Ask the Pharmacist

Q) I am a senior and would like a flu shot. How come you can’t give me the high dose one?

A) That is a justified question and one that we have been asked several times each and every day. The Ontario government has done a wonderful job of marketing how important getting a flu shot is, in particular this year with the second wave of the pandemic appearing to be ramping up as you read this.

They have also done a nice job of patting themselves on the back by letting us know that for the first time ever they are making the high dose version of the influenza vaccine available for seniors. What they have royally messed up (beyond COVID testing, contact tracing, $1 beer…..) is displaying even a semblance of competence when it comes to organizing and honestly communicating their vaccine program.

The result is that pharmacies (and I assume other vaccine administers) don’t know how many actual vaccines they will receive (although a good assumption is that it will be less than what they requested), what type (high dose versus the normal quadrivalent) or when they will actually show up.

To control numbers and maximize social distancing, it is our preference to run predetermined flu clinics that are scheduled and staffed to meet the requirements rather than offering flu shots by drop ins and losing control of the number of patients in the store. However, the unknown quantity and delivery date of the serum adds an element of surprise we would rather not have to deal with.

The other result is that many seniors now know that the high dose vaccine is recommended for anyone over the age of 65 but they are not aware that their government is only giving pharmacies one high dose version for every 4 to 5 flu vaccines they send. Considering that roughly 80% of our flu vaccine recipients are seniors, it’s pretty simple to see that the math doesn’t work.

The upshot is that most people over the age of 65 will not be able to be given the high dose variant. Pharmacies will have to take what doses they have and triage the high dose versions to those who are most at risk of suffering serious complications from the flu. The difficult part is that anyone over the age of 65 is at high risk by definition and ideally would receive this version but the reality is that there are subsets of patients that are in greater jeopardy from the influenza virus due to other medical conditions they have (called comorbidities).

These high risk groups include those who are being treated for cancer, other immune compromising conditions, diabetes, lung diseases (like asthma or COPD), heart disease, anemia, obesity, kidney disease and neurological conditions (like MS). Other high priority seniors include those who live in nursing homes or other long-term care facilities as well as those who may live in congested living conditions such as a shelter where a virus can (and as we know has) spread like a wild fire.

So why didn’t the government order more of the high dose version? This answer more than likely comes down to economics. The high dose version is undoubtedly considerably more costly for the government than the other version (other than the nasal mist which is also prohibitively expensive).

A 2018 Globe and Mail article cited that its cost per dose was 5 times higher than the regular flu shot and a vaccine researcher in Nova Scotia pegged it at $88 per dose back then. Multiplied by our seniors, that’s a lot of money when debt levels are already at historically high levels and no one is voting in governments that even speculate on the possible need to raise taxes. This in fact may not be the wrong decision by them, although it still would be nice if they actually communicated this and treated us like adults who understand the need to live within one’s means.

There are experts who feel that the high dose version does not provide much bang for the buck. While the high dose version has four times the amount of antigen, a study published in the New England Journal of Medicine found this version to be 24% more effective in preventing flu in adults 65 years and older. This is actually less impressive than it sounds.

It is also important to also focus on the number of patients needed to treat. This term refers to how many people have to take the drug in order to have one positive outcome. In this case, it would refer to the number of people who would need to receive the high dose version in order to prevent one more case of influenza than the regular dose version did.

According to the now deservedly famous Dr. Bonnie Henry of B.C.0- COVID fame, about 200 seniors would have to be vaccinated with the high-dose shot to prevent one case of influenza. That’s not insignificant when you factor in the potential for loss of life and the high costs of hospitalization, but it’s not exactly a game changer either, especially at that price point.

So, hopefully, that answers your question. Everyone should get vaccinated but patience will be a virtue and please don’t feel like you’re being treated like a second class citizen if you’re only offered the normal flu vaccine. It is still an effective product that is not wildly less potent than the high-dose version and is less likely to give you a sore arm or flu-symptoms to boot. For more information about this or any other health related questions contact your pharmacist.