Monitoring the responses to hepatitis B and C epidemics in the EU/EEA Member States, 2019
This report provides the first collation of data relating to the monitoring of the progress towards the elimination of hepatitis B and C for EU/EEA countries. Data were collated from a range of existing sources pertaining to epidemiological context, prevention and control, and impact. Data were also collected directly from all Member States on testing and treatment indicators for the continuum of care in relation to hepatitis B and C. Despite the limitations of existing data sources and inherent difficulties arising from the diversity of data and gaps in completeness, this collated information represents an important step towards understanding the priority areas for action and gaps in the national responses to the hepatitis B and C epidemics. The data also provide an important baseline to help map progress towards the WHO elimination targets and ultimately achieve the 2030 sustainable development goals.
- Based on estimates of prevalence in the general population, there are an estimated total of 4.7 million chronic hepatitis B virus (HBV) cases and 3.9 million chronic hepatitis C virus (HCV) cases in the European Union/European Economic Area (EU/EEA). Although the region is a low prevalence region for both infections, there is wide variation among countries with estimates of hepatitis B surface antigen (HBsAg) prevalence in the general population up to 4.4% and anti-HCV prevalence to 5.9%. Estimates of HBsAg among key risk groups show similar variation with very high prevalence of HBsAg reported among prisoners (25.2% in Bulgaria) and injecting drug users (5.6% in Cyprus), highlighting gaps in vaccination programmes. There is greater variation in the range prevalence of anti-HCV among key risk groups with extremely high levels of infection (>50%) reported among injecting drug users in most countries with available data and among prisoners (45.8% in Finland).
- Estimates of the size of key populations affected by hepatitis are important but are lacking in most countries. Estimates of the prevalence of injecting drug use are available from the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and these show variation between countries. Data from three countries indicate that nearly a half of those injecting report having shared needles/syringes in the last four weeks.
- Vaccination is a major component of any hepatitis B prevention strategy and data indicate that although four countries lack a national policy for universal vaccination of children, 83% of EU/EEA countries that implement childhood vaccination have achieved 90% coverage with three doses of HBV vaccine. Robust data on coverage among key populations such as prisoners and people who inject drugs (PWID) are lacking and available information suggests gaps in local policies targeting these groups.
- Perinatal transmission of HBV is not commonly reported in EU/EEA countries. Countries implement different strategies to prevent mother-to-child transmission but data are lacking on these programmes. Available data from the five countries that implement universal new-born vaccination indicate that four of these countries (80%) report 85% coverage with a timely HBV birth dose1 and all the countries that implement antenatal screening and have available data report 85% coverage of screening in pregnant women and 90% coverage with post-exposure prophylaxis.
- In terms of blood safety, the prevalence of HBV and HCV infections among first time blood donors is low and the number of transfusion associated HBV and HCV infections reported by EU/EEA countries is low. All EU/EEA countries screen blood donations using quality assured methods in accordance with to EU standards and have haemovigilance systems in place.
- Transmission of infection among men who have sex with men (MSM) was reported to account for around one in seven acute HBV and HCV infections in 2017. Evidence from the recent European Men-Who-Have-Sex-With-Men Internet Survey (EMIS) indicates gaps in service provision in relation to HBV vaccination targeting MSM.
- PWID are disproportionally affected by HBV and HCV infections due to the sharing of injecting equipment and epidemiological evidence indicates a high prevalence of both infections, especially HCV, and ongoing transmission. Countries have implemented prevention programmes targeting PWID but data on the coverage are lacking from half the countries. The available data indicate that only a small proportion of countries have achieved the 2020 target for coverage of needle and syringe programmes (NSP) but the majority of countries with data have reached the 40% coverage target for opioid substitution therapy (OST).
- Around a third of all EU/EEA countries reported no action plan or strategy for hepatitis prevention and control and, of those with a plan/strategy, nearly half reported there was no funding for implementation. However, it should be noted that the existence of an action plan or strategy does not always correlate with progress made at the local level towards elimination.
- Overall, 23 countries provided data for at least one of the four key stages of the continuum of hepatitis B care and 27 countries provided data for hepatitis C care. Two countries were able to provide data along the continuum for hepatitis B and 11 countries provided data for hepatitis C. There were significant gaps in the completeness of data and the robustness of the data is suboptimal in many areas. Increasing the availability and robustness of data is important, as it enables countries to assess with confidence the effectiveness of their hepatitis B and C response; monitor progress towards the Sustainable Development Goals (SDGs) and European Action Plan targets and identify areas that require greater attention, particularly the significant health inequalities faced by certain key population groups.
- In terms of diagnosis, for hepatitis B, among the 12 countries with data only one in five people with the infection have been diagnosed. Among these 12 countries, only four have already achieved the 2020 target of having 50% of all persons with chronic infection diagnosed. For hepatitis C, among the 16 countries with data available just over a quarter of the cases were reported to have been diagnosed. Among these 16 countries, six have already achieved the 2020 target for diagnosis. Among the limited number of countries with estimates of the proportion of newly diagnosed HBV and HCV cases with end-stage liver disease, estimates varied across countries, reaching up to 49.3% for HBV and 45% for HCV.
- Few countries had data available regarding linkage to care. Only six countries had data on both the number of people with HBV infection diagnosed and the number receiving care for HBV, and seven countries had data on numbers diagnosed and receiving care for HCV. None of the countries with available data achieved the 2020 target of having 90% of diagnosed HBV or HCV patients linked to care.
- In terms of treatment, no country was able to provide data on the number of patients diagnosed with chronic HBV infection who were eligible for treatment and receiving treatment to assess progress towards the target of having over 75% on treatment. For hepatitis C, only one of the 12 countries reporting data had achieved the target of having 75% of the diagnosed eligible patients with chronic HCV infection receive effective treatment. One of the three countries with available data on viral suppression has reached the target of having 90% of those on long-term treatment achieving viral suppression for hepatitis B. All of the 12 countries with available data for hepatitis C have achieved the target of having at least 90% of those treated cured.
- In terms of mortality, the total number of deaths in 2015 from end-stage liver diseases, as defined by WHO, was 65 029. When compared with 2011, the mortality rate in 2015 for all cases of hepatocellular carcinoma and chronic viral hepatitis increased by 5.3% and 2.3%, respectively, but the rate decreased for non-alcohol related cirrhosis and chronic liver disease by 9.5% and 7.2%. None of these trends were statistically significant. Progress towards the 2030 elimination target of a 65% reduction in mortality from the 2015 baseline is currently sub-optimal.