Introduction
As of 2023, 45.33% of Romania’s population resides in rural areas (1), many in remote regions with limited access to healthcare and education.
Aims & Methods
This study aimed to assess the prevalence of viral hepatitis and the prevalence, metabolic characteristics and fibrosis burden of MASLD among Romania’s remote rural population. To our knowledge, this is the first study to assess the health profile of this population, with a focus on liver diseases.
Between 2022 and 2024, medical Caravans were conducted in 17 villages across Central and North Romania. Participants underwent hepatology consultations, laboratory testing (including rapid tests for hepatitis B and C), abdominal ultrasound and non-invasive assessment of steatosis and fibrosis using ultraportable devices. MASLD was defined by the presence of hepatic steatosis on ultrasound and at least one cardiometabolic risk factor (obesity, diabetes or prediabetes, dyslipidemia or hypertension) (2). Fibrosis was staged using liver stiffness measurement(LSM), FIB-4 and NAFLD Fibrosis Score(NFS). Data for this study was colected prospectively on-site.
Results
1,935 individuals were screened, 1,721 had blood tests, 1,692 had rapid tests for hepatitis B and C, and 1,208 underwent ultrasound. The prevalence of hepatitis B was 2.18% and of hepatitis C was 3.19%. MASLD status could be assessed in 1,305 participants, of whom 617 (47.3%) met the diagnostic criteria. MASLD was significantly associated with obesity (OR=5.07, 95%CI[3.93–6.54], p<0.001), diabetes or prediabetes (OR=3.43, 95%CI[2.56–4.61], p<0.001) and dyslipidemia (OR=2.29, 95%IC[1.80–2.91], p<0.001). Most MASLD patients had multiple metabolic risk factors(RF): 17.02% had 1 risk factor, 30.47% had 2, 52.51% had 3 or more.
Median values for liver stiffness(5.2–5.3 kPa) and FIB-4 score(1.14-1.28) showed minimal variation across individual cardiometabolic risk factors. Fibrosis staging methods showed increasing trends of advanced fibrosis with higher cardiometabolic burden, but only the NFS demonstrated statistically significant differences between risk groups(p=0.0025 for 1vs3+, p=0.0012 for 2vs3+).
Advanced fibrosis prevalence among MASLD patients based on different tests was: LSM 6.24% (vs.3.29% in non-MASLD, p=0.001), FIB-4 5.3% ( vs. 6.1%, p=0.144), NFS 7.8% (vs.4.0%, p < .001). Dyslipidemia was associated with the highest prevalence of advanced fibrosis among MASLD patients based on LSM (6.86%) and NFS (8.44%), and diabetes or prediabetes based on FIB-4 (3.56%). Among those with advanced fibrosis,diabetes was present in over 90% of patients across all methods.
Conclusion
There is a substantial burden of preventable and underdiagnosed diseases in Romania’s remote rural communities. The prevalence of hepatitis B and C was at or above national estimates, underscoring the need for expanded screening and vaccination. MASLD affected nearly half of this large rural cohort. The presence of advanced fibrosis and clustering of metabolic risk factors in these underserved populations highlights the need for continued outreach, early detection and integrated liver care strategies.
References
1. National Institute of Statistics. Romania in figures-statistical abstract. https://insse.ro/cms/ro/content/rom%C3%A2nia-%C3%AEn-cifre-breviar-statistic-limba-englez%C4%83-4
2. European Association for the Study of the Liver (EASL); European Association for the Study of Diabetes (EASD); European Association for the Study of Obesity (EASO). EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). J Hepatol. 2024 Sep;81(3):492-542. doi: 10.1016/j.jhep.2024.04.031.
Disclosure
The HE-RO-I Project (State-of-the-art colaborativ ROmânia-Islanda în managementul HEpatopatiilor cronice și a complicaţiilor acestora, ciroza hepatică și cancerului hepatic, destinat grupurilor vulnerabile din România, inclusiv Romi) was initiated by a team of physicians from the Gastrointestinal and Hepatology Institute of Cluj-Napoca, in collaboration with Caravana cu Medici – Cluj-Napoca Branch and Landspítali University Hospital in Reykjavik, Iceland, under the coordination of the Romanian Ministry of Health. The project aimed to deliver health education and conduct screening—primarily for liver diseases—among vulnerable populations (including roma people) from remote areas of Central and Northern Romania.
Financed by the Finance Mechanism of European Economic Space 2014-2021.