EASL calls on the EU to accelerate public health policies to reduce the high human and financial burden of liver diseases

EASL is the largest professional body in Europe devoted to liver health. EASL’s overarching goal is to spread knowledge and expertise in best practices and the latest scientific breakthroughs in the field of hepatology. It also advocates at national, European, and global levels for patients, caregivers, and all who are impacted by liver disease.

In 2020, an EASL-Lancet Commission reported on the status of liver health and care across Europe. A key message of this report was a call to action for health professionals, nations, and the international community to implement a significant paradigm shift within liver care. This paradigm shift included an emphasis on prevention of liver disease through evidence-based public health measures that reduce per capita intake of alcohol and unhealthy foods, and tackle obesity, viral hepatitis, and stigma. EASL is focused on public health and policy activities which reduce 4 key diseases:

1. Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)
2. Alcohol-related Liver Disease (ArLD)
3. Viral Hepatitis
4. Liver Cancer

With this statement, EASL reiterates evidence-based recommendations to the European Union Institutions for the next political term, to address boldly the human and financial burden of liver disease in Europe. We can no longer ignore the enormous impact on millions of lives across Europe, and on health budgets in every country.

As we move beyond the European Parliament elections and the new European Commission is appointed, we will work intensively with our sister organisations in public health and with the EU Institutions to accelerate the changes that are urgently needed in these four key liver diseases areas and in non-communicable diseases more broadly.

MASLD is the most widespread liver disease with an estimated 38% of the global adult population being diagnosed with the disease and 13% of children and adolescents [I]. This disease shares common metabolic risk factors with obesity, diabetes type 2, and cardiovascular disease. The burden of MASLD is expected to grow in the coming decades with wide-ranging implications for public health and health systems, yet countries are ill-prepared to face this challenge. The burden of advanced liver disease due to MASLD will more than double during 2016-2030, and the annual predicted economic burden of MASLD in Europe will be more than €35 billion in direct costs and a further €200 billion in societal costs [II]. Unhealthy diets and sedentary lifestyles are the strongest risk factors for MASLD, and the disease remains preventable and treatable through lifestyle modification.

EASL recognises that reducing the morbidity and mortality of MASLD in Europe requires coordinated action to implement evidence-based health policies directed at reducing behavioural risk factors and improving health environments at local, national, and international levels [III]. EASL believes in a Health-in-All-Policies approach and strongly advocates for the following policy recommendations.

1. Increase excise taxes on sugar-sweetened beverages (SSBs), index-linked with inflation.
2. Introduce a complete ban on the marketing of SSBs, including on social media and digital media.
3. Introduce or strengthen food labelling and removal of cartoons and other children-oriented branding on high fat, salt, and sugar (HFSS) products.
4. Introduce a complete ban on all SSB sponsorships of sports and events.
5. Restrict the physical availability of SSBs and ensure that healthy and nutritious choices are available and affordable to all consumers.

Implement multicomponent school-based education programmes and interventions focusing on both physical activity and healthy diet in children.

Alcohol causes huge personal and economic harms in Europe. Alcohol consumption is responsible for more than 3 million deaths per year worldwide. Europe is the highest alcohol-consuming region in the world. Almost half of deaths due to liver disease in Europe are due to alcohol [IV]. All of these diseases and deaths are preventable. Alcohol consumption is a significant public health problem that needs immediate and focused attention by policymakers in Europe, with proven measures available.

The most effective and cost-effective means to reduce death and harm from ARLD are interventions which reduce alcohol consumption in the general population. Partial implementation of such policies correlate with a reduction in alcohol consumption, according to data from 15 European countries [V]. There is a strong economic case for investing in preventing harmful alcohol consumption and in treatment of alcohol use disorder. For every €1 invested in a comprehensive policy package to reduce population alcohol consumption, up to €16 is returned in economic benefits [VI].

Key evidence-based recommendations to reduce alcohol harms, from EASL’s Alcohol Policy Statement on Reducing Alcohol Harms and Hepahealth II are:

1. All European Union and European countries devise and implement a strategy to reduce alcohol-related harms and share learnings.
2. Introduce a minimum unit price (MUP) on alcohol products and increase excise duties, index-linked with inflation.
3. Introduce a complete ban on alcohol marketing, including on social media and digital media.
4. Introduce a complete ban on all alcohol sponsorship of sports and events.
5. Utilize an alcohol licensing system to restrict hours of alcohol sales, the density of alcohol outlets, and the separation of alcohol in mixed-trading outlets.
6. Introduce strict legislation and enforcement of the minimal legal purchasing age of 18 years.
7. Ensure strict enforcement of drink-driving countermeasures.
8. Introduce mandatory health warnings and ingredient labelling on all alcohol products.
9. Introduce a levy on the alcohol industry to recoup the cost of alcohol harms, a cost currently borne by the taxpayer.
10. Use levy on alcohol industry to fund treatment of alcohol-related illnesses, social care, justice costs, and research.

Viral hepatitis affects over 350 million people worldwide. Nine out of ten people living with viral hepatitis are unaware of their diagnosis. According to the World Health Organization (WHO) 2024 Global Hepatitis Report, the number of lives lost due to viral hepatitis is increasing. The disease is the second leading infectious cause of death globally. New data from 187 countries show that the estimated number of deaths from viral hepatitis increased from 1.1 million in 2019 to 1.3 million in 2022.  Of these, 83% were caused by Hepatitis B and 17% by Hepatitis C. Every day, 3,500 people die from viral hepatitis. The combined burden of viral hepatitis B and C is greater than HIV/AIDS and Tuberculosis combined. According to WHO, viral hepatitis could be eliminated by 2030 if the appropriate measures are implemented [VII]. In the WHO European Region, an estimated 15 million people live with chronic hepatitis B, and an estimated 14 million people are infected with hepatitis C.

EASL recommends the following activities for viral hepatitis:

1. Leverage the Council Recommendation on vaccine-preventable cancers to close the vaccination gap for all children, adolescents and adults at risk of contracting viral hepatitis B.
2. Address the gaps in country policies to address the lack of hepatitis B vaccination in key adult populations
3. Recommend enhanced awareness on transmission, prevention and testing for viral hepatitis B and C and investments to scale up case-finding and screening for viral hepatitis in selected community settings (e.g. harm reduction or drug services).
4. Encourage the scaling up of diagnosis treatment for hepatitis C (HCV) to eliminate HCV infection. Treatment of key populations must be emphasised alongside harm reduction measures to prevent new infections.
5. Improve health literacy on prevention of cancer related to infections, including viral hepatitis B and C by making use of the dedicated funding in the EU4Health Work Programme.
6. Address the need for system improvements to reduce the impact of stigma and discrimination on the lives of people living with or at risk of contracting viral hepatitis.
7. Address social determinants of health and decentralise service delivery prioritising outreach programs for marginalised and vulnerable populations affected by viral infections.
8. Engage affected communities and civil society in advancing research for improved diagnostics and potential vaccines for Hepatitis C cures for Hepatitis B.

In Europe, the number of deaths from liver cancer has doubled in the past 30 years. Around 80-90% of patients with liver cancer have an underlying chronic liver disease. The strong relationship between chronic liver disease and liver cancer means that prevention and treatment of chronic liver disease equate to primary prevention of liver cancer.

EASL urges European Member States to prioritise screening policies which focus on at-risk populations [VIII], ensure equal access for all patients to optimal information, measures, and treatment, and increase preventative methods targeted at environmental and behavioural risk factors [IX]. The following recommendations were proposed by EASL and more than 30 health organisations, with the aim of giving the liver greater priority in European public health [X].

1. Educate health practitioners and the general population on the potential prevention of liver cancer through physical activity, healthy eating and avoiding smoking and excessive alcohol consumption.
2. Develop evidence-based multilevel public health interventions that reduce the disproportionate burden of liver cancer placed on marginalised and vulnerable populations.
3. Address the essential activities for the integration of social needs into liver cancer health policy
4. Raise awareness about liver cancer screening as a means to reduce mortality from liver cancer.
5. Introduce liver cancer screening for high-risk groups into national strategies.
6. Improve access to better disease management and integrative care for all patients and ensure the highest standards of care for all.
7. Set up specific liver cancer patient registries to collect and share data to advance medical knowledge and clinical practice.

EASL is the largest professional body in Europe devoted to liver health. EASL’s overarching goal is to spread knowledge and expertise in best practices and the latest scientific breakthroughs in the field of hepatology. It also advocates at the national, European, and global level for patients, caregivers, and all who are impacted by liver disease. If you want to know more, please get in touch with our advocacy team: easloffice@easloffice.eu

[I] Lazarus JV, Mark HE, Allen AM, Arab JP, Carrieri P, Noureddin M, Alazawi W, Alkhouri N, Alqahtani SA, Arrese M, Bataller R, Berg T, Brennan PN, Burra P, Castro-Narro GE, Cortez-Pinto H, Cusi K, Dedes N, Duseja A, Francque SM, Hagström H, Huang TT, Wajcman DI, Kautz A, Kopka CJ, Krag A, Miller V, Newsome PN, Rinella ME, Romero D, Sarin SK, Silva M, Spearman CW, Tsochatzis EA, Valenti L, Villota-Rivas M, Zelber-Sagi S, Schattenberg JM, Wong VW, Younossi ZM; Healthy Livers, Healthy Lives Collaborators. A global research priority agenda to advance public health responses to fatty liver disease. J Hepatol. 2023 Sep;79(3):618-634. doi: 10.1016/j.jhep.2023.04.035. Epub 2023 Jun 20. PMID: 37353401.

[II] ^[1] Karlsen TH, Sheron N, Zelber-Sagi S, et al. The EASL-Lancet Liver Commission: protecting the next generation of Europeans against liver disease complications and premature mortality. Lancet. 2022;399(10319):61-116. doi:10.1016/S0140-6736(21)01701-3

[III] Retat L, Webber L, Jepsen P, Martin A, Cortez-Pinto H, Lazarus JV, Negro F, Mitchyn M, Guzek J, Card-Gowers J, Graff H, Nahon P, Sheron N, Sagi SZ, Buti M. Preventing liver disease with policy measures to tackle alcohol consumption and obesity: The HEPAHEALTH II study. J Hepatol. 2024 Apr;80(4):543-552. doi: 10.1016/j.jhep.2023.11.021. Epub 2023 Dec 11. PMID: 38092157.

[IV] ^[1] Karlsen TH, Sheron N, Zelber-Sagi S, et al. The EASL-Lancet Liver Commission: protecting the next generation of Europeans against liver disease complications and premature mortality. Lancet. 2022;399(10319):61-116. doi:10.1016/S0140-6736(21)01701-3

[V] ^[1] Karlsen TH, Sheron N, Zelber-Sagi S, et al. The EASL-Lancet Liver Commission: protecting the next generation of Europeans against liver disease complications and premature mortality. Lancet. 2022;399(10319):61-116. doi:10.1016/S0140-6736(21)01701-3

[VI] OECD (2021), Preventing Harmful Alcohol Use, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/6e4b4ffb-en.

[VII] United Nations. (2015). Transforming our world: the 2030 Agenda for Sustainable Development. New York.

(https://sustainabledevelopment.un.org/ post2015/transformingourworld/)

[VIII] European Association for the Study of the Liver. EASL Policy Statement on risk-based surveillance for hepatocellular carcinoma among patients with cirrhosis, https://easl.eu/publication/easl-policy-statement-risk-based/ (accessed on 15.04.2024)

[IX] Kondili LA, Lazarus JV, Jepsen P, Murray F, Schattenberg JM, Korenjak M, Craxì L, Buti M. Inequities in primary liver cancer in Europe: The state of play. J Hepatol. 2024 Apr;80(4):645-660. doi: 10.1016/j.jhep.2023.12.031. Epub 2024 Jan 17. PMID: 38237866.

[X] European Association for the Study of the Liver. Open letter: 10 asks to improve liver cancer care in Europe. https://easl.eu/wp-content/up-loads/2021/08/easl-open-letter-on-liver-cancer-care.pdf (accessed on 05-04-2002)