High risk of HBV infection and unmet case

High risk of HBV infection and
unmet case-finding need among
migrants in Bristol, UK – a cross
sectional study.
Iro Evlampidou, Charles Irish, Matt Hickman, Sophie Gillet,
Suzanne Ingle, Alex Cochrane.
Presented by: Isabel Oliver
Natural History of HBV infection
 Diagnosis allows monitoring and treatment where
indicated, which improves outcome and has been
shown to be cost effective
UK burden of chronic
hepatitis B

Estmated 320 000 people in the UK with
chronic hepatitis B infection
Chronic HBV infection arising from acute
HBV infection in resident UK
population
Chronic HBV infection imported by
people who acquired infection prior
to migration to the UK
269 per year
6,571 per year
From ‘Rising Curve’ Hepititis B foundation, after Hahné et al (2004)
http://www.hepb.org.uk/information/resources/rising_curve_chronic_hepatitis_b_infection_in_the_uk/rising_curve.pdf
2006 adapted from CDC
Cost effectiveness of screening
migrants

ICER of £20,900 per additional QALY
respectively, assuming:




HBV prevalence 2%,
cost of the intervention was £20 per person
invited for a test,
17.5% chance of testing over a period of 6
months as a result of the intervention.
Large amount of uncertainty
Miners AG, A; Martin, NK; Vickerman, P; 2012 (report for NICE)
Local implementation


The NICE recommendation was not
accompanied by a national screening
program.
NICE recommended that the increased
testing should be commissioned at a local
or regional level
Gaps in knowledge



Are GPs already routinely testing migrants
for hepatitis B?
What proportion of UK migrants have
already been tested?
What is the prevalence of chronic hepatitis
B in UK migrant populations?
Our project aimed to answer
these questions for the Bristol
migrant population through
three studies
Study 1: GP questionnaire
Number of
Number of
General Practices General Practices
invited to
where at least
complete
one GP
questionnaire
responded
23
13 (57%)
GPs who
completed
questionnaire
19
Good response from GP practices in high BME areas
Results: HBV testing practice
Question: Prior to NICE guidance (December 2012
PH43), did you perform opportunistic testing for
hepatitis B for patients born in regions of high
hepatitis B prevalence (eg. China, sub-Saharan
Africa)?
No this was not
Yes this was my
my routine
routine practice.
practice
3 (17%)
13 (72%)
Other
2
Study 2: proportion of migrants
who have been hepatitis B
tested – retrospective data
analysis

Data sources


NHAIS ‘Exeter’ database contains patient ID
and place of birth of patients registered with
GP in Bristol
Public Health Laboratory Bristol database
contains all HBV tests requested in Bristol,
searchable back to 2006.
Cleaned NHAIS patient demographic dataset
n=687,483
Country of birth not stated or not
recognisable n= 194,025 (28%)
Country of birth not within region
recommended by NICE for
hepatitis B testing (n=410,897)
Study population ‘eligible
migrants’ n= 82561
HBV tested
n=9627 (12% of
eligible migrants)
PHLB HBV
testing dataset
Not
HBV tested n=72934
Demographics
Demographic
All
Sex
Age
(years)
Female
Male
<18
18-34
35-54
>54
Number of
‘eligible
migrants’
82,561
41,255
41,306
7715
40,296
27,931
6,619
Number of
Proportion of
‘eligible
‘eligible
migrants’ who migrants’ who
were ‘HBV
were ‘HBV
tested’
tested’ (%)
9,627
7,201
2,426
98
4539
4457
533
12
17
6
0.5
11
16
8
Region of birth
Region/Sub-region of
birth
Total
Africa
Asia and Oceania
Eastern Asia
Southern Asia
Europe (eastern and
southern)
Latin America and
Caribbean
Number of
'eligible
migrants'
Number of
'eligible
migrants who
were HBV
tested
Proportion of
'eligible
migrants' who
were HBV
tested (%)
82,561
20,038
32,431
7,801
14,446
9,627
3,486
3,269
427
1,895
12
17
10
5
13
24,134
2,165
9
5,958
707
12
Local challenges

5 GP
practices
with
>3000
eligible
patients
GP practices
Study 3: Prevalence of chronic
hepatitis B in Bristol migrant
populations – retrospective data
analysis

We used the prevalence in women who
gave birth as a surrogate for population
prevalence as pregnant women are
routinely screened for HBV
Study population and results
HBV tested eligible
migrant n=9627
Dataset of women with live
birth in Bristol
Study population =
eligible migrant HBV
tested women with live
birth in Bristol during
study period; n=5840
HBV infected n= 101,
prevalence = 1.7% (95% CI 1.4 – 2.1)
HBV prevalence in Bristol
migrants born in Africa
Region/ Subregion
of birth
Number tested
Africa
1965
Eastern Africa
1372
Middle Africa
51
Number with
HBV infection
49
31
4
Period
prevalence of
HBV infection
as % (95% CI)
2.5 (1.9-3.3)
2.3 (1.5-3.2)
7.8 (2.2-18.9)
Northern Africa
81
1
1.2 (0.0-6.7)
Southern Africa
Western Africa
140
321
0
13
0.0 (0.0-2.6)
4.0 (2.2-6.8)
HBV prevalence in Bristol
migrants born in Asia
Asia and Pacific
Islands
Central Asia
Eastern Asia
Southern Asia
South Eastern
Asia
Western Asia
Pacific Islands
Number
tested
Number
with HBV
infection
Period prevalence of
HBV infection as %
(95% CI)
1917
7
201
1219
37
0
20
8
1.9 (1.4-2.7)
0.0 (0.0-41.0)
10.0 (6.2-14.9)
0.7 (0.3-1.3)
261
219
10
8
1
0
3.1 (1.3-5.9)
0.5 (0.0-2.5)
0.0 (0.0-30.8)
HBV prevalence in Bristol migrants born in
Europe, Latin America or the Caribbean
Number
tested
1625
Number
with HBV
infection
13
Period prevalence of
HBV infection as %
(95% CI)
0.8 (0.4-1.4)
Eastern Europe
1276
12
0.9 (0.5-1.6)
Southern Europe
349
1
0.3 (o.0-1.6)
Latin America and
Caribbean
333
2
0.6 (0-2.2)
Caribbean
215
2
0.9 (0.1-3.3)
Central America
14
0
0.0 (0.0-23.2)
South America
104
0
0.0 (0.0-3.5)
Europe
Conclusions (1)




Data suggests that most Bristol GPs have not
been routinely testing migrants
The majority of Bristol migrants eligible for
testing under NICE were not tested locally
during the study period
Testing of children is particularly poor
HBV infection will continue to cause avoidable
mortality and morbidity amongst migrants unless
testing increases.
Conclusions (2)


There is a considerable range of HBV
infection prevalence within Bristol migrant
populations
More than half of the population of Bristol
migrants eligible for testing under NICE
belong to populations with local estimated
prevalence <2%
Acknowledgements
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Matthew Barber
Ewan Cameron
Phil Shrimpton,
Zheng Jurong,
Trevor Foster,
Matthew Donati
Paul North.

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Isabel Oliver,
Debbie Sharp
Isabel Oliver (PHE)
Christina Gray,
Nicholas Young,
Shivani Datta,
Supported with an educational grant via the
Gilead UK and Ireland Fellowship Programme