The Cost of an Outbreak

Navigating our aged population's often difficult and complex care involves providing compassionate support, ensuring high-quality care, and managing the delicate balance of available resources. However, one significant challenge that can disrupt this balance and impose a substantial financial burden is an infectious disease outbreak in an aged care facility. Understanding not only what constitutes an outbreak but also the many costs associated with such an event is crucial for aged care providers, policymakers, and the wider community. This post aims to shed light on these vital aspects, with insights from available research to explore the definition of an outbreak, the key drivers of its costs, and the essential role and costs of infection prevention and control. It is also important to consider the incorporation of data from the specific region, where possible.

Before discussing the financial implications, it's essential to understand what an "outbreak" means in the context of an aged care facility. It's more than just a few residents feeling unwell; it signifies a situation requiring a coordinated response and carries specific criteria for identification, often guided by detailed surveillance definitions.

An outbreak occurs when there are more disease cases than usually expected within a specific location and for a target population, such as residents in a long-term care facility. Related is the term "cluster," referring to a group of cases in a place and time that are suspected to be greater than expected, even if the expected number isn't known.

A critical step in effectively investigating an outbreak is the development of a clear case definition, which helps to standardise the identification, consequently, the tracking of cases. A case definition includes specific criteria related to the person, place, time, and clinical features associated with the outbreak. Laboratory criteria may also be included for confirmation of the disease present. Case definitions can be categorised by the degree of diagnostic certainty, such as suspected, probable, or confirmed cases, and may be adjusted as more information becomes available.

In aged care settings specifically, the identification of healthcare-associated infections (HAIs) that might signal an outbreak or require enhanced surveillance often relies on detailed surveillance definitions for common syndromes, such as the McGeer Criteria (detailed in the previous post). Examples of criteria for various infections include Urinary Tract Infection (UTI), Respiratory Tract Infection (RTI), Skin and Soft Tissue Infection (SSTI), and Gastrointestinal Tract Infection (GITI). These definitions often combine constitutional criteria (like fever or leukocytosis) with specific signs, symptoms, and sometimes laboratory findings, adding specificity to the infection. These specific, criteria-based definitions are crucial for consistent surveillance and outbreak identification in long-term care facilities.

Infectious disease outbreaks in Australian and New Zealand aged care facilities are acknowledged as posing a significant economic challenge, impacting the costs of operation, staffing, and the overall sustainability of the aged care sector. While precise average cost figures for a single outbreak aren't readily available, the existing evidence points to a substantial financial burden driven by several key factors.

Drawing on estimates for a single infectious disease outbreak in Australian aged care, the total estimated cost can range significantly from $10,000 to over $100,000, depending on several factors. This estimate highlights the potential scale of expenditure, even without the availability of a definitive average number.

Specific examples of costs and impacts include:

To provide a broader Australasian context, research on Healthcare-Associated Infections (HAIs) in New Zealand public hospitals estimated a significant economic burden annually. For 2021, the total estimated burden was $955 million. This was comprised of several major components:

These New Zealand figures highlight the substantial economic consequences of HAIs, estimating 24,191 HAIs, 699 deaths, and 76,861 lost bed days in public hospitals in 2021. The burden measured by Disability-Adjusted Life Years (DALYs) for HAIs (24,165 DALYs) was shown to be greater than many other measured injuries and conditions in New Zealand, such as motor vehicle traffic crashes (20,328 DALYs) or colorectal cancer (24,012 DALYs). While these specific figures are for hospitals, they demonstrate the considerable economic impact of infections within the healthcare system, translating easily to significant costs in an aged care context.

The scale and duration of an outbreak are crucial factors to consider, as they directly influence the associated costs; longer or larger outbreaks will naturally incur greater expenses. Key cost drivers identified during an aged care outbreak include:

The social impact of disease outbreaks is far-reaching, affecting individuals, communities, and societies in profound ways. Psychological distress, anxiety, and depression will often surge during and after outbreaks, driven by the fear of infection, loss of loved ones, economic insecurity, and social isolation. These mental health challenges can have long-lasting consequences for individuals and communities, particularly among vulnerable groups and young adults.

Fear of infection triggers significant behavioural changes, including adherence to social distancing measures, reduced travel, and shifts in consumerism. The extent of these behavioural changes and the overall "social response" to an outbreak are influenced by factors such as the perceived risk of the disease and the level of media involvement.

Outbreaks can increase existing social inequalities, leading to stigma, discrimination, and an erosion of social cohesion and trust. Vulnerable populations often experience a disproportionate burden of infection and its social and economic consequences. Trust in government and public health institutions can also decline during and after pandemics, potentially hindering future response efforts.

Given the significant costs incurred during an outbreak, investing in measures to prevent them becomes all-important. Robust infection prevention and control (IPC) practices are vitally important in aged care facilities, as many healthcare-associated infections (HAIs) are preventable through appropriate measures. However, funding and implementing effective IPC also comes with costs, and these efforts often must compete for resources within facilities facing budget constraints.

While the financial burden of treating HAIs is understood, there is limited specific research showing the costs of efforts focused solely on preventing HAIs in long-term care settings. Despite this, it's clear that maintaining effective IPC requires ongoing expenditure. These ongoing costs include:

Beyond routine IPC practices within facilities, the broader argument for proactive investment in prevention highlights the economic benefits. Investing in robust public health infrastructure, including strengthening surveillance systems and the public health workforce, is crucial for preparedness and prevention. This emphasises the economic benefits of proactive investment in preparedness to significantly outweigh the staggering costs associated with responding to full-scale pandemics. Implementing effective IPC programs, supported by strong evidence for reducing HAIs, is a key part of this beneficial proactive investment, and the significant burden of HAIs highlights the need for such national strategies.

While a precise average cost for a single infectious disease outbreak in an aged care facility in Australia or New Zealand remains elusive due to the variability of outbreaks and limited specific financial data, the available evidence points to a significant economic burden. COVID-19 and norovirus outbreaks appear to be particularly costly due to the intensive resources required for their management. The primary drivers of these costs include staffing expenditure, especially using replacement staff and overtime, as well as the procurement and utilisation of PPE and testing. Healthcare expenses, such as treatment and hospitalisation, also contribute substantially to the financial impact.

Government support is available to assist aged care facilities in Australia to manage these outbreaks through supplements and grants. However, challenges related to accessing and efficiently disbursing these funds have been reported by the sector. The scale and duration of an outbreak are critical factors influencing the overall cost, with prompt detection and response playing a vital role in mitigation. Regional variations in outbreak costs may exist, particularly for facilities in rural and remote areas. Further research is required to establish more precise financial benchmarks for different types of outbreaks and to gain a more comprehensive understanding of the total annual cost to the aged care sector.


PS: Learning from Outbreaks in History

Spanish Flu: 50-100 million, Significant GDP, Decline in social trust

Black Death: 75-200 million, Long-term economic restructuring, Decline of feudalism, social and cultural transformations

SARS: ~800 deaths, $30-80 billion, Fear, psychological trauma, impact on travel and tourism

Ebola (W. Africa): ~11,000 deaths, $30-50 billion, Community devastation, long-term sequelae, reversal of economic gains in affected countries

MERS: ~850 deaths, ~$8 billion (South Korea), Decline in tourism

Zika: Relatively low, ~$3.5 billion (Americas), Long-term healthcare costs for microcephaly

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