Challenges in fighting hepatitis A, B and C across the EU/EEA. Presentation at IUSTI Europe 2016 conference, Budapest, Hungary.

1. The challenges of fighting viral hepatitis
in Europe
Lara Tavoschi
European Centre for Disease Prevention and Control
Budapest, 16 September 2016
Hepatitis A, B and C

2. Hepatitis C
2
Hepatitis B

3. Rate and prevalence of chronic HBV infection across the
EU/EEA countries
Source: ECDC. Systematic review on hepatitis B and C prevalence in the EU/EEA. 2016. Unpublished &
ECDC. Surveillance of hepatitis B and C in the EU/EEA, 2014. 2016
* Chronic HBV infection was defined as presence of HBsAg
marker in serum or blood
Prevalence of chronic HBV infection*, 2005-2015Rate of reported chronic HBV cases*,
2014
*Data for UK exclude Scotland
22 442 HBV cases reported (all cases)
4.2 per 100 000
0.9% (95% CI0.7–1.2)
4.7 million HBsAg positive individuals

4. Rate and prevalence of HCV infection across the EU/EEA
countries
Prevalence of HCV infection*, 2005-2015Rate of reported HCV cases*, 2014
*HCV infection was defined as presence of anti-HCV antibodies in
serum, blood or saliva
*Countries included if their surveillance systems captured data on both
acute and chronic cases.
Source: ECDC. Systematic review on hepatitis B and C prevalence in the EU/EEA. 2016. Unpublished &
ECDC. Surveillance of hepatitis B and C in the EU/EEA, 2014. 2016
35 321 HCV cases reported (all cases)
8.8 per 100 000
1.1% (95% CI0.9–1.4),
5.6 million anti-HCV positive individuals

5. Viral hepatitis – high on the global and regional agenda
• The 69th World Health Assembly has adopted the Global Health Sector Strategy for
Viral Hepatitis (2016-2021)
• WHO Europe has developed a regional Hepatitis Action Plan
• The goal for Europe is to eliminate viral hepatitis as a public health threat in the
European Region by 2030
2020 proposed targets include:
– Prevention of sexual transmission: Access for all individuals to full range of services
relevant to STIs
– Diagnosing Hepatitis infection: 50% of all persons with chronic HBV and HCV diagnosed;
75% of patients with late stage of viral hepatitis liver disease diagnosed
– Enhancing care and treatment: 90% chronic viral hepatitis patients are linked to care and
adequately monitored; 75% on treatment
– Vaccination: National guidelines on risk group HBV vaccination developed and implemented
– Surveillance and data: national hepatitis infection surveillance programme to provide
strategic information

6. Viral hepatitis continuum of care
Source: WHO. Global Health Sector Strategy for Viral Hepatitis (2016-2021)

7. Estimating the undiagnosed fraction
Country Cases of undiagnosed HBV Cases of undiagnosed HCV
Estimat
e
Year Source Estimate Year Source
Denmark 50% 2013 Expert opinion 50% 2013 Expert opinion
France 55% 2004 National
seroprevalence
survey
43% 2004 National
seroprevalence
survey
Ireland - - - 50-67% 2014 Expert opinion
Poland - - - 78% 2015 Cross-sectional
population study
Scotland 45% 2014 Data synthesis
and modelling
using population
datasets
42% 2014 Data synthesis and
modelling using
population
datasets
Source: ECDC. Hepatitis B and C testing activities, needs and priorities in the EU/EEA. 2016 (unpublished)
National estimates of HBV and HCV infections undiagnosed fraction by
country with available information, EU/EEA (N=21/31)

8. Reported transmission category for acute and chronic
hepatitis B and C cases, EU/EEA 2014
0 10 20 30 40 50 60 70
Heterosexual transmission
Nosocomial (includes hospital,…
Non-occupational injuries (needle…
Men who have sex with men (MSM)
Injecting drug use
Household
Other
Sexual transmission (not specified)
Blood and blood products
Mother-to-child transmission
Needle-stick and other occupational…
Haemodialysis
Organ and tissues
Proportion of cases (%)
Transmissioncategory
Acute
Chronic
0 20 40 60 80
Injecting drug use
Blood and blood products
Heterosexual transmission
Nosocomial (includes hospital,…
Other
Nosocomial (includes hospital,…
Sexual transmission (not specified)
Mother-to-child transmission
Needle-stick and other…
Haemodialysis
Household
Men who have sex with men…
Organ and tissues
Proportion of cases (%)
Acute
Chronic
HBV infection HCV infection
Source: ECDC. Surveillance of hepatitis B and C in the EU/EEA, 2014. 2016

9. HBV infection HCV infection
Men who have sex with men:
Prevalence of HBV and HCV infection, EU/EEA, 2005-2015
HCV infection was defined as presence of anti-HCV antibodies in
serum, blood or saliva
*EU/EEA general population prevalence estimate plotted for
reference purposes
HBV infection was defined as presence of HBsAg in serum or blood
*EU/EEA general population prevalence estimate plotted for
reference purposes
Source: ECDC. Systematic review on hepatitis B and C prevalence in the EU/EEA. 2016. Unpublished

10. People born outside their country of residence:
Estimated number of chronic HBV and HCV cases among
migrant communities in the EU/EEA
Source: ECDC. Epidemiological assessment of hepatitis B and C among migrants in the EU/EEA. Stockholm: ECDC; 2016.
* low-endemic country for HBV (HBsAg prevalence <2%)
# low-endemic country for HCV (anti-HCV prevalence <1%)
Migrant defined as person born outside of the country of residence

11. Gaps in HBV and HCV testing policy and practice in
EU/EEA countries
Gap in testing policy Number (%) of countries
HBV HCV
Country with testing policy 12 (57%) 13 (63%)
Risk groups missing from testing policy
Current or former People Who Inject Drugs
Migrant groups
Men who have sex with men
People in prison
Healthcare workers
Commercial sex workers
5 (24%)
4 (19%)
5 (24%)
3 (14%)
2 (10%)
3 (14%)
6 (29%)
5 (24%)
6 (29%)
3 (14%)
3 (14%)
2 (10%)
Source: ECDC. Hepatitis B and C testing activities, needs and priorities in the EU/EEA. 2016 (unpublished)
N=21/31
EU/EEA Member States
Gap in testing practice Number (%) of countries
HBV HCV
Risk groups not targeted effectively
Lack of practitioner awareness of HBV/HCV
Lack of practitioner awareness of national HBV/HCV testing policy
Lack of public awareness of HBV/HCV and/or risk factors
Lack of access to or use of point-of-care or rapid diagnostic tests
User-fee to access testing
16 (76%)
9 (43%)
6 (29%)
8 (38%)
7 (33%)
6 (29%)
15 (71%)
9 (43%)
6 (29%)
9 (43%)
8 (38%)
6 (29%)

12. Hepatitis A

13. Hepatitis A seroprevalence in the EU/EEA, 1975-2014
1975-1989 1990-1999 2000-2014
Seroprevalence classification Assessment criteria: HAV seroprevalence
Very low <50% by age 30 years
Low ≥50% by age 30 years, with <50% by age 15
Seroprevalence classification Assessment criteria: HAV seroprevalence
Intermediate ≥50% by age 15 years, with <90% by age 10 years
High ≥90% by age 15 years
Source: ECDC http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1542
Seroprevalence classification based on general population prevalence at age 15 and 30 years

14. Size of the EU/EEA population by seroprevalence profile,
1975-2014
NB. EU/EEA population from Eurostat as of 1980; 1990 and 2000. France metropolitan population only.
1975-1989 1990-1999 2000-2014
Source: ECDC http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1542

15. Source: ECDC http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1542
Hepatitis A susceptibility in adults, EU/EEA, 2000-2014
Susceptibility classification Assessment criteria: HAV susceptibility
Very high >70% at 30 years; and >50% at 50 years
High 50-70% at 30 years; and 30-50% at 50 years
Susceptibility classification Assessment criteria:
Moderate 30-50% at 30 years; and <30% at 50 years
Low <30% at 30 and 50 years
Susceptibility classification based on general population prevalence at age 30 and 50 years

16. HAV vaccination strategies in the EU/EEA
*Children with migration background visiting family and friends and close contacts of adoptees from endemic countries
**Catalonia (Spain) and Apulia (Italy) not included
Source: ECDC http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1542
N=31
0 5 10 15 20 25
Universal (funded)**
Children living in low-…
Universal (not funded)
Children entering…
Children with…
People who inject drugs
Recipients of blood…
Men who have sex…
Adults at occupational…
Persons with chronic…
Outbreak control
Travellers to endemic…
Number of countries

17. Conclusions
Hepatitis B and C
 High numbers of newly diagnosed hepatitis B and C cases notified across
the EU/EEA
 The proportion of individuals who are aware of their status is low, and
unknown in many countries
 Targeted testing and increasing awareness among general public and
health care practitioners are essential to reach regional targets
Hepatitis A
 EU/EEA population is becoming increasingly susceptible to HAV infection
 Risk groups vaccinations is an effective intervention and may require
scale up

18. Acknowledgements
ECDC
Andrew Amato-Gauci
Sandro Bonfigli
Paloma Carrillo-Santisteve
Erika Duffell
Pierluigi Lopalco
Teymur Noori
Ettore Severi
Johanna Takkinen
Member States National Focal Points for
viral hepatitis, HIV and STI; food- and
water-borne and for vaccine preventable
diseases
ECDC Library
Ana-Belen Escriva
Irene Munoz Guajardo
EPIET fellow
Michael Edelstein
Netherlands National Institute for
Public Health and the Environment
Amena Ahmad
Abby Falla
Susan Hahne
Sanne Hofstraat
Irene Veldhuijzen
Public Health Scotland
Ester Aspinall
Sharon Hutchinson
David Goldberg