updated vaccine targets the current circulating strains. The vaccines are available. The fact that the CDC’s language is more cautious than the medical societies’ this season doesn’t make the vaccine less protective. It reflects a disagreement at the guidance level, not at the clinical level.

If you haven’t had an updated COVID vaccine in the past six months, it’s worth a conversation with your doctor or pharmacist about your specific health situation. That’s not hedging. That’s genuinely the right call when the official guidance is ambiguous.

RSV: one shot, not annual, and who needs it

RSV, respiratory syncytial virus, is not only a disease of infants. In older adults it can cause serious pneumonia and lower respiratory tract infections, and the complications can be severe.

The CDC recommends a single dose of an RSV vaccine for adults seventy-five and older. For adults fifty to seventy-four, the recommendation applies to those at increased risk: people with chronic heart or lung conditions, weakened immune systems, or certain other underlying conditions. This is not an annual vaccine. One shot.

The preferred timing is late summer through early fall, since RSV season typically runs October through March. If you’re seventy-five or older and haven’t had an RSV vaccine, this month is exactly the right time to ask. If you’re between fifty and seventy-four, the question is whether your health history puts you in the higher-risk category. That’s a five-minute conversation with your physician or pharmacist.

Shingles: this is the one I need you to take seriously

I spent fourteen years as a nurse watching the results of various preventable conditions that people hadn’t gotten around to preventing. Shingles is near the top of that list because the outcomes can be so disproportionate to what people expect.

The virus that causes shingles is varicella-zoster, the same one responsible for chickenpox. If you had chickenpox (and most adults over sixty did), the virus is still in your nervous system, dormant, waiting. It can reactivate at any time, and the risk increases with age. The rash is one thing. What I saw in that hospital room in 2001, and in other patients since, is what comes after: postherpetic neuralgia, nerve pain that the medical system has very limited tools to treat, that can last months or years and that changes how a person lives. Shingles can also affect the eye, with the potential for serious vision complications. These are not rare outcomes. They are common enough that every nurse I’ve known who works with older patients has seen them.

Shingrix, the recombinant zoster vaccine, is given in two doses for adults fifty and older. The doses are spaced two to six months apart. It works regardless of whether you’ve had shingles before, and it replaces the older Zostavax, which is no longer used in the United States. Studies showed efficacy above ninety percent in adults fifty and older when the series is complete. Both doses are necessary for that protection; the second dose is not optional.

People skip the second dose. This is a known problem. The pharmacist who gives you the first shot can schedule the second one. Write it down.

If you had Zostavax years ago, talk to your provider. The guidance is to get Shingrix regardless, since Zostavax’s protection has waned.

Pneumococcal: the age threshold changed, and it’s worth knowing

Pneumococcal disease is caused by a bacterium called Streptococcus pneumoniae. It causes pneumonia, meningitis, and serious bloodstream infections. The vaccines that protect against it have been updated significantly in recent years, and the recommended starting age has shifted.

The CDC now recommends pneumococcal vaccination for all adults fifty and older who haven’t previously received a conjugate pneumococcal vaccine. This is a meaningful change from older guidance that emphasized sixty-five as the key threshold. If you’re in your fifties and haven’t had one, it’s worth bringing up.

The current vaccines, PCV20 and PCV21, offer broad coverage in a single dose. An older formulation, PCV15, calls for a follow-up PPSV23 dose about a year later. If you received PCV13 and PPSV23 at or after sixty-five, your situation is more nuanced: you may opt for a newer vaccine or not get an additional dose, and your physician can advise based on your history.

One practical note: Medicare Part B covers pneumococcal vaccination, as well as flu and COVID vaccines, with no cost-sharing when given by an enrolled provider; the RSV vaccine is covered under Part D, also with no cost-sharing. There’s no financial reason to skip any of these.

The question I hear most in October is some version of: do I really need all of these? The honest answer is that it depends on your age, your health history, and what you’ve had before. Which is exactly why I’ll close with the same thing I’ve been telling readers for years: pull together a list of which vaccines you’ve received and when, bring it to your next appointment, and ask your doctor where you stand. The conversation takes less time than postherpetic neuralgia by a very wide margin.

Carol Gifford worked as a registered nurse for fourteen years before moving into health writing. Her column appears twice weekly. This column is informational only; please consult your healthcare provider about the right choices for your situation.