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Background The risk of contracting rabies is low for travellers. However, the number of Dutch travellers potentially exposed abroad following an animal-associated injury and needing post-exposure prophylaxis (PEP) has increased, resulting in increased costs. Aim Here, we evaluated the costs and the cost-effectiveness of different pre- and post-exposure interventions in the Netherlands, taking into account the 2018 World Health Organization (WHO) recommendations for the prevention of rabies. Methods A decision tree-based economic model was constructed. We calculated and compared the cost of different WHO pre-exposure prophylaxis (PrEP) recommendations, intramuscular vs intradermal vaccination and PEP subsequent to increased vaccination coverage in risk groups. We estimated cost-effectiveness, expressed as incremental costs per rabies immunoglobulin (RIG) administration averted, using a societal perspective. Statistical uncertainty regarding number of travellers and vaccination coverage was assessed. Results Total costs at the national level were highest using previous WHO recommendations from 2012, estimated at EUR 15.4 million annually. Intradermal vaccinations in combination with the current recommendations led to the lowest costs, estimated at EUR 10.3 million. Higher vaccination uptake resulted in higher overall costs. The incremental costs per RIG administration averted varied from EUR 21,300-46,800. Conclusions The change in rabies PrEP and PEP recommendations in 2018 reduced total costs. Strategies with increased pre-travel vaccination uptake led to fewer RIG administrations and fewer vaccinations after exposure but also to higher total costs. Although larger scale intradermal administration of rabies vaccine can reduce total costs of PrEP and can positively influence vaccination uptake, it remains a costly intervention.

Toxoplasma gondii infections cause a large disease burden in the Netherlands, with an estimated health loss of 1,900 Disability Adjusted Life Years and a cost-of-illness estimated at Euro44 million annually. Infections in humans occur via exposure to oocysts in the environment and after eating undercooked meat containing tissue cysts, leading to asymptomatic or mild symptoms, but potentially leading to the development of ocular toxoplasmosis. Infection in pregnant women can lead to stillbirth and disorders in newborns. At present, prevention is only targeted at pregnant women. Cat vaccination, freezing of meat destined for undercooked consumption and enhancing biosecurity in pig husbandries are possible interventions to prevent toxoplasmosis. As these interventions bear costs for sectors in society that differ from those profiting from the benefits, we perform a social cost-benefit analysis (SCBA). In an SCBA, costs and benefits of societal domains affected by the interventions are identified, making explicit which stakeholder pays and who benefits. Using an epidemiological model, we consider transmission of T.gondii after vaccination of all owned cats or cats at livestock farms. To identify relevant high-risk meat products that will be eaten undercooked, a quantitative microbial risk assessment model developed to attribute predicted T.gondii infections to specific meat products will be used. In addition, we evaluate serological monitoring of pigs at slaughter followed by an audit and tailor made advice for farmers in case positive results were found. The benefits will be modelled stochastically as reduction in DALYs and monetized in Euro's following reference prices for DALYs. If the balance of total costs and benefits is positive, this will lend support to implementation of these preventive interventions at the societal level. Ultimately, the SCBA will provide guidance to policy makers on the most optimal intervention measures to reduce the disease burden of T.gondii in the Netherlands.

Introduction Rabies is a fatal but preventable infectious disease with a large disease burden in endemic countries. The risk of contracting rabies for travellers from a Western country is low. However, an increasing number of Dutch travellers, potentially exposed to rabies abroad, consult a clinician for post-exposure prophylaxis. In this study, several interventions were examined on how they might influence costs involved in rabies treatment and prevention, including the most recent vaccination guidelines and the use of intradermal vaccination. Methods A decision tree based economic model was constructed. Costs of new versus old guidelines, intramuscular versus intradermal vaccination, and post-exposure treatment subsequent to increased vaccination coverage in several risk groups were calculated and compared to each other. Statistical uncertainty with respect to numbers of travellers and vaccination coverage was assessed. Results Costs were highest using the old guidelines, estimated at €15.1 million (€405 per vaccinated person). Intradermal vaccinations in combination with the new guidelines led to the lowest costs, estimated at €10.1 million (€270 per vaccinated person). A higher vaccination uptake resulted in higher overall costs. The ratio between the additional vaccinated persons and additional costs in all risk groups was similar, around €104 per person. Conclusions The new rabies vaccination guidelines reduced total costs. Strategies with increased vaccination uptake led to fewer rabies immunoglobulin administrations and fewer vaccinations after exposure but at higher total costs. Although intradermal administration of rabies vaccination on a large scale can reduce total costs of pre-exposure prophylaxis and can positively influence vaccination uptake, it remains a costly intervention. Key messages The new vaccination guidelines reduce total costs of rabies prevention. Intradermal administration of rabies vaccination on a large scale can further reduce total costs of pre-exposure prophylaxis. Strategies with increased vaccination uptake lead to fewer rabies immunoglobulin administrations and fewer vaccinations after exposure but at higher total costs.

Introduction Estimating burden of disease (BoD) is an essential first step in the decision-making process on introducing new vaccines into national immunisation programmes (NIPs). For varicella, a common vaccine-preventable disease, BoD in the Netherlands was unknown. Aim To assess national varicella BoD and compare it to BoD of other vaccine-preventable diseases before their introduction in the NIP. Methods In this health estimates reporting study, BoD was expressed in disability-adjusted life years (DALYs) using methodology from the Burden of Communicable Diseases in Europe (BCoDE)-project. As no parameters/disease model for varicella (including herpes zoster) were available in the BCoDE toolkit, incidence, disease progression model and parameters were derived from seroprevalence, healthcare registries and published data. For most other diseases, BoD was estimated with existing BCoDE-parameters, adapted to the Netherlands if needed. Results In 2017, the estimated BoD of varicella in the Netherlands was 1,800 (95% uncertainty interval (UI): 1,800–1,900) DALYs. Herpes zoster mainly contributed to this BoD (1,600 DALYs; 91%), which was generally lower than the BoD of most current NIP diseases in the year before their introduction into the NIP. However, BoD for varicella was higher than for rotavirus gastroenteritis (1,100; 95%UI: 440–2,200 DALYs) and meningococcal B disease (620; 95%UI: 490–770 DALYs), two other potential NIP candidates. Conclusions When considering the introduction of a new vaccine in the NIP, BoD is usually estimated in isolation. The current approach assesses BoD in relation to other vaccine-preventable diseases’ BoD, which may help national advisory committees on immunisation and policymakers to set vaccination priorities.

Consumption of raw or undercooked meat increases the risk of infection with Toxoplasma gondii. Freezing meat products can eliminate this risk. Freezing of meat may affect consumers' valuation of meat products in two different ways: it may be valued positively because of increased food safety or valued negatively because of (perceived) loss of quality. In a Discrete Choice Experiment on four different meat products we studied the difference in willingness to pay for frozen and non-frozen meat products in the Netherlands. Analyses revealed that most Dutch consumer groups prefer non frozen meat. Price was important in consumer decisions, whereas the meat being frozen appeared to play a minor role in the decision to purchase meat products. Even though it may seem obvious that people would prefer safe food to unsafe food, in a context where consumers presume food being safe, many consumers appear unwilling to pay for freezing of meat as additional measure to reduce the risk of food borne infections such as toxoplasmosis.

Background and objective Since 2013, a biennial rotavirus pattern has emerged in the Netherlands with alternating high and low endemic years and a nearly 50% reduction in rotavirus hospitalization rates overall, while infant rotavirus vaccination has remained below 1% throughout. As the rotavirus vaccination cost-effectiveness and risk-benefit ratio in high-income settings is highly influenced by the total rotavirus disease burden, we re-evaluated two infant vaccination strategies, taking into account this recent change in rotavirus epidemiology. Methods We used updated rotavirus disease burden estimates derived from (active) surveillance to evaluate (1) a targeted strategy with selective vaccination of infants with medical risk conditions (prematurity, low birth weight, or congenital conditions) and (2) universal vaccination including all infants. In addition, we added herd protection as well as vaccine-induced intussusception risk to our previous cost-effectiveness model. An age- and risk-group structured, discrete-time event, stochastic multi-cohort model of the Dutch pediatric population was used to estimate the costs and effects of each vaccination strategy. Results The targeted vaccination was cost-saving under all scenarios tested from both the healthcare payer and societal perspective at rotavirus vaccine market prices (€135/child). The cost-effectiveness ratio for universal vaccination was €51,277 at the assumed vaccine price of €75/child, using a societal perspective and 3% discount rates. Universal vaccination became cost-neutral at €32/child. At an assumed vaccine-induced intussusception rate of 1/50,000, an estimated 1707 hospitalizations and 21 fatal rotavirus cases were averted by targeted vaccination per vaccine-induced intussusception case. Applying universal vaccination, an additional 571 hospitalizations and

Foodborne diseases (FBD) represent a constant threat to public health and a significant impediment to socioeconomic development worldwide. At the same time, food safety remains a marginalized policy objective, especially in developing countries. A major obstacle to adequately addressing food safety concerns is the lack of accurate data on the full extent and burden of FBD.

Background: In 2012, the Netherlands experienced the most extensive food-related outbreak of Salmonella ever recorded. It was caused by smoked salmon contaminated with Salmonella Thompson during processing. In total, 1149 cases of salmonellosis were laboratory confirmed and reported to RIVM. Twenty percent of cases was hospitalised and four cases were reported to be fatal. The purpose of this study was to estimate total costs of the Salmonella Thompson outbreak. Methods: Data from a case–control study were used to estimate the cost-of-illness of reported cases (i.e. healthcare costs, patient costs and production losses). Outbreak control costs were estimated based on interviews with staff from health authorities. Using the Dutch foodborne disease burden and cost-of-illness model, we estimated the number of underestimated cases and the associated cost-of-illness. Results: The estimated number of cases, including reported and underestimated cases was 21 123. Adjusted for underestimation, the total cost-of-illness would be €6.8 million (95% CI €2.5–€16.7 million) with productivity losses being the main cost driver. Adding outbreak control costs, the total outbreak costs are estimated at €7.5 million. Conclusion: In the Netherlands, measures are taken to reduce salmonella concentrations in food, but detection of contamination during food processing remains difficult. As shown, Salmonella outbreaks have the potential for a relatively high disease and economic burden for society. Early warning and close cooperation between the industry, health authorities and laboratories is essential for rapid detection, control of outbreaks, and to reduce disease and economic burden.

Burden assessment plays an increasingly important and accepted role in food safety decision making. Burden assessment is a top–down approach that uses available epidemiological data, for example, generated through surveillance systems, to generate estimates of the health and economic impact of the concerned foodborne disease. In this Chapter, we review methods for quantifying the health and economic impact of Campylobacter. Estimates of the health impact of Campylobacter, quantified as the number of disability-adjusted life years due to acute illness, sequelae, and death, are now available at global and national level. Campylobacter is estimated to be the sixth most important contributor to the global burden of foodborne disease, and is consistently ranked among the leading causes of foodborne disease burden in high-income countries. Estimates of the Campylobacter cost-of-illness (COI) are available for several countries, and information is increasingly being generated on industry and government costs.

To address the persistent problems of foodborne and zoonotic disease, public health officials worldwide face difficult choices about how to best allocate limited resources and target interventions to reduce morbidity and mortality. Data-driven approaches to informing these decisions have been developed in a number of countries. Integrated comparative frameworks generally share three methodological components: estimating incidence of acute illnesses, chronic sequelae, and mortality; attributing pathogen-specific illnesses to foods; and calculating integrated measures of disease burden such as cost of illness, willingness to pay, and health-adjusted life years (HALYs). To discuss the similarities and differences in these approaches, to seek consensus on principles, and to improve international collaboration, the E.U. MED-VET-NET and the U.S.-based Food Safety Research Consortium organized an international conference convened in Berlin, Germany, on July 19-21, 2006. This article draws in part on the deliberations of the conference and discusses general principles, data needs, methodological issues and challenges, and future research needs pertinent to objective data-driven analyses and their potential use for priority setting of foodborne and zoonotic pathogens in public health policy.

A representative serosurveillance study (1995) resulted in an estimate of 0.2% for the HBsAg prevalence in the Netherlands. Some risk groups, especially migrants, were not well represented in the study, which probably led to an underestimation of the true HBsAg prevalence. The aim of this study was to calculate an adjusted HBsAg prevalence estimate for the total Dutch population including these risk groups.According to their country of origin first-generation migrants (FGM) were classified into groups with low, intermediate and high prevalence using data from the WHO and Statistics Netherlands. The number of chronic HBsAg carriers in different age and population groups was estimated based on studies about age-specific prevalence in different countries. The number of carriers in the indigenous population was estimated using the serosurveillance study. A combination of these estimates led to an estimate of the total prevalence rate in the Netherlands.Nearly 10% of the Dutch population are FGM. Of these, about 18% were born in low-endemic, 71% in middle-endemic and 11% in high-endemic countries. The overall prevalence of HBsAg in FGM is estimated to be at 3.77%. Combining these results with the results of the serosurveillance study the HBsAg prevalence in the Dutch population is estimated to be between 0.32 and 0.51%, and when including injecting drug users and mentally handicapped persons the prevalence rates are 0.36 and 0.55%, respectively.Our results show the high importance of targeting migrants and their close contacts adequately in screening programmes, vaccination and treatment for chronic hepatitis B.

Rotarix and RotaTeq are both prophylactic vaccines against rotavirus (RV) gastroenteritis. In 2006, these vaccines obtained a European license and because RV infections are widespread among Dutch children inclusion of these vaccines in the Dutch National Immunization Program (NIP) should be considered. Using an evaluation model for introducing a new vaccine, we assessed the introduction of universal RV vaccination in the Netherlands. Although post-marketing surveillance will be essential, both RV vaccines have proven to be safe and effective. Furthermore, the vaccines will prevent most of the RV-related hospitalizations and deaths. However, for the Netherlands with the current vaccine prices, universal RV vaccination is not expected to be cost-effective.

The goal of the CARMA (Campylobacter risk management and assessment) project was to advise the Dutch government on the effectiveness and efficiency of interventions aimed at reducing campylobacteriosis cases in the Netherlands. The burden of disease, expressed in Disability-Adjusted Life Years (DALYs) and the corresponding cost-of-illness, were estimated using data from epidemiological studies. With the help of a risk assessment model, the reduction in the incidence of Campylobacter infections due to a set of possible interventions in the broiler meat (chicken) chain was modeled. Separately, costs related to the implementation of these interventions in the broiler meat chain were estimated. For each intervention to be modeled, the net costs of an intervention - additional costs in the broiler meat chain minus reduced cost-of-illness - were related to the reduced burden of disease. This resulted in a cost-utility ratio, expressing the relative efficiency of several policy options to reduce Campylobacter infections

The burden of disease framework facilitates the assessment of the health impact of diseases through the use of summary measures of population health such as Disability- Adjusted Life Years (DALYs). However, calculating, interpreting and communicating the results of studies using this methodology poses a challenge. The aim of the Burden of Communicable Disease in Europe (BCoDE) project is to summarize the impact of communicable disease in the European Union and European Economic Area Member States (EU/EEA MS). To meet this goal, a user-friendly software tool (BCoDE toolkit), was developed. This stand-alone application, written in C++, is open-access and freely available for download from the website of the European Centre for Disease Prevention and Control (ECDC). With the BCoDE toolkit, one can calculate DALYs by simply entering the age group- and sexspecific number of cases for one or more of selected sets of 32 communicable diseases (CDs) and 6 healthcare associated infections (HAIs). Disease progression models (i.e., outcome trees) for these communicable diseases were created following a thorough literature review of their disease progression pathway. The BCoDE toolkit runs Monte Carlo simulations of the input parameters and provides disease-specific results, including 95% uncertainty intervals, and permits comparisons between the different disease models entered. Results can be displayed as mean and median overall DALYs, DALYs per 100,000 population, and DALYs related to mortality vs. disability. Visualization options summarize complex epidemiological data, with the goal of improving communication and knowledge transfer for decision-making.

SUMMARYSetting priorities in the field of infectious diseases requires evidence-based and robust baseline estimates of disease burden. Therefore, the European Centre for Disease Prevention and Control initiated the Burden of Communicable Diseases in Europe (BCoDE) project. The project uses an incidence- and pathogen-based approach to measure the impact of both acute illness and sequelae of infectious diseases expressed in disability-adjusted life years (DALYs). This study presents first estimates of disease burden for four pathogens in Germany. The number of reported incident cases adjusted for underestimation served as model input. For the study period 2005–2007, the average disease burden was estimated at 33 116 DALYs/year for influenza virus, 19 115 DALYs/year for Salmonella spp., 8708 DALYs/year for hepatitis B virus and 740 DALYs/year for measles virus. This methodology highlights the importance of sequelae, particularly for hepatitis B and salmonellosis, because if omitted, the burden would have been underestimated by 98% and 56%, respectively.

Background Most estimates of disease burden due to infectious diseases focus on the impact of acute infections and do not fully capture the effects of (long-term) sequelae. To provide evidence-based and comparable estimates, the European Centre for Disease Prevention and Control (ECDC) initiated the Burden of Communicable Diseases in Europe (BCoDE) project. Methods Disability-adjusted life-years (DALYs) were used in an incidence-based and pathogen-based approach to accommodate infectious disease characteristics. This approach involves outcome trees representing the natural history of diseases and links future sequelae to the initial infection by conditional probabilities. For calculating years of life lost (YLLs), life expectancy at birth for males and females was set to 79·9 and 82·5 years, respectively (Global Burden of Disease [GBD] 2004 study standards). For YLLs due to disability, disability weights were taken from the 2004 GBD study and from additional sets or proxies. Multiplication factors (MFs) were used to adjust for underestimation of country-specific incidences (average reported cases 2005–2007). Disease models for 32 pathogens were built in Excel, where @Risk was used to model uncertainty. No time discounting or age weighting was applied. Findings Taking the example of hepatitis B in Germany, a loss of 7745 DALYs per year (95% CI 5527–10 256) was estimated, resulting in 9·4 DALYs per 100 000 (95% CI 6·7–12·4). 2·2% (170·4) of DALYs were due to acute infections. Chronic infections resulted in a loss of 2852 DALYs per year (95% CI 2455–3275). The disease burdens due to compensated liver cirrhosis, decompensated liver cirrhosis, and hepatocellular carcinoma were estimated at 637 DALYs per year (95% CI 478–792), 2150 DALYs per year (1294–3049), and 1790 DALYs per year (464–3376), respectively, together accounting for 59% (4577) of the overall DALYs. Interpretation The BCoDE methodology quantifies the burden of short-term and long-term sequelae due to present infection. Quality of notification data and choice of appropriate MFs are crucial as these are the most sensitive inputs. Funding The BCoDE consortium has been funded by the European Centre for Disease Prevention and Control (Specific agreement No. 1 to Framework Partnership Agreement GRANT/2008/003) for the conduct of burden of infectious disease studies in Europe. The funding source had no influence on writing the manuscript or on the decision to submit the abstract for publication. The corresponding author did not get any payment for writing the abstract from a pharmaceutical industry or other agency. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

In 2009, the European Centre for Disease Prevention and Control initiated the ‘Burden of Communicable Diseases in Europe (BCoDE)’ project to generate evidence-based and comparable burden-of-disease estimates of infectious diseases in Europe. The burden-of-disease metric used was the Disability-Adjusted Life Year (DALY), composed of years of life lost due to premature death (YLL) and due to disability (YLD). To better represent infectious diseases, a pathogen-based approach was used linking incident cases to sequelae through outcome trees. Health outcomes were included if an evidence-based causal relationship between infection and outcome was established. Life expectancy and disability weights were taken from the Global Burden of Disease Study and alternative studies. Disease progression parameters were based on literature. Country-specific incidence was based on surveillance data corrected for underestimation. Non-typhoidal Salmonella spp. and Campylobacter spp. were used for illustration. Using the incidence- and pathogen-based DALY approach the total burden for Salmonella spp. and Campylobacter spp. was estimated at 730 DALYs and at 1,780 DALYs per year in the Netherlands (average of 2005–2007). Sequelae accounted for 56% and 82% of the total burden of Salmonella spp. and Campylobacter spp., respectively. The incidence- and pathogen-based DALY methodology allows in the case of infectious diseases a more comprehensive calculation of the disease burden as subsequent sequelae are fully taken into account. Not considering subsequent sequelae would strongly underestimate the burden of infectious diseases. Estimates can be used to support prioritisation and comparison of infectious diseases and other health conditions, both within a country and between countries.

Mirjam Kretzschmar and colleagues describe the BCoDE project, which uses a pathogen-based incidence approach to better estimate the infectious disease burden in Europe.

Reliable, comprehensive and comparable information on the impact of (zoonotic) diseases on population health are important for policy decision making in Public Health to support allocation processes of scarce resources with best available evidence. Although the availability and quality of health data has increased in the recent past (Boerma et al. 2007, Murray, 2007), there are still relevant limitations when traditional health indicators are used to prioritize diseases and to allocate resources for intervention measures. Difficulties especially come up when comparisons over time, between sub-groups or even between diseases are intended.

Cost-effectiveness analyses are usually not directly comparable between countries because of differences in analytical and modelling assumptions. We investigated the cost-effectiveness of rotavirus vaccination in five European Union countries (Belgium, England and Wales, Finland, France and the Netherlands) using a single model, burden of disease estimates supplied by national public health agencies and a subset of common assumptions. Under base case assumptions (vaccination with Rotarix, 3% discount rate, health care provider perspective, no herd immunity and quality of life of one caregiver affected by a rotavirus episode) and a cost-effectiveness threshold of euro30,000, vaccination is likely to be cost effective in Finland only. However, single changes to assumptions may make it cost effective in Belgium and the Netherlands. The estimated threshold price per dose for Rotarix (excluding administration costs) to be cost effective was euro41 in Belgium, euro28 in England and Wales, euro51 in Finland, euro36 in France and euro46 in the Netherlands.

We used a mathematical model for the transmission of hepatitis B infection to compare the effectiveness of different vaccination strategies in the Netherlands. Vaccination of children of immigrants from high and medium endemic countries is an effective strategy in countries with substantial immigration of carriers from high and medium endemic countries. A targeted vaccination programme for sexually highly active risk groups has a moderate additional effect if continued over a long time period. Universal vaccination has the largest effect on the incidence of new infections at the cost of having to vaccinate many more individuals than in targeted programmes. The impact on the prevalence of chronic hepatitis B infection, however, remains limited.

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.

Background Foodborne diseases are an important cause of morbidity and mortality in populations across the globe. Estimates of the burden of these diseases are scarce. As infectious diseases are highly dynamic, the trends in food-related disease incidence over a 6-year period and the associated variation in disease burden are examined. Methods We selected 14 food-related enteric and parasitic pathogens and estimated the burden of these pathogens in the Netherlands in 2009. The model estimates agent-based and incidence-based disability-adjusted life-years (DALYs) for acute illness and for major sequelae. Attribution to major exposure pathways (food, environment, human–human or animal–human transmission, and travel abroad) as well as 11 food groups within the food pathway was based on structured expert elicitation. Trend information, available for only six pathogens from national surveillance statistics, was used to evaluate changes in the incidence and burden from 2006 to 2011. Findings In 2009, the disease burden by 14 food-related pathogens was 13 500 DALYs (82 per 100 000 inhabitants). Of these, 6100 DALYs were related to foodborne exposure, while two-thirds of the foodborne burden was attributed to foods of animal origin. Incidence was highest for viral agents, while burden was highest for Toxoplasma gondii and Campylobacter spp., due to long-term sequelae. At the individual level, Listeria monocytogenes and T gondii caused the highest burden. Compared with the baseline year 2006, annual disease incidences varied with relative changes up to 30% while (foodborne) burden varied less substantially with relative changes up to 10%. Interpretation Presenting foodborne disease burden rather than trends in the incidence of individual pathogens has added value because it provides a more robust, integrated perspective. High-quality surveillance data are required. Funding Ministry of Health, Welfare, and Sports, The Hague, Netherlands.