Abstract
Objective
Influenza vaccination rates remain far below national goals in the US. Expanding influenza vaccination in non-traditional settings such as worksites and pharmacies may be a way to enhance vaccination coverage for adults, but scant data exist on the cost effectiveness of this strategy. The aims of this study were to (i) describe the costs of vaccination in non-traditional settings such as pharmacies and mass vaccination clinics; and (ii) evaluate the projected health benefits, costs and cost effectiveness of delivering influenza vaccination to adults of varying ages and risk groups in non-traditional settings compared with scheduled doctor’s office visits. All analyses are from the US societal perspective.
Methods
We evaluated the costs of influenza vaccination in non-traditional settings via detailed telephone interviews with representatives of organizations that conduct mass vaccination clinics and pharmacies that use pharmacists to deliver vaccinations. Next, we constructed a decision tree to compare the projected health benefits and costs of influenza vaccination delivered via non-traditional settings or during scheduled doctor’s office visits with no vaccination. The target population was stratified by age (18–49, 50–64 and ≥65 years) and risk status (high or low risk for influenza-related complications). Probabilities and costs (direct and opportunity) for uncomplicated influenza illness, outpatient visits, hospitalizations, deaths, vaccination and vaccine adverse events were derived from primary data and from published and unpublished sources.
Results
The mean cost (year 2004 values) of vaccination was lower in mass vaccination ($US17.04) and pharmacy ($US11.57) settings than in scheduled doctor’s office visits ($US28.67). Vaccination in non-traditional settings was projected to be cost saving for healthy adults aged ≥50 years, and for high-risk adults of all ages. For healthy adults aged 18–49 years, preventing an episode of influenza would cost $US90 if vaccination were delivered via the pharmacy setting, $US210 via the mass vaccination setting and $US870 via a scheduled doctor’s office visit. Results were sensitive to assumptions on the incidence of influenza illness, the costs of vaccination (including recipient time costs) and vaccine effectiveness.
Conclusion
Using non-traditional settings to deliver routine influenza vaccination to adults is likely to be cost saving for healthy adults aged 50–64 years and relatively cost effective for healthy adults aged 18–49 years when preferences for averted morbidity are included.
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References
US Department of Health and Human Services.Office of Disease Prevention and Health Promotion. Healthy People 2010 [online]. Available from URL: http:/Avww.healthypeople.gov [Accessed 2007 Nov 26]
Thompson WW, Shay D, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 2003; 289 (2): 179–186
Thompson WW, Shay D, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA 2004; 292 (11): 1333–1340
Smith NM, Shay D, Uyeki TM, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP) [published erratum appears in MMWR Morb Mortal Wkly Rep 2006; 55 (29): 800]. MMWR Recomm Rep 2006; 55 (RR-10): 142
Alios BM, Bresee JS. Influenza vaccine session introduction. Advisory Committee on Immunization Practices; 2006 Oct 25; Atlanta (GA)
Singleton JA, Poel AJ, Lu P-J, et al. Where adults reported receiving influenza vaccination in the United States. Am J Infect Control 2005; 33: 563–570
Coleman MS, Fontanesi J, Meltzer MI, et al. Estimating medical practice expenses from administering adult influenza vaccinations. Vaccine 2005; 23: 915–923
Hebert PL, Frick KD, Kane RL, et al. The causes of racial and ethnic differences in influenza vaccination rates among elderly Medicare beneficiaries. HSR 2005; 40 (2): 517–537
US Department of Labor, Bureau of Labor Statistics. National compensation survey: occupational wages in the United States, July 2003 [online]. Available from URL: http://www.bls.gov/ncs/ocs/sp/ncbl0658.pdf [Accessed 2007 Nov 21]
Cornelius L, Beauregard K, Cohen J. Usual sources of medical care and their characteristics. National Medical Expenditure Survey Research Findings 11. AHCPR Publication No. 90-00042. Rockville (MD): Agency for Health Care Policy and Research, Public Health Service, 1991
Edwards KM, Dupont WD, Westrich MK, et al. A randomized controlled trial of cold-adapted and inactivated vaccines for the prevention of influenza A disease. J Infect Dis 1994; 169: 68–76
Bridges CB, Thompson WW, Meltzer MI, et al. Effectiveness and cost-benefit of influenza vaccination of healthy working adults: a randomized controlled trial. JAMA 2000; 284 (13): 1655–1663
Keitel WA, Cate TR, Couch RB, et al. Efficacy of repeated annual immunization with inactivated influenza virus vaccines over a five year period. Vaccine 1997; 15 (10): 1114–1122
Gorse GJ, O’Connor fTZ, Young SL, et al. Efficacy trial of live, cold-adapted and inactivated influenza virus vaccines in older adults with chronic obstructive pulmonary disease: a VA cooperative study. Vaccine 2003; 21 (17-18): 2133–2144
Govaert TME, Thijs CTMCN, Masurel N, et al. The efficacy of influenza vaccination in elderly individuals. JAMA 1994; 272 (21): 1661–1665
Nichol KL, Mendelman P, Mallon KP, et al. Effectiveness of live, attenuated intranasal influenza virus vaccine in healthy, working adults: a randomized controlled trial. JAMA 1999; 282 (2): 137–144
Nichol KL, Lind A, Margolis KL, et al. The effectiveness of vaccination against influenza in healthy, working adults. N Engl J Med 1995: 333 (14): 889–893
Nichol KL, Wuorenma J, Von Sternberg T. Benefits of influenza vaccination for low-, intermediate-, and high-risk senior citizens. Arch Intern Med 1998; 158 (16): 1769–1776
Hak E, Nordin J, Wei F, et al. Influence of high-risk medical conditions on the effectiveness of influenza vaccination among elderly members of 3 large managed-care organizations. Clin Infect Dis 2002; 35: 370–377
Meltzer MI, Cox NJ, Fukuda K. The economic impact of pandemic influenza in the United States: priorities for intervention. Emerg Infect Dis 1999; 5 (5): 659–671
Nichol KL, Nordin J, Mullooly J, et al. Influenza vaccination and reduction in hospitalizations for cardiac disease and stroke among the elderly. N Engl J Med 2003; 348 (14): 1322–1332
Gross PA, Hermogenes AW, Sacks HS, et al. The efficacy of influenza vaccine in elderly persons: a meta-analysis and review of the literature. Ann Intern Med 1995; 123 (7): 518–527
Armstrong BG, Mangtani P, Fletcher A, et al. Effect of influenza vaccination on excess deaths occurring during periods of high circulation of influenza: cohort study in elderly people. BMJ 2004; 329: 660–663
Nichol KL, Margolis KL, Lind A, et al. Side effects associated with influenza vaccination in healthy working adults: a randomized, placebo-controlled trial. Arch Intern Med 1996; 156 (14): 1546–1550
Halperin SA, Smith B, Mabrouk T, et al. Safety and immunogenicity of a trivalent, inactivated, mammalian cell culture-derived influenza vaccine in healthy adults, seniors, and children. Vaccine 2002; 20 (7–8): 1240–1247
Scheifele DW, Bjornson G, Johnston J. Evaluation of adverse events after influenza vaccination in hospital personnel. CMAJ 1990; 14 (2): 127–130
Treanor JJ, Kotloff K, Betts RF, et al. Evaluation of trivalent, live, cold-adapted (CAIV-T) and inactivated (TIV) influenza vaccines in prevention of virus infection and illness following challenge of adults with wild-type influenza A (H1N1), A (H3N2), and B viruses. Vaccine 1999; 18 (9–10): 899–906
Margolis KL, Nichol KL, Poland GA, et al. Frequency of adverse reactions to influenza vaccine in the elderly: a randomized, placebo-controlled trial [published erratum appears in JAMA 1991 Jun 5; 265 (21): 2810]. JAMA 1990; 264 (9): 1139–1141
Retailliau HF, Curtis AC, Storr G, et al. Illness after influenza vaccination reported through a nationwide surveillance system, 1976–1977. Am J Epidemiol 1980; 111: 270–278
Institute of Medicine of the National Academies: Immunization Safety Review Committee BoHPaDP. Immunization safety review: influenza vaccines and neurological complications. Washington, DC: The National Academies Press, 2004
Molinari NA, Ortega-Sanchez IR, Messonnier ML, et al. The annual impact of seasonal influenza in the US: measuring disease burden and costs. Vaccine 2007; 25 (27): 5086–5096
Grosse SD. Prevention effectiveness: a guide to decision analysis and economic evaluation [appendix I: productivity loss tables]. 2nd ed. New York: Oxford University Press, 2003: 245–257
Nichol KL. Clinical effectiveness and cost effectiveness of influenza vaccination among healthy working adults. Vaccine 1999; 17: S67–S73
Nichol KL. The efficacy, effectiveness and cost-effectiveness of inactivated influenza virus vaccines. Vaccine 2003; 21: 1769–1775
Simonsen L, Reichert TA, Viboud C, et al. Impact of influenza vaccination on seasonal mortality in the US elderly population. Arch Intern Med 2005; 165 (3): 265–272
Viscusi WK, Aldy JE. The value of a statistical life: a critical review of market estimates throughout the world. J Risk Uncertainty 2003: 27 (1): 5–76
Weinstein MC, O’Brien B, Hornberger M, et al. Principles of good practice for decision analytic modeling in health-care evaluation: report of the ISPOR Task Force on Good Research Practices. Modeling studies. Value Health 2003; 6 (1): 9–17
Hunink MGM, Glasziou PP, Siegel JE, et al. Decision making in health and medicine: integrating evidence and values. New York: Cambridge University Press, 2001
US Department of Health and Human Services. Influenza and pneumococcal vaccination coverage among persons aged > 65 years: United States, 2004–2005. MMWR Morb Mortal Wkly Rep 2006; 55 (39): 1065–1068
Turner D, Wailoo A, Nicholson K, et al. Systematic review and economic decision modelling for the prevention and treatment of influenza A and B. Health Technol Assess (Rockv) 2003; 7 (15): 1–178
Demicheli V, Rivetti D, Deeks J, et al. Vaccines for preventing influenza in healthy adults. Cochrane Database Syst Rev 2004; (3): CD001269
Reuer J, Brown C, Eulger GL, et al. Factors associated with where people go for their influenza vaccination. National Immunization Program Conference; 2004 May 12; Atlanta (GA)
Prosser LA, Bridges CB, Uyeki TM, et al. Values for preventing influenza-related morbidity and vaccine adverse events in children. Health Qual Life Outcomes 2005; 3 (18): 1–16
Lee PY, Matchar DB, Clements DA, et al. Economic analysis of influenza vaccination and antiviral treatment for healthy working adults. Ann Intern Med 2002; 137: 225–231
Nichol KL, Mallon KP, Mendelman PM. Cost benefit of influenza vaccination in healthy, working adults: an economic analysis based on the results of a clinical trial of trivalent live attenuated influenza virus vaccine. Vaccine 2003; 21: 2207–2217
Jackson LA, Jackson ML, Nelson JC, et al. Evidence of bias in estimates of influenza vaccine effectiveness in seniors. Int J Epidemiol 2006; 35 (2): 337–344
Bearden DT, Holt T. Statewide impact of pharmacist-delivered adult influenza vaccinations. Am J Prev Med 2005; 29 (5): 450–452
Acknowledgements
We would like to acknowledge Dr Pascale Wortley for helpful comments throughout the course of this project, and Andra Barnette and Christina Kara for expert administrative assistance. We are especially grateful to our expert panel who assisted in the development of input assumptions: Drs Carolyn Bridges, Paul Glezen, Kathleen Neuzil and Gregory Poland.
Dr Nichol has served as a consultant, or on medical advisory boards, for MedImmune, GSK, Novartis and Sanofi Pasteur. Dr Nichol has also received research grants from Sanofi Pasteur and GSK.
Funding for this study was provided by the Centers for Disease Control and Prevention through the Harvard/CDC Joint Initiative in Vaccine Economics. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
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Prosser, L.A., O’Brien, M.A., Molinari, NA.M. et al. Non-Traditional Settings for Influenza Vaccination of Adults. Pharmacoeconomics 26, 163–178 (2008). https://doi.org/10.2165/00019053-200826020-00006
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DOI: https://doi.org/10.2165/00019053-200826020-00006