Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries : 2020 data.
Date: 2022-11-08
Institutions: European Centre for Disease Prevention and Control
Subjects: European Centre for Disease Prevention and Control, data collection, disease prevention, epidemiology, infectious disease, public health, research report

TECHNICAL REPORT

Monitoring of responses to 
the hepatitis B and C 
epidemics in EU/EEA 
countries – 2020 data 

www.ecdc.europa.eu

ECDC TECHNICAL REPORT 

Monitoring of responses to the hepatitis B 
and C epidemics in EU/EEA countries – 
2020 data 

 
 
This report was produced by Katherine Sharrock (National AIDS Trust), Erika Duffell (European Centre for Disease 
Prevention and Control) and Katherine Turpie (National AIDS Trust). 

Acknowledgements 
The authors would like to thank the following individuals for their invaluable input in providing data and in 
reviewing the document. 

Austria: Ziad El-Khatib, Irene Kászoni-Rückerl, Sigrid Kiermayr, Anna Nagel; Maria Paulke-Korinek, Elise Schabus, 
Irrene Schmuttere, Margit Winterleitner 

Belgium: Benoit Kabamba, Sofieke Klamer, Els Plettinckx, Vanessa Suin, Dominique van Beckhoven, Thomas 
Vanwolleghem 

Bulgaria: Mariya Tyufekchieva, Tonka Varleva 

Croatia: Maja Ilic, Tatjana Nemeth-Blažić, Adriana Vince 

Cyprus: Fani Theophanous 

Czechia: Jitka Cástková, Vratislav,Nemecek 

Denmark: Peer Brehm Christensen, Susan Cowan, Martine Grosos Aabye, Anne Øvrehus 

Estonia: Jevgenia Epštein, Kristi Rüütel 

Finland: Henrikki Brummer, Kirsi Liitsola, Henna Rautiainen, Päivi Viitanen 

France: Cécile Brouard, Mathias Bruyand, Florcence Lot, Joisane Pillonel 

Germany: Sandra Dudavera, Gyde Steffen, Ruth Zimmermann 

Greece: Stergios Georgoulas, Georgia Nikolopoulou, George Papatheodoridis, Ioanna Samiou, Panagiota Touloumi, 
Sois Zoutsos 

Hungary: Agnes Danielisz, Maria Dudas, Emese Kozma, Zsuzsanna Molnár 

Iceland: Guðrún Aspelund, Már Kristjánsson 

Ireland: Jeff Connell, Suzanne Cotter, Cillian De Gascun, Joanne Moran, Aiden McCormick, Niamh Murphy, Aisling 
O'Leary, Mary O'Riordan 

Italy: Loreta Kondili, Francesco Maraglino, Barbara Suligoi, Maria Elena Tosti, Sabrina Valle 

Latvia: Inga Ažiņa, Raina Nikiforova, Serges Nikisins 

Liechtenstein: Silvia Dehler, Esther Walser-Domjan 

Lithuania: Brigita Kairiene 

Luxembourg: Carole Devaux 

Malta: Jackie Melillo, Tanya Melill 

The Netherlands: Silke David, Jaap Maas, Annemarie Meiberg, Eline Op de Coul, Marleen van Dijk, Irene 
Veldhuijzen 

Norway: Hilde Kløvstad 

Poland: Robert Flisiak, Małgorzata Stępień, Karolina Zakrzewska 

Portugal: Joana Bettencourt, Rui Tato Marinho, Sofia Ribeiro 

Romania: Odette Popovici, Corina Silvia Pop 

Slovakia: Mária Avdicová 

Slovenia: Marta Grgič-Vitek, Jože Hren, Irena Klavs, Janja Križman Miklavčič, Eva Leban, Mojca Matičič, Mario 
Poljak, Urška Rahne Potokar 

Spain: Agustín Albillos, Maria Buti, Javier Crespo, Julia del Amo, Asunción Diaz, José Luis Calleja, Javier García-
Samaniego, Victoria Hernando, Oriana Ramírez-Rubio, Pablo Ryan 

Sweden: Soo Aleman, Maria Axelsson, Hanna Edberg, Josefine Lundberg Ederth, Martin Kåberg 

ECDC: Emilia Lindquist, Teymur Noori 

European Monitoring Centre for Drugs and Drug Addiction: Thomas Seyler 

WHO Regional Office for Europe: Giorgi Kuchukhidze, Antons Mozalevskis 

ii 

TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Suggested citation: European Centre for Disease Prevention and Control. Monitoring of responses to the hepatitis B 
and C epidemics in EU/EEA countries – 2020 data. Stockholm: ECDC; 2022. 

Stockholm, June 2022 

ISBN 978-92-9498-574-3 
doi: 10.2900/245108 
Catalogue number TQ-09-22-253-EN-N 

© European Centre for Disease Prevention and Control, 2022 

Reproduction is authorised, provided the source is acknowledged. 

iii 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Contents 
Abbreviations ............................................................................................................................................... vi 
1. Background ............................................................................................................................................... 2 
Context .................................................................................................................................................... 2 
Aims and objectives .................................................................................................................................. 2 
2. Methods .................................................................................................................................................... 4 
Data collection from EU/EEA countries ........................................................................................................ 4 
3. Results ...................................................................................................................................................... 5 
Policy on testing and treatment for hepatitis B and C ................................................................................... 5 
Hepatitis response plan or strategy ........................................................................................................ 5 
Policy related to HBV and HCV testing .................................................................................................... 5 
Policy related to HBV and HCV treatment .............................................................................................. 10 
The continuum of care for hepatitis B ....................................................................................................... 11 
Background on the HBV continuum of care ........................................................................................... 11 
Data availability for hepatitis B ............................................................................................................. 12 
Estimated number of people living with chronic HBV infection ................................................................. 13 
Diagnosed patients with chronic HBV infection who were linked to care and on treatment ......................... 16 
Viral suppression among patients on treatment for chronic HBV .............................................................. 17 
The continuum of care for hepatitis C ....................................................................................................... 18 
Background on the HCV continuum of care ........................................................................................... 18 
Data availability for hepatitis C ............................................................................................................. 18 
Estimated number of people living with chronic HCV infection ................................................................. 19 
Diagnosed patients with chronic HCV infection who were treated ............................................................ 25 
Sustained virologic response among those treated ................................................................................. 27 
Hepatitis C monitoring in key populations .................................................................................................. 27 
The impact of the COVID-19 pandemic on hepatitis B and C services, March 2020 to September 2021 ........... 29 
4. Discussion and conclusions ....................................................................................................................... 34 
Policy on testing and treatment ................................................................................................................ 34 
The hepatitis B and C continuum of care ................................................................................................... 34 
Challenges with the HBV indicators ........................................................................................................... 35 
Challenges with the HCV indicators........................................................................................................... 36 
The impact of the COVID-19 pandemic on hepatitis services ....................................................................... 37 
Limitations ............................................................................................................................................. 38 
Conclusions ............................................................................................................................................ 38 
Priority areas for action ........................................................................................................................... 39 
References .................................................................................................................................................. 40 

Figures 

Figure 1. Existence of a national plan or strategy that covers the response to viral hepatitis and funding to 
implement the plan/strategy, 2021 ................................................................................................................ 11 
Figure 2. Existence of general national testing guidance for HBV and HCV, 2021 ................................................. 6 
Figure 3. Existence of an HBV testing policy or programme for key populations, 2021 .......................................... 6 
Figure 4. Existence of an HCV testing policy or programme for key populations, 2021 .......................................... 7 
Figure 5. Coverage of HBV/HCV testing costs by the individual, 2021 .................................................................. 7 
Figure 6. Additional HBV and HCV testing-related policy questions, 2021 ............................................................ 9 
Figure 7. Existence of restrictions on access to HBV/HCV treatment, 2021 ........................................................ 10 
Figure 8. Coverage of HBV/HCV treatment costs, 2021 .................................................................................... 11 
Figure 9. Number of EU/EEA countries reporting data for the hepatitis B continuum of care indicators, 2021 
monitoring questionnaire .............................................................................................................................. 12 
Figure 10. Number of EU/EEA countries reporting data for hepatitis B continuum of care indicators, 2018 compared 
with 2021 .................................................................................................................................................... 13 
Figure 11. Estimated number of people living with chronic HBV infection (diagnosed and undiagnosed) per 100 000 
population in the EU/EEA, 2020 ..................................................................................................................... 13 
Figure 12. WHO indicator: Proportion of people living with chronic HBV infection ever diagnosed by the end of 
2020 ........................................................................................................................................................... 14 
Figure 13. Number of people ever diagnosed and living with chronic HBV infection per 100 000 population in the 
EU/EEA, 2020 .............................................................................................................................................. 15 
Figure 14. Number of people diagnosed with chronic HBV infection per 100 000 population in the EU/EEA, 2020 . 15 

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TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Figure 15. Proportion of people ever diagnosed with chronic HBV infection and linked to care (of those ever 
diagnosed by the end of 2020), 2020 ............................................................................................................ 16 
Figure 16. Proportion of patients on antiviral treatment for chronic HBV infection achieving viral suppression, with 
documented treatment outcome, 2020 .......................................................................................................... 17 
Figure 17. Number of EU/EEA countries reporting data for the hepatitis C continuum of care indicators, 2021 
monitoring questionnaire .............................................................................................................................. 18 
Figure 18 Number of EU/EEA countries reporting data for the hepatitis C continuum of care indicators, 2018 
compared with 2021 .................................................................................................................................... 19 
Figure 19. Estimated number of people living with chronic HCV infection (RNA positive) per 100 000 population, 
2020 ........................................................................................................................................................... 21 
Figure 20. Estimated number of people ever infected with HCV (anti-HCV positive), diagnosed and undiagnosed, 
per 100 000 population by the end of 2020 .................................................................................................... 21 
Figure 21. Proportion of people living with chronic HCV infection ever diagnosed by the end of 2020 .................. 22 
Figure 22. Number of people ever diagnosed and living with chronic HCV infection by the end of 2020, per 100 000 
population ................................................................................................................................................... 23 
Figure 23. Number of people diagnosed with chronic HCV infection during 2020, per 100 000 population ............ 23 
Figure 24 Estimated number of people with chronic HCV infection who remained undiagnosed by the end of 2020 
a, per 100 000 population ............................................................................................................................. 24 
Figure 25. Proportion of patients ever diagnosed and living with chronic HCV infection who received treatment 
during 2020 ................................................................................................................................................. 25 
Figure 26. Number of people with chronic HCV infection who were ever treated with antivirals per 100 000 
population, 2020 .......................................................................................................................................... 26 
Figure 27. Proportion of people ever diagnosed with chronic HCV infection who were ever treated, by the end of 
2020a .......................................................................................................................................................... 26 
Figure 28. Proportion of people receiving antiviral treatment for chronic HCV infection with documentation of 
treatment outcome who achieved sustained virologic response during 2020 ...................................................... 27 
Figure 29. Data availability for the hepatitis C continuum of care for people who inject drugs, including data at 
national, regional, city and clinic levels, 2021 ................................................................................................. 28 
Figure 30. Data availability for the hepatitis C continuum of care for people in prison, including data at national, 
regional, city and prison levels, 2021 ............................................................................................................. 29 
Figure 31. Hepatitis B and C services affected by COVID-19, starting March 2020. ............................................. 30 
Figure 32. Interventions introduced in response to the COVID-19 pandemic, 2020-2021 .................................... 31 
Figure 33. Reassignment of human resources away from hepatitis work and towards COVID-19 work, 2020-2021 31 
Figure 34. Number of people tested for hepatitis B (HBsAg) in 2017 and 2020 .................................................. 32 
Figure 35. Number of people tested for hepatitis C in 2017 and 2020 ............................................................... 33 

Tables 
Table 1. Types of HBV/HCV treatment restrictions, by country, 2020 ................................................................ 10 
Table 2. Proportion of people with chronic HBV infection who had decompensated cirrhosis or hepatocellular 
carcinoma at the time of diagnosis ................................................................................................................ 16 
Table 3. Proportion of people with chronic HCV infection who had decompensated cirrhosis or hepatocellular 
carcinoma at the time of diagnosis, 2020 ....................................................................................................... 24 

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Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Abbreviations 

CLD  

CVH  

Chronic liver disease 

Chronic viral hepatitis 

COVID-19 

Coronavirus disease 2019 

EAP  

EASL 

EEA  

EU  

GHSS  

HBV  

HBsAg  

HCC  

HCV  

HDV 

HIV  

MSM  

NFP 

European Action Plan 

European Association for the Study of the Liver 

European Economic Area 

European Union 

Global Health Sector Strategy 

Hepatitis B virus 

Hepatitis B surface antigen 

Hepatocellular carcinoma 

Hepatitis C virus 

Hepatitis D virus 

Human immunodeficiency virus 

Men who have sex with men 

National Focal Point 

SARS-CoV-2 

Severe acute respiratory syndrome coronavirus 2 

SDGs  

UN  

WHO  

Sustainable Development Goals 

United Nations 

World Health Organization 

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TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Executive summary 

Beginning in 2016, the European Centre for Disease Prevention and Control (ECDC) developed a monitoring system for 
hepatitis B and C in the EU/EEA that is aligned with the indicators and targets of the Global Health Sector Strategy 
(GHSS) and the WHO European Region Action Plan. The primary aims of the system are to support EU/EEA countries in 
monitoring their responses to the epidemics of hepatitis B and C in a standardised, high-quality manner and to analyse 
these data and disseminate reports that can guide the European Commission, WHO and other European agencies and 
organisations to support countries in achieving their goal of hepatitis elimination. An additional aim of the system is to 
minimise reporting burden by using existing data from other sources where possible.  

The first data collection effort for this monitoring system occurred in 2017 and 2018. The second round of data 
collection took place in 2021, with the aim of collecting standardised, high-quality data that reflected the hepatitis B 
and C epidemics in 2020 (or the most recent year with available data), aligned with the WHO European Region Action 
Plan targets for 2020. Six of the 26 European Union/European Economic Area (EU/EEA) countries responding to the 
2021 monitoring survey reported no action plan or strategy for viral hepatitis prevention and control. Of the 19 
countries which reported a national plan/strategy, only 11 reported that there was national funding for implementation. 
Twenty-two countries reported that there was testing guidance for hepatitis B and/or C. However, many countries’ 
guidance did not include one or more of the key populations at risk for hepatitis infections. Three countries reported 
that not all test costs were reimbursed, nine reported that testing was available in community-based drug service 
settings and 18 countries reported the existence of policies that require that hepatitis tests be performed by healthcare 
workers, indicating another policy area that could be revised to allow for improved accessibility of testing. Fourteen of 
26 countries reported there were no restrictions on access to treatment for chronic HBV and HCV infection. Of the 
countries with restrictions on access to treatment, nine identified restrictions for undocumented migrants and three 
identified restrictions for people who use drugs. Two countries reported that costs for treatment was primarily ‘out of 
pocket’. 

Overall, 20 countries provided data for at least one of the four key stages of the hepatitis B continuum of care and 23 
countries provided data for at least one of the four key stages for the hepatitis C continuum of care. The number of 
countries which were able to report data related to the continuum of care for both hepatitis B and C has fallen since 
2018 and significant gaps in data completeness and robustness remain. Data was collected on WHO-defined indicators 
as well as newly proposed continuum of care indicators. 

The estimated number of people living with chronic HBV infection by country varied 18-fold from 183 to 3 312 per 100 
000 population. However, these estimates were derived from a range of methods of varying quality and were often 
based on studies from before 2016. The estimated number of people living with current chronic HCV infection by 
country ranged 100-fold from 24 to 2 411 per 100 000 population. These estimates were also sourced from a range of 
methods and most estimates were from 2018 or earlier. 

For hepatitis B, it was not possible to assess progress towards the 2020 WHO European Region Action Plan targets for 
most of the targets due to lack of data. For the 2020 diagnosis target, four of eight countries reporting relevant data 
had met the 50% target and in terms of viral suppression two countries had met the target of 90% of those on 
treatment being virally suppressed.  

For hepatitis C, data availability along the continuum of care was generally greater compared to hepatitis B but it is still 
difficult to assess region-wide progress. Four of seven countries reporting relevant data achieved the 50% diagnosed 
target. The best progress was seen in the HCV sustained virologic response (SVR) target, with ten of the eleven 
countries reporting data exceeding the 90% target for those achieving SVR of those treated with antiviral medications. 

The COVID-19 pandemic had wide-reaching impacts on hepatitis services in the EU/EEA region. It has negatively 
impacted some hepatitis B and C prevention and testing services. Most countries reported negative impacts of the 
pandemic on clinic visits for routine care, testing for HBV and HCV, and/or the provision of community-based services. 
Additionally, 46% of countries reported that there was reduced laboratory capacity for hepatitis B/C testing. However, 
some routine hepatitis B prevention services, such as routine antenatal screening, were not largely affected by the 
pandemic. Six countries reported that routine infant/childhood hepatitis B vaccination was negatively affected. 

The COVID-19 pandemic did not appear to have a large impact on hepatitis B and C treatment and governmental 
funding for hepatitis programmes. The pandemic prompted some countries to implement new and innovative 
strategies, such as virtual appointments and alternative modes of medication delivery.  

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Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

1. Background 

Context 
Chronic infection with hepatitis B virus (HBV) and hepatitis C virus (HCV) is a major cause of chronic liver disease, 
cirrhosis and hepatocellular carcinoma. It was estimated in 2017 that 4.7 million people were living with chronic HBV 
infection and 3.9 million people were living with chronic HCV infection in the European Union (EU) and European 
Economic Area (EEA) [1]. In the EU/EEA, deaths attributed to HBV and HCV are estimated to account for around 55% 
of liver cancer deaths and 45% of all deaths due to cirrhosis and other chronic liver disease [2]. While incidence of HBV 
and HCV infections has declined across Europe due to effective HBV vaccination programmes and a range of other 
prevention strategies, modelling has suggested that associated morbidity and mortality could increase if responses are 
not scaled up [3,4]. Hepatitis B and C are epidemiologically complex diseases that affect a wide variety of key 
populations, have varying modes of transmission, are largely asymptomatic and have low awareness among healthcare 
providers and patient populations [5]. Given these characteristics, reducing hepatitis infections and associated 
morbidity and mortality requires a strong multi-disciplinary approach, informed by robust data collected from 
comprehensive and sustainable monitoring systems. 

The United Nations member states adopted the Sustainable Development Goals (SDGs) for 2030 in 2015, including 
goal 3, to promote health and wellbeing, and target 3.3: ‘End the epidemics of AIDS, tuberculosis, malaria and 
neglected tropical diseases and combat hepatitis, waterborne and other communicable diseases’ [6]. The adoption of 
the SDGs put the control of viral hepatitis on the global public health agenda. The EU/EEA is committed to 
implementing the 2030 Agenda for Sustainable Development and the SDGs, as well as monitoring progress towards 
these goals in EU/EEA countries. 

The World Health Assembly endorsed the first Global Health Sector Strategy (GHSS) for viral hepatitis in 2016, with the 
goal of eliminating viral hepatitis as a major threat to public health by 2030 in alignment with the SDGs [7]. The 
concept of elimination for these infections is based on the global targets set by the World Health Organization (WHO) 
for reducing the incidence of chronic infections by 90% and the attributable mortality by 65% by 2030. The first action 
plan for the health sector response to viral hepatitis in the WHO European Region, published in 2017, adapts the GHSS 
for the context of the countries of the WHO European Region, taking epidemiological, political and social factors into 
account [8]. The European Action Plan specifies service and impact targets for the WHO European Region, some of 
which are more ambitious than the global targets, in recognition of the existing prevention and control efforts in the 
Region and the capacity of existing systems to have further impact on progress against the epidemics. 

Beginning in 2016, the European Centre for Disease Prevention and Control (ECDC) developed a monitoring system for 
hepatitis B and C in the EU/EEA that is aligned with the indicators and targets of the GHSS and the WHO European 
Region Action Plan. The primary aims of the system are to support EU/EEA countries in monitoring their responses to 
the epidemics of hepatitis B and C in a standardised, high-quality manner and to analyse these data and disseminate 
reports that can guide the European Commission, WHO and other European agencies and organisations to support 
countries in achieving their goal of hepatitis elimination. An additional aim of the system is to minimise reporting 
burden by using existing data from other sources where possible. 

The first data collection effort for this monitoring system occurred in 2017 and 2018, and led to multiple outputs, 
including the technical report Monitoring the responses to hepatitis B and C epidemics in EU/EEA Member States, 2019 
[9].  

Aims and objectives 
The second round of data collection using the EU/EEA hepatitis B and C monitoring system took place in 2021, with the 
aim of collecting standardised, high-quality data that reflected the hepatitis B and C epidemics in 2020 (or the most recent 
year with available data), aligned with the WHO European Region Action Plan targets for 2020 (see Box 1). 

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TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Box 1. Action plan targets for hepatitis elimination in the WHO European Region, 2020 

Diagnosis 
• 

50% of all persons with chronic hepatitis B virus (HBV), hepatitis C virus (HCV) and hepatitis D virus 
(HDV) are diagnosed 
75% of the estimated number of patients at a late stage of viral hepatitis-related liver disease (cirrhosis 
or hepatocellular carcinoma (HCC)) are diagnosed 

Linkage to care and treatment 
• 

Treatment for chronic HBV, HCV and HDV infection, in line with international standards, is available and 
affordable for all 
90% of diagnosed patients with chronic HBV, HCV and HDV infections are linked to care and adequately 
monitored 
75% of the diagnosed patients with chronic HBV and HDV infection, who are eligible for treatment, 
begin treatment  
75% of the diagnosed eligible patients with chronic HCV infection receive effective treatment 

• 

• 

• 

• 

Viral suppression and cure (sustained viral response) 
• 

75% of the diagnosed patients with chronic HBV and HDV infection, who are eligible for treatment, 
begin treatment and, among those on long-term treatment for HBV, 90% obtain viral suppression 
75% of the diagnosed eligible patients with chronic HCV infection receive effective treatment and at 
least 90% of them are cured 

• 

Source: WHO Regional Office for Europe [8] 

The objectives of this report are to: 

•  Describe and interpret the data collected in 2021 on the hepatitis B and C continua of care (number of chronic 

infections, number of individuals diagnosed, number of individuals receiving treatment and treatment outcomes), 
policy related to testing and treatment, and the impact of the COVID-19 pandemic on hepatitis services; 

•  Describe progress in the EU/EEA towards the WHO European Region 2020 interim Action Plan targets for hepatitis 

elimination; and 

•  Discuss the reporting capacity of EU/EEA countries and methodological issues with the data, and identify priority 

areas for future action for monitoring and services for the elimination of hepatitis B and C in the EU/EEA. 

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TECHNICAL REPORT 

2. Methods 

Data collection from EU/EEA countries 
Beginning in 2017, indicators and potential existing sources of data were mapped and gaps in available data were 
identified. The monitoring questionnaire, with standardised indicators, was developed by ECDC in consultation with an 
expert advisory group to address gaps in data. The online questionnaire was built and administered by ECDC, and was 
distributed to in-country hepatitis experts, called National Focal Points (NFPs).  

The questionnaire was revised for the 2021 data collection following consultation with the expert advisory group. The 
questionnaire sections on hepatitis policy and prevention, and the continua of care, were expanded. Sections were 
added for the key populations people who inject drugs and people in prison, as well as for the impact of the COVID-19 
pandemic on hepatitis services. The 2021 tool was built using Snap Survey Software, pilot tested by three countries 
revised, and then distributed to all NFPs online. NFPs were asked to provide national data for 2020, when possible. 
However, data from before 2020 or from subnational geographic regions were accepted when national data for 2020 
were not available. Data collection took place from May to September 2021 and data were validated in October 2021. 
Subsequent notifications of corrections were used to update the reported data. 

There were some additional changes to the data collection process in 2021. Data for the number of individuals with 
chronic HBV and HCV infections, diagnosed, tested and treated, as well as treatment outcomes, were pre-populated 
into the online questionnaire before it was distributed, where possible (i.e. when the 2017 indicator definition matched 
the 2020 indicator definition). Countries were asked to update the 2017 figures if newer data were available. However, 
this was not possible for the newly defined indicators that were included in the second data collection round but not 
the first. Additionally, while the United Kingdom (UK) was included in the first round of data collection, it was not 
included in the 2021 data collection, as the UK left the EU on 31 January 2020. 

In the 2021 questionnaire, there was a focus on updating and refining some indicators along the hepatitis B and C 
continua of care. While data were still collected in line with the WHO continuum of care indicator definitions, additional 
data were collected for the updated indicators following close consultation with the expert advisory group. The WHO 
indicators and the updated indicators are identified throughout the results section. The updated indicators were 
collected with the intention of providing more context on the progress that has been made along the patient pathway 
and to address the limitations of the WHO indicators, as identified by the ECDC team and the expert advisory group. 
The main analyses conducted on the monitoring data were a summary of the data at national and EU/EEA levels, an 
assessment of the progress towards the European Region Action Plan targets and a summary of the updated indicators 
developed to supplement the WHO monitoring framework. 

The analyses in this report focused on national policy related to hepatitis testing and treatment, national data on the continua 
of care and national data on the impact of the COVID-19 pandemic on hepatitis services in the EU/EEA. Monitoring data on 
other topics, primarily hepatitis B and C prevention, were also collected in the 2021 monitoring questionnaire and newer data 
from other sources were also collated for 2021. These data are not presented in this report. 

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Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

3. Results 

Of the 30 countries in the EU/EEA, 26 countries responded to the monitoring questionnaire in 2021. Three countries 
(Hungary, Luxembourg and Slovakia) were in contact with the monitoring team but were not able to submit data. 
Liechtenstein did not submit data, as the country’s data are reported to Switzerland.  

Policy on testing and treatment for hepatitis B and C 

Hepatitis response plan or strategy 

Countries were asked whether a national plan or strategy existed that covered the response to viral hepatitis. Of the 26 
responding countries, 19 (73.1%) reported that there was a plan or strategy and 11 reported that there were funds 
allocated from the national budget to implement the plan or strategy (Figure 1). 

Figure 1. Existence of a national plan or strategy that covers the response to viral hepatitis and funding 
to implement the plan/strategy, in the EU/EEA, 2021 

In Slovenia, hepatitis prevention and control is integrated in different national strategies and guidelines for experts. 

Policy related to HBV and HCV testing  

Countries were asked whether they have testing guidance covering HBV and HCV. Of the 26 responding countries, 21 
reported that they had testing guidance covering HBV and 22 reported that they had testing guidance covering HCV 
(Figure 2). Three countries reported that they did not have any guidance. 

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TECHNICAL REPORT 

Figure 2. Existence of general* national testing guidance for HBV and HCV, in the EU/EEA, 2021 

* Several countries reported specific testing guidance for key risk groups. 

Countries were asked whether they have a policy or programme for HBV testing for a list of key populations (Figure 3). 
Of the 26 responding countries, 25 reported that they had a policy or programme for HBV testing for pregnant women, 
making this the most frequently reported group. Migrants and men who have sex with men were the least frequently 
reported groups, with 13 countries each. Under the category of ‘Other’, countries reported that there were policies or 
programmes for HBV testing for: patients with haematological malignancies, autoimmune diseases, liver disease, renal 
disease and tuberculosis; who were on chronic dialysis or immunocompromised; or who were sex workers, applying for 
refugee status or aged older than 40 years. 

Figure 3. Existence of an HBV testing policy or programme for key populations, 2021 

30

25

20

15

10

5

0

s
e
i
r
t
n
u
o
c

f
o
r
e
b
m
u
N

6 

Healthcare
workers

Migrants Men who
have sex
with men

People in
prison

People
living with
HIV

Pregnant
women

People who
inject drugs

Other

Yes

No

 
 
 
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Countries were also asked whether they have a policy or programme for HCV testing for a list of key populations 
(Figure 4). Of the 26 responding countries, 21 reported that they had policies or programmes for HCV testing for 
people who inject drugs and people living with HIV (PLHIV), making these the most frequently reported groups. 
Healthcare workers were the least frequently reported group, with eight countries. Under the category of ‘Other’, 
countries reported that there were policies or programmes for HCV testing for: patients undergoing in-vitro fertilisation, 
with liver disease, with renal disease or on chronic dialysis, as well as those who were immunosuppressed, applying for 
refugee status, aged older than 40 years or born between 1945 and 1980. 

Figure 4. Existence of an HCV testing policy or programme for key populations, 2021 

30

25

20

15

10

5

0

s
e
i
r
t
n
u
o
c

f
o
r
e
b
m
u
N

Healthcare
workers

Migrants

Men who
have sex
with men

People in
prison

People living
with HIV

Pregnant
women

People who
inject drugs

Other

Yes

No

Countries were asked how costs of HBV and HCV testing were covered for the individual. Fourteen countries reported that 
testing is free at the point of use, with other cost-covering mechanisms reported less frequently (Figure 5). 

Figure 5. Coverage of HBV/HCV testing costs by the individual, 2021 

16

14

12

10

8

6

4

2

0

s
e
i
r
t
n
u
o
c

f
o
r
e
b
m
u
N

Free at point of use Mixed payment

structure

User fee reimbursed
by health system or
insurance

User fee not
reimbursed

Other

Respondents were able to choose more than one option. 

7 

 
 
 
 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

8 

 
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Additional testing-related policy questions were asked, including: 

• 
• 
• 
• 

Are peer-to-peer testing services for HBV/HCV implemented in harm reduction and/or community settings? 
Is there a policy that any type of HBV/HCV test has to be performed by a healthcare worker? 
Are rapid tests for HCV available in your country? 
Are self-tests for HCV available in your country? 

The responses to these questions are displayed in Figure 6. Nine countries reported that peer-to-peer testing was 
available in community and harm reduction settings. Eighteen countries reported that there was a policy that tests 
must be performed by a healthcare worker. Rapid HCV tests were reported to be available in 23 countries, while no 
countries reported that HCV self-tests were available. 

Figure 6. Additional HBV and HCV testing-related policy questions, 2021 

16

14

12

10

8

6

4

2

0

25

20

15

10

5

0

s
e
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f
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N

s
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t
n
u
o
c

f
o
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e
b
m
u
N

Peer-to-peer HBV/HCV
tests in community and
harm reduction settings

Tests have to be
performed by a healthcare
worker

Rapid HCV tests available Self-tests for HCV available

No

Don't know

Peer-to-peer HBV/HCV
tests in community and
harm reduction settings

Tests have to be
performed by a healthcare
worker

Rapid HCV tests available Self-tests for HCV available

Yes

No

Don't know

9 

 
 
 
 
 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Policy related to HBV and HCV treatment 

Of 26 responding countries, 14 reported that there were no restrictions on access to HBV/HCV treatment (Figure 7). For the 
11 countries that reported restrictions on access to treatment, the populations with restricted access are listed in Table 1.  

Figure 7. Existence of restrictions on access to HBV/HCV treatment, in the EU/EEA, 2021 

Table 1. Types of HBV/HCV treatment restrictions, by country, 2020 

Type of HBV/HCV treatment restrictions 
Undocumented migrants 
Undocumented migrants (treatment available only if considered urgent medical care) 
Undocumented migrants 
People who inject drugs (current injectors) 
Undocumented migrants 
Other (unspecified) 
Undocumented migrants 
Undocumented migrants 
Undocumented migrants 
People who inject drugs (current injectors) 
People with active alcohol dependence 
Undocumented migrants 
People who inject drugs (current injectors) 
People who inject drugs (former injectors) 
For patients accessing treatment through national health insurance, treatment is restricted to 
those in F1-F4 stages of fibrosis 
Undocumented migrants (restricted to treatment that cannot be postponed for medical reasons) 

Country 
Austria 
Belgium 
Croatia 

Denmark 
Estonia 
Finland 
Greece 
Lithuania 
Poland 

Romania 

Sweden 

10 

 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Countries were asked how the costs of HBV/HCV treatment are covered. Costs were reported to primarily be covered 
by national healthcare systems, with 19 countries reporting this option (Figure 8). 

Figure 8. Coverage of HBV/HCV treatment costs in the EU/EEA, 2021 

20

18

16

14

12

10

8

6

4

2

0

s
e
i
r
t
n
u
o
c

f
o
r
e
b
m
u
N

Costs covered by national
healthcare system

Costs covered by health
insurance

Primarily out-of-pocket
costs

Other

Respondents were able to choose more than one option. 

The continuum of care for hepatitis B 

Background on the HBV continuum of care 

The continuum of care for hepatitis B is a conceptual framework of the sequential stages of services along the patient 
pathway: from number living with chronic infection to diagnosis, linkage to care, treatment and treatment outcome. 
This framework allows for monitoring of the effectiveness of the response to these epidemics in a geographic region or 
population. The continuum provides a snapshot of important stages in achieving viral suppression for those living with 
chronic HBV infection. Achieving a high rate of viral suppression for chronic HBV infection plays a major role in reducing 
the impact of hepatitis B, resulting in reduced morbidity and mortality and a lower incidence of new infections from 
decreased transmission.  

In the HIV field, the continuum (or cascade) of care has been used to identify where gaps in services need to be 
addressed to ensure patients living with HIV receive the care needed to lead to viral suppression. It has served as the 
basis for the global HIV control targets, known as the ‘90-90-90’ targets (90% of people living with HIV diagnosed, 
90% of people diagnosed on treatment, and 90% of people on treatment with viral suppression). These targets were 
introduced by the Joint United Nations Program on HIV/AIDS (UNAIDS) in 2014 [10]. 

In the viral hepatitis field, the GHSS and WHO European Region Action Plan have also created targets that align with 
the major stages of the hepatitis continuum of care. For chronic HBV infection, the WHO European Region Action Plan 
targets for 2020 are listed in Box 2. 

11 

 
 
 
 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Box 2. WHO European Region Action Plan targets for hepatitis B, 2020 

Diagnosis 
• 

50% of all persons with chronic HBV are diagnosed 

Linkage to care and treatment 
• 
• 

90% of diagnosed patients with chronic HBV infections are linked to care and adequately monitored 
75% of diagnosed patients with chronic HBV infection eligible for treatment begin treatment  

Viral suppression 
• 

90% of those on long-term treatment for HBV obtain viral suppression 

Source: WHO Regional Office for Europe [8] 

Data availability for hepatitis B 

The monitoring questionnaire asked countries to report data on the stages of the continuum of care for indicators 
aligned with the WHO European Region Action Plan targets, as well as for supplemental indicators that were refined 
and updated to capture additional relevant information along the continuum (see Methods). 

Of the 30 EU/EEA countries, 26 countries submitted responses to the questionnaire. Overall, 20 countries could provide 
national data for at least one stage of the continuum for hepatitis B (Figure 9). 

Figure 9. Number of EU/EEA countries reporting data for the hepatitis B continuum of care indicators, 
2021 monitoring questionnaire 

30

25

20

15

10

5

0

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Chronic HBV Diagnosed

(ever)

Diagnosed
(in most
recent year
with data)

Diagnosed
(eligible for
treatment)

Treated
(among
those
eligible)

Virally
suppressed

Retained in
care (among
those not
eligible for
antivirals)

Data

No data

Compared with the first reporting round in 2018, fewer countries were able to report data during the second reporting 
round in 2021 (Figure 10). This is especially true for the number of people with chronic HBV infection (18 reporting 
countries decreased to 13) and the number of people diagnosed (17 reporting countries decreased to 10). 

12 

 
 
 
 
 
 
 
 
 
 
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Figure 10. Number of EU/EEA countries reporting data for hepatitis B continuum of care indicators, 2018 
compared with 2021 

r
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2021

2018

2021

2018

2021

2018

2021

2018

Infected with HBV   |              Diagnosed              |             Treated                     |      Virally suppressed

Estimated number of people living with chronic HBV infection 

In total, 13 countries provided data on the estimated number of people living with chronic HBV infection (defined as 
being HBsAg positive), diagnosed and undiagnosed, by the end of 2020 or the most recent year with national data 
available (Annex 1). Estimates ranged from 10 668 people in Denmark (based on a modelling study from 2007) to 640 
176 people in Romania (based on a seroprevalence study from 2015). Estimates of the number of people infected per 
100 000 population varied 18-fold, from 183 to 3 312 per 100 000 population (Figure 11). 

Estimates were based on the results of prevalence surveys, modelling studies and other types of studies, some with 
unpublished data, in the general population. These studies represent a range in quality of data. Estimates also 
represented a wide variety of years, from 2001 to 2018, although most estimates were from before 2016 (see Annex 
1). No country reported subnational data for this indicator.  

Figure 11. Estimated number of people living with chronic HBV infection (diagnosed and undiagnosed) 
per 100 000 population in the EU/EEA, 2020* 

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13 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

** Country did not provide data. 

Diagnosis with chronic HBV infection 

EU/EEA progress towards 2020 targets 

Four of the eight countries that reported data have achieved the 2020 target of having 50% of all people 
with chronic HBV diagnosed. 

Among the eight countries that reported data on both the estimated number of people living with HBV infection and 
the number of people diagnosed, there were an estimated 730 874 people with chronic HBV infection, of whom 
337 023 (46%) were estimated to have been diagnosed. This falls below the target of 50%, but represents an increase 
from the estimated 20.3% diagnosed in the first reporting round in 2018 (however, fewer countries reported data in 
2021 and the countries reporting data differed) [9]. At the national level, the proportion diagnosed ranged from 17.5% 
in France to 66.7% in Denmark, with four of eight countries achieving the 2020 target of 50% of cases diagnosed 
(Figure 12). 

Figure 12. WHO indicator: Proportion of people living with chronic HBV infection ever diagnosed by the 
end of 2020a in the EU/EEA 

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a 2020 or most recent year with available data (see Annex 1). 
* Country did not provide data. 

The data on the number of people diagnosed (the numerator of the proportion) came from a wide range of sources of 
varying quality, including modelling, surveillance/notification data, cohort studies and blood transfusion centre data. 

To provide additional context on diagnosis, the number of people ever diagnosed per 100 000 population and the 
number of people diagnosed in 2020 (or the year with the most recent data) per 100 000 population are presented in 
Figures 13 and 14. The number of people ever diagnosed and living with chronic HBV infection per 100 000 population 
ranged from 35.3 in France to 1258.1 in Latvia. The number of people diagnosed with chronic HBV infection per 100 
000 population in 2020 ranged from 0.3 in Portugal to 11.6 in Romania.  

14 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Figure 13. Number of people ever diagnosed and living with chronic HBV infection per 100 000 
population in the EU/EEA, 2020a 

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* Country did not provide data. 

Figure 14. Number of people diagnosed with chronic HBV infection per 100 000 population in the 
EU/EEA, 2020a 

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* Country did not provide data. 

Three countries reported estimates on the proportion of individuals with chronic HBV infection who had end-stage liver 
disease, including decompensated cirrhosis or hepatocellular carcinoma, at the time of diagnosis. Estimates ranged 
from 1.5-40% of diagnosed cases presenting with end-stage liver disease (Table 2). While eight countries reported 
estimates for this indicator in the 2018 questionnaire, the indicator definition changed to specify decompensated 
cirrhosis rather than cirrhosis in 2021, so fewer countries were able to report with the updated indicator definition.  

15 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Table 2. Proportion of people with chronic HBV infection who had decompensated cirrhosis or 
hepatocellular carcinoma at the time of diagnosis in the EU/EEA 

Country 

Germany 

Poland 

Romania 

Proportion of people with end-
stage liver disease at time of 
diagnosis 
6.2-28% cirrhosis; 1.6-9.9% 
hepatocellular carcinoma 

1.5% 

40% 

Year of data 

2011-2012 

2019 

2019 

Diagnosed patients with chronic HBV infection who were linked to care 
and on treatment 

EU/EEA progress towards 2020 targets 

None of the three countries with data on the proportion of people with end-stage liver disease at the time of 
diagnosis achieved the 2020 target of having at least 90% of diagnosed HBV patients linked to care. 
Romania was the only country that reported national data, allowing for calculation of the proportion of 
diagnosed patients eligible for treatment who are on treatment. In Romania, this proportion was 11%, falling 
short of the 75% target. 

Linkage to care 
Three countries provided national data on the number of people living with chronic HBV infection ever diagnosed and 
the number of people ever diagnosed who were linked to care in 2020 (or the year with most recent data), which is the 
WHO monitoring and evaluation indicator1 [11]. The proportion linked to care ranged from 6.1% in Latvia to 46.3% in 
Denmark (see Figure 15). 

Figure 15. Proportion of people ever diagnosed with chronic HBV infection and linked to care (of those 
ever diagnosed by the end of 2020), 2020a in the EU/EEA 

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a 2020 or most recent year with available data (see Annex 1). 
* Country did not provide data. 
Subnational data reported from the west of Denmark (Regions: north, central and south) were scaled up to the national level.  

1 Indicator A.8: Numerator (Number of HBV/HCV-infected persons who received care in the past 12 months)/Denominator 
(Estimated population of persons with chronic HBV/HCV infection) [11]. 

16 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Proportion of patients retained in care of those who are not eligible for treatment 
with antivirals 
Countries were asked to report the number of patients who were diagnosed with chronic HBV infection and were 
eligible for treatment with antivirals based on clinical guidelines from the European Association of the Study of the Liver 
(EASL). This figure was used to calculate how many diagnosed patients were not eligible for treatment with antivirals in 
order to derive the proportion of those not eligible for treatment who were retained in care (defined as receiving 
specialist or follow-up care) by the end of 2020 or the most recent year with data. This is not a WHO indicator, but is 
intended to monitor progress among those with chronic HBV infection who are not eligible for treatment with antivirals. 
One issue identified during data collection was that there was insufficient data on treatment eligibility for all diagnosed 
cases, so any calculation based on the collected data would not be accurate. Therefore, the proportion of those 
retained in care, diagnosed and not eligible for treatment could not be calculated for any country. 

Proportion of patients on treatment with antivirals of those who have been diagnosed 
and are eligible for treatment 
Three countries reported the number of patients who were diagnosed with chronic HBV infection and were eligible for 
treatment based on EASL criteria. Six countries (Belgium, German, the Netherlands, Poland, Romania and Slovenia) 
reported the number of patients who were ever diagnosed with chronic HBV infection, were eligible for treatment and 
were receiving antiviral treatment at the national level. Two countries reported data on both figures (Romania and 
Slovenia). However, Slovenia determined that the calculation could not be performed with the reported data, as the 
treatment eligibility of all patients who were ever diagnosed was not known. Romania reported that 11% of those 
eligible for treatment were receiving treatment.  

Viral suppression among patients on treatment for chronic HBV 

EU/EEA progress towards 2020 targets 

Three countries reported data on the number of patients with chronic HBV infection who were receiving 
treatment and the number of patients with viral suppression. Two countries (Romania and Slovenia) met and 
exceeded the 90% target of proportion with viral suppression. 

Three countries reported sufficient data for the number of patients receiving antiviral treatment and the number of 
patients with viral suppression in 2020. For this WHO indicator, both Romania and Slovenia reported achieving 100% 
viral suppression, exceeding the 2020 target (Figure 16). 

Figure 16. Proportion of patients on antiviral treatment for chronic HBV infection achieving viral 
suppression, with documented treatment outcome, 2020 in the EU/EEA 

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* Country did not provide data in monitoring survey. 
Subnational data from the west of Denmark (Regions: north, central and south) were scaled up to the national level.  

17 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

The continuum of care for hepatitis C 

Background on the HCV continuum of care 

As with hepatitis B, the continuum of care provides a framework of important stages in achieving sustained virologic 
response for those living with chronic HCV infection. Achieving a high rate of sustained virologic response for chronic 
HCV infection is a critical aspect of reducing the impact of hepatitis C, resulting in reduced morbidity and mortality and 
a lower incidence of new infections. The WHO European Region Action Plan targets for 2020 that align with the major 
stages of the hepatitis C continuum of care are listed in Box 3. 

Box 3. WHO European Region Action Plan targets for hepatitis C, 2020 

Diagnosis 
• 

50% of all persons with chronic HCV are diagnosed 

Linkage to care and treatment 
• 
• 

90% of diagnosed patients with chronic HCV infections are linked to care and adequately monitored 
75% of diagnosed patients with chronic HCV receive effective treatment  

Viral suppression 
• 

90% of those on effective treatment for chronic HCV infection are cured (achieve sustained virologic 
response)  

Source: WHO Regional Office for Europe [8] 

As for hepatitis B, the monitoring questionnaire asked countries to report data on the stages of the continuum of care 
for indicators aligned with the WHO European Region Action Plan targets and for additional indicators that have been 
refined and updated to capture relevant information along the continuum (see Methods). These data on the hepatitis C 
continuum of care are presented to follow. 

Data availability for hepatitis C 

Overall, 23 of the 26 responding countries provided national-level data for at least one stage of the continuum for 
hepatitis C (Figure 17).  

Figure 17. Number of EU/EEA countries reporting data for the hepatitis C continuum of care indicators, 
2021 monitoring questionnaire 

18 

TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

30

25

20

15

10

5

0

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Chronic HCV
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Data

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Cured
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Fewer countries were able to report data in 2021, compared with the first reporting round in 2018 (Figure 18), 
especially for the indicators number of people with chronic HCV infection and number of people diagnosed. However, a 
similar number of countries reported data for the number of patients treated and the number of patients with sustained 
virologic response in 2018 and 2021. 

Figure 18 Number of EU/EEA countries reporting data for the hepatitis C continuum of care indicators, 
2018 compared with 2021 

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2018

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2018

2021

2018

Infected with HCV               |               Diagnosed                     |                Treated                       

|    Sustained Virological Response  

Estimated number of people living with chronic HCV infection 

Seventeen countries provided data on the estimated number of people living with chronic HCV infection (RNA positive), 
diagnosed and undiagnosed, by the end of 2020 or the most recent year with available data (Annex 2). Estimated 
numbers ranged from 88 people in Iceland (based on a surveillance study from 2020) to 410 775 people in Italy (based 
on a modelling study from 2019). Estimates were based on the results of seroprevalence surveys, surveillance and 

19 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

modelling studies in the general population of varying quality. Eight of the estimates reflected data from 2018 and later 
(see Annex 2 for years of data estimates). Figure 19 presents the estimated number of people living with chronic HCV 
infection per 100 000 population. Czechia provided subnational data, which were included in Annex 2, but not in any of 
the figures. 

20 

 
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Figure 19. Estimated number of people living with chronic HCV infection (RNA positive) per 100 000 
population, in the EU/EEA. 2020a 

2 500

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* Country did not provide data. 
Data for Poland refer to the adult population only. 

Thirteen countries provided data on the estimated number of people ever infected with HCV (anti-HCV positive), 
diagnosed and undiagnosed, by the end of 2020 or the most recent year with available data (Annex 2). While the 
number of people living with chronic HCV infection can provide a snapshot of the current burden of disease, reflecting 
recent progress made on reducing active cases via treatment, the number ever infected can give a historical 
perspective of the burden of disease in a country. Estimates of the numbers ever infected ranged from 1 501 in Iceland 
based on surveillance data to 663 981 in Romania based on a nationwide screening programme. Figure 20 presents the 
estimated number of people ever infected with chronic HCV infection per 100 000 population. All but two of these 
estimates are from before 2018 (Annex 2).   

Figure 20. Estimated number of people ever infected with HCV (anti-HCV positive), diagnosed and 
undiagnosed, per 100 000 population, in the EU/EEA, by the end of 2020a 

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21 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Data for Poland refer to the adult population only. 

Diagnosis with chronic HCV infection 

EU/EEA progress towards 2020 targets 

Four of the seven countries reporting data achieved the 2020 target of having 50% of all people living with 
chronic HCV infection diagnosed. 

The proportion of people living with chronic HCV infection who had ever been diagnosed is the WHO indicator for HCV 
diagnosis. Among the seven countries reporting data on both the estimated number of people living with chronic HCV 
infection and the number of people ever diagnosed, there were an estimated 914 037 people with chronic HCV 
infection, of whom 471 006 (52%) were estimated to have been diagnosed. This exceeds the target of 50% and 
represents an increase from the estimated 26.8% diagnosed in the first round of reporting in 2018; however, fewer 
countries reported in 2021 [9]. At the country level, the proportion diagnosed ranged from 13.3% in Greece to 80.6% 
in France, with four of seven countries achieving the 2020 target of 50% of cases diagnosed (Figure 21).  

Figure 21. Proportion of people living with chronic HCV infection ever diagnosed, in the EU/EEA,  by the 
end of 2020a 

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Additional indicators were proposed to monitor country-level progress on diagnosis of chronic HCV infection: the 
number of people diagnosed during 2020 (or the year with most recent data) and the number of people ever 
diagnosed with chronic HCV infection by the end of 2020 (or the year with most recent data), excluding those with 
resolved infection (cured or naturally cleared) and those who had died. Based on the second figure, the number of 
remaining undiagnosed people was calculated. Data on the number of people diagnosed were provided from a variety 
of sources, including surveillance, cohort studies, surveys, modelling studies and expert opinions. The data reported for 
these three indicators are presented in Figures 22 to 24. 

22 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Figure 22. Number of people ever diagnosed and living with chronic HCV infection by the end of 2020a, 
per 100 000 population in the EU/EEA 

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Figure 23. Number of people diagnosed with chronic HCV infection during 2020a, per 100 000 population 
in the EU/EEA 

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p

60

50

40

30

20

10

0

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l

l

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s
d
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N

a 2020 or most recent year with available data (see Annex 2). 
* Country did not provide data. 

*
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b
m
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x
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L

23 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Figure 24. Estimated number of people with chronic HCV infection who remained undiagnosed by the 
end of 2020a, per 100 000 population in the EU/EEA 

1 200

1 000

 800

 600

 400

 200

 0

l

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n
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l

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n
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p
S

*
n
e
d
e
w
S

a 2020 or most recent year with available data (see Annex 2). 
* Country did not provide data. 
Estimates exclude those with resolved infection and those who died. 

Five countries reported estimates of the proportion of individuals with chronic HCV infection who had end-stage liver 
disease, including decompensated cirrhosis or hepatocellular carcinoma, at the time of diagnosis. It was estimated that 
as many as 27.2% of diagnosed cases presented with end-stage liver disease (Table 3). As with hepatitis B, more 
countries reported estimates for this indicator in the 2018 questionnaire. As the indicator definition changed to specify 
decompensated cirrhosis rather than cirrhosis in the 2021 questionnaire, fewer countries were able to report with the 
updated definition. 

Table 3. Proportion of people with chronic HCV infection who had decompensated cirrhosis or 
hepatocellular carcinoma at the time of diagnosis, in the EU/EEA, 2020 

Country 

Denmark 
Germany 

Poland 
Romania 
Spain* 

Proportion of people with 
end-stage liver disease at the time of 
diagnosis 
13% 
2-34% cirrhosis; 1.2% hepatocellular 
carcinoma 
4.5% 
25% 
27.2% 

Year of data 

2016 
2011-2012 

2019 
2019 
2017 

*Data from Spain are regional. 

24 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Diagnosed patients with chronic HCV infection who were treated 

EU/EEA progress towards 2020 targets 

None of the nine countries that reported data on the proportion of diagnosed patients starting on treatment 
in 2020 met the 75% target. 

Linkage to care 
The linkage to care indicator could not be calculated for HCV due to insufficient data collected.  

Proportion receiving treatment with antivirals 
Nine countries reported data on both the number of people diagnosed with chronic HCV infection and the number of 
those diagnosed who received treatment in 2020 (or the most recent year with data), which is the WHO monitoring 
and evaluation indicator2 [11]. There were an estimated 578 587 people with current chronic HCV infection diagnosed, 
of whom 43 928 (0.08%) received treatment in 2020. This estimate falls far below the target of 75%. The proportion 
ranged from 2.3% in Portugal to 16.2% in Romania, with no country meeting the target.  

Figure 25. Proportion of patients ever diagnosed and living with chronic HCV infection who received 
treatment,  in the EU/EEA, during 2020a 

f
o
0
2
0
2
g
n
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)

%

(
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t

100

90

80

70

60

50

40

30

20

10

0

e
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n
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i

a
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2020 target 75%

*
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p
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*
d
n
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n
F

i

l

a 2020 or most recent year with available data (see Annex 2). 
* Country did not provide data. 
Subnational data from the west of Denmark (regions: north, central and south) were scaled up to the national level.  

Data was collected for two additional indicators relating to the monitoring of HCV treatment: number of people with chronic 
HCV infection who were ever treated with antivirals per 100 000 population (Figure 26) and proportion of people ever 
diagnosed with chronic HCV infection that were ever treated (Figure 27). The reported estimates of the number of people 
with chronic HCV infection who were ever treated per 100 000 population showed a 16-fold difference, ranging from 45.8 per 
100 000 population in the Netherlands to 712.7 in Romania. The proportion of people ever diagnosed with chronic HCV 
infection who were ever treated ranged from 18.0% in Portugal to 100% in Croatia.  

2Indicator C.7.b: Numerator (Number of persons already diagnosed with chronic HCV infection (defined as positive for HCV RNA or 
positive for HCV Ag) who initiated treatment during a specified time frame (e.g. 12 months))/Denominator (Number of persons 
already diagnosed with chronic HCV infection (defined as positive for HCV RNA or positive for HCV Ag) for the specified time period 
(12 months)) [11]. 

25 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Figure 26. Number of people with chronic HCV infection who were ever treated with antivirals per 
100 000 population in the EU/EEA, 2020a 

800

700

600

500

400

300

200

100

0

n
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a 2020 or most recent year with available data (see Annex 2). 
* Country did not provide data. 
Subnational data from the west of Denmark (Regions: north, central and south) were scaled up to the national level.  

Figure 27. Proportion of people ever diagnosed with chronic HCV infection who were ever treated, by the 
end of 2020a in the EU/EEA 

V
C
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f
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100

90

80

70

60

50

40

30

20

10

0

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a2020 or most recent year with available data (see Annex 2). 
* Country did not provide data. 
Subnational data from the west of Denmark (Regions: north, central and south) were scaled up to the national level.  

26 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Sustained virologic response among those treated 

EU/EEA progress towards 2020 targets 

Eleven countries reported data on the number of people with chronic HCV who were treated and who 
achieved sustained virologic response in 2020 (or the most recent year with data), of which 10 had met and 
exceeded the target of 90% of those treated being cured. 

Ten of the eleven countries reporting data on the WHO indicator for HCV treatment outcome, the number of patients 
receiving antiviral treatment with documentation of treatment outcome during 2020 (or the most recent year with data) 
and the number of patients who achieved sustained virologic response during that year, exceeded the target of 90% of 
those treated cured (Figure 28). 

Figure 28. Proportion of people receiving antiviral treatment for chronic HCV infection with 
documentation of treatment outcome who achieved sustained virologic response during 2020a in the 
EU/EEA 

n
o
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t
c
e
f
n

i

V
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)

%

(
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n
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g
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a

i

100

90

80

70

60

50

40

30

20

10

0

i

a
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l

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l

2020 target 90%

*
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d
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N

a 2020 or most recent year with available data (see Annex 2). 
* Country did not provide data. 
Subnational data from the west of Denmark (Regions: north, central and south) were scaled up to the national level.  

Hepatitis C monitoring in key populations 
The 2021 monitoring questionnaire contained sections to collect data for the hepatitis C continuum of care for two key 
populations who are disproportionately affected by chronic HCV infection: people who inject drugs and people in 
prison. In the questionnaire, the option was given to report data at the national, regional, city, clinic or prison level. 
Data availability was poor for the continuum of care for both people who inject drugs and people in prison, regardless 
of the geographical level of data reported. See Figure 29 for data availability for people who inject drugs.  

27 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Figure 29. Data availability for the hepatitis C continuum of care for people who inject drugs, including 
data at national, regional, city and clinic levels, in the EU/EEA, 2021 

r
o
t
a
c
i
d
n

i

h
c
a
e
r
o
f
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t
a
d
h
t
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w
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t
n
u
o
c

f
o
r
e
b
m
u
N

30

25

20

15

10

5

0

Current chronic
HCV

Diagnosed
(ever)

Diagnosed (in
most recent
year with data)

Diagnosed
(excluding
resolved
infection and
deaths)

Data

No data

Treated (ever)

Treated (in
most recent
year with data)

With cure
(sustained viral
response)

Figure 30 presents the data availability for the continuum of care for people in prison. While there was slightly better 
data availability compared to for people who inject drugs, there is overall poor data availability for all stages along the 
continuum, even when considering data for subnational geographic coverage. 

28 

 
 
 
 
 
 
 
 
 
 
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Figure 30. Data availability for the hepatitis C continuum of care for people in prison, including data at 
national, regional, city and prison levels, in the EU/EEA, 2021 

30

25

20

15

10

5

0

h
c
a
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f
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w
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n
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c

f
o
r
e
b
m
u
N

r
o
t
a
c
i
d
n

i

Current
chronic HCV

Diagnosed
(ever)

Diagnosed (in
most recent
year with
data)

Diagnosed
(excluding
resolved
infection and
deaths)

Data

No data

Treated
(ever)

Treated (in
most recent
year with
data)

With cure
(sustained
viral
response)

The impact of the COVID-19 pandemic on hepatitis B and C 
services, March 2020 to September 2021 
To gauge the impact of the COVID-19 pandemic on hepatitis services in the EU/EEA, countries were asked several 
questions about different services and types of impact from March 2020 to the time of reporting (responses were 
submitted between July and September 2021).  

Countries were asked whether the pandemic had an impact on the following services: clinic visits for routine care 
related to chronic HBV or HCV, including attendance for treatment; routine infant/childhood hepatitis B vaccinations; 
antenatal screening for HBV infection; testing for HBV and HCV; and services provided by community-based 
organisations like testing and peer counselling. The services most frequently reported to have been affected were 
services provided by community-based organisations, while the services least frequently reported were routine 
infant/childhood vaccinations and antenatal screening for HBV (Figure 31). No country reported that any service 
became more available during this period. 

29 

 
 
 
 
 
 
 
 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Figure 31. Hepatitis B and C services, in the EU/EEA, affected by COVID-19, starting March 2020 

s
e
i
r
t
n
u
o
c

f
o
r
e
b
m
u
N

30

25

20

15

10

5

0

Clinic visits for
routine care for
chronic hepatitis

Routine
infant/childhood
HBV vaccinations

Antenatal
screening for HBV

Testing for HBV

Testing for HCV Services provided

by community-
based
organisations*

Yes - service less available

No - stayed the same

Yes - service more available

Don't know

Countries were asked whether certain interventions had been introduced in response to the COVID-19 pandemic. 
These interventions included (full text of questionnaire response options): 

Increased pill volume of prescriptions (example: >1 month supply) 
Alternative modes of delivery of medications (example: mail or volunteer delivery) 
Scale-up of self-testing/self-sampling kits for HCV 

•  HBV/HCV care appointments conducted via telephone or online 
• 
• 
• 
•  Decentralisation of care with non-specialist service models 
• 

Campaigns for outreach testing for HBV and/or HCV in the community 

Fifteen out of 26 countries reported that HBV/HCV care appointments conducted via telephone or online were 
introduced, making this the most frequently reported intervention introduced in response to the pandemic (Figure 32).  

30 

 
 
 
 
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Figure 32. Interventions introduced in response to the COVID-19 pandemic in the EU/EEA. 2020-2021 

s
e
i
r
t
n
u
o
c

f
o
r
e
b
m
u
N

30

25

20

15

10

5

0

Remote HBV/HCV
care appointments

Increased pill volume
of prescriptions

Alternative modes of
delivery of
medications
(mail/volunteer
delivery)

Scale-up of self-
testing/sampling kits
for HCV

Decentralisation of
care with non-
specialist service
models

Campaigns for
outreach testing in
the community

Yes

No

Don't know

Countries were asked how the pandemic affected human resources, in terms of types of professionals and staff being 
reassigned away from hepatitis work and towards work on COVID-19. Twenty-one countries reported that government 
public health staff and hepatitis public health specialists were reassigned to work on COVID-19 (Figure 33). Non-
governmental and civil society sector staff were least frequently reported to have been reassigned away from hepatitis 
work. 

Figure 33. Reassignment of human resources away from hepatitis work and towards COVID-19 work in 
the EU/EEA. 2020-2021 

s
e
i
r
t
n
u
o
c

f
o
r
e
b
m
u
N

30

25

20

15

10

5

0

Hepatitis clinicians/care
providers

Government public health
staff

Non-governmental and civil
society sector staff

Public health specialists
usually working on hepatitis

Yes -impact on core services

Yes - not impact on core services

No

Don’t know

31 

 
 
 
 
 
 
 
 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Countries were asked whether there were issues with procurement, stock or supply of hepatitis treatments due to 
COVID-19, resulting in reduced patient access to treatment. For hepatitis B treatment, one country (4%) reported that 
there were issues, 17 countries (65%) reported no issues and eight countries (31%) reported that they didn’t know. 
For hepatitis C treatment, two countries reported issues (8%), 17 countries (64%) reported no issues and seven 
countries (27%) reported that they didn’t know. 

Countries were asked whether laboratory capacity for hepatitis testing had been affected by COVID-19. For both 
hepatitis B and C, 12 countries (46%) reported that laboratory capacity had stayed the same, 10 countries (38%) 
reported reduced capacity for hepatitis testing, four countries (15%) reported that they didn’t know and no countries 
reported increased testing capacity. 

Countries were also asked whether governmental funding for hepatitis B and C services had been affected by the 
COVID-19 pandemic. Twenty-one countries (81%) reported no impact on funding, one country (4%) reported reduced 
governmental funding, four countries (15%) didn’t know and no countries reported increased funding. 

Data on the number of people tested for hepatitis B and C in each country were compared for the first round of data 
collection (2017 data) with the most recent round of data collection (2020 data) to see if there was any evidence that 
there was a change in number of individuals tested. Only two countries (Portugal and Romania) reported the number 
of people tested in 2017 and provided updated data for the number of people tested in 2020, allowing for this 
comparison. For hepatitis B testing, the number of individuals tested in Portugal remained very similar from 2017 to 
2020 and declined somewhat in Romania in 2020 (Figure 34). For hepatitis C testing, the number of people tested in 
Portugal appeared to increase slightly in 2020 and to remain fairly stable in Romania (Figure 35). The COVID-19 
pandemic did not appear to have had a strong impact on the number of people tested in these two countries. 

Figure 34. Number of people tested for hepatitis B (HBsAg) in the EU/EEA, in 2017 and 2020  

559 229

519 301

438 300

439 234

Portugal

Romania

2017

2020

7
1
0
2
n

i

B
s
i
t
i
t
a
p
e
h
r
o
f
d
e
t
s
e
t
e
p
o
e
p
f
o
r
e
b
m
u
N

l

0
2
0
2
d
n
a

600 000

500 000

400 000

300 000

200 000

100 000

 0

32 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Figure 35. Number of people tested for hepatitis C (anti-HCV) in the EU/EEA, in 2017 and 2020  

d
n
a
8
1
0
2
n

i

C
s
i
t
i
t
a
p
e
h
r
o
f
d
e
t
s
e
t
e
p
o
e
p
f
o
r
e
b
m
u
N

l

600 000

500 000

400 000

0
2
0
2

300 000

200 000

100 000

 0

523 043

518 675

337 040

351 413

Portugal

Romania

2017

2020

33 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

4. Discussion and conclusions 

This report presents findings related to the hepatitis B and C continuum of care, policy on testing and treatment, and 
the impact of the COVID-19 pandemic on hepatitis services in the EU/EEA from the second data collection conducted in 
2021. Data on these topics were collected directly from National Focal Points (NFPs) in 26 of the 30 countries in the 
EU/EEA. Data on the continuum of care were requested for 2020 or the most recent year with data; data on policy and 
the impact of COVID-19 reflect NFPs’ views in 2021, during the period of data collection (July–September 2021). The 
monitoring questionnaire aimed to capture data that would inform progress towards the 2020 WHO European Region 
Action Plan service targets for the elimination of viral hepatitis. Policy and COVID-19 impact data are presented to 
provide information on the context and healthcare system environment in which hepatitis services were delivered. 

Policy on testing and treatment 
Having a national plan or strategy for the response to the hepatitis B and C epidemics is a crucial component of 
effectively prioritising the delivery of hepatitis services and making progress towards the goal of elimination. The 
successful development and implementation of such a plan requires funding and subsequent monitoring and 
evaluation. Nineteen of 26 reporting EU/EEA countries responded that there was a national plan or strategy for 
hepatitis response, but only 11 countries responded that the plan or strategy was funded from the national budget.  

An effective policy framework for hepatitis B and C testing can play a key role in encouraging testing in a variety of 
settings and among key populations, reducing barriers to diagnosis. With 21 countries reporting having national testing 
guidance for HBV and 22 countries for HCV, there is fairly wide coverage of testing guidance among the 26 reporting 
countries. The identified gaps that need to be addressed in HBV and HCV testing policies and programmes were for 
healthcare workers, migrants, men who have sex with men and people in prison. Testing policies and programmes for 
other key populations had fewer gaps, with 21 or more countries reporting policies and programmes for people living 
with HIV and pregnant women for HBV and for people living with HIV and people who inject drugs for HCV.  

Regarding the costs of hepatitis B and C testing for the individual, most countries reported that testing was free (either 
‘free at point of use’ or ‘user fee reimbursed by health system or insurance’), with three countries reporting ‘user fee 
not reimbursed’. Only nine countries responded that tests were available in community and harm reduction settings 
from peer testers. There is evidence that testing coverage and positivity rates are high in community drug service 
settings, including both fixed settings and outreach settings [5], and that peer-supported and peer-led services can 
improve testing accessibility [12,13,14]. This indicates that it would be beneficial to address gaps in peer testing in 
countries where this testing strategy is not available. Similarly, 18 countries reported the existence of policies that 
require that hepatitis tests be performed by healthcare workers, highlighting another policy area that could be revised 
to allow for improved accessibility of testing. While almost all countries reported that rapid HCV tests were available, no 
country reported that self-tests for HCV had become available. New guidelines from WHO in 2021 strongly recommend 
HCV self-testing as an effective tool to accelerate progress towards diagnosis targets, as self-tests have been found to 
have high acceptability and usability [15]. 

Regarding policy on hepatitis B and C treatment, treatment restrictions for certain populations were reported in 10 
countries, with undocumented migrants being the population identified most frequently as being subject to these 
restrictions. Only three countries reported treatment restrictions for people who inject drugs, which reflects progress 
(as a paper from 2018 reported such restrictions in seven countries [16]). In relation to the costs of hepatitis B and C 
treatment, in all 26 reporting countries there was an option for costs to be covered either by a national healthcare 
system or health insurance. However, three countries also reported that treatment was primarily covered by out-of-
pocket costs for HBV or HCV treatment, with these costs presenting a likely barrier to treatment in these areas.  

The hepatitis B and C continua of care 
While the monitoring system aims to provide a comprehensive overview of the hepatitis B and C epidemics to guide the 
European Commission and other European agencies in their support of EU/EEA countries in achieving the goal of 
elimination, the availability of monitoring data on the continuum of care for hepatitis B and C in the general population 
and for hepatitis C in people who inject drugs and people in prison was very poor. Given the number of countries 
unable to report data on the stages of the continuum of care – including estimates of the numbers of people infected, 
diagnosed and treated, as well as treatment outcomes – it is not possible to obtain a comprehensive EU/EEA-wide 
assessment of progress towards the elimination targets. Data availability for the hepatitis C continuum of care was 
better than for the hepatitis B continuum of care overall, which is in line with data availability from the first round of 

34 

TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

data collection in 2018 [9]. However, for both hepatitis B and C, data availability in 2021 was poorer than in 2018 for 
indicators related to the numbers of people infected and diagnosed. A major factor that likely contributed to the change 
in reporting ability was the COVID-19 pandemic, which had dramatic and wide-ranging impacts on countries’ healthcare 
systems, data collection capabilities and human resources. As was reported by NFPs in the monitoring questionnaire, 
21 countries saw public health specialists that usually work on hepatitis reassigned to COVID-19 work (16 affecting 
core services and five not affecting core services) and 21 countries saw governmental public health staff reassigned (15 
affecting core services and six not affecting core services). Another factor that may have contributed to the decrease in 
the number of countries reporting certain indicators could be the revision of some of the indicator definitions.   

Regarding the 50% diagnosis target for HBV for 2020, eight countries reported data and four countries met the target, 
with countries reporting a proportion diagnosed ranging from 17.5% to 66.7%. The other targets for HBV, for linkage 
to care, treatment and viral suppression, have very limited data that does not allow for a regional estimate of progress. 

For the HCV diagnosis target of 50% for 2020, seven countries reported data and four met the target (range: 13.3%-
80.6%). For the HCV treatment target, nine countries reported data on the proportion of cases ever diagnosed and 
receiving treatment in 2020 (range: 2.3% to 16.2%), with no country achieving the 2020 target. However, there were 
significant issues with the interpretation of this indicator, as discussed in the next section. The best progress towards 
reaching the elimination targets along the HCV continuum of care can be seen for the sustained virological response 
target among those initiating treatment. Ten of the eleven reporting countries exceeded the 90% target for sustained 
virological response among those treated, which aligns with evidence that the direct acting antivirals (DAAs) that are 
now in wide use have a high efficacy [17].  

Aside from large gaps in data availability, there were several important methodological issues with the data that made 
it difficult to aggregate and compare for an assessment of progress at the EU/EEA level. Estimates of the number of 
people living with chronic HBV infection were available from 13 of the 26 reporting countries, but the quality of the 
estimates and methods for obtaining estimates (including surveys, modelling, the workbook method, surveillance and 
grey literature) were wide ranging and many of the estimates were out of date (with some dating back to 2001). 
Addressing the need for robust, up-to-date and comparable estimates for the number of people with chronic HBV 
infection is essential to understanding the scope of the epidemic in the region and to serve as the foundation for the 
rest of the stages of the continuum of care. Data on numbers ever diagnosed also came from a wide range of sources 
and methodologies, making comparison challenging. But these data were much more up to date with most of the data 
points updated for 2020. The large gaps in data for indicators on linkage to care, treatment and viral suppression 
reflect a lack of impetus and urgency to monitor the hepatitis B epidemic compared with the renewed push to monitor 
the hepatitis C epidemic in response to the introduction of highly effective DAA treatments for chronic HCV infection.  

For the indicator ‘number of people living with chronic HCV infection’, data reporting in 2021 showed that existing 
estimates are often from older studies (most estimates were from 2001 to 2016). Newer, more reliable estimates are 
needed for accurate monitoring, as the increasing number of people being treated with DAAs and being subsequently 
cured in many countries will have had a large impact on the number of people currently living with chronic HCV 
infection. In addition, estimates should be adjusted for cases resolving naturally, deaths and migrating in or out of a 
country, as is also true for HBV estimates. The data collection efforts described here show that reliable data or 
estimates of current numbers infected are simply lacking. Addressing this gap in information is a high priority going 
forward to improve hepatitis monitoring and to inform response efforts. 

Challenges with the HBV indicators 
The major factor that creates difficulty with measuring and interpreting continuum of care indicators for hepatitis B is 
that many cases of chronic HBV infection are not clinically eligible for treatment with antiviral medications. It is 
estimated that 12 to 25% of chronic HBV cases are eligible for treatment in accordance with different guidelines [18]. 
This characteristic disrupts the continuity of the continuum from step to step and does not allow for assessment of 
progress towards targets in the many cases where treatment eligibility data are not available. This characteristic of 
hepatitis epidemiology mainly affects the indicators for linkage to care and proportion treated of those diagnosed.  

The WHO indicator for proportion of chronic cases diagnosed is ‘proportion of people living with chronic HBV infection 
who have been diagnosed with HBV’. While this indicator does not have any inherent issues, two updated indicators 
were added to the 2021 monitoring round: number of people ever diagnosed with chronic HBV per 100 000 population 
and number of people diagnosed in 2020 (or most recent year with data) per 100 000 population. This was done to 
overcome the issue of poor quality, out-of-date or missing estimates for ‘number of people with chronic HBV infection’ 
and to create indicators that show both current and historical testing efforts in a country in a way that is comparable 
across countries in the region.  

35 

 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

The WHO indicator for proportion of HBV cases who are linked to care has issues that prevent clear and useful 
interpretation. The indicator is defined in the WHO monitoring and evaluation technical report [11] as ‘number of HBV-
infected persons who received care in the past 12 months over estimated population of persons with chronic HBV’, with 
a different denominator than the WHO European Region Action Plan indicator. The target in the WHO European Region 
Action Plan is ‘90% of patients diagnosed with chronic HBV infection to be linked to care and adequately monitored’, 
which is more in line with most continuum of care frameworks but does not provide detail about time periods for the 
numerator and denominator.  Defining the time periods for both the numerator and denominator is important to 
provide greater standardisation. While this is not specifically suggested by Safreed-Harmon et al. [19] for a linkage to 
care indicator, their framework for defining time periods for indicators would be useful for a linkage to care indicator 
(e.g. number of people linked to care in 2020, of those diagnosed with chronic HBV and eligible for antiviral treatment 
in 2019 or 2020). 

The main continuum of care indicator that is affected by variation in treatment eligibility is the proportion of people 
receiving treatment of those diagnosed. This indicator is defined by WHO as the number of people ‘with chronic HBV 
infection who are currently receiving treatment’ over the number of people ‘with chronic HBV infection’. Again, the 
indicator ‘number with chronic HBV diagnosed’ does not have a standard denominator in different continuum of care 
frameworks. The numerators and denominators often do not specify that the indicator should only include those who 
are eligible for antiviral treatment. The target in the WHO European Region Action Plan is ‘75% of patients diagnosed 
with chronic HBV and eligible for treatment, to begin treatment,’ which serves as a more accurate indicator. The 
monitoring survey collected data on the number of people ever diagnosed and eligible for treatment (denominator) and 
the number of people on treatment in 2020 or the most recent year with data (numerator), but only one country, 
Romania, reported both the numerator and the denominator for this stage of the continuum of care.  

An additional HBV treatment indicator was included: proportion of people retained in care, of those diagnosed with 
chronic HBV and not clinically eligible for antiviral treatment (according to EASL criteria). This was added because 
tracking retention in care among those with chronic HBV infection who are not eligible for antiviral treatment is 
important. It was proposed that this would be calculated by subtracting ‘treatment-eligible’ diagnosed cases from all 
diagnosed cases for use in the denominator. Through input from NFPs, it was determined that it would be incorrect to 
assume that all people diagnosed but not determined to be eligible for treatment are not eligible for treatment, as the 
treatment eligibility status for those cases is unknown. In the future, the indicator may be modified to have a 
denominator of those linked to care and not eligible for treatment, as treatment eligibility would be determined after 
linkage to care is established. 

Challenges with the HCV indicators 
As for the HBV indicators, no inherent issues were found with regards to the measurement and interpretation of the 
WHO HCV indicators for number of people with chronic infection or for proportion of cases who had initiated treatment 
and achieved sustained virological response. For these indicators, the monitoring system collected the data for the 
WHO indicators, and no supplementary indicators were added. 

The WHO European Region indicator for proportion diagnosed is the proportion of all people living with chronic HCV 
infection who have been diagnosed [8] or, as clarified by the 2016 WHO monitoring and evaluation technical report, the 
‘Number of persons with chronic HCV infection who have been diagnosed over estimated number of persons with 
chronic HCV infection’ [11]. This proportion is difficult to calculate and monitor because the denominator, ‘all persons 
with chronic HCV’ infection, is constantly changing as individuals with chronic HCV infection are treated and cured. It is 
critical that the denominator reflects the number of people living with current chronic infection. Many countries were 
unable to adjust their estimate of people with chronic HCV infection over time to account for these changes. The 
numerator, those living with chronic HCV infection who have been diagnosed, is also constantly shifting and should also 
reflect those living with current chronic infection who are diagnosed; however, it should not include those who have 
been diagnosed and subsequently treated and cured. The monitoring data collection has shown that it is challenging 
for countries to accurately report both of these figures. The indicator is also difficult to interpret over time and between 
different countries, as many countries have substantially increased their treatment efforts in the past few years with 
the advent of highly effective DAAs and as many diagnosed cases have been treated, resulting in large changes in both 
the numerator and the denominator.  

36 

 
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

In response to these challenges, the ECDC team and expert advisory group proposed new indicators to supplement the 
WHO indicator. The following new indicators were included in the 2021 data collection: 

• 

• 

• 

The number of people with chronic HCV infection ever diagnosed per 100 000 population. This indicator provides 
limited information but clarifies the historical context of HCV disease burden and testing efforts in a country. 
The number of people diagnosed in the most recent year with available data per 100 000 population. This indicator 
provides a current snapshot of testing efforts. 
The number of people with current chronic HCV infection who remain undiagnosed per 100 000 population. This 
indicator provides a measure of the unmet need for testing and diagnosis – a measure of the progress a country 
has yet to make. While this indicator still requires information on the number of people diagnosed, excluding those 
with resolved infection and those who died or migrated in or out of the country, the denominator is fixed as the 
population of the country, allowing for more straightforward comparison over time. 

Taken together, these indicators may provide more meaningful information for regional monitoring, allowing for 
comparisons between countries. They also serve to overcome the challenge of having weak estimates for the number 
of people living with chronic HCV infection that don’t account for those treated and cured. However, in the 2021 
reporting round, most countries were still unable to provide the requested data. 

The WHO European Region indicator for the proportion of people on treatment is the ‘proportion of eligible patients 
diagnosed with chronic HCV infection receiving effective treatment’ [8] and is defined in the WHO monitoring and 
evaluation technical report as the number of people ‘already diagnosed with chronic HCV infection who initiated 
treatment during a specified time period (e.g. 12 months) over the number already diagnosed with chronic HCV 
infection for the specified time period’ with a note for the denominator that ‘all those already diagnosed to date but 
treated and cured would be excluded’ [11]. With the denominator constantly changing due to the removal of those 
treated and cured, this data point is also difficult for countries to measure and report and the indicator is challenging to 
interpret over time. Additionally, this indicator only represents numerator data from a limited time period (e.g. one 
year) over a cumulative count of chronic HCV infection cases diagnosed, which underestimates progress towards 
treatment targets. This indicator also does not reflect historical efforts and progress made on HCV treatment, adding to 
the difficulty of interpretation. 

To supplement the WHO indicator, two new indicators were proposed and collected in the 2021 monitoring survey: 

• 

• 

The number ever treated with antivirals for chronic HCV infection per 100 000 population. This indicator provides 
more information about the historical efforts towards HCV treatment, but it is influenced by the burden of disease 
in a country and doesn’t distinguish between different eras or phases of treatment provision (e.g. before and after 
the advent of DAAs). Like the other proposed indicators showing population rates, it allows for comparison across 
a geographic region.  
The proportion of people ever diagnosed who were ever treated by the end of a specified year (e.g. 2020). This 
indicator addresses the issue of a constantly shifting denominator due to cases who have been cured (or have 
died) by having a denominator that is cumulative over time. This indicator provides more of a historical, additive 
view and is more in line with the treatment indicators for HIV and HBV.  

For the monitoring of HCV treatment progress, a combination of an indicator showing context and historical progress 
(e.g. the two proposed above) along with an indicator that considers cases diagnosed and started on treatment within 
a recent time frame (as presented in the consensus cascade of care from Safreed-Harmon et al [19]) is recommended.  

The impact of the COVID-19 pandemic on hepatitis services 
Widespread impacts of the COVID-19 pandemic were reported on different types of hepatitis services, from clinic visits 
for routine care, testing and reassignment of human resources, to the introduction of innovative new interventions. 
While most countries reported no impact on routine hepatitis B prevention activities (including antenatal screening and 
routine infant/childhood vaccinations), 17 or more countries reported negative impacts on clinic visits for routine care, 
testing for HBV and HCV, and services provided by community-based organisations. The reports of reduced hepatitis B 
and C testing align with the findings of several other studies in the European region, indicating hepatitis screening and 
diagnosis may have been one of the areas of hepatitis services that was most affected by the pandemic [20,21]. Only 
two countries (Portugal and Romania) reported data on the number of people tested for hepatitis B and C in 2017 and 
2020 in order to compare monitoring data. Portugal’s data showed stable levels of HBV testing and slightly increased 
HCV testing from 2017 to 2020, while Romania’s data showed slightly decreased HBV testing and stable testing levels 
for HCV from 2017 to 2020. With little data availability for comparison, it is challenging to detect trends in the impact of 
COVID-19 on testing levels in EU/EEA countries. Additionally, 10 countries (38%) reported reduced laboratory capacity 
for hepatitis testing. 

37 

 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Maintaining and improving hepatitis prevention measures is key to staying on track to meet regional and global targets 
for viral hepatitis elimination. The questionnaire responses indicated that routine infant/childhood hepatitis B 
vaccination was negatively affected in six countries. In terms of coverage, data from WHO shows that the 55 countries 
in the European Region had a 1% overall decrease in the third dose of childhood DTP3 vaccine (used as a trace 
indicator) from 2019 to 2020, but that there was wide variation in the decreases seen by each country [22].  

Hepatitis B and C treatment and governmental funding for hepatitis programmes appeared to be protected, with few 
countries reporting changes to these factors. Reassignment of human resources away from hepatitis work and towards 
COVID-19 work seemed to be more common, particularly governmental public health staff and public health specialists, 
the categories of workers most closely tied to surveillance and monitoring. 

Although the COVID-19 pandemic has presented major challenges to many hepatitis services in the EU/EEA, some 
countries have taken the opportunity to implement new innovative strategies to minimise service disruptions. The 
intervention most frequently reported was the introduction of remote hepatitis care appointments via telephone or 
internet, but treatment-related interventions (e.g. increased volume of prescriptions and alternative modes of 
medication delivery), were also implemented in many countries. Introduction of interventions for testing, including 
campaigns for outreach testing in the community and self-sampling and self-testing approaches were least frequently 
reported, indicating missed opportunities to address identified reductions in testing. 

Limitations 
While there is extensive discussion of limitations on the availability and quality of data and issues with indicators in the 
above sections, there were additional limitations that limited the ability to draw conclusions from the data presented to 
enable a comprehensive understanding of the hepatitis B and C epidemics in the EU/EEA. One key limitation was that this 
analysis did not include prevention indicators, impact indicators or progress towards related targets, such as vaccination 
coverage or incidence, which are key to having a full understanding of progress towards elimination. 

Additionally, the data collected in the monitoring questionnaire on the impacts of the COVID-19 pandemic on hepatitis 
services in the region are categorical, not quantitative, in nature. It is important to interpret these findings considering 
other sources of data, including quantitative data, as the pandemic continues to progress. The data on COVID-19 
impacts and on policies related to testing and treatment rely on reporting from a small number of in-country NFPs. 
While these data can provide valuable context in which to interpret the recent data on hepatitis testing, treatment and 
treatment outcomes, data on these topics may be improved by validation with other country experts, including 
community-based and civil society organisations.  

Conclusions 
This report assesses data availability and progress towards the 2020 WHO European Region Action Plan targets for the 
continuum of care for hepatitis B and C in the EU/EEA. It also provides an overview of hepatitis B and C testing and 
treatment policies and impacts of the COVID-19 pandemic on hepatitis services in the EU/EEA. Data were collected via 
an online survey in 2021 for the purpose of monitoring the hepatitis response and progress towards the 2020 targets, 
as an interim step towards the 2030 targets for hepatitis elimination in the WHO Global Health Sector Strategy (GHSS). 
The 2030 targets for viral hepatitis from the WHO GHSS are, for the continuum of care, that 90% of those with 
hepatitis B and C are diagnosed and that 80% are treated. The results of the 2021 monitoring survey show that there 
is still a severe lack of country-level monitoring data on hepatitis B and C prevalence, diagnosis, treatment and 
treatment outcomes in the EU/EEA, preventing a clear or comprehensive region-wide assessment of progress towards 
the targets. While there are data from countries for some of the indicators that show varying levels of progress towards 
targets, the need to increase the collection of up-to-date, robust data is urgent. This is especially challenging given 
reports from countries of the wide-spread negative impacts of the COVID-19 pandemic on human resources in public 
health and governmental organisations.  

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TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Priority areas for action 
To address the findings and practical and methodological limitations presented in this report, select priority areas for 
action have been identified: 

• 

Significant gaps in the data related to the prevalence, diagnosis, treatment and treatment outcomes for hepatitis B 
and C in EU/EEA countries present a major challenge to monitoring progress towards the 2020 and 2030 targets of 
elimination for hepatitis. To guide national responses to hepatitis B and C, countries should prioritise improving the 
quality of their monitoring systems. Data are especially lacking for the general population for hepatitis B and for 
the key populations presented here (people who inject drugs and people in prison) for hepatitis C.  

•  Methodological issues with some of the WHO-defined indicators for the continuum of care must be addressed to 

• 

consider the nuances of hepatitis B and C epidemiology and to provide clarity and improved accuracy for 
standardised data collection. For hepatitis B, this means highlighting eligibility for antiviral treatment in indicator 
definitions; for hepatitis C, this includes highlighting the constantly shifting numerators and denominators of 
indicators to account for the chronic infections that are cured using newer, more effective and widely accessible 
DAA treatments. 
The 2021 monitoring survey included the collection of data for several additional continuum of care indicators 
formulated by the ECDC hepatitis expert advisory group. These additional indicators were added to try to address 
the methodological issues mentioned above. The survey results show that many countries do not have data to 
report for these indicators. Some of the additional indicators, like proportion of those with HBV not eligible for 
antiviral treatment who are retained in care, were found to not sufficiently address the identified issues. We 
propose reducing the number of data points/indicators collected in the next monitoring survey, due to the lack of 
reported data and in order to minimise the reporting burden for countries. 

•  While the number of indicators on the continuum of care should be streamlined, indicator definitions should be 

• 

• 

• 

further refined to provide accurate data that reflects the complex epidemiology of hepatitis B and C, the progress 
made towards elimination and the remaining effort needed to address gaps in services. 
The collection of robust, up-to-date information using epidemiologically sound methods could be greatly improved 
by increased collaboration between different stakeholders in the field of viral hepatitis, including public health 
departments, clinical bodies, and civil society and community-based organisations.  
ECDC has several projects planned to improve the availability of data and estimates, and to support countries in 
their hepatitis monitoring efforts. These projects include the modelling of new estimates for the number of people 
infected, data collection on mortality caused by hepatitis and a sentinel site surveillance project to improve data 
collection on testing and late diagnosis in different service settings. 
As the COVID-19 pandemic continues to create unprecedented global challenges to responses to other infectious 
diseases, it is critical to continue to measure the impact of the pandemic on the viral hepatitis response. The data 
on the impact of COVID-19 on hepatitis services presented here should be considered alongside other sources of 
data on this issue, including qualitative data on impacts on prevention, testing and treatment services. The 
possibility of aligning the collection of high-quality data on hepatitis with the collection of COVID-19 data, such as 
estimates of seroprevalence through well-conducted population surveys, should be explored.  

39 

 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

References 

1.  Hofstraat SH, Falla AM, Duffell EF, Hahné SJ, Amato-Gauci AJ, Veldhuijzen IK, et al. 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. Epidemiology and infection. 2017 Oct;145(14): 2873-85. 

2.  Mårdh O, Quinten C, Amato-Gauci AJ, Duffell E. Mortality from liver diseases attributable to hepatitis B and C in 
the EU/EEA – descriptive analysis and estimation of 2015 baseline. Infectious Diseases. 2020;52(9):625-37. 
3.  Blachier M, Leleu H, Peck-Radosavljevic M, Valla DC, Roudot-Thoraval F. The burden of liver disease in Europe: a 

review of available epidemiological data. J Hepatol. 2013;58(3):593-608. 

4.  Dultz G, Zeuzem S. Hepatitis C. A European perspective. Gastroenterol Clin North Am. 2015;44(4):807-24. 
5.  European Centre for Disease Prevention and Control. Hepatitis B and C testing strategies in healthcare and 

community settings in the EU/EEA. Stockholm: ECDC; 2018. 

6.  United Nations. Transforming our world: the 2030 agenda for sustainable development. New York: UN; 2015. 
7.  World Health Organization. Global health sector strategy on viral hepatitis 2016-2021. Towards ending viral 

hepatitis. Geneva: WHO; 2016. 

8.  World Health Organization Regional Office for Europe. Action plan for the health sector response to viral hepatitis 

in the WHO European Region. Copenhagen: WHO/Europe; 2016. 

9.  European Centre for Disease Prevention and Control. Monitoring the responses to hepatitis B and C epidemics in 

EU/EEA Member States, 2019. Stockholm: ECDC; 2020. 

10.  Joint United Nations Programme on HIV/AIDS. 90-90-90 An ambitious treatment target to help end the AIDS 

epidemic. Geneva: UNAIDS; 2014. 

11.  World Health Organization. Technical Report: Monitoring and evaluation for viral hepatitis B and C: recommended 

indicators and framework. Geneva: WHO; 2016. 

12.  Suijkerbuijk AWM, van Hoek AJ, Koopsen J, de Man RA, Mangen MJ, de Melker HE, et al. Cost-effectiveness of screening for 

chronic hepatitis B and C among migrant populations in a low endemic country. PloS one. 2018;13(11):e0207037. 

13.  Ward Z, Mafirakureva N, Stone J, Keevans M, Betts-Symonds G, Crowley D, et al. Cost-effectiveness of mass screening for 

Hepatitis C virus among all inmates in an Irish prison. International Journal of Drug Policy. 2021;96:103394. 

14.  Martin NK, Hickman M, Miners A, Hutchinson SJ, Taylor A, Vickerman P. Cost-effectiveness of HCV case-finding for people 

who inject drugs via dried blood spot testing in specialist addiction services and prisons. BMJ Open. 2013;3(8):e003153. 

15.  World Health Organization. WHO releases first guidelines on hepatitis C virus self-testing. Copenhagen: 

WHO/Europe; 2021. Available from: https://www.who.int/news/item/15-07-2021-who-releases-first-guidelines-on-
hepatitis-c-virus-self-testing 

16.  Marshall AD, Cunningham EB, Nielsen S, Aghemo A, Alho H, Backmund M, et al. Restrictions for reimbursement of 

interferon-free direct-acting antiviral drugs for HCV infection in Europe. Lancet Gastroenterol Hepatol. 2018;3(2):125-33. 

17.  Pawlotsky J-M, Negro F, Aghemo A, Berenguer M, Dalgard O, Dusheiko G, et al. EASL recommendations on 

treatment of hepatitis C: Final update of the series. Journal of Hepatology. 2020;73(5):1170-218. 

18.  Tan M, Bhadoria AS, Cui F, Tan A, van Holten J, Easterbrook P. Estimating the proportion of people with chronic 
hepatitis B virus infection eligible for hepatitis B antiviral treatment worldwide: a systematic review and meta-
analysis. Lancet Gastroenterol Hepatol. 2021;6(2):106-119. 

19.  Safreed-Harmon K, Blach S, Aleman S, Bollerup S, Cooke G, Dalgard O, et al. The Consensus Hepatitis C Cascade 
of Care Standardized Reporting to Monitor Progress Toward Elimination. Clin Infect Dis. 2019;69(12):2218–2227. 

20.  Coalition for Global Hepatitis Elimination. European Region: Impact of the COVID-19 Response on Hepatitis 

Elimination Efforts. Atlanta: Coalition for Global Hepatitis Elimination; 2021. 

21.  Simoes D, Stengaard AR, Combs L, Raben D, 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):2001943. Available from: 
https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2020.25.47.2001943 

40 

TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

22.  World Health Organization Regional Office for Europe. Varied impact of COVID-19 on routine immunization in the 

European Region. Copenhagen: WHO/Europe; 2021. Available from: https://www.euro.who.int/en/health-
topics/communicable-diseases/hepatitis/news/news/2021/7/varied-impact-of-covid-19-on-routine-immunization-in-
the-european-region  

41 

 
 
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Annex 1. Data on the hepatitis B continuum of 
care 

Table 1A. Number of people with chronic HBV infection 

Country 

Population 

A. Estimated number of people living with 
chronic HBV infection (HBsAg positive), 
diagnosed and undiagnosed, by the end of 
2020* 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czechia 

Denmark 

Estonia 

Finland 

France 

8 901 064 

11 522 440 

6 951 482 

4 058 165 

888 005 

10 693 939 

5 822 763 

1 328 976 

5 525 292 

67 320 216 

Germany 

83 166 711 

Greece 

Hungary 

Iceland 

Ireland 

Italy 

Latvia 

10 718 565 

9 769 526 

364 134 

4 964 440 

59 641 488 

1 907 675 

Liechtenstein 

38 747 

Lithuania 

2 794 090 

Luxembourg 

Malta 

626 108 

514 564 

Netherlands 

17 407 585 

Norway 

Poland 

5 367 580 

37 958 138 

Portugal 

10 295 909 

Romania 

19 328 838 

Slovakia 

Slovenia 

Spain 

5 457 873 

2 095 861 

47 332 614 

Sweden 

10 327 589 

Year (A) 

A per 100 000 
population 

-  

-  

-  

-  

-  

-  

 - 

 - 

 - 

25 000 

2013 

616.0 

-  

-  

10 668 

-  

17 900 

135 706 

247 000 

-  

-  

2007 

-  

2006 

2016 

2013 

 - 

 - 

183.2 

 - 

324.0 

201.6 

297.0 

200 000 

2015-2018 

1865.9 

-  

-  

18 000 

332 000 

49 600 

-  

-  

-  

-  

49 000 

-  

250 000 

-  

-  

Mixed 

2016 

2001 

-  

-  

-  

-  

2016 

-  

2016 

~40 000 

2015-2016 

640 176 

2015 

-  

-  

-  

-  

-  

-  

-  

-  

 - 

 - 

362.6 

556.7 

2600.0 

 - 

 - 

 - 

281.5 

 - 

658.6 

400 

3312.0 

 - 

 - 

 - 

 - 

* 2020 or the most recent year with data. 
All geographic coverage is at the national level unless otherwise specified. Subnational data (at the regional, city, or clinic level) are 
reported in these tables, but were not used in the graphs and data presented in the body of the report. Estimates/data in bold have 
been updated since the 2018 survey. Blue column headings are calculated indicators. Population data are from EuroStat. 

42 

 
  
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Table 2A. HBV infection diagnosis 

B. Number of 
people ever 
diagnosed and 
living with 
chronic HBV 
infection 
(HBsAg) by 
the end of 
2020* 

C. Number of 
people 
diagnosed 
with chronic 
HBV infection 
(HBsAg) 
during 2020* 

B/A (%) 
Proportion 
of people 
diagnosed 

B per 
100  000 
population 

C per 
100  000 
population 

Year (B and 
C) 

 - 

 - 

2 887 

 - 

 - 

 - 

7 112 

7 578 

23 749 

 - 

120 000 

 - 

 - 

11 584 

 - 

24 000 

 - 

 - 

 - 

 - 

948 

 - 

 - 

 - 

 - 

142 

400 

 - 

160 

 - 

3 071 

 - 

 - 

 - 

327 

 - 

214 

 - 

 - 

 - 

 - 

2020 

 - 

2020 

 - 

 - 

2020 

2007; 2020 

 - 

2020 

2016 

2020 

2015-2018 

 - 

-  

2020 

-  

2020 

-  

-  

-  

-  

 - 

 - 

 - 

 - 

 - 

 - 

66.7 

 - 

42.3 

17.5 

 - 

60.0 

 - 

 - 

64.4 

 - 

 48.4 

 - 

 - 

 - 

 - 

 - 

 - 

41.5 

 - 

 - 

 - 

122.1 

-  

137.2 

35.3 

 - 

1 119.6 

 - 

 - 

233.3 

 - 

1 258.1 

 - 

 - 

 - 

 - 

10.7 

 - 

 - 

 - 

 - 

1.3 

6.9 

 - 

2.9 

 - 

3.7 

 - 

 - 

 - 

6.6 

 - 

11.2 

 - 

 - 

 - 

 - 

28 000 

688 

2000-2020 

57.1 

160.8 

4.0 

D. % of people 
with chronic 
HBV infection 
who have 
decompensated 
cirrhosis and/or 
HCC at the time 
of diagnosis 

E. Number 
of people 
tested for 
hepatitis B 
(HBsAg) in 
2020*, 
including 
rapid tests 
(if 
possible) 

Testing data, 
2018 survey: 
number of 
people tested 
for HBsAg in 
2017 (or most 
recent data) 

Year 
(E) 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 
6.2-28% 
cirrhosis;  
1.6-9.9% HCC 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

- 

- 

- 

- 

- 

- 

- 

- 

- 

4 300 000 

2016 
- 

  - 

  - 

  - 

  - 

  - 

  - 

53 848 

  - 

  - 

  - 

  - 

  - 

- 

- 

- 

- 

- 

2017 
- 

- 

- 

- 

- 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

145 798 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

Country 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czechia 

Denmark 

Estonia 

Finland 

France 

Germany 

Greece 

Hungary 

Iceland 

Ireland 

Italy 

Latvia 

Liechtenstein 

Lithuania 

Luxembourg 

Malta 

Netherlands 

43 

 
  
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Norway 

Poland 

Portugal 

Romania 

Slovakia 

Slovenia* 

Spain 

Sweden 

 - 

115 000 

- 

-  

-  

2 597 

 - 

- 

 - 

979 

 35 

2 246 

-  

231 

 - 

679 

 - 

2016; 2020 

 - 

46.0 

 - 

303.0 

2020 

2020 

-  

2020 

 - 

2018, 2020 

- 

-  

-  

-  

 - 

 - 

- 

-  

-  

-  

 - 

- 

 - 

2.6 

0.3 

11.6 

-  

-  

 - 

6.6 

 - 

  - 

- 

0.015 

430 267 

2020 

439 234 

2020 

0.4 

519 301 

-  

-  

 - 

 - 

-   

102 484 

 - 

 - 

2020 
- 

2020 
- 

- 

 - 

 - 

438 300 

559 229 

-  

-  

 - 

 - 

HCC: Hepatocellular carcinoma 
* 2020 or the most recent year with data 
All geographic coverage is at the national level unless otherwise specified. Subnational data (at the regional, city, or clinic level) are reported in these tables, but were not used in the 
graphs and data presented in the body of the report. Data in red italics are subnational, at the regional level. Estimates/data in bold have been updated since the 2018 survey. Blue 
column headings are calculated indicators. Population data are from EuroStat. 
Slovenia: subnational data are from the Central region of Slovenia (570 773 inhabitants). 

44 

  
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Table 3A. HBV infection linkage to care and treatment 

F. Number of 
people ever 
diagnosed 
with chronic 
HBV infection 
(HBsAg) linked 
to care in 
2020* 

F/B (%) 
Proportion 
of people 
linked to 
care 

Year (F) 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

G. Number 
people 
diagnosed with 
chronic HBV 
infection 
(HBsAg) not 
eligible for 
treatment* who 
are retained in 
care** by the 
end of 2020* 

 - 

 - 

 - 

 - 

 - 

 - 

Year (G) 

 - 

 - 

 - 

 - 

 - 

 - 

3 296 

2016 

           46.3 

2 686 

2016 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

1 467 

2017 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

6.1 

 - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

Country 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czechia 

Denmark 

Estonia 

Finland 

France 

Germany 

Greece 

Hungary 

Iceland 

Ireland 

Italy 

Latvia 

Liechtenstein 

  - 

 - 

H. Number of 
people 
diagnosed with 
chronic HBV 
infection by the 
end of 2020* 
who are eligible 
for treatment* 

I. Number of people 
ever diagnosed with 
chronic HBV infection 
(HBsAg) and eligible 
for treatment from a 
clinical perspective* 
receiving antiviral 
treatment during 2020* 

I/H (%) 
Proportion of 
people treated 
of those 
diagnosed and 
eligible 

Year (I) 

Year (H) 

 - 

 - 

 - 

 - 

2 887 

2020 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

2 485 

2019 

  - 

  - 

  - 

  - 

 - 

 - 

 - 

 - 

610 

2016 

  - 

  - 

  - 

26 035 

  - 

  - 

  - 

  - 

  - 

320 

  - 

 - 

 - 

 - 
2008-
2020 

 - 

 - 

 - 

 - 

 - 

2020 

-  

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

45 

 
  
  
  
  
  
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Lithuania 

Luxembourg 

Malta 

Netherlands 

Norway 

Poland 

Portugal 

Romania 

Slovakia 

Slovenia 

Spain 

Sweden 

  - 

  - 

  - 

  - 

  - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

26481 

2020 

23.0 

  - 

 - 

2 246 

2020 

  - 

 - 

1 493 

2020 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

  - 

  - 

  - 

  - 

  - 

  - 

  - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

100 000 

2020 

20 500 

2020 

  - 

692 

 - 

 - 

 - 

2020 

 - 

 - 

  - 

801 

 - 

 - 

 - 

2020 

 - 

 - 

  - 

  - 

  - 

 - 

 - 

 - 

4 750 

2020 

  - 

 - 

8 833 

2020 

  - 

 - 

2 246 

2020 

  - 

801 

 - 

 - 

 - 

2020 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

11.0 

 - 

100 

 - 

 - 

* 2020 or the most recent year with data 
All geographic coverage is at the national level unless otherwise specified. Subnational data (at the regional, city, or clinic level) are reported in these tables, but were not used in the 
graphs and data presented in the body of the report. Data in red italics are subnational, at the regional level. Estimates/data in bold have been updated since the 2018 survey. Blue 
column headings are calculated indicators. Population data are from EuroStat. 
Denmark: subnational data from the west of Denmark (Regions: north, central and couth) were scaled up to the national level.  
Latvia: subnational data are at the clinic level (Riga East University Hospital). 

46 

  
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Table 4A. HBV infection viral suppression 

J. Number of people 
receiving antiviral 
treatment for chronic HBV 
infection (HBsAg) who have 
achieved viral suppression 
during 2020* 

K. Number of people ever diagnosed 
with chronic HBV infection (HBsAg) 
and eligible for treatment receiving 
antiviral treatment during 2020*, with 
documentation of treatment 
outcome 

Year (J and K) 

J/K (%) 
Proportion 
with viral 
suppression 
of those 
treated 

 - 

 - 

 - 

 - 

 - 

 - 

107 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

1 960 

  - 

801 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

154 

 - 

 - 

 - 

 -- 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

1 960 

  - 

801 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

2016 

69.5 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

2020 

 - 

2020 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

100 

 - 

100 

 - 

 - 

Country 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czechia 

Denmark 

Estonia 

Finland 

France 

Germany 

Greece 

Hungary 

Iceland 

Ireland 

Italy 

Latvia 

Liechtenstein 

Lithuania 

Luxembourg 

Malta 

Netherlands 

Norway 

Poland 

Portugal 

Romania 

Slovakia 

Slovenia 

Spain 

Sweden 

* 2020 or the most recent year with data 
All geographic coverage is at the national level unless otherwise specified. Subnational data (at the regional, city, or clinic level) are 
reported in these tables, but were not used in the graphs and data presented in the body of the report. Data in red italics are 
subnational, at the regional level. Estimates/data in bold have been updated since the 2018 survey. Blue column headings are 
calculated indicators. Population data are from EuroStat. 
Denmark: Subnational data from the west of Denmark (Regions: north, central and south) were scaled up to the national level. 

47 

 
  
 
 
Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

TECHNICAL REPORT 

Annex 2. Data on the hepatitis C continuum of care 

Table 5A. Number of people living with chronic HCV infection 

A. Estimated number of people living with 
current chronic HCV infection (RNA 
positive), diagnosed and undiagnosed, by 
the end of 2020* 

A per 
100  000 
population 

Year (A) 

B. Estimated number of 
people ever infected with HCV 
infection (anti-HCV positive), 
diagnosed and undiagnosed, 
by the end of 2020* 

Year 
(B) 

B per 
100  000 
population 

Country 

Population 

 - 

 - 

 - 

 - 

 - 

 - 

18 800 

2014-2020 

163.2 

25 000 

2014 

217.0 

 - 

2018 

 - 

492.8 

 - 

20 000 

 - 

60 000 

 - 

 - 

 - 

 - 

  - 

 - 

 - 

 - 

133 466 

254 000 

2016 

2013 

75 000 

2015-2018 

 - 

88 

9 000 

410 775 

46 000 

 - 

 - 

 - 

 - 

 - 

2020 

2020 

2019 

2010 

 - 

 - 

 - 

 - 

23 000 

 - 

2016 

 - 

165 000 

2013-2016 

~30 000 

  2017 

 - 

- 

 - 

 - 

 - 

198.3 

305.4 

699.7 

 - 

24.2 

181.3 

688.7 

2 411.3 

 - 

 - 

 - 

 - 

132.1 

 - 

434.7 

 300 

 - 

 - 

 - 

40 000 

2013 

985.7 

 - 

 - 

 - 

 - 

 - 

 - 

9 975 

2016 

171.3 

 - 

 - 

 - 

 - 

344 500 

2011 

307 000 

100 000 

2013 
2015-
2016 

 - 

 - 

1 501 

2019 

33 708  Mixed 

534 007 

2019 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

349 650 

- 

 - 

 - 

 - 

 - 

 - 

 - 
2013-
2016 

~150 000 

 2001 

 - 

 - 

511.7 

369.1 

933.0 

 - 

412.2 

 679.0 

895.4 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

921.1 

 1 500 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czechia 

Denmark 

Estonia 

Finland 

France 

8 901 064 

11 522 440 

6 951 482 

4 058 165 

888 005 

10 693 939 

5 822 763 

1 328 976 

5 525 292 

67 320 216 

Germany 

83 166 711 

Greece 

Hungary 

Iceland 

Ireland 

Italy 

Latvia 

10 718 565 

9 769 526 

364 134 

4 964 440 

59 641 488 

1 907 675 

Liechtenstein 

38 747 

Lithuania 

2 794 090 

Luxembourg 

Malta 

626 108 

514 564 

Netherlands 

17 407 585 

Norway 

5 367 580 

Poland 

Portugal 

37 958 138 

10 295 909 

Romania 

19 328 838 

Slovakia 

Slovenia 

5 457 873 

2 095 861 

Spain 

47 332 614 

Sweden 

10 327 589 

261 119 

2016 

1 350.9 

663 981 

2016 

3 435.2 

 - 

 - 

  1 677 

2020  

76 839 

2017-2018 

29 700 

2019 

 - 

 80.0 

162.3 

287.6 

 - 

-  

337 107 

 - 

 - 
2017-
2018 

 - 

 - 

 - 

 - 

712.2 

 - 

* 2020 or the most recent year with data 
All geographic coverage is at the national level unless otherwise specified. Subnational data (at the regional, city, or clinic level) are 
reported in these tables, but were not used in the graphs and data presented in the body of the report. Data in red italics are 
subnational, with descriptions of the geographical coverage below the table. Estimates/data in bold have been updated since the 
2018 survey. Blue column headings are calculated indicators. Population data are from EuroStat. 
Czechia: subnational data are at the city level (Prague and Brno).  
Poland: data refer to the adult population only.  

48 

 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Table 6A. HCV infection diagnosis 

D. Number of people 
ever diagnosed with 
chronic HCV infection 
(HCV RNA) by the 
end of 2020*, 
excluding those with 
resolved infection or 
who have died: 

E. Number of 
people 
diagnosed 
with chronic 
HCV infection 
(HCV RNA) 
during 2020* 

(A-D) per 
100  000: 
those 
remaining 
undiagnosed 

E per 
100  000 
population 

F. % of people with 
chronic hepatitis C 
who have 
decompensated 
cirrhosis and/or HCC 
at the time of 
diagnosis 

G. Number 
of people 
tested for 
hepatitis C 
(anti-HCV) 
in 2020* 

Year (G) 

Year (C, D, E) 

C per 
100 000 
population 

C. Number of 
people ever 
diagnosed 
with chronic 
HCV infection 
(HCV RNA) 
by the end of 
2020* 

 - 

 - 

 - 

8 000 

 - 

 - 

7 581 

  - 

  - 

  - 

  - 

2020 

 - 

2020 

2020 

 - 

2020 

2016  

 - 

 - 

2016 

2020 

 - 

 - 

 - 

197.1 

 - 

 - 

130.2 

 - 

 - 

 - 

 - 

35 000 

2015-2018 

326.5 

  - 

  - 

15 000 

346 364 

25 000 

  - 

  - 

  - 

1 300 

18 400 

 - 

 - 

2020 

2019-2020 

 - 

 - 

302.1 

580.7 

2020 

1 310.5 

 - 

 - 

 - 

2018 

2020 

 - 

 - 

 - 

252.6 

105.7 

Country 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czechia 

Denmark 

Estonia 

Finland 

France 

Germany 

Greece 

Hungary 

Iceland 

Ireland 

Italy 

Latvia 

Liechtenstein 

Lithuania 

Luxembourg 

Malta 

Netherlands 

 - 

 - 

 - 

 - 

 - 

 - 

7 581 

  - 

  - 

107 574 

  - 

10 000 

 - 

 - 

6 000 

300 000 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

38.5 

 - 

606.4 

 - 

 - 

60.4 

185.7 

 - 

 - 

 - 

 - 

 - 

839 

 - 

810 

206 

 - 

771 

300 

 - 

 - 

 - 

4 188 

 - 

 - 

 - 

326 

 - 

1 139 

 - 

 - 

 - 

 - 

3 700 

110.9 

384 

9.4 

 - 

11.7 

5.1 

 - 

7.2 

5.2 

 - 

 - 

 - 

5.0 

 - 

 - 

 - 

6.6 

 - 

59.7 

 - 

 - 

 - 

 - 

2.2 

 - 

 - 

 - 

 - 

 - 

 - 

13 

 - 

 - 

 - 
2-34% cirrhosis;  
1.2% HCC 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

Number of 
people 
tested for 
hepatitis C 
(anti-HCV) in 
2018 

 - 

700 000 

 - 

 - 

 - 

 - 

 - 

 - 

 - 

4 100 000 

 - 

 - 

 - 

 - 

123 309 

 - 

53 288 

 - 

 - 

53 429 

 - 

 - 

49 

  
  
Title here  

Norway 

Poland 

Portugal 

Romania 

Slovakia 

Slovenia 

Spain 

Sweden 

TECHNICAL REPORT 

  - 

 - 

37 125 

2016; 2020 

150 000 

  - 

  - 

4 049 

54 361 

 - 

2020 

2020 

 - 

1997-2020 

2017-2018 

- 

 - 

97.8 

1 456.9 

 - 

 - 

193.2 

114.8 

 - 

 - 

 - 

100 000 

42 560 

 - 

1 172 

 - 

- 

 - 

 - 

 - 

955 

300 

1 130.7 

6 900 

 - 

 - 

 - 

- 

 - 

82 

 - 

614 

 - 

2.5 

2.9 

35.7 

 - 

3.9 

 - 

4.5 

 - 

25 

 - 

 - 

 - 

27.2% cirrhosis/HCC 

5.9 

 - 

 - 

310 107 

351 413 

518 675 

 - 

 - 

 - 

 - 

 - 

2020 

2020 

2020 

 - 

 - 

 - 

 - 

 - 

 - 

337 040  
523 043 

 - 

 - 

 - 

 - 

* 2020 or the most recent year with data 
All geographic coverage is at the national level unless otherwise specified. Subnational data (at the regional, city, or clinic level) are reported in these tables, but were not used in the graphs and data presented 
in the body of the report. Data in red italics are subnational, with descriptions of the geographical coverage below the table. Estimates/data in bold have been updated since the 2018 survey. Blue column 
headings are calculated indicators. Population data are from EuroStat. 
Data from Spain are regional data. 
Poland: estimates for numbers diagnosed refer to the adult population only.  

50 

  
 
TECHNICAL REPORT 

Monitoring of responses to the hepatitis B and C epidemics in EU/EEA countries – 2020 data 

Table 7A. HCV infection treatment 

I. Number of 
people with 
chronic HCV 
infection 
(HCV RNA) 
who have 
ever been 
treated by 
the end of 
2020* 

J. Number of 
people with 
chronic HCV 
infection (HCV 
RNA) who 
received antiviral 
treatment during 
2020* 

Year (J) 

J/D (%) 

I per 
100 000 
population 

I/C (%) 

Year (I) 

10 444 

2020 

117.3 

  - 

  - 

-  

-  

 - 

 - 

 - 

 - 

 - 

8 000 

2021 

197.1 

100 

Country 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czechia 

Denmark 

Estonia 

Finland 

France 

Germany 

Greece 

Hungary 

Iceland 

Ireland 

Italy 

Latvia 

Liechtenstein 

Lithuania 

Luxembourg 

Malta 

  - 

  - 

6 934 

  - 

  - 

-  

2020 

-  

-  

73 000 

2014-2018 

76 400 

2014-2020 

25 000 

  - 

  - 

7 000 

217 398 

-  

-  

2020 

2020 

9 500 

2016-2020 

  - 

  - 

  - 

  - 

-  

-  

-  

-  

Netherlands 

7 964 

2014-2020 

Norway 

Poland 

Portugal 

Romania 

Slovakia 

Slovenia 

Spain 

Sweden 

17 014 

  - 

27 038 

137 760 

  - 

-  

2021 

2020 

-  

2 823 

1997-2020 

146 668 

2015-2020 

  - 

-  

 - 

 - 

 - 

 - 

 119.1 

 91.5 

 - 

 - 

108.4 

91.9 

233.2 

 - 

 - 

141.0 

364.5 

498.0 

 - 

 - 

 - 

 - 

45.8 

317.0 

 - 

262.6 

712.7 

 - 

134.7 

309.9 

 - 

 - 

 - 

 - 

 - 

71.4 

 - 

 - 

46.7 

62.8 

38.0 

 - 

 - 

 - 

 - 

43.3 

 - 

 - 

18.0 

 - 

 - 

69.7 

 - 

 - 

1 103 

960 

 - 

350 

 - 

 - 

736 

 - 

1 964 

16 117 

6 500 

1 271 

 - 

 - 

542 

15 435 

2 640 

 - 

 - 

 - 

199 

512 

1 364 

6 748 

2 311 

6 900 

  - 

104 

8 440 

4 800 

2020 

2020 

 - 

2021 

 - 

 - 

2020 

2020 

2016 

2020 

2020 

 - 

 - 

2020 

2020 

2020 

 - 

 - 

 - 

2019 

2020 

2020 

2020 

2020 

2020 

 - 

2020 

2020 

2019 

 - 

 - 

 - 

 - 

-  

 - 

 9.7 

 - 

 - 

15.0 

 - 

12.7 

 - 

 - 

9.0 

5.1 

 - 

 - 

 - 

 - 

 - 

13.8 

 - 

 - 

2.3 

16.2 

 - 

8.9 

- 

* 2020 or the most recent year with data 
All geographic coverage is at the national level unless otherwise specified. Subnational data (at the regional, city, or clinic level) 
are reported in these tables, but were not used in the graphs and data presented in the body of the report. Data in red italics are 
subnational, with descriptions of the geographical coverage below the table. Estimates/data in bold have been updated since the 
2018 survey. Blue column headings are calculated indicators. Population data are from EuroStat. 
Austria: data on cases ever treated are from 2014 to 2020.  
Denmark: Data from the west of Denmark (Regions: north, central and south) were scaled up to the national level. 

51 

 
  
  
  
  
 
 
 
Title here  

TECHNICAL REPORT 

Table 8A. HCV infection sustained virologic response 

K. Number of 
people who 
received antiviral 
treatment for HCV 
infection who 
achieved sustained 
virologic response 
during 2020* 

Year (K) 

L. Number of 
people who 
received antiviral 
treatment for HCV 
during 2020*, with 
documentation of 
treatment outcome 

Year (L) 

K/L (%) Proportion 
with sustained 
virological 
response of those 
treated  

 - 

 - 

 - 

345 

  - 

  - 

399 

 - 

 - 

 - 

 - 

 - 

 - 

190 

332 

 - 

 - 

 - 

 - 

2018 

 - 

 - 

2020 

 - 

 - 

 - 

 - 

 - 

2018 

2020 

1 019 

2020 

 - 

 - 

 - 

 - 

 - 

 - 

146 

2019 

 - 

 - 

 - 

2 732 

6 486 

 - 

214 

 - 

 - 

 - 

2017 

2020 

 - 

2019 

36 694 

2015-2019 

1 451 

2020 

 - 

 - 

 - 

350 

  - 

  - 

409 

  - 

1 900 

 - 

 - 

 - 

 - 

 - 

347 

1 069 

 - 

 - 

 - 

154 

 - 

 - 

 - 

2 822 

6 900 

 - 

216 

38 626 

2 253 

 - 

 - 

 - 

2021 

 - 

 - 

2020 

 - 

2020 

 - 

 - 

 - 

 - 

 - 

2020 

2020 

 - 

 - 

 - 

2019 

 - 

 - 

 - 

2017 

2020 

 - 

2019 

2015-2019 

2020 

 - 

 - 

 - 

98.6 

 - 

 - 

97.6 

 - 

 - 

 - 

 - 

98.0 

 - 

 - 

95.7 

95.3 

 - 

 - 

 - 

94.8 

 - 

 - 

 - 

96.8 

94.0 

 - 

99.1 

95.0 

64.4 

Country 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czechia 

Denmark 

Estonia 

Finland 

France 

Germany 

Greece 

Hungary 

Iceland 

Ireland 

Italy 

Latvia 

Liechtenstein 

Lithuania 

Luxembourg 

Malta 

Netherlands 

Norway 

Poland 

Portugal 

Romania 

Slovakia 

Slovenia 

Spain 

Sweden 

HCC: Hepatocellular carcinoma 
* 2020 or the most recent year with data 
All geographic coverage is at the national level unless otherwise specified. Subnational data (at the regional, city, or clinic level) 
are reported in these tables, but were not used in the graphs and data presented in the body of the report. Data in red italics are 
subnational, with descriptions of the geographical coverage below the table. Estimates/data in bold have been updated since the 
2018 survey. Blue column headings are calculated indicators. Population data are from EuroStat. 
Data from the west of Denmark (Regions: north, central, and south) were scaled up to the national level. 

52 

 
 
 
  
  
  
  
  
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