title: Disease burden of enterovirus infection in Taiwan: Implications for vaccination policy.
abstract: OBJECTIVE
  This study aimed to assess the disease burden and economic impacts of human nonpolio enteroviruses (NPEV) and enterovirus A71 (EV-A71) infection in Taiwan.
  
  
  METHODS
  We included children under five years old (n=983,127-1,118,649) with ICD-9-CM codes 0740 (herpangina) or 0743 (hand-foot-and-mouth disease) from the 2006 to 2010 National Health Insurance Database. Severity of enterovirus infection was assessed from outpatient/emergency visits, hospitalization (with/without intensive care unit [ICU] admission), infection with severe complications, and death. We estimated medical costs and indirect costs from the societal perspective.
  
  
  RESULTS
  The annual rates of NPEV events for children under five years old ranged from 13.9% to 38.4%, of which 5.1-8.8% were hospitalized. EV-A71 accounted for 7.8% of all NPEV medical costs, but 79.1% of NPEV ICU costs. Travel costs and productivity loss of caregivers were $37.1 (range: $24.5-$64.7) million per year. These costs were not higher in the EV-A71 dominant year ($34.4 million) compared with those in the other years. Productivity losses resulting from premature mortality by NPEV infection were $0.8 (range: $0.0-$2.9) million per year, of which 96.3% were caused by EV-A71.
  
  
  CONCLUSIONS
  Diseases associated with NPEV other than EV-A71 were responsible for most of the medical expenses. In addition, caregiver productivity loss by high rates of NPEV infection impacted the society much more than medical costs. A multi-valent vaccine that includes EV-A71 and other serotypes, for example coxsackievirus A16, may be beneficial to the health of children in Taiwan.
authors.affiliation: Epidemic Intelligence Center, Centers for Disease Control, Taipei, Taiwan; Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan. Electronic address: dpliu@cdc.gov.tw.
authors.forename: Ding-Ping
authors.initials: DP
authors.lastname: Liu
authors.affiliation: Division of Acute Infectious Diseases, Centers for Disease Control, Taipei, Taiwan. Electronic address: tanwang@cdc.gov.tw.
authors.forename: Ting-Ann
authors.initials: TA
authors.lastname: Wang
authors.affiliation: Office of Preventive Medicine, Centers for Disease Control, Taipei, Taiwan; Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan. Electronic address: muagi@cdc.gov.tw.
authors.forename: Wan-Ting
authors.initials: WT
authors.lastname: Huang
authors.affiliation: Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan. Electronic address: lychang@ntu.edu.tw.
authors.forename: Luan-Yin
authors.initials: LY
authors.lastname: Chang
authors.affiliation: Division of Acute Infectious Diseases, Centers for Disease Control, Taipei, Taiwan. Electronic address: etwang@cdc.gov.tw.
authors.forename: En-Tzu
authors.initials: ET
authors.lastname: Wang
authors.affiliation: Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan. Electronic address: shcheng@ntu.edu.tw.
authors.forename: Shou-Hsia
authors.initials: SH
authors.lastname: Cheng
authors.affiliation: Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan. Electronic address: mcyang637@ntu.edu.tw.
authors.forename: Ming-Chin
authors.initials: MC
authors.lastname: Yang
mesh_terms: D002675:Child, Preschool; D017281:Cost of Illness; D004196:Disease Outbreaks / Q000191:economics; D029821:Enterovirus A, Human; D004769:Enterovirus Infections / Q000191:economics* / Q000453:epidemiology*; D006232:Hand, Foot and Mouth Disease / Q000191:economics* / Q000453:epidemiology*; D017048:Health Care Costs; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D038801:International Classification of Diseases; D011159:Population Surveillance; D013624:Taiwan / Q000453:epidemiology
keywords: Cost of illness; Economic burden of disease; Enterovirus A71; Hand, foot, and mouth disease; Human enterovirus; Vaccine economics