Call to Action for a Europe free of hepatitis C
We, the signatories of this Call to Action, launched at the 3rd European Union HCV Virtual Policy Summit (Securing Wider EU Commitment to the Elimination of HCV) on 24 March 2021, call on policymakers to commit to the elimination of hepatitis C throughout Europe. We, in turn, commit to reviewing progress on achieving the goals set out in this Call to Action on a regular basis and promoting it to key stakeholders at all relevant opportunities.
Despite the progress that has been made since the publication of the first European Union (EU) HCV Elimination Manifesto (Our vision for a Hepatitis C-free Europe) in 2016,  hepatitis C remains a major public health challenge in Europe:
In 2016, the World Health Organization (WHO) estimated that more than seven million lives would be saved worldwide by 2030 if hepatitis elimination targets were reached. 
A key step in addressing the problem is improving diagnosis rates. However, according to recent European Centre for Disease Prevention and Control (ECDC) data, three out of four people with hepatitis C infection across the European Union and European Economic Area (EU/EEA) and the United Kingdom have not been diagnosed – far below the 2020 target of the WHO European Action Plan of diagnosing 50% of people with chronic hepatitis C. 
- In the WHO European region (which consists of 53 countries), 33 countries now have viral hepatitis action plans; and a further 17 countries are developing plans. 
- Hepatitis C has a substantial morbidity and premature death burden, particularly in marginalised groups:
- In the European Union (EU) more people die each year from hepatitis C than from AIDS. 
- In the WHO European Region, an estimated 14 million people are infected with hepatitis C  and the European Centre for Disease Control estimates that there are 3.9 million chronic hepatitis C cases in European Union member states. 
- New infections are still occurring, with an estimated hepatitis C incidence of 8.7 per 100,000 in the Member States of the EU. 
- People who inject drugs are particularly vulnerable to hepatitis C  and unsafe injecting drug use is one of the main drivers of the epidemic. 
- Hepatitis C is often asymptomatic and, left untreated, chronic hepatitis is a major cause of liver cirrhosis and liver cancer. 
Europe’s Beating Cancer Plan commits the European Commission to helping ‘ensure access to ... treatments to prevent liver … cancers associated with the hepatitis C virus’. 
In the current context of strained healthcare systems and shifting priorities, particularly as a result of the COVID-19 pandemic, it is essential to ensure that the importance of eliminating hepatitis C is not forgotten.
Initial data confirm that the pandemic has had a considerable impact on testing for infectious diseases including hepatitis C in the WHO European Region.  For example, in a survey of 34 countries in the region it was found that almost all reported a reduction in testing during the first months of the COVID-19 pandemic (March to May 2020), with more than 65% reporting severe disruptions in hepatitis C testing.
For chronic infections such as viral hepatitis, delayed diagnosis and treatment may result in further long-term consequences for individual patients and even a stalling of progress achieved to date in controlling these infections in the WHO European Region.  It is vital that testing, linkage to care, and treatment must continue, and quickly be scaled up. In fact, the current pandemic should underline the need for widespread and effective public health responses, and synergies such as viral hepatitis testing linked to COVID-19 vaccination should be explored.
In the midst of the health system challenges resulting from the COVID-19 pandemic, renewed political action is needed to address the growing hepatitis C public health threat and re-focus on achieving the WHO viral hepatitis elimination targets.
We share the vision that eliminating hepatitis C in Europe by 2030 will require policymakers to:
- Ensure that data on the impact of the COVID-19 pandemic on efforts to eliminate hepatitis C is collected and analysed and that the findings are published in an official report.
Relevant agencies such as the ECDC, EMCDDA and the WHO Regional Office for Europe should collaborate on regularly collecting assessing and publishing data from all Member States. The official report should include recommendations and a roadmap for getting elimination efforts back on track.
- Make hepatitis C elimination in Europe an explicit and adequately resourced public health priority.
Hepatitis C elimination should be pursued using appropriate means at all levels – through collaboration between individual citizens, civil society organisations, healthcare professionals, medical associations, researchers, the private sector, local and national governments, European Union institutions – including the European Commission, ECDC, EMCDDA and the WHO Regional Office for Europe. The new EU public health programme, EU4Health, must ensure that hepatitis C elimination is advanced through the adequate funding of projects which promote prevention, diagnosis and linkage to care in all countries.
- Ensure every country has a published national viral hepatitis elimination action plan or strategy, and that key stakeholders are involved in developing and implementing these plans.
Where national viral hepatitis elimination plans/strategies do not exist, developing and publishing a plan should be prioritised. Every country should ensure that patients, civil society groups and other relevant stakeholders – including at-risk groups – are directly involved in developing and implementing such plans. Surveillance and tracking of HCV cases and mortality, as well as agreed markers to monitor implementation, should be in place. Existing best practice examples and guidelines should serve as the basis for people-centred, health system-based strategies that emphasise tailored implementation at the local level.
- Ensure integrated care pathways are included in national plans/strategies.
Make the development of integrated care pathways a core component of viral hepatitis elimination plans/strategies, taking into account the specific health system barriers and other challenges related to the management of viral hepatitis infection, such as community-based care, for example, harm reduction services, which may not be linked to the national health system. Implementation of integrated care pathways should embed monitoring of their effectiveness over time.
- Support efforts to reduce the impact of hepatitis C on rates of liver disease and liver cancer through access to testing, treatment, screening and improved follow up.
In line with Europe’s Beating Cancer Plan,  support efforts to improve access to hepatitis C treatments to prevent liver cancer attributed to hepatitis C. Promote long-term follow up/screening programmes for hepatitis C patients to reduce the risk of liver disease and liver cancer.
- Remove barriers to people who inject drugs (PWID) accessing care, including decriminalisation.
Political resistance to harm reduction services is a major barrier to appropriate access to hepatitis C prevention services for PWID, as are laws and policies which criminalise drug use, drug possession, and drug users.  In line with community statements and the European Association for the Study of the Liver’s (EASL) policy statement,  we therefore call for the decriminalisation of minor, non-violent drug offences and call for political support for harm reduction services in all European countries.
- Address stigma and discrimination, and protect the human rights, particularly of marginalised communities at risk for hepatitis C.
All hepatitis C elimination-related strategies must be consistent with fundamental human rights principles including non-discrimination, equality, participation, and the right to health. Stigma about hepatitis affects people accessing testing or treatment, and can cause fear of disclosure, all of which hinder elimination efforts. Even once hepatitis C is cured, stigma and discrimination can persist and have real consequences for the individuals affected. The links between hepatitis C and social marginalisation are well established, and particular care and attention should be focused on addressing stigma and discrimination in these populations.
- Pursue micro-elimination strategies to maximise impact on reducing incidence of hepatitis C.
Micro-elimination strategies pragmatically target hepatitis C prevention and treatment to achieve the WHO targets in specific at-risk sub-populations (e.g., people living with HIV, people who inject drugs, people with haemophilia, people with liver disease), settings (e.g. hospitals, prisons, addiction centres), generational cohorts or geographic areas (e.g. a city or region).  This approach maximises the impact of limited resources and allows for countries to work towards the elimination of hepatitis C in a phased manner.
- Support the introduction of standardised continuum of care (CoC) monitoring in every European country.
Strengthen efforts to harmonise and improve the surveillance of hepatitis C across the European Union to inform and evaluate hepatitis C elimination strategies, by asking every country to publish a continuum of care starting with prevalence estimates, and continuing through numbers diagnosed, linked to care, had treatment initiated, and achieved sustained virologic response.
- In developing this Call to Action, the following documents were taken into consideration:
- Hatzakis A, Lazarus J, Cholongitas E et al. Securing sustainable funding for viral hepatitis elimination plans. Liver Int 2020 Feb; 40(2): 260-270.
- Safreed-Harmon K, Blach S, Aleman S et al. The consensus hepatitis C cascade of care: standardized reporting to monitor progress toward elimination. Clin Infect Dis 2019; 69(12): 2218–2227. Available at: https://academic.oup.com/cid/article-abstract/69/12/2218/5540024
- Pedrana A, Howell J, Scott N et al. Global hepatitis C elimination: an investment framework. Lancet Gastroenterol Hepatol 2020; 5(10): 927-939. Available at: https://www.sciencedirect.com/science/article/abs/pii/S2468125320300108
- Cox AL, El-Sayed MH, Kao JH et al. Progress towards elimination goals for viral hepatitis. Nat Rev Gastroenterol Hepatol 2020; 17: 533–542. Available at: Progress towards elimination goals for viral hepatitis | Nature Reviews Gastroenterology & Hepatology
- Laury J, Hiebert L, Ward JW. Impact of COVID-19 Response on Hepatitis Prevention Care and Treatment: Results From Global Survey of Providers and Program Managers. Clin Liver Dis 2021; 17(1): 41-46. Available at: Impact of COVID-19 Response on Hepatitis Prevention Care and Treatment: Results From Global Survey of Providers and Program Managers. - Abstract - Europe PMC
- Wingrove C, Ferrier L, James C, Wang S. COMMENT: The impact of COVID-19 on hepatitis elimination. Lancet 2020; 5(9): 792-794. Available at: https://doi.org/10.1016/S2468-1253(20)30238-7
- Papatheodoridis GV, Hatzakis A, Cholongitas E et al. Hepatitis C: The beginning of the end—key elements for successful European and national strategies to eliminate HCV in Europe. J Viral Hepat 2018; 25: 6–17.
- World Health Organization (2016). Make the elimination of viral hepatitis our next greatest achievement. (Last accessed 28 Jan 2021)
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- World Health Organization, Regional Office for Europe. Data presented at European Liver Patients’ Association stakeholder meeting 2 December 2020.
- European Commission (2019). Timely testing saves lives: Statement by Commissioner Andriukaitis on the World Hepatitis Day. (Last accessed 28 Jan 2021)
- World Health Organization, Regional Office for Europe (2021). Hepatitis. (Last accessed 28 Jan 2021)
- European Centre for Disease Control. Monitoring the responses to hepatitis B and C epidemics in the EU/EEA Member States, 2019. Technical report. 2020. Available at: Monitoring the responses to hepatitis B and C epidemics in the EU/EEA Member States, 2019 (europa.eu) (Last accessed 17 Feb 2021)
- World Health Organization, Regional Office for Europe (2021). Hepatitis: data and statistics. (Last accessed 28 Jan 2021)
- European Monitoring Centre for Drugs and Drug Addiction. TECHNICAL REPORT Monitoring the elimination of viral hepatitis as a public health threat among people who inject drugs in Europe. 2019. Available at: Technical report_The elimination barometer for viral hepatitis among PWID in Europe_0.pdf (europa.eu) (Last accessed 17 Feb 2021)
- European Commission (2021). 2021 01 25 Communication - Europe’s Beating Cancer Plan v.24 - CLEAN EVENING (europa.eu). (Last accessed 03 Feb 2021)
- Simões D, Stengaard AR, Combs L, Raben D on behalf of The EuroTEST COVID-19 impact assessment consortium of partners. Impact of the COVID-19 pandemic on testing services for HIV, viral hepatitis and sexually transmitted infections in the WHO European Region, March to August 2020. Euro Surveill 2020; 25(47): pii=2001943. Available at: https://doi.org/10.2807/1560-7917.ES.2020.25.47.2001943
- European Association for the Study of the Liver (2020). EASL policy statement on drug use and the global hepatitis C elimination goal - EASL-The Home of Hepatology. (Last accessed 03 Feb 2021)
- Lazarus JV, Wiktor S, Colombo M, Thursz M, on behalf of the EASL International Liver Foundation. J Hepatol 2017; 67: 665–666. Available at: Micro-elimination – A path to global elimination of hepatitis C - Journal of Hepatology (journal-of-hepatology.eu)