Primary Care Must Up Its Game to End Hepatitis in Europe

The European Centre for Disease Prevention and Control estimates that about 5.4 million people in the European Union and European Economic Area (EU/EAA) live with chronic hepatitis B or C infection.

Many of these people are undiagnosed.

Still many others who do get diagnosed do so at advanced stages when severe health issues have developed. Chronic hepatitis resulting from B or C virus infection is one of the main risk factors for primary liver cancer — the sixth leading cause of cancer-related deaths in Europe, with 55,000 deaths in 2022 alone.

“Primary care practitioners have a critical role in supporting the achievement of elimination of hepatitis,” said Erika Duffell, MB, ChB, principal expert in hepatitis at the European Centre for Disease Control and Prevention, speaking to Medscape Medical News.

But there’s a major stumbling block.

Hepatitis B and C virus (HBV/HCV) infections are highest among vulnerable groups, including some migrant populations, people who inject drugs, and people in prison. And there is evidence that stigma surrounding hepatitis in healthcare is often preventing people from coming forward for testing or treatment.

A 2024 pilot survey by the World Hepatitis Alliance found that more than a third of people with hepatitis C (39%) and nearly a quarter with hepatitis B (24%) have avoided accessing healthcare because they fear they’ll be treated differently because of it.

“Stigma and discrimination still have a negative effect on outreach, linkage to care, and retention of patients,” according to Dr Stela Bivol, leader of the Joint Infectious Disease Unit of WHO/Europe.

She told Medscape Medical News, “Great progress has been made with hepatitis C treatment in the last decade, yet millions of people are living with hepatitis C and do not know it. It’s vital to offer testing, especially in key populations, without stigma or discrimination.”

She also believes that primary healthcare professionals have a fundamental role to play in disease prevention.

What Do Primary Care Physicians Need to Know?

Various rapid diagnostic tests are available for both HBV and HCV, explained Bivol. “These tests enable quick screening with a finger prick — a drop of blood — or even with an oral swab. There are many tests that have been prequalified by the WHO, including self-tests for hepatitis C,” she said.

There is a highly effective vaccine for HBV, she continued, with a recommendation for infants to receive their first dose within 24 hours of birth. “Member States are encouraged to work proactively to vaccinate key populations with higher risk of infection.”

Although there is no curative treatment for HBV, there are treatments that are effective at preventing liver injury and reducing the risk of developing cirrhosis and cancer.

“There is no vaccine for hepatitis C, but there is an effective and curative treatment that can be completed in 12 weeks,” Bivol continued.

Awareness of Prevalence Is Key

For primary care physicians to play an effective role in supporting the 2030 target of the WHO Regional Office for Europe for eliminating viral hepatitis as a public health threat, they need to be aware of the scale of undiagnosed HBV and HCV infections in their communities and countries.

“The prevalence of these infections varies significantly across different countries and populations,” explained Duffell. Some countries are closer than others in reaching the WHO elimination target.

For example, there is widespread HBV vaccination across the EU/EAA, but coverage is inconsistent: Less than 40% of countries reached their target of 95% of HBV vaccination.

Across the EU/EEA, it is estimated that 1% of the population is currently living with chronic HBV infection. But that prevalence can range from as low as 0.1% in Ireland to as high as 4.5% in Romania. Also, the prevalence of undiagnosed HBV is estimated to range from 0% in Denmark to 95% in Hungary. A whole 8% of patients with HBV have advanced liver disease when first diagnosed with the condition.

The figures for HCV aren’t much better. The EU/EEA-wide prevalence is around 0.5%. But that ranges from less than 0.1% in the Netherlands and Slovenia to 2.3% in Romania. Undiagnosed HCV ranges from 0% in Spain and Norway to 97% in Portugal. And about 6% of patients with HCV have advanced liver disease when first diagnosed.

“Primary care physicians need to know the prevalence in their country, the clinical consequences of infection, how to screen, how to confirm the diagnosis, and how to refer the patient to a specialist if necessary,” Professor Jean-Michel Pawlotsky, MD, PhD, director of the National Reference Center for Viral Hepatitis at the Henri Mondor University Hospital in Créteil, France, told Medscape Medical News.

“They need to know the difference between active infection and cured HCV or asymptomatic HBV carriage in order to counsel their patients appropriately,” he added. “Primary care physicians can play an important role if they are well informed about the disease, its prevention, and diagnosis.”

Marko Korenjak, MA, president of the European Liver Patients’ Association, said primary care physicians also have a significant role in informing patients about transmission prevention and vaccination.

“They are essential in the ongoing care of patients by monitoring disease progression and treatment regimens and managing comorbid conditions that can exacerbate liver disease, such as obesity, diabetes, and alcohol use. They act as the central point for coordinating care between specialists, ensuring patients receive comprehensive and cohesive treatment.”

Duffell stressed it is crucial that primary care physicians stay well informed about hepatitis, be aware of local testing guidance, understand the diagnostic tests, and know the local care pathway that follows once a person receives a diagnosis.

Vaccination remains the cornerstone of hepatitis B prevention and primary care practitioners can play a key role in helping to address the gaps in coverage.

“Recent declines in vaccine coverage seen in some countries across Europe are concerning and primary care practitioners are well placed to support local efforts in maximizing hepatitis B vaccine coverage as part of the childhood vaccination schedule and in reaching out to vulnerable populations at increased risk who may not be vaccinated,” stressed Duffell.

Siobhan Harris has been a health and medical journalist for WebMD/Medscape Medical News since 2009. She has a law degree from the University of Sheffield and a postgraduate diploma in journalism. She has worked as a national/international news journalist at ITN, BBC, and BFBS Forces News.