Economic burden of varicella in children 1-12 Years of age in Hungary, 2011-2015

Global Prevalence of Varicella-Associated Complications: A Systematic Review and Meta-Analysis

INTRODUCTION

Varicella (chickenpox) is an infectious disease caused by the varicella zoster virus affecting children, adolescents, and adults. Varicella symptoms are usually self-limiting; however, different complications with widespread and systemic manifestations can occur. This systematic literature review aims to explore and quantify varicella-associated complication rates.

METHODS

Two databases (Embase and MEDLINE), congress abstracts, and reference lists of systematic reviews were screened to identify evidence on varicella complications. Complications were identified and grouped into 14 clinically relevant categories. Proportional meta-analyses were conducted using a random-effects model and tests for heterogeneity and publication bias were performed. Subgroup, sensitivity, and meta-regression analyses were also conducted. A total of 78 studies, spanning 30 countries, were included in the meta-analysis.

RESULTS

Pooled prevalence was highest in severe varicella (22.42%; 95% confidence interval [CI] 10.13-37.77), skin-related complications (20.12%; 95% CI 15.48-25.20), and infection-related complications (10.03%; 95% CI 7.47-12.90). Cardiovascular (0.55%; 95% CI 0.08-1.33), genitourinary (1.17%; 95% CI 0.55-1.99), and musculoskeletal (1.54%; 95% CI 1.06-2.11) complications had the lowest pooled prevalence. The remaining complication categories ranged between 1% and 10%. Subgroup analysis showed that complications were more prevalent in children versus adults and in hospitalized patients versus outpatients. Meta-regression analysis found that no ecological level covariates were accurate predictors for the overall prevalence of varicella-associated complications. There was substantial heterogeneity and publication bias across all meta-analyses.

CONCLUSION

Results suggest that different types of varicella-associated complications could be frequent, impacting quality of life, and healthcare resource utilisation and budgets. These findings are crucial to raise awareness of the health and economic burden of varicella disease.

Healthcare resource use and costs of varicella and its complications: A systematic literature review

Varicella is a highly contagious disease caused by the varicella zoster virus (VZV). While the disease is usually mild, severe complications can occur requiring costly hospitalization. A thorough understanding of the healthcare resource use (HCRU) and costs of varicella is needed to inform health-economic models of preventive strategies. A systematic literature review was carried out to retrieve relevant publications between 1999 and 2021, reporting HCRU and cost outcomes for varicella and its complications. Data were extracted and stratified according to pre-specified age groups and complication categories. Costs were re-based to a $US2020 footing using both purchasing power parity and the medical component of consumer price indexes. Data were summarized descriptively due to high heterogeneity in study design and outcome reporting. Forty-four publications fulfilled the inclusion and exclusion criteria of which 28 were conducted in Europe, 6 in Middle East and Asia, 5 in South America, 3 in North America, and 2 in multiple regions. Primary healthcare visits accounted for 30% to 85% of total direct costs. Hospitalization costs varied between $1,308 and $38,268 per episode depending on country, complication type, and length of stay, contributing between 2% and 60% to total direct costs. Indirect costs, mostly driven by workdays lost, accounted for approximately two-thirds of total costs due to varicella. The management of varicella and related complications can lead to substantial HCRU and costs for patients and the healthcare system. Additional research is needed to further characterize the varicella-associated economic burden and its broader impact from a societal standpoint.

Antimicrobial use for the management of varicella in Thailand: a retrospective observational study

OBJECTIVE

To describe the clinical characteristics of varicella patients seeking medical consultation and the use of antimicrobials for their management in Thailand in the absence of universal varicella vaccination (UVV).

METHODS

A multicenter, retrospective chart review of 260 children and adults with a primary diagnosis of varicella was conducted at one private and three public hospitals in Bangkok, Thailand. Charts of varicella patients (inpatient or outpatient) were randomly selected over a 5-year period. Key outcomes included clinical complications and the use of antibiotics, antivirals, and other medications.

RESULTS

Charts of 200 children (mean age 5.7 years, range 0.3-16 years) and 60 adults (mean age 27.9 years, range 18-50 years) were reviewed. Fourteen patients (including 8 children) were hospitalized. Five percent of the children and none of the adults were immunocompromised. At least 1 varicella-related complication was reported by 7.3% (7% of children, 8.3% of adults, p = .778) of all patients, including 57.1% (62.5% of children, 50% of adults) of inpatients (p < .001, compared with outpatients). Skin/soft tissue infection (47.7%) and dehydration (47.4%) were the most common complications. Antivirals (mainly oral acyclovir) were prescribed to 46.5% of patients (31.5% of children, 96.7% of adults, p < .001). Antibiotics were prescribed to 20.8% of patients (19% of children, 26.7% of adults, p = .199). Topical, oral, and intravenous antibiotics were prescribed to 12.3%, 8.5%, and 1.2% of patients, respectively. Antimicrobial prescriptions were higher among adults (p < .001) and immunocompromised patients (p = .025). Apart from antimicrobials, acetaminophen (62.3%) and oral antihistamines (51.5%) were the most prescribed.

CONCLUSION

A considerable number of varicella patients, both children and adults, seeking medical consultation in Thai hospitals are prescribed antibiotics and antivirals, with one-fifth of patients being prescribed an antibiotic and almost half prescribed an antiviral. The study may be of interest to policymakers in Thailand and other Asia-Pacific countries considering UVV implementation.

Effectiveness of varicella vaccination during an outbreak in a large one-dose-vaccinated population in Shanghai

Emergency vaccination (EV) is used as effective postexposure prophylaxis (PEP) to control varicella outbreaks within 3-5 days. However, the advantages of a second dose of varicella vaccine (VarV) in students who had received one dose before an outbreak and the potential benefits of EV at more than 5 days after exposure have not been fully evaluated. This study evaluated the vaccine effectiveness (VE) of EV in preventing disease development during a varicella outbreak in Shanghai, China, in 2020. Questionnaires were used to obtain student demographic information, clinical manifestations, varicella history, vaccination status, and willingness to receive EV. The VE of EV was calculated as [1-relative risk (RR)] ×100%. Among the 1455 students included in this study, 31 cases were identified, resulting in an overall attack rate of 2.13%. There were 6 cases in unvaccinated students and 25 cases in one-dose-vaccinated students. A total of 788 students received one EV dose. The attack rates were 6.38% (6/94), 4.26% (19/446), 2.82% (2/71), and 0.56% (4/717) among unvaccinated students, students who received 1 dose of VarV, and students who received EV with the 1^st and 2^nd dose of VarV, respectively. Compared to that in unvaccinated students, the VE of EV with the 2^nd dose of VarV was 88% (95% CI 49% to 97%). EV should be performed as soon as possible after exposure. Nevertheless, vaccination is still recommended at more than 5 days post exposure to control varicella outbreaks.

Trends in Varicella Burden of Disease Following Introduction of Routine Childhood Varicella Vaccination in Argentina: A 12-Year Time Series Analysis

One-dose universal varicella vaccination (UVV) was introduced in the Argentinian National Immunization Program in July 2015. This study examined the impact of one-dose UVV on varicella incidence and mortality in Argentina. Incidence and mortality data were obtained from official databases for pre-UVV (January 2008–June 2015) and post-UVV (July 2015–December 2019) periods. Time series analyses with autoregressive integrated moving average (ARIMA) modeling predicted varicella incidence and mortality in absence of UVV in the target (aged 1–4 years) and overall population. Predicted and observed values post-UVV were compared to estimate UVV impact. Mean annual incidence rates per 100,000 reduced from 1999 (pre-UVV) to 1122 (post-UVV) in the target population and from 178 to 154 in the overall population. Significant declines in incidence were observed, reaching reductions of 83.9% (95% prediction interval [PI]: 58.9, 90.0) and 69.1% (95% PI: 23.6, 80.7) in the target and overall populations, respectively, during peak months (September-November) post-UVV. Decreasing trends in mortality rate from 0.4 to 0.2 per 1,000,000 population were observed. Over the last four years, one-dose UVV has significantly reduced varicella burden of disease in Argentina. Continuous efforts to improve vaccination coverage rates and long-term follow-up are needed to better understand the benefits of the UVV program.

Economic burden of varicella in Europe in the absence of universal varicella vaccination

Background

Though the disease burden of varicella in Europe has been reported previously, the economic burden is still unknown. This study estimated the economic burden of varicella in Europe in the absence of Universal Varicella Vaccination (UVV) in 2018 Euros from both payer (direct costs) and societal (direct and indirect costs) perspectives.

Methods

We estimated the country specific and overall annual costs of varicella in absence of UVV in 31 European countries (27 EU countries, plus Iceland, Norway, Switzerland and the United Kingdom). To obtain country specific unit costs and associated healthcare utilization, we conducted a systematic literature review, searching in PubMed, EMBASE, NEED, DARE, REPEC, Open Grey, and public heath websites (1/1/1999–10/15/2019). The number of annual varicella cases, deaths, outpatient visits and hospitalizations were calculated (without UVV) based on age-specific incidence rates (Riera-Montes et al. 2017) and 2018 population data by country. Unit cost per varicella case and disease burden data were combined using stochastic modeling to estimate 2018 costs stratified by country, age and healthcare resource.

Results

Overall annual total costs associated with varicella were estimated to be €662,592,061 (Range: €309,552,363 to €1,015,631,760) in Europe in absence of UVV. Direct and indirect costs were estimated at €229,076,206 (Range €144,809,557 to €313,342,856) and €433,515,855 (Range €164,742,806 to €702,288,904), respectively. Total cost per case was €121.45 (direct: €41.99; indirect: €79.46). Almost half of the costs were attributed to cases in children under 5 years, owing mainly to caregiver work loss. The distribution of costs by healthcare resource was similar across countries. France and Germany accounted for 49.28% of total annual costs, most likely due to a combination of high numbers of cases and unit costs in these countries.

Conclusions

The economic burden of varicella across Europe in the absence of UVV is substantial (over 600 M€), primarily driven by caregiver burden including work productivity losses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12343-x.

Has Clinical and Epidemiological Varicella Burden Changed over Time in Children? Overview on Hospitalizations, Comorbidities and Costs from 2010 to 2017 in Italy

According to WHO estimates, varicella disease is responsible of a worldwide significant burden in terms of hospitalizations, complications, and deaths, with more than 90% of cases under 12 years old. This study aims at evaluating the clinical, epidemiological, and economic burden of varicella in Ligurian children, about comorbidities, organizational variables, and vaccination coverages from 2010 to 2017, in terms of Emergency Department accesses and hospitalizations. The overall hospitalization rate was 179.76 (per 100,000 inhab.), with a gradual but significant decline since 2015, when universal varicella vaccination was introduced in Liguria (p < 0.0001). The risk of being hospitalized for complicated varicella in subjects with at least one comorbidity was significantly higher than in subjects without comorbidities (p = 0.0016). The economic analysis showed higher costs in subjects with complicated varicella who were 0-3 years old. This age group showed higher costs also considering extra-hospital costs for both outpatient procedures and pharmaceutical costs (p < 0.0001). The results confirm the relevant burden of varicella, especially in the 0-3 age group and in children with comorbidities. Thus, vaccination with the achievement of adequate vaccination coverages is confirmed to be a necessary control strategy to reduce hospitalizations and associated complications with important economic benefits.

Indirect costs associated with skin infectious disease in children: a systematic review

BACKGROUND

There are limited data in the literature on the indirect costs associated with skin and soft tissue infections (SSTIs) in the pediatric population. This study aimed to conduct a systematic review of the indirect costs associated with SSTIs in children.

METHODS

The search was conducted in PubMed, SCOPUS, and Web of Science up to January 2020. Thirteen search strategies were designed combining MeSH terms and free terms. SSTIs were defined as bacterial or viral infections, dermatomycoses, and parasitic infestations. Only primary studies were included. All analyzed costs were converted to 2020 Euros.

RESULTS

Thirteen of the identified publications presented indirect costs of SSTIs in children and were conducted in Argentina, Australia, Brazil, Hungary, New Zealand, Poland, Spain, Taiwan, and the USA. Nine studies described indirect costs associated with infection of Varicella-zoster virus: lost workdays by outpatient caregivers ranged from 0.27 to 7.8, and up to 6.14 if caring for inpatients; total productivity losses ranged from €1.16 to €257.46 per patient. Three studies reported indirect costs associated with acute bacterial SSTIs (community-associated methicillin-resistant Staphylococcus aureus) in children: total productivity losses ranged from €1,814.39 to €8,224.06 per patient, based on impetigo, cellulitis, and folliculitis. One study of parasitic infestations (Pediculus humanus capitis) reported total indirect costs per patient of €68.57 (formal care) plus €21.41 due to time lost by parents in purchasing treatment.

CONCLUSIONS

The economic burden of SSTIs is highly relevant but underestimated due to the lack of studies reporting indirect costs. Further cost studies will allow a better understanding of the magnitude of the financial burden of the disease.

Pediatric Hospitalization for Varicella in an Italian Pediatric Hospital: How Much Does It Cost?

BACKGROUND

Varicella is a common pediatric infection. Even if it generally has a benign course, it may complicate and require hospitalization. The aim of our study was to estimate the acute hospitalization cost (AHC) for varicella in the acute phase in a pediatric population.

METHODS

We calculated the AHC of pediatric patients admitted for varicella at Bambino Gesù Children Hospital, Rome, Italy, from 1 November 2005 to 1 November 2020.

RESULTS

In the study period, 825 pediatric patients affected by varicella were hospitalized. The mean hospitalization cost was EUR 4015.35 (range from EUR 558.44 to EUR 42,608.00). Among patients, 55% were unvaccinable due to either their age or their immunosuppression status. They would benefit from herd immunity, reducing the overall AHC by EUR 182,196,506. Since the introduction of the compulsory vaccination against varicella in Italy, we observed a significant reduction in AHC cost of 60.6% in 2019 and of 93.5% in 2020. Finally, from the beginning of the COVID-19 pandemic, we documented a decline of 81.2% and 76.9% in varicella hospitalization, compared to 2018 and 2019, respectively.

CONCLUSIONS

Varicella AHC is an important economic and health assessment point and can be useful for improving preventive strategies.

Phase 3, open-label, Russian, multicenter, single-arm trial to evaluate the immunogenicity of varicella vaccine (VARIVAX™) in healthy infants, children, and adolescents

Varicella (chickenpox) is a common, highly contagious disease caused by primary infection with varicella zoster virus (VZV), which can result in bacterial superinfection, central nervous system complications, and hospitalization. Stage 2 of this Phase 3 open-label study (ClinicalTrials.gov identifier: NCT03843632) enrolled 100 healthy infants, children, and adolescents (12 months–6 years, n = 37; 7–12 years, n = 33; 13–17 years, n = 30) without a clinical history of varicella. Participants aged 12 months–12 years were administered 1 dose of VARIVAX™ 0.5 mL (Varicella Virus Vaccine Live [Oka/Merck]) and adolescents aged 13–17 years were administered 2 doses 6 weeks apart. For participants seronegative at baseline (VZV antibody titer <1.25 glycoprotein enzyme-linked immunosorbent assay [gpELISA] units/mL), immunogenicity was assessed by seroconversion (VZV antibody titer ≥5 gpELISA units/mL) and VZV antibody geometric mean titers 6 weeks after the final dose. For participants who were VZV seropositive at baseline (VZV antibody titer ≥1.25 gpELISA units/mL), immunogenicity was assessed by antibody titer geometric mean fold rise and percentage of participants with ≥4-fold rise in antibody titer 6 weeks after the final dose. A Vaccine Report Card was used to report solicited and unsolicited adverse events through 42 days post-vaccination. After series completion among seronegative participants across age groups (n = 74), 98.6% demonstrated seroconversion 6 weeks post-vaccination; among seropositive participants (n = 26), 65.4% had ≥4-fold rise in antibody titer 6 weeks post-vaccination. No new safety signals were observed. Administering VARIVAX to infants, children, and adolescents resulted in an acceptable immune response with a safety profile consistent with the licensed product.

Varicella Admissions in Children and Adolescents in Portugal: 2000-2015

OBJECTIVES

Varicella is a common, usually benign, and autolimited disease in children but can lead to severe complications and hospitalization. With this study, we aim to analyze all varicella hospitalizations to provide epidemiological information to help outline preventive policies.

METHODS

We assessed all varicella hospitalizations in children aged 0 to 17 years, from 2000 to 2015, in mainland, public Portuguese hospitals using a Portuguese administrative database. Seasonality, geographic distribution, severity, complications, risk factors, use of diagnostic and treatment procedures and hospitalization costs were analyzed.

RESULTS

A total of 5120 hospitalizations were registered, with an annual rate of 17.3 hospitalizations per 100 000 inhabitants. A higher number of hospitalizations occurred during the summer period and in Southern regions. The median length of stay was of 4 days (interquartile range: 3.0-7.0). We found a high rate of severe complications, mostly dermatologic (19.6%), neurologic (6.0%), and respiratory (5.1%). Of the total number of patients, 0.8% were immunocompromised and 0.1% were pregnant. Total direct hospitalization costs during the 16-year period were estimated to be 7 110 719€ (8 603 970 USD), with a mean annual cost of 444 419.92€ (537 748.10 USD).

CONCULSIONS

This is the first national study in which useful epidemiological data to evaluate the burden and impact of varicella in Portugal is provided.

Acceptance of varicella vaccination

Varicella is a common vaccine-preventable disease that usually presents in children as a mild infection; however, severe complications also occur. The burden of varicella is significant in the terms of incidence, complication, and hospitalization rate related to varicella and economic disease burden. Despite the evidence of overall positive effects of varicella vaccination, there are great differences in the implementation of varicella vaccination and in the uptake of the vaccine from country to country. Improving acceptance of varicella vaccination on the national and on the individual level would decrease the burden of the disease on the health of children and on health-care resources. In studies determining factors of parental acceptance of varicella vaccination questions specific for varicella vaccination were highlighted. Addressing these issues with open, evidence based communication is important to improve and maintain the trust of the public in varicella vaccination.

Attitudes towards varicella vaccination in parents and paediatric healthcare providers in Hungary

BACKGROUND

Varicella vaccination is important in prevention of childhood infection. Aim of this cross-sectional study was to survey attitudes and determinants of support or refusal of varicella vaccination in parents and in paediatric healthcare professionals, mainly health visitors in Hungary prior to the introduction of this vaccine in National Immunization Program in 2019.

METHODS

Between October 2018 and February 2019, 1042 parents and 198 healthcare professionals completed a self-administered anonymous questionnaire regarding sociodemographic background, knowledge and attitudes towards varicella vaccination, and reasons for non-vaccination.

RESULTS

From the participating parents 53.3% have vaccinated at least one of their children. Vaccination rate was significantly higher in families with <3 children, living in the capital, among those who have seen complications of varicella and among parents with university degree. Most important positive determinant was recommendation of the vaccine by healthcare professionals: 77.8% of parents accepted vaccination when recommended by the paediatrician, despite the cost of the vaccine, whereas only 17.3% of parents vaccinated their children when the vaccine was not recommended by paediatrician. Most important reasons for non-vaccination was finding the vaccine unnecessary, concerns regarding side effects, and not believing in the vaccine's effectiveness. Among paediatric healthcare professionals, support rate of universal varicella vaccination was 76.3%. Support rate was higher among those who have seen complications of varicella more often and those who consider varicella a severe infection. Reasons of professionals who do not support universal varicella vaccination were similar to those of vaccine hesitant parents. Practice of intentional exposure of non-immune child to infected ones still exist.

CONCLUSIONS

Educational programs are needed for parents and health visitors to address concerns regarding vaccination. Paediatricians are the most trusted source of information for parents hence they have a significant responsibility and parents likely follow their recommendations.

The clinical and economic burden of varicella in the Middle East: a systematic literature review

This systematic literature review was conducted to better understand the epidemiology and burden of varicella across the Middle East, gain insight into the evidence to support using universal varicella vaccination (UVV), and identify potential data gaps. Both epidemiology and economic data on the burden of varicella were limited and varied significantly. Most of the data focussed on varicella burden in the absence of a UVV program. In the absence of UVV, varicella incidence is increasing across this region with varicella infection associated with substantial morbidity. Although limited, data on the impact of vaccination at a population level indicated UVV programs reduce varicella incidence and hospitalizations, in line with global experience. Further research and action are needed to better understand varicella epidemiology in the Middle East, increase awareness and understanding in the region, and provide local data to support national public-health decisions regarding the implementation of UVV programs.

The use of antibiotics in the treatment of pediatric varicella patients: real-world evidence from the multi-country MARVEL study in Latin America & Europe

Background

Varicella is a highly contagious childhood disease. Generally benign, serious complications necessitating antibiotic use may occur. The objective of this study was to characterize the rate, appropriateness and patterns of real-world antibiotic prescribing for management of varicella-associated complications, prior to universal varicella vaccination (UVV) implementation.

Methods

Pooled, post-hoc analysis of 5 international, multicenter, retrospective chart reviews studies (Argentina, Hungary, Mexico, Peru, Poland). Inpatient and outpatient primary pediatric (1–14 years) varicella cases, diagnosed between 2009 and 2016, were eligible. Outcomes, assessed descriptively, included varicella-associated complications and antibiotic use. Three antibiotic prescribing scenarios were defined based on complication profile in chart: evidence of microbiologically confirmed bacterial infection (Scenario A); insufficient evidence confirming microbiological confirmation (Scenario B); no evidence of microbiological confirmation (Scenario C). Stratification was performed by patient status (inpatient vs. outpatient) and country.

Results

Four hundred one outpatients and 386 inpatients were included. Mean (SD) outpatient age was 3.6 (2.8) years; inpatient age was 3.1 (2.8) years. Male gender was predominant. Overall, 12.2% outpatients reported ≥1 infectious complication, 3.7% ≥1 bacterial infection, and 0.5% ≥1 microbiologically confirmed infection; inpatient complication rates were 78.8, 33.2 and 16.6%, respectively. Antibiotics were prescribed to 12.7% of outpatients and 68.9% of inpatients. Among users, β-lactamases (class), and clindamycin (agent), dominated prescriptions. Scenario A was assigned to 3.9% (outpatients) vs 13.2% (inpatients); Scenario B: 2.0% vs. 6.0%; Scenario C: 94.1% vs. 80.8%.

Conclusions

High rates of infectious complications and antibiotic use are reported, with low rates of microbiological confirmation suggesting possible antibiotic misuse for management of varicella complications.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7071-z) contains supplementary material, which is available to authorized users.

Burden of varicella in Central and Eastern Europe: findings from a systematic literature review

INTRODUCTION

Vaccination against varicella rapidly reduces disease incidence, resulting in reductions in both individual burden and societal costs. Despite these benefits, there is no standardization of varicella immunization policies in Europe, including countries in Central and Eastern Europe (CEE).

AREAS COVERED

This systematic literature review identified publications on the epidemiology of varicella, its associated health and economic burden, and vaccination strategies within the CEE region, defined as Albania, Bosnia-Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Serbia, Slovakia, and Slovenia. Twenty-six studies were identified from a search of PubMed, Embase®, and MEDLINE® biomedical literature databases, supplemented by gray literature and country-specific/global websites.

EXPERT COMMENTARY

Limited information exists in published studies on the burden of varicella in CEE. The wide variability in incidence rates between countries is likely explained by a lack of consistency in reporting systems. Funded universal varicella vaccination (UVV) in CEE is currently available only in Latvia as a one-dose schedule, but Hungary together with Latvia are introducing a two-dose strategy in 2019. For countries that do not provide UVV, introduction of vaccination is predicted to provide substantial reductions in cases and rates of associated complications, with important economic benefits.

Varicella healthcare resource utilization in middle income countries: a pooled analysis of the multi-country MARVEL study in Latin America & Europe

Varicella is a mild and self-limited illness in children, but can result in significant healthcare resource utilization (HCRU). To quantify/contrast varicella-associated HCRU in five middle-income countries (Hungary, Poland, Argentina, Mexico, and Peru) where universal varicella vaccination was unimplemented, charts were retrospectively reviewed among 1-14 year-olds. Data were obtained on management of primary varicella between 2009-2016, including outpatient/inpatient visits, allied healthcare contacts, tests/procedures, and medications. These results are contrasted across countries, and a regression model is fit to extrapolated country-level costs as a function of gross domestic product (GDP). A total of 401 outpatients and 386 inpatients were included. Significant differences between countries were observed in the number of skin lesions among outpatients, ranging from 5.3% to 25.4% of patients with ≥250 lesions. Among inpatients, results were less variable. Average ambulatory medical visits ranged from 1.1 to 2.2. Average hospital stay ranged from 3.6 to 6.8 days. Use of tests/procedures was infrequent in outpatients, except in Argentina (13.3%); among inpatients, a test/procedure was ordered for 81.3% of patients, without regional variation. Prescription medications were administered in 44.4% of outpatients (range 9.3%-80.0%), and in 86% of inpatients (range 70.4%-94.9%). Total estimated spending on varicella treatment in the absence of vaccination was predicted from income levels (GDP) with an exponential function (R² = 0.89). This study demonstrates that substantial HCRU is associated with varicella resulting in significant public health burden that could be alleviated through the use of varicella vaccination. Differences observed between countries possibly reflect treatment guidelines, healthcare resource availabilities and physician practices.

Acute Cerebellitis in Children: A Variable Clinical Entity

Acute cerebellar ataxia is the most common cause of acute ataxia in children and it usually runs a self-limiting and ultimately benign clinical course. A small proportion of children have evidence of inflammatory swelling in the cerebellum. Many of these children suffer more severe and potentially life-threatening forms of cerebellar ataxia and may need more intensive treatments including urgent neurosurgical treatments. This more severe form of acute cerebellar ataxia is often termed acute cerebellitis. Many children with acute cerebellitis have long-term neurological sequela and evidence of structural cerebellar changes on follow-up imaging. Several patterns of cerebellar inflammation have been described. The authors describe the variabilities in the clinical and radiological patterns of disease in the cases that have been described in the literature.

Varicella in Poland: economic burden in children 1-12 years of age in Poland, 2010-2015

Background

The safety and efficacy of live-attenuated varicella zoster virus (VZV) vaccines in preventing varicella and reducing associated morbidity and mortality in real-world have been previously shown. In Poland, VZV vaccination is only mandatory for certain high-risk individuals. Here, we have conducted an evaluation of the clinical and economic burden of varicella in Poland.

Methods

Multicenter, retrospective chart review of varicella inpatients and outpatients aged 1–12 years with a primary diagnosis between 2010 and 2015. Varicella-related outcomes included the incidence of complications, the proportion of patients reporting healthcare resource utilization (HCRU), and frequency of HCRU. Direct costs were derived from per patient resource use multiplied by unit costs, and indirect costs were calculated as loss of revenue of caregivers reporting work days missed. The overall annual cost of varicella in Poland was estimated based on the calculated direct and indirect costs per case and the estimated number of varicella cases. All costs are presented in 2015 Polish złoty (PLN) / Euros (€).

Results

A total of 150 children with varicella were included, of which 75 were outpatients and 75 were inpatients with a mean (± SD) age of 3.9 (±2.6) and 4.2 (±2.3) years, respectively. Complications were experienced by 14.7% of outpatients and 82.7% of inpatients, of which the most common were skin and soft tissue infections and dehydration. The rate of HCRU was as follows: over-the-counter medications (80.0% outpatients, 81.3% inpatients), prescription medications (80.0% outpatients, 93.3% inpatients), tests/procedures (0.0% outpatients, 69.3% inpatients), and allied health professional consults (0.0% outpatients, 24.0% inpatients). Total (direct and indirect) cost per varicella case was 5013.3 PLN (€ 1198.1) for inpatients and 1027.2 PLN (€ 245.5) for outpatients, resulting in an estimated overall annual (2015) cost of varicella in Poland of 178,198,320 PLN (€ 42,588,385) among children aged 1–15 years.

Conclusions

Significant clinical and economic burden is associated with varicella in Poland. These results may be used to foster discussion related to the implications of implementing routine VZV vaccination in Poland.