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Human H5N1 Influenza Infections in Cambodia 2005-2011: Case Series

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Human H5N1 Influenza Infections in Cambodia 2005-2011: Case Series Humphries-Waa et al. BMC Public Health 2013, 13:549 http://www.biomedcentral.com/1471-2458/13/549 RESEARCH ARTICLE Open Access Human H5N1 influenza infections in Cambodia 2005–2011: case series and cost-of-illness Karen Humphries-Waa1*, Tom Drake1, Anthony Huszar1, Marco Liverani1, Khieu Borin2, Sok Touch3, Teng Srey3 and Richard Coker1 Abstract Background: Southeast Asia has been identified as a potential epicentre of emerging diseases with pandemic capacity, including highly pathogenic influenza. Cambodia in particular has the potential for high rates of avoidable deaths from pandemic influenza due to large gaps in health system resources. This study seeks to better understand the course and cost-of-illness for cases of highly pathogenic avian influenza in Cambodia. Methods: We studied the 18 laboratory-confirmed cases of avian influenza subtype H5N1 identified in Cambodia between January 2005 and August 2011. Medical records for all patients were reviewed to extract information on patient characteristics, travel to hospital, time to admission, diagnostic testing, treatment and disease outcomes. Further data related to costs was collected through interviews with key informants at district and provincial hospitals, the Ministry of Health and non-governmental organisations. An ingredient-based approach was used to estimate the total economic cost for each study patient. Costing was conducted from a societal perspective and included both financial and opportunity costs to the patient or carer. Sensitivity analysis was undertaken to evaluate potential change or variation in the cost-of-illness. Results: Of the 18 patients studied, 11 (61%) were under the age of 18 years. The majority of patients (16, 89%) died, eight (44%) within 24 hours of hospital admission. There was an average delay of seven days between symptom onset and hospitalisation with patients travelling an average of 148 kilometres (8-476 km) to the admitting hospital. Five patients were treated with oseltamivir of whom two received the recommended dose. For the 16 patients who received all their treatment in Cambodia the average per patient cost of H5N1 influenza illness was US$300 of which 85.0% comprised direct medical provider costs, including diagnostic testing (41.2%), pharmaceuticals (28.4%), hospitalisation (10.4%), oxygen (4.4%) and outpatient consultations (0.6%). Patient or family costs were US$45 per patient (15.0%) of total economic cost. Conclusion: Cases of avian influenza in Cambodia were characterised by delays in hospitalisation, deficiencies in some aspects of treatment and a high fatality rate. The costs associated with medical care, particularly diagnostic testing and pharmaceutical therapy, were major contributors to the relatively high cost-of-illness. Keywords: Avian, Influenza, H5N1, Cambodia, Cost-of-illness Background have been a number of cases of highly pathogenic avian A future influenza pandemic has the potential to cause influenza (HPAI) subtype H5N1 in the region which has millions of deaths and significantly impact on the global had a serious impact on the poultry industry and associated economy [1]. Southeast Asia has been identified by the livelihoods [3,4]. Whilst mortality in domestic poultry has World Health Organisation (WHO) as being at risk for been very high, it is the potential to cause serious disease emerging diseases including avian influenza [2]. There in humans and the subsequent risk of pandemic spread that causes particular concern [4]. For many patients, * Correspondence: [email protected] HPAI infections follow an unusually aggressive clinical 1Communicable Disease Policy Research Group, London School of Hygiene & Tropical Medicine, Faculty of Public Health, 9th Fl. Satharanasukwisit Building, course, with rapid deterioration and high fatality [4,5]. 420/1 Rajvithi Road, Bangkok 10400, Thailand Between 2003 and 2011, 574 human cases of H5N1 were Full list of author information is available at the end of the article © 2013 Humphries-Waa et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Humphries-Waa et al. BMC Public Health 2013, 13:549 Page 2 of 9 http://www.biomedcentral.com/1471-2458/13/549 reported worldwide [6]. Of these, 60% of the cases and on poultry production are more likely to have difficulty 72% of the deaths have been in the Southeast Asia [6]. in overcoming the costs of culling and restocking [15]. A number of factors contribute to Southeast Asia’s Backyard systems of poultry farming have traditionally vulnerability to infectious diseases including population dominated the industry in Cambodia with close proximity growth and movement, urbanisation, environmental factors of fowl in villages or backyards, minimal biosecurity and such as agriculture, land use, water and sanitation, local consumption [15]. Those living or working closely health system factors and the development of drug with poultry are more at risk of contracting HPAI and resistance [3]. The close contact between animals and incurring illness-related costs. Unfortunately it is the poor humans, particularly in rural settings also enhances the who are particularly at risk of the zoonoses associated vulnerability for outbreaks of zoonotic infections such with livestock keeping; they are also those least able to as HPAI [3]. Countries with the lowest income will suffer afford the cost-of-illness (COI), the resources expended or the greatest burden from disease [3]. Cambodia is one foregone as a result of disease [3,16]. There has been no of the poorest countries in Southeast Asia ranking 138th research published regarding the COI for HPAI in the on the United Nations Development Program Human Southeast Asia. This study seeks to determine the COI in Development Index [7]. Data from the WHO Burden of Cambodia, one of the most vulnerable countries in that Disease, confirms the burden of communicable disease region. weighs more heavily on Cambodia than other countries At the end of 2011, eighteen laboratory-confirmed within the region [8]. cases of H5N1 had been reported in Cambodia [6]. Here The WHO has expressed concern regarding the inad- we present details of these cases, estimate the COI and equacy of global preparedness for an influenza pandemic compare these findings, where possible, with others [3]. Cambodia, like many other developing countries, reported from the region. We do so with the aim of has a limited and likely insufficient level of pandemic better understanding the course of HPAI in Cambodia preparedness to deal with an outbreak of a highly patho- and to provide a foundation on which to develop recom- genic and transmissible strain of influenza [3,9-12]. Based mendations for policies and plans to facilitate pandemic on data collected regarding key health system resources, mitigation. Cambodia has been identified as having some of the largest resource gaps and potentially the highest rate of Methods avoidable deaths when compared to other countries in All cases included in this study were identified between Southeast Asia, including Indonesia, Lao PDR, Taiwan, January 2005 and August 2011 and confirmed as positive Thailand and Vietnam [12]. Cambodia has the lowest for the H5N1 virus using the polymerase chain reaction density of health professionals per capita in the region; (PCR) test by the laboratories of the Institut Pasteur, in insufficient healthcare facilities with no surge capacity; either Phnom Penh or Ho Chi Minh. These cases had equipment shortages including mechanical ventilators; then been reported to the Centre for Communicable and only 0.025% of the WHO recommended national Diseases in the Cambodian Ministry of Health (MOH), stock of anti-viral tablets [3,9-12; Sok Touch, Ministry of Phnom Penh. Data for these patients was collected, with Health Cambodia, personal communication]. Additionally permission from the MOH, through review of medical Cambodia does not have any discretionary budget for records and interviews with staff at the admitting hospitals local level administration for influenza or pandemic during a field visit in December 2011. A general study preparation [10]. To address these issues, the Royal consent form was utilised for in-depth interviews. Verbal Government of Cambodia has developed a comprehensive assent was used in place of written consent for information multi-sectoral pandemic preparedness plan [13]. gathered in the hospital setting from shorter, less formal An influenza pandemic may not only result in significant interactions. loss of life but also have a substantial impact on the This study takes a societal perspective regarding the economy. The 2003 SARS outbreak demonstrated that cost-of-illness for HPAI, meaning indirect costs to patients even a disease with relatively limited health impacts can and their families are included in addition to medical have a major effect on the economy of a region [14]. provider costs [17]. This approach was taken in order to The Asian Development Bank estimate the impact of determine the full economic cost of illness. Data collection SARS in East Asia was approximately US$18 billion and utilised an ingredients approach with micro-costing of suggest that an influenza pandemic could be substantially key elements [17]. Costs were gathered in or converted, more [14]. Compared to SARS, HPAI has not significantly where necessary, to US dollars [18]. Whilst all reported impacted tourism however it has been extremely damaging patients originated in Cambodia and were reported to to the poultry industry [3,14]. The cost to the poultry sector the Cambodian MOH, two patients were hospitalised in in Cambodia, Thailand and Vietnam has been estimated Vietnam. These cases were excluded from the cost-of-illness at US$560 million [14]. Smallholder farmers dependent analysis since data, regarding some aspects of care and the Humphries-Waa et al. BMC Public Health 2013, 13:549 Page 3 of 9 http://www.biomedcentral.com/1471-2458/13/549 associated costs, was not available.
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