Keywords: allergic disease. prevalence, economic burden, prevention

1. Health Economics Perspective in
Allergy Prevention in Children
Prof Ariyanto Harsono MD PhD SpA(K)
Department of Child Health
Airlangga University /Dr Soetomo Hospital
Surabaya, Indonesia

2. Background
 Prevalence of allergic disease is increasing.
 Allergies are the most frequent chronic diseases in children
and young adults.
 The impact of allergies:
o Individual sufferers
Impairment in quality of life, sleep and mood,
competence at work or school and overall personal
development.
Costs
o Society as a whole.
Costs
A European Declaration on Immunotherapy

3. GENETIC
FACTOR
•ALLERGEN
•INFECTION
• POLUTANT
ENVIRONMENT
FACTOR
ALLERGIC DISEASES
Gern JE, Lemanske Jr RF. Immunol Allergy North Amer 1999; 19:233-52
3Prof DR Dr Ariyanto Harsono SpA(K)

4. Allergic diseases
A European Declaration on Immunotherapy

5. 5Prof DR Dr Ariyanto Harsono SpA(K)

6. Prevalence of asthma
Prevalence of asthma symptoms by country among
children 13 to 14 years of age according to the 1999-
2004 International Study of Asthma and Allergies in
Childhood (ISAAC)
Prevalence of asthma symptoms by country among
children 6 to 7 years of age according to the 1999-2004
International Study of Asthma and Allergies in
Childhood (ISAAC) III study.
Asher MI, et al. Lancet. 2006;368:733-43.

7. The Rising Incidence of Atopic Dermatitis
• Atopic dermatitis is
now one of the
most common
childhood
disorders in the
Asia Pacific region
• Its prevalence has
increased markedly
in the past decade
Adapted from Asher et al, 2006
Change in incidence of atopic dermatitis

8. Prevalence of allergy
6.9%
9.0%
4.9%
8.9%
14.2%
3.9%
13.9%
12.3%
24.6%
0%
5%
10%
15%
20%
25%
Jakarta Pusat (1990) ISAAC Jakarta Timur
(2001)
EAAEL Jakarta (2006)
Asma Rinitis alergi Dermatitis atopi
Courtesy of Dr. dr. Zakiudin Munasir, SpA(K)

9. Economic impact of allergic diseases
• Hospital
(in/outpatient)
• Physician services
• Medication
• Diagnostic tests
Direct costs,
medical
• Transportation
• Homecare devices
• Special diet
Direct costs,
non-medical
• Loss of work and
school days
• Loss potential
earning
• Home modification
• Mortality
Indirect
costs

10. Direct costs to society of allergy in
Europe (1998 euros)
• Asthma 6.4bn
• Contact dermatitis 2.3bn
• Allergic rhinitis 1.3bn
• Food allergy [???]
Source: European allergy white paper (1997)

11. Estimated costs of allergic diseases in
Europe
A European Declaration on Immunotherapy

12. HOW CAN WE PREVENT ALLERGIC
DISEASES?

13. Prof DR Dr Ariyanto Harsono SpA(K) 13

14. Prevention of allergic diseases
Preventionofallergicdisease Primary
Secondary
Tertiary

15. Primary prevention
Recognize the high risk infants

16. Nutrition factor in allergy prevention
Nutrition Recommendation
Breastfeeding Infants should be exclusively breast-fed in the first four
months to prevent atopic diseases
Maternal nutrition during
pregnancy and/or
breastfeeding
Balanced and fully nutritious diet is recommended
during pregnancy and breastfeeding.
There is no well-documented evidence favoring a
recommendation for any type of dietary restriction
during pregnancy or breastfeeding (avoidance of potent
dietary allergens)
Feeding of children at risk
with mother’s milk
substitutes
Infants at high risk of allergic disease should be given
hydrolyzed formula (partially or extensively hydrolyzed
formula).
Soy-based infant formula is not recommended for the
purpose of allergy prevention.
Introduction of solid food
in the first year
Introducing complementary solid foods from around 4–6
months, with no specific avoidance of allergenic foods.
Muche-Borowski C. Allergy prevention. Dtsch Arztebl Int. 2009; 106: 625–31.
Prescott S, Nowak-Wegrzyn A. Ann Nutr Metab 2011;59:28–42.

17. Hydrolyzed Formula
• Systematic review (2005):
– Extensively hydrolyzed casein formulas and
partially hydrolyzed whey formulas are
appropriate alternatives to breast milk for allergy
prevention in infants at risk.
– The use of these formulas in the general
population should be considered, and one must
weigh cost, compliance, and long-term benefits.
Arch Pediatr Adolesc Med. 2005;159:810-6

18. Hydrolyzed formula
(German Infant Nutrition Study)
Adjusted cumulative incidence of parent-reported physician-diagnosed eczema
Von Berg A, et al. J Allergy Clin Immunol. 2013 Jun;131(6):1565-73

19. ECONOMIC IMPACT OF HYDROLYZED
FORMULA AS ALLERGIC PREVENTION

20. Three perspectives of economic
evaluation
The public
healthcare
system
(Ministry of
Health)
Family
Society
Iskedjian M, et al. J Med Econ.2012; 15: 394-408
Iskedjian M, et al. J Med Econ.2012; 15: 378-93

21. PARTIALLY HYDROLYZED FORMULA
VS STANDARD FORMULA

22. Costs associated with PHF-W and standard
formula for allergy prevention:
Perspective of the Switzerland’s MOH
Cost of
formula
Physician
costs
Treatment
costs
Hospitaliza
tion costs
Costs of
lab test
PHF-W 14398641 173830 109013 46457 10844
SF 12519931 299444 196925 80029 18681
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
CHF
Item
Expected numbers of cases:
PHF-W: 2287; SF: 39040; Avoided cases: 1653
Iskedjian M, et al. J Med Econ.2012; 15: 394-408

23. Costs associated with PHF-W and standard
formula for allergy prevention:
Perspective of the Switzerland’s family
Cost of
formula
Physicia
n costs
Treatm
ent
costs
Hospita
lization
costs
Costs of
lab test
Cost of
time
lost
Travel
cost
PHF-W 1602980 19314 12113 5162 1205 5019849 221129
SF 1402632 33272 21881 8892 2076 8672290 380506
0
1000000
2000000
3000000
4000000
5000000
6000000
7000000
8000000
9000000
10000000
CHF
Item
Expected numbers of cases:
PHF-W: 2287; SF: 39040; Avoided cases: 1653
Iskedjian M, et al. J Med Econ.2012; 15: 394-408

24. Cost-effectiveness
6881752
10521547
-3639795
-1220
-6000000
-4000000
-2000000
0
2000000
4000000
6000000
8000000
10000000
12000000
CHF
Total cost PHF-W Total cost SF
Incremental costs Incremental cost-effectiveness ratio
• PHF-W vs SF
Iskedjian M, et al. J Med Econ.2012; 15: 394-408

25. PARTIALLY HYDROLYZED FORMULA VS
EXTENSIVELY HYDROLYZED FORMULA

26. Costs associated with PHF-W, EHF-W, EHF-C for
allergy prevention:
Perspective of the Danish family
Expected numbers of cases:
PHF-W: 453; EHF-W: 728; EHF-C: 428; Avoided cases: 274 (EHF-W); 26 (EHF-C)
Cost of
formula
Treatment
costs
Cost of time
lost
Travel cost
EHF-C 26594813 292829 4359488 271090
EHF-W 26658963 498312 7412350 461447
PHF-W 7157386 310399 4621057 287355
0
10000000
20000000
30000000
40000000
50000000
60000000
70000000
DKK
Iskedjian M, et al. J Med Econ.2012; 15: 378-93

27. Cost effectiveness
PHF-W vs EHF-W
12376196
35031072
-22654875
-82565
-40000000
-20000000
0
20000000
40000000
Total cost PHF-W
Total cost EHF-W
Incremental costs
Incremental cost-effectiveness ratio
PHF-W vs EHF-C
12376196
31518220
-19142024
-746073
-30000000
-20000000
-10000000
0
10000000
20000000
30000000
40000000
Total cost PHF-W
Total cost EHF-C
Incremental costs
Incremental cost-effectiveness ratio
Iskedjian M, et al. J Med Econ.2012; 15: 378-93

28. pHF-W is not only clinically effective, it is also
cost effective – European
Based on the
European studies,
families with children
at risk of atopic
dermatitis will save
between EUR 624
and EUR 2,200 per
year compared with
using standard
formula
Adapted from Spleindenner, 2011
Number of cases of atopic dermatitis avoided and
cost saving from the perspective of the family

29. pHF-W is not only clinically effective, it is also
cost effective – Thailand and Australia
• Thailand
Every single child with atopic dermatitis represent a
direct cost of THB 5,432 (US $ 175)
• Australia

30. Decision making:
1. “ benefit > risk”
2. low “cost”
3. “applicable”
Choices of nutrition for allergy prevention
1. Breastfed
2. Soy Protein Formula
3. p-Hydrolyzed Whey
4. p-Hydrolyzed Casein
5. e-Hydrolyzed Whey
6. e-Hydrolyzed Casein
APPLICABILITY
+
+
+
+
+
+
LOW COST
+
+
+
+
-
-
LOW RISK
+
-
+
+
+
+
BENEFIT
+
-
+
-
-
+

31. Infant
Child
Sensitization
Clinical Manifestation
History of
Atopic family
•Breast Milk
•pHF
•Probiotik
Primary Prevention
Secondary Prevention
Tertiary Prevention
•Elimination Diet
•Substitution Formula
(AAF/eHF/Soy)
•Steroid, antihistamine
•Emergency Treatment
•Promising Treatment
•Immunotherapy
Prevention Strategy
SPT
IgE RAST
31Prof DR Dr Ariyanto Harsono SpA(K)
Atopic Dermatitis
Asthma, Allergic Rhinitis
Gastrointestinal Allegy
•eHF
•Soy F

32. Conclusions
• Prevalence of allergic diseases are increasing
• Burden of the diseases includes symptom
burden, impaired quality of life and
productivity, co-morbidities, complications, and
disease management (economic burden)
• Prevention of allergic diseases should be started
in early life.
• If breastfeeding is not possible, a partially
hydrolyzed formula is cost-effective for infants
at high risk of allergic disease.

33. THANK YOU