The flu shot is one of the best weapons in Canada’s arsenal to combat what health experts are calling a “multi-demic” of flu, respiratory syncytial virus (RSV) and COVID-19 that is making people sick and straining health-care systems.
Despite the mass availability of the flu shot, the uptake is lower than what’s needed to effectively protect populations — particularly for older adults, according to a new survey from the National Institute on Aging, a public policy think tank within Toronto Metropolitan University.
And it’s a combination of general indifference, lack of convenience, and lack of information that is stopping Canadians from getting flu shots in arms, the survey shows. However, the COVID-19 pandemic has increased confidence in vaccinations, and strategies need to be implemented to capitalize on positive attitudes to boost influenza vaccination at a crucial time, according to the Institute’s report.
During a typical flu season, influenza causes about 175,000 emergency room visits, 12,200 hospitalizations, and approximately 3,500 deaths, according to the federal government.
“The good overall news is that people are pretty positive about vaccines, yet that makes you scratch your head a bit as to why we’re still stagnating at getting more people vaccinated against influenza,” said Dr. Samir Sinha, the Institute's director of health policy research and the director of geriatrics at Mount Sinai Hospital in Toronto.
It’s clear the public is worried enough about COVID-19 to get vaccinated, but they aren’t being told clearly the risks of flu, leading to lower vaccine uptake, said Sinha.
Canada is in a flu epidemic, and hospital workers are reporting patients being treated in hallways. At the same time, RSV has overwhelmed pediatric ICU units, with children’s health facilities across the country reporting wards are near full, or beyond capacity.
And in terms of the flu, for older adults, the outcomes from infection are far worse. Though those 65 and older make up one fifth of the population, they account for more than half of hospitalizations due to flu and 70 per cent of deaths, according to the Institute.
The study found that only 48 per cent of Canadians reported receiving the flu vaccine in the 2021-2022 flu season, which is far below the 93 per cent at the time who reported getting two doses of a COVID-19 vaccine.
As well, though 70 per cent of those 65 and older reported being vaccinated against the flu during last year’s flu season, that remains below the 80 per cent goal the Public Health Agency of Canada has outlined as needed to properly protect that population.
Older adults were particularly zealous when it came to the COVID-19 vaccine, with 97 per cent receiving two doses, and 92 per cent having three or more as of last fall, indicating that there is enthusiasm around vaccination, the survey explains.
Across racial groups, about one in four across all backgrounds said they were now more likely to get the flu shot in fall 2022 due to the pandemic. That number was slightly higher among South Asian people, with 40 per cent stating the pandemic has made it more likely they will get the flu shot.
But the Institute states the numbers are “stubbornly” stuck at 70 per cent for those 65 and older, as uptake rates were similar in the previous three years.
The COVID-19 pandemic has made Canadians more confident in vaccinations, as 53 per cent of those surveyed said their attitudes toward had not changed, and 58 per cent of older adults said the same.
What’s more, 28 per cent of adult Canadians said they now hold a more positive view of vaccines and 31 per cent of older adults said the same.
Another 16 per cent of Canadians said their views had become more negative. In older adults, nine per cent reported they had garnered more negative views toward vaccination.
For the vast majority, the reasons for not getting the flu shot had nothing to do with negative views toward vaccines, the survey shows.
For adults who reported not receiving the shot in the 2021-2022 flu season, 30 per cent said there was no specific reason, they just “didn’t get it”. That was the most common response.
The second most common reason was “I did not get around to it” (14 per cent) and the third was the belief that they are “healthy/never get the flu” (12 per cent).
In older adults, 23 per cent said they just “didn’t get it” and there was no specific reason for not taking it, 18 per cent said they believe they are “healthy/never get the flu” and the third reason differed from adults overall, with 10 per cent stating they have concerns about vaccines or side effects.
The Institute identifies five ways to increase uptake for Canadians in an urgent flu season.
The first is to improve messaging around the importance of flu vaccines, with targeted messaging particularly for older adults, it states in its report.
Older adults are not being given enough information about the risk of flu and higher chance of hospitalization and death, as the survey found that people over 65 believed they were healthy and therefore didn’t need the shot, despite the evidence of risk, the institute states.
“When the perceived risks of a disease seem low, individuals are more likely to remain unvaccinated,” the study report states.
Beyond information being shared on government sites and by health care organization, primary care providers and any other health care professional a person interacts with should discuss the flu shot, including pharmacists, it states.
Another method to improve vaccination would be to offer the flu shot at the same time as Canadians receive other shots.
Clinics and pharmacies should be explicitly telling patients that are coming in for a vaccine that they can receive multiple vaccinations at once, including the flu shot, COVID-19 vaccines and the pneumococcal vaccine, said Sinha.
A targeted public information and flu vaccination campaign is urgently needed, especially ahead of the holiday season when more people will gather, he explained.
“I haven’t really seen that clear level of messaging,” he said. He gave an example where he had a patient who is 100-years old and only received a COVID-19 booster shot recently, when the clinic should have given her a flu shot at the same time.
For older people, it’s difficult to arrange travel and assist them to a health care provider, so creating a situation where they have to make repeat trips is not ideal, he said.
Travelling to get the shot, especially during the colder months, was reported as an inconvenience for Canadians, particularly for older adults.
The Institute also states other issues preventing older adults specifically from being protected, is patchwork coverage of the enhanced flu vaccine.
Quebec, Newfoundland and Labrador, Nova Scotia, the Northwest Territories and Nunavut only offer the standard flu vaccine for older adults, unless they live in specific care settings like long-term care.
“Providing enhanced influenza vaccines free of cost to all older Canadians will remove financial barriers to accessing these vaccines and likely promote better uptake,” the report researchers state.
There’s also concern around making vaccines more widely available when older adults interact with the health care system. Those include pharmacies, primary care providers, and targeted vaccination clinics for homebound adults, the report states.
Older adults report issues of being homebound and having various disabilities along with lack of support to help them reach clinics for vaccinations. The Institute reports there are an estimated 100,000 adults in Canada who are homebound.
“For example, many local health units created in-home vaccination programs for COVID-19, which means they now have more detailed data on homebound older adults,” said Dr. Samir Sinha, the Institute's director of health policy research in a press release. “There is a huge opportunity to leverage this information to deliver more influenza vaccines to protect this vulnerable population.”
Finally, culturally inclusive strategies would help increase flu vaccination rates, the researchers explain.
Studies show there are “various types of barriers to immunization among newcomer immigrants, including vaccine hesitancy, cultural factors and knowledge barriers,” the researchers state.
Culturally inclusive resources, which include bilingual information on the flu vaccine and diverse providers who understand cultural nuances, would make a difference, the report states.
While governments have created multiple resources for multilingual COVID-19 resources, the same efforts have not happened for the flu in jurisdictions across the country, it states.
With COVID-19, specific communities were targeted for vaccination, especially groups that have historic mistrust of the health-care system due to mistreatment, said Sinha. This includes Black people and Indigenous people, said Sinha.
But that kind of awareness and education campaign is not occurring at the same level when it comes to the flu shot, he said.
“Again, another lost opportunity to make sure people feel fully confident in these vaccine options that are available to them,” he said.
Health-care providers have been “terrified” by multiple viruses circulating, and simple public health measures and information will keep people out of hospital by getting them vaccinated, he said.
“Just in the same way we rallied around COVID-19, if we had a concerted effort, we probably wouldn’t see the pressure we’re anticipating we’re going to see from influenza overall,” he said.
In the case of RSV, a vaccine isn’t available yet. But behind COVID-19, the flu is the second most-preventable cause of death in Canada, he said.
“Within a few weeks we’re going to have more Christmas get-togethers, Hanukkah get-togethers, it’s the perfect time for people to get boosted and get influenza vaccines,” he said.
The NIA’s national survey was conducted online with 1,503 Canadians aged 18 years and older using the Leger LEO Panel between Aug. 2-12, 2022. The findings have a margin of error of +/- 2.53 per cent, 19 times out of 20. More detailed information on methodology can be found in the report.
Matt Birnholz, MDPeer