Socioeconomic impacts of airborne and droplet-borne infectious diseases on industries: a systematic review

BACKGROUND

Recent pandemics have had far-reaching effects on the world's largest economies and amplified the need to estimate the full extent and range of socioeconomic impacts of infectious diseases outbreaks on multi-sectoral industries. This systematic review aims to evaluate the socioeconomic impacts of airborne and droplet-borne infectious diseases outbreaks on industries.

METHODS

A structured, systematic review was performed according to the PRISMA guidelines. Databases of PubMed, Scopus, Web of Science, IDEAS/REPEC, OSHLINE, HSELINE, and NIOSHTIC-2 were reviewed. Study quality appraisal was performed using the Table of Evidence Levels from Cincinnati Children's Hospital Medical Center, Joanna Briggs Institute tools, Mixed Methods Appraisal Tool, and Center of Evidence Based Management case study critical appraisal checklist. Quantitative analysis was not attempted due to the heterogeneity of included studies. A qualitative synthesis of primary studies examining socioeconomic impact of airborne and droplet-borne infectious diseases outbreaks in any industry was performed and a framework based on empirical findings was conceptualized.

RESULTS

A total of 55 studies conducted from 1984 to 2021 were included, reporting on 46,813,038 participants working in multiple industries across the globe. The quality of articles were good. On the whole, direct socioeconomic impacts of Coronavirus Disease 2019, influenza, influenza A (H1N1), Severe Acute Respiratory Syndrome, tuberculosis and norovirus outbreaks include increased morbidity, mortality, and health costs. This had then led to indirect impacts including social impacts such as employment crises and reduced workforce size as well as economic impacts such as demand shock, supply chain disruptions, increased supply and production cost, service and business disruptions, and financial and Gross Domestic Product loss, attributable to productivity losses from illnesses as well as national policy responses to contain the diseases.

CONCLUSIONS

Evidence suggests that airborne and droplet-borne infectious diseases have inflicted severe socioeconomic costs on regional and global industries. Further research is needed to better understand their long-term socioeconomic impacts to support improved industry preparedness and response capacity for outbreaks. Public and private stakeholders at local, national, and international levels must join forces to ensure informed systems and sector-specific cost-sharing strategies for optimal global health and economic security.

Cost-effectiveness of seasonal influenza vaccination of children in China: a modeling analysis

BACKGROUND

China has a high burden of influenza-associated illness among children. We aimed to evaluate the cost-effectiveness of introducing government-funded influenza vaccination to children in China (fully-funded policy) compared with the status quo (self-paid policy).

METHODS

A decision tree model was developed to calculate the economic and health outcomes, from a societal perspective, using national- and provincial-level data. The incremental cost-effectiveness ratio (ICER) [incremental costs per quality-adjusted life year (QALY) gained] was used to compare the fully-funded policy with the self-paid policy under the willingness-to-pay threshold equivalent to national and provincial GDP per capita. Sensitivity analyses were performed and various scenarios were explored based on real-world conditions, including incorporating indirect effect into the analysis.

RESULTS

Compared to the self-paid policy, implementation of a fully-funded policy could prevent 1,444,768 [95% uncertainty range (UR): 1,203,446-1,719,761] symptomatic cases, 92,110 (95% UR: 66,953-122,226) influenza-related hospitalizations, and 6494 (95% UR: 4590-8962) influenza-related death per season. The fully-funded policy was cost-effective nationally (7964 USD per QALY gained) and provincially for 13 of 31 provincial-level administrative divisions (PLADs). The probability of a funded vaccination policy being cost-effective was 56.5% nationally, and the probability in 9 of 31 PLADs was above 75%. The result was most sensitive to the symptomatic influenza rate among children under 5 years [ICER ranging from - 25,612 (cost-saving) to 14,532 USD per QALY gained]. The ICER of the fully-funded policy was substantially lower (becoming cost-saving) if the indirect effects of vaccination were considered.

CONCLUSIONS

Introducing a government-funded influenza policy for children is cost-effective in China nationally and in many PLADs. PLADs with high symptomatic influenza rate and influenza-associated mortality would benefit the most from a government-funded influenza vaccination program.

Correspondence to: Estimating the full health and economic benefits of current and future influenza vaccines

We recently published an article in BMC Medicine looking at the potential health and economic impact of paediatric vaccination using next-generation influenza vaccines in Kenya: a modelling study. In their commentary on our article, Lafond et al. highlight the potential importance of the wider benefits of vaccination on cost-effectiveness. Whilst we agree with many points raised in the commentary, we think it raises further interesting discussion points, specifically around model complexity, model assumptions and data availability. These points are both relevant to this manuscript but have wider implications for vaccine cost-effectiveness studies.

Estimating the full health and economic benefits of current and future influenza vaccines

In the dynamic landscape of respiratory virus vaccines, it is crucial to assess the value of novel mRNA and combination influenza/COVID-19 vaccines in low- and middle-income countries. Modeling studies, such as the one conducted by Waterlow et al., provide vital information about the cost-benefit potential of these products compared to currently licensed vaccines. However, this approach only accounts for directly measured medically attended influenza-associated illnesses and has two major limitations. First, this method fails to capture the full disease burden of influenza (including non-respiratory and non-medically attended influenza illnesses), which are particularly important drivers of disease burden in infants and older adults. Second, the model does not describe the ancillary benefits of influenza vaccination such as the attenuation of severe disease, prevention of severe non-respiratory outcomes (e.g., myocardial infarctions), or reduced antibiotic use. To obtain a comprehensive understanding of the benefits of influenza vaccines, we must strive to improve the inputs for future modeling-based evaluations.

Impact of Adding Oseltamivir to Usual Care on Quality-Adjusted Life-Years During Influenza-Like Illness

OBJECTIVES

The ALIC⁴E trial has shown that oseltamivir reduces recovery time while increasing the risk of nausea. This secondary analysis of the ALIC⁴E trial aimed to determine the gain in quality-adjusted life-years (QALYs) associated with adding oseltamivir to usual primary care in patients presenting with influenza-like illness (ILI).

METHODS

Patients with ILI were recruited during the influenza season (2015-2018) in 15 European countries. Patients were assigned to usual care with or without oseltamivir through stratified randomization (age, severity, comorbidities, and symptom onset). Patients' health status was valued with the EQ-5D and visual analog scale (VAS) for up to 28 days. Average EQ-5D and VAS scores over time were estimated for both treatment groups using one-inflated beta regression in children (<13 years old) and adults (≥13 years old). QALY gain was calculated as the difference between the groups. Sensitivity analysis considered the value set to convert EQ-5D answers to summary scores and the follow-up period.

RESULTS

In adults, oseltamivir gained 0.0006 (95% confidence interval 0.0002-0.0010) QALYs, whereas no statistically significant gain was found in children (14-day follow-up, EQ-5D). QALY gains were statistically significant in patients aged ≥65 years, patients without relevant comorbidities, or patients experiencing symptoms for ≤48 hours. Using VAS and accounting for 28-day follow-up resulted in higher QALY gain.

CONCLUSIONS

QALY gain owing to oseltamivir is limited compared with other diseases, and its clinical meaningfulness remains to be determined. Further analysis is needed to evaluate whether QALY gain and its impact on ILI treatment cost render oseltamivir cost-effective.

Delayed Influenza Treatment in Children With False-Negative Rapid Antigen Test: A Retrospective Single-Center Study in Korea 2016-2019

BACKGROUND

We aimed to examine the delay in antiviral initiation in rapid antigen test (RAT) false-negative children with influenza virus infection and to explore the clinical outcomes. We additionally conducted a medical cost-benefit analysis.

METHODS

This single-center, retrospective study included children (aged < 10 years) with influenza-like illness (ILI), hospitalized after presenting to the emergency department during three influenza seasons (2016-2019). RAT-false-negativity was defined as RAT-negative and polymerase chain reaction-positive cases. The turnaround time to antiviral treatment (TAT) was from the time when RAT was prescribed to the time when the antiviral was administered. The medical cost analysis by scenarios was also performed.

RESULTS

A total of 1,430 patients were included, 7.5% were RAT-positive (n = 107) and 2.4% were RAT-false-negative (n = 20). The median TAT of RAT-false-negative patients was 52.8 hours, significantly longer than that of 4 hours in RAT-positive patients (19.2-100.1, P < 0.001). In the multivariable analysis, TAT of ≥ 24 hours was associated with a risk of severe influenza infection and the need for mechanical ventilation (odds ratio [OR], 6.8, P = 0.009 and OR, 16.2, P = 0.033, respectively). The medical cost varied from $11.7-187.3/ILI patient.

CONCLUSION

Antiviral initiation was delayed in RAT-false-negative patients. Our findings support the guideline that children with influenza, suspected of having severe or progressive infection, should be treated immediately.

Why Does Influenza Hit the Poor More Than the Rich? A 1931 Social Epidemiology Article That Broke New Ground in the History of Confounding, Mediation, and Interaction

In 1931, Edgar Sydenstricker, the former statistician of the US Public Health Service, challenged the common belief that the 1918 influenza outbreak had affected "the rich and the poor alike." Using data from 112,317 participants in a 1918 US national survey, he observed that, on the contrary, both morbidity and mortality from the flu had been higher among the poor than among the rich. To explain these differences, Sydenstricker stratified the analyses by 2 measures of affluence collected in the survey: "economic status" (from "very poor" to "well-to-do") and household crowding (i.e., number of people per household room). Economic status was associated with influenza attack rates within categories of crowding, but not the opposite, suggesting that characteristics of poverty other than "household congestion" were the culprit of the poor's higher influenza burden. Attack rate ratios for influenza in infants and older adults were greater for the poor or very poor. Sydenstricker reanalyzed an already 12-year-old data set in the context of the Great Depression to build the evidence base relating poverty to ill health. For this purpose he used a stratification approach to assess confounding, mediation, and interaction before the concepts were formally named.

Global burden of influenza-associated lower respiratory tract infections and hospitalizations among adults: A systematic review and meta-analysis

BACKGROUND

Influenza illness burden is substantial, particularly among young children, older adults, and those with underlying conditions. Initiatives are underway to develop better global estimates for influenza-associated hospitalizations and deaths. Knowledge gaps remain regarding the role of influenza viruses in severe respiratory disease and hospitalizations among adults, particularly in lower-income settings.

METHODS AND FINDINGS

We aggregated published data from a systematic review and unpublished data from surveillance platforms to generate global meta-analytic estimates for the proportion of acute respiratory hospitalizations associated with influenza viruses among adults. We searched 9 online databases (Medline, Embase, CINAHL, Cochrane Library, Scopus, Global Health, LILACS, WHOLIS, and CNKI; 1 January 1996-31 December 2016) to identify observational studies of influenza-associated hospitalizations in adults, and assessed eligible papers for bias using a simplified Newcastle-Ottawa scale for observational data. We applied meta-analytic proportions to global estimates of lower respiratory infections (LRIs) and hospitalizations from the Global Burden of Disease study in adults ≥20 years and by age groups (20-64 years and ≥65 years) to obtain the number of influenza-associated LRI episodes and hospitalizations for 2016. Data from 63 sources showed that influenza was associated with 14.1% (95% CI 12.1%-16.5%) of acute respiratory hospitalizations among all adults, with no significant differences by age group. The 63 data sources represent published observational studies (n = 28) and unpublished surveillance data (n = 35), from all World Health Organization regions (Africa, n = 8; Americas, n = 11; Eastern Mediterranean, n = 7; Europe, n = 8; Southeast Asia, n = 11; Western Pacific, n = 18). Data quality for published data sources was predominantly moderate or high (75%, n = 56/75). We estimate 32,126,000 (95% CI 20,484,000-46,129,000) influenza-associated LRI episodes and 5,678,000 (95% CI 3,205,000-9,432,000) LRI hospitalizations occur each year among adults. While adults <65 years contribute most influenza-associated LRI hospitalizations and episodes (3,464,000 [95% CI 1,885,000-5,978,000] LRI hospitalizations and 31,087,000 [95% CI 19,987,000-44,444,000] LRI episodes), hospitalization rates were highest in those ≥65 years (437/100,000 person-years [95% CI 265-612/100,000 person-years]). For this analysis, published articles were limited in their inclusion of stratified testing data by year and age group. Lack of information regarding influenza vaccination of the study population was also a limitation across both types of data sources.

CONCLUSIONS

In this meta-analysis, we estimated that influenza viruses are associated with over 5 million hospitalizations worldwide per year. Inclusion of both published and unpublished findings allowed for increased power to generate stratified estimates, and improved representation from lower-income countries. Together, the available data demonstrate the importance of influenza viruses as a cause of severe disease and hospitalizations in younger and older adults worldwide.

Consultations for Influenza-Like Illness in Primary Care in The Netherlands: A Regression Approach

OBJECTIVES

To estimate the general practitioner (GP) consultation rate attributable to influenza in The Netherlands.

METHODS

Regression analysis was performed on the weekly numbers of influenza-like illness (ILI) GP consultations and laboratory reports for influenza virus types A and B and 8 other pathogens over the period 2003-2014 (11 influenza seasons; week 40-20 of the following year).

RESULTS

In an average influenza season, 27% and 11% of ILI GP consultations were attributed to infection by influenza virus types A and B, respectively. Influenza is therefore responsible for approximately 107 000 GP consultations (651/100 000) each year in The Netherlands. GP consultation rates associated with influenza infection were highest in children under 5 years of age, at 667 of 100 000 for influenza A and 258 of 100 000 for influenza B. Influenza virus infection was found to be the predominant cause of ILI-related GP visits in all age groups except children under 5, in which respiratory syncytial virus (RSV) infection was found to be the main contributor.

CONCLUSIONS

The burden of influenza in terms of GP consultations is considerable. Overall, influenza is the main contributor to ILI. Although ILI symptoms in children under 5 years of age are most often associated with RSV infection, the majority of visits related to influenza occur among children under 5 years of age.

Cost-Effectiveness of Quadrivalent Versus Trivalent Influenza Vaccination in the Dutch National Influenza Prevention Program

OBJECTIVES

As of 2019, quadrivalent influenza vaccine (QIV) has replaced trivalent influenza vaccine (TIV) in the national immunization program in The Netherlands. Target groups are individuals of 60+ years of age and those with chronic diseases. The objective was to estimate the incremental break-even price of QIV over TIV at a threshold of €20 000 per quality-adjusted life-year (QALY).

METHODS

An age-structured compartmental dynamic model was adapted for The Netherlands to assess health outcomes and associated costs of vaccinating all individuals at higher risk for influenza with QIV instead of TIV over the seasons 2010 to 2018. Influenza incidence rates were derived from a global database. Other parameters (probabilities, QALYs and costs) were extracted from the literature and applied according to Dutch guidelines. A threshold of €20 000 per QALY was applied to estimate the incremental break-even prices of QIV versus TIV. Sensitivity analyses were performed to test the robustness of the model outcomes.

RESULTS

Retrospectively, vaccination with QIV instead of TIV could have prevented on average 9500 symptomatic influenza cases, 2130 outpatient visits, 84 hospitalizations, and 38 deaths per year over the seasons 2010 to 2018. This translates into 385 QALYs and 398 life-years potentially gained. On average, totals of €431 527 direct and €2 388 810 indirect costs could have been saved each year.

CONCLUSION

Using QIV over TIV during the influenza seasons 2010 to 2018 would have been cost-effective at an incremental price of maximally €3.81 (95% confidence interval, €3.26-4.31). Sensitivity analysis showed consistent findings on the incremental break-even price in the same range.

Cost-Effectiveness of Pediatric Influenza Vaccination in The Netherlands

OBJECTIVE

This study evaluates the cost-effectiveness of extending the Dutch influenza vaccination program for elderly and medical high-risk groups to include pediatric influenza vaccination, taking indirect protection into account.

METHODS

An age-structured dynamic transmission model was used that was calibrated to influenza-associated GP visits over 4 seasons (2010-2011 to 2013-2014). The clinical and economic impact of different pediatric vaccination strategies were compared over 20 years, varying the targeted age range, the vaccine type for children or elderly and high-risk groups. Outcome measures include averted symptomatic infections and deaths, societal costs and quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Costs and QALYs were discounted at 4% and 1.5% annually.

RESULTS

At an assumed coverage of 50%, adding pediatric vaccination for 2- to 17-year-olds with quadrivalent live-attenuated vaccine to the current vaccination program for elderly and medical high-groups with quadrivalent inactivated vaccine was estimated to avert, on average, 401 820 symptomatic cases and 72 deaths per year. Approximately half of averted symptomatic cases and 99% of averted deaths were prevented in other age groups than 2- to 17-year-olds due to herd immunity. The cumulative discounted 20-year economic impact was 35 068 QALYs gained and €1687 million saved, that is, the intervention was cost-saving. This vaccination strategy had the highest probability of being the most cost-effective strategy considered, dominating pediatric strategies targeting 2- to 6-year-olds or 2- to 12-year-olds or strategies with trivalent inactivated vaccine.

CONCLUSION

Modeling indicates that introducing pediatric influenza vaccination in The Netherlands is cost-saving, reducing the influenza-related disease burden substantially.

Cost-Effectiveness of Routine Childhood Vaccination Against Seasonal Influenza in Germany

OBJECTIVES

In Germany, routine influenza vaccination with quadrivalent influenza vaccines (QIV) is recommended and reimbursed for individuals ≥60 years of age and individuals with underlying chronic conditions. The present study examines the cost-effectiveness of a possible extension of the recommendation to include strategies of childhood vaccination against seasonal influenza using QIV.

METHODS

A dynamic transmission model was used to examine the epidemiological impact of different childhood vaccination strategies. The outputs were used in a health economic decision tree to calculate the costs per quality-adjusted life year (QALY) gained from a societal and a third-party payer (TPP) perspective. Strain-specific epidemiology, vaccine uptake, and vaccine efficacy data from the 10 non-pandemic seasons from 2003/2004 to 2013/2014 were used, and cost data were drawn mainly from a health insurance claims data analysis and supplemented by estimates from literature. Uncertainty is explored via scenario, deterministic, and probabilistic sensitivity analyses.

RESULTS

Vaccinating 2- to 9-year-olds with QIV assuming a vaccine uptake of 40% is cost-saving with a benefit-cost ratio of 1.66 from a societal perspective and an incremental cost-effectiveness ratio of €998/QALY from a TPP perspective. Lower and higher vaccine uptakes show marginal effects, while extending the target group to 2- to 17-year-olds further increases the health benefits while still being below the willingness-to-pay (WTP) threshold. Assuming no vaccine-induced herd protection has a negative effect on the cost-effectiveness ratio, but childhood vaccination remains cost-effective.

CONCLUSION

Routine childhood vaccination against seasonal influenza in Germany is most likely to be cost-saving from a societal perspective and highly cost-effective from a TPP perspective.

Optimising age coverage of seasonal influenza vaccination in England: A mathematical and health economic evaluation

For infectious disease prevention, policy-makers are typically required to base policy decisions in light of operational and monetary restrictions, prohibiting implementation of all candidate interventions. To inform the evidence-base underpinning policy decision making, mathematical and health economic modelling can be a valuable constituent.

Applied to England, this study aims to identify the optimal target age groups when extending a seasonal influenza vaccination programme of at-risk individuals to those individuals at low risk of developing complications following infection. To perform this analysis, we utilise an age- and strain-structured transmission model that includes immunity propagation mechanisms which link prior season epidemiological outcomes to immunity at the beginning of the following season. Making use of surveillance data from the past decade in conjunction with our dynamic model, we simulate transmission dynamics of seasonal influenza in England from 2012 to 2018. We infer that modified susceptibility due to natural infection in the previous influenza season is the only immunity propagation mechanism to deliver a non-negligible impact on the transmission dynamics. Further, we discerned case ascertainment to be higher for young infants compared to adults under 65 years old, and uncovered a decrease in case ascertainment as age increased from 65 to 85 years of age.

Our health economic appraisal sweeps vaccination age space to determine threshold vaccine dose prices achieving cost-effectiveness under differing paired strategies. In particular, we model offering vaccination to all those low-risk individuals younger than a given age (but no younger than two years old) and all low-risk individuals older than a given age, while maintaining vaccination of at-risk individuals of any age. All posited strategies were deemed cost-effective. In general, the addition of low-risk vaccination programmes whose coverage encompassed children and young adults (aged 20 and below) were highly cost-effective. The inclusion of elder age-groups to the low-risk programme typically lessened the cost-effectiveness. Notably, elderly-centric programmes vaccinating from 65-75 years and above had the least permitted expense per vaccine.

Vaccination is an established method to provide protection against seasonal influenza and its complications. Yet, a need to administer an updated vaccine on an annual basis presents significant operational challenges and sizeable costs. Consequently, policy makers typically have to decide how to deploy a finite amount of resource in a cost-effective manner. A combination of mathematical and health economic modelling can be used to address such a question. Here, we developed an age- and strain-structured mathematical model for seasonal influenza transmission dynamics that incorporates mechanisms for immunity propagation, which we used to reconstruct transmission dynamics of seasonal influenza in England from 2012 to 2018.

We then performed a health economic evaluation assessing the cost-effectiveness of extending a seasonal influenza vaccination programme of at-risk individuals to also include, for targeted age groups, those individuals at low risk of developing complications following infection. The findings suggest the inclusion of low-risk vaccination programmes whose coverage encompassed children and young adults (aged 20 and below) to be highly cost-effective. In contrast, the inclusion of elder age-groups to the low-risk programme typically lessened the cost-effectiveness.

Seasonal influenza vaccination in Kenya: an economic evaluation using dynamic transmission modelling

BACKGROUND

There is substantial burden of seasonal influenza in Kenya, which led the government to consider introducing a national influenza vaccination programme. Given the cost implications of a nationwide programme, local economic evaluation data are needed to inform policy on the design and benefits of influenza vaccination. We set out to estimate the cost-effectiveness of seasonal influenza vaccination in Kenya.

METHODS

We fitted an age-stratified dynamic transmission model to active surveillance data from patients with influenza from 2010 to 2018. Using a societal perspective, we developed a decision tree cost-effectiveness model and estimated the incremental cost-effectiveness ratio (ICER) per disability-adjusted life year (DALY) averted for three vaccine target groups: children 6-23 months (strategy I), 2-5 years (strategy II) and 6-14 years (strategy III) with either the Southern Hemisphere influenza vaccine (Strategy A) or Northern Hemisphere vaccine (Strategy B) or both (Strategy C: twice yearly vaccination campaigns, or Strategy D: year-round vaccination campaigns). We assessed cost-effectiveness by calculating incremental net monetary benefits (INMB) using a willingness-to-pay (WTP) threshold of 1-51% of the annual gross domestic product per capita ($17-$872).

RESULTS

The mean number of infections across all ages was 2-15 million per year. When vaccination was well timed to influenza activity, the annual mean ICER per DALY averted for vaccinating children 6-23 months ranged between $749 and $1385 for strategy IA, $442 and $1877 for strategy IB, $678 and $4106 for strategy IC and $1147 and $7933 for strategy ID. For children 2-5 years, it ranged between $945 and $1573 for strategy IIA, $563 and $1869 for strategy IIB, $662 and $4085 for strategy IIC, and $1169 and $7897 for strategy IID. For children 6-14 years, it ranged between $923 and $3116 for strategy IIIA, $1005 and $2223 for strategy IIIB, $883 and $4727 for strategy IIIC and $1467 and $6813 for strategy IIID. Overall, no vaccination strategy was cost-effective at the minimum ($17) and median ($445) WTP thresholds. Vaccinating children 6-23 months once a year had the highest mean INMB value at $872 (WTP threshold upper limit); however, this strategy had very low probability of the highest net benefit.

CONCLUSION

Vaccinating children 6-23 months once a year was the most favourable vaccination option; however, the strategy is unlikely to be cost-effective given the current WTP thresholds.

Coinfection with SARS-CoV-2 and influenza A virus

Since December 2019, coronavirus disease 2019 (COVID-19) has been an international public health emergency. The possibility of COVID-19 should be considered primarily in patients with new-onset fever or respiratory tract symptoms. However, these symptoms can occur with other viral respiratory illnesses. We reported a case of severe acute respiratory syndrome coronavirus 2 and influenza A virus coinfection. During the epidemic, the possibility of COVID-19 should be considered regardless of positive findings for other pathogens.

Incidence and costs of hospitalized adult influenza patients in The Netherlands: a retrospective observational study

OBJECTIVE

Influenza virus infections cause a high disease and economic burden during seasonal epidemics. However, there is still a need for reliable disease burden estimates to provide a more detailed picture of the impact of influenza. Therefore, the objectives of this study is to estimate the incidence of hospitalisation for influenza virus infection and associated hospitalisation costs in adult patients in the Netherlands during two consecutive influenza seasons.

METHODS

We conducted a retrospective study in adult patients with a laboratory confirmed influenza virus infection in three Dutch hospitals during respiratory seasons 2014-2015 and 2015-2016. Incidence was calculated as the weekly number of hospitalised influenza patients divided by the total population in the catchment populations of the three hospitals. Arithmetic mean hospitalisation costs per patient were estimated and included costs for emergency department consultation, diagnostics, general ward and/or intensive care unit admission, isolation, antibiotic and/or antiviral treatment. These hospitalisation costs were extrapolated to national level and expressed in 2017 euros.

RESULTS

The study population consisted of 380 hospitalised adult influenza patients. The seasonal cumulative incidence was 3.5 cases per 10,000 persons in respiratory season 2014-2015, compared to 1.8 cases per 10,000 persons in 2015-2016. The arithmetic mean hospitalisation cost per influenza patient was €6128 (95% CI €4934-€7737) per patient in 2014-2015 and €8280 (95% CI €6254-€10,665) in 2015-2016, potentially reaching total hospitalisation costs of €28 million in 2014-2015 and €20 million in 2015-2016.

CONCLUSIONS

Influenza virus infections lead to 1.8-3.5 hospitalised patients per 10,000 persons, with mean hospitalisation costs of €6100-€8300 per adult patient, resulting in 20-28 million euros annually in The Netherlands. The highest arithmetic mean hospitalisation costs per patient were found in the 45-64 year age group. These influenza burden estimates could be used for future influenza cost-effectiveness and impact studies.

From trivalent to quadrivalent influenza vaccines: Public health and economic burden for different immunization strategies in Spain

PURPOSE

Quadrivalent influenza vaccine (QIV) includes the same strains as trivalent influenza vaccine (TIV) plus an additional B strain of the other B lineage. The aim of the study was to analyse the public health and economic impact of replacing TIV with QIV in different scenarios in Spain.

METHODS

A dynamic transmission model was developed to estimate the number of influenza B cases prevented under TIV and QIV strategies (<65 years (high risk) and ≥65 years). This model considers cross-protective immunity induced by different lineages of influenza B. The output of the transmission model was used as input for a decision tree model that estimated the economic impact of switching TIV to QIV. The models were populated with Spanish data whenever possible. Deterministic univariate and probabilistic multivariate sensitivity analyses were performed.

RESULTS

Replacing TIV with QIV in all eligible patients with current vaccine coverage in Spain may have prevented 138,707 influenza B cases per season and, therefore avoided 10,748 outpatient visits, 3,179 hospitalizations and 192 deaths. The replacement could save €532,768 in outpatient visit costs, €13 million in hospitalization costs, and €3 million in costs of influenza-related deaths per year. An additional €5 million costs associated with productivity loss could be saved per year, from the societal perspective. The budget impact from societal perspective would be €6.5 million, and the incremental cost-effectiveness ratio (ICER) €1,527 per quality-adjusted life year (QALY). Sensitivity analyses showed robust results. In additional scenarios, QIV also showed an impact at public health level reducing influenza B related cases, outpatient visits, hospitalizations and deaths.

CONCLUSIONS

Our results show public health and economic benefits for influenza prevention with QIV. It would be an efficient intervention for the Spanish National Health Service with major health benefits especially in the population ≥65-year.

Cost-effectiveness of introducing national seasonal influenza vaccination for adults aged 60 years and above in mainland China: a modelling analysis

BACKGROUND

China has an aging population with an increasing number of adults aged ≥ 60 years. Influenza causes a heavy disease burden in older adults, but can be alleviated by vaccination. We assessed the cost-effectiveness of a potential government-funded seasonal influenza vaccination program in older adults in China.

METHODS

We characterized the health and economic impact of a fully funded influenza vaccination program for older adults using China-specific influenza disease burden, and related cost data, etc. Using a decision tree model, we calculated the incremental costs per quality-adjusted life year (QALY) gained of vaccination from the societal perspective, at a willingness-to-pay threshold equivalent to GDP per capita (US$8840). Moreover, we estimated the threshold vaccination costs, under which the fully funded vaccination program is cost-effective using GDP per capita as the willingness-to-pay threshold.

RESULTS

Compared to current self-paid vaccination, a fully funded vaccination program is expected to prevent 19,812 (95% uncertainty interval, 7150-35,783) influenza-like-illness outpatient consultations per year, 9418 (3386-17,068) severe acute respiratory infection hospitalizations per year, and 8800 (5300-11,667) respiratory excess deaths due to influenza per year, and gain 70,212 (42,106-93,635) QALYs per year. Nationally, the incremental costs per QALY gained of the vaccination program is US$4832 (3460-8307), with a 98% probability of being cost-effective. The threshold vaccination cost is US$10.19 (6.08-13.65). However, variations exist between geographical regions, with Northeast and Central China having lower probabilities of cost-effectiveness.

CONCLUSIONS

Our results support the implementation of a government fully funded older adult vaccination program in China. The regional analysis provides results across settings that may be relevant to other countries with similar disease burden and economic status, especially for low- and middle-income countries where such analysis is limited.

Program cost analysis of influenza vaccination of health care workers in Albania

BACKGROUND

Since 2012, WHO has recommended influenza vaccination for health care workers (HCWs), which has different costs than routine infant immunization; however, few cost estimates exist from low- and middle-income countries. Albania, a middle-income country, has self-procured influenza vaccine for some HCWs since 2014, supplemented by vaccine donations since 2016 through the Partnership for Influenza Vaccine Introduction (PIVI). We conducted a cost analysis of HCW influenza vaccination in Albania to inform scale-up and sustainability decisions.

METHODS

We used the WHO's Seasonal Influenza Immunization Costing Tool (SIICT) micro-costing approach to estimate incremental costs from the government perspective of facility-based vaccination of HCWs in Albania with trivalent inactivated influenza vaccine for the 2018-19 season based on 2016-17 season data from administrative records, key informant consultations, and a convenience sample of site visits. Scenario analyses varied coverage, vaccine presentation, and vaccine prices.

RESULTS

In the baseline scenario, 13,377 HCWs (70% of eligible HCWs) would be vaccinated at an incremental financial cost of US$61,296 and economic cost of US$161,639. Vaccine and vaccination supplies represented the largest share of financial (89%) and economic costs (44%). Per vaccinated HCW financial cost was US$4.58 and economic cost was US$12.08 including vaccine and vaccination supplies (US$0.49 and US$6.76 respectively without vaccine and vaccination supplies). Scenarios with higher coverage, pre-filled syringes, and higher vaccine prices increased total economic and financial costs, although the economic cost per HCW vaccinated decreased with higher coverage as some costs were spread over more HCWs. Across all scenarios, economic costs were <0.07% of Albania's estimated government health expenditure, and <5.07% of Albania's estimated immunization program economic costs.

CONCLUSIONS

Cost estimates can help inform decisions about scaling up influenza vaccination for HCWs and other risk groups.

Estimating the Effect of a National Pharmacy-Led Influenza Vaccination Voucher Program on Morbidity, Mortality, and Costs

BACKGROUND

Influenza (also known as "flu") is estimated to cause between 12,000 and 79,000 deaths annually. Vaccinations are beneficial in preventing influenza cases and reducing the likelihood of severe outcomes. Unfortunately, vaccination coverage is low among uninsured populations. Removing the cost barrier can help increase vaccination coverage in this group, averting flu cases and related morbidity and costs.

OBJECTIVE

To model the potential effect of providing no-cost flu vaccinations to uninsured individuals on influenza-related morbidity, mortality, and costs.

METHODS

In collaboration with the Department of Health and Human Services and local agencies, Walgreens pharmacies provided free flu vaccinations through a nationwide voucher distribution program. We calculated the redemption rate, potentially averted cases, and estimated cost savings for the 2015-2016 and 2016-2017 flu seasons. Using incidence and vaccine effectiveness estimates from the Centers for Disease Control and Prevention, we calculated the rate of influenza in the general population and the estimated cases averted based on the number of redeemed vouchers. We applied patient age along with parameters from published studies to estimate averted ambulatory care visits, hospitalizations, mortality, productively losses, and overall related costs.

RESULTS

During the 2015-2016 flu season, the pharmacy chain distributed 600,000 vouchers with a redemption rate of 52.3%, resulting in 314,033 flu vaccinations. Improvements were subsequently made to the distribution process to increase utilization rates. There were 400,000 vouchers distributed during the 2016-2017 season with a higher redemption rate of 87.2%, resulting in 348,924 flu vaccinations. The estimated number of potentially averted cases was higher during the 2016-2017 season (13,347) than the 2015-2016 season (11,537) due to a higher redemption rate and increased flu activity. Taken together, we estimated that 8,621 ambulatory care visits, 314 hospitalizations, and 15 deaths were averted due to the flu voucher program. Averted health care costs totaled $937,494 in ambulatory care visits and $3,510,055 in hospitalizations. Averted productivity losses ranged from $4,473,509 to $14,613,502.

CONCLUSIONS

This study demonstrates the effectiveness of a pharmacy-led partnership with local community-based organizations to promote flu vaccinations among uninsured individuals. Our model found that a no-cost flu voucher program has the potential to reduce influenza-related morbidity, mortality, and costs.

DISCLOSURES

This study was funded by Walgreen Co. All authors are employees of Walgreen Co. and affiliated with Walgreens Center for Health and Wellbeing Research. Findings from this study were presented as a podium presentation at the Academy of Managed Care Pharmacy Nexus 2018; October 22-25, 2018; Orlando, FL.

Future epidemiological and economic impacts of universal influenza vaccines

The efficacy of influenza vaccines, currently at 44%, is limited by the rapid antigenic evolution of the virus and a manufacturing process that can lead to vaccine mismatch. The National Institute of Allergy and Infectious Diseases (NIAID) recently identified the development of a universal influenza vaccine with an efficacy of at least 75% as a high scientific priority. The US Congress approved $130 million funding for the 2019 fiscal year to support the development of a universal vaccine, and another $1 billion over 5 y has been proposed in the Flu Vaccine Act. Using a model of influenza transmission, we evaluated the population-level impacts of universal influenza vaccines distributed according to empirical age-specific coverage at multiple scales in the United States. We estimate that replacing just 10% of typical seasonal vaccines with 75% efficacious universal vaccines would avert ∼5.3 million cases, 81,000 hospitalizations, and 6,300 influenza-related deaths per year. This would prevent over $1.1 billion in direct health care costs compared to a typical season, based on average data from the 2010-11 to 2018-19 seasons. A complete replacement of seasonal vaccines with universal vaccines is projected to prevent 17 million cases, 251,000 hospitalizations, 19,500 deaths, and $3.5 billion in direct health care costs. States with high per-hospitalization medical expenses along with a large proportion of elderly residents are expected to receive the maximum economic benefit. Replacing even a fraction of seasonal vaccines with universal vaccines justifies the substantial cost of vaccine development.

Clinical and economic analysis of the 2009 H1N1 influenza pandemic among pregnant Korean women

BACKGROUND/AIMS

Unlike Western countries, the 2009 pandemic influenza infection among pregnant women was reported as mild in a previous interim study in South Korea. However, several mortalities were reported thereafter, suggesting that nationwide data were lacking.

METHODS

This case-control study covers the entire 2009 pandemic inf luenza period, from May 2009 to February 2010. The clinical and economic data of pregnant (case) and age-matched non-pregnant (control) women with influenza A (H1N1) pdm09 virus (H1N1pdm09) infection were retrospectively collected from nine hospitals in South Korea.

RESULTS

A total of 130 pregnant women with H1N1pdm09 infection were identified. The mean age of the pregnant women was 31.1 years (range, 19 to 41) and mean gestational age was 18.4 weeks (range, 3 to 40). Both case and control groups were similar in terms of age (p = 0.43) and comorbidities (p = 0.18). The overall rate of complications was comparable between the two groups (p = 0.648). However, mortality was reported only among the cases, so mean economic per capita burden is estimated to be higher for pregnant women compared to the control (4,821,992 Korean won [KRW] vs. 351,233 KRW, p = 0.31). Obstetric complications were observed in 12 cases, including preterm labor (n = 7), low birth-weight (n = 3), miscarriage (n = 1), stillbirth (n = 1), and cleft lip (n = 1).

CONCLUSION

Although statistically insignificant, the detrimental impact of influenza A H1N1pdm09 on pregnancy can be serious in some complicated cases in South Korea. Thus, the strong recommendation of influenza vaccination should be maintained for pregnant women as a high priority.

Cost-Benefit Analysis of Real-Time Influenza Testing for Patients in German Emergency Rooms

Background: Seasonal influenza causes significant morbidity worldwide and has a substantial economic impact on the healthcare system. Objective: To assess the cost–benefit relation of implementing a real-time influenza test in emergency rooms (ER) of German hospitals. Methods: A deterministic decision-analytic model was developed simulating the incremental costs of using the Solana^® Influenza A+B test, compared to those of using conventional clinical judgement alone to confirm or exclude influenza in adult ILI (influenza-like illness) patients, in German ER, prior to hospitalization. Direct costs were evaluated from the hospital perspective, considering resource use directly related to influenza testing and treatment, as well as indirect costs incurred by nosocomial influenza transmission. Results: Through base-case analysis and assuming an influenza prevalence of 42.6%, real-time testing with Solana^® reduced average costs of hospitalized ILI patients by €132.61, per tested patient. Moreover, the Solana^® saved €6.9 per tested patient in favor of the hospital. In probabilistic sensitivity analysis, under all reasonable assumptions, implementing the Solana^® saved on average €144.13 as compared to applying the clinical-judgement-only strategy, thus, it was found to be constantly less expensive. Conclusions: Using highly sensitive and specific real-time influenza tests in ILI patients at German ER might significantly reduce hospital expenditures

Evaluating costs and health consequences of sick leave strategies against pandemic and seasonal influenza in Norway using a dynamic model

OBJECTIVES

To quantify population-level health and economic consequences of sick leave among workers with influenza symptoms.

INTERVENTIONS

Compared with current sick leave practice (baseline), we evaluated the health and cost consequences of: (1) increasing the proportion of workers on sick leave from 65% (baseline) to 80% or 90%; (2) shortening the maximum duration from symptom onset to sick leave from 4 days (baseline) to 2 days, 1.5 days, 1 day and 0.5 days; and (3) combinations of 1 and 2.

METHODS

A dynamic compartmental influenza model was developed using Norwegian population data and survey data on employee sick leave practices. The sick leave interventions were simulated under 12 different seasonal epidemic and 36 different pandemic influenza scenarios. These scenarios varied in terms of transmissibility, the proportion of symptomatic cases and illness severity (risk of primary care consultations, hospitalisations and deaths). Using probabilistic sensitivity analyses, a net health benefit approach was adopted to assess the cost-effectiveness of the interventions from a societal perspective.

RESULTS

Compared with current sick leave practice, sick leave interventions were cost-effective for 31 (65%) of the pandemic scenarios, and 11 (92%) of the seasonal scenarios. Economic benefits from sick leave interventions were greatest for scenarios with low transmissibility, high symptomatic proportions and high illness severity. Overall, the health and economic benefits were greatest for the intervention involving 90% of sick workers taking sick leave within one-half day of symptoms. Depending on the influenza scenario, this intervention resulted in a 44.4%-99.7% reduction in the attack rate. Interventions involving sick leave onset beginning 2 days or later, after the onset of symptoms, resulted in economic losses.

CONCLUSIONS

Prompt sick leave onset and a high proportion of sick leave among workers with influenza symptoms may be cost-effective, particularly during influenza epidemics and pandemics with low transmissibility or high morbidity.

Child Influenza Vaccination and Adult Work Loss: Reduced Sick Leave Use Only in Adults With Paid Sick Leave

INTRODUCTION

Children are a population of interest for influenza. They are at increased risk for severe influenza, comprise a substantial portion of influenza morbidity, and significantly contribute to its transmission in the household and subsequent parental work loss. The association between influenza vaccination and work loss prevention, however, has rarely been studied, and the sparse existing literature has very limited generalizability to U.S. adults, thus requiring better characterization.

METHODS

Using pooled National Health Interview Survey data (2013-2015, analyses conducted in 2018) nationally representative of working U.S. adults with household children (n=23,014), zero-inflated negative binomial regression examined the association of child influenza vaccination (exposure) with sick days (outcome) stratified by paid sick leave (no: n=10,741, yes: n=12,273).

RESULTS

Child influenza vaccination was associated with significantly lower sick day usage, but only among adults with paid sick leave (prevalence rate ratio=0.79, 95% CI=0.67, 0.93), equating to average annual sick days of 4.07 vs 3.29 in adults with unvaccinated versus vaccinated household children (difference=0.78 fewer days annually).

CONCLUSIONS

Influenza vaccination of children is associated with reduced sick leave in household adults, helping to keep the workforce healthy and reduce influenza's costly annual economic burden. This only occurred among adults with paid sick leave, however, which is distributed inequitably by income, education, gender, occupation, and race/ethnicity. Health in All Policies considers downstream health effects of social and economic policy; the failure of federal policy to ensure paid sick leave likely contributes to propagating influenza and health inequities.

Excess influenza hospital admissions and costs due to the 2009 H1N1 pandemic in England

Influenza pandemics considerably burden affected health systems due to surges in inpatient admissions and associated costs. Previous studies underestimate or overestimate 2009/2010 influenza A/H1N1 pandemic hospital admissions and costs. We robustly estimate overall and age-specific weekly H1N1 admissions and costs between June 2009 and March 2011 across 170 English hospitals. We calculate H1N1 admissions and costs as the difference between our administrative data of all influenza-like-illness patients (seasonal and pandemic alike) and a counterfactual of expected weekly seasonal influenza admissions and costs established using time-series models on prepandemic (2004-2008) data. We find two waves of H1N1 admissions: one pandemic wave (June 2009-March 2010) with 10,348 admissions costing £20.5 million and one postpandemic wave (November 2010-March 2011) with 11,775 admissions costing £24.8 million. Patients aged 0-4 years old have the highest H1N1 admission rate, and 25- to 44- and 65+-year-olds have the highest costs. Our estimates are up to 4.3 times higher than previous reports, suggesting that the pandemic's burden on hospitals was formerly underassessed. Our findings can help hospitals manage unexpected surges in admissions and resource use due to pandemics.

Economic and operational impact of an improved pathway using rapid molecular diagnostic testing for patients with influenza-like illness in a German emergency department

To evaluate the economic and operational effects of implementing a shorted diagnostic pathway during influenza epidemics. This retrospective study used emergency department (ED) data from the 2014/2015 influenza season. Alere i influenza A & B rapid molecular diagnostic test (RDT) was compared with the polymerase chain reaction (PCR) pathway. Differences in room occupancy time in the ED and inpatient ward and cost differences were calculated for the 14-week influenza season. The process flow was more streamlined with the RDT pathway, and the necessary isolation time in the ED was 9 h lower than for PCR. The difference in the ED examination room occupancy time was 2.9 h per patient on a weekday and 4 h per patient on a weekend day, and the difference in the inpatient room occupancy time was 2 h per patient on a weekday and 3 h per patient on a weekend day. Extrapolated time differences across the influenza season were projected to be 2733 h in the ED examination room occupancy and 1440 h in inpatient room occupancy. In patients with a negative diagnosis, the RDT was also estimated to reduce the total diagnostic costs by 41.52 € per patient compared with PCR. The total cost difference was projected to be 31,892 € across a 14-week influenza season. The improved process and earlier diagnosis with the RDT pathway compared with conventional PCR resulted in considerable savings in ED, inpatient room occupancy time and cost across the influenza season.

People's perception and cost-effectiveness of home confinement during an influenza pandemic: evidence from the French case

In France, home confinement is not a common preventive measure against an influenza pandemic, although it is used around the world. Based on a stated method approach, we analyze the attitude that the French would adopt if this measure were put in place. Next, we propose a cost-benefit analysis to discuss the cost-effectiveness of this measure. We find that over three-quarters of respondents report complying with home confinement. Their choice depends on their individual characteristics, the interaction they may have with an infected person and home confinement conditions, but not their experience with preventive measures. We find that behaviors such as sensitivity to certainty, selfishness and altruism emerge. As far as cost-effectiveness is concerned, our study shows that home confinement is a prevention path that should not be neglected and should even be prescribed.

Cost Effectiveness of Quadrivalent Influenza Vaccines Compared with Trivalent Influenza Vaccines in Young Children and Older Adults in Korea

INTRODUCTION

Trivalent influenza vaccines (TIVs) are currently reimbursed for subjects aged ≥ 65 years and children between 6 and 59 months of age under a national immunization program in South Korea. Quadrivalent influenza vaccines (QIVs) are expected to address the potential problem of influenza B-lineage mismatch for TIVs.

OBJECTIVE

The objective of this analysis was to compare the cost effectiveness of QIV versus TIV in children aged 6-59 months and older adults ≥ 65 years of age in South Korea.

METHODS

A 1-year static population model was employed to compare the costs and outcomes of a QIV vaccination program compared with TIV in children aged 6-59 months and older adults ≥ 65 years of age in South Korea. Influenza-related parameters (probabilities, health resource use, and costs) were derived from an analysis of the National Health Insurance System claims database between 2010 and 2013 under a broad and narrow set of International Classification of Diseases, Tenth Revision (ICD-10) codes used to identify influenza. Other inputs were extracted from published literature. Incremental cost-effectiveness ratios (2016 South Korean Won [KRW] per quality-adjusted life-year [QALY] gained) were estimated using a 'limited' societal perspective as per the Korean pharmacoeconomic guidelines. QALYs lost due to premature mortality were discounted at 5% annually.

RESULTS

For both age groups combined, under the narrow definition of influenza, QIV is expected to prevent nearly 16,000 (2923 in children and 13,011 in older adults) medically attended influenza cases, nearly 8000 (672 in children, 7048 in older adults) cases of complications, and over 230 (0 in children, 238 in older adults) deaths annually compared with TIV. The impact of using QIV versus TIV in this setting translates into savings of KRW 24 billion (KRW 0.6 billion in children, KRW 23.4 billion in older adults) in annual medical costs, and over 2100 (18 in children, 2084 in older adults) QALYs. Under the broad definition, the corresponding results are over 190,000 (50,697 in children, 140,644 in older adults) influenza cases, over 37,000 (12,623 in children, 24,526 in older adults) complications, 270 deaths (0 in children, 270 in older adults), KRW 94.22 billion (KRW 16 billion in children, KRW 78.2 billion in older adults), and over 3500 QALYs saved (316 in children, 3260 in older adults).

CONCLUSION

The use of QIV over TIV was estimated to not be cost effective in children 6-59 months of age, but cost saving in older adults, using the narrow definition of influenza; however, QIV use was cost saving in both age groups using the broad definition. QIV is expected to yield more benefits in older adults ≥ 65 years of age than in children aged 6-59 months due to higher influenza-related mortality and costs among the older adults. Further analyses considering the indirect effects of influenza vaccination in children are required.

[Comprehensive Care Home Unit: reduction of hospital resources during influenza outbreaks]

OBJECTIVE

The Comprehensive Care Home Unit of the General Hospital of Villarrobledo is a unit formed by a geriatrician who sees people in nursing homes to improve their quality of care. The activity of the Unit has been analyzed, mainly with the objective of avoiding referral to the emergency room, avoiding hospital admissions, avoiding hospital readmissions and reducing the number of hospital admission days.

METHODS

We retrospectively described the clinical activity of the Unit during the influenza outbreak of 2017 and 2018. We selected sociodemographical variables, functional assessment scales (Katz index, Barthel index and the Functional Ambulation Classification), and the Global Deterioration Scale. We registered mortality, type of treatment, oncological patients and patients with supplementary tests. The population was divided into four subgroups: hospital admission avoided, hospital re-admission avoided, referral to the emergency department avoided and reduction of admission days. The demographic characteristics were described, including the mode or mean of the variables. An economic report was made, and an analysis of cost per process according to the subgroups, means of Related Groups for the Diagnosis and degree of dependency measured by the Barthel index.

RESULTS

We selected 112 patients, they had a mean age of 82.2 years, Katz G (34.8%), IB 28.8 (DE 34.9), FAC 0 (63.4%) and GDS 7 (22.3%). The most frequent disease seen was respiratory infection (63.2%), 71.4% received active treatment, 10.7% complementary tests were performed, 17.9% oncological and 17% mortality. Cost analysis: hospital readmission avoided (€ 4,128 per patient) and patients with total disability (BI 0-20, € 3,623 per patient) presented more economic saving. The economic savings were more than € 230,000.

CONCLUSIONS

The contribution of the Unit during periods of influenza outbreak is cost saving because of reduced numbers of admissions, numbers of readmissions, days of admission and emergency room visits.

[Cost-effectiveness of vaccines for the prevention of seasonal influenza in different age groups: a systematic review]

BACKGROUND

Given the economic burden of seasonal influenza for the healthcare system, we performed a systematic review aiming to update available evidence on the cost-effectiveness of vaccination of seasonal influenza in different age groups, including children.

METHODS

A systematic review of the literature on economic evaluations of seasonal influenza vaccination programs in children and adults was carried out. The following databases were searched (January 2013 - April 2018): Medline and PREMEDLINE, EMBASE, EconLit and databases of the Centre for Reviews and Dissemination (DARE, HTA, NHS EED).

RESULTS

A total of 11 economic evaluations were included. Methodological quality of included studies was acceptable. Scientific evidence shows that seasonal influenza vaccination programs in school-age children can be a cost-effective alternative from national health system perspective and can be cost-saving from societal perspective in European countries. However, available evidence does not allow us to conclude that influenza vaccination programs in healthy adults under 65 years of age were a cost-effective alternative in our context, due to the high uncertainty and the lack of studies carried out in Spanish context.

CONCLUSIONS

Vaccination programs for the prevention of seasonal influenza in school-age children (3-16 years) can be a cost-effective strategy.

Cost of influenza and influenza-like syndromes (I-LSs) in Italy: Results of a cross-sectional telephone survey on a representative sample of general population

OBJECTIVES

Influenza and Influenza-like syndromes (I-LSs) are very common events in general practice, and their relevance is frequently underestimated. Aim of the study was to assess the economic impact of influenza and Influenza-like syndromes (I-LSs) in the Italian general population by using real-world data from a retrospective database.

METHODS

A cross-sectional survey via Computer Assisted Telephone Interview (CATI) was carried out by using a specific questionnaire which is able to assess the rate of infectious episodes, together with subject's behavior in case of influenza or I-LSs, and prescribed therapy. Collected data were statistically analyzed to calculate the economic impact of influenza and I-LSs episodes according to both the National Health System Perspective (NHS-P) and the Italian Families Perspective (S-P). The components of cost were: influenza vaccination, used drugs, General Practitioner (GP) visits, Emergency Room (ER) visits, hospitalizations, and productivity loss.

RESULTS

According to the NHS-P, the annual cost for managing influenza or I-LSs amounted to € 60.24, corresponding to € 38.71 per episode. About 72% of the cost was due to GP/ER visits and hospitalization; 22% to drugs, and 6% to vaccination. In the IF-P, the annual cost increased to € 249.70 (€ 140.33 per episode) and almost 90% of the cost was related to workdays lost, while only 11% and 1.3% were due to drugs and vaccination, respectively. Annual cost was highly related to the mean duration of influenza or I-LSs episodes in both perspectives (€ 111─388 in IF-P and € 56─68 in NHS-P). Furthermore, the number of workdays lost due to these episodes showed a significant impact on the overall cost (€ 195─304) only in the NHS-P.

CONCLUSIONS

Influenza and I-LSs have a not negligible economic impact, both for the NHS and for the society. Resource consumption is considerable in the NHS-P, while the productivity loss due to people absenteeism causes the most relevant impact in the IF-P.

Cost-effectiveness of switching from trivalent to quadrivalent inactivated influenza vaccines for the at-risk population in Italy

Seasonal influenza is caused by two subtypes of influenza A and two lineages of influenza B. Although trivalent influenza vaccines (TIVs) contain both circulating A strains, they contain only a single B-lineage strain. This can lead to mismatches between the vaccine and predominant circulating B lineages, a concern especially for at-risk populations. Quadrivalent influenza vaccines (QIVs) containing a strain from both B lineages have been developed to improve protection against influenza. Here, we used a cost-utility model to examine whether switching from TIV to QIV would be cost-effective for the at-risk population in Italy. Costs were estimated from the payer and societal perspectives. The discount rate for outcomes was 3.0%. Univariate and probabilistic sensitivity analyses were performed to examine the effects of variations in parameters. Switching from TIV to QIV in Italy was estimated to increase quality-adjusted life-years (QALYs) and produce cost savings, including €1.6 million for hospitalization and approximately €2 million in productivity. The incremental cost-effectiveness ratio was €23,426 per QALY from a payer perspective and €21,096 per QALY from a societal perspective. Switching to QIV was most cost-effective for individuals ≥ 65 years of age (€19,170 per QALY). Probabilistic sensitivity analysis showed that the switching from TIV to QIV would be cost-effective for > 91% of simulation at a maximum willingness-to-pay threshold of €40,000 per QALY gained. Although the model did not take herd protection into account, it predicted that the switch from TIV to QIV would be cost-effective for the at-risk population in Italy.

A systematic review and meta-analysis of the direct epidemiological and economic effects of seasonal influenza vaccination on healthcare workers

BACKGROUND

Influenza vaccination is a commonly used intervention to prevent influenza infection in healthcare workers (HCWs) and onward transmission to other staff and patients. We undertook a systematic review to synthesize the latest evidence of the direct epidemiological and economic effectiveness of seasonal influenza vaccination among HCW.

METHODS

We conducted a systematic search of MEDLINE/PubMed, Scopus, and Cochrane Central Register of Controlled Trials from 1980 through January 2018. All studies comparing vaccinated and non-vaccinated (i.e. placebo or non-intervention) groups of HCWs were included. Research articles that focused on only patient-related outcomes or monovalent A(H1N1)pdm09 vaccines were excluded. Two reviewers independently selected articles and extracted data. Pooled-analyses were conducted on morbidity outcomes including laboratory-confirmed influenza, influenza-like illnesses (ILI), and absenteeism. Economic studies were summarized for the characteristics of methods and findings.

RESULTS

Thirteen articles met eligibility criteria: three articles were randomized controlled studies and ten were cohort studies. Pooled results showed a significant effect on laboratory-confirmed influenza incidence but not ILI. While the overall incidence of absenteeism was not changed by vaccine, ILI absenteeism was significantly reduced. The duration of absenteeism was also shortened by vaccination. All published economic evaluations consistently found that the immunization of HCW was cost saving based on crude estimates of avoided absenteeism by vaccination. No studies, however, comprehensively evaluated both health outcomes and costs of vaccination programs to examine cost-effectiveness.

DISCUSSION

Our findings reinforced the influenza vaccine effects in reducing infection incidence and length of absenteeism. A better understanding of the incidence of absenteeism and comprehensive economic program evaluations are required to ensure the best possible management of ill HCWs and the investment in HCW immunization in increasingly constrained financial environments. These steps are fundamental to establish sustainability and cost-effectiveness of vaccination programs and underpin HCW immunization policy.

Early use of Antibiotics for at Risk CHildren with InfluEnza (ARCHIE): protocol for a double-blind, randomised, placebo-controlled trial

INTRODUCTION

Influenza and influenza-like illness (ILI) create considerable burden on healthcare resources each winter. Children with pre-existing conditions such as asthma, diabetes mellitus and cerebral palsy are among those at greatest risk of clinical deterioration from influenza/ILI. The Antibiotics for at Risk CHildren with InfluEnza (ARCHIE) trial aims to determine whether early oral treatment with the antibiotic co-amoxiclav reduces the likelihood of reconsultation due to clinical deterioration in these 'at risk' children.

METHODS AND ANALYSIS

The ARCHIE trial is a double-blind, parallel, randomised, placebo-controlled trial. 'At risk' children aged 6 months to 12 years inclusive who present within the first 5 days of an ILI episode will be randomised to receive a 5-day course of oral co-amoxiclav 400/57 twice daily or placebo. Randomisation will use a non-deterministic minimisation algorithm to balance age and seasonal influenza vaccination status.To detect respiratory virus infections, a nasal swab will be obtained from each participant before commencing study medication. To identify carriage of potential bacterial respiratory pathogens, we will also obtain a throat swab where possible.The primary outcome is reconsultation in any healthcare setting due to clinical deterioration within 28 days of randomisation. We will analyse this outcome using log-binomial regression model adjusted for region, age and seasonal influenza vaccination status.Secondary outcomes include duration of fever, duration of symptoms and adverse events. Continuous outcomes will be compared using regression analysis (or equivalent non-parametric method for non-normal data) adjusting for minimisation variables. Binary outcomes will be compared using χ²/Fisher's exact test and log-binomial regression.

ETHICS

The ARCHIE trial has been reviewed and approved by the North West-Liverpool East Research Ethics Committee, Health Research Authority and Medicines and Healthcare Products Regulatory Agency. Our findings will be published in peer-reviewed journals and disseminated via our study website (www.archiestudy.com) and links with relevant charities.

TRIAL REGISTRATION NUMBERS

ISRCTN 70714783; Pre-results. EudraCT 2013-002822-21; Pre-results.

Resource utilization and cost of influenza requiring hospitalization in Canadian adults: A study from the serious outcomes surveillance network of the Canadian Immunization Research Network

BACKGROUND

Consideration of cost determinants is crucial to inform delivery of public vaccination programs.

OBJECTIVES

To estimate the average total cost of laboratory-confirmed influenza requiring hospitalization in Canadians prior to, during, and 30 days following discharge. To analyze effects of patient/disease characteristics, treatment, and regional differences in costs.

METHODS

Study utilized previously recorded clinical characteristics, resource use, and outcomes of laboratory-confirmed influenza patients admitted to hospitals in the Serious Outcomes Surveillance (SOS), Canadian Immunization Research Network (CIRN), from 2010/11 to 2012/13. Unit costs including hospital overheads were linked to inpatient/outpatient resource utilization before and after admissions.

RESULTS

Dataset included 2943 adult admissions to 17 SOS Network hospitals and 24 Toronto Invasive Bacterial Disease Network hospitals. Mean age was 69.5 years. Average hospital stay was 10.8 days (95% CI: 10.3, 11.3), general ward stays were 9.4 days (95% CI: 9.0, 9.8), and ICU stays were 9.8 days (95% CI: 8.6, 11.1) for the 14% of patients admitted to the ICU. Average cost per case was $14 612 CAD (95% CI: $13 852, $15 372) including $133 (95% CI: $116, $150) for medical care prior to admission, $14 031 (95% CI: $13 295, $14 768) during initial hospital stay, $447 (95% CI: $271, $624) post-discharge, including readmission within 30 days.

CONCLUSION

The cost of laboratory-confirmed influenza was higher than previous estimates, driven mostly by length of stay and analyzing only laboratory-confirmed influenza cases. The true per-patient cost of influenza-related hospitalization has been underestimated, and prevention programs should be evaluated in this context.

WHO guide on the economic evaluation of influenza vaccination

Influenza is responsible for substantial morbidity and mortality across the globe, with a large share of the total disease burden occurring in low- and middle-income countries (LMICs). There have been relatively few economic evaluations assessing the value of seasonal influenza vaccination in LMICs. The purpose of this guide is to outline the key theoretical concepts and best practice in methodologies and to provide guidance on the economic evaluation of influenza vaccination in LMICs. It outlines many of the influenza vaccine-specific challenges and should help to provide a framework for future evaluations in the area to build upon.

Impact of increased influenza vaccination in 2-3-year-old children on disease burden within the general population: A Bayesian model-based approach

Introduction

During the 2013–2014 influenza season, Public Health England extended routine influenza vaccination to all 2- and 3-year-old children in England. To estimate the impact of this change in policy on influenza-related morbidity and mortality, we developed a disease transmission and surveillance model informed by real-world data.

Methods

We combined real-world and literature data sources to construct a model of influenza transmission and surveillance in England. Data were obtained for four influenza seasons, starting with the 2010–2011 season. Bayesian inference was used to estimate model parameters on a season-by-season basis to assess the impact of targeting 2- and 3-year-old children for influenza vaccination. This provided the basis for the construction of counterfactual scenarios comparing vaccination rates of ~2% and ~35% in the 2- and 3- year-old population to estimate reductions in general practitioner (GP) influenza-like-illness (ILI) consultations, respiratory hospitalizations and deaths in the overall population.

Results

Our model was able to replicate the main patterns of influenza across the four seasons as observed through laboratory surveillance data. Targeting 2- and 3-year-old children for influenza vaccination resulted in reductions in the general population of between 6.2–9.9% in influenza-attributable GP ILI consultations, 6.1–10.7% in influenza-attributable respiratory hospitalizations, and 5.7–9.4% in influenza-attributable deaths. The decrease in influenza-attributable ILI consultations represents a reduction of between 4.5% and 7.3% across all ILI consultations. The reduction in influenza-attributable respiratory hospitalizations represents a reduction of between 1.2% and 2.3% across all respiratory hospitalizations. Reductions in influenza-attributable respiratory deaths represent a reduction of between 0.9% and 2.4% in overall respiratory deaths.

Conclusion

This study has provided evidence that extending routine influenza vaccination to all healthy children aged 2 and 3 years old leads to benefits in terms of reduced utilization of healthcare resources and fewer respiratory health outcomes and deaths.

Age- and risk-related appropriateness of the use of available influenza vaccines in the Italian elderly population is advantageous: results from a budget impact analysis

INTRODUCTION

Nowadays, four different types of influenza vaccines are available in Italy: trivalent (TIV), quadrivalent (QIV), MF59-adjuvanted (aTIV) and intradermal TIV (idTIV) inactivated vaccines. Recently, a concept of the appropriateness (i.e. according to the age and risk factors) of the use of different vaccines has been established in Italy. We conducted a budget impact analysis of switching to a policy, in which the Italian elderly (who carry the major disease burden) received the available vaccines according to their age and risk profile.

METHODS

A novel budget impact model was constructed with a time horizon of one influenza season. In the reference scenario the cohort of Italian elderly individuals could receive either available vaccine according to 2017/18 season market share. The alternative scenario envisaged the administration of TIV/QIV to people aged 65-74 years and at low risk of developing influenza-related complications, while aTIV/idTIV were allocated to high-risk 65-74-year-olds and all subjects aged ≥ 75 years.

RESULTS

Switching to the alternative scenario would result in both significant health benefits and net budget savings. Particularly, it would be possible to prevent an additional 8201 cases of laboratory-confirmed influenza, 988 complications, 355 hospitalizations and 14 deaths. Despite the alternative strategy being associated with slightly higher vaccination costs, the total savings derived from fewer influenza events completely resets this increase with net budget savings of € 0.13 million.

CONCLUSIONS

An immunization policy in which influenza vaccines are administered according to the age and risk profile of Italian elderly individuals is advisable.

Economic benefits of sharing and redistributing influenza vaccines when shortages occurred

Background

Recurrent influenza outbreak has been a concern for government health institutions in Taiwan. Over 10% of the population is infected by influenza viruses every year, and the infection has caused losses to both health and the economy. Approximately three million free vaccine doses are ordered and administered to high-risk populations at the beginning of flu season to control the disease. The government recommends sharing and redistributing vaccine inventories when shortages occur. While this policy intends to increase inventory flexibility, and has been proven as widely valuable, its impact on vaccine availability has not been previously reported.

Material and methods

This study developed an inventory model adapted to vaccination protocols to evaluate government recommended polices under different levels of vaccine production. Demands were uncertain and stratified by ages and locations according to the demographic data in Taiwan.

Results

When vaccine supply is sufficient, sharing pediatric vaccine reduced vaccine unavailability by 43% and overstock by 54%, and sharing adult vaccine reduced vaccine unavailability by 9% and overstock by 15%. Redistributing vaccines obtained greater gains for both pediatrics and adults (by 75%). When the vaccine supply is in short, only sharing pediatric vaccine yielded a 48% reduction of unused inventory, while other polices do not improve performances.

Conclusions

When implementing vaccination activities for seasonal influenza intervention, it is important to consider mismatches of demand and vaccine inventory. Our model confirmed that sharing and redistributing vaccines can substantially increase availability and reduce unused vaccines.

Pricing Externalities to Balance Public Risks and Benefits of Research

How should scientific funders evaluate research with public health risks? Some risky work is valuable, but accepting too much risk may be ethically neglectful. Recent controversy over H5N1 influenza experiments has highlighted the difficulty of this problem. Advocates of the research claim the work is needed to understand pandemics, while opponents claim that accidents or misuse could release the very pandemic the work is meant to prevent. In an attempt to resolve the debate, the US government sponsored an independent evaluation that successfully produced a quantitative estimate of the risks involved, but only a qualitative estimate of the benefits. Given the difficulties of this “apples-to-oranges” risk-benefit analysis, what is the best way forward? Here we outline a general approach for balancing risks and benefits of research with public risks. Instead of directly comparing risks and benefits, our approach requires only an estimate of risk, which is then translated into a financial price. This estimate can be obtained either through a centrally commissioned risk assessment or by mandating liability insurance, which allows private markets to estimate the financial burden of risky research. The resulting price can then be included in the cost of the research, enabling funders to evaluate grants as usual—comparing the scientific merits of a project against its full cost to society. This approach has the advantage of aligning incentives by assigning costs to those responsible for risks. It also keeps scientific funding decisions in the hands of scientists, while involving the public on questions of values and risk experts on risk evaluation.

How should scientific funders evaluate research with public health risks? Some risky work is valuable, but accepting too much risk may be ethically neglectful. Recent controversy over H5N1 influenza experiments has highlighted the difficulty of this problem. The authors outline a general approach for balancing risks and benefits of research with public risks.

Cost-effectiveness of molecular point-of-care testing for influenza viruses in elderly patients at ambulatory care setting

Background

Early initiation of antiviral therapy in elderly patients with influenza is associated with reduced risk of extra clinic visit, hospitalization and death. This study examined the cost-effectiveness of molecular POCT for detection of influenza viruses in Hong Kong elderly patients with influenza-like illness (ILI) in the outpatient clinics.

Methods

A decision analytic model was used to simulate outcomes of a hypothetical cohort of elderly patients presented with ILI at outpatient clinics during peak season of influenza with two diagnostic approaches: Rapid molecular assay (POCT-PCR group) and clinical judgement with no POCT. Outcome measures included influenza-associated direct medical cost, hospitalization and mortality rates, quality-adjusted life year loss (QALY loss), and incremental cost per QALY saved (ICER).

Results

In base-case analysis, POCT-PCR group was expected to reduce hospitalization (1.38% versus 2.85%) and mortality rate (0.08% versus 0.16%) and save 0.00112 QALYs at higher cost (by USD33.2 per ILI patient), comparing with clinical judgement group. The ICER of POCT-PCR was 29,582 USD/QALY saved. One-way sensitivity analyses found ICER sensitive to: Hospitalization rate without prompt antiviral therapy; odds ratio of hospitalization with prompt therapy; influenza prevalence; patient age and mortality rate of hospitalized patients. POCT-PCR was cost-effective in 60.6% and 99.4% of 10,000 Monte Carlo simulations at willingness-to-pay threshold of 1x and 3x gross domestic product per capita of Hong Kong, respectively.

Conclusions

Molecular POCT for influenza detection in elderly patients with ILI at outpatient clinics during peak influenza season appeared to be cost-effective in Hong Kong.

Cost-effectiveness analysis of N95 respirators and medical masks to protect healthcare workers in China from respiratory infections

BACKGROUND

There are substantial differences between the costs of medical masks and N95 respirators. Cost-effectiveness analysis is required to assist decision-makers evaluating alternative healthcare worker (HCW) mask/respirator strategies. This study aims to compare the cost-effectiveness of N95 respirators and medical masks for protecting HCWs in Beijing, China.

METHODS

We developed a cost-effectiveness analysis model utilising efficacy and resource use data from two cluster randomised clinical trials assessing various mask/respirator strategies conducted in HCWs in Level 2 and 3 Beijing hospitals for the 2008-09 and 2009-10 influenza seasons. The main outcome measure was the incremental cost-effectiveness ratio (ICER) per clinical respiratory illness (CRI) case prevented. We used a societal perspective which included intervention costs, the healthcare costs of CRI in HCWs and absenteeism costs.

RESULTS

The incremental cost to prevent a CRI case with continuous use of N95 respirators when compared to medical masks ranged from US $490-$1230 (approx. 3000-7600 RMB). One-way sensitivity analysis indicated that the CRI attack rate and intervention effectiveness had the greatest impact on cost-effectiveness.

CONCLUSIONS

The determination of cost-effectiveness for mask/respirator strategies will depend on the willingness to pay to prevent a CRI case in a HCW, which will vary between countries. In the case of a highly pathogenic pandemic, respirator use in HCWs would likely be a cost-effective intervention.

Evaluation of Unintended Social and Economic Consequences of an Unplanned School Closure in Rural Illinois

BACKGROUND

School closure is one of the primary measures considered during severe influenza pandemics and other emergencies. However, prolonged school closures may cause unintended adverse consequences to schools, students, and their families. A better understanding of these consequences will inform prepandemic planning, and help public health and education authorities in making informed decisions when considering school closures.

METHODS

We conducted a household survey and interviewed school officials following an 8-day long closure of a school district in rural Illinois. We described household responses regarding difficulties of school closure, and summarized main themes from school official interviews.

RESULTS

A total of 208 (27%) household surveys were completed and returned. This school closure caused difficulties to 36 (17%) households; uncertain duration of closure, childcare arrangements, and lost pay were the most often reported difficulties. Having 1 adult in the household losing pay and household income below $25,000 were significantly associated with overall difficulty during this school closure. Concern about student health and safety was the most frequent theme in school administrator interviews.

CONCLUSIONS

Whereas the majority of responding households did not report difficulties during this school closure, households with 1 adult losing pay during the closure reported incurring additional expenses for childcare.

Protecting an island nation from extreme pandemic threats: Proof-of-concept around border closure as an intervention

Background

Countries are well advised to prepare for future pandemic risks (e.g., pandemic influenza, novel emerging agents or synthetic bioweapons). These preparations do not typically include planning for complete border closure. Even though border closure may not be instituted in time, and can fail, there might still plausible chances of success for well organized island nations.

Objective

To estimate costs and benefits of complete border closure in response to new pandemic threats, at an initial proof-of-concept level. New Zealand was used as a case-study for an island country.

Methods

An Excel spreadsheet model was developed to estimate costs and benefits. Case-study specific epidemiological data was sourced from past influenza pandemics. Country-specific healthcare cost data, valuation of life, and lost tourism revenue were imputed (with lost trade also in scenario analyses).

Results

For a new pandemic equivalent to the 1918 influenza pandemic (albeit with half the mortality rate, “Scenario A”), it was estimated that successful border closure for 26 weeks provided a net societal benefit (e.g., of NZ$11.0 billion, USD$7.3 billion). Even in the face of a complete end to trade, a net benefit was estimated for scenarios where the mortality rate was high (e.g., at 10 times the mortality impact of “Scenario A”, or 2.75% of the country’s population dying) giving a net benefit of NZ$54 billion (USD$36 billion). But for some other pandemic scenarios where trade ceased, border closure resulted in a net negative societal value (e.g., for “Scenario A” times three for 26 weeks of border closure–but not for only 12 weeks of closure when it would still be beneficial).

Conclusions

This “proof-of-concept” work indicates that more detailed cost-benefit analysis of border closure in very severe pandemic situations for some island nations is probably warranted, as this course of action might sometimes be worthwhile from a societal perspective.

A systematic review of economic evaluations of seasonal influenza vaccination for the elderly population in the European Union

OBJECTIVES

The Council of the European Union (EU) has recommended that action should be taken to increase influenza vaccination in the elderly population. The aims were to systematically review and critically appraise economic evaluations for influenza vaccination in the elderly population in the EU.

METHODS

Electronic searches of the NHS Economic Evaluation, Health Technology Assessment, MEDLINE and Embase databases were run to identify full economic evaluations. Two levels of screening were used, with explicit inclusion criteria applied by two independent reviewers at each stage. Prespecified data extraction and critical appraisal were performed on identified studies. Results were summarised qualitatively.

RESULTS

Of the 326 search results, screening identified eight relevant studies. Results varied widely, with the incremental cost-effectiveness ratio ranging from being both more effective and cheaper than no intervention to costing €4 59 350 per life-year gained. Cost-effectiveness was most sensitive to variations in influenza strain, vaccination type and strategy, population and modelling characteristics.

CONCLUSIONS

Most studies suggest that vaccination is cost-effective (seven of eight studies identified at least one cost-effective scenario). All but one study used economic models to synthesise data from different sources. The results are uncertain due to the methods used and the relevance and robustness of the data used. Sensitivity analysis to explore these aspects was limited. Integrated, controlled prospective clinical and economic evaluations and surveillance data are needed to improve the evidence base. This would allow more advanced modelling techniques to characterise the epidemiology of influenza more accurately and improve the robustness of cost-effectiveness estimates.

Value for Money in H1N1 Influenza: A Systematic Review of the Cost-Effectiveness of Pandemic Interventions

BACKGROUND

The 2009 A/H1N1 influenza pandemic generated additional data and triggered new studies that opened debate over the optimal strategy for handling a pandemic. The lessons-learned documents from the World Health Organization show the need for a cost estimation of the pandemic response during the risk-assessment phase. Several years after the crisis, what conclusions can we draw from this field of research?

OBJECTIVE

The main objective of this article was to provide an analysis of the studies that present cost-effectiveness or cost-benefit analyses for A/H1N1 pandemic interventions since 2009 and to identify which measures seem most cost-effective.

METHODS

We reviewed 18 academic articles that provide cost-effectiveness or cost-benefit analyses for A/H1N1 pandemic interventions since 2009. Our review converts the studies' results into a cost-utility measure (cost per disability-adjusted life-year or quality-adjusted life-year) and presents the contexts of severity and fatality.

RESULTS

The existing studies suggest that hospital quarantine, vaccination, and usage of the antiviral stockpile are highly cost-effective, even for mild pandemics. However, school closures, antiviral treatments, and social distancing may not qualify as efficient measures, for a virus like 2009's H1N1 and a willingness-to-pay threshold of $45,000 per disability-adjusted life-year. Such interventions may become cost-effective for severe crises.

CONCLUSIONS

This study helps to shed light on the cost-utility of various interventions, and may support decision making, among other criteria, for future pandemics. Nonetheless, one should consider these results carefully, considering these may not apply to a specific crisis or country, and a dedicated cost-effectiveness assessment should be conducted at the time.