In the UK, annual influenza immunisation is advised for everyone aged 65 years and over. Immunisation can reduce the incidence of infection and has been shown to reduce morbidity and mortality in both institutionalised and non-institutionalised older people. Dr Steve Allsup explores the pharmacoeconomic evidence base to determine whether vaccinating all people over 65 years represents a cost effective strategy.
First published September 2006, updated July 2021
- Influenza vaccination is a highly cost effective strategy in helping to reduce the economic consequences of influenza-associated morbidity and mortality in people aged over 65 years.
- Vaccination is most cost effective and even cost saving in the highest risk groups.
- Increasing vaccine uptake in the targeted groups will help to prepare for the next influenza pandemic.
- To reduce transmission of influenza to frail older patients initiatives need to be in place to encourage vaccine uptake amongst healthcare workers.
Influenza is a highly contagious acute respiratory disease that typically presents with a sudden onset of fever accompanied by a headache, sore throat, malaise and dry cough. In young healthy adults, the illness is usually self-limiting with the fever lasting between one and five days1. However, in older people and those with chronic disease, influenza can be a serious illness and the resulting morbidity and mortality is often underestimated. For example, during the last influenza epidemic to affect England and Wales (1989-90), it was estimated that 24,877 excess deaths occurred; 82 per cent of these were in individuals aged 75 years or older while only three per cent were in people aged less than 65 years2. Institutional care, chronic obstructive pulmonary disease, asthma and neurological disease were all identified as independent risk factors for certified influenza death during this period3.
Influenza immunisation, using inactivated trivalent preparations containing antigens from two influenza A strains and one B strain is the cornerstone of current influenza prevention policy. Some studies have shown that immunisation can reduce mortality from influenza and pneumonia in both institutionalised and non-institutionalised older people, and may halve the incidence of influenza infection3-8. Because of ethical concerns about the use of a placebo in frail older people, many of these studies were non-randomised and likely to have been affected by selection bias. The uptake of influenza vaccine is affected by many factors including age, gender, health and socio-economic status, concern about adverse effects and prior utilisation of healthcare resources. A recent systematic review concluded that vaccination was most effective in people aged 65 years or older living in long-term care facilities, but it had only a modest effect on those living in the community9.
A cost benefit analysis usually translates health gains into pure monetary terms. Costs are weighted against the benefits and the outcome may be expressed by the benefit-to-cost ratio, where a value of greater than one indicates net cost savings. When the ratio is less than one, further quantification of health gains are needed using either a cost effectiveness or cost utility analysis.
A cost effectiveness analysis expresses net costs (costs minus benefits) in terms of health gains such as the number of infections avoided. A cost utility analysis takes into consideration the patient’s quality of life as well as number of life years gained from the intervention, and the quality adjusted life year (QALY) is used as an outcome measure. However, the practical problems of to be either ineffective or capable of causing significant side effects. Consequently, vaccine uptake in older people was typically poor, although this is now changing.
Intense efforts by doctors and policy makers to raise the profile of influenza – and recent media reports about the threat of a future pandemic from avian (H5N1) influenza – will no doubt help to increase the annual uptake of influenza vaccine still further. It is likely that in the future, age recommendations for influenza vaccination will fall and different groups will be targeted (e.g., children and healthy working adults) as further pharmacoeconomic data becomes available. Greater vaccine uptake will then help to ensure that increased capacity and large-scale production of vaccine is possible in a pandemic situation when demand will be high. Future work should focus on initiatives to improve vaccine uptake in healthcare workers, which has remained low in many countries18. Vaccinating healthcare workers can reduce staff sickness during times of ‘winter pressure’ as well as reduce the transmission of infl uenza to frail older patients, which may help to reduce mortality19.
- Cox NJ, Subbarao K. Influenza. Lancet 1999; 354:1277-82
- Curwen M, Dunnell K, Ashley J. Hidden influenza deaths 1989/90. Popul Trends 1990; 61:31-3
- Ahmed AE, Nicholson KG, Nguyen-Van-Tam JS. Reduction in mortality associated with influenza vaccine during 1989-90 epidemic. Lancet 1995;346:591-5
- Patriarca PA, Weber JA, Parker RA, et al. Efficacy of influenza vaccine in nursing homes. JAMA 1985; 253:1136-39
- Gross PA, Hermogenes AW, Sacks HS, et al. The efficacy of influenza vaccine in elderly persons – a meta analysis and review of the literature. Ann Intern Med Ann Intern Med 1995;123:518-27
- Nichol KL, Wuorenma J, von Sternberg T. Benefits of influenza vaccination for low-, intermediate-, and high-risk senior citizens. Arch Intern Med Arch Intern Med 1998;158:1769-76
- Monto AS, Hornbuckle K, Ohmit SE. Influenza vaccine effectiveness among elderly nursing home residents: a cohort study. Am J Epidemiol 2001; 154:155-60
- Govaert TM, Thijs CT, Masurel N, et al. The efficacy of influenza vaccination in elderly individuals. A randomised double-blind placebo-controlled trial. JAMA 1994; 272:1661-5
- Jefferson T, Rivetti D, Rivetti A, et al. Efficacy and effectiveness of influenza vaccines in elderly people: a systematic review. Lancet 2005; 366:1165-74
- Van Damme P and Beutels P. Economic evaluation of vaccination. Pharmacoeconomics 1996;9 Suppl 3:8-15
- Patriarca PA, Arden NH, Koplan JP, Goodman RA. Prevention and control of type A influenza infections in nursing homes. Benefits and costs of four approaches using vaccination and amantadine. Ann Intern Med Ann Intern Med 1987;107:732- 40
- Mullooly JP, Bennett MD, Hornbrook MC, et al. Influenza vaccination programs for elderly persons: cost effectiveness in a health maintenance organisation. Ann Intern Med 1994; 121:947-52.
- Hak E, van Essen GA, Buskens E, et al. Is immunising all patients with chronic lung disease in the community against influenza cost effective? Evidence from a general practice based clinical prospective cohort study in Utrecht, the Netherlands. J Epidemiol Community Health 1998; 52:120-5
- Postma MJ, Baltussen RM, Heijnen ML, et al. Pharmacoeconomics of influenza vaccination in the elderly: reviewing the available evidence. Drugs Aging 2000; 17:217-27
- Wongsurakiat P, Lertakyamanee J, Maranetra KN, et al. Economic evaluation of influenza vaccination in Thai chronic obstructive pulmonary disease patients. J Med Assoc Thai 2003; 86:497-508
- Scott WG, Scott HM. Economic evaluation of vaccination against infl uenza in New Zealand. Pharmacoeconomics 1996; 9:51-60
- Allsup S, Haycox A, Regan M, Gosney M. Is influenza vaccination cost effective for healthy people between ages 65 and 74 years? A randomised controlled trial. Vaccine 2004; 23:639-45
- Canning HS, Phillips J, Allsup S. Health care worker beliefs about influenza vaccine and reasons for non-vaccination – a cross sectional survey. J Clin Nurs 2005; 14:922-5
- Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 2000; 355:93-7