Economic impact of dengue episode: multicenter study across four Brazilian regions

First Regional Dengue SymposiumRio de Janeiro, November 2015

Celina Maria Turchi MartelliVisiting Researcher - CPqAM / Fiocruz-Pernambuco

2003:517 thousand 2009-2012: 1 million 2013: > 2 million

Brazil

Mexico

Colombia

Venezuela

Four countries registered 80% of dengue cases

Dengue in America, 2006 -2014

J.L. San Martin / OPAS

Background

• Increased number of reported dengue cases in Brazil

• Cost studies in Brazil and Guideline: – Cost of dengue cases in eight countries in the Americas and Asia (Suaya et al, 2009)

– Direct costs of dengue hospitalization in Brazil (Vieira, 2014)

– Guideline for Costing dengue cases and outbreaks (2012)

Rev Panam Salud Publica 34(3), 2013

Economic impact of dengue episode in Brazil

Objective: To evaluate the economic burden of dengue from

the public payer and societal perspectives

Sponsor: Sanofi Pasteur

Institution: University of Pernambuco, Brazil

Ethical clearance at national level: CONEP

• Cohort: probable dengue cases

• Ambulatory/hospitalized

• Health System: Sectors

Public and Private

Perspectives:

Public Payer: Direct medical costs

Societal:Direct cost, direct non-medical costs, indirect costsDeaths

• Period of study: dengue transmission – high/low

Methods - Study Design

Study sites in Brazil

TeresinaRecife Coordinator Center

Rio de Janeiro

Belo Horizonte

Goiânia

Belém

CityPopulation

(million)Incidence, 2013

(1,000 inhab.)

Goiania 1,2 50.1Belo Horizonte 2,4 55.3Rio de Janeiro 6,3 11.8Teresina 1,2 2.2Recife 1,5 2.7Belem 1,4 1.3

Teresina Recife

Rio de Janeiro Belo HorizonteGoiânia

Belém

Methods - Interviews and Data management

• Phase 1. Hospital/ambulatory settings – recruitment of patients, to

obtain informed consent and schedule household interviews

• Phase 2. Household interview – 15-20 days after the onset of

clinical symptoms

Quanto custa a Dengue para

você e para a sociedade?

Caso seja solicitado, colabore.

Methods - Data collection

• Questionnaire: multi-country cost study (Suaya et al, 2009)

• Patients interview: date of symptoms/signs, use of medical service,

work/school absence, out-of-pocket expenses

• Hospitalized patients: data extracted from the patient´s file

Methods - Costing dengue episode

• Ambulatory and hospital settings, public and private sectors

• Unit cost for medical visit for outpatients

• Public sector - SUS value (USD 4.85)

• Private sector - private health insurance value (USD 26.45)

• Direct cost of hospitalized patients: cost and resource use

2,223 screened dengue cases

188 cases excluded

2,035 dengue cases

1,657 Ambulatory cases

378 Hospitalized cases

Public sectorn=1,144

Private sectorn=513

Public sectorn=217

Private sectorn=161

Public payer perspectiveDirect costs

Societal perspectivePublic and Private sectorsDirect and Indirect costs

Household interview

Flowchart of the study

Dengue epidemiology in Brazil - September 2012 - August 2013

Health care access, Brazil 2013

0

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60

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D+E C2 C1 B2 B1 A1+A2He

alth

car

e a

cce

ss (

%)

Economic classes

Public

Private

Cost per hospitalized dengue case (2013 US$)

Cost distribution of dengue episode (2013 US$)Ambulatory

Hospital

Public payer perspective

Without Expansion Factor With Expansion Factor

Ambulatory 1.8 million cases 5.8 million cases (EF=3.2)

Direct cost per case $ 64 (48-80) unit cost

Cost $ 116 million (87-145) $ 371 million (278-464)

Hospital 201 thousand cases 322 thousand cases (EF=1.6)

Direct cost per case $ 237 (177-297) unit cost

Cost $ 48 million (36-60) $ 76 million (57-96)

Total cost $ 164 million (123-205) $ 447 million (335-560)

Societal perspective

Without Expansion Factor With Expansion Factor

Ambulatory 1.8 million cases 5.8 million cases (EF=3.2)

Cost per case $ 173 (129-218) unit cost

Cost $ 313 million (234-395) $ 1,003 million (748-1,264)

Hospital 201 thousand cases 322 thousand cases (EF=1.6)

Cost per case $ 448 (333-562) unit cost

Cost $ 90 million (67-113) $ 144 million (107-181)

Total cost $ 404 million (301-508) $ 1,147 million (855-1,445)

Number of fatal cases 529 (395-665)

Fatal costs $ 65 million (48-81)

Grand total cost $ 468 million (349-590) $ 1,212 million (904-1,526)

Estimated costs of dengue in Brazil (2013 US$)

Estimated cost of dengue 2009–2013 (2013 US$)

AcknowlegmentsUniversidade de Pernambuco - UPE

Centro de Pesquisa Aggeu Magalhães – Fiocruz/PE

Universidade Federal de Goiás - UFG

Universidade Estadual do Piauí - UESPI

Universidade do Estado do Rio de Janeiro – UERJ

Secretaria Municipal de Belo Horizonte- SMBH

Universidade do Estado do Pará – UEPA

Institute of Health Technology - IATS

Fellowships Grants CNPq

Sanofi Pasteur for support

Researcher Team

Celina Maria Turchi MartelliJoão Bosco Siqueira JuniorMirian Perpetua Palha Dias ParenteAna Laura de Sene Amancio ZaraConsuelo Silva OliveiraCynthia BragaFabiano Geraldo Pimenta JuniorFanny CortesLuciana Ribeiro BahiaMárcia Costa Ooteman MendesMichelle Quarti Machado RosaNoêmia Teixeira Siqueira FilhaWayner Vieira Souza

Dagna ConstenlaJuan Guillermo Lopez

Halasa et al, 2012 EF = 10 EF = 2.42 EF ambulatory : 5 - 27

Wettstein et al, 2012

Epidemic period EF = 10 cases DF (variation: 8-14) Probabilistic (Monte

Carlo simulation),

univariate

Endemic period EF = 20 (variation: 18-25)

DHF cases, EF = 6 (variation 5-10)

Suaya et al, 2009 EF = 3 EF = 3 Univariate (EF 2, 3 e 6)

Shepard et al, 2011Brazil EF = 5 ; Colombia EF = 9 ; Nicaragua EF = 20,4 ;

Panama EF = 6 ; Puerto Rico & other countries EF = 15

Brazil EF = 1.6 ; Colombia,

Panama & Nicaragua EF =

2.3 ; Puerto Rico EF = 2.4 ;

Other countries EF = 2.3

Probabilistic. Monte

Carlo simulation

Author, year of

publicationEF ambulatory EF hospital Sensitivity analysis

Armien et al, 2008 EF = 6 EF = 6 Univariate (EF 1-10)

Cost per ambulatory dengue case (2013 US$)

Cost of illness Americas

Ambulatory Hospital

Medical Non-medical Indirect Total I$, 2014

Brazil

El Salvador

Guatemala

PanamaVenezuela

Venezuela

Venezuela

Argentina

Cuba

Colombia

Puerto Rico

Nicaragua

Brazil

Brazil