Objective To investigate whether a single optimal vaccination strategy exists across countries to deal with a future influenza pandemic by comparing the cost effectiveness of different strategies in various pandemic scenarios for three European countries. Design Economic and epidemic modelling study. Settings General populations in Germany, the Netherlands, and the United Kingdom. Data sources Country specific patterns of social contact and demographic data. Model An age structured susceptible-exposed-infected-recovered transmission model that describes how an influenza A virus will spread in the populations of Germany, the Netherlands, and the United Kingdom. Interventions Comparison of four vaccination strategies: no vaccination, blanket vaccination, vaccination of elderly people (>= 65 years), and vaccination of high transmitters (5-19 years). The four strategies were evaluated for scenarios in which a vaccine became available early or at the peak of the pandemic, and in which either everyone was initially susceptible or older age groups had pre-existing immunity. Main outcome measure Cost per quality adjusted life years (QALYs) gained. Results All vaccination strategies were cost effective (incremental cost per QALY gained, comparing intervention with non-intervention). In scenarios where the vaccine became available at the peak of the pandemic and there was pre-existing immunity among elderly people the incremental cost effectiveness ratios for vaccinating high transmitters were (sic)7325 (5815; pound $10 470) per QALY gained for Germany, (sic)10 216 per QALY gained for the Netherlands, and (sic)7280 per QALY gained for the United Kingdom. The most cost effective strategy not only differed across the pandemic scenarios but also between countries. Specifically, when the vaccine was available early in the pandemic and there was no pre-existing immunity, in Germany it would be most cost effective to vaccinate elderly people ((sic)940 per QALY gained), whereas it would be most cost effective to vaccinate high transmitters in both the Netherlands ((sic)525 per QALY gained) and the United Kingdom ((sic)163 per QALY gained). This difference in optimal strategies was due to differences in the demographic characteristics of the countries: Germany has a significantly higher proportion of elderly people compared with the Netherlands and the United Kingdom. Conclusions No single vaccination strategy was most cost effective across countries. With aging populations, pre-existing immunity in particular could be of crucial importance for the cost effectiveness of options to mitigate a future influenza pandemic
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