Cost of Respiratory Syncytial Virus Hospitalisation in Brazilian Infants: A Micro-costing Study from the Perspective of a Brazilian Tertiary Public Hospital, 2020-2023

doi:10.21203/rs.3.rs-5306412/v1

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Research Article

Cost of Respiratory Syncytial Virus Hospitalisation in Brazilian Infants: A Micro-costing Study from the Perspective of a Brazilian Tertiary Public Hospital, 2020-2023

https://doi.org/10.21203/rs.3.rs-5306412/v1

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Background. Respiratory Syncytial Virus (RSV) is the leading cause of hospitalisation for respiratory diseases among young children. Costing studies are essential for planning prevention strategies. Additional costing studies in middle-income countries (MIC) are still needed to understand the impact of hospitalisations given the high economic burden of RSV in these countries. We aimed to identify and quantify the resources required and associated costs of paediatric RSV hospitalisations at a tertiary hospital in a MIC.

Methods. A retrospective micro-costing study of RSV-related hospitalisations among children under the age of one year, from January 2020 to November 2023, was conducted at a tertiary public hospital in Brazil. Only cases of RSV isolated on molecular respiratory panel tests were eligible for inclusion. The study used direct and indirect expenses to calculate the average cost (AC) per hospitalisation, AC per hospital day, and the total financial impact of RSV-related hospitalisations using the absorption model. The analysis was clustered by age group and the necessity of intensive care admission. Financial data is presented in Brazilian reais(BRL) and United States dollars using purchasing power parity (USD-PPP).

Results. After excluding 1,354 positive tests (i.e., individuals aged one year or older), we included 231 hospital admissions. Of these, 83.1% required intensive care support. The AC per hospitalisation was BRL$29,285.47 (USD-PPP$12,051.63), with an average length of stay of 8.51 days, equivalent to BRL$3,801.00 (USD-PPP$1,564.19) AC cost per day. A total of 1,965 hospital days were counted, resulting in the financial impact at BRL$6.76 million (USD-PPP$2.78 million) due to RSV-related hospitalisations of infants in the study period. Hospitalisation episodes with intensive care unit admission were significantly more expensive, with the higher costs concentrated in the younger group (<2 months old).

Conclusions. RSV-related hospitalisations impose a significant economic burden on this Brazilian tertiary public hospital, mainly related to bed cost per day and intensive care needs in young infants. These findings highlight the need for cost-effective RSV management and prevention strategies in Brazil.

Costs

Micro-costing

Economic evaluation

Cost of illness

Burden of illness

Infectious Diseases

Respiratory Syncytial Viruses

Respiratory syncytial virus (RSV) is the leading cause of hospitalisation for respiratory diseases among children under 5 years of age, and over half of severe episodes occur in the first year of life, especially in the first 6 months of life (1–3). In 2019, 33 million episodes of RSV-associated acute lower respiratory infection (ALRI), 3.6 million RSV-associated ALRI hospital admissions, and 101,400 deaths in children younger than 5 years occurred worldwide (2). This scenario is even more worrying in preterm infants, where 1,650,000 RSV-associated ALRI episodes, 533,000 RSV-associated hospital admissions, 3,050 RSV-associated inpatient deaths, and 26,760 RSV-attributable deaths occurred in 2019 (3). Additionally, over 95% of RSV-associated ALRI episodes and over 97% of RSV-attributable deaths across all age groups occurred in low and middle income countries (2).

A recent systematic review by Zhan et al. (2020) (4) included 41 studies covering the management of 365,828 RSV disease episodes (338,542 inpatient cases). The global direct medical costs for the management of RSV-ALRI in children younger than 5 years amounted to approximately €4.82 billion euros from the healthcare payer's perspective in 2017; of this amount, approximately 55% were hospitalisation costs. While the general RSV management cost is higher in high-income countries (€3,602) than in middle-income countries (€925), most inpatient costs are generated in middle-income countries, even exceeding the inpatient expenses when compared to high-income nations (€1.53 billion vs. 1.15 billion, respectively) (4).

Despite the heavy economic burden, more detailed costing studies specific to RSV hospitalisations within the context of middle-income countries (MICs) are essential. The lack of such economic studies is even more significant in Latin American settings (4, 5). In Zhang's review, inpatient management in MICs was mainly reported in studies from the Western Pacific Region, and cost data from low-income countries was unavailable (4). A systematic review published by Rocha-Filho et al. (5) included two studies from the Latin America setting, specifically Mexico (6) and Colombia (7–9). Moreover, a study was published in 2024 with findings about the cost of RSV illness among infants hospitalized in Argentina (10).

Brazil is no exception to trends seen globally for RSV illness in infants. RSV is a leading cause of hospitalisation for respiratory infections among infants and young children. The virus has a seasonal pattern with regional variability, which affects the timing and effectiveness of preventive interventions (11, 12). Costing studies are needed to assess RSV-related hospitalisations within the Brazilian context. This study aims to fill these gaps by providing a detailed financial summary of the direct medical and overhead costs associated with RSV-related hospitalization of infants at a tertiary public hospital in Brazil. The data may help shape effective preventive strategies and policies in the Brazilian Unified Health System (Sistema Único de Saúde or SUS).

Study design

A retrospective micro-costing study from January 2020 to November 2023 was conducted. It followed the methodological guideline recommended by the Brazilian Ministry of Health (13) and focused on financial data of RSV-related hospitalisations in a tertiary public hospital. We followed the principles of the ‘Reference Case for Estimating the Costs of Global Health Services and Interventions’ proposed by the Global Health Cost Consortium (14), as detailed in the Supplementary Table 1S.

Study context

The Brazilian Secretariat for Health and Environmental Surveillance (Secretaria de Vigilância em Saúde e Ambiente or SVSA) is critical for the surveillance and control of RSV disease, and other infectious diseases. The SVSA is responsible for coordinating efforts to detect, monitor, and respond to outbreaks by integrating data from hospitals and laboratories into the national epidemiological surveillance system. This system allows for near real-time monitoring of cases, which is essential for timely public health interventions, including implemention of preventive measures, public awareness campaigns, and vaccination programs where applicable (15). Additionally, Brazil participates in the Global Influenza Surveillance and Response System through its national influenza surveillance program. Since 2012, this program has included tracking severe acute respiratory syndrome caused by RSV as well (16).

In 2017, the Brazilian Society of Pediatrics released the national guideline for managing RSV infection (17). The Brazilian Ministry of Health has recently updated the national guideline for managing RSV infection, which includes prophylactic approaches, such as administration of palivizumab (Synagis®). This is the only product currently available in the SUS to prevent RSV infections (18). Three more products have recently been approved by the Brazilian regulatory agency (Agência Nacional de Vigilância Sanitária - Anvisa). Nirsevimab (Beyfortus®) is recommended for prevention of RSV-ALRI in newborns and children under 24 months (19). The Arexvy® vaccine is indicated for the prevention of ALRI caused by RSV-A and RSV-B subtypes in adults aged 60 years and older (20). The Abrysvo® vaccine is indicated for the prevention of ALRI and severe ALRI caused by RSV-A and RSV-B in children from birth to 6 months of age by active immunization of pregnant women, and in individuals 60 years of age and older by active immunization (21). However, these products are not currently incorporated in the SUS. Therefore, it is critical to understand the financial impact of RSV-associated ALRI for future economic evaluations of new products to prevent infections caused by RSV in Brazil.

Study population

The data for this study came from the Hospital Municipal Vila Santa Catarina (HMVSC), a tertiary public hospital in Brazil. We selected the hospital based on three criteria: it is part of the Unified Healthcare System, it has a high number of RSV cases, and it has structured financial data available. The HMVSC is part of the philanthropic society network administration named Sociedade Beneficente Israelita Brasileira Albert Einstein. It covers a population of 2.6 million individuals in São Paulo city, in the Southeastern region of Brazil. The HMVSC has 193 operational beds, including 30 adult intensive care unit (ICU) beds and nine paediatric/neonatal ICU beds.

Included in the study were hospitalized ALRI paediatric patients younger than 1 year of age (up to 11 months and 29 days) with a positive RSV isolate detected by a molecular respiratory panel test. Not included were patients with other types of hospitalisations unrelated to viral respiratory infection, infections acquired after hospital admission to HMVSC (i.e., symptoms starting 48 hours after admission), more than one respiratory virus detected in a molecular respiratory panel test (including RSV with coinfections), and missing data (e.g., detailed per-patient cost data). The temporal framework for this study was anchored to the implementation of the electronic surveillance system in the HMVSC institutional network, which started in January 2020. Cases from January 2020 through November 30, 2023 were included.

Data preparation

Data on age, utilization of intensive care, date and time of admission, and molecular viral respiratory panel results were extracted. Admission was defined as the use of a hospital bed for at least 24 hours. The Financial Department of the philanthropic network where HMVSC is embedded supervised this critical collection stage, ensuring full compliance with all data protection laws. Data was extracted using the platform for care and qualitative data Cerner Millennium System – Medical Suite and the financial data system SAP®. No case had to be excluded from analysis due to missing data.

Once de-identified, the fixed cost (FC) and variable cost (VC) of the reported medical care were extracted for each participant and validated at a granular level of medical records, hospital admissions, and consumer items. Each participant was assigned a unique code, ensuring a distinct and accurate financial record for each hospital admission, preventing any duplication or double-counting of costs.

Fixed cost are expenses that do not depend on the number of patients or care provided; they depend on hospital capacity (i.e., salaries of professionals, depreciation, inputs, supplies, commonly used medications, and maintenance costs of the facilities). In contrast, VC refers to those expenses that are directly dependent on the medical care provided to each patient. The VC appropriation of materials and medicines is based on the moving average price. The total cost (total cost = FC + VC) of each patient was estimated using these data.

The bed cost per day comprised salaries/wages of physicians, nurses, and nurse technicians, external consultations, vacation provision, social charges, 13th salary provision, night shifts, gratuity, health insurance plan and in-house medical assistance, sick leave, food vouchers and meals, employee transportation, compensations/agreements, service time guarantee fund, health assistance for dependents, dental insurance plan, overtime, social integration program and service time guarantee fund without vacation, ‘Mais Vida’ program, and pharmacy benefits. Other costs related to the bed cost per day were for administrative resources, electricity and water supply, and general services including nutrition, maintenance, cleaning, linen items, pharmacy, and security.

Costs attributable to some professional services, such as physical therapy, psychology and occupational therapy, are not included in the bed cost per day and were considered separately, for they had been accounted for in exclusive cost centres and items.

Cost analysis

In all cases, the cost calculation for RSV hospitalisation considered FC and VC for direct medical and overhead costs involved in providing care and assistance. The direct medical costs include all expenses directly associated with patient care, covering materials, drugs, laboratory tests, medical procedures. Overhead costs are expenses that are not directly related to care but are essential for the provision of medical assistance. These include human resources (such as salaries and benefits for healthcare professionals), expenses linked to infrastructure (like rent, utilities, and maintenance), and other institutional costs required for providing care. We calculated the estimated average cost (AC) per hospitalisation by applying this financial information (i.e., total cost and total hospital admission), employing a designated formula:

$$\:Average\:hospitalization\:cost=\:\frac{\:Hospitalization\:cost}{\:Hospital\:admission}$$

Equation 1. The average cost of hospitalisation per patient

The denominator represents the observed hospital occupation. Maximum hospital occupations were not calculated.

The average length of stay (LOS) in days was also recorded. Thus, we also estimated the AC per day:

$$\:Average\:cost\:per\:day\:=\:\frac{\:Hospitalization\:cost\:}{\:Length\:of\:stay\:\left(in\:days\right)}$$

Equation 2. The average cost of hospitalisation per day

The bottom-up absorption model was used following the Brazilian micro-costing guidelines (13). Absorption costing is the method that consists of providing products all production costs, direct or indirect, fixed or variable. One characteristic of the method is the distribution of indirect accounting costs, which are related to support areas, through apportionment criteria defined a priori (13).

Results are presented in tables and figures summarising the main findings. Additionally, the aggregate AC by age group and with and without ICU use are presented in a box-plot graphic. The main expenses by category are presented in a Tornado plot. Parametric assumptions were evaluated against normal plots, and the U Mann-Whitney test was used to compare groups. Aggregate AC was correlated with average LOS, and Spearman’s rank test was calculated. The significance level was set to ∂ = 5%. The graphs and statistical analysis were performed using Visual Studio Code, version 1.86.0 (USA), Power BI, version 2.128.1177 (USA), and Python, version 3.11.7 (USA).

This study reports all values in Brazilian reais (BRL), followed by conversion to United States dollars using purchasing power parity (USD-PPP) based on the Organisation for Economic Co-operation and Development (OECD) conversion of the last corresponding year: 2023 (USD-PPP 1 = BRL 2.43) (22).

A total of 1,585 positive panel tests were initially screened, of which 230 patients were included, totalling up 231 hospital admissions (Fig. 1). There were 124 male infants admitted (46.5%) and the mean age was 3.5 months (±2.67 months). The majority of the patients were of mixed race or white (52.6% and 46.2%, respectively), while a minority of the patients were Black and Asian (4.3% and 0.4%, respectively). It is important to note that 83.1% of these patients required intensive care support for at least 24 hours during their hospitalisation.

The AC per hospitalisation was BRL$29,285.47 (USD-PPP$12,051.63), with a mean LOS of 8.51 days, equivalent to BRL$3,801 (USD-PPP$1,564.19) AC cost per day. The financial impact of RSV hospitalisation of infants was BRL$6.76 million (USD-PPP$2.78 million) over a total volume of 1,965 days.

The breakdown of hospitalisation costs can be seen in Fig. 2A. The bed cost per day was the highest expense (BRL$5.4 million), accounting for almost 80% of total costs. Physical therapy and materials/drugs also accounted for a significant portion of the costs (7.9% and 7.4%), followed by images and laboratory exams.

A strong and positive correlation between the AC per hospitalisation and the mean LOS is suggested in Fig. 2B, with hospital length of stay being a key driver of associated RSV cost (R² = 0.83; P < .001).

Hospitalisations clustered by age group

Admissions, AC per hospitalisation, mean LOS, and total cost for each age group can be seen in Table 1.

Table 1

Cost of Hospitalization for RSV Disease for Paediatric Patients by Age Group in the Public Tertiary Care Hospital.
Age Group	Number of Admissions	AC per Hospitalisation in BRL (95%CI)	AC per Hospitalisation in USD-PPP$ (95%CI)	Mean LOS (95%CI)	Total Cost in BRL$ and USD-PPP$
<6 months	172	BRL$31,264.86 (27,150.69–35,379.04)	USD-PPP$12,866.19 (11,173.12–14,559.27)	8.97 (7.89–10.03)	BRL$5,377,557.00 [USD-PPP$2.21 million]
$\:\ge\:$6 months to < 12 months	59	BRL$23,515.05 (18,906.60–28,123.50)	USD-PPP$9,676.97 (7,780.49–11,573.45)	7,17 (5.77–8.57)	BRL$1,387,388.00 [USD-PPP$570,941]
Key. AC: Average cost; 95%CI: 95% confidence interval; LOS: length of stay (in days); BRL$: Brazilian reais; USD-PPP$: United States dollar [using OECD purchasing power parity] (21)

There is a significant difference in the AC per hospitalisation between infants younger than 6 months than infants aged between 6 months and 1 year (P < .001). Breakdown of hospitalisation costs by age group can be seen in Fig. 3A.

A further age subgroup analysis suggested that the AC per hospitalisation was significantly higher in the first two months of life (BRL$37,650.89 [95% confidence interval (CI), 23,890.59–51,411.19] and BRL$43,242.62 [95% CI, 30.334,85–56.150,37]) for < 1 month, and 1 month to < 2 months, respectively) when compared to the other two subgroups (P < .05 for all) (Fig. 2C). However, the groups of 2 to < 6 months and 6 months to < 1 year have a higher number of admissions, accounting for 115 (49.8%) and 59 (25.5%) admissions, respectively. The higher number of admissions results in a higher total cost for these groups (BRL$3.01 million and BRL$1.38 million, respectively). Further details can be found in Supplementary Table 2S.

Hospitalisations with and without intensive care admission

We analysed 39 patients with AC of BRL$8,297.42 (USD-PPP$3,414.57) per hospitalisation and a mean LOS of 3.85 days, equivalent to BRL$2,157.00 (USD-PPP$887.65) AC per day. This was for hospitalisation only in the general ward (with no admission to ICU). Considering the number of admissions, the financial impact of RSV hospitalisation with no admission to ICU was BRL$323,598.08 (USD-PPP$133,167.93). In contrast, 192 patients were analysed in the ICU admission group, with AC of BRL$33,548.69 (USD-PPP$13,806.04) per hospitalisation and a mean LOS of 9.45 days, equivalent to BRL$3,549.00 (USD-PPP$1,460.49) AC per day (Table 2).

Table 2

Hospitalisation Cost by Age Group in the General Ward with and without Intensive Care Unit Admission
Unit	Age Group	Number of Admissions	AC per Hospitalisation in BRL$ (95%CI)	AC per Hospitalisation in USD-PPP$ (95%CI)	Mean LOS (95%CI)	Total Cost in BRL$ and USD-PPP$
General ward	< 6 months	20	BRL$7,830.05 (6,305.86–9,354.14)	USD-PPP$3,222.24 (2,595.00–3,849.44)	3.80 (3.08–4.52)	BRL$156,601.00 [USD-PPP$64,444.85]
	≥ 6 months to <12 months	19	BRL$8,789.32 (7,086.80–10,491.8)	USD-PPP$3,617.00 (2,916.37–4,317.61)	3.89 (3.16–4.63)	BRL$166,997.08 [USD-PPP$68,723.07]
	Total	39	BRL$8,297.42 (7,200.51–9,394.20)	USD-PPP$3,414.57 (2,963.17–3,865.92)	3.85 (3.35–4.33)	BRL$323,599.38 [USD-PPP$133,168.46]
General ward with ICU admission	< 6 months	152	BRL$34,348.40 (29,923.11–38,773.69)	USD-PPP$14,135.14 (12,314.03–15,956.25)	9.64 (8.48–10.81)	BRL$5.22 million [USD-PPP$2.14 million]
	≥ 6 months to <12 months	40	BRL$30,509.78 (24,938.28–36,081.26)	USD-PPP$12,555.46 (10,262.66–14,848.25)	8.73 (6.86–10.59)	BRL$1.22 million [USD-PPP$502,057.61]
	Total	192	BRL$ 33,548.69 (29,871.67–37,225.70)	USD-PPP$13,806.04 (12,292.86–15,319.21)	9.45 (8.46–10.45)	BRL$6.44 million [USD-PPP$2.65 million]
Key. ICU: intensive care unit; AC: Average cost; 95%CI: 95% confidence interval; LOS: length of stay (in days); R$: Brazilian reais; USD-PPP$: United States dollar [using OECD purchasing power parity] (21)

The difference in AC per hospitalisation between infants admitted exclusively to general wards and patients requiring ICU support during hospitalisation is shown in Fig. 2D. This demonstrates there is a higher inpatient cost when critical care is required (P < .001). The professional care time allocated to each hospital admission by each unit is detailed in the Supplementary Table 3S. The breakdown of hospitalisation costs clustered by the need for intensive care is seen in Fig. 3B. The costs by resource category, grouped by age and the need for intensive care are shown in Table 3. The expenses related to medication and imaging exams, displayed by drug class and imaging modality, are shown in Supplementary Tables 4S and 5S.

Table 3

Cost of Resources Clustered by Age Group and Need of Intensive Care Unit.
Resource Category	General Ward			Intensive Care Unit
Resource Category	AC (BRL$) 0 to < 6 months old	AC (BRL$) 6 months to <12 months	Aggregated AC in BRL$ and USD-PPP$	AC (BRL$) 0 to < 6 months old	AC (BRL$) 6 months to <12 months	Aggregated AC in BRL$ and USD-PPP$
Bed cost per day	BRL$6,844.66	BRL$7,307.17	BRL$7,069.99 (USD-PPP$2,909.46)	BRL$27,177.58	BRL$24,872.64	BRL$26,697.38 (USD-PPP$10,986.57)
Physical therapist	BRL$586.18	BRL$828.98	BRL$701.19 (USD-PPP$288.55)	BRL$2,796.12	BRL$2,391.66	BRL$2,710.52 (USD-PPP$1,115.44)
Materials and Drugs	BRL$188.77	BRL$354.39	BRL$269.46 (USD-PPP$110.88)	BRL$2,683.73	BRL$2,167.75	BRL$2,576.23 (USD-PPP$1,060.17)
Imaging exams	BRL$184.01	BRL$234.27	BRL$214.94 (USD-PPP$88.45)	BRL$679.36	BRL$585.81	BRL$659.89 (USD-PPP$271.55)
Laboratory exams	BRL$119.22	BRL$243.83	BRL$179.93 (USD-PPP$74.04)	BRL$453.48	BRL$420.28	BRL$446.56 (USD-PPP$183.76)
Other services	BRL$0	BRL$0	BRL$0 (USD-PPP$0)	BRL$481.92	BRL$83.67	BRL$398.08 (USD-PPP$163.81)
Other exams	BRL$452.12	BRL$0	BRL$452.12 (USD-PPP$186.05)	BRL$305.16	BRL$124.07	BRL$281.94 (USD-PPP$116.02)
TOTAL	BRL$7,830.05	BRL$8,789.38	BRL$8,297.42 (USD-PPP$3,414.57)	BRL$34,348.39	BRL$30,509.76	BRL$33,548.67 (USD-PPP$13,806.0)

Key. AC: average cost; BRL$: Brazilian reals; USD-PPP$: United States dollar [using OECD purchasing power parity]; ²¹ In bold: Total amount.

This study presents the cost of RSV hospitalisations in paediatric patients under one year of age at a tertiary public hospital in Brazil during a four-year period. Our findings provide insights into the cost of RSV-related hospitalization of infants in Brazil. The findings also provide a benchmark for similar tertiary care public hospitals, emphasising the need for cost-effective and targeted interventions (23).

Studies in Colombia and Argentina have reported significant economic strains due to RSV hospitalisations, underscoring the regional economic impact of RSV across distinct healthcare infrastructures (7–10). In Argentina, Dvorkin et al. (10) conducted a prospective cohort study of 256 infants with RSV ALRI-related hospitalisations in two public hospitals of Buenos Aires between 2014 and 2016, and found an AC per hospitalisation of US$587.79 [95% CI, US$535.24–640.33]. This study aligned with the previous report on hospitalisation caused by respiratory viruses in Argentina (24). Likewise, in Colombia, Rodriguez-Martinez et al. (7) showed a similar cost in a retrospective study including children under two years in Bogotá, where the AC was USD$518.0 when a general ward was used. The costs identified in our study are higher than those reported in these countries, potentially due to differences in healthcare service costs and hospitalisation practices. The HMVSC is a tertiary care referral hospital in the region; thus, our sample include referred cases that require more complex medical management. In the study conducted by Dvorkin, only 3.1% of the sample required critical care, while in our sample, 83.1% of patients spent at least one day in the intensive care unit (10). Additionally, the use of different methods for converting local currencies to USD contributes to the discrepancies in cost estimation. The studies conducted in Colombia and Argentina applied exchange rates for conversion, which may have resulted in an underestimation of costs in USD.

In a review by Zhang, in 2016, focusing on severe pneumonia in young children, the authors found a wide range of costs between MICs and differences in managing hospitalised patients (25). These cost divergences emphasise a common economic challenge across the region: managing severe cases of RSV requires resources that disproportionately affect healthcare budgets in MICs. This reinforces the importance of our study in Brazilian settings, since it supports the need for country-specific cost estimates to drive decision-making at the local level.

Another important factor contributing to cost discrepancies is age. RSV disease in young children, mainly those younger than one year, is more severe than in older children (1–3). As our findings show, the cost in infants < 2 months is significantly higher compared with the other subgroups, or when compared to the 0 to < 6 months and 6 months to < 1 year. This finding is consistent with a South African study that found the highest healthcare costs were associated with youngest ages (26). Our study findings suggest that the longer stay is the reason for the highest hospitalization cost in infants aged < 2 months. The mean LOS for children < 1 month is 10.83 days, and for children aged 1 month to < 2 months is 12.46 days. This contrasts to the mean LOS for children aged 2 to < 6 months, and 6 to < 12 months: 7.11 and 7.17 days, respectively. Other factor that potentially influence RSV-related hospitalization costs are seasonality and the Covid-19 pandemic. However, these factors deserve further investigation (12, 27).

Physical therapy during the hospital stay was among the resources driving the highest costs. As previously stated, bed cost per day encompasses medical expenses associated with, but not limited to, physician and nursing team salaries and other human resources. However, costs of physical therapy, psychology services, and occupational therapy are not included in the bed cost per day. A total of 3,692 sessions of physical therapy occurred at an AC of BRL$2,333.04 (USD-PPP$960.09) per hospitalization episode. Similarly, psychology services were provided to support family members and caregivers in 19% of admissions at an AC of BRL$349.75 (USD-PPP$143.93), whereas occupational therapy was mainly used to promote motor stimulation and prevent pressure ulcers in 1.2% of hospitalisations, at an AC of BRL$160.23 (USD-PPP$65.93).

As Rocha-Filho et al. have already highlighted (5), the inappropriate use of medications among RSV-infected patients significantly impacts RSV hospitalisation costs, including the use of antimicrobials. Antimicrobials were the second most expensive drug class included in RSV hospitalisation costs, at a total cost of BRL$11,797.27 (USD-PPP$4,854.84). Unnecessary use of antimicrobials may lead to adverse events (28) and selection of resistant organisms (29), and may not have benefits in terms of reduced symptom days, length of hospital stays, O₂ requirement, and hospital admission rate (16). Although antimicrobial therapy is necessary in some cases of bacterial and/or fungal coinfection with RSV, their inappropriate use may result in worse clinical outcomes, increasing the LOS and consequently raising hospitalisation costs.

Our findings are relevant in the context of global RSV control and prevention strategies. In high income countries, robust RSV prophylaxis protocols are in place, including less restrictive use of palivizumab and advanced healthcare facilities. In MICs, however, less preventive resources are available. Our study highlights the need to implement cost-effective strategies to prevent RSV hospitalization among young children (30, 31). Additionally, the World Health Organization has recognised the necessity for integrated RSV control strategies that include preventive and therapeutic measures tailored to the resource settings of each country (32).

Our study includes some limitations. Firstly, a retrospective approach was used to analyse structured financial data, which meant that some critical features could not be assessed. These included the medical history, such as prematurity, comorbidities, and medications in use; baseline conditions, such as severity scores and other medical conditions; and relevant outcomes, including mortality. Furthermore, some crucial information, such as the use of mechanical ventilation, was unavailable. This may require further study. Secondly, we were unable to ascertain the precise number of ICU days for each hospitalisation. We reported the inpatient cost when ICU admission was required, but future studies should address how many days the patient stays in each unit type. Additionally, the retrospective analysis did not employ Time-Driven Activity-Based Costing (13), and the exact period of care for each RSV hospitalisation could not be estimated. Thirdly, it is unclear whether the inclusion of cases during the Covid-19 pandemic may have impacted on the cost estimates. Since there is no historical data for comparison, it is difficult to determine such impact and its magnitude. Cases of co-infection were excluded from analyses, however the coordination of care during the pandemic may have been substantially different from the non-pandemic period, reflecting on cost differences. Finally, the study effectively captured the costs associated with paediatric hospital care, but it did not account for outpatient care and long-term healthcare costs associated with post-hospitalisation complications of RSV. Further studies are warranted to provide a broader understanding of the total economic impact of paediatric RSV disease.

Our micro-costing study shows that paediatric hospitalization for RSV disease places a significant economic burden on a tertiary hospital in the public healthcare system in Brazil. Higher cost is related to prolonged hospital stays and the need for intensive care, particularly among infants under two months old, suggesting the need for tailored, cost-effective strategies to manage and prevent paediatric RSV-related hospitalization. Understanding the costs of RSV-related hospitalizations is important for policymakers to optimize allocation of resources for prevention and treatment of RSV disease in the paediatric population. It should be noted that the study was conducted at a single tertiary public hospital in Southeastern Brazil and, as so, the findings may not be generalizable to other settings

AC Average cost

ALRI Acute lower respiratory infection

Anvisa Agência Nacional de Vigilância Sanitária

BRL Brazilian reais

CI Confidence interval

Covid Coronavirus disease

FC Fixed cost

HMVSC Hospital Municipal Vila Santa Catarina

ICU Intensive care unit

LOS Length of stay

MIC Middle-income countries

OECD Organisation for Economic Co-operation and Development

RSV Respiratory Syncytial Virus

SUS Sistema Único de Saúde

SVSA Secretaria de Vigilância em Saúde e Ambiente

USD-PPP United States dollars using purchasing power parity

VC Variable cost

Ethical Approval and consent to participate

The local Human Research Ethics Committees (under CAAE 66698023.7.0000.0071), approved access to the financial database, with the consent of the São Paulo Health Secretary and the HMVSC Director. The database provided financial data only and did not include any information about the patients involved.

Consent for publication

Not applicable.

Availability of data and materials

All relevant data are included in the article or uploaded as supplementary information. The database supporting the findings of this study is available from the corresponding author, DVP, upon reasonable request.

Competing interests

NOS, SBS, EJK, CPN, LFBH, LHFM, FNP, AHFS, LMB, ACD, CSBP, and SV are employees of the Escritório de Excelência at Hospital Israelita Albert Einstein, which received funding from Pfizer to develop this manuscript.

RFA, PHRFA, APF, and DVP are employees of Pfizer Brazil.

Funding

Pfizer sponsored the micro-costing study, which was designed and led by a steering committee comprising health economics specialists, academic investigators, and representatives from Pfizer. The Escritório de Excelência Einstein in São Paulo conducted the costing and statistical analyses. Pfizer provided the study budget, including all costing analysis-related expenses.

Authors' contributions

NOS, SBS, EJK, CPN, LHFM, FNP, AHFS, and LMB contributed to data curation, formal analysis, investigation, methodology, validation, visualisation, and writing. Furthermore, EJK provided software and statistical analysis. LFBH, RFA, PHRFA, and APF were responsible for the visualisation and writing. ACD, CSBP, and DVP contributed to project administration and supervision. CSBP and DVP also contributed to conceptualising and writing the paper. SV was responsible for formal analysis, investigation, methodology, validation, visualisation, and writing. CSBP, DVP, and SV are the guarantors.

Acknowledgements

We would like to thank the health economics team of the Escritório de Excelência Einstein. We are also grateful the technical and administrative teams for their support in developing this project.

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Competing interest reported. NOS, SBS, EJK, CPN, LFBH, LHFM, FNP, AHFS, LMB, ACD, CSBP, and SV are employees of the Escritório de Excelência at Hospital Israelita Albert Einstein, which received funding from Pfizer to develop this manuscript. RFA, PHRFA, APF, and DVP are employees of Pfizer Brazil.

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Cost of Respiratory Syncytial Virus Hospitalisation in Brazilian Infants: A Micro-costing Study from the Perspective of a Brazilian Tertiary Public Hospital, 2020-2023

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Hospitalisations clustered by age group

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