Title: Chronic viral hepatitis in ethnic minorities. Strategies to prevent the predicted increase in mortality
Funder: Department of Health (England)

Abstract: Aims & Objectives We will determine whether screening immigrants for chronic viral hepatitis in primary care is feasible, acceptable to the communities at risk, and cost effective. We will determine whether therapy for viral hepatitis in primary care is achievable, and both clinically and cost effective. We will determine whether community treatment improves engagement and increases the number of patients who access the effective therapies that are NICE approved for these potentially lethal infections. Background Chronic viral hepatitis (persistent infection with either hepatitis B or hepatitis C) causes an asymptomatic disease that leads to cirrhosis and death in a large proportion of those who are infected. These asymptomatic diseases are often not associated with abormalities of liver function tests precluding identification by simple non-specific testing. The prevalence of viral hepatitis is at least ten fold greater in immigrants than in the indigenous community (prevalence in the UK is ~0.5% but > 5% in immigrants) and there is abundant data (from the Health Protection Agency and liver transplant programs - see later) that the mortality and morbidity in ethnic minorities is growing rapidly. Early identification of people with chronic viral hepatitis allows effective therapy, shown by NICE to be highly cost effective. Given the rising mortality in ethnic minorities from chronic viral hepatitis the Advisory Group on Hepatitis and The National Screening Committee have considered screening in immigrants but there is no data on whether this is feasible and clinically/cost effective. The UK has one of the lowest rates of therapy for viral hepatitis in Europe and this is undoubtedly contributing to the rising mortality from liver disease in the UK (mortality is falling in the rest of Europe). UK studies have shown that access to therapy for patients known to have viral hepatitis is poor with only a tiny minority of diagnosed patients going on to receive treatment. Strategies that improve access to treatment are likely to have a major impact on treatment uptake but alternatives to hospital based treatment have not been studied. Research Plans We will address the evidence gap in screening immigrants for chronic viral hepatitis. We will examine community attitudes to screening (to ensure that screening is acceptable and determine how best to provide information about it). We will critically evaluate opportunistic screening (testing patients from high risk countries when they attend their GP) and targetted screening (contacting patients at risk and asking them to attend). We will complete a cluster randomised clinical trial of antiviral therapy in primary care to determine whether community treatment is feasible and determine whether it improves engagement and increases the proportion of immigrants who access antiviral therapy. We will complete a full cost effectiveness analysis of our interventions and model the burden of disease to allow a national assessment of the impact of viral hepatitis in immigrants. Research Team The research team includes practising research hepatologists,virologists and academic general practitioners who have completed studies of screening in primary care. All have published extensively in this field. Experts in qualitative research, health economics and the chairman of a national patient group are co-applicants. An experienced trials unit will manage the trial. Program management We will establish a management and steering committee with independent chairmen, financial expertise and patient representatives Outputs We will determine the best way to engage immigrant communities at risk of viral hepatitis and determine how best to involve them in health care screening We will determine how best to screen immigrants for chronic viral hepatitis and make an evidence based recommendation to The National Screening Committee that may lead to a national program. We will determine the cost effectiveness of screening. Our clinical trial of engagement with community therapy is of enormous importance for the estimated 400,000 people with viral hepatitis living in the UK - it has the potential to transform the delivery of care and to provide the evidence to support a transfer of care from tertiary centres to the community Patient Involvement Patients have been involved throughout the development of this proposal and representatives from African, Chinese and Muslim groups will dominate the management committees. Ethics We have piloted critical, ethically challenging parts of the work and these preliminary studies demonstrate that our plans are viable. The Prof. of ethics at QMUL is a co-applicant and has been heavily involved in developing the research plans to ensure that they are acceptable Resources Funding for research fellows as well as support for the many GPs who will participate in this program is requested.


Research activity codes: 4.4 POPULATION SCREENING
Health categories: INFECTION