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Prevalence and estimation of hepatitis B and C infections in the
WHO European Region: a review of data focusing on the
countries outside the European Union and the European
Free Trade Association
V. D. HOPE
1,2
*, I. ERAMOVA
3
,D.CAPURRO
3
AND M. C. DONOGHOE
3
1
Centre for Research on Drugs & Health Behaviour, London School of Hygiene & Tropical Medicine,
London, UK
2
Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
3
HIV/AIDS, Sexually Transmitted Infections and Viral Hepatitis Programme, World Health Organization
(WHO) Regional Office for Europe, Copenhagen, Denmark
Received 21 December 2012; Final revision 1 February 2013; Accepted 26 March 2013;
first published online 29 May 2013
SUMMARY
Knowledge of hepatitis B and C prevalence, and numbers infected, are important for planning
responses. Published HBsAg and anti-HCV prevalences for the 20 WHO European Region
countries outside the EU/EFTA were extracted, to complement published data for the
EU/EFTA. The general population prevalence of HBsAg (median 3·8%, mean 5·0%, seven
countries) ranged from 1·3% (Ukraine) to 13% (Uzbekistan), and anti-HCV (median 2·3%, mean
3·8%, 10 countries) from 0·5% (Serbia, Tajikistan) to 13% (Uzbekistan). People who inject drugs
had the highest prevalence of both infections (HBsAg: median 6·8%, mean 8·2%, 13 countries;
anti-HCV: median 46%, mean 46%, 17 countries), and prevalence was also elevated in men who
have sex with men and sex workers. Simple estimates indicated 13·3 million (1·8%) adults have
HBsAg and 15·0 million (2·0%) HCV RNA in the WHO European Region; prevalences were
higher outside the EU/EFTA countries. Efforts to prevent, diagnose, and treat these infections
need to be maintained and improved.
This article may not be reprinted or reused in any way in order to promote any commercial
products or services.
Key words: Epidemiology, European Region, hepatitis B, hepatitis C, prevalence.
INTRODUCTION
Infection with the hepatitis B and C viruses (HBV and
HCV) causes significant morbidity and mortality.
Even though HBV infection can be prevented through
vaccination, the World Health Organization (WHO)
has estimated that globally around 240 million people
are chronically infected [1,2] with between 500 000 and
700 000 deaths each year [1,3]. WHO estimates also
indicate that 2–3% of the world’s population are
HCV-infected, equating to 120–170 million people
[4]. About 1·0 million people die annually (∼2·7%
of all deaths) from causes related to viral hepatitis,
most commonly liver disease, including liver cancer
[5]. An estimated 57% of liver cirrhosis cases and
78% of primary liver cancers result from HBV or
HCV infection [6]. Co-infections with HIV are an
increasing problem in countries with HIV epidemics
in people who inject drugs (PWID), and in those
treated with HIV anti-retrovirals, and underlying
viral hepatitis is becoming a major cause of death [5].
Globally there are geographical variations in the
extent of both HBV and HCV infection including
within Europe [4]. In the European Union (EU) and
* Author for correspondence: Dr V. D. Hope, Centre for Research
on Drugs & Health Behaviour, London School of Hygiene &
Tropical Medicine, London, UK.
(Email: vivian.hope@lshtm.ac.uk)
Epidemiol. Infect. (2014), 142, 270–286. © Cambridge University Press and World Health Organization 2013
WHO has granted permission to Cambridge University Press to publish the contribution written by WHO.
This article may not be reprinted or reused in any way in order to promote any commercial products or services.
doi:10.1017/S0950268813000940
The online version of this article is published within an Open Access environment subject to the conditions of the Creative Commons Attribution-
NonCommercial-ShareAlike licence <http://creativecommons.org/licenses/by-nc-sa/3.0/>.
European Free Trade Association (EFTA) area,
prevalence in the general population varies from
0·4% to 5·2% for anti-HCV and from 0·1% to 5·6%
for HBsAg [7]. Hepatitis prevalence in the rest of the
WHO European Region, mainly eastern Europe and
central Asia countries, has not been assessed even
though this part of the Region has recently experi-
enced an accelerating HIV epidemic and an increase
in the population of PWID [8].
HBV and HCV are bloodborne viruses that are easily
transmitted through blood-to-blood contact [2,9–11].
Parenteral routes, particularly injecting drug use or
poor hygiene in clinical settings, are major sources of
transmission [2,9–12]. HBV can also be transmitted
sexually, and this route has also been reported for
HCV in certain circumstances [10,13]. Perinatal trans-
mission of both HBV and HCV can also occur [2,9,10].
The majority of adults infected with HBV spon-
taneously resolve their infection and develop protective
immunity [11]. Less commonly chronic infection results
and, in rare cases, causes potentially fatal acute liver
failure [11]. In contrast to HBV, the majority of
HCV-infected adults develop chronic disease [14].
Those with chronic infections remain infectious to
others and are at risk of developing serious liver disease
such as cirrhosis or hepatocellular cancer [15,16]. The
available antiviral treatments for both HBV and
HCV infections have increased and become more effec-
tive [17,18]. Treatment may also have a role in preven-
tion through reducing the pool of infectious people [19].
As chronic HBV and HCV infections are largely
asymptomatic, many patients who might benefit
from treatment remain undetected [20]. Efforts are
needed to detect those infected and who would
benefit from treatment, so that the costly sequelae
of infection can be reduced [21,22]. To target case-
finding it is necessary to know which population
groups are most affected; and information on the
likely numbers infected is needed for healthcare plan-
ning, for example, to assess the cost of providing treat-
ment. Examination of these at a regional level allows
comparison of the burden between countries as well as
informing international responses.
The aims of this study were to: (a) assess the pre-
valence of HBV and HCV infection in the WHO
European Region countries outside the EU/EFTA
through a literature review; (b) generate simple esti-
mates of the numbers living with HBV and HCV
infection in these countries, and (c) to compare this
burden with that in the rest of the WHO European
Region obtained from published data [7].
MATERIALS AND METHODS
Literature review
Studies that had measured HBV and HCV seropre-
valence since 2000 were identified through a literature
review. To be included, studies had to: (a) have tested
a biological sample (self-reports were excluded) to
measure prevalence of HBsAg or anti-HCV in a
WHO European Region country outside the EU/
EFTA area (n= 20, Table 1); (b) do so in one or
more of these adult population groups: general popu-
lation, blood donors, pregnant women, PWID, men
who have sex with men (MSM), and sex workers;
and (c) have been published from 2000 to 2010 inclus-
ive. Studies not meeting these criteria or reporting
sample sizes <100 were excluded.
Medline and EMBASE were searched for studies
on the prevalence of HBV and HCV (see Sup-
plementary online material for search terms). The
grey literature were indentified through searches of
documents held by the WHO Regional Office for
Europe, the European Monitoring Centre for Drugs
and Drug Addition (EMCDDA) website, and the
sources identified in a systematic review on HIV in
the WHO European Region –which had system-
atically collected data on seroprevalence studies (in-
cluding those with a focus on viral hepatitis) [8].
Bibliographies were checked for further sources. The
titles and abstracts were first reviewed to identify
relevant publication (in English or Russian), the full
text was then assessed for inclusion and data extracted
(including secondary reports). Data relating to screen-
ing of first-time blood donors was obtained from the
Council of Europe report [23].
The prevalences in pregnant women were combined
with the general population data. The nature of this
population, women of child-bearing age, could mean
that the prevalence might not reflect that overall in
the general population, particularly if prevalence dif-
fers by gender or age, or if fertility rates are higher
in migrant groups with higher prevalences; however,
we have assumed that such differences are likely to
be small overall. Prevalence in first-time blood donors
was not combined with the general population data,
as blood donors are a highly select group. In most
countries those who may have been at risk of infection
with bloodborne viruses are excluded from giving
blood, thus blood donors are usually likely to be at
lower risk overall than the general population.
A‘selected prevalence’estimate in the general
population was obtained for each country using the
Hepatitis B and C in the European Region 271
Table 1. Number and geographical coverage of studies that had measured the prevalence of hepatitis B surface antigen (HBsAg) or antibodies to the hepatitis C
virus (anti-HCV) in each population group by country: countries in the WHO European Region outside EU/EFTA
(a) General population and blood donors
Country
General population Blood donors
HBsAg Anti-HCV HBsAg Anti-HCV
No. of
studies
Coverage
of studies
No. of
studies
Coverage
of studies
No. of
studies
Coverage
of studies
No. of
studies
Coverage
of studies
Albania 3 National (x2),
1 city/area
1 1 city/area 2 1 city/area, n.s. 2 1 city/area, n.s.
Armenia 0000
Azerbaijan 0000
Belarus 0000
Bosnia & Herzegovina 0 0 1 National 2 National,
1 city/area
Croatia 0 0 1 National 1 National
Georgia 0 1 1 city/area 0 0
Israel 0 0 1 National 1 National
Kazakhstan 1 1 city/area 2 National,
1 city/area
1 National 0
Kyrgyzstan 0 1 2 cities/areas 0 0
Montenegro 0 0 1 National 1 National
Republic of Moldova 0000
Russian Federation 2 ?National,
1 city/area
2 ?National,
1 city/area
1 1 city/area 1 1 city/area
Serbia (incl. Kosovo*) 1 1 city/area 1 1 city/area 1 1 city/area 1 1 city/area
Tajikistan 0 1 Multi-site 1 National 1 National
The former Yugoslav
Republic of Macedonia
0 0 1 1 city/area 1 1 city/area
Turkey 9 Multi-site (x2),
1 city/area (x7)
7 Multi-site,
1 city/area (x6)
3 National,
1 city/area (x2)
3 National,
1 city/area (x2)
Turkmenistan 0000
Ukraine 4 Unclear 3 Unclear 3 Unclear 2 Unclear
Uzbekistan 1 Multisite 1 Multisite 1 Multisite 2 Multisite
Total 21 20 18 18
272 V. D. Hope and others
Table 1 (cont.)
(b) People who injecting drugs (PWID)
PWID
HBsAg Anti-HCV
No. of
studies
Coverage
of studies
No. of
studies Coverage of studies
Albania 1 1 city/area 2 1 city/area
Armenia 0 0
Azerbaijan 1 Multi-site 2 Multi-site, 2 cities/areas
Belarus 1 Multi-site 2 Multi-site, 1 city/area
Bosnia & Herzegovina 2 Multi-site 2 Multi-site
Croatia 3 National multi-site,
1 city/area
3 National, multi-site, 1 city/area
Georgia 3 1 city/area 4 Multi-site, 1 city/area (x3)
Israel 1 National 1 National
Kazakhstan 1 2 cities/areas 2 National, 2 cities/areas
Kyrgyzstan 0 2 Multi-site, 2 cities/areas
Montenegro 1 Unclear 2 1 city/area, unclear
Republic of Moldova 1 National 1 National
Russian Federation 2 2 cities/areas, 1 city/area 16 Multi-site (x2), 1 city/area (x12), unclear (x2)
Serbia (incl. Kosovo*) 1 1 city/area 3 Multi-site, 1 city/area (x2)
Tajikistan 0 2 Multi-site, 1 city/area
The former Yugoslav Republic
of Macedonia
00
Turkey 1 Multi-site 1 1 city/area
Turkmenistan 0 0
Ukraine 3 1 city/area (x1),
unclear (x2)
6 1 city/area (x4), unclear (x2)
Uzbekistan 0 2 National multi-site
Total 22 53
Hepatitis B and C in the European Region 273
Table 1 (cont.)
(c) Men who have sex with men (MSM) and sex workers
MSM Sex workers
HBsAg Anti-HCV HBsAg Anti-HCV
No. of
studies
Coverage
of studies
No. of
studies
Coverage
of studies
No. of
studies
Coverage
of studies
No. of
studies
Coverage
of studies
Albania 1 1 city/area 0 0 0
Armenia 0 0 0 0
Azerbaijan 1 1 city/area 1 1 city/area 1 Multi-site 1 Multi-site
Belarus 0 0 0 0
Bosnia & Herzegovina 1 National 1 National 1 National 1 National
Croatia 1 1 city/area 2 1 city/area, national 0 1 National
Georgia 1 1 city/area 1 1 city/area 0 0
Israel 0 0 0 0
Kazakhstan 0 1 National 0 1 National
Kyrgyzstan 0 1 National 0 3 National multi-site,
1 city/area
Montenegro 0 0 0 0
Republic of Moldova 0 1 1 city/area 0 1 1 city/area
Russian Federation 0 1 2 cities/areas 0 3 Multi-site,
1 city/area (x2)
Serbia (incl. Kosovo*) 1 1 city/area 1 1 city/area 1 1 city/area 1 1 city/area
Tajikistan 0 0 0 1 National
The former Yugoslav Republic
of Macedonia
00 0 0
Turkey 1 Multi-site 0 2 Multi-site,
1 city/area
1 1 city/area
Turkmenistan 0 0 0 0
Ukraine 1 Unclear 1 Unclear 1 Unclear 1 Unclear
Uzbekistan 0 0 0 2 Multi-site,
1 city/area
Total 8 11 6 17
EU/EFTA, European Union and European Free Trade Association area; n.s., not stated.; ‘?’, preceding a detail indicates that the information available on this item in the
source was limited.
* According to United Nations Security Council Resolution 1244 (1999).
274 V. D. Hope and others
algorithm in Table 2. This was applied to other groups
if sufficient studies were identified.
Simple estimates of number infected
The total number of adults currently infected with
HBV and HCV was estimated by applying the
HBsAg and anti-HCV prevalences to the 2008
national adult (aged 515 years) population estimates
[24]. In countries that had a selected prevalence in
blood donors only, the prevalence in the general popu-
lation was simply imputed from the blood-donor data.
This was done by using the median ratio of the blood-
donor estimates to the general population estimates
for those countries with selected estimates for both
of these groups. For countries with no general popu-
lation and no blood-donor estimate the median of
the selected general population’s prevalences was
used. Medians were used as the distributions were
skewed, with a small number of countries having a
much higher prevalence than the rest; the median
thus gives a more conservative estimate than would
be obtained using the mean. For HCV, 74% of those
anti-HCV positive were assumed to have current
infection [25].
To obtain comparable simple estimates of the num-
bers living with these infections in the EU/EFTA
countries the same method was applied to published
data (n= 30, excluding four with populations
<100 000). Prevalence in first time blood donors was
taken from the Council of Europe report [23], with
additional data from an European Centre for
Disease Prevention and Control (ECDC) review [7]
(HBsAg prevalence for 27 countries, anti-HCV for
26). General population prevalences were obtained
from the ECDC review, this had obtained selected
prevalences for the EU/EFTA countries using a simi-
lar method (13 countries HBsAg, 12 anti-HCV) [7].
The numbers of current PWID infected with HBV
and HCV were obtained by applying the selected
PWID HBsAg and anti-HCV prevalences to pub-
lished national estimates of the number of current
injectors [26,27]. Where national estimates of the cur-
rent injecting population were not available the
median of the national prevalences of injecting drug
use was used to impute the number of PWID from
the adult population data. For countries with no
HBsAg or anti-HCV prevalence estimate for PWID
the median of the selected national prevalences was
used. Medians were again used as the distributions
were skewed. As with the general population for
HCV, 74% of those anti-HCV positive were assumed
to have current infection [25].
To obtain comparable simple estimates of the
number of PWID living with these infections in the
EU/EFTA countries prevalence data from studies
undertaken since 1999 was downloaded from the
EMCDDA website [27] (all EU states and Norway
report HBV and HCV seroprevalences for PWID to
EMCDDA) and literature searches for Switzerland
and Iceland (not members of EMCDDA). Selected
prevalence estimates were then derived using the
same algorithm as above. Numbers were then esti-
mated using the same approach, including impu-
tations for missing data, as for the countries outside
EU/EFTA.
RESULTS
After accounting for studies reported by more than
one publication, a total 86 sources were identified
(Supplementary Fig. S1).
Prevalence: general population and blood donors
Twenty-one studies, undertaken in seven countries
(35% of total), had measured HBsAg prevalence in a
group representing the general population (Table 1):
11 recruited from the general population, five preg-
nant women, and five other groups (Supplementary
Table S1). Half of these studies had recruited from one
city/area (Table 1). Thirteen countries (65%) had
measured HBsAg prevalence in blood donors
(18 studies, 39% had national coverage, Table 1).
Together the general population and blood donor
studies covered 13 countries. The study HBsAg prev-
alences ranged from 0·1% (blood donors, Bosnia &
Herzegovina) to 13% (general population, Uzbekistan,
Supplementary Table S1). The selected country
Table 2. Algorithm used to select a national
prevalence
Prevalences were selected using the following hierarchy:
(1) National studies.
(2) Studies with multiple sites across the country.
(3) Regional/city levels studies.
If more there was than one study (for example several
multi-site studies) then the weight mean was used
(or mean if this could not be calculated) to obtain
the selected prevalence.
Hepatitis B and C in the European Region 275
HBsAg prevalence estimates (Table 3,Fig. 1) ranged
from 1·3% to 13% for the general population (median
3·4%, mean 5·0%) and from 0·1% to 8·4% for blood
donors (median 1·1%, mean 2·2%). The selected gen-
eral population prevalence was higher than the
selected blood-donor prevalence in five of the seven
countries with both (Table 3), the median of the ratio
between these was 1·4 (range 0·57–2·6, mean 1·6).
Ten countries (50%) had measured the anti-HCV
prevalence in groups representing the general popu-
lation (20 studies: nine recruited from the general popu-
lation, six pregnant women, five other groups), with
two-thirds of these studies covering one city/area
(Table 1). Twelve countries (60%) had measured
anti-HCV prevalence in blood donors (18 studies,
39% recruited from one city/area, Table 1). Together
these measures covered 15 countries (75%). The study
anti-HCV prevalences ranged from 0·03% (blood
donors, Bosnia & Herzegovina) to 13% (general popu-
lation, Uzbekistan, Supplementary Table S1). The
selected country estimates (Table 3,Fig. 1) ranged
from 0·5% to 13% for the general population (median
2·3%, mean 4·3%) and from 0·03% to 6·4% for blood
donors (median 0·46%, mean 1·3%). The selected gen-
eral population prevalence was higher than the selected
blood-donor prevalence in six of the seven countries
with measures of both (Table 3), the median of the
ratio between these was 2·1 (range 0·17–9·2, mean 3·0).
Prevalence: PWID
Fourteen (70%) countries had measured HBsAg preva-
lence and 17 (85%) anti-HCV prevalence in PWID
(Table 1). In total 54 studies were identified, including
30 that had recruited from community settings; eight
from needle and syringe programmes, low-threshold
facilities, harm reduction, or outreach services; three
from addiction treatment settings; four through other
service types; and five through mixed settings (setting
was unclear in four, see Supplementary Table S2).
The mean sample size was 650 (range 60–4860, median
319). Twenty-two studies had measured HBsAg
(38% recruited in one city/area, Table 1) and 53 studies
anti-HCV prevalence (53% recruited in one city/area,
Table 1). The study HBsAg prevalences ranged from
0% to 34%, and the anti-HCV prevalences from 5·3%
to 95% (Supplementary Table S2). The selected
country prevalence estimates (Table 4,Fig. 1) ranged
from 0·8% to 31% for HBsAg (median 6·8%, mean
9·2%) and from 5·3% to 73% for anti-HCV (median
46%, mean 46%).
Prevalence: MSM
Thirteen studies were found that had measured the
prevalence of either HBsAg or anti-HCV in MSM
(Supplementary Table S3). The samples sizes ranged
from 61–741 (mean 235, median 157), and the
majority had recruited MSM from community set-
tings (11, 85%). Eight (40%) countries had undertaken
a single study that had measured the HBsAg preva-
lence in MSM (five recruited from one city/area,
Table 1). The prevalences ranged from 0% to 18%
(Supplementary Table S3) with a median of 6·4%
(mean 6·9%). Eleven studies (from 10 countries,
50%) reported anti-HCV prevalence in MSM (five
recruited from one city/area, Table 1). The median
of study anti-HCV prevalence was 4·2% (mean
7·8%, range 0–16%, Supplementary Table S3).
Prevalence: sex workers
Seventeen studies (Supplementary Table S4) had
measured the prevalence of either HBsAg or anti-
HCV in sex workers: samples sizes ranged from
138–2249 (mean 591, median 315). Almost half of the
studies (eight, 47%) recruited sex workers from com-
munity settings, with four recruiting through services
(23%) and two (12%) from both community settings
and services (setting unclear for three, Supplementary
Table S4). Six studies, from five countries (25%),
reported an HBsAg prevalence in sex workers (two
recruited from one city/area, Table 1); prevalence
ranged from 2% to 18% (Supplementary Table S4),
the median was 2·9% (mean 6·1%). Seventeen studies
from 12 countries (60%), reported an anti-HCV preva-
lence in sex workers (seven recruited from one city/area,
Table 1); prevalences ranged from 2·4% to 40% (median
11%, mean 14%).
Imputation of general population prevalence from
blood donors
General population prevalence estimates were im-
puted from the blood-donor prevalence using the
median ratio of the general population to the blood-
donor prevalence derived from those countries with
both (Table 3). Applying this ratio to the blood-
donor prevalence in those countries from which
it was derived, gave a median difference between
the countries measured and the imputed general popu-
lation prevalence of 0·004% for HBsAg (range −3·3%
to 6·2%, mean 0·6%) and −0·02% for anti-HCV
276 V. D. Hope and others
Table 3. Simple estimates of the number of adults with hepatitis B surface antigen (HBsAg) and hepatitis C virus (HCV) in WHO European Region
Population
aged 515 yr
in 2008
Prevalence in first
time blood donors
Prevalence in studies
representing general
population
Prevalence in general
population imputed
from blood donors* Prevalence estimate used
Estimated numbers
with infection
(rounded to nearest 100)
Country aged 515 yr HBsAg Anti-HCV HBsAg Anti-HCV HBsAg Anti-HCV HBsAg Anti-HCV HBsAg Anti-HCV Chronic HCV
Those outside EU/EFTA
Albania 2 389 000 7·0% 0·7% 9·0% 3·0% 11% 2·5% Measured Measured 215 000 71 700 53000
Armenia 2 431 000
Azerbaijan 6 549 000
Belarus 8 228 000
Bosnia & Herzegovina 3 170 000 0·1% 0·03% 0·1% 0·1% Imputed from BD Imputed from BD 4700 1900 1400
Croatia 3760 000 0·2% 0·1% 0·3% 0·2% Imputed from BD Imputed from BD 10 200 7600 5600
Georgia 3 575 000 6·7% Measured 239500 177 200
Israel 5077 000 0·1% 0·1% 0·2% 0·2% Imputed from BD Imputed from BD 8300 10400 7700
Kazakhstan 11 796 000 1·8% 3·8% 1·0% 2·4% Measured Measured 448 200 118 000 87300
Kyrgyzstan 3 790 000 1·6% Measured 60 600 44 900
Montenegro 498000 0·7% 0·6% 1·0% 1·2% Imputed from BD Imputed from BD 5000 5900 4400
Republic of Moldova 3016 000
Russian Federation 120 185 000 1·1% 2·1% 1·5% 3·6% 1·5% 4·3% Measured Measured 1 802 800 4326 700 3 201 700
Serbia 8 068 000 4·2% 0·3% 2·4% 0·5% 5·7% 0·6% Measured Measured 193 600 40 300 29 900
Tajikistan 4 239 000 3·0% 2·9% 0·5% 4·1% 5·9% Imputed from BD Measured 171 800 21 200 15 700
FYR Macedonia 1 674 000 1·0% 0·2% 1·4% 0·5% Imputed from BD Imputed from BD 22 800 7500 5600
Turkey 53958 000 2·1% 0·3% 3·4% 0·7% 2·9% 0·7% Measured Measured 1 834 600 377 700 279500
Turkmenistan 3 531 000
Ukraine 39 554 000 1·0% 1·3% 1·3% 12% 1·3% 2·7% Measured Measured 514 200 4 746 500 3 512 400
Uzbekistan 19 034 000 5·2% 6·4% 13·3% 13·1% 7·1% 13% Measured Measured 2 531 500 2 493 500 1 845 200
Countries without HBsAg 31120 000 3·4% Estimated from median prevalence 1058 100
Anti-HCV 15527 000 2·3% Estimated from median prevalence 357100 264300
Total (rounded to nearest 1000) 8 821 000 12886 000 95 360 000
Those in EU/EFTA
Austria 7 087 000 0·1% 0·1% 0·3% 0·5% Imputed from BD Imputed from BD 24 300 37 900 28 000
Belgium 8 790000 0·1% 0·03% 0·7% 0·6% 0·4% 0·3% Measured Measured 61 500 52700 39000
Bulgaria 6 606 000 1·8% 0·4% 1·3% 7·9% 4·5% Imputed from BD Measured 520 800 85 900 63500
Cyprus 707000 0·1% 0·02% 0·9% 0·4% 0·2% Measured Imputed from BD 6400 1400 1 000
Czech Republic 8 875 000 0·04% 0·13% 0·6% 0·2% 1·3% Measured Imputed from BD 53 300 118 000 87300
Denmark 4476 000 0·03% 0·03% 0·1% 0·3% Imputed from BD Imputed from BD 6100 12 400 9200
Estonia 1140 000 0·3% 0·7% 1·2% 7·0% Imputed from BD Imputed from BD 13 600 79600 58900
Finland 4 403 000 0·03% 0·04% 0·2% 0·1% 0·4% Measured Imputed from BD 8800 17 900 13200
France 50 870 000 0·03% 0·02% 1·3% 0·1% 0·2% Imputed from BD Measured 61 400 661 300 489400
Germany 70 748 000 0·1% 0·1% 0·6% 0·4% 0·6% 0·8% Measured Measured 424 500 283 000 209400
Greece 9 578 000 2·0% 0·3% 2·1% 1·0% 8·4% 3·3% Measured Measured 201 100 95 800 70900
Hepatitis B and C in the European Region 277
Table 3 (cont.)
Population
aged 515 yr
in 2008
Prevalence in first
time blood donors
Prevalence in studies
representing general
population
Prevalence in general
population imputed
from blood donors* Prevalence estimate used
Estimated numbers
with infection
(rounded to nearest 100)
Country aged 515 yr HBsAg Anti-HCV HBsAg Anti-HCV HBsAg Anti-HCV HBsAg Anti-HCV HBsAg Anti-HCV Chronic HCV
Hungary 8511 000 0·0% 0·3% 0·0% 3·1% Imputed from BD Imputed from BD 2600 267 400 197900
Iceland 249 000
Ireland 3 506 000 0·01% 0·01% 0·1% 0·1% 0·1% Measured Imputed from BD 3500 3100 2300
Italy 51 260 000 0·4% 1·4% 5·2% 1·7% Measured Measured 717 600 2 665 500 1 972 500
Latvia 1 943 000
Lithuania 2 823 000 0·6% 1·0% 2·6% 10·3% Imputed from BD Imputed from BD 73 900 289 800 214500
Luxembourg 395000 0·1% 0·1% 0·4% 0·6% Imputed from BD Imputed from BD 1700 2500 1800
Malta 342 000
Netherlands 13553 000 0·1% 0·02% 0·1% 0·4% 0·3% 0·2% Measured Measured 13 600 54 200 40 100
Norway 3 862 000 0·03% 0·03% 0·1% 0·4% Imputed from BD Imputed from BD 4400 13 600 10 000
Poland 32 389 000 0·5% 0·2% 1·9% 2·0% 1·9% Imputed from BD Measured 659 800 615 400 455 400
Portugal 9 076 000 0·1% 0·2% 0·4% 1·7% Imputed from BD Imputed from BD 36 900 157 000 116 100
Romania 18 157 000 3·7% 0·9% 5·6% 3·5% 15·8% 9·2% Measured Measured 1 016 800 635 500 470300
Slovakia 4 536 000 0·1% 0·1% 0·6% 0·6% 0·5% Measured Imputed from BD 27 200 24000 17700
Slovenia 1 733 000 0·1% 0·03% 0·4% 0·4% Imputed from BD Imputed from BD 7500 6100 4500
Spain 37 814 000 0·2% 0·1% 1·0% 2·0% 0·7% 1·4% Measured Measured 378 100 756 300 559 600
Sweden 7641 000 0·05% 0·1% 0·2% 0·4% 0·2% 0·6% Measured Measured 15 300 30 600 22 600
Switzerland 6 335 000 0·2% 0·1% 0·7% 0·6% Imputed from BD Imputed from BD 44 800 40 600 30 000
United Kingdom 50210 000 0·04% 0·04% 0·7% 0·2% 0·4% Imputed from BD Measured 86 400 351 500 260100
Countries without HbsAg 2 534 000 0·6% Estimated from median prevalence 15 200
Anti-HCV 2 534 000 1·2% Estimated from median prevalence 29 100 21600
Total (rounded to nearest 1000) 4 487 000 7 387 900 5 467 000
Total Europe
732 137 000
13 308 000 20274 000 15 003 000
1·8% 2·8% 2·0%
BD, Blood donors; FYR Macedonia, Former Yugoslav Republic of Macedonia; Anti-HCV, antibodies to the hpatitis C virus; EU/EFTA, European Union and European
Free Trade Association area.
* Estimated using median of the national ratios of the general population prevalence to prevalence in blood donors.
278 V. D. Hope and others
(a) Prevalence in the general adult population
Hatched countries in maps are those outside the WHO Europeon Region.
(b) Prevalence in people who inject drugs (PWID)
Legend
Anti-HCV prevalence
Legend
Anti-HCV prevalence PWID
Legend
HBsAg prevalence PWID
Legend
HBsAg prevalence
No data
1–5%
<1%
>5–10%
>10%
No data
20–50%
<20%
>50–70%
>70%
No data
1–5%
<1%
>5–10%
>10%
No data
1–5%
<1%
>5–10%
>10%
Fig. 1. Prevalence of antibodies to hepatitis C virus (anti-HCV) and hepatitis B surface antigen (HBsAg) in (a) the general adult population; (b) people who inject drugs
(PWID) in the WHO European region, by country. Hatched areas on maps indicate countries outside the WHO European Region.
Hepatitis B and C in the European Region 279
(range −5·4% to 9·3%, mean 0·7%). This variability
indicates that a country prevalence imputed this way
should be treated with caution.
Simple estimates of total numbers infected
The selected and imputed prevalences obtained here
were applied to population data to produce simple
estimates of the numbers infected. These estimates
indicate that of the 304·5 million adults living outside
the EU/EFTA area 8·8 million (2·9%) have HBsAg
and 9·5 million (3·1%) have HCV RNA (Table 3).
Comparable estimates for the EU/EFTA countries
obtained by applying the same method to published
data [7](Table 3,Fig. 1; the median ratio between
the selected general population and the selected
blood-donor prevalence used in the imputations was
4·3 for HBsAg and 11 for anti-HCV). These indicated
that of the 427·6 million adults in the EU/EFTA
countries 4·5 million (1·0%) have HBsAg and
5·5 million (1·3%) have HCV RNA (Table 3). These
levels are respectively around one-third and one
half of the levels estimated for the area outside the
EU/EFTA. Combining these simple estimates in-
dicates that of the 732·1 million adults in the WHO
European Region 13·3 million (1·8%) have HBsAg
and 15·0 million (2·0%) have HCV RNA; with
two-thirds of those living with each infection outside
the EU/EFTA area (Table 4).
Simple estimates of total number of infected PWID
The selected and imputed estimates of prevalence in
PWID were used to derive simple estimates of the num-
ber of current PWID living with HBV and HCV infec-
tion outside the EU/EFTA. Considering the wide range
in the estimated prevalences of injecting drug use
(0·077–3·6%) and in the prevalences of the two infec-
tions in PWID (see above) the imputed data should
be viewed with great caution. These estimates indicate
that of the estimated 3·2 million current PWID outside
the EU/EFTA 0·7 million (21%) have HBsAg and
1·5 milion (47%) have HCV RNA (Table 5).
Comparable estimates for current PWID living in
EU/EFTA countries were derived from published
data [27] by applying the same method (Table 5,
Fig. 1). These estimates for EU/EFTA should be
viewed cautiously, as due to the substantial variability
in the prevalences (injecting drug use: 0·06–1·2%,
median 0·28%, mean 0·31%; HBsAg: 0·3–10%,
median 3·5%, mean 3·7%; anti-HCV: 12–88%, median
59%, mean 58%) the imputed data used here are likely
to be subject to much uncertainty. The estimation pro-
cess indicates that of the estimated 1·2 million current
PWID in the EU/EFTA area 45000 (3·7%) have
HBsAg and 0·5 million (43%) have HCV RNA
(Table 5). The proportion with anti-HCV is compar-
able with the level outside of the EU/EFTA; however,
the proportion with HBsAg is much lower (Table 4).
Combining these estimates indicates that in current
PWID (estimated 4·5 million) across the WHO
European Region 0·7 million (15%) have HBsAg
and 2·0 million (44%) have HCV RNA (Table 5).
DISCUSSION
Our simple estimates suggest that almost 1/50 adults
in the WHO European Region have HBV infection
and a similar proportion chronic HCV. Outside of
the EU/EFTA area prevalence was around three
times higher for HBsAg and over twice as high for
Table 4. Estimates of number of current hepatitis B and C infections in the WHO European Region: EU/EFTA
and non-EU/EFTA comparisons
Adult population (%) Current HBV (%) Current HCV (%)
EU/EFTA* 427 615 000 (58) 4487 000 (34) 5 467 000 (36)
Non EU/EFTA†304 522 000 (42) 8821 000 (66) 9 536 000 (64)
WHO European Region 732 137 000 (100) 13 308 000 (100) 15 003000 (100)
EU/EFTA, European Union and European Free Trade Association area.
* Twenty-seven EU Member States: Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Denmark, Estonia, Finland,
France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, The Netherlands, Poland,
Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, United Kingdom.
Four EEA/EFTA countries: Norway, Iceland, Liechtenstein, Switzerland.
†Albania, Armenia, Azerbaijan, Belarus, Bosnia & Herzegovina, Croatia, Georgia, Israel, Kazakhstan, Kyrgyzstan,
Montenegro, Republic of Moldova, Russian Federation, Serbia (incl. Kosovo), Tajikistan, The former Yugoslav Republic
of Macedonia, Turkey, Turkmenistan, Ukraine.
280 V. D. Hope and others
Table 5. Simple estimates of the number of people who inject drugs with hepatitis B surface antigen (HBsAg) and hepatitis C virus (HCV) in
WHO European Region
Country
Population aged
515 yr in 2008
Estimated number of current PWID* Prevalence
Estimated numbers with infection
(rounded to nearest 100)
Number Prevalence
Imputed from
median prevalence HBsAg Anti-HCV HBsAg Anti-HCV
Chronic
HCV
Those outside EU/EFTA
Albania 2 389 000 10 000 15% 13% 1500 1300 900
Armenia 2 431 000 2000 0·08%
Azerbaijan 6 549 000 300 000 4·58% 5·9% 54% 17700 162 700 120 400
Belarus 8 228 000 6308 0·08% 13% 39% 800 2500 1800
Bosnia and Herzegovina 3 170 000 5500 0·17% 2·7% 38% 100 2100 1500
Croatia 3 760 000 16 740 0·45% 0·8% 46% 100 7700 5700
Georgia 3575 000 127 833 3·58% 2·9% 67% 3700 85 600 63 400
Israel 5077 000 21 000 4·3% 62% 900 13 000 9600
Kazakhstan 11 796 000 100000 0·85% 7·9% 60% 7900 60000 44 400
Kyrgyzstan 3 790 000 25 000 0·66% 54% 13 600 10 000
Montenegro 498 000 2000 38% 800 600
Republic of Moldova 3016 000 3810 0·13% 6·8% 43% 300 1600 1200
Russian Federation 120 185 000 1 825 000 1·52% 31% 73% 565 800 1 332 300 985 900
Serbia 8068 000 18 000 0·22% 15% 52% 2600 9400 6900
Tajikistan 4 239 000 17 000 0·40% 33% 5500 4100
FYR Macedonia 1 674 000 2691 0·16%
Turkey 53 958 000 226 000 2·9% 5·3% 6600 12 000 8900
Turkmenistan 3 531 000 14 000
Ukraine 39 554 000 375 000 0·95% 12% 71% 44 000 266 300 197 000
Uzbekistan 19 034 000 80 000 0·42% 36% 28 800 21 300
Median prevalence of injecting drug use 0·4%
Countries without HBsAg estimated
using median prevalence
142 691 6·8% 9700
Countries without anti-HCV
estimated using median prevalence
18 691 46% 8600 6400
Total (rounded to nearest 1000) 662 000 2 014 000 1 490 000
Those in UE/EFTA
Austria
2
7 087 000 17 500 0·25% 53% 9300 6900
Belgium
4
8 790 000 25 800 0·29% 3·7% 74% 1000 19 100 14 100
Bulgaria
5
6 606 000 20 250 0·31% 5·5% 58% 1100 11 700 8700
Cyprus
1
707 000 446 0·06% 3·5% 36% 20 200 100
Czech Republic
1
8 875 000 31 200 0·35% 12% 3700 2700
Denmark
1
4 476 000 12 754 0·28% 53% 6700 5000
Estonia
4
1 140 000 13 801 1·21% 90% 12 400 9200
Finland
3
4 403 000 15 650 0·36% 42% 6600 4900
Hepatitis B and C in the European Region 281
Table 5 (cont.)
Country
Population aged
515 yr in 2008
Estimated number of current PWID* Prevalence
Estimated numbers with infection
(rounded to nearest 100)
Number Prevalence
Imputed from
median prevalence HBsAg Anti-HCV HBsAg Anti-HCV
Chronic
HCV
France
3
50 870 000 122 000 0·24% 45% 54900 40 600
Germany
5
70 748 000 94 250 0·13% 2·0% 75% 1900 70 700 52 300
Greece
2
9 578 000 8148 0·09% 2·5% 50% 200 4100 3000
Hungary
1
8 511 000 3941 0·05% 0·5% 23% 20 900 700
Iceland 249 000 600
Ireland
5
3 506 000 6289 0·18% 0·4% 72% 30 4500 3400
Italy
1
51 260 000 326 000 0·64% 59% 193 000 142 800
Latvia
5
1 943 000 5500 74% 4100 3000
Lithuania
4
2 823 000 5123 0·18% 5·9% 73% 300 3700 2800
Luxembourg
1
395 000 1482 0·38% 3·9% 81% 100 1200 900
Malta
1
342 000 900 33% 300 200
Netherlands
4
13 553 000 3115 0·02% 3·0% 77% 100 2400 1800
Norway
1
3 862 000 10 032 0·26% 1·2% 74% 100 7400 5500
Poland
4
32 389 000 88 000 4·6% 59% 4000 51 900 38 400
Portugal
2
9 076 000 16 425 0·18% 5·0% 46% 800 7600 5600
Romania
5
18 157 000 49 000 10% 64% 5000 31400 23 200
Slovakia
5
4 536 000 18 841 0·42% 50% 9400 7000
Slovenia
1
1 733 000 7310 0·42% 3·4% 22% 200 1600 1200
Spain
3
37 814 000 83 972 0·22% 73% 61 600 45 500
Sweden
5
7 641 000 29 513 0·39% 88% 26 000 19 300
Switzerland
1
6 335 000 31 653 0·50% 78% 24 700 18 300
United Kingdom
4
50 210 000 142 650 0·28% 46% 65600 48 600
Median prevalence of injecting drug use 0·3%
Countries without HBsAg estimated
using median prevalence
852 534 3·5% 29 800
Countries without anti-HCV estimated
using median prevalence
600 59% 400 300
Total (rounded to nearest 1000) 45 000 697 000 516 000
Total Europe (rounded to nearest 1000) 706 000 2 711 000 2 006 000
FYR, The Former Yugoslav Republic of Macedonia; Anti-HCV, antibodies to the hepatitis C virus; EU/EFTA, European Union and European Free Trade Association area;
EU/EFTA HBsAg and anti-HCV data from EMCDDA website plus a literature search for Switzerland and Iceland (
1
National study;
2
weighted mean of national studies;
3
multi-city;
4
weighted mean from city/sub-region studies;
5
one city/region.)
* Mathers et al.[26], plus data for Bosnia & Herzegovina, Croatia, Czech Republic, Cyprus, Estonia, Greece, Luxembourg, Macedonia, Portugal, Sweden, and United
Kingdom from EMCDDA website; and data for Serbia from the Republic of Serbia UNGASS Country Progress Report on AIDS 2010.
282 V. D. Hope and others
HCV RNA. Prevalence of these infections was highest
in PWID (15% and 44%, respectively). Although the
estimates here need to be viewed with caution, they
do suggest a sizable burden due to these two viral
infections in the Region, particularly outside the
EU/EFTA area.
First, it is important to consider the limitations
of this study. The prevalence data on HBsAg and
anti-HCV were obtained from literature searches,
while grey literature was included, it is possible
studies will still have been missed particularly if
they have recently been undertaken, reported in
languages other than Russian or English, or un-
published. Second, measures of the prevalence of
HBsAg and anti-HCV were not identified in all
populations or in all countries. In many countries
no national studies had been undertaken, thus local
and regional data were assumed to be reflective of
the whole country. Small studies (n< 100) and those
where population was not specifically or clearly
defined were excluded; however, we did not asses
the methodological quality of the studies, in part
because data available was often limited. The studies
used a range of designs and thus the robustness of the
resulting data is likely to be variable. Where no
measure of prevalence was found, simple imputation
approaches were applied. Considering these limit-
ations it is important that the findings are viewed
cautiously. Even so, the extensive nature of searches
undertaken in this assessment mean that it is likely
to provide as robust an estimation as is currently
practical at the regional level.
In the WHO European Region outside the EU/
EFTA, the measured HBsAg and anti-HCV preva-
lences were highest in PWID, but infection was also
common in the general population (3·8% and 2·3%,
respectively), MSM (8·7% and 4·2%, respectively),
and in sex workers (3·3% and 11%, respectively).
There was substantial variation between countries,
while prevalence of these infections in PWID was
high in most countries; Uzbekistan had a prevalence
of 13% for both infections in the general population.
The general population HCV prevalence estimate
was also elevated in the Ukraine and Georgia, and
in Albania the general population HBsAg prevalence
estimate was elevated. While these differences might
be related to the methodologies used in the studies,
they warrant further investigation.
For the general population, PWID and MSM
prevalences were higher than in the EU/EFTA area
[7], although comparable data for EU/EFTA was
very limited for MSM. The ECDC review [7] found
only two studies from the EU/EFTA countries that
had measured HBsAg in MSM [4% Sweden
1993–1997, and <1% UK (Scotland) 1993–2003] and
one study that had measured anti-HCV [1·3%
Amsterdam (The Netherlands) 2003], indicating a
need for further studies of prevalence for MSM and
other transmission risk populations. For sex workers
data on the prevalence of these infections has not
been reviewed for the EU/EFTA area, but considering
the elevated prevalence found here this is needed.
In the countries outside the EU/EFTA, MSM have
a higher prevalence of both HBsAg and anti-
HCV than the general population, and sex workers
had higher anti-HCV prevalence. The high anti-
HCV prevalence in MSM and sex workers possibly
reflects an overlap with the PWID population
[8]. The higher prevalences of both infections in
MSM is a concern considering the evolving epidemic
of HIV in this group in parts of central and eastern
Europe [28].
The ratios between the general population estimates
and the blood-donor estimates were higher for the
EU/EFTA area compared to outside (almost three
times higher for HBsAg and about five times higher
for anti-HCV). The reasons for this difference are
unclear, but it could for example, be due to more
success in excluding those who have been at risk of
infection from blood donation in the EU/EFTA
countries, or be a reflection of the higher prevalence
of these infections in the general population outside
the EU/EFTA area. This difference needs further
investigation.
The estimates of the numbers infected simply
applied prevalence to population data; with the preva-
lences derived from studies using a range of method-
ologies and imputed for countries with no data
(the majority lacked a general population HBsAg
estimate). There is some corroboration for the esti-
mates obtained from comparison with published
national estimates for HCV. In Italy a modelling
approach estimated 2·1 million people chronically
infected with HCV in 2000 and 1·9 million in 2005
[29] compared to the 2·0 million estimated here. In
the UK, modelling approaches suggest that around
200 000 people are living with chronic HCV infec-
tion [30,31], while the simple UK estimate here
(n= 260 100) is higher it is within the confidence range.
For the PWID estimates there is some corrobor-
ation from the UK, where 66 000 current PWID
were estimated as HCV-infected in England and
Hepatitis B and C in the European Region 283
Wales [30] compared to the simple UK estimate here
of 48 600 –though the study had estimated a larger
injecting population than the one used here. The esti-
mates of the number of infected PWID obtained here
will be particularly uncertain, as estimates of infection
prevalence are being simply applied to estimates of the
number of current PWID. Both of these are difficult to
measure due to the illicit and marginalized nature of
injecting drug use, and are thus are likely to be subject
to much uncertainty. The estimated number of PWID
should thus be used very cautiously. In the UK almost
as many former PWID were estimated to have HCV
as current PWID [30]. The estimates obtained here
relate to number of infected current PWID, but
there will also be many former PWID that will have
been infected. It is thus likely that many of the infec-
tions in the region not in current PWID will be in for-
mer PWID.
A previous estimate had suggested that 14 million
people were living with chronic HBV [32] in the
WHO European Region, although the method used
for this estimate is not given, it provides some cor-
roboration for the 13·3 million estimated here. In the
1990s, it was estimated from national prevalence data,
that there were 8·9 million people living with HCV [4]
in the WHO European Region (prevalence 1·0%), our
estimate suggest that HCV infection might have
increased over time to 15 million (prevalence 2·0%). If
so, this might reflect transmission in PWID, particu-
larly in the east of the Region, where there has been a
recent and accelerating epidemic of HIV in PWID [33].
Viral hepatitis has been recognized as a global pub-
lic health problem and a World Health Assembly
Resolution [34] has called on Member States to take
action to strengthen preventive and control measures.
Our findings indicate a large pool of individuals
infected with HBV and HCV in the WHO European
Region, and so the potential for further transmission.
The WHO’s recent Framework for Global Action to
prevent and control viral hepatitis [1] describes the
work needed. Interventions to prevent transmission
[2,9,35], including information on safer sex, condom
distribution, needle and syringe programmes, and
strict infection control practices in healthcare and
other settings, need to be maintained and expanded
as appropriate. HBV can be prevented through vacci-
nation, national policies should be reviewed regularly,
and in those countries with universal vaccination
programmes targeted vaccination of high-risk groups
should be considered, as recommended by WHO
[36]. Both HBV and HCV can, to varying degrees,
be successfully treated. Easy access to diagnostic test-
ing is an important entry point for accessing both
prevention and treatment programmes, and in higher
prevalence countries targeted screening programmes
should be considered for those at greatest risk. Other
measures can also reduce the transmission of viral
hepatitis, such as, ensuring a safe blood supply.
This study provides useful data for policy makers
on the scale of HBV and HCV infection in the region.
Policy makers need consider the extent of these dis-
eases when planning health services in order to ensure
that appropriate interventions [35–37] are provided on
a sufficient scale to reduce the burden arising from
these two preventable infections.
These findings indicate that there may be over
13 million adults living with HBV and 15 million
with HCV in the WHO European Region –indicating
a large burden for treatment and care. The prevalence
of these infections appears to be higher outside the
EU/EFTA, with these countries (mainly in eastern
Europe and central Asia) accounting for 66% of
those with HBsAg and 64% of those with HCV
RNA, yet only 42% of the European Region’s adult
population (Table 4). Efforts to prevent, diagnose
and treat these infections need to be maintained and
improved. Surveillance of the seroprevalence of these
infections and related risk behaviours in the affected
populations is needed to monitor trends and allow
assessment of the impact of interventions.
SUPPLEMENTARY MATERIAL
For supplementary material accompanying this paper
visit http://dx.doi.org/10.1017/S0950268813000940.
ACKNOWLEDGEMENTS
This work was funded by the World Health Organ-
ization Regional Office for Europe. The authors thank
Dr Lucy Platt for her assistance with the literature
in Russian.
DECLARATION OF INTEREST
None.
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