Mortality from liver diseases associated with hepatitis B and C in the EU/EEA – descriptive analysis and estimation of 2015 baseline

Dr Otilia Mårdh

International Viral Hepatitis Elimination Meeting, Amsterdam, 22 November 2019

Background and objectives

• To describe mortality from liver diseases as defined by WHO Core-10 indicator for EU/EEA for 2015

• To calculate a EU/EEA baseline mortality estimate (2015) for monitoring progress towards HBV, HCV elimination

WHO Core 10 indicatorMortality = no. of deaths from HCC (C22.0) and CLD (K72 - K75) x AF (% infected with HBV, HCV). Disaggregation by gender and age

AF: attributable fraction

2015 baseline

ICD-10 codes (WHO)HCC: C22.0Chronic liver disease (CLD): K72 – K75

Chronic viral hepatitis B* and C (CVH): B18.0 – B18.2

Descriptive analysis

• Mortality and population data from Eurostat

• Age standardised mortality rates per 100,000 by gender, age-group and EU/EEA country

*with or without delta-agent

Methods

Hepatocellular carcinoma (C22.0), 2015

23,883 deaths, EU/EEA rate 4.6/100,000

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Age-standardised mortality rates per 100 000 population from hepatocellular carcinoma (ICD-10 code C22.0) in EU/EEA countries in 2015

M:F 1.2

77% ≥65 years old

≤24 years 25-44 years 45-64 years ≥65 years

Chronic liver disease (K72-K75), 2015

41,146 deaths, EU/EEA rate 8.0/100,000

.

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Age-standardised mortality rates per 100 000 population from chronic liver diseases (ICD-10 codes K72-K75) in EU/EEA countries in 2015

M:F 1.6

≤24 years 25-44 years 45-64 ≥65 years

59% ≥65 years old

≤24 years 25-44 years 45-64 years ≥65 years

Chronic viral hepatitis B* and C (B18.0-B18.2), 2015

6475 deaths, EU/EEA rate 1.3/100,000

*with or without delta-agent 6

Age-standardised mortality rates per 100 000 population from chronic viral hepatitis B and C (ICD-10 B18.0, B18.1, B18.2) in EU/EEA countries in 2015

M:F 1.6

64% ≥65 years old

Methods

Mortality attributable to HBV, HCV

CVH B180-B182

Liver cancer C22

CLD K72-K75

Baseline mortality 2015

AF estimates****AF estimates:

for liver cancer: GBD Study 2015, JAMA oncology 2017

for chronic liver diseases: GBD Study 2016, The Lancet 2017

No AF estimates for HCC (C22.0)!CVH

Mortality baseline, 2015 EU/EEA

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6475 6475

53250

29029

1

41146

32558

0

20,000

40,000

60,000

80,000

100,000

120,000

Total mortality(liver cancer, CLD and CVH)

Mortality attributableto HBV, HCV

Nu

mb

er o

f d

eath

s

CLD

Liver cancer

CVH

A baseline mortality of 68,062 deaths attributable to HBV/HCV is proposed for the EU/EEA, comprising:

• 79% of chronic liver diseases• 55% of liver cancer

• all chronic viral hepatitis B/C deaths

79%

55%

Mortality attributable to HBV and HCV in 2015, EU/EEA – number of death from Eurostat adjusted by attributable fraction (AF) estimates from published literature

Chronic liver disease (K72-K75)

Liver cancer (C22)

CVH (B180-B182)

Total

deaths

Total mortality

attributable to

HBV/HCVDeaths AF GBD* Mortality attr. to HBV/HCV

(deaths x AF GBD*)

Deaths AF GBD** Mortality attr. to HBV/HCV

(deaths x AF GBD**)

Deaths

Austria 826 0.87 722 929 0.45 418 262 2017 1402

Belgium 770 0.81 622 948 0.44 417 34 1752 1073

Bulgaria 1748 0.71 1244 677 0.48 325 8 2433 1577

Croatia 464 0.68 315 495 0.36 178 60 1019 553

Cyprus 36 0.87 31 51 0.58 30 4 91 65

Czech Republic 643 0.61 395 818 0.39 319 26 1487 740

Denmark 123 0.87 107 441 0.44 194 15 579 316

Estonia 85 0.69 59 103 0.33 34 5 193 98

Finland 152 0.88 134 505 0.54 273 6 663 413

France 3460 0.87 3007 8544 0.53 4528 502 12506 8037

Germany 6719 0.86 5779 7870 0.41 3227 855 15444 9860

Greece 670 0.87 585 1558 0.6 935 56 2284 1576

Hungary 418 0.74 308 862 0.4 345 185 1465 837

Iceland 6 0.97 6 19 0.61 12 3 28 20

Ireland 119 0.85 101 295 0.55 162 21 435 284

Italy 5386 0.85 4558 9702 0.71 6888 2637 17725 14083

Latvia 202 0.69 139 134 0.55 74 54 390 267

Liechtenstein 1 NA NA 0 1 NA

Lithuania 459 0.69 317 210 0.35 74 28 697 418

Luxembourg 33 0.85 28 43 0.53 23 3 79 54

Malta 7 0.88 6 25 0.63 16 32 22

Netherlands 566 0.85 480 956 0.55 526 34 1556 1039

Norway 102 0.86 88 265 0.63 167 12 379 267

Poland 2116 0.68 1431 2031 0.47 955 293 4440 2678

Portugal 551 0.87 481 1134 0.54 612 128 1813 1221

Romania 8222 0.66 5401 3061 0.38 1163 55 11338 6619

Slovakia 374 0.70 261 403 0.41 165 20 797 446

Slovenia 17 0.70 12 250 0.4 100 1 268 113

Spain 3726 0.90 3357 5044 0.72 3632 790 9560 7779

Sweden 362 0.48 172 688 0.56 385 78 1128 635

United Kingdom 2783 0.87 2414 5189 0.55 2854 300 8272 5568

EU/EEA 41146 0.79 32558 53250 0.55 29029 6475 100871 68062

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*Global Burden of Disease Study 2016 (GBD 2016) Results. Available from http://ghdx.healthdata.org/gbd-results-tool** Global Burden of Disease Liver Cancer Collaboration. The burden of primary liver cancer and underlying aetiologies from 1990 to 2015 at the global, regional, and national level. JAMA Oncology 2017.

0

10000

20000

30000

40000

50000

60000

70000

80000

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

Num

ber

of

death

s

For 65% reduction

44,374

Deaths to prevent for reaching the elimination targets, EU/EEA

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Total mortality attributable to HBV, HCV: deaths from CVH B and C (B180-B182), liver cancer (C22) and CLD (K72-K75)

For 10% reduction

6827

203020202015

• 2015 baseline 68,062

Conclusions

• Mortality from liver diseases in EU/EEA is high and there are large variations across countries

• A 2015 baseline mortality of 68,000 deaths attributable to HBV and HCV is proposed for EU/EEA

• AF estimates matching the WHO Core 10 indicator are lacking!

• Pilot completed by ECDC and EASL to collect AF estimates though a standardised approach (BG, PT, NO)

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Check out our poster!

Acknowledgements

ECDC colleagues: Andrew J Amato-Gauci, Erika Duffell, Chantal Quinten, Josep Jansa, Piotr Kramarz

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