Screening the Chinese Community for Hepatitis B

1. Screening the Chinese Community for Hepatitis B Hazel Younger Consultant Gastroenterologist Raigmore Hospital, Inverness

2. 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

3. 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

4. 2001 Census • Scottish population 5,062,011 • Ethnic Chinese 16,310 • Glasgow 5000 (7500) • Lothian 4000 • Grampian 1600

5. Chinese Population

6. 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

7. 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

8. 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

9. 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

10. Topics Covered • Chinese endemicity • Carrier state • Modes of transmission • Preventing transmission • Explanation of project and hospital clinic

11. 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

12. Demographics

13. Demographics

14. Serology Testing

15. 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

16. Serology

17. Serology by Age

18. 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

19. ‘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)

20. 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

21. 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

22. 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)

23. 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?

24. 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

25. 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

26. Personal Thoughts • Think through whole process, from contact with population to vaccination or treatment • Use interpreters • Lunchtime meetings!