Optimal vaccination in aging populations under age-dependent infection fatality risks

Background Vaccination programs have greatly reduced the burden of infectious diseases, particularly in childhood. As populations age, however, the burden of respiratory infections such as influenza A, respiratory syncytial virus (RSV), and SARS-CoV-2 increasingly falls on older adults. Because infection fatality rates rise steeply with age, vaccination strategies that alter the age distribution of infections may have complex population-level consequences. We used transmission models to examine how the timing and frequency of vaccination influence infection-induced mortality and years of life lost (YLL) in aging populations. Methods and findings We analyzed age-structured transmission models that incorporate demographic change, age-specific infection fatality rates, and waning immunity after infection or vaccination. We varied the age at first vaccination, vaccination intervals, and coverage across a wide range of pathogen characteristics, including transmissibility and the duration of natural and vaccine-induced immunity. For single-dose vaccination programs with long-lived protection (5-50 years), the age at vaccination minimizing mortality in older adults for pathogens with strongly age-increasing fatality risk typically ranges from 60 to 80 years. The optimal age shifted toward older ages when transmissibility was higher or natural immunity lasted longer. Repeated vaccination produced qualitatively different outcomes. When vaccine-induced immunity was short-lived ($<$5 years), vaccination can shift infections toward the oldest ages where fatality risks are highest, increasing both mortality and YLL compared with no vaccination. This study has limitations. Our analysis used stylized transmission models and assumed vaccines that fully prevent infection, which may overestimate age-shifting effects compared with real-world vaccines that primarily reduce disease severity. Conclusions Optimal adult vaccination strategies depend jointly on pathogen transmissibility, the duration of immunity, and population demography. Vaccination programs that suppress infections earlier in life without protecting individuals into late life may shift infections toward ages with higher fatality risk. These findings highlight the need to evaluate adult vaccination strategies across the full life course and have important implications for vaccination policies against influenza A and other pathogens with strongly age-dependent infection fatality rates.