The adjuvanted influenza vaccines are cost effective in the 65+ elderly populations in Canadian settings. The RCT used here in the analysis was done in the community settings as opposed to earlier trials done in frail institutionalized population. It should be remembered that the efficacy of vaccines is dependent on close match between the virus strains used in the vaccine and circulating virus strains. The RCT results also show the adjuvanted do not reduce the rate of infections in the elderly but reduce the costs associated with infections by reducing the number of flu related complications in the vaccinated individuals. This is due to immune-senescence and reduced levels of antibodies in the elderly but the protection against severity is elicited by such immune responses. Hence future RCTs need not look at antibody levels in the elderly but consider looking at other immune mechanisms. We can also conclude that developing efficacious and safe vaccines for the elderly with be more cost-effective. This is important with respect to changing demographics of the Canadian population and increased proportion of elderly and associated escalation of healthcare costs.

1. Economic evaluation of
adjuvanted and non-
adjuvanted flu vaccines
in the elderly 65+
Course Instructor: Chris Simms
Presenter: Srinivas Garlapati

2. Influenza and it’s Control

3. Review of literature
 The Cochrane Collaboration revealed that the
best effectiveness for vaccination for influenza-related
complications is for persons in long-term care
facilities, and the worst for those in community-
dwelling people

4. Review of literature (2)
“Any conclusions regarding the effects of influenza
vaccines for people aged 65 years or older cannot be
drawn” because of the poor quality of evidence (Jefferson
et al 2009).

5. Review of literature (3)
Medline search for reports between 2009-2012, with the
search terms “elderly”, “65 years”, “seasonal”, “influenza”,
and “vaccine” identified no studies of efficacy or
effectiveness estimates of seasonal flu vaccines

6. Drawbacks of current
studies
 Few studies in elderly
 Data of poor quality
 Cochrane review: 75 studies, of which only five were
RCTs
 Most RCTs conducted on frail institutionalized elders
 No RCTs in community settings

7. Vaccine Efficacy
TIV
<6 Y 0.5 (0-0.83)
6-64 Y 0.9 (0.7-0.9)
>64 Y 0.2 (0-0.2)
ATIV
6-64 Y 0.9 (0-0.9)
>64 Y 0.4 (0.2-0.4)

9. Study parameters
• Largest RCT comparing non adjuvanted (TIV) and
Adjuvanted (ATIV)
• Study done in 15 countries including Canada
• The first efficacy estimate in elderly population
• Study was done in 43,802 participants
• Randomized into two groups (TIV v/s ATIV)
• Study done in community settings
• ATIV compared against current standard of care
• Study done over two year period

10. Results
 ATIV demonstrated higher efficacy in reducing
infections but was not significant statistically
 ATIV was efficacious in reducing the number of cases
of pneumonia, hospital admissions, and deaths
 ATIV was effective against Influenza A virus infections
 No Economic evaluation

12. Figure 2. Projected health benefits of using adjuvanted influenza vaccine.
Fisman DN, Tuite AR (2011) Estimation of the Health Impact and Cost-Effectiveness of Influenza Vaccination with Enhanced
Effectiveness in Canada. PLoS ONE 6(11): e27420. doi:10.1371/journal.pone.0027420
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0027420

13. Results
 The use of Adjuvanted flu vaccine was highly cost
effective in the elderly
 ICER = $2111/QALY gained
 Use of ATIV instead of TIV confers benefit to both
vaccinated and unvaccinated people
 Projections were robust with wide ranging sensitivity
analysis

14. Cost effectiveness analysis of
Adjuvanted Flu Vaccination
in the elderly
using
Decision Tree Analysis

15. Steps in decision tree
analysis
 Define the problem
 Structure the decision and make a tree
 Fill in the probabilities and the corresponding health
outcomes
 Conduct cost-effectiveness analysis
 Interpret results

16. Steps in decision tree
analysis
 Define the problem
 Structure the decision and make a tree
 Fill in the probabilities and the corresponding health
outcomes
 Conduct cost-effectiveness analysis
 Interpret results

17. TIV

18. TIV
Protected
Infections
Complications
Protected
Infections
Complications
Protected
Infections
Complications

19. Infections
Complications
Infections
Infections
Complications
Complications
Protected
Protected
Protected
0.0
0.7
0.3
0.2
0.25
0.55
0.4
0.125
0.475
$0
$0
$0
$50
$50
$50
$3587
$3587
$3587
TIV
$7.5
Expected Costs:
No vaccine = $0 + 0.0 X 0 + 0.7 X 50 + 0.3 X 3587 = $1111
TIV = $7.5 + 0.2 X 0 + 0.55 X 50 + 0.25 X 3587 = $ 931
ATIV = $12.59 + 0.4 X 0 + 0.475 X 50 + 0.125 X 3587 = $ 484

20. No vaccine = $0 + 0.0 X 0 + 0.7 X 50 + 0.3 X 3587 = $1111
TIV = $7.5+ 0.2 X 0+ 0.55 X 50+ 0.25 X 3587= $ 931
ATIV = $12.59 + 0.4 X 0+ 0.475 X 50 + 0.125 X 3587 = $ 484
Cost effective analysis
= (1111-931)/(7.5-0) = 24
=(1111-484)/(12.59-0)
=49.8=(931-484)/(12.59-7.5)
=87.6

21. ‘Drummond’ checklist
1. Was a well-defined question posed in answerable form?
2. Was a comprehensive description of alternatives given?
3. Was there evidence that effectiveness had been established?
4. Were all the important and relevant costs and consequences for each alternative
identified?
5. Were costs and consequences measured accurately/appropriately?
6. Were costs and consequences valued credibly?
7. Were costs and consequences adjusted for differential timing?
8. Was an incremental analysis performed?
9. Was allowance made for uncertainty?
10. Did presentation/discussion of results include all issues of concern?

22. Conclusions and
recommendations
 Adjuvanted vaccines are more effective
 Replacement of current vaccines with adjuvanted
vaccines is economically viable
 Need for development of more efficacious vaccines