Elimination of hepatitis C in Europe requires greater focus on prisoners and people who inject drugs

Efforts to eliminate viral hepatitis in Europe will need to focus on people who inject drugs and prisoners if European Union nations are to achieve the World Health Organization target of elimination by 2030, a systematic review published this month in BMC Infectious Diseases suggests.

Elimination depends on screening, diagnosis, linkage to care and treatment, and on effective prevention measures in populations where the incidence of viral hepatitis is high. Elimination of hepatitis B requires a high coverage of vaccination in these populations.

For screening to be cost-effective in most countries it must be targeted to populations with a higher prevalence of viral hepatitis, so it is essential to know which groups to prioritise for screening.

Researchers from Rotterdam Public Health Service and Erasmus University, Rotterdam, carried out a systematic review of studies published between 2005 and 2015 to identify prevalence estimates for three key populations: people who inject drugs, prisoners, and men who have sex with men.

The review identified 68 prevalence estimates covering 23 countries in the European Union and European Economic Area. The studies estimated prevalence by measuring hepatitis B surface antigen (HBsAg) or hepatitis C antibodies (which indicate exposure but are not diagnostic of chronic infection).

Prevalence estimates were reviewed for HIV-negative and unknown HIV status men who have sex with men (MSM). Despite noting evidence of increasing sexual transmission among HIV-positive MSM, the study authors do not explain why they excluded HIV-positive MSM from the analysis.

Hepatitis B prevalence was reported in six studies in HIV-negative or unknown HIV status MSM and ranged from 0.6% in Croatia to 1.4% in France. These estimates date from studies carried out between 2001 and 2013. The investigators say that “the findings of this study do not seem to strongly support the continued classification of MSM as a high risk group for chronic hepatitis B infection.” But they are cautious about this conclusion due to the wide confidence estimates.

Hepatitis C antibody prevalence was reported in eleven studies covering seven countries. Prevalence ranged from 0.6% in Sweden to 4.7% in Estonia, with estimates of 1.6 to 2.1% in the United Kingdom and 2.5 to 2.9% in Croatia. The studies were published between 2007 and 2013.

HBsAg prevalence estimates were available for prison populations in 12 countries. These estimates ranged from < 1% in Ireland, Finland and France to 1.6% in the United Kingdom, 6.7% in Italy, 10.7% in Portugal and 25.2% in Bulgaria. The studies were published between 2005 and 2014.

Hepatitis C antibody prevalence was reported in 37 studies in eleven countries. Prevalence ranged from 4.3% among juvenile offenders in Croatia to 86.3% in Luxembourg. Pooled estimates from countries where multiple studies have taken place showed a prevalence of 6.3% in France, 17.4% in the United Kingdom, 20.3% in Spain and 26.3% in Bulgaria.

The authors say that the prevalence of viral hepatitis in prisons is partly related to the availability of harm reduction measures and infection control procedures in prisons.

HBsAg prevalence estimates were available for people who inject drugs in seven countries. Prevalence ranged from 0.5% in Croatia, Hungary, and Ireland, to 2.1% in Latvia, 3% in Greece, 6.1% in Cyprus and 6.3% in Portugal.

Hepatitis C antibody prevalence estimates were available for 16 countries. Prevalence ranged from 13.8% in Malta and 14.6% in the Czech Republic to 49% in the United Kingdom, 60.5% in Italy, 70.1% in Latvia and 84.3% in Portugal. The studies were published between 2007 and 2013.

On the basis of their findings the authors recommend:

• Systematic screening for viral hepatitis and linkage to care for prisoners
• Treatment of viral hepatitis as a prevention measure in high-burden populations
• Hepatitis C screening and treatment needs to be offered in accessible locations
• Adequate resourcing of hepatitis B vaccination, especially childhood immunisation.