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Flu Vaccine for Older Adults: Is there a "Goodest" Option?


Our physician author is over age 65 years and needs to choose among more than 10 flu vaccines. All are good, but is one "gooder" for him?

I have always been fascinated by and interested in how preschoolers intuitively figure out grammar rules. In fact, English grammar would make a little more sense if we let them write the grammar book. My own example: “Good-gooder-goodest” makes more sense in some comparative scenarios than “good-better-best.”

Now that I am over 65, I have a new interest:  which influenza vaccine should I get? I have a choice among 11 options of trivalent, quadravalent, adjuvanted, standard dose, high dose, and recombinant formulations. My age precludes another two, intradermal, and live, inactivated. The CDC basically says all are good and does not voice a preference. I don't want just a “good” vaccine, though; I want the “goodest.”

How they rank
Quadravalent vaccines are a better bet than trivalents. Two families or lineages of B influenza viruses exist. Little or no cross protection exists if your trivalent vaccine has the wrong lineage in it. The experts in the last few decades have been wrong as often as right when trying to predict which B family to include in the trivalent, the Yamagata or the Victoria lineages. (FYI, this year they have chosen Victoria for the trivalent. The quadravelent will have a strain from each lineage.)

Two flu vaccines have been designed with seniors in mind and are in fact only approved for use in this age group:  Fluad and Fluzone High-Dose (HD). Both have been shown to be more effective versus a standard trivalent flu vaccine. Fluzone HD was 24% more effective than the standard dose vaccine. Fluad, in an observational study had an increased efficacy of 63%. Fluad has an adjuvant added to boost the immune response and Fluzone HD just quadrupled the amount of antigen as compared to the standard dose. Unfortunately, neither comes in a quadravalent form yet.

There is yet another quadravalent influenza vaccine that has been shown to be roughly 30% more effective in a trial of adults over 50 years of age than the standard quadravalent vaccine.

Which one is it?A. Flublok

B. Flulaval

C. Flucelvax

D. Afluria

For answer and discussion, please click below.

The correct answer is A. Flublok

Flublok was shown in a 9000-subject trial published in the NEJM to be about 30% more effective than the standard quadravalent vaccine. Flublok is a recombinant, totally egg-free vaccine.

So which vaccine is best for seniors-trivalent Fluzone HD, trivalent Fluad, or quadravalent Flublok?  No one knows; no head-to-head studies among the 3 have been done. All seem to be a better choice than the standard dose vaccines for seniors. So these three are, I think, “gooder” than the usual vaccines, but I am not sure which is “goodest.”  If you are over 65, let me know below which you plan to ask for-and why?



Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices - United States, 2017–18 Influenza Season. MMWR Recomm Rep 2017;66(No. RR-2):1–20.

Dunkle LM, Izikson R, Patriarca P, et al. Efficacy of recombinant influenza vaccine in adults 50 years of age or older. N Engl J Med 2017; 376:2427-2436.

Vaccines and Related Products Advisory Committee. FDA Advisory Committee Briefing Document. Fluad-seasonal adjuvanted trivalent influenza vaccine (aTIV). Meeting date: September 15, 2015

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