Health Economics Perspective in Allergy Prevention in Children

Prof Ariyanto Harsono MD PhD SpA(K)Department of Child Health

Airlangga University /Dr Soetomo HospitalSurabaya, Indonesia

Background Prevalence of allergic disease is increasing. Allergies are the most frequent chronic diseases in children

and young adults. The impact of allergies:

o Individual sufferers Impairment in quality of life, sleep and mood,

competence at work or school and overall personal development.

Costso Society as a whole.

Costs

A European Declaration on Immunotherapy

Prof DR Dr Ariyanto Harsono SpA(K)

3

GENETIC FACTOR

• ALLERGEN• INFECTION• POLUTANT

ENVIRONMENT FACTOR

ALLERGIC DISEASESGern JE, Lemanske Jr RF. Immunol Allergy North Amer 1999; 19:233-52

Allergic diseases

A European Declaration on Immunotherapy

Prof DR Dr Ariyanto Harsono SpA(K)

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Prevalence of asthma

Prevalence of asthma symptoms by country among children 13 to 14 years of age according to the 1999-2004 International Study of Asthma

and Allergies in Childhood (ISAAC)

Prevalence of asthma symptoms by country among children 6 to 7 years of age according to

the 1999-2004 International Study of Asthma and Allergies in Childhood (ISAAC) III study.

Asher MI, et  al. Lancet. 2006;368:733-43.

The Rising Incidence of Atopic Dermatitis

• Atopic dermatitis is now one of the most common childhood disorders in the Asia Pacific region

• Its prevalence has increased markedly in the past decade

Adapted from Asher et al, 2006

Change in incidence of atopic dermatitis

Prevalence of allergy

Courtesy of Dr. dr. Zakiudin Munasir, SpA(K)

Economic impact of allergic diseases

• Hospital (in/outpatient)

• Physician services• Medication• Diagnostic tests

Direct costs, medical

• Transportation• Homecare devices• Special diet

Direct costs, non-medical

• Loss of work and school days

• Loss potential earning

• Home modification• Mortality

Indirect costs

Direct costs to society of allergy in Europe (1998 euros)

• Asthma 6.4bn

• Contact dermatitis 2.3bn

• Allergic rhinitis 1.3bn

• Food allergy [???]

Source: European allergy white paper (1997)

Estimated costs of allergic diseases in Europe

A European Declaration on Immunotherapy

HOW CAN WE PREVENT ALLERGIC DISEASES?

Prof DR Dr Ariyanto Harsono SpA(K) 13

Prevention of allergic diseases

Prev

entio

n of

alle

rgic

dis

ease

Primary

Secondary

Tertiary

Primary prevention

Recognize the high risk infants

Nutrition factor in allergy preventionNutrition Recommendation

Breastfeeding Infants should be exclusively breast-fed in the first four months to prevent atopic diseases

Maternal nutrition during pregnancy and/or breastfeeding

Balanced and fully nutritious diet is recommended during pregnancy and breastfeeding. There is no well-documented evidence favoring a recommendation for any type of dietary restriction during pregnancy or breastfeeding (avoidance of potent dietary allergens)

Feeding of children at risk with mother’s milk substitutes

Infants at high risk of allergic disease should be given hydrolyzed formula (partially or extensively hydrolyzed formula).Soy-based infant formula is not recommended for the purpose of allergy prevention.

Introduction of solid food in the first year

Introducing complementary solid foods from around 4–6 months, with no specific avoidance of allergenic foods.

Muche-Borowski C. Allergy prevention. Dtsch Arztebl Int. 2009; 106: 625–31. Prescott S, Nowak-Wegrzyn A. Ann Nutr Metab 2011;59:28–42.

Hydrolyzed Formula

• Systematic review (2005):– Extensively hydrolyzed casein formulas and

partially hydrolyzed whey formulas are appropriate alternatives to breast milk for allergy prevention in infants at risk.

– The use of these formulas in the general population should be considered, and one must weigh cost, compliance, and long-term benefits.

Arch Pediatr Adolesc Med. 2005;159:810-6

Hydrolyzed formula(German Infant Nutrition Study)

Adjusted cumulative incidence of parent-reported physician-diagnosed eczemaVon Berg A, et al. J Allergy Clin Immunol. 2013 Jun;131(6):1565-73

ECONOMIC IMPACT OF HYDROLYZED FORMULA AS ALLERGIC PREVENTION

Three perspectives of economic evaluation

The public

healthcare system (Ministry of Health)

Family

Society

Iskedjian M, et al. J Med Econ.2012; 15: 394-408Iskedjian M, et al. J Med Econ.2012; 15: 378-

93

PARTIALLY HYDROLYZED FORMULA VS STANDARD FORMULA

Costs associated with PHF-W and standard formula for allergy prevention:

Perspective of the Switzerland’s MOH

Cost of for-mula

Physician costs

Treatment costs

Hospitaliza-tion costs

Costs of lab test

PHF-W

14398641 173830 109013 46457 10844

SF 12519931 299444 196925 80029 18681

10000003000000500000070000009000000

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Item

CHF

Expected numbers of cases:PHF-W: 2287; SF: 39040; Avoided cases: 1653

Iskedjian M, et al. J Med Econ.2012; 15: 394-408

Costs associated with PHF-W and standard formula for allergy prevention:

Perspective of the Switzerland’s family

Cost of formula

Physi-cian costs

Treat-ment costs

Hospital-ization costs

Costs of lab test

Cost of time lost

Travel cost

PHF-W

1602980 19314 12113 5162 1205 5019849 221129

SF 1402632 33272 21881 8892 2076 8672290 380506

5000002500000450000065000008500000

Item

CHF

Expected numbers of cases:PHF-W: 2287; SF: 39040; Avoided cases: 1653

Iskedjian M, et al. J Med Econ.2012; 15: 394-408

Cost-effectiveness

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Total cost PHF-W Total cost SFIncremental costs Incremental cost-effectiveness ratio

CHF

• PHF-W vs SF

Iskedjian M, et al. J Med Econ.2012; 15: 394-408

PARTIALLY HYDROLYZED FORMULA VS EXTENSIVELY HYDROLYZED FORMULA

Costs associated with PHF-W, EHF-W, EHF-C for allergy prevention:

Perspective of the Danish family

Expected numbers of cases:PHF-W: 453; EHF-W: 728; EHF-C: 428; Avoided cases: 274 (EHF-W); 26 (EHF-C)

Cost of formula Treatment costs

Cost of time lost

Travel cost

PHF-W 7157386 310399 4621057 287355

EHF-W 26658963 498312 7412350 461447

EHF-C 26594813 292829 4359488 271090

5000000150000002500000035000000450000005500000065000000

DKK

Iskedjian M, et al. J Med Econ.2012; 15: 378-93

Cost effectiveness

PHF-W vs EHF-W

Series1

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Total cost PHF-WTotal cost EHF-WIncremental costsIncremental cost-effectiveness ratio

PHF-W vs EHF-C

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Iskedjian M, et al. J Med Econ.2012; 15: 378-93

pHF-W is not only clinically effective, it is also cost effective – European

Based on the European studies, families with children at risk of atopic dermatitis will save between EUR 624 and EUR 2,200 per year compared with using standard formula

Adapted from Spleindenner, 2011

Number of cases of atopic dermatitis avoided and cost saving from the

perspective of the family

pHF-W is not only clinically effective, it is also cost effective – Thailand and Australia

• ThailandEvery single child with atopic dermatitis represent a direct cost of THB 5,432 (US $ 175)

• Australia

Decision making:1. “ benefit > risk”2. low “cost”3. “applicable”

Choices of nutrition for allergy prevention

1. Breastfed

2. Soy Protein Formula

3. p-Hydrolyzed Whey

4. p-Hydrolyzed

Casein

5. e-Hydrolyzed Whey

6. e-Hydrolyzed

Casein

APPLICABILITY

+

+

+

+

+

+

LOW COST

+

+

+

+

-

-

LOW RISK

+

-

+

+

+

+

BENEFIT

+

-

+

-

-

+

InfantChild

Sensitization

Clinical Manifestation

History of Atopic family

• Breast Milk• pHF

• Probiotik

Primary PreventionSecondary Prevention

Tertiary Prevention• Elimination Diet

• Substitution Formula (AAF/eHF/Soy)

• Steroid, antihistamine• Emergency Treatment• Promising Treatment

• Immunotherapy

Prevention Strategy

SPTIgE RAST

31Prof DR Dr Ariyanto Harsono

SpA(K)

Atopic Dermatitis

Asthma, Allergic Rhinitis

Gastrointestinal Allegy

• eHF• Soy F

Conclusions

• Prevalence of allergic diseases are increasing

• Burden of the diseases includes symptom burden, impaired quality of life and productivity, co-morbidities, complications, and disease management (economic burden)

• Prevention of allergic diseases should be started in early life.

• If breastfeeding is not possible, a partially hydrolyzed formula is cost-effective for infants at high risk of allergic disease.

THANK YOU