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Influenza disease burden and cost estimates in Indonesia

Poster · August 2019

DOI: 10.13140/RG.2.2.28738.94401

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 Influenza disease burden
and cost estimates in Indonesia
Soewarta Kosen 1 , Endang Indriasih 2 , Tita Rosita 2 , Vivi Setiawaty 2 , Muhammad Karyana 2 , Herman Kosasih 2 , Iris Rengganis 3 , Anne-Frieda Taurel 4 ,
Joshua Nealon 4 , Stephen Nawawi 5 , Cissy Kartasasmita 6
1
Independent Consultant, Jakarta, Indonesia 2 National Institute of Health research & Development, Ministry of Health, Jakarta, Indonesia
3
Dept. of Internal Medicine, School of Medicine University of Indonesia, Jakarta, Indonesia 4 Regional Epidemiology and Health Economics, Sanofi Pasteur Asia JPAC
5
Medical Affairs, Sanofi Pasteur Indonesia 6 Dept. of Child Health, School of Medicine, University of Pajajaran, Bandung, Indonesia

BACKGROUND OBJECTIVES
 Influenza epidemiological data in tropical countries remains scarce, and while the  Lower respiratory tract infections (LRTI) are also a contributor of influenza disease burden,  In order to generate recent and robust influenza
contribution to morbidity and mortality may be significant, the disease is frequently under- as influenza virus is 1 of the 4 causative etiologies in addition to respiratory syncytial virus, disease burden and cost estimates to support
reported. Indonesia has been monitoring Severe Acute Respiratory Infections (SARI) and Heamophilus influenzae type B and Streptococcus pneumonia1
national policy making, a retrospective
Influenza Like Illness (ILI) since 1975 with 48 sentinel sites in 22 out of 34 provinces2 • Seasonal Influenza may complicate lower respiratory tract involvement and remains a
substantial contributor to the growing number of cases of LRTI worldwide secondary data analysis is proposed to be
• During 2013-2016, about 14 % Influenza positive found from 1,392 specimens tested;
with Influenza A and B circulating year-round with rainy seasonal peaks2  At present, less than 2.0 % of the population receives seasonal Influenza vaccine, conducted in Indonesia to generate national
• In 2012, Kosen and al. estimates that influenza SARI was associated with an annual especially among Hajj Pilgrim aged more than 50 years5,6. Understanding of the economic LRTI attributable to influenza disease burden
cost of US$152.4 million3 burden of disease is required to make evidence-based assessments of the value of public and cost estimates in 2017
health interventions

MATERIAL AND METHODS

Epidemiological data Indirect cost estimates
Figure 1. Data sources and analysis flow chart
 The clinical diagnosis of pneumonia or bronchiolitis were used as case  To estimate the indirect cost of influenza attributed LRTIs, Global Burden of
definition for LRTI Disease (GBD) methods were applied10
Data Sources Identification: • ICD-10 codes: A48.1, J09-J22, J85.1, P23.0, and P23.9 • Age at death, CFR and standard expectation of life by age-group were
• Completeness (data to be collected all year round)
• Representativeness of the catchment are population (type of
 Disease burden estimates (clinical attack rates, hospitalizations and deaths) extracted from the Indonesia Burden of Study 201712
hospital, individual sociodemographic data, such as gender, were generated through expert consensus extrapolated from: • DALYs, a health gap measure that combines both time lost due to
age, ect.)
Data Sources
• Accuracy of case count • SARI sentinel sites: Surveillance of Influenza in Indonesia 2003-2007 and premature mortality and non-fatal conditions, are used in the GBD
Identification:
• SARI/ILI Sentinel
- at least a proportion of cases, laboratory confirmed
- date of collection
incidence of Influenza-associated Severe Acute Respiratory Infections in  Total DALYs for each cause-age-sex group are calculated as the sum of the
Study, NIHRD
• INA RESPOND - address (to be associated with catchment area) Indonesia 2013-20161,2 non-fatal burden (YLD) and the burden of premature mortality (YLL): DALY
• Bias assessment
(Fever Study),
- Sampling scheme
• Hospital records of LRTI patients admitted to hospitals in Non SARI = YLL + YLD
NIHRD
Sentinel Sites: Hospitalized Pneumonia Data at Hasan Sadikin General
YLLi = KCera /(r+βr)2 x [e–(β+r)(L+a) x (r+βr) x ((L+a) –1 – e–
• UNPAD Data - Diagnostic assay
- Case definitions
Hospital 2012-20167
• Characteristics and study results: location, time, population,
sample (total, positive influensa), number of death, confirmed • ILI sentinel sites: Indonesia Research Partnership on Infectious Disease (r+βr)a x((–(r+βr)(a–1))]+[(1–K/r)(1–e–rL)]
by type, by sex and age
(INA RESPOND) and Fever Study 2014-20168 where: r = the discount rate (r = 0.03),
 Using the GBD framework, total hospitalized cases were assumed to be one C = the age weighting correction constant (C = 1),
Cost of Influenza third from total number of ambulatory Influenza LRTI patients β = the parameter from the age-weighting function,
Data (Decree of the
Minister of Health  To extrapolate at population level, the 2017 estimates population of K = the age-weighting modulation factor,
Indonesia from Population Projection of Indonesia 2015-2045 was used9
a = the age of death,
Population Data to
generate national
Direct cost estimates L = the standard expectation of life at age a
estimates
 Direct health care costs/medical expenditures include: out-patient cost, YLLi = D{KCera /(r+βr)2 x [e–(β+r)(L+a) [–(r+β) x ((L+a) –1] – e–
hospitalization cost, physician service fees, laboratory services, radiological (r+βr)a x [–(r+β)a–1]]+1–K/r)(1–e–rL)}
YLLs of YLDs of services, drugs (exclude: over the counter drugs)
Influenza Influenza  Direct non-medical costs (transportation cost, care-giver cost) were not where: a = the age of onset of the disability,
estimated L = the duration of disability,
 Following the GBD method10, the normative health services tariff of the r = the discount rate (r = 0.03),
DALYs Loss
National Health Insurance for out-patient services and hospitalization of
β = the age weighting parameter,
dus to Influenza LRTI were applied11,
Influenza • limited validation step were performed, i.e. looking at compliance of several K = the age- weighting modulation factor,
Jakarta Hospitals to the National Health insurance tariff C = the adjustment constant necessary because of unequal age weights

RESULTS CONCLUSIONS
Disease burden estimates Direct Medical Cost estimates  This study show a significant impact of influenza attributable LRTI in
2017 in Indonesia with:
In 2017 the estimated incidence and number of Lower Respiratory Infections  Unit cost for one out-patient per visit: Rp. 150,000,-
• A disease burden estimated at 3,358,418 influenza attributable LRTI
Attributable to Influenza, among all ages, in Indonesia was:  Unit cost for one hospitalized patient per episode: Rp. 5,734,200,- clinical episodes, including 40,435 hospitalizations and 4,097 deaths
 1,285 LRTI attributable to influenza clinical episodes per 100,000 population  Total medical expenditures for out-patient services: Rp. 18,195,750,000,- • A cost estimates at a total of US $ 866.7 Million, including US $ 847.5
• With higher incidence observed in younger age group 0-4 years old with  Total medical expenditures for hospitalized cases: Rp 231,862,377,000,- million in indirect cost (productivity loss) and US $ 19.2 million in
720 clinical episodes per 100,000 pop. (Table 1) Thus, the total medical expenditures in Indonesia for influenza direct medical cost
 3,358,418 LRTI attributable to influenza clinical episodes attributable LRTI in 2017 was US$19.2 Million* (equal to Rp. 250,05 billion)  Our results are limited by the availability, representativeness and
 1,204 LRTI attributable to influenza hospitalizations per 100,000 population quality of the epidemiological and surveillance data sources, however
 40,435 LRTI attributable to influenza hospitalizations Table 2. Disability Adjusted Life Years (DALY) Loss, Years of Life it benefited Indonesian experts consensus methods and from data
Loss (YLL) and Years Live with Disability (YLD) due to influenza from the GBD disease burden analysis.
 0.122 per 100 case fatality rate
attributable lower respiratory tract infections by age group,  These data are important to estimate the cost-effectiveness of a
 4,097 LRTI attributable to influenza deaths Indonesia 2017 potential influenza vaccine for public health intervention program and
could support decision making to enhance efforts and prioritize
Age group DALY YLL YLD
Table 1. Influenza attributable lower tract respiratory infection resources to avert the burden of Influenza attributable LRTI.
(years)
clinical episodes incidence and case fatality rates estimates per  Additional data are still needed to better describe the broader influenza
age group in Indonesian population in 2017 0–4 9.635 6.200 3.436 burden and its impact in Indonesia, in particular in vulnerable groups.
5–9 6.259 4.271 1.987
Age Group Incidence 10 – 14 6.614 4.423 2.192
CFR % 15 – 19 5.848 5.503 0.345
(years) per 100,000
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ACKNOWLEDGMENTS DECLARATION OF INTEREST CONTACT AUTHOR

We acknowledge the Institute for Health Metrics and Evaluation (IHME), University of Washington, Funding was provided by Sanofi Pasteur. AFT, JN and SN Dr Soewarta Kosen
Seattle, USA who provided comparative information for the Article; and we thank Dr. are employees of Sanofi Pasteur. soewarta.kosen7@gmail.com
Samsuridjal.Djauzi and Dr. Siti Setiati from the School of Medicine, University of Indonesia who
reviewed the data used in the study.

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