Friday, September 6, 2013

The High Cost of Recovering From an A(H7N9) Infection

Influenza A(H7N9) has infected more than 130 people in the People’s Republic of China. It is a severe disease; more than 40 individuals have died. Those individuals that do survive often require long hospital stays including many days in an intensive care unit (ICU). Hospitalization in ICUs is expensive.
For example, the first A(H7N9) case from Guangdong Province, spent 20 days in ICU,  with the hospital costs totaling about 220,000 yuan [1]. In China, the average annual wage is 42,000 yuan.[2] Putting the hospitalization cost for A(H7N9) for this patient in perspective, it would take an average individual in China more than five years to pay off this cost providing 100% of the salary went to pay the hospital bill. 
This individual is not an isolated case. Based on limited publicly available data, 28 of the individuals infected with A(H7N9) from China who recovered were hospitalized between 6-30+ days, with a median hospital stay of 18 days, although not all of them were treated in the ICU. Information is available on 23 of the individuals in China who died from A(H7N9). These 23 individuals were treated in the hospital between 2-30+ days before death, with a median hospital stay of 11 days among these individuals who died. What these statistics indicate is that extended hospital treatment is required for most A(H7N9) patients, up to 30 days with no guarantee of recovery. These data also suggest the extraordinary costs being absorbed by Chinese government to treat these infected individuals. 

Comparison with the USA
In an article published in 2012 in the Annals of Intensive Care, the authors studied the total hospitalization cost for various categories of patients including 23 Influenza A(H1N1)pdm09 patients from Cleveland, Ohio.[3] The total hospital costs in Cleveland in 2009-2010 for treating influenza patients in intensive care units averaged about  $342,000, about 6.5 times the median annual household income ($52,700) in the USA.[4]
ICU care is comparatively expensive both in China and the US and is primarily related to occurrence of acute respiratory distress syndrome (ARDS). ARDS is among the most expensive conditions encountered in the ICU. [4]  ARDS is also  a common occurrence in individuals infect with novel influenza A(H5N1) and A(H7N9). In fact, a recent study of A(H7N9) patients from Zhejiang Province in China showed that 100% of the cases had complications from ARDS.[5]
If a novel influenza pandemic breaks out, many sick individuals will require extended hospital care in ICUs. The cost of this care to governments and health insurance companies will be enormous. The more ominous concern is that if a new influenza pandemic occurs, there will simply not be enough medical facilities to care for all the individuals that may need hospitalization regardless of whether an individual can pay or not. 
[1] Guangdong's first H7N9 patient can be discharged next week, nearly 220,000 yuan treatment fee  h/t Pathfinder
[2] Average wages in China
[3] Relative cost and outcomes in the intensive care unit of acute lung injury (ALI) due to pandemic influenza compared with other etiologies: a single-center study [4] US Census Bureau Quick Facts
[5] Epidemiological, clinical and viral characteristics of fatal cases of human avian influenza A (H7N9) virus in Zhejiang Province, China

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