1
|
Estimating the economic burden of typhoid in children and adults in Blantyre, Malawi: A costing cohort study. PLoS One 2022; 17:e0277419. [PMID: 36417455 PMCID: PMC9683590 DOI: 10.1371/journal.pone.0277419] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 10/26/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Typhoid causes preventable death and disease. The World Health Organization recommends Typhoid Conjugate Vaccine for endemic countries, but introduction decisions depend on cost-effectiveness. We estimated household and healthcare economic burdens of typhoid in Blantyre, Malawi. METHODS In a prospective cohort of culture-confirmed typhoid cases at two primary- and a referral-level health facility, we collected direct medical, non-medical costs (2020 U.S. dollars) to healthcare provider, plus indirect costs to households. RESULTS From July 2019-March 2020, of 109 cases, 63 (58%) were <15 years old, 44 (40%) were inpatients. Mean hospitalization length was 7.7 days (SD 4.1). For inpatients, mean total household and provider costs were $93.85 (95%CI: 68.87-118.84) and $296.52 (95%CI: 225.79-367.25), respectively. For outpatients, these costs were $19.05 (95%CI: 4.38-33.71) and $39.65 (95%CI: 33.93-45.39), respectively. Household costs were due mainly to direct non-medical and indirect costs, medical care was free. Catastrophic illness cost, defined as cost >40% of non-food monthly household expenditure, occurred in 48 (44%) households. CONCLUSIONS Typhoid can be economically catastrophic for families, despite accessible free medical care. Typhoid is costly for government healthcare provision. These data make an economic case for TCV introduction in Malawi and the region and will be used to derive vaccine cost-effectiveness.
Collapse
|
2
|
Hsiao A, Ramani E, Seo HJ, Pak G, Vuntade D, M'bang'ombe M, Ngwira B, Quentin W, Marks F, Mogasale V. Economic impact of cholera in households in rural southern Malawi: a prospective study. BMJ Open 2022; 12:e052337. [PMID: 35649608 PMCID: PMC9161053 DOI: 10.1136/bmjopen-2021-052337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 03/08/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Cholera remains a significant contributor to diarrhoeal illness, especially in sub-Saharan Africa. Few studies have estimated the cost of illness (COI) of cholera in Malawi, a cholera-endemic country. The present study estimated the COI of cholera in Nsanje, southern Malawi, as part of the Cholera Surveillance in Malawi (CSIMA) programme following a mass cholera vaccination campaign in 2015. METHODS Patients ≥12 months of age who were recruited as part of CSIMA were invited to participate in the COI survey. The COI tool captured household components of economic burden, including direct medical and non-medical costs, and indirect lost productivity costs. RESULTS Between April 2016 and March 2020, 40 cholera cases were enrolled in the study, all of whom participated in the COI survey. Only two patients had any direct medical costs and five patients reported lost wages due to illness. The COI per patient was US$14.34 (in 2020), more than half of which was from direct non-medical costs from food, water, and transportation to the health centre. CONCLUSION For the majority of Malawians who struggle to subsist on less than US$2 a day, the COI of cholera represents a significant cost burden to families. While cholera treatment is provided for free in government-run health centres, additional investments in cholera control and prevention at the community level and financial support beyond direct medical costs may be necessary to alleviate the economic burden of cholera on households in southern Malawi.
Collapse
Affiliation(s)
- Amber Hsiao
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
| | - Enusa Ramani
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
- Policy and Economic Research, International Vaccine Institute, Seoul, The Republic of Korea
| | - Hye-Jin Seo
- Epidemiology, Public Health, Impact, International Vaccine Institute, Seoul, The Republic of Korea
| | - GiDeok Pak
- Biostatistics & Data Management, International Vaccine Institute, Seoul, The Republic of Korea
| | - Dan Vuntade
- Department of Environmental Health, University of Malawi the Polytechnic, Blantyre, Malawi
| | | | - Bagrey Ngwira
- Department of Environmental Health, University of Malawi the Polytechnic, Blantyre, Malawi
| | - Wilm Quentin
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
| | - Florian Marks
- Epidemiology, Public Health, Impact, International Vaccine Institute, Gwanak-gu, The Republic of Korea
- Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge Institute of Therapeutic Immunology and Infectious Disease, Cambridge, UK
| | - Vittal Mogasale
- Policy and Economic Research, International Vaccine Institute, Seoul, The Republic of Korea
| |
Collapse
|
3
|
Mejia N, Ramani E, Pallas SW, Song D, Abimbola T, Mogasale V. Methodological Considerations for Cost of Illness Studies of Enteric Fever. Clin Infect Dis 2021; 71:S111-S119. [PMID: 32725239 PMCID: PMC7388717 DOI: 10.1093/cid/ciaa481] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
This article presents a selection of practical issues, questions, and tradeoffs in methodological choices to consider when conducting a cost of illness (COI) study on enteric fever in low- to lower-middle-income countries. The experiences presented are based on 2 large-scale COI studies embedded within the Surveillance for Enteric Fever in Asia Project II (SEAP II), in Bangladesh, Nepal, and Pakistan; and the Severe Typhoid Fever Surveillance in Africa (SETA) Program in Burkina Faso, Ethiopia, Ghana, and Madagascar. Issues presented include study design choices such as controlling for background patient morbidity and healthcare costs, time points for follow-up, data collection methods for sensitive income and spending information, estimating enteric fever-specific health facility cost information, and analytic approaches in combining patient and health facility costs. The article highlights the potential tradeoffs in time, budget, and precision of results to assist those commissioning, conducting, and interpreting enteric fever COI studies.
Collapse
Affiliation(s)
- Nelly Mejia
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Enusa Ramani
- Policy and Economic Research Department, Public Health, Access and Vaccine Epidemiology Unit, International Vaccine Institute, Seoul, Korea
| | - Sarah W Pallas
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dayoung Song
- Policy and Economic Research Department, Public Health, Access and Vaccine Epidemiology Unit, International Vaccine Institute, Seoul, Korea
| | - Taiwo Abimbola
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Vittal Mogasale
- Policy and Economic Research Department, Public Health, Access and Vaccine Epidemiology Unit, International Vaccine Institute, Seoul, Korea
| |
Collapse
|
4
|
Mogasale V, Ngogoyo SM, Mogasale VV. Model-based estimation of the economic burden of cholera in Africa. BMJ Open 2021; 11:e044615. [PMID: 33757949 PMCID: PMC7993295 DOI: 10.1136/bmjopen-2020-044615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 02/13/2021] [Accepted: 03/01/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To estimate the economic burden of cholera in Africa. SETTINGS Cholera affected 44 countries in Africa. PARTICIPANTS The analysis used data from public sources in Africa published until September 2019. METHODS Based on existing data from field-based cost-of-illness studies, estimated cholera incidence rates, and reported cholera cases to WHO, this research estimates the economic burden of cholera in Africa from a societal perspective with 2015 as the base year. The estimate included out-of-pocket costs, public health system costs, productivity loss related to illness and an optional productivity loss related to premature deaths valued by the human capital approach. As various input data such as cholera incidence, hospitalisation rates and the number of workdays lost were not well defined, a series of scenario analyses and uncertainty analyses, accounting for unknowns and data variability, was conducted. Similarly, the value of time lost due to illness and deaths using the human capital approach was explored through scenario analyses. RESULTS In 2015, an estimated 1 008 642 cases in 44 African countries resulted in an economic burden of US$130 million from cholera-related illness and its treatment. When the estimated 38 104 cholera deaths were included in the analysis, the economic burden increased to US$1 billion or international $2.4 billion for the same year. At the same time, when only the 71 126 cases and 937 deaths reported to the WHO are considered, the economic burden was only US$68 million for the year 2015. The estimates of economic burden are thus heavily dependent on the cholera incidence rate, how time lost due to illness and deaths are calculated, hospitalisation rates and hospitalisation costs. CONCLUSION The findings can be used as an economic justification for cholera control in Africa and for generating value-for-money evidence to underpin Ending Cholera-A Global Roadmap to 2030 with considerations to study limitations.
Collapse
Affiliation(s)
- Vittal Mogasale
- Policy and Economic Research, International Vaccine Institute, Gwanak-gu, Korea
| | | | | |
Collapse
|
5
|
Ilboudo PG, Mengel MA, Gessner BD, Ngwira B, Cavailler P, Le Gargasson JB. Cost-effectiveness of a reactive oral cholera immunization campaign using Shanchol™ in Malawi. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:17. [PMID: 33691725 PMCID: PMC7945304 DOI: 10.1186/s12962-021-00270-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 03/02/2021] [Indexed: 11/10/2022] Open
Abstract
Background Oral cholera vaccines (OCV) have been recommended as additional measures for the prevention of cholera. However, little is known about the cost-effectiveness of OCV use in sub-Saharan Africa, particularly in reactive outbreak contexts. This study aimed to investigate the cost-effectiveness of the use of OCV Shanchol in response to a cholera outbreak in the Lake Chilwa area, Malawi. Methods The Excel-based Vaccine Introduction Cost-Effectiveness model was used to assess the cost-effectiveness ratios with and without indirect protection. Model input parameters were obtained from cost evaluations and epidemiological studies conducted in Malawi and published literature. One-way sensitivity and threshold analyses of cost-effectiveness ratios were performed. Results Compared with the reference scenario i.e. treatment of cholera cases, the immunization campaign would have prevented 636 and 1 020 cases of cholera without and with indirect protection, respectively. The cost-effectiveness ratios were US$19 212 per death, US$500 per case, and US$738 per DALY averted without indirect protection. They were US$10 165 per death, US$264 per case, and US$391 per DALY averted with indirect protection. The net cost per DALY averted was sensitive to four input parameters, including case fatality rate, duration of immunity (vaccine’s protective duration), discount rate and cholera incidence. Conclusion Relative to the Malawi gross domestic product per capita, the reactive OCV campaign represented a cost-effective intervention, particularly when considering indirect vaccine effects. Results will need to be assessed in other settings, e.g., during campaigns implemented directly by the Ministry of Health rather than by international partners. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-021-00270-y.
Collapse
Affiliation(s)
- Patrick G Ilboudo
- Agence de Médecine Préventive, 10 BP 638, Ouagadougou, Burkina Faso.
| | - Martin A Mengel
- Agence de Médecine Préventive, 21 boulevard Pasteur, Paris, 75015, France
| | - Bradford D Gessner
- Agence de Médecine Préventive, 21 boulevard Pasteur, Paris, 75015, France.,Pfizer Inc, Collegeville, PA, USA
| | | | - Philippe Cavailler
- Agence de Médecine Préventive, 21 boulevard Pasteur, Paris, 75015, France
| | - Jean-Bernard Le Gargasson
- Agence de Médecine Préventive, Bureau Ferney-Voltaire, Bat. JB Say, 4e, aile A, 13, chemin du Levant, Ferney-Voltaire, 01210, France
| |
Collapse
|
6
|
Nakovics MI, Brenner S, Bongololo G, Chinkhumba J, Kalmus O, Leppert G, De Allegri M. Determinants of healthcare seeking and out-of-pocket expenditures in a "free" healthcare system: evidence from rural Malawi. HEALTH ECONOMICS REVIEW 2020; 10:14. [PMID: 32462272 PMCID: PMC7254643 DOI: 10.1186/s13561-020-00271-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/08/2020] [Indexed: 06/01/2023]
Abstract
BACKGROUND Monitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. Our study investigated out-of-pocket expenditure (OOPE) on curative healthcare services and their determinants in rural Malawi, a country that has consistently aimed at providing free healthcare services. METHODS Our study used data from two consecutive rounds of a household survey conducted in 2012 and 2013 among 1639 households in three districts in rural Malawi. Given our explicit focus on OOPE for curative healthcare services, we relied on a Heckman selection model to account for the fact that relevant OOPE could only be observed for those who had sought care in the first place. RESULTS Our sample included a total of 2740 illness episodes. Among the 1884 (68.75%) that had made use of curative healthcare services, 494 (26.22%) had incurred a positive healthcare expenditure, whose mean amounted to 678.45 MWK (equivalent to 2.72 USD). Our analysis revealed a significant positive association between the magnitude of OOPE and age 15-39 years (p = 0.022), household head (p = 0.037), suffering from a chronic illness (p = 0.019), illness duration (p = 0.014), hospitalization (p = 0.002), number of accompanying persons (p = 0.019), wealth quartiles (p2 = 0.018; p3 = 0.001; p4 = 0.002), and urban residency (p = 0.001). CONCLUSION Our findings indicate that a formal policy commitment to providing free healthcare services is not sufficient to guarantee widespread financial protection and that additional measures are needed to protect particularly vulnerable population groups.
Collapse
Affiliation(s)
- Meike Irene Nakovics
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Grace Bongololo
- Research for Equity and Community Health (REACH) Trust, Lilongwe, Malawi
| | - Jobiba Chinkhumba
- University of Malawi College of Medicine, Blantyre, Southern Region Malawi
| | - Olivier Kalmus
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Gerald Leppert
- German Institute for Development Evaluation (DEval), Bonn, Germany
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
7
|
Tembo T, Simuyandi M, Chiyenu K, Sharma A, Chilyabanyama ON, Mbwili-Muleya C, Mazaba ML, Chilengi R. Evaluating the costs of cholera illness and cost-effectiveness of a single dose oral vaccination campaign in Lusaka, Zambia. PLoS One 2019; 14:e0215972. [PMID: 31150406 PMCID: PMC6544210 DOI: 10.1371/journal.pone.0215972] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 04/11/2019] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION In 2016, for the very first time, the Ministry of Health in Zambia implemented a reactive outbreak response to control the spread of cholera and vaccinated at-risk populations with a single dose of Shancol-an oral cholera vaccine (OCV). This study aimed to assess the costs of cholera illness and determine the cost-effectiveness of the 2016 vaccination campaign. METHODOLOGY From April to June 2017, we conducted a retrospective cost and cost-effectiveness analysis in three peri-urban areas of Lusaka. To estimate costs of illness from a household perspective, a systematic random sample of 189 in-patients confirmed with V. cholera were identified from Cholera Treatment Centre registers and interviewed for out-of-pocket costs. Vaccine delivery and health systems costs were extracted from financial records at the District Health Office and health facilities. The cost of cholera treatment was derived by multiplying the subsidized cost of drugs by the quantity administered to patients during hospitalisation. The cost-effectiveness analysis measured incremental cost-effectiveness ratio-cost per case averted, cost per life saved and cost per DALY averted-for a single dose OCV. RESULTS The mean cost per administered vaccine was US$1.72. Treatment costs per hospitalized episode were US$14.49-US$18.03 for patients ≤15 years old and US$17.66-US$35.16 for older patients. Whereas households incurred costs on non-medical items such as communication, beverages, food and transport during illness, a large proportion of medical costs were borne by the health system. Assuming vaccine effectiveness of 88.9% and 63%, a life expectancy of 62 years and Gross Domestic Product (GDP) per capita of US$1,500, the costs per case averted were estimated US$369-US$532. Costs per life year saved ranged from US$18,515-US$27,976. The total cost per DALY averted was estimated between US$698-US$1,006 for patients ≤15 years old and US$666-US$1,000 for older patients. CONCLUSION Our study determined that reactive vaccination campaign with a single dose of Shancol for cholera control in densely populated areas of Lusaka was cost-effective.
Collapse
Affiliation(s)
- Tannia Tembo
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Kanema Chiyenu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Anjali Sharma
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | | | | | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| |
Collapse
|
8
|
Richterman A, Franke MF, Constant G, Jerome G, Ternier R, Ivers LC. Food insecurity and self-reported cholera in Haitian households: An analysis of the 2012 Demographic and Health Survey. PLoS Negl Trop Dis 2019; 13:e0007134. [PMID: 30699107 PMCID: PMC6370226 DOI: 10.1371/journal.pntd.0007134] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 02/11/2019] [Accepted: 01/06/2019] [Indexed: 11/30/2022] Open
Abstract
Background Both cholera and food insecurity tend to occur in impoverished communities where poor access to food, inadequate sanitation, and an unsafe water supply often coexist. The relationship between the two, however, has not been well-characterized. Methods We performed a secondary analysis of household-level data from the 2012 Demographic and Health Survey in Haiti, a nationally and sub-nationally representative cross-sectional household survey conducted every five years. We used multivariable logistic regression to evaluate the relationship between household food security (as measured by the Household Hunger Scale) and (1) reported history of cholera since 2010 by any person in the household and (2) reported death by any person in the household from cholera (among households reporting at least one case). We performed a complete case analysis because there were <1% missing data for all variables. Results There were 13,181 households in the survey, 2,104 of which reported at least one household member with history of cholera. After adjustment for potential confounders, both moderate hunger in the household [Adjusted Odds Ratio (AOR) 1.51, 95% Confidence Interval (CI) 1.30–1.76; p <.0001] and severe hunger in the household (AOR 1.73, 95% CI 1.45–2.08; p <.0001) were significantly associated with reported history of cholera in the household. Severe hunger in the household (AOR 1.85, 95% CI 1.05–3.26; p = 0.03), but not moderate hunger in the household, was independently associated with reported death from cholera in households with at least one case of cholera. Conclusions In this study we identified an independent relationship between household food insecurity and both reported history of cholera and death from cholera in a general population. The directionality of this relationship is uncertain and should be further explored in future prospective research. In this study, we identified an independent relationship between household food insecurity, defined as a persistent lack of access to food in adequate quantity or quality and measured using the Household Hunger Scale, and reported history of cholera and death from cholera in a general population. We performed a secondary analysis of household-level data from the 2012 Demographic and Health Survey (DHS) in Haiti, a nationally and sub-nationally representative cross-sectional household survey conducted every five years. The 2012 survey was conducted during the height of the cholera epidemic, with 453,536 suspected cases and 3,835 deaths in Haiti from 2011–2012. We used multivariable logistic regression to control for measured confounders. The underlying mechanisms and directionality of the association between food insecurity and reported history of cholera are uncertain and should be explored in future prospective research. A better understanding of the relationship between food insecurity and cholera could inform both future cholera outbreak prediction and response, particularly in settings where poor food access and cholera risk factors are known to co-exist.
Collapse
Affiliation(s)
- Aaron Richterman
- Department of Medicine, Brigham & Women’s Hospital, Boston, Massachusetts, United States of America
- * E-mail:
| | - Molly F. Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | | | | | | | - Louise C. Ivers
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Massachusetts General Hospital, Center for Global Health, Boston, Massachusetts, United States of America
| |
Collapse
|