The Effect of Influenza Vaccination for the Elderly on Hospitalization and Mortality: An Observational Study With a Regression Discontinuity Design

Ann Intern Med. 2020 Apr 7;172(7):445-452. doi: 10.7326/M19-3075. Epub 2020 Mar 3.


Background: Observational studies using traditional research designs suggest that influenza vaccination reduces hospitalizations and mortality among elderly persons. Accordingly, health authorities in some countries prioritize vaccination of this population. Nevertheless, questions remain about this policy's effectiveness given the potential for bias and confounding in observational data.

Objective: To determine the effectiveness of the influenza vaccine in reducing hospitalizations and mortality among elderly persons by using an observational research design that reduces the possibility of bias and confounding.

Design: A regression discontinuity design was applied to the sharp change in vaccination rate at age 65 years that resulted from an age-based vaccination policy in the United Kingdom. In this design, comparisons were limited to individuals who were near the age-65 threshold and were thus plausibly similar along most dimensions except vaccination rate.

Setting: England and Wales.

Participants: Adults aged 55 to 75 years residing in the study area during 2000 to 2014.

Intervention: Seasonal influenza vaccine.

Measurements: Hospitalization and mortality rates by month of age.

Results: The data included 170 million episodes of care and 7.6 million deaths. Turning 65 was associated with a statistically and clinically significant increase in rate of seasonal influenza vaccination. However, no evidence indicated that vaccination reduced hospitalizations or mortality among elderly persons. The estimates were precise enough to rule out results from many previous studies.

Limitation: The study relied on observational data, and its focus was limited to individuals near age 65 years.

Conclusion: Current vaccination strategies prioritizing elderly persons may be less effective than believed at reducing serious morbidity and mortality in this population, which suggests that supplementary strategies may be necessary.

Primary funding source: National Institute on Aging.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Female
  • Hospitalization / statistics & numerical data*
  • Humans
  • Influenza Vaccines / administration & dosage*
  • Influenza, Human / epidemiology
  • Influenza, Human / mortality*
  • Influenza, Human / prevention & control*
  • Male
  • Middle Aged
  • Mortality / trends*
  • United Kingdom / epidemiology


  • Influenza Vaccines