Simple intervention to improve detection of hepatitis B and hepatitis C in general practice

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Hugh Gilmore
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1 Simple itervetio to improve detectio of hepatitis B ad hepatitis C i geeral practice Zayab al-lami (GP-Birmigham) Co-authors:-Sarah Powell, Sally Bradshaw, Amada Lambert, David Mutimer ad Adrew Rouse Presetatio Outlie Itroductio Hepatitis B/C as a public health problem Aims ad Methods Results Coclusios Fial thoughts

Itroductio The Problem of Hepatitis B ad C ifectio

public health problem it is thought to affect

highest prevalece rates are foud i o-uk bor

majority puttig them at risk of ifectig others Such

ad hepatocellular carcioma a Uddi et al (2010)

South Asia ethicity livig i Eglad: the prevalece

Approximately 50% of cases with chroic hepatitis C

carcioma 15-25% of cases with chroic hepatitis B

carcioma Worldwide approximately 80% of all cases

2 Itroductio The Problem of Hepatitis B ad C ifectio Chroic hepatitis B ad C ifectio remais a importat public health problem it is thought to affect approximately half a millio people i the UK The highest prevalece rates are foud i o-uk bor idividualsa It remais asymptomatic i the vast majority puttig them at risk of ifectig others Such idividuals are at high risk of developig cirrhosis ad hepatocellular carcioma a Uddi et al (2010) Prevalece of chroic viral hepatitis i people of South Asia ethicity livig i Eglad: the prevalece caot ecessarily be predicted from the prevalece i the coutry of origi; J Viral Hepat. May 17(5): Epub 2009 Dec 9. Itroductio The Problem of Hepatitis B ad C ifectio Approximately 50% of cases with chroic hepatitis C ifectio will progress to cirrhosis & hepatocellular carcioma 15-25% of cases with chroic hepatitis B will die prematurely of cirrhosis or hepatocellular carcioma Worldwide approximately 80% of all cases of hepatocellular carcioma are due to chroic hepatitis B ifectio

Aims To use a simple protocol to improve

practice The protocol would allow o-uk bor

referral to a specialist for review to decide

Practices withi the Heart of Birmigham PCT with

regardig offerig opportuistic hepatitis B/C

to participate Eligibility criteria for patiet

GP surgery for a blood test for a o-liver

hepatitis B/C status Betwee April 2009 ad July

3 Aims To use a simple protocol to improve detectio of hepatitis B ad hepatitis C i geeral practice The protocol would allow o-uk bor idividuals to be opportuistically screeed for asymptomatic hepatitis B ad C ifectio Idetificatio of such idividuals would the allow referral to a specialist for review to decide whether treatmet was eeded or ot Methods Practices withi the Heart of Birmigham PCT with a sizeable o-uk bor populatio were approached regardig offerig opportuistic hepatitis B/C testig to patiets Six were idetified ad agreed to participate Eligibility criteria for patiet screeig icluded all of the followig: - Attedig GP surgery for a blood test for a o-liver related coditio - Bor outside the UK - Ukow hepatitis B/C status Betwee April 2009 ad July 2010, practice staff idetified patiets usig those criteria as part of ew patiet registratio, scheduled phlebotomy cliics ad at routie GP cosultatios 1012 patiets coseted to screeig

Methods Positive cases were idetified by the relevat screeig

(HBsAg) - Hepatitis C presece of Hepatitis C atibody

recordig template was key i facilitatig data collectio

4%) tested positive for hepatitis B surface atige 24 of 1012

4 Methods Positive cases were idetified by the relevat screeig marker: - Hepatitis B presece of Hepatitis B surface atige (HBsAg) - Hepatitis C presece of Hepatitis C atibody (ati-hcv) Developmet of a electroic (EMIS) based data recordig template was key i facilitatig data collectio Results 14 of 1006 samples (1.4%) tested positive for hepatitis B surface atige 24 of 1012 (2.4%) tested positive for hepatitis C atibody 38 positive cases were idetified i total Results are show by Table 1

5 Table showig Hepatitis B/C prevalece by ethicity Coutry/Ethicity Prevalece of Hep B Prevalece of Hep C Bagladeshi 1/52 (1.9%) 2/49 (4.1%) Middle East 2/93 (2.2%) 4/95 (4.2%) Pakistai 2/263 (0.76%) 8/262 (3.1%) Africa 3/131 (2.3%) 1/142 (0.7%) Idia 2/191 (1.0%) 0/180 (0%) Caribbea 1/90 (1.1%) 0/89 (0%) All other 3/185 (1.6%) 9/195 (4.6%) All groups 14/1006 (1.4%) 24/1012 (2.4%) Case Study A 56 year old lady of Bagladeshi origi atteded her GP surgery. Her hepatitis B ad C status was ukow The GP ordered blood tests for aother reaso; the lady was offered hepatitis B ad C screeig as per protocol Blood tests revealed that she was hepatitis C positive ad she was referred to the QEH Liver Uit for a review

6 Case Study Further ivestigatios showed that she had cirrhosis ad scas revealed a 3cm lesio i her liver represetig early stage hepatocellular carcioma The appropriate treatmet was liver trasplatatio ad this was udertake successfully four moths after the idex GP attedace The patiet remaied well oe year later - it is likely that opportuistic screeig saved this lady s life Trasplatatio is oly successful whe the tumour is less tha 5 cm i diameter ad there is o curative treatmet for larger tumours Results Outcomes of Patiets with a positive status 37 of the 38 positive cases were referred to a specialist 35 of these were reviewed i secodary care 11 of the 35 cases had defiitive treatmet (10 had ativiral therapy, 1 had a liver trasplat)

7 Results Outcomes of Patiets with a positive status Of those that did ot have treatmet:- - treatmet was ot ecessary for 10 patiets - 2 patiets declied treatmet - 2 patiets had medical illesses where ativiral treatmet was cotraidicated - 10 patiets were havig ivestigatios prior to startig ay treatmet Flow chart of positive cases 14 Hep B; 24 Hep C 14 Hep, 23 Hep C Hep C 13 Hep B; 22 Hep C Hep C Hep B 5 Hep B, 9 Hep C 6 Hep B ;4 Hep C 2 Hep B, 9 Hep C 5 Hep B; 5 Hep C 2 Hep C ep C 2 Hep B; 8 Hep C Hep C

8 Coclusios 38 people were idetified that merited specialist ivestigatio; ad of those see i cliic oly oe did ot atted because of health problems demostratig that the protocol was highly acceptable to patiets 97% attedace rate at specialist cliic Cotact tracig ca be implemeted o idetificatio of positive cases to idetify ay secodary cases ad close cotacts ca be vacciated agaist hepatitis B if ot ifected this clearly has much public health beefit Coclusios Our fidigs support existig evidece that hep B/C prevalece i o-uk bor idividuals is 4-6 times higher tha those bor i the UK prevalece varies betwee ethic groups We have show that a simple, iexpesive, opportuistic screeig protocol appears effective, acceptable to patiets ad will have added public health beefit Therefore, it is likely that about 4% of people (NNT = 1:25) would directly beefit from testig

Fial thoughts This opportuistic screeig protocol demostrates a

resources It simply requires health care professioals to idetify

K the offerig them a blood test for hepatitis.

patiet registratio cliics, routie phlebotomy cliics ad GP/urse

9 Fial thoughts This opportuistic screeig protocol demostrates a good example of how to fid positive cases withi acceptable resources It simply requires health care professioals to idetify patiets bor outside the U.K the offerig them a blood test for hepatitis. Idetifyig patiets ca be achieved i various ways such as: durig ew patiet registratio cliics, routie phlebotomy cliics ad GP/urse lead cliics Per-patiet tests for hep B/C testig were 4.24 for a hep B surface atige scree, for a hep B surface atige cofirmatory blood test ad 6.73 for a hep C atibody scree We believe that this simple protocol could ad should be implemeted i may other practices

Information Following Treatment for Patients with Early Breast Cancer. Bradford Teaching Hospitals. NHS Foundation Trust

Information Following Treatment for Patients with Early Breast Cancer. Bradford Teaching Hospitals. NHS Foundation Trust Iformatio Followig Treatmet for Patiets with Early Breast Cacer Bradford Teachig Hospitals NHS Foudatio Trust What happes ext? You have ow completed your iitial treatmet to remove your breast cacer. There