Cost-effectiveness analysis of using probiotics, prebiotics, or synbiotics to control Campylobacter in broilers.

Campylobacter is a food safety hazard, which causes a substantial human disease burden. Infected broiler meat is a common source of campylobacteriosis. The use of probiotics, prebiotics, or synbiotics has been associated with controlling Campylobacter infections in broilers, although efficacy remains a contentiously debated issue. On-farm use of probiotics, prebiotics, or synbiotics is gaining momentum. Therefore, it is interesting to analyze the economic viability of this potential intervention to reduce Campylobacter prevalence in broilers. A normative cost-effectiveness analysis was conducted to estimate the cost-effectiveness ratio of using probiotics, prebiotics, or synbiotics in broiler production in Denmark, the Netherlands, Poland, and Spain. The cost-effectiveness ratio was defined as the estimated costs of probiotics, prebiotics, or synbiotics use divided by the estimated public health benefits expressed in euro (€) per avoided disability-adjusted life year (DALY). The model considered differences between the countries in zootechnical and economic farm performance, in import, export, and transit of live broilers, broiler meat and meat products, and in disease burden of Campylobacter-related human illness. Simulation results revealed that the costs per avoided DALY were lowest in Poland and Spain (€4,000-€30,000 per avoided DALY) and highest in the Netherlands and Denmark (€70,000-€340,000 per avoided DALY) at an efficacy ranging from 10 to 20%. In Poland and Spain, using probiotics can be classified as a moderately expensive intervention if efficacy is more than 10%, otherwise it is relatively expensive. In the Netherlands and Denmark, using probiotics is a relatively expensive intervention irrespective of efficacy. However, if probiotics, prebiotics, or synbiotics were assumed to enhance broiler performance, it would become a relatively cost-effective intervention for Campylobacter even at low efficacy levels of 1 to 10%.

Incidence of Campylobacter-Associated Guillain-Barré Syndrome Estimated from Health Insurance Data.

Guillain-Barré syndrome (GBS) is sometimes preceded by Campylobacter infection. We estimated the cumulative incidence of Campylobacter-associated GBS in the United States using a retrospective cohort design. We identified a cohort of patients with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code of "intestinal infection due to Campylobacter" (008.43) using MarketScan Research Databases for 2004-2013. Campylobacter patients with an encounter for "acute infective polyneuritis" (AIP; ICD-9-CM 357.0) were identified. Patients with an inpatient encounter having AIP as the principal diagnosis were considered probable GBS cases. Patients with probable GBS ≤8 weeks after the Campylobacter encounter were considered probable Campylobacter-associated GBS cases. For comparison, we repeated this analysis for patients with "other Salmonella infections" (ICD-9-CM: 003). Among 9315 Campylobacter patients, 16 met the case definition for probable GBS. Two were hospitalized with probable GBS ≤8 weeks after the encounter listing a Campylobacter diagnosis (9 and 54 days) and were considered probable cases of Campylobacter-associated GBS; this results in an estimated cumulative incidence of 21.5 per 100,000 Campylobacter patients (95% confidence interval [CI]: 3.7-86.6), or 5% of all estimated GBS cases. The remaining 14 patients were diagnosed with probable GBS on the same encounter (n = 12) or 1-3 days (n = 2), before the encounter listing the Campylobacter diagnosis. Including these cases increased the cumulative incidence to 172 per 100,000 Campylobacter cases (95% CI: 101.7-285.5), 41% of estimated GBS cases. This study, using a method not previously applied to United States data, supports other data that Campylobacter is an important contributor to GBS, accounting for at least 5% and possibly as many as 41% of all GBS cases. These data can be used to inform estimates of the burden of Campylobacter infections, including economic cost.

Proximity to Other Commercial Turkey Farms Affects Colonization Onset, Genotypes, and Antimicrobial Resistance Profiles of Campylobacter spp. in Turkeys: Suggestive Evidence from a Paired-Farm Model.

Campylobacter is a leading foodborne pathogen, and poultry products are major vehicles for human disease. However, determinants impacting Campylobacter colonization in poultry remain poorly understood, especially with turkeys. Here, we used a paired-farm design to concurrently investigate Campylobacter colonization and strain types in two turkey breeds (Hybrid and Nicholas) at two farms in eastern North Carolina. One farm (the Teaching Animal Unit [TAU]) was a university teaching unit at least 40 km from commercial turkey farms, while the other (SIB) was a commercial farm in an area with a high density of turkey farms. Day-old birds were obtained from the same breeder flock and hatchery and placed at TAU and SIB on the same day. Birds were marked to identify turkey breed and then commingled on each farm. TAU birds became colonized 1 week later than SIB and had lower initial Campylobacter levels in the cecum. Interestingly, Campylobacter genotypes and antimicrobial resistance profiles differed markedly between the farms. Most TAU isolates were resistant only to tetracycline, whereas multidrug-resistant isolates predominated at SIB. Multilocus sequence typing revealed that no Campylobacter genotypes were shared between TAU and SIB. A bovine-associated genotype (sequence type 1068 [ST1068]) predominated in Campylobacter coli from TAU, while SIB isolates had genotypes commonly encountered in commercial turkey production in the region. One multidrug-resistant Campylobacter jejuni strain (ST1839) showed significant association with one of the two turkey breeds. The findings highlight the need to further characterize the impact of farm-specific factors and host genetics on antimicrobial resistance and genotypes of C. jejuni and C. coli that colonize turkeys.IMPORTANCE Colonization of poultry with Campylobacter at the farm level is complex, poorly understood, and critically linked to contamination of poultry products, which is known to constitute a leading risk factor for human campylobacteriosis. Here, we investigated the use of a paired-farm design under standard production conditions and in the absence of experimental inoculations to assess potential impacts of farm and host genetics on prevalence, antimicrobial resistance and genotypes of Campylobacter in commercial turkeys of two different breeds. Data suggest impacts of farm proximity to other commercial turkey farms on the onset of colonization, genotypes, and antimicrobial resistance profiles of Campylobacter colonizing the birds. Furthermore, the significant association of a specific multidrug-resistant Campylobacter jejuni strain with turkeys of one breed suggests colonization partnerships at the Campylobacter strain-turkey breed level. The study design avoids potential pitfalls associated with experimental inoculations, providing novel insights into the dynamics of turkey colonization with Campylobacter in actual farm ecosystems.

Campylobacter control measures in indoor broiler chicken: critical re-assessment of cost-utility and putative barriers to implementation.

As campylobacteriosis is one of the most important foodborne infections, a European Union (EU)-27 level cost-effectiveness model has been developed on the socio-economic costs and benefits of applying certain control measures for the reduction of Campylobacter in broiler meat. This is expected to be a gold standard for food safety policymakers in the EU; hence, the validity of its modelling assumptions is essential. The authors of the present paper conducted an independent review of model input parameters on health and economic burden and found that the model most probably overestimated the burden of human campylobacteriosis. A discounted, quality-adjusted life year (QALY)-based European estimate has been developed for human campylobacteriosis and resulted in 15.23 QALY loss per 1000 human gastroenteritis cases. Country-specific cost of illness estimates have been developed for various countries in the EU-27. Based on these model adaptations, a selected Campylobacter control strategy was re-assessed and its high cost-effectiveness was confirmed at the EU level, and also in all but three Member States. Bacteriocin treatment or vaccination of the animals, two alternative control measures were also re-evaluated, and these strategies seemed to be far less cost-effective than the investigated strategy. Putative barriers to the rapid implementation of the investigated Campylobacter control strategy are discussed, and potential solutions are proposed. Further research is required on stakeholder perspectives pertaining to the realistic barriers and implementation opportunities.

Cost of Illness for Five Major Foodborne Illnesses and Sequelae in Sweden.

OBJECTIVES: The main objective of this study was to derive cost estimates of five major foodborne illnesses (campylobacteriosis, salmonellosis, enterohemorrhagic Escherichia coli (EHEC), yersiniosis and shigellosis) in Sweden. These estimates provide a necessary contribution to perform future cost-benefit analyses aimed at reducing the burden of foodborne disease. A secondary aim was to obtain estimates of the true number of cases that occur in the community, thus providing necessary ground for calculating costs. METHODS: The true number of cases for each foodborne illness was simulated by multiplying the reported number of cases by sequential multipliers, one for each potential source of information loss about a case. This assessment of the true number of cases was then used to estimate the number of cases of sequelae for each illness. An incidence-based analysis was then used to calculate direct medical and non-medical costs, as well as indirect costs. Data for estimating the true number of cases for each illness were primarily based on an expert panel, while the derivation of costs mainly utilized national registries, databases and published literature. RESULTS: The estimated number of cases was between 7- and 11-fold higher than the reported number of cases, indicating the importance of taking information loss into account when calculating costs. By far the most common pathogen of the five was campylobacter, with an estimated 101,719 (90% credibility interval [CI] 59,640-158,025) human cases occurring annually. For salmonella, 19,678 (90% CI 8394-40,456) cases were estimated to occur each year, while the other three pathogens were less common, with a yearly incidence of approximately 2500-5500 cases each. The total cost for the five pathogens (including sequelae) amounted to €142 million annually. Campylobacter was the most costly pathogen, representing 69% of the total costs. Salmonellosis and EHEC constituted 18 and 9% of these costs, respectively, while yersiniosis and shigellosis represented approximately 2% each. Costs for sequelae were significant and accounted for approximately 50% of the total costs. CONCLUSIONS: Our simulations indicated that campylobacter infection was more common and more costly than salmonella, EHEC, yersinia and shigella combined. Estimated costs for all illnesses were highly influenced by (1) considering potential information losses about cases in the population (which increased costs 7- to 11-fold), and (2) taking account of post-infection sequelae (which doubled the costs).

Burden of salmonellosis, campylobacteriosis and listeriosis: a time series analysis, Belgium, 2012 to 2020.

Salmonellosis, campylobacteriosis and listeriosis are food-borne diseases. We estimated and forecasted the number of cases of these three diseases in Belgium from 2012 to 2020, and calculated the corresponding number of disability-adjusted life years (DALYs). The salmonellosis time series was fitted with a Bai and Perron two-breakpoint model, while a dynamic linear model was used for campylobacteriosis and a Poisson autoregressive model for listeriosis. The average monthly number of cases of salmonellosis was 264 (standard deviation (SD): 86) in 2012 and predicted to be 212 (SD: 87) in 2020; campylobacteriosis case numbers were 633 (SD: 81) and 1,081 (SD: 311); listeriosis case numbers were 5 (SD: 2) in 2012 and 6 (SD: 3) in 2014. After applying correction factors, the estimated DALYs for salmonellosis were 102 (95% uncertainty interval (UI): 8-376) in 2012 and predicted to be 82 (95% UI: 6-310) in 2020; campylobacteriosis DALYs were 1,019 (95% UI: 137-3,181) and 1,736 (95% UI: 178-5,874); listeriosis DALYs were 208 (95% UI: 192-226) in 2012 and 252 (95% UI: 200-307) in 2014. New actions are needed to reduce the risk of food-borne infection with Campylobacter spp. because campylobacteriosis incidence may almost double through 2020.

Estimating healthcare costs of acute gastroenteritis and human campylobacteriosis in Switzerland.

Rising numbers of campylobacteriosis case notifications in Switzerland resulted in an increased attention to acute gastroenteritis (AG) in general. Patients with a laboratory-confirmed Campylobacter infection perceive their disease as severe and around 15% of these patients are hospitalized. This study aimed at estimating healthcare costs due to AG and campylobacteriosis in Switzerland. We used official health statistics, data from different studies and expert opinion for estimating individual treatment costs for patients with different illness severity and for extrapolating overall costs due to AG and campylobacteriosis. We estimated that total Swiss healthcare costs resulting from these diseases amount to €29-45 million annually. Data suggest that patients with AG consulting a physician without a stool diagnostic test account for €9·0-24·2 million, patients with a negative stool test result for Campylobacter spp. for €12·3 million, patients testing positive for Campylobacter spp. for €1·8 million and hospitalized campylobacteriosis patients for €6·5 million/year. Healthcare costs of campylobacteriosis are high and most likely increasing in Switzerland considering that campylobacteriosis case notifications steadily increased in the past decade. Costs and potential cost savings for the healthcare system should be considered when designing sectorial and cross-sectorial interventions to reduce the burden of human campylobacteriosis in Switzerland.

The consequences of Campylobacter infection.

PURPOSE OF REVIEW: The purpose of this review is to provide an update on the clinical, public health and economic consequences of Campylobacter infection. RECENT FINDINGS: Campylobacter is a leading bacterial cause of food-related illness. Its importance is enhanced by the chronic sequelae that can result from acute infection. Recent advances include a new clinical classification system for neurological sequelae with the aim of speeding accurate diagnosis and appropriate treatment, a better understanding of the mechanisms underlying postinfectious functional gastrointestinal disorders, the emergence of Campylobacter concisus and Campylobacter showae as potential aetiological agents in inflammatory bowel disease, a new mechanism for antimicrobial resistance in campylobacters and a better appreciation of the economic costs. SUMMARY: Campylobacter infection is very common and can lead to serious chronic sequelae and considerable personal, healthcare and societal costs.

Economic Cost of Campylobacter, Norovirus and Rotavirus Disease in the United Kingdom.

OBJECTIVES: To estimate the annual cost to patients, the health service and society of infectious intestinal disease (IID) from Campylobacter, norovirus and rotavirus. DESIGN: Secondary data analysis. SETTING: The United Kingdom population, 2008-9. MAIN OUTCOME MEASURES: Cases and frequency of health services usage due to these three pathogens; associated healthcare costs; direct, out-of-pocket expenses; indirect costs to patients and caregivers. RESULTS: The median estimated costs to patients and the health service at 2008-9 prices were: Campylobacter £50 million (95% CI: £33m-£75m), norovirus £81 million (95% CI: £63m-£106m), rotavirus £25m (95% CI: £18m-£35m). The costs per case were approximately £30 for norovirus and rotavirus, and £85 for Campylobacter. This was mostly borne by patients and caregivers through lost income or out-of-pocket expenditure. The cost of Campylobacter-related Guillain-Barré syndrome hospitalisation was £1.26 million (95% CI: £0.4m-£4.2m). CONCLUSIONS: Norovirus causes greater economic burden than Campylobacter and rotavirus combined. Efforts to control IID must prioritise norovirus. For Campylobacter, estimated costs should be considered in the context of expenditure to control this pathogen in agriculture, food production and retail. Our estimates, prior to routine rotavirus immunisation in the UK, provide a baseline vaccine cost-effectiveness analyses.

Estimated community costs of an outbreak of campylobacteriosis resulting from contamination of a public water supply in Darfield, New Zealand.

AIM: To estimate the economic costs to the community of an outbreak of campylobacteriosis in August 2012 resulting from contamination of a public water supply in Darfield, New Zealand. METHOD: Probable incidence of waterborne disease was estimated. Reported cases were scrutinised to identify symptoms, duration, hospital admissions and those in the paid workforce. Extra public health and local authority costs were calculated. Estimated time off work was multiplied by the average wage to obtain a conservative estimate of lost production. Sensitivity analysis was used to estimate unreported cases and their associated costs. RESULTS: There were 138 cases of confirmed or probable campylobacter, of whom 46 sought a medical consultation. Taking into account the usual pyramid of non-notified cases, estimates of the population infected range between approximately 828 and 1987. The dominant societal cost is lost production from time off paid work. Forty-six per cent were in the paid workforce, indicating a total estimated economic cost of at least $714,527 but it could have been as high as $1.26 million, depending on estimates of unreported cases. CONCLUSION: The likely cause of the Darfield outbreak was faecal contamination of the water supply, which with a multi-barrier approach would have been entirely preventable. The results provide economic evidence to support upgrading of water supplies to provide safe water and prevent waterborne disease.

Determining the health benefits of poultry industry compliance measures: the case of campylobacteriosis regulation in New Zealand.

I undertake a cost benefit analysis of the food safety regulation of production of poultry for the New Zealand domestic market and the reduction in foodborne illness following this. I take a societal perspective to demonstrate that regulation brings both benefits and costs. I derive a cost of illness (COI) estimate of foodborne campylobacteriosis from three previous studies. I apply a cost benefit analysis (CBA) to this estimate, combined with the cost data supplied by industry and the regulator. The benefit:cost ratio was remarkable, showing a good return from the combined efforts of industry and the regulator in reduction of campylobacteriosis; in dollar terms a gain of at least $57.4 million annually. In summary the study demonstrates the high value to the New Zealand economy of investment in food safety compliance at the primary industry level.

Public health burden due to infections by verocytotoxin-producing Escherichia coli (VTEC) and Campylobacter spp. as estimated by cost of illness and different approaches to model disability-adjusted life years.

AIMS: To estimate disability-adjusted life years (DALY) and cost of illness (COI) associated with the gastrointestinal bacterial pathogens Campylobacter and verocytotoxin-producing Escherichia coli (VTEC) in Sweden and to investigate the impact of variability in health outcomes, data availability, and different assumptions about underreporting on DALY. METHODS: Data from the Swedish notification system, public databases, and the literature were used to estimate COI and DALY. DALY was modelled using a deterministic and a stochastic approach, the latter describing variation in health outcomes between individuals. Effects of different assumptions about underreporting of gastroenteritis were evaluated in separate scenarios. RESULTS: COI and DALY were greater for Campylobacter than for VTEC. Years of life lost due to haemolytic uraemic syndrome and years lived with gastroenteritis constituted most of DALY for VTEC and Campylobacter, respectively. Productivity losses due to gastroenteritis constituted the main cost associated with both pathogens. Degree of underreporting had a greater impact on DALY for Campylobacter, due to higher estimated incidence of gastroenteritis associated with campylobacteriosis. CONCLUSIONS: Pathogen-specific health outcomes and data quality may influence the preferred modelling approach. There was a fair agreement between modelling approaches, but the stochastic model reflected the contribution of some rare health outcomes not captured in the deterministic model. Health outcomes excluded due to lack of data lead to an underestimation of the total burden associated with the pathogens. Increased knowledge, especially on the degree of underreporting and the contribution of the pathogens to sequelae, is needed to further improve public health burden estimates for these pathogens in Sweden.

Reducing Campylobacter and Salmonella infection: two studies of the economic cost and attitude to adoption of on-farm biosecurity measures.

To date there has been little research in the UK on farmer adoption of biosecurity measures to control food-borne zoonoses that have little or no impact on animal health or production but which threaten public health. Campylobacteriosis and salmonellosis are the two most common causes of food-borne infectious intestinal disease in people in Great Britain, causing approximately 57,000 and 13,000 reported cases in 2007 respectively (Anon 2008a) with an important cost to society. Poultry are an important source of both infections, while pigs may also contribute to human salmonellosis. However, these infections in poultry and pigs seldom cause disease. Research has shown that improved farm biosecurity may reduce the prevalence of these infections in livestock and if the majority of farmers were prepared to enhance biosecurity then there could be an important impact on public health. This article reports on the findings of two studies of farmer attitudes to and cost of the adoption of on-farm biosecurity measures to reduce the risk of animal diseases and therefore enhance food safety. One study, of Campylobacter infection among broiler flocks, is based on a survey of farmers faced with a hypothetical biosecurity intervention, while the other study, of Salmonella infection among pigs, is based on the participation of a group of farmers in an intervention study. In both cases, the results show a clear inverse relationship between the willingness of farmers to adopt a biosecurity measure and its estimated cost. This finding has implications for the success of on-farm biosecurity-enhancement policies based on voluntary adoption by farmers. In particular, financial inducements or penalties to farmers could be necessary to facilitate adoption of these measures.

Economics of reducing Campylobacter at different levels within the Belgian poultry meat chain.

Campylobacter infections pose a serious public health problem in Belgium. Poultry meat is most likely responsible for 40% of human campylobacteriosis cases in Belgium. On a yearly basis, consumption of poultry meat causes at least 22,000 campylobacteriosis cases, with a cost of illness of Euro 10.9 million. Several intervention measures have been proposed in literature, aiming to reduce the contamination of poultry meat and thus lead to significant reductions of human campylobacteriosis cases. This study aimed to evaluate the cost-benefit ratio, i.e., the ratio of reduced costs of illness on intervention costs of various intervention measures. These measures were selected by representatives from the poultry meat sector and experts in the field of poultry science. The selection comprised measures at the farm level (phage therapy), at the processing plant (spraying of carcasses with lactic acid or electrolyzed oxidizing water, crust freezing, or irradiation), and at the consumer level (improving kitchen hygiene and application of home freezing). Among these measures, the decontamination of carcasses with electrolyzed oxidizing water applied in the processing plant was the most efficient (17.66), followed by the use of lactic acid (4.06). In addition, phage therapy generated a positive cost-benefit ratio (2.54). Irradiation indicated the highest efficacy, but its cost-benefit ratio was rather low (0.31). There seems to be less gain by trying to improve food handling in the kitchen. The cost to reach consumers is large, while only a very limited fraction of the consumers is willing to change its behavior. The outcome of this study poses valuable information for future risk-management decisions in Belgium.

Cost-utility analysis to control Campylobacter on chicken meat: dealing with data limitations.

The current article describes the economic evaluation of interventions to control Campylobacter on chicken meat by means of a cost-utility analysis. Apart from the methodology used, the main focus of this article is on data gaps and assumptions made, and their impact on results and conclusions. The direct intervention costs, the relative risk, the disease burden (expressed in disability-adjusted life years (DALYs)), and the costs of illness for the various interventions are necessary inputs for the cost-utility analysis. The cost-utility ratio (CUR) -- the measure for efficiency -- is expressed in net costs per avoided DALY. Most data gaps were of a biological order, but for some interventions, information on costs was also scarce. As a consequence, assumptions had to be made, which had some impact on the estimated CUR. A higher (lower) incidence of Campylobacter infections associated with chicken meat, higher (lower) effectiveness, and lower (higher) intervention costs, respectively, would result in absolute better (worse) CUR estimates. By taking the perspective of all consumers eating Dutch chicken meat, rather than only the Dutch society, absolute better CUR estimates could be obtained. Indirect costs or a shift toward non-Dutch chicken meat would both result in higher CUR estimates. Despite the assumptions made, three interventions showed for most of the applied sensitivity analyses relatively favorable CUR estimates: limiting fecal leakage during processing, carcass decontamination by dipping in a chemical solution, and the phage therapy. However, all three do have some clauses.

FoodNet estimate of the burden of illness caused by nontyphoidal Salmonella infections in the United States.

To determine the burden of Salmonella infections in the United States, Foodborne Diseases Active Surveillance Network (FoodNet) investigators conducted population-based active surveillance for culture-confirmed Salmonella infections during 1996-1999 at FoodNet laboratories. In addition, all clinical microbiology FoodNet laboratories were surveyed to determine their practices for isolating Salmonella. Telephone interviews were also conducted among residents of the FoodNet sites to determine the proportion of persons with diarrheal illness who sought medical care and the proportion who submitted stool specimens for bacterial culture. Using our model, we estimated that there were 1.4 million nontyphoidal Salmonella infections in the United States, resulting in 168,000 physician office visits per year during 1996-1999. Including both culture-confirmed infections and those not confirmed by culture, we estimated that Salmonella infections resulted in 15,000 hospitalizations and 400 deaths annually. These estimates indicate that salmonellosis presents a major ongoing burden to public health.

Epidemiology of sporadic Campylobacter infection in the United States and declining trend in incidence, FoodNet 1996-1999.

Campylobacter species are a leading cause of foodborne illness in the United States, but few population-based data describing patterns and trends of disease are available. We summarize data on culture-confirmed cases of Campylobacter infection reported during 1996-1999 to the Foodborne Diseases Active Surveillance Network (FoodNet) system. The average annual culture-confirmed incidence was 21.9 cases/100,000 population, with substantial site variation (from 43.8 cases/100,000 population in California to 12.2 cases/100,000 population in Georgia). The incidence among male subjects was consistently higher than that among female subjects in all age groups. The incidence trended downward over the 4 years, with incidences of 23.6, 25.2, 21.4, and 17.5 cases/100,000 population for 1996-1999, respectively--a 26% overall decrease. This trend was sharpest and most consistent in California. Overall, we estimate that ~2 million people were infected with Campylobacter in the United States each year during this time period. Although the number of Campylobacter infections appears to have decreased in the United States during 1996-1999, the disease burden remains significant, which underscores the need to better understand how the disease is transmitted.

The study of infectious intestinal disease in England: socio-economic impact.

To assess the socio-economic impact of infectious intestinal disease (IID) on the health care sector, cases and their families, cases of IID ascertained from a population cohort component and those presenting to general practices were sent a socio-economic questionnaire 3 weeks after the acute episode. The impact of the illness was measured and the resources used were identified and costed. The duration, severity and costs of illness linked to viruses were less than those linked to bacteria. The average cost per case of IID presenting to the GP was Pound Sterling253 and the costs of those not seeing a GP were Pound Sterling34. The average cost per case was Pound Sterling606 for a case with salmonella, Pound Sterling315 for campylobacter, Pound Sterling164 for rotavirus and Pound Sterling176 for SRSV. The estimated cost of IID in England was Pound Sterling743m expressed in 1994/5 prices. The costs of IID are considerable and the duration of the illness was found to be longer than previous reports have suggested.