By Arthur Allen April 6, 2022

At Whitman-Walker Health, Dr. David Fessler and his staff administer high-dose influenza vaccine to all HIV-positive and senior patients. Although the vaccine is roughly three times as expensive as standard flu vaccine, it seems to do a better job at protecting those with weakened immune systems — a major focus of the nonprofit’s Washington, D.C., clinics.

At the University of New Mexico Hospital in Albuquerque, meanwhile, Dr. Melissa Martinez runs a drive-thru clinic providing 10,000 influenza vaccines each year for a community made up largely of Black and Hispanic residents. It’s open to all comers, and they all get the standard vaccine.

These different approaches to preventing influenza, a serious threat to the young and old even with covid-19 on the scene, reflect the fact that federal health officials haven’t taken a clear position on whether the high-dose flu vaccine — on the market since 2010 — is the best choice for the elderly. Another factor is cost. While Medicare reimburses both vaccines, the high-dose shot is three times as expensive, and carrying both vaccines for different populations requires additional staffing and logistics.

“We’ve focused on giving the standard-dose vaccine, trying to get as many people vaccinated as possible,” Martinez said. And they will keep doing so, she added, until the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices decides whether to preferentially recommend the enhanced vaccines.

The CDC historically has been reluctant to pick winners among manufacturers’ competing products to prevent or treat disease. It recommended all three licensed covid vaccines after establishing that each met its disease-fighting goals. In a given year, most influenza vaccines are not very effective. Drug companies vying for market share aren’t generally motivated to compare them, since they might lose out. And federal officials generally don’t fund such studies, so they are left to rely on research offered by the companies.

In the meantime, older minority patients, especially Black seniors, are getting the short end of the stick, say some advocates for eliminating racial disparities in health care. Blacks are about 20% less likely than whites to get flu shots, although they are at higher risk of severe flu. Even those who get the vaccine are about 30% less likely to get the high-dose version.

“Since you have an increased risk of diabetes and heart disease in the African American community, it inherently disadvantages this population to give them the standard-dose vaccine,” said Dr. Keith Ferdinand, a cardiologist and professor of medicine at Tulane University. While the data on the high-dose vaccines is not ironclad, “any tool we have in our toolbox to reduce ethnic/racial disparities should be embraced,” he said.

A CDC workgroup has been investigating the issue since before the pandemic, with plenty of covid-caused delays. On Feb. 23, committee members heard evidence that the high-dose flu vaccine and two other “enhanced” vaccines — one containing an immune-boosting substance, the other a recombinant protein — were better than low-dose vaccine produced in hens’ eggs, the standard product for the past 80 years.

The committee may vote at its next meeting, probably in June, on the matter. At February’s meeting, one CDC official estimated that switching to those vaccines for seniors could reduce influenza-related hospitalizations by thousands a year.

But even a June vote would be too late to affect vaccinations before the fall flu season. Pharmacies and health systems have already ordered next season’s vaccine, and drug companies are committing their facilities now to meet the demand, said Dr. Michael Greenberg, a Sanofi vice president.

Sanofi stands to gain from expanded use of its more expensive high-dose vaccine (it also produces a standard-dose version). Germany, Canada, and other countries provide the vaccine free to residents of long-term care facilities, but not to all seniors. In the United States, an estimated 75% of elders who are vaccinated receive an enhanced shot.

But the remainder, who get the standard vaccine, are disproportionately members of ethnic and racial minorities, according to a study of the 2015-16 flu season.

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