Assessment of Economic Burden of Concurrent Measles and Rubella Outbreaks, Romania, 2011-2012.
In coordination with other World Health Organization European Region countries, Romania has a goal of measles and rubella elimination by 2020. During 2000-2003, coverage with a first dose of measles-containing vaccine in Romania was reported to be [greater than or equal to]95%; for 2004-2010, combined measles and rubella vaccine first dose coverage was [greater than or equal to]95% and second dose coverage was [greater than or equal to]88%. In spite of these high national coverage rates among recent birth cohorts, unvaccinated subpopulations exist among older age cohorts and subnationally, which create conditions for continued measles or rubella outbreaks.
During 2011-2012, Romania experienced concurrent outbreaks of measles and rubella. Measles cases were primarily reported among children from the northwest part of the country, and rubella cases were reported primarily among adolescents and adults throughout Romania. The outbreaks resulted in 12,427 measles cases and 24,627 rubella cases during 2011-2012 (the number of measles cases officially associated with the outbreak was subsequently revised to 12,234 after our analysis was conducted) (7). We estimated the economic cost of these outbreaks and response activities incurred by the health sector and households of persons with measles or rubella infection.
Definitions and Costs
We assessed the cost of the measles and rubella outbreaks by collecting data on direct and indirect costs from households and the health sector. We defined economic cost as the sum of financial costs (i.e., the monetary value of goods and services provided to treat case-patients and to contain the outbreak) and opportunity costs (i.e., the value of the best alternative forgone by the health sector or households caused by measles or rubella illness or treatment) by using the societal costing perspective. The health sector included government entities from primary to tertiary level (i.e., health facilities, agencies, or departments) involved in providing treatment to measles or rubella case-patients and in designing and implementing the public health response to the outbreaks.
Data Sources and Collection Process
Household Direct and Indirect Costs
To collect household costs, we conducted a survey among a purposely selected sample of households that had recent cases (within the previous 18 months to minimize recall bias) drawn from the national measles and rubella surveillance database (Table 1; Appendix Figure, https://wwwnc.cdc.gov/EID/ article/25/6/18-03 39-App 1.pdf). An initial sample of 1,217 persons met the inclusion criteria; of these, 789 case-patients or their representatives could not be reached or declined to participate and 428 were interviewed (response rate 35%).
Healthcare Provider Costs
Reimbursement data were obtained from the National Health Insurance House (Casa Nationala de Asigurari de Sanatate), which covered all registered government healthcare providers in Romania (Table 1). There were [approximately equal to]10,000 primary care physicians or family doctors and >500 secondary or tertiary hospitals in the 42 health districts in Romania (8). Reimbursement fees are typically paid when doctors and hospitals submit claims to national health insurance funds for the service provided.
National Outbreak Response Costs
To assess national outbreak response costs, personnel involved in outbreak response activities were interviewed on the basis of referral from the National Institute for Public Health, Romanian Ministry of Health, which was charged with coordinating the national outbreak response. These open-ended interviews were conducted by members of the research team in Romanian at the offices of respondents and focused on collecting information about actual expenses incurred in measles and rubella outbreak response activities, including costs of enhanced surveillance, outbreak investigation, and outbreak response vaccination and vaccine stockpiling (Table 1).
Congenital Rubella Syndrome Costs
We requested reimbursement data for health services received by the 27 identified congenital rubella syndrome (CRS) cases from birth up to the date of data collection (at which point the surviving 15 CRS case-patients were 3-4 years old) from the National Health Insurance House; we obtained records for 18 (11 surviving and 7 who had died) of the 27 case-patients. The projection of their lifetime productivity losses used the same data sources and definitions as the main analysis of costs during the outbreak (Table 1). These 27 CRS case-patients were the only CRS cases included in the calculation of CRS costs during the outbreak.
All data collection activities occurred from mid-January through the end of May 2014. A post-hoc analysis of the costs of CRS cases was conducted in March-May 2016.
We analyzed data by using Access and Excel (Microsoft, https://www.microsoft.com), and Stata version 13 (StataCorp LLC, https://www.stata.com). We calculated districtlevel weights on the basis of the number of measles and rubella cases as a proportion of the total population in each of the 42 districts of Romania. We then applied these weights to the household survey data, with the costs reported by a respondent multiplied by the weight of the district in which that respondent resided, to estimate the mean, median, and interquartile range of treatment expenditures per household for measles and rubella infections and the proportion of cases receiving treatment by admission status.
We calculated the indirect costs of measles or rubella infections by first calculating the number of measles and rubella case-patients and caregivers [greater than or equal to] 18 years of age who were employed (based on employment rates reported in the patient survey). We then assumed that each of these employed case-patients and caregivers [greater than or equal to] 18 years of age lost the average number of workdays missed on the basis of the household survey. We valued each day of work missed at the minimum wage of Romania.
We used a human capital approach to estimate the lifetime productivity losses for CRS case-patients (9). We assumed that had these children not been born with CRS, their working years would have been 18-63 years of age (until median retirement age in Romania) with the same labor force participation, employment rates, minimum wage, and exchange rate during these years as those used in the main analysis (i.e., constant 2012-2013 rates). We discounted lifetime productivity losses to 2013 US dollars by using a 3% discount rate.
All costs were adjusted for inflation by using the Romanian Consumer Price Index to 2013 prices and converted from Romanian local currency (Lei) into US dollars by using 2013 exchange rates (3.32 Lei/1 US dollar). Costs are presented in 2013 US dollars (10,11).
We conducted univariate sensitivity analysis to characterize how total costs would change with different input values to reflect uncertainty. Reported number of outbreak cases, healthcare provider costs, and national outbreak response costs varied by [+ or -] 10%. Out-of-pocket treatment costs, number of days of work missed by cases and caregivers, and CRS case direct medical costs varied from the 25th to 75th percentiles, and proportion of cases receiving care varied from the 5th to 95th percentiles of the sample distribution. CRS case indirect costs were also calculated from birth to an average life expectancy of 74 years.
Ethics Approval and Informed Consent
The assessment protocol was approved by the Romanian National Health Research Ethics Review Board and determined not to be human subjects research by the US Centers for Disease Control and Prevention. Informed consent was obtained from participants after the objectives of the assessment were described to them. Participants were informed that the information would be confidential, there were no unique identifiers, and that participation was voluntary. The authors certify that this study has been conducted in an ethical way according to the international standards for authors.
A retrospective review of the Romanian national measles and rubella surveillance database showed that 12,427 laboratory-confirmed and epidemiologically linked cases of measles and 24,627 laboratory-confirmed and epidemiologically linked cases of rubella were reported during the 2011-2012 outbreaks (Figure). In addition, 27 confirmed cases of CRS were reported.
Household Survey Results
The number of households with measles or rubella cases that were included in the survey was evenly split between urban and rural areas, and 46% of case-patients were employed (Table 2). Although approximately one third of responding measles or rubella case-patients were <18 years of age, more case-patients in this age range were infants and preschoolers for measles (85%) than for rubella (44%). A slightly higher proportion of rubella case-patients (10%) sought care on multiple occasions compared with measles case-patients (4%). However, measles case-patients were 3.5 times more likely to have been admitted to a hospital than rubella case-patients (Table 2). Few measles or rubella case-patients (<2%) sought care at a private health facility. The distribution of sampled case-patients by sex was similar to those for the outbreaks overall, whereas in terms of age the sampled case-patients included a higher share of adults >18 years of age than the outbreaks overall.
Household Direct Medical and Nonmedical Costs
More than 90% of responding households with either measles or rubella cases incurred some type of treatment expense (Table 2). Case-patients with measles (36%) and rubella (7%) reported having to borrow money to pay for costs related to an episode of measles or rubella (Table 2). The largest share of household spending was on medications, followed by transportation. We found no notable differences in transportation or overall spending for households residing in rural areas compared with those in urban settings, which might reflect the history of widespread geographic availability of healthcare by state-owned polyclinics throughout Romania. Average household spending for measles and rubella patients <18 years old was more than that for patients [greater than or equal to] 18 years old (US $112.51 vs. US $45.85). Weighted median inpatient costs for measles were 2.2 times higher than for rubella, and outpatient costs for measles were 1.5 times higher than for rubella (Table 3). Total estimated direct medical and nonmedical household costs for treatment were US $888,338 for the 12,427 measles cases and US $477,261 for the 24,627 rubella cases (Table 4).
Household Indirect Costs
Among responding patients participating in the labor market, a median of 11.45 days were lost for measles and 9.62 days for rubella (Table 3). The maximum number of workdays lost were 68 days for a single episode of measles and 21 days for an episode of rubella. Of those [greater than or equal to] 18 years of age, 27% reported working while ill. Among those who continued to work, the average number of days worked while ill with measles or rubella was 4 days. Students and schoolchildren reported an average of 10 days that they were unable to attend school because of measles or rubella infection. Total estimated indirect household costs were US $779,917 for the 12,427 measles cases and US $1,043,281 for the 24,627 rubella cases (Table 4).
Total Estimated Household Costs
We determined total estimated direct and indirect household costs. These values were US $1.7 million for 12,427 measles cases (US $133.84/case) and US $1.5 million for 24,627 rubella cases (US $61.74/case) (Tables 4, 5).
Healthcare Provider Costs
Healthcare providers received direct reimbursement fees from health insurance. These totals were US $3,275,757 for services provided to treat measles and US $674,633 for services provided to treat rubella infections during the outbreak (Table 4).
National Outbreak Response Costs
National response activities included enhanced surveillance, laboratory diagnostic testing, and immunization of at-risk populations at a total cost of US $1,559,975, of which [approximately equal to]60% were for activities related to diagnosis and containment of rubella (Table 4). Virtually equal amounts of national resources were spent on measles and rubella containment efforts per case (US $41.55/case for measles and US $42.38/case for rubella) (Table 5). Most (87%) costs were incurred for laboratory reagents, laboratory tests, and overtime salaries for laboratory technicians (Table 3).
CRS Case Costs
Estimated health service reimbursement costs for the 27 CRS cases up to May 2016 were US $130,143 (Table 4). Estimated discounted lifetime productivity losses for the 12 CRS case-patients who had died by May 2016 were US $470,774. Under the assumption that the 15 surviving CRS case-patients would also be unable to work during their lifetimes, their estimated discounted lifetime productivity losses would be US $588,467 (US $1,059,241 for all 27 case-patients) (Table 4).
Total societal costs of the measles and rubella outbreaks were US $9.9 million, of which US $5.5 million was for measles-related activities and US $4.4 million for rubella-related activities (the rubella-related activities included US $1.2 million in CRS-related costs) (Table 4). These costs translated to a total cost per case of US $439 for measles, US $132 for rubella (not including CRS), and US $44,051 for CRS (Table 5). Sensitivity analysis showed that total costs varied between US $9,266,779 (when the lower bound of measles treatment costs was used) and US $10,989,560 (when the upper bound of lifetime CRS case indirect costs was used) (Table 4).
The large concurrent outbreaks of measles and rubella in Romania provided a major opportunity for an economic assessment of both diseases, as well as for CRS, in a middle-income country setting. Our key study findings were that households incurred a high economic burden of measles or rubella infection compared with income, the health sector bore most of the economic cost of the measles and rubella outbreaks, and CRS case costs were substantial and relevant to include in rubella outbreak cost studies. Our study contributes to the limited literature on measles and rubella outbreak costs in middle-income countries and to the evidence gap in this global research priority.
The economic burden of the measles and rubella outbreaks on the outbreak-affected households was substantial. Almost every household incurred costs relating to measles or rubella treatment. The direct household cost per case of measles or rubella was high compared with the average income in Romania in 2012: 30% of monthly income and 3% of annual income for measles, 9% of monthly income and 1% of annual income for rubella. Previous studies indicated that, when illness-related economic costs are >10% of annual household income, it is considered catastrophic because it potentially forces households to cut consumption of necessities, such as food and water, and leads to increased debt or greater poverty (12-14). Although direct household costs per case in our study in general did not exceed this threshold in Romania ([approximately equal to]US $263 in 2013), the highest cost households did; moreover, these costs were for only 1 medical event, and the financial burden would increase if other illnesses were considered.
For households, the unexpected measles and rubella treatment costs had to be met in the short term. High medical costs incurred in a short period are considered more detrimental than high costs incurred over a long period (12). Approximately 36% of households with measles and 7% with rubella reported borrowing money to pay for these expenses. Similar medical bill coping strategies, including informal payments, have also been confirmed in other studies in Romania (15,16). As a consequence of these expenses, studies in Romania and other countries in eastern Europe have reported that up to 60% of patients are forced to postpone or completely forgo treatments because of lack of money to pay their medical bills (15,17). Because per capita health spending in Romania was less than that in the United States (US $580) during 2013 (18), the estimated direct household and health sector costs per case of measles (US $376) and rubella (US $89, not including CRS costs) were high.
The health sector bore 70% of the economic cost of the outbreak for measles and 39% for the outbreak of rubella. For measles, 86% of the health sector costs were for provider reimbursement. For rubella, 61% was for national outbreak response activities. More than 85% of the national outbreak response activities were for laboratory reagents and test kits for measles and rubella, but only 12% was for emergency vaccine purchase because large-scale supplemental immunization activities were not conducted. Assuming a cost per dose administered of US $5, the cost of vaccinating all 36,861 confirmed case-patients with measles or rubella with 2 doses of the measles and rubella vaccine before the outbreak would have cost the health sector 10% of the amount paid for health sector costs for the measles outbreak and 21% of the amount paid for health sector costs for the rubella outbreak. Any pre-outbreak vaccination campaign would have had to vaccinate more than just the 36,861 persons who were infected during the outbreak to prevent the outbreak, and the costs of strategies to reach persistently unvaccinated subpopulations in Romania might be higher than typical campaign or routine immunization costs. Even so, such preemptive campaigns to reduce immunity gaps, coupled with continued robust routine immunization delivery, would have provided protection and reduced costs to the health sector, not only during the 2011-2012 outbreaks but also for future outbreaks. This finding is critical because Romania continues to have measles outbreaks.
Our study contributes to the ongoing efforts to document evidence of the economic burden of vaccine-preventable diseases in middle-income countries, with particular focus on measles and rubella. A study from Ethiopia reported an estimated household cost of US $29.18/case of measles treated during a measles outbreak in 2011 (2). As in Romania, the Ethiopian health sector bore most (80%) of the outbreak cost. A study in Latin America found the costs of measles treatment to range from US $43 in Nicaragua to US $210 in Argentina; the average cost was US $190 for the entire Latin America region (19). As an upper-middle-income country, economic costs for Romania are more comparable to those reported for countries such as the Netherlands, the United Kingdom, and Canada; a study from these countries in 2002 reported the societal costs of measles treatment as US $254 in Canada, US $276 in the Netherlands, and US $307 in the United Kingdom (20).
Our post-hoc analysis of CRS direct medical costs and estimated productivity losses adds to the limited literature on CRS costs in different economic settings (21). Studies from Brazil, Oman, and Uzbekistan reported that estimated CRS costs ranged from US $18,644 to >US $1.18 million/ case (22-24). More than 90% of these costs constitute indirect CRS costs. Future studies of CRS economic burden in low- and middle-income countries are needed. In this assessment, we did not quantify the value of life lost because of measles or rubella infections occurring during the outbreak, aside from the CRS cost estimates.
Our cost estimates are subject to several limitations. The household cost estimates were retrospective, and some persons might have been susceptible to recall bias. The purposive sampling of recent cases and district-level weighting procedures used for the household survey do not necessarily provide a nationally representative estimate of household costs, and no adjustment was made to account for survey nonresponse (response rate 35%), which might introduce selection bias; household costs might be underestimated because of the smaller proportion of case-patients <18 years of age in our sample compared with the outbreaks overall. We only recorded the provider reimbursement claims that were actually paid by the national insurance companies. However, anecdotal information suggested that claims were sometimes reimbursed at lower standard amounts based on limited availability of funds at the national level. National outbreak response costs were based on interviews with key informants from the agencies responsible for response implementation and are believed to be exhaustive of the costs incurred. However, other agencies might have also provided outbreak response and might not have been known to the national health authorities we used as key informants for the agencies involved in outbreak response.
For the CRS cost analysis, we did not obtain information on 9 of the reported cases (response rate 67%), which might introduce selection bias in our results, although no systematic differences in clinical profiles between included and excluded cases were observed. Information on some types of future CRS care costs (e.g., special schooling, government disability payments) were not available and are therefore not included in the analysis. The CRS productivity losses assume that all surviving case-patients are fully unable to work; this assumption might overestimate the indirect costs of CRS if some of these case-patients are ultimately able to work for income. Because of the nonrepresentative sampling techniques used and nonresponse, no uncertainty bounds were calculated for these cost estimates. Finally, the estimation of economic costs was not fully comprehensive. The opportunity costs of healthcare workers devoting their time to doing other public health activities was not estimated because of incomplete data.
In conclusion, the costs of the 2011-2012 measles and rubella outbreaks in Romania were high, especially when compared with total average household incomes and national health expenditures per capita. In addition to the health consequences of these outbreaks, households faced major threats of financial insecurities during these outbreaks and the long-term economic impacts of productivity losses. Preventing outbreaks through routine vaccination also reduces the economic burden on the health sector. This study makes a major contribution to identifying the overall societal economic burden of measles and rubella outbreaks in Romania and improves our understanding of the magnitude of the costs of measles and rubella outbreaks in middle-income economies.
At the time of study, Dr. Njau was an economist with the Global Immunization Program, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA. He is currently a consultant at JoDon Consulting Group LLC, Atlanta, GA. His research interests are the economics of infectious diseases, including malaria, Ebola, and vaccine-preventable diseases, such as measles, rubella, rotavirus infection, and hepatitis B.
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Address for correspondence: Laura Zimmerman, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mailstop H24-3, Atlanta, GA 30329-4017, USA; email: firstname.lastname@example.org
Joseph Njau,  Denisa Janta, Aurora Stanescu, Sarah L. Pallas, Adriana Pistol, Nino Khetsuriani,  Susan Reef, Daniel Ciurea, Cassandra Butu, Aaron S. Wallace, Laura Zimmerman
Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (J. Njau, S.L. Pallas, S. Reef, A.S. Wallace, L. Zimmerman); National Public Health Institute, Bucharest, Romania (D. Janta, A. Stanescu, A. Pistol); Centers for Disease Control and Prevention, Tbilisi, Georgia (N. Khetsuriani); Center for Health Policies and Services, Bucharest (D. Ciurea); World Health Organization Country Office, Bucharest (C. Butu)
 Current affiliation: JoDon Consulting Group LLC, Atlanta, Georgia, USA.
 Current affiliation: Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
Caption: Figure. Reported cases of measles and rubella during concurrent outbreaks, Romania, 2011-2012. Values reflect revision of official case counts after analysis was completed.
Table 1. Definitions and data sources used for cost components during assessment of economic burden of concurrent measles and rubella outbreaks, Romania, 2011-2012 * Cost component Definition Data sources Healthcare provider All reimbursements for Reimbursement data diagnostic testing for from National Health measles and rubella, Insurance House (CNAS) inpatient and covering all outpatient care, registered government emergency treatment, healthcare providers case management using the Romanian national clinical diagnosis codes associated with measles and rubella diagnoses, outpatient and inpatient care, and vaccinations (Appendix Table, https://wwwnc.cdc. National outbreak Enhanced surveillance, Interviews with key response laboratory diagnosis personnel, including and confirmation, the Director of the field activities such National Institute for as case Public Health, investigations, and Romanian MOH; the Team outbreak response Leads for Measles and immunization, Rubella, National including actual Center for expenses incurred for Surveillance and personnel, laboratory Control of supplies, and vaccine Communicable Diseases, doses provided to MOH; a measles and contacts of cases and rubella epidemiologist to high-risk from the District communities Public Health Authorities, MOH; the Director of the reimbursement department and an analyst at the National Health Insurance House (CNAS); and the Head of Country Office and a public health officer at the World Health Organization country office in Romania Direct medical and Medical costs (e.g., Household survey of nonmedical household consultation fees, 428 recent case- laboratory tests and patients (within last medications) and 18 months) by using nonmedical costs structured telephone (e.g., transport, food interviews and lodging) paid out- of-pocket by cases and caregivers Indirect household Workdays lost by cases Household survey of and caregivers because 428 recent case/ of measles or rubella patients (within last infections 18 months) by using structured telephone interviews; 2012 Romanian national minimum wage of 700 Lei/month was used as proxy to quantify the value of lost workdays by patients and caretakers [greater than or equal to] 18 y of age (8). CRS cases healthcare All diagnostic Reimbursement data provider services, inpatient from National Health and outpatient care Insurance House (CNAS) reimbursements related covering all to CRS diagnostic registered government codes for identified healthcare providers CRS cases during for the 27 CRS cases timeframe identified from the time of the outbreak up to the date of data collection; reimbursement data were obtained for 18 (11 surviving and 7 who had died) of the 27 case-patients CRS cases lifetime Workdays lost by CRS 2012 Romanian national discounted indirect cases over assumed minimum wage of 700 lifetime productive Lei/month was used as working years (18-63 a proxy to quantify y) the value of lost workdays by patients [greater than or equal to]18 y of age (8) * CNAS, Casa Nationala de Asigurari de Sanatate; CRS, congenital rubella syndrome; MOH, Ministry of Health. Table 2. Descriptive characteristics of case-patients responding to household survey for assessment of economic burden of concurrent measles and rubella outbreaks, Romania, 2011-2012 No. (%) case-patients Characteristic Measles Rubella Total Total sample 219 209 428 Age <18 y 74 (34) 63 (30) 137 (32) Male sex 109 (50) 107 (51) 216 (50) Urban domicile 98 (55) 115 (45) 213 (50) Multiple care visits 8 (4) 21 (10) 29 (7) Admission to hospital 185 (84) 38 18) 223 (52) Care at private clinics 3 (1) 4 (2) 7 (2) Age [greater than or equal to]18 y 145 146 291 Formal or informal employment 72 (50) 63 (43) 135 (46) Students 13 (9) 66 (45) 79 (27) Retired, unemployed, or housewives 60 (41) 17 (12) 77 (26) Age <18 y 74 63 137 Infants and preschoolers 63 (85) 28 (44) 91 (66) Schoolchildren 11 (15) 35 (56) 46 (34) Treatment expenses 219 209 428 Incurred some treatment expenses 206 (94) 194 (93) 400 (93) Borrowed money for treatment expenses 79 (36) 14 (7) 93 (22) Table 3. Main analysis input and sensitivity analysis values used for cost analysis of economic burden of concurrent measles and rubella outbreaks, Romania, 2011-2012 * Cost component Disease Input Case Measles No. cases distribution Rubella No. cases Rubella No. CRS cases Rubella Patients who died as of May 2016 Rubella Patients who survived as of May 2016 Measles Cases in 2011, % Measles Cases in 2012, % Rubella Cases in 2011, % Rubella Cases in 2012, % Healthcare Measles Reimbursement to healthcare provider providers for diagnostic codes, 2011 Measles Reimbursement to healthcare providers for diagnostic codes, 2012 Rubella Reimbursement to healthcare providers for diagnostic codes, 2011 Rubella Reimbursement to healthcare providers for diagnostic codes, 2012 National Measles Personnel time for outbreak outbreak response response Measles Reagent/test for outbreak response Measles Emergency vaccine purchases Rubella Personnel time for outbreak response Rubella Reagent/test for outbreak response Rubella Emergency vaccine purchases Direct Measles Out-of-pocket cost for inpatient care medical and Rubella Out-of-pocket cost for inpatient care nonmedical household Measles Out-of-pocket cost for outpatient care Rubella Out-of-pocket cost for outpatient care Measles Patients receiving outpatient care, % Measles Patients receiving inpatient care, % Rubella Patients receiving outpatient care, % Rubella Patients receiving inpatient care, % Indirect Measles Employment rate for case-patients household and caregivers, % Rubella Employment rate for case-patients and caregivers, % Measles No. work days missed by case-patients Rubella No. work days missed by case-patients Measles Case caregivers who missed work, % Rubella Case caregivers who missed work, % Measles No. work days missed by caregivers Rubella No. work days missed by caregivers Both Minimum daily wage CRS, direct Rubella Reimbursement to healthcare medical providers for patients who survived Rubella Reimbursement to healthcare providers for patients who died CRS, Rubella Minimum daily wage lifetime Rubella Years (range) of productivity loss discounted Rubella Labor force participation rate, % indirect Rubella Unemployment rate, % Rubella Discount rate, % Cost Median (25th- Proportion component Disease Input value 75th percentiles) (95% CI) Case Measles 12,427 NA NA distribution Rubella 24,627 NA NA Rubella 27 NA NA Rubella 12 NA NA Rubella 15 NA NA Measles 39 NA NA Measles 61 NA NA Rubella 16 NA NA Rubella 85 NA NA Healthcare Measles $1,313,049 NA NA provider Measles $1,962,708 NA NA Rubella $107,494 NA NA Rubella $567,138 NA NA National Measles $5,164 NA NA outbreak response Measles $449,225 NA NA Measles $61,962 NA NA Rubella $10,437 NA NA Rubella $907,951 NA NA Rubella $125,235 NA NA Direct Measles NA $66.87 NA medical ($21.27-$110.94) and Rubella NA $30.70 NA nonmedical ($15.20-$82.06) household Measles NA $18.23 NA ($4.55-$39.51) Rubella NA $12.50 NA ($6.07-$24.32) Measles NA NA 19 (24-60) Measles NA NA 81 (80-109) Rubella NA NA 62 (17-27) Rubella NA NA 38 (24-91) Indirect Measles 34 NA NA household Rubella 32 NA NA Measles NA 11.45 (7-18) NA Rubella NA 9.62 (7-14) NA Measles 89 NA NA Rubella 68 NA NA Measles NA 7 (3-10) NA Rubella NA 4.5 (3-7) NA Both $10.44 NA NA CRS, direct Rubella NA $6,455 NA medical ($1,749-$10,296) Rubella NA $2,777 NA ($1,734-$3,309) CRS, Rubella $10.44 NA NA lifetime Rubella 46 (18-63) NA NA discounted Rubella 65 NA NA indirect Rubella 11 NA NA Rubella 3 NA NA Cost Sensitivity Sensitivity component Disease analysis LB analysis UB Case Measles 11,184 13,670 distribution Rubella 22,164 27,090 Rubella NA NA Rubella NA NA Rubella NA NA Measles NA NA Measles NA NA Rubella NA NA Rubella NA NA Healthcare Measles $1,181,744 $1,444,353 provider Measles $1,766,437 $2,158,979 Rubella $96,745 $118,244 Rubella $510,425 $623,852 National Measles $4,648 $5,680 outbreak response Measles $404,303 $494,148 Measles $55,766 $68,158 Rubella $9,393 $11,481 Rubella $817,156 $998,746 Rubella $112,712 $137,759 Direct Measles $21.27 $110.94 medical and Rubella $15.20 $82.06 nonmedical household Measles $4.55 $39.51 Rubella $6.07 $24.32 Measles 24 60 Measles 80 100 Rubella 17 27 Rubella 34 91 Indirect Measles NA NA household Rubella NA NA Measles 7 18 Rubella 7 14 Measles NA NA Rubella NA NA Measles 3 10 Rubella 3 7 Both NA NA CRS, direct Rubella $1,749 $10,296 medical Rubella $1,734 $3,309 CRS, Rubella NA NA lifetime Rubella NA 74 (LE) discounted Rubella NA 100 indirect Rubella NA 0 Rubella NA NA * Monetary values are in US 2013 dollars. CRS is an outcome of rubella. CRS, congenital rubella syndrome; LB, lower bound; LE, life expectancy; NA, not applicable; UB, upper bound. Table 4. Estimated total costs by component for base case and sensitivity analyses for assessment of economic burden of concurrent measles and rubella outbreaks, Romania, 2011-2012 * Disease or Main analysis Sensitivity Cost component outcome base case analysis variable Healthcare Measles $3,275,757 Healthcare provider provider costs Rubella $674,633 Healthcare provider costs National Measles $516,351 National outbreak outbreak response costs response Rubella $1,043,623 National outbreak response costs Direct medical Measles $883,338 Out-of-pocket and nonmedical inpatient and household outpatient treatment costs Proportion of patients receiving inpatient or outpatient treatment No. cases Rubella $477,261 Out-of-pocket inpatient and outpatient treatment costs Proportion of patients receiving inpatient or outpatient treatment No. cases Indirect Measles $779,917 No. work days household missed by case- patients No. work days missed by caregivers Rubella $1,043,281 No. work days missed by case- patients No. work days missed by caregivers CRS cases Rubella $130,143 Reimbursement direct medical to healthcare providers for CRS cases CRS cases Rubella $1,059,241 Productive years lifetime (labor force discounted participation, indirect unemployment rate) Total Measles $5,455,363 NA Rubella $4,428,182 NA Both $9,883,545 NA Disease or Sensitivity Sensitivity Cost component outcome analysis LB analysis UB Healthcare Measles $2,948,181 $3,603,332 provider Rubella $607,169 $742,096 National Measles $464,716 $567,986 outbreak response Rubella $939,261 $1,147,985 Direct medical Measles $266,573 $1,572,347 and nonmedical household $716,509 $915,498 $795,004 $971,672 Rubella $141,497 $1,136,431 $310,302 $768,764 $429,535 $524,988 Indirect Measles $583,614 $1,068,856 household $622,875 $897,698 Rubella $827,714 $1,403,658 $959,358 $1,183,153 CRS cases Rubella $47,038 $194,145 direct medical CRS cases Rubella NA $2,165,257 lifetime discounted indirect Total Measles NA NA Rubella NA NA Both NA NA Total measles Total measles Disease or and rubella and rubella Cost component outcome costs with LB costs with UB Healthcare Measles $9,555,968 $10,211,120 provider Rubella $9,816,081 $9,951,007 National Measles $9,831,909 $9,935,179 outbreak response Rubella $9,779,182 $9,987,906 Direct medical Measles $9,266,779 $10,572,553 and nonmedical household $9,716,715 $9,915,704 $9,795,210 $9,971,878 Rubella $9,547,779 $10,542,713 $9,716,584 $10,175,046 $9,835,818 $9,931,270 Indirect Measles $9,687,241 $10,172,484 household $9,726,502 $10,001,325 Rubella $9,667,976 $10,243,920 $9,799,621 $10,023,416 CRS cases Rubella $9,800,438 $9,947,546 direct medical CRS cases Rubella NA $10,989,560 lifetime discounted indirect Total Measles NA NA Rubella NA NA Both NA NA * CRS, congenital rubella syndrome; LB, lower bound; NA, not applicable; UB, upper bound. Table 5. Estimated overall cost per case of measles, rubella, or congenital rubella syndrome during concurrent outbreaks, Romania, 2011-2012 * Cost per case (sensitivity analysis lower bound-upper bound; 2013 US $) Cost type Measles Rubella, not CRS Household direct medical and nonmedical $71 ($21-$127) $19 ($6-$46) Household indirect $63 ($47-$86) $42 ($34-$57) Healthcare provider $264 ($237-290) $27 ($25-30) National outbreak response $42 ($37-46) $42 ($38-47) CRS cases direct medical NA NA CRS cases lifetime discounted indirect NA NA Estimated total societal/case $439 ($389-494) $132 ($118-$158) Cost per case (sensitivity analysis lower bound-upper bound; 2013 US $) Cost type CRS Household direct medical and nonmedical NA Household indirect NA Healthcare provider NA National outbreak response NA CRS cases direct medical $4,820 ($1,742-$7,191) CRS cases lifetime discounted indirect $39,231 (UB: $80,195) Estimated total societal/case $44,051 ($40,973-$85,015) * CRS, congenital rubella syndrome; NA, not applicable; UB, upper bound of sensitivity analysis.
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|Author:||Njau, Joseph; Janta, Denisa; Stanescu, Aurora; Pallas, Sarah L.; Pistol, Adriana; Khetsuriani, Nino;|
|Publication:||Emerging Infectious Diseases|
|Article Type:||Clinical report|
|Date:||Jun 1, 2019|
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