Influenza vaccination policies of 28 European countries were compared with those of the US Immunization Practices Advisory Committee. Twenty-four of 28 (86%) European countries had immunization policies for influenza. European and US recommendations were in complete agreement concerning immunization of those with heart and lung disease. Within Europe there was 81-86% agreement concerning immunization of the elderly, irrespective of their health status, and patients with diabetes, renal dysfunction and immunosuppression, and 71% agreement concerning those in residential care and occupational groups that can transmit influenza to high-risk patients. Unlike the US, 62-71% of European countries did not target those with haemoglobinopathies, children and teenagers taking salicylates or household members of those at high risk. Few recommendations were endorsed by relevant medical or patient organizations. The observed variation in vaccination policies in Europe and North America possibly reflect uncertainties concerning risks from influenza and benefits from vaccination, and differences in public health systems and attitudes towards preventive medicine.