Cost-effectiveness of ongoing COVID-19 vaccination in the context of high population immunity: A structured review of international economic evidence.

BACKGROUND

In the context of ongoing SARS-CoV-2 circulation and high population immunity, jurisdictions face decisions about which population groups should receive ongoing annual vaccination. Economic evaluations are increasingly central to these deliberations but the growing body of global cost-effectiveness evidence has not been synthesized.

OBJECTIVE

To summarize cost-effectiveness evidence for COVID-19 vaccination from 2023 onwards, organized by population groups of policy relevance.

METHODS

We conducted a structured literature search in December 2025 across MEDLINE, Embase, and EconLit, supplemented by grey literature searches of National Immunization Technical Advisory Group (NITAG) websites. From 644 screened references, 21 studies met inclusion criteria: economic evaluations of COVID-19 vaccination from 2023 onwards reporting cost-effectiveness of annual vaccination compared to no additional vaccination in quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs). Results were synthesized by population group.

RESULTS

Annual COVID-19 vaccination was economically favourable for older adults (≥60-65 years) across all 18 contributing studies spanning 12 countries and using diverse analytic approaches. For individuals with underlying conditions or comorbidities, results were more variable, with cost-effectiveness depending on age, specific conditions, and vaccine price. Vaccination of healthy working-age adults (3 of 4 studies) and children (2 of 3 studies) was generally unfavourable at standard cost-effectiveness thresholds. Limited evidence was identified for healthcare workers and no economic evaluations from 2023 onwards were identified for pregnancy. The evidence base was geographically concentrated in high-income countries, with approximately half of included studies reporting industry funding. Sequential US economic evaluations demonstrated progressive declines in cost-effectiveness as disease burden decreased over time.

CONCLUSIONS

The economic evidence supports a risk-stratified approach to COVID-19 vaccination, with the strongest economic value observed for older adults and individuals with comorbidities. Cost-effectiveness is dynamic, sensitive to disease burden, vaccine price, and population characteristics, and should be reassessed regularly as epidemiological conditions evolve.