Vaccine 39 (2021) 6762–6780

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Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Programme costs for introducing age/gestation-based universal

influenza vaccine schedules for young children and pregnant women in
Hong Kong
Thomas D.J. de Haas a, Karene Hoi Ting Yeung b,⇑, Raymond Hutubessy c, Ingeborg Maria van der Putten a,
E. Anthony S. Nelson b
a
CAPHRI, Care and Public Health Research Institute, Department of Health Services Research, Maastricht University, Maastricht, the Netherlands
b
Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong
c
Department of Immunization, Vaccines and Biologicals, World Health Organization, Switzerland

a r t i c l e i n f o a b s t r a c t

Article history: Background: Hong Kong experiences year-round influenza activity with winter and summer peaks. The
Received 25 July 2021 government’s Vaccination Subsidy Scheme (VSS) provides vaccine to high-risk groups prior to the larger
Received in revised form 3 October 2021 winter peak. The VSS is predominantly administered through the private sector. This study aimed to cost
Accepted 6 October 2021
the two theoretical routine influenza vaccination schedules using both northern and southern hemi-
Available online 30 October 2021
sphere vaccines, administered according to child’s age and women’s gestation, from a governmental per-
spective; and compare these costs to the costs of government’s seasonal VSS assuming equivalent
Keywords:
coverage estimates to determine the budget impacts of these influenza vaccination programmes in
Influenza
Immunisation
Hong Kong.
Economic evaluation Methods: We used the World Health Organization’s Flutool Plus to estimate the incremental annual costs
Young children for immunising young children aged 6 months to 2 years and pregnant women with influenza vaccine
Pregnant women during 2021, assuming the latter group accesses the public system for some antenatal care. Inputs were
High income countries based on literature review, publicly available data and expert opinions. Sensitivity analyses were done
with various coverage rates and vaccine costs.
Results: The annual incremental cost (including vaccine price) to vaccinate young children with three
doses of influenza vaccine during the first two years of life was estimated at USD 1,175,146 (per-dose-
cost of USD 10.55) at 75% coverage while that to vaccinate pregnant women with one dose at 60% cov-
erage was estimated at USD 398,555 (per-dose-cost of USD 13.39). Across a range of sensitivity analyses
we predict that routine year-round schedules could be cost-saving to the government compared to the
VSS. Implementing routine immunisation to both risk groups equates to USD 1,573,701, i.e., 0.012% of
Hong Kong’s annual healthcare spending.
Conclusion: Proposed year-round universal schedules providing influenza immunisation according to the
child’s age or the woman’s gestation are predicted to be cost-saving compared to the current seasonally
administered subsidised vaccine programme.
Ó 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).

Abbreviations: CIP, Childhood Immunisation Programme; DTaP-IPV, Diphtheria, 1. Introduction

Tetanus, acellular Pertussis and Inactivated Polio vaccine; HKD, Hong Kong Dollar;
MCHC, Maternal and Child Health Centre; SIICT, Seasonal Influenza Immunisation
Costing Tool; USD, United States dollar; VSS, Vaccination Subsidy Scheme; WHO,
World Health Organization.
⇑ Corresponding author at: Department of Paediatrics, The Chinese University of
Hong Kong, 6/F, Lui Che Woo Clinical Sciences Building, Prince of Wales Hospital,
Shatin, Hong Kong.
E-mail addresses: t.dehaas@student.maastrichtuniversity.nl (T.D.J. de Haas),
karene@link.cuhk.edu.hk (K.H.T. Yeung), hutubessyr@who.int (R. Hutubessy),
i.vanderputten@maastrichtuniversity.nl (I.M. van der Putten), tony-nelson@cuhk.
edu.hk (E. Anthony S. Nelson).
High-risk groups for seasonal influenza include the elderly,
pregnant women, children under five years of age and individuals
with chronic conditions [1]. The incidence rates of influenza in
Hong Kong during a 6-year period 2005–2011 were 1295–2906
per 100,000 children under 5 years [2], and during 2015 to 2016
influenza vaccines were 64–68% effective in preventing hospitali-
sation in children below 6 years of age [3]. Hong Kong’s universal
Childhood Immunisation Programme (CIP) provides recommended

https://doi.org/10.1016/j.vaccine.2021.10.009
0264-410X/Ó 2021 The Author(s). Published by Elsevier Ltd.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
T.D.J. de Haas, K.H.T. Yeung, R. Hutubessy et al.
vaccines at no cost to parents but seasonal influenza vaccine is not
included [4]. Instead, influenza vaccine is available through the
Hong Kong Government’s Vaccination Subsidy Scheme (VSS). How-
ever, influenza vaccine coverage was only 14.7% for children
between 6 months and 2 years in 2013 [5], in contrast to vaccines
included in CIP which achieve coverage rates greater than 95% [6].
Uptake of influenza vaccine for pregnant women before the VSS
was only 1.7–6.2% [7–10].
Each year, the World Health Organization (WHO) recommends
seasonal influenza vaccine composition for the northern and
southern hemispheres [11]. Hong Kong has year-round influenza
activity [12] but its influenza immunisation programme only runs
from October to April/May [13]. Children are recommended to
receive seasonal influenza vaccine from the age of six months
[1], but may miss vaccination in their first year of life if they reach
the age of six months between May to September. Children below
the age of 6 months obtain some degree of protection if their moth-
ers have been immunised with influenza vaccine during pregnancy
[14].
Year-round schedules for influenza immunisation in Hong Kong
are theoretically feasible using a combination of northern and
southern hemisphere vaccines administered according to the age
of the child and the stage of gestation, rather than according to
the peak of the influenza season [15]. Although influenza vaccines
have been shown to be cost-effective in Hong Kong [16], no study
has looked at potential cost-savings of including influenza vaccines
in the CIP and routine antenatal care using age or gestation-based
schedules.
This study used a WHO tool to cost, from the governmental per-
spective, two theoretical routine influenza vaccination schedules
for 2021 [15]. The first schedule would give three doses of influ-
enza vaccine to children aged 6 months to 2 years (at 6 months,
12 months and 18 months) as part of the CIP. The second schedule
would give one dose of influenza vaccine to pregnant women at
7 months of gestation, together with pertussis vaccination, as part
of routine antenatal care. The study then compares these costs to
estimated costs of the current VSS assuming similar vaccine cover-
age rates.
2. Methods
2.1. Costing tool
The study was conducted using the Seasonal Influenza Immuni-
sation Costing Tool (SIICT) [17], referred to in short as Flutool Plus.
Flutool Plus is a validated Excel-based tool, developed by the WHO
to assess the incremental costs to add influenza vaccine to the
existing national immunisation programme. Flutool Plus allows
users to estimate costs of different vaccination activities:
microplanning; procurement; distribution; training; social mobili-
sation; service delivery; supervision and supplemental cold chain
equipment. The costs are presented as recurrent financial and eco-
nomic costs and annualised capital financial and economic costs of
the proposed immunisation programme in the tool. From a govern-
mental perspective costing exercise, financial costs represent only
the value of resources purchased by the health provider (i.e., the
Department of Health in Hong Kong) that were used in developing
the programme; with straight-line depreciation for capital goods.
Economic costs represent financial outlays plus opportunity costs
such as costs for the use of existing health workers and any
donated items; where depreciation of capital goods includes annu-
alising and discounting [18]. This study has been conducted on a
territory-wide level in the Hong Kong Special Administrative
Region.
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2.2. Theoretical year-round paediatric vaccination schedule
This study used a year-round seasonal influenza vaccination
schedule for 2021 that consists of three doses administered at
the Maternal and Child Health Centres (MCHCs) as part of the
CIP at the ages of 6 months, 12 months and 18 months [15]. This
schedule was designed to synchronise with other routine visits
for CIP vaccinations [4]:
 At the age of 6 months with the third dose of Diphtheria, Teta-
nus, acellular Pertussis and Inactivated Polio vaccine (DTaP-IPV)
and Hepatitis B vaccine.
 At the age of 12 months with the first doses of Measles, Mumps
and Rubella vaccine and varicella vaccine and booster dose of
pneumococcal conjugate vaccine.
 At the age of 18 months with the booster dose of DTaP-IPV and
the second dose of the combined Measles, Mumps, Rubella and
varicella vaccine.
A vaccine-naïve child younger than 9 years old is recommended
to receive two doses of influenza vaccine with an interval of at least
four weeks [19]. Two options for a year-round immunisation
schedules for young children were proposed for children aged
6 months to 2 years [15]: 1) three doses during the first two years
with no booster at 7 months; and 2) four doses during the first two
years with a booster dose at 7 months of age. The 6 months to
2 years age range was selected for several reasons: attendance to
MCHC for other routine immunisations; high influenza disease
burden; low influenza vaccine uptake; and absence of school-
based programmes for this group [20]. This analysis focuses on
the three-dose schedule since there is no regular MCHC appoint-
ment for children at 7 months of age and it was also reasoned that
parents would be reluctant to have four doses of influenza vaccine
in the first two years of life at 6, 7, 12 and 18 months. However the
second schedule, including the 7-month booster dose, is also
costed in an alternate scenario.
2.3. Theoretical year-round obstetric vaccination schedule
Two options for year-round immunisation for pregnant women
were proposed [15]: 1) one dose administered at the same visit for
the pertussis vaccine in the third trimester; and 2) two doses with
one at the booking visit and the other with pertussis vaccine during
the third trimester. From 2 July 2020, women between 26 and
34 weeks of pregnancy can receive pertussis vaccination free of
charge when they attend antenatal check-ups at MCHCs [21]. This
analysis used the proposed one-dose schedule since it was rea-
soned that pregnant women may have some hesitancy receiving
vaccine during the first trimester and there are potential logistical
concerns about administering the vaccine during the busy booking
visit.
2.4. Data collection for model inputs
Costing data were collected through literature review, consult-
ing with content experts and through communication with health
authority representatives. The literature review was conducted
with PubMed to identify realistic costs for the data inputs for Flu-
tool Plus when inputs could not be sourced from local data sources
or experts. Separate searches were done for young children and
pregnant women. The following selection criteria were considered
when assessing relevance: articles published in the past five years
to ensure up-to-date information on prices; articles in English lan-
guage; and articles related to Hong Kong or comparable high-
income countries in the South East Asian region. Data related to
population, government budgets and financial reports were
T.D.J. de Haas, K.H.T. Yeung, R. Hutubessy et al.
obtained from Hong Kong Government reports. Details of data
inputs used in Flutool Plus are shown in the Appendices 1a and 1b.
2.4.1. Demographics and coverage
The Census and Statistics Department of Hong Kong projected
49,600 births in 2021 [22] and the infant mortality rate in Hong
Kong has varied between 1.8 and 1.5 per 1000 live births during
2013–2017 [23]. Since there was no obvious increasing or decreas-
ing trend in infant mortality rate, we assumed average mortality
rate (0.165%) to calculate the total eligible population of young
children per annum (49,518). Rates of failed pregnancies and mul-
tiple births were not adjusted for in the model, resulting in 49,600
pregnant women per annum.
Children aged six months to five years had a 14.7% uptake of
influenza vaccine in the 2012/13 season [5]. An estimated 85% of
children obtain the routine recommended CIP vaccines from
MCHCs, with the remainder getting the vaccines through the pri-
vate sector. We assumed a base coverage rate for seasonal influ-
enza vaccine provided by the government at MCHCs would be
75% for all young children if it were to be included as a routine uni-
versal vaccine in the CIP, i.e., 10 percent points less than the 85%
attending MCHCs for CIP vaccines. The model does not consider
any influenza vaccines given in the private sector. The overall
uptake rate of CIP recommended vaccines is >95% [6] which
includes the vaccines given both at the MCHCs (at no cost to par-
ents) and in the private sector (with a cost to parents). Although
it is unusual for parents to refuse CIP vaccines when they attend
MCHC (personal communication), we assumed that influenza vac-
cine uptake would be somewhat lower than the 85% of Hong Kong
children that routinely attend MCHCs. This was based on a previ-
ous study showing that compared to rotavirus vaccine (also not
currently in the CIP), parents had more concerns about the side
effects and effectiveness of influenza vaccine [24].
For our base-case analysis, we assumed that all women in Hong
Kong receive some antenatal care in the public sector, and that 60%
of all pregnant women would agree to receive influenza vaccine
while attending antenatal care in the public system (Fig. 1). We
assumed that 20% of these pregnant women would be considered
‘high risk’ (i.e., twins, diabetes, complications in pregnancy, etc.)
and receive all or most of their antenatal care in public hospitals
Fig. 1. Scenarios of women using public and private antenatal services. Description of scenarios where the assumption is that either all or no women giving birth in the
private sector receive antenatal care in the public sector, resulting in either a 60% or a 39% uptake of influenza vaccine administered through the public sector.
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Vaccine 39 (2021) 6762–6780
and the remaining 80% would receive most of their antenatal care
at MCHCs. We therefore assumed that of the base coverage rate of
60% for pregnant women, 48% would receive vaccine at MCHCs and
12% in public hospitals. An estimated 35% of pregnant women deli-
ver in private hospitals and 65% deliver in public hospitals [25]
(Fig. 1). Although it is apparent that most women delivering in
the private sector will also have some antenatal care in the public
sector, no data could be sourced that reported the extent of this
practice. We therefore included an additional scenario that
assumed no women giving birth in the private sector would have
any antenatal care or influenza vaccination in the public sector,
resulting in an overall coverage of 39% of the total birth cohort
(Fig. 1).
2.4.2. Procurement and service delivery costs
The Centre for Health Protection in Hong Kong recommends
inactivated influenza vaccines for children older than 6 months
and pregnant women in Hong Kong. Quadrivalent influenza vac-
cine was recommended for Hong Kong in the 2019/2020 season
[19]. There are three common presentations for influenza vaccine:
prefilled syringe, single-dose vial and multi-dose vial [26], of
which, the prefilled syringe is standard practice in Hong Kong
[27]. The baseline procurement price per dose was considered to
be USD 6.21 (HKD 48.15) based on information obtained from ten-
der documents and press releases (USD 5,101,932 [HKD
39,539,975] tender for 814,000 doses in 2019) [28]. It was assumed
that the adult and paediatric vaccines have the same procurement
price [29]. Safety boxes and 5% of wastage of vaccine have also
been costed.
The only incremental service delivery cost would be the extra
nursing time for administering influenza vaccine, which was
assumed to be five minutes if vaccine is given at the same appoint-
ment with another vaccine during a MCHC visit. Since the children
are already coming to the MCHC for vaccination, we assume the
additional workload would be minimal [15]. A salary cost for an
experienced nurse (USD 6728.07 [HKD 52,143] per month) was
used to calculate these staff costs (annual salaries for 2020/21,
Finance Department of the Prince of Wales Hospital), i.e., USD
3.19 equating to five minutes of ‘‘nurse time” to administer influ-
enza vaccine to a young child receiving other vaccines during a
T.D.J. de Haas, K.H.T. Yeung, R. Hutubessy et al.
CIP visit. We assumed no additional time needed for administrative
duties, as administrative duties for the other vaccines would
already be included in the visit. In the alternate paediatric sched-
ule, including a 7-month booster dose, the extra nursing time
was assumed to be 20 min, which would include explanation about
the vaccine, administering the vaccine and settling the child. Since
the 7-month booster dose requires an additional MCHC visit, addi-
tional administrative cost was assumed to be 10-minute clerical
work time. Similar to the base case of the paediatric schedule,
we used five minutes of ‘‘nurse time” for pregnant women receiv-
ing influenza vaccine at a MCHC. We assumed ten minutes of
‘‘nurse time” in a public hospital, to account for administering
and additional administrative duties.
2.4.3. Programme support activities costs
Microplanning activities were assumed to be done by a team of
a programme manager, an accountant, a logistics manager, an epi-
demiologist and a senior nurse. These disciplines can provide the
elements required for microplanning of an immunisation pro-
gramme, according to a WHO guidebook on polio eradication
[30]. Distribution of the northern and southern hemisphere vacci-
nes would incur distribution costs twice a year. Each delivery of
vaccines was assumed to reach the MCHCs and public hospitals,
which includes two drivers for ten days each, 600 L of fuel for each
distribution activity and a single annual distribution plan by a
logistician. Training was assumed to be a web-based training for
each nurse of 4 h per year. Web-based training is currently used
in Hong Kong for infection control. Social mobilisation activities
would be led by a programme manager. We assumed that medical
professionals can be requested to make public announcements to
recommend immunisation to patients through press releases and
the population can be informed through posters at MCHCs. A sim-
ilar notification to doctors was issued for pertussis vaccine for
pregnant women [31]. Supervision was assumed to be done by a
senior nurse of each MCHC. We assumed the workload for the
senior nurse to be four hours per week throughout the whole year
to travel to each clinic for supervision activities [32].
2.4.4. Capital costs
We assumed that the same brand of refrigerators currently used
by MCHCs will be acquired if cold chain expansion is needed and
the MCHCs would have enough physical space to put the additional
refrigerators. We identified two licensed vaccines that matched the
vaccine composition of previous government tenders. The volume
of these two vaccine products are 51.28 cm3 and 75.17 cm3 per
dose in a 10-pack presentation. The year-round paediatric vaccina-
tion schedule would require a cold chain expansion with a pur-
chase of a 280 L refrigerator in each of the 31 MCHCs for both
vaccine products. The year-round obstetric vaccination schedule
would require a cold chain expansion with a purchase of a 95 L
refrigerators in each of the 31 MCHCs for both vaccine products.
No cold storage expansion was assumed in public hospitals, as
public hospitals are assumed to be able to cover the additional
storage size of vaccines due to the smaller number of women being
vaccinated there.
2.5. Data analysis
The cost analysis was done with the Flutool Plus. The paediatric
and obstetric schedules were analysed in two separate Flutool Plus
models, to provide policy decision makers with evidence for each
group. This was also considered a conservative assumption, since
if both programmes are launched together, there would be poten-
tial cost-savings in a combined approach.
The Flutool Plus is a validated tool that operates with complex
calculations that are embedded in Excel for the use in influenza
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Vaccine 39 (2021) 6762–6780
immunisation programme costing studies. The incremetnal finan-
cial and economic costs are calculated by multiplying the data
input quantities with the financial and economic unit costs. The
Flutool Plus was set for the year 2021 and covers a time horizon
of one year. A fixed discount rate of 3% was used throughout the
study. The results were presented in 2020 U.S. Dollars, at an
exchange rate of HKD 7.75 to USD 1 [33]. Inflation was assumed
to be 3% through 2020, based on the inflation rate in 2019 [33].
The Flutool Plus provides output for financial and economic
costs for each cost category. Economic costs are reported here since
the aim of the study is to identify the cost impact of all incremental
resources on the healthcare sector from a governmental perspec-
tive. The estimated recurrent costs and annualised capital costs
were summed to obtain the total annual incremental cost for the
immunisation programme. This process was done for both young
children and pregnant women and the final total cost was assessed
as a proportion of Hong Kong’s annual healthcare spending.
A subsidiary analysis was then undertaken to compare these
costs with the estimated costs of the current VSS should a similar
level of vaccine coverage for both target groups be achieved, i.e.,
75% coverage for children and 60% coverage for pregnant women.
The VSS provides a subsidy of USD 27.10 (HKD 210) per dose
administered by a private doctor enrolled in the VSS in the
2019/2020 influenza season. The subsidy is a set amount per
administered dose, i.e., the cost is unchanged, regardless of vaccine
coverage, administration time or vaccine cost. The subsidy is avail-
able for high-risk groups, including pregnant women and children
aged 6 months to 12 years [34]. We then undertook a number of
sensitivity analyses with a series of coverages and vaccine costs.
We changed coverage assumptions from 5% to 100% in increments
of 5%, excluding 0% coverage since no programme would be imple-
mented. We repeated the analyses but with an increased and
decreased procurement price. A pre-order commercial price for
2020/2021 of USD 16.52 (HKD 128) was used for the upper bound
price (personal communication) and an assumed 10% reduction in
the tender price was used as the lower bound price (USD 5.59).
These two parameters were included in the sensitivity analyses
since they have the greatest impact to the total programme cost.
3. Results
3.1. Programme costs
The cost analysis for children aged 6 months to 2 years showed
the main recurrent costs were procurement (63%) and service
Table 1a
Annual incremental costs per category for a year-round influenza vaccination
schedule in Hong Kong for children aged 6 months to 2 years (all costs in 2020
USD and capital costs are annualised) estimated with Seasonal Influenza Immunisa-
tion Costing Tool.
Annual Incremental Cost Category overview for young children
Cost type Activity Financial Economic
cost (USD) cost (USD)
Recurrent Procurement 728,000 728,000
costs
Service delivery – 355,415
Microplanning – 11,226
Distribution 2632 5525
Training – 52,007
Information, education and 141 2,588
communication/social mobilisation
Supervision 1316 9627
Capital Supplemental cold chain 9176 10,757
costs
Total cost for young children 741,265 1,175,146 *
* The sum of costs may not add up to the total cost due to rounding.
T.D.J. de Haas, K.H.T. Yeung, R. Hutubessy et al.
Table 1b
Annual incremental costs per category for a year-round influenza vaccination
schedule in Hong Kong for pregnant women (all costs in 2020 USD and capital costs
are annualised) estimated with Seasonal Influenza Immunisation Costing Tool.
Annual Incremental Cost Category overview for pregnant women
Cost type Activity Financial Economic
cost (USD) cost (USD)
Recurrent Procurement 194,455 194,455
costs
Service delivery – 113,921
Microplanning – 11,226
Distribution 2632 5525
Training – 52,007
Information, education and 141 2588
communication/social mobilisation
Supervision 1316 9627
Capital Supplemental cold chain 7852 9205
costs
Total cost for pregnant women 206,397 398,555 *
* The sum of costs may not add up to the total cost due to rounding.
delivery (31%), with capital costs for cold chain expansion being
only 1% of the total predicted cost (Table 1a). Similarly, the main
costs for pregnant women were procurement (50%) and service
delivery (29%), with capital costs for cold chain expansion being
2% of the total (Table 1b). The overall incremental annual costs
required to include seasonal influenza vaccine in the CIP is USD
1,175,146 for a base coverage of 75%, i.e., 111,416 doses adminis-
tered with a three-dose schedule for children aged from 6 months
to 2 years. This equates to a cost-per-dose of USD 10.55. The overall
annual costs for giving seasonal influenza vaccination during rou-
tine antenatal care is USD 398,555 at base coverage of 60%, i.e.,
one dose in the third trimester for 29,760 pregnant women. This
equates to a cost-per-dose of USD 13.39. The total annual incre-
mental costs for this public sector seasonal influenza vaccine pro-
gramme for both groups would be USD 1,573,701 at base coverage
rates of 75% for children and 60% pregnant women. The cost of
implementing both proposed programmes would amount to
0.012% of the USD 13,632.5 million annual Hong Kong government
health expenditure in 2020/2021 [35]. In the alternate paediatric
schedule, including a 7-month booster dose, the incremental
annual costs would be USD 1,952,607 for a base coverage of 75%
(cost-per-dose at USD 13.14), and the total annual incremental
costs for both groups would be USD 2,351,162.
3.2. Sensitivity analyses
The sensitivity analyses assessed the predicted cost-per-dose
versus coverage rate for the year-round schedules for children aged
6 months to 2 years and pregnant women (Fig. 2a and Fig. 2b) and
compared upper bound vaccine procurement price (lowest private
sector vaccine purchase price) and lower bound vaccine procure-
ment price (90% of base price) with the base vaccine procurement
price (USD 6.21 [HKD 48.15] based on previous vaccine tender
price). The base case cost-per-dose includes all costs from the
implementation of the programme, not only the vaccine procure-
ment cost. We found that both the procurement price and coverage
rate have significant impact on the costs per dose. With the base
case procurement price, the cost-per-dose varies from USD 10.34
(100% coverage) to USD 22.07 (5% coverage) for young children
(Table 2a) and USD 12.49 (100% coverage) to USD 47.18 (5% cover-
age) for pregnant women (Table 2b). Should the upper bound of
vaccine price be used (a pre-order commercial price at USD
16.52), the respective costs per dose for the same range of coverage
rates were between USD 20.65 and USD 32.38 for young children
and between USD 22.80 and USD 57.49 for pregnant women. With
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Vaccine 39 (2021) 6762–6780
the lower bound of vaccine price (10% reduction in the tender
price, USD 5.59), the respective costs per dose were from USD
9.72 to USD 21.45 for young children and from USD 11.87 to USD
46.56 for pregnant women.
If we assume that no women delivering in the private sector
receive influenza vaccine (scenario 2 in Fig. 1) then only 39% of
women would be vaccinated in the public sector. The annual incre-
mental cost to the Government would be USD 296,771 equating to
a cost-per-dose of USD 15.34 (upper bound USD 25.65 to lower
bound USD 14.72) (Table 2b).
3.3. Comparison to the Vaccination Subsidy Scheme
The subsidy amount of an influenza vaccine in the VSS was USD
27.10 (HKD 210) for 2019/2020 influenza season [34]. However
private doctors often charge patients consultation and other fees
that in total exceed the subsidy amount [36]. We compared the
cost-per-dose of the VSS (by taking the full subsidy amount of
one vaccine dose without any administrative costs) to the cost-
per-dose of the proposed year-round schedules. If the base cover-
age of the VSS could be increased to 75% for children aged 6 months
to 2 years and to 60% for pregnant women, the annual costs of sub-
sidising vaccines would cost the government USD 3,019,360 for
children and USD 806,496 for pregnant women. Overall the VSS
at these coverage rates, for a three-dose schedule for children
and a one-dose schedule for women, would cost the government
USD 3,825,856 annually, which is USD 2,252,155 more costly than
the proposed year-round vaccination programme, at USD
1,573,701. Figs. 2a and 2b show the proposed year-round sched-
ules are very likely to be cost-saving compared to the VSS with dif-
ferent combination of vaccination coverages and procurement
prices.
4. Discussion
The estimated total annual incremental cost of routinely giving
children three doses of influenza vaccine at 6, 12 and 18 months
would be USD 1,175,146 (USD 10.55 per dose) for 75% coverage
and that of giving pregnant women one dose of influenza vaccine
at the antenatal visit for pertussis vaccination during the third tri-
mester would be USD 398,555 (USD 13.39 per dose) for 60% cover-
age. The combined total annual cost of USD 1,573,701 would
equate to 0.012% of current government expenditures on health.
However the actual costs could be lower than this combined total,
since some costs such as cold chain expansion, microplanning,
transport, training, social mobilisation and supervision could be
partially or entirely shared between the two programmes requiring
vaccination at MCHCs. The results also show the potential for con-
siderable cost-saving to government when this programme is com-
pared to the VSS (assuming comparable vaccine coverage; and no
administrative cost for VSS is included).
The main cost drivers of the proposed influenza immunisation
programmes are vaccine procurement cost and service delivery.
The current typical private sector price for low purchase volume
is significantly higher than the recent government tender price
used in this study. Should influenza vaccine be incorporated into
routine schedules, then it is possible that even lower tender prices
may be obtained.
We have assumed a wastage rate of 5% for the vaccines in the
models, which may be viewed as conservative, because of the
one-year shelf-life of the prefilled syringe. However, given the pro-
posed year-round schedules require a switch between formula-
tions of the vaccines, there may be a potential increase in the
wastage of vaccine. We additionally conducted a sensitivity analy-
sis with an increase of the wastage rate to 10%, which result in a
T.D.J. de Haas, K.H.T. Yeung, R. Hutubessy et al. Vaccine 39 (2021) 6762–6780

Fig. 2a. Cost-per-dose versus coverage rate in USD, for the proposed year-round schedule for children aged 6 months to 2 years for base price and compared to the upper
bound price (lowest private sector purchase price), lower bound price (90% of base price) and the Vaccine Subsidy Scheme.

Fig. 2b. Cost-per-dose versus coverage rate in USD, for the proposed year-round schedule for pregnant women for base price and compared to the upper bound price (lowest
private sector purchase price), lower bound price (90% of base price) and the Vaccine Subsidy Scheme.

total annual incremental cost of USD 1,209,740 (per-dose-cost USD
10.86) at base uptake rate for children. For pregnant women the
increase would result in a total cost of USD 407,795 (per-dose-
cost USD 13.70) at base uptake rate. The combined programme
would cost USD 1,617,535.
Introduction of influenza vaccine in routine immunisation pro-
grammes could have other benefits. It is reasonable to expect
increased uptake when it is offered in routine public immunisation
programmes, compared to the VSS through private doctors, where
patients often pay higher charges than they receive from subsidy,
while at the same time private doctors have stated that working
with the VSS is not financially attractive and causes too much
paperwork [36]. A study in the Northern Territory of Australia pre-
dicted an increase in annual vaccination coverage for pregnant
women as a result of a year-round schedule, rather than a seasonal
schedule [37].
The implementation of these year-round schedules could face
practical barriers resulting from the change between northern
and southern hemisphere vaccines, such as labelling, and licensing
requirements and risk of giving ‘‘old vaccine” during the switch to
a ‘‘new vaccine”. Also, any possible downsides to age-based and
gestation-based schedules need to be identified.
Increased influenza vaccine coverage will result in reduced hos-
pitalisation and potential cost savings to the government and
health benefits and cost saving to the society. A full economic eval-
uation focusing on the effectiveness of the programme will be
required to determine whether the costs of this proposed schedule
(with high coverage, low cost of vaccine through tendering, lower
hospital admission and outpatient visits, and lower cost of
influenza-related treatment) are lower than the currently imple-
mented VSS (with low coverage, high cost of subsidy, higher hospi-
tal admissions and outpatient visits and higher cost of influenza-
related treatment). However, real-life confirmation is needed to
see whether the uptake outcomes predicted (75% for children
and 60% for pregnant women) can be achieved with routine uni-
versal schedules. Similarly, more data is needed to determine

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Table 2a
Overview of estimated annual incremental costs and cost-per-dose of influenza vaccination in USD with a year-round schedule for young children in Hong Kong.

Young children
Inputs Outcomes
Scenario Uptake % Procurement Service delivery Cold storage Total costs Upper Bound Price Lower Bound Price
Economic cost % Economic cost % Economic cost % Economic cost Per dose
5 $ 48,533 32 $ 23,694 15 $ 9,205 6 $ 163,958 $22.07 $32.38 $21.45
10 $ 97,067 43 $ 47,389 21 $ 9,205 5 $ 236,185 $15.90 $26.21 $15.28
15 $ 145,600 49 $ 71,083 24 $ 9,205 3 $ 308,413 $13.84 $24.15 $13.22
20 $ 194,133 52 $ 94,777 26 $ 9,205 2 $ 380,641 $12.81 $23.12 $12.19
25 $ 242,667 55 $ 118,472 27 $ 9,205 2 $ 452,869 $12.19 $22.50 $11.57
30 $ 291,200 57 $ 142,166 28 $ 9,205 2 $ 525,096 $11.78 $22.09 $11.16
35 $ 339,733 58 $ 165,861 28 $ 9,205 2 $ 597,324 $11.49 $21.80 $10.87
40 $ 388,267 59 $ 189,555 29 $ 9,576 1 $ 669,552 $11.27 $21.58 $10.65
45 $ 436,800 60 $ 213,249 29 $ 9,576 1 $ 741,779 $11.10 $21.41 $10.48
50 $ 485,333 60 $ 236,944 30 $ 10,757 1 $ 814,007 $10.96 $21.27 $10.34
55 $ 533,867 61 $ 260,638 30 $ 10,757 1 $ 886,235 $10.85 $21.16 $10.23
60 $ 582,400 61 $ 284,332 30 $ 10,757 1 $ 958,462 $10.75 $21.06 $10.13
65 $ 630,933 62 $ 308,027 30 $ 10,757 1 $ 1,030,690 $10.67 $20.98 $10.05
70 $ 679,467 62 $ 331,721 30 $ 10,757 1 $ 1,102,918 $10.61 $20.92 $9.99
Base 75 $ 728,000 63 $ 355,415 31 $ 10,757 1 $ 1,175,146 $10.55 $20.86 $9.93
80 $ 776,533 63 $ 379,110 31 $ 10,757 1 $ 1,247,373 $10.50 $20.81 $9.88
85 $ 825,067 63 $ 402,804 31 $ 10,757 1 $ 1,319,601 $10.45 $20.76 $9.83
90 $ 873,600 63 $ 426,499 31 $ 10,757 1 $ 1,391,829 $10.41 $20.72 $9.79
95 $ 922,133 63 $ 450,193 31 $ 10,757 1 $ 1,464,056 $10.37 $20.68 $9.75
100 $ 970,667 64 $ 473,887 31 $ 10,757 1 $ 1,536,284 $10.34 $20.65 $9.72

Upper bound price represents the lowest private sector purchase price identified and the lower bound price represents 90% of base cost.

Table 2b
Overview of estimated annual incremental costs and cost-per-dose of influenza vaccination in USD with a year-round schedule for pregnant women in Hong Kong.

Pregnant women
Inputs Outcomes
Scenario Uptake % Procurement Service delivery Cold storage Total costs Upper Bound price Lower Bound Price
Economic cost % Economic cost % Economic cost % Economic cost Per dose
5 $ 16,576 15 $ 9,498 9 $ 9,205 8 $ 116,248 $46.87 $57.18 $46.25
10 $ 32,747 25 $ 18,987 14 $ 9,205 7 $ 141,912 $28.61 $38.92 $27.99
15 $ 48,918 31 $ 28,480 18 $ 9,205 6 $ 167,576 $22.52 $32.83 $21.90
20 $ 65,089 35 $ 37,974 21 $ 9,205 5 $ 193,241 $19.48 $29.79 $18.86
25 $ 81,259 39 $ 47,467 23 $ 9,205 4 $ 218,905 $17.65 $27.96 $17.03
30 $ 97,430 42 $ 56,961 24 $ 9,205 4 $ 244,569 $16.44 $26.75 $15.82
35 $ 113,601 44 $ 66,454 25 $ 9,205 3 $ 270,234 $15.57 $25.88 $14.95
Scenario 2 39 $ 126,538 45 $ 74,049 26 $ 9,205 3 $ 290,765 $15.03 $25.34 $14.41
40 $ 129,772 45 $ 75,948 27 $ 9,205 3 $ 295,898 $14.91 $25.22 $14.29
45 $ 145,943 47 $ 85,441 27 $ 9,205 3 $ 321,562 $14.41 $24.72 $13.79
50 $ 162,114 48 $ 94,934 28 $ 9,205 3 $ 347,226 $14.00 $24.31 $13.38
55 $ 178,285 49 $ 104,428 29 $ 9,205 3 $ 372,891 $13.67 $23.98 $13.05
Scenario 1 60 $ 194,455 50 $ 113,921 29 $ 9,205 2 $ 398,555 $13.39 $23.70 $12.77
65 $ 210,626 51 $ 123,415 30 $ 9,205 2 $ 424,219 $13.16 $23.47 $12.54
70 $ 226,797 51 $ 132,908 30 $ 9,205 2 $ 449,883 $12.96 $23.27 $12.34
75 $ 242,968 52 $ 142,402 31 $ 9,205 2 $ 475,548 $12.78 $23.09 $12.16
80 $ 259,139 53 $ 151,895 31 $ 9,205 2 $ 501,212 $12.63 $22.94 $12.01
85 $ 275,310 53 $ 161,388 31 $ 9,205 2 $ 526,876 $12.50 $22.81 $11.88
90 $ 291,480 54 $ 170,882 31 $ 9,205 2 $ 552,541 $12.38 $22.69 $11.76
95 $ 307,651 54 $ 180,375 32 $ 9,205 2 $ 578,205 $12.27 $22.58 $11.65
100 $ 328,822 54 $ 189,869 32 $ 9,205 2 $ 603,869 $12.17 $22.48 $11.55

Upper bound price represents the lowest private sector purchase price identified and the lower bound price represents 90% of base cost.

whether these age/gestation-based schedules have comparable
vaccine effectiveness to current seasonal-based schedules, and
whether the young children will be exposed to a higher risk of
infection when the second dose of influenza vaccine is adminis-
tered 6 months apart from the first dose, rather than 4 weeks apart.
This study used a WHO costing tool which has been reviewed
by independent experts through WHO’s Immunisation and
Vaccines-related Implementation Research Advisory Committee.
This prospective tool is able to provide policy makers with cost
estimates for different scenarios to better inform decisions about
influenza vaccination programmes. In addition, the main cost dri-
vers in the current cost analyses are vaccine procurement and ser-
vice delivery costs. In Hong Kong, the costs of programme support
activities such as microplanning, distribution, training, social
mobilisation and supervision are relatively low.
Limitations of this study include the uncertainty in the assump-
tions of vaccine coverage resulting from the implementation of
routine age/gestation-based schedules. However, these assump-
tions are explored in the sensitivity analyses which show potential
cost-savings to the Hong Kong government even with relatively
low vaccine uptake rates. Also, we did not explore a two-dose
schedule during pregnancy which could be technically feasible

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but is likely to be less acceptable to women with concerns about
vaccines given in early pregnancy.
The proposed year-round universal schedules for providing
influenza immunisation according to child’s age or women’s gesta-
tion and included in the routine CIP schedule and antenatal care
are predicted to be cost-saving compared to the current govern-
ment’s VSS. Not only are these proposed schedules likely of eco-
nomic benefit to Hong Kong, they are anticipated to increase
vaccine coverage. However further research is required to deter-
mine whether these age-based and gestation-based schedules will
provide similar effectiveness to current seasonal-based schedules.
Funding
Karene Hoi Ting Yeung: Methodology, Validation, Writing –
review & editing. Raymond Hutubessy: Validation, Writing –
review & editing. Ingeborg Maria van der Putten: Methodology,
Validation, Supervision, Writing – review & editing. E. Anthony
S. Nelson: Conceptualization, Methodology, Validation, Supervi-
sion, Writing – review & editing.
Declaration of Competing Interest
The authors declare the following financial interests/personal
relationships which may be considered as potential competing
interests: Raymond Hutubessy reports a relationship with World
Health Organization that includes: employment.

This research did not receive any specific grant from funding Acknowledgement
agencies in the public, commercial or non-profit sectors.
We thank the Department of Health, Government of Hong Kong
SAR and Prof W.H. Tam for providing help with data inputs. We
CRediT authorship contribution statement
also would like to thank A.T.G. Paulus for reviewing an earlier ver-
sion of the manuscript.
Thomas D.J. de Haas: Methodology, Validation, Formal analysis,
Investigation, Writing – original draft, Writing – review & editing.

Appendix 1a. Data inputs in the Seasonal influenza immunization Costing Tool (SIICT, Flutool Plus) for the estimation of annual
incremental costs of a year-round influenza immunization schedule for young Hong Kong children

Young children
Parameter Value Rationale Reference
General
Baseline price year 2020 Baseline prices can be calculated up to the –
current year of 2020
Annual discount rate % 3 Standard discount rate for costing studies –
Programme Year 2021 Study is conducted for the year 2021 –

Demographics
Group 1 Children aged Children would receive the first dose at –
6 months 6 months old
Group 1 amount 49,518 Annual birth rate (49600) minus infant Census and Statistics Department, H. K. S.
mortality rate (0.165%) A. R. (2017). Demographic Trends in Hong
Kong 1986–2016. Census and Statistics
Department, HKSAR (2020). Trends of
Infant Mortality in Hong Kong, 1951 to
2018.
Group 2 Children aged Children would receive the second dose at –
12 months 12 months old
Group 2 amount 49,518 Annual birth rate (49,600) minus infant Census and Statistics Department, H. K. S.
mortality rate (0.165%) A. R. (2017). Demographic Trends in Hong
Kong 1986–2016. Census and Statistics
Department, HKSAR (2020). Trends of
Infant Mortality in Hong Kong, 1951 to
2018.
Group 3 Children aged Children would receive the third dose at –
18 months 18 months old
Group 3 amount 49,518 Annual birth rate (49,600) minus infant Census and Statistics Department, H. K. S.
mortality rate (0.165%) A. R. (2017). Demographic Trends in Hong
Kong 1986–2016. Census and Statistics
Department, HKSAR (2020). Trends of
Infant Mortality in Hong Kong, 1951 to
2018.
Group 4 7 Months booster [Alternate scenario] Booster dose at –
dose (alternate 7 months of age, approx. 4 weeks after first
scenario) dose.

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Appendix 1a (continued)

Young children
Parameter Value Rationale Reference
Group 4 amount 49,518 [Alternate scenario] Annual birth rate Census and Statistics Department, H. K. S. A.
(49,600) minus infant mortality rate R. (2017). Demographic Trends in Hong Kong
(0.165%) 1986–2016. Census and Statistics
Department, HKSAR (2020). Trends of Infant
Mortality in Hong Kong, 1951 to 2018.
Other groups Unused
Coverage group 75% The uptake is presumed to be high, due to Author’s assumption
Coverage group 2 75% the inclusion in the CIP. 75% was set as the
base coverage assumption
Procurement
Vaccine type 1 Quadrivalent IIV This is paediatric dose, specific for children –
0,25 ml aged 6 to 35 months
Vaccine type 2 Unused
Number of vaccine 1 111,416 Based on 3 doses to fully immunise a child Dang et al. Feasibility of age- and
administered (2 doses in year 1 and 1 dose in year 2) gestation-based routine universal
influenza vaccines schedules for children
aged 6 months 2 years and pregnant
women. Vaccine. 2021.
Number of vaccine 2 Unused
administered
Injection Supply 1 Safety Box (100 Used for safe disposal of used syringes –
capacity) to hold
administered
syringes
Injection Supply 2 Unused
Number of injection 1114 For all administered vaccines
supply 1 used
Number of injection Unused
supply 2 used
Wastage % Vaccine 5 Wastage is expected, as the vaccines are Author’s assumption
type 1 ordered before uptake becomes clear.
Estimated reserve/ Unused
buffer
Vaccine procurement Commercial Vaccines are tendered through commercial The Government of Hong Kong Special
source 1 methods in Hong Kong Administrative Region. (2019). 2019/20
seasonal influenza vaccination
programmememes to be launched in
October. Press Releases. Retrieved from
https://www.info.gov.hk/gia/general/
201907/17/P2019071600660.htm
Unit cost vaccine 6.21 (USD) The procurement price per dose was The Government of Hong Kong Special
source 1 estimated to be USD 6.21 (HKD 48.15) by Administrative Region. (2019). 2019/20
using tender documents and press releases seasonal influenza vaccination
of previous years, which stated that a total programmememes to be launched in
cost of HKD 39,539,975.00 was paid for October. Press Releases. Retrieved from
814,000 doses in 2019 https://www.info.gov.hk/gia/general/
201907/17/P2019071600660.htm
Add-on charges Unused
Number procured, 113,644 Based on 3 doses to fully immunise a child –
vaccine source 1 (2 in year 1 and 1 in year 2) and including
the ’wasted’ vaccines in this number
Injection supplies Commercial Supplies are tendered through commercial The Government of Hong Kong Special
procurement source methods in Hong Kong Administrative Region. (2019). 2019/20
1 seasonal influenza vaccination
programmememes to be launched in
October. Press Releases. Retrieved from
https://www.info.gov.hk/gia/general/
201907/17/P2019071600660.htm
Unit cost injection 1.36 (USD) procurement price as listed by https://supply.unicef.org/s0782216.html

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Appendix 1a (continued)

Young children
Parameter Value Rationale Reference
supplies source 1 UNICEF Supplies website
Add-on charges Unused
Number procured, 1136 Based on disposing all syringes –
injection Supplies
source 1

Service delivery
Routine Activity 1 First dose at Dose 1 at 6 months –
6 months at
MCHC
Routine Activity 2 Second dose at Dose 2 at 12 months –
12 months at
MCHC
Routine Activity 3 Third dose at Dose 3 at 18 months –
18 months at
MCHC
Routine Activity 4 7 Months booster [Alternate scenario] Dose at 7 months
dose
Single instances Unused
Activity 1 coverage % 100 100% of cohort receives the dose at –
6 months
Activity 1 Number of 1 One dose is delivery per child –
vaccinations
Activity 1 Unit cost – No financial costs are incurred in this –
(financial) activity
Activity 1 Unit cost 3.19 (USD) Based on 5 min of incremental time Assumption, based on communication of
(economic) required for an experienced nurse in the the Finance department in Price of Wales
MCHC Hospital.
Activity 2 coverage % 100 100% of cohort receives the dose at –
12 months
Activity 2 Number of 1 One dose is delivery per child –
vaccinations
Activity 2 Unit cost – No financial costs are incurred in this –
(financial) activity
Activity 2 Unit cost 3.19 (USD) Based on 5 min of incremental time Assumption, based on communication of
(economic) required for an experienced nurse in the the Finance department in Price of Wales
MCHC Hospital.
Activity 3 coverage % 100 100% of cohort receives the dose at –
18 months
Activity 3 Number of 1 One dose is delivery per child –
vaccinations
Activity 3 Unit cost – No financial costs are incurred in this –
(financial) activity
Activity 3 Unit cost 3.19 (USD) Based on 5 min of incremental time Assumption, based on communication of
(economic) required for an experienced nurse in the the Finance department in Price of Wales
MCHC Hospital.
Activity 4 coverage % 100 [Alternate scenario] 100% of cohort –
receives the dose at 7 months
Activity 4 Number of 1 [Alternate scenario] One dose is delivery –
vaccinations per child
Activity 4 Unit cost – [Alternate scenario] No financial costs are –
(financial) incurred in this activity
Activity 4 Unit cost 14.40 [Alternate scenario] (USD) Based on 20 and Assumption, based on communication of
(economic) 10 min of incremental time required for an MCHC nurse
experienced nurse and a clerical worker in
the MCHC respectively
Cold Chain Storage
Packed volume per 51.3 (cm3) Requested from manufacturer of one Manufacturer specifications through
dose vaccine type 1 of the approved products in Hong Kong customer service
which fits the 2019/2020 tender
requirements

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Appendix 1a (continued)

Young children
Parameter Value Rationale Reference
Expansion activity 1 MCHC Cold Only MCHC are considered for cold chain –
Storage expansion for this study
Expansion
Expansion activity 2 Unused
and 3
Storage proportion % 100 All vaccines must be stored in a cold –
vaccine type 1 environment
Cold storage space 0 (cm3) We assume all storage space must be –
available acquired for this study, to show
incremental costs for this vaccine
Name of storage 280L cold storage The standard brand for MCHC cold chain Expert opinion by healthcare professional
equipment equipment, according to a previous costing in MCHC
study for a Rotavirus immunization
programme
Number of Units 31 One piece of equipment for each of the 31 –
MCHC in Hong Kong
Other equipment Unused

Microplanning
Activity 1 Develop Annual Annual Plan and Budget Developed –
Influenza
Programme Plan
and Budget
Activity 1 Financial 0 No financial costs are incurred in this –
costs activity
Activity 1 Economic 9868 (USD) costs incurred are according to Hong World Health Organization. (2018). Best
costs Kong average salaries for a programme Practices in Microplanning for Polio
manager, accountant, epidemiologist, Eradication.
logistician and a senior nurse, according to
polio vaccine microplanning guide
Number of activity 1 1 This activity is done once annually –
Activity 2 Publication of Plan and Informational Materials Provided –
Influenza
Programme Plan
Activity 2 Financial 0 No financial costs are incurred in this –
costs activity
Activity 2 Economic 1358 (USD) based on average salaries for a World Health Organization. (2018). Best
costs programme manager and a marketing Practices in Microplanning for Polio
officer in Hong Kong for the publication of Eradication.
the programme plan
Number of activity 2 1 This activity is done once annually –
Activity 3 Unused

Distribution
Activity 1 Distribution of Plan and Preparation Completed –
Vaccines to MCHC
Activity 1 Financial 1316 (USD) Two drivers and (un)loaders for Author’s assumption
costs 10 days per year, including 600 L of fuel to
Activity 1 Economic 2489 deliver vaccines to MCHC.
costs
Number of activity 1 2 Delivery of vaccines and supplies is done –
annually
Activity 2 Distribution Plan for distribution by Logistics Manager –
planning
Activity 2 Financial 0 No financial costs are incurred in this –
costs activity
Activity 2 Economic 547 (USD) based on average salaries for a Author’s assumption
costs logistics manager in Hong Kong
Number of activity 2 1 This activity is done once annually –
Activity 3 Unused

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Appendix 1a (continued)

Young children
Parameter Value Rationale Reference
Training
Activity 1 Annual afternoon One afternoon of web-based training for Expert opinion by Healthcare professional
for web-based each of the nurses is required. Web-based in paediatric care
training trainings are currently already given to
train health care providers
Activity 1 Financial 0 No financial costs are incurred in this –
costs activity
Activity 1 Economic 52,007 (USD) One afternoon (4 h) of lost working Author’s assumption
costs hours for each registered nurse to train on
annual influenza vaccine programme.
Number of activity 1 1 This training is done once annually –
Activity 2 Unused
Activity 3 Unused

Social mobilisation
Activity 1 National press Creation of press release and spreading of –
release for Health posters
Care Worker
vaccination
Activity 1 Financial 141 (USD) financial costs are induced the Author’s assumption
costs creation of a press publication and in the
purchase and spread of posters in each of
the MCHC and several other key places
Activity 1 Economic 2588 (USD) Costs are based on average salaries –
costs for the programme manager and a
marketing officer in Hong Kong
Number of activity 1 1 This activity is only done once –
Activity 2 Unused
Activity 3 Unused

Supervision
Activity 1 Supervision from A senior nurse visits the clinics for Author’s assumption
Senior Nurse in inspection for vaccination procedure
MCHC inspection
Activity 1 Financial 1316 (USD) Fuel consumption costs Based on Shell Fuel Price board for Hong
costs Kong and Macau. https://www.shell.com.
hk/en_hk/motorists/shell-fuels/price-
board.html
Activity 1 Economic 9627 (USD) Based on average wage for an Author’s assumption
costs experienced nurse in Hong Kong for 3 h per
week during the entire year
Number of activity 1 1 Calculation of salary and fuel was done for –
the entire year, therefore one instance of
this activity is counted
Activity 2 Unused
Activity 3 Unused

Others
Unused

Cost ingredients
Conversion rate 7.75 HKD 7.75 equals USD 1, currency is linked Hong Kong Monetary Authority. (2019).
2019 Annual Report. Retrieved from Hong
Kong:
Monthly personnel Accountant (IPH) 3387 Payscale.com (HKD 26,250)
costs (USD) DPH Head of 2409 indeed.com salary indication (HKD 18,666)
Vaccinators
Driver (IPH) 1290 Payscale.com (HKD 10,000)
Epidemiologist 6806 Payscale.com (HKD 52,750)
Logistics manager 2409 Payscale.com (HKD 18,666)
Senior Nurse 7032 Salaryexpert.com (HKD 54,500)
Program Manager 5946 Payscale.com (HKD 46,083)

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Appendix 1a (continued)

Young children
Parameter Value Rationale Reference
(IPH)
Registered Nurse 6730 PWH Finance Department (HKD 52,160)
Marketing Officer 2409 Payscale.com (HKD 18,666)
MCHC Clerical 1741 Payscale.com (HKD 13,496)
Worker
Other direct costs Fuel (litre) 2.19 (USD)_Based on Shell Fuel Price board for
Hong Kong and Macau. https://www.
shell.com.hk/en_hk/motorists/shell-fuels/
price-board.html
Supplemental cold 280L cold storage 280000 cm3 / $3,295.00 https://kirsch-medical.de/
chain (10 years service/downloads/preisliste.html(prices
useful) (USD) 2020)
170L cold storage 170000 cm3 / $3,374.39 https://kirsch-medical.de/
service/downloads/preisliste.html(prices
2020)
120L cold storage 120000 cm3 / $2,712.34 https://kirsch-medical.de/
service/downloads/preisliste.html(prices
2020)
95L cold storage 95000 cm3 / $2,778.00 https://kirsch-medical.de/
service/downloads/preisliste.html(prices
2020)
Others Unused

Appendix 1b. Data inputs in the Seasonal influenza immunization Costing Tool (SIICT, Flutool Plus) for the estimation of annual
incremental cost of a year-round influenza immunization schedule for pregnant women in Hong Kong

Pregnant women
Parameter Value Rationale Reference
General
Baseline price 2020 Baseline prices can be calculated up to the –
year current year of 2020
Annual 3 Standard discount rate for costing studies –
discount rate
%
Programme 2021 Study is conducted for the year 2021 –
Year
Group 1 Pregnant women Group of Women receiving vaccination in the –
receiving MCHC during antenatal care check-ups
vaccination in
MCHC
Group 1 39,680 Annual birth rate (49,600) X proportion of Census and Statistics Department, HKSAR
amount pregnant women receiving antenatal care in (2017). Demographic Trends in Hong Kong
MCHCs (80%) 1986–2016.
Rates of failed pregnancies and multiple
births were not adjusted for in the model
Group 2 Pregnant women Group of Women receiving vaccination in the –
receiving public hospitals due to high risk cases, such as
vaccination in twins, diabetes or other complications
public hospital
Group 2 9920 Annual birth rate (49,600) X proportion of Census and Statistics Department, HKSAR
amount pregnant women receiving antenatal care in (2017). Demographic Trends in Hong Kong
public hospitals (20%) 1986–2016. Rates of failed pregnancies and
multiple births were not adjusted for in the
model

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Appendix 1b (continued)

Pregnant women
Parameter Value Rationale Reference
Other groups Unused
Coverage group 48% We assumed a base uptake of 60% for Expert opinion by healthcare professional in
1 pregnant women in the public sector for the Obstetrics and gynaecology
influenza vaccine, of these 60%, 90% would
have their antenatal care check-ups in the
MCHC
Coverage group 12% And 10% of this 60% would be high risk cases, Expert opinion by healthcare professional
2 and these women only have antenatal care in Obstetrics and gynaecology
the public hospitals
Procurement
Vaccine type 1 Quadrivalent IIV Adult doses for Influenza vaccine are usually –
0,5ml 0,5ml
Vaccine type 2 Unused
Number of 29,760 60% of the total population, based on 1-dose –
vaccine 1 schedule
administered
Number of Unused
vaccine 2
administered
Injection Safety Box (100 Used for safe disposal of used syringes –
Supply 1 capacity) to hold
administered
syringes
Injection Unused
Supply 2
Number of 298 For all administered vaccines
injection
supply 1 used
Number of Unused
injection
supply 2 used
Wastage % 5 Wastage rate is expected to be low, as the Author’s assumption
Vaccine type proposal is for single-use syringes, which can
1 only be wasted through expiry
Estimated Unused
reserve/
buffer
Vaccine Commercial Vaccines are tendered through commercial The Government of Hong Kong Special
procurement methods in Hong Kong Administrative Region. (2019). 2019/20
source 1 seasonal influenza vaccination
programmememes to be launched in October.
Press Releases. Retrieved from https://www.
info.gov.hk/gia/general/201907/17/
P2019071600660.htm
Unit cost 6,21 (USD) The procurement price per dose was The Government of Hong Kong Special
vaccine estimated to be USD 6.21 (HKD 48.15) by Administrative Region. (2019). 2019/20
source 1 using tender documents and press releases of seasonal influenza vaccination
previous years, which stated that a total cost programmememes to be launched in October.
of HKD 39,539,975.00 was paid for 814,000 Press Releases. Retrieved from https://www.
doses in 2019 info.gov.hk/gia/general/201907/17/
P2019071600660.htm
Add-on charges Unused
Number 30,355 Based on 1 dose to immunise a pregnant –
procured, woman and including the ’wasted’ vaccines in
vaccine this number
source 1

(continued on next page)

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Appendix 1b (continued)

Pregnant women
Parameter Value Rationale Reference
Injection Commercial Supplies are tendered through commercial The Government of Hong Kong Special
supplies methods in Hong Kong Administrative Region. (2019). 2019/20
procurement seasonal influenza vaccination
source 1 programmememes to be launched in October.
Press Releases. Retrieved from https://www.
info.gov.hk/gia/general/201907/17/
P2019071600660.htm
Unit cost 1.36 (USD) procurement price as listed by UNICEF https://supply.unicef.org/s0782216.html
injection Supplies website
supplies
source 1
Add-on charges Unused
Number 298 Based on disposing all syringes, excluding –
procured, wasted ones, as these do not need to be safely
injection disposed
Supplies
source 1
Service delivery
Routine Activity Administering at Administering of 1 vaccine –
1 MCHC check-up
appointment
Routine Activity Administering at Administering of 1 vaccine –
2 Public Hospital
appointment
Routine Activity Unused
3
Single instances Unused
Activity 1 100 100% of women receiving vaccine in the –
coverage % MCHC use this method
Activity 1 1 One dose per woman –
Number of
vaccinations
Activity 1 Unit – No financial costs are incurred in this activity –
cost
(financial)
Activity 1 Unit 3.19 (USD) Based on 5 min of incremental time Assumption, based on communication of the
cost required for an experienced nurse in the Finance department in Price of Wales
(economic) MCHC Hospital.
Activity 2 100 100% of women receiving vaccine in the –
coverage % Public Hospital use this method
Activity 2 1 One dose per woman –
Number of
vaccinations
Activity 2 Unit – No financial costs are incurred in this activity –
cost
(financial)
Activity 2 Unit 6.38 (USD) Based on 10 min of incremental time Assumption, based on communication of the
cost required for an experienced nurse in the Finance department in Price of Wales
(economic) MCHC, vaccine preparation and registration is Hospital.
necessary because this is not additional to
other vaccines
Cold Chain Storage
Packed volume 51.3 (cm3) Requested from manufacturer of one of Manufacturer specifications through
per dose the approved products in Hong Kong which customer service
vaccine type fits the 2019/2020 tender requirements
1
Expansion MCHC Cold Storage Only MCHC are considered for cold chain –

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Appendix 1b (continued)

Pregnant women
Parameter Value Rationale Reference
activity 1 Expansion expansion for this study, we expect the public
hospitals to have sufficient storage for the
small amount of vaccines needed
Expansion Unused
activity 2 and
3
Storage 100 All vaccines must be stored in a cold –
proportion % environment
vaccine type
1
Cold storage 0 (cm3) We assume all storage space must be –
space acquired for this study, to show incremental
available costs for this vaccine
Name of storage 100L cold storage The standard brand for MCHC cold chain Expert opinion by healthcare professional in
equipment equipment, according to a previous costing MCHC
study for a rotavirus immunization
programme
Number of 31 One piece of equipment for each of the 31 –
Units MCHC in Hong Kong
Other Unused
equipment
Microplanning
Activity 1 Develop Annual Annual Plan and Budget Developed –
Influenza
Programme Plan
and Budget
Activity 1 0 No financial costs are incurred in this activity –
Financial
costs
Activity 1 9868 (USD) costs incurred are according to Hong World Health Organization. (2018). Best
Economic Kong average salaries for a programme Practices in Microplanning for Polio
costs manager, accountant, epidemiologist, Eradication.
logistician and a senior nurse, according to
polio vaccine microplanning guide
Number of 1 This activity is done once annually –
activity 1
Activity 2 Publication of Plan and Informational Materials Provided –
Influenza
Programme Plan
Activity 2 0 No financial costs are incurred in this activity –
Financial
costs
Activity 2 1358 (USD) based on average salaries for a World Health Organization. (2018). Best
Economic programme manager and a marketing officer Practices in Microplanning for Polio
costs in Hong Kong for the publication of the Eradication.
programme plan
Number of 1 This activity is done once annually –
activity 2
Activity 3 Unused
Distribution
Activity 1 Distribution of Plan and Preparation Completed –
Vaccines to MCHC
Activity 1 1316 (USD) Two drivers and (un)loaders for Author’s assumption
Financial 10 days per year, including 600 L of fuel to
costs deliver vaccines to MCHC.
Activity 1 2489
Economic
costs

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Appendix 1b (continued)

Pregnant women
Parameter Value Rationale Reference
Number of 2 Delivery of vaccines and supplies is done –
activity 1 annually
Activity 2 Distribution Plan for distribution by Logistics Manager –
planning
Activity 2 0 No financial costs are incurred in this activity –
Financial
costs
Activity 2 547 (USD) based on average salaries for a logistics Author’s assumption
Economic manager in Hong Kong
costs
Number of 1 This activity is done once annually –
activity 2
Activity 3 Unused
Training
Activity 1 Annual afternoon One afternoon of web-based training for each Expert opinion by Healthcare professional in
for web-based of the nurses is required. Web-based paediatric care
training trainings are currently already given to train
health care providers
Activity 1 0 No financial costs are incurred in this activity –
Financial
costs
Activity 1 52,007 (USD) One afternoon (4 h) of lost working Author’s assumption
Economic hours for each registered nurse to train on
costs annual influenza vaccine programme.
Number of 1 This training is done once annually –
activity 1
Activity 2 Unused
Activity 3 Unused
Social mobilisation
Activity 1 National press Creation of press release and spreading of –
release for Health posters
Care Worker
vaccination
Activity 1 141 (USD) financial costs are induced the creation Author’s assumption
Financial of a press publication and in the purchase and
costs spread of posters in each of the MCHC and
several other key places
Activity 1 2588 (USD) Costs are based on average salaries for –
Economic the programme manager and a marketing
costs officer in Hong Kong
Number of 1 This activity is only done once –
activity 1
Activity 2 Unused
Activity 3 Unused
Supervision
Activity 1 Supervision from A senior nurse visits the clinics for inspection Author’s assumption
Senior Nurse in for vaccination procedure inspection
MCHC
Activity 1 1316 (USD) Fuel consumption costs Based on Shell Fuel Price board for Hong Kong
Financial and Macau. https://www.shell.com.hk/en_
costs hk/motorists/shell-fuels/price-board.html
Activity 1 9627 (USD) Based on average wage for an Author’s assumption
Economic experienced nurse in Hong Kong for 3 h per
costs week during the entire year
Number of 1 Calculation of salary and fuel was done for the –
activity 1 entire year, therefore one instance of this
activity is counted

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Appendix 1b (continued)

Pregnant women
Parameter Value Rationale Reference
Activity 2 Unused
Activity 3 Unused
Others
Unused
Cost ingredients
Conversion rate 7.75 HKD 7.75 equals USD 1, currency is linked Hong Kong Monetary Authority. (2019). 2019
Annual Report. Retrieved from Hong Kong:
Monthly Accountant (IPH) 3387 Payscale.com (HKD 26,250)
personnel DPH Head of 2409 indeed.com salary indication (HKD 18,666)
costs (USD) Vaccinators
Driver (IPH) 1290 Payscale.com (HKD 10,000)
Epidemiologist 6806 Payscale.com (HKD 52,750)
Logistics manager 2409 Payscale.com (HKD 18,666)
Senior Nurse 7032 Salaryexpert.com (HKD 54,500)
Program Manager 5946 Payscale.com (HKD 46,083)
(IPH)
Registered Nurse 6730 PWH Finance Department (HKD 52,160)
Marketing Officer 2409 Payscale.com (HKD 18,666)
MCHC Clerical 1741 Payscale.com (HKD 13,496)
Worker
Other direct Fuel (litre) 2.19 (USD)_ Based on Shell Fuel Price board for
costs Hong Kong and Macau. https://www.
shell.com.hk/en_hk/motorists/shell-fuels/
price-board.html
Supplemental 280L cold storage 280,000 cm3 / $3,295.00 https://kirsch-medical.de/service/downloads/
cold chain preisliste.html(prices 2020)
(10 years 170L cold storage 170,000 cm3 / $3,374.39 https://kirsch-medical.de/service/downloads/
useful) (USD)
preisliste.html(prices 2020)
120L cold storage 120,000 cm3 / $2,712.34 https://kirsch-medical.de/service/downloads/
preisliste.html(prices 2020)
95L cold storage 95,000 cm3 / $2,778.00 https://kirsch-medical.de/service/downloads/
preisliste.html(prices 2020)
Others Unused

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