Prevalence of hepatitis C in Romania: Different from European rates?

We have read with much interest the review by Esteban et al. on the changing epidemiology of hepatitis C virus (HCV) infection in Europe []. Hepatitis C has become a major public health problem worldwide with significant geographical and temporal heterogeneity. The burden of HCV infection in Romania is an area of great concern for at least three main reasons: (1) based on scarce and outdated information, Romania is considered the European country with the highest prevalence rate (double that of Spain or Greece, for example); (2) Romania is one of the most important sources of migrant population towards Western Europe, in particular to countries such as Spain and Italy, therefore altering the decreasing trend of HCV prevalence in these countries; (3) last but not least, there is an urgent need for a national strategy for the active detection and control of the silent epidemic of HCV-infected population in Romania. Although HCV infection is a major public health problem in Romania, its prevalence in the general population and its routes of transmission are largely unknown. Before 1989, during the communist era, data on the prevalence of viral hepatitis in Romania were scarce. The reported prevalence of HCV infection in Romania used in the review by Esteban et al. is the result of a seroprevalence survey conducted between April and July 1990 on a sample of 1355 persons recruited from the population of Bucharest []. The population studied consisted of a low-risk sample, comprising the following groups: (1) children hospitalized for non-infectious diseases, (2) pregnant women, and (3) healthy adults, and a high-risk group comprising (1) children from five orphanages in Bucharest and (2) healthcare workers from four different health facilities in Bucharest. The reported prevalence of HCV infection in healthy adults was 4.5% as compared with 16.9% in the high-risk group of orphans []. From this point on, some other studies on HCV prevalence in Romanian population were published. In 1994, Molnar et al. reported a 4.9% HCV prevalence in general population in three counties in North-Western Transylvania []. In a multicentre study, Grigorescu et al. analyzed the aetiological profile of chronic hepatitis and liver cirrhosis in Romania, showing that HCV infection is responsible for 64% of chronic hepatitis and 59% of liver cirrhosis []. In 2005, our group found HCV infection to be responsible of 27.5% of end-stage liver disease in patients awaiting liver transplantation []. As Esteban et al. pointed out, the figures described above have changed in Romania, such as in all of Europe, in the last two decades due to the eradication of transfusion-acquired infections, the great improvement in healthcare facilities and the limited increase in intravenous drug users (IDU) in our country. We take this opportunity to present the preliminary data of a nationwide cross-sectional survey scheduled to be carried out between 2006 and 2008, aimed to determine the prevalence and risk factors for HCV infection in the general population in Romania through a multicentre stratified random cluster sampling investigation. To represent the geographical, economic, demographic, ethnic, and behavioural characteristics of the whole population, Romania was divided into three initial main strata representing the three geo-historical regions of Romania (Table 1). Serum samples from 8039 healthy adults (response rate 72%, aged 19–69 years) were tested for anti-HCV antibodies with a third generation EIA and confirmed by PCR testing. Overall, 273 anti-HCV positive patients were detected (3.50%; CI 3.10–3.92%). The prevalence of HCV infection for all of the 54 centres was significantly higher in rural areas (4.43%; CI 3.60–5.23%) as compared to urban areas (2.76%; CI 2.26–3.67%). A higher prevalence of HCV is associated with older age groups (P = 0.002), lower education level (P = 0.006) and lower income level (P = 0.0001). HCV infection independently associated with the history of transfusion, parenteral treatment, haemodialysis, and IDU, suggesting that transfusions and contaminated equipment used for medical procedures has played a key role in HCV transmission among the Romanian population. Finally, we fully agreed with Esteban et al. that large-scale epidemiological studies, including molecular investigation, are required in order to estimate the HCV burden and characteristics, especially in new European countries, where scarce data are available, along with immediate measures to control (prevention of nosocomial transmission, control of HCV epidemic among IDU) and treat HCV infection.