Cost-effectiveness of tick-borne encephalitis vaccination in Slovenian adults.

Vaccine 2012;30(44):6301-6).

Renata Šmit

University of Ljubljana, Slovenia


Background: Slovenia is an endemic country with a high incidence rate of tick-borne encephalitis (TBE) and low vaccination coverage. TBE causes high costs for the health care insurances as well as the society due to hospitalization and frequent long term or permanent neurological sequelae. Vaccination is effective and a safe prophylaxis against TBE.

Objective: The purpose of this study was to evaluate the incremental cost-effectiveness ratio (ICER) between vaccination and no vaccination in Slovenia. The results are shown as cost per quality-adjusted life year (QALY) gained from the view of the health care payer and the society.

Methods: Based on the natural course of the disease, the Markov model was used for comparing the economic and health outcomes of vaccinated and unvaccinated groups from 18 to 80 years of age.

Results: The incremental cost-effectiveness ratio from the current Slovenian vaccination programme for FSME-Immun® compared to no vaccination amounts to 15,128 € per QALY gained and for Encepur® 20,099 € per QALY gained from the view of the health care payer. From the view of the society vaccination is cost saving, mainly due to avoiding the high indirect costs.

Conclusions: According to the cost-effectiveness threshold as proposed by the Slovenian Health Council, the current Slovenian vaccination programme against TBE is cost-effective from the health care payer’s perspective and also economical from the society’s perspective.

PMID: 22885012



In various parts of Europe the incidence of tick-borne encephalitis (TBE) is increasing and new foci have appeared due to increasing mobility, changes in lifestyle, human leisure activities, agricultural practices, effects of climate changes on vectors, and reservoir hosts [1]. TBE is a huge public health problem not only in Slovenia but also worldwide. In 2005, for calculating cost-benefit of vaccination against TBE among French Troops a decision tree was used [2]. In 1993, some efforts were made to evaluate the economic benefits of vaccination [3], although it was proposed to investigate the exact benefits of vaccination.

Although Slovenia is a small country, it is also one of the countries with the highest incidence of TBE in Europe and very low vaccination coverage. The cost-effectiveness of vacination against TBE in Slovenia has not yet been done. Therefore the article about the cost-effectiveness of tick-borne encephalitis vaccination (CE of TBE vaccination) is an innovation and gives more detailed information about the cost-effectiveness of vaccination using the Markov model. The use of the Markov model for evaluating the cost-effectiveness of vaccination against TBE is a novelty. The further importance of the study is from the view of public health in Slovenia. The findings of the research may be supportive in decision making for effective planning and prioritizing of limited public health resources to reduce the burden of TBE and protect public health. Vaccination is the most effective way of reducing the burden.

TBE is a neurological disease and the European subtype of the virus causes a tipically biphasic course of the disease. The first stage of the disease is characterized by symptoms similar to flu. The second stage of the disease is characterized by high fever and central nervous system involment with signs of meningitis, encephalitis or radiculitis. Most of these patients need medical advice and hospitalization. Some patients recover and become immune, some develop disabling sequelae that affect their quality of life and sometimes change their individual lifestyle. The fatality rate in Europe is less than 2%.

On the basis of the natural course of the disease (Figure 1), a Markov model was developed. The susceptible, permanent neurological sequelae (mild, moderate, severe), and death due to TBE, recovered and immune are health states that are included in the model (Figure 2).

Renata Šmit-fig1

Figure 1. Natural course of TBE.

Renata Šmit-fig2

Figure 2. Markov model with six health states. The mild, moderate and severe sequelae are all permanent. Death occurs from the disease as well as from other causes.

The Markov model was used to evaluate the cost-effectiveness of vaccination. It compared the economic and health outcomes (quality-adjusted life years) of vaccinated and no vaccinated adults between the age of 18 and 80. The modelling was performed in TreeAge Software 2011. The results are presented from the view of the health care payer and the society. Results of the study show that vaccination is cost-effective for adults from the health care payer’s perspective and cost saving from the society’s perspective. With the sensitivity analyses it was tested which parameters have the greatest influence on the result. The probability of severe sequelae has the greatest influence on incremental cost effectivenes ratio (ICER), followed by probability of contracting TBE, probability of permanent moderate sequelae, discount rate for costs and quality weights and quality weights of permanent moderate sequelae. Even if parameter values change within a fixed range, vaccination is still cost-effective from the view of the health care payer (Figure 3).

Renata Šmit-fig3

Figure 3. The one-way sensitivity analysis for vaccination for both vaccines from the view of the health care payer. ICER presents the cost per quality-adjusted life year gained. The quality weights are relative values according to the health state in terms of the psychological aspect and functional handicap. Value 1 represents perfect mental and physical health and value 0 represents death. Costs and outcomes are discounted at 5%.

In 1981 an extended vaccination campaign was started through the national universal vaccination programme in Austria. Interventions increased vaccination and thereby reduced the incidence of TBE [4]. In 1993 [3], an estimate for Austria suggested that the TBE vaccine may be cost-effective, at least in countries where TBE is widespread and highly endemic. In 2003 it was concluded by Kunz [4] that TBE will not be a public health problem in Austria if the universal programme is continued.

The impact of CE of TBE vaccination is seen as follows:

  • The County Council of Sörnland in Sweden used the model in CE for TBE vaccination to make a decision about vaccination against TBE [5].
  • The Central European Vaccination Awareness Group [6] as well as Italian researchers [7] acknowledged the results of this article in their publications.
  • The study is important and supportive in the decision making process.

It is advisable that a bigger portion of individuals should be vaccinated either free of charge or with a reduced price under the national universal vaccination programme. This will prevent morbidity and its consequences with resulting economic returns in Slovenia.



[1] Kunze U. et al. The Golden Agers and Tick-borne encephalitis Conference report and position paper of the International Scientific Working Group on Tick-borne encephalitis. Wien Med Wochenschr 2005;155(11–12): 289–94.

[2] Desjeux G, Galoisy-Guibal L, Colin C. Cost-benefit analysis of vaccination against tick-borne encephalitis among French troops. Pharmacoeconomics 2005;23(9):913-26.

[3] Scwarz B. Health economics of early summer meningoecephalitis in Austria. Effect of a vaccination campaign 1981 to 1990. Wien Med Wochenschr 1993;143(21):551-5.

[4] Kunz C. TBE vaccination and the Austrian experience. Vaccine 2003 Apr 1;21 Suppl 1:S50-5.

[5] Ola-Engman K, Kallings-Larsson C, Feldman I. Hälsoekonomisk analys av allmän TBE-vaccinering av invȧnarna I Sörmland Available from: [accessed 18.08.13].

[6] Zavadska D, Anca I, André F, Bakir M, Chlibek R, Cižman M et al. Recommendations for tick-borne encephalitis vaccination from the Central European Vaccination Awareness Group (CEVAG). Hum Vaccin Immunother 2013 Jan 4;9(2).

[7] Amicizia D, Domnich A, Panatto D, Luigi Lai P, Luisa Cristina M, Avio U, Gasparini R. Epidemiology of tick-borne encephalitis (TBE) in Europe and its prevention by available vaccines. Hum Vaccin Immunother 2013 Feb 1;9(5).



Renata Šmit᾿s doctoral study is partially funded by a scholarship from the European Union and the Ministry of Education, Science and Sport of the Republic of Slovenia.



Renata Šmit

11 Peričeva Street

1000 Ljubljana



Tel: +361 436 11 05


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