infection with the hepatitis b and c viruses ( hbv and hcv ) causes significant morbidity and 
 mortality . even though hbv infection can be prevented through vaccination , the world health 
 organization ( who ) has estimated that globally around 240 million people are chronically 
 infected [ 1 , 2 ] with between 500  000 and 700  000 deaths each year [ 1 , 3 ] . who estimates also 
 indicate that 23% of the world 's population are hcv - infected , equating to 120170 million 
 people .
about 10 million people die annually 
 ( 27% of all deaths ) from causes related to viral hepatitis , most commonly liver disease , 
 including liver cancer .
an estimated 57% of 
 liver cirrhosis cases and 78% of primary liver cancers result from hbv or hcv infection 
 .
co - infections with hiv are an increasing 
 problem in countries with hiv epidemics in people who inject drugs ( pwid ) , and in those 
 treated with hiv anti - retrovirals , and underlying viral hepatitis is becoming a major cause 
 of death .
globally there are geographical variations in the extent of both hbv and hcv infection 
 including within europe . in the european union 
 ( eu ) and european free trade association ( efta ) area , prevalence in the general population 
 varies from 04% to 52% for anti - hcv and from 01% to 56% for hbsag .
hepatitis prevalence in the rest of the who european region , mainly 
 eastern europe and central asia countries , has not been assessed even though this part of 
 the region has recently experienced an accelerating hiv epidemic and an increase in the 
 population of pwid .
hbv and hcv are bloodborne viruses that are easily transmitted through blood - to - blood 
 contact [ 2 , 911 ] .
parenteral routes , particularly 
 injecting drug use or poor hygiene in clinical settings , are major sources of transmission 
 [ 2 , 912 ] .
hbv can also be transmitted 
 sexually , and this route has also been reported for hcv in certain circumstances [ 10 , 13 ] . 

perinatal transmission of both hbv and hcv can also occur [ 2 , 9 , 10 ] .
the majority of adults infected with hbv spontaneously resolve their infection and develop 
 protective immunity .
less commonly chronic 
 infection results and , in rare cases , causes potentially fatal acute liver failure .
in contrast to hbv , the majority of hcv - infected 
 adults develop chronic disease .
those with 
 chronic infections remain infectious to others and are at risk of developing serious liver 
 disease such as cirrhosis or hepatocellular cancer [ 15 , 16 ] .
the available antiviral treatments 
 for both hbv and hcv infections have increased and become more effective [ 17 , 18 ] . 

treatment may also have a role in prevention through reducing the pool of infectious people 
 .
as chronic hbv and hcv infections are largely asymptomatic , many patients who might benefit 
 from treatment remain undetected .
efforts are 
 needed to detect those infected and who would benefit from treatment , so that the costly 
 sequelae of infection can be reduced [ 21 , 22 ] . to target
case - finding it is necessary to know 
 which population groups are most affected ; and information on the likely numbers infected is 
 needed for healthcare planning , for example , to assess the cost of providing treatment . 

examination of these at a regional level allows comparison of the burden between countries 
 as well as informing international responses .
the aims of this study were to : ( a ) assess the prevalence of hbv and hcv 
 infection in the who european region countries outside the eu / efta through a literature 
 review ; ( b ) generate simple estimates of the numbers living with hbv and 
 hcv infection in these countries , and ( c ) to compare this burden with that 
 in the rest of the who european region obtained from published data .
studies that had measured hbv and hcv seroprevalence since 2000 were identified through a 
 literature review . to be included , studies had to : ( a ) have tested a 
 biological sample ( self - reports were excluded ) to measure prevalence of hbsag or anti - hcv 
 in a who european region country outside the eu / efta area ( n  =  20 , table 1 ) ; ( b ) do so in one or more 
 of these adult population groups : general population , blood donors , pregnant women , pwid , 
 men who have sex with men ( msm ) , and sex workers ; and ( c ) have been 
 published from 2000 to 2010 inclusive .
table 1.number and geographical coverage of studies that had measured the prevalence of 
 hepatitis b surface antigen ( hbsag ) or antibodies to the hepatitis c virus 
 ( anti - hcv ) in each population group by country : countries in the who european region 
 outside eu / efta(a ) general population 
 and blood donorscountrygeneral populationblood donorshbsaganti - hcvhbsaganti - hcvno . of studiescoverage of studiesno . of studiescoverage of studiesno . of studiescoverage of studiesno . of studiescoverage of studiesalbania3national ( x2 ) ,
1 city / area11 city / area21 city / area , n.s.21 city / area , n.s.armenia0000azerbaijan0000belarus0000bosnia & herzegovina001national2national , 1 city / areacroatia001national1nationalgeorgia011 city / area00israel001national1nationalkazakhstan11 city / area2national , 1 city / area1national0kyrgyzstan012 cities / areas00montenegro001national1nationalrepublic of moldova0000russian federation2?national , 1 city / area2?national , 1 city / area11 city / area11 city / areaserbia ( incl .
kosovo*)11 city / area11 city / area11 city / area11 city / areatajikistan01multi - site1national1nationalthe former yugoslav republic of macedonia0011 city / area11 city / areaturkey9multi - site ( x2 ) , 1 city / area ( x7)7multi - site , 1 city / area ( x6)3national , 1 city / area ( x2)3national , 1 city / area ( x2)turkmenistan0000ukraine4unclear3unclear3unclear2unclearuzbekistan1multisite1multisite1multisite2multisite 
 total 

 21 

 20 

 18 

 18 
 ( b ) people who 
 injecting drugs ( pwid)pwidhbsaganti - hcvno .
/ area21 city / areaarmenia00azerbaijan1multi - site2multi - site , 2 cities / areasbelarus1multi - site2multi - site , 1 city / areabosnia & herzegovina2multi - site2multi - sitecroatia3national multi - site , 1 city / area3national , multi - site , 1 city / areageorgia31 city / area4multi - site , 1 city / area ( x3)israel1national1nationalkazakhstan12 cities / areas2national , 2 cities / areaskyrgyzstan02multi - site , 2 cities / areasmontenegro1unclear21 city / area , unclearrepublic of moldova1national1nationalrussian federation22 cities / areas , 1 city / area16multi - site ( x2 ) , 1 city / area ( x12 ) , unclear 
 ( x2)serbia ( incl .
kosovo*)11 city / area3multi - site , 1 city / area ( x2)tajikistan02multi - site , 1 city / areathe former yugoslav republic of macedonia00turkey1multi - site11 city / areaturkmenistan00ukraine31 city / area ( x1 ) , unclear ( x2)61 city / area ( x4 ) , unclear ( x2)uzbekistan02national multi - sitetotal2253(c ) men who have sex 
 with men ( msm ) and sex workersmsmsex workershbsaganti - hcvhbsaganti - hcvno .
of studiescoverage of studiesalbania11 city / area000armenia0000azerbaijan11 city / area11 city / area1multi - site1multi - sitebelarus0000bosnia & herzegovina1national1national1national1nationalcroatia11 city / area21 city / area , national01nationalgeorgia11 city / area11 city / area00israel0000kazakhstan01national01nationalkyrgyzstan01national03national multi - site , 1 city / areamontenegro0000republic of moldova011 city / area011 city / arearussian federation012 cities / areas03multi - site , 1 city / area ( x2)serbia ( incl .
kosovo*)11 city / area11 city / area11 city / area11 city / areatajikistan0001nationalthe former yugoslav republic of macedonia0000turkey1multi - site02multi - site , 1 city / area11 city / areaturkmenistan0000ukraine1unclear1unclear1unclear1unclearuzbekistan0002multi - site , 1 city / areatotal811617eu / efta , european union and european free trade association area ; n.s . , not 
 stated . ;  ?  , preceding a detail indicates that the information available on this 
 item in the source was limited.*according to united nations security council resolution 1244 ( 1999 ) .
number and geographical coverage of studies that had measured the prevalence of 
 hepatitis b surface antigen ( hbsag ) or antibodies to the hepatitis c virus 
 ( anti - hcv ) in each population group by country : countries in the who european region 
 outside eu / efta eu / efta , european union and european free trade association area ; n.s . , not 
 stated . ;  ?
 , preceding a detail indicates that the information available on this 
 item in the source was limited . according to united nations security council resolution 1244 ( 1999 ) .
medline and embase were searched for studies on the prevalence of hbv and hcv ( see 
 supplementary online material for search terms ) .
the grey literature were indentified 
 through searches of documents held by the who regional office for europe , the european 
 monitoring centre for drugs and drug addition ( emcdda ) website , and the sources identified 
 in a systematic review on hiv in the who european region  which had systematically 
 collected data on seroprevalence studies ( including those with a focus on viral hepatitis ) 
 .
the titles and abstracts were first reviewed to identify relevant publication ( in 
 english or russian ) , the full text was then assessed for inclusion and data extracted 
 ( including secondary reports ) .
data relating to screening of first - time blood donors was 
 obtained from the council of europe report .
the prevalences in pregnant women were combined with the general population data . the 
 nature of this population , women of child - bearing age
, could mean that the prevalence 
 might not reflect that overall in the general population , particularly if prevalence 
 differs by gender or age , or if fertility rates are higher in migrant groups with higher 
 prevalences ; however , we have assumed that such differences are likely to be small 
 overall .
prevalence in first - time blood donors was not combined with the general 
 population data , as blood donors are a highly select group . in most countries those who 
 may have been at risk of infection with bloodborne viruses are excluded from giving blood , 
 thus blood donors are usually likely to be at lower risk overall than the general 
 population .
a  selected prevalence estimate in the general population was obtained for each country 
 using the algorithm in table 2 .
table 2.algorithm used to select a national prevalenceprevalences were selected using the following 
 hierarchy:(1 )  national studies.(2 )  studies with multiple sites across the 
 country.(3 )  regional / city levels studies.if more there was than one study ( for example 
 several multi - site studies ) then the weight mean was used ( or mean if this 
 could not be calculated ) to obtain the selected 
 prevalence .
algorithm used to select a national prevalence the total number of adults currently infected with hbv and hcv was estimated by applying 
 the hbsag and anti - hcv prevalences to the 2008 national adult ( aged 15 years ) population 
 estimates . in countries that had a selected 
 prevalence in blood donors only , the prevalence in the general population was simply 
 imputed from the blood - donor data .
this was done by using the median ratio of the 
 blood - donor estimates to the general population estimates for those countries with 
 selected estimates for both of these groups . for countries with no general population and 
 no blood - donor estimate
medians were used as the distributions were skewed , with a small number of countries 
 having a much higher prevalence than the rest ; the median thus gives a more conservative 
 estimate than would be obtained using the mean .
for hcv , 74% of those anti - hcv positive 
 were assumed to have current infection . to obtain comparable simple estimates of the numbers living with these infections in the 
 eu / efta countries the same method
was applied to published data ( n  =  30 , 
 excluding four with populations < 100  000 ) .
prevalence in first time blood donors 
 was taken from the council of europe report , 
 with additional data from an european centre for disease prevention and control ( ecdc ) 
 review   ( hbsag prevalence for 27 countries , 
 anti - hcv for 26 ) .
general population prevalences were obtained from the ecdc review , this 
 had obtained selected prevalences for the eu / efta countries using a similar method ( 13 
 countries hbsag , 12 anti - hcv ) .
the numbers of current pwid infected with hbv and hcv were obtained by applying the 
 selected pwid hbsag and anti - hcv prevalences to published national estimates of the number 
 of current injectors [ 26 , 27 ] .
where national estimates of the current injecting population 
 were not available the median of the national prevalences of injecting drug use was used 
 to impute the number of pwid from the adult population data . for countries with no hbsag 
 or anti -
hcv prevalence estimate for pwid the median of the selected national prevalences 
 was used .
medians were again used as the distributions were skewed . as with the general 
 population for hcv , 74% of those anti - hcv positive
were assumed to have current infection 
 . to obtain comparable simple estimates of the number of pwid living with these infections 
 in the eu / efta countries prevalence data from studies undertaken since 1999
was downloaded 
 from the emcdda website   ( all eu states and 
 norway report hbv and hcv seroprevalences for pwid to emcdda ) and literature searches for 
 switzerland and iceland ( not members of emcdda ) .
numbers were then estimated using the same 
 approach , including imputations for missing data , as for the countries outside 
 eu / efta .
after accounting for studies reported by more than one publication , a total 86 sources were 
 identified ( supplementary fig .
twenty - one studies , undertaken in seven countries ( 35% of total ) , had measured hbsag 
 prevalence in a group representing the general population ( table 1 ) : 11 recruited from the general population , five pregnant 
 women , and five other groups ( supplementary table s1 ) .
half of these studies had recruited 
 from one city / area ( table 1 ) .
thirteen countries 
 ( 65% ) had measured hbsag prevalence in blood donors ( 18 studies , 39% had national 
 coverage , table 1 ) .
the study hbsag prevalences 
 ranged from 01% ( blood donors , bosnia & herzegovina ) to 13% ( general population , 
 uzbekistan , supplementary table s1 ) .
1 ) ranged from 13% to 13% for the general population ( median 34% , mean 
 50% ) and from 01% to 84% for blood donors ( median 11% , mean 22% ) .
the selected 
 general population prevalence was higher than the selected blood - donor prevalence in five 
 of the seven countries with both ( table 3 ) , the 
 median of the ratio between these was 14 ( range 05726 , mean 16 ) .
1.prevalence of antibodies to hepatitis c virus ( anti - hcv ) and hepatitis b surface 
 antigen ( hbsag ) in ( a ) the general adult population ; 
 ( b ) people who inject drugs ( pwid ) in the who european region , by 
 country .
. 
 table 3.simple estimates of the number of adults with hepatitis b surface antigen ( hbsag ) 
 and hepatitis c virus ( hcv ) in who european regioncountrypopulation aged 15 yr in 2008prevalence in first time blood donorsprevalence in studies representing 
 general populationprevalence in general population 
 imputed from blood donors*prevalence estimate usedestimated numbers with infection 
 ( rounded to nearest 100)aged 15 yrhbsaganti - hcvhbsaganti - hcvhbsaganti - hcvhbsaganti - hcvhbsaganti - hcvchronic hcv 
 those outside eu / efta 
 albania2  389  00070%07%90%30%11%25%measuredmeasured215  00071  70053  000armenia2  431  000azerbaijan6  549  000belarus8  228 
000bosnia & herzegovina3  170  00001%003%01%01%imputed from bdimputed from bd470019001400croatia3  760  00002%01%03%02%imputed from bdimputed from bd10  20076005600georgia3  575  00067%measured239  500177  200israel5  077  00001%01%02%02%imputed from bdimputed from bd830010  4007700kazakhstan11  796  00018%38%10%24%measuredmeasured448  200118  00087  300kyrgyzstan3  790  00016%measured60  60044 
900montenegro498  00007%06%10%12%imputed from bdimputed from bd500059004400republic of moldova3  016  000russian federation120  185  00011%21%15%36%15%43%measuredmeasured1 
802  8004  326  7003  201  700serbia8  068  00042%03%24%05%57%06%measuredmeasured193  60040  30029  900tajikistan4  239  00030%29%05%41%59%imputed from bdmeasured171  80021  20015  700fyr macedonia1  674  00010%02%14%05%imputed from bdimputed from bd22  80075005600turkey53  958  00021%03%34%07%29%07%measuredmeasured1  834  600377  700279  500turkmenistan3  531  000ukraine39  554  00010%13%13%12%13%27%measuredmeasured514  2004  746  5003  512  400uzbekistan19  034  00052%64%133%131%71%13%measuredmeasured2  531  5002  493  5001  845  200countries without hbsag31  120  00034%estimated from median prevalence1  058 
100anti - hcv15  527  00023%estimated from median prevalence357  100264  300total ( rounded to nearest 1000)8  821  00012  886  00095  360  000 
 those in eu / efta 
 austria7  087  00001%01%03%05%imputed from bdimputed from bd24  30037  90028  000belgium8  790  00001%003%07%06%04%03%measuredmeasured61  50052  70039  000bulgaria6  606  00018%04%13%79%45%imputed from bdmeasured520  80085  90063  500cyprus707  00001%002%09%04%02%measuredimputed from bd640014001  000czech republic8  875  000004%013%06%02%13%measuredimputed from bd53  300118  00087  300denmark4  476  000003%003%01%03%imputed from bdimputed from bd610012  4009200estonia1  140  00003%07%12%70%imputed from bdimputed from bd13  60079  60058  900finland4  403  000003%004%02%01%04%measuredimputed from bd880017  90013  200france50  870  000003%002%13%01%02%imputed from bdmeasured61  400661  300489  400germany70  748  00001%01%06%04%06%08%measuredmeasured424  500283  000209  400greece9  578  00020%03%21%10%84%33%measuredmeasured201  10095  80070  900hungary8  511  00000%03%00%31%imputed from bdimputed from bd2600267  400197  900iceland249  000ireland3  506  000001%001%01%01%01%measuredimputed from bd350031002300italy51  260  00004%14%52%17%measuredmeasured717  6002  665  5001  972  500latvia1 
943  000lithuania2  823  00006%10%26%103%imputed from bdimputed from bd73  900289  800214  500luxembourg395  00001%01%04%06%imputed from bdimputed from bd170025001800malta342  000netherlands13  553  00001%002%01%04%03%02%measuredmeasured13  60054  20040  100norway3  862  000003%003%01%04%imputed from bdimputed from bd440013  60010  000poland32  389  00005%02%19%20%19%imputed from bdmeasured659  800615  400455  400portugal9  076  00001%02%04%17%imputed from bdimputed from bd36  900157  000116  100romania18  157  00037%09%56%35%158%92%measuredmeasured1  016  800635  500470  300slovakia4  536  00001%01%06%06%05%measuredimputed from bd27  20024  00017  700slovenia1  733  00001%003%04%04%imputed from bdimputed from bd750061004500spain37  814  00002%01%10%20%07%14%measuredmeasured378  100756  300559  600sweden7  641  000005%01%02%04%02%06%measuredmeasured15  30030  60022 
600switzerland6  335  00002%01%07%06%imputed from bdimputed from bd44  80040  60030  000united kingdom50  210  000004%004%07%02%04%imputed from bdmeasured86  400351  500260  100countries without hbsag2  534  00006%estimated from median prevalence15  200anti - hcv2  534  00012%estimated from median prevalence29  10021  600total ( rounded to nearest 1000)4  487  0007  387  9005  467  000total europe 732  137  00013  308  00020  274  00015  003  00018%28%20%bd , blood donors ; fyr macedonia , former yugoslav republic of macedonia ; anti - hcv , 
 antibodies to the hpatitis c virus ; eu / efta , european union and european free 
 trade association area.*estimated using median of the national ratios of the general population 
 prevalence to prevalence in blood donors .
prevalence of antibodies to hepatitis c virus ( anti - hcv ) and hepatitis b surface 
 antigen ( hbsag ) in ( a ) the general adult population ; 
 ( b ) people who inject drugs ( pwid ) in the who european region , by 
 country . hatched areas on maps indicate countries outside the who european 
 region .
simple estimates of the number of adults with hepatitis b surface antigen ( hbsag ) 
 and hepatitis c virus ( hcv ) in who european region bd , blood donors ; fyr macedonia , former yugoslav republic of macedonia ; anti - hcv , 
 antibodies to the hpatitis c virus ; eu / efta , european union and european free 
 trade association area . estimated using median of the national ratios of the general population 
 prevalence to prevalence in blood donors .
ten countries ( 50% ) had measured the anti - hcv prevalence in groups representing the 
 general population ( 20 studies : nine recruited from the general population , six pregnant 
 women , five other groups ) , with two - thirds of these studies covering one city / area ( table 1 ) .
twelve countries ( 60% ) had measured 
 anti - hcv prevalence in blood donors ( 18 studies , 39% recruited from one city / area , table 1 ) .
the study anti - hcv prevalences ranged from 003% ( blood donors , bosnia 
 & herzegovina ) to 13% ( general population , uzbekistan , supplementary table s1 ) . 
 the selected country estimates ( table 3 , fig .
1 ) ranged from 05% to 13% for the general 
 population ( median 23% , mean 43% ) and from 003% to 64% for blood donors ( median 046% , 
 mean 13% ) .
the selected general population prevalence was higher than the selected 
 blood - donor prevalence in six of the seven countries with measures of both ( table 3 ) , the median of the ratio between these was 
 21 ( range 01792 , mean 30 ) .
fourteen ( 70% ) countries had measured hbsag prevalence and 17 ( 85% ) anti - hcv prevalence 
 in pwid ( table 1 ) . in total 54 studies
were 
 identified , including 30 that had recruited from community settings ; eight from needle and 
 syringe programmes , low - threshold facilities , harm reduction , or outreach services ; three 
 from addiction treatment settings ; four through other service types ; and five through 
 mixed settings ( setting was unclear in four , see supplementary table s2 ) .
twenty - two studies had measured hbsag ( 38% 
 recruited in one city / area , table 1 ) and 53 
 studies anti - hcv prevalence ( 53% recruited in one city / area , table 1 ) .
the study hbsag prevalences ranged from 0% to 34% , and the 
 anti - hcv prevalences from 53% to 95% ( supplementary table s2 ) .
( median 
 68% , mean 92% ) and from 53% to 73% for anti - hcv ( median 46% , mean 46% ) .
table 4.estimates of number of current hepatitis b and c infections in the who european 
 region : eu / efta and non - eu / efta comparisonsadult population(%)current hbv(%)current hcv(%)eu / efta*427  615  000(58)4  487  000(34)5  467  000(36)non eu / efta304  522  000(42)8  821  000(66)9  536  000(64)who european region732  137  000(100)13  308  000(100)15  003  000(100)eu / efta , european union and european free trade association area.*twenty - seven eu member states : austria , belgium , bulgaria , cyprus , czech 
 republic , denmark , estonia , finland , france , germany , greece , hungary , ireland , 
 italy , latvia , lithuania , luxembourg , malta , the netherlands , poland , portugal , 
 romania , slovakia , slovenia , spain , sweden , united kingdom.four eea / efta countries : norway , iceland , liechtenstein , switzerland.albania , armenia , azerbaijan , belarus , bosnia & herzegovina , croatia , 
 georgia , israel , kazakhstan , kyrgyzstan , montenegro , republic of moldova , russian 
 federation , serbia ( incl .
kosovo ) , tajikistan , the former yugoslav republic of 
 macedonia , turkey , turkmenistan , ukraine .
estimates of number of current hepatitis b and c infections in the who european 
 region : eu / efta and non - eu / efta comparisons eu / efta , european union and european free trade association area .
twenty - seven eu member states : austria , belgium , bulgaria , cyprus , czech 
 republic , denmark , estonia , finland , france , germany , greece , hungary , ireland , 
 italy , latvia , lithuania , luxembourg , malta , the netherlands , poland , portugal , 
 romania , slovakia , slovenia , spain , sweden , united kingdom .
albania , armenia , azerbaijan , belarus , bosnia & herzegovina , croatia , 
 georgia , israel , kazakhstan , kyrgyzstan , montenegro , republic of moldova , russian 
 federation , serbia ( incl .
kosovo ) , tajikistan , the former yugoslav republic of 
 macedonia , turkey , turkmenistan , ukraine .
thirteen studies were found that had measured the prevalence of either hbsag or anti - hcv 
 in msm ( supplementary table s3 ) .
the samples sizes ranged from 61741 ( mean 235 , median 
 157 ) , and the majority had recruited msm from community settings ( 11 , 85% ) .
eight ( 40% ) 
 countries had undertaken a single study that had measured the hbsag prevalence in msm 
 ( five recruited from one city / area , table 1 ) . 
 the prevalences ranged from 0% to 18% ( supplementary table s3 ) with a median of 64% ( mean 
 69% ) .
eleven studies ( from 10 countries , 50% ) reported anti - hcv prevalence in msm ( five 
 recruited from one city / area , table 1 ) .
the 
 median of study anti - hcv prevalence was 42% ( mean 78% , range 016% , supplementary table 
 s3 ) .
seventeen studies ( supplementary table s4 ) had measured the prevalence of either hbsag or 
 anti - hcv in sex workers : samples sizes ranged from 1382249 ( mean 591 , median 315 )
. almost 
 half of the studies ( eight , 47% ) recruited sex workers from community settings , with four 
 recruiting through services ( 23% ) and two ( 12% ) from both community settings and services 
 ( setting unclear for three , supplementary table s4 ) .
six studies , from five countries 
 ( 25% ) , reported an hbsag prevalence in sex workers ( two recruited from one city / area , 
 table 1 ) ; prevalence ranged from 2% to 18% 
 ( supplementary table s4 ) , the median was 29% ( mean 61% ) .
seventeen studies from 12 
 countries ( 60% ) , reported an anti - hcv prevalence in sex workers ( seven recruited from one 
 city / area , table 1 ) ; prevalences ranged from 
 24% to 40% ( median 11% , mean 14% ) .
general population prevalence estimates were imputed from the blood - donor prevalence 
 using the median ratio of the general population to the blood - donor prevalence derived 
 from those countries with both ( table 3 ) . 
 applying this ratio to the blood - donor prevalence in those countries
from which it was 
 derived , gave a median difference between the countries measured and the imputed general 
 population prevalence of 0004% for hbsag ( range 33% to 62% , mean 06% ) and 002% for 
 anti - hcv ( range 54% to 93% , mean 07% ) .
this variability indicates that a country 
 prevalence imputed this way should be treated with caution .
the selected and imputed prevalences obtained here were applied to population data to 
 produce simple estimates of the numbers infected .
these estimates indicate that of the 
 3045 million adults living outside the eu / efta area 88 million ( 29% ) have hbsag and 95 
 million ( 31% ) have hcv rna ( table 3 ) . 

comparable estimates for the eu / efta countries obtained by applying the same method to 
 published data   ( table 3 , fig . 1 ; the median 
 ratio between the selected general population and the selected blood - donor prevalence used 
 in the imputations was 43 for hbsag and 11 for anti - hcv ) .
these indicated that of the 
 4276 million adults in the eu / efta countries 45 million ( 10% ) have hbsag and 55 
 million ( 13% ) have hcv rna ( table 3 ) .
these 
 levels are respectively around one - third and one half of the levels estimated for the area 
 outside the eu / efta . combining these simple estimates
indicates that of the 7321 million 
 adults in the who european region 133 million ( 18% ) have hbsag and 150 million ( 20% ) 
 have hcv rna ; with two - thirds of those living with each infection outside the eu / efta area 
 ( table 4 ) .
the selected and imputed estimates of prevalence in pwid were used to derive simple 
 estimates of the number of current pwid living with hbv and hcv infection outside the 
 eu / efta . considering the wide range in the estimated prevalences of injecting drug use 
 ( 007736% ) and in the prevalences of the two infections in pwid ( see above ) the imputed 
 data should be viewed with great caution .
these estimates indicate that of the estimated 
 32 million current pwid outside the eu / efta 07 million ( 21% ) have hbsag and 15 milion 
 ( 47% ) have hcv rna ( table 5 ) .
table 5.simple estimates of the number of people who inject drugs with hepatitis b surface 
 antigen ( hbsag ) and hepatitis c virus ( hcv ) in who european regioncountrypopulation aged 15 yr in 2008estimated number of current pwid*prevalenceestimated numbers with infection 
 ( rounded to nearest 100)numberprevalenceimputed from median prevalencehbsaganti - hcvhbsaganti - hcvchronic hcv 
 those outside eu / efta 
 albania2  389  00010  00015%13%15001300900armenia2  431  0002000008%azerbaijan6  549  000300  000458%59%54%17  700162  700120  400belarus8  228  0006308008%13%39%80025001800bosnia and herzegovina3  170  0005500017%27%38%10021001500croatia3  760  00016  740045%08%46%10077005700georgia3  575  000127  833358%29%67%370085  60063  400israel5  077  00021  00043%62%90013  0009600kazakhstan11  796  000100  000085%79%60%790060  00044  400kyrgyzstan3  790  00025  000066%54%13  60010  000montenegro498  000200038%800600republic of moldova3  016  0003810013%68%43%30016001200russian federation120  185  0001  825  000152%31%73%565  8001  332  300985  900serbia8  068  00018  000022%15%52%260094006900tajikistan4  239  00017  000040%33%55004100fyr macedonia1  674  0002691016%turkey53 
958  000226  00029%53%660012  0008900turkmenistan3  531  00014  000ukraine39  554  000375  000095%12%71%44  000266  300197  000uzbekistan19  034  00080 
000042%36%28  80021  300median prevalence of injecting drug use04%countries without hbsag estimated using 
 median prevalence142  69168%9700countries without anti - hcv estimated 
 using median prevalence18  69146%86006400total ( rounded to nearest 1000)662  0002  014  0001  490  000 
 those in ue / efta 
 austria7  087  00017  500025%53%93006900belgium8  790  00025  800029%37%74%100019  10014  100bulgaria6  606  00020  250031%55%58%110011  7008700cyprus707  000446006%35%36%20200100czech republic8  875  00031 
200035%12%37002700denmark4  476  00012  754028%53%67005000estonia1  140  00013  801121%90%12  4009200finland4  403  00015  650036%42%66004900france50  870  000122  000024%45%54  90040  600germany70  748  00094  250013%20%75%190070  70052  300greece9  578  0008148009%25%50%20041003000hungary8  511  0003941005%05%23%20900700iceland249  000600ireland3  506  0006289018%04%72%3045003400italy51  260  000326  000064%59%193  000142  800latvia1  943  000550074%41003000lithuania2  823  0005123018%59%73%30037002800luxembourg395  0001482038%39%81%1001200900malta342  00090033%300200netherlands13  553  0003115002%30%77%10024001800norway3  862  00010  032026%12%74%10074005500poland32  389  00088  00046%59%400051  90038  400portugal9  076  00016  425018%50%46%80076005600romania18  157  00049  00010%64%500031  40023  200slovakia4  536  00018  841042%50%94007000slovenia1  733  0007310042%34%22%20016001200spain37  814  00083  972022%73%61  60045  500sweden7  641  00029  513039%88%26  00019  300switzerland6  335  00031  653050%78%24  70018  300united kingdom50  210  000142 
650028%46%65  60048  600median prevalence of injecting drug use03%countries without hbsag estimated using 
 median prevalence852  53435%29  800countries without anti - hcv estimated 
 using median prevalence60059%400300total ( rounded to nearest 1000)45  000697  000516  000total europe ( rounded to nearest 1000)706  0002  711  0002  006  000fyr , the former yugoslav republic of macedonia ; anti - hcv , antibodies to the 
 hepatitis c virus ; eu / efta , european union and european free trade association 
 area ; eu / efta hbsag and anti - hcv data from emcdda website plus a literature search 
 for switzerland and iceland ( national study ;   weighted 
 mean of national studies ;   multi - city ;   weighted mean from 
 city / sub - region studies ;   one city / region.)*mathers et al . , 
 plus data for bosnia & herzegovina , croatia , czech republic , cyprus , 
 estonia , greece , luxembourg , macedonia , portugal , sweden , and united kingdom from 
 emcdda website ; and data for serbia from the republic of serbia ungass country 
 progress report on aids 2010 .
simple estimates of the number of people who inject drugs with hepatitis b surface 
 antigen ( hbsag ) and hepatitis c virus ( hcv ) in who european region fyr , the former yugoslav republic of macedonia ; anti - hcv , antibodies to the 
 hepatitis c virus ; eu / efta , european union and european free trade association 
 area ; eu / efta hbsag and anti - hcv data from emcdda website plus a literature search 
 for switzerland and iceland ( national study ;   weighted 
 mean of national studies ;   multi - city ;   weighted mean from 
 city / sub - region studies ;   one city / region . ) mathers et al .
, 
 plus data for bosnia & herzegovina , croatia , czech republic , cyprus , 
 estonia , greece , luxembourg , macedonia , portugal , sweden , and united kingdom from 
 emcdda website ; and data for serbia from the republic of serbia ungass country 
 progress report on aids 2010 .
comparable estimates for current pwid living in eu / efta countries were derived from 
 published data   by applying the same method 
 ( table 5 , fig .
these estimates for eu / efta should be viewed cautiously , as due to the 
 substantial variability in the prevalences ( injecting drug use : 00612% , median 028% , 
 mean 031% ; hbsag : 0310% , median 35% , mean 37% ; anti - hcv : 1288% , median 59% , mean 
 58% ) the imputed data used here are likely to be subject to much uncertainty .
the 
 estimation process indicates that of the estimated 12 million current pwid in the eu / efta 
 area 45000 ( 37% ) have hbsag and 05 million ( 43% ) have hcv rna ( table 5 ) .
the proportion with anti - hcv is comparable with the level 
 outside of the eu / efta ; however , the proportion with hbsag is much lower ( table 4 ) . combining these estimates
indicates that 
 in current pwid ( estimated 45 million ) across the who european region 07 million ( 15% ) 
 have hbsag and 20 million ( 44% ) have hcv rna ( table 
 5 ) .
our simple estimates suggest that almost 1/50 adults in the who european region have hbv 
 infection and a similar proportion chronic hcv . outside of the eu / efta area prevalence was 
 around three times higher for hbsag and over twice as high for hcv rna .
prevalence of these 
 infections was highest in pwid ( 15% and 44% , respectively ) .
although the estimates here need 
 to be viewed with caution , they do suggest a sizable burden due to these two viral 
 infections in the region , particularly outside the eu / efta area .
the prevalence data on 
 hbsag and anti - hcv were obtained from literature searches , while grey literature was 
 included , it is possible studies will still have been missed particularly if they have 
 recently been undertaken , reported in languages other than russian or english , or 
 unpublished .
second , measures of the prevalence of hbsag and anti - hcv were not identified in 
 all populations or in all countries . in many countries
no national studies had been 
 undertaken , thus local and regional data were assumed to be reflective of the whole country . 

small studies ( n  <  100 ) and those where population was not 
 specifically or clearly defined were excluded ; however , we did not asses the methodological 
 quality of the studies , in part because data available was often limited .
the studies used a 
 range of designs and thus the robustness of the resulting data is likely to be variable . 
 where no measure of prevalence was found , simple imputation approaches were applied . 

even 
 so , the extensive nature of searches undertaken in this assessment mean that it is likely to 
 provide as robust an estimation as is currently practical at the regional level . in the who european region outside the eu / efta , the measured hbsag and anti - hcv prevalences 
 were highest in pwid , but infection was also common in the general population ( 38% and 
 23% , respectively ) , msm ( 87% and 42% , respectively ) , and in sex workers ( 33% and 11% , 
 respectively ) .
there was substantial variation between countries , while prevalence of these 
 infections in pwid was high in most countries ; uzbekistan had a prevalence of 13% for both 
 infections in the general population .
the general population hcv prevalence estimate was 
 also elevated in the ukraine and georgia , and in albania the general population hbsag 
 prevalence estimate was elevated . while these differences might be related to the 
 methodologies used in the studies , they warrant further investigation . for the general population , pwid and
msm prevalences were higher than in the eu / efta area 
 , although comparable data for eu / efta was very 
 limited for msm .
the ecdc review   found only two 
 studies from the eu / efta countries that had measured hbsag in msm [ 4% sweden 19931997 , and 
 < 1% uk ( scotland ) 19932003 ] and one study that had measured anti - hcv [ 13% amsterdam 
 ( the netherlands ) 2003 ] , indicating a need for further studies of prevalence for msm and 
 other transmission risk populations . for sex workers data on the prevalence of these 
 infections has not been reviewed for the eu / efta area , but considering the elevated 
 prevalence found here this is needed . in the countries outside the eu / efta
, msm have a 
 higher prevalence of both hbsag and anti - hcv than the general population , and sex workers 
 had higher anti - hcv prevalence . the high anti - hcv prevalence in msm and sex workers
the higher prevalences of both infections in msm is a concern considering the evolving 
 epidemic of hiv in this group in parts of central and eastern europe .
the ratios between the general population estimates and the blood - donor estimates were 
 higher for the eu / efta area compared to outside ( almost three times higher for hbsag and 
 about five times higher for anti - hcv ) .
the reasons for this difference are unclear , but it 
 could for example , be due to more success in excluding those who have been at risk of 
 infection from blood donation in the eu / efta countries , or be a reflection of the higher 
 prevalence of these infections in the general population outside the eu / efta area .
the estimates of the numbers infected simply applied prevalence to population data ; with 
 the prevalences derived from studies using a range of methodologies and imputed for 
 countries with no data ( the majority lacked a general population hbsag estimate ) .
there is 
 some corroboration for the estimates obtained from comparison with published national 
 estimates for hcv . in italy a modelling approach estimated 21 million people chronically 
 infected with hcv in 2000 and 19 million in 2005   compared to the 20 million estimated here . in the uk , modelling approaches 
 suggest that around 200  000 people are living with chronic hcv infection [ 30 , 31 ] , while 
 the simple uk estimate here ( n  =  260  100 ) is higher it is within the 
 confidence range . for
the pwid estimates there is some corroboration from the uk , where 66  000 current pwid 
 were estimated as hcv - infected in england and wales   compared to the simple uk estimate here of 48  600  though the study had 
 estimated a larger injecting population than the one used here .
the estimates of the number 
 of infected pwid obtained here will be particularly uncertain , as estimates of infection 
 prevalence are being simply applied to estimates of the number of current pwid .
both of 
 these are difficult to measure due to the illicit and marginalized nature of injecting drug 
 use , and are thus are likely to be subject to much uncertainty .
the estimated number of pwid 
 should thus be used very cautiously . in the uk almost as many former pwid were estimated to 
 have hcv as current pwid .
the estimates 
 obtained here relate to number of infected current pwid , but there will also be many former 
 pwid that will have been infected .
it is thus likely that many of the infections in the 
 region not in current pwid will be in former pwid .
a previous estimate had suggested that 14 million people were living with chronic hbv 
  in the who european region , although the 
 method used for this estimate is not given , it provides some corroboration for the 133 
 million estimated here . in the 1990s , it was estimated from national prevalence data , that 
 there were 89 million people living with hcv   in 
 the who european region ( prevalence 10% ) , our estimate suggest that hcv infection might 
 have increased over time to 15 million ( prevalence 20% ) .
if so , this might reflect 
 transmission in pwid , particularly in the east of the region , where there has been a recent 
 and accelerating epidemic of hiv in pwid .
viral hepatitis has been recognized as a global public health problem and a world health 
 assembly resolution   has called on member 
 states to take action to strengthen preventive and control measures .
our findings indicate a 
 large pool of individuals infected with hbv and hcv in the who european region , and so the 
 potential for further transmission .
the who 's recent framework for global action to prevent 
 and control viral hepatitis   describes the work 
 needed .
interventions to prevent transmission [ 2 , 
 9 , 35 ] , 
 including information on safer sex , condom distribution , needle and syringe programmes , and 
 strict infection control practices in healthcare and other settings , need to be maintained 
 and expanded as appropriate .
hbv can be prevented through vaccination , national policies 
 should be reviewed regularly , and in those countries with universal vaccination programmes 
 targeted vaccination of high - risk groups should be considered , as recommended by who .
easy access to diagnostic testing is an important entry point for 
 accessing both prevention and treatment programmes , and in higher prevalence countries 
 targeted screening programmes should be considered for those at greatest risk .
other 
 measures can also reduce the transmission of viral hepatitis , such as , ensuring a safe blood 
 supply .
this study provides useful data for policy makers on the scale of hbv and hcv infection in 
 the region .
policy makers need consider the extent of these diseases when planning health 
 services in order to ensure that appropriate interventions [ 3537 ] are provided on a 
 sufficient scale to reduce the burden arising from these two preventable infections .
these findings indicate that there may be over 13 million adults living with hbv and 15 
 million with hcv in the who european region  indicating a large burden for treatment and 
 care .
the prevalence of these infections appears to be higher outside the eu / efta , with 
 these countries ( mainly in eastern europe and central asia ) accounting for 66% of those with 
 hbsag and 64% of those with hcv rna , yet only 42% of the european region 's adult population 
 ( table 4 ) .
efforts to prevent , diagnose and 
 treat these infections need to be maintained and improved .
surveillance of the 
 seroprevalence of these infections and related risk behaviours in the affected populations 
 is needed to monitor trends and allow assessment of the impact of interventions .
 summaryknowledge of hepatitis b and c prevalence , and numbers infected , are important for 
 planning responses . published hbsag and anti - hcv prevalences for the 20 who european 
 region countries outside the eu / efta were extracted , to complement published data for the 
 eu / efta . 
 the general population prevalence of hbsag ( median 38% , mean 50% , seven 
 countries ) ranged from 13% ( ukraine ) to 13% ( uzbekistan ) , and anti - hcv ( median 23% , mean 
 38% , 10 countries ) from 05% ( serbia , tajikistan ) to 13% ( uzbekistan ) . people who inject 
 drugs had the highest prevalence of both infections ( hbsag : median 68% , mean 82% , 13 
 countries ; anti - hcv : median 46% , mean 46% , 17 countries ) , and prevalence was also elevated 
 in men who have sex with men and sex workers . 
 simple estimates indicated 133 million 
 ( 18% ) adults have hbsag and 150 million ( 20% ) hcv rna in the who european region ; 
 prevalences were higher outside the eu / efta countries . 
 efforts to prevent , diagnose , and 
 treat these infections need to be maintained and improved.this article may not be reprinted or reused in any way in order to promote any commercial 
 products or services . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
SUPPLEMENTARY MATERIAL
DECLARATION OF INTEREST