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Objectives To investigate the magnitude and characteristics of the economic burden resulting from acute pesticide poisoning (APP) in South Korea.
Methods The total costs of APP from a societal perspective were estimated by summing the direct medical and non-medical costs together with the indirect costs. Direct medical costs for patients assigned a disease code of pesticide poisoning were extracted from the Korean National Health Insurance Reimbursement Data. Direct non-medical costs were estimated using the average transportation and caregiving costs from the Korea Health Panel Survey. Indirect costs, incurred by pre-mature deaths and work loss, were obtained using 2009 Life Tables for Korea and other relevant literature.
Results In 2009, a total of 11 453 patients were treated for APP and 1311 died, corresponding to an incidence of 23.1 per 100 000 population and a mortality rate of 2.6 per 100 000 population in South Korea. The total costs of APP were estimated at approximately US$ 150 million, 0.3% of the costs of total diseases. Costs due to pre-mature mortality accounted for 90.6% of the total costs, whereas the contribution of direct medical costs was relatively small.
Conclusion Costs from APP demonstrate a unique characteristic of a large proportion of the indirect costs originating from pre-mature mortality. This finding suggests policy implications for restrictions on lethal pesticides and safe storage to reduce fatality and cost due to APP.
Objectifs: Investiguer l’ampleur et les caractéristiques de la charge économique résultant d’une intoxication aiguë aux pesticides en Corée du Sud.
Méthodes: Les coûts totaux des intoxications aiguës d’un point de vue sociétal ont été estimés en additionnant les coûts directs médicaux et non-médicaux ainsi que les coûts indirects. Les coûts médicaux directs pour les patients à qui un code de maladie d’empoisonnement a été alloué ont été extraits des données du service de Remboursement d’Assurance Santé Nationale Coréenne. Les coûts directs non médicaux ont été estimés en utilisant la moyenne des coûts de transport et des soins de la Surveillance du Jury de Santé Coréen. Les coûts indirects encourus par les décès prématurés et la perte de travail, ont été obtenus en utilisant les Tables de Vie 2009 pour la Corée et d’autres documents pertinents.
Résultats: En 2009, au total 11.453 patients ont été traités pour une intoxication aiguë aux pesticides et 1.311 sont décédés, ce qui correspond à une incidence de 23,1/100.000 habitants et un taux de mortalité de 2,6 pour 100.000 habitants en Corée du Sud. Le coût total de l’intoxication aiguë aux pesticides a été estiméà environ 150 millions de dollars US, soit 0,3% des coûts totaux des maladies. Les coûts liés à la mortalité prématurée représentaient 90,6% des coûts totaux, tandis que la contribution des coûts directs médicaux était relativement faible.
Conclusion: Les coûts des intoxications aiguës aux pesticides montrent une caractéristique unique d’une grande partie des coûts indirects provenant de la mortalité prématurée. Cette constatation suggère des implications politiques de restrictions sur les pesticides mortels et un stockage sécurisé afin de réduire la fatalité et le coût liéà une intoxication aiguë aux pesticides.
Objetivos: Investigar la magnitud y características de la carga económica que resulta del envenenamiento agudo con pesticidas en el sur de Corea.
Métodos: Los costes totales del envenenamiento agudo con pesticidas desde una perspectiva social, se calcularon sumando los costes directos, médicos y no-médicos junto con los costes indirectos. Los costes médicos directos para los pacientes a los que se les había asignado el código de envenenamiento con pesticida se extrajeron de datos de reembolso del Seguro Nacional de Salud Coreano. Los costes directos no-médicos se calcularon utilizando una media de costes de transporte y cuidados tomados del Panel de Encuestas de Salud Coreana. Los costes indirectos, incurridos por muerte prematura y pérdida de trabajo, se obtuvieron utilizando las Tablas de Vida para Corea del 2009 y otra literatura relevante.
Resultados: En el 2009 se trató a un total of 11 453 pacientes por envenenamiento agudo con pesticida y 1,311 murieron, correspondiendo a una incidencia de 23.1 por 100 000 habitantes y una tasa de mortalidad de 2.6 por 100 000 habitantes en Corea del Sur. Los costes totales del envenenamiento agudo con pesticida se estimaron en aproximadamente US$150 millones, 0.3% de los costes del total de enfermedades. Los costes debido a una mortalidad prematura eran responsables del 90.6% de los costes totales, mientras que la contribución de los costes médicos directos era relativamente pequeña.
Conclusión: Los costes del envenenamiento agudo con pesticidas presentan la característica peculiar de una gran proporción de costes indirectos generados a partir de una mortalidad prematura. Este hallazgo sugiere la necesidad de la implicación política para generar restricciones sobre pesticidas letales y un almacenaje seguro con el fin de reducir la mortalidad y el coste debido al envenenamiento agudo por pesticidas.
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Pesticide poisoning is one of the major public health issues worldwide. Although there is a paucity of information on its incidence and mortality, it is estimated that global annual number of self-inflicted deaths from pesticide has reached a quarter million (Gunnell et al. 2007). Acute pesticide poisoning (APP) is one of the leading causes of morbidity and mortality due to poisoning in East and South-East Asian countries (Awang et al. 2003; Li et al. 2009; Chien et al. 2011). Self-ingestion of pesticide is believed to be one of the commonest methods of suicide, especially in Asia (Bertolote et al. 2006).
In South Korea, highly toxic pesticides remain easily accessible on the market, and pesticide-related illnesses and deaths are prevalent. The age-standardised mortality rate for pesticide poisoning was reported as 5.32 per 100 000 population between 1996 and 2005 (Lee et al. 2009), using registered deaths data. Recent studies have reported an annual pesticide-related hospitalisation rate of 17.8 per 100 000 population (Kim et al. 2012), and a 26.8 per 100 000 population annual average rate of emergency department visits due to pesticide poisoning in South Korea (Ko et al. 2012). Deliberate pesticide self-poisoning is among the most preferred means of suicide in South Korea (Kim et al. 2011). Accidental pesticide poisoning, such as when pesticides are misidentified as cooking ingredients or beverages, is a further common form of pesticide poisoning (Shin et al. 2004) and can lead to fatal consequences. However, the economic burden related to pesticide use has not been examined and pesticide poisoning has failed to draw a corresponding level of attention from either the government or society in South Korea.
Previous studies have been undertaken in several countries to quantify the economic burden of the adverse health effects of pesticide use. These studies, however, are only weakly comparable with one another due to their varying scopes, perspectives, types of exposure treated and economic contexts (Table 1). In Zimbabwe, 280 cotton growers were surveyed to examine the direct and indirect costs of the acute health effects of pesticides (Maumbe & swinton 2003). The costs of pesticide poisoning and pesticide-related illnesses in the US were also calculated based on an estimated number of cases (Pimentel 2005). The costs incurred due to pesticide exposure were also examined in a region in Kerala, India (Devi 2007). Using Nicaraguan surveillance data, the average out-of-pocket costs per pesticide poisoning episode were estimated (Corriols et al. 2008). The estimation of annual costs related to occupational pesticide use based on a survey of 291 farm households, including the cost of averting actions, was also conducted in a single area in Nepal (Atreya 2008).
Table 1. Preceding studies on the economic burden of the adverse health effects from pesticide exposure
|Country (Year)||Type of exposure||Perspective/Range of cost components||Type of data||Findings*||Reference|
|Ecuador (1991–1992)||Occupational, accidental and intentional||Governmental and patient perspective/public and social security health care direct costs, private health costs and lost-time indirect costs||Local active surveillance||Public and social security health care costs – US $9.85/case, Private health care costs - US$ 8.33/case, Lost-time indirect costs – US$ 8.33/case|| Cole et al. 2000 |
|Italy (1999)||General, occupational and self-poisoning||Governmental perspective/direct medical costs||Local poison control centre survey||Total annual spending for the treatment of acute pesticide poisoning – Lit 1.8 billion (US$ 1 084 991). Cost per case – Lit 1 330 530 (US$ 802)|| Brenna 2001 |
|Zimbabwe (1998–1999)||Occupational||Patient perspective||Local survey||Cotton growers lost Z$ 180–316 (US$ 4.74–8.32) per year on pesticide-related direct and indirect acute health effects|| Maumbe & swinton 2003 |
|US||Overall poisonings and related illnesses||Societal perspective/medical costs, costs of lost work, fatalities and pesticide cancers||N/A||Costs of pesticide poisonings and other pesticide-related illnesses each year – US$ 1.2 billion, cost per fatality case – US$ 3.7 million case|| Pimentel 2005 |
|India (2004–2005)||Occupational||Patient perspective/medical costs and work days loss||Local survey||Welfare loss to an applicator from pesticide exposure -annually US$ 36 per applicator and US$ 0.86 per spraying day per applicator|| Devi 2007 |
|Nicaragua (2000)||Overall||Patient perspective/patients’ out-of-pocket costs||Nationwide survey||The mean out-of-pocket cost for treatment of a single pesticide poisoning episode – US$ 41|| Corriols et al. 2008 |
|Nepal (2005)||Occupational||Patient perspective/treatment costs, productivity loss, averting action costs||Local survey||The actual annual health costs for pesticides users – NPR 143.72 (US$ 2.05)|| Atreya 2008 |
|Sri Lanka (2005–2006)||Self-poisoning||Societal and patient perspectives/ward staff, laboratory testing, drug, non-drug treatment, capital and maintenance costs of hospitals and transfer costs||Local, hospital resource use||Average total treatment cost for pesticide self-poisoning – US$ 49.12|| Wickramasinghe et al. 2009 |
However, most of these studies were confined to limited areas and focused primarily on specific types of exposure, such as occupational and/or intentional pesticide poisoning. In addition, previous studies have mainly depended on self-reported data and included some potential uncertainty and underestimation in their methods. No study that examined the comprehensive cost components beyond purely direct medical costs, and including productivity or work loss has been reported.
This study, therefore, was designed to investigate the overall economic burden incurred by all treated APP incidents in South Korea, regardless of type of exposure (i.e. occupational, accidental and self-inflicted) using national level data. In particular, this study attempted to explore the indirect economic impact of APP by estimating costs of productivity lost due to mortality and morbidity.
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In 2009, a total of 11 453 patients, including 5732 inpatients and 5721 outpatients, were treated for APP (Table 3). Patients between 20 and 64 years of age accounted for 60.2%. Deaths from APP totalled 1311 in 2009 and patients aged 65 or older accounted for 54.7% of all mortality. The overall incidence and mortality rates of APP were 23.1 per 100 000 and 2.6 per 100 000, respectively. Both incidence and mortality rates were higher among men and were highest in the age group of 65 or older. The case fatality rate based on NHI data was 11.4%.
Table 3. Incidence and mortality rates for acute pesticide poisoning by age and gender in South Korea, 2009
| ||Both sexes||Male||Female|
|Number of patients or deaths||Incidence or mortality rate (per 100 000)||Number of patients or deaths||Incidence or mortality rate (per 100 000)||Number of patients or deaths||Incidence or mortality rate (per 100 000)|
|Total patients||11 453||23.1||6820||27.4||4633||18.7|
| Average hospitalisation days||8.6 days||8.7 days||8.5 days|
| Average number of visits||1.5 visits||1.4 visits||1.6 visits|
The total costs of APP in 2009 were estimated at approximately US$ 150 million (Table 4). Of this amount, indirect costs of US$ 135 million, which mainly originated from pre-mature mortality, accounted for 90.6% of the total costs of APP, while direct medical costs accounted for <8.5%. Transportation and caregiving costs were negligible compared with other cost components. The NHI reimbursement for APP of US$ 7.8 million was 0.05% of the total NHI reimbursement for all diseases of US$ 16.6 billion in 2009 (NHIC/HIRA 2010).
Table 4. Economic burden of APP in South Korea, 2009 (US$)
|Categories||Base case (Age range: 20–69, Discount rate 5%)||Alternative scenario 1 (20–69, 3%)||Alternative scenario 2 (20–69, 7%)||Alternative scenario 3 (15–79, 5%)|
|Total costs||149 451 273||177 190 229||129 674 579||157 110 214|
|Direct medical costs||12 645 318||12 645 318||12 645 318||12 645 318|
| NHI reimbursement||7 797 631||7 797 631||7 797 631||7 797 631|
| NHI copayment||2 057 166||2 057 166||2 057 166||2 057 166|
| NHI drug cost||36 938||36 938||36 938||36 938|
| Non-NHI copayment||2 753 583||2 753 583||2 753 583||2 753 583|
|Direct non-medical costs||1 378 178||1 378 178||1 378 178||1 378 178|
| Transportation cost||127 288||127 288||127 288||127 288|
| Caring cost||1 250 890||1 250 890||1 250 890||1 250 890|
|Indirect costs||135 427 777||163 166 733||115 651 083||143 086 718|
| Productivity loss due to pre-mature deaths||132 410 977||160 149 933||112 634 283||139 735 936|
| Work loss due to hospitalisations and outpatient visits||3 016 800||3 016 800||3 016 800||3 350 782|
In the first and second alternative scenarios, when 3% and 7% discount rates for future income were applied without changes in the age range total APP costs changed to US$ 177 million and US$ 130 million, respectively. Meanwhile, when the productive age range was extended to 15–79, total costs increased to US$ 157 million. Most changes in the cost resulted from changes in mortality cost, while work loss due to hospitalisation and outpatient visits were not affected greatly, and direct cost components remained constant.
Age-specific costs of APP by cost component are shown in Table 5. Although the age group of 40–49 recorded the highest in terms of total costs, the cost per patient was greatest among those aged 30–39. Direct medical costs per patient were relatively higher among teenagers and young adults (US$ 1726 for the 10–19 age group, US$ 1674 for the 20–29 age group). Work loss due to hospitalisations and outpatient visits per patient showed the highest cost in the 30–39 age group, followed by 40–49. Lost productivity per death also peaked among the young adult groups (US$ 295 306 for the 30–39 age group and US$ 291 151 for the 20–29 group), which reflected longer life expectancies and the resulting greater loss of productive years among relatively younger age groups. In general, when judged according to per capita cost, young adult groups were more responsible for costs due to APP.
Table 5. Age-specific costs of APP in South Korea, 2009 (US$)
| ||Overall costs||Direct medical costs||Work loss due to hospitalisation and outpatient visits||Productivity loss due to pre-mature mortality|
|Total||Per patient||Total||Per patient||Total||Per patient||Total||Per deaths|
|Sum||149 451 273||13 049||12 645 318||1104||3 016 800||263||132 410 977||101 000|
|0–9||82 841||262||69 769||221||–||–||–||–|
|10–19||1 828 123||11 719||269 251||1726||–||–||1 540 118||220 017|
|20–29||9 533 792||23 775||671 192||1674||81 175||202||8 734 523||291 151|
|30–39||30 174 474||28 359||1 537 282||1445||439 827||1097||28 054 025||295 306|
|40–49||45 644 681||20 607||2 876 462||1299||1 094 662||1029||41 388 880||240 633|
|50–59||36 585 133||16 728||2 194 764||1004||996 102||450||33 138 822||171 704|
|60–69||23 050 031||10 217||2 852 872||1265||405 034||185||19 554 609||76 685|
|70+||2 552 198||893||2 173 726||761||–||–||–||–|
The mortality cost per APP death was estimated and compared with that of other disease groups (Table 6). In the human capital approach, the mortality cost per death is largely dependent on the mean age of death; as the mean age of death decreases, mortality cost per death increases. The mortality cost per APP death was higher than that of most other disease groups – second only to infectious disease – and twice as much as that of overall diseases. This implicates that younger patients are more affected by fatal APP cases compared with other diseases.
Table 6. Comparison of mortality cost per death from APP with other disease groups in South Korea
|Cause of death (year)||Number of deaths||Cost due to pre-mature deaths (US$ in 2009 value)||Cost per mortality case (US$ in 2009 value)*|
|APP (2009)||1311||132 410 977||101 000|
|Infectious diseases (2007)||5349||619 357 402||115 789|
|Cancers (2007)||68 335||5 393 748 772||78 931|
|Cardiovascular diseases (2007)||57 574||2 735 042 304||47 505|
|Respiratory diseases (2007)||14 864||336 764 890||22 656|
|Injuries (2006)†||29 495||19 960 046 055||676 726|
|All diseases except for injuries (2007)||244 874||14 006 733 025||57 200|
Figure 1 illustrates the comparison of different cost component shares between APP and other disease groups. Whereas the proportions of direct medical costs for other major disease groups, such as infectious diseases, cancers, cardiovascular diseases and respiratory diseases, ranged from 31.8% to 60.4%, that of APP comprised only 8.5% of total costs. Instead, the majority of APP costs stem from pre-mature death (88.6%). Although injuries was the only group comparable to APP in terms of proportion of indirect costs, its proportion of mortality cost (61.2%) was still much smaller than that of APP.
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This study based on national data estimated total APP costs at US$ 150 million in 2009, which accounted for 0.30% of the estimated costs of all diseases in South Korea (Jung 2010). Meanwhile, the NHI reimbursement for APP patients was US$ 7.8 million, which accounted for only 0.05% of total 2009 NHI reimbursement for all diseases (NHIC/HIRA 2010), a negligible level compared with other major diseases when viewed from the government-run NHI perspectives. When compared with other disease groups, however, the cost of APP includes a unique characteristic in that the majority of the total cost was explained by indirect cost resulting from pre-mature mortality. Although total APP costs make up a small proportion of the costs of all diseases, it is important to understand that significant policy implications can be drawn from the large proportion of pre-mature mortality cost.
The substantial proportion of indirect costs can be mainly attributed to the high case fatality rate of APP in South Korea. Because intentional self-poisoning accounted for 84.8% of total deaths from pesticide poisoning in South Korea (Lee et al. 2009), the large proportion of mortality cost should be closely linked to suicide. The case fatality rate of 11.4% in this study is comparable to that of emergency room visit patients of 15.0% (Ko et al. 2012) and that of hospitalised patients of 19.1% (Kim et al. 2012), considering that NHI data included ambulatory and/or non-emergency cases as well. This high fatality may result from the possible exclusion of mild cases, which did not receive medical attention because NHI data do not capture such cases. The high proportion of self-poisoning from paraquat and the advanced age of the victims may also partially explain the reason.
The unique cost structure could be a disadvantage for APP as a public health issue. Acute pesticide poisoning is likely to be ignored by the government and hardly becomes an intervention focus because elevated indirect costs do not directly impose any additional burden upon the NHI at the time of incidence. Consequently, APP may fail to attract the attention it deserves from both the government and the public. Thus, the high mortality cost of APP remains a neglected or hidden cost to society.
The results of this study offer the following policy implications. Firstly, given the elevated proportion of costs due to pre-mature deaths and the fact that pesticide ingestion is a common means of suicide, reinforcing regulatory oversight is required for reducing the burden of APP. A number of studies have shown that the wide availability of pesticides is among the most common risk factors for suicide by self-poisoning, and that a ban on the production and distribution of highly lethal pesticides would reduce the number of deaths from pesticide poisoning (Konradsen et al. 2003; Mann et al. 2005; Eddleston et al. 2006; Gunnell et al. 2007). However, a number of highly toxic pesticides, such as paraquat dichloride, which have already been banned in many industrialised countries, remain on the market in South Korea. Even though a ban may not be a thorough intervention strategy for reducing intentional poisonings, based on results in Sri Lanka (Eddleston et al. 2012), it should be considered an urgent and effective technique to reduce the incidence and subsequent cost of APP in the South Korean context of a high suicide rate and inadequacy of current pesticide regulations.
Ease of access to pesticides is particularly problematic if a suicide attempt is impulsive or minimally planned (Chen et al. 2012). Pesticide self-poisoning can be impeded when pesticides are unavailable in a moment of emotional crisis (Gunnell & Eddleston 2003). Thus, establishing appropriate storage system could also provide an effective strategy for minimising costs due to self-inflicted poisonings, most of which occurred in impulsive attempts.
It is also important to improve accessibility to medical services. A recent nationwide survey showed that the incidence rate of occupational APP was 24.7 per 100 male farmers, and that only 12% of the cases among South Korean farmers received medical attention (Lee et al. 2012). In addition, according to another national survey, roughly one-quarter of farmer respondents answered that long distance from healthcare facilities was a crucial difficulty facing agricultural healthcare service (as opposed to 4.2% among urban residents), while 15% of the farmers pointed to reducing the travel time to medical service providers as the most needed change for improving healthcare conditions (compared to 2.6% among urban citizen; Statistics Korea 2008). Considering that the majority of death and emergency department visits due to pesticide poisoning occurred in rural areas (Lee et al. 2009; Ko et al. 2012) where residents experience a greater deprivation of healthcare services than urban citizens, access to high-quality medical service in agricultural areas should be improved for proper and timely care.
This study is the initial attempt to estimate the economic burden of APP in South Korea based mainly on NHI data. The advantage of using NHI data includes that the estimation was able to incorporate all APP cases reimbursed by NHI or NMA because the entire population is enroled in either programme. This study also included all types of exposure and was based on comprehensive elements of the cost of APP, including direct and indirect medical costs.
National Health Insurance data, as secondary data, have a limitation as well that they lack precise information such as the occupation of individual patients, exposure details and/or the validity of each case that would be needed for detailed analysis. A lack of information on the validity of NHI data for APP is being a potential weakness of our study. However, APP cases may be more accurately reported than other causes of diseases because pesticide poisoning may be more likely to evoke action from family or friends in seeking medical attention. But there could be a degree of under-reporting of occupational pesticide poisoning cases, and this may lead to underestimation of APP incidence and costs.
Another limitation is that APP costs in this study could be underestimated because there may exist untreated or self-treated cases of occupational APP due to impediments to access to healthcare service in agricultural regions. Because such cases were not captured in the NHI data, NHI costs may represent only a portion of the full economic burden of APP. Transportation cost may be another source of underestimation. Because patients in agricultural areas generally are required to travel farther to find hospitals capable of providing appropriate services, especially for severe APP cases, transportation costs for farmers may be higher than estimated in this study. Disability costs were not included in this analysis due to lack of information regarding the proportion of disability after APP and in the appropriate quantification data for estimation of disability cost. However, the inclusion in the analysis of disability costs after poisoning might provide a more precise cost value of APP. Further, the impact of suicide on the community was not included in the estimation, which led to the underestimation of the societal burden of APP.
To better understand the actual characteristics of economic burden of APP and to verify the accuracy of secondary data, efforts need to be given to establishing active surveillance system through which more detailed information on causative pesticides, type of exposure and outcome of treatment could be obtained. Voluntary or mandatory notification programmes from affected persons, hospital staff and poisoning control centres are required to be activated as the core of active surveillance system. Sentinel centres could also provide reliable epidemiological information on the magnitude and causative chemicals of pesticide poisoning. None of these programmes, however, is currently in operation in South Korea. Despite a potential problem of under-reporting (Corriols et al. 2008), an active surveillance system for pesticide-related illnesses could provide policymakers and researchers with a source of appropriate information.
In summary, the total costs of APP in South Korea are relatively small compared with other major diseases. The majority of the costs originated from pre-mature deaths, however, are occluded from the insurer’s perspective, which does not incorporate societal burden. Acute pesticide poisoning costs need to be judged from a societal perspective in order to understand their true economic burden and informative share among cost components. Considering only direct costs inevitably leads to underestimation of the cost of APP and may result in inadequate intervention strategies.