T

E

PS

a

Nb

Bc

d

RA

aRT

@

0d

ransactions of the Royal Society of Tropical Medicine and Hygiene (2008) 102, 570—577

avai lab le at www.sc iencedi rec t .com

journa l homepage: www.e lsev ierhea l th .com/ journa ls / t rs t

conomic burden of dengue infections in India

ankaj Garga,b,∗, Jitender Nagpalb, Prakash Khairnarc,uranjith L. Seneviratned

Department of Pediatrics, Central Hospital and Research Centre, 69, Sector 20A, Faridabad, Haryana,ational Capital Region, IndiaDepartment of Pediatrics and Clinical Epidemiology, Sitaram Bhartia Institute of Science and Research,-16, Qutub Institutional Area, New Delhi 110016, IndiaDepartment of Critical Care, Artemis Hospital, Sector 51, Gurgaon, IndiaDepartment of Clinical Immunology, Imperial College AHSC, St Mary’s Hospital, Praed Street, London W2 1NY, UK

eceived 29 October 2007; received in revised form 19 February 2008; accepted 19 February 2008vailable online 9 April 2008

KEYWORDSDengue;Economic burden;Costs;Healthcare costs;India

Summary Dengue infections are a significant cause of morbidity and mortality and lead toadverse economic effects in many developing tropical countries. In this study, we estimatedthe economic burden faced by India during the 2006 dengue epidemic. Costs incurred in man-aging a cohort of serologically confirmed dengue patients at a tertiary-level private hospital innorth India were calculated. The median cost of treatment per hospitalised dengue patient wasUS$432.2 (95% CI US$343.6—625). A sensitivity analysis was performed to estimate the costs tothe health system in India using a regression model. Variables with potentially large variations,including the ratio of unreported to reported cases and of hospitalised to ambulatory cases,the proportion requiring transfusions, loss of economic activities due to loss of workdays anddeaths, were used. The average total economic burden was estimated to be US$27.4 million(95% CI US$25.7—29.1 million). Costs in the private heath sector were estimated to be almost

four times public sector expenditures. Considerable economic losses (at a macro level) areincurred by developing countries like India during each dengue epidemic. Accurate estimatesof the proportions of reported to unreported and of hospitalised to ambulatory dengue cases inIndia are needed to refine further the estimates of financial burden due to dengue in India.

opica

© 2008 Royal Society of Tr reserved.

∗ Corresponding author. Present address: Department of Pediatricsnd Clinical Epidemiology, Sitaram Bhartia Institute of Science andesearch, B-16, Qutub Institutional Area, New Delhi 110016, India.el.: +91 11 4054 0110; fax: +91 11 2653 3027.

E-mail addresses: pankajparul8@rediffmail.com, pankaj.gargsitarambhartia.org (P. Garg).

1

DpAdid

035-9203/$ — see front matter © 2008 Royal Society of Tropical Medicinoi:10.1016/j.trstmh.2008.02.015

l Medicine and Hygiene. Published by Elsevier Ltd. All rights

. Introduction

engue infections are an important global public health

roblem and an increasing number of people from the Southsian region have been directly or indirectly affected byengue (Guha-Sapir and Schimmer, 2005). Although the clin-cal patterns of dengue infection in South Asia have beenescribed, estimates of its economic and social burden

e and Hygiene. Published by Elsevier Ltd. All rights reserved.

vn

nwtwt

22

TID2thu

2e

DsI(r1aHHlRsihtsS

3

3

TetI(ulwCo

Economic burden of dengue

are poorly documented (Guha-Sapir and Schimmer, 2005;Halstead et al., 2007).

In 2006, many states in India suffered a major dengueepidemic that strained the already stretched healthcare sys-tem in India (Mudur, 2006). Estimates of costs incurred inIndia during such dengue epidemics are lacking. This may inpart be related to the multiplicity of healthcare providers(public sector 42—52% and private sector 48—58%) and thelargely unregulated private health sector in India (Bhat,1996; Purohit, 2001).

In this report, we have attempted to estimate the eco-nomic burden of dengue within the private and state healthsectors in India. Such cost information is needed for appro-priate allocation of scarce health resources for a singleinfectious disease.

2. Methods and materials

2.1. Dengue in India

A literature search of several databases (Old Medline1950—1965, Medline 1966—June 2007, EMBASE, PsycINFOand WHOLIS) was performed using the keywords ‘Dengue’and ‘India’ and ‘DHF’ or ‘Dengue hemorrhagic fever’. Atotal of 267 and 164 citations were extracted from Medlineand EMBASE; cross-references were searched and impor-tant studies were collected in full text. Websites of theWHO, the National Vector Borne Disease Control Programme(NVBDCP) (http://www.nvbdcp.gov.in), the National Insti-tute of Communicable Diseases (http://www.nicd.org) andthe Ministry of Health and Family Welfare, Government ofIndia, were searched for publications and information ondengue and dengue haemorrhagic fever (DHF) from India. Inaddition, all articles originating from India and publishedin Dengue Bulletin were retrieved. Relevant studies anddata were sorted into three epoch periods (1963—1980,1981—1995 and 1996—2007) and according to four regions(North and Central, West, East and South India). For thepresent evaluation, we focused only on studies highlightingthe clinical-epidemiological and haematological profile inthe third epoch (1996—2007). Studies on virological, serolog-ical and entomological investigations were not consideredrelevant for the economic evaluation to the health system.

2.2. Data on hospitalised patients at a singlehospital during a dengue epidemic, 2006

Patients hospitalised at a tertiary private hospital in NorthIndia from September—November 2006 with serologicallyconfirmed acute dengue infection were studied. StandardWHO dengue classification criteria and IgM and IgG serolog-ical testing were used. Demographic and clinical findings ineach patient were recorded on a standardised pro forma.

Total patient expenditure was calculated in thesepatients by summing the costs for investigations, drugs,disposables, room charges and physician time using figures

obtained from the hospital’s electronic receipts database.

The normality of the cost data was checked using his-tograms in SPSS statistical software (SPSS Inc., Chicago, IL,USA). Mean, median and 95% CIs were calculated for esti-mating the unit costs incurred in our series. The median

dt

ed

571

alue (95% CI) was used for unit costs because of the skewedature of the data.

Furthermore, the cost patterns charged by two privateursing homes in the region running for more than 10 yearsere studied to determine inpatient costs in the private sec-

or at the secondary level of care. Average costs chargedere noted to be almost two-thirds of the expenses at the

ertiary private hospital.

.3. Data on dengue cases and deaths during the006 dengue epidemic in India

he total number of reported dengue cases during the 2006ndian dengue epidemic was obtained from the Indian NVB-CP (National Vector Borne Disease Control Programme,007). Data on age- and gender-specific cases and deaths,he proportion of DHF grade III/IV, and national data onospitalisation versus ambulatory cases and on reported tonreported cases were not available.

.4. Health infrastructure and economicxpenditure on health in India

etails on the health infrastructure, utilisation of healthervices, urban—rural differences and gender variations inndia were derived from the National Family Health Survey2005—2006), the National Sample Survey Report 52ndound, 1995—1996 (National Sample Survey Organization,998), the Report of the Commission on Macroeconomicsnd Health (National Commission on Macroeconomics andealth, 2005), the National Health Accounts (Nationalealth Accounts India, 2001—2002) and from relevant pub-

ications of the National Council For Applied Economicesearch (NCAER) household survey (Duraisamy, 2001). Aearch for economic models of the health system in Indian leading economic journals and international journals onealth policy and management was carried out. Studies onhe economic impact of dengue on the population, healthystems and at the family level from Southeast Asia andouth America were also retrieved.

. Key assumptions

.1. Dengue epidemiology

o reflect the economic burden of dengue in India and toxtrapolate the limited data available, some key assump-ions were made. With regard to dengue epidemiology inndia, assumptions were made from the published literatureTable 1). Since there were no data from India to account fornreported cases, multiplication factors from earlier pub-ished literature from Southeast Asia and South Americaere used, as suggested by the WHO (Anez et al., 2006;lark et al., 2005; Suaya et al., 2006). Furthermore, basedn recent data from Thailand, a ratio of 1:4 was used to

etermine the proportion of reported cases requiring hospi-al admission (Anderson et al., 2007) (Table 1).

Overall, dengue was assumed to affect both sexesqually, although some studies have reported a male pre-ominance (Kishore et al., 2006; Vijaykumar et al., 2005).

572 P. Garg et al.

Table 1 Average range of major uncertain variables considered in the sensitivity analysis

Uncertain variable Rangea Source

Unreported to reported cases (multiplicationfactor)

10—27 Clark et al. (2005); Suaya et al.(2006)

Ambulatory to hospitalised cases(multiplication factor)

4—10 Anderson et al. (2007)

Proportion of cases who are children aged <15years (%)

10—30 Hati (2006)

Proportion of cases at tertiary care needingintensive care (%)

2.5—20b Chandralekha et al. (2008); Kamathand Ranjit (2006); Walia et al. (1999)

Proportion of hospitalised patients needingtransfusion (%)

10—30 Chaudhury et al. (2006); Kumar et al.(2000); Makroo et al. (2007)

Loss of workdaysc 2.2—5.8 Duraisamy (2001)Loss of productive years due to deaths 10—30 EstimateOutpatient visit cost (US$) 0.75—4.0d Sundar and Sharma (2002)a Data derived from published literature (minimum to maximum estimates).b A higher maximum was estimated than that reported, as recent dengue epidemics are reported to have a higher proportion of severecases.

arch

h faci

Tiai2hiS(ofaMieTaosr

3

Fpltttaetooc

r

UbmBflp

3e

T11aNSp(Imv2

hassd6

∑

c Data derived from the National Council for Applied Economic Rese2001).d Maximum outpatient visit may cost up to US$10, but such healt

he age group affected by dengue has varied across regionsn India. At present it is predominantly a disease of youngdults (21—30 years, median 30—35 years), and an increas-ng proportion of infections are secondary in nature (Hati,006; Vijaykumar et al., 2005). The proportion of childrenas been variable between 10% and 30% in almost all stud-es (Vijaykumar et al., 2005). However, in some studies fromouth India, children <15 years were affected predominantlyHoti et al., 2006; Kabilan et al., 2005). The proportionf patients needing platelet transfusions for dengue variesrom 11.3% to 40%, with almost 10% being given inappropri-te transfusions (Chaudhury et al., 2006; Kumar et al., 2000;akroo et al., 2007). The proportion of patients needing

ntensive care also varies from 2.5% to 12% (Chandralekhat al., 2008; Kamath and Ranjit, 2006; Walia et al., 1999).he exact proportion of severe cases is difficult to determines most studies are hospital-based, with a selection bias ofnly severe cases being hospitalised. Therefore, the ratio ofevere and non-severe cases was assumed to be close to theatio of hospitalised to ambulatory cases.

.2. Cost of investigations and transfusions

or public health sector patients, a sum of US$25 was com-uted to be added per managed case for dengue serology,iver function tests, complete blood counts and other inves-igations, assuming that all hospitalised cases underwenthese investigations. This figure was computed by addinghe approximate costs of each test from the existing costnalysis studies in the public health sector of India (Krishnant al., 2004; Misra and Sharma, 1999). For the private sec-or, the costs of investigations and transfusions incurred in

ur series of 49 patients were utilised. Also, certainty inur costs was obtained by assessing costs of investigationsharged by two private laboratories in the same region.

The cost of a platelet and plasma transfusion for patientsequiring transfusions at a pubic hospital was assumed to be

wl

(fever of all aetiologies, not specific to dengue fever) (Duraisamy,

lities are a very small proportion.

S$150. This was based on costs reported by a non-profitlood bank providing free blood components to a govern-ent medical school hospital in South India (Jeevan Bloodank and Research Centre; http://jeevan.org). Unit costsor intensive care were assumed as those calculated ear-ier for a neurosurgical intensive care unit in a tertiary-levelublic hospital (Singh et al., 2006).

.3. Mortality due to dengue and potential loss ofconomic productive years

he case fatality rate from dengue varies from 1.5% to0.9% across different regions in India (Agarwal et al.,999; Daniel et al., 2005; Gupta et al., 2006; Kabilan etl., 2005; Kamath and Ranjit, 2006; Kumar et al., 2001;ational Vector Borne Disease Control Programme, 2007;ingh et al., 2005; Walia et al., 1999). However, for theresent work the death rate was considered to be 1.5%184/12 317) as reported by the NVBDCP for the 2006 denguendian epidemic. It is reasonable to assume that 50—70% ofortality would be in public sector hospitals as these ser-

ices cater to lower income quintiles (Sundar and Sharma,002).

Potential life-years of economic productive loss will beighly complex and vary widely across regions. However,n average loss of 10—30 years was presumed as a rea-onable estimate. This figure was also obtained using atandard formula and considering average age at deathue to dengue to be 30 years and life expectancy to be5 years:

dx(L − x), (x = 0 to x = 1),

here dx is deaths at age x and L is the potential limit toife (Murray, 1994).

Economic burden of dengue 573

Table 2 Sensitivity analysis using a regression model to study the effect of uncertain assumptions on total cost (r2 = 0.91)

Uncertain variable Estimated mean differencea 95% CI Standardised coefficient t P-value

Unreported to reported cases 18.57 17.56—19.59 0.67 36 <0.001*

Proportion of children −0.38 −1.4 to 0.63 −0.01 −0.75 0.46Hospitalised to ambulatory

ratio17.33 16.3—18.3 0.63 33.58 <0.001*

Proportion needing intensivecare admission

1.32 0.31—2.34 0.05 2.57 0.011*

Proportion needing transfusion 0.15 −0.87 to 1.17 0.01 0.29 0.77Loss of workdays 1.54 0.53—2.56 0.06 2.99 0.003*

Loss of economic productiveyears due to deaths

7.15 6.13—8.16 0.26 13.85 <0.001*

Outpatient cost 1.04 0.02—2.05 0.04 2.01 0.05

een t

ae

3

Tvwwcswt(tt

4

Tta(TeatamoisttpM

a This column reports the difference in total calculated cost betwin Table 1).* Statistically significant.

3.4. Loss of workdays

Estimates on loss of workdays for fever of any aetiology fromIndia are available from the working paper No. 78 publishedby the NCAER (2.2—5.8 days) (Duraisamy, 2001).

3.5. Economic loss due to loss of workdays

An economic loss of US$3/day at a public sector hospital andUS$10/day in the private sector was assumed consideringthe average per capital income in India for 2005 (Sundarand Sharma, 2002; World Bank, 2007).

3.6. Health infrastructure

The split for utilisation of services between primary,secondary and tertiary care sectors is reported to be48.1% and 24.1%, 15.1% and 60%, and 21% and 19% in thepublic and private health sectors, respectively (NationalHealth Accounts India, 2001—2002). Private doctors andclinics and nursing homes provide inpatient care to almostthree-quarters of patients seeking care in the health sectorin India at approximately two-thirds to one-half of thecost at larger tertiary hospitals (Bhat, 1996; NationalCommission on Macroeconomics and Health, 2005; Purohit,2001). The cost of utilisation of outpatient services alsovaries across the quintiles of income, with the lowestamounting to approximately US$0.5/visit to US$1.5/visitamong higher quintiles both in private and public healthsectors. Utilisation of private and public health servicesacross the lower quintiles remains at 30—45% but risesin favour of private sector utilisation to almost 70%among higher income quintiles (National Sample SurveyOrganization, 1998; Sundar and Sharma, 2002). Ninety-eightpercent of expenditure in the private health sector is inthe form of out-of pocket payments (Devadasan and Van

Damme, 2006; National Health Accounts India, 2001—2002;Roy and Howard, 2007). Provider costs in public sectorhospitals have been calculated at different levels of careas US$1.5/outpatient visit in primary care adjusted forinflation, to US$9.1/day and US$23/day for inpatient care

vwiU(

he maximum and minimum reported values of the variable (given

t secondary and tertiary level care, respectively (Anandt al., 1993; Krishnan et al., 2004, 2005).

.7. Sensitivity analysis

o have confidence in the cost analysis and the effect ofarious uncertain variables on costs, a regression modelas formed adjusting for all covariates. Separate equationsere derived accounting for all the uncertain variables foralculation of cost expenditure at the public and privateector hospitals. For the purpose of modelling, all variablesere re-coded into dummy variables to enable estima-

ion of the impact of variation in individual assumptionsbetween the minimum and maximum reported values) onhe total costs. SPSS for Windows (SPSS Inc.) was used forhe statistical analysis.

. Results

he average total economic burden adjusting for all poten-ial variables likely to influence the costs both at privatend public sector hospitals was estimated as US$27.4 million95% CI US$25.7—29.1 million, range US$9.2—57.7 million).he average burden at private and public sector levels wasstimated at US$21.7 million (95% CI US$20.2—23.1 million)nd US$5.7 million (95% CI US$5.39—5.98 million), respec-ively. Tables 1 and 2 show the variables with variationsnd the results of sensitivity analysis using a regressionodel, respectively. Tables 3 and 4 indicate the number

f reported cases and deaths and the costs of managementn our cohort of hospitalised patients, respectively. Table 5hows the baseline characteristics and clinical profiles ofhe 49 hospitalised dengue patients studied by us duringhe dengue epidemic of 2006. The median cost incurreder managed patient was US$432.2 (95% CI US$343.6—625).edian fixed (infrastructure, electricity, water, etc.) and

ariable (disposables, doctors, investigations, etc.) costsere US$233.3 and US$182.4, respectively. Median costs

ncurred for patients admitted to an intensive care unit wereS$643.6 (95% CI US$463.5—758.1) compared with US$341.9

95% CI US$285.44—452.95) for a patient managed in a ward

574

Table 3 Number of cases of dengue for 2006 assumed forcalculations (minimum to maximum estimates)

Reported dengue cases (2006)a 12 317Total no. estimated (multiplication factor

10—27)123 170—332 559

Private health sector (58%) 71 438—192 884Public health sector (42%) 51 732—139 675No. of ambulatory patients (estimated

ambulatory/hospitalised ratio 4:1 to10:1)

98 536—302 326

Reported deaths (2006)a 184a Source: National Vector Borne Disease Control Programme(2007).

Table 4 Cost estimates for management of denguepatients in the private sector of health care

Item Cost (US$)a

Investigations 70Complete blood count 5Dengue serology 25Liver function tests 10Othersb 30

Drugs 110Antibiotics 40Fluids 60Others 10

Disposables 50Physicians 80Room charges 100a Smaller hospitals will charge two-thirds of the costs incurredat larger hospitals.b Includes kidney function, repeated platelet count measure-ments, coagulation profile, blood culture, etc.

Table 5 Baseline characteristics and clinical profile of hos-pitalised dengue patients (N = 49)

Variable n (%)a

Median age (years) (range) 25.5 (8—82)Male:female ratio 2.3:1

Dengue serologyIgM-positive 11 (22.4)IgM- and IgG-positive 38 (77.6)

Diagnostic categoryDengue 22 (44.9)Dengue haemorrhagic fever (grade I/II) 11 (22.4)Dengue shock syndrome 16 (32.7)

Platelet transfusion 12 (24.5)Intensive care admissionb 21 (42.9)Median duration of stay (days) (range) 4 (3—5)a Data are n (%) unless otherwise stated.b Median stay 1.5 days.

scco

5

Wdrtlpdi

sream

pmefoOoctelra7a(hsho

tctamcapda2

5

FiId

P. Garg et al.

etting (P = 0.01). Figures 1 and 2 show a model of costalculations at private and public sectors of care using cal-ulation values within the maximum and minimum estimatesf uncertain variables.

. Discussion

e estimate the total economic burden of the 2006 Indianengue epidemic to be approximately US$27.4 million. Theange was noted to be US$9.2—57.7 million depending uponhe various uncertain estimations. These estimates includeoss of workdays and productivity owing to the illness androvide an economic and financial context to the previouslyescribed clinical aspects of this expanding health problemn South Asia.

Some aspects of the economic impact of dengue on healthystems, populations and families have been previouslyeported in Southeast Asia and South America (Andersont al., 2007; Anez et al., 2006; Clark et al., 2005; Harvingnd Ronsholt, 2007; Torres and Castro, 2007). However, esti-ates from South Asia have so far been poorly documented.The total economic burden of dengue in the private and

ublic health sectors in India was estimated at US$21.7illion and US$5.7 million, respectively, for the dengue

pidemic of 2006. This value did not include costs incurredor transportation, food or economic loss due to simultane-us affliction of multiple family members (Figures 1 and 2).ur estimates of burden are similar to those reported fromther regions (Kouri et al., 1989; Meltzer et al., 1998). Thisan be explained by the similar multiplication factor usedo account for unreported cases (Meltzer et al., 1998). Thepidemiology of dengue in India as noted from the publishediterature appears to be different from the South Easternegion. Thus, several of our assumptions for calculationsre different from other regions, such as in Thailand where0—75% of patients are reported to be 5—14 years of agend the average age of death has been noted as 10 yearsClark et al., 2005). The economic burden in the privateealth sector was almost four times that in the publicector, reiterating the cost ineffectiveness of the privateealth sector as well as the predominant private expansionf services (Purohit, 2001).

Sensitivity analysis using a regression model revealed thathe variations in the proportion of unreported to reportedases, the ratio of ambulatory to hospitalised cases andhe average loss of economic productive years would have

large impact on the total economic burden. Further-ore, variations in loss of economic workdays, outpatient

osts and proportion of patients needing intensive care willccount for small variations in costs. The proportion ofatients needing transfusion and the proportion of childrenid not affect the estimated costs (Table 2). We obtainednticipated results in the sensitivity analysis (Suaya et al.,006).

.1. Strengths of the study

irst, our report is an initial attempt to quantify the grow-ng economic consequences of regular dengue epidemics inndia. We have estimated that on a macro level, althoughengue could not be ascribed the same burden as tubercu-

Economic burden of dengue 575

Figure 1 Estimate of the economic burden of dengue incurred in the private sector of India. a Costs two-thirds that incurred atlarger hospitals (median stay 4 days). b Twenty-five percent of total hospitalised patients assumed to be children. c One to threevisits and average medication (paracetamol only) US$0.75/patient included. d US$3650/year loss. e These costs are calculated ifthe multiplication factor for unreported cases is 10 and the ratio of ambulatory to hospitalised patients is 4:1.

Figure 2 Estimate of the economic burden of dengue incurred in the public sector of India. a US$9.1/day for secondaryand US$23/day for tertiary (median duration of stay 4 days), US$25 added for investigations, US$150 for platelet transfusions.b Twenty-five percent of total hospitalisations assumed to be children. c Assumed 10% required platelet/plasma transfusion.d US$61.4 = [(9.1 × 4) + 25]; US$211.4 = (61.4 + 150); US$117 = [(23 × 4) + 25]; US$267 = (117 + 150). e US$1095/year and assumingaverage 20 years of productive life lost. f One to three outpatient visits. g Higher range calculated if 10% need intensive care atpublic sector hospital for a mean duration of 2 days/patient. h These costs are calculated if the multiplication factor for unreportedcases is 10 and the ratio of ambulatory to hospitalised patients is 4:1. MUS$: million US$; OPD: outpatient department.

5

lt

ma

ammIia

ednshe

5

WIptoA2ameOptvatfwmo(

aiedl

cpea(

da

ao

thtswinhfisf

6

OctTdrcndlme

Asjtgcthfi

ADRfMc

F

C

E

R

A

76

osis and malaria, it is still a growing economic burden withinhe country.

Second, we performed sensitivity analyses to account forany of the potentially uncertain variables and thus evalu-

ted their affect on total costs.Third, we calculated the economic burden both at public

nd private sector hospitals and thus took into account theajor health providers in India. We also made some adjust-ents for the heterogeneity in the private health sector in

ndia by taking into consideration the likely costs incurredn smaller private health facilities (nursing homes) as wells larger specialised tertiary-level corporate hospitals.

Fourth, we gained some insight into the out-of-pocketxpenditure incurred by patients hospitalised with dengueuring a dengue epidemic, as 41 (84%) of our patients wereot insured and made out-of-pocket payments. Although oureries of patients is small, the quality of data on costs isigh as all the information was captured from the hospital’slectronic receipts database system.

.2. Limitations of the study

e faced some challenges in estimating costs for dengue inndia, as discussed below. The first and main challenge wasossible underreporting of dengue cases and working outhe exact split in numbers of patients seen in an ambulatoryr hospitalised setting. We had to use data from Southeastsian and South American countries as a guide (Anez et al.,006; Clark et al., 2005) because there were no data avail-ble for India to make such estimates. We used a maximumultiplication factor of 27 as has been suggested in the sci-

ntific report of the WHO on dengue (Suaya et al., 2006).ne may argue about the applicability of the use of a multi-lication factor from other regions to India, but consideringhe poor laboratory facilities and utilisation of health ser-ices in India, especially among the lower income quintiles,s well as the media reports of gross underreporting in Indiahis may be a reasonable estimate. Similarly, to accountor the proportion of ambulatory to hospitalised patientse used a minimum estimate of 4:1 to an arbitrary maxi-um value of 10:1. The impact of these uncertain factors

n total costs can be easily seen from the sensitivity analysisTable 2).

Second, for assessing the burden of dengue, disability-djusted life-years (DALY), a non-monetary economicndicator, has been described as a standard measure (Lopezt al., 2006). However, because of a lack of estimates onisability weights for dengue patients in India, these calcu-ations could not be done by us (Zaidi et al., 2004).

Third, health cost calculations in India pose a particularhallenge owing to poor networking and integration of therivate and public sectors of health care and marked het-rogeneity within the private heath sector as well as urbannd rural and interregional and intraregional differencesPurohit, 2001; Zaidi et al., 2004).

Fourth, we did not highlight interstate and interregional

ifferences and future studies should further explore thesespects.

Finally, for calculating indirect costs, we took intoccount only workdays lost by hospitalised patients and lossf economically productive years due to deaths. It is likely

A

P. Garg et al.

hat many economically productive family members of theospitalised patient may also have missed work, adding tohe total economic burden. A comprehensive communityurvey during and immediately following a dengue epidemicould have allowed us to get a more accurate estimate of

ndirect costs such as transportation and food and simulta-eous affliction of family members. This would also haveelped in determining the economic impact of dengue at aamily and population level using internationally acceptedndicators such as DALY. However, we could not do such aurvey owing to logistic and practical issues and studies inuture should attempt to explore these aspects.

. Conclusions

ur estimates of cost during a dengue epidemic suggest thatonsiderable economic losses are borne by developing coun-ries like India owing to a single preventable viral disease.here may be huge variations in the total economic bur-en on a macro level in India depending upon the number ofeported to unreported cases and hospitalised to ambulatoryases. Accurate calculations of these variables are urgentlyeeded to be more certain of the exact economic burden ofengue in India. This has immense implications for India’simited health budget and financial resource availability foranaging other communicable and non-communicable dis-

ases.

uthors’ contributions: PG and SLS conceptualised thetudy; PG and PK collected the data; PG and JN hadoint sessions of manuscript writing and data interpreta-ion; JN was critical in drafting the manuscript and inuiding the economic considerations in India; JN and PGarried out the statistical analysis; SLS critically appraisedhe manuscript, contributed to the intellectual content andelped in drafting the manuscript. All authors approved thenal manuscript. PG is guarantor of the paper.

cknowledgements: The authors acknowledge the help ofr Vibha Gupta, Managing Director, Central Hospital andesearch Centre, Faridabad, Haryana, for giving permissionor data collection and to conduct the study; and Mr S.S.allik, Medical Records Department, for help in retrieval ofase records.

unding: None.

onflicts of interest: None declared.

thical approval: Not required.

eferences

garwal, R., Kapoor, S., Nagar, R., Misra, A., Tandon, R., Mathur, A.,Misra, A.K., Srivastava, K.L., Chaturvedi, U.C., 1999. A clinicalstudy of patients with dengue hemorrhagic fever during the epi-

demic of 1996 at Lucknow, India. Southeast Asian J. Trop. Med.Public Health 30, 735—740.

nand, K., Kapoor, S.K., Pandav, C.S., 1993. Cost analysis of a pri-mary health centre in northern India. Natl. Med. J. India 6,160—163.

K

L

M

M

M

M

M

N

N

N

N

N

P

R

S

S

S

S

T

V

W

W

Economic burden of dengue

Anderson, K.B., Chunsuttiwat, S., Nisalak, A., Mammen, M.P.,Libraty, D.H., Rothman, A.L., Green, S., Vaughan, D.W., Ennis,F.A., Endy, T.P., 2007. Burden of symptomatic dengue infectionin children at a primary school in Thailand: a prospective study.Lancet 369, 1452—1459.

Anez, G., Balza, R., Valero, N., Larreal, Y., 2006. Economic impactof dengue and dengue hemorrhagic fever in the State of Zulia,Venezuela, 1997—2003. Rev. Panam. Salud Publica 19, 314—320.

Bhat, R., 1996. Regulation of the private health sector in India. Int.J. Health Plann. Manage. 11, 253—274.

Chandralekha, Gupta, P., Trikha, A., 2008. The north Indian dengueoutbreak 2006: a retrospective analysis of intensive care admis-sions in a tertiary care hospital. Trans. R. Soc. Trop. Med. Hyg.102, 143—147.

Chaudhury, R., Khetan, D., Sinha, S., Sinha, P., Sonker, A., Pandey,P., Das, S.S., Agarwal, P., Ray, V., 2006. Transfusion support todengue patients in a hospital based blood transfusion service innorth India. Transfus. Apher. Sci. 35, 239—244.

Clark, D.V., Mammen Jr, M.P., Nisalek, A., Puthimethee, V., Endy,T.P., 2005. Economic impact of dengue fever/dengue hemor-rhagic fever in Thailand at the family and population levels. Am.J. Trop. Med. Hyg. 72, 786—791.

Daniel, R., Rajamohanan, Philip, A.Z., 2005. A study of clinical pro-file of dengue fever in Kollam, Kerala, India. Dengue Bull. 29,197—202.

Devadasan, N., Van Damme, W., 2006. Payments for health care inIndia. Lancet 368, 2209.

Duraisamy, P., 2001. Health Status and Curative Health Care inIndia. Working Paper 78. National Council for Applied EconomicResearch (NCAER), New Delhi, India.

Guha-Sapir, D., Schimmer, B., 2005. Dengue fever: new paradigmsfor a changing epidemiology. Emerg. Themes Epidemiol. 2, 1.

Gupta, E., Dar, L., Kapoor, G., Broor, S., 2006. The changing epi-demiology of dengue in Delhi, India. Virol. J. 3, 92.

Halstead, S.B., Suaya, J.A., Shephard, D.S., 2007. The burden ofdengue infection. Lancet 369, 1410—1411.

Harving, M.L., Ronsholt, F.F., 2007. The economic impact of denguehemorrhagic fever on family level in Southern Vietnam. Dan.Med. Bull. 54, 170—172.

Hati, A.K., 2006. Studies on dengue and dengue hemorrhagic fever(DHF) in West Bengal state, India. J. Commun. 38, 124—129.

Hoti, S.L., Soundravally, R., Rajendran, G., Das, L.K., Ravi, R.,Das, P.K., 2006. Dengue and dengue hemorrhagic fever outbreakin Pondicherry, South India, during 2003—2004: emergence ofDENV-3. Dengue Bull. 30, 42—50.

Kabilan, L., Balasubramanian, S., Keshava, S.M., Satyanarayanan,K., 2005. The 2001 dengue epidemic in Chennai, Indian. J. Pedi-atr. 72, 919—923.

Kamath, S.R., Ranjit, S., 2006. Clinical features, complications, andatypical manifestations of children with severe forms of denguehemorrhagic fever in South India. Indian J. Pediatr. 73, 889—895.

Kishore, J., Singh, J., Dhole, T.N., Ayyagiri, A., 2006. Clinical andserological study of first large epidemic of dengue in and aroundLucknow, India, in 2003. Dengue Bull. 30, 72—79.

Kouri, G.P., Guzman, M.G., Bravo, J.R., Triana, C., 1989. Denguehemorrhagic fever/dengue shock syndrome: lessons from theCuban epidemic, 1981. Bull. World Health Organ. 67, 375—380.

Krishnan, A., Sahariah, S.U., Kapoor, S.K., 2004. Cost of epilepsy inpatients attending a secondary-level hospital in India. Epilepsia45, 289—291.

Krishnan, A., Arora, N.K., Pandav, C.S., Kapoor, S.K., 2005. Cost of

pediatric curative services in a public health care setting. IndianJ. Pediatr. 72, 657—660.

Kumar, N.D., Tomar, V., Singh, B., Kela, K., 2000. Platelet trans-fusion practice during dengue fever epidemic. Indian J. Pathol.Microbiol. 43, 55—60.

Z

577

umar, A., Sharma, S.K., Padbidri, B.S., Thakare, J.P., Jain, D.C.,Datta, K.K., 2001. An outbreak of dengue in rural areas of northIndia. J. Commun. Dis. 33, 274—281.

opez, A.D., Mathers, C.D., Ezzati, M., Jamison, D.T., Murray,C.J.L., 2006. Global Burden of Disease and Risk Factors. OxfordUniversity Press/World Bank, New York.

akroo, R.N., Raina, V., Kumar, P., Kanth, R.K., 2007. Role ofplatelet transfusion in the management of dengue in a tertiarycare hospital. Asian J. Transf. Sci. 1, 4—7.

eltzer, M.I., Rigua-Perez, J.G., Clark, G.G., Reiter, P., Gubler,D.G., 1998. Using disability-adjusted life years to assess the eco-nomic impact of dengue in Puerto Rico: 1984—1994. Am. J. Trop.Med. Hyg. 59, 265—271.

isra, V., Sharma, A.K., 1999. The need for cost-effective protocolsfor laboratory investigations. Natl. Med. J. India 12, 248.

udur, G., 2006. Failure to control mosquitoes has led to two feverepidemics in India. BMJ 333, 773.

urray, C.J.L., 1994. Quantifying the burden of disease: the tech-nical basis for disability-adjusted life years. Bull. World HealthOrgan. 72, 429—445.

ational Commission on Macroeconomics Health, 2005. Financingand Delivery of Health Care Services in India. Background papersof the NCMH. Ministry of Health and Family Welfare, Governmentof India, New Delhi, India.

ational Family Health Survey, 2005—2006. National Report NFHS-3. Indian Institute of Population Sciences, Macros ORS, Mumbai,India.

ational Health Accounts India, 2001—2002. National HealthAccount Cells. Ministry of Health and Family Welfare, Govern-ment of India, New Delhi, India.

ational Sample Survey Organization, 1998. Morbidity and Treat-ment of Ailments. National Sample Survey 52nd Round,1995—1996. Ministry of Statistics and Program Implementation,Government of India, New Delhi, India.

ational Vector Borne Disease Control Programme, 2007. DengueCases and Deaths Since 2001. Ministry of Health and Family Wel-fare, Government of India, New Delhi, India.

urohit, B.C., 2001. Private initiatives and policy options: recenthealth system experience in India. Health Policy Plan. 16,87—97.

oy, K., Howard, D.H., 2007. Equity in out-of-pocket payments forhospital care: evidence from India. Health Policy 80, 297—307.

ingh, N.P., Jhamb, R., Agarwal, S.K., Gaiha, M., Dewan, R., Daga,M.K., Chakravarti, A., Kumar, S., 2005. The 2003 outbreak ofdengue in India. Southeast Asian J. Trop. Med. Public Health 36,1174—1178.

ingh, M., Vaishya, S., Gupta, S., Mehta, V.S., 2006. Economics ofhead injuries. Neurol. India 54, 78—80.

uaya, J.A., Shephard, D.S., Beathy, M.E., 2006. Dengue: burdenof disease and cost of illness. Working Paper 3.2. Report of theScientific Working Group on Dengue. World Health Organization,Geneva.

undar, R., Sharma, A., 2002. Morbidity and utilisation of healthcareservices. Econ. Polit. Wkly 37, 4729—4740.

orres, J.R., Castro, J., 2007. The health and economic impactof dengue in Latin America. Cad. Saude Publica 23 (Suppl. 1),S23—S31.

ijaykumar, T.S., Chandy, S., Narayanan, S., Abraham, M., Abra-ham, P., Gopalan, S., 2005. Is dengue emerging as a major publichealth problem? Indian J. Med. Res. 121, 100—107.

alia, J.P., Biswas, A., Handa, R., Aggarwal, P., Wig, N., Dwivedi,S.N., 1999. Dengue hemorrhagic fever in adults: a prospectivestudy of 110 cases. Trop. Doct. 29, 27—30.

orld Bank, 2007. World Development Indicators Database.

GNI Per Capita Income, 2006. http://siteresources.worldbank.org/DATASTATISTICS/Resources/GNIPC.pdf [accessed 23 October2007].

aidi, A.K.M., Awasthi, S., deSilva, H.J., 2004. Burden of infectiousdiseases in South Asia. BMJ 328, 811—815.