Can the United Kingdom control viral hepatitis?

The Viral Hepatitis Prevention Board (VHPB) held its autumn meeting, November 17-18, 2005, in Edinburgh, United Kingdom (UK). The meeting comprised experts from the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), as well as healthcare representatives, decision-makers, academics, and clinicians, with specialist expertise in the control of viral hepatitis.

The primary objective of the meeting was to review current practice relating to the control of viral hepatitis in the United Kingdom. In an introductory presentation, insight was provided on how England, Wales, Scotland, and Northern Ireland fit together in terms of health policy, healthcare, decision making, research, and funding. The meeting subsequently focussed on an update of the epidemiological situation of hepatitis A, hepatitis B, and hepatitis C in the United Kingdom, including information relating to virological and clinical aspects. An overview of national and regional prevention strategies was also presented while discussions focussed on testing, vaccination policies, disease management, as well as burden of disease and health economics models. The meeting ended with lessons learnt from the UK experience.

Control of viral hepatitis in the UK: how England, Wales, Scotland, and Northern Ireland fit together

Prevention of viral hepatitis in the UK is articulated around a three-step decision-making process. The Health Protection Centres (HPC) in England, Wales, Scotland, and Northern Ireland collect epidemiological data that are used as a basis for the Advisory Group on Hepatitis (AGH) to provide advice to the ministers of health, while the Joint Committee on Vaccination and Immunisation (JCVI) eventually delivers advice on childhood vaccination programmes. In parallel to this process, delivery of care is based on guidelines from the National Health and Institute for Health and Clinical Excellence (NICE), recommending cost-effective therapies while treatment of patients with chronic hepatitis B (CHB) or chronic hepatitis C (CHC) should be managed within Managed Clinical Networks (MCNs).

In practice, hepatitis A and hepatitis B prevention in the UK is based on risk group vaccination, while many other European countries apply hepatitis B risk group vaccination in addition to universal hepatitis B vaccination programmes. In terms of prevention and treatment of chronic hepatitis, a national strategy and action plan are in place for CHC, including the establishment of MCNs, while such measures are not available but urgently needed for CHB. Improved prevention and delivery of treatment for CHC is also needed. Current epidemiological issues regarding rising mortality rates related to chronic liver disease (CLD) and missed prevention opportunities should be addressed, including alcohol consumption and obesity as complicating risk factors.

Hepatitis B: epidemiology and control

The UK is a low-incidence and low-prevalence country regarding hepatitis B. Acute hepatitis B cases predominantly occur in adults, mainly in identified but difficult-to-reach highrisk groups, while ethnic minority children may also be at risk. A substantial proportion of cases are also diagnosed in individuals with no known risk.

The role of universal hepatitis B vaccination appears to be limited in the UK because carriage rates are high in ethnic minorities, with a large proportion of carriers with infection acquired in childhood, prior to their immigration to the UK.

Current challenges for the improvement of hepatitis B control measures include the reinforcement of surveillance programmes, using reliable laboratory reporting and case notifications. Screening programmes also need to be enhanced and vaccination strategies implemented, favouring regional initiatives, such as those initiated in the Glasgow region. National immunisation programmes might also need to be reconsidered. In terms of secondary prevention, treatment strategies should be revised so as to reconcile theoretical paradigms with economic decisions.

Hepatitis C: epidemiology and control

The overall prevalence of hepatitis C virus (HCV) in the UK is low but the burden of infection is greatest among injecting drug users (IDUs), resulting in high incidence levels in this population comprising a large proportion of individuals who are unaware of their infection. Current challenges for the control of HCV infection in the UK should mainly address the implementation of specific prevention measures among current IDUs, coupled with improved case-finding programmes among past IDUs.

Enhanced diagnosis of HCV-infected persons should contribute to the identification of individuals who most need therapy to prevent disease progression. Best treatment options should also be considered for mild- / moderate-stage patients as it might be more cost-effective to provide antiviral treatment at a mild rather than at a moderate stage.

Hepatitis A: epidemiology and control

Hepatitis A incidence is at historically low levels in the UK, with a majority of cases found in highest risk groups such as IDUs, men who have sex with men (MSM), South Asian immigrant populations, and travellers. Disease surveillance programmes are currently incomplete and need to be improved while the utility of hepatitis A virus (HAV) genotyping might need to be evaluated. National control policies are based on hygiene, administration of human normal immunoglobulin (HNIg), and hepatitis A vaccination, although local practice varies.

Concluding remarks and suggested areas for future research

The meeting was generally concluded with a statement agreed among all participants that the control of viral hepatitis in the UK might benefit from the lessons learnt in other countries of the European Union. There was also a general consensus that a more accurate appreciation of current UK needs and challenges in terms of prevention strategies should require a direct comparison with data obtained from other countries.

In terms of national health strategy against HCV infection, in addition to the need for improved control measures against hepatitis C, it was felt by the audience that more consideration should be given to the management of HCV-positive subjects who do not benefit from treatment after screening. In terms of a national health strategy against hepatitis B virus (HBV) infection, it was recommended that, similarly to the current US recommendations [1], more emphasis should be put on preventive measures targeting specific groups, such as immigrant populations. It was also stated that specific groups should be targeted to benefit from hepatitis B treatment. Results from modelled economic evaluations of selective and universal hepatitis B immunisation strategies should be interpreted with caution, taking balanced information into account. These should, for instance, include a price range for hepatitis B vaccine in sensitivity analyses as the procurement of vaccine through a call for tenders could considerably lower the cost of vaccination programmes and make these more economically attractive for implementation in the UK.

Reference [1] Mast EE, Margolis HS, Fiore AE et al., on behalf of the Advisory Committee on Immunization Practices (ACIP). A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part 1: immunization of infants, children, and adolescents. MMWR Recomm Rep 2005; 54(RR-16):1-31.

Further information is available in the corresponding Viral Hepatitis Issue or  meeting web page