During decision taking on new vaccines implementation within the frames of the government, besides the matter concerning the burden of disease (its morbidity, severity and mortality), the economic factor plays an important role, i.e. whether vaccination implementation is light from the economic point of view, and profitable sometimes. Congenital Rubella Syndrome (CRS) is a rare human disease; nevertheless, its damage can result in great economic consequences.
The objective of this survey was to estimate economic burden of CRS in Tashkent City.
The prospective epidemiological study of disease based on all children's hospitals of Tashkent was carried out in 2007. In total 26 CRS cases were included in the study. The data for estimation of direct medical and non-medical expenses were gathered, as well as on the basis of retrospective study analysis of CRS’s morbidity CRS’s burden was assessed by the example of Tashkent City, including indirect expenses.
The total burden of disease in Tashkent city was equal to USD 1.18 million. Indirect expenses compose 97% of this amount (including losses of working days, living expenses and payments on disability benefits). The cost of direct medical and non-medical expenses on the basis of one CRS case of initial hospitalization caused by CRS was equal to US$ 269, of which 56% are covered by the government. CRS results in great economic burden by the example of Tashkent City, while vaccination implementation shall permit to reduce these expenses by 60%.
Immunization has resulted in a significant reduction in the number of cases and outbreaks of vaccine preventable diseases (VPD) in Europe. While many infectious diseases are now rare in Europe, VPR still cause disease, incapacity, and death. Every year 1.4 million children worldwide die as a result of VPD before the age of five. The risk of dying from VPD is ten times higher for children in the developing world than in Western countries. According to the World Health Organization (WHO), 32,000 children in the European region die from VPD annually (1).
Despite improved public health during the last decades, vaccination is still a priority for VPD control.
The goals of the strategic plan of WHO/Europe for the 2005-2010 include the elimination of endemic rubella by 2010 and the prevention of congenital rubella syndrome (CRS). For a quantitative assessment, less than one case of CRS per 100,000 infants is the recommended indicator of achievement (2). In Uzbekistan, CRS control was obtained following the mass vaccine campaign implemented in Tashkent at the end of 2007, and in the whole territory of Uzbekistan in 2008. Vaccination reduced the number of CRS cases from 6.2 to 1.3 cases per 1000 infants (unpublished data).
Nevertheless, rubella control must not be restricted to the implementation of single mass vaccination campaigns. Immunization against rubella virus should be included in national vaccination schedule. However, the decision to include new vaccines in national immunization programs should be based on several factors including the economic consequences caused by rubella infection and the economic benefits of vaccination in comparison with other disease control strategies. Economic assessments of rubella immunization program were conducted in several countries (3,4). The results indicated that vaccination against rubella can be cost effective and reduce public health expenses (5,6). This study assessed the economic burden of CRS in Uzbekistan. The results may be used to analyze the economic benefits of rubella vaccination and support a decision to include the vaccine in the national vaccination schedule.
Uzbekistan population is approximately 27 million and annual birth rate is 600,000 (7). The Gross Domestic Product (GDP) per head is 930 USD (8). Uzbekistan is thus entitled to receive financial support from GAVI (the Global Alliance for Vaccination and Immunization), which only supports countries with a GDP under 1000 USD. Vaccines are provided by the national program and vaccination coverage is 90% (9). Vaccination is free-of-charge and state-financed.
Comprehensive information about expenditures related to CRS is necessary for cost efficiency analysis and decision-making regarding which measures should be taken, including vaccination, to control rubella.
Materials and Methods
Epidemiological surveillance was conducted in 2007 to register cases of congenital rubella and the related economic expenses. All children’s hospitals, prenatal centers and maternity hospitals in Tashkent were included. The study included children under the age of one with congenital rubella symptoms according to the standard WHO definition of CRS and hospitalized due to congenital disease. All expenses in 2007 are given in USD (1 USD = 1263.22 Uzbek som).
The total cost included expenses prior to the hospital admission (policlinic visits, diagnostics expenses and drugs), transportation to the hospital, transportation expenses for visits from relatives and miscellaneous expenses during hospitalization.
The data on diagnostic procedures and drugs prescribed were obtained from the patient’s record. Data regarding the total expenses were provided by the parents during an interview with the parents.
The cost of one day’s stay at the hospital (bed day cost) was calculated as follows: The total annual budget of the hospital was divided by the total number of hospitalized patients and average number of days of hospitalization. The hospital’s budget included capital expenses, equipment, salaries and hotel expenses for family members or guardians. Expenses for laboratory services, drugs and catering were not included in the bed day, and were calculated separately for each patient. Expenses for drugs were obtained by multiplying a unit price by the amount of drugs prescribed. Laboratory expenses were calculated based on a unit price multiplied by the number of laboratory tests conducted for each patient, and included fees for use of equipment, chemicals and personnel. Catering costs provided by the hospital were estimated using the hospitals’ fixed prices.
All expenses per unit (bed day, catering) were multiplied by hospitalization duration, and an average hospitalization cost per patient plus treatment and laboratory expenses was calculated. The total expenses for policlinic visits were adjusted according to the number of patients registered at the policlinics.
Indirect expenses included loss of income incurred by the parents as a result of absence from the work prior to and during hospitalization, as well as the cost of the life lost. The loss of income was assessed by multiplying the number of days of absence from work by an average daily benefit based on the data obtained from the respondents. The value of the life lost was calculated by the human life capitalization method (10). Due to the lack of data for Uzbekistan, an average duration of life was calculated using annual tables of duration of life for Kazakhstan (7). The number of fatal CRS cases was determined by retrospective analysis. The total cost due to incapacity was calculated using a life capitalization method, and a monthly payment for incapacity to persons disabled from childhood.
The total burden of CRS for Tashkent was calculated by multiplying the number of CRS cases by the cost per case. The number of CRS cases, as well as the number of persons disabled as a result of CRS, was determined by retrospective analysis.
Uncertainty of results was evaluated by likelihood sensitivity analysis using TreeAge Pro data (TreeAge, Williamstown, MA, USA) and a 95 % of confidence interval (11). Data uncertainty was calculated for each input value using gamma-distribution. We conducted 10,000 simulations using the Monte Carlo method for the description of the distribution of total expenses for CRS in Tashkent.
Twenty six cases of hospitalization due to congenital pathology were included in the economic analysis (table 1). Boys accounted for 42.3% of the cases. The average age of patients was 14.5 days and 50% of all patients were hospitalized during the first three days of illness (Fig. 1). Premature newborns comprised 23.1% of the patients with an average weight at birth of 2879 grams. In 65% of the cases patients visited policlinics, 30% of cases came directly to the hospital and approximately 4% presented to private general practitioners.
The average distance from the hospital to the patient’s house was 9.8 km (variation 1-30 km) and the average travel time from the house to the hospital was more than 30 minutes. An average family size was 4-5 persons with 2-3 adults. The family average income per month was USD 241.44.
The total cost of expenses incurred by the government and parents prior to hospitalization was USD 35.50. According to WHO, a twenty minute visit at a policlinic costs the government USD 3.54. The expenses for policlinic services in our analysis can be adjusted to USD 2.18 because only 65% of the patients visited a policlinic prior to hospitalization. The parents spent an average of USD 33.32 prior to hospitalization. Medications accounted for the majority (69%) of the expenses. In general, the expenses (90%) during pre-hospitalization are incurred by a child’s parents.
The total cost of hospitalization was USD 260.85 per one hospitalized CRS case. Almost 40% (USD 101.98) was the cost of a bed day. Medications amounted to USD 55.58 (21%) and catering USD 39.07 (15%). Generally, 60% of all expenses during hospitalization are covered by the government.
The total direct medical and non-medical cost per hospitalized CRS case was USD 296.36 (95% CI 271.17-321.55). The government bears 53% of all expenses.
An average duration of stay at the hospital was 8.03 (SD 5.24) days. It may be assumed that the parents will lose income due to absence from work during this period. Combining the average duration of stay at the hospital and an average monthly income, the average loss of income was USD 68.87 (table 3).
When using a life capitalization method, average living expenses (in case of a child’s death) were USD 30,873.48 while government payments in the form of disability benefits during the whole life may amount to USD 12,666.04 per case.
Data from the pre-vaccination period (table 4) in Tashkent concerning CRS prevalence (121 cases), number of fatal cases (3 cases) and disability (78 cases) were used. The total economic burden of CRS for Tashkent was approximately USD 1.18 million. Payment of government benefits due to incapacity accounted for 88% of the total. Hospitalization expenses were 3% of the total.
The analysis was conducted in order to obtain evidence for the implementation of rubella vaccination in Uzbekistan.
Currently there is a lack of long-term data concerning rubella and CRS prevalence in Uzbekistan and thus it is difficult to assess the extent of the problem. Retrospective analysis uncovered the extent of the problem within Tashkent and these results became the basis for conducting an economic survey. In addition, there is little data concerning disability and mortality caused by CRS. It is also possible that symptoms indicative of CRS are not always identified and diagnosed. Moreover, the data obtained from the parents that were used in the analyses may differ from the average indicator for the entire country. CRS in not common and limited studies have been conducted. Thus statistical analysis may be inaccurate. In order to minimize possible inaccuracies, likelihood sensitivity analyses were conducted Hospitalization of children due to primary disease was not considered in our analysis. The disability level and economic burden of disability were identified. Monthly payments can reflect the expenses for refresher course of treatment.
The GDP of Uzbekistan constitutes 0.003% of our calculated indicator of US$ 1.18 million (8). There is a lack of data on economic burden in the literature. In general, the data on medical and non-medical expenses are published without mentioning about the indirect expenses that comprise the lion’s share of burden according to our data. In a study from Brazil 45 CRS cases were registered in 2002 (12). The economic burden during the first life year for these children that corresponds to the initial hospitalization indicator used in our study was USD 61,824. This corresponds to USD 13,800 per child and exceeds the same indicator obtain in our analysis by forty times. A study conducted in Japan indicates the amount of USD 12,000 per CRS case, a figure that also significantly exceeds our indicator (13). This great difference may be due to the cost of treatment; these services in the hospitals of Uzbekistan are free of charge. In addition, a significant difference in salary and cost of treatment between the studies was noted; in almost all cases micro surgeons and cardiac surgeons were needed. Thus, we are unable to compare the economic burden in Uzbekistan with the other countries due to differences in treatment opportunities and public health systems.
It should be emphasized that according to our results the burden of disease is born by the government. This should play an important role in decisions regarding the design and implementation of preventive measures.
The economic burden of CRS is enormous. While indirect expenses constitute the majority of the total cost, these figures are not included in simple economic analysis. Indirect expenses must considered when calculating the cost of implementing new vaccines. The economic efficiency results of the mass campaign indicate that vaccination reduced the CRS burden by 60%. This is very significant for the state budget of the country.
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