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Description
HE-RO-I, project for investment and development of medical services in Romania for chronic liver diseases, liver cirrhosis and liver cancer, is a pilot project that integrates three major components adapted to the medical needs of our country: rapid response regarding access to medical services-of-the-art for vulnerable groups in Romania, including Roma, long-term access to primary, secondary, tertiary prevention programs, complete diagnosis, monitoring and follow-up for those in need, awareness program for beneficiaries regarding the importance of prevention and continuous medical follow-up.
-Organization in 16 counties included in the project of at least 16 mobile caravans, 1 caravan/county. - Establishing a regional registry for chronic liver diseases and liver cancer.- Establishing a telemedicine system for chronic liver diseases, liver cirrhosis and liver cancer.- Carrying out at least 2 mobilities (experience exchanges) between the two teams of experts (Romania, Iceland) with the aim of professional training of the medical personnel involved in the implementation of the project. The transversal activity involves the exchange of experience and the transfer of knowledge between Iceland and Romania with the aim of good implementation, efficiency and quality improvement of all the activities provided for in the project. The activity will involve continuous Iceland-Romania communication, the organization of regular meetings, the organization of mobilities, the publication in the consortium of at least 5 scientific articles presenting the results of the project. By carrying out the mobilities, the Romanian doctors in the implementation team will benefit from state-of-the-art professional training from the partners in the donor state.
Summary of project results
Chronic liver diseases are defined as a progressive deterioration of liver functions lasting longer than 6 months. In these conditions, the most affected liver functions are the synthesis of coagulation factors, detoxification processes, and, not least, bile excretion. Chronic liver diseases represent a continuous, partially reversible process characterized by inflammation, destruction, and regeneration of the liver parenchyma, which can eventually lead to fibrosis and liver cirrhosis and/or the development of primary liver neoplasms as a consequence of chronic injury.
The spectrum of etiologies for these diseases is broad, including chronic infections with hepatotropic viruses, especially hepatitis B and C viruses, chronic alcohol consumption, metabolic toxins, autoimmune diseases, and genetic disorders. Cirrhosis is the final stage of chronic liver disease, resulting in a global alteration of liver architecture through the formation of micro- and/or macronodules of regeneration, vascular reorganization through neoangiogenesis, and the deposition of an extracellular matrix. The mechanism preceding fibrosis and liver cirrhosis is not yet fully elucidated. Scientific literature indicates that, at the cellular level, hepatic stellate cells and fibroblasts, with fibrogenic roles, are recruited and compete with hepatic stem cells responsible for the continuous regeneration of the liver parenchyma.
Chronic liver disease is a common clinical entity, with a focus on etiopathogenesis, clinical manifestations, and management.
INCIDENCE AND PREVALENCE: According to statistical data, globally, 1.5 billion people suffer from at least one chronic liver disease. Among the most common risk factors are: non-alcoholic fatty liver disease (NAFLD) (60%), hepatitis B virus (HBV) (29%), hepatitis C virus (HCV) (9%), and chronic alcohol consumption (2%) [1]. In Europe, the average prevalence of chronic liver diseases is 833 per 100,000 people, ranging from 447 to 1100. Data regarding the prevalence of cirrhosis in some European countries, especially in disadvantaged regions and countries with limited financial and infrastructural resources, is scarce or even nonexistent; thus, these figures represent only approximate data [2, 3]. Based on official data from the "Global Burden of Disease" study, this is a pathology with an exponentially increasing rate.
The major complications of chronic liver diseases include cirrhosis, with 1.2 million annual deaths, and liver cancer, accounting for 790,000 annual deaths, representing 3.5% of total global deaths [4]. Globally, the incidence of liver cirrhosis in these patients was 20.7 per 100,000 people in 2015, an increase of 13% compared to 2000. The estimated incidence of cirrhosis in Europe is 26.1 per 100,000 people, while in Asia, it varies from 16.5 per 100,000 people in the eastern part of the continent to 23.6 per 100,000 in Southeast Asia [5].
In countries like Japan or Taiwan, implementing national immunization programs against HBV and HAV has led to a decrease in cirrhosis cases. However, in many countries like the USA, which has high rates of obesity, metabolic syndrome, and chronic alcohol abuse, the number of cirrhosis cases remains high [5, 6, 7]. Mortality rates exhibit geographic variability, being lower in East Asia, the Middle East, and the Pacific, and higher in South Asia, the Americas, and Eastern Europe. These disproportionate trends can be explained by differences in implementing national prevention and treatment strategies.
Viral hepatitis remains the leading cause of mortality in chronic liver diseases due to its major complication, cirrhosis. In developed countries with well-defined public health programs, mortality caused by HBV is decreasing due to population immunization and viral hepatitis treatment. Another major risk factor for cirrhosis-related deaths in Europe is chronic alcohol consumption. Mortality rates vary between countries: lower rates are recorded in Austria, Denmark, France, Iceland, Germany, Hungary, while higher rates are observed in Finland, Ireland, the United Kingdom, as well as Eastern European countries, including Romania. Thus, in countries with official registries, national screening programs, vaccination campaigns, and adequate awareness regarding the elimination of risk factors responsible for the onset and progression of chronic liver diseases, the number of cases is significantly decreasing.
The HE-RO-I project (“State-of-the-art Collaborative Romania-Iceland in the Management of Chronic Liver Diseases and Their Complications”) was designed as an innovative pilot program aimed at improving access to high-quality healthcare for vulnerable populations in Romania, including the Roma community. Implemented over 24 months, the project targeted both immediate and long-term needs related to the prevention, early diagnosis, and continuous monitoring of chronic liver diseases such as hepatitis B and C, cirrhosis, and liver cancer.
Key activities and deliverables included:
1. Mass screening across 16 regions – Mobile screening campaigns were conducted in rural and underserved areas. In collaboration with local authorities, family physicians, and community nurses, the project provided on-site testing for viral hepatitis B/C, alcohol use (AUDIT/CAGE), dietary risks, sleep disturbances (Epworth), anxiety (ASQ), physical inactivity (Duke), and nicotine dependence (Fagerstrom). At least 16,000 individuals received at least one type of liver disease screening.
2. Advanced mobile diagnostic caravans – For 1,600 individuals identified at higher risk, the project delivered state-of-the-art diagnostic services, including ultrasound and elastography, biochemical markers (e.g., FIB-4, APRI, HOMA-IR), and specialized medical assessments in line with European guidelines (EASL). Personalized monitoring plans were created based on individual medical needs.
3. Awareness and health education campaigns – These targeted the project''s vulnerable populations to raise health literacy, enhance understanding of disease prevention, and improve trust in the healthcare system. Communication strategies included printed materials, community meetings, and collaboration with media outlets.
4. Creation of a Regional Registry – A digital health registry was developed to enable continuous monitoring of patients diagnosed with chronic liver diseases or cancer. Initially, 300 individuals were enrolled. The system records clinical and laboratory data, schedules follow-ups, and tracks treatments.
5. Development of a Telemedicine Platform – Romania’s first telemedicine service dedicated to chronic liver diseases and liver cancer was established, providing real-time remote consultations for patients with limited access to specialists.
6. Hackathon-style public health event – Toward the end of the project, a participatory innovation event was organized with stakeholders, experts, authorities, and citizens to generate scalable and sustainable solutions based on the project’s field experience.
The project was carried out through a strong partnership between the Regional Institute of Gastroenterology and Hepatology in Cluj-Napoca (Romania), the NGO ''Caravana cu Medici'', and Iceland’s Landspítali University Hospital, combining clinical expertise, public health innovation, and international collaboration.
The HE-RO-I project achieved substantial outcomes in terms of improved healthcare access, early detection, and public health literacy for underserved populations. It succeeded in bringing advanced liver disease prevention and monitoring services directly to vulnerable communities that traditionally face major healthcare disparities.
Key results and impacts include:
1. 16,000+ beneficiaries screened – Individuals from 16 rural regions underwent health screening for liver diseases and associated risk factors, many for the first time. This helped identify hidden cases of hepatitis B/C and metabolic liver disease.
2. 1,600 high-risk individuals assessed with advanced tools – These persons received detailed medical evaluations including elastography and biomarker testing. They now have access to ongoing follow-up plans.
3. 300 patients enrolled in a long-term registry – These cases are being continuously monitored through a new digital platform that supports personalized care planning, facilitating better outcomes and early intervention.
4. Awareness improved in vulnerable groups – Through education campaigns, the project increased knowledge about hepatitis transmission, safe hygiene, risks of alcohol abuse, and the value of early diagnosis and treatment. This fostered greater health-seeking behavior.
5. First liver disease telemedicine system in Romania – A major innovation that expanded access to medical specialists and allowed real-time consultation for patients in remote or underserved areas.
6. Stronger bilateral cooperation – The Iceland-Romania partnership created a model for international collaboration in public health, with opportunities for future joint projects, research, and knowledge transfer.
Overall, HE-RO-I empowered communities to take ownership of their health, improved the quality of care available to vulnerable populations, and established systems for long-term impact, including digital health infrastructure, mobile care delivery, and stakeholder engagement platforms like the hackathon.