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. 2025 Jan;19(1):e70059.
doi: 10.1111/irv.70059.

Costs of Influenza Illness and Acute Respiratory Infections by Household Income Level: Catastrophic Health Expenditures and Implications for Health Equity

Natalie Wodniak  1   2 , Radhika Gharpure  1 , Luzhao Feng  3 , Xiaozhan Lai  4 , Hai Fang  5   6 , Jianmei Tian  7 , Tao Zhang  8 , Genming Zhao  8 , Fernando Salcedo-Mejía  9 , Nelson J Alvis-Zakzuk  9   10   11 , Jorge Jara  12 , Fatimah Dawood  1 , Gideon O Emukule  13 , Linus K Ndegwa  13 , I-Ching Sam  14 , Tsogt Mend  15 , Baigalmaa Jantsansengee  15 , Stefano Tempia  16   17   18 , Cheryl Cohen  16   17 , Sibongile Walaza  16   17 , Wanitchaya Kittikraisak  1   2 , Arthorn Riewpaiboon  19 , Kathryn E Lafond  1 , Nelly Mejia  20 , William W Davis  1   2
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Costs of Influenza Illness and Acute Respiratory Infections by Household Income Level: Catastrophic Health Expenditures and Implications for Health Equity

Natalie Wodniak et al. Influenza Other Respir Viruses. 2025 Jan.

Abstract

Background: Seasonal influenza illness and acute respiratory infections can impose a substantial economic burden in low- and middle-income countries (LMICs). We assessed the cost of influenza illness and acute respiratory infections across household income strata.

Methods: We conducted a secondary analysis of data from a prior systematic review of costs of influenza and other respiratory illnesses in LMICs and contacted authors to obtain data on cost of illness (COI) for laboratory-confirmed influenza-like illness and acute respiratory infection. We calculated the COI by household income strata and calculated the out-of-pocket (OOP) cost as a proportion of household income.

Results: We included 11 studies representing 11 LMICs. OOP expenses, as a proportion of annual household income, were highest among the lowest income quintile in 10 of 11 studies: in 4/4 studies among the general population, in 6/7 studies among children, 2/2 studies among older adults, and in the sole study for adults with chronic medical conditions. COI was generally higher for hospitalizations compared with outpatient illnesses; median OOP costs for hospitalizations exceeded 10% of annual household income among the general population and children in Kenya, as well as for older adults and adults with chronic medical conditions in China.

Conclusions: The findings indicate that influenza and acute respiratory infections pose a considerable economic burden, particularly from hospitalizations, on the lowest income households in LMICs. Future evaluations could investigate specific drivers of COI in low-income household and identify interventions that may address these, including exploring household coping mechanisms. Cost-effectiveness analyses could incorporate health inequity analyses, in pursuit of health equity.

Keywords: acute respiratory infection; catastrophic health expenditure; cost of illness; health equity; household income; influenza.

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Conflict of interest statement

CC has received grant funds from the U.S. CDC to the institution in support of this work. She has also received granted funds to the institution unrelated to this work from Sanofi Pasteur, Wellcome Trust, Bill and Melinda Gates Foundation, and the Taskforce for Global Health. The other authors have no conflicts to report. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention.

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