Economic impact of chikungunya epidemic: out-of-pocket health expenditures during the 2007 outbreak in Kerala, India.

The southern state of Kerala, India was seriously affected by a chikungunya epidemic in 2007. As this outbreak was the first of its kind, the morbidity incurred by the epidemic was a challenge to the state's public health system. A cross sectional survey was conducted in five districts of Kerala that were seriously affected by the epidemic, using a two-stage cluster sampling technique to select households, and the patients were identified using a syndromic case definition. We calculated the direct health expenditure of families and checked whether it exceed the margins of catastrophic health expenditure (CHE). The median (IQR) total out-of-pocket (OOP) health expenditure in the study population was USD7.4 (16.7). The OOP health expenditure did not show any significant association with increasing per-capita monthly income.The major share (47.4%) of the costs was utilized for buying medicines, but costs for transportation (17.2%), consultations (16.6%), and diagnoses (9.9%) also contributed significantly to the total OOP health expenditure. The OOP health expenditure was high in private sector facilities, especially in tertiary care hospitals. For more than 15% of the respondents, the OOP was more than double their average monthly family income. The chikungunya outbreak of 2007 had significantly contributed to the OOP expenditure of the affected community in Kerala.The OOP health expenditure incurred was high, irrespective of the level of income. Governments should attempt to ensure comprehensive financial protection by covering the costs of care, along with loss of productivity.

Impact of Chikungunya on health related quality of life Chennai, South India.

BACKGROUND: Chikungunya Virus (CHIKV) infection affects large populations and leads to prolonged and debilitating pain affecting health related quality of life (HRQoL). We assess the impact of CHIKV on HRQoL of clinical CHIKV (C-CHIKV) patients in a suburban locality of Chennai City, South India. Further, we determined factors associated with clinical recovery among C-CHIKV patients. METHODS: We followed-up 403 of 425 adult C-CHIKV cases identified during an outbreak. On the basis of a reassessment of their current clinical status through self-reporting, we categorized them as 'clinically recovered' (n = 308) or 'not recovered' (n = 95). In the absence of base-line information on HRQoL, we included a comparison group of healthy normal's recruited by frequency matching for age and sex from the neighbourhood (n = 308). We conducted a comparative cross-sectional study of these three groups and estimated HRQoL scores using SF-36 questionnaire. We tested the differences in the median scores by Kruksall Wallistest. We identified factors associated with 'recovery' as compared to not-recovery by calculating Adjusted Odds Ratio (AOR) and 95% Confidence Intervals through multiple regression analysis. RESULTS: As compared to 'normals', we observed a 20 and five-fold reductions in HRQoL scores for C-CHIKV patients 'not recovered' and 'recovered' respectively. Differences in HRQoL scores for all the domains were statistically significant between three groups (p<0·001). Younger age, male, absence of rashes, affliction of less than five types of joints and two weeks of joint swelling were significantly associated with recovery. HRQoL scores improved with time among those 'clinically recovered'. CONCLUSION: This study provides evidence for sharp reductions in quality of life not only during active C-CHIKV associated illness but also for several months after clinical recovery compared to healthy normals. This has implications for developing intervention programmes in countries with high risk of CHIKV outbreaks.

Optimal control of chikungunya disease: larvae reduction, treatment and prevention.

Since the 1980s, there has been a worldwide re-emergence of vector-borne diseases including Malaria, Dengue, Yellow fever or, more recently, chikungunya. These viruses are arthropod-borne viruses (arboviruses) transmitted by arthropods like mosquitoes of Aedes genus. The nature of these arboviruses is complex since it conjugates human, environmental, biological and geographical factors. Recent researchs have suggested, in particular during the Reunion Island epidemic in 2006, that the transmission by Aedes albopictus (an Aedes genus specie) has been facilitated by genetic mutations of the virus and the vector capacity to adapt to non tropical regions. In this paper we formulate an optimal control problem, based on biological observations. Three main efforts are considered in order to limit the virus transmission. Indeed, there is no vaccine nor specific treatment against chikungunya, that is why the main measures to limit the impact of such epidemic have to be considered. Therefore, we look at time dependent breeding sites destruction, prevention and treatment efforts, for which optimal control theory is applied. Using analytical and numerical techniques, it is shown that there exist cost effective control efforts.

[Coverage of the chikungunya epidemic on Reunion Island in 2006 by the French healthcare system]. / Prise en charge de l'épidémie de chikungunya de 2006 a l'île de la réunion par l'Assurance Maladie.

The chikungunya epidemic that occurred on Reunion Island between 2005 and 2006 was covered by the French health insurance system. This coverage involved a major increase in the number of paid sick leave days and prescription drug refunds in the first quarter of 2006. Special governmental measures such as full reimbursement of certain medications and waiving of the waiting period for sick leave in case of relapse greatly reduced the impact of the epidemic. Five years after, the database of the health insurance systems indicates a low incidence of chronic forms. Only cases managed on an outpatient basis were included in this study.

[Administrative issues linked to health insurance coverage of chronic post-chikungunya rheumatism]. / Aspects médico-administratifs nouveaux liés a la phase chronique du chikungunya.

The chikungunya outbreak on Reunion Island in 2005-2006 was followed by a high incidence of persistent arthralgia. A small group of patients developed chronic, sometimes destructive, post-chikungunya inflammatory rheumatism presenting as rheumatoid polyarthritis or spondylarthritis that required disease-modifying antirheumatic drugs such as methotrexate. We describe two patients under this treatment confronted with financial health insurance issues due to the lack of administrative recognition of post-chikungunya rheumatism as a long-term affliction or an occupational disease.

[Judicial or administrative settlement of medical malpractice claims. Update on medical liability]. / Recours juridictionnels ou administratifs en cas d'accident médical l'actualité de la responsabilité médicale.

Settlement of medical malpractice claims was radically changed by the Kouchner Law that set up a rapid, effective system of indemnification. Victims can choose between conventional court proceedings and a non-judicial conciliation procedure. Choice between the two processes depends on the circumstances of the case.

[Physiopathology of chronic arthritis following chikungunya infection in man]. / L'epidémie de chikungunya a La Réunion ou le parcours du combattant d'une elue de la République.

This article relates the problems initially encountered by an elected official of the French Republic in drawing the attention of authorities to the ravages of the chikungunya epidemic that occurred on Reunion Island in 2005-2006. Due to inadequate medical knowledge, the benign reputation of the disease, and slow reaction of authorities, the virus affected more than one third of the population. A great deal of further study will be needed to understand this public health crisis and to transform the lessons learned into a decisive breakthrough that will doubtless be of equal benefit for mainland France.

The Chikungunya epidemic on La Réunion Island in 2005-2006: a cost-of-illness study.

BACKGROUND: This study was conducted to assess the impact of chikungunya on health costs during the epidemic that occurred on La Réunion in 2005-2006. METHODOLOGY/PRINCIPAL FINDINGS: From data collected from health agencies, the additional costs incurred by chikungunya in terms of consultations, drug consumption and absence from work were determined by a comparison with the expected costs outside the epidemic period. The cost of hospitalization was estimated from data provided by the national hospitalization database for short-term care by considering all hospital stays in which the ICD-10 code A92.0 appeared. A cost-of-illness study was conducted from the perspective of the third-party payer. Direct medical costs per outpatient and inpatient case were evaluated. The costs were estimated in Euros at 2006 values. Additional reimbursements for consultations with general practitioners and drugs were estimated as € 12.4 million (range: € 7.7 million-€ 17.1 million) and € 5 million (€ 1.9 million-€ 8.1 million), respectively, while the cost of hospitalization for chikungunya was estimated to be € 8.5 million (€ 5.8 million-€ 8.7 million). Productivity costs were estimated as € 17.4 million (€ 6 million-€ 28.9 million). The medical cost of the chikungunya epidemic was estimated as € 43.9 million, 60% due to direct medical costs and 40% to indirect costs (€ 26.5 million and € 17.4 million, respectively). The direct medical cost was assessed as € 90 for each outpatient and € 2,000 for each inpatient. CONCLUSIONS/SIGNIFICANCE: The medical management of chikungunya during the epidemic on La Réunion Island was associated with an important economic burden. The estimated cost of the reported disease can be used to evaluate the cost/efficacy and cost/benefit ratios for prevention and control programmes of emerging arboviruses.

Estimating the burden of disease and the economic cost attributable to chikungunya, Andhra Pradesh, India, 2005-2006.

To estimate the burden and cost of chikungunya in India, we searched for cases of fever and joint pain in the village of Mallela, Andhra Pradesh, and collected information on the demography, signs, symptoms, healthcare utilization and expenditure associated with the disease. We estimated the burden of the disease using disability-adjusted life years (DALYs). We estimated direct and indirect costs and made projections for the district and state using surveillance data corrected for under-reporting. On average, from December 2005 to April 2006, each of the 242 cases in the village led to a burden of 0.0272 DALYs (95% CI 0.0224-0.0319) and a cost of US$37.50 (95% CI 30.6-44.3). Overall, chikungunya in Mallela led to 6.57 DALYs and a loss of US$9100. Out-of-pocket direct medical costs accounted for 68% of the total. From January to December 2006 the burden for Kadapa district was 160 DALYs (cost: US$290 000). Over the same period the burden for Andhra Pradesh was 6600 DALYs (cost: US$12 400 000). While the burden was moderate, costs were high and mostly out of pocket.

Household economic impact of an emerging disease in terms of catastrophic out-of-pocket health care expenditure and loss of productivity: investigation of an outbreak of chikungunya in Orissa, India.

BACKGROUND & OBJECTIVES: To examine the household economic impact of an outbreak of chikungunya in terms of out-of-pocket health care expenditure and income foregone due to loss of productive time in Orissa, India. METHODS: Structured interviews were conducted on 150 respondents, bread winners from the affected households of a village with maximum number of reported cases in the state, during August 2007. We looked at the economic profile, treatment history, and patient-side cost of care, loss of productivity and consequent income loss. RESULTS: The median out-of-pocket health care expenditure was US$ 84, of which the proportion of cost of diagnosis was the highest (US$ 77). One hundred and forty nine respondents incurred cost of care more than 10% of their monthly household income (catastrophic health expenditure). The median catastrophic health care expenditure was 37%. The respondents depended more on private health care providers (49%) and 31% of them accessed care from both public and private health care providers. The median work days lost was 35 with a consequent loss of income of US$ 75. INTERPRETATION & CONCLUSION: Outbreak of an emerging disease creates unforeseen catastrophic health care expenditure and reinforcing the poverty ill-health nexus. The priorities of tackling emerging diseases should include; discretionary public health spending, financial protection against the cost of illness and productivity with special emphasis on people living on daily wages with less financial reserves, and further research on therapeutic measures to reduce the duration of suffering and consequent economic loss.

Cost of illness due to Chikungunya during 2006 outbreak in a rural area in Tamil Nadu.

OBJECTIVE: To estimate the burden of chikungunya in terms of financial and opportunity costs through a cross sectional survey from an affected area in Tamil Nadu. METHODS: A survey of 809 households with a population of 4393 showed 59 individuals suffered from clinical symptoms of chikungunya. Using pre-tested questionnaire, information on the source of treatment, costs and income foregone were generated. RESULTS: Both public and private health facilities were utilized by the patients. The per capita cost on treatment and average loss of income was Rs.223 and Rs.543 respectively. Extrapolation of this result to the entire village with 615 suspected cases showed estimates of Rs.1.38 and 3.35 lakhs towards treatment and productivity loss respectively. The cost saving per patient would be Rs. 59.93 if recommended line of treatment was followed. CONCLUSION: The results of the study justify the need for appropriate preventive measures with active surveillance support towards epidemic preparedness.

Natural history of Ross River virus-induced epidemic polyarthritis.

OBJECTIVE: To describe the natural history, treatment and cost of Ross River virus-induced epidemic polyarthritis (RRV disease). DESIGN: Questionnaire-based longitudinal prospective study. PARTICIPANTS AND SETTING: Patients in the greater Brisbane area, Queensland, diagnosed with RRV disease by their general practitioners based on clinical symptoms and paired serological tests between November 1997 and April 1999. MAIN OUTCOME MEASURES: Scores on two validated quality-of-life questionnaires (Clinical Health Assessment Questionnaire and Medical Outcomes Study Short Form 36) were obtained soon after diagnosis and one, two, three, six and 12 months thereafter. Scores were compared between patients diagnosed with RRV disease alone and those with RRV disease plus other conditions. RESULTS: 67 patients were enrolled. Most patients with RRV disease alone had severe acute symptoms, but followed a consistent path to recovery within three to six months. Other conditions, often chronic rheumatic diseases or depression, were identified in half the cohort; their quality-of-life scores suggested stable chronic illness between six and 12 months after diagnosis. Non-steroidal anti-inflammatory drugs (NSAIDs) were taken by 58% of patients (average use, 7.6 weeks; range, 2-22 weeks). Time off work averaged 1.9 days, and direct cost to the community was estimated as 1018 Australian dollars per patient. CONCLUSIONS: Symptom duration and frequency of long-term symptoms may have been overestimated by previous studies of RRV disease. Disease persisting six to 12 months after RRV diagnosis was largely attributable to other conditions, highlighting the need to seek other diagnoses in RRV patients with persistent symptoms.

Ross River virus infection on the North Coast of New South Wales.

A retrospective follow-up survey was undertaken of residents of the North Coast of New South Wales infected with Ross River virus in 1992. The aims of the study were to describe the epidemiology and acute symptomatology of Ross River virus infection, its natural history during the first 12 months of infection, and its effects on those infected. Questionnaires were distributed to both cases and their medical practitioners. Of 129 people infected, aged between six and 85 years, 81 (63 per cent) were male and 48 (37 per cent) were female. The peak age-specific incidence was in the age group 50 to 59 years. The most common symptoms were arthralgia (95 per cent) and tiredness (91 per cent). Over 60 per cent took time off work. At 12 months follow-up, over 50 per cent reported persistent arthralgia, 35 per cent reported persistent tiredness and 15 per cent were still unable to carry out their normal activities. The median duration of symptoms was in the range 7 to 12 months, and of incapacity was in the range five weeks to three months. There were some differences from previous reports of Ross River virus outbreaks, in the incidence of major symptoms and the duration of illness and incapacity. These are likely to be at least partly due to inconsistent measurement methods. In this study, there were systematic differences between medical practitioners' and patients' estimates of periods of incapacity. Previous estimates of the direct economic costs and indirect human costs of infection based on data obtained from medical practitioners, although alarming, are almost certainly underestimates.