Eligibility Without Equity: Rethinking Age-Based Adult Vaccine Policies

Embedding equity into vaccine eligibility is essential for reducing health inequalities. Yet, adult vaccine eligibility in most European countries is primarily based on fixed age thresholds, prioritising cost-effectiveness. This approach risks excluding the most vulnerable populations living in deprived communities with poorer health and shorter survival into older age. Extending eligibility based on clinical risk partially addresses this gap. Higher rates of underdiagnosis and delayed diagnosis in deprived populations limit the fairness of this approach, however, with the status quo of adult vaccine eligibility criteria likely doing active harm. In this perspective, we demonstrate the extent of this inequity in England. For example, the average male living in Hyde Park in the northern city of Leeds dies 9.5 years too early to ever receive the RSV vaccine offer at age 75. Meanwhile, a male living in Hyde Park, London, lives much longer and may receive the benefits of the RSV vaccine for 10 years or more. Drawing on lessons from the COVID-19 pandemic, we propose further evaluation of alternative eligibility models that incorporate local place-based disadvantage, which will inherently account for life expectancy and deprivation levels. These models will ensure earlier access to vaccines for communities with the greatest need and improve health equity without overwhelming health systems.