Economic burden of rotavirus disease in children under 5 years in Kazakhstan

Cost of illness for childhood diarrhea in low- and middle-income countries: a systematic review of evidence and modelled estimates

Background

Numerous studies have reported the economic burden of childhood diarrhea in low- and middle-income countries (LMICs). Yet, empirical data on the cost of diarrheal illness is sparse, particularly in LMICs. In this study we review the existing literature on the cost of childhood diarrhea in LMICs and generate comparable estimates of cost of diarrhea across 137 LMICs.

Methods

The systematic literature review included all articles reporting cost estimates of diarrhea illness and treatment from LMICs published between January 2006 and July 2018. To generate country-specific costs, we used service delivery unit costs from the World Health Organization’s Choosing Interventions that are Cost-Effective (WHO–CHOICE database). Non-medical costs were calculated using the ratio between direct medical and direct non-medical costs, derived from the literature review. Indirect costs (lost wages to caregivers) were calculated by multiplying the average GDP per capita per day by the average number of days lost to illness identified from the literature. All cost estimates are reported in 2015 USD. We also generated estimates using the IHME’s service delivery unit costs to explore input sensitivity on modelled cost estimates.

Results

We identified 25 articles with 64 data points on either direct or indirect cost of diarrhoeal illness in children aged < 5 years in 20 LMICs. Of the 64 data points, 17 were on the cost of outpatient care, 28 were on the cost of inpatient care, and 19 were unspecified. The average cost of illness was US$36.56 (median $15.73; range $4.30 – $145.47) per outpatient episode and $159.90 (median $85.85; range $41.01 – $538.33) per inpatient episode. Direct medical costs accounted for 79% (83% for inpatient and 74% for outpatient) of the total direct costs. Our modelled estimates, across all 137 countries, averaged (weighted) $52.16 (median $47.56; range $8.81 – $201.91) per outpatient episode and $216.36 (median $177.20; range $23.77 –$1225.36) per inpatient episode. In the 12 countries with primary data, there was reasonable agreement between our modelled estimates and the reported data (Pearson’s correlation coefficient = .75).

Conclusion

Our modelled estimates generally correspond to estimates observed in the literature, with a few exceptions. These estimates can serve as useful inputs for planning and prioritizing appropriate health interventions for childhood diarrheal diseases in LMICs in the absence of empirical data.

Household Costs of Diarrhea by Etiology in 7 Countries, The Global Enterics Mulitcenter Study (GEMS)

Background

Although there are many overlapping features, pediatric diarrheal diseases can vary in severity, duration, clinical manifestations, and sequelae according to the causal pathogen, which in turn can impact the economic burden on patients and their families. We aimed to evaluate the household costs of diarrheal disease by pathogen in 7 countries.

Methods

We analyzed data from the Global Enteric Multicenter Study (GEMS), a prospective, age-stratified, matched case–control study of moderate to severe diarrheal disease among children aged 0–59 months in 7 low-income countries; 4 in Africa (Kenya, Mali, Mozambique, The Gambia) and 3 in Asia (Bangladesh, India, Pakistan). Demographic, epidemiological, economic, and clinical data were collected, and a stool sample was obtained for microbiological analysis at enrollment. We used a multivariate generalized linear model to assess the effect of rotavirus, Cryptosporidium, heat-stable toxin (ST)–producing enterotoxigenic Escherichia coli (ETEC [ST only or LT plus ST]), Shigella, Campylobacter jejuni, norovirus GII, Vibrio cholerae O1, age, gender, in/outpatient, and country on total costs to the patient/family.

Results

Household out-of-pocket costs were higher in Mali than any other country. Within countries, household cost differences between pathogens were minimal and not statistically significantly different.

Conclusions

We found no significant differences in household costs by pathogen. Despite data limitations, understanding pathogen-specific household costs (or lack thereof) is useful, as decision-makers could consider broader illness cost information and its relevance to a particular pathogen’s economic burden and contribution to poverty when deciding which pathogens to target for interventions.

Healthcare Costs of Rotavirus and Other Types of Gastroenteritis in Children in Norway

BACKGROUND

Norway has initiated a publicly funded rotavirus immunization program for all age-eligible children in 2014. We aimed to estimate the healthcare costs of rotavirus gastroenteritis in children younger than 5 years old.

METHODS

We identified all gastroenteritis cases in children younger than 5 years old treated during 2009-2013 through the national claims database for primary care and the national hospital registry. We estimated direct medical costs of rotavirus-associated primary care consultations and hospital encounters (inpatient admission, outpatient visit and ambulatory care). We performed a range of one-way sensitivity analyses to explore uncertainty in the cost estimates.

RESULTS

Before vaccine introduction, the mean healthcare cost of rotavirus gastroenteritis in children younger than 5 years old was €4,440,337 per year. Among rotavirus-associated costs, 92% were hospital costs and the remaining 8% were primary care costs. The mean annual cost of rotavirus-associated hospital encounters was €4,083,691, of which 95% were costs of inpatient hospital admissions. The average healthcare cost of medically attended gastroenteritis in children younger than 5 years old was approximately €8 million per year, of which rotavirus-related costs represented 56%.

CONCLUSIONS

Healthcare costs of rotavirus gastroenteritis in Norway are substantial. The cost-effectiveness of ongoing rotavirus immunization program should be reassessed.

Dynamic modeling of cost-effectiveness of rotavirus vaccination, Kazakhstan

The government of Kazakhstan, a middle-income country in Central Asia, is considering the introduction of rotavirus vaccination into its national immunization program. We performed a cost-effectiveness analysis of rotavirus vaccination spanning 20 years by using a synthesis of dynamic transmission models accounting for herd protection. We found that a vaccination program with 90% coverage would prevent ≈880 rotavirus deaths and save an average of 54,784 life-years for children <5 years of age. Indirect protection accounted for 40% and 60% reduction in severe and mild rotavirus gastroenteritis, respectively. Cost per life year gained was US $18,044 from a societal perspective and US $23,892 from a health care perspective. Comparing the 2 key parameters of cost-effectiveness, mortality rates and vaccine cost at <US $2.78 per dose, vaccination program costs would be entirely offset. To further evaluate efficacy of a vaccine program, benefits of indirect protection conferred by vaccination warrant further study.

Burden of rotavirus gastroenteritis and distribution of rotavirus strains in Asia: a systematic review

BACKGROUND

Rotavirus is the leading cause of severe diarrhea in children worldwide. We systematically reviewed the burden of rotavirus gastroenteritis (RVGE) and distribution of rotavirus strains in Asia.

METHODS

We searched MEDLINE, EMBASE and the World Health Organization (WHO) website for the term "rotavirus" and the name of each country. We included studies that were conducted in children between 2000 and 2011 and that examined the epidemiology, health and/or economic burden of RVGE, and G and P-type distribution in Eastern, South East, Southern and Central Asia. Random effects models were used to pool the proportions of RVGE. We also estimated child mortality due to RVGE using the updated WHO and United Nations Children's Fund's mortality estimates in 2008.

RESULTS

The search identified 113 eligible articles. The incidence rates of rotavirus-related hospitalizations in children under 5 years of age ranged from 2.1 to 20.0 cases per 1000 children per year with the highest rates reported in Bangladesh, South Korea, Taiwan, Thailand, and Vietnam. Rotavirus accounted for 37.5% of year-round hospitalized gastroenteritis cases, with higher proportions reported in South East Asia. Rotavirus was associated with approximately 145,000 deaths every year in Asia, with the greatest numbers occurring in India, Pakistan, and Indonesia. The highest annual societal costs of treating RVGE were reported in China (US$365 million), followed by Japan (US$254 million) and India (US$41-72 million). A diversity of rotavirus G and P-types was observed across Asia and the distribution of strains differed by country and year. The most common strains were G1P[8] (23.6%), G2P[4] (11.8%), G3P[8] (18.9%), and G9P[8] (7.4%).

CONCLUSIONS

Rotavirus is associated with substantial hospitalizations and deaths among children and causes large healthcare expenditures throughout Asia. Safe and effective rotavirus vaccines could substantially reduce the burden of disease.