Potential Cost Savings Attributable to Influenza Vaccination of
School-aged Children
Terry White*; Suzanne Lavoie, MD*‡; and Mary D. Nettleman, MD, MS*
ABSTRACT. Objective. To analyze the costs and benefits of influenza vaccination of healthy school-aged children.
Design. The analysis was based on data from the literature. Total costs included direct medical costs for vaccination, physician visits, and treatment as well as indirect costs. Indirect costs were in the form of lost
productivity when working parents stayed home to care
for ill children or to take children to an office for vaccination. The total costs of vaccination strategies were compared with the total cost of not vaccinating. For the base
case, the vaccine was assumed to have no effect on rates
of otitis media.
Setting. Two hypothetical scenarios were investigated 1) individual-initiated vaccination and 2) vaccination in a group-based setting. The former scenario required the child to be accompanied to a clinic by a parent
during usual work hours.
Results. Vaccination resulted in a net savings per
child vaccinated of $4 for individual-initiated vaccination and of $35 for group-based vaccination. The savings
were caused primarily by averted indirect costs. Moderate increases in the cost of vaccination or reductions in
the rate of influenza would eliminate the savings for
individual-initiated vaccination but not for group-based
vaccination. Alternatively, if influenza vaccination was
effective in reducing rates of otitis media, the net savings
from vaccination would be substantially higher than the
base case.
Conclusion. Vaccination of school-aged children
against influenza could have substantial financial benefits to society, especially if performed in a group-based
setting. Pediatrics 1999;103(6). URL: http://www.
pediatrics.org/cgi/content/full/103/6/e73; influenza, costeffectiveness, vaccination, children, cost.
I
nfluenza causes illness among all age groups with
significant mortality among the elderly and other
high-risk groups. A secondary effect of influenza
is its ability to disrupt communities by causing
school and work-place absenteeism.1,2 This lost productivity, the indirect costs of influenza, creates a
substantial cost to our society.
Numerous studies have suggested that immunization in communities would not only prevent infection but would also reduce the indirect economic
costs. For example, recent studies have documented
the cost-effectiveness of vaccination of healthy working adults and in the elderly.2,3
Considering the public health and economic problems that are associated with influenza, vaccination
of school-aged children may help control the spread
of disease and reduce the economic costs. There are
several reasons to consider vaccination of children.
Although children are at low risk for complications
of influenza, the disease causes them discomfort and
often requires them to stay home from school.1,4 Time
lost from school attributable to illness can result in
missed learning opportunities. Infection rates are
much higher in children than in adults.5–7 Moreover,
children are efficient spreaders of the disease and a
major factor in the introduction of influenza into
households.8 Finally, working parents may have to
stay home to care for a sick child, resulting in lost
productivity. Vaccinating healthy workers would
not eliminate the lost productivity caused by caring
for ill children.
We investigated the cost of vaccinating school children in two hypothetical settings 1) a relatively inefficient system in which individuals schedule appointments for their children at physician offices
during the parent or guardian’s normal work hours
and 2) a relatively efficient system in which children
are vaccinated in a group setting that does not require parents to take time off from work. An example
of the latter scenario could be a health fair or schoolbased vaccination.
METHODS
The population was to be made up of school-aged children in
kindergarten through grade 12. The cost of each vaccination strategy was compared with a nonvaccination strategy to obtain the
net cost. Results were expressed as the net cost (or net savings) per
vaccine recipient. Net cost included direct and indirect costs.
Indirect costs included the time lost from work by working parents. Time was lost from work when working parents stayed
home with ill children and when the disease was transmitted to a
parent from the child. Under the individual-initiated vaccination
strategy, time was lost from work when a working parent had to
visit a physician’s office or clinic to get the child vaccinated. In the
following description, the terms “parent,” “mother,” or “father”
refer to a parent, guardian, or other adult who is a primary
caretaker of the child.
Direct Cost of Vaccination
From the Departments of *Internal Medicine and ‡Pediatrics, Virginia Commonwealth University School of Medicine, Richmond, Virginia.
Received for publication Oct 26, 1998; accepted Jan 25, 1999.
Reprint requests to (M.D.N.) Box 980102, Richmond, VA 23298. E-mail:
[email protected]
PEDIATRICS (ISSN 0031 4005). Copyright © 1999 by the American Academy of Pediatrics.
The cost of influenza vaccination has been reported to be as low
as $43 including the costs of the vaccine, supplies, advertising,
mailings, personnel, and administrative costs. This figure was the
cost to a staff-model health maintenance organization for influenza vaccination of enrollees attending the doctor’s offices. In
another study, these same costs were found to total $10 per
recipient6 when patients were recruited through advertisements to
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PEDIATRICS Vol. 103 No. 6 June 1999
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attend an outpatient clinic. For the purposes of this analysis, the
more conservative $10 figure was used to represent the cost of an
individual-initiated physician office visit for influenza vaccination. It was assumed that the group-based vaccination strategy
would be more efficient and that the direct cost of vaccination
would be $4 per dose.3 Sensitivity analysis was performed to
determine the effect of increased vaccine costs on the analysis.
It was assumed that unvaccinated children ,9 years of age9
would require an initial vaccination series consisting of 2 doses. In
subsequent years, it was assumed that only a single vaccination
was required. To be conservative, it was assumed that no child
had received previously the primary series. This had the effect of
increasing the average cost of the vaccine per child by 1/13. Other
costs and probabilities were derived from the literature (Table 1).
Other Direct Costs
Direct costs included the cost of a physician visit for the ill
children and for the secondary contacts that sought medical care.
According to the National Health Interview Survey, a physician
was contacted during 32.5% of influenza illnesses in school-aged
children, but only 83.3% of these contacts were face-to-face visits.10
Thus, it was assumed that a face-to-face physician visit occurred
during 27.1% of all influenza cases in school-aged children. The
cost of the visit was assumed to be $51 based on the cost of an
average visit to a pediatrician.11 The cost for adults to visit a
physician was assumed to be $69.51,2 and 27.1% of ill adults were
assumed to visit a physician.10
Indirect Costs
Indirect costs included time lost from work that accrued when
an employed caretaker had to stay home with an ill child. The
National Health Interview study found that there were .793 school
days lost per school-aged child annually attributable to influenza.10 This is nearly identical to the findings of a randomized,
placebo-controlled trial that found that unvaccinated children
missed .79 days of school per year because of influenza illness.1
The .793 figure was adopted for this analysis and represented the
average burden of illness in the population; children with influenza-associated illness would have more lost school days and
uninfected children would not miss school because of influenza.
It was assumed that all infected children required an adult
caretaker to stay home with them. Sometimes, the caretaker might
not be used in which case no indirect costs were incurred. For the
purposes of the analysis, it was assumed that the mother (or
another female caretaker) would be the primary caretaker of an ill
child. This choice provided a conservative estimate of time lost
from work because a higher proportion of mothers do not earn
wages, and wages for women are lower than for men. Wages were
assumed to be lost when employed mothers had to stay home
with sick children. No indirect costs were incurred when an
unemployed mother cared for a sick child. The effect of unpaid
caretakers being available to some working mothers was examined by sensitivity analysis.
Of mothers with school-aged children, ;76% work, although a
quarter of these mothers only work part-time.12 It was assumed
that the mother would stay home when the child became too ill to
send to school. The cost of a lost day’s work was assumed to be
$85.40 based on the average salary for women.12 Part time workers
were assumed to lose only half as much salary as full time workers. Unemployed mothers were assumed not to incur any wage
loss from caring for an ill child.
TABLE 1.
The individual-initiated vaccination strategy involved vaccination of children in a physician’s office during regular work hours.
In families in which the mother worked full-time, it was assumed
that 4 hours of wages would be lost if vaccinations were provided
in a physician’s office. This provided a conservative estimate of
the cost of vaccination. Lower costs would be possible if physicians provided evening hours or if mothers had unpaid caretakers
available to accompany their child.
It is certainly possible that an employed male in the household
might take off work to be with a sick child rather than a woman.
However, we used the salary of working women rather than
working men to provide a more conservative estimate of the
indirect costs of influenza.
We assumed that if the mother worked, she had no source of
free child care in the household and that she would have to take
off work to care for a sick school-aged child. This may not be
strictly true. In some cases, an unemployed family member or
friend might be available to take care of a sick child while the
mother continued working. However, national estimates on this
possibility were not available. We chose to examine this effect in
the sensitivity analysis by varying the proportion of women who
would have to take time off from work.
Indirect costs also included the time lost from work attributable
to secondary transmission to an employed adult. A sick adult with
influenza was assumed to take 1.5 days off work.10 For the purposes of the baseline analysis, two groups were assumed to be at
risk for time lost from work attributable to secondary transmission
1) working mothers of ill children and 2) working fathers in the
72% of households in which a married couple was present. When
fathers were present in the household, it was assumed that 97%
would be employed.12
Probabilities
In the United States, annual influenza rates range from 10% to
20% of the general population, but the rate is much higher in
children.13 For this analysis, the annual incidence of influenza in
children was taken from a prospective study and was 47.7/100
school-aged children ,11 years of age, and 40/100 between the
ages of 11 and 17 years.14 These numbers correlate well with
results from the National Health Interview Survey of 45 705 US
households10 that found an average rate of 46.3/100 children per
year. Other longitudinal studies have found that 40% to 54% of
school children acquired the infection.15 Lower infection rates may
be present in some years or in some settings. The effect of lower
rates was investigated by sensitivity analysis.
Studies to investigate the efficacy of the vaccine have used
various methodologies resulting in a range of values. The ability
of the vaccine to prevent infection, influenza-type symptoms, and
missed school days has been studied. The inactivated influenza
vaccine has been shown to be up to 80% to 90% effective in
preventing infection in children.16 –18 However, not all infections
are symptomatic enough to result in missed school days. Two
recent studies found that influenza vaccination reduced missed
school days by 56%1 and 75%.4 Similarly, the inactivated vaccine
was found to be 62% to 73% effective in preventing influenza-type
illness in school-aged children.19 –21 However, Nichol et al2 found
the vaccine to reduce missed work days by only 43% in adults. For
our analysis, the vaccine was assumed to be 56% effective. The
effect of varying this number from 43% to 75% was investigated by
sensitivity analysis.
The side effects from vaccination of healthy working adults are
Key Assumptions
Cost of individual-initiated vaccination
Cost of vaccination in a group setting
Proportion of children requiring a 2-dose initial series
Efficacy of vaccine
Base case
Best case
Worst case
Risk of transmission from an infected child to an adult in household
Proportion of households with 2 parents
Probability that mother is employed
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Base Estimate
Reference
$10
$4
1/13
2
3
9
56%
75%
43%
18%
72%
76%
1
4
2
23
24
12
minor.2 We assumed that no costs would be incurred from vaccine
side effects. Low-grade fever is the most common reported side
effect.22 Sensitivity analysis was used to investigate the impact on
results if all children with low-grade fevers stayed home from
school for 1 day. The risk of Guillan Barré in vaccine recipients
,45 years of age was found recently to be 0.23 Sensitivity analysis
was used to investigate the impact of a rate of Guillan Barré that
was similar to the rate in older adults: 1 case per million recipients.
The risk of transmitting influenza from an ill child to an adult
contact was assumed to be 18% based on a prospective study by
Hayden and colleagues24 that was confirmed by older studies.25
This transmission rate seems low because some adults would have
already acquired the infection outside the home, and others would
be immune or semiimmune.
In 1997, married couples made up 72% of all households with
families.26 For these households, it was assumed that 2 adults per
household would be at risk to acquire influenza from an infected
child. For all other households, only 1 adult was assumed to be at
risk.
Influenza vaccination may also prevent otitis media infections.
However, there are no prospective studies of the effect of influenza vaccination on the incidence of otitis media in school-aged
children. For the purposes of the base case analysis, the vaccine
was postulated to have no effect on the incidence of otitis in
school-aged children. This assumption was investigated by sensitivity analysis.
RESULTS
Vaccination of school-aged children with the inactivated vaccine resulted in a net cost savings of $3.99
per child under the individual-initiated strategy. Under the group vaccination strategy, influenza vaccination would result in a net cost savings of $34.79 per
child vaccinated. The cost savings were primarily
attributable to averted indirect costs (Table 2).
Sensitivity Analysis
Our results were based on certain assumptions
about the probability of disease and the characteristics of the vaccine. Sensitivity analysis was performed by varying key assumptions to determine the
point at which the vaccine no longer resulted in a net
cost savings. This showed that vaccination remained
cost-effective even with wide variation in the assumptions.
For example, if indirect costs were excluded from
the analysis, individual-initiated vaccination would
no longer result in a net cost savings, but rather
would result in a net cost of $6. In this instance, the
cost of time lost from work caused during vaccination and illness was eliminated from the analysis.
The net savings for group-initiated vaccination
would be retained if only direct costs were considered.
For the original analysis, we assumed an 56% efficacy rate. In the best case scenario, if the efficacy of
the influenza vaccine were 75%, the net cost savings
attributable to vaccination would increase. For example, individual-initiated vaccination would result in
a total $17.25 savings per vaccine recipient. In the
TABLE 2.
worst case, with only a 43% efficacy, the group-based
vaccination program would continue to result in a
net cost savings, but the individual-initiated vaccination would not (Table 3). The efficacy of the vaccine
may be lower in years where the fit with circulating
strains is poor. However, the efficacy would have to
drop below 10% to negate the cost savings of a
group-based vaccination program.
We examined cost-effectiveness over a range of
vaccination costs. Under the individual-initiated vaccination strategy, caretakers had to miss work to take
children to be vaccinated. The large indirect cost
associated with the lost work time was far in excess
of the vaccine and administration costs. If the vaccination costs were raised by $4 per recipient, there
would no longer be a net cost savings attributable to
individual-initiated vaccination. If vaccination cost
$20 per child, group-based vaccination would result
in a net cost savings of $19 per vaccine recipient. In
fact, under the group vaccination strategy, vaccination costs would have to exceed $39 per child to
eliminate the net cost savings caused by vaccination.
Several factors might increase the cost of vaccination. Notably, we did not include the costs of serious
complications or fatalities caused by vaccination because recent studies have not found evidence of
these occurrences.2 If serious side effects did occur,
they would raise the cost of vaccination. Although
large-scale studies are not available, a smaller study
suggested that inactivated vaccine was associated
with low-grade fever (37–37.5°C) in an excess of 2.4%
of vaccine recipients compared with placebo recipients.22 Even if all these children stayed home from
school for 1 day, the cost of side effects per vaccine
recipient would only be $1.36. From the above sensitivity analysis, it may be seen that the cost of side
effects would have to exceed $34 per child to erase
the cost savings attributable to group-based vaccination.
The incidence of influenza vaccine-associated
Guillan Barré syndrome in subjects ,45 years of age
was found to be 0 in a recent study.23 The risk in
older adults was ;1 per million doses of the vaccine.
If this level of risk occurred in children, a case of
Guillan Barré would have to cost .$34 million to
negate the cost savings attributable to group-based
vaccination.
We assumed that parents needed to take time off
from work to get their children vaccinated. If mothers vaccinated .1 child during the half-day, this cost
would be lower.
Influenza rates vary from year to year. If rates
were 90% of the base rate that we assumed, individual-initiated vaccination would no longer result in a
net cost savings. Only if rates were #15% of the base
Costs of Influenza and Net Savings Attributable to Vaccination
No vaccination
Individual-initiated vaccination
Group-based vaccination
Direct Costs of
Influenza
Indirect Costs of
Influenza
Vaccination
Costs
Total
Net Cost (Savings)
$8.49
$3.73
$3.73
$61.33
$26.99
$26.99
$0
$35.11
$4.31
$69.82
$65.83
$35.03
Base
(3.99)
(34.79)
All figures are per school-aged child eligible for vaccination. All numbers are rounded off to the nearest $.01.
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TABLE 3.
Sensitivity Analysis: Efficacy and Strategy
Best case
Best case
Worst case
Efficacy of
Vaccine
Reference
75%
56%
43%
4
1
2
Net Cost (Savings) From
Individual-initiated Vaccination
rate, would the net savings from group-based vaccination be eliminated.
We assumed that wages were lost for children
with working mothers, because the mother would
stay home to take care of the ill child. However, some
working mothers may have unpaid caretakers available to them such as neighbors or relatives. The
unpaid caretakers are at risk to acquire influenza, but
do not incur lost wages. Unpaid caretakers would
also be available to accompany the child to a doctor’s
office to get vaccinated. Sensitivity analysis showed
that the presence of unpaid caretakers had little effect on the outcome of the analysis. For example,
vaccination under either strategy continued to result
in a net cost savings even if 90% of the working
mothers had unpaid caretakers.
In some cases, an employed father will choose to
stay home with an ill child. Because men’s wages are
usually higher than those of women,12 this would
enhance the savings attributable to vaccination.
The base case did not include the possibility that
vaccination might reduce otitis media. It has been
estimated that virtually all children with otitis media
visit a physician and that the annual incidence of
otitis is 13.6/100 school-aged children.10 Unfortunately, the proportion of otitis attributable to influenza is not known. In two studies of preschool children, 30% of otitis was prevented by both the
inactivated vaccine and an investigational live attenuated vaccine.27,28 If this efficacy was true for schoolaged children, there would be additional savings
from influenza vaccination. To be specific, there
would be a total net savings of $20 for individualinitiated vaccination and $50 for group-based vaccination. It was assumed that all children with otitis
visited a physician.10
We based family transmission rates on a prospective treatment trial and literature showing that children are the major vectors of disease transmission in
families and communities.8 Transmission of the virus
to employed adults other than the mother or father
would further enhance the attractiveness of vaccination. The latter is likely to occur,8 but is difficult to
quantify.
We analyzed the cost of influenza vaccination using a steady-state model. In other words, only 1/13
of children were assumed to receive 2 doses of the
vaccine. Although some authors do not advocate a
2-dose initial series, most recommend it for unvaccinated children who are ,9 years of age. It is possible
that some children will have already received the
vaccine before starting school or in other settings.
This would decrease the total cost of vaccination of
school-aged children. Alternatively, if a mass vaccination program were introduced, it is likely that
most children under age 9 would require 2 doses of
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Net Cost (Savings) From
Group-based Vaccination
($17.25)
($3.99)
$5.09
($48.06)
($34.79)
($25.71)
vaccine in the start-up year. This would increase the
start-up costs of a program.
DISCUSSION
Influenza vaccination of school children would result in a net cost savings from a societal perspective.
A hypothetical low-cost, group-based vaccination
program that did not require parents to take time off
from work resulted in substantial savings. Such a
program would be similar to the work-based vaccination program proposed by Nichol et al2 in their
analysis of vaccinating healthy, working adults
against influenza.
Our analysis found that the indirect economic effects were central to the benefits of immunization.
The importance of the indirect economic effects of
influenza vaccination was also demonstrated in a
recent study on the effectiveness of influenza vaccination of healthy, working adults.2 Clearly, worker
absenteeism attributable to illness in workers or their
children is a major consequence of influenza within
the community.
Older studies have suggested that mass immunization of school children would be an appropriate
strategy for reducing the spread of influenza within
communities.29 –31 There are several reasons for targeting this group. First, school children are an easy
group to reach and offer an excellent opportunity for
mass immunization. School-based immunization
programs or health fairs would preclude the need for
a visit to a physician’s office to receive the vaccine.
Furthermore, children and schools are the major
pathways that spread influenza to families and
neighborhoods.5–7 In an older but important study,
Monto et al31 followed the influenza infection rates in
the town of Tecumseh, Michigan, in which .85% of
the children were vaccinated and the adjacent unvaccinated community of Adrian, Michigan. The mean
illness rate in all age groups in Adrian was three
times higher than in Tecumseh. In addition, school
absenteeism in Tecumseh was reduced markedly.
Additional impetus for vaccinating school-aged
children comes from the recent development of a
novel, intranasal influenza vaccine. The nasal spray
delivery system may provide significant advantages
over needle injection, especially in terms of patient/
parent acceptance.32 Our analysis shows that the cost
of the nasal vaccine will be a critical component in
determining its cost-effectiveness.
Side effects of vaccination are shown to be minor
in children. However, no vaccine is completely safe
or risk-free. Sensitivity analysis showed that the cost
savings from vaccination were retained even if all
children with minor side effects stayed home from
school. Currently, more catastrophic side effects such
as Guillan Barré syndrome are believed to be rare.
INFLUENZA VACCINATION OF CHILDREN
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Indeed, the recent analysis by the Centers for Disease
Control and Prevention found no Guillan Barré syndrome associated with the vaccination of children.
Possibly, more widespread vaccination would result
in detection of cases of this syndrome. Economically,
rates similar to those found in older adults would not
negate the cost savings from vaccination. Some parents may not be willing to vaccinate children even if
the risk of serious complications approaches 0.
On the other hand, we did not consider deaths
from influenza, complications of infection, or hospitalizations. These events are rarely associated with
influenza in healthy children or healthy adults. However, it seems reasonable to conclude that vaccination would potentially prevent a small number of
deaths, complications, and hospitalizations and that
total cost savings would be augmented. Potential
reductions in cases of otitis media would also contribute to the benefits of vaccination.33 Finally, we
did not include any potential benefits from herd
immunity, because it is not clear what proportion of
children would have to be vaccinated to induce benefits in unvaccinated persons. If any herd immunity
did occur, this would further enhance the benefits of
vaccination.
The primary goal of an influenza vaccination program in school-aged children would be to prevent
illness in the population and to prevent disruption in
the community. In that spirit, we analyzed the magnitude of the number of lost school days and worker
absenteeism attributable to influenza and the potential to mitigate these societal losses with available
means. The pain and suffering from influenza infection, although not readily quantifiable, would also be
reduced significantly by vaccination.
CONCLUSION
In summary, we believe that influenza vaccination
of school-aged children could result in a net cost
savings from a societal perspective and have health
benefits within the community. Policymakers should
give serious attention to a vaccination strategy that
targets school-aged children and takes advantage
of emerging epidemiologic, technological, demographic, and societal factors.
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Potential Cost Savings Attributable to Influenza Vaccination of School-aged
Children
Terry White, Suzanne Lavoie and Mary D. Nettleman
Pediatrics 1999;103;e73
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 1999 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on April 19, 2017
Potential Cost Savings Attributable to Influenza Vaccination of School-aged
Children
Terry White, Suzanne Lavoie and Mary D. Nettleman
Pediatrics 1999;103;e73
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/103/6/e73.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 1999 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on April 19, 2017