ECONOMIC IMPACT of DENGUE in TOURISM in BRAZIL Alvaro Mitsunori Nishikawa1, Otávio Clark1, Victoria Genovez2, Amanda Pinho2, Laure Durand3

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ECONOMIC IMPACT OF DENGUE IN TOURISM IN BRAZIL Alvaro Mitsunori Nishikawa1, Otávio Clark1, Victoria Genovez2, Amanda Pinho2, Laure Durand3

1Kantar Health _ Evidências, São Paulo, Brazil; 2Sanofi Pasteur, São Paulo, Brazil;3 Sanofi Pasteur, Ciudad de Mexico, Mexico PIN29

2013 was considered the base year, since i) a dengue outbreak have occurred in the country, ii) there are data on tourism and epidemiology of the disease, iii) any unusual international events occurred this year. Introduction Methodology

Dengue is an endemic disease that is rapidly growing worldwide. A recent study estimates 2013 was considered the base year, since i) a dengue outbreak have occurred in the that 390 million annual infections occur around the world. country, ii) there are data on tourism and epidemiology of the disease, iii) any unusual Dengue has become one of the major diseases affecting the Brazilian public health.1 international events occurred this year. The rising incidence of the disease and its unpredictable outbreaks result in a significant economic impact in the health system and society. 18 Literature review: Published articles, grey and non-scientific In Brazil, tourism revenue is an important part of the GDP, and the Ministry of Health has Step 1 already recognized the importance of dengue on tourism revenues.2 literature focusing on the impact of dengue on tourism. Estimation on tourism: Number of international tourists arrivals Step 2 and national tourists transits; Expenditure from national and international tourists in Brazil. Calculation: The most conservative impact of dengue on tourism, Step 3 from literature review, was applied to the Brazilian tourism for the Objective most epidemic months (Jan-May).17 Sensitivity Analysis: Deterministic sensitivity analysis on the Step 4 To estimate the economic impact of a dengue outbreak (incidence ≥300 dengue cases most uncertain parameters. /100,000 hab.) on national and international tourism revenues in Brazil.

Results

Step 1: Literature Review Step 2: Tourism Estimation The review was extended to international literature due Tourism data was obtained from official data provided by Ministry of Tourism.3, 4 In 2013, there were 5,813,342 to the lack of detailed analysis published on the impact international tourists and 94,649,146 national tourists in Brazil.3 On average, US$ 863,73*3 are spent per of dengue in tourism for Brazil. international tourist and US$ 1.236,71*4 are spent per national tourists. Most publications estimate the economic impact on Due to the lack of information for the national scenario, the following assumptions were required: tourism (non–observational) 5,6,10,15,16 considering the National tourist performs at least two landings during his travel. impact of Chikungunya outbreak in French Reunion 3% of domestic travels are done by international tourists. This percentage is based on the number of international Island and Mauritius in 2005(observational) 5,6 tourist in Brazil3 divided by the Brazilian population in 2013. Tourists profile published by Minister of Tourism was applied to estimate the number of passengers travelling by car.4 In Brazil, estimation was provided by authorities to the To be conservative, it was considered that only travelers for tourism are impacted by dengue, which was assumed local media during the dengue outbreak in 2008. In 2015, as 50% of national tourists. dengue outbreaks round the whole country significantly Differently of the international evaluation, for the national, just tourists moving to states reporting outbreak were impacted on the tourism in some states and cities, which considered as impacted.3,17 canceled the Carnival festival in order to prioritize the use of the resources in disease control programs.12, 13

Resulting economic Country / Outbreak impact impact of Methods Source Region on tourist (%) dengue outbreak (US$) Step 3: Calculation of Impact Observational communications Insee French b) AIR TRANSPORT 4% 40% and 17% website; a) ROAD TRANSPORT French Impact related to the (2005, 2006, 2007) NA Mavalankar, Buses Own vehicle Reúnion Chikungunya 2005 outbreak 3 5 813 342 respectively 2009; Vasan Number of travelers Number of arrivals3 88 943 789 56 571 458 not informed 2009 % Travelers for tourism (68%)3 3 970 513 Impact related to the Number arrivals per traveler Mavalankar, 44 471 895 28 285 729 not informed moderate Chikungunya % Tourists in the epidemic period (assumption: 2) Mauritius 4% NA 2009; Vasan outbreak in 2005, affecting 3,17 2009 (Jan - May: 46.7%) 1 853 599 1% of the population Discounting international 43 137 738 27 437 157 not informed Rio Grande Statement from authorities tourists travelling inside Authorities in do Norte during dengue outbreak in 30% NA (assumption 3%) Media paper Expenditure (USD2013) (Brazil) 2008 1 601 009 206 Estimation of travelers by Statement from authorities 3 Rio de Janeiro USD 13,9 Authorities in 863.73 / traveler on average) own car (34% airplane; 24% 51 483 955 during dengue outbreak in 15 - 30% Table 1. Summary of observational millionand (2008) non Mediaobser paper- bus; 42% own car)4 (Brazil) 2008 Impact of dengue outbreak Considering travelling Non-vational Observational studies communications from literature review. 64 040 368 113 044 448 (base case: 4%, USD2013) companion4 Based on chikungunya outbreak impact in French % Travelers for tourism 21 568 869 13 718 579 56 522 224 Reunion in 2005, and (assumption 50%) Mavalankar, Gujarat considering that half of the USD 8 million 2% 2009; Vasan non residents Indians are (2008) (India) 2008 % Tourists in the epidemic likely to avoid traveling due 3,17 8 537 002 3 801 837 15 664 035 to infectious disease c) period (Jan-May) outbreak Epidemic states as Based on chikungunya Mavalankar, 37% 40% 40% USD 65 17 Malaysia outbreak impact in French 4% 2009; Vasan Total economic impact of Dengue Outbreak on destination million (2008) Reunion in 2005 2009 Based on chikungunya Mavalankar, Brazilian Tourism USD 363 Tourists impacted by Thailand outbreak impact in French 4% 2009; Vasan 3 196 253 1 505 528 6 202 958 million (2008) dengue outbreak Reunion in 2005 2009 Based on chikungunya International tourism 64 040 368 Expenditure (USD2013: USD 387 4 Florida (USA) outbreak impact in French 4% O’Shea 2013 1236.71/traveler on average) 3 952 835 839 1 861 899 695 7 671 254 803 million (2008) National tourism 539 439 613 Reunion in 2005 Costa Rica Based on dengue outbreak USD 125,2 20% Costa 2004 (Caribe) in Cuba 1977 million (1994) Total 603 479 982 Total revenue, if no outbreaks (USD2013) 13 485 990 337 Table 1. Summary of observational and non observational

studies from literature review. Impact of dengue outbreak 539 439 613 (base case 4%, USD2013) Therefore, for the base case of the current study, a conservative 4% reduction in the international and national tourists flow in Brazil due to a dengue outbreak Figure 1. Dengue outbreak impact on international tourism (a) and national tourism (b) and total economic was assumed. Variation of this parameter was done in impact for the base case (4% of impact) (c). the sensitivity analysis.

*values were updated to 2013 using IPCA (Wide National Consumer’s Price Index ) and exchange rate when necessary– Source: Instituto Brasileiro de Geografia e Estatística, IBGE, Exchange rate 2013 : 1USD = 2,20 BRL

Discounting Non observational studies have evaluated the revenue lost on tourism a dengue National international tourists 1% 3% 5% outbreak could represent, based on the impact reported in the findings from Only travelling inside observational data. In comparison with Brazilian results provided by this analysis, % of travelers National 40% 50% 60% the tourism revenue for Brazil would be the highest, even considering a conservative for tourism Only impact of 4%. Limitations of this study include those directly associated with the International Mar-May Jan-May Dec-Jun % Tourism in the (Air transport) (24.2%) (46.7%) (62.8%) assumptions made for national tourism. epidemic period National Mar-May Jan-May Dec-Jun (Air/Road Transport) (23.9%/14.9%) (39.6%/27.7%) (56.8%/38.9%) Avg Expenditure International 690.98 863.73 1 036.48 (+/-20%) National 989.37 1 236.71 1 484.05 Impact on Tourism Both - 4% 30%

Base case Lower-Bound b) 603 479 982 Upper-Bound 4 526 099 863 650% Impact on tourism Conclusion

482 783 985 -20% 20% 724 175 978 Avg Expenditure (+/- 20%) Dengue outbreak impact on tourism, which is poorly reported in the literature, causes significant revenue losses for Brazil. Considering a conservative decrease of 4% in 333 885 407 -45% 41% 848 493 618 % Tourists in the epidemic period tourism in Brazil due to dengue outbreak, we obtained an economic impact of dengue of US$ 64 million from international tourism and US$ 0.54 billion from local tourism in 495 592 059 -18% 18% 711 367 904 % of Travelers for Tourism 2013, totaling US$ 603.5 million (2013). This economic impact could reach US$ 4.5 billion when the decrease of tourists of 30% from Rio de Janeiro (2008) is considered. 592 357 515 -2% 2% 614 602 448 Discounting international tourists travelling inside These findings can help policy-makers decide on the introduction of a dengue vaccination program in Brazil considering the recent license of the first dengue vaccine, *Lower – and Upper-bound were based on the observational data and limited by the and also considering that in addition to a public health cost burden, dengue could impact maximum of impact reported in Brazilian scenario. the country even in a social sphere, as the tourism sector.

Figure 2. Univariate sensitivity analysis of the impact of a dengue outbreak on tourism in Brazil for the year 2013 , (a ) parameters and (b) results . Acknowledgement: We wish to thank Denizar Vianna for his assistance in producing this analysis.

References

1. World Health Organization; 2015 Available from: http://www.who.int/mediacentre/factsheets/fs117/en/. 9. La epidemia de dengue en Brasil está fuera de control y ya afecta al turismo: Clarín.com; 2008 2. Ministry of Health. 2015. Available from: http://www.blog.saude.gov.br/35357-brasil-vai-promover-acoes-para-prevenir-doencas-transmissi- 10.Rio: turismo registra queda de 20% devido à dengue: Combate a dengue; 2008 veis-durante-olimpiadas-2016 11. Epidemia de dengue provoca redução na atividade turistica do RN, Federação dos municípios do Rio Grande do Norte (FEMURN); 3. Anuário Estatístico de Turismo - 2014, year base 2013, vol 41. Ministry of Tourism 12.Torres A. Surto de dengue cancela Carnaval em SC; gabinete de crise é criado Florianópolis: UOL. Notícias. Saúde; 2015 4. Hábitos de consumo do turismo brasileiro , Ministry of Tourism , 2009 13.Crise, água e dengue fazem Carnaval ser cancelado em 15 cidades: GCN; 2015 5. Vasan SS, Murtola TM, Mavalankar DV (2009) Impact of the 2005‐2006 chikungunya outbreak on tourism revenues of French Réunion. 14. IBGE, Projeção da população por sexo e grupos de idade, em 1º de julho - 2000/2060 6. Mavalankar D, Puwar T, Murtola T, Vasan S. Quantifying the impact of chikungunya and dengue on tourism revenues. W.P.No. 2009- 02-03. 15. O’Shea J, Niekus MR. Potential Social, economic, and health impacts of dengue on Florida. Adv Trop Med Pub Health Int. 2013; 3(2): 32 - 64. Indian Institute of Management Working Paper Series. 2009. 16 Costa, G.A.M.. Economic Impact of Dengue on Tourism; Turismo em Análise, v. 15, n. 1, p. 13-21, may2004 7. Dengue faz turismo cair até 30% no Rio, diz Associação Rio de Janeiro, Folha de São Paulo; 2008 17. SINAN. DATABASE. Ministério da Saúde, Brasil. 8. Dengue é repelente para turistas’, diz jornal argentino: BBC Brasil; 2008 18. Martelli CMT, et al., Economic Impact of Dengue: Multicenter Study across Four Brazilian Regions. PLoS Negl Trop Dis 9(9), 2015

ISPOR - 21st Annual International Meeting - May 2016. This research was funded by Sanofi Pasteur - VG, AP, LD are employees of Sanofi Pasteur, AMN was employed with the consulting group at the time of the analysis. FOR FURTHER INFORMATION: Please contact – Otávio Clark ([email protected]) or Laure Durand ([email protected])