The economic burden of Hepatitis B in Germany Stephan Harbarth 1 , Thomas Szucs 2 , Karin Berger 3 & Wolfgang Jilg 4 1 Department of Epidemiology, Harvard School of Public Health, Boston, USA; 2 Department of Medical Economics, University Hospital, Zurich, Switzerland; 3 Forschungsgruppe Medizinische O È konomie, Mu Ènchen, Germany; 4 Institut fu Èr Medizinische Mikrobiologie & Hygiene, Universita Èt Regensburg, Germany Accepted in revised form 20 January 2000 Abstract. Despite the widespread distribution of Hepatitis B virus (HBV) infection and the ongoing controversy about HBV immunization, surprisingly few published studies examined in detail the eco- nomic impact of HBV infection in Europe. Therefore, we investigated a cohort of 180 patients throughout Germany to evaluate the economic burden of HBV- associated disease. In 58 patients with acute and 122 patients with chronic HBV infection, cost-consuming events including direct medical costs and work-loss costs were documented. The direct costs were DM 7702 (95% con®dence interval (CI): 5473±9931) for each acute HBV infection and DM 4247 (CI: 1601± 6893) per patient-year of chronic HBV infection, with marked dierences between dierent stages of HBV disease. The derived overall costs (1997 price levels) per year were DM 10,018 (CI: 7613±12,421) and DM 4860 (CI: 2185±7536), respectively. Based on crude population-based estimates (30,000 acute and 420,000 chronic HBV cases), we calculated the total HBV-related costs in Germany to exceed DM 1200 millions in 1997 (CI: 924.2±1536.7), with the treat- ment of patients with chronic active HBV disease as the major cost determinant. Previously published data from Germany probably overestimated the ®nancial impact of acute HBV infection. In summary, our results illustrate the ongoing economic impor- tance of this potentially life-threatening, but pre- ventable disease and support the call for more accurate HBV surveillance and control in Germany. Key words: Costs, Epidemiology, Germany, Hepatitis B Introduction Hepatitis B virus (HBV) infections occur worldwide with a substantial impact on morbidity and mortality [1, 2]. They produce a wide range of manifestations, which include no discernible disease, acute hepatitis with or without jaundice, fulminant hepatitis or persistent infection leading to chronic liver disease or hepatocellular carcinoma [3]. Europe is divided into three types of epidemio- logical patterns based on dierent rates of HBV surface antigen carriage in the general population [4± 6]. Germany with a carrier rate between 0.1 and 1.0% is a typical example of a western-European country with type II pattern, compared to Sweden (type I, <0.1%) or Italy (type III, 1±5%). In 1997, 6010 cases of HBV infection were noti®ed in Germany (inci- dence, 7.3 infections per 100,000) [7]. Because of under-reporting and missed subclinical cases, the true annual incidence of HBV infection in Germany is estimated to account for 30,000 cases; with 5% of infected patients developing chronic disease [7]. Despite the widespread distribution of HBV infec- tion and the ongoing controversy about HBV immu- nization [8±10], surprisingly few published studies examined in detail the economic burden of HBV in- fection in Europe [11, 12]. In the belief that accurate data on the economic impact of HBV infection are necessary to allow informed decisions about disease prevention and treatment, we investigated a cohort of 180 patients to determine direct and indirect costs associated with HBV infection in Germany. Methods The aim of this observational cohort study was to determine the costs associated with HBV infection in a representative sample of patients from Germany, and to estimate the population-based burden. We, there- fore, contacted more than 1500 ambulatory care physicians and gastroenterologists, as well as 100 hospitals throughout Germany to report recently treated HBV cases. Only one doctor per hospital was contacted. Following this preliminary survey, we identi®ed 86 physicians and hospitals yielding more than 500 HBV patients, willing to participate in the study. Between December 1996 and May 1998, 180 randomly selected patients with serologically proven HBV infection (122 patients with chronic HBV in- fection, 58 with acute HBV disease) were included in the study. Variables recorded at baseline included: age, gender, profession and other socio-economic information, primary diagnosis, histological and European Journal of Epidemiology 16: 173±177, 2000. Ó 2000 Kluwer Academic Publishers. Printed in the Netherlands.