Liver Disease in Tower Hamlets Needs Assessment

Liver Disease in Tower Hamlets Needs Assessment Tower Hamlets Public Health

Liver Disease in Tower Hamlets Needs Assessment Contents 1 Introduction... 1 1.1 What is liver disease?... 1 2 Liver Disease Scale of the Problem (National and Tower Hamlets Picture)... 2 2.1 National scale of liver disease... 2 2.2 Burden of disease: Tower Hamlets picture... 4 2.2.1 Liver disease mortality... 4 2.2.2 Cirrhosis... 4 2.2.3 Primary liver cancer... 4 2.3 Possible causes of this local variation... 5 2.4 What is being done... 6 2.5 Gaps in what is being done... 6 2.6 Recommendations... 6 3 Types of Liver Disease... 7 3.1 Hepatitis B... 7 3.1.1 Burden of disease: Tower Hamlets picture... 7 3.1.2 Possible causes of this local variation... 8 3.1.3 Guidelines... 8 3.1.4 What is being done... 9 3.1.5 Gaps in what is being done... 10 3.1.6 Recommendations... 10 3.2 Hepatitis C... 11 3.2.1 Burden of disease: Tower Hamlets picture... 11 3.2.2 Possible causes of this local variation... 12 3.2.3 Guidelines... 13 3.2.4 What is being done... 13 3.2.5 Gaps in what is being done... 14 3.2.6 Recommendations... 14 3.3 Non-Alcoholic Fatty Liver Disease (NAFLD)... 15 3.3.1 Burden of disease: Tower Hamlets picture... 15 3.3.2 Possible causes of this local variation... 17 3.3.3 Guidelines... 17 3.3.4 What is being done... 17 i

3.3.5 Gaps in what is being done... 18 3.3.6 Recommendations... 18 3.4 Alcoholic Liver Disease (ALD)... 19 3.4.1 Burden of disease: Tower Hamlets picture... 19 3.4.2 Possible causes of this local variation... 20 3.4.3 Guidance... 21 3.4.4 What is being done... 22 3.4.5 Gaps in what is being done... 22 3.4.6 Recommendations... 22 4 Recommendations... 23 ii

Liver Disease in Tower Hamlets Needs Assessment 1 Introduction Liver disease is a significant problem in Tower Hamlets and nationally. Tower Hamlets has one of the highest mortality rates from liver disease nationally in people aged under 75, per 100,000 population (Tower Hamlets 26.6 per 100,000, England average 14.7 per 100,000) 1. The number of people suffering from liver disease and cirrhosis is increasing in England - while it is falling in other European countries. 1.1 What is liver disease? Liver disease is a term that describes many diseases that cause the liver to function improperly or stop functioning. 2 It can be caused by a range of conditions including autoimmune causes (such as primary biliary cirrhosis or primary sclerosing cholangitis), hereditary causes (such as haemochromatosis or Wilson s disease) or drug induced damage. The main causes of liver disease are hepatitis B, hepatitis C, non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD), this report focuses on these causes (Figure 1). Prolonged damage to the liver due to the liver disease can cause cirrhosis (irreversible scarring of the liver), liver failure or liver cancer. Figure 1 Main causes of liver disease Liver disease NAFLD Alcoholic liver disease Viral hepatitis Diabetes Obesity Hepatitis B Hepatitis C 1 Tower Hamlets: regional public health outcomes framework June 2012 Http://hna.londonhp.nhs.uk/documents/PHOF/Tower%20Hamlets%20Regional%20PHOF.pdf 2 MedlinePlus, US National Institute for Health, http://www.nlm.nih.gov/medlineplus/ency/article/000205.htm 1

2 Liver Disease Scale of the Problem (National and Tower Hamlets Picture) 2.1 National scale of liver disease Liver disease is one of the leading causes of death in England and people are dying from this at younger ages. The number of people dying from liver disease and cirrhosis is increasing in England (Figure 2) - while it is falling in other European countries (Figure 3). 3 Figure 2 Trends in mortality from liver disease in relation to trends in mortality from other causes, England, 1971-2007 Figure 3 Premature mortality from chronic liver disease and cirrhosis in people aged under 65 years in the UK and European Union countries (EU-15, EU-27, France and Sweden) 3 NHS Liver Care (2013) NHS Atlas of Variation in Healthcare for People with Liver Disease 2

Premature death from chronic liver disease is rising in England, largely as a result of lifestyle issues such as alcohol abuse, drug-taking and obesity with an 88% increase in age-standardised mortality rate from chronic liver disease between 1993 and 2010. 4 However, there is widespread variation across the country in terms of risk factors, services, expenditure and outcomes for patients and the wider population. A recent report highlights that: 5 Deprivation is a key factor in the significant variation in premature loss of life between areas (Figure 4) There is a significantly growing impact of alcohol misuse, estimated to cost the NHS 3.5bn a year Up to 20% of the population are potentially at risk of developing some liver damage Growing obesity in children is increasing the risk of serious liver disease in later life Viral hepatitis is becoming more prevalent, with significant national variations in drug use increasing the risk of the disease Figure 4 Years of life lost in people aged <75 due to mortality from chronic liver disease per 100 000 population by PCT 2008-2010 compared with deprivation 6 4 NHS Liver Care (2013) NHS Atlas of Variation in Healthcare for People with Liver Disease 5 NHS Liver Care (2013) NHS Atlas of Variation in Healthcare for People with Liver Disease 6 NHS Liver Care (2013) NHS Atlas of Variation in Healthcare for People with Liver Disease 3

2.2 Burden of disease: Tower Hamlets picture 2.2.1 Liver disease mortality The Public Health Outcomes Framework baseline data (June 2012) highlighted the high mortality rate from liver disease, relative to other Local Authorities, for persons aged under 75 in Tower Hamlets (Table 1). 7,8 Table 1 Age-standardised mortality rate in persons aged under 75 per 100,000 population Mortality rate from liver disease for persons aged under 75 per 100 000 population Tower Hamlets 26.6 England average 14.7 London Average 16.2 London worst 27.4 2.2.2 Cirrhosis Tower Hamlets also has the highest rate of admission for cirrhosis nationally (207.9) per 100,000 population (Figure 5). 9 Figure 5 Hospital admission rate for cirrhosis per 100,000 population 2.2.3 Primary liver cancer Tower Hamlets has the highest rate of primary liver cancer mortality in under 75 year olds nationally per 100,000 population (Figure 6). 10 Figure 6 Mortality rates for primary liver cancer in under 75 year olds per 100,000 population 7 Tower Hamlets: regional public health outcomes framework June 2012 Http://hna.londonhp.nhs.uk/documents/PHOF/Tower%20Hamlets%20Regional%20PHOF.pdf 8 Directly age-standardised mortality rate from liver disease for persons aged <75 per 100 000 European standardised population based on 2010 data from NHS Information Centre (Indicator 4.6i) 9 NHS Liver Care (2013) NHS Atlas of Variation in Healthcare for People with Liver Disease 10 NHS Liver Care (2013) NHS Atlas of Variation in Healthcare for People with Liver Disease 4

Data from the UK Cancer Information Service (July 2013) were reviewed to consider trends over time. The small numbers of local cases mean that confidence intervals are wide and frequently overlap with those of London/national estimates. It is therefore difficult to draw conclusions, but data are suggestive that rates in Tower Hamlets are consistently relatively high (Figure 7) 55. 25.0 20.0 15.0 Figure 7 Liver and intrahepatic bile duct cancers in Tower Hamlets 2010 ASR TH ASR London ASR England 10.0 5.0 0.0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2001 2010 age-standardised rates (ASR) of liver and intrahepatic bile duct cancers (C22), plus 95 % confidence intervals, for Tower Hamlets (TH), London and England are displayed 2.3 Possible causes of this local variation Tower Hamlets has a significant burden of disease from cirrhosis and high mortality from liver cancer. Cirrhosis and liver cancer occur from continued liver disease. The main causes of liver disease are viral hepatitis (hepatitis B and C), alcoholic liver disease and non-alcoholic fatty liver disease. These main causes and their local variation are discussed later in this report. Viral hepatitis is spread by bodily fluids and by vertical transmission, alcoholic liver disease is caused by dangerous levels of drinking, non-alcoholic fatty liver disease is caused by obesity and diabetes. Local causes that will increase the rates of liver disease include Ethnic mix of Tower Hamlets o High levels of immigration from areas of high viral hepatitis prevalence o Travel to and from areas of high viral hepatitis prevalence o High birth rates to Bangladeshi population (45%), 11 potentially at increased risk of vertical transmission of viral hepatitis High rates of sexually transmitted infection (8 th highest rate of STI per 100,000 nationally) 12 Established commercial sex worker population Significant numbers of men who have sex with men (MSM). IV drug misuse High rates of risky alcohol use Unknown access to services full mapping of services still not performed 11 Tower Hamlets Annual Public Health report 2010 12 Tower Hamlets Joint Strategic Needs Assessment 2010-2011 Sexual health 5

2.4 What is being done There is currently limited provision of hepatology services at Barts. Services include: Weekday hepatologist cover (weekends are covered by gastroenterology / medical teams with hepatology consultants providing advice as required) Currently 0.8 FTE of a hepatology consultant is paid for by BLT Trust. Other funding for the consultants comes from academia and the Royal Free Hospital 3 clinics per week for liver disease at BLT Liver / gastroenterology ward at RLH Outreach clinics Nurse-led viral hepatitis clinic Alcohol Nurse Specialist service Liver transplant services are provided by RFH and King s College Hospital. There is currently a very good working relationship between RFH and BLT with e.g. 1 transplant clinic for BLT patients held every fortnight Liver cancer services include twice weekly clinics; reasonable interventional support but no dedicated hepatobiliary cancer support service Barts Health hepatology service is currently running two trials testing drug treatments on 80 patients with hepatitis B and C. These trials are academically funded, so Tower Hamlets commissioners are not paying for the treatment of these patients, saving the NHS significant amounts of money. 2.5 Gaps in what is being done Assessment of the supply gaps is limited as no activity data was obtained and the services examined were only provided by one provider (Barts Health). 2.6 Recommendations Developing strategies that allow for risk assessment, prevention, early diagnosis and treatment will allow interventions before advanced disease has occurred. This will lead to better outcomes, reduced cost and reduced future burden of liver disease. A stakeholder meeting is required to thoroughly map the use of available services and pathways currently available. This will allow services across primary and secondary care to work collaboratively to optimise care outcomes. By improving clinical links and pathways for liver disease between services, this allows for clarity of management and avoids tests being unnecessarily repeated. Tower Hamlets has the highest admission rate for cirrhosis nationally. The care pathway of patients with cirrhosis should be reviewed to see whether improvements can be made. 6

3 Types of Liver Disease 3.1 Hepatitis B 3.1.1 Burden of disease: Tower Hamlets picture A recent London Hepatitis B report highlights that Tower Hamlets has the fifth highest incidence of acute hepatitis B in the country at 2.2 / 100,000. 13 This compares with a national incidence of 1.13 / 100,000 and London incidence of 2.06 / 100,000. This high rate locally is likely due to a high rate of immigration from Bangladesh which has a high incidence of hepatitis B. There is a high local burden of chronic hepatitis B, with The Royal London Hospital reporting the highest number of cases of any hospital in London in 2011 (n=1069, though not all will be Tower Hamlets residents). Two-thirds of the chronic cases occur in men aged between 25 and 44, which may be due to the young population in Tower Hamlets: having the lowest median age nationally (29). 14 95% of new chronic hepatitis B infections occur in migrant populations, having been acquired perinatally in the country of birth. Hospital data for Tower Hamlets between 2007 and 2012 was analysed for admissions for liver disease attributable to hepatitis B. There was no clear identifiable trend. The ethnicity of the admissions for liver disease caused by hepatitis B in Tower Hamlets was examined over the period from 2007 2012 (Figure 8). This shows that the majority of cases of hepatitis B occur in Asians with only 21% of cases occurring in the white population. Figure 8 Tower Hamlets admissions for liver disease caused by hepatitis B (2007-2012) 21% 19% 2% White males White females Asian males Asian females 58% 13 Hepatitis B in London. Annual report 2011 data: Health Protection Agency London Regional Epidemiology Unit. December 2012 14 Source: London Datastore, GLA 2012 http://data.london.gov.uk/census/themes/demography 7

3.1.2 Possible causes of this local variation Tower Hamlets has the fifth highest incidence of acute hepatitis B in the country at 2.2 / 100,000. 15 This compares with a national incidence of 1.13 / 100,000 and London incidence of 2.06 / 100,000. Data from the Royal London Hospital showed that 95% of new chronic hepatitis B infections occur in migrant populations, having been acquired perinatally in the country of birth. 79% of admissions to hospital for liver disease from hepatitis B between 2007 and 2012 occurred in the Asian population. This local high incidence of hepatitis B is likely due to the large immigrant population in Tower Hamlets. 32% of the population are Bangladeshi, 50% are non-white. 16 There is a significantly higher prevalence of hepatitis B in Africa and Asia. Nationally in 2010, around 60% of UK blood donors testing positive for markers of hepatitis B infection were born in Africa or Asia. 17 South-west Asia and Eastern Europe have higher infectivity rates 20-55% of the population have markers of past hepatitis B infection and 2-7% are hepatitis B carriers. 18 Hepatitis B can be transmitted by sexual intercourse. Tower Hamlets has a high incidence of sexually transmitted infections. The incidence of STIs was rising in 2008-09 and was ranked the highest 8 th in the country. 19 Tower Hamlets is also known to have an established sex worker population, which increases the risk of sexually transmitted infection. 20 This problem with sexually transmitted disease may play a role in the high rates of hepatitis B in Tower Hamlets. Tower Hamlets had an estimated 3849 problematic drug users in 2008-2009, and 85% identifying heroin as their first drug. 21 Poor hygiene with injecting drug use can contribute to the spread of hepatitis B. 3.1.3 Guidelines The UK currently has a selective hepatitis B vaccination policy which targets people at continuing risk of exposure. Patients who are, or have been in any of the following risk groups should be offered testing for hepatitis B infection: Individuals who have ever injected drugs Individuals who change sexual partners frequently, particularly MSM and male and female commercial sex workers Close family contacts of a case or individual with chronic hepatitis B infection Families adopting children from countries with a high / intermediate prevalence of hepatitis B and foster carers Patients with chronic liver disease Individuals in residential accommodation for those with learning difficulties 15 Hepatitis B in London. Annual report 2011 data: Health Protection Agency London Regional Epidemiology Unit. December 2012 16 Tower Hamlets Annual Public Health report 2010 17 Davies, S.C. Annual Report of the Chief Medical Officer, Volume Two, 2011, Infections and the rise of antimicrobial resistance London: Department of Health (2013) 18 WHO Hepatitis B, http://www.who.int/csr/disease/hepatitis/whocdscsrlyo20022/en/index1.html 19 Tower Hamlets Annual Public Health report 2010 20 Tower Hamlets Alcohol and substance misuse JSNA factsheet 2010-2011 21 Tower Hamlets Alcohol and substance misuse JSNA factsheet 2010-2011 8

People travelling to or going to reside in areas of high or intermediate prevalence Individuals at occupational risk NICE guidance on hepatitis B and C was published in December 2012. 22 This guidance includes: Awareness-raising for people at increased risk of hepatitis B or C infection and in the general population Commissioning locally appropriate integrated services for hepatitis B and C testing and treatment Effective delivery and auditing of neonatal hepatitis B vaccination Contact tracing Testing for hepatitis B and C in sexual health and genitourinary medicine clinics; drugs services; primary care Developing the knowledge and skills of healthcare professionals and others providing services for people at increased risk of hepatitis B or C infection 3.1.4 What is being done 3.1.4.1 Neonatal vaccination Pregnant mothers are offered hepatitis B screening as part of their antenatal care. Uptake of the hepatitis B screening was 100% at the Royal London and Newham clinics and 95% at Homerton. This compares with a screening rate of 99% across London and 97% across England. This screening program identified positive tests in 14.2/1000 at Newham, 13.4/1000 at Royal London and 12.5/1000 at Homerton. 23 This compares with positive rate of 10.2/1000 across London and 4.2/1000 across England. There is scope to improve the uptake of screening at Homerton to maximise the diagnosis of hepatitis B, which allows vaccination of the child and treatment of the mother. Children of hepatitis B positive mothers are vaccinated against the disease. In Tower Hamlets, this has excellent initial coverage of 100% 1 year olds, but this drops to 91% at 2 years. This is due to some not receiving the required booster at 12 months after the initial 3 vaccinations. There is scope to increase uptake of this booster. 3.1.4.2 GP practice screening and vaccination Screening for hepatitis B is performed in GP practice for patients as part of the sexual health local enhanced service (LES). It is also recommended that screening for hepatitis B is incorporated into new patient registrations and considered for midlife health checks. Any patients identified as hepatitis B positive should have their sexual contacts informed to offer them screening for hepatitis B and immunised against hepatitis B if susceptible. High risk patients such as men who have sex with men, injecting drug users or people with multiple or frequent sexual partners should be offered the hepatitis B vaccine if there is no evidence of past or present infection. 22 NICE, Hepatitis B and C - ways to promote and offer testing, http://guidance.nice.org.uk/ph43 23 Hepatitis B in London. Annual report 2011 data: Health Protection Agency London Regional Epidemiology Unit. December 2012 9

3.1.4.3 GUM service The genitourinary medicine service screens patients at high risk (men who have sex with men, patients born in high risk areas, injecting drug users and sex workers for hepatitis B and C). Patients with new infections are either referred to the Barts Health hepatology clinic or back to their GP for onward referral. HIV co-infected patients who attend the HIV clinic will be treated for their hepatitis at the HIV clinic with input from hepatology. 3.1.4.4 Substance misuse The substance misuse LES facilitates the referral of patients into the Shared Care Scheme enabling care to be provided in the community in partnership with pharmacies and services commissioned by the Drug and Alcohol Action Team (DAAT). This care is coordinated by key workers and includes screening, vaccination and treatment of hepatitis. Primary care should test patients for hepatitis B and hepatitis C or refer patients on to other services that can. 3.1.4.5 Blood Borne Virus (BBV) team The BBV team operate out of the Specialist Addiction Unit (SAU) at Mile End Hospital. The DAAT commission East London NHS Foundation Trust (ELFT) to provide this service. They offer interventions including access to BBV screening, immunisation and treatment, wound care, safe injecting, advice and sexual health screening. The team operates from a range of community settings in Tower Hamlets In December 2013, the BBV team had a case load of 33 patients being treated for chronic hepatitis B. There are challenges around the sharing of patient information between the BBV team and the patient s GP so general practice are not made aware which of their patients are being screened, vaccinated or treated for hepatitis by the BBV team. 3.1.5 Gaps in what is being done Assessment of the supply gaps is limited as no activity data was obtained and the services examined were only provided by one provider (Barts Health). 3.1.6 Recommendations Developing strategies that allow for risk assessment, prevention, early diagnosis and treatment of hepatitis B will allow interventions before advanced disease has occurred and reduce transmission. This will lead to better outcomes, reduced cost and reduced future burden of liver disease. Targeting populations at high risk of contracting hepatitis B and increasing the vaccination uptake will reduce transmission of hepatitis B. Maximising uptake of antenatal screening for hepatitis B improves diagnosis of the disease and allows treatment and vaccination of the baby. A thorough mapping of the use of currently available services and pathways will allow services across primary and secondary care to develop a local integrated service to optimise care outcomes. 10

3.2 Hepatitis C 3.2.1 Burden of disease: Tower Hamlets picture 3.2.1.1 Hepatitis C prevalence Tower Hamlets has a chronic hepatitis prevalence rate of 1088.6 per 100,000 population. This is the fourth highest rate nationally (Figure 9). 24 However, it has been estimated by a local hepatologist that possibly no more than 20% of hepatitis C cases are currently identified in Tower Hamlets, in keeping with national data, with no more than 10% referred and therefore 5% treated. Figure 9 Prevalence of chronic hepatitis C per 100,000 population The Health Protection Agency (HPA) produced modelled estimates of hepatitis C prevalence, burden, treatment and cost of treatment in London in 2011. 25 For the Tower Hamlets Drug Action Team it was estimated that the total infected population was 2677, with 1766 cases of mild to moderate liver disease and 84 cases with cirrhosis or end stage liver disease. This report estimated the estimated annual additional number requiring treatment as 28 with an estimated annual cost of treating these additional cases of 264,980. 3.2.1.2 Hospital admissions for hepatitis C Hospital data for Tower Hamlets was analysed for admissions for liver disease attributable to hepatitis C (Figure 10). Hepatitis C admissions appear to be increasing over the five year period, increasing from 12.7 to 19.3 per 100,000 between 2007 and 2012. 24 NHS Liver Care (2013) NHS Atlas of Variation in Healthcare for People with Liver Disease 25 HPA (2011) Hepatitis C in London http://www.hpa.org.uk/webc/hpawebfile/hpaweb_c/1317135974202 11

25 Figure 10 Tower Hamlets rates of admissions to hospital for liver disease related to hepatitis C per 100,000 population 20 15 10 5 0 2007/08 2008/09 2009/10 2010/11 2011/12 The ethnicity of the admissions for liver disease caused by hepatitis C in Tower Hamlets was examined over the period from 2007 2012 (Figure 11). This shows that the majority of cases of hepatitis C occur in white males, but a quarter of cases occur in females and a quarter in the Asian population. Figure 11 Tower Hamlets admissions for liver disease caused by hepatitis C (2007-2012) 8% 17% 17% 58% White males White females Asian males Asian females 3.2.2 Possible causes of this local variation Hepatitis C is transmitted by contaminated bodily fluids. This is most commonly by sexual transmission or by injecting drug use. Tower Hamlets has a high incidence of sexually transmitted infections. The incidence of STIs was rising in 2008-09 and was ranked the highest 8 th in the country. 26 Tower Hamlets is also known to have an established sex worker population, which increases the risk of sexually transmitted infection. 27 This problem with sexually transmitted disease may play some role in the high rates of hepatitis C in Tower Hamlets. 26 Tower Hamlets Annual Public Health report 2010 27 Tower Hamlets Alcohol and substance misuse JSNA factsheet 2010-2011 12

Tower Hamlets had an estimated 3849 problematic drug users in 2008-2009, and 85% identifying heroin as their first drug. 28 Poor hygiene with injecting drug use can contribute to the spread of hepatitis C. 3.2.3 Guidelines NICE guidance on hepatitis B and C was published in December 2012. 29 This guidance includes: Awareness-raising for people at increased risk of hepatitis B or C infection and in the general population Commissioning locally appropriate integrated services for hepatitis B and C testing and treatment Contact tracing Testing for hepatitis B and C in sexual health and genitourinary medicine clinics; drugs services; primary care Developing the knowledge and skills of healthcare professionals and others providing services for people at increased risk of hepatitis B or C infection There is no vaccine for hepatitis C. As such strategies that prevent transmission of the disease need to be encouraged. These include Not sharing any injecting equipment, such as needles, syringes, spoons and filters Not sharing razors, toothbrushes or towels that might be contaminated with blood Using condoms If known to be hepatitis C positive, cleaning and covering any cuts or grazes with a waterproof dressing; cleaning any blood from surfaces with household bleach and not donating blood Continual awareness of perinatal transmission in high-risk groups is warranted for targeted prevention of transmission within families 3.2.4 What is being done 3.2.4.1 GUM service The genitourinary medicine service screens patients at high risk (men who have sex with men, patients born in high risk areas, injecting drug users and sex workers for hepatitis B and C). Patients with new infections are either referred to the Barts Health hepatology clinic or back to their GP for onward referral. HIV co-infected patients who attend the HIV clinic will be treated for their hepatitis at the HIV clinic with input from hepatology. 3.2.4.2 Substance misuse The substance misuse LES facilitates the referral of patients into the Shared Care Scheme enabling care to be provided in the community in partnership with pharmacies and services commissioned by the DAAT. This care is coordinated by key workers and includes screening, vaccination and treatment of hepatitis. Primary care should test patients for hepatitis B and hepatitis C or refer patients on to other services that can. 28 Tower Hamlets Alcohol and substance misuse JSNA factsheet 2010-2011 29 NICE, Hepatitis B and C - ways to promote and offer testing, http://guidance.nice.org.uk/ph43 13

3.2.4.3 Blood Borne Virus (BBV) team The BBV team operate out of the Specialist Addiction Unit (SAU) at Mile End Hospital. The DAAT commission ELFT to provide this service. They offer interventions including access to BBV screening, immunisation and treatment, wound care, safe injecting, advice and sexual health screening. Consultant led hepatitis C clinics are held at the SAU on a monthly basis. The team operates from a range of community settings in Tower Hamlets In December 2013, the BBV team had a case load of 426 patients being treated for chronic hepatitis C. The challenge that this service faces is around uptake of treatment for hepatitis C. The treatment can be difficult for some patients causing negative side effects especially in those with a severe mental illness. Treatment of hepatitis C involves taking daily oral medication and weekly injections. Once a patient begins treatment bloods need to be taken in order to control the dosage of medication. This makes treating patients with chaotic lifestyles extremely challenging. There are also challenges around the sharing of patient information between the BBV team and the patient s GP so general practice are not made aware which of their patients are being screened, vaccinated or treated for hepatitis by the BBV team. 3.2.5 Gaps in what is being done It has been identified by the blood borne virus team that the uptake of treatment for hepatitis C is sub-optimal. Some patients find the treatment difficult as it can cause negative side effects especially in those with a severe mental illness. Treatment of hepatitis C involves taking daily oral medication, weekly injections and regular monitoring blood tests. This makes treating patients with chaotic lifestyles extremely challenging. Assessment of the supply gaps is limited as no activity data was obtained and the services examined were only provided by one provider (Barts Health). 3.2.6 Recommendations Developing strategies that allow for risk assessment, prevention, early diagnosis and treatment of hepatitis C will allow interventions before advanced disease has occurred and reduce transmission. This will lead to better outcomes, reduced cost and reduced future burden of liver disease. Screening populations at high risk of contracting hepatitis C allows treatment and reduction of transmission and improved outcomes. A thorough mapping of the use of currently available services and pathways will allow services across primary and secondary care to develop a local integrated service for the management of hepatitis C to optimise care outcomes. The treatment of hepatitis C has been identified by the BBV team as being difficult for some patients, so these barriers to treatment should be reviewed and plans made to address these issues. 14

3.3 Non-Alcoholic Fatty Liver Disease (NAFLD) Non-alcoholic fatty liver disease represents a spectrum of liver disease with fatty infiltration in the absence of excessive alcohol. It can be simple fatty infiltration of the liver (steatosis), fat and inflammation (non-alcoholic steatohepatitis (NASH)) or cirrhosis. 30 3.3.1 Burden of disease: Tower Hamlets picture 3.3.1.1 Risk factors for disease Obesity and diabetes are a significant risk factor for the development of nonalcoholic fatty liver disease (NAFLD). 3.3.1.1.1 Obesity Data from 2010-2011 shows that Tower Hamlets falls in the second highest quintile for child obesity in 4-5 year olds (Figure 12). Figure 12 Obesity prevalence rate in 4-5 year olds by PCT (% of children in reception class classified as overweight or obese), 2010-2011 31 Tower Hamlets has the ninth highest rate for child obesity in 10-11 year olds nationally (Figure 13). Figure 13 Obesity prevalence rate in 10-11 year olds by PCT (% of children in school year 6 classified as overweight or obese), 2010-2011 32 However, the Tower Hamlets adult obesity rate is in the lowest quintile (Figure 14). The Tower Hamlets Health and Lifestyle survey, data obtained from GPs and 30 Anstee, Q.M., McPherson, S., BMJ 2011;343:d3897, 1-5, How big a problem is non-alcoholic fatty liver disease? 31 NHS Liver Care (2013) NHS Atlas of Variation in Healthcare for People with Liver Disease 32 NHS Liver Care (2013) NHS Atlas of Variation in Healthcare for People with Liver Disease 15

modelling on HSE data, agrees that the adult obesity rate is no higher than the national average. 33 This survey indicated that 4 in 10 adults are a healthy weight, 3 in 10 are overweight and 3 in 10 are obese. Figure 14 Obesity prevalence rate in adults by PCT (% of adults classified as overweight or obese), 2010-2011 34 3.3.1.1.2 Diabetes In March 2010, there were 11,859 diagnosed cases of diabetes in Tower Hamlets (6.1% of the population). Prevalence is higher in Tower Hamlets than the national (5.4%) and London averages (5.3%). Prevalence is also increasing at a faster rate in Tower Hamlets than the national average and diabetes prevalence in Tower Hamlets is predicted to reach 10.1% by 2030 (Figure 15). 35 Figure 15 Diabetes prevalence projections in Tower Hamlets 2010-2030, APHO Diabetes Prevalence Model, 2010 2010 2015 2020 2025 2030 Number 13,674 14,987 16,871 18,968 21,314 Prevalence 7.8% 8.1% 8.7% 9.3% 10.1% 3.3.1.2 Scale of disease Current research at The Royal London Hospital is using both local hepatology clinic and EMISweb GP data to determine the frequency of NAFLD among the different ethnic groups in East London. 36 Preliminary results showed that almost 800 patients from Tower Hamlets had been diagnosed with NAFLD. The proportion of patients with NAFLD of Bangladeshi ethnicity was statistically significantly higher than the population proportion. The mean age of Bangladeshi NAFLD patients was also significantly lower than Caucasians (hospital: 43 vs 57 years; TH community: 46 vs 55 years). Hospital data for Tower Hamlets between 2007-2012 was analysed for admissions for liver disease attributable to NAFLD. There is no strong trend in the admissions over the 5 year period analysed. The ethnicity of the admissions for liver disease caused by NAFLD in Tower Hamlets was examined over the period from 2007 2012 (Figure 16). This shows that half the NAFLD admissions occur in white females. 33 Tower Hamlets Health and Lifestyle Survey (2009) 34 NHS Liver Care (2013) NHS Atlas of Variation in Healthcare for People with Liver Disease 35 Diabetes: Tower Hamlets Joint Strategic Needs Assessment factsheet 2010-2011 36 Alazawi et al (2013) Population based study of non-alcoholic fatty liver disease (NAFLD) shows disease is more common among Bangladeshis in ethnically diverse boroughs of London (not published) 16

Figure 16 Tower Hamlets admissions for liver disease caused by NAFLD (2007-2012) 12% 22% White males 16% White females Asian males Asian females 50% 3.3.2 Possible causes of this local variation Although the adult obesity rates in Tower Hamlets are no higher than the national average, the diabetes prevalence (6.1%) is higher than nationally (5.4%) or across London (5.3%). Additionally, there is evidence that the Bangladeshi population is more susceptible to NAFLD particularly in the presence of diabetes. 37 3.3.3 Guidelines The Foresight Report presented a complex system map of the determinants of obesity and argued that a bold whole system approach with broad integrated policies across all areas of the obesity system is required. They stated that the evidence is clear that policies aimed solely at individuals will be inadequate and recommended the following policy responses are likely to have the greatest impact on levels of obesity 38 : Early life interventions at birth or in infancy Controlling the availability of / exposure to obesogenic food and drink Increasing the walkability / cycle-ability of the built environment Increasing the responsibility of organisations for the health of their employees Targeting weight management interventions to those at greatest risk (only if reinforced by interventions at the population level) 3.3.4 What is being done The Weight Management service is commissioned by local authority and is a three tier service. Patients with NAFLD are not currently referred to this service. However, Public Health, who are responsible for designing the service, are including patients with NAFLD in the referral criteria of the Weight Management Service specification. There is a Diabetes LES which streams patients with type 2 diabetes into four categories dependent on control and complexity and suggests a tailored treatment 37 Alam S, Noor-E-Al S, Nonalcoholic steatohepatitis in nonalcoholic fatty liver disease patients of Bangladesh World J Hepatol 2013; 5(5): 281-287 38 Tackling Obesities: Future Choices: Foresight Report http://www.bis.gov.uk/foresight/ourwork/projects/published-projects/tackling-obesities/reports-and-publications 17

for each. GPs are financially incentivised to ensure patients are well medically managed and have had the recommended tests. 3.3.5 Gaps in what is being done Assessment of the supply gaps is limited as no activity data was obtained and the services examined were only provided by one provider (Barts Health). 3.3.6 Recommendations Recommendations for the prevention and management of obesity and diabetes will be detailed in the Healthy Lives Strategy, which will address the underlying cause of non-alcoholic fatty liver disease. Services and pathways currently available to prevent and treat NAFLD have not been clearly identified. As part of the stakeholder engagement it is important to fully assess what services are currently provided and in what ways these can be improved. 18

3.4 Alcoholic Liver Disease (ALD) 3.4.1 Burden of disease: Tower Hamlets picture 3.4.1.1 Alcohol use Alcoholic liver disease is caused by dangerous levels of drinking. Tower Hamlets has a large abstinent population: the Tower Hamlets Health and Lifestyle survey 2009/2010 noted that 1 in 2 adults had not had an alcoholic drink in the last year. 39 This means that problems due to alcohol excess are worse than implied by the data. 3.4.1.2 Hospital admissions for alcohol Alcohol related admissions data from 2011/12 shows that the directly standardised rate of hospital admissions (directly or indirectly) attributable to alcohol was 2213: higher than the London (1911.7) and England averages (1,895) (Figure 17). 40 Figure 17 Alcohol-related admissions of all ages by PCT 2011/2012 41 Admissions to hospital attributable to alcohol per 100,000 population increased between 2006 and 2011 in males (from 1435 to 1859) and females (from 672 to 916) (Figure 18). 42 Figure 18 Alcohol-attributable hospital admissions in Tower Hamlets 2006-2011 39 Tower Hamlets Health and Lifestyle Survey (2009) 40 NHS Liver Care (2013) NHS Atlas of Variation in Healthcare for People with Liver Disease 41 NHS Liver Care (2013) NHS Atlas of Variation in Healthcare for People with Liver Disease 42 Local Alcohol Profiles for England. http://www.lape.org.uk/ 19

3.4.1.3 Hospital admissions for alcoholic liver disease Hospital data for Tower Hamlets was analysed for admissions for liver disease attributable to alcohol (Figure 19). This was shown to be increasing over the past five year period from 2007-2012 (from 31.6 to 54.6 per 100,000 population). Figure 19 Tower Hamlets rates of admissions to hospital for liver disease related to alcohol per 100,000 population 50 45 40 35 30 25 20 15 10 5 0 2007/08 2008/09 2009/10 2010/11 2011/12 The ethnicity of admissions for liver disease caused by alcohol in Tower Hamlets over the period from 2007 2012 were examined (Figure 20). This shows that the majority of admissions due to alcoholic liver disease occur in the white population with only 6% occurring in Asian males and no recorded cases in Asian females. Figure 20 Tower Hamlets admissions for liver disease caused by alcohol (2007-2012) 6% White males 29% White females 65% Asian males 3.4.2 Possible causes of this local variation Alcohol consumption across Tower Hamlets shows high levels of risky drinking across all socioeconomic groups (even when taking ethnicity into account). There is a large abstinent population in Tower Hamlets (1 in 2 of adults had not had an alcoholic drink in the previous year 43 ), so the problem of alcohol misuse is worse than implied by the data. High risk drinking in the population who do drink is common of those who do drink, 43% have harmful or hazardous drinking patterns. 44 In the white ethnic group 40% are classified harmful drinkers or at risk of harm compared to 43 Tower Hamlets Joint Strategic Needs Assessment 2010-2011, Alcohol Consumption and Misuse: Factsheet 44 Tower Hamlets Joint Strategic Needs Assessment 2010-2011, Alcohol Consumption and Misuse: Factsheet 20

20% nationally. 45 This high level of dangerous drinking is likely to be responsible for the levels of alcoholic liver disease. 3.4.3 Guidance 3.4.3.1 NICE guidance NICE recommends a combination of interventions aimed at both the whole population and individuals. 46 Population level approaches help create an environment where lower-risk drinking behaviour is the norm. Interventions aimed at individuals can help make people aware of the potential risks they are taking and harm they may be causing at an earlier stage. The 3 key areas of intervention are: 1) Strategy and policy including: Advertising restrictions Education programmes e.g. in school and community-based programmes Licensing and enforcement e.g. ensuring sufficient resources are in place to prevent under-age sales of alcohol Price: making alcohol less affordable 2) Prevention and screening including: Commissioning services for people with alcohol-use disorders including joined-up alcohol screening, referral and advice services Screening children thought to be at risk of drinking alcohol Screening young people and adults: routinely carry out screening as integral part of practice Providing advice: both brief and extended evidence-based interventions on risk of alcohol-related problems. Consider referral to specialist treatment for those who have not benefitted from structured brief advice and an extended brief intervention 3) Addressing alcohol-related problems Follow NICE guidance on (a) alcohol dependence and harmful alcohol use and (b) Alcohol-use disorders: physical complications Further, the NICE Public Health Briefing recommends that local authorities in collaboration with their local partners 47 : can influence where and when alcohol is consumed or sold can enforce laws on underage sales have an important role in ensuring licensed premises operate responsibly and collaborate to reduce alcohol-related harm have a role in promoting and advising people about sensible drinking have responsibility for commissioning alcohol prevention and specialist treatment 45 Tower Hamlets Joint Strategic Needs Assessment 2010-2011, Alcohol Consumption and Misuse: Factsheet 46 http://publications.nice.org.uk/alcohol-lgb6/what-nice-says#a-two-pronged-approach 47 http://publications.nice.org.uk/alcohol-phb6 21

have responsibility for Health Check. From April 2013, this will include an assessment of how much alcohol someone drinks (NHS Health Check assessments are carried out nationwide on eligible adults aged 40 74). 3.4.3.2 Government Alcohol Strategy The Government s Alcohol Strategy 48 highlights the role of the Health and Wellbeing Board to bring together local authority council, the NHS, and the CCG to develop a joint Health and Wellbeing Strategy based on local need to tackle the issue of alcohol use. This strategy highlights: 1) Identification and Brief Advice, which is proven to be effective in reducing the drinking of people at risk of ill health, and specialised treatment for those with greater needs 2) Alcohol liaison nurses within A&E, which have been shown to reduce representations which may in future be co-funded by Clinical Commissioning Groups alongside Local Authorities. 3.4.4 What is being done Patients diagnosed with liver disease are screened for alcohol misuse as part of the alcohol LES. If alcohol misuse is determined as the cause of the liver disease then the patient is referred to the Community Alcohol Team (CAT) for community or residential detox. Patients referred to the CAT should be assigned a key worker who is responsible for coordinating any health care needs. 3.4.5 Gaps in what is being done Assessment of the supply gaps is limited as no activity data was obtained and the services examined were only provided by one provider (Barts Health). 3.4.6 Recommendations A thorough mapping of the use of currently available services and pathways will allow services across primary and secondary care to develop a local integrated service to optimise care outcomes. Opportunities for early detection and treatment of alcoholic liver disease throughout health service should be identified. Targeting interventions at vulnerable groups at higher risk of hazardous drinking will aid prevention, improve early diagnosis and allow early intervention for alcoholic liver disease. Provisions for the treatment of alcohol use disorders should be reviewed and ensured that they are effective and optimised, including the availability of psychological interventions. The services and pathways currently available to prevent and treat alcoholic liver disease have not been clearly identified. As part of the stakeholder engagement it is important to fully assess what services are currently provided and in what ways these can be improved. 48 Home office, Government Alcohol Strategy, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224075/alcoholstrategy.pdf 22

4 Recommendations Key Recommendations for Addressing Liver Disease in Tower Hamlets Targeted work with higher risk populations in Tower Hamlets to increase hepatitis B vaccination uptake Improve screening of hepatitis B and C, particularly amongst hard to reach and high risk populations. Targeted work with higher risk populations to increase awareness of risky drinking patterns, early diagnosis and early intervention for this group. Recommendations for obesity, diabetes, sexual health and drug use will be detailed in the Healthy Lives Strategy Set up Liver Disease Working Group to: o Review existing pathways o Ensure optimal provision and uptake of liver disease services in Tower Hamlets o Identify gaps/areas for further improvement and ways to address this to maximally benefit the local population. Viral Hepatitis (Hepatitis B and C) Sexual Health Drug use Review the screening of hepatitis C in sexual health Audit proportion of patients accessing GUM services offered hepatitis B testing and vaccination (vaccination recommended for people who change sexual partners frequently (Green Book and NICE PH43)) Clarify the treatment and testing pathways for hepatitis C in patients attending HIV clinics Review uptake of hepatitis B vaccine as part of sexual health NIS against Green book recommendations Review extent of hepatitis B testing and vaccination for patients accessing drug services and compare against guidance from Green Book and NICE PH43. Review percentage of people accessing drug services who are offered and accept hepatitis C testing and compare against guidance in NICE PH43 Review staff update and induction training to ensure hepatitis C protocols are embedded into drug services. Agree and implement strategies to improve hepatitis C testing uptake and access to treatment Review uptake of hepatitis C treatment amongst drugs users Review effectiveness of local drug treatment services in achieving recovery and identify scope for improvement in local drug treatment services and systems Vaccination 23

Review and set targets for uptake of testing for hepatitis B in pregnant mothers and compare against national guidelines from Department of Health Screening of pregnant women for hepatitis B and immunisation of babies at risk (1998). Annually audit and set targets for uptake of hepatitis B booster in children born to hepatitis B positive mothers and compare with guidelines in the Green Book and NICE PH43. Prepare an options paper considering the benefits of locally adopting a universal hepatitis B childhood vaccination programme. Migration/Port Health Prepare a cost-benefit analysis for offering free travel clinics for hepatitis B vaccination for people travelling to or from areas of high hepatitis B prevalence (vaccination recommended for travellers to areas of high or intermediate prevalence who place themselves at risk (Green Book)). Testing and diagnosis Audit the testing for hepatitis B in GP new patient sexual health and substance misuse checks and compare with the guidance in NICE PH43. Review the evidence for testing for hepatitis B in mid-life patient checks. Review the arrangements for contact tracing for patients who test positive hepatitis B or C and communicate these current pathways to primary care and other relevant professionals. Follow national guidance on ways to promote and offer testing to people at an increased risk of hepatitis C infection and compare with the guidance in NICE PH43 Treatment Review barriers to treatment for hepatitis C patients and how to tackle these Other Review locally available services for hepatitis B and C testing and treatment and develop and commission a fully integrated care pathway involving primary and secondary care (as recommended in NICE PH43 guideline). Quantify extent of local discrepancy between number of people who need to be treated and the resources necessary to provide treatment Review treatment outcomes of people testing positive for hepatitis C locally to identify barriers to successful treatment outcome and how to address barriers Review strategies for prevention and case-identification locally and their success in reducing risk of hepatitis C Review degree of contact with patients with viral hepatitis Non-Alcoholic Fatty Liver Disease Recommendations for the prevention of obesity and diabetes will be covered by the Healthy Lives Strategy, which will address the underlying cause of nonalcoholic fatty liver disease. 24

Alcoholic Liver Disease Review provision of Identification and Brief Advice (IBA) Review coverage and availability of alcohol liaison nurses in A&E Review integrated services available for young people at risk of alcohol misuse (NTA Substance Misuse guidance) Explore opportunities for early detection of alcoholic liver disease in the health service Review current patterns of acute service provision and ascertain whether alternatives to admission are possible Provide psychological interventions for alcohol use disorders (e.g. CBT) as per NICE guidance CG115 Improve effectiveness and capacity of specialist alcohol treatment Ensure targeted interventions for alcohol are directed at vulnerable groups Conduct rigorous monitoring and evaluation of alcohol interventions Review trends in diagnosis of alcohol misuse from prescribing trends of acamprosate and disulfiram Update action plan in drugs and alcohol strategy Prevention, early diagnosis and effective management Develop strategies that focus on risk assessment, prevention, early diagnosis and early treatment to prevent the development of advanced liver disease Stakeholder engagement: Thorough mapping of use of available services and pathways currently available o Map available services to maximise collaborative working and optimal care outcomes Development of clinical network and integrated care pathway for liver disease across primary and secondary care o Agree pathways for investigation and management of liver disease at local level o Agree mechanisms for interpreting tests o Agree pathways for abnormal test results o Agree protocols for tests to avoid inappropriate duplication o Develop local protocols between primary and secondary care to ensure clear pathways for medical and social needs are in place Ensure that patients receive appropriate and early intervention with effective combination therapy, to reduce progression to ESLD (secondary prevention) Make available specialised services for patients with ESLD to reduce mortality ensure access to expert care Review current pathway for people presenting to hospital with cirrhosis to identify improvements Review configuration of services and management of primary liver cancer to identify improvements and opportunities for improving early diagnosis 25