Use of High-Dose Influenza and Live Attenuated Influenza Vaccines by US Primary Care Physicians



Several different types of influenza vaccine are licensed for use in adults in the USA including high-dose inactivated influenza vaccine (HD-IIV) and live attenuated influenza vaccine (LAIV). HD-IIV is licensed for use in adults ≥ 65 years, and recommendations for use of LAIV have changed several times in recent years.


We sought to examine family physicians’ (FPs) and general internal medicine physicians’ (GIMs) perceptions, knowledge, and practices for use of HD-IIV and LAIV during the 2016–2017 and 2018–2019 influenza seasons.


E-mail and mail surveys conducted February–March 2017, January–February 2019.


Nationally representative samples of FPs and GIMs.

Main Measures

Surveys assessed HD-IIV practices (2017), knowledge and perceptions (2019), and LAIV knowledge and practices (2017, 2019).

Key Results

Response rates were 67% (620/930) in 2017 and 69% (642/926) in 2019. Many physicians believed HD-IIV is more effective than standard dose IIV in patients ≥ 65 years (76%) and reported their patients ≥ 65 years believe they need HD-IIV (67%). Most respondents incorrectly thought ACIP preferentially recommends HD-IIV for adults ≥ 65 years (88%); 65% “almost always/always” recommended HD-IIV for adults ≥ 65 years. Some physicians incorrectly thought ACIP preferentially recommends HD-IIV for adults < 65 years with cardiopulmonary disease (38%) or immunosuppression (48%); some respondents recommended HD-IIV for these groups (25% and 28% respectively). In 2017, 88% of respondents knew that ACIP recommended against using LAIV during the 2016–2017 influenza season, and 4% recommended LAIV to patients. In 2019, 63% knew that ACIP recommended that LAIV could be used during the 2018–2019 influenza season, and 8% recommended LAIV.


Many physicians incorrectly thought ACIP had preferential recommendations for HD-IIV. Physicians should be encouraged to use any available age-appropriate influenza vaccine to optimize influenza vaccination particularly among older adults and patients with chronic conditions who are more vulnerable to severe influenza disease.

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Figure. 1



American Academy of Family Physicians


(Advisory Committee on Immunization Practices


American College of Physicians


Centers for Disease Control and Prevention


Family physician


Food and Drug Administration


General internal medicine physician


High-dose inactivated influenza vaccine


Health maintenance organization


Inactivated influenza vaccine


Live attenuated influenza vaccine


United States


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The authors would like to thank Bellinda Schoof, MHA, at the AAFP, Arlene Weissman, PhD, and Linda Harris from the ACP, and the leaders of the AAFP and ACP for collaborating in the establishment of the sentinel networks in family medicine and general internal medicine. The authors would like to thank Erin Burns, Alicia Fry, and Mark Thompson from the Centers for Disease Control and Prevention for assistance developing the survey questions. We would also like to thank all general internists and family medicine physicians in the networks for participating and responding to this survey.


This publication was supported by Cooperative Agreement Number 1 U01 IP000849-03, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the U.S. Department of Health and Human Services.

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Correspondence to Jessica R. Cataldi MD, MSCS.

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Cataldi, J.R., Hurley, L.P., Lindley, M.C. et al. Use of High-Dose Influenza and Live Attenuated Influenza Vaccines by US Primary Care Physicians. J GEN INTERN MED (2021).

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  • influenza vaccine
  • immunization
  • vaccination
  • influenza