12 Volume 80 • Number 7 ADVANCEMENT OF THE SCIENCE ADVANCEMENT OF THE SCIENCE Introduction Economic Burden of Norovirus Disease Characterization of the impact of norovirus disease among the school-age population should involve estimating its health burden, as well as its economic burden. Estimates of health burden in terms of mortality and mor- bidity provide important insight into disease risk and severity. The economic burden, on the other hand, provides insight into the healthcare resource utilization associated with the disease. Researchers conducting an economic burden study of a disease should also examine all potential costs. Many studies report only direct medical costs (i.e., outpatient, inpatient, medications, diagnostic tests, etc.) while ignoring the direct nonmedical costs (i.e., transportation, over-the-counter medications) and indirect costs (i.e., lost productivity incurred by the caregivers) borne by the patient, caregivers, healthcare system, employers, and society at large. Economic burden estimation that fac- tors in these costs and provides a more accu- rate assessment of the true burden of a dis- ease can then help to identify and prioritize influential cost drivers, as well as offer greater insight into future cost trends. Research evidence suggests that noro- virus and 13 other foodborne pathogens account for 95% of all confirmed foodborne illnesses and associated hospitalizations. These 14 foodborne pathogens account for 98% of foodborne deaths in the U.S. (Batz, Hoffmann, & Morris, 2012). Given its high incidence and severity of symptoms such as vomiting and diarrhea, the health burden and resultant economic burden of norovirus dis- ease were reported to be significant by pre- vious studies (Debbink, Lindesmith, Don- aldson, & Baric, 2012; Scallan et al., 2011). Norovirus-associated hospitalizations alone were estimated to cost $500 million per year in the U.S. (Batz, Hoffmann, & Morris, 2011). When the cost for lost average daily wages, that is, “lost labor market productiv- ity,” were added to healthcare costs, the cost of norovirus gastroenteritis was estimated to be $2 billion (Batz et al., 2011). In a simulation model, researchers exam- ined the annual disease and economic burdens of norovirus in the absence of a vaccine. They estimated that 16.7 million norovirus cases result in 1.8 million outpatient visits, 69,000 hospitalizations, and 800 deaths in a year, at an annual cost of $5.5 billion in direct medi- cal costs (Bartsch, Lopman, Hall, Parashar, & Lee, 2012). In a study conducted by Hall and coauthors (2013), incidence data from previous studies spanning 1979–2009 were analyzed in order to derive greater accuracy for estimates of acute gastroenteritis associ- ated with norovirus. They estimated that there are 19–21 million cases of norovirus, 1.7–1.9 million outpatient visits, 400,000 emergency room visits, and 570–800 deaths, resulting in an annual healthcare cost of approximately $777 million (Hall et al., 2013). Gastañaduy and coauthors (2013) used rates of emergency room and outpatient visits for gastroenteritis from July 2001–June 2009 to estimate the economic burden of norovi- rus in ambulatory settings. They extrapolated MarketScan rates to the U.S. population- Abstract The health burden and resultant economic burden of foodborne norovirus disease among school-age children in the U.S. is unknown, but believed to be significant. The economic burden encompasses not only direct medical costs associated with medical care but also indirect costs such as loss of work days and direct nonmedical costs. National passive surveillance data from norovirus outbreaks spanning 2009–2013 were used to identify cases, health outcomes, interventions, and healthcare resource utilization among the school-age population. The cost of supportive care was $2,483,379, outpatient healthcare was $57,672, hospitalization was $48,670, and emergency care was $38,336. The cost of providing supportive care (direct nonmedical costs) was relatively low. When indirect costs were factored in, however, the total cost of care escalated, which illustrates the high burden of loss of productivity. It is important to incorporate the indirect and direct nonmedical costs of disease to more accurately characterize the total economic burden of a disease. Margaret M. Venuto, MA, MPH, DrPH Management, Policy, and Community Health University of Texas School of Public Health San Antonio Regional Campus Sharon P. Cooper, PhD Hasanat Alamgir, PhD Epidemiology, Human Genetics, and Environmental Sciences University of Texas School of Public Health San Antonio Regional Campus An Estimate of the Economic Burden of Norovirus Disease Among School-Age Children in the United States (2009–2013)