text:
Q: How to Count or Sum the String columns values I have employees attendance table from date 1 to 31 with column names like 1, 2, 3, 4 5.....31
and datatype is nVarchar(5)
I am adding values in those columns (P, H, A) for example:
P = Present
A = Absence
H = Holiday
Now i want to calculate Total (P=Present) in last column that is [TotalPresnets] of Employee.
How to calculate (Count) the string values.

A: Because you made 31 columns, every type of manipulation will involve fetching all 31 of those columns. This is one of a million reasons why this design is going to cause you a lot of pain. So, I have to say you need to consider changing this design!
If you must stick with this, you will end up with code something like this:
select
    EmployeeID,
    (
        case when Day0 = 'P' then 1 else 0 end
        + case when Day1 = 'P' then 1 else 0 end
        + case when Day2 = 'P' then 1 else 0 end
        ...
        + case when Day31 = 'P' then 1 else 0 end
    ) as TotalPresent
from
    Attendance

Another ugly solution would be to use dynamic SQL to generate the query above.
In general, when you are forced into such ugly solutions, it's a good indication that you are approaching the problem wrong.
Note also that this is some 40 lines of code for a very basic operation on a single row. Carrying this technique into the rest of your application is going to cause far more headaches. Imagine if you had to change any logic in here; what should be one line is now 31.
A better design would yield more intuitive / maintainable / readable code:
select
    EmployeeID,
    count(*) TotalPresent
from
    EmployeeDailyAttendance eda
    inner join Days d on d.ID = eda.DayID
where
    eda.Code = 'p'
group by
    EmployeeID

A: SQL Server 2008 is wonderful. Have a look at this examples:
Table for discussion
create table attendance(
empid int,
[1] char(1), [2] char(1), [3] char(1), [4] char(1),
[5] char(1), [6] char(1), [7] char(1), [8] char(1));

insert attendance values
(1,'P','P','H','A','A','P','P','P'),
(2,'P','P','P','P','P','P','P',null),
(3,'P','P','H','P','P','P',null,null);

Your select statement options (expand as required to 31 days)
Nested select
select empid,
 (select COUNT(*)
  from (values([1]),([2]),([3]),([4]),([5]),([6]),([7]),([8])) t(Day)
  where Day='P')
from attendance

Unpivot
select empid, count(day)
from attendance
unpivot (type for day in ([1],[2],[3],[4],[5],[6],[7],[8])) unp
where type='P'
group by empid

A: I have to agree with Mark here.  Your current design makes it very difficult to query by date.  I recommend using a date field and a status field.  You'll have one row per employee, per day, but it will much easier to get the results you're looking for.

A: I know that what folks have said is true. Still, you have to most likely deliver the project rather soon, so i thought i'd give you a hand
<?php
$month = escape_month_securely();
$result = mysql_query("SELECT * FROM table WHERE month = '$month'");

// loop through rows.
while(false !== ($row = mysql_fetch_object())) {
    // loop through cols
    foreach($row as $key => $col) {
        if($key != $userID)
        $split = str_split($col);
        // loop through letters
        foreach($split as $letter) {
            $final_results[$row->userID][$letter]++;
        }
    }
}

print_r($final_results);

/*
 * outputs something like
 * array(
 *  '15' => array(
 *      'P' => 19,
 *      'A' => 4,
 *      'H' => 1
 * )
 *  '13' => array(
 *      'P' => 19,
 *      'A' => 4,
 *      'H' => 1
 * )
 * );
*/

Most likely you are not using PHP but some other language, but the idea is simple. Loop through all columns, skipping only columns that are not days, summing every individual letter and storing it into an array.
Hope this is of use to you.
Regards,
Pedro

A: I posted as a comment, but think it may be better as an answer.
Create a view of your table:
SELECT EmployeeID, '1' As DayOfMonth, Day1 As AttendanceValue FROM TableName
UNION
SELECT EmployeeID, '2', Day2 FROM TableName
....
SELECT EmployeeID, '31', Day31 FromTableName

now you can use a query similar to tenfour's:
SELECT AttendanceValue, COUNT(AttendanceValue) FROM ViewName GORUP BY AttendanceValue


text:
US marines enter the Black Sea aboard the USS Fort McHenry
United StatesEurasiaRussiaUkraine
"To reassure our NATO allies and partners"
By Tom Winter Last updated Jan 7, 2019
Fort McHenry. US Navy photo
Kharkov News Agency:
A large landing ship of the US Navy entered the Black Sea
Kiev, January 7th.
The large landing ship of the US Navy Fort McHenry passed through the Dardanelles and has entered the Black Sea. On board the ship are soldiers of the 22nd expeditionary detachment of the US Marine Corps.
The ship's visit to the Black Sea was announced last month, when some officials in Washington claimed that the sending of American forces to the Black Sea was connected with the provocation of Kiev in the Kerch Strait.
The commander of the Sixth Fleet of the US Navy, which is responsible for the Mediterranean Sea and the adjacent waters of the Atlantic Ocean, Vice-Admiral Liza Franchetti called the ship's entry into the Black Sea necessary for security in the region, as well as for strengthening US ties with NATO allies and partners. [We note that the North Atlantic Treaty Organization members with a Black Sea Coast are Romania, Bulgaria, and Turkey.]
"The passage of USS Fort McHenry confirms our collective determination to provide security on the Black Sea and strengthens our strong relations with NATO allies and partners in the region," the admiral posted on the Sixth Fleet Facebook page.
We note that NATO warships periodically enter the Black Sea. So, at the end of December 2018, Britain sent a ship to Odessa. As British Defense Secretary Gavin Williamson said, London thereby "sent a signal to Russia." In addition, he called the presence of the ship in the region a sign that Ukraine "can count on a reliable partner in the United Kingdom."
In turn, the Russian embassy in London criticized the decision of the British authorities to incite Kiev to the next military provocations under the pretext of "resolving the internal Ukrainian conflict."
It is curious that the so-called British "signal to Russia" was ridiculed even by the American magazine The National Interest. As the author noted, the UK sent a multi-purpose hydrographic ship to Odessa that is capable of performing only scientific tasks, being armed only with two twenty-millimeter cannons. According to the magazine, even the boats of the Ukrainian Navy, which organized a provocation in the Kerch Strait, had better armament. Note: we found the article. Click on it — it's a fun read.
Black SeaFort McHenryNATOUS Navy
Tom Winter1431 posts 0 comments
Contributing editor and volunteer translator Tom Winter, retired Classics professor, monitors the news in 6 languages, and sometimes cannot help writing satire, since that's what today's news mostly deserves
American Stocks Inspected After US Ship Entered Russian-dominated Black Sea
US Preparing a New Intervention in Venezuela But Maduro Will Overcome Imperialist Aggression
MAJOR: Turkey admits possibility of abandoning NATO
Asian NATO: Could China create a military alliance with its neighbors?
HERE WE GO AGAIN: Useless and Over-priced, Row with Lockheed Martin Means Interrupted…
JUST TO TURKEY? S-400 to be delivered to other Middle Eastern countries

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It's fun to play with the latest shiny new object and marketing tools, but remember marketing success rarely happens because of the tool. Success happens because of what the people and process you have in place do with the tool. Invest in your people, please.


text:
Home » News » Even in Polarized U.S., Sequel to Gore Climate Doc Has Potential to Engage Millions
Even in Polarized U.S., Sequel to Gore Climate Doc Has Potential to Engage Millions
The long-awaited sequel to "An Inconvenient Truth" — which will be screened at Yale on July 28 — arrives at a time when the U.S. is even more polarized on climate change than it was a decade ago. Nonetheless, a Yale researcher who studies public opinion on climate change says the film, if done well, has the potential to engage millions of Americans.
By Kevin Dennehy
"An Inconvenient Sequel: Truth to Power," the sequel to "An Inconvenient Truth," will be screened at 6 p.m. July 28 at the Yale School of Management, 165 Whitney Ave., New Haven. More about the event
With his 2006 documentary, "An Inconvenient Truth," former Vice President Al Gore helped raise climate change as an issue of concern — at least for some Americans.
For all its success and acclaim, researchers at Yale found that only about 10 percent of country saw the film. And to date most Americans don't consider climate change a top national priority despite mounting scientific evidence of its far-reaching impacts.
Anthony Leiserowitz
Yet as the film's long-awaited sequel, "An Inconvenient Sequel," opens across the country this week — including the Connecticut premiere at Yale on July 28 — there is an opportunity to engage millions of Americans, says Anthony Leiserowitz, Director of the Yale Program on Climate Change Communication.
In an interview, Leiserowitz, whose "Global Warming's Six Americas" research has examined how different audiences within the public respond to this issue, says that about 9 percent of Americans will likely remain "dismissive" of climate change regardless of what the film presents. But if the story is told well, the film could engage many other Americans.
"Most people just don't know much about the issue and some are skeptical about it because of political reasons," Leiserowitz said. "But they're not opposed to having a constructive conversation. That's part of the complicated political and cultural landscape in which this new film lands."
On July 28, New Haven will be one of several U.S. cities to premiere the new film. The screening will begin at 6 p.m. at the Yale School of Management, 165 Whitney Ave. After the screening, Leiserowitz and Kalee Kreider, UN Foundation senior climate advisor and former communications director for Gore, will give brief remarks and answer questions.
Tickets are available through EventBrite. (The film premieres at BowTie Cinemas on August 3.) The event is hosted by YPCCC, the Yale Center for Business and the Environment, and the Citizens' Climate Lobby of Greater New Haven.
Here is the interview.
Q: Many Americans are familiar with the story of Al Gore's "An Inconvenient Truth" and its impact on American audiences. What story is he telling with his new film, "An Inconvenient Sequel"?
ANTHONY LEISEROWITZ: I haven't seen it yet so I don't fully know. However, my understanding is that it provides an update on how the climate has changed in the decade since the first film was released. I believe it also includes a much greater emphasis on solutions.
In the first film there were basically two stories. One was about climate science and climate change — the famous Al Gore slideshow. The other was Al Gore's personal story: the story of a leading politician who came from a tobacco-growing family in Tennessee, interwoven with what the tobacco industry had done to create doubts about the impacts of smoking and how those same principles were adopted by the fossil fuel industry to confuse the public about climate change. It was more a biopic than a science documentary. Yet "An Inconvenient Truth" did not talk much about solutions, and it received a lot of criticism for that. It focused on the gravity of the problem and some of the worrying aspects of the problem without providing a complementary sense of what we can do about it. In this film, I hope Gore will highlight what people around the world are doing, what policymakers have done, what companies are doing.
This is important because our research has shown that there's a "hope gap"; even among those Americans who are most alarmed about climate change – they often don't know what to do about it. I hope that this film will help fill in that knowledge gap.
Q: So often we hear that simply sharing horror stories — or for that matter, focusing simply on scientists and other talking heads — just isn't an effective way to convince people of the urgency of the problem.
LEISEROWITZ: It's important to think in terms of audience. First off, I would actually disagree that scientists talking about climate change or communicating the science of climate change simply doesn't work. That's not true — it can't be true. You and I are talking about the issue right now; most people in the US have heard of and know at least a little about the issue; some climate policies have been enacted, and the world just signed an international agreement to limit global warming. Yet most communication about climate change to this point has been dominated by the discourse of science and policy and economics. So you can't say that it doesn't work at all.
But I think it is appropriate to say that communicating the science and risks of climate change has only worked well for a limited set of audiences. Those audiences have tended to be knowledgeable about the issue and more interested about the issue in the first place because of their underlying values. Many, many environmentalists have engaged this issue and decided it is critical because of what the scientists are telling us. So it's not that just talking about the science doesn't work. It just works with a certain set of people. And unfortunately, that hasn't been enough.
In broad-brush terms the primary voices that we've heard talking about climate change have been scientists, environmentalists, and some liberal politicians — Al Gore being Exhibit A. And they deserve enormous credit for getting this issue as far as they have. However, it's also clear that it hasn't been enough from a political standpoint. That just because it has appeared in newspapers and just because most people have heard about climate change doesn't mean they understand how urgent it is to take action now. And that the decisions we're making now are going to have very significant, long-term consequences. That effort to communicate thus far has not gone far enough, it hasn't reached enough people, and it hasn't engaged enough people.
So as you start to think about other audiences, those old approaches of just talking about the science, or just talking about the impacts on non-human nature — like, to be simplistic, the impact on polar bears — has worked with a small segment of global society, but only a small segment. The real challenge is how do you connect this issue with all those other audiences who are more motivated by other values or other concerns. Whether this new film can help expand that conversation remains to be seen.
Q: You've done a lot of research on which climate communication strategies have proved effective in reaching people and why. In fact, you studied the impact of "An Inconvenient Truth." What did you learn?
LEISEROWITZ: We basically found that about 9 or 10 percent of the American public saw the original film, which made it one of the most successful documentaries of all time. Most documentaries are seen by a couple-thousand people and then disappear. By comparison, "An Inconvenient Truth" was enormously successful. However it also means that 90 percent of the country did not see it.
When we then analyzed who saw it, we found that they tended to be women, well-educated, liberal Democrats, et cetera. What many people say when they hear that is, "Aha, he was preaching to the choir!" I always find this religious metaphor problematic. But if we're going to go with that metaphor, it's not very accurate. The choir is composed of people who show up several times a week to study, practice and memorize the hymns so they can perform during services. To translate to climate change, that would be the people who live and breathe climate change 24-7. These are the people who are constantly thinking about and working on it because it's their lives. That's not who Gore predominantly reached with this film.
Al Gore in "An Inconvenient Truth"
If you're going to stick with the religious metaphor, I think he reached "the congregation." Most of the viewers were mainstream liberal Democrats. They were people who had heard of climate change before and maybe had a sense that it was an important issue, but they had never really learned much about it. Their primary concerns were more mainstream Democratic issues, like civil rights, women and labor rights, health care, etc. They went to that film because of its protagonist. They liked Al Gore, they had voted for Al Gore, they trusted Al Gore. In fact they were willing to plunk down $12 or so to basically watch him give a slide show. And they were treated to a powerful experience and came out engaged and motivated. Gore and that first film deserve a lot of credit for activating the liberal Democratic base.
The film was also seen by many political elites. I think most elected officials in Congress and across the country saw that film and so they, too, learned something about climate change that they didn't already know. And of course it had a tremendous influence internationally. Again, because Gore was the former vice president of the United States, who came within a whisker of becoming president, the film got seen by an elite set of decision-makers that most films don't. The Academy Award and the Nobel Peace Prize just amplified the effect.
Q: Of course it also politicized the issue of climate change as it had never been before.
LEISEROWITZ: Yes, in many ways. It helped polarize the issue. In terms of public opinion, Democrats and Republicans were not very far apart from each other on climate change up until 1997. That year was a critical moment; that's when VP Gore went to Kyoto, Japan and signed the Kyoto Protocol, which for the first time aimed to put legally binding emissions reduction obligations on the United States and other major polluters. President Clinton never submitted it to the Senate for ratification, however, because it was clear that the Senate was not going to pass it. But that moment and the political furor it sparked was the moment at which the two parties began to diverge and the partisan gap has since just gotten wider and wider ever since. "An Inconvenient Truth" was a part of that polarization because many Americans increasingly saw this issue through partisan, political lenses rather than a scientific or environmental lens.
It's the double-edged sword effect of "An Inconvenient Truth." For all those people who went to that film because they liked and trusted Al Gore, there were just as many people who did not see the film, and in fact dismissed the film, because it was about Al Gore. And that's where you can't separate the messenger from the message. You can't divorce Gore from his political career. He was vice president to Bill Clinton, who was an incredibly polarizing figure in American politics at the time. Gore himself became the subject of heated criticism from the Republican right. And then he became a protagonist in the most hotly contested presidential race in modern history. The film also came out around the time Gore started speaking out publicly in opposition to the George W. Bush administration, for instance the decision to invade Iraq. And most people just aren't very good at compartmentalizing. It was very difficult for some people to say, "You know, I detest Al Gore for his political views, but when he starts talking about climate change he's pretty smart."
Who knows how the country will respond to the new film, but much of this hasn't changed. If anything climate change politics is even more politicized than it was 10 years ago.
Q: For these reasons it seems highly unlikely that the film will convince those who are so entrenched in their opposition to climate action. But based on your research, how many people fall into that category? And what share of the American public is willing to listen to this story, even if Al Gore is again the messenger?
LEISEROWITZ: For one thing, it just has to be a good film. If it's not a good story then forget about it, nobody will watch and nobody will be inspired by it. And we won't know that until we actually see it. But assuming that it's a good film, the challenge is how they've constructed it. Again, if it's all Al Gore-all-the-time, it's going to limit the audience to those people who like him, trust him, and are willing to even watch the film. It's possible that the film is so good that even conservatives will find lots to love in it, but many of them won't even go over the threshold of watching the film because they still dislike Gore.
But he has the potential to reach many millions of Americans who are beyond the 18 percent that [the Yale Program on Climate Change Communication] has labeled as "the Alarmed" in our Global Warming's Six Americas framework [According to their analysis, the Alarmed are fully convinced climate change is happening and are committed to taking action]. The next major group in that research is "the Concerned." This group, which is 34 percent of the country, also thinks climate change is happening, human-caused and a serious problem, but they tend to think of it as distant in time and space. Gore could potentially help convince those folks that, no, it's here and now. If he does nothing more than reach that audience with this film, then it would be a tremendous accomplishment.
The next group of people we identify — which is 23 percent of the country — is "the Cautious." They're still trying to figure out if global warming is real or not, human or natural, a serious problem or not. If it's a well-crafted film he could potentially reach many of those people. At least those who trust him enough to listen to him. He can get them more engaged as well.
Q: What media have most effectively told this story in a way that has engaged the greater public? Any particular projects?
LEISEROWITZ: Well, in terms of the overall trajectory of communicating this issue, the most important messenger has been news reporters. The reason most Americans have heard of climate change and at least know a little something about it is because of news reporting. It's not because of "An Inconvenient Truth." It's because of this long, multi-decades body of work done by the nation's reporters. They deserve credit, too, for building that basic level of understanding and awareness. It's not nearly enough, but let's at least recognize that they've created a foundation of public understanding, though it's not evenly distributed — there are many millions who are really engaged, and many others who don't know much at all. But the point is that the fact most of American society knows something about the issue is predominantly because of the news media.
Q: You also evaluated the impact of "The Day After Tomorrow," a feature film about the global impacts of climate change. How effective was that in reaching people?
LEISEROWITZ: It's arguable that in some ways it had a bigger impact on public opinion — not "elite" opinion, but public opinion — than "An Inconvenient Truth." And that's simply because at the time it was one of the 50 highest grossing films of all time. It had a far larger audience than "An Inconvenient Truth" ever did and made way more money, too. And it told a story of climate change through fiction — not as a biopic or scientific story, but a story with characters and relationships and all against this backdrop of climate-related disasters happening across the world. Clearly the film took a lot of artistic license with the science, but climate change was the key driving dynamic of the film. And it introduced Americans to a different conceptual model of climate change. In our study we found that Americans who saw the film became more likely to say that climate change is real, that it's human-caused, that they were worried about it, they became more supportive of policy action, and were more willing to take action themselves.
Even more interestingly, until that time the dominant way that climate change had been described in the media was as a slow, gradual, incremental, and linear warming trend that eventually, some day in the distant future, would become a serious problem. "The Day After Tomorrow" drew on relatively new climate science at the time that demonstrated that that is not how the climate system works. If you look back over the past million years, the climate system doesn't change slowly, incrementally. There are all sorts of thresholds and abrupt events. The more recent science tells us that the climate system is capable of abrupt, catastrophic change from a human perspective.
And "The Day After Tomorrow" introduced this new concept of climate change to a mass audience. It did so in a very Hollywood blockbuster-y kind of way — including compressing things that would probably unfold over hundreds of years into the course of a few weeks or having the Northern Hemisphere suddenly enter a deep freeze. But nonetheless, the movie did shift watchers' understanding of how the climate system works.
Q: It comes back to what you said earlier: the power of storytelling. There's obviously an incredibly important story to tell with this issue. If you do it powerfully, if you do it clearly, you can move people, regardless of whom they voted for.
LEISEROWITZ: Yes, at least to some extent. People still bring their pre-loaded beliefs and values to the movie theater. And those beliefs and values can prevent them from walking into the theater in the first place. If you're a hard-core climate denier, you're probably not going to go see "The Day After Tomorrow" or "An Inconvenient Truth." And even if you do see it, you're probably not going to be convinced because you're already so committed to your worldview. But that's not most people.
And that's important to remember. In the Six Americas framework, only 9 percent of Americans are "Dismissive," meaning that they think scientists are just making this up, that it's all a hoax. That's not most people. Most people just don't know much about the issue and some are skeptical about it because of political reasons. But they're not opposed to having a constructive conversation. I think that's the complicated landscape in which this new film lands. So we'll see how it does. We're incredibly lucky to have the opportunity to premiere the movie for the New Haven community on opening day. It should be fun!


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George Russell Is Your 2018 Formula 2 Champion
Posted on November 24, 2018 | by Dan Thorn
Much like in GP3, there was a technically a chance that the F2 championship leader heading into this weekend could lose it, but it was very unlikely. Russell tightened his grasp on the title by taking pole position and four extra points, leaving title rival Alexander Albon relying heavily on luck to take the championship to the final race on Sunday.
At the start Albon had some luck but unfortunately for him, it was of the bad variety – he stalled on the grid. So did teammate Nicolas Latifi, who was hit hard by an unsighted Arjun Maini. Both drivers were fine, but the accident led to a safety car and a lengthy clean-up operation. Albon got going again but his race was essentially ruined as he hoped for a safety car that would never come.
That was a big one… #F2 pic.twitter.com/Ed7I5D42aH
— Formula 2 (@FIA_F2) November 24, 2018
Russell had lost the lead to Nyck de Vries at the start but looked faster once the safety car came in. Despite only needing to cruise to the end to take the title he had a go at taking the lead, even making contact with De Vries. During the pit stop phase, Russell seized the initiative and pinched the lead back with the undercut before cruising off to his seventh win of the season and securing the championship in the process.
It's been quite a year for Russell. To win the F2 championship so convincingly in one of the most talented F2 fields for years is quite the achievement. He also joins Nico Rosberg, Lewis Hamilton, Nico Hulkenberg and Charles Leclerc as a driver who won the F2/GP2 championship in their rookie year – and they've all gone on to do pretty well in F1. It's no wonder Williams has snapped him up for next year!


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This international benchmarking event brings together several thought leaders in the Supply Chain & Risk Management spheres to assist you to derive maximum benefit from this unique interactive seminar.
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• Modeling the economic value of effective supply chain risk management.
• How a proactive partnership between Shipper & LSP can mitigate the risk for both Parties!


Summary from Goodreads: Inspired by the sigil from the award-winning television series Game of Thrones, this official book contains a full-sized 3D House Tragaryen Dragon mask and wall mount. Assemble it yourself from the beautifully illustrated push-out pieces, then wear it, mount it on the wall, or simply admire it. And remember the House Targaryen motto: "Fire and Blood."
Review: This was a really fun project. The quality of the paper was great. It was thick and I had no problem with tearing it away from the page. It folded easily as well. The instructions were easy enough to follow. The only complaint that I had was the numbers weren't in order making me have to search for what went next. Total build time was about three and a half hours.
The total size was way bigger than I expected. You can actually wear the mask, which I knew from the beginning, but seeing it put together is a magnificent thing. The mounting portion was easy to use and the mask slips off and on easily. It was fun from start to finish.


text:
Government carbon trading scheme downsized
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Health Minister's briefing book that the government didn't want you to see
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Pipelines of information, the real issue of election 2013
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Anyone working at the Ministry of Labour?
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The British Columbia Government and Service Employees' Union represents more than 25,000 government workers in B.C. and on Sept. 27…


If you're looking for a strong central character and are tired of female characters being portrayed as helpless, always waiting on a man to save or rescue them rather than doing the job themselves, then Shannon Kirk's The Method might be the book for you.
You're sixteen, you're pregnant and you've been kidnapped.
If you're anyone else you give in, but if you're a manipulative prodigy you fight back in the only way you can. You use what you've been given against your captors.
You have only one chance to save your life and that of your unborn child. You're calculating, methodical, and as your kidnappers are about to discover, they made a big mistake in abducting you.
It was the book's blurb that first made me want to read The Method. The premise is as intriguing and different as its main protagonist. A pregnant teen doesn't sound like your average victim, so while I had my suspicions about why she was targeted, I needed to know for certain what and who were behind her disappearance. And, as quickly becomes apparent, her kidnappers might have chosen the wrong girl. If they thought they were choosing a vulnerable and troubled teenager, they're about to find out the extent to which appearances can be deceiving and just how fatal an error underestimating someone is.
For our narrator is anything but victim material: she's already survived one traumatic event in her childhood. She has been raised to be one of life's survivors. That, together with the pretty unusual skill-set she's honed, means that this girl is about to turn her time in captivity into one big science project. And while some of her calculations are of their nature repetitive, as she finds a pattern to her days, there are also enough slight twists and upsets that this isn't a huge problem. Besides, it's interesting to try and work out if and how she'll use each asset she identifies and labels throughout the book, and here Shannon Kirk will misdirect you, before reaching Show and Tell day.
That's not to say there weren't aspects of The Method that were problematical for me: I baulked at what causes the agents' delay in getting to the place where our girl is being held. And I questioned the lack of exercise and fresh air she enjoyed, along with the restrictive diet, while appreciating that allowing one and altering another could have risked the kidnappers being exposed for what they were.
The Method is a refreshingly different take on a kidnapping drama: where the victim refuses to be one and instead turns the tables on her abductors. She can play the demure, helpless female but she's steely and fighting all the time: she's fighting against the monotony of her days in confinement, the boredom she knows is her enemy, the heat of her cell, the hate she feels coursing from, and back towards, her captors, and an inbuilt countdown clock telling her her time is running out. The Method has at its core a brutal crime committed by desperate people, who are pitted against their poorly chosen victim: a young mother-to-be using who she is and what she knows together with what she finds around her to create a safe place for her and her unborn child, and to transform herself from victim to survivor once more. It's an experiment not without its setbacks and false data, but for being conducted out in the field, it's certainly far more entertaining than any lab-based control. Recommended.
The Method by Shannon Kirk is published by Sphere, an imprint of Little, Brown, in the UK. It is available as an ebook and audiobook and in paperback and you can buy it from Amazon UK, Audible UK, Foyles, Hive (supporting your local independent bookshop) and Waterstones.
Shannon Kirk is a practicing attorney and law professor. She has been honoured three times by the Faulkner Society in the William Faulkner-William Wisdom Creative Writing Competition. She lives in Massachusetts with her husband, a physicist, and their son.
My thanks to the publisher for sending me a review copy of The Method.


text:
Study design.
Research procedures.
Data collection and management.
Analytic framework.
Standardization of costs across countries.
Statistical analysis for cost per dengue case.
Aggregate national and regional dengue cost estimates.
Ethical considerations.
Role of the funding source.
Demographic and illness characteristics.
Use of medical services.
Economic costs of a dengue case.
Aggregate national, regional, and global cost of officially reported cases in eight countries.
Location of study sites.
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Immunological Properties of Antivenins
I. Bivalent Cerates cerastes and Cerastes vipera Antivenin
Authors: F. Hassan and M. F. S. El-Hawary
The Results of Recent Studies of Hookworm in Eight Southern States
Authors: Alvin E. Keller, W. S. Leathers, and Paul M. Densen
Intestinal Parasite Infections of the Ambulatory White Clinic Population of New Orleans
Authors: Ernest Carroll Faust and William Hugh Headlee
Approved Laboratory Technic. Clinical, Pathological, Bacteriological, Serological, Biochemical, Histological
Prepared under the auspices of The American Society of Clinical Pathologists. By John A. Kolmer, M.D., Dr.P.H., D.Sc., LL.D., and Fred Boerner, V.M.D. Assisted by C. Z. Garber, A.B., M.D., and Committees of The American Society of Clinical Pathologists. Pp. I–XXII. 1–663. D. Appleton and Company, New York and London, 1931
Author: Charles F. Craig
Antibodies to the PF155 Antigen of Plasmodium falciparum: Measurement by Cell-ELISA and Correlation with Expected Immune Protection
Authors: Philippe Deloron, Jacques Le Bras, Jean Savel, and Jean Pierre Coulaud
Cost of Dengue Cases in Eight Countries in the Americas and Asia: A Prospective Study
Jose A. Suaya1, Donald S. Shepard1, João B. Siqueira1, Celina T. Martelli1, Lucy C. S. Lum1, Lian Huat Tan1, Sukhontha Kongsin1, Sukhum Jiamton1, Fàtima Garrido1, Romeo Montoya1, Blas Armien1, Rekol Huy1, Leticia Castillo1, Mariana Caram1, Binod K. Sah1, Rana Sughayyar1, Karen R. Tyo1, and Scott B. Halstead1
1 Schneider Institutes for Health Policy, Heller School, Brandeis University, Waltham, Massachusetts; Federal University of Goiás, Goiania, Brazil; University of Malaya Medical Center, Kuala Lumpur, Malaysia; Mahidol University, Bangkok, Thailand; Ministry of Health and Social Development, Caracas, Venezuela; Ministry of Health and Social Assistance, San Salvador, El Salvador; Instituto Conmemorativo Gorgas de Estudios de la Salud, Panama City, Panama; The National Dengue Control Program at the National Center for Malaria, Phnom Penh, Cambodia; National Health Laboratory, Guatemala City, Guatemala; Pediatric Dengue Vaccine Initiative (PDVI), International Vaccine Institute, Seoul, Korea
Despite the growing worldwide burden of dengue fever, the global economic impact of dengue illness is poorly documented. Using a common protocol, we present the first multicountry estimates of the direct and indirect costs of dengue cases in eight American and Asian countries. We conducted prospective studies of the cost of dengue in five countries in the Americas (Brazil, El Salvador, Guatemala, Panama, and Venezuela) and three countries in Asia (Cambodia, Malaysia, and Thailand). All studies followed the same core protocol with interviews and medical record reviews. The study populations were patients treated in ambulatory and hospital settings with a clinical diagnosis of dengue. Most studies were performed in 2005. Costs are in 2005 international dollars (I$). We studied 1,695 patients (48% pediatric and 52% adult); none died. The average illness lasted 11.9 days for ambulatory patients and 11.0 days for hospitalized patients. Among hospitalized patients, students lost 5.6 days of school, whereas those working lost 9.9 work days per average dengue episode. Overall mean costs were I$514 and I$1,394 for an ambulatory and hospitalized case, respectively. With an annual average of 574,000 cases reported, the aggregate annual economic cost of dengue for the eight study countries is at least I$587 million. Preliminary adjustment for under-reporting could raise this total to $1.8 billion, and incorporating costs of dengue surveillance and vector control would raise the amount further. Dengue imposes substantial costs on both the health sector and the overall economy.
Dengue fever, a viral infection transmitted by the Aedes aegypti mosquito, is a rapidly growing public health problem in tropical and sub-tropical countries. A large share of the world population is at risk, as over 2.5 billion people live in affected areas,1 and an additional 120 million people travel to affected areas annually.2 The annual number of dengue infections is estimated at 50 to 100 million.2–5 Cases reported to the World Health Organization (WHO) over the past four decades show an upward trend, partly resulting from an increased spread of vector mosquitoes and increases in total human population, including specific increases in urban populations at risk of dengue infection.6 In preliminary studies, potential dengue vaccines7 and certain vector control strategies8 were highly cost effective, but more and better cost information are needed to evaluate preventive interventions in multiple settings.
Cost of illness studies quantify the economic value of resources lost because of disease or consumed in its prevention, treatment, and care.9 Endemic and epidemic dengue imposes economic and social stress on health care systems, affected households, and society at large. Previous cost studies have been limited to a single country and did not address all these associated economic losses. 10–17
The objectives of this study were to measure the cost of a dengue case (either ambulatory or hospitalized) comprehensively in several countries in Asia and the Americas, collecting data prospectively using a common protocol, which included data on lost productivity, school absenteeism, and unpaid time of caregivers. The countries participating in this collaborative study represent 64% of worldwide reported dengue cases. Therefore, this analysis provides some indication of the global costs imposed by dengue illnesses. 7,18,19
We conducted prospective health care facility-based studies on disease burden and cost of dengue illnesses in eight endemic countries. Five of the countries were in the Americas (Brazil, El Salvador, Guatemala, Panama, and Venezuela) and three were in Asia (Cambodia, Malaysia, and Thailand) (Figure 1).
The study population consisted of patients with febrile illness that met the WHO clinical case definition for dengue. 20 In Panama and Venezuela, only laboratory confirmed dengue cases were included. Investigators chose age groups and facilities based on dengue endemicity and access in consultation with national authorities (see Table 1). All sites included children (< 15 year of age) and five also included adults. All sites enrolled patients admitted to major provincial or national reference public hospitals. Six sites (those in urban areas) also enrolled ambulatory patients from outpatient facilities linked to the selected hospitals. In Brazil, patients attending private facilities were also recruited into the study. The studies used a core protocol under the supervision of a coordinating institution. This protocol sought to document, but not to change, patterns of visits and hospital days.
Patients were selected consecutively or systematically (where patient volume exceeded interviewer capacity). Selected patients or legal guardians (for children) were invited to participate, asked to sign an informed consent form, and then enrolled in the study. Although the number of individuals choosing not to participate in the study was minimal, no systematic effort was made to characterize these individuals. Recruitment periods varied by country, extending from September 2004 through January 2007, with most patients enrolled during the 2005 dengue season.
We developed, piloted, and translated (into Khmer, Malay, Portuguese, Spanish, and Thai) a patient questionnaire. This questionnaire documented demographic and socio-economic data for patients and other household members, characteristics of the illness episode and its effects on health status, use of medical services, work and school absences, hours of patient care provided by household members, household spending, and household income lost. We abstracted medical records of hospitalized patients to obtain clinical data, including length of hospital stay. Additionally, we used a hospital cost form to collect each facility's annual operating expenses, number of beds, occupancy rates, and number of emergency and outpatient visits for calculating unit costs.
Patients were interviewed by a trained health interviewer using the patient questionnaire. Each study participant had a final interview around or after the time of his/her recovery. In six countries, an additional interview was administered during the acute stage of illness. All patients received at least one in-person interview (at the health facility or the patient's home or workplace). The additional interviews, when performed, were conducted either in-person or by telephone. Data were entered into a Microsoft Access database (2003, Microsoft Corp, Redmond, WA). To standardize data accession, quality control, analytical procedures, and training of interviewers, site investigators participated in at least one of three international workshops, received site visits, accessed a list serve from the coordinating unit, and conferred regularly with the coordinating unit via e-mail and phone. Missing data were generally imputed from other items from the same household (e.g., missing transportation cost was imputed of other household members).
The unit of analysis is a dengue case, defined as a documented acute febrile illness with a clinical diagnosis of dengue. This study examined all dengue illnesses, regardless of severity, using the WHO case definition. 20 In countries located in the American hemisphere, the diagnosis of dengue syndromes complied with the Pan-American Health Organization (PAHO) case definition, 21 whereas in Asian countries the WHO case definitions of dengue fever and dengue hemorrhagic fever were used. 22 However, the case definitions between the two regions are very similar and the minor differences, which lie in the criteria for dengue shock syndrome, were not consequential for this study. Although dengue laboratory confirmation was a condition for enrollment only in Panama and Venezuela, the majority of the patients enrolled in all the other countries, except Thailand, had dengue laboratory testing. Dengue testing was based on IgM capture enzyme-linked immunosorbent assay (ELISA) performed in provincial or national reference laboratories, which followed WHO guidelines. 20 In addition, four countries (Cambodia, Guatemala, Panama, and Malaysia) also performed virus isolation on appropriately timed samples. Among recruited and interviewed patients, we excluded from analysis in all countries except Panama patients discharged from the hospital with a non-dengue diagnosis or patients whose first interview was later than 30 days after the onset of symptoms. In Panama, where laboratory testing took unexpectedly longer, we extended this period to 60 days. We estimated the economic cost of a case by summing direct medical costs, direct non-medical costs, and indirect costs borne by government, households, and employers during the entire illness episode.
We estimated direct medical costs as a sum of the products of the quantity of services used (ambulatory or inpatient) by sector (public or private) times their respective average unit costs. We calculated unit costs of uninsured private medical care by dividing household payments by numbers of visits, as providers needed to recover their costs from users. In Malaysia, where panel doctors were paid directly by employers, we assumed the payment equaled 80% of average out-of-pocket payments for private consultations on the assumption that panel doctors agreed to a volume discount. In Brazil, where the major private insurer (Uniao Medios) (UNIMED) paid negotiated fees, we used these reimbursements as proxies for unit costs for both private and public facilities. In all other countries, unit costs were based on the cost of an average hospital day in the participating hospitals following a macro-costing approach, dividing the hospitals' expenses by their weighted units. 23 This macro-costing approach found that the average cost of a hospital outpatient visit ranged from 12–60% of the cost of inpatient day, with an average of 32%. 23 As dengue visits require few medicines or procedures, we assumed that its cost would be 20% of the cost of an inpatient day (i.e., in the lower half of this range). Furthermore, as less sophisticated health facilities tend to have lower unit costs, 24 we assumed that the average unit cost of all public-sector out-patient visits (which include health centers and dispensaries, as well as hospitals) would be 75% of the cost of the hospital outpatient visit. In Brazil, where the reimbursement prices paid by the public health insurance, Sistema Único de Saúde (SUS, Unified Health System) generally do not cover the full economic costs of care, 25,26 we used private sector reimbursement rates. Table 1 summarizes the unit cost of health services provided by the studied public facilities by country as well as the country–specific economic indicators used for other cost calculations.
Direct non-medical costs included patients' out-of-pocket payments for transportation, food, lodging, and miscellaneous expenses associated with seeking and obtaining medical care and/or household members visiting patients at the hospital. Indirect costs were the monetary values of 1) days of school lost, 2) lost days of work for pay, and 3) other days lost by either the patient or any other household member who provided care to the patient during an illness episode. The personal and societal cost of school absence is difficult to value. 27,28 Because all countries fund primary education publicly, the economic value of a day of school must be at least equal to the cost of providing a day of public primary school. Being conservative, we assumed that this economic was equal to the cost of schooling, as shown in Table 1. 29 We then calculated the economic loss attributed to school days lost as the product of the daily cost times the number of school days lost. We valued a day of work lost to the worker or to the employer 30 as the higher of the reported daily loss or the country–specific minimum daily wage (Table 1),3–5 and then calculated the total economic costs of work days lost as the product of this average daily loss times the number of work days lost. To value "other" days (caregiver and patient days lost other than for school or work) we used a country's daily minimum wage for patients or household members 15 years of age or above. Household total days affected are the sum of school, work, and other days lost. As there were no deaths in our cohorts, the economic costs of premature deaths were not incorporated into the facility-based estimates of cost per case, but are included subsequently under aggregate national and multi-country estimates.
To standardize measurements of economic impact across countries and facilitate comparisons and interpretations, we expressed all direct and indirect costs in 2005 international dollars (I$), which adjust for purchasing power parity (PPP), using the ratio of the gross domestic product (GDP) per capita in I$ to the GDP per capita in US dollars (US$) at the market exchange rate (see Table 1). Specifically, WHO describes I$ as "the costs in local currency units converted to international dollars using PPP exchange rates. The PPP exchange rate is the number of units of a country's currency required to buy the same amount of goods and services in the domestic market as the US$ would buy in the United States." 31
In addition, we expressed total cost in US$ to facilitate within-country interpretation. To compare dengue costs with economic costs calculated for previous studies of dengue and other acute infectious diseases in low- and middle-income countries, we also expressed costs in days of GDP per capita (per capita GDP divided by 365).
We conducted separate analyses for each country by type of care—ambulatory (participants without any hospitalization) and hospitalized (participants with a hospital stay of at least one day). Using SPSS, 32 we calculated unweighted means and standard deviations for continuous variables and cross tabulated categoric variables, which provide a natural weighting for all the participants. We could also have used the true number of treated dengue cases by setting in a country as the weighting factor if known, but such data were not available. To our knowledge, no two patients came from the same household, and no patient had repeat dengue episodes during the study period. We treated each patient as an independent observation.
To help the reader quantify the magnitude of dengue costs, we also constructed a preliminary economic model. It estimates the average annual aggregate cost of dengue by country and region based on 2001–2005 dengue cases and deaths officially reported to the WHO, 33 with updates from participating countries. Because neither WHO nor standard surveillance reports provided the breakdown by setting, we requested supplementary data. The actual shares hospitalized (mean ± standard error) were available for Brazil (which includes both ambulatory and hospitalized patients) for 2001–2005 (11.7% ± 2.4%), Malaysia (which includes primarily hospitalized patients) for 2005–2006 (95% ± 1.9%), and Thailand (which also includes primarily hospitalized patients) for 2002–2005 (83.0% ± 1.7%). The share for Cambodia (98% ± 2.0%) resulted from the structure of its reporting system, which is almost exclusively based on hospitalizations. For the remaining American countries, following expert opinion, we used Brazilian rates. On the basis of epidemiologic similarities, we used the annual average age at death (mean ± standard error) for 2001–2005 of Brazil (38.6 ± 1.1) as the proxy for other American countries and Malaysia, and of Thailand (7.6 ± 2.0) for Cambodia.
The model's country–specific inputs were dengue cases, percentage of cases by setting (ambulatory and hospitalized), cost of a dengue case by setting, number of deaths by age, and GDP per capita.
Assuming that the distribution of cost per case by setting in our study was representative of the country's dengue cases, we estimated each country's aggregate cost by multiplying its average annual reported cases by its cost per case. To estimate the economic cost associated with reported dengue deaths, we used official 2001–2005 reports on the number of dengue deaths by age, and calculated the years of premature life lost as the remaining life expectancies at the ages of death based on the country–specific life tables. 34 To adjust for standard time preferences, we discounted years lost at an annual rate of 3%. On the basis of the conservative "livelihood" approach, 35 we then multiplied the discounted years lost by the country's 2005 GDP per capita. The livelihood approach is considered the lower bound for the economic value of a discounted year of life lost. 33,36
Countries exhibited variations by year in the number of reported cases, setting of care, number of deaths, and ages at death. Therefore, we used Monte Carlo simulation methods to analyze the effect of variations in these inputs on aggregate costs. 37 Because each input could be skewed to the right and had to be non-negative, we fitted lognormal distributions, commonly used in economic models, to each input. We used the means and standard errors of historic data of reported cases and deaths (from national data) and costs per case from our study. Combining Crystal Ball version 7.3 38 and Excel 2003 software, 39 we then ran a simulation with 200,000 iterations to generate precise estimates of standard deviations. Each iteration randomly drew values from the distribution of each input. From the resulting empirical distributions, we obtained means and standard deviations of the average annual aggregate cost of dengue in the study countries and the weighted (combining hospitalized and ambulatory cases and deaths) mean cost per reported case.
The study protocol was approved by Institutional Review Boards at Brandeis University, participating sites, and the sponsor.
One author (SBH) directs a different program sponsored by the funding source. In addition, other officers at the funding source read an early draft of this manuscript and suggested clarifications.
Of the 1,796 patients recruited and interviewed, 1,695 dengue cases in eight countries met the inclusion criteria for analysis. Table 2 summarizes demographic and illness attributes of study cases. Overall, 55% were treated in ambulatory settings, 45% were hospitalized for at least one day, 86% were treated in the public sector, 54% were females, 48% were < 15 years of age, and 83% were from urban areas. Study participants spanned the full range of socio-economic strata based on the household maximum level of education. No participants died during the study.
On average, ambulatory patients reported 11.9 days of illness, including 5.0 days with fever, and 78% had dengue documented by laboratory testing. On average, hospitalized participants reported 11.0 days of illness, including 5.9 days with fever. The majority of this cohort had evidence of bleeding (73%), leakage (vasculopathy, 62%), and laboratory documentation of dengue (75%).
Table 3 shows the burden placed by an ambulatory or hospitalized dengue case on the health system and patients' households. The proportion of patients who were studying or working at the time of the illness varies considerably by site, reflecting their target populations. Ambulatory and hospitalized patients averaged 4.2 and 4.6 ambulatory care visits, respectively, with country means ranging from 2.8 (Guatemala) to 6.3 (El Salvador) among ambulatory patients, and from 2.0 (El Salvador) to 7.1 (Malaysia) among hospitalized patients. The average hospitalized patient spent 3.8 days in the hospital, with country means ranging from 2.8 days (Malaysia) to 6.4 (Guatemala). Although no patients outside of Brazil were enrolled from private facilities, interview data found that visits to private facilities during the course of illness were not uncommon; they accounted for 30% of all visits in the ambulatory cohort in Guatemala and 42% in the hospitalized cohort in Cambodia.
Dengue illness episodes affected school attendance and other productive activities of patients and household members. Patients in school at the time of the illness comprised 40% of the ambulatory cohort and 65% of the hospitalized cohort. They lost an average of 4.2 and 5.6 days of school, respectively. Similarly, patients who were working for pay at the time of the illness, constituting 43% of ambulatory and 18% of hospitalized cases, lost an average of 6.6 and 9.9 days of work, respectively. The burden on household members in addition to the patient was substantial. This impact represented 30% and 73% of work days lost in the ambulatory and hospitalized cohorts, respectively.
Table 4 summarizes the costs of ambulatory and hospitalized dengue cases by country and overall. Cost varied greatly within each country, as reflected by the relatively large standard deviations (about 60% of the respective means). In the ambulatory group, indirect costs represented the largest share (overall 72%) of case costs in all countries except Malaysia. For hospitalized cases, direct costs represented the largest share of total costs. Expressed in terms of days of GDP per capita, the total cost of an ambulatory case ranged from 12 days in Venezuela to 31 days in Brazil and from 45 days in Venezuela to 110 days in Cambodia for a hospitalized case. The mean unweighted cost per case was I$514 for ambulatory patients and I$1,394 for hospitalized patients in our cohorts.
The yearly reported dengue cases by these eight countries for 2001–2005 averaged 574,000, but ranged from 253,000 to 1,020,000, reflecting variations in outbreaks by year. 33 On average, during the same years there were 399 reported deaths (range 260 to 596) leading to 10,283 discounted years of life lost. Based only on these officially reported cases and deaths, the estimated annual total cost associated with dengue illness was I$587 million (range: I$448 to I$768 million). About 89% and 11% of this cost was imposed by dengue morbidity and dengue mortality, respectively. Dengue in Brazil and Thailand was responsible for 94% and 60% of the aggregate cost in the American and Asian study countries, respectively. The mean cost of a dengue reported case, weighted by the official numbers of deaths and cases by setting, was I$1,031 in the eight countries, but 2.7 times larger (I$2,005 versus I$759) in Asia than in the Americas.
This was a prospective study in which dengue patients were identified using WHO case definition guidelines. 20–22 A high rate of serologic confirmation of recent dengue infection was achieved. Reflective of the real world, a marked heterogeneity of demographic and socio-economic characteristics in these studies demonstrates the diversity in treatment sites, disease expression, or in disease descriptions in different country settings. Although some deaths might have been expected in this cohort of 1,695 patients, none were observed. Using the overall case fatality rates implicit in Table 5 in the Americas (0.014%) and Asia (0.27%), we would have expected two deaths. This absence of deaths may reflect chance or slight under enrollment of severely ill patients. As all facilities, which range from ambulatory clinics and small provincial hospitals to major university hospitals, were predominant providers in their catchment areas, they were collectively representative of treatment locations for dengue across these countries. Although in three countries (Cambodia, El Salvador, and Thailand) patients were enrolled only from pediatric locations, the majority of reported cases from those countries were in children. Furthermore, the study did not appear to influence care, as the majority of medical providers were involved in the research.
This study incorporated empirical values for most of the components of health services used, and most of their unit costs. Furthermore, it examined actual medical practice, rather than the more expensive setting of a formal prospective clinical study of laboratory confirmed dengue infections. 40
Not surprisingly, hospitalized patients had more severe illness than ambulatory patients, as evidenced by their higher incidence of bleeding phenomena, longer duration of fever, and more days affected. Within the six countries in which ambulatory and hospitalized cohorts were included, the total cost of a hospitalized case averaged 3.7 times that of an ambulatory case. This relationship could help estimate the cost of ambulatory cases, where direct costs are not available.
The variations in costs among countries might reflect many factors, such as the case-mix of the study participants, the type of facility at which they were enrolled, the cost of health services, patterns of treatment, the country's wage rates, and cost of living. Nevertheless, as the cost per case in days of GDP per capita varied less than threefold across countries within ambulatory and hospitalized cohorts, the economic burden of dengue per case was fairly similar across the sites.
The absence of universal laboratory testing on all cases of suspected dengue reflected the standard practices at the participating institutions. A clinical diagnosis of dengue without laboratory confirmation is usual in ambulatory settings and in some hospitals, such as those in Thailand, where clinicians have extensive experience with dengue. 41 In a few instances, laboratory diagnosis was not possible because properly spaced sera were not obtained for laboratory testing. Although 22% of study patients did not have confirmatory laboratory tests, we found no statistically significant overall differences in their clinical characteristics or cost between suspect dengue cases with or without laboratory confirmation. For costs, the relationships between the confirmed and non-confirmed cases were variable. The only significant difference was the ambulatory cohort in Brazil, where confirmed cases cost 40% more than unconfirmed cases (I$756 versus I$540), respectively. Possible reasons include the small sample size for cases without confirmatory tests and reliance on length of stay for calculating hospital costs. Although dengue secondary infections tend to be more severe than primary infections 42,43 and some serotypes or sequences may be more severe than others, 16,44–46 the necessary laboratory tests for these distinctions were not part of routine care and were not available in this study.
Previous research on the economic impact of dengue has been limited to single-country studies and using less comprehensive costing methods. 10–17 Cost per case in these studies, translated to days of GDP per capita, varied from 8 days 14 to 56 days. 13 Earlier estimates of the cost of dengue illnesses were below those estimated in our study. For example, previous studies found costs per case of $44 in Kampaeng Phet, Thailand in 2001, 14 $120 and $140 for Suphan Buri and Bangkok regions of Thailand, respectively, in 1994, 10 and $121 for Venezuela from 1997 to 2003. 15 Less comprehensive analysis of government subsidies for public services and valuation of indirect costs, inflation, and use of US$ instead of I$ were major reasons for the lower estimates.
We compared the total cost of inpatient dengue cases with those for other acute infectious diseases, such as influenza, bronchitis, pneumonia, rotavirus, or typhoid fever, requiring inpatient care in low- or middle-income countries in The Americas and Asia. Of the examples found, only a few studies examined both direct and indirect costs. 47–51 The wide range in total costs measured in terms of days of GDP per capita, from 4 days 47 to 112 days, 50 mainly reflects variations in methodologies and study scope (e.g., household versus societal perspective) rather than differences in impact among the diseases. Nevertheless, the range for these diseases overlaps substantially with the range for dengue, indicating that the economic cost of a dengue case is comparable to that of other infectious diseases.
A limitation of our research is that in the three Asian study countries, dengue cases were included from only a single institution. Nevertheless, this is the most comprehensive study of dengue costs published to date and the first to develop comparable data across two hemispheres, and comprises an important step to documenting the global burden of dengue. Earlier comparative economic evaluations across countries for other diseases, such as for rotavirus, encountered challenges in data interpretation because of methodologic differences among studies. 52
Although it may be premature to extrapolate these preliminary data, we appreciated the interest in generating preliminary estimates of dengue costs using currently available case reporting data. The I$587 million estimate for the average annual cost of dengue in the eight study countries was based only on the officially reported dengue cases for the 2001–2005 periods. The validity of our estimate relies on our assumption that the distributions of cost per case in our study are representative for the country. On the basis of other studies, 24 our estimate may be too high for countries where our site was a national referral hospital (such as in El Salvador and Malaysia), and too low where it was a small provincial hospital (such as Cambodia and Venezuela). These effects may tend to offset one another for the eight-country aggregate. The American countries bore only 17% of the reported dengue deaths, but 79% of the reported cases and 58% of the estimated total cost of dengue. These contrasts are a result of regional differences in both epidemiology 53 and reporting of dengue. 53 In the Americas, where dengue usually occurs as dengue fever (DF), 53 patients generally receive care in ambulatory settings, which are included in dengue surveillance and reporting systems. In Asia, by contrast, more dengue cases are believed to develop dengue hemorrhagic fever (DHF), dengue shock syndrome (DSS), and death, 53 and surveillance and reporting systems are mainly limited to hospitalizations. 53 For example, because Cambodia had the highest average annual death rate (151 deaths out of 11,000 reported cases, or 1.4%) it had one of the highest resulting average costs per case (I$1,733).
Our estimate of the eight-country cost of dengue illness is conservative. Official reports substantially underestimate the true number of cases and highlight the need for expansion factors to adjust for this underreporting.6 Previous research indicates expansion factors from 1.6 to 3.2 for hospitalized dengue, 54,55 from 10 to 27 for ambulatory dengue, 11 and 6 for all dengue cases. 56 As a preliminary illustration, an overall expansion factor of 3 would suggest a cost of dengue illness in these eight countries averaging I$1.8 billion per year, but ranging from I$1.3 to I$2.3 billion. With expansion factors of 2 or 6, the eight-country costs would range from I$1.2 to I$3.6 billion. Further analysis of the performance of each country's treatment reporting system would be needed to refine unit costs and expansion factors and project trends.
Furthermore, these estimates also exclude the substantial costs associated with dengue surveillance and vector control programs. For example, Brazil's budget for vector control in 1997 was US$0.6 billion, equivalent to I$1.2 billion in 2005 prices. 57 Panama, with a population of only 3.2 million people, spent US$5.0 million, equivalent to I$7.9 million in 2005. 56 Mass larviciding efforts against the dengue vector A. aegypti in two urban areas of Cambodia with a population of 2.9 million people between 2001 through 2005 had an annual average gross cost of US$ 568,000 in 2005 US$, or US$ 0.20 (I$ 1.31) per person covered.8
In summary, this study shows that dengue poses a heavy economic cost to the health system and society, that the cost varies by setting (ambulatory and hospitalized), that improved surveillance and reporting efforts are necessary to include ambulatory patients from at least sentinel sites (mainly in Asia), to officially report cases by setting, and to reduce underreporting. The study also suggests the potential economic benefits associated with promising dengue prevention interventions, such as dengue vaccines and vector control innovations.
Dengue epidemiologic and economic indicators for study countries and sites*
Participants' and illness characteristics by study site
Utilization of health services and impact per dengue case by study site
Means (± standard deviations) of cost components per dengue case by study site*
Estimation of average annual national cost of dengue morbidity and mortality associated with 2001–2005 official reports*
Citation: The American Journal of Tropical Medicine and Hygiene Am J Trop Med Hyg 80, 5; 10.4269/ajtmh.2009.80.846
Address correspondence to Jose A. Suaya, Schneider Institutes for Health Policy, Heller School, MS 035, Brandeis University, Waltham, MA 02454-9110. E-mail: Suaya@Brandeis.edu
Authors' addresses: Jose A. Suaya and Mariana Caram, Schneider Institutes for Health Policy, Heller School, MS 035, Brandeis University, Waltham, MA 02454-9110, Tel: +1-781-736-3904, Fax: +1-781-736-1905, E-mails: jsuaya@brandeis.edu and mcaram@brandeis.edu. Donald S. Shepard, Schneider Institutes for Health Policy Heller School, MS 035, Brandeis University, Waltham, MA 02454-9110, Tel: +1-781-736-3975, Fax: +1-888-429-2672, E-mail: shepard@brandeis.edu. João Bosco Siqueira and Celina T. Martelli, Institute of Tropical Pathology and Public Health, Department of Public Health, Federal University of Goiás, Rua Delenda Resende de Mello S/N. Setor Universitário, CEP:74605-050 Goiânia-Goiás, Brazil, Tel: (55 62) 202-0605, E-mails: siqueirajb@gmail.com and celina@iptsp.ufg.br. Lucy Chai See Lum, Department of Pediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia, Tel: +60-3-7949-2192, +60-3-7949-2428, Fax: +60-3-7955-6114, E-mails: lumcs@ummc.edu.my or lucylum@gmail.com. Lian Huat Tan, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia, Tel: +60-3-7949-2192, +60-3-7949-2428, Fax: +60-3-7955-6114, E-mail: hutan07@gmail.com. Sukhontha Kongsin, Department of Public Health Administration, Faculty of Public Health, Mahidol University, Bangkok, Thailand, Tel: +66-2354-8543-49 ext 1124, Fax: +66-2644-8833, E-mail: phsks@mahidol.ac.th. Sukhum Jiamton, Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, Tel: +66-2419-7000 ext 4323, Fax: +66-2411-5031, E-mail: sisjt@mahidol.ac.th. Fàtima Garrido, Ministry of Health and Social Development, Caracas, Venezuela, E-mail: fatimill@yahoo.com. Romeo Montoya, Ministry of Health and Social Assistance, San Salvador, El Salvador, E-mail: montoyarh@els.ops-oms.org. Blas Armien, Department of Genomics and Proteomics, Instituto Conmemorativo Gorgas de Estudio de la Salud de Panamá, Panamá, Tel: +507-527-4838, Fax: +507-527-4869, E-mails: barmien@gorgas.gob.pa or blasarmien@yahoo.com.mx. Rekol Huy, Epidemiologist, National Center for Parasitology, Entomology and Malaria Control, No. 372, Blvd. Monivong, Corner Street 322, Phnom Penh, Cambodia, Tel: +855-23-219271, Fax: +855-23-219271, E-mail: Rekolh@cnm.gov.kh. Leticia Castillo, National Health Laboratory, Guatemala City, Guatemala, E-mail: leticiadel-carmen@gmail.com. Binod K. Sah, Rama Sughayyar, and Karen R. Tyo, Schneider Institutes for Health Policy, Heller School, MS 035, Brandeis University, Waltham, MA 02454-9110, Tel: +1-781-736-3904, Fax: +1-781-736-3905, E-mails: bsah@brandeis.edu, rana@brandeis.edu, and karentyo@brandeis.edu. Scott B. Halstead, International Vaccine Institute, Pediatric Dengue Vaccine Initiative, Seoul, Korea, Tel: +1-301-984-8704, E-mail: halsteads@erols.com.
Acknowledgments: We thank all the site research groups for careful study implementation and Martha Baez, Elizabeth HaileSelassie, Clare L. Hurley, Aung Lwin, Ali MacLean, Chrisann Newransky, and William B. Stason from Brandeis University, Moh Seng Chang from WHO Cambodia, and PDVI officials for thoughtful comments.
Financial Support: This research was supported by research agreements from the Pediatric Dengue Vaccine Initiative (PDVI) (a program of the International Vaccine Institute) to the authors' institutions and by the endowment of the Schneider Institutes for Health Policy at Brandeis University.
Disclosure: The views expressed in this article are those of the authors and do not necessarily reflect the views of the authors' institutions or the sponsor. This analysis was completed while J. Suaya was a full-time employee at Brandeis University; he is currently working at GlaxoSmithKline on activities unrelated to dengue. D. Shepard is the principal investigator of a grant to Brandeis University from Sanofi Pasteur for a dengue study in a country not included in this manuscript. This grant began after all analyses reported in this manuscript were completed. This statement is made in the interest of full disclosure and not because the authors consider this a conflict of interest.
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