Impact of a Nonfatal Dengue Episode on Disability-Adjusted Life Years: A Systematic Analysis.

As dengue causes about 4,000 symptomatic nonfatal episodes for every dengue death globally, quantitative disability assessments are critical to assess the burden of dengue and the cost-effectiveness of dengue control interventions. This systematic analysis of disability or quality of life lost from a symptomatic nonfatal dengue episode combined a systematic literature review, statistical modeling, and probabilistic sensitivity analyses. We conceptualized a dengue episode as having two phases: acute and persistent symptoms. Our estimates for the acute phase, consisting of onset and recovery periods and defined as the first 20 days (0.054 year), were based on literature review. We searched PubMed, POPLINE, EconLit, Google Scholar, scientific conferences, and other sources, for "dengue" plus "quality of life" or related terms. From 4,322 initial entries, six met our criteria (original studies with empirical data). The median disability-adjusted life year (DALY) burden for the acute phase was 0.011 (95% certainty interval [CI]: 0.006-0.015) for ambulatory episodes, 0.015 (CI: 0.010-0.020) for hospitalized episodes, and 0.012 (CI: 0.006-0.019) overall. Using literature reviews about persistent dengue, we estimated that 34% of episodes experienced persistent symptoms with a median duration of symptoms of 0.087 (CI: 0.040-0.359) year, which resulted in median DALYs of 0.019 (CI: 0.008-0.082). Thus, the overall median DALY burden was 0.031 (CI: 0.017-0.092) for ambulatory episodes, 0.035 (CI: 0.024-0.096) for hospitalized episodes, and 0.032 (CI: 0.018-0.093) overall. Our dengue-specific burden of a dengue episode was 2.1 times the 2013 Global Burden of Disease estimate. These literature-based estimates provide an empirical summary for policy and cost-effectiveness analyses.

The economic impact of providing dengue vaccination in the workplace in Brazil / O impacto econômico da vacinação contra dengue no local de trabalho no Brasil

Objective: To estimate the economic value of implementing a workplace dengue vaccination program from an employer perspective. Methods: The cost of a vaccination program was compared with the economic benefits in terms of reduced absenteeism and presenteeism in companies in Brazil. Input data were obtained from published literature and national databases. The time horizon was five years, including a 2-year vaccination program. Sensitivity analyses were performed to evaluate the impact of key parameters' uncertainty. Results: 846 cases were simulated among the employees over five years, accountable for 2,112 sick leave days and 7,120 sick days at work. Assuming a coverage rate of 30%, vaccination reduced the number of sick leave days and sick days at work by 17.5% over five years compared to no vaccination. Considering an employee vaccine copayment of 50%, the levels of remaining investment per dose administered for the employer in the retail sector ranged from US$ 17.99 to US$ 27.99, according to different vaccine price scenarios, and from US$ 6.10 to US$ 16.10 in the service sector. In the energy sector, vaccination was cost-saving in all price scenarios, ranging from a profit for the employer of US$ 21.14 to US$ 31.14. Results were most sensitive to the level of co-payment, overall time horizon of the analysis, dengue incidence, and employee contribution to operating income. Conclusions: Dengue contributes a significant proportion of absenteeism and presenteeism in private companies. Our analysis suggests that dengue vaccination in the workplace may be considered as a valuable investment and, in some cases, a cost-saving option for employers.

Objetivo: Estimar o valor econômico da implementação de um programa de vacinação contra a dengue no local de trabalho sob a perspectiva do empregador. Métodos: O custo de um programa de vacinação foi comparado com os benefícios econômicos em termos de redução do absenteísmo e do presenteísmo em empresas no Brasil. Os dados foram baseados na literatura publicada e em bases de dados nacionais. O horizonte temporal foi de cinco anos, incluindo um programa de vacinação de dois anos. Foram realizadas análises de sensibilidade para avaliar o impacto das incertezas de parâmetros-chave. Resultados: Oitocentos e quarenta e seis casos foram simulados entre os empregados em cinco anos, os quais foram responsáveis por 2.112 dias de licença médica e 7.120 dias com a doença no ambiente de trabalho. Assumindo uma taxa de cobertura de 30%, a vacinação reduziu o número de dias de licença médica devido à doença e os dias com a doença no ambiente de trabalho em 17,5% ao longo de cinco anos em comparação com a não realização da vacinação. Considerando um copagamento da vacinação pelos funcionários de 50%, os níveis de investimento remanescente por dose administrada para o empregador no setor varejista variaram de US$ 17,99 a US$ 27,99 de acordo com diferentes cenários de preços da vacina e de US$ 6,10 a US$ 16,10 no setor de serviços. No setor de energia, a vacinação resultou em economia de custos em todos os cenários de preços, que vão desde uma economia para o empregador de US$ 21,14 até US$ 31,14. Os resultados foram mais sensíveis ao nível de copagamento, horizonte de tempo global da análise, incidência de dengue e contribuição dos funcionários para a receita operacional. Conclusões: A dengue contribui com uma parcela significativa do absenteísmo e do presenteísmo em empresas privadas. Nossa análise sugere que a vacinação contra dengue no local de trabalhopode ser considerada um investimento valioso e, em alguns casos, uma opção que traz economia para os empregadores.

Cost-effectiveness of dengue vaccination in Brazil / Custo-efetividade da vacinação contra dengue no Brasil

Objective: To define the economic value of a tetravalent dengue vaccine in Brazil by estimating the cost-effectiveness vaccine price threshold per dose. Methods: A dengue dynamic transmission model was used to estimate the public health impact of dengue vaccination and related economic parameters. Two vaccination strategies were assessed: routine vaccination at 9 years old plus either a catch-up campaign of 7 cohorts (10 to 16 years old; R9&10-16) or 16 cohorts (10 to 25 years old; R9&10-25). Brazilian-specific demographic, epidemiological and economic data were used. The economic impact over 10 years was estimated from the public payer and societal perspectives. All costs were expressed in BRL2016. Results: Over 10 years, the R9&10-16 and R9&10-25 vaccination strategies would prevent 9 million and 15 million dengue cases, respectively, avoiding 269,906 (95% CI: 410,097­154,653) and 434,334 (95% CI: 547,052­304,799) disability-adjusted life years. This would result in savings of up to BRL7.4 billion (US$2.1 billion) from a societal perspective with the larger vaccination program. The cost-effective vaccine price threshold per dose for the R9&10-16 and R9&10-25 strategies would be BRL187.5 (95% CI: 109­276) (US$52.1) and BRL183.6 (95% CI: 129­230) (US$51.0), respectively, from the public payer perspective, and BRL221.5 (95% CI: 129­326) (US$61.5) and BRL216.8 (95% CI: 153­271) (US$60.2), respectively, from the societal perspective. Conclusion: The high threshold of vaccine price per dose demonstrates the significant economic value of dengue vaccination in Brazil, even for a large program with 16 catch-up cohorts.

Objetivo: Definir o valor econômico da vacina tetravalente contra dengue no Brasil por meio da estimativa do limiar de preço custo-efetivo por dose. Métodos: Um modelo dinâmico de transmissão foi utilizado para estimar o impacto em saúde pública da vacinação contra dengue e os parâmetros econômicos relacionados. A análise avaliou duas estratégias de vacinação: rotina aos 9 anos, mais campanha de vacinação com 7 coortes (10 a 16 anos; R9&10-16) ou 16 coortes (10 a 25 anos; R9&10-25). Foram utilizados dados demográficos, epidemiológicos e econômicos específicos para o Brasil. O impacto econômico foi estimado em 10 anos sob a perspectiva do pagador público e da sociedade. Todos os custos foram expressos em BRL2016. Resultados: Em 10 anos, as estratégias de vacinação R9&10-16 e R9&10-25 preveniriam 9 milhões e 15 milhões de casos de dengue, respectivamente, evitando 269,906 (95% CI: 410,097­154,653) e 434,334 (95% CI: 547,052­304,799) anos de vida ajustados por incapacidade. Isso resultaria em uma economia de até BRL7,4 bilhões (US$2,1 bilhões) sob a perspectiva da sociedade com o maior programa de vacinação. O limiar de preço custo-efetivo por dose para as estratégias R9&10-16 e R9&10-25 seria BRL187,5 (95% CI: 109­276) (US$52,1) e BRL183,6 (95% CI: 129­230) (US$51,0), respectivamente, sob a perspectiva do público pagador, e BRL221,5 (95% CI: 129­326) (US$61,5) e BRL216,8 (95% CI: 153­271) (US$60,2), respectivamente, sob a perspectiva da sociedade. Conclusão: Os altos limiares de preço custo-efetivo por dose demonstram o significativo valor econômico da vacinação contra dengue no Brasil, mesmo para um programa amplo com campanha com 16 coortes.

Costing Dengue Fever Cases and Outbreaks: Recommendations from a Costing Dengue Working Group in the Americas.

OBJECTIVES: The overall aim of this article was to present a step-by-step guideline for determining the costs associated with dengue in dengue-endemic countries of the Latin American and the Caribbean region and to illustrate how each of these steps can be applied in dengue costing studies. METHODS: An expert panel was convened to develop standards for costing dengue so that over the next decade, decision makers will have access to improved information on the true cost of dengue in endemic countries of the Latin American and the Caribbean region. We described the outcome of the expert panel meeting, which resulted in the provision of a step-by-step dengue costing guideline that aims to provide direction to planners and program managers on how to estimate dengue economic burden studies, and provide a discussion forum of the methods used to cost dengue fever cases and outbreaks in a manner that should be accessible to persons with some familiarity with a cost study. RESULTS: The guideline includes nine sequential steps: 1) definition of the scope of the study; 2) identification of the target population; 3) description of the study perspective; 4) definition of the time horizon; 5) calculation of the sample size; 6) definition of the unit of analysis; 7) identification of the cost items; 8) measurement and valuation of the cost items; and 9) handling of uncertainty. The trade-off between accurate, patient-level cost estimates and data availability constraints is discussed. CONCLUSIONS: The current guideline is the result of constructive collaboration among a multidisciplinary research team to better ascertain the true economic burden of dengue across countries of the region.

Annual public health and economic benefits of seasonal influenza vaccination: a European estimate.

BACKGROUND: Vaccination is currently the most effective means of preventing influenza infection. Yet evidence of vaccine performance, and the impact and value of seasonal influenza vaccination across risk groups and between seasons, continue to generate much discussion. Moreover, vaccination coverage is below recommended levels. METHODS: A model was generated to assess the annual public health benefits and economic importance of influenza vaccination in 5 WHO recommended vaccination target groups (children 6 - 23 months of age; persons with underlying chronic health conditions; pregnant women; health care workers; and, the elderly, 65 years of age) in 27 countries of the European Union. Model estimations were based on standard calculation methods, conservative assumptions, age-based and country-specific data. RESULTS: Out of approximately 180 million Europeans for whom influenza vaccination is recommended, only about 80 million persons are vaccinated. Seasonal influenza vaccination currently prevents an annual average of between 1.6 million and 2.1 million cases of influenza, 45,300 to 65,600 hospitalizations, and 25,200 to 37,200 deaths. To reach the 75% vaccination coverage target set by the EU Council Recommendation in 2009, an additional 57.4 million person would need to be vaccinated in the elderly and other risk groups. By achieving the 75% target rate set in EU-27 countries, average annual influenza- related events averted would increase from current levels to an additional +1.6 to +1.7 million cases, +23,800 to +31,400 hospitalization, +9,800 to +14,300 deaths, +678,500 to +767,800 physician visits, and +883,800 to +1,015,100 lost days of work yearly. Influenza-related costs averted because of vaccination would increase by an additional + €190 to + €226 million yearly, in vaccination target groups. CONCLUSIONS: Full implementation of current influenza vaccination recommendations of 75% vaccination coverage rate (VCR) in Europe by the 2014-2015 influenza season could immediately reduce an important public health and economic burden.

Medical and economic burden of influenza in the elderly population in central and eastern European countries.

Influenza affects 5-15% of the population during an epidemic. In Western Europe, vaccination of at-risk groups forms the cornerstone of influenza prevention. However, vaccination coverage of the elderly (> 65 y) is often low in Central and Eastern Europe (CEE); potentially because a paucity of country-specific data limits evidence-based policy making. Therefore the medical and economic burden of influenza were estimated in elderly populations in the Czech Republic, Hungary, Kazakhstan, Poland, Romania, and Ukraine. Data covering national influenza vaccination policies, surveillance and reporting, healthcare costs, populations, and epidemiology were obtained via literature review, open-access websites and databases, and interviews with experts. A simplified model of patient treatment flow incorporating cost, population, and incidence/prevalence data was used to calculate the influenza burden per country. In the elderly, influenza represented a large burden on the assessed healthcare systems, with yearly excess hospitalization rates of ~30/100,000. Burden varied between countries and was likely influenced by population size, surveillance system, healthcare provision, and vaccine coverage. The greatest burden was found in Poland, where direct costs were over EUR 5 million. Substantial differences in data availability and quality were identified, and to fully quantify the burden of influenza in CEE, influenza reporting systems should be standardized. This study most probably underestimates the real burden of influenza, however the public health problem is recognized worldwide, and will further increase with population aging. Extending influenza vaccination of the elderly may be a cost-effective way to reduce the burden of influenza in CEE.

Cost-effectiveness of polysaccharide pneumococcal vaccination in people aged 65 and above in Poland.

INTRODUCTION: Invasive pneumococcal disease is associated with substantial morbidity, mortality and cost implications, which could be reduced by vaccination. AIM: To assess the cost-effectiveness of a 23-valent pneumococcal vaccine in the elderly (65 and older) in Poland. METHODS: A Markov model with a 1-year cycle length was developed, allowing up to 10 cohorts to enter the model over the lifetime horizon (35 years). In the base case, costs and benefits were assessed using the public health care payer (NFZ) perspective. The analysis included routine vaccination of all elderly and high-risk (HR) elderly versus no vaccination. The analysis assumed that the government would reimburse 50% of the vaccine price. Costs and benefits were discounted 5%, with costs expressed in 2009 Polish Zloty (PLN). Extensive sensitivity analyses were carried out. RESULTS: PPV23 vaccination targeting all elderly and HR elderly in Poland would avoid 8,935 pneumococcal infections, 2,542 hospitalisations, 671 deaths and 5,886 infections, 1,673 hospitalisations and 441 deaths respectively. The incremental cost per QALY gained would be PLN 3,382 in all elderly and PLN2,148 in HR elderly. CONCLUSION: Vaccinating adults 65 and older regardless of risk status with a 23-valent pneumococcal vaccine, is cost-effective, resulting in clinical and economic benefits including a non-negligible reduction of ambulatory doctor visits, hospitalizations and, deaths in Poland.

Cost-effectiveness analysis of pneumococcal polysaccharide vaccination from age 60 in São Paulo State, Brazil.

Vaccination of adults aged 60 years and older against Streptococcus pneumonia is not recommended in Brazil. The 23-valent polysaccharide pneumococcal vaccine (PPV23) is only available for institutionalized persons or with underlying diseases despite the substantial medical and economic burden related to pneumococcal infections in adults over than 59 years. The study aimed at evaluating the cost effectiveness of implementing a large PPV program in this population. This analysis was performed using a static decision tree model. Demographic and epidemiological data were obtained from Brazilian official sources and international literature. Economic data were obtained from a study performed in 2007 in a public and a private hospital located in Sao Paulo. Vaccination was assumed to protect for 5 years with 60% effectiveness against bacteremic pneumococcal pneumonia (BPP) and 21% effectiveness against non bacteremic pneumococcal pneumonia (NBPP). Deterministic and sensitivity analyses were performed. The pneumococcal polysaccharide vaccination saved 5,218 life year gained (LYG). The vaccination program was found to be cost effective in the social security and public health care perspectives with a mean incremental cost-effectiveness ratio of R$10,887 and R$8,281 per LYG respectively. Results were sensitive to the vaccine effectiveness against NBPP, the incidence and case-fatality rate of NBPP. From a societal perspective, PPV23 program for adults 60 and older was found to be cost-saving. Pneumococcal polysaccharide vaccination is clinically and economically favored over the present vaccination strategy, in which persons aged over 59 years in Sao Paulo, have not been vaccinated.

Cost of pneumococcal infections and cost-effectiveness analysis of pneumococcal vaccination at risk adults and elderly in Turkey.

Pneumococcal infections have a substantial burden in Turkey, particularly in the elderly (> 60 years) and at-risk adults (18-59 years). VCR are low at approximately 2%. The first aim of this study was the evaluation of the burden of pneumococcal infections (pneumonia and bacteremia) from a public payer perspective in elderly and at-risk adults. The second aim was the evaluation of cost effectiveness of implementing a large PPV program in these populations. A decision tree model was employed using demographic and epidemiological input obtained from Turkish official sources and international literature. Vaccination was assumed to protect for 5 years with 60% and 50% effectiveness against BPP in elderly and at-risk adults respectively. Vaccination effectiveness of 21% against NBPP was assumed for both populations. Costs input were obtained from a previous study conducted between 2002 and 2008 in a public university hospital in Ankara, Turkey. Univariate sensitivity analyses and Monte-Carlo simulations were performed. The vaccination program was cost effective and cost saving compared to no vaccination, pneumococcal vaccination with 60% coverage led to a mean of 4,695 LYG in the elderly and 2,134 LYG in at-risk adults with 40% coverage. Mean incremental savings reached 45.4 million YTL in the elderly and 21.8 million YTL in at-risk adults. This analysis suggests that pneumococcal vaccination of elderly and at-risk adults is associated with a positive return on investment from a public payer perspective and supports the continued recommendation of pneumococcal vaccines, as well as their full funding in Turkey.