Ageism and Influenza

By Michael Hodin

Surely, one of the more powerful and enduring legacies of the 20th century is the miracle of longevity. Long lives to a hundred as a matter of course have been bequeathed to us as a consequence of scaled sanitation across society and the antibiotic revolution, followed by the multiplicity of biomedical innovations and the near universal application of childhood immunization. It is now our turn in our 21st century to realize a healthy longevity, one pillar of which is extending the immunization achievement across the life course, including to older adults.

The pandemic has only reinforced the critical importance of getting the best vaccines to as many older adults as possible, especially those in marginalized communities. However, policymakers have not yet expanded this lesson to other communicable diseases — particularly influenza, where the U.S. still has a de-facto two-tier system that keeps the most vulnerable seniors from receiving the vaccine that will best protect them.

But, to get this right, details are essential, including the “dirty little secret” of ill-informed health practice, leading to a missed opportunity for healthier aging for millions and the knock-on effects of unnecessary healthcare costs and deterioration stemming from illness that could have been avoided entirely. Among those areas that needs fixing is prevention of influenza and its complications, where getting the right vaccine is critical and, therefore, recognition that not all flu vaccines are equally protective for all people.

There is a high-dose vaccine for influenza designed for people 65 and older. It has been shown to provide higher antibody levels, lower hospitalizations, and reduce risk of pneumonia and cardio-respiratory events for older adults. While this is the vaccine that around two-thirds of older Americans do get, millions still receive the so-called “standard” flu vaccine, which works fine for the average 30-year-old but is too often inadequate for older adults and others with weakened immune systems. Moreover, overwhelmingly, those who receive this less protective, standard vaccine are seniors of color. And the adverse consequences for them and for our health system are considerable, as the flu remains a life-threatening illness that disproportionately affects older adults. For example, in the 2017–2018 flu season, people aged 65+ comprised 85% of all flu-related deaths and 66% of all flu-related hospitalizations.

This two-tier vaccine system driving unequal health outcomes is all the more troubling, since there is a quick, pretty easy fix that will also save our health system billions in unnecessary costs:

Indeed, the CDC’s Advisory Committee on Immunization Practice (ACIP) could remedy this by recommending the more effective vaccine for older adults at their upcoming meeting in the fall. However, they have been hesitant to issue this decision, despite the clear disparities within the current system. Sure, the high-dose vaccine does cost Medicare slightly more to reimburse, reflecting its innovative advance, but haven’t we just been through a pandemic where we cleared cost hurdles without a second thought, just to give the public the very best protection that medical science has to offer? Certainly, we can do the same when it comes to older adults and influenza.

Sadly, ACIP seems to be living with a holdover from a previous era of unchecked ageism. In fact, ACIP does not currently include an aging expert in its ranks who might focus on the needs of older adults, especially the African American, Hispanic, and Asian older adults who are most impacted by these bad policies.

At the upcoming meeting, ACIP has the opportunity to make a clear-cut decision that will protect millions of older Americans, help to advance health equity, and save money being unnecessarily spent down the road because of inadequate immunization today. Even better, it could help to jumpstart a wider update of public health policy to prioritize healthy aging with a few key actions:

· Recommend the more protective flu vaccine for all older Americans. This should be an easy decision. By recommending the high-dose vaccine, ACIP can end an inherently ageist system that is leading to health inequities for under-served communities. This would be an important step for U.S. vaccine policy and deliver real benefits every flu season, especially as we also face the long-term challenge of endemic COVID-19. We would also be in line with the global Decade of Healthy Ageing, which has “combatting ageism” as one of its core pillars.

· Add an aging expert to ACIP. It’s long past time to recognize that older adults are a critical constituency for vaccine policy. Keep up the pace on childhood immunization, but in a 21st century society where there are more old than young, it is both the right thing to do and in our national self-interest to keep older adults healthier. The incredible success of childhood immunization efforts should be a model and inspiration for ACIP to bring the same urgency and expertise to the challenge of vaccine-preventable diseases for adults. Doing so would help to save lives and improve quality-of-life, while also reducing costs for an already strained U.S. health system.

· Consider partnerships and innovations to elevate adult immunization more broadly. Flu is just the start. A range of other communicable diseases such as shingles, pneumococcal disease, HPV, and hepatitis B, would benefit from greater focus, resources, and smart policymaking. Our goal should be faster innovation to deliver better vaccines and therapies for these diseases, supported by policies that get these new innovations to those who need them most.

A chorus of voices is now calling on ACIP to recommend the high-dose flu vaccine — an easy step to protect older adults and advance health equity. Importantly, it can also be the first step in a wider effort to re-orient vaccine policy for the needs of older adults and align our immunization policies to the life-course approach of the 21st century.