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Analytical Review
Economic burden of acute lower respiratory
tract infection in South African children
Anushua Sinha
1
, Soyeon Kim
1
, Gary Ginsberg
2
, Heather Franklin
1
,
Robert Kohberger
3
, David Strutton
4
, Shabir A. Madhi
5
, Ulla K. Griffiths
6
,
Keith P. Klugman
5,7
1
Department of Preventive Medicine and Community Health, New Jersey Medical School–UMDNJ, Newark, USA,
2
Department of Medical Technology Assessment, Ministry of Health, Jerusalem, Israel,
3
Blair & Company,
Greenwich, USA,
4
Pfizer Inc., Collegeville, USA,
5
Respiratory and Meningeal Pathogens Research Unit, University
of Witwatersrand and National Institute for Communicable Diseases, Johannesburg, South Africa,
6
London
School of Hygiene and Tropical Medicine, London, UK,
7
Hubert Department of Global Health, Rollins School of
Public Health, Emory University, Atlanta, USA
Background: Acute lower respiratory tract infections (ALRTI) are a leading cause of childhood mortality, but
there are few data on disease costs in developing countries.
Objectives: This study’s purpose was to analyse ALRTI’s costs-of-illness and economic burden in urban
South African children.
Methods: ALRTI costs-of-illness (expressed in US$ 2010) at a tertiary hospital were measured using a
micro-costing approach nested within a clinical trial. Demographic, epidemiological and data on use of
health resources were integrated with costs-of-illness to estimate the economic burden of ALRTI in urban
South African children aged ,5 years.
Results: 745 children experiencing 858 ALRTI episodes were studied. 338 (39.4%), 513 (59.8%) and 7
(0.8%) episodes were managed in short-stay, paediatric ward and intensive care settings, respectively.
Mean lengths of stay in short-stay, paediatric ward and intensive care (ICU) were 1.4, 8.1 and 14.4 days,
respectively. The societal costs-of-illness per ALRTI episode managed in short-stay and paediatric ward
settings, respectively, were US$266 (95% CI 245–286) and 1287 (95% CI 1174–1401) in HIV-infected
patients, and US$257 (95% CI 247–267) and 1032 (95% CI 931–1133) in HIV-uninfected patients. Family
costs were not collected in ICUs. ICU direct medical costs were US$5968 (95% CI 4025–8056) in HIV-
uninfected patients and US$7849 in one HIV-infected patient. Under-5 children experienced an estimated
424,220 episodes annually of ALRTI. ALRTI treatment cost the public health system an estimated
US$28,975,000 while an additional US$539,000 of costs were borne by families.
Conclusion: ALRTIs in children ,5 years impose a heavy economic burden on families and the South
African public health-care system.
Keywords: Child health, Cost and cost analysis, Health economics, Modelling, Respiratory tract diseases
Introduction
Acute lower respiratory tract infections (ALRTI),
comprised of pneumonia and bronchiolitis, are a
leading cause of disease and death in children under
5. Worldwide, roughly 1.6 million deaths of young
children and infants annually are attributed to
ALRTI,
1
and the burden of ALRTI deaths falls largely
in low- and middle-income countries.
2,3
While inte-
grated management strategies have been implemented
in many of these settings to reduce ALRTI-associated
morbidity and mortality,
4
Haemophilus influenzae type
B and pneumococcal polysaccharide-protein conjugate
vaccines prevent pneumonia when introduced into
national immunisation schedules.
5
Cost analyses for inclusion in cost-utility analyses
of vaccine-preventable respiratory disease are needed
to support decision-makers as they formulate policy
regarding vaccine introduction and financing. Globally,
relatively few such analyses have been published from
low- and middle-income countries
6–13
and only two
such analyses have been published previously from
sub-Saharan Africa.
8,13
As an upper middle-income
country with a significant childhood ALRTI burden,
cost analyses from South Africa could help address
this knowledge gap. We estimated cost-of-illness for
Correspondence to: A Sinha, Medical Science Building, Room F506, 185
South Orange Avenue, Newark, NJ 07101, USA. Fax: z1 973 972 7625;
email: sinhaan1@umdnj.edu
ßW. S. Maney & Son Ltd 2012
DOI 10.1179/2046905512Y.0000000010 Paediatrics and International Child Health 2012 VOL.32 NO.2 65
ALRTI at a large South African tertiary-level hospi-
tal and integrated this information with demographic
and epidemiological data to develop a model of the
economic burden of ALRTI in urban South African
children. Given the urban context within which the
cost data were gathered and the relative paucity of
information regarding differences in health-care pro-
cesses between urban and rural health-care settings,
we chose to restrict our analysis to urban South
Africa.
Methods
Overview
In a randomised, placebo-controlled trial (RCT) of
nine-valent pneumococcal conjugate vaccine (PCV9),
39,836 urban South African children were assigned to
receive either three doses of PCV9 or a placebo.
Enrolment was begun on 2 March 1998 and ended
on 30 October 2000. Follow-up continued until 15
November 2001. Commercialisation of PCV9 was not
pursued by the manufacturer.
The trial and follow-up care were conducted at Chris
Hani Baragwanath Hospital (CHB), a secondary and
tertiary hospital that serves more than 90% of the
children in Soweto. At the time, Soweto had a popula-
tion of approximately 1.2 million, with y120,000
residents under the age of 5.
14
A detailed description of
the trial has been published previously.
15
During the RCT, detailed cost data on the direct
medical and non-medical costs associated with hospi-
talisation were gathered for a convenience sample of
trial enrollees presenting to CHB with acute illnesses
of any kind, but, to be included in this cost analysis, an
RCT participant had to experience ALRTI. Because
the cost study was initiated during the latter part of the
trial, cost data for young infants under 6 weeks of age
were not collected. Medical care at CHB was provided
by hospital nurses and physicians who were not
employed by the study.
Cost data were collected retrospectively through
chart review for admission dates between 1 January
2000 and 31 December 2000, and prospectively
between 1 January 2001 and 30 June 2001. Data
were collected from children enrolled in the trial and
admitted to CHB’s short-stay ward, the paediatric
ward and the paediatric ICU. Retrospective data
were not collected for short-stay ward admissions.
For a subset of the children prospectively evaluated, a
family impact survey assessed out-of-pocket, direct
non-medical costs of ALRTI as well as out-of-pocket
medication expenses, using methods described below.
Data were also collected on an additional 246
children not enrolled in the RCT and 474 children
without an ALRTI diagnosis. In order to focus on
costs of ALRTI using well-defined trial criteria, these
data are not included in this report.
Case definition
The RCT-defined endpoint of ALRTI was used.
15
A
case of ALRTI was defined as a clinical diagnosis by
the study physician of either pneumonia or bronch-
iolitis. All clinical encounters within 14 days of each
other were considered to be part of one episode of
illness. Children with unknown HIV status were
excluded.
Data collection
Direct medical costs. Full methods are contained
in the technical appendix (Supplementary Material
http://dx.doi.org/10.1179/2046905512Y.0000000010.S1).
Unit costs were based on CHB expenditure for the
budgetary year ending March 2001. All costs were
inflation-adjusted to Rands 2010 using the South
African Consumer Price Index.
16,17
Costs were
converted to US$ using an average exchange rate of
7.32 Rands 2010/US$1 2010.
18
All costs are reported
in Rands 2010 and US$ 2010.
Measurement of direct medical costs had three
components. First, total annual costs of services
provided at CHB were calculated by adding adminis-
tration, laundry, food, cleaning, utilities and grounds
expenditures. The cost of each of these services
included salaries, supplies, office equipment, utilities
and building. These costs were then converted to
ward-specific overheads per bed-day by dividing the
total costs by total outputs, either square meter or
total number of hospital days, as appropriate to the
service centre.
Next, ward-specific overhead costs per bed-day
were calculated by adding ward-specific personnel,
amortised furniture and amortised equipment costs
to the corresponding service costs. These data were
obtained either from the individual wards or from
CHB’s department of statistics.
Finally, patient-specific costs per hospital stay
were tallied for drugs, laboratory tests, radiographs,
supplemental oxygen and procedures (e.g. lumbar
puncture, thoracentesis and central venous access).
Lengths of stay and sites of care (short-stay, ward,
ICU) were also collected. Unit costs of drugs were
obtained from hospital price lists, and those for
radiographs, diagnostic tests and procedures were
obtained from price lists of the South African
Institute for Medical Research, which also accounted
for overheads associated with provision of these
goods and services.
Family costs. Patient-level, family costs of ALRTI
were determined among participants in a family
impact sub-study. A survey was administered by
study nurses to the families of children admitted to
the paediatric ward between 1 January 2001 and 30
June 2001 to determine caregiver income losses
(assuming one day-time and one night-time caregiver
per child), transportation costs, traditional healing
Sinha et al. Economic burden of childhood ALRTI
66 Paediatrics and International Child Health 2012 VOL.32 NO.2
costs, and other out-of-pocket pre-hospitalisation
costs associated with illness. Family costs equal direct
non-medical costs plus out-of-pocket pre-hospitalisa-
tion medication costs. Data on the socio-economic
status of the family, care-givers, family structure,
housing and mode of transport were also collected.
Other information. Data concerning ALRTI end-
points, date of birth, demographics, HIV status and
randomised treatment assignment (PCV9 vs placebo)
were obtained from the RCT data files.
Costs of illness associated with ALRTIs
The cost data collected at CHB were used to estimate
the cost of ALRTI per illness episode for urban
South African children treated in tertiary public
hospitals. Costs of illness per episode were calculated
from both the public health system and societal
perspectives. For the public health system perspec-
tive, the costs of facility and personnel, drugs,
diagnostic testing, radiographs and procedures were
aggregated for the illness episode. For the societal
perspective, the above costs were aggregated, as
well as caregiver productivity losses, transportation,
traditional healing and out-of-pocket medication
costs. Site of care was determined as follows: hospi-
talisations with an ICU component were categorised
as ICU regardless of care provided in other wards;
paediatric ward hospitalisations were categorised as
such, even if additional care was provided in the
short-stay ward.
Economic burden of ALRTI
The economic burden model considered ALRTIs
experienced by all South African urban children ,5
during one calendar year. The model began by
estimating the disease burden of ALRTI in these
children, with and without HIV. A proportion of cases
were assumed to receive medical care while other cases
failed to reach medical attention (Table 1).
Of the cases receiving medical attention, all cases of
severe ALRTI were assumed to be managed in hospital
settings, while non-severe ALRTI was assumed to be
managed in outpatient settings. Hospitalised patients
were managed in either primary-, secondary- or
tertiary-level hospital facilities, with the proportion
managed in each type of facility equal to the proportion
of total South African hospital beds available in that
setting (Table 1). It was assumed that each illness
Table 1 Inputs used in economic burden model
Inputs Estimate Lower bound Upper bound Ref. no.
Demographic inputs
Population of South African children ,5 yrs*4,449,814 – – 14
Proportion of South African children ,5 yrs
who are ,1 yr old*
0.202 – – 14
Proportion of South Africans living in an urban setting*0.575 – – 14
Epidemiological inputs
Proportion of ALRTI cases that are severe 0.086 0.084 0.088 2
Incidence rate of ALRTI per child-year 0.166 0.161 0.177 2
Proportion HIVzamong mothers attending antenatal clinics*0.249 – – 22
HIV mother-to-child transmission probability 0.225 0.150 0.300 30
Proportion of severe ALRTI HIVzcases 0.451 0.423 0.479 31
Proportion of severe ALRTI HIV- cases 0.549 0.521 0.577 31
Proportion of severe ALRTI cases ,1 yr 0.463 0.418 0.509 32
Proportion of severe ALRTI cases aged 1–4 yrs 0.537 0.491 0.582 32
Odds ratio (OR) severe ALRTI, HIVz:HIV- 6.4 5.8 7.0 15
Proportion of ALRTI cases ,1yr*0.390 – – 2
Proportion of ALRTI cases aged 1–4 yrs*0.610 – – 2
Case fatality proportion HIVz0.168 0.13 0.36 33
Case fatality proportion HIV- 0.034 0.02 0.14 33
Case fatality proportion 0–1 yrs 0.069 0.055 0.083 34
Case fatality proportion 1–4 yrs 0.034 0.028 0.040 34
Health system and cost-related inputs
Proportion of urban children with access to medical care 0.777 0.736 0.815 35
Proportion of severe ALRTI treated in secondary hospital 0.339 0.339 0.454 36
Proportion of severe ALRTI treated in tertiary hospital 0.231 0.115 0.231 36
Societal cost of ALRTI episode by care setting
Tertiary hospital R8491 R7926 R9056 Current study
(US$1160) (US$1083) R(US$1237) Current study, adjusted
(see Methods)
Secondary hospital R6215 R5802 RR6629 Current study, adjusted
(see Methods)
(US$849) (US$793) R(US$906)
Primary hospital R4763 R4447 RR5080
(US$651) (US$607) R(US$694)
Outpatient clinic*R139 – –
(US$19) 19
*Not varied in sensitivity analysis.
Sinha et al. Economic burden of childhood ALRTI
Paediatrics and International Child Health 2012 VOL.32 NO.2 67
episode was managed in only one facility type. Inputs to
the model were drawn both from the results of the
current study and from the literature. In each modelling
step, the proportion who were HIV-positive and the
proportion falling within any given age stratum were
assumed to be independent.
Cost data from the CHB cost-of-illness analysis
were used to populate estimates for children manag-
ed in tertiary-level hospital facilities. For children
managed in primary- and secondary-level hospital
facilities, the CHB paediatric ward costs were extra-
polated, using facility-stratified bed-day costs for
South Africa from the World Health Organization’s
Choosing Interventions that are Cost Effective (WHO
CHOICE) project as weights.
19
For example, the cost
of illness for a child managed in a secondary-level
hospital would be equal to CHB paediatric ward
cost-of-illness6(WHO CHOICE secondary-level hos-
pital bed-day cost/WHO CHOICE tertiary-level hos-
pital bed-day cost). WHO CHOICE costs were used
for children managed in outpatient settings.
19
One-
way sensitivity analyses to test the robustness of the
economic burden model were performed. The model
was implemented in Microsoft Excel and SAS 9.2.
Additional methods can be found in the Web
Appendix.
Statistical methods
Because we had multiple episodes per child and had
both medical and family costs, generalised estimating
equations (GEE) using an exchangeable correlation
structure were used to estimate the mean costs of an
illness episode and mean length of an episode,
stratifying by HIV status and the section of the
hospital where the child received care. We considered
normal, inverse Gaussian, zero-inflated Poisson and
gamma distributions with identity and log link
functions. The gamma distribution with an identity
link was selected because, among models that con-
verged, it had the best Akaike information criterion
and the errors best fit modelling assumptions. GEEs
were used to estimate the proportion with radio-
graphic confirmation. We used the GENMOD proce-
dure in SAS 9.2 for all analyses.
Human subjects
The study was approved by the Committee for the
Study of Human Subjects at the University of the
Witwatersrand, by the UMDNJ Newark campus’s
Institutional Review Board, and by the World Health
Organization Research Ethics Review Committee. All
RCT participants were enrolled after written informed
consent had been obtained from a parent or legal
guardian.
Results
Study subjects
Of the randomised clinical trial (RCT) participants,
1921 children experienced 2351 episodes of ALRTI
between 1 January 2000 and 30 June 2001, and health
resource use and cost data were collected for 872
episodes (approximately 41%). Fourteen of the
children were of unknown HIV status and were
excluded; therefore, 858 ALRTI episodes experienced
by 745 children were analysed (Fig. 1). Data for 400
episodes (46.6%) were collected retrospectively and
for 458 (53.4%) prospectively. Care-givers of 324
(43.5%) children completed family impact question-
naires for 352 episodes which were used in the
estimation of family costs.
A higher proportion of children enrolled in the cost
study and undergoing retrospective chart review
(172/367, 47%) were HIV-positive relative to RCT
participants with ALRTI, not enrolled in the cost
study, during the same time period (276/1041, 24%).
Cost study enrollees were otherwise similar to RCT
participants with ALRTI not enrolled, in terms of
age, the proportion with ALRTI chest radiograph-
confirmed, the proportion who were HIV-positive for
prospectively evaluated children, and the proportion
enrolled in the vaccine vs placebo arms (data not
shown).
ALRTI episodes
In this analysis, children experienced between one
and four episodes of ALRTI, with 12.6% having
more than one episode (Table 2). A mean 1.2 episodes
of ALRTI (95% CI 1.1–1.2) were observed during the
18 months of observation within this analysis, with
HIV-positive children having an average 1.3 episodes
Figure 1 Diagram of study participants
Sinha et al. Economic burden of childhood ALRTI
68 Paediatrics and International Child Health 2012 VOL.32 NO.2
(95% CI 1.2–1.4) and HIV-negative children 1.1
episodes (95% CI 1.1–1.1) (P,0.001) (Table 2). In
HIV-positive children, 39% (95% CI 34–45%) of
ALRTIs were confirmed by chest radiograph and, in
HIV-negative children, 20% (95% CI 16–23%) were
confirmed by chest radiograph.
Health resource use and costs-of-illness per
episode of ALRTI
Mean lengths of stay for children admitted to short-
stay, the paediatric ward and the ICU were, respec-
tively, 1.4 (95% CI 1.3–1.6), 8.1 (95% CI 7.4–8.8) and
14.4 (95% CI 10.3–18.5) days. HIV-positive and -
negative children had similar mean lengths of short stay
(1.3 vs 1.5 days, P50.37), and longer mean lengths of
stay in the paediatric ward (9.3 vs 7.0 days, P50.001).
Of children in the cost study, only one who was HIV-
positive was admitted to the ICU.
Selected unit costs are summarised in Table 3.
From the public health system perspective, the mean
direct medical cost per episode of ALRTI managed
on the short-stay ward was US$245 (95% CI 236–254,
1793 Rand, 95% CI 1728–1859), with an additional
US$14 (95% CI 12–16, 100 Rand, 95% CI 86–114) in
family costs from the societal perspective (Table 4).
From the public health system perspective, the mean
direct medical cost per episode managed on the
paediatric ward was US$1139 (95% CI 1062–1215,
8336 Rand, 95% CI 7776–8895), with an additional
US$21 (95% CI 15–27, 155 Rand, 95% CI 111–200) in
family costs from the societal perspective. The mean
direct medical cost of an episode managed in the ICU
was US$6236 (95% CI 4502–7971, 45,649 Rand, 95%
CI 32,952–58,347); none of the seven cases admitted
to the ICU was interviewed regarding family costs.
In each category, three-quarters or more of direct
medical costs were facility and personnel costs, and,
for the paediatric ward and ICU, facility and
personnel costs were driven by length of stay
(Table 4). Family costs accounted for a modest
proportion of total cost per episode for the short-
stay ward (5.3%) and for the paediatric ward (1.8%);
we are unable to estimate the proportion for ICU
cases. Because of longer lengths of stay, HIV-positive
children also had higher direct medical costs per
illness episode in the paediatric ward (P,0.001) but
not in the short-stay ward (P50.56). There were no
differences in family costs by HIV status in the
paediatric (P50.83) or short-stay (P50.61) wards.
Table 2 Characteristics of study participants*
Characteristic Cost study Family impact study
n5745 n5324
Sex, n(%) Female 327 (43.9) 138 (42.6)
Male 418 (56.1) 186 (57.4)
Age
{
,n(%) (1 mth 1 (0.1) -
.1–11 mths 394 (52.9) 90 (27.8)
12–,24 mths 249 (33.4) 154 (47.5)
>24 mths 101 (13.6) 80 (24.7)
HIV status, n(%) HIV-infected 256 (34.4) 67 (20.7)
HIV-uninfected 489 (65.6) 257 (79.3)
Sampling period, n(%) Retrospective only 328 (44.0) -
Prospective only 384 (51.5) 313 (96.6)
Retrospective & prospective 33 (4.4) 11 (3.4)
ALRTI episodes included in analysis, n(%) 1 651 (87.4) 289 (89.2)
2 78 (10.5) 29 (9.0)
3 13 (1.7) 6 (1.9)
4 3 (0.4) -
No. of siblings
{
, median (IQR) - 1 (0–2)
Housing, n(%) Missing information - 6 (1.9)
Informal - 57 (17.6)
Flat - 2 (0.6)
Back garden - 49 (15.1)
House - 210 (64.8)
Trips to hospital
{
, median (IQR) - 2 (1–3)
Mode of transport
{
,n(%) Car - 46 (14.2)
Taxi - 226 (69.8)
Clinic car - 9 (2.8)
Ambulance - 39 (12.0)
Other - 4 (1.2)
Relationship of caregiver
{
,n(%) Mother 302 (93.2)
Father - 2 (0.6)
Grandmother - 16 (4.9)
Other - 4 (1.2)
Overnight caregiver
{
,n(%) Missing information - 24 (7.4)
Mother - 283 (87.3)
Father - 1 (0.3)
Grandmother - 13 (4.0)
Other - 3 (0.9)
*IQR, interquartile range (25th and 75th percentiles);
{
taken from the first episode;because of rounding, some numbers do not total 100%.
Sinha et al. Economic burden of childhood ALRTI
Paediatrics and International Child Health 2012 VOL.32 NO.2 69
Economic burden of ALRTI in urban South African
children
In the base case analysis, it was estimated that
children aged ,5 years in urban South Africa had
424,220 episodes of ALRTI annually, with 3230
fatalities. Treatment was estimated to cost the public
health system US$29,515,100 (216,050,300 Rands),
and an estimated additional US$540,500 (3,956,400
Rands) in costs were borne by families.
Using the upper and lower bounds for plausible
intervals shown in Table 1 (results across the plausible
interval shown within parentheses), results were most
sensitive to the proportion of urban children with
access to medical care (US$26,947,800–32,048,800,
Rands 197,258,000–234,597,500), length of hospital
stay (US$27,503,700–31,522,900, Rands 201,327,400–
230,747,700), incidence of ALRTI (US$28,516,000–
31,507,900, Rands 208,737,500–230,637,700), propor-
tion of ALRTIs which were severe (US$28,449,000–
30,554,500, Rands 208,246,600–223,659,200), and
proportion who were HIV-positive (US$28,183,600–
29,852,700, Rands 206,304,100–218,521,900). Increas-
ing length of stay, ALRTI incidence, proportion of
severe ALRTIs, access to care, and proportion who
were HIV-positive were each associated with a greater
economic burden in these one-way sensitivity analyses.
Of note, the economic burden analysis did not include
productivity losses owing to child mortality.
Discussion
Our analysis suggests that in 1999–2000 it cost South
Africa’s public health-care system $29 million annu-
ally to treat ALRTIs (pneumonia and bronchiolitis)
in urban children ,5 years of age, and that another
half million dollars of costs were borne by their
families. The estimated total public health system
expenditure for children under 5 in 2000 was US$764
million (2010).
20,21
If we assume that the amount
spent on urban children was proportionate to their
population size, then US$439 million would have
been spent in urban settings, of which $29 million
spent on ALRTI management would represent 7%.
This is a substantial economic burden of disease, a
large proportion of which has been vaccine-avertable
by two vaccines since incorporated into the South
African national childhood immunisation schedule,
Haemophilus influenzae type B (introduced in 1999)
and pneumococcal conjugate vaccine (introduced in
2009).
22–24
It is worth noting that our estimated bed-day cost
(US$113), based on a micro-costing study done at a
single urban tertiary-care centre and focusing only on
those hospital units providing paediatric care, is lower
than other investigators’ estimates of US$150 per bed-
day for South Africa, a bed-day cost developed using
gross costing methods and meant to be applicable
across all (paediatric and non-paediatric) care sites.
25
Conversely, the WHO CHOICE bed-day cost for
tertiary hospitals in South Africa is US$71, which is
less than the bed-day cost estimated in this analysis.
Country-level estimates from WHO CHOICE are
developed using ordinary least squares (OLS) regres-
sion models populated with international data and are
meant to be applied to both paediatric and non-
paediatric care settings.
26
The differences between the
Table 3 Selected health resource unit costs
Resource
Unit cost
Rands 2010 US$ 2010
Bed-day costs
Short-stay ward, facility and personnel 813 111.10
Paediatric ward, facility and personnel 826 112.80
ICU, facility and personnel 3,137 428
Diagnostic tests
Complete blood count 35 4.80
C-reactive protein 27 3.70
T-cell subsets 136 18.60
Aerobic blood culture, with and without growth 82 & 47 11.20 & 5.90
Urine culture 47 6.40
Sputum culture 47 6.40
Chest radiograph, per study 203 27.70
Therapeutics
Ampicillin injection, per 1000 mg 32.60 4.45
Gentamicin injection, per 60 mg 6.75 1.65
Trimethoprim-sulfamethoxasole suspension, per 160 mg (trimethoprim component) 0.19 0.03
Oxygen support, per 100 L 0.20 0.03
Procedures
IV line insertion 75 10.20
Urine catheterization 1 0.20
Central venous line placement 539 74
Tracheal aspiration 61 8.40
Suprapubic urine sampling 0.70 0.10
Intubation 27 3.80
Sinha et al. Economic burden of childhood ALRTI
70 Paediatrics and International Child Health 2012 VOL.32 NO.2
estimated bed-day cost in this study and these two
other analyses probably reflects the broader range of
care settings considered by the other two analyses, as
well as the large methodological differences between all
three studies.
Compared with other sub-Saharan African cost-of-
illness studies for childhood ALRTI or pneumonia in
Kenya and Zambia,
8,13
the estimated cost per illness
episode in this study was higher and closer in
magnitude to costs of ALRTI in Latin America,
perhaps because of the middle-income position of
South Africa and many Latin American countries.
6,9
As a single-centre study, we were unable to identify
provincial differences in the delivery of health care or
disease burden, although restricting our analysis to
urban South Africa might have mitigated this limita-
tion. In addition, the economic burden analysis used
country-level data from an international source
19
to
model variations in costs across all care settings,
including primary- and secondary-level facilities.
This study was conducted in 2000–2001 and so
does not reflect the evolution of paediatric health
care in South Africa over the last decade. For
example, revisions to South Africa’s Medical
Schemes Act over the past decade might have resulted
in a decreasing population proportion and changing
case mix receiving care in South Africa’s public
health-care system.
27
Also, it should be kept in mind
that, at the time of the study, Hib conjugate vaccine
had just been introduced, and pneumococcal con-
jugate vaccine had not yet been introduced. HIV/
AIDS is a substantial risk factor for paediatric
ALRTI. This study precedes the public availability
of HIV antiretroviral therapy, as well as the
Table 4 Cost of ALRTI episode by cost component*
Category
Retrospective period Prospective period
HIVzHIV- HIVzHIV-
Paediatric ward costs
Direct medical costs, n 200 193 63 57
Mean (95% CI) Rand 8895 (8025–9765) 7378 (6532–8223) 10,248 (8184–12,312) 7424 (5930–8916)
US$ 1215 (1096–1334) 1008 (892–1123) 1400 (1118–1682) 1014 (810–1218)
Percentage attributed to
Facilityzpersonnel 83.5% 81.9% 81.8% 81.7%
Procedure 1.4% 1.4% 0.7% 0.4%
Diagnostic tests 11.3% 12.4% 11.1% 13.7%
Drugs 3.9% 4.3% 6.3% 4.2%
Family costs, n0
{
0
{
30 33
Mean (95% CI) Rand – – 150 (91–247) 156 (113–216)
US$ 21 (12–34) 21 (15–30)
Percentage attributed to
Travel – – 80.3% 66.5%
Traditional healing – – 12.8% 22.7%
Pre-admission drugs – – 0.0% 0.5%
Work lost by care-givers – – 6.8% 10.4%
Short-stay ward costs
Direct medical costs, n0
{
0
{
64 274
Mean (95% CI) Rand – – 1819 (1691–1948) 1782 (1709–1855)
US$ 249 (231–266) 243 (233–253)
Percentage attributed to
Facilityzpersonnel – – 86.8% 88.2%
Procedure – – 0.4% 0.0%
Diagnostic tests – – 9.7% 7.6%
Drugs – – 3.1% 4.2%
Family costs, n0
{
0
{
53 236
Mean (95% CI) Rand 109 (77–155) 98 (84–114)
US$ 15 (11–21) 13 (11–16)
Percentage attributed to
Travel – – 62.3% 56.2%
Traditional healing – – 24.0% 20.5%
Pre-admission drugs – – 0.0% 1.9%
Work lost by care-givers – – 13.7% 21.3%
ICU costs
Direct medical costs, n1 6 0
{
0
{
Mean (95% CI) Rand 57,451 (–) 43,683 (29,466–58,972) – –
US$ 7849 (–) 5968 (4025–8056)
Percentage attributed to
Facilityzpersonnel 74.3% 76.1% – –
Procedure 4.8% 10.7% – –
Diagnostic tests 9.1% 6.9% – –
Drugs 11.8% 6.3% – –
*Rands 2010, US$ 2010;
{
data not collected; because of rounding, some numbers do not add up to 100%.
Sinha et al. Economic burden of childhood ALRTI
Paediatrics and International Child Health 2012 VOL.32 NO.2 71
contemporary prevention of mother-to-child HIV
transmission in South Africa, with an anticipated
future decline in the number of HIV-infected children
under 5.
28
The introduction of vaccines and changes
in paediatric HIV epidemiology should reduce the
economic burden of ALRTI.
Nonetheless, our study substantiates the consider-
able economic burden imposed by respiratory infec-
tions on South Africa’s public health-care system,
with implications for the cost-effectiveness of vac-
cines targeting these infections. As a simplified
example, if pneumococcal conjugate vaccine had
been introduced close to the time period of this
study, had a vaccine efficacy of 9% against all clinical
ALRTIs,
22
cost US$20–30 per dose in a three-dose
schedule and been received by 69% of eligible infants,
then, considering all under-5 children in one calendar
year only and using the societal perspective, the
implications of the current study’s results would be
that pneumococcal conjugate vaccine would have
been associated with an incremental cost-effectiveness
ratio of yUS$840–1240 per DALY averted,*well
below WHO’s threshold value for highly cost-
effective interventions of one times South Africa’s
per capita GDP (US$3020 in 2000).
29
The unit costs
from this analysis, generated from micro-cost data,
should prove useful to investigators elaborating full
cost-effectiveness models of childhood ALRTI pre-
vention in the contemporary era. Such full models
would incorporate a longer time horizon, model all of
the intervention’s direct and indirect effects, and
represent current epidemiology and health-care pro-
vision, rather than the situation in 2000.
The family out-of-pocket costs appear to be modest –
only 155 Rand (US$21) per case of illness managed on
the paediatric ward. However, these modest costs must
be put in the context of family incomes, given a median
individual monthly income of Rands 2028 among
employed Black Africans in the province in 2001
(expressed in Rands 2010, or US$277).
14
Then,
ALRTI-related out-of-pocket expenses would represent
y8% of monthly income in a single-earner household.
ALRTIs in children under 5 years of age continue
to impose a significant disease burden in low- and
middle-income countries. In this analysis, we have
demonstrated that the economic burden accompany-
ing this disease burden is significant in an upper
middle-income setting, South Africa. Interventions to
prevent ALRTIs and improve its outcomes hold the
promise of averting the heavy cost burden on health
systems and families of these serious infections.
Conflict of interest disclosures
AS received research funding from Wyeth Inc. which
was acquired by Pfizer Inc. in October 2009. She
received travel funding from Pfizer Inc. and an hono-
rarium plus travel funding from GlaxoSmithKline
Biologicals. RK received consultancy funding from
Wyeth Inc. and Pfizer Inc. DS is an employee of
Pfizer Inc. SAM and KPK received research and
consultancy funding from Wyeth Inc. and from
GlaxoSmithKline Biologicals. They have received
honoraria from GlaxoSmithKline. SK, GG, HF
and UG report no conflicts of interest.
Acknowledgments
This work was originally funded by the World Health
Organization, Geneva, with subsequent funding
through Wyeth Inc., Collegeville, PA, which was
acquired by Pfizer Inc. in October 2009. The authors
thank Azadeh Tasslimi, previously at UMDNJ–New
Jersey Medical School, for support with data
management and analysis.
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