Universal influenza vaccination: the time to act is now

Annual influenza epidemics create a significant public health burden each year in the United States. That influenza continues to pose a public health threat despite being largely preventable through vaccination is indicative of continuing weaknesses in the U.S.'s public health system. Moreover, the burden of annual influenza epidemics and the fragility and instability of the capacity to respond to them underscore the U.S.'s ongoing vulnerability to pandemic influenza and highlights gaps in bioterrorism preparedness and response efforts. This article examines the burden of annual influenza epidemics in the U.S., efforts to combat that burden with vaccination, shortcomings of influenza vaccination efforts, and how those shortcomings exemplify weaknesses in pandemic influenza and bioterrorism preparedness efforts. We make the case for establishing an annual universal influenza vaccination program to assure access to influenza vaccination to anyone who can safely receive vaccination and desires it. Such a program could greatly reduce the annual burden of influenza while advancing and maintaining U.S. pandemic influenza and bioterrorism preparedness and response efforts.

Modelling the health-economic impact of the next influenza pandemic in The Netherlands

To optimally develop or adjust national contingency plans to respond to the next influenza pandemic, we developed a decision type model and estimated the total health burden and direct medical costs during the next possible influenza pandemic in the Netherlands on the basis of health care burden during a regular epidemic. Using an arithmetic decision tree-type model we took into account population characteristics, varying influenza attack rates, health care consumption according to the Dutch health care model and all-cause mortality. Actual direct medical cost estimates were based on the Dutch guidelines for pharmaco-economic evaluation. In the base-case scenario with no preventive measure available and an average influenza attack rate of 30%, 4,958,188 influenza infections, 1,552,687 GP consultations, 83,515 hospitalizations and 173,396 deaths will take place in The Netherlands. The burden is highest in adults aged 20 to 64 years. If minimizing the total mortality and sustaining highest net economic returns is the objective, this group needs to be targeted in interventions.

Effectiveness of virosomal subunit influenza vaccine in preventing influenza-related illnesses and its social and economic consequences in children aged 3–14 years: A prospective cohort study

To evaluate the effectiveness of a virosomal subunit influenza vaccine in preventing influenza-related illnesses and its social and economic consequences in children aged 3-14 years, a prospective cohort study was carried out during the 2004-2005 influenza season in 11 private pediatric clinics in the Barcelona metropolitan area. One dose of a virosomal subunit inactivated influenza vaccine (Inflexal V Berna) was given during September and October 2004 to healthy children aged 3-14 years attended in 5 of the 11 clinics. Who comprised the vaccinated cohort (n=966). The non-vaccinated cohort (n=985) was comprised of children attended in the other six clinics. Informed consent was obtained from all parents. The follow up was performed between 1 November 2004 and 31 March 2005. Using a self-administered questionnaire, information was collected from parents or guardians on any type of acute, febrile respiratory illness suffered by their children during the study period, including antibiotic use, and absence from school or work-loss of parents as a result of the illness. RT-PCR (influenza A+B+C) was carried out on pharyngeal and nasal samples obtained from children attended by pediatricians during this period in these clinics with the following symptoms: fever> or =38.5 degrees lasting at least 72h, cough or sore throat (influenza-like illness). Adjusted vaccination effectiveness was 58.6% (95% CI 49.2-66.3) in preventing acute febrile respiratory illnesses, 75.1% (95% CI 61.0-84.1) in preventing cases of influenza-like illnesses and 88.4% (95% CI 49.2-97.3) in preventing laboratory-confirmed cases of influenza A. The adjusted vaccination effectiveness in reducing antibiotic use (18.6%, 95% CI -4.2 to 3.64), absence from school (57.8%, 95% CI 47.9-65.9) and work-loss of parents (33.3%, 95% CI 8.9-51.2) in children affected by an acute febrile respiratory illness was somewhat lower. Vaccination of children aged 3-14 years in pediatric practices with one dose of virosomal subunit inactivated influenza vaccine has the potential to considerably reduce the health and social burdens caused by influenza-related illnesses.

Does pneumococcal vaccine reduce influenza morbidity in humans?

A retrospective study was conducted to verify the possibility that people immunized with pneumococcal vaccine (PV) show lower morbidity not only for pneumonia but also for influenza. A total of 450 individuals were enrolled between 1999 and 2003 and allocated to one of the following groups: (A) not vaccinated; (B) immunized with PV during 1999; (C) immunized with anti-influenza vaccine (Flu-V) each year; and (D) immunized with PV once in 1999 and Flu-V every consecutive year. People from group B showed significantly lower percentage of influenza-related diseases during the year 2000 in comparison with those from group A (p<0.01), whereas in the course of 2001 the morbidity of patients from group B was lower compared with the other groups (p<0.01). The results point to a way to decrease the morbidity of influenza-related diseases by immunization with PV only, at least for 2-3 years, avoiding Flu-V administration and permitting considerable saving for health care providers. Therefore, it is concluded that PV can reduce the morbidity of influenza at a greater rate than the Flu-V.

Influenza vaccination: the paediatric perspective

Influenza in young children represents a significant problem to families and to society, as this population is most susceptible to developing complications and is also a major route of disease spread within communities. However, there is a paucity of European data for the burden of disease in children and the health benefits and cost-effectiveness of vaccination, leading to a lack of awareness by governments, authorities, healthcare professionals and parents. The experience in elderly individuals and the paediatric experience in the US may provide some guidance in developing studies that will provide evidence for the creation of guidelines and educational strategies within Europe.

Health benefits, risks, and cost-effectiveness of influenza vaccination of children

We estimated cost-effectiveness of annually vaccinating children not at high risk with inactivated influenza vaccine (IIV) to range from US $12,000 per quality-adjusted life year (QALY) saved for children ages 6-23 months to $119,000 per QALY saved for children ages 12-17 years. For children at high risk (preexisting medical conditions) ages 6-35 months, vaccination with IIV was cost saving. For children at high risk ages 3-17 years, vaccination cost $1,000-$10,000 per QALY. Among children notat high risk ages 5-17 years, live, attenuated influenza vaccine had a similar cost-effectiveness as IIV. Risk status was more important than age in determining the economic effects of annual vaccination, and vaccination was less cost-effective as the child's age increased. Thus, routine vaccination of all children is likely less cost-effective than vaccination of all children ages 6-23 months plus all other children at high risk.

The effects of socioeconomic factors on the decision to be vaccinated: the case of flu shot vaccination

BACKGROUND

Anti-influenza vaccination has proven cost-effective for society. In Israel, however, vaccination rates remain relatively low in comparison to other countries.

OBJECTIVES

To analyze the socioeconomic and health status factors affecting the decision to be vaccinated against flu and to compare these factors to results from other countries in order to determine which segments of the adult population should be targeted for increased coverage in influenza vaccination programs.

METHODS

Our source was the 1999/2000 Health Survey of the Central Bureau of Statistics for the group aged 25 and above, comprising 16,033 individuals. We used statistical methods such as the Probit regression model to estimate the effects of socioeconomic and health status variables on the decision to get a flu shot. The variables included gender, age, marital status, education, ethnic origin, religious affiliation and housing density, as well as chronic illnesses, smoking, hospitalizations, membership in health management organizations and kibbutz membership.

RESULTS

Our findings indicate that being a post-1990 immigrant from the former Soviet Union, living in a densely populated house, being unmarried and smoking heavily are important factors in predicting the decision not to be vaccinated. In contrast, chronic illness, previous hospitalizations, older age, and kibbutz membership positively affected the decision to take the vaccine.

CONCLUSIONS

It is necessary to identify the socioeconomic and health variables marking population sectors that are less likely to be vaccinated in order to design a suitable policy to encourage vaccination.

The health care response to pandemic influenza

The threat of an H5N1 influenza virus (avian flu) pandemic is substantial. The success of the current U.S. influenza pandemic response plan depends on effective coordination among state and local public health authorities and individual health care providers. This article is a summary of a public policy paper developed by the American College of Physicians to address issues in the U.S. Department of Health and Human Services Pandemic Influenza Plan that involve physicians. The College's positions call for the following: 1) development of local public health task forces that include physicians representing all specialties and practice settings; 2) physician access to 2-way communication with public health authorities and to information technology tools for diagnosis and syndrome surveillance; 3) clear identification and authorization of agencies to process licensing and registration of volunteer physicians; 4) clear guidelines for overriding standard procedures for confidentiality and consent in the interest of the public's health; 5) clear and fair infection control measures that do not create barriers to care; 6) analysis of and solutions to current problems with seasonal influenza vaccination programs as a way of developing a maximally efficient pandemic flu vaccine program; 7) federal funding to provide pandemic flu vaccine for the entire U.S. population and antiviral drugs for 25% of the population; and 8) planning for health care in alternative, nonhospital settings to prevent a surge in demand for hospital care that exceeds supply. *This paper is an abridged version of a full-text position paper (available at http://www.acponline.org/college/pressroom/as06/pandemic_policy.pdf) written by Laura Barnitz, BJ, MA, and updated and adapted for publication in Annals of Internal Medicine by Michael Berkwits, MD, MSCE. The original position paper was developed for the Health and Public Policy Committee of the American College of Physicians: Jeffrey P. Harris, MD (Chair); David L. Bronson, MD (Vice Chair); CPT Julie Ake, MD; Patricia P. Barry, MD; Molly Cooke, MD; Herbert S. Diamond, MD; Joel S. Levine, MD; Mark E. Mayer, MD; Thomas McGinn, MD; Robert M. McLean, MD; Ashley E. Starkweather; and Frederick E. Turton, MD. It was approved by the Board of Regents on 3 April 2006.

Cost-effectiveness of universal influenza vaccination in a pregnant population

OBJECTIVE

The purpose of this study was to estimate whether universal influenza vaccination of pregnant women was cost-effective in the management of influenza-like illness during influenza season.

METHODS

A decision analysis model was developed to investigate the cost-effectiveness of providing inactivated trivalent influenza vaccine to all pregnant women. This scenario was compared with providing supportive care only on a case-by-case basis to the unvaccinated pregnant population.

RESULTS

Vaccination of 100% of pregnant women would save approximately 50 dollars per woman, resulting in a net gain of approximately 45 quality-adjusted hours relative to providing supportive care only.

CONCLUSION

Universal vaccination with inactivated trivalent influenza vaccine is cost-saving relative to providing supportive care alone in the pregnant population.

LEVEL OF EVIDENCE

III.

Influenza vaccination health impact and cost effectiveness among adults aged 50 to 64 and 65 and older

BACKGROUND

Influenza causes approximately 36,000 deaths per year in the United States despite the presence of an effective vaccine. This assessment of the value of influenza vaccination to the U.S. population is part of an update to the 2001 ranking of clinical preventive services recommended by the U.S. Preventive Services Task Force. The forthcoming ranking will include the new recommendation of the Advisory Committee on Immunization Practices to extend influenza vaccination to adults aged 50 to 64 years.

METHODS

This service is evaluated on the two most important dimensions: burden of disease prevented and cost effectiveness. Study methods, described in a companion article, are designed to ensure consistency across many services.

RESULTS

Over the lifetime of a birth cohort of 4 million, it is estimated that about 275,000 quality-adjusted life years (QALYs) would be saved if influenza vaccination were offered annually to all people after age 50. Eighty percent of the QALYs saved (220,000) would be achieved by offering the vaccine only to persons aged 65 and older. In year 2000 dollars, the cost effectiveness of influenza vaccination is $980 per QALY saved in persons aged 65 and older, and $28,000 per QALY saved in persons aged 50 to 64. When the costs of patient time and travel are excluded, the cost effectiveness ratio of vaccinating 50- to 64-year-olds decreases to $7200 per QALY saved, and vaccinating those aged 65 and older saves $17 per person vaccinated.

CONCLUSIONS

Influenza vaccination is a high-impact, cost-effective service for persons aged 65 and older. Vaccinations are also cost effective for persons aged 50 to 64.

Vacuna anti-influenza en niños: Estado del arte

Influenza is an acute respiratory illness that year to year causes considerable morbidity and mortality. . All children, healthy or at high risk, are susceptible to this infection. Influenza vaccine seems to be effective in preventing influenza-like illness, laboratory-confirmed infection, and hospitalizations and deaths, demonstrating cost-effectiveness. Inactivated and live-attenuated vaccines have a similar efficacy profile. . Due to high influenza associated hospitalization rates in children, some countries have recommended incorporating influenza vaccination into the universal immunization program for healthy infants between 6-24 months of age. Considering that this public-health policy has been incorporated in Chile, local studies assessing its impact are needed.

Análisis de un modelo económico de una estrategia poblacional de vacunación gripal en trabajadores sanos

BACKGROUND

A debate exists as to whether it is advisable to extend the influenza immunization programs to the entire population, possibly due to the economic impact of this measure. This study is aimed at analyzing the cost-benefit ratio of an influenza immunization strategy among our country's working population.

METHODS

Economic study from a social standpoint, including the direct and indirect costs (lost productive time, adverse effects) of the immunization. The costs avoided include the loss of productivity (from the human capital standpoint) and the health costs avoided when the infection is prevented. A costs avoided/costs incurred ratio, known as the Return Rate (RR) is constructed. The costs are converted into constant 2003 Euros. The data was compiled from published sources and a sensitivity analysis presented.

RESULTS

The average cost of each immunization is 13.58 (95% CI 13.54-13.62) Euros. Each case of influenza avoided saves an average expense of 374.71 (95% CI 372.59-376.83) Euros. Every 1000 immunizations would avoid an average of 29.3 influenza cases (95% CI 29.0-29.5). The net cost of immunization is 2.60 (95% CI 2.51-2.70) euros. The RR has an average value of 0.80 (95% CI 0.79-0.81), median 0.74, interquartile range (0.53-1.02) Euros. In the case of avoiding more than 36 cases of influenza per 1000 immunizations, the RR takes on values >1.

CONCLUSIONS

The influenza immunization strategy for the working population is solely cost-effective for situations of high influence incidence and high vaccine effectiveness.

The business of making vaccines

With a growing need for better and more plentiful vaccines, traditional vaccine companies are responding by increasing manufacturing capacity, the biotech industry, with innovative products. Both are surely needed.

Cost-effectiveness of influenza vaccination of healthy children

Influenza vaccination of children 6-23 months of age is recommended in the United States and Canada because of high rates of influenza-associated hospitalisations, but few other countries have adopted similar policies. Most children with influenza are treated in the primary care setting, and the cost-effectiveness of influenza vaccination of children has not been fully established. We used a decision analysis model to assess the cost-effectiveness of influenza vaccination of children 6 months to 13 years of age in Finland. The analyses were based on comprehensive clinical data on virologically confirmed influenza infections, hospital medical records, and national registers. We estimated the impact of influenza on outpatient and hospitalised children and their families, and performed the analyses from the health care provider and societal perspective. Influenza vaccination resulted in savings in all programs including children <or=13 years of age from both the health care provider and societal perspective. Investing 1.7 million euros in vaccination of children <5 years of age yielded savings of 2.7 million euros in health care costs. From the health care provider perspective, the savings per vaccinated child ranged between 5.7 and 12.6 euros in any program including children up to 13 years of age. The vaccination was cost saving in all age groups even with assumed vaccine efficacy of 60%. The results show that influenza vaccination would be cost saving in all children <or=13 years of age in Finland, which advocates reconsideration of the current influenza vaccine recommendations in all countries.

Could a federal program to promote influenza vaccination among elders be cost-effective?

BACKGROUND

Influenza-related mortality predominately and disproportionately impacts the elderly. Rates of annual influenza vaccination among the elderly are approximately 65%, far below the Healthy People 2010 target of 90%. We estimated the cost-effectiveness of a 10-year federal program to promote influenza vaccine, intended to increase vaccination rates among persons > or = 65 years old.

METHODS

Published estimates regarding influenza-associated mortality rates and vaccine efficacy among the US elderly were used to calculate the number needed to vaccinate (NNV) to prevent one all-cause death due to influenza, as well as the mortality reduction expected from increased vaccination rates. The costs per life-year saved were estimated for a hypothetical federal promotional campaign, patterned after a direct-to-consumer (DTC) advertising program (2006-2015). The base case scenario presumed a 25-percentage-point increase in vaccination rates to 90%; in sensitivity analyses, we examined programs that increased rates by 10-20 points.

RESULTS

The base case NNV was 1116 (95% CI: 993-1348). Over the 10-year DTC-style influenza vaccine promotion program, 6516 (5576-7435) elderly lives would be saved. The incremental cost-effectiveness (C/E) of the program was dollar 16,300 (dollar 11,347-dollar 25,174) per life-year saved in 2006 and increased to dollar 199,906 (dollar 138,613-dollar 307,423) per life-year saved by 2015. Overall, the C/E for the 10-year program was dollar 37,621 (dollar 32,644-dollar 43,939) per life-year saved. Programs that yielded a 15-percentage-point increase or less in vaccination rates would have C/E values exceeding dollar 50,000 per life-year saved and save fewer than 4000 total lives.

CONCLUSIONS

DTC-style promotional campaigns for influenza vaccine among elders may represent a cost-effective strategy for the federal government to pursue as a means of increasing elders' vaccination rates and reducing influenza-related mortality.

Evaluación de la eficiencia de la vacunación antigripal en la población laboral española

INTRODUCTION

Influenza is a major cause of morbidity and mortality worldwide. Currently, licensed influenza vaccines are safe and effective. Any intervention aimed at reducing the burden of illness is worth analyzing from a clinical and economic perspective.

OBJECTIVE

To assess the costs and benefits of an influenza vaccination program in the Spanish working population.

METHODS

A theoretical model of costs and benefits in terms of productivity savings was developed to compare 2 strategies (vaccination and non-vaccination) in 2 cohorts of 1,000 workers each. The time horizon was 1 year and the study's perspective was societal.

MAIN OUTCOME MEASURES

epidemiological and clinical data on the incidence of influenza and the effectiveness of the vaccine. Data on the use of direct and indirect resources were obtained from an expert panel of 5 experts in preventive medicine, microbiology, occupational health, and health economics. Unit costs (euros 2003) were extracted from local databases. A sensitivity analysis was performed with the data on incidence, effectiveness, and work absenteeism due to influenza.

RESULTS

In the base case scenario, influenza vaccine saved 35 Euros per worker, of which 88% were savings in work loss days avoided. Threshold values in the sensitivity analysis were 6% for the incidence of influenza and 1.5 days for absence from work, above which the vaccine leads to net savings.

CONCLUSIONS

Influenza vaccination in the Spanish working population might result in net resource savings to society at large.