It’s more important than ever to get vaccinated against the flu this year and, as always, over-65s are particularly at risk. But a vaccine developed specifically for them, which was free in 2021, is no longer funded. 

You might have already started adding a merino layer under your outfits and popping an umbrella in your bag as you get ready for work. You’re probably craving warming soups and cosy nights at home more and more. Winter is coming, and that means flu season is upon us. 

It’s always a good idea to get the flu vaccine but this year, it’s even more important than in previous winters. Over the last two years, restrictions to slow the spread of Covid-19 have kept us all healthier. They’ve also meant that the regular circulation of bugs that act like natural boosters when flu season hits have dwindled. Now, as Covid-19 restrictions are eased and borders begin to open up, experts say it’s vital we get our jabs – and the more of us who do the better. 

For over-65s, people with particular health conditions, pregnant people and, since this flu season, Māori and Pasifika over-55s, the flu vaccine is fully funded – which means it’s free. The risk of influenza-related hospitalisation is greater for older people compared with healthy adults aged under 65 years. Increasing levels of frailty and the presence of chronic conditions like diabetes or heart, kidney, neurological or respiratory diseases add to the risk for this group. 

However, some are raising concerns that those aged 65 and over are being offered a potentially less effective vaccine than they were last year. 

Under a four-year supply agreement for the 2020 to 2023 influenza seasons, independent drug-buying agency Pharmac is funding the flu vaccine Afluria Quad – making it free for the eligible groups. But last year, supply delays of Afluria Quad meant that for over-65s, Pharmac temporarily funded an alternative. Called Fluad Quad, it’s the only available flu vaccine that works with an immune enhancer or adjuvant – an ingredient that improves the immune response to the vaccine in people aged 65 and over. But Pharmac hasn’t yet agreed to fund it permanently, meaning those who want Fluad Quad this year must pay for it.

Last week an Auckland woman, who described herself as “well over 65”, told The Spinoff she went to get her flu vaccine. Ahead of her vaccine, which was advertised as free, she was asked “did I want the free one, or the one specially made for older people who may need help making the antibodies?” That vaccine, Fluad Quad, would cost $35. “I was told that it was the one given free last year,” she said.

She paid the $35 for Fluad Quad and said her concern is not that she personally had to pay for the vaccine. She could afford it, and “naturally enough, I wanted the best to protect me”. Instead, she’s worried “that this seems like a two-tier system: one for those with money to choose, and one for those without”. She’s also concerned that others may not be informed of the choice or variation between the vaccines.

“I’m just indignant on behalf of all the poor immunocompromised or elderly people who either could not afford or who are not informed about this option,” she said.

When contacted by The Spinoff, Pharmac’s chief medical officer Dr David Hughes said in an emailed statement that in 2020, the Immunisation Advisory Committee advised the agency “there was limited evidence and no direct comparison to show the difference between Fluad Quad and Afluria Quad’s effectiveness”. For that reason, Fluad Quad was placed on the “cost-neutral list”, which, according to the Pharmac website, means “it may get funded if we can negotiate a deal that saves money, or at least doesn’t cost more than something already funded”.

In 2021, “the supplier marketed it as a more effective vaccine”, said Hughes, “but it has only been recently that they have supplied more evidence to Pharmac to support their application for Fluad Quad being more effective than Afluria Quad in people over 65 years of age”. The Immunisation Advisory Committee that advises Pharmac will be considering the more up-to-date evidence and providing advice on it at their meeting next month, he said.

The data to date on the Fluad vaccine suggests it does to some extent give the best immune response for elderly, explained professor Nikki Turner, the director of the Immunisation Advisory Centre at the University of Auckland. Because the traditional flu vaccine is less effective in older adults than in younger people, the Fluad vaccine has an enzyme specifically designed to make it more effective for elderly. But, “it’s tricky”, said Turner. “We can’t simply say this vaccine is better than this vaccine.” Turner would like to see Pharmac continue reviewing the data to “better quantify the gains for the cost”.

Associate professor Helen Petousis-Harris, a vaccinologist at the University of Auckland, agreed, saying the decision to not fund the potentially more effective vaccine was a symptom of budget constraints within the drug-buying mechanisms. “I like the idea that you have the best vaccine available, but it’s difficult when you have a constrained budget,” she said.

Studies that compare the enhanced Fluad vaccine with the regular vaccine “consistently show that it provides extra protections”, she said. But Petousis-Harris wanted to reassure over-65s that the difference between the vaccines is only slight. “What’s most important,” she said, “is that the vaccine is a match with the flu that’s circulating”. Both the Fluad and Afluria vaccines protect against the four strains of the virus identified by the World Health Organisation as circulating this year.

“It’s important people know they have other options,” Petousis-Harris added. However, even if they were notified of the difference, “it’s inequitable because people can’t afford it”, she noted.

“For people who are most at risk of complications, like Māori and Pasifika, it would be good to see the best vaccine available for these groups if we want to be genuine about reducing inequity.”

It’s difficult to know what our flu season will look like this year, but there are concerns across the board that Aotearoa will be hit hard by the virus in the coming months. Hughes said he wanted to “encourage all who are eligible for the free flu vaccine to book their vaccination as soon as possible”, adding that “the funded flu vaccine, Afluria Quad, is an effective layer of protection against this season’s flu”. 

Like the Covid-19 vaccine, flu vaccines are “about community protection, not individual protection”, said Turner. Thankfully, we can apply the same practices we’ve learnt from reducing the spread of Covid-19 to help protect those most vulnerable to the flu, and ease the burden on our health system, which is already under strain because of Covid-19. That means getting vaccinated (especially if you’re around older adults) and staying home if you’re sick. “Flu vaccines do help stop the spread, and that’s more effective when we immunise collectively,” said Hughes.