Flu Shots for Older Adults: What to Know & Do

It’s October, which means it’s that time of the year again: flu vaccination time!

Back when I worked in a primary care clinic, this is when we made a big push to offer the seasonal flu shot to all of our patients. (And we got ourselves immunized, as well.)

Not all of our patients agreed. Many older adults are skeptical of the need to get a yearly vaccination against influenza. They aren’t sure it will help. Or they think that the vaccination will actually give them a mild case of the flu. Or they just don’t like needles.

Or maybe they aren’t sure which type of seasonal flu shot to get: the regular one or one of the newer “stronger” versions, designed for older adults?

I’m never surprised when people bring up these questions. Vaccination for seasonal influenza can indeed be a confusing topic.

But it’s certainly important to consider. Depending on the year, the Centers for Disease Control (CDC) estimates that every year, influenza affects 9-60 million Americans, causes 140,000-710,100 hospitalizations, and results in 12,000-56,000 deaths. (Influenza is more severe in some years than others.) Most people get better without needing hospitalization, but some people get very sick. Older adults are especially likely to get dangerously ill from catching the flu.

So I agree with the CDC’s recommendation: everyone over the age of 6 months should get their seasonal flu shot.

In fact, I’m about to go get mine. As a healthy woman in her 40s, I’m not that concerned about getting dangerously ill from influenza. Instead, I get my annual flu shot because I want to minimize my chance of getting sick and perhaps exposing my older patients to influenza.

This month, you’ll probably be encouraged to get vaccinated too. So in this article, I’ll address some key things to know about influenza and the flu shot, along with some common questions and concerns. Here’s what I’ll cover:

• The basics of influenza and vaccination against the flu
• What to know about flu shots for older adults
• What’s new and resources for the 2017-2018 flu season
• Which influenza vaccination is probably best for most older adults
• What to do if your older parent or relative is unwilling or unable to get vaccinated

The basics of influenza and vaccination against the flu

Q: What is influenza?

A: Influenza is a contagious respiratory viral illness, caused by influenza A or influenza B virus. It usually causes symptoms such as sore throat, stuffy nose, cough, fever, and body aches. In the Northern hemisphere, influenza is most common in the winter. Peak influenza activity usually occurs between December and February, but it can start as early as October and occur as late as May.

In “uncomplicated” influenza, the flu causes symptoms similar to — but usually worse than — a very bad cold, and then these get better over 5-7 days. Most people who catch the flu experience uncomplicated influenza, with some people experiencing more significant symptoms than others. In fact, some people (14%, in one study) will catch the flu and shed some flu virus, yet not report any symptoms!

However, influenza does sometimes cause more serious health problems, which we call “complications.” These are more likely to happen to people who are older, have other chronic conditions, or have a weakened immune system.

The most common complication of influenza is pneumonia, which means a serious infection of the lungs. Such pneumonias are sometimes purely viral. But it’s more common for them to be caused by bacteria, who are able to infect the lungs due to the body being weakened by influenza infection.

Many older adults also appear to experience worsenings of any chronic heart or lung conditions, when they experience influenza. These complications of influenza often cause hospitalization or even death.

To learn more about the basics of influenza, and for more on diagnosing and treating the flu, see:

• Key Facts About Influenza (Flu)
• Diagnosing Flu
• Flu Treatment

Q: How does the flu shot help protect one from influenza, and how effective is it?

A: The flu vaccine works by stimulating the body to produce antibodies against whatever strains of influenza were included in that year’s vaccine.  After vaccination, it takes about two weeks for the body’s immune system to create its influenza antibodies.

Our bodies are able to fight off viral infections much more quickly, if we already have matching antibodies available when a virus tries to create illness in our bodies. If we don’t have matching antibodies available, then we’ll experience more illness, and it will take longer for our immune systems to control the infection.

The tricky thing about influenza is this: both influenza A and B have a tendency to be constantly changing into slightly different strains. This means that every year, scientists must study what influenza strains are present, and try to predict which ones we’ll be exposed to, during the coming winter. Influenza vaccines are then developed, to match those strains. (This is why the flu shot has to be given every year.)

Sometimes the scientific prediction works out well. In this case, we say that the vaccine was well matched to the influenza viruses circulating that winter, and influenza vaccination will have been more effective in preventing the flu.

But there are years in which the influenza strains that circulate the most in the winter are not the ones that scientists were expecting. These are the years in which the influenza vaccine is not well matched, and there tends to be more illnesses and hospitalizations.

The CDC estimates that when the vaccine is well-matched to the circulating influenza viruses, flu vaccination reduces the risk of flu illness by between 40% and 60%, for the overall population.

Several different flu vaccines are available every year. “Trivalent” flu vaccines have been available for the longest: these protect against two strains of influenza A and one strain of influenza B. “Quadrivalent” flu vaccines, available since 2012, protect against two types of influenza A and two strains of influenza B.

Vaccines also vary in terms of whether they are “standard-dose” versus “high-dose,” and one type includes an “adjuvant,” which is an additive designed to increase the immune system’s response to the vaccine. (More response is better, in that it means more protection from future infection.) I’ll discuss high-dose and adjuvant vaccines later in this article, in the section addressing flu shots for aging adults.

You can find a list of all available influenza vaccines in the Table listed below.

For more information:

• Key Facts About Seasonal Flu Vaccine (CDC)
• Vaccine Effectiveness – How Well Does the Flu Vaccine Work? (CDC)
• Understanding How Vaccines Work (CDC)
• TABLE 1. Influenza vaccines — United States, 2017–18 influenza season

Q: Can you get the flu from the flu shot? What are the risks and side effects of influenza vaccination?

A: No, you can’t get the flu from a flu shot. The currently recommended vaccines are made with either “inactivated” virus (which means the virus has been killed and can’t become alive again) or “recombinant” technology (which means they have cobbled together virus proteins). It is not possible for these vaccines to give you influenza.

There used to a “live attenuated” form of flu shot, available for people ages 2-49, which was given by nasal spray and was especially popular with children. (This did contain a weakened form of influenza virus.) However, the CDC advised against using this vaccine for the 2016-2017 flu season, and also for the 2017-2018 flu season.

The most common side-effect of the flu shot is arm soreness, and sometimes redness. People do sometimes report body aches, fever, or cough after the flu shot. But a randomized trial found that these are equally common in people who just had saline injected, so these symptoms are either due to getting sick from something else after your flu shot, or perhaps to even expecting to feel lousy after your flu shot.

Serious adverse effects related to the flu shot are very rare.

For more information:

• Misconceptions about Seasonal Flu and Flu Vaccines
• Flu Vaccine Safety Information

Q: What are best ways to protect oneself from influenza and its complications?

A: To reduce your risk of getting sick from the flu, it’s best to combine two approaches:

1. Minimize your exposure to people spreading influenza virus in the winter.
2. Take steps to bolster your immune system, so that if you do get exposed to influenza virus, you’ll be less likely to get very sick.

Older adults should also make sure they are up-to-date on pneumococcal vaccination, which now requires two different vaccinations. (These are one-time, not yearly). Pneumococcal vaccination helps reduce the risk of certain types of bacterial pneumonia and other potential complications of influenza. A 2016 meta-analysis concluded that being vaccinated for both influenza and pneumococcus was associated with a lower risk of pneumonia and death. For more on pneumococcal vaccination, see: 26 Preventive Services for Older Adults (Vaccination section).

Minimizing your exposure to influenza virus

The main way people get exposed to influenza is when they breathe in air droplets containing influenza virus. These droplets are created when people infected with influenza virus talk, sneeze, or cough. The CDC estimates that a person infected with influenza virus may be contagious for one day prior to developing symptoms, and 5-7 days after getting sick.

Influenza virus can also survive on hard household surfaces for up to a day. The virus survives for much less time on soft surfaces, such as used tissues and bed linens.

Based on these facts, the best ways to minimize exposure to influenza are to:

• Avoid exposure to people who may be infected with influenza.
• Clean household surfaces, especially hard surfaces such as counters, and especially if someone living with you has been sick.
• Wash your hands often, especially before touching your eyes, nose, or mouth.
• Minimize your time near people who have not been vaccinated for influenza.
  • Your risk of influenza exposure is reduced if people around you — family members, co-workers, fellow residents of your living facility — are vaccinated for influenza.

Bolstering your immune system

Since we are social creatures and live in communities, we all have a good chance of being exposed to the influenza virus at some point. Whether we get sick from this exposure, and how sick we get, depends on how well our immune system can fight off the influenza virus.

Ways to bolster your immune system are:

• Be vaccinated against seasonal influenza. If the vaccine is a good match with circulating viruses and you have a good antibody response, this is probably the best way to prepare your immune system to beat influenza.
• Take good care of your health and body. This includes addressing healthy lifestyle basics such as not smoking, getting adequate sleep, avoiding chronic stress, and more. For a good review of what’s known about strengthening the immune system, see: How to boost your immune system (Harvard Health Review)

What to know about flu shots for older adults

Q: Is the flu vaccine effective for older adults?

A: You may have heard people say that the flu shot doesn’t work in older people. This is not entirely correct.

Now, it’s true that flu vaccine is usually less effective in older adults, because aging immune systems tend to not respond as vigorously to the vaccine. In other words, older adults tend to create fewer antibodies in response to vaccination. So if they are later exposed to flu virus, they have a higher chance of falling ill, compared to younger adults.

But “less effective” doesn’t mean “not at all effective.” For the 2015-2016 flu season, the CDC estimates that “vaccination prevented 23% of influenza-related hospitalizations,” for adults aged 65 and older.

For more on the effectiveness of influenza vaccination in older adults, see:

• Vaccine Effectiveness – How Well Does the Flu Vaccine Work? (You can jump to the section “How effective is the flu vaccine in the elderly?” by using the “On this Page” menu, to the right.)

To provide more effective vaccination to aging immune systems, vaccine makers have developed “stronger” vaccines against the flu, which I explain in the next section.

Q: Are there flu shots specifically designed for older adults?

Yes, over the past several years, vaccine makers have developed vaccines that are designed to work better with an aging immune system. Most research studies to date show that these stimulate aging immune systems to produce more antibodies to influenza. There’s also some evidence that these vaccines reduce the risk of being hospitalized for influenza.

However, so far the CDC’s Advisory Committee on Immunization Practices (ACIP) has not particularly recommended these vaccines for older adults. Instead, the ACIP says that older adults should get any influenza vaccination approved for their age.

There are two influenza vaccines that are specifically approved for people aged 65 and older:

• Fluzone High-Dose: This trivalent vaccine contains four times the amount of antigen, compared to Fluzone standard-dose. It is approved for adults age 65+.
  • Studies have found that the high-dose vaccine does improve antibody response. A study published in 2017 also found that use of the high-dose vaccine in nursing-homes was associated with a lower risk of hospitalization during flu season.

• Fluad: This trivalent vaccine contains an “adjuvant,” which is an additive meant to stimulate a better immune response to the vaccine. It is a newer vaccine in the U.S., but had been licensed in Canada and several European countries prior to receiving approval here in 2015.
  • An Italian study found that this vaccine resulted in higher antibody titers, among older adults.
  • But no recent clinical trials of efficacy have been published. (Which means we don’t yet know whether people given this vaccine actually have a lower chance of being hospitalized during flu season.)

For more information on flu shots for older adults, see:

• Fluzone High-Dose Seasonal Influenza Vaccine
• FLUAD Flu Vaccine With Adjuvant
• New Guidance Clarifies Use of Pneumococcal, Influenza Vaccines in Older Adults (this is for professionals working in long-term care, so more technical and includes good details regarding research evidence)

Q: Does Medicare cover the cost of influenza vaccination?

Yes, yearly influenza vaccination is 100% covered by Medicare, with no deductible or co-pay. So if you get your flu shot from a health provider that accepts Medicare payment, there should be no cost.

What’s new and resources for the 2017-2018 flu season

The CDC maintains a page dedicated to the current flu season. There is a section for the public and also a section for providers. This is a good place to get up-to-date information on influenza and influenza vaccination. You can find it here:

• 2017-2018 Flu Season (main page)
• Frequently Asked Flu Questions 2017-2018 Influenza Season (main page for the public)
• 2017-2018 Information for Health Care Professionals

The CDC also provides information specific to older adults here:

• What You Should Know and Do this Flu Season If You Are 65 Years and Older

Also important to know for the 2017-2018: the nasal flu vaccine (technically called “live attenuated” vaccine and branded as FluMist) has never been approved for adults age 50 and older. But in case you are wondering: it’s not recommended for anyone of any age to use, for the 2017-2018 flu season.

Which influenza vaccination is best for older adults?

Looking at the list of available flu shots can be overwhelming. In looking at this year’s CDC table of available influenza vaccines, I counted eleven options that are available for people aged 65 or older:

• 4 standard-dose quadrivalent inactivated vaccines (Afluria Quadrivalent, Fluarix Quadrivalent, FluLaval Quadrivalent, Fluzone Quadrivalent)
• 1 standard-dose quadrivalent inactivated vaccine manufactured with a newer “cell culture-based” technology (Flucelvax Quadrivalent)
• 2 standard-dose trivalent inactivated vaccines (Afluria, Fluvirin)
• 1 standard-dose trivalent adjuvanted inactivated vaccine (Fluad)
• 1 high-dose trivalent inactivated vaccine (Fluzone High-Dose)
• 1 quadrivalent recombinant vaccine (Flublok Quadrivalent)
• 1 trivalent recombinant vaccine (Flublok)

Only Fluzone High-Dose and Fluad carry an age indication specific to 65 years or older.

However, the CDC does not recommend any influenza vaccine over another, for adults aged 65 or older.

So if you are an older adult, or if you’re trying to arrange a flu shot for an aging relative, which flu vaccine should you try to get?

My take is this: if you have a choice, go for one of the vaccines designed for older adults.

Why? Because we know that as people get older, their immune systems tend to respond less vigorously to immunization. And because research suggests that the high-dose flu shot generates higher antibody titers and has been associated with better influenza outcomes.

We do have more research and experience for Fluzone High-Dose than for Fluad, so unless you are enrolling in a clinical trial of Fluad, I would suggest going with the Fluzone High-Dose.

Now, both flu vaccines designed for older adults are trivalent and not quadrivalent. Quadrivalent vaccines do provide protection against an additional influenza B strain. However, experts say that older adults are less likely to be seriously ill from influenza B than from influenza A. Also, no published study has compared a quadrivalent vaccine against a high-dose trivalent vaccine. So for now, there does not seem to be a particular reason that an older adult should choose a quadrivalent vaccine over a high-dose trivalent vaccine.

You may have also heard that the New England Journal of Medicine published a study this past summer, about a newer influenza vaccine in older adults. That study, funded by the manufacturer of recombinant influenza vaccines, compared the effectiveness of a recombinant quadrivalent vaccine with a standard-dose quadrivalent inactivated vaccine, in adults aged 50 and older. Confirmed influenza cases were 2.2% in the  group receiving recombinant vaccine and 3.2% in the group receiving inactivated vaccine.  Hence the probability of influenza-like illness was 30% lower with the recombinant vaccine than with the inactivated vaccine. But again, this study did not compare the recombinant vaccine against a high-dose inactivated vaccine.

Bottom line:

• What is most important is to get any type of flu vaccination that is approved for your age.
• Research suggests that older adults are more likely to benefit from a high-dose influenza vaccination, such as Fluzone High-Dose.
• If you are under age 65, you might get better protection from an influenza vaccine that is quadrivalent compared to trivalent. You also might get better protection from a vaccine that is recombinant rather than made from inactivated vaccine.
• Flumist, the nasally administered vaccine, is not recommended for anyone of any age, for the 2017-2018 season. All influenza vaccinations for this season will require a needle poke.

What to do if your older parent or relative is unwilling or unable to get vaccinated

Now, what if your older parent won’t, or can’t, get a flu shot?

Some older adults just don’t want to get it. Here are some things you can try:

• Ask them to clarify what their concerns are. It’s important to start by listening, in order to understand what an older person believes about the flu and the flu shot.
• Provide information to dispel myths and misunderstandings. Sometimes all people need is a little of the right kind of information.
• Point out that it can benefit an older person’s family members and neighbors. Getting a flu shot can reduce the risk that we pass the flu on to another person. People are sometimes more willing to take action to protect others than to protect their own health.
• Make sure they know they won’t have to pay for the flu shot. If you get the shot from a provider who takes Medicare, it shouldn’t cost anything.
• Offer to go together to get your flu shots. Sometimes it helps to make it a family outing.

There are also some older adults for whom it’s hard to get a flu shot, such as people who are homebound or have very limited transportation options.

If this is your situation, the main thing to do is encourage flu shots for family and others coming to the house. For older adults who don’t get out much, their main source of exposure to influenza will be from those who come to them.

Above all, don’t panic if your older loved one can’t or won’t get a flu shot.

Although I’ve just written a long article encouraging flu vaccination for older adults, the truth is this: most years, the chance of getting very sick or dying from influenza are small.

Being vaccinated certainly helps make this chance smaller. But not every older person is interested in doing everything possible to reduce the danger of illness. Vaccination is important from a public health perspective, but most people survive flu season whether or not they’ve been vaccinated.

Personally, I think it’s worth getting vaccinated because there’s a small chance that you’ll avoid the misery of having influenza.  And, there’s maybe an even better chance that you’ll help reduce the spread of influenza to people around you.

The downsides of getting a flu shot are small. You’ll have to get to a place where they are offering the flu shot. The needle poke will hurt for a moment. Your arm might be sore for a day or so.

And then that’s it! You’ll have done your small part to protect yourself and others.

So, have you decided where to go to get your flu shot? You can find a place to get one here: VaccineFinder.org.

Questions about influenza vaccination for older people? Comments? Post them below!