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A Prospective Study on the Impact and Out-of-Pocket Costs of Dengue Illness in International Travelers
Yesim Tozan
Yesim Tozan
New York University College of Global Public Health, New York, New York;
New York University Abu Dhabi, Abu Dhabi, United Arab Emirates;
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New York University Abu Dhabi, Abu Dhabi, United Arab Emirates;
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Tyler Y. Headley
Tyler Y. Headley
New York University Abu Dhabi, Abu Dhabi, United Arab Emirates;
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Maquines Odhiambo Sewe
Maquines Odhiambo Sewe
Department of Public Health and Clinical Medicine, Epidemiology and Global Health Unit, Umeå University, Umeå, Sweden;
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Eli Schwartz
Eli Schwartz
Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel;
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Tamar Shemesh
Tamar Shemesh
Sheba Medical Center, Institute of Tropical and Travel Medicine, Ramat-Gan, Israel;
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Jakob P. Cramer
Jakob P. Cramer
Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine and I Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany;
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Kirsten A. Eberhardt
Kirsten A. Eberhardt
Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine and I Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany;
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Michael Ramharter
Michael Ramharter
Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine and I Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany;
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Nicole Harrison
Nicole Harrison
Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria;
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Karin Leder
Karin Leder
School of Public Health and Preventive Medicine, Monash University and Victorian Infectious Disease Service, Royal Melbourne Hospital, Melbourne, Australia;
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Andrea Angheben
Andrea Angheben
Centre for Tropical Diseases, IRCCS Hospital Sacro Cuore–Don Calabria, Verona, Italy;
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Christoph Hatz
Christoph Hatz
Swiss Tropical and Public Health Institute, Basel, Switzerland;
University of Basel, Basel, Switzerland;
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University of Basel, Basel, Switzerland;
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Andreas Neumayr
Andreas Neumayr
Swiss Tropical and Public Health Institute, Basel, Switzerland;
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Lin Hwei Chen
Lin Hwei Chen
Mount Auburn Hospital, Cambridge, and Harvard Medical School, Boston, Massachusetts;
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Cornelis A. De Pijper
Cornelis A. De Pijper
Division of Internal Medicine, Department of Infectious Diseases, Center for Tropical Medicine and Travel Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands;
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Martin P. Grobusch
Martin P. Grobusch
Division of Internal Medicine, Department of Infectious Diseases, Center for Tropical Medicine and Travel Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands;
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Annelies Wilder-Smith
Annelies Wilder-Smith
Department of Public Health and Clinical Medicine, Epidemiology and Global Health Unit, Umeå University, Umeå, Sweden;
Heidelberg Global Health Institute, University of Heidelberg, Heidelberg, Germany;
Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Heidelberg Global Health Institute, University of Heidelberg, Heidelberg, Germany;
Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Although the costs of dengue illness to patients and households have been extensively studied in endemic populations, international travelers have not been the focus of costing studies. As globalization and human travel activities intensify, travelers are increasingly at risk for emerging and reemerging infectious diseases, such as dengue. This exploratory study aims to investigate the impact and out-of-pocket costs of dengue illness among travelers. We conducted a prospective study in adult travelers with laboratory-confirmed dengue and recruited patients at travel medicine clinics in eight different countries from December 2013 to December 2015. Using a structured questionnaire, we collected information on patients and their health-care utilization and out-of-pocket expenditures, as well as income and other financial losses they incurred because of dengue illness. A total of 90 patients participated in the study, most of whom traveled for tourism (74%) and visited countries in Asia (82%). Although 22% reported hospitalization and 32% receiving ambulatory care while traveling, these percentages were higher at 39% and 71%, respectively, after returning home. The out-of-pocket direct and indirect costs of dengue illness were US$421 (SD 744) and US$571 (SD 1,913) per episode, respectively, averaging to a total out-of-pocket cost of US$992 (SD 2,052) per episode. The study findings suggest that international travelers incur important direct and indirect costs because of dengue-related illness. This study is the first to date to investigate the impact and out-of-pocket costs of travel-related dengue illness from the patient’s perspective and paves the way for future economic burden studies in this population.
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Author Notes
Disclosure: L. C. reports personal fees from Shoreland, Inc. and Valneva, Inc., outside the submitted work.
Authors’ addresses: Yesim Tozan, College of Global Public Health, New York University, New York, NY, E-mail: tozan@nyu.edu. Tyler Y. Headley, Department of Political Science, NYU Abu Dhabi, Abu Dhabi, United Arab Emirates, E-mail: tyler.headley@nyu.edu. Maquines Odhiambo Sewe, Department of Public Health and Clinical Medicine, Epidemiology and Global Health Unit, Umeå Center for Global Health Research, Umeå University, Umeå, Sweden, E-mail: maquines.sewe@umu.se. Eli Schwartz, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel, E-mail: eli.schwartz@sheba.health.gov.il. Tamar Shemesh, Sheba Medical Center, Institute of Tropical and Travel Medicine, Ramat-Gan, Israel, E-mail: tamarshem@gmail.com. Jakob P. Cramer, Kirsten A. Eberhardt, and Michael Ramharter, Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine and I Dep of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany, E-mails: cramer@bni-hamburg.de, k.eberhardt@bnitm.de, and ramharter@bnitm.de. Nicole Harrison, Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria, E-mail: nicole.harrison@meduniwien.ac.at. Karin Leder, School of Public Health and Preventive Medicine, Monash University and Victorian Infectious Disease Service, Royal Melbourne Hospital, Melbourne, Australia, E-mail: karin.leder@monash.edu. Andrea Angheben, Centre for Tropical Diseases, IRCCS Hospital Sacro Cuore – Don Calabria, Verona, Italy, E-mail: andrea.angheben@sacrocuore.it. Christoph Hatz, Swiss Tropical and Public Health Institute and University of Basel, Basel, Switzerland, E-mail: christoph.hatz@swisstph.ch. Andreas Neumayr, Swiss Tropical and Public Health Institute, Basel, Switzerland, E-mail: andreas.neumayr@swisstph.ch. Lin Hwei Chen, Travel Medicine Center, Mount Auburn Hospital, and Department of Medicine, Harvard Medical School, Boston, MA, E-mail: lin-hwei_chen@hms.harvard.edu. Cornelis A. De Pijper and Martin P. Grobusch, Division of Internal Medicine, Department of Infectious Diseases, Center of Tropical Medicine and Travel Medicine, Amsterdam University Medical Centers, University of Amsterdam, E-mails: c.a.depijper@amc.uva.nl and m.p.grobusch@amc.uva.nl. Annelies Wilder-Smith, Department of Public Health and Clinical Medicine, Epidemiology and Global Health Unit, Umeå University, Umeå, Sweden, Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany, and Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom, E-mail: wilder-smith@uni-heidelberg.de.
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-
1.
Wilder-Smith A, Gubler DJ, Weaver SC, Monath TP, Heymann DL, Scott TW, 2017. Epidemic arboviral diseases: priorities for research and public health. Lancet Infect Dis 17: e101–e106.
-
2.
Glaesser D, Kester J, Paulose H, Alizadeh A, Valentin B, 2017. Global travel patterns: an overview. J Travel Med 24: tax007.
-
3.
Quam MB, Sessions O, Kamaraj US, Rocklov J, Wilder-Smith A, 2016. Dissecting Japan’s dengue outbreak in 2014. Am J Trop Med Hyg 94: 409–412.
-
4.
Quam MB, Wilder-Smith A, 2015. Importation index of dengue to determine the most probable origin of importation. J Travel Med 22: 72.
-
5.
Quam MB, Khan K, Sears J, Hu W, Rocklov J, Wilder-Smith A, 2015. Estimating air travel-associated importations of dengue virus into Italy. J Travel Med 22: 186–193.
-
6.
Wilder-Smith A, Quam M, Sessions O, Rocklov J, Liu-Helmersson J, Franco L, Khan K, 2014. The 2012 dengue outbreak in Madeira: exploring the origins. Euro Surveill 19: 20718.
-
7.
Sessions OM, Khan K, Hou Y, Meltzer E, Quam M, Schwartz E, Gubler DJ, Wilder-Smith A, 2013. Exploring the origin and potential for spread of the 2013 dengue outbreak in Luanda, Angola. Glob Health Action 6: 21822.
-
8.
Masyeni S, Yohan B, Somia IKA, Myint KSA, Sasmono RT, 2018. Dengue infection in international travellers visiting Bali, Indonesia. J Travel Med 25: tay061.
-
9.
Perez-Molina JA et al. 2017. 6-year review of +Redivi: a prospective registry of imported infectious diseases in Spain J Travel Med 24: tax035.
-
10.
Wilder-Smith A, Boggild AK, 2018. Sentinel surveillance in travel medicine: 20 years of GeoSentinel publications (1999–2018). J Travel Med 25: tay139.
-
11.
Griffiths KM, Savini H, Brouqui P, Simon F, Parola P, Gautret P, 2018. Surveillance of travel-associated diseases at two referral centres in Marseille, France: a 12-year survey. J Travel Med 25: tay007.
-
12.
Liu-Helmersson J, Quam M, Wilder-Smith A, Stenlund H, Ebi K, Massad E, Rocklöv J, 2016. Climate change and Aedes vectors: 21st century projections for dengue transmission in Europe. EBioMedicine 7: 267–277.
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