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      Economic Impact of Dengue Illness and the Cost-Effectiveness of Future Vaccination Programs in Singapore

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          Dengue illness causes 50–100 million infections worldwide and threatens 2.5 billion people in the tropical and subtropical regions. Little is known about the disease burden and economic impact of dengue in higher resourced countries or the cost-effectiveness of potential dengue vaccines in such settings.

          Methods and Findings

          We estimate the direct and indirect costs of dengue from hospitalized and ambulatory cases in Singapore. We consider inter alia the impacts of dengue on the economy using the human-capital and the friction cost methods. Disease burden was estimated using disability-adjusted life years (DALYs) and the cost-effectiveness of a potential vaccine program was evaluated. The average economic impact of dengue illness in Singapore from 2000 to 2009 in constant 2010 US$ ranged between $0.85 billion and $1.15 billion, of which control costs constitute 42%–59%. Using empirically derived disability weights, we estimated an annual average disease burden of 9–14 DALYs per 100 000 habitants, making it comparable to diseases such as hepatitis B or syphilis. The proportion of symptomatic dengue cases detected by the national surveillance system was estimated to be low, and to decrease with age. Under population projections by the United Nations, the price per dose threshold for which vaccines stop being more cost-effective than the current vector control program ranged from $50 for mass vaccination requiring 3 doses and only conferring 10 years of immunity to $300 for vaccination requiring 2 doses and conferring lifetime immunity. The thresholds for these vaccine programs to not be cost-effective for Singapore were $100 and $500 per dose respectively.


          Dengue illness presents a serious economic and disease burden in Singapore. Dengue vaccines are expected to be cost-effective if reasonably low prices are adopted and will help to reduce the economic and disease burden of dengue in Singapore substantially.

          Author Summary

          Dengue illness is a tropical disease transmitted by mosquitoes that threatens more than one third of the worldwide population. Dengue has important economic consequences because of the burden to hospitals, work absenteeism and risk of death of symptomatic cases. Governments attempt to reduce the disease burden using costly mosquito control strategies such as habitat reduction and spraying insecticide. Despite such efforts, the number of cases remains high. Dengue vaccines are expected to be available in the near future and there is an urgent need to evaluate their cost-effectiveness, i.e. whether their cost will be justified by the reduction in disease burden they bring. For such an evaluation, we estimated the economic impacts of dengue in Singapore and the expected vaccine costs for different prices. In this way we estimated price thresholds for which vaccination is not cost-effective. This research provides useful estimates that will contribute to informed decisions regarding the adoption of dengue vaccination programs.

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          Most cited references 62

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          Quantifying the burden of disease: the technical basis for disability-adjusted life years.

          Detailed assumptions used in constructing a new indicator of the burden of disease, the disability-adjusted life year (DALY), are presented. Four key social choices in any indicator of the burden of disease are carefully reviewed. First, the advantages and disadvantages of various methods of calculating the duration of life lost due to a death at each age are discussed. DALYs use a standard expected-life lost based on model life-table West Level 26. Second, the value of time lived at different ages is captured in DALYs using an exponential function which reflects the dependence of the young and the elderly on adults. Third, the time lived with a disability is made comparable with the time lost due to premature mortality by defining six classes of disability severity. Assigned to each class is a severity weight between 0 and 1. Finally, a three percent discount rate is used in the calculation of DALYs. The formula for calculating DALYs based on these assumptions is provided.
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            The friction cost method for measuring indirect costs of disease.

            A new approach for estimating the indirect costs of disease, which explicitly considers economic circumstances that limit production losses due to disease, is presented (the friction cost method). For the Netherlands the short-term friction costs in 1990 amount to 1.5-2.5% of net national income (NNI), depending on the extent to which short-term absence from work induces production loss and costs. The medium-term macro-economic consequences of absence from work and disability reduce NNI by an additional 0.8%. These estimates are considerably lower than estimates based on the traditional human capital approach, but they better reflect the economic impact of illness.
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              Economic Impact of Dengue Illness in the Americas

              The growing burden of dengue in endemic countries and outbreaks in previously unaffected countries stress the need to assess the economic impact of this disease. This paper synthesizes existing studies to calculate the economic burden of dengue illness in the Americas from a societal perspective. Major data sources include national case reporting data from 2000 to 2007, prospective cost of illness studies, and analyses quantifying underreporting in national routine surveillance systems. Dengue illness in the Americas was estimated to cost $2.1 billion per year on average (in 2010 US dollars), with a range of $1–4 billion in sensitivity analyses and substantial year to year variation. The results highlight the substantial economic burden from dengue in the Americas. The burden for dengue exceeds that from other viral illnesses, such as human papillomavirus (HPV) or rotavirus. Because this study does not include some components (e.g., vector control), it may still underestimate total economic consequences of dengue.

                Author and article information

                Role: Editor
                PLoS Negl Trop Dis
                PLoS Neglected Tropical Diseases
                Public Library of Science (San Francisco, USA )
                December 2011
                20 December 2011
                : 5
                : 12
                [1 ]Department of Statistics and Applied Probability, National University of Singapore, Singapore, Singapore
                [2 ]Communicable Disease Centre, Tan Tock Seng Hospital, Singapore, Singapore
                [3 ]Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
                [4 ]Biodefence Centre, Ministry of Defence, Singapore, Singapore
                [5 ]Centre for Health Services Research, National University of Singapore, Singapore, Singapore
                [6 ]Program in Emerging Infectious Diseases, Duke-NUS Graduate Medical School, Singapore, Singapore
                [7 ]Brandeis University, Waltham, Massachusetts, United States of America
                [8 ]Program in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore
                [9 ]Department of Medicine, School of Medicine, National University of Singapore, Singapore, Singapore
                [10 ]Environmental Health Institute, National Environment Agency, Singapore, Singapore
                Pediatric Dengue Vaccine Initiative, United States of America
                Author notes

                Conceived and designed the experiments: LRC VJL DL LCN YSL ARC. Performed the experiments: LRC LKL EEO TLT VG. Analyzed the data: LRC VJL LKL EEO ARC. Contributed reagents/materials/analysis tools: LRC LKL EEO TLT VG DL LCN YSL DSS. Wrote the paper: LRC LKL VJL EEO ARC DL LCN YSL DSS.

                Carrasco et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                Page count
                Pages: 9
                Research Article
                Infectious Diseases
                Neglected Tropical Diseases
                Dengue Fever
                Non-Clinical Medicine
                Health Economics
                Cost Effectiveness
                Environmental Health
                Socioeconomic Aspects of Health
                Science Policy
                Science Policy and Economics
                Cost-Benefit Analysis

                Infectious disease & Microbiology


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