High-Dose Influenza Vaccine for Elderly Patients
The Advisory Committee on Immunization Practices (ACIP) recommends preferential use of high-dose or adjuvanted influenza vaccines for all adults aged 65 years and older. 1, 2
Age-Based Recommendations
High-dose influenza vaccine (Fluzone High-Dose) is FDA-licensed exclusively for adults aged ≥65 years and should not be administered to younger patients without specific medical indications. 1, 2
The high-dose formulation contains 60 μg of hemagglutinin per vaccine strain—four times the amount in standard-dose vaccines—to overcome age-related immunosenescence. 1, 3
For patients aged 65 and older, any age-appropriate inactivated influenza vaccine (standard-dose, high-dose, or adjuvanted) is acceptable, but ACIP now expresses a preferential recommendation for higher-dose or adjuvanted formulations in this age group. 4, 1
Clinical Evidence Supporting High-Dose Vaccine
Fluzone High-Dose met prespecified criteria for superior efficacy compared to standard-dose vaccine in a randomized trial of 31,989 persons aged ≥65 years, with a relative efficacy of 24.2% (95% CI: 9.7%–36.5%) for preventing laboratory-confirmed influenza. 4
High-dose vaccine has demonstrated consistent benefits across multiple studies in reducing hospitalizations for pneumonia and influenza, cardiorespiratory illnesses, and mortality in elderly populations. 4
Among nursing home residents aged >65 years, high-dose vaccine reduced respiratory-related hospital admissions (3.4% vs. 3.9%) and mortality (17.1% vs. 18.3%) compared to standard-dose vaccine. 4
The effectiveness is most pronounced in adults aged ≥75 years, though benefits extend to all individuals ≥65 years regardless of comorbidities, frailty, or prior vaccination history. 4, 5
Administration Protocol
Administer 0.5 mL intramuscularly in the deltoid muscle as a single dose per influenza season. 1
The vaccine is available as a prefilled syringe and should not be confused with standard-dose formulations. 4
Only one dose is required per season; no booster doses are needed. 1
Special Populations Under Age 65
Patients aged 18-64 years taking immunosuppressive medications (such as those with rheumatic diseases or solid organ transplant recipients) may benefit from high-dose vaccine, though this represents off-label use. 1, 6, 2
For immunocompromised individuals who have received hematopoietic cell or solid organ transplantation, clinicians could consider administering 2 doses of high-dose vaccine. 1
Insurance barriers frequently prevent coverage of high-dose vaccine for patients <65 years, even when clinically indicated. 6
Common Pitfalls and Caveats
Do not delay vaccination if high-dose vaccine is unavailable—standard-dose vaccine should be administered rather than postponing immunization, as any influenza vaccine is superior to none. 1, 2
High-dose vaccine recipients may experience more frequent injection site reactions and systemic symptoms compared to standard-dose recipients, though the safety profile remains favorable. 4, 7
Avoid administering influenza vaccine in July and August for adults ≥65 years due to concerns about waning immunity before peak influenza season. 1
Do not administer high-dose vaccine to patients <65 years without specific immunocompromising conditions, as this is not FDA-approved and represents off-label use. 1, 2
Cost-Effectiveness Considerations
High-dose vaccine is cost-effective in elderly populations and can reduce healthcare costs by 2.75% and years of life lost by over 50%. 4
The benefit-to-cost ratio is most favorable in adults aged ≥75 years, though vaccination of all adults ≥65 years with high-dose formulations remains recommended. 4, 5