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BMC Public Health. 2019 Mar 8;19(1):280. doi: 10.1186/s12889-019-6600-0.

Economic consequences of Japanese schools' recovery certificate policy for seasonal influenza.

Tsuzuki S1,2,3.

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Sapporo Maternity Women's Hospital, Kita 13 jo Nishi 4 cho-me, Kita-ku, Sapporo, Hokkaido, Postal code: 001-0013, Japan.
Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan.
Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.



Like other countries, Japan experiences a seasonal influenza epidemic every year. In order to return to school after a influenza-related absence, most Japanese students are required to submit a recovery certificate (chiyu-shoumeisyo in Japanese). The objective of this study was to estimate the economic consequences of this practice.


A cost analysis was conducted to estimate the additional costs incurred by the issuance of recovery certificates from a restricted societal perspective. The estimated number of influenza patients under 15 years old from the 2013/14 season to the 2017/18 season, the proportion of working mothers were used to calculate the estimated total number of recovery certificates issued per year. The cost of return visits to physicians and the cost for issuing certificates were included in the direct costs. Productivity loss was estimated using the mean monthly salary of women and was included in indirect costs.


The recovery certificate policy imposed an additional cost of 0.94 million USD per one million population. One-way deterministic sensitivity analysis demonstrated that the additional cost of the recovery certificate policy amounted to between 0.55 and 2.27 million USD per one million population. Probabilistic sensitivity analysis showed similar results.


The recovery certificate policy has a substantial negative economic impact on the Japanese healthcare system and society from a restricted societal perspective.


Cost analysis; Healthcare system; Influenza; Japan; Recovery certificate

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