Extending the elderly- and risk-group programme of vaccination against seasonal influenza in England and Wales: a cost-effectiveness study

Abstract

Background: The present study aims to evaluate the cost-effectiveness of extending the pre-2013 influenza immunisation programme for high-risk and elderly individuals to those at low risk of developing complications following infection with seasonal influenza.

Methods: We performed an economic evaluation comparing different extensions of the pre-2013 influenza programme to seven possible age groups of low-risk individuals (aged 2-4 years, 50-64 years, 5-16 years, 2-4 and 50-64 years, 2-16 years, 2-16 and 50-64 years, and 2-64 years). These extensions are evaluated incrementally on four base scenarios (no vaccination, risk group only with coverage as observed between 1995 and 2009, risk group and 65+, and risk group with 75% coverage and 65+). Impact of vaccination is assessed using a transmission model built and parameterised from a previously published study. The study population is all individuals of all ages in England and Wales representing an average total of 52.6 million people over 14 influenza seasons (1995-2009).

Results: The influenza programme (risk group and elderly) prior to 2013 is likely to be cost effective (incremental cost effectiveness ratio: 7,475 £/QALY, net benefit: 253 M£ [15-829]). Extension to any one of the low-risk target groups defined earlier is likely to be cost-effective. However, strategies that do not include vaccination of school-aged children are less likely to be cost-effective. The most efficient strategy is extension to the 5-16 year age group while universal vaccination (extension to all low-risk individuals over 2 years) will achieve the highest net benefit. While extension to the 2-16 year age group is likely to be very cost effective, the cost-effectiveness of extensions beyond 2-16 years is very uncertain. Extension to the 5-16 year age group would likely remain cost-effective even without herd immunity effects to other age groups. As our study includes a strong historical component, our results depend on the efficacy of the influenza vaccine remaining at levels similar to the ones achieved in the past over a long-period of time (assumed to vary between 28% and 70% depending of the circulating strains and age groups).

Conclusions: Making use of surveillance data from over a decade in conjunction with a dynamic model, we find that vaccination of children in the United Kingdom is likely to be highly cost-effective, not only for their own benefit but also to reduce the disease burden in the rest of the community.

Fig. 1

Incremental analysis with costs and quality-adjusted life years (QALYs) gained. Estimated change in costs and QALYs gained over the elderly- and risk-group strategy, for each of the extensions to the vaccination programme. Note that the comparison in each case is with the elderly- and risk-group strategy. Each contour line represents 90 % of the Monte Carlo simulations with the coloured point inside being the mean outcome of the scenario. The two diagonal lines represent £20,000 (solid) and £30,000 per QALY gained. Unfilled circles indicate strategies which are dominated by others. The arrows indicate the pathway of increasing costs for the incremental analysis

Fig. 2

Incremental net benefit over the elderly- and risk-group programme. Incremental net benefit of different extension over the elderly- and risk-group programme for different levels of coverage (left panel) and net benefit for the base case at 50 % coverage (right panel). Dominated scenario are indicated by empty disk and bars

Fig. 3

Benefits from extension to low-risk 2–16-year-old children. Benefits (in terms of non-death and death-associated Quality-Adjusted Life Days per year and per person of that age and risk group) gained from extension of vaccination to low-risk 2–16-year-old children. The benefit is given for each age and risk group (pink bars low risk, blue bars high risk). Note the change of scale in the last panel