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!