Costs of Clinical Hepatitis E in Germany: A Cost-of-Illness Analysis

Background: Hepatitis E virus (HEV) infection is endemic in Germany, where most notified cases are acquired domestically. Contemporary German cost-of-illness estimates are lacking. Sewer workers are an occupationally relevant group because HEV may occur in wastewater environments; German occupational-safety guidance classifies their infection risk as equal to or possibly slightly increased compared with the general population. We therefore additionally considered an employed-adult scenario, with sewer workers as an illustrative occupational example. Methods: A cost-of-illness model combined 2025 German HEV surveillance data, 2025 InEK hospital data valued with 2026 German hospital reimbursement parameters, 2026 statutory outpatient tariffs (EBM), and productivity losses valued by the human-capital approach. The base case used the RKI surveillance hospitalization proportion of 49.3%; deterministic scenarios included an alternative 32.9% proportion derived from 2025 InEK principal-diagnosis admissions, alternative outpatient resource use, and broader productivity assumptions. The base-case population comprised adults aged ≥18 years meeting the RKI reference definition for acute HEV disease. Results: In 2025, 5310 reference-defined HEV cases were notified, including 5215 in adults aged ≥18 years. The age-weighted outpatient pathway cost was €122.06 and inpatient reimbursement was €4245.96 per admission. Base-case expected direct medical expenditure was €2157.45 per adult case. Mean sickness absence of 28.10 days yielded €4494.35 in productivity loss per employed case assumed to incur sickness absence; after employment weighting, expected productivity loss was €2647.53 and modeled societal cost was €4804.98 per adult case. The employed-adult scenario yielded €6651.80. Applied to 5215 notified adult cases, the base case implied €25.06 million in annual modeled costs. Using the InEK principal-diagnosis admission ratio reduced direct expenditure to €1478.84 and modeled societal cost to €4126.37 per case. Varying sickness-absence duration from 14 to 42 days changed modeled societal cost from €3476.31 to €6114.03. Conclusions: Hospitalization is the principal driver of direct medical expenditure, while productivity loss is a major component of modeled societal cost. Notified acute HEV disease in adults is associated with substantial economic costs in Germany. The model provides an updated German benchmark for disease costs and illustrates the additional societal burden associated with productivity loss in employed adults. With respect to the probability of sickness absence, the base-case societal cost represents an upper-bound estimate, while the choice of hospitalization parameter is a key source of model variation.