Economic Consequences of an Infectious Disease Event for a Small, Island Economy

Transcription

1 National Center for Immunization & Respiratory Diseases Economic Consequences of an Infectious Disease Event for a Small, Island Economy Jamison Pike, MS, PhD Prevention Effectiveness Fellow Society for Benefit-Cost Analysis 9 th Annual Conference and Meeting March 16, 2017

2 Outline Introduction Methods Results Discussion Limitations Implications Further Research

3 Introduction

4 Measles Highly contagious rash illness, transmitted from person to person by direct contact with respiratory droplets or airborne spread Despite the availability of a safe and effective vaccine, measles remains one of the leading causes of death among young children. According the World Health Organization (WHO), from , measles mortality decreased by 79%. WHO Global Vaccine Action Plan for aims to eliminate measles in at least five WHO Regions by Photos from Gopalani et al. 2016

5 Federated States of Micronesia (FSM) Independent country, freely associated with the US through the Compact of Free Association (COFA) 607 islands in Western Pacific 271 square miles land mass spread over 1,000,000 square miles of ocean Smaller than New York City Population: 102,843* 4 states: Chuuk (54,595), Kosrae(6,616), Pohnpei(36,196), Yap (16,436) Member country of the WHO Western Pacific Region. Committed to eliminating measles. *2010 census From ISD presentation by Mimi Larzelere, December 12, 2014.

6 Outbreak and Response On May 15, 2014, CDC was notified of two cases testing positive for measles-specific immunoglobulin M (IgM) antibodies in FSM. From February -August 2014, 393 cases of measles were confirmed in FSM. Fifty-nine cases were imported to the US. Collaborative effort FSM public health officials FSM Volunteers CDC Staff Contributions were also made by United Nations Children s Emergency Fund (UNICEF) and WHO.

7 Objective During a measles outbreak, the resources needed to identify and treat contacts can strain local public health resources. Exacerbated by the unique logistical, economic, and geographical challenges in confirming diagnosis and containing the outbreak. Objective to determine the economic implications to FSM, as well as the economic responsibilities of the US, given the idiosyncrasies of this event coupled with the FSM Compact of Free Association with the US.

8 Methods

9 Setting 4 states Yap, Chuuk, Pohnpei and Kosrae 607 islands dispersed across 1 million square miles of ocean.

10 Outbreak FSM, assisted by CDC, investigated suspected cases, identified contacts, conducted analyses to guide outbreak vaccination response, and reviewed vaccine cold chain practices. Median patient age was 24 years. 64% patients aged >19 years. Among adults 20 years, 49% had received 2 doses of measles-containing vaccine. Measles incidence was lower among children than adults, except infants <12 months who were too young for vaccination.

11 Breakwell, L., et al., Measles Outbreak Associated with Vaccine Failure in Adults--Federated States of Micronesia, February-August MMWR Morb Mortal Wkly Rep, (38): p

12 Cost Analysis Analysis period -May 1, 2014 through December 10, Standard cost analysis methods. Costs retrospectively collected. Costs categorized: 1. Outbreak containment costs, 2. Direct medical and non-medical costs, 3. Productivity losses All expenses are in 2014 US dollars.

13 Containment (1) Outbreak Investigation Contact tracing, conducting a retrospective review of prior fever and rash cases, conducting vaccination record checks, and assessing vaccine storage and handling practices. (2) Mass Vaccination Campaign Followed up with children age 6 months through adults up to age 57 years 82,472 individuals (80% of the national population) Boats - primary mode of transportation for the outreach vax teams. Fixed and outreach vax posts, mobile vax units and door-to-door efforts.

14 Photos from Gopalani et al. 2016

15 Photos from Gopalani et al. 2016

16 Photos from Gopalani et al. 2016

17 Photos from Gopalani et al. 2016

18 Direct Costs Direct medical costs - incurred to secure medical treatment. Direct nonmedical costs -incurred in connection with a health outcome, such as shipment of specimens for testing. This study (1) laboratory testing, supplies, shipping, and labor, (2) hospitalization costs, and (3) non-hospitalization costs. Due to limited capacity to perform diagnostic tests for measles, samples were sent to laboratories in Atlanta, Guam, and Hawaii for confirmation.

19 Productivity Losses Productivity losses Costs foregone due to disability or death resulting from a health problem, such as absenteeism, job loss, or reduced productivity while at work (presenteeism). Losses due to illness or injury include -gross earnings Losses due to mortality - US value per statistical life (VSL) Following Hammittand Robinson (2011), a sensitivity analysis is applied to the income elasticity when transferring values from the US to FSM.

20 Results

21 Results Containment Costs $3.5 million incurred by FSM, US, UNICEF, and WHO. CDC labor costs totaled approximately $80,000 FSM labor costs totaled approximately $300,000. Vaccine purchase totaled nearly $2.4 million.

22 Table 1 Estimated resources and costs of the containment of the FSM measles outbreak, May 15 December 10, Variable FSM US WHO UNICEF Total Labor Approximate number of personnel directly involved Vaccine doses 2,620 79,510 10,000 92,130 Materials Ice lined refrigerators 3 3 Freezers 5 5 Domestic refrigerators 5 5 Cold boxes Vaccine carriers Estimated costs (US$) Labor $325,094 $79,652 $404,745 Vaccines $74,664 $1,987,526 $370,854 $2,433,044 Materials $42,000 $42,000 Logistics $114,597 $490,833 $81,411 $686,841 Total Costs $556,355 $2,558,010 $81,411 $370,854 $3,566,630

23 Table 1 Estimated resources and costs of the containment of the FSM measles outbreak, May 15 December 10, Variable FSM US WHO UNICEF Total Labor $325,094 $79,652 $404,745 Vaccines $74,664 $1,987,526 $370,854 $2,433,044 Materials $42,000 $42,000 Logistics $114,597 $490,833 $81,411 $686,841 Total Costs $556,355 $2,558,010 $81,411 $370,854 $3,566,630

24 Results Direct Costs $141,000 in direct costs were incurred. Laboratory testing labor, materials, and shipping incurred by US totaled nearly $99,000 Hospitalization and non-hospitalizations costs incurred by FSM totaled almost $42,000.

25 Results Productivity Losses Losses due to illness average daily wage of $31.65 applied. 124 cases were hospitalized assume not able to work for 15 working days resulting in lost productivity costs of approximately $59, cases were outpatient assume not able to work for 5 working days resulting in lost productivity costs of approximately $42,500.

26 Results Productivity Losses Losses due to mortality One infant (21 months old) fatality from measles occurred in the state of Pohnpei. Lost productivity estimate ranging from $2.3 million (ε=0.5) to $37,000 (ε=2.0). We estimated lost productivity due to death as $148,000 (income elasticity = 1.5).

27 Results Table 2 Extrapolated VSL Compared to Future Income (2014$, 3 percent discount rate, PPP) Country Annual Per Midpoint Future Extrapolated VSL Capita GNI Life Expectancy Income US $55, $1,282,753 $9,100,000 $9,100,000 $9,100,000 FSM $3, $76,570 $584,419 $148,104 $37,532

28 Results Table 3 Estimated costs by type and payer for the FSM measles outbreak, May 15 December 10, FSM US WHO UNICEF SUBTOTAL COST Containment $556,355 $2,558,010 $81,411 $370,854 $3,546,915 Direct $41,838 $98,825 $140,663 Productivity $249,549 $249,549 subtotal $847,742 $2,656,835 $81,411 $370,854 $3,956,842

29 Discussion

30 Discussion Total costs incurred as a result of the 2014 Measles Outbreak were nearly $4,000,000; approximately $10,000 per case. Costs in perspective relative to the US and FSMs respective economies. Table 4 Estimated cost of the 2014 FSM measles outbreak to FSM and the US relative to each respective economy (2014$) Cost of Outbreak (COO) GNI PPP COO relative to country economy FSM $847,742 $373,216, % US $2,656,835 $17,823,200,000, %

31 Limitations

32 Limitations 1. Due to lack of data, many costs were excluded. 2. In the productivity cost component of the cost of outbreak, payroll taxes and employer paid benefits were not included in gross earnings, nor imputed household earnings. 3. Many proxies were used for true costs or donations. 4. Did not consider costs incurred to the US from the 59 imported cases.

33 Implications

34 Implications 1. According to the World Bank, because FSM is a narrowly-based economy with large distances to major markets, the country is vulnerable to unpredictable events, which can affect growth and often lead to a high degree of economic volatility. 2. During 2010 and 2011, WHO supported FSM in performing a climate change and health vulnerability and adaptation assessment. Infectious diseases were among the highest priority climate-sensitive health risks identified in FSM. 3. We demonstrated that although FSM was heavily assisted by the US in responding to the 2014 Measles Outbreak, the outbreak nontrivial impacted their economy.

35 Further Research

36 Further Research Review of Cost of Outbreak Studies work in progress Measles single outbreak 10 studies since 1990 Public Health and Healthcare Perspective Duration Reporting total costs, per case costs, per contact costs Prospective v. Retrospective Multiple outbreaks Other Infectious Diseases, including Vaccine Preventable Diseases Use with dynamic transmission modelto look at cost-effectiveness of different levels of prevention and intervention including business as usual.

37 Dynamic Transmission Model Analysis Plan Stochastic mathematical model of measles transmission. Parameterize by observed R values early during the outbreak. Estimate duration and number of cases by policy for US and FSM Hospitalized Outpatient Deaths

38 Dynamic Transmission Model Analysis Plan Baseline Business-as-Usual model Policy A Observed level of intervention with vaccination, other control measures, and community behavior Policy B Intervention with less vaccination / more other control measures model Policy C Intervention with only other control measures model Policy D Compare to cost of prevention no cases Policy E

39 Cost-Effectiveness Analysis Plan Determine Cost and Effectiveness by Policy What is the best estimate of effectiveness in FSM? QALYs DALYs Life years Lives saved Cases averted cost-benefit What is the optimal mix of intervention that maximizes cost-effectiveness?

40 For more information, contact CDC CDC-INFO ( ) TTY: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

41 Additional Slides

42 Acknowledgements Ashley Tippins Mike Underwood Mimi (Larzelere)Eckert Mawuli Nyaku Louisa Helgenberger Paul Gastanaduy Team of Hales et al Team of Breakwellet al EPI Unit, Department of Health, FSM

43 Cost Analysis FSM Department of Health CDC FSM Office of Statistics, Budget and Economic Management, Overseas Development Assistance and Compact Management UNICEF WHO Feds Data Center from FedSmith, Inc. International Monetary Fund World Bank