International Journal of Infectious Diseases 84S (2019) S64–S67

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International Journal of Infectious Diseases

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Direct cost of illness for dengue in hospitalized children and adults

at a referral hospital in India
Kakhangchung Panmeia , Arjun Kang Josephb , Winsley Rosec , O.C. Abrahamd,
Alice J. Mathuramd, Sathish Kumarc, Asha Mary Abrahama,*
a
Department of Clinical Virology, Christian Medical College, Vellore, TN 632004, India
b
Translational Health Science and Technology Institute, Faridabad, Haryana 121001, India
c
Department of Child Health, Christian Medical College, Vellore, TN 632004, India
d
Department of General Medicine, Christian Medical College, Vellore, TN 632004, India

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: To describe the direct cost of illness in pediatric and adult inpatients at a referral hospital in
Received 18 December 2018 India.
Received in revised form 21 February 2019 Methods: Inpatients who tested positive for dengue were identified in the hospital records of a single
Accepted 22 February 2019
private non-profit hospital over a period of 1 year and line-listed. Hospital discharge bills were obtained
for pediatric and adult patients and the median costs by severity of illness for bed and treatment were
Keywords: estimated. Costs were also converted to US dollars (1 USD = 64.6 Indian rupees (INR)).
Dengue
Results: The median and interquartile range (IQR) direct costs for pediatric dengue without warning signs,
Economic burden
India
dengue with warning signs, and severe dengue were 179.80 (IQR 85.51–428.51) USD, 145.06 (IQR 90.89–
321.86) USD, and 933.51 (IQR 400.50–1117.43) USD, respectively. The median and IQR direct costs for
adult dengue without warning signs, dengue with warning signs, and severe dengue were 312.75 (IQR
174.55–531.03) USD, 287.22 (IQR 210.96–389.34) USD, and 720.39 (IQR 389.23–1035.51) USD,
respectively.
Conclusions: Children and adults with dengue incur high costs when hospitalized for dengue. Since most
medical costs in India are out-of-pocket expenses, these illnesses can impact households.
© 2019 Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Methods

Dengue is one of the most prevalent mosquito-borne viral
infections and has been a global health problem for many decades
(World Health Organization, 2018). India is considered to be endemic
for dengue, and many cases of dengue hemorrhagic fever and dengue
shock syndrome, which constitute the severe end of the disease
spectrum, are reported every year. In recent decades, outbreaks of
dengue have grown to be more frequent, larger, and with a greater
proportion of severe cases or mortality (Chakravarti et al., 2012).
While there have been studies on the economic burden of dengue in
Southeast Asia (Shepard et al., 2013), only one study, published in
2014, has previously collected data and reported the economic burden
in India (Shepard et al., 2014). This report from a single hospital
provides more recent data on the direct costs incurred by pediatric
and adult patients hospitalized with dengue of varying severity.
* Corresponding author at: Department of Clinical Virology, Christian Medical
College, Vellore 632004, India.
E-mail address: asha_ma@cmcvellore.ac.in (A.M. Abraham).
The study was conducted in the Virology Department of the
Christian Medical College (CMC), Vellore, India, from April 2017 to
March 2018. The CMC is a private, not-for-profit hospital where all
expenses are cost-accounted to estimate charges for general ward
patients on a no-profit, no-loss calculation. The Department of
Clinical Virology line-listed all patients who tested positive for
dengue and then categorized these cases into adults and children
and into in-patients and out-patients. A total of 230 children
(under 18 years of age) and 391 adults (18 years or older) were
admitted to the CMC during the study period.
The sample size determination was based on the objective of
this study, which was to determine the cost of admission to the
CMC, Vellore with a diagnosis of dengue. Since the study was a
pilot, it was aimed to include 30 patients in each of the smallest
subsets. However, it was not possible to identify 30 patients in each
of the subsets, but it was possible to recruit more than 30 in the
categories of dengue without and with warning signs (37 in the
pediatric group and 32 in the adult group). The number of patients
with severe dengue is known to be the lowest of the clinical

https://doi.org/10.1016/j.ijid.2019.02.033
1201-9712/© 2019 Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
 K. Panmei et al. / International Journal of Infectious Diseases 84S (2019) S64–S67 S65

spectrum. As it was not possible to identify 30 patients in each
subset, the pilot aimed for approximately 50 pediatric and 50 adult
patients, and every nth patient was selected (where n = total/50).
The nature of the disease as well as the costs associated with
treatment for these patients were recorded. The hospital inpatient
records were reviewed and patients were categorized based on the
severity of dengue as follows: dengue without warning signs,
dengue with warning signs and severe dengue which included
dengue resulting in mortality.
Dengue patients were identified as those who tested positive
for dengue NS1 antigen or dengue IgM antibody by capture ELISA
and had a clinical presentation based on the World Health
Organization classification of 2009, as follows: (1) dengue without
warning signs was defined as fever and two of the following:
nausea/vomiting; rash; headache, eye pain, muscle ache, or joint
pain; leukopenia; positive tourniquet test. (2) Dengue with
warning signs was defined as dengue with warning signs of
severe infection, including dengue infection as defined above in
addition to any of the following: abdominal pain or tenderness;
persistent vomiting; clinical fluid accumulation (ascites, pleural
effusion); mucosal bleeding; lethargy or restlessness; hepatomeg-
aly >2 cm; increase in hematocrit concurrent with a rapid decrease
in platelet count. (3) Severe dengue was defined as a severe dengue
infection with at least one of the following: severe plasma leakage
leading to shock; fluid accumulation with respiratory distress;
severe bleeding (as evaluated by a clinician); severe organ
involvement: aspartate aminotransferase (AST) or alanine amino-
transferase (ALT) 1000 U/l; impaired consciousness; organ
failure.
The hospital accounts department was provided with the
hospital numbers of each patient and the patient billing records
were obtained in 2018 Indian rupees (INR). From the bills, the
categories of costs for each set of patients were extracted and
summarized as median values (with interquartile range, IQR).
Costs were then also calculated in US dollars (USD) at the exchange
rate of 64.6 INR to 1 USD, which was the average of the rate during
the study period.
Results
Table 1 shows characteristics of the patients by clinical stage of
dengue, area of residence, type of infection, duration of illness
before admission, duration of hospitalization, and transfusion
history. Sixteen (32%) children had dengue without warning signs,
23 (46%) had dengue with warning signs, and 11 (22%) had severe
dengue. For each of these categories, the numbers of adults were 18
(36%), 14 (28%), and 18 (36%), respectively. The majority of patients
were from Tamil Nadu, with smaller numbers from Andhra
Pradesh (which is about 13.5 km north of Vellore) and a few from
other neighboring states. For both children and adults, more
presented with secondary infections (IgG-positive with or without
NS1 antigen and/or IgM positivity) than primary dengue infections
(NS1 antigen with or without IgM positivity). The duration of
illness before admission was a median of 5 days (IQR 3–7 days) for
both children and adults. The median duration of hospitalization
was 4 days (IQR 3–7 days) for children, while it was marginally
higher for adults (median 5 days, IQR 4–-7 days). Only 7 (14%) of
children required transfusion while 10 (20%) of adults needed
blood.
Table 2 shows the median (IQR) charges for the pediatric and
adult cases of dengue admitted to the CMC, Vellore during the
study period. Patients having dengue with warning signs had the
lowest median cost of treatment (145.06 USD/9371 INR and 287.22
USD/18 555 INR, respectively, for children and adults), followed by
patients having dengue without warning signs for both children
(179.80 USD/11 615 INR) and adults (312.75 USD/20 204 INR). As
expected, both children and adults admitted with severe dengue
had costs that were much higher than those for patients in the
other two categories of dengue (933.51 USD/60 305 INR and 720.39
USD/46 538 INR, respectively), as depicted in a box plot
comparison in Figure 1. Three children with severe dengue died,
while only one adult with severe dengue died. In pediatric cases,
the most common single item with the highest charge was bed and
nursing care, while charges for investigations were the second
most common item. For adults, the most common single item with
the highest charge was investigations, with bed and nursing
charges coming second. Only nine of the 100 patients had their
hospital costs paid by their insurance or employers.
Discussion
Dengue is an important cause of febrile illness in India, with
many outbreaks reported every year. Most of the patients
presenting to the study hospital are from around the city and
state of Tamil Nadu, with a smaller proportion from the state of
Andhra Pradesh north of the hospital and fewer from other
southern states. Among children, most of the patients with dengue
had the milder categories of disease, whereas among adults, this

Table 1
Characteristics of the patients by clinical stage of dengue, area of residence, type of infection, duration of illness before admission, duration of hospitalization, and transfusion
history.

Characteristics Pediatric Adult

Number % Number %
Dengue
Dengue without WS 16 32 18 36
Dengue with WS 23 46 14 28
Severe dengue 11 22 18 36
Area
Tamil Nadu 39 78 34 68
Andhra Pradesh 10 20 14
Other 1 2 18
Type of infection
Primary 22 44 15 30
Secondary 28 56 35 70
Duration of illness before admission (days), median (IQR) 5 (3–7) 5 (3–7)
Hospital duration (days), median (IQR) 4 (3–5) 5 (4–7)
Transfusion
Yes 7 14 10 20
No 43 86 40 80

WS, warning signs; IQR, interquartile range.

S66 K. Panmei et al. / International Journal of Infectious Diseases 84S (2019) S64–S67

Table 2
Cost of treatment for pediatric and adult cases of dengue admitted to the Christian Medical College, Vellore in 2017–2018 in US dollars (USD) and Indian rupees (INR) (2018)a ;
median (IQR) values.

Cost for: Dengue Pediatrics, median (IQR) Adults, median (IQR)

INR USD INR USD

Bed charges Dengue without WS 4400 (2120–7078) 68.11 (32.82–109.56) 6360 (3230–13 160) 98.45 (50.00–203.72)
Dengue with WS 3330 (2275–6373) 51.55 (35.22–98.65) 4770 (3625–7617) 73.84 (56.11–117.92)
Severe dengue 13 800 (6480–40 198) 213.62 (100.31–622.26) 10 600 (5565–13 837) 164.09 (86.15–214.20)

Investigations Dengue without WS 2450 (1431–10 188) 37.93 (22.16–157.70) 8435 (4398–12 248) 130.57 (68.07–189.59)
Dengue with WS 2598 (1474–5251) 40.21 (22.81–81.29) 6095 (4240–9300) 94.35 (65.63–143.96)
Severe dengue 8985 (4190–19 255) 139.09 (64.86–298.07) 16 807 (8675–22 198) 260.16 (134.29–343.61)

Medications and supplies Dengue without WS 876 (534–4073) 13.56 (8.27–63.05) 892 (446–2091) 13.81 (6.91–32.37)
Dengue with WS 497 (303–2105) 7.69 (4.69–32.59) 865 (471–2371) 13.38 (7.29–36.70)
Severe dengue 7033 (2382–15 481) 108.87 (36.87–239.64) 2655 (1434–5214) 41.10 (22.19–80.72)

Procedure/intervention Dengue without WS 1443 (214–11 514) 22.33 (3.31–178.23) 775 (470–2300) 12.00 (7.28–35.60)
Dengue with WS 530 (218–985) 8.20 (3.37–15.25) 1070 (513–3665) 16.56 (7.93–56.73)
Severe dengue 2293 (1081–7879) 35.49 (16.74–121.96) 6643 (2463–13 362) 102.83 (38.12–206.84)

Professional services Dengue without WS 3080 (1392–4115) 47.68 (21.54–63.70) 5930 (3478–7540) 91.80 (53.83–116.72)
Dengue with WS 2650 (1550–4536) 41.02 (23.99–70.22) 3950 (3600–5089) 61.15 (55.73–78.77)
Severe dengue 5100 (4700–10 835) 78.95 (72.76–167.72) 6585 (4400–7698) 101.94 (68.11–119.16)

Blood transfusions Dengue without WS 10 775 (3990–) 166.80 (61.76–0.00) 4000 (4000–4000)) 61.62 (61.92–61.92)
Dengue with WS 3440 (2440–) 53.25 (37.77–0.00) 3440 (309–7119) 53.25 (4.78–110.20)
Severe dengue 7000 (1330–33 895) 108.36 (20.59–524.69) 6435 (3896–14 656) 99.61 (60.31–226.88)

Total charge Dengue without WS 11 615 (5524–27 682) 179.80 (85.51–428.51) 20 204 (11 276–34 304) 312.75 (174.55–531.03)
Dengue with WS 9371 (5871–20 792) 145.06 (90.89–321.86) 18 555 (13 628–25 151) 287.22 (210.96–389.34)
Severe dengue 60 305 (25 872–72 186) 933.51 (400.50–1117.43) 46 538 (25 144–66 894) 720.39 (389.23–1035.51)

WS, warning signs; IQR, interquartile range.

a
Average exchange rate during the study period: 64.6 INR to 1 USD.

Figure 1. Box plot comparison of total charges (USD) for pediatric and adult cases of dengue admitted to the Christian Medical College, Vellore in 2017–2018.

study showed an equal proportion of dengue without warning
signs as severe dengue (36%). Among children, more than 50%
presented with secondary dengue, while this was 70% in adults,
and children spent about 4 days in hospital while adults stayed a
day longer. These results are similar to the findings of an earlier
costing study from India (Shepard et al., 2014). In the study
hospital, only 14% of children required transfusion; among adults,
only 20% required blood products.
To estimate the burden of disease, the cost of illness is an
important primary source of data. However, in a system where
private healthcare is preferred over governmental services and
out-of-pocket expenses are the major source of payments for
health, keeping track of escalating costs of illness can be
challenging. There are very limited data on costs of illness in
India. One study performed from 2006 to 2012 reported that the
average cost of a hospitalized case of dengue was about 235 USD
(approximately 15 000 INR at the time, 2012) (Shepard et al., 2014).
The present study stratified pediatric and adult patients by severity
of disease. Dengue with warning signs had the lowest median cost
of treatment (145.06 USD/9371 INR and 287.22 USD/18 555 INR for
 K. Panmei et al. / International Journal of Infectious Diseases 84S (2019) S64–S67
children and adults, respectively) and this was followed by dengue
without warning signs for both children (179.80 USD/11 615 INR)
and adults (312.75 USD/20 204 INR). This may be explained by the
fact that these children and adults had come earlier in the course of
illness, requiring a longer period of monitoring through to
recovery, which is the case for most patients.
While the charges in dengue without and with warning signs
were higher for adults than children, total charges in severe dengue
were higher in children. This was because three children died from
severe dengue, while only one adult died. The single case in which
mortality occurred among adults was a severe case of dengue in
which the patient died within 3 days of admission, resulting in a
lower cost. Severe disease had two- to five-times higher costs than
the milder categories of disease. The costs in this pilot study were
also three- to four-times higher than the estimates in the previous
study, highlighting the need for continual cost monitoring over
time and type of facility. This increase in cost could be attributed to
a number of factors, such as inflation, or increases in costs of
hospitalization, investigations, medicines and supplies, and fees
for professional services.
The costs estimated in this study are the direct costs of
hospitalization; they did not include indirect costs such as travel,
accommodation, food, loss of earnings, etc., or any societal costs. It is
important to note that the costs for treatment were paid by the
patient’s insurance or employers in less than 10% of the cases.
Therefore, in 90% of cases, the costs were being borne by the patients or
their families. This is higher than the estimate of over 70% of healthcare
in India being out-of-pocket expenses (Selvaraj et al., 2018), and may
be because the hospital is known to be a private facility.
The costs of treatment combined with the indirect costs have
significant implications for most Indians, with an estimated 55
million Indians pushed into poverty by healthcare costs every year
(Selvaraj et al., 2018). Although this study contributes to the sparse
literature on the economic burden of dengue, it has the limitation
of being conducted in a single type of facility and for a limited
duration, with a small number of patients. Economic studies are
rarely done in India but are an essential component of
understanding the burden of illness and supporting the planning
of health services and policy.
S67
Acknowledgements
The authors would like to thank the study team for help in
conducting the study, Dr Jayaprakash Muliyil, Wellcome Research
Unit, CMC, and Dr L. Jeyaseelan and Mr Bijesh Yadav, Department of
Biostatistics, CMC for their advice on the analysis.
Funding
This article is part of a supplement entitled ‘Dengue Fever in
India’ which is sponsored by the Department of Biotechnology,
Government of India, and collated by the Translational Health
Science and Technology Institute.
Ethical approval
The Institutional Review Board of the Christian Medical College
Vellore granted ethical approval.
Conflict of interest
The authors report no conflict of interest.
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