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Dengue infections are a significant cause of morbidity and mortality and lead to adverse economic effects in many developing tropical countries. In this study, we estimated the economic burden faced by India during the 2006 dengue epidemic. Costs incurred in managing a cohort of serologically confirmed dengue patients at a tertiary-level private hospital in north India were calculated. The median cost of treatment per hospitalised dengue patient was US$432.2 (95% CI US$343.6-625). A sensitivity analysis was performed to estimate the costs to the 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 and deaths, 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) are incurred by developing countries like India during each dengue epidemic. Accurate estimates of the proportions of reported to unreported and of hospitalised to ambulatory dengue cases in India are needed to refine further the estimates of financial burden due to dengue in India.
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Transactions of the Royal Society of Tropical Medicine and Hygiene (2008) 102, 570—577
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/trst
Economic burden of dengue infections in India
Pankaj Garga,b,, Jitender Nagpalb, Prakash Khairnarc,
Suranjith L. Seneviratned
aDepartment of Pediatrics, Central Hospital and Research Centre, 69, Sector 20A, Faridabad, Haryana,
National Capital Region, India
bDepartment of Pediatrics and Clinical Epidemiology, Sitaram Bhartia Institute of Science and Research,
B-16, Qutub Institutional Area, New Delhi 110016, India
cDepartment of Critical Care, Artemis Hospital, Sector 51, Gurgaon, India
dDepartment of Clinical Immunology, Imperial College AHSC, St Mary’s Hospital, Praed Street, London W2 1NY, UK
Received 29 October 2007; received in revised form 19 February 2008; accepted 19 February 2008
Available online 9 April 2008
KEYWORDS
Dengue;
Economic burden;
Costs;
Healthcare costs;
India
Summary Dengue infections are a significant cause of morbidity and mortality and lead to
adverse economic effects in many developing tropical countries. In this study, we estimated
the 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 in
north India were calculated. The median cost of treatment per hospitalised dengue patient was
US$432.2 (95% CI US$343.6—625). A sensitivity analysis was performed to estimate the costs to
the 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 and
deaths, were used. The average total economic burden was estimated to be US$27.4 million
(95% CI US$25.7—29.1 million). Costs in the private heath sector were estimated to be almost
four times public sector expenditures. Considerable economic losses (at a macro level) are
incurred by developing countries like India during each dengue epidemic. Accurate estimates
of the proportions of reported to unreported and of hospitalised to ambulatory dengue cases in
India are needed to refine further the estimates of financial burden due to dengue in India.
© 2008 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights
reserved.
Corresponding author. Present address: Department of Pediatrics
and Clinical Epidemiology, Sitaram Bhartia Institute of Science and
Research, B-16, Qutub Institutional Area, New Delhi 110016, India.
Tel.: +91 11 4054 0110; fax: +91 11 2653 3027.
E-mail addresses: pankajparul8@rediffmail.com,pankaj.garg
@sitarambhartia.org (P. Garg).
1. Introduction
Dengue infections are an important global public health
problem and an increasing number of people from the South
Asian region have been directly or indirectly affected by
dengue (Guha-Sapir and Schimmer, 2005). Although the clin-
ical patterns of dengue infection in South Asia have been
described, estimates of its economic and social burden
0035-9203/$ — see front matter © 2008 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.trstmh.2008.02.015
Economic burden of dengue 571
are poorly documented (Guha-Sapir and Schimmer, 2005;
Halstead et al., 2007).
In 2006, many states in India suffered a major dengue
epidemic that strained the already stretched healthcare sys-
tem in India (Mudur, 2006). Estimates of costs incurred in
India during such dengue epidemics are lacking. This may in
part be related to the multiplicity of healthcare providers
(public sector 42—52% and private sector 48—58%) and the
largely 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 health
sectors in India. Such cost information is needed for appro-
priate allocation of scarce health resources for a single
infectious disease.
2. Methods and materials
2.1. Dengue in India
A literature search of several databases (Old Medline
1950—1965, Medline 1966—June 2007, EMBASE, PsycINFO
and WHOLIS) was performed using the keywords ‘Dengue’
and ‘India’ and ‘DHF’ or ‘Dengue hemorrhagic fever’. A
total of 267 and 164 citations were extracted from Medline
and EMBASE; cross-references were searched and impor-
tant studies were collected in full text. Websites of the
WHO, the National Vector Borne Disease Control Programme
(NVBDCP) (http://www.nvbdcp.gov.in), the National Insti-
tute of Communicable Diseases (http://www.nicd.org) and
the Ministry of Health and Family Welfare, Government of
India, were searched for publications and information on
dengue and dengue haemorrhagic fever (DHF) from India. In
addition, all articles originating from India and published
in Dengue Bulletin were retrieved. Relevant studies and
data 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 the
present evaluation, we focused only on studies highlighting
the clinical-epidemiological and haematological profile in
the third epoch (1996—2007). Studies on virological, serolog-
ical and entomological investigations were not considered
relevant for the economic evaluation to the health system.
2.2. Data on hospitalised patients at a single
hospital during a dengue epidemic, 2006
Patients hospitalised at a tertiary private hospital in North
India from September—November 2006 with serologically
confirmed acute dengue infection were studied. Standard
WHO dengue classification criteria and IgM and IgG serolog-
ical testing were used. Demographic and clinical findings in
each patient were recorded on a standardised pro forma.
Total patient expenditure was calculated in these
patients 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
value (95% CI) was used for unit costs because of the skewed
nature of the data.
Furthermore, the cost patterns charged by two private
nursing homes in the region running for more than 10 years
were studied to determine inpatient costs in the private sec-
tor at the secondary level of care. Average costs charged
were noted to be almost two-thirds of the expenses at the
tertiary private hospital.
2.3. Data on dengue cases and deaths during the
2006 dengue epidemic in India
The total number of reported dengue cases during the 2006
Indian dengue epidemic was obtained from the Indian NVB-
DCP (National Vector Borne Disease Control Programme,
2007). Data on age- and gender-specific cases and deaths,
the proportion of DHF grade III/IV, and national data on
hospitalisation versus ambulatory cases and on reported to
unreported cases were not available.
2.4. Health infrastructure and economic
expenditure on health in India
Details on the health infrastructure, utilisation of health
services, urban—rural differences and gender variations in
India were derived from the National Family Health Survey
(2005—2006), the National Sample Survey Report 52nd
round, 1995—1996 (National Sample Survey Organization,
1998), the Report of the Commission on Macroeconomics
and Health (National Commission on Macroeconomics and
Health, 2005), the National Health Accounts (National
Health Accounts India, 2001—2002) and from relevant pub-
lications of the National Council For Applied Economic
Research (NCAER) household survey (Duraisamy, 2001). A
search for economic models of the health system in India
in leading economic journals and international journals on
health policy and management was carried out. Studies on
the economic impact of dengue on the population, health
systems and at the family level from Southeast Asia and
South America were also retrieved.
3. Key assumptions
3.1. Dengue epidemiology
To reflect the economic burden of dengue in India and to
extrapolate the limited data available, some key assump-
tions were made. With regard to dengue epidemiology in
India, assumptions were made from the published literature
(Table 1). Since there were no data from India to account for
unreported cases, multiplication factors from earlier pub-
lished literature from Southeast Asia and South America
were used, as suggested by the WHO (Anez et al., 2006;
Clark et al., 2005; Suaya et al., 2006). Furthermore, based
on recent data from Thailand, a ratio of 1:4 was used to
determine the proportion of reported cases requiring hospi-
tal admission (Anderson et al., 2007)(Table 1).
Overall, dengue was assumed to affect both sexes
equally, although some studies have reported a male pre-
dominance (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 RangeaSource
Unreported to reported cases (multiplication
factor)
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 <15
years (%)
10—30 Hati (2006)
Proportion of cases at tertiary care needing
intensive care (%)
2.5—20bChandralekha et al. (2008);Kamath
and Ranjit (2006);Walia et al. (1999)
Proportion of hospitalised patients needing
transfusion (%)
10—30 Chaudhury et al. (2006);Kumar et al.
(2000);Makroo et al. (2007)
Loss of workdaysc2.2—5.8 Duraisamy (2001)
Loss of productive years due to deaths 10—30 Estimate
Outpatient visit cost (US$) 0.75—4.0dSundar and Sharma (2002)
aData derived from published literature (minimum to maximum estimates).
bA higher maximum was estimated than that reported, as recent dengue epidemics are reported to have a higher proportion of severe
cases.
cData derived from the National Council for Applied Economic Research (fever of all aetiologies, not specific to dengue fever) (Duraisamy,
2001).
dMaximum outpatient visit may cost up to US$10, but such health facilities are a very small proportion.
The age group affected by dengue has varied across regions
in India. At present it is predominantly a disease of young
adults (21—30 years, median 30—35 years), and an increas-
ing proportion of infections are secondary in nature (Hati,
2006; Vijaykumar et al., 2005). The proportion of children
has been variable between 10% and 30% in almost all stud-
ies (Vijaykumar et al., 2005). However, in some studies from
South India, children <15 years were affected predominantly
(Hoti et al., 2006; Kabilan et al., 2005). The proportion
of patients needing platelet transfusions for dengue varies
from 11.3% to 40%, with almost 10% being given inappropri-
ate transfusions (Chaudhury et al., 2006; Kumar et al., 2000;
Makroo et al., 2007). The proportion of patients needing
intensive care also varies from 2.5% to 12% (Chandralekha
et al., 2008; Kamath and Ranjit, 2006; Walia et al., 1999).
The exact proportion of severe cases is difficult to determine
as most studies are hospital-based, with a selection bias of
only severe cases being hospitalised. Therefore, the ratio of
severe and non-severe cases was assumed to be close to the
ratio of hospitalised to ambulatory cases.
3.2. Cost of investigations and transfusions
For public health sector patients, a sum of US$25 was com-
puted to be added per managed case for dengue serology,
liver function tests, complete blood counts and other inves-
tigations, assuming that all hospitalised cases underwent
these investigations. This figure was computed by adding
the approximate costs of each test from the existing cost
analysis studies in the public health sector of India (Krishnan
et al., 2004; Misra and Sharma, 1999). For the private sec-
tor, the costs of investigations and transfusions incurred in
our series of 49 patients were utilised. Also, certainty in
our costs was obtained by assessing costs of investigations
charged by two private laboratories in the same region.
The cost of a platelet and plasma transfusion for patients
requiring transfusions at a pubic hospital was assumed to be
US$150. This was based on costs reported by a non-profit
blood bank providing free blood components to a govern-
ment medical school hospital in South India (Jeevan Blood
Bank and Research Centre; http://jeevan.org). Unit costs
for intensive care were assumed as those calculated ear-
lier for a neurosurgical intensive care unit in a tertiary-level
public hospital (Singh et al., 2006).
3.3. Mortality due to dengue and potential loss of
economic productive years
The case fatality rate from dengue varies from 1.5% to
10.9% across different regions in India (Agarwal et al.,
1999; Daniel et al., 2005; Gupta et al., 2006; Kabilan et
al., 2005; Kamath and Ranjit, 2006; Kumar et al., 2001;
National Vector Borne Disease Control Programme, 2007;
Singh et al., 2005; Walia et al., 1999). However, for the
present work the death rate was considered to be 1.5%
(184/12 317) as reported by the NVBDCP for the 2006 dengue
Indian epidemic. It is reasonable to assume that 50—70% of
mortality would be in public sector hospitals as these ser-
vices cater to lower income quintiles (Sundar and Sharma,
2002).
Potential life-years of economic productive loss will be
highly complex and vary widely across regions. However,
an average loss of 10—30 years was presumed as a rea-
sonable estimate. This figure was also obtained using a
standard formula and considering average age at death
due to dengue to be 30 years and life expectancy to be
65 years:
dx(Lx),(x=0tox=1),
where dxis deaths at age xand Lis the potential limit to
life (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 differencea95% CI Standardised coefficient tP-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 0.46
Hospitalised to ambulatory
ratio
17.33 16.3—18.3 0.63 33.58 <0.001*
Proportion needing intensive
care 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 0.77
Loss of workdays 1.54 0.53—2.56 0.06 2.99 0.003*
Loss of economic productive
years 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
aThis column reports the difference in total calculated cost between the maximum and minimum reported values of the variable (given
in Table 1).
*Statistically significant.
3.4. Loss of workdays
Estimates on loss of workdays for fever of any aetiology from
India are available from the working paper No. 78 published
by 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 and
US$10/day in the private sector was assumed considering
the average per capital income in India for 2005 (Sundar
and 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 be
48.1% and 24.1%, 15.1% and 60%, and 21% and 19% in the
public and private health sectors, respectively (National
Health Accounts India, 2001—2002). Private doctors and
clinics and nursing homes provide inpatient care to almost
three-quarters of patients seeking care in the health sector
in India at approximately two-thirds to one-half of the
cost at larger tertiary hospitals (Bhat, 1996; National
Commission on Macroeconomics and Health, 2005; Purohit,
2001). The cost of utilisation of outpatient services also
varies across the quintiles of income, with the lowest
amounting to approximately US$0.5/visit to US$1.5/visit
among higher quintiles both in private and public health
sectors. Utilisation of private and public health services
across the lower quintiles remains at 30—45% but rises
in favour of private sector utilisation to almost 70%
among higher income quintiles (National Sample Survey
Organization, 1998; Sundar and Sharma, 2002). Ninety-eight
percent of expenditure in the private health sector is in
the 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 sector
hospitals have been calculated at different levels of care
as US$1.5/outpatient visit in primary care adjusted for
inflation, to US$9.1/day and US$23/day for inpatient care
at secondary and tertiary level care, respectively (Anand
et al., 1993; Krishnan et al., 2004, 2005).
3.7. Sensitivity analysis
To have confidence in the cost analysis and the effect of
various uncertain variables on costs, a regression model
was formed adjusting for all covariates. Separate equations
were derived accounting for all the uncertain variables for
calculation of cost expenditure at the public and private
sector hospitals. For the purpose of modelling, all variables
were re-coded into dummy variables to enable estima-
tion of the impact of variation in individual assumptions
(between the minimum and maximum reported values) on
the total costs. SPSS for Windows (SPSS Inc.) was used for
the statistical analysis.
4. Results
The average total economic burden adjusting for all poten-
tial variables likely to influence the costs both at private
and public sector hospitals was estimated as US$27.4 million
(95% CI US$25.7—29.1 million, range US$9.2—57.7 million).
The average burden at private and public sector levels was
estimated at US$21.7 million (95% CI US$20.2—23.1 million)
and US$5.7 million (95% CI US$5.39—5.98 million), respec-
tively. Tables 1 and 2 show the variables with variations
and the results of sensitivity analysis using a regression
model, respectively. Tables 3 and 4 indicate the number
of reported cases and deaths and the costs of management
in our cohort of hospitalised patients, respectively. Table 5
shows the baseline characteristics and clinical profiles of
the 49 hospitalised dengue patients studied by us during
the dengue epidemic of 2006. The median cost incurred
per managed patient was US$432.2 (95% CI US$343.6—625).
Median fixed (infrastructure, electricity, water, etc.) and
variable (disposables, doctors, investigations, etc.) costs
were US$233.3 and US$182.4, respectively. Median costs
incurred for patients admitted to an intensive care unit were
US$643.6 (95% CI US$463.5—758.1) compared with US$341.9
(95% CI US$285.44—452.95) for a patient managed in a ward
574 P. Garg et al.
Table 3 Number of cases of dengue for 2006 assumed for
calculations (minimum to maximum estimates)
Reported dengue cases (2006)a12 317
Total no. estimated (multiplication factor
10—27)
123 170—332 559
Private health sector (58%) 71 438—192 884
Public health sector (42%) 51 732—139 675
No. of ambulatory patients (estimated
ambulatory/hospitalised ratio 4:1 to
10:1)
98 536—302 326
Reported deaths (2006)a184
aSource: National Vector Borne Disease Control Programme
(2007).
Table 4 Cost estimates for management of dengue
patients in the private sector of health care
Item Cost (US$)a
Investigations 70
Complete blood count 5
Dengue serology 25
Liver function tests 10
Othersb30
Drugs 110
Antibiotics 40
Fluids 60
Others 10
Disposables 50
Physicians 80
Room charges 100
aSmaller hospitals will charge two-thirds of the costs incurred
at larger hospitals.
bIncludes 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 serology
IgM-positive 11 (22.4)
IgM- and IgG-positive 38 (77.6)
Diagnostic category
Dengue 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 admissionb21 (42.9)
Median duration of stay (days) (range) 4 (3—5)
aData are n(%) unless otherwise stated.
bMedian stay 1.5 days.
setting (P= 0.01). Figures 1 and 2 show a model of cost
calculations at private and public sectors of care using cal-
culation values within the maximum and minimum estimates
of uncertain variables.
5. Discussion
We estimate the total economic burden of the 2006 Indian
dengue epidemic to be approximately US$27.4 million. The
range was noted to be US$9.2—57.7 million depending upon
the various uncertain estimations. These estimates include
loss of workdays and productivity owing to the illness and
provide an economic and financial context to the previously
described clinical aspects of this expanding health problem
in South Asia.
Some aspects of the economic impact of dengue on health
systems, populations and families have been previously
reported in Southeast Asia and South America (Anderson
et al., 2007; Anez et al., 2006; Clark et al., 2005; Harving
and Ronsholt, 2007; Torres and Castro, 2007). However, esti-
mates from South Asia have so far been poorly documented.
The total economic burden of dengue in the private and
public health sectors in India was estimated at US$21.7
million and US$5.7 million, respectively, for the dengue
epidemic of 2006. This value did not include costs incurred
for transportation, food or economic loss due to simultane-
ous affliction of multiple family members (Figures 1 and 2).
Our estimates of burden are similar to those reported from
other regions (Kouri et al., 1989; Meltzer et al., 1998). This
can be explained by the similar multiplication factor used
to account for unreported cases (Meltzer et al., 1998). The
epidemiology of dengue in India as noted from the published
literature appears to be different from the South Eastern
region. Thus, several of our assumptions for calculations
are different from other regions, such as in Thailand where
70—75% of patients are reported to be 5—14 years of age
and the average age of death has been noted as 10 years
(Clark et al., 2005). The economic burden in the private
health sector was almost four times that in the public
sector, reiterating the cost ineffectiveness of the private
health sector as well as the predominant private expansion
of services (Purohit, 2001).
Sensitivity analysis using a regression model revealed that
the variations in the proportion of unreported to reported
cases, the ratio of ambulatory to hospitalised cases and
the average loss of economic productive years would have
a large impact on the total economic burden. Further-
more, variations in loss of economic workdays, outpatient
costs and proportion of patients needing intensive care will
account for small variations in costs. The proportion of
patients needing transfusion and the proportion of children
did not affect the estimated costs (Table 2). We obtained
anticipated results in the sensitivity analysis (Suaya et al.,
2006).
5.1. Strengths of the study
First, our report is an initial attempt to quantify the grow-
ing economic consequences of regular dengue epidemics in
India. We have estimated that on a macro level, although
dengue 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. aCosts two-thirds that incurred at
larger hospitals (median stay 4 days). bTwenty-five percent of total hospitalised patients assumed to be children. cOne to three
visits and average medication (paracetamol only) US$0.75/patient included. dUS$3650/year loss. eThese costs are calculated if
the 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. aUS$9.1/day for secondary
and US$23/day for tertiary (median duration of stay 4 days), US$25 added for investigations, US$150 for platelet transfusions.
bTwenty-five percent of total hospitalisations assumed to be children. cAssumed 10% required platelet/plasma transfusion.
dUS$61.4 = [(9.1 ×4) + 25]; US$211.4 = (61.4 + 150); US$117 = [(23 ×4) + 25]; US$267 = (117 + 150). eUS$1095/year and assuming
average 20 years of productive life lost. fOne to three outpatient visits. gHigher range calculated if 10% need intensive care at
public sector hospital for a mean duration of 2 days/patient. hThese costs are calculated if the multiplication factor for unreported
cases is 10 and the ratio of ambulatory to hospitalised patients is 4:1. MUS$: million US$; OPD: outpatient department.
576 P. Garg et al.
losis and malaria, it is still a growing economic burden within
the country.
Second, we performed sensitivity analyses to account for
many of the potentially uncertain variables and thus evalu-
ated their affect on total costs.
Third, we calculated the economic burden both at public
and private sector hospitals and thus took into account the
major health providers in India. We also made some adjust-
ments for the heterogeneity in the private health sector in
India by taking into consideration the likely costs incurred
in smaller private health facilities (nursing homes) as well
as larger specialised tertiary-level corporate hospitals.
Fourth, we gained some insight into the out-of-pocket
expenditure incurred by patients hospitalised with dengue
during a dengue epidemic, as 41 (84%) of our patients were
not insured and made out-of-pocket payments. Although our
series of patients is small, the quality of data on costs is
high as all the information was captured from the hospital’s
electronic receipts database system.
5.2. Limitations of the study
We faced some challenges in estimating costs for dengue in
India, as discussed below. The first and main challenge was
possible underreporting of dengue cases and working out
the exact split in numbers of patients seen in an ambulatory
or hospitalised setting. We had to use data from Southeast
Asian and South American countries as a guide (Anez et al.,
2006; Clark et al., 2005) because there were no data avail-
able for India to make such estimates. We used a maximum
multiplication factor of 27 as has been suggested in the sci-
entific report of the WHO on dengue (Suaya et al., 2006).
One may argue about the applicability of the use of a multi-
plication factor from other regions to India, but considering
the poor laboratory facilities and utilisation of health ser-
vices in India, especially among the lower income quintiles,
as well as the media reports of gross underreporting in India
this may be a reasonable estimate. Similarly, to account
for the proportion of ambulatory to hospitalised patients
we used a minimum estimate of 4:1 to an arbitrary maxi-
mum value of 10:1. The impact of these uncertain factors
on total costs can be easily seen from the sensitivity analysis
(Table 2).
Second, for assessing the burden of dengue, disability-
adjusted life-years (DALY), a non-monetary economic
indicator, has been described as a standard measure (Lopez
et al., 2006). However, because of a lack of estimates on
disability weights for dengue patients in India, these calcu-
lations could not be done by us (Zaidi et al., 2004).
Third, health cost calculations in India pose a particular
challenge owing to poor networking and integration of the
private and public sectors of health care and marked het-
erogeneity within the private heath sector as well as urban
and rural and interregional and intraregional differences
(Purohit, 2001; Zaidi et al., 2004).
Fourth, we did not highlight interstate and interregional
differences and future studies should further explore these
aspects.
Finally, for calculating indirect costs, we took into
account only workdays lost by hospitalised patients and loss
of economically productive years due to deaths. It is likely
that many economically productive family members of the
hospitalised patient may also have missed work, adding to
the total economic burden. A comprehensive community
survey during and immediately following a dengue epidemic
would have allowed us to get a more accurate estimate of
indirect costs such as transportation and food and simulta-
neous affliction of family members. This would also have
helped in determining the economic impact of dengue at a
family and population level using internationally accepted
indicators such as DALY. However, we could not do such a
survey owing to logistic and practical issues and studies in
future should attempt to explore these aspects.
6. Conclusions
Our estimates of cost during a dengue epidemic suggest that
considerable economic losses are borne by developing coun-
tries like India owing to a single preventable viral disease.
There may be huge variations in the total economic bur-
den on a macro level in India depending upon the number of
reported to unreported cases and hospitalised to ambulatory
cases. Accurate calculations of these variables are urgently
needed to be more certain of the exact economic burden of
dengue in India. This has immense implications for India’s
limited health budget and financial resource availability for
managing other communicable and non-communicable dis-
eases.
Authors’ contributions: PG and SLS conceptualised the
study; PG and PK collected the data; PG and JN had
joint sessions of manuscript writing and data interpreta-
tion; JN was critical in drafting the manuscript and in
guiding the economic considerations in India; JN and PG
carried out the statistical analysis; SLS critically appraised
the manuscript, contributed to the intellectual content and
helped in drafting the manuscript. All authors approved the
final manuscript. PG is guarantor of the paper.
Acknowledgements: The authors acknowledge the help of
Dr Vibha Gupta, Managing Director, Central Hospital and
Research Centre, Faridabad, Haryana, for giving permission
for data collection and to conduct the study; and Mr S.S.
Mallik, Medical Records Department, for help in retrieval of
case records.
Funding: None.
Conflicts of interest: None declared.
Ethical approval: Not required.
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