Influenza Vaccination Implementation in Sri Lanka: A Cost-Effectiveness Analysis.


Influenza causes an estimated 3 to 5 million cases of severe illness annually, along with substantial morbidity and mortality, particularly in low- and middle-income countries (LMICs). Currently, Sri Lanka has no influenza vaccination policies and does not offer vaccination within the public healthcare sector. Therefore, we performed a cost-effectiveness analysis of influenza vaccine implementation for the Sri Lankan population. We designed a static Markov model that followed a population cohort of Sri Lankans in three age groups, 0-4, 5-64, and 65+ years, through two potential scenarios: trivalent inactivated vaccination (TIV) and no TIV across twelve-monthly cycles using a governmental perspective at the national level. We also performed probabilistic and one-way sensitivity analyses to identify influential variables and account for uncertainty. The vaccination model arm reduced influenza outcomes by 20,710 cases, 438 hospitalizations, and 20 deaths compared to no vaccination in one year. Universal vaccination became cost-effective at approximately 98.01% of Sri Lanka's 2022 GDP per capita (incremental cost-effectiveness ratio = 874,890.55 Rs/DALY averted; 3624.84 USD/DALY averted). Results were most sensitive to the vaccine coverage in the 5-64-year-old age group, the cost of the influenza vaccine dose in the 5-64-years-old age group, vaccine effectiveness in the under-5-years-old age group, and the vaccine coverage in the under-5-years-old age group. No value for a variable within our estimated ranges resulted in ICERs above Rs. 1,300,000 (USD 5386.15) per DALY adverted. Providing influenza vaccines was considered highly cost-effective compared to no vaccines. However, large-scale national studies with improved data are needed to better inform estimates and determine the impact of vaccination implementation.





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Publication Info

Neighbors, Coralei E, Evan R Myers, Nayani P Weerasinghe, Gaya B Wijayaratne, Champica K Bodinayake, Ajith Nagahawatte, L Gayani Tillekeratne, Christopher W Woods, et al. (2023). Influenza Vaccination Implementation in Sri Lanka: A Cost-Effectiveness Analysis. Vaccines, 11(5). p. 932. 10.3390/vaccines11050932 Retrieved from

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Coralei Neighbors


Coralei Neighbors is a Ph.D. Student at the Department of Population Health Sciences in the Duke School of Medicine. She received her Bachelor of Science in Education for Health Science Studies from Baylor University and her Master of Science in Global Health from Duke University. Coralei has experience in national and international infectious disease research, with interests in infectious disease surveillance, health economics, and global health policy.


Evan Robert Myers

Walter L. Thomas Distinguished Professor of Obstetrics and Gynecology in the School of Medicine

My research interests are broadly in the application of quantitative methods, especially mathematical modeling and decision analysis, to problems in women's health. Recent and current activities include integration of simulation modeling and systematic reviews to inform decisions surrounding cervical, ovarian, and breast cancer prevention and control, screening for postpartum depression, and management of uterine fibroids.    We are also engaged in exploring methods for integrating guidelines development and research prioritization.    In addition, I have ongoing collaborations using the tools of decision analysis with faculty in other clinical areas  Research is conducted through the Division of Reproductive Sciences in the Department of Obstetrics and Gynecology, the Evidence Synthesis Group in the Duke Clinical Research Institute, and the Duke Cancer Institute.  I'm also the course director for CRP 259, "Decision Sciences in Clinical Research", in Duke's Clinical Research Training Program.


Gayani Tillekeratne

Associate Professor of Medicine

Global health
Antimicrobial resistance/ stewardship
Acute respiratory tract infections 
Emerging infections/ dengue


Christopher Wildrick Woods

Wolfgang Joklik Distinguished Professor of Global Health

1. Emerging Infections
2. Global Health
3. Epidemiology of infectious diseases
4. Clinical microbiology and diagnostics
5. Bioterrorism Preparedness
6. Surveillance for communicable diseases
7. Antimicrobial resistance

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