Hepatitis B and C are a public health threat in the EU, with an estimated 4.7 million people living with chronic hepatitis B virus (HBV) infection and 3.9 million living with chronic hepatitis C virus (HCV) infection in the EU/EEA countries.
These infections are a major cause of cirrhosis, liver cancer, and mortality. Available information indicates that many living with chronic HBV and HCV infections in the region remain undiagnosed and unaware of their infection.
Testing for HBV and HCV is critical for diagnosing those living with chronic infections and linking them to treatment, leading to improved health outcomes.
In line with the United Nations Sustainable Development Goals, the WHO has set global and regional targets for the elimination of hepatitis B and C as a public health threat. The WHO Regional Office for Europe developed a hepatitis action plan for the European Region, with targets for 2020 for the steps along the continuum of care: testing, treatment, and cure/viral suppression. The testing target is that 50% of people living with chronic HBV and HCV infections will be diagnosed and thus made aware of their condition.
Among the 12 countries reporting sufficient data, there were an estimated 1,597, 377 people with chronic HBV infection, of whom only 20.3% had been diagnosed.
Among the 15 countries reporting data on both the estimated number of people living with HCV infection and the number diagnosed via RNA test, there were an estimated 1,422,285 people with chronic HCV infection, of whom only 26.8% were diagnosed.
It is important to note that estimating the proportion of chronic HBV and HCV cases diagnosed is currently very challenging as there is a lack of robust data regarding both the numerator (number diagnosed) and the denominator (current numbers infected). Although the available data have gaps and limitations, they indicate that, as of 2017, the EU/EEA region was far from meeting WHO’s 2020 target of 50% diagnosed. An increase in resources in terms of monitoring and implementation are urgently needed.
Target populations for screening
There are several routes of transmission for HBV and HCV. HBV is transmitted via blood, semen, and other body fluids through the following routes: sexual transmission, patient and healthcare worker exposure in healthcare settings, injection drug use, and vertical (or ‘mother to child’) transmission. While vertical transmission is rare within the European region, it occurs more frequently in regions of the world with a higher prevalence of HBV.
HCV is transmitted through blood, most commonly through the use of injectable drugs, but also sexually, mainly between men who have sex with men. HBV and HCV can also be transmitted between the patient and caregiver in a hospital setting, through accidental puncture with infected blood or blood products or unscreened organ/tissue transplantation.
Barriers to testing
From the individual patient level to wider policy and structural levels, there are several important barriers to hepatitis testing. Generally, there are low levels of knowledge and awareness of HBV/HCV infections and the need to test for them among patients, the general public, and healthcare workers. The asymptomatic nature of much of the course of chronic HBV and HCV likely prevents individuals living with these infections from seeking testing.
A lack of training, education, advocacy, and promotion of testing may often present a barrier to offering testing for clinicians and administrators in healthcare institutions. In addition, many populations at risk of hepatitis B and hepatitis C are socially marginalised. Poverty, unstable or unstructured lives, other health and social problems, and fear and/or experience of stigma and discrimination can prevent members of key, more vulnerable populations from seeking and accessing testing.
Priority areas for action
- Significant gaps in HBV and HCV testing data in the EU/EEA present a major challenge to monitoring progress towards the WHO and Sustainable Development Goals targets for elimination of hepatitis as a threat to public health. In order to guide national responses to hepatitis B and C, there is a need for countries to prioritise improving the collection and reporting of high-quality hepatitis testing data;
- A high proportion of people living with hepatitis B and C infections appear to remain undiagnosed. There is a need for countries to urgently prioritise the improvement of testing offering and coverage, especially among more vulnerable populations.