Influenza Vaccination Recommendations for Individuals 65 Years and Older
For individuals 65 years and older, high-dose influenza vaccine, adjuvanted influenza vaccine, or recombinant influenza vaccine is preferentially recommended over standard-dose influenza vaccines. 1
Preferred Vaccine Options for Adults ≥65 Years
High-Priority Options:
- High-dose quadrivalent inactivated influenza vaccine (HD-IIV4) - Fluzone High-Dose Quadrivalent 1
- Adjuvanted quadrivalent inactivated influenza vaccine (aIIV4) - Fluad Quadrivalent 1
- Recombinant quadrivalent influenza vaccine (RIV4) - Flublok Quadrivalent 1
Rationale for Preferential Recommendation:
The Advisory Committee on Immunization Practices (ACIP) made a preferential recommendation in June 2022 for these enhanced vaccines in adults 65 years and older based on:
- Superior efficacy: High-dose Fluzone demonstrated superior efficacy compared to standard-dose vaccines in a large randomized controlled trial involving 31,989 adults ≥65 years 1
- Enhanced immunogenicity: These vaccines produce higher hemagglutination inhibition (HAI) titers compared to standard-dose formulations 2, 3
- Reduced disease burden: High-dose vaccine was associated with lower risk of laboratory-confirmed influenza infections (Relative Risk 0.76,95% CI 0.65 to 0.90) 3
Clinical Evidence Supporting Enhanced Vaccines
High-Dose Vaccine:
- Contains 4 times the amount of antigen (60μg hemagglutinin per strain vs. 15μg in standard-dose) 1, 2
- Demonstrated superior efficacy in a large randomized trial with 31,989 participants aged ≥65 years 1
- FDA approved since December 2009 for adults ≥65 years 2
Adjuvanted Vaccine:
- Contains MF59 adjuvant to enhance immune response 4
- More effective against laboratory-confirmed influenza than unadjuvanted standard-dose vaccine in observational studies 1
Recombinant Vaccine:
- Produced using recombinant DNA technology rather than egg-based methods 1
- In an exploratory analysis from a single-season randomized trial with 8,604 adults ≥50 years, RIV4 showed greater efficacy than standard-dose quadrivalent vaccine 1
Important Considerations
Timing and Availability:
- Vaccination should not be delayed if a specific preferred product is not readily available 1
- Standard-dose influenza vaccine should be administered rather than delaying vaccination when enhanced vaccines are unavailable 5
- Delays of 3-6 weeks in vaccination or 10-20% reductions in coverage due to waiting for preferred vaccines could potentially increase hospitalizations and deaths by over 7% 5
Safety Profile:
- Enhanced vaccines have similar safety profiles to standard-dose vaccines 3
- Some solicited injection site and systemic adverse events may be more frequent with high-dose vaccine but are typically mild and transient 1
Administration:
- All these vaccines are administered as a single 0.5 mL dose via intramuscular injection 4
- Preferred injection site is the deltoid muscle 1
Practical Approach to Vaccine Selection
- First choice: Offer one of the three enhanced vaccines (high-dose, adjuvanted, or recombinant)
- If enhanced vaccines are unavailable: Administer standard-dose influenza vaccine rather than delay vaccination
- Contraindications: Consider patient-specific contraindications to any particular formulation
- Timing: Vaccinate as early as possible before or during influenza season
While the American College of Rheumatology conditionally recommends high-dose or adjuvanted influenza vaccines for patients with rheumatic diseases on immunosuppressive medications regardless of age 1, the strongest evidence and clearest recommendations apply to adults ≥65 years, for whom these enhanced vaccines are specifically licensed and preferentially recommended.
The goal is to maximize protection against influenza in this vulnerable population while ensuring timely vaccination, as delayed or missed vaccination poses a greater risk than receiving a standard-dose vaccine when enhanced vaccines are not readily available.