Screening the Chinese Community for Hepatitis B

Hazel Younger Consultant Gastroenterologist Raigmore Hospital, Inverness

The Problem

• 90% chronic Hepatitis B infection with vertical transmission

• Chronic Hepatitis B causes cirrhosis and hepatocellular carcinoma

• In SE Asia and China in particular, approximately 10% of population has chronic Hepatitis B

• Immigration to areas of low endemicity can lead to personal and public health difficulties

The Problem

• Knowledge of Hepatitis B is poor in SE Asian immigrant populations

• Stigma attached to having Hepatitis B• Less than half of those eligible will request

screening• Different health beliefs and cultures

2001 Census

• Scottish population 5,062,011• Ethnic Chinese 16,310

• Glasgow 5000 (7500)• Lothian 4000• Grampian 1600

Chinese Population

Chinese Hepatitis B Education Project

• March 2002 – February 2004• Lothian population• Establish education programme• Dedicated Chinese clinic• Identify and treat individuals with chronic

Hepatitis B and evidence of active replication

Outline

• Run by Centre for Liver and Digestive Disorders at RIE in liaison with the Lothian Health Protection Team and Minority Ethnic Health Inclusion Project (MEHIP)

• Used the ‘Social Diffusion’ model – targeting easy-to-reach members of the Community and through them communicate with members who are harder to reach

Project

• Communication by letter to all local GPs• List of possible Chinese community groups

contacted via MEHIP• Search for suitable educational material already

available• Leaflet design and translation• Evaluation questionnaires• Education video sourced (Cantonese)• Clinic space found

Meetings

• Church groups, schools, elderly and womens’ groups, lunch club, health fair

• Video in Cantonese• Talk from CLDD doctor (with interpreter)• Question and answer session• Issued with bilingual information leaflet, letter

for GP and identifiable virology request form• Encouraged to attend GP for testing

Topics Covered

• Chinese endemicity• Carrier state• Modes of transmission• Preventing transmission• Explanation of project and hospital clinic

Meetings

• 14 education sessions, 13 in Cantonese• Evaluated by questionnaire – age, gender,

assessment of usefulness• Approx 400 attended in total, 329

questionnaires returned• Day-time meetings best, most held at

weekends

Demographics

Demographics

Serology Testing

Evaluation of Meetings

• 86% found sessions very useful, 13% useful

• 97% were happy with the format of the meetings, finding it a good way to learn

• Others would have preferred information from their GP or Chinese support worker

Serology

Serology by Age

Problems

• GP sub-committee not consulted• ‘Unaware’ of project• Testing and referral, vaccination of contacts

through primary care

• Vaccination provided as ‘travel’ service – considerable cost to individuals

‘Resolution’ of Problems

• Offered serology testing at RIE if GP unable

• Negotiations with Bloodbourne Virus Committee re payment for vaccination of household contacts (£7/vaccination)

Evaluation of Project• Overall well-received by Chinese community• Group-based meetings better attended than

general public (advertised)• Diffusion model appeared to work• Chinese Hepatitis B clinic established at RIE (58

patients at conclusion of project) • < 1% DNA rate!• Printed bilingual leaflet for general use

• Difficulty with local (primary care) politics

National Screening for Hepatitis B

• ‘Screening for Hepatitis B and Hepatitis C among ethnic minorities born outside the UK’

• August 2010, report for the National Screening Committee

• Did not support screening

Chronic Hepatitis B Case-finding

• Systematic case-finding in high risk populations (health services identify and invite for test)

• Opportunistic (testing offered to high risk individuals when make contact with health services for another reason)

• Voluntary testing (eg at community venues)

Systematic Screening – Research Required

• Systems for identifying high risk patients from GP records and confirming country of birth

• ? Difference in acceptability and number of cases found between systematic and opportunistic testing

• What will uptake be for patients offered systematic screening?

Systematic Screening – Research Required

• Incremental cost-effectiveness of systemic over opportunistic testing– Proportion of HBV actually treated– Emigration of immigrants after testing and

treatment– Effect of broadening criteria to country of origin

rather than birth

• No of cases HBV prevented by vaccination

Personal Thoughts

• Involvement of target community in organisation of project

• Involvement of primary care as well as public health

• Very little evidence but probably supports opportunistic case finding and voluntary testing sessions

• Methodical screening should be set up as a formal pilot study

Personal Thoughts

• Think through whole process, from contact with population to vaccination or treatment

• Use interpreters

• Lunchtime meetings!