CHIKV in the Americas: Socioeconomic consequences of outbreaks
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Las consecuencias socioeconómicas de los brotes de CHIKV incluyen costos directos e indirectos tanto en la fase aguda como en los casos crónicos. Los costos directos incluyen gastos de salud, pérdida de productividad y turismo, mientras que los costos indirectos incluyen años de vida ajustados por discapacidad. Los estudios muestran que los costos van desde miles a millones de dólares, afectando significativamente los sistemas de salud y economías locales.
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CHIKV in the Americas: Socioeconomic consequences of outbreaks
- 1. CHIKV in the Americas Consecuencias socioeconómicas inmediatas y a largo plazo de brotes previos de chikungunya Pilar Ramon-Pardo 5 noviembre 2015 Enfermedades transmisibles y análisis de salud OPS/OMS
- 2. Chikungunya es letal en muy raras ocasiones, pero en algunas personas, el dolor articular que causa el dolor en las articulaciones que causa puede persistir durante meses o incluso años. Los adultos mayores son más susceptibles a sufrir los síntomas a largo plazo. Un dolor que no desaparece… photo:LuzSosaPAHO/WHO
- 3. Title of the Presentation2 Economic impact of the outbreak ? Las consecuencias socioeconómicas de los brotes de CHIKV deben considerarse en relación con dos etapas: - brote agudo - casos crónicos Impacto en los gastos de salud, pérdida de productividad, impacto sobre los ingresos por turismo, calidad de vida
- 4. Title of the Presentation3 Casos sospechosos: 1.589.309 Casos confirmados: 39. 388 TOTAL: 1.628.697 Fallecidos: 253 www.paho.org/chikungunya La carga de enfermedad se puede expresar de muchas maneras
- 5. Temas • Años de vida ajustados por discapacidad (AVAD) o India, 2006 o Comparación AVAD - cuatro infecciones por arbovirus, 2010 o Costos AVAD - Andhra Pradesh, India, 2005-2006 • Costo de la enfermedad o Gastos de bolsillo (Kerala, India, 2007; Orissa, India, 2007) o Costo de la enfermedad (Reunión, 2005-2006) o Costo de DEN + CHIK (Gujarat, India, 2007) • Costes adicionales - Italia, 2007 • Impacto de CHIK y DEN en los ingresos por turismo Title of the Presentation4
- 6. 1,39 millones de casos sospechosos 213 distritos 15 estados 77,5% de los pacientes, buscaron atención en servicios privados
- 7. DALY (AVAD): medida de la pérdida de días de salud en una sociedad debido a la mortalidad y la morbilidad DALY = YLL + YLDacute + YLD chronic No se atribuyeron muertes a CHIKV 45,26 DALY por millón de población
- 8. Agudo 31% Crónico 69% AVAD • Artralgia a largo plazo 11% casos 69% del total de AVAD perdidos • Pérdidas económicas: Rs.391millones (USD6.13 millones) infraestimado - Salario mínimo USD 0.82/día 7
- 9. CHIKV in the Americas8 1. Fiebre amarilla 2. Encefalitis japonesa 3. Chikungunya 4. Fiebre del Valle del Rift
- 10. 9
- 11. Las fuentes de las estimaciones de peso discapacidad de morbilidad a largo plazo relacionada CHIKV: Valores proxy basados en el Proyecto Mundial de Carga de Enfermedad (GBD) por estados análogos de salud Secuelas y prevalencia esperada Peso de enfermedad (PE) de morbilidades análagos del listado del GBD Rango de peso de enfermedad (PE) por YLD Estimaciones 5 - 50% de los sobreviviente tendran un estado reumatológico posinfeccioso prolongado y complicaciones neurológicas ≈ Osteoartritis, PE = 0.156 o ≈ Artritis reumatoide, PE = 0.233 0.16-0.23 DALY = YLL + YLDacute + YLD chronic YLL = (Incident deaths) × (standard expected years of life lost at median age of death) YLD acute = (Incident cases with acute disease only) ×DW acute × (duration acute disease) YLDchronic = (Incident cases progressing to chronic disease) × DWchronic × (duration of chronic disease)
- 12. 11 0 500 1000 1500 2000 2500 YVF JEV CHIKV RVF Thousands2005, DALY estimates Sin considerar la diseminación en las Américas
- 13. Estimación de la carga de la enfermedad y el costo económico atribuible a chikungunya, Andhra Pradesh, India, 2005-2006 Mallela - Malella: 242 casos - Carga por caso: 0.0272 DALYs (costo: US$37.50) TOTAL: 6.57 DALYs y una pérdida de US$9100. Costos médicos directos, de bolsillo: 68% del total. - Carga para el distrito Kadapa: 160 DALYs (costo: US$290 000). - Carga para Andhra Pradesh: 6600 DALYs (costo: US$12 400 000). 12Trans R Soc Trop Med Hyg. 2010 Feb;104(2):133-8. doi: 10.1016/j.trstmh.2009.07.014. Epub 2009 Aug 25. Estimating the burden of disease and the economic cost attributable to chikungunya, Andhra Pradesh, India, 2005-2006. Seyler T1, Hutin Y, Ramanchandran V, Ramakrishnan R, Manickam P, Murhekar M. "Map AP dist all shaded". Licensed under CC BY-SA 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Map_AP_dist_all_shaded.png#/medi a/File:Map_AP_dist_all_shaded.png
- 14. Impacto económico de la epidemia de chikungunya: gastos de bolsillo en salud duraten el brote de 2007 en Kerala, India 47.4% 17.2% 16.6% 9.9% Gastos de bolsillo para salud medicines transportation consultations diagnoses - No hay una asociación significativa con el incremento del ingreso mensual percápita. - Mayor en los centros privados. - Para más del 15% de los que respondieron, el gasto de bolsillo fue más que el doble de su ingreso mensual their average monthly family income 13 Southeast Asian J Trop Med Public Health. 2013 Jan;44(1):54-61. Economic impact of chikungunya epidemic: out-of-pocket health expenditures during the 2007 outbreak in Kerala, India. Vijayakumar K1, George B, Anish TS, Rajasi RS, Teena MJ, Sujina CM. Mediana (IQR) = USD7.4 (16.7)
- 15. $32.1 $30.0 $7.1 $6.8 $7.1 Gasto de bolsillo en salud Diagnosis Drugs & Consultation Transport Stay & Food Escort Mediana = USD 84 por paciente Orissa, India - 2007 Entrevista estucturada: 150 px Mediana de días de trabajo perdidos: 35 - En consecuencia, pérdida del ingreso: US$ 75.
- 16. Title of the Presentation 33 36 24 63 0 10 20 30 40 50 60 70 Sex Duration of illness Male Female < 30 d > 30 d Pérdida de días de trabajo por sexo y duración de la enfermedad, Orissa, 2007 Mediana: días de trabajo perdidos Days
- 17. Costs (€ million , 2016) Reimbursements GP €12.4 (7.7 – 17.7) Reimbursements drugs €5 (1.9 – 8.1) Hospitalization for CHIKV €8.5 (5.8 – 8.7) 26.34 17.56 Costs € million Direct medical costs Indirect costs Direct medical costs: • €90 for each outpatient • €2,000 for each inpatient
- 19. 18
- 20. Preliminary estimate of immediate cost of chikungunya and dengue to Gujarat, India Tiina M. Murtolaa, S.S. Vasanb,c, Tapasvi I. Puward, Dipti Govild, Robert W. Fielde, Hong-Fei Gongb, Ami Bhavsar- Vyasf,g, Jose A. Suayag, Marion Howardg, Donald S. Shepardg, Vijay Kumar Kohlih, P.B. Prajapatii, Amarjit Singhi and Dileep V. Mavalankard# CHIKV in the Americas19 Dengue Bulletin – Volume 34, 2010 Immediate cost to households: US$ 90 million (range US$ 38 - US$ 217 million) per year 3.8 (range 1.6–9.1) billion Indian rupees (INR)
- 21. Collateral costs 13 Transfusion Services
- 22. Risk Assessment for Donations: Mathematical Model • Based on viremia risk • 1/380000 acceptable (~HBV) • Duration of CHIK viremia: 8 days, 15% asymptomatic • Two premises: a) the precautionary measure of quarantining blood components had to be in place b) any symptomatic blood donor was expected to self-defer or be excluded from donation by the pre-donation medical examination.
- 23. Impacto económico • Unidades de plasma no colectados, eliminado o no entregados a la empresa farmacéutica privada con licencia para la fabricación por contrato causaron una pérdida de los ingresos brutos de los productos derivados medicinales (albúmina, inmunoglobulinas específicas intravenosos, factor VIII, factor IX, complejo de protrombina, la antitrombina): € 944.600 • Deduciendo los costos no realizados de fabricación por contrato de plasma, la pérdida calculada de producto neto: € 574.000 • Eliminación de 725 unidades de glóbulos rojos: € 101.000 • 304 unidades de glóbulos rojos comprados a través de la oferta extra- regional: € 47.000 • La pérdida de los ingresos brutos de 4405 unidades de glóbulos rojos no cobrados: € 614.000 Total € 1,336,000
- 24. Cuantificar el impacto de CHIK y DEN en los ingresos por turismo Dileep V. Mavalankar, Tapasvi I. Puwar, Tiina M. Murtola, S.S. Vasan W.P. No. 2009-02-03 - February 2009 0 50 100 150 200 250 300 350 400 Gujarat Malaysia Thailand loss turism revenues cost DEN + CHIKV Se asume: 4% disminución anual de turismo 0.40% 1.60% 1.80% 0.00% 0.50% 1.00% 1.50% 2.00% Gujarat Malaysia Thailand Share of world turism US$ millions
- 25. Mathematical model (Markov) Castro J, Abadí A. Prodavinci Abril 24, 2015 http://prodavinci.com/blogs/quiere-saber-cuanto-costo-la-epidermia-de-chikungunya-en-venezuela-por-julio-castro-y-anabella-abadi/ Impacto económico del brote (Venezuela, 2015) Variable Premisas Número total de casos Jun-Dic 2014, 10% población infectada (3 millones de personas) Atención en centros públicos o privados 50% en sector público, 50% en sector privado Hospitalización 1/1000 casos graves Exámentes de laboratorio 40% de los pacientes requirieron exámenes de laboratorio Medicamentos 4-5 días de tratamiento. Precios de septiembre 2014 Gravedad Impacto en las primeras dos semanas (fase aguda) Pérdida de días de trabajo e impacto económico 2 días por los casos leves, 4 d por los moderados y 9 d por los graves
- 26. Mathematical model (Markov) Castro J, Abadí A. Prodavinci Abril 24, 2015 http://prodavinci.com/blogs/quiere-saber-cuanto-costo-la-epidermia-de-chikungunya-en-venezuela-por-julio-castro-y-anabella-abadi/ Impacto económico del brote (Venezuela, 2015) Variable Premisas Número total de casos Jun-Dic 2014, 10% población infectada (3 millones de personas) Atención en centros públicos o privados 50% en sector público, 50% en sector privado Hospitalización 1/1000 casos graves Exámentes de laboratorio 40% de los pacientes requirieron exámenes de laboratorio Medicamentos 4-5 días de tratamiento. Precios de septiembre 2014 Gravedad Impacto en las primeras dos semanas (fase aguda) Pérdida de días de trabajo e impacto económico 2 días por los casos leves, 4 d por los moderados y 9 d por los graves En total, la epidemia de Chikungunya resultó en: - 9,6 millones de días de trabajo perdidos - 5,1 millones de consultas médicas - 1,5 millones de pruebas de laboratorio - 148 millones de comprimidos de paracetamol - Alrededor de 1.200 hospitalizaciones
- 27. Castro J, Abadí A. Prodavinci Abril 24, 2015 Economic impact of the outbreak (Venezuela, 2015) 0.5, 7% 1.8, 27% 4.4, 66% Venezuelan Bolivars BsF (billions) Direct costs (public) Direct costs (private) Indirect costs Total 6.7 BsF billions ~ 1,2 USD billions
- 28. Impacto económico del brote (Venezuela, 2015) Impacto económico total de la epidemia CHIKV (6,7 millones de Bs) es igual a: • 8% del gasto en salud, según la Memoria y Cuenta 2014 - Ministerio de Salud • 12% del Plan de Presupuesto de la Salud para 2015, de acuerdo con el Presupuesto Nacional • Un año de salario mínimo a finales de 2014 (BsF 4.889) a 114,200 venezolanos Supera la deuda del Gobierno Central con el sector de alimentos y el 25% de la participación de la deuda con las empresas farmacéuticas.
- 29. Impacto económico de CHIKV en Colombia • Cuatro centros hospitalarios • Muestreo: o 51 o 67 niños + 8 adultos
- 30. Resultados (costos en miles de COP) 72 755 211 957 0 200 400 600 800 1000 1200 Ambulatorios Hospitalizados Niños Adultos
- 31. Resultados (costos en miles de COP)
- 35. El CHIK Gauzere BA & Aubry P, Path Exot Ed. 2006 La epidemia de chikungunya: Arbovirus + Alphavirus Un impacto doble El Choque El Cheque
- 36. Conclusiones • Evidencias sobre el impacto económico de CHIK: o AVAD o Gastos de bolsillo o Costo de la enfermedad o Pérdida de productividad • Limitaciones o La vigilancia debe ser fortalecida para la obtención de datos epidemiológicos de calidad o Difícil de medir los costos de las medicinas alternativas o No está determinado el peso específico de la enfermedad (DW) para CHIK aguda / crónica
- 37. Conclusiones Aspectos pendientes • Proponer que la OMS recalcule las estimaciones globales del impacto en la salud de las infecciones por arbovirus (teniendo en cuenta CHIK y ZIKV) • Las estimaciones de costos de CHIK se pueden utilizar para evaluar la relación coste / beneficio de los programas de vigilancia, prevención y control, incluyendo futuras vacunas
- 38. Gracias por su atención Title of the Presentation37
Notas del editor
- 20 minutes
- Chikungunya (CHIK) fever is described as a two-stage disease: acute and chronic. In public health terms, the huge acute impact of CHIK is followed by a significant proportion of patients with inflammatory relapses, long-lasting rheumatism, and a significant loss of quality of life. The CHIK outbreaks’ socioeconomic consequences should be considered in relation to these two stages. In addition to the direct impact on health expenditures and loss of productivity, an impact on tourism revenues should be pondered especially in the countries where tourism represents a relevant contribution to the Gross Domestic Product (GDP).
- Chikungunya (CHIK) fever is described as a two-stage disease: acute and chronic. In public health terms, the huge acute impact of CHIK is followed by a significant proportion of patients with inflammatory relapses, long-lasting rheumatism, and a significant loss of quality of life. The CHIK outbreaks’ socioeconomic consequences should be considered in relation to these two stages. In addition to the direct impact on health expenditures and loss of productivity, an impact on tourism revenues should be pondered especially in the countries where tourism represents a relevant contribution to the Gross Domestic Product (GDP).
- Explosive disemination in the continent – limitations also to estimate the burden of disease – only acute cases.
- Background & objectives: During 2006, chikungunya emerged as a major ever known epidemic in India. Disability adjusted life years (DALY) is an appropriate summary measure of population health to express epidemiological burden of diseases. We estimated the burden due to suspected chikungunya using DALYs for the first time and compared between the states and also with the burden due to other vector-borne diseases in India. The economic burden was also assessed in terms of productivity loss. Methods: Data on the reported cases of fever/suspected cases of chikungunya from different states during 2006 in India were used. Years lived with disability (YLD) were calculated for non-fatal cases to estimate DALY. Since the disability weight for chikungunya is not available, the weights available for rheumatic arthritis, comparable to the disease outcome of chikungunya were used for the estimation. The burden was estimated for both acute and chronic cases. It is considered that about 11.5% of cases were reported to have extended morbidity with persisting arthralgia. For acute disease, the average duration of illness was considered to be nine days and for chronic cases it was six months on an average. The productivity loss due to income foregone by the working class was calculated using minimum official wage. Results: National burden of chikungunya was estimated to be 25,588 DALYs lost during 2006 epidemic, with an overall burden of 45.26 DALYs per million. It varied from 0.01 to 265.62 per million in different states. Karnataka alone contributed as high as 55% of the national burden. Persistent arthralgia was found to impose heavy burden, accounting for 69% of the total DALYs. The productivity loss in terms of income foregone was estimated to be a minimum of Rs. 391 million. Interpretation & conclusion: The chikungunya epidemic in the year 2006 imposed heavy epidemiological burden and productivity loss to the community. The burden of chikungunya in terms of DALY was estimated for the first time. In view of re-emergence and spread of this infection in recent times it is warranted for derivation of disability weight for different health states of chikungunya to facilitate realistic estimates of DALYs. Quality epidemiological data from surveillance system to monitor vector-borne and zoonotic diseases would pave way for more realistic estimates of burden. The productivity loss in-terms of income foregone could be minimal as the estimation was made by using the minimum wage fixed by the government although the actual loss is expected to be higher.
- 45,26 DALY por millón de población
- Duration of illness: 9 days Minumum wage: Rs. 52.69 = US$0.82
- Model – estimated from different studies and paramethers
- YLL = (Incident deaths) × (standard expected years of life lost at median age of death) YLD acute = (Incident cases with acute disease only) ×DW acute × (duration acute disease) YLDchronic = (Incident cases progressing to chronic disease) × DWchronic × (duration of chronic disease). For calculation of DALY (3, 0) estimates, 3% per annum time-discounting was applied to future SEYLL and disease duration values.
- To estimate the burden and cost of chikungunya in India, we searched for cases of fever and joint pain in the village of Mallela, Andhra Pradesh, and collected information on the demography, signs, symptoms, healthcare utilization and expenditure associated with the disease. We estimated the burden of the disease using disability-adjusted life years (DALYs). We estimated direct and indirect costs and made projections for the district and state using surveillance data corrected for under-reporting. On average, from December 2005 to April 2006, each of the 242 cases in the village led to a burden of 0.0272 DALYs (95% CI 0.0224-0.0319) and a cost of US$37.50 (95% CI 30.6-44.3). Overall, chikungunya in Mallela led to 6.57 DALYs and a loss of US$9100. Out-of-pocket direct medical costs accounted for 68% of the total. From January to December 2006 the burden for Kadapa district was 160 DALYs (cost: US$290 000). Over the same period the burden for Andhra Pradesh was 6600 DALYs (cost: US$12 400 000). While the burden was moderate, costs were high and mostly out of pocket.
- The southern state of Kerala, India was seriously affected by a chikungunya epidemic in 2007. As this outbreak was the first of its kind, the morbidity incurred by the epidemic was a challenge to the state's public health system. A cross sectional survey was conducted in five districts of Kerala that were seriously affected by the epidemic, using a two-stage cluster sampling technique to select households, and the patients were identified using a syndromic case definition. We calculated the direct health expenditure of families and checked whether it exceed the margins of catastrophic health expenditure (CHE). The median (IQR) total out-of-pocket (OOP) health expenditure in the study population was USD7.4 (16.7). The OOP health expenditure did not show any significant association with increasing per-capita monthly income.The major share (47.4%) of the costs was utilized for buying medicines, but costs for transportation (17.2%), consultations (16.6%), and diagnoses (9.9%) also contributed significantly to the total OOP health expenditure. The OOP health expenditure was high in private sector facilities, especially in tertiary care hospitals. For more than 15% of the respondents, the OOP was more than double their average monthly family income. The chikungunya outbreak of 2007 had significantly contributed to the OOP expenditure of the affected community in Kerala.The OOP health expenditure incurred was high, irrespective of the level of income. Governments should attempt to ensure comprehensive financial protection by covering the costs of care, along with loss of productivity.
- Background & objectives: To examine the household economic impact of an outbreak of chikungunya in terms of out-of-pocket health care expenditure and income foregone due to loss of productive time in Orissa, India. Methods: Structured interviews were conducted on 150 respondents, bread winners from the affected households of a village with maximum number of reported cases in the state, during August 2007. We looked at the economic profile, treatment history, and patient-side cost of care, loss of productivity and consequent income loss. Results: The median out-of-pocket health care expenditure was US$ 84, of which the proportion of cost of diagnosis was the highest (US$ 77). One hundred and forty nine respondents incurred cost of care more than 10% of their monthly household income (catastrophic health expenditure). The median catastrophic health care expenditure was 37%. The respondents depended more on private health care providers (49%) and 31% of them accessed care from both public and private health care providers. The median work days lost was 35 with a consequent loss of income of US$ 75.
- This study aims to provide a preliminary estimate of the immediate cost of chikungunya and dengue to household in the Indian state of Gujarat. Combining nine earlier studies and data from interviews, we analysed the costs of non-fatal illness and of intervention programmes; building a more comprehensive picture of the immediate cost of these Aedes aegypti mosquito-borne diseases to Gujarat. The “RUHA matrix” was used to estimate the cost of illness by combining the shares of reported (R) and unreported (U) hospitalized (H) and ambulatory (A) cases of chikungunya and dengue with ambulatory and hospitalization costs per case and the number of reported cases. Using Monte Carlo sensitivity analysis, the immediate cost to households incurred on account of chikungunya and dengue to Gujarat was estimated to be 3.8 (range 1.6–9.1) billion Indian rupees (INR) per annum (US$ 90 million, range US$ 38 and US$ 217 million). It is hoped that this preliminary estimate will trigger more refined studies on cost of illness as well as cost-effectiveness of vaccines and other interventions to combat these neglected tropical diseases
- The mathematical model developed allowed a dynamic estimate of the risk during the decreasing phase of the epidemic and a retrospective weekly estimate of its highest level, thus providing a reasonable approximation to the mean risk of CHIKV transmission through blood transfusion. It also provided the right order of magnitude of the risk and proved to be a useful tool for "pragmatic“ risk assessment and management when precautionary measures had to be modified or interrupted and blood collection was restarted. e calculated 8 days for the total duration of CHIKV viraemia: 2 days before the first symptoms and 6 days after them, including the day of symptom onset. Moreover, we assumed that the total duration of viraemia was similar in symptomatic and asymptomatic infections. A seroprevalence study conducted among the general population of La Réunion Island40 suggested that 15 percent of infected individuals were asymptomatic. I
- Plasma units uncollected, eliminated or undelivered (as detailed in table II) to the licensed private pharmaceutical company for contract manufacturing caused a loss of gross proceeds from derived medicinal products (albumin, intravenous aspecific immunoglobulins, factor VIII, factor IX, prothrombin complex, antithrombin) quantified at € 944, 600. Deducing the costs not sustained for plasma contract manufacturing, the calculated loss of net proceeds totalled € 574,000. The complete calculation of the regional economic loss must also include € 101,000 due to the elimination of 725 RBC units and €47,000 for 304 RBC units purchased through extra-regional supply. To this sum, a further € 614,000 loss of gross proceeds from the remaining 4405 RBC units not collected should be added. In addition, reliable and tested mechanisms of extraordinary blood supply are necessary for a national blood system to sustain the impact of the outbreak on the blood inventory. Indeed, the precautionary measures adopted - justified by the unavailability of a laboratory test for routine biological qualification of blood components - produced a considerable impact on the blood supply of Emilia-Romagna that changed its role from being an exporter of blood components to being an importer. In fact other Italian regions balanced Emilia-Romagna's lack of extraregional output of RBC units.
- Exchange rate preference Cencoex 6.3 BsF / 1 US $, equivalent to 1.07 billion dollars.
- Exchange rate preference Cencoex 6.3 BsF / 1 US $, equivalent to 1.07 billion dollars.
- Outbreak of an emerging disease creates unforeseen catastrophic health care expenditure and reinforcing the poverty ill-health nexus. The priorities of tackling emerging diseases should include; discretionary public health spending, financial protection against the cost of illness and productivity with special emphasis on people living on daily wages with less financial reserves, and further research on therapeutic measures to reduce the duration of suffering and consequent economic loss.
- Outbreak of an emerging disease creates unforeseen catastrophic health care expenditure and reinforcing the poverty ill-health nexus. The priorities of tackling emerging diseases should include; discretionary public health spending, financial protection against the cost of illness and productivity with special emphasis on people living on daily wages with less financial reserves, and further research on therapeutic measures to reduce the duration of suffering and consequent economic loss.