Brussels, 27 July 2018 – The European Liver Patients’ Association (ELPA) annual update on the state of viral hepatitis C (HCV) policy in Europe shows that many European countries have yet to enact focused policies in pursuit of hepatitis elimination.
Results from this years’ Hep-CORE 2018 survey on hepatitis C virus (HCV) micro-elimination are the most recent piece in the puzzle for the ELPA-directed Hep-CORE study.
Hep-CORE is a longitudinal patient-led study which has engaged in an assessment of the national policy response to viral hepatitis C in Europe since 2016. This year, a new survey assesses opportunities for “micro-elimination”: targeted national elimination of viral hepatitis C in well-defined populations.(1)
Data on hepatitis prevalence, not to mention testing and treatment uptake, are woefully lacking. Researchers, advocates, and policymakers have often been forced to make decisions based on broad estimates that can change drastically from one year to another. The Hep-CORE study seeks to fill this gap for monitoring viral hepatitis policy in Europe from the patient perspective.
A viral hepatitis strategy, especially one with specific goals for addressing the highest-risk populations, is the first step for any country to begin facing this epidemic. At present, HCV has a higher burden of disease than either HIV or tuberculosis in the World Health Organization (WHO) European Region, with an estimated 15 million people infected. (2,3) Twenty-five patient groups, representing 23 European countries and 2 countries from the Mediterranean Basin, were respondents for the study. Results show that only 14 of the 25 (56%) countries involved in the study have a national viral hepatitis strategy in their country.
At present only 12 countries globally are on track to eliminate viral hepatitis and six of them are among the countries we studied: Egypt, France, Italy, Netherlands, Spain, and the United Kingdom.(4) ELPA has noted that many countries find the idea of viral hepatitis elimination to be daunting, complex and one of many competing challenges for their health system.
Therefore, part one of this years’ Hep-CORE survey focuses on micro-elimination, which breaks down national elimination goals into smaller goals focusing on individual population segments.
The patient group responses show that high-risk populations are unevenly targeted for action; however, those already engaged in healthcare services such as haemodialysis and haemophilia patients, as well as transplant donors and recipients are the most likely to be engaged in care. Study results show that people who inject drugs (PWID), in spite of their high burden of HCV, are actively addressed by HCV services in 16 (64%) of the study countries. However, this is only if they are engaged in harm reduction programmes such as needle and syringe programmes and opioid substitution therapy. Current or former PWID who are not engaged in harm reduction programmes are reported to only be considered for targeted action in six countries (24%) for active PWID and only two countries (8%) for former PWID.
Patient group respondents were asked to select which target populations would be the easiest and most difficult to target in their country context. Across the board, for easiest to target, most groups selected blood donors (40%) and haemodialysis patients (40%), followed by haemophilia patients (36%) due in most cases to existing screening protocols. The most difficult populations to identify and treat from the patient group perspective were reported to be active PWID not engaged in harm reduction programmes (68%) and homeless people (52%).
Results show that there are systematic gaps where high-risk populations are ignored if they are difficult to access outside of existing pathways. Hepatitis in healthcare workers is a major concern and yet stigma and fear of losing employment, are some of the barriers that prevent this crucial population from accessing testing and care. Migrants are another often overlooked group that should be targeted for care, but lack of investment in integration into the healthcare system, as well as a general lack of guidelines were cited as some of the reasons that this does not happen.
Tatjana Reic, the President of the ELPA Board states that “Measuring whether access to hepatitis C services is fair across all population groups and the development pathways for management for patients who are the most marginalised is key in the micro-elimination approach to disease elimination. This is why patient groups must be at the fore, and why they serve as the national respondents for the Hep-CORE study.”
Two previous reports, from studies in 2016 and 2017, showed an overall picture of viral hepatitis policy in Europe and the gaps between national policy and WHO European Region recommendations for addressing the HCV epidemic.(5) The 2018 survey results, shared here for World Hepatitis Day on 28 July, provide a measure of whether the viral hepatitis response is equitable in Europe.(6)
Prof. Jeffrey V. Lazarus of ISGlobal, University of Barcelona, the Hep-CORE study PI says, “The micro-elimination of hepatitis C offers a sensible way forward to operationalize the widespread call to action for hepatitis elimination within the framework of the WHO goal of eliminating viral hepatitis as a public health threat by 2030. It is also an important reminder that viral hepatitis cannot be declared eliminated if it has not been done equitably.” (7)
ELPA represents patient groups with unrestricted memberships and aims that all patients, regardless of their demographics and, according to ELPA president Tatjana Reic, “are diagnosed in time, are treated with respect, and have equal access to the best standard of medical care – regardless of origin, lifestyle, and type of liver disease.”
Results from the Hep-CORE 2018 study help to identify important groups to focus on and highlight those who are being left behind. ELPA is committed to turning these actions into findings and call on all stakeholders to join us in the effort.
ELPA member patient groups and respondents (n=25) to the 2018 Hep-CORE micro-elimination study represent:
Bosnia & Herzegovina
*Countries with patient groups who are not yet full ELPA members
 Lazarus JV, Safreed-Harmon K, Thursz MR, et al. The micro-elimination approach to eliminating hepatitis C: strategic and operational considerations. Seminars in Liver Disease, July 2018.
 Hepatitis C. World Health Organization. http://www.who.int/news-room/fact-sheets/detail/hepatitis-c, accessed 24 July 2018.
 Hepatitis – Data and Statistics. World Health Organization. http://www.euro.who.int/en/health-topics/communicable-diseases/hepatitis/data-and-statistics.
 Polaris Observatory. Center for Disease Analysis Foundation. http://cdafound.org/polaris/,
 Hep-CORE Study. European Liver Patients’ Association. http://elpa.eu/project/hep-core-study
 World Hepatitis Day. World Hepatitis Alliance. http://www.worldhepatitisday.org/.
 Lazarus JV, Pericàs JM, Colombo M, et al. Viral hepatitis: ‘‘E’’ is for equitable elimination. J Hepatology 2018.