Accounting for an estimated 300,000 deaths in Europe each year, liver diseases are a public health threat that must be addressed. 

[This post has been written by Aina Nicolàs, research assistant at the Health Systems team at ISGlobal, and Jeffrey V Lazarus, head of the Health Systems team at ISGlobal.]

Liver cirrhosis, the most severe stage of liver fibrosis, and liver cancer pose a substantial burden on healthcare systems, greatly affecting people’s quality of life. Liver cancer is the fourth most common cause of death globally, accounting for over 800,000 deaths annually, and hepatocellular carcinoma (HCC) represents approximately 90% of primary liver cancers. The most common aetiological factors of liver cirrhosis and HCC are viral hepatitis, heavy alcohol use and metabolic-dysfunction associated liver disease (MASLD). These diseases often progress silently until severe symptoms and complications arise. However, if liver disease is detected early, severe outcomes can be prevented or even reversed.

At the Barcelona Institute of Global Health (ISGlobal), the Health Systems Research team works daily to put the liver at the centre of health policies, strategies, and interventions, particularly addressing liver conditions among those most vulnerable.

Towards meeting Europe’s liver screening needs

To address the unmet liver screening needs in Europe, our team has committed to leading the public health actions of the LiverAim project. This six-year, €24,8 million project, led by Hospital Clínic-IDIBAPS, was launched on March 1^st, 2024. LiverAim will design and validate a pioneering screening platform with biomarkers for population-wide use in Europe, contributing to reducing morbidity, mortality, and inequities related to liver disease. Our team will assess liver screening gaps in Europe, and examine the public health and health system implications of liver screening uptake.

VH-COMSAVAC project.

Advocating for the big unknown: MASLD and MASH

MASLD is the most common chronic liver disease worldwide, affecting an estimated 38% of adults and 10% of children. MASLD can progress into metabolic dysfunction-associated steatohepatitis (MASH), leading to fibrosis, cirrhosis and HCC. While other liver diseases, such as viral hepatitis, have been recognised as a public health threat since 2016, MASLD and MASH are just beginning to be acknowledged as a public health challenge.

While other liver diseases, such as viral hepatitis, have been recognised as a public health threat since 2016, MASLD and MASH are just beginning to be acknowledged as a public health challenge.

In recent years, our team has led efforts for the recognition of MASLD and MASH as a public health threat, including the first global consensus-built research and action priorities agenda on steatotic liver disease (SLD), which encompasses both MASLD and MASH. It involved 344 experts from 90 countries, and provided a unified vision on how to address SLD in the coming decade. Further, we led the methodology for a multi-year study which resulted in the new nomenclature for fatty liver disease, namely steatotic liver disease with subclassifications incluing MASLD and MASH. Over 100 organisations endorsed the findings, resulting in an affirmative nomenclature to diagnose without using stigmatising language.

Addressing MASLD and MASH in Spain

To enhance the detection and treatment of MASLD and MASH in Spain, our team and Hospital Universitario Virgen del Rocío in Seville (led by Dr. Manuel Romero-Gómez) are spearheading the Clinical Care Pathway Assessment Project (CARPA). This three-year project aims to determine the optimal referral pathway for patients living with MASLD and MASH, from primary care to liver specialists. About 7,000 patients at risk of MASLD-related fibrosis will be recruited, and two diagnostic pathways (ELF testing vs Fibroscan®) will be assessed across 11 primary care and other non-hepatology specialist settings (e.g., endocrinologists, diabetologists).

Chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections can result in chronic liver disease, and are responsible for over half of HCC cases globally, accounting for 1.3 million deaths annually

Hepatitis C Free Balears project.

Towards the Elimination of Viral Hepatitis as Public Health Threat

Chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections can result in chronic liver disease, and are responsible for over half of HCC cases globally, accounting for 1.3 million deaths annually (WHO). Additionally, over 85% of people living with chronic HBV, and over 60% living with HCV remain undiagnosed. Our team is committed to reducing their burden by implementing novel models of care for their prevention, treatment and care of among underserved and at-risk populations.

Contributing to migrants and refugees’ health in Europe

In 2020, our team at ISGlobal led the co-development of a community-centred pilot programme in Barcelona, which has been scaled up to three implementation countries (Italy, Greece and Spain), after receiving co-funding from the European Union (EU). This new project, Viral Hepatitis Multi-Country COMmunity Screening, VAccination, and Care (VH-COMSAVAC), implements a novel community-based model for the prevention and care of viral hepatitis infections among migrants and refugees. It includes the use of simplified people-centred diagnostic tools, prevention strategies, and expedited referral pathways to overcome the barriers to access and utilise health services. Consequently, since 2020, we have successfully provided screening and care services to migrant communities, testing over 1,400 individuals in Spain, Italy and Greece.

Micro-elimination of HCV on the Balearic Islands

People who use drugs are the most affected by HCV infections, often facing a greater health burden due to additional risk factors and barriers to access healthcare (e.g., stigma and discrimination). Consequently, the WHO proposed a decentralised model to simplify access to HCV testing and treatment, from high-level facilities to lower-level facilities (e.g., harm reduction (HR) centres).

Our team has worked to effectively implement this decentralised model for the micro-elimination of HCV infections among people who use drugs on the Balearic Islands through the Hepatitis C Free Balears project. Between 2021 and 2023, we have provided decentralised HCV screening to 1,423 people, and successfully linking 86% of those with an active HCV infection to care and providing them with treatment.

Advocating for Increased Health among People Who Use Drugs in Europe

To combat viral hepatitis and end the AIDS epidemic across Europe, our team is participating in the BOOST project, a three-year project co-funded by the European Commission. By taking a comprehensive, people-centred, and integrated approach, BOOST is strengthening and supporting community-based and community-led HR organisations in providing high-quality services to effectively manage these diseases.

We look forward to continuing to expand the community of practice and ending MASLD/MASH and viral hepatitis as public health threats by 2030, in line with the United Nations’ Sustainable Development Goals.