1. Multi-country Study of Costs of Dengue among Ambulatory and Hospitalized Patients Presentation at: American Society of Tropical Medicine and Health 56th Annual Meeting, Philadelphia, PA, Nov. 5, 2007 Abstract in: Am J Trop Med Hyg 77(5, Suppl): 9.

2. 2 Jose A. Suaya, Donald S. Shepard, Blas Armien, Mariana Caram, Leticia Castillo, Ngan Chantha, Fàtima Garrido, Sukhontha Kongsin, Lucy Lum, Romeo Montoya, Binod K. Sah, João B. Siqueira, Rana Sughayyar, Karen Tyo Brandeis University and other institutions ASTMH Annual Meeting Philadelphia, PA Nov. 5, 2007 Multi-country Study of Costs of Dengue among Ambulatory and Hospitalized Patients

3. 3 Objectives  Understand the disease burden and economic burden per dengue episode  Examine these burdens across the diversity of countries and settings in which dengue is treated.  Strengthen research capacity and focus on dengue in dengue-endemic countries

4. 4 Participating countries  The Americas  Brazil  El Salvador  Guatemala  Panama  Venezuela  Asia  Cambodia  Malaysia  Thailand

5. 5 Joint core protocol included  Common patient survey instrument  Common medical record extraction form  Common spreadsheet for hospital cost analysis  Common data base  Common data cleaning procedures  Common data analysis procedures

6. 6 Core features for study cohort  Clinical dengue cases  Inpatients in public hospital  Both sexes  Children aged 0-14  Urban populations  Interview at end of the illness period

7. 7 Consent, contact and follow-up form

8. 8 Patient survey -- information on:  patient’s health  health seeking behaviors  types and amounts of ambulatory and inpatient medical services obtained  types and amounts of non-medical services consumed  amounts of out-of-pocket payments by type of service, days of school and work absenteeism  income lost by the patient or household members  days of illness by patient  hours of patient care by household members

9. 9 Investigators in Americas Participants, left to right: Front: Clare Hurley (Brandeis), Leticia Castillo (Guatemala), Evelia Quiroz (Panama), Donald Shepard (Brandeis), Fatima Garrido (Venezuela), Celina Turchi Martelli (Brazil); Middle: Romeo Montoya (El Salvador), Rafael Chacon (El Salvador), Jose Suaya (Brandeis), Joao Siquiera (Brazil); Back: Blas Armien (Panama), Carlos Ovando (Guatemala), Mariana Caram (Brandeis).

10. 10 Investigators in Asia Back row, left to right: Padejsak Chobtum, MSc. cand. (Thailand), Nootchawon Boonruang, MSc. cand. (Thailand), Kanoksak Wongpeng, MSc. cand. (Thailand), Tan Lian Huat, M.D. (Malaysia), Sukhum Jiamton, M.D., Ph.D. (Thailand), Sukhontha Kongsin, Ph.D. (Thailand), Jose Suaya, M.D., Ph.D. (Heller), Sirenda Vong, M.D. (Cambodia), Chantha Ngan, M.D. (Cambodia), Rekol Huy, M.D. (Cambodia), Lucy Lum Chai See, M.D. (Malaysia), Siriyaporn Khantasorn, MSc. cand. (Thailand), Petcherut Sirisuvan, MSc. cand. (Thailand).

11. 11 Unit of analysis: clinical dengue case  Patient seeking care for acute febrile illness  Clinical diagnosis of dengue  Treated at health facility  With or without laboratory confirmation

12. 12 Economic impact components  Direct medical cost  Direct non-medical cost  Indirect cost  Patients and households  Employers

13. 13 Participant characteristics by country From Table H1a

14. 14

15. 15 Self-reported economic impact on household in hospitalized patients From Table H9

16. 16 Costs in hospitalized cohort

17. 17 Costs in ambulatory cohort

18. 18 Cost per dengue case in terms of days of GDP per capita  Hospitalized cases  Mean: 76 days  Range (days): 46 in Venezuela to 111 in Cambodia  Ambulatory cases  Mean: 24 days  Range (days): 12 in Venezuela to 31 in Brazil

19. 19 The cost per case of dengue is generally higher than previously estimated  These studies generally find a higher cost of illness per case than previous dengue research due to more comprehensive assessment  The average for our ambulatory cohort (24 days of GDP per capita) is at the mid point of other studies  The average for our hospitalized cohort (80 days of GDP per capita) is higher than all of the other studies

20. 20 Previous studies of dengue cost compared to present study  Previous studies were single country  Generally topical in scope  E.g. Several focused on out-of-pocket expenditure, but excluded government subsidy  Used multiple assumptions in the absence of actual data.

21. 21 The cost per case of dengue is generally higher than that for other infectious diseases  The average cost of illness of the ambulatory dengue cases (equivalent to 24 days of GDP) ranks moderately high (at the 71 st percentile) against 14 comparators  The average cost of the hospitalized dengue cases (equivalent to 76 days of GDP) is very high (at the 93 rd percentile) against 14 comparators For references see Scientific Report

22. 22 Conclusions  On a per case basis, the cost of a dengue episode is substantial  Both direct and indirect components are important  Costs fall on all sectors:  Government  Employers  Households  Policymakers are very interested in costs of dengue For references see Scientific Report

23. 23 Acknowledgments  Other collaborating researchers  PDVI staff and advisors: Mark Beatty, Diana Edgil, Scott Halstead, Susie Kliks, Joel Kuritsky, Bill Letson, Richard Mahoney, Harold Margolis  Sponsor: Pediatric Dengue Vaccine Initiative

24. 24 THANK YOU!  Shepard@brandeis.edu  Suaya@brandeis.edu