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Which Flu Shot Is Right for You?

Standard, high-dose, quadrivalent, tiny-needle — the menu for the 2013 flu season is a long one, but the advice is the same: Just make sure you get one

spinner image flu shot influenza symptoms vaccine stomach needle nasal options health winter (Rich Pedroncelli/AP Photo)
Get your flu shot before flu season begins.
Rich Pedroncelli/AP Photo

How do we know it's fall?

It's not the leaves turning, it's the "get your flu shot" signs that are popping up everywhere from doctor's offices to pharmacy clinics.

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This year the menu of flu vaccine choices is even longer, so for people age 50 and up, the big question is: Which one should I get?

New for the 2013-14 flu season is a so-called quadrivalent shot that protects against four strains of flu instead of the usual three.

Also new are injectable "cell-based" flu vaccines produced with novel technologies that don't involve growing the flu virus in chicken eggs — a safe choice for those allergic to eggs.

There's also a high-dose flu shot for people age 65 and older, introduced in 2010, and a tiny-needle version rolled out in 2011 that injects the active ingredient just under the skin (an appealing alternative for people who dread shots). There is a nasal spray flu vaccine, but it's approved only for individuals ages 2 to 49.

"This is the first time that people have had to worry about which one to choose," says John Treanor, M.D., a flu vaccine expert at the University of Rochester Medical Center. "In the past we just said, OK, you should get a flu vaccine. That's simple. Now you have all these different options without evidence that would really favor one over the other."

Indeed, the Centers for Disease Control and Prevention (CDC) and most vaccine experts stress that for the great majority of people, the regular flu shot — a standard-dose "trivalent" vaccine protecting against three flu strains — is perfectly fine.

"Getting some type of vaccine is important," according to Richard K. Zimmerman, M.D, a flu vaccine specialist at the University of Pittsburgh. "Which one you get matters less."

Price can also be a consideration. Medicare Part B covers any flu vaccine appropriate for people 65 and older with no copay. Some private insurance plans also don't charge a copay for flu shots. For the uninsured paying cash at the pharmacy, the high-dose version retails for nearly twice the price ($50-$60) of the standard dose ($25-$35). The quadrivalent shot sells for several dollars more than the standard-dose trivalent shot.

HealthMap Vaccine Finder ( is a handy tool for finding a flu shot provider by town or ZIP code. The site lists the types of vaccines offered, but it's a good idea to call ahead to check on supplies.

Flu vaccine options vary according to a person's age. Here are some questions and answers to guide you:

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If You're Age 65 and Older

The choices include the regular flu shot (standard dose of the trivalent), the high-dose flu shot (double dose of trivalent), the quadrivalent flu shot (a new four-strain version) and the egg-free shot called Flucelvax.

Should you get the high-dose vaccine or standard one?

Talk to your doctor about whether you need a high-dose vaccine, but studies do show that people who receive the high-dose vaccine produce more antibodies — infection-fighting proteins in the blood — than those who get the regular dose. That's important because vaccines work by provoking the immune system's defenses against the target disease, and older people tend to mount a weaker response.

In fact, the high-dose vaccine was developed to address concerns that the standard-dose shot doesn't work very well in people 65 and older, the very group most likely to be hospitalized or die from flu complications. Last year, for example, the CDC reported that season's regular vaccine lowered an older person's risk of flu by only 27 percent, an unexpectedly low level of effectiveness compared with a 63 percent reduction for people ages 50 to 64.

Whether the high-dose shot's effect on blood antibodies will translate into substantially fewer people getting sick is not yet clear. But signs are good that it offers at least some advantage. In August the vaccine's maker, Sanofi Pasteur, issued preliminary findings from an ongoing clinical trial showing the higher dose increased flu prevention by 24 percent over the standard dose.

What about the new quadrivalent vaccine?

While the high-dose shot seems to offer stronger protection against flu, the quadrivalent shot gives broader protection. Every year public-health authorities design the trivalent vaccine to build immunity against the three strains of flu deemed most likely to circulate that season — two strains of type A flu and one strain of type B.

The trouble is, two separate subtypes of B virus are common causes of illness, and it's not easy to predict which one will predominate in a given year. "We're wrong about half the time," says Gregory Poland, M.D., a vaccinologist who founded and leads the Vaccine Research Group at the Mayo Clinic in Rochester, Minn.

The quadrivalent shot solves that by including both common B subtypes, so its protection is broader. However, the B viruses tend to be more virulent in children, while the A strains are more likely to cause severe illness in older people. For this reason, all three experts we spoke with recommended that people 65-plus get the high-dose standard shot — with its extra dose of A-strain vaccine — rather than the quadrivalent. The high-dose also may be easier to find than the quadrivalent, which is in shorter supply.

If You're Ages 50 to 64

The choices include the regular flu shot, the new quadrivalent flu shot, the tiny-needle shot and the egg-free Flucelvax.

Should I get the quadrivalent vaccine?

For somewhat younger adults, the quadrivalent shot may be ideal in terms of protection against flu. But here as well, studies have yet to prove superior performance over regular vaccine. And because it's brand new this year, supplies are limited. Zimmerman says that if all the alternatives were offered at the same price, for people 50 to 64 he'd choose the quadrivalent vaccine. "However, I would not travel an extra 20 minutes for it," he adds.

Is the tiny-needle shot a good option?

Those wary of needles can also opt for the tiny-needle or "intradermal" shot, which deposits the medicine under the skin rather than in the muscle, as a standard shot does. It's been approved for people ages 18 to 64 and protects against three viral strains, same as the standard flu shot. It also can be harder to find than the standard flu shot.

What about the egg-free vaccine?

Anyone 18 or older who is hypersensitive to eggs — a problem that's actually far more common in young children — can choose a vaccine whose virus is grown in mammalian cells rather than chicken eggs.

Katharine Greider is a freelance writer.

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