The civil society monitoring of hepatitis C response related to the WHO 2030 elimination goals in 35 European countries.

BACKGROUND: People who inject drugs (PWID) account for the majority of new cases of hepatitis C virus (HCV) infection in Europe; however, HCV testing, and treatment for PWID remain suboptimal. With the advent of direct acting antivirals (DAAs) the World Health Organization (WHO) adopted a strategy to eliminate HCV as public health threat by 2030. To achieve this, key policies for PWID must be implemented and HCV continuum of care needs to be monitored. This study presents results of the first monitoring led by civil society that provide harm reduction services for PWID. METHODS: In 2019, harm reduction civil society organizations representing focal points of Correlation-European Harm Reduction Network in 36 European countries were invited to complete a 27-item online survey on four strategic fields: use/impact of guidelines on HCV testing and treatment for PWID, availability/functioning of continuum of care, changes compared to the previous year and, the role of harm reduction services and non-governmental organizations (NGOs) of PWID. A descriptive analysis of the responses was undertaken. RESULTS: The response rate was 97.2%. Six countries reported having no guidelines on HCV treatment (17.1%). Twenty-three (65.7%) reported having treatment guidelines with specific measures for PWID; guidelines that impact on accessibility to HCV testing/treatment and improve access to harm reduction services in 95.6% and 86.3% of them, respectively. DAAs were available in 97.1% of countries; in 26.4% of them they were contraindicated for active drug users. HCV screening/confirmatory tests performed at harm reduction services/community centers, prisons and drug dependence clinics were reported from 80.0%/25.7%, 60.0%/48.6%, and 62.9%/34.3% of countries, respectively. Provision of DAAs at drug dependence clinics and prisons was reported from 34.3 to 42.9% of countries, respectively. Compared to the previous year, HCV awareness campaigns, testing and treatment on service providers' own locations were reported to increase in 42.9%, 51.4% and 42.9% of countries, respectively. NGOs of PWID conducted awareness campaigns on HCV interventions in 68.9% of countries, and 25.7% of countries had no such support. CONCLUSION: Further improvements in continuum-of-care interventions for PWID are needed, which could be achieved by including harm reduction and PWID organizations in strategic planning of testing and treatment and in efforts to monitor progress toward WHO 2030 elimination goal.

Hepatitis B and C among healthcare workers and patient groups at increased risk of iatrogenic transmission in the European Union/European Economic Area.

In the European Union/European Economic Area (EU/EEA) approximately 9 million people are chronically infected with hepatitis B virus (HBV) or hepatitis C virus (HCV), and many are undiagnosed. Targeted active case finding initiatives are needed. Iatrogenic transmission of HBV/HCV is relevant in Europe but people at risk of infection are often overlooked. This study aimed to identify groups at increased risk of HBV/HCV infection due to iatrogenic transmission, including healthcare workers, and to estimate incidence and prevalence. PubMed and Embase were systematically searched in February 2017 using strings combining terms for HBV/HCV, occurrence and population subgroups. All retrieved publications were screened and included articles were quality assessed. A predefined set of variables were extracted, and detailed summary tables were developed per population group of interest, virus and outcome. Thirty-eight articles were included, two reported on HBV, 22 on HCV and 16 on both, contributing 70 estimates of prevalence or incidence among: haemodialysis recipients, diabetes patients, recipients of substances of human origin, recipients of medical/dental procedures and healthcare workers. Estimates varied widely from 0.4% to 11.7% for HBV and from 0.7% to over 90% for HCV with most being higher than in the general population. Despite the limited number of studies retrieved, mostly old and focused on populations with multiple risk factors, our findings highlight the importance of considering population groups at higher risk for HBV/HCV iatrogenic transmission as target groups for active case finding in the EU/EEA. Test offers should be guided by individual risk assessment alongside local epidemiological data and local context.

Monitoring response to hepatitis B and C in EU/EEA: testing policies, availability of data on care cascade and chronic viral hepatitis-related mortality - results from two surveys (2016).

OBJECTIVES: The World Health Organization (WHO) developed a European Regional Action Plan (EAP) to fast-track action towards the goal of eliminating viral hepatitis. Robust monitoring is essential to assess national programme performance. The purpose of this study was to assess the availability of selected monitoring data sources in European Union/European Economic Area (EU/EEA) Member States (MS). METHODS: Availability of data sources at EU/EEA level was assessed using two surveys distributed to 31 EU/EEA MS in 2016. The two surveys covered (A) availability of policy documents on testing; testing practices and monitoring; monitoring of diagnosis and treatment initiation, and; (B) availability of data on mortality attributable to chronic viral hepatitis. RESULTS: Just over two-thirds of EU/EEA MS responded to the surveys. 86% (18/21) reported national testing guidance covering HBV, and 81% (17/21) covering HCV; while 33% (7/21) and 38% (8/21) of countries, respectively, monitored the number of tests performed. 71% (15/21) of countries monitored the number of chronic HBV cases diagnosed and 33% (7/21) the number of people treated. Corresponding figures for HCV were 48% (10/21) and 57% (12/21). 27% (6/22) of countries reported availability of data on mortality attributable to chronic viral hepatitis. CONCLUSIONS: The results of this study suggest that sources of information in EU/EEA Member States to monitor the progress towards the EAP milestones and targets related to viral hepatitis diagnosis, cascade of care and attributable mortality are limited. Our analysis should raise awareness among EU/EEA policy makers and stimulate higher prioritisation of efforts to improve the monitoring of national viral hepatitis programmes.

Estimating the scale of chronic hepatitis C virus infection in the EU/EEA: a focus on migrants from anti-HCV endemic countries.

BACKGROUND: Increasing the proportion diagnosed with and on treatment for chronic hepatitis C (CHC) is key to the elimination of hepatitis C in Europe. This study contributes to secondary prevention planning in the European Union/European Economic Area (EU/EEA) by estimating the number of CHC (anti-HCV positive and viraemic) cases among migrants living in the EU/EEA and born in endemic countries, defining the most affected migrant populations, and assessing whether country of birth prevalence is a reliable proxy for migrant prevalence. METHODS: Migrant country of birth and population size extracted from statistical databases and anti-HCV prevalence in countries of birth and in EU/EEA countries derived from a systematic literature search were used to estimate caseload among and most affected migrants. Reliability of country of birth prevalence as a proxy for migrant prevalence was assessed via a systematic literature search. RESULTS: Approximately 11% of the EU/EEA adult population is foreign-born, 79% of whom were born in endemic (anti-HCV prevalence ≥1%) countries. Anti-HCV/CHC prevalence in migrants from endemic countries residing in the EU/EEA is estimated at 2.3%/1.6%, corresponding to ~580,000 CHC infections or 14% of the CHC disease burden in the EU/EEA. The highest number of cases is found among migrants from Romania and Russia (50-60,000 cases each) and migrants from Italy, Morocco, Pakistan, Poland and Ukraine (25-35,000 cases each). Ten studies reporting prevalence in migrants in Europe were identified; in seven of these estimates, prevalence was comparable with the country of birth prevalence and in three estimates it was lower. DISCUSSION: Migrants are disproportionately affected by CHC, account for a considerable number of CHC infections in EU/EEA countries, and are an important population for targeted case finding and treatment. Limited data suggest that country of birth prevalence can be used as a proxy for the prevalence in migrants.

Current prevalence of chronic hepatitis B and C virus infection in the general population, blood donors and pregnant women in the EU/EEA: a systematic review.

This systematic review aimed at estimating chronic hepatitis B (HBV) and C virus (HCV) prevalence in the European Union (EU) and Economic Area (EEA) countries in the general population, blood donors and pregnant women. We searched PubMed©, Embase© and Cochrane Library databases for reports on HBV and HCV prevalence in the general population and pregnant women in EU/EEA countries published between 2005 and 2015. Council of Europe data were used for HBV and HCV blood donor prevalence. HBV general population estimates were available for 13 countries, ranging from 0·1% to 4·4%. HCV general population estimates were available for 13 countries, ranging from 0·1% to 5·9%. Based on general population and blood donor estimates, the overall HBV prevalence in the EU/EEA is estimated to be 0·9% (95% CI 0·7-1·2), corresponding to almost 4·7 million HBsAg-positive cases; and the overall HCV prevalence to be 1·1% (95% CI 0·9-1·4), equalling 5·6 million anti-HCV-positive cases. We found wide variation in HCV and HBV prevalence across EU/EEA countries for which estimates were available, as well as variability between groups often considered a proxy for the general population. Prevalence estimates are essential to inform policymaking and public health practice. Comparing to other regions globally, HBV and HCV prevalence in the EU/EEA is low.

Survey of surveillance systems and select prevention activities for hepatitis B and C, European Union/European Economic Area, 2009.

Hepatitis B and C viral infections are leading causes of hepatic cirrhosis and cancer. The incidence and prevalence of both hepatitis B and C varies across European countries. European wide surveillance data help to understand the dynamic epidemiology of hepatitis B and C, which is important for the implementation and effectiveness of prevention and control activities.Comparison of surveillance data between countries in Europe is hampered by the differences in national healthcare and reporting systems. This report presents the results of a survey in 2009 which was undertaken to collect baseline information on surveillance systems and core prevention programmes for hepatitis B and C in individual European Union/ European Economic Area countries. The results provide key information to aid the interpretation of surveillance data, and while indicating heterogeneity in national surveillance systems and programmes, they highlight the potential of these systems. This resource has supported the implementation of a standardised European enhanced surveillance programme.

Enhanced surveillance of hepatitis C in the EU, 2006 - 2012.

Hepatitis C is a major public health issue across Europe, and with rapidly evolving developments in the therapeutic field, it is essential that countries have access to epidemiological information. In 2011, The European Centre for Disease Prevention and Control (ECDC) introduced enhanced surveillance of hepatitis C across EU/EEA countries collecting routine data from national notification systems using standardized case definitions. Data collected from 2006 to 2012 indicate a high burden of disease with great variation in reported cases between countries. Most cases occurred among young adult males, and although injecting drug use dominated across all cases, there were increasing numbers of acute cases reported among men who have sex with men. Geographically, the reported data were the inverse of what may be expected based on findings from recent prevalence surveys in a number of EU/EEA countries. Unexpectedly, low figures were reported through notification systems in some southern and eastern European countries where prevalence is known from surveys to be high. This discrepancy highlights the limitation of surveillance data for a disease such as hepatitis C which is largely asymptomatic until a late stage, so that notifications reflect testing practices rather than real occurrence of disease. Further improvements to the quality of the data are important to increase data utility. Improved understanding of national testing practices is necessary to allow a better interpretation of surveillance results. Additional epidemiological studies alongside routine case-based reporting in notification systems should also be considered to better estimate the true disease burden across Europe.

Enhanced surveillance of hepatitis B in the EU, 2006-2012.

Robust epidemiological information on hepatitis B is important to help countries plan prevention and control programmes and evaluate public health responses to control transmission. European Centre Disease Prevention and Control (ECDC) introduced enhanced surveillance of hepatitis B at EU/EEA level in 2011 to collate routine surveillance data from national notification systems. Analysis of the data collected for the years 2006-2012 shows a high burden of hepatitis B across Europe with 110 005 cases reported over the period with the majority of these cases being chronic infections. The most commonly reported routes of transmission in acute cases included heterosexual transmission, nosocomial transmission, injecting drug use and transmission among men who have sex with men. Mother-to-child transmission was the most common route reported for chronic cases. Trends over time were difficult to analyse as national reporting practices changed, but data suggest a downward trend in acute cases, which probably reflects the impact of the widespread implementation of vaccination programmes. Notifications of chronic infection varied across countries and showed discrepancy with the expected results based on findings from recent prevalence surveys. This indicated that notifications mirror local testing practices rather than real occurrence of disease. Improving the quality of the data and considering reported notifications alongside other data sources, such as local screening practices and vaccination policies, will improve the utility of the data.

Five hepatitis B outbreaks in care homes in the UK associated with deficiencies in infection control practice in blood glucose monitoring.

Healthcare-associated hepatitis B virus (HBV) outbreaks have been reported in the USA and from several countries in Europe. Patient-to-patient transmission of HBV in these settings has been linked to several different types of exposure but one of the most common exposures implicated is the use of 'finger-stick' lancet devices for blood glucose testing. This article is an account of the investigations into a series of HBV outbreaks linked to the use of lancing devices in community healthcare settings in the UK. Between February 2004 and December 2006, nine individuals with acute HBV infection were reported to five local units of the Health Protection Agency. Investigations identified a further 12 individuals with HBV infection in residents in these settings. The epidemiological and environmental evidence suggests that HBV transmission occurred mostly from a significant breakdown in infection control measures in blood glucose testing. The occurrence of these outbreaks has highlighted the confusion that exists and the need for clear recommendations regarding the use of such devices in the UK.

Investigation of a tuberculosis cluster at a job centre in Manchester, United Kingdom.

During the summer of 2005, four cases of active tuberculosis from the same occupational setting were investigated in Manchester, UK. The index case had been diagnosed in December of the previous year. At that stage the closest occupational contacts had been screened, all of whom were assessed as being free from active disease, and none had met nationally recommended criteria for chemoprophylaxis for latent tuberculosis infection (LTBI). In June 2005, two work contacts developed progressive primary extrapulmonary (pleural) TB. Following a detailed risk assessment, the screening programme was widened to include 137 staff who worked at the job centre (employment agency) where the first four cases had been found. This screening programme was based on tuberculin Mantoux testing, CXR and gamma-interferon testing. Of these 137 contacts screened, one additional person was found to have active disease and six others were offered chemoprophylaxis for LTBI. The isolates from the index case and the first two secondary cases were indistinguishable on VNTR-MIRU (variable number tandem repeat--mycobacterial interspersed repetitive unit) typing at 15 loci. No samples were available for testing from the fourth case of active disease. Management of this incident has benefited from the evolving fields of both genotyping and diagnostic testing for LTBI. However, further research into the epidemiological inferences made through genotyping, as well as the significance of a positive gamma-interferon test in assessing the risk of development of active disease, is still required.

Investigation of a tuberculosis cluster at a job centre in Manchester, United Kingdom.

During the summer of 2005, four cases of active tuberculosis from the same occupational setting were investigated in Manchester, UK. The index case had been diagnosed in December of the previous year. At that stage the closest occupational contacts had been screened, all of whom were assessed as being free from active disease, and none had met nationally recommended criteria for chemoprophylaxis for latent tuberculosis infection (LTBI). In June 2005, two work contacts developed progressive primary extrapulmonary (pleural) TB. Following a detailed risk assessment, the screening programme was widened to include 137 staff who worked at the job centre (employment agency) where the first four cases had been found. This screening programme was based on tuberculin Mantoux testing, CXR and gamma-interferon testing. Of these 137 contacts screened, one additional person was found to have active disease and six others were offered chemoprophylaxis for LTBI. The isolates from the index case and the first two secondary cases were indistinguishable on VNTR-MIRU (variable number tandem repeat - mycobacterial interspersed repetitive unit) typing at 15 loci. No samples were available for testing from the fourth case of active disease. Management of this incident has benefited from the evolving fields of both genotyping and diagnostic testing for LTBI. However, further research into the epidemiological inferences made through genotyping, as well as the significance of a positive gamma-interferon test in assessing the risk of development of active disease, is still required.

Investigation of an outbreak of E. coli O157 infections associated with a trip to France of schoolchildren from Somerset, England.

A retrospective cohort study was conducted after 2 confirmed and 8 probable cases of VTEC 0157 occurred in a schoolgroup from Somerset following a trip to France. The strain of the 2 confirmed cases was vero-cytotoxin type 2, phage type 34. Despite its low statistical power due to small numbers, this study suggested the most likely vehicle of infection was cucumber salad (crude RR=4.3, 95%CI [0.6-29], adjusted OR=107, 95%CI indeterminate, p=0.08). The cucumbers were purchased from Belgium but it was not possible to trace them back to source. The international nature of this outbreak emphasises the importance of close collaboration between organisations in the management of outbreaks, of ensuring international standards in food safety, and of agreeing a common standard in VTEC typing across Europe.

UK measles outbreak in non-immune anthroposophic communities: the implications for the elimination of measles from Europe.

We describe the epidemiology of the first nationwide outbreak of measles infection in the UK since the implementation of a mass vaccination campaign. Notifications of infectious diseases, interview and postal questionnaire identified 293 clinical cases, 138 of which were confirmed by salivary IgM, measles virus isolation and PCR. Twelve were epidemiologically linked to confirmed cases. The outbreak began in London, after contact with measles infection probably imported from Italy. Measles genotyping determined by sequence analysis confirmed spread to other unimmunized anthroposophic communities in the north, south west and south coast of England. Only two cases had been vaccinated against measles infection, and 90% of cases were aged under 15 years. Measles virus can selectively target non-immune groups in countries with high vaccine uptake and broader herd immunity. Without harmonization of vaccination policies and uniform high coverage across Europe, the importation and spread of measles virus amongst non-immune groups may prevent the elimination of measles.