title: Systematic review of the cost-effectiveness of influenza immunization programs.
abstract: Seasonal influenza immunization programs vary widely across jurisdictions. In Canada, some provinces offer universal programs while others target specific population groups. However, whether targeted or universal programs provide more benefit and value-for-money is unclear. The cost-effectiveness of influenza immunization programs was systematically reviewed to inform policy.
  
  
  
  Citation databases and the grey literature were searched for economic evaluations of influenza immunization programs. Eligible studies were appraised using the Scottish Intercollegiate Guidelines Network (SIGN) checklist with supplemental WHO vaccine-related questions. Data from high quality studies was extracted and the studies reviewed.
  
  
  
  A total of 41influenza immunization studies were identified. Of these, 31 were high quality. For pregnant and postpartum women, vaccinating all versus only high risk women study results ranged from dominance (less costly and more effective) to $9773 per QALY gained (societal) and from dominance to $58,000 per QALY gained (healthcare system). Studies of vaccinating all versus only high risk children found vaccination to be dominant to $47,000 per QALY gained (societal), and dominant to $18,000 per QALY gained (healthcare system). Vaccinating high risk adults was highly cost-effective and vaccinating health care workers resulted in $35,000 per QALY gained. Results for healthy working adults were mixed and sensitive to vaccine uptake, efficacy, and productivity loss.
  
  
  
  From the societal perspective, vaccination was cost-effective for children, pregnant and postpartum women, high risk groups, and in some cases, healthy working age adults. Immunization programs using group administration are more cost-effective than programs using individual administration. The perspective, programmatic design, setting, and inclusion of herd immunity affects cost-effectiveness. In regions with targeted programs, re-evaluating "high risk" criteria and consideration of a universal program is warranted.
authors.affiliation: Institute of Health Policy, Management & Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, ON M5T 3M6, Canada; Program of Child Health Evaluative Sciences, The Hospital for Sick Children Peter Gilgan Centre for Research and Learning, 11th floor, 686 Bay Street, Toronto, ON M5G 0A4, Canada; AstraZeneca Canada Inc., 1004 Middlegate Road, Mississauga, ON L4Y 1M4, Canada.
authors.forename: Eon E K
authors.initials: EEK
authors.lastname: Ting
authors.affiliation: Institute of Health Policy, Management & Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, ON M5T 3M6, Canada; Public Health Ontario, #300 - 480 University Avenue, Toronto, ON M5G 1V2, Canada.
authors.forename: Beate
authors.initials: B
authors.lastname: Sander
authors.affiliation: Institute of Health Policy, Management & Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, ON M5T 3M6, Canada; Program of Child Health Evaluative Sciences, The Hospital for Sick Children Peter Gilgan Centre for Research and Learning, 11th floor, 686 Bay Street, Toronto, ON M5G 0A4, Canada. Electronic address: wendy.ungar@sickkids.ca.
authors.forename: Wendy J
authors.initials: WJ
authors.lastname: Ungar
mesh_terms: D002170:Canada / Q000453:epidemiology; D003362:Cost-Benefit Analysis; D006801:Humans; D017589:Immunization Programs / Q000191:economics*; D007251:Influenza, Human / Q000191:economics* / Q000453:epidemiology / Q000517:prevention & control*
keywords: Adults; Children; Cost-effectiveness; High-risk; Influenza immunization; Pregnant women