GASTROENTEROLOGY 2009;136:1851–1862
The Economics of Enteric Infections: Human Foodborne Disease Costs
Jean C. Buzby Tanya Roberts*
US Department of Agriculture, Economic Research Service, Washington, DC
The World Health Organization estimates that in 2005,
1.5 million people died, worldwide, from diarrheal dis-
eases. A separate study estimated that 70% of diarrheal
diseases are foodborne. The widely cited US estimate is
that there are 76 million foodborne illnesses annually,
resulting in 325,000 hospitalizations and 5200 deaths.
However, there are epidemiologic and methodologic
challenges to accurately estimate the economic burden
of foodborne disease on society, either in terms of mon-
etary costs or non-monetary units of measurement.
Studies on the economic burden of foodborne disease
vary considerably: some analyze the effects of a single
pathogen or a single outbreak, whereas others attempt
to estimate all foodborne disease in a country. Differ-
ences in surveillance systems, methodology, and other
factors preclude meaningful comparisons across exist-
ing studies. However, if it were possible to completely
estimate the societal costs for all acute foodborne dis-
eases and their chronic sequelae worldwide, on the basis
of currently available data, worldwide costs from these
illnesses would be substantial. Moreover, foodborne
infections are largely manifested as intestinal illnesses
and are largely preventable. Total costs of foodborne
disease would be much smaller in the United States and
the world if economic incentives for industry to pro-
duce safer food were improved. However, costs of im-
plementing new food safety prevention and control
rules must be weighed against the estimated benefits of
reducing foodborne disease to determine net benefits so
that governments have information to efficiently allo-
cate funds among competing programs.
T he World Health Organization (WHO) estimates
that 1.5 million people died, worldwide, from diar-
rheal diseases in 2005.1 A separate study estimated that
70% of diarrheal diseases are foodborne.2 Data on the
extent of foodborne illnesses and associated deaths are
incomplete and understate the problem in both devel-
oped and developing countries.3 The widely cited US
estimate by Mead et al4 at the Centers for Disease Con-
trol and Prevention (CDC) is that 76 million foodborne
illnesses occur annually in the United States, resulting in
325,000 hospitalizations and 5200 deaths.
Every illness has an economic cost. For the practitio-
ner, such costs have bearings if they influence decisions
to diagnose or to treat, either consciously or uncon-
sciously. Global macroeconomic consequences of such
illnesses do not, however, influence daily practice. None-
theless, infections of the gastrointestinal tract, and, most
particularly, those that are foodborne and theoretically
preventable exact considerable expense worldwide. Be-
cause of the role of gastroenterologists in the manage-
ment of affected patients, and as advocates for patients
and populations who wish not to acquire these infec-
tions, we take the opportunity of this review to present
large-scale implications of foodborne illnesses.
On a per patient scale, foodborne disease costs can be
considerable, particularly for the more severe cases. For
example, Table 1 presents total cost estimates for STEC
O157 (ie, Shiga toxin-producing Escherichia coli O157) and
shows how average estimated costs per case vary by se-
verity level. The estimated average cost for STEC O157 is
$6256 per case.5
Much of the US data on foodborne disease are from
the Foodborne Diseases Active Surveillance Network
*Dr Roberts is retired from the US Department of Agriculture, Eco-
nomic Research Service, Washington, DC.
Abbreviations used in this paper: CDC, Centers for Disease Control
and Prevention; CEA, cost-effectiveness analysis; COI, cost-of-illness;
DALY, disability-adjusted life year; ERS, Economic Research Service;
FDA, Food and Drug Administration; FoodNet, Foodborne Diseases
Active Surveillance Network; GBS, Guillain-Barré syndrome; HALY,
health-adjusted life year; HUS, hemolytic uremic syndrome; OMB,
Office of Management and Budget; PR/HACCP, Pathogen Reduction/
Hazard Analysis and Critical Control Program; STEC O157, Shiga toxin-
producing Escherichia coli O157; USDA, US Department of Agriculture;
WHO, World Health Organization; WTP, willingness-to-pay.
© 2009 by the AGA Institute
0016-5085/09/$36.00
doi:10.1053/j.gastro.2009.01.074
1852 BUZBY AND ROBERTS GASTROENTEROLOGY Vol. 136, No. 6

Table 1. Estimated STEC O157 Costs, From All Sources, 2007 Dollars
Severity level Total cases (n) Total costs ($) Average cost per case ($)
Not hospitalized
Did not visit physician; survived 57,656 1,645,024 29
Visited physician, survived 13,656 7,045,354 516
Hospitalized
Did not have HUS; survived 1797 12,438,459 6922
Had HUS but not ESRD; survived 300 11,608,420 38,695
Had HUS and ESRD; survived 10 58,687,607 5,868,761
Did not have HUS; died 23 103,657,247 4,506,837
Had HUS, died 38 264,625,382 6,963,826
Total 73,480 459,707,493 6256

NOTE: Although these figures are for STEC O157 illnesses from all sources, average foodborne illness costs are usually considered to be the
same as costs for those illnesses from non-foodborne sources.
ESRD, end-stage renal disease; HUS, hemolytic uremic syndrome, which is characterized by red blood cell destruction, kidney failure, and
neurologic complications, such as seizures and strokes;
Source: Economic Research Service.5

(FoodNet), which is a collaborative effort between the
CDC, the US Department of Agriculture (USDA), the
Food and Drug Administration, and 10 participating
state health departments.6,7 FoodNet performs active,
population-based laboratory surveillance in selected sites
around the United States and covers a select group of
pathogens (ie, Campylobacter, Cryptosporidium, Cyclospora,
Listeria monocytogenes, STEC O157, STEC non-O157, Sal-
monella, Shigella, Vibrio, and Yersinia enterocolitica).6,7 Food-
Net augments surveillance information with surveys of
clinical laboratories and the general public to better un-
derstand the burden of disease. Population demograph-
ics from FoodNet find that the young are more likely to
be infected with a foodborne pathogen, yet those older
than 70 years are more likely to die of the illness (Table 2).
Collectively, foodborne diseases pose enormous fi-
nancial costs on communities, individual nations, and
the world. For example, US foodborne costs for 6
bacterial pathogens and 1 parasite were estimated at
$6.5 billion to $34.9 billion annually,8 which is an
underestimate of total foodborne disease costs because
there may be ⬎200 microbiologic agents that cause
foodborne disease.4 Other countries have also esti-
mated annual costs for foodborne diseases, and global
estimates of the burden of foodborne disease are cur-
rently being developed. Snowdon et al9 speculated that
the economic consequences of foodborne disease are
substantial in both industrialized and developing na-
tions, although the consequences may be greater in
developing countries because of high incidence of in-
fant mortality, malnutrition, and chronic diarrhea.
Foodborne illness generates costs that are borne by
households whose members become ill, the food in-
dustry, and the regulatory and public health sectors
(Figure 1). The array of societal costs of foodborne
illnesses in these 3 main groups is shown in Table 3.
Analyses that estimate the costs of foodborne disease
often include only the medical costs of individuals or
household, costs of lost productivity, and premature
death and exclude others costs (eg, pain and suffering,
institutional care) because of lack of adequate data.
The WHO defines the burden of disease as “the inci-
dence and prevalence of morbidity, disability, and mor-
tality associated with acute and chronic manifestations
of diseases.”10 Here, we take this one step further and are
interested in the economic burden of foodborne disease,
meaning that we are interested in translating the differ-
ent outcomes or effect of foodborne disease into a com-

Table 2. Illnesses, Hospitalizations, and Deaths in FoodNet as a Result of Pathogens Commonly Transmitted Through Food
by Age, 2001–2005
Age

0–14 y 15–69 y ⱖ70 y

Case severity Total cases (n) n % n % n %

Illnessesa 63,422 25,821 41 35,263 55 2338 4
Required hospitalization 15,420 4828 31 8444 55 2148 14
Death from foodborne illness 368 36 10 158 43 174 47

NOTE: The illness severity categories are mutually exclusive and include the pathogens covered by FoodNet.
aPersons who have visited a doctor because of an illness, a stool sample has been taken, and the infection is confirmed and is in the FoodNet
database.
Source: Age breakdown of FoodNet data (Ida Rosenblum, FoodNet CDC, e-mail communication April 2007).
May 2009
Figure 1. Costs of foodborne illness are borne by households whose
members become ill, the food industry, and the regulatory and public
health sectors.
mon unit of measurement, such as monetary costs or a
non-monetary unit of measurement.
Why is it important to estimate the economic burden
of a foodborne disease? These estimates can be used in
the following multiple ways:
● Evaluate the economic burden of all or a group of
foodborne diseases.
● Provide justification for the need to strengthen sup-
port for increased surveillance and prevention of
foodborne diseases by national or by international
organizations, such as the WHO.
● Provide input to a benefit– cost analysis of a proposed
food safety rule or a cost-effectiveness analysis (CEA),
to obtain information needed in policy making. From
an economic perspective, the societal benefits of a food
safety regulation are the costs of foodborne disease
that would be prevented if the regulation was put in
place, such as savings in disease prevention and miti-
gation expenditures, increases in worker productivity,
and reductions in medical costs, pain and suffering.
● Aid comparisons and other analyses, such as for:
ΠComparing the estimated costs for different food-
borne diseases. Although this information can help
determine the order for targeting pathogen preven-
tion and control efforts toward the most costly dis-
eases, information on prevention and control costs
is also needed to determine whether and where there
are positive net benefits from implementing food
safety programs.
HUMAN FOODBORNE DISEASE COSTS 1853
ΠComparing benefits and costs of alternative patho-
gen prevention and control programs and strategies
to find cost-effective interventions so that resources
are appropriately allocated.
ΠMonitoring and evaluating food safety measures
over time. They can also give countries a sense of
what to expect in terms of the disease burden in
the future.10
Epidemiologic Challenges
There are 5 main epidemiological challenges when
estimating the economic burden of foodborne disease.
Estimating the Number of Illnesses
Estimating the annual number of illnesses each
year caused by a particular pathogen is difficult. This is a
challenge because some unknown portion of ill people
never see a doctor, many visits do not result in a diag-
nosable pathogen because the specimen is not obtained,
or the laboratory testing does not seek or identify the
causative agent.11 Figure 2 illustrates the steps that must
occur for a person who becomes ill to be identified as a
laboratory-confirmed case that is reported to public
health surveillance.
In 2007, FoodNet identified a total of 17,883 labora-
tory-confirmed cases of foodborne infection.12 This esti-
mate represents those laboratory-confirmed cases in
which an illness is linked to a specific pathogen and
reported to the CDC. As previously mentioned, FoodNet
uses a variety of tools to make its estimates. Information
from active surveillance and the FoodNet surveys of clin-
ical laboratories and the general population are used to
estimate the total number of foodborne illnesses in the
population. With this information, Mead et al4 estimated
that 76 million foodborne disease cases occur annually in
the United States. FoodNet now covers 15% of the US
population6,7; FoodNet also conducts a variety of epide-
miologic studies, including case– control studies for spo-
radic cases from specific pathogens.6
One particular difficulty in estimating the total cost of
foodborne disease is that the causes of most cases of
gastrointestinal distress are never identified. Because of
the mild nature of most of these illnesses, the causes are
usually not investigated, and, as a result, they are fre-
quently excluded from cost studies. Mead et al4 found
that unknown agents accounted for approximately 81%
of foodborne illnesses in the United States and 64% of
deaths. Hence, the actual spectrum of all causes of food-
borne disease is not definitive, and, as a result, the overall
economic analysis will be similarly restricted. Total esti-
mated costs of foodborne disease will be underestimated
if the economic studies do not include the unknown
pathogens from Mead et al4 or other sources, particularly
the more severe cases. Frenzen13 estimated that gastro-
enteritis of unknown cause was responsible for 4400
deaths in the United States each year but found no direct
1854 BUZBY AND ROBERTS GASTROENTEROLOGY Vol. 136, No. 6

Table 3. Societal Costs of Foodborne Illness Table 3. Continued

Costs to individuals or householdsa Reduced product demand because of outbreak:
Human illness costs Generic animal product, all firms affected
Medical costs Reduction for specific firm at wholesale or retail level
Physician visits Increased advertising or consumer assurances after outbreak
Laboratory costs Regulatory and public health sector costs for foodborne pathogens
Hospitalization or nursing home Disease surveillance costs to
Drugs and other medications Monitor incidence or severity of human disease by foodborne
Ambulance or other travel costs pathogens
Income or productivity loss for Monitor pathogen incidence in the food chain
Ill person or person dying Develop integrated database from farm to table for foodborne
Caregiver for ill person pathogens
Other illness costs Research to
Travel costs to visit ill person Identify new foodborne pathogens for acute and chronic human
Home modifications illnesses
Vocational/physical rehabilitation Establish high-risk products and production and consumption
Child care costs practices
Special educational programs Identify which consumers are at high risk for which pathogens
Institutional care Develop cheaper and faster pathogen tests
Lost leisure time Risk assessment modeling for all links in the food chain
Psychological costs Outbreak costs
Pain and other psychological suffering Costs of investigating outbreak
Risk aversion Testing to contain an outbreak (eg, serum testing and
Averting behavior costs administering immunoglobulin in persons exposed to
Extra cleaning or cooking time costs hepatitis A)
Extra cost of refrigerator, freezer, etc Costs of cleanup
Flavor changes from traditional recipes (especially meat, milk, Legal suits to enforce regulations that may have been violatedc
egg dishes) Other considerations:
Increased food cost when more expensive but safer foods are Distributional effects in different regions, industries, etc
purchased Equity considerations, such as special concern for children
Altruism (willingness to pay for others to avoid illness)
aWillingness-to-pay estimates for reducing risks of foodborne disease
Industry costsb
Costs of animal production is a comprehensive estimate of all these categories (assuming that
Morbidity and mortality of animals on farms the individuals have included employer-funded sick leave and medical
Reduced growth rate or feed efficiency and increased time to programs in their estimates). The estimate is comprehensive and
market covers reduced risks for everyone: those who will become ill as well as
Costs of disposal of contaminated animals on farm and at those who will not.
bSome industry costs may fall with better pathogen control, such as
slaughterhouse
Increased trimming or reworking at slaughterhouse and reduced product spoilage, possible increases in product shelf-life,
processing plant and extended shelf-life, permitting shipment to more distant markets
Illness among workers because of handling contaminated or lowering shipment costs to nearby markets.
cIn adding up costs, care must be taken to assure that product liability
animals or products
Increased meat product spoilage because of pathogen costs to firms are not already counted in the estimated pain and
contamination suffering cost to individuals. However, the legal and court expenses
Control costs for pathogens at all links in the food chain incurred by all parties are societal costs.
New farm practices (age-segregated housing, sterilized feed, etc)
Altered animal transport and marketing patterns (animal
identification, feeding or watering) evidence that unknown foodborne agents were a main
New slaughterhouse procedures (hide wash, knife sterilization, cause of these deaths.14
carcass sterilizing)
New processing procedures (pathogen tests, contract Attributing Foodborne Disease to Particular
purchasing requirements) Foods
Altered product transport (increased use of time or
temperature indicators) Information about the share of illnesses that are a
New wholesale or retail practices (pathogen tests, employee result of specific foods is limited. Economic analyses need
training, procedures) this information to estimate the number of foodborne
Risk assessment modeling by industry for all links in the food disease cases that might be prevented by a proposed
chain
regulation. For example, the official regulatory impact
Price incentives for pathogen-reduced product at each link in
the food chain analysis of the Pathogen Reduction/Hazard Analysis and
Outbreak costs Critical Control Program (PR/HACCP) for federally in-
Herd slaughter or product recall spected meat and poultry slaughter and processing
Plant closings and cleanup plants required assumptions about what portion of all
Regulatory fines
cases of salmonellosis, campylobacteriosis, and other se-
Product liability suits from consumers and other firms
lect foodborne disease cases were due to meat and poul-
try.15 The proportion attributed to foodborne transmis-
May 2009
Figure 2. FoodNet surveillance, burden of illness pyramid. Adapted
from CDC. Available at: www.cdc.gov/foodnet/surveillance_pages/
burden/pyramid.htm. Accessed September 4, 2008.
sion varies greatly, from 1% for rotaviruses to 100% for
Bacillus cereus.4 FoodNet conducted case– control studies
to determine the foods that cause sporadic illnesses. The
best information linking pathogens to specific foods are
from foodborne disease outbreak data. However, Mead et
al4 estimated that only 0.008% of all foodborne illness
cases in the United States are identified in an outbreak,
and more recent research suggests that in sporadic cases
vehicles can differ considerably from those implicated in
outbreaks.16 For estimation purposes, the share of a par-
ticular foodborne disease to a particular food vehicle is
often obtained from expert opinion or targeted studies
Figure 3. Disease outcome tree of arthropathies (acute foodborne disease [FBD] after exposure to bacterial foodborne pathogens. Adapted from
Raybourne et al.18
HUMAN FOODBORNE DISEASE COSTS 1855
and literature on that pathogen. A variety of analytical
approaches and data sources are used to attribute illness
to particular foods, such as case– control studies and
microbial subtyping.17
Estimating Acute Illness Outcome Severity
For most pathogens, data are limited on the dis-
tribution of outcome severity. A thorough economic eval-
uation requires information on the severity of illness, the
duration, and outcomes, ranging from regaining full
health to death. Although FoodNet collects information
on 3 illness severities (Table 2), it covers only a handful of
pathogens.
Estimating Chronic Complications
A fourth challenge is that most foodborne patho-
gens cause one or more chronic complications that can
have lifetime health consequences or cause premature
death. These chronic sequelae include paralysis, kidney
failure, irritable bowel syndrome, Guillain–Barré syn-
drome (GBS), and arthritis. Reactive arthritis is a good
example of a chronic sequela because it is an autoim-
mune disease caused in response to infections, such as by
many foodborne bacterial pathogens. The disease out-
come tree (Figure 3) shows the range of lifetime out-
comes, starting with reactive arthritis, in approximately
8% of cases of foodborne disease (ie, this is the best
estimate, with the ranges given).18 It is important to
include chronic sequelae in cost studies because they can
result in high average and total costs. For example, Max-
1856 BUZBY AND ROBERTS
ion–Bergemann et al19 estimated per patient costs for
irritable bowel syndrome and concluded that it is an
expensive and common disorder. Estimated annual total
US costs of Campylobacter-associated GBS linked to food
were $136.0 million to $1.3 billion in 1995.20
Additional epidemiologic challenges
Most foodborne illnesses do not result in chronic
complications or loss of life. However, acute and chronic
complications from a given exposure to a foodborne
pathogen can vary and can be difficult to measure and
compare across countries for the following reasons:
● Immune system variability between individuals.
Some individuals have a better immune response to
pathogens than others.
● Pathogen strain variability. Some strains of food-
borne disease exhibit greater ease of interpersonal
transmission, such as STEC O157.21 In addition,
some strains are associated with more severe out-
comes. For example, O157:H7 has the strongest as-
sociation with hemolytic uremic syndrome (HUS)
worldwide among STEC.22
● Pathogen variability under different conditions.
A study on STEC found that antibiotics can trigger
a response that increased toxin production by ⱕ140-
fold.23
● Treatment variability. Physicians use different
treatments that create different outcomes for their
patients. For example, intravenous volume expan-
sion may be used to treat illness from STEC
O157:H7 before the development of HUS, to lessen
the severity of renal injury or failure.24
● Prevention actions. The incidence and severity of a
foodborne disease is also affected by the effect of
actions in the public health sector to limit the
spread. For example, Werber et al21 found that
household transmission of STEC O157 might be
prevented by separating siblings at the first signs of
illness.
In summary, there is great uncertainty about the
course of a foodborne illness. The economic costs, how-
ever, are greatest for the minority of cases that result in
chronic sequelae or death. Greater information on dis-
ease variability and treatment will increase the precision
of the estimates of the economic burden of disease, either
in monetary terms or in non-monetary measures.
Economic Methodologic Challenges
Four methodologic challenges confront attempts
to estimate the economic burden of foodborne disease.
Choosing the Method
The first methodologic challenge is that analysts
must decide which method to use among monetary (eg,
GASTROENTEROLOGY Vol. 136, No. 6
cost-of-illness [COI], willingness-to-pay [WTP]) and non-
monetary methods (eg, versions of the health-adjusted
life years [HALYs] method) for translating the different
outcomes or effect of foodborne disease into a common
unit of measurement. A detailed description of these
methods is beyond the scope of this article, but Figure 4
provides a brief outline of the main advantages and
disadvantages and provides some information as context
for discussing the remaining methodologic challenges.
The method of choice depends on the goal. If the goal
is a benefit– cost analysis of a potential food safety regu-
lation to determine whether it is worthwhile to imple-
ment, then economic theory suggests estimating the ben-
efits of the regulation using the WTP method.26 A
benefit– cost analysis weighs the pros (ie, benefits) and
cons (ie, costs) of a proposed regulation against a base-
line (ie, the best assessment of the current state without
the regulation). The Office of Management and Budget
(OMB) “best practices” document states that WTP is the
preferred approach when valuing reductions in fatality
risks that are expected by implementing a proposed reg-
ulation.29 In general, benefits and costs should be ideally
expressed in monetary terms, which makes it easier to
calculate net benefits. Positive net benefits means that the
regulation may be a good use of public spending whereas
negative net benefits means that it is not. In addition,
expressing net benefits in dollars means that the cost of
the proposed regulation can be compared with other
options for public expenditures.
The OMB recommends that all major rule making be
supported by both a benefit– cost analysis and a CEA
wherever possible29; a CEA provides complementary in-
formation to a benefit– cost analysis for decision makers,
by identifying the most cost-effective means to attain a
specific health target, such as lowering the suicide rate of
teenagers. In essence, CEA is an approach that compares
ⱖ2 programs that address a particular problem by look-
ing at the “number” of adverse outcomes averted per
dollar spent on a regulation(s). CEA may be less useful
when there are multiple health outcomes that have to be
described and counted in multiple dimensions, such as
the typical foodborne pathogen that can cause a mild
illness, premature death, or chronic sequelae.
If the goal is to value foodborne disease costs, then
the COI method is the preferred approach. The COI
method can also be used to value the benefits of an-
ticipated reductions of foodborne disease after the im-
plementation of a food safety regulation. Although
monetization of the main benefits and costs is preferred,
sometimes monetization is not possible because of
analytical limitations, ethical issues, and other factors.
This is when non-monetary methods, such as HALYs that
look at health-related quality of life, in healthy-time
equivalents, are used. HALYs are also sometimes used
in a CEA.
May 2009 HUMAN FOODBORNE DISEASE COSTS 1857

Monetary Methods
(1) Cost-of-Illness (COI) method is an accounting or tally of the annual dollars spent on the following:
● Direct medical costs (eg, physician and hospital services, supplies, medications, and special procedures required for a specific foodborne
illness)
● Direct non-medical costs (eg, transportation to health care, relocation expenses, special education, residential care)
● Indirect costs such as the dollars of employment compensation that are foregone as a result of morbidity or mortality (eg, lost productivity
because workers were ill and either missed work, performed poorly at work, were unable ever to return to work, or died prematurely).

In general, a COI analysis for a particular foodborne disease traditionally starts with estimates of the annual number of cases and then
divides this number into severity groups, such as those who (1) only had mild illnesses, (2) sought the advice of a physician, (3) were
hospitalized, and (4) died prematurely because of their illness (See Buzby et al25 for detailed food safety examples). Total costs for each
severity group are then estimated. Additional analysis may identify what portion of these costs could potentially be averted by a proposed
regulation.

COI Advantages
● Provides easy to understand monetary measure of foodborne disease costs or the benefits of a program that reduces foodborne disease
● Represents real costs to society

COI Disadvantages
● May not be a good measure of disease severity because estimates are influenced by income, education, and other factors.
● Estimating direct medical expenses can be difficult because of the intricacies of disease coding and insurance arrangements.
● Estimating lost productivity costs may also be difficult because of the various forms of compensation available to employees and because
large portions of the US population are not in the workforce, such as children, retirees, or homemakers and home caregivers.
● Provides a partial estimate of economic costs because it excludes more difficult to measure costs to individuals or households, industry,
and the regulatory or public health sector (eg, pain, suffering, lost leisure time, loss of business, liabilities from lawsuits [to the food
industry] and most chronic complications associated with foodborne disease). Therefore, estimates may underestimate the actual benefits
of a proposed food safety policy.

(2) Willingness-to-Pay (WTP) “approach measures the resources individuals are willing and able to give up for a reduction in the
probability of encountering a hazard that will compromise their health.”26 WTP estimates are often the result of labor market studies, which
evaluate the small statistical risk of premature death and the increase in wages to compensate for taking this risk.

Advantages
● Reflects individual preferences for risk reduction
● Theoretically superior measure
● Includes valuation of pain and suffering, lost leisure time, and other costs

Disadvantages
● Estimates are sensitive to the study populations, type of risk, and level of risk so they may not be applicable if used in a different study.
● May not be practical to have a study focused on the risk being evaluated.
● Has some measurement difficulties, especially for nonfatal outcomes. As a result, some analysts prefer simpler, non-monetary methods.

Non-Monetary Methods
Other evaluation methods are non-monetary methods and look at health-related quality of life, such as in healthy-time equivalents,
that are useful in cost-effectiveness analyses. Health-adjusted life years (HALY) is an umbrella group of non-monetary methods that measure
the years of full health lost because of living with a morbidity. Two methods within this group are quality-adjusted life years (QALYs) and
disability-adjusted life years (DALYs).27 Some analyses monetize the estimates in a separate step. For example, the US Food and Drug
Administration has been monetizing QALYs in their benefit– cost analyses.

Disability-Adjusted Life Years (DALYs)

According to the WHO, “the DALY measure combines the years of life lost due to premature death (YLL) and the years lived with
disability (YLD) for varying degrees of severity, making time itself a common metric for death and disability. One DALY is a health measure,
equating to 1 year of healthy life lost.”10

DALY Advantages
● Is an internally consistent common metric
● Can develop and incorporate downstream effects on agricultural, social, and trade costs that are traditionally missing from a cost or global
burden analysis
● Can segregate comorbidity (ie, when several pathologies coexist and contribute and compete for the cause of death)
● Uses the same value of a human life in rich and poor countries and also levels the playing field between acute and chronic disease because
it takes into account the duration of the syndrome and its severity28

DALY Disadvantages
● Poorly represents some social costs (eg, reduced production and trade of cattle because of a food safety issue)
● Still requires subjective value judgments on how to weight or discount for age of onset, disability weights, and future losses

Figure 4. Monetary and non-monetary methods to estimate the costs and burdens of foodborne disease.
1858 BUZBY AND ROBERTS
Selecting the Value of Statistical Life
The second methodologic challenge lies in selecting
the dollar or point estimate(s) of the value of a statistical life
to use. This is a particularly crucial challenge because the
valuation of death can be the largest component of total
estimated costs in a proposed regulation. What is clear is
that, although the method for how economists value pre-
mature deaths has evolved over time, WTP is now the “gold
standard” among economists as equating to benefits. What
is less clear is which WTP dollar or point estimate(s) to use
as a value of a statistical life. This choice matters when
estimating total anticipated benefits and net benefits of
implementing a food safety rule. For example, Roberts et
al30 performed a sensitivity analysis of using either a value of
statistical life estimate of $12,000 –$1,585,000, depending
on age, or a $5 million value per statistical life in their
benefit– cost analysis of the HACCP for meat and poultry.
Estimates of maximum potential benefits of HACCP over
20 years varied dramatically between these 2 scenarios.
Members of different parts of the US federal government
use different WTP point estimates of the value of a statis-
tical life.31
Deciding Whether to Adjust for Age or
Preexisting Health Status
The third methodologic issue under debate is
whether the WTP value of statistical life estimate(s)
should be adjusted for age or preexisting health status.
That is, there is controversy whether WTP for mortality
risk reductions should be calculated on the expected
remaining years of life lost as a result of the premature
death or if it should account for the preexisting health
status.32 For example, the elderly may be more suscepti-
ble to a foodborne illness because they are more likely to
have a comorbidity that affects their ability to respond.
In theory, there is no reason to suspect that individuals
(ie, particularly of different ages) would all have the same
WTP. The practical questions are whether such differ-
ences really exist, and can these differences be accounted
for when estimating WTP. The analysis of STEC O157
infections by Frenzen et al33 is one example of a study
that adjusted for age. Estimated costs of premature death
ranged from $1.8 million for an adult older than 85 years
to $9.3 million for an infant. Deaths were grouped into
5-year intervals for age.
Estimating the Anticipated Effect of a
Proposed Rule
A fourth methodologic challenge is to estimate
the number of foodborne disease cases that would be
prevented if a proposed food safety rule were imple-
mented. Given the uncertainty of predicting the outcome
of a proposed rule, there is variability in the economic
analysis, and the economic benefits of the foodborne
disease reduction can be overestimated or underesti-
mated. Often sensitivity analyses use a plausible range of
GASTROENTEROLOGY Vol. 136, No. 6
model specifications and values of key variables to ac-
count for this and other types of uncertainty. Economists
often rely on risk assessors and epidemiologists for this
technical information.
Some Estimates of the Costs of
Foodborne Disease
Golan et al31 reviewed the history of cost estimates
of foodborne illness. The Economic Research Service
(ERS) of the USDA conducted some of the earliest stud-
ies on the economic costs of foodborne illness in the
United States (eg, Roberts, 198934; Roberts and Pinner,
199035; Roberts and Frenkel, 199036). Over time, ERS
updated and expanded these analyses with improved es-
timation methods and better data. Each series of ERS
estimates incorporated better information on disease in-
cidence, more detailed data on the health consequences
of foodborne illness, and advances in the economic meth-
ods for valuing health outcomes. The initial estimates
reflected the limited information then available about the
incidence of foodborne illness and used the COI method
to tally expenditures on medical care and lost productiv-
ity because of nonfatal illness and premature death.
Figure 5 presents an example of a disease-outcome tree
for an ERS COI study on STEC O157. The initial acute
illnesses (all cases, not just foodborne) are subdivided by the
severity of the outcome over the patients’ lifetime. The most
severe complication in this example is HUS. Some HUS
cases develop end-stage renal disease. Although only a small
share of cases develop HUS, the results are severe, are long-
lasting, and have higher per capita costs than those with
milder illnesses. Recently, ERS’s online Foodborne Illness
Cost Calculator began providing information on the as-
sumptions behind foodborne illness cost estimates for Sal-
monella and STEC O157, giving Internet users a chance to
make their own assumptions and to calculate cost estimates
themselves.37,38
Several studies around the world were published about
foodborne disease costs, mostly in developed countries
where better incidence and other data are available. A
sample of published cost estimates for foodborne disease
both from the United States and other countries are
provided in Table 4. Study coverage varied considerably.
In some cases, estimates were for a single pathogen or a
single outbreak, and, in other cases, estimates were for all
foodborne disease in a country. Estimated costs also
varied considerably. WTP, COI, and disability-adjusted
life years (DALYs) are used in the studies presented in
Table 4 (see Figure 4 for details on each method).
In a study that used the DALY method (Figure 4),
Havelaar et al43 estimated the average burden, in terms of
DALYs, during 1990 –1995 of Campylobacter-associated
illness in The Netherlands. The study included acute
gastroenteritis, gastroenteritis-related mortality, and re-
sidual symptoms of GBS. The study is an example that
May 2009 HUMAN FOODBORNE DISEASE COSTS 1859

Figure 5. ERS distribution of estimated annual US STEC O157 cases by disease outcomes.

shows that the health burden would have been underes-
timated if only diarrheal illness was accounted for.
Using the COI method, Abelson et al47 estimated that
the annual cost of foodborne illness in Australia was
AU$1249 million. This estimate includes costs to indi-
viduals (eg, productivity losses, premature mortality),
business (eg, food safety recalls), health care services,
government foodborne illness surveillance and investiga-
tion, and maintenance of food safety systems. Costs were
based on foodborne illness as a result of gastroenteritis,
invasive listeriosis, toxoplasmosis, hepatitis A, and select
sequelae (HUS, irritable bowel syndrome, GBS, and reac-
tive arthritis). The study used a human capital valuation
of a life lost (ie, estimates that represent the value of
future earnings foregone because of the illness) at AU$2.5
million when the data were not age specific; otherwise the
study converted this amount to an annual figure for use
for each year of life lost (ie, $108,000).
Intercountry extrapolations and comparisons of food-
borne disease cases, deaths, and costs are hindered by
differences in surveillance systems, estimation methods,
variations in pathogens included in studies across coun-
tries, and the structure of databases on foodborne dis-
eases and treatments. For example, if estimated costs of
lost productivity are based on real wages, differences in
the average income level between developing and devel-
oped countries would prohibit a reasonable comparison
and may be deemed unethical by some. These are some of

Table 4. Sample of Estimated Costs of Foodborne Diseases

Study Estimated
Study method Foodborne disease cost Country costs/burden
Yule et al, 198839 COI Poultry-borne salmonellosis outbreak) Scotland £200,000–£900,000
Todd, 198940 COI Acute bacterial FBD Canada ⬍$1.1 billion
United States ⬍$7 billion
Roberts, 198934 COI All bacterial FBD United States $4.8 billion
Roberts and Pinner, 199035 COI Listeria monocytogenes United States $480 million
Roberts and Frenkel, 199036 COI Congenital toxoplasmosis United States $0.4–$8.8 billion
Razem and Katusin–Razem, 199441 COI All reported FBD Croatia ⬎$2 million
Roberts and Upton, 200042 COI STEC O157:H7 outbreak United Kingdom £11,930,347
Buzby and Roberts, 19978 COI 6 bacteria, 1 parasite United States $6.5–$34.9 billion
Havelaar et al, 200043 DALY Campylobacter sp. Netherlands 1400 DALY per case
Scott et al, 200044 COI All FBD New Zealand $55.1 million
Lindqvist et al, 200145 COI FBD Sweden $123 million
Abe et al, 200246 COI STEC O157:H7 outbreak Japan ¥82,686,000
Frenzen et al, 200533 COI STEC O157 United States $344 million
Abelson et al, 200647 COI All FBD Australia AU$1,249 million
Roberts, 200748 WTP All FBD United States $1.4 trillion

COI, cost-of-illness; DALY, disability-adjusted life year; FBD, foodborne disease; STEC O157, Shiga toxin-producing Escherichia coli O157; WTP,
willingness-to-pay.
1860 BUZBY AND ROBERTS
the reasons for the trend toward using DALYs instead of
monetary measures. In addition, the use of different
values of statistical life estimates can lead to dramatic
differences in the per capita costs in the total cost esti-
mates, which might preclude meaningful comparisons.
For example, the value of statistical life of AU$2.5 million
used by Abelson et al47 in Australia is much less than the
$5.4 million currently used as the default in the ERS cost
calculator for deaths from salmonellosis, even after ac-
counting for the exchange rate.37 Although surveillance
systems will never be the same for all countries (eg,
different coverage of foodborne diseases and their
chronic complications), the more similar they are, the
more defensible the intercountry comparisons of food-
borne cases and associated deaths.
As an extension of the WHO consultation to esti-
mate the Global Burden of Foodborne Disease initia-
tive, the Foodborne Disease Burden Epidemiology
Reference Group was established.49 This group is fol-
lowing through on a set of recommendations and a
strategic framework that were developed in September
2006. These recommendations included elements of a
standard protocol for conducting the studies in coun-
tries around the world to obtain estimates for all major
causes of foodborne disease, including microbial, par-
asitic, and chemical contamination of food. The study
builds on existing protocols in countries and modifies
them according to regional or national capacities. The
initiative encourages countries with limited data to
estimate their foodborne disease burden because these
estimates can catalyze valuable research and can assist
policy development.10 Countries are encouraged to
translate the effect of each disease into a single mea-
sure, the DALY. Preliminary incidence estimates have
been developed in some countries, but at the time of
writing this article, published DALYs from this study
were not available.
US Policy Evaluations
Different US agencies have estimated foodborne
disease costs when this information is required, and some
of these estimates have been used in food safety rule
making. For example, Buzby et al50 provide a detailed
explanation of 3 food safety rules that incorporated the
costs of foodborne illnesses in their economic analyses:
(1) USDA’s Food Safety and Inspection Service PR/
HACCP rule for meat and poultry in 1996, (2) the Salmo-
nella Enteritidis rule for shell eggs in 2000, and (3) FDA’s
proposed rule for ready-to-eat meat and poultry prod-
ucts. Golan et al31 also provided examples of US federal
agencies’ evaluations of the benefits of food safety pro-
grams which estimated the value of reductions in food-
borne health risks.
In the United States, Executive Order 12866 (and the
updated version, Executive Order 13422) directs agencies
to conduct an economic analysis of all regulations that
GASTROENTEROLOGY Vol. 136, No. 6
meet certain conditions.29,51,52 In particular, the eco-
nomic analysis requires agencies to provide a detailed
benefit– cost analysis for all regulatory action that is
likely to result in a rule that could have an annual effect
on the economy of ⱖ$100 million.29 In short, US policy
makers usually need cost estimates for ⱖ1 specific food-
borne diseases, at a minimum, to put efficient, appropri-
ate, and targeted programs in place to prevent or reduce
foodborne disease.
No blueprint is available for conducting an economic
analysis, and different regulations may call for different
analytical approaches and emphases.29 OMB’s Circular
A-4 (2003) provides greater detail on the purpose of these
economic analyses and the elements that most economic
analyses should include.29 The economic analysis should
include a benefit– cost analysis, in which the estimated
costs of a foodborne illness are often incorporated, to
represent the benefits that might accrue if a proposed
program reduces or prevents foodborne illnesses and
associated deaths. In general, governments are increas-
ingly required to make greater use of benefit– cost anal-
yses to evaluate policy changes, because of increased
demand for regulatory accountability.3
Discussion
To completely estimate the societal costs for all
foodborne diseases worldwide, all foodborne diseases would
need to be included in the analysis. Such a study would
include all known viral, bacterial, parasitic, and non-micro-
biologic agents and the gastrointestinal foodborne diseases
of unknown causes as well as all of the chronic sequelae
caused by acute foodborne infection. Such a study would
also account for all of the costs to individuals or house-
holds, industry, and the regulatory and public health sector
listed in Table 3 for each disease transmitted through food.
To date, the empirical evidence is noncomparable and piece-
meal.3 But if such a study were possible, the worldwide costs
could be substantial. Roberts48 estimated the annual cost of
all foodborne diseases in the United States to be $1.4 tril-
lion; this value might be too high because of factors such as
protest bids, but there are also reasons why this study might
have underestimated the total costs, such as the chronic
sequelae that were not included. If instead, we consider the
more modest cost estimate for 6 foodborne bacteria and 1
parasite in the United States of $6.5–$34.9 billion as a base
from which to informally extrapolate to a global estimate of
foodborne disease,8 we would then need to consider that
there may be ⬎200 other microbiologic agents that cause
foodborne disease and that there are ⬎200 other countries
that also incur foodborne disease costs.
Developing estimates of the cost or burden of disease,
either nationally or globally, is challenging because data
on foodborne disease and their chronic sequelae are fre-
quently only partially available or fragmented.10 Collec-
tively, the epidemiologic and methodologic challenges
discussed here weaken the ability of analysts to provide
May 2009
federal regulators with accurate information needed for
efficient and effective decision making on food safety
policies and public health priorities. All aspects of the
economic analyses for food safety regulations could ben-
efit from better epidemiologic data and more refined
methods that are more widely supported. Despite these
data limitations and challenges, understanding the eco-
nomics behind foodborne disease, particularly total
costs, can enhance our understanding of food safety
issues and how best to control them. However, costs of
implementing new food safety prevention and control
rules must be weighed against the estimated benefits of
reducing foodborne disease (ie, costs of adverse health
outcomes averted because of the rule) to determine net
benefits so that governments have information to effi-
ciently allocate funds among competing programs.
Foodborne diseases are preventable. The incidence of
some foodborne diseases has diminished during the past
decade because food safety regulations and improve-
ments in the food industry’s food safety practices and
processes were implemented. If the food production and
marketing chain supplied meals to consumers virtually
free of pathogens, there would be very little foodborne
disease. To produce food virtually free of pathogens, the
food industry and the government would have to take
additional actions to prevent contamination with food-
borne pathogens.
Much better pathogen control could be produced at
low cost if industry were given stronger economic incen-
tives to produce safer food, particularly by government.
For a number of economic reasons discussed in Golan et
al,31 the food industry has weak incentives to supply the
optimal level of food safety for society. Buzby et al53
found that the risk of court-awarded compensation from
lawsuits for microbial foodborne illness creates only
weak economic incentives for firms to produce safer
food. One use of information on the economic costs of
foodborne disease is to help government set priorities for
foodborne disease prevention and control. In turn, using
information is one way that the government could pro-
vide stronger economic incentives for industry to provide
safer food. For example, if the government required that
more pathogen testing be done weekly for each food
plant and required that these tests be publicly available
(such as posted on the Internet), companies would have
much stronger incentives to invest in new food safety
innovations and adopt existing methods to provide safer
food. These methods include more sensitive tests, new
equipment, as well as new management systems. For
many foodborne diseases, it is preferable to implement
several prevention steps simultaneously.54
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Received October 31, 2008. Accepted January 13, 2009.
Reprint requests
Address requests for reprints to: Jean C, Buzby, PhD, Economic
Research Service, 1800 M Street NW, Room S2080, Washington,
D.C. 20036-5831. e-mail: jbuzby@ers.usda.gov; fax: (202) 694-5688.
Acknowledgments
The views expressed here are those of the authors and may not
be attributed to the Economic Research Service or the US
Department of Agriculture.
Conflicts of interest
The authors disclose no conflicts.