How to tackle rising rates of liver disease in the UK
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f807 (Published 08 February 2013) Cite this as: BMJ 2013;346:f807All rapid responses
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Dear Sir,
In their otherwise excellent editorial on tackling the growing burden of liver disease in the UK1, Bhala et al. omit to mention a major recent advance in the non-invasive assessment of liver disease, which is likely to have a major impact in helping secondary care (and possibly primary care) in dealing with the large potential number of referrals that are likely to arise from the early detection of risk factors and early intervention that they advocate.
Existing methods, including liver function tests and ultrasonography, have low specificity and sensitivity for the detection of liver fibrosis. Liver biopsy carries a potential risk and is reserved for selected patients, and new serological markers of fibrosis have as yet failed to make an impact on routine clinical practice.
The advent of elastography (the measurement of liver stiffness) may offer the highest chance of reliably identifying those patients with significant liver damage, upon whom valuable secondary care resources need to be targeted2. In general, combined use of panels of serological measurements have the usual disadvantages of “surrogate” markers, whereas liver stiffness is a “real” measurement performed on a window of liver tissue approximately 250 times larger than a liver biopsy specimen3.
Currently there is evidence for two established competing technologies – transient elastography or TE (Fibroscan©) and acoustic radiation force impulse elastography or ARFI (Virtual Touch©)4,5. Whereas the former is a free standing single function technology, the latter is more widely available by software modification of an ultrasound machine in general use, and has the advantage of being combined with real time imaging.
Both have high overall predictive performance for underlying liver fibrosis and cirrhosis in a variety of liver diseases, although TE has been more extensively validated in trials6.
However, the use of ARFI would appear to be more cost effective when used at the primary secondary care interface as many institutions may already possess such a machine and also because the technology (in conjunction with colour coded strain elastograms) is useful in a number of other specialties eg breast, thyroid, salivary glands etc7.
Therefore, in addition to a higher referral rate to liver clinics advocated by the authors, elastography promises to be a highly useful diagnostic tool utilised within a “one stop” set up combined with both clinical assessment and serological tests, allowing rapid triage of patients to either discharge, further monitoring or other interventions by hepatologists. With more widespread availability, it is likely that in the near future such technology may also become more accessible to primary care via both “open access” systems and community clinics.
DAVID I.SHERMAN1 david.sherman@nhs.net
MINAL JAGTIANI2 drminaljagtiani@yahoo.co.uk
PHILIP SHORVON2 p.shorvon@nhs.net
Departments of Gastroenterology1 and Radiology2, Central Middlesex Hospital, North West London Hospitals NHS Trust, London, United Kingdom
References :
1. Bhala et al. BMJ 2013; 346: f807.
2. Castera et al. Lancet 2010; 375: 1419-1420.
3. Castera. Gastroenterology 2012; 142: 1293–1302.
4. Friedrich-Rust et al. Gastroenterology 2008; 134: 960–74.
5. Lupsor M et al. J Gastrointestin Liver Dis. 2009;18: 303-10.
6. Friedrich-Rust et al. Radiology 2008; 252(2): 595-604.
7. The use of ultrasound elastography for the detection and assessment of liver fibrosis: A technology implementation study within secondary care. NHS Technology Adoption Centre, 2013: www.ntac.nhs.uk/publications/
Competing interests :
The authors disclose no competing interests.
Fibroscan is copyright of Echosens; Virtual Touch is copyright of Siemens.
Competing interests: No competing interests
The authors would like to acknowledge Prof. Martin Lombard, National Clinical Director for Liver Disease, for comments on the paper. The views expressed in the editorial are those of the authors and do not necessarily reflect those of their institutions.
Competing interests: No competing interests
Re: How to tackle rising rates of liver disease in the UK
Liver diseases are becoming one of the major killers and are emerging as a serious public health issue .The article very efficiently brings into attention the complexity and gravity of the problem. The annual report of the chief medical officer for England states liver disease to be the only major cause of mortality and morbidity that is on the rise in England whilst it is decreasing among other European countries (1). High alcohol consumption, obesity and chronic viral hepatitis B and C are serious leading contributors to deaths associated with liver diseases (2). “Prevention is better than cure”, it is high time to deal with this rapidly growing problem especially looking at various preventive strategies.
Heavy drinking is one of the main reason for liver dysfunction in the UK. According to the Information Centre for health and Social care UK, there was a 2.1% increase of primary hospital admissions attributable to alcohol in 2010/11 when compared with 09/10 (3). The Net Ingredient Cost of drugs prescribed for the treatment of alcohol dependence added a 3.3 % increase on to the 2010 figures (3). More children and young adults are exposed to alcohol advert compared to adults in England (4). Though used as a relaxant (5), a study found that 36.6% of people with alcohol abuse or dependence suffer from some or the other psychiatric disorder compared to 19.9% in the general population(6). So it is essential to catch them young and treat mental health problems before they get into this vicious circle. Preventive measures have shown reasonably good results. Recently a Canadian study has found that a 10% increase in the average minimum price of alcohol was associated with a 32% reduction in alcohol attributable deaths(7,8). A recent document published by the Home Office , UK indicates an established association between alcohol consumption and negative health outcomes and increasing alcohol prices are associated with decreases in health harms (9). The long term benefit of adapting such a policy in the UK in order to prevent heavy drinking is to be evaluated on the available data.
Obesity and metabolic disorders contribute much to chronic liver diseases imposing a great burden on the country's health care system. The chairman of the Academy of Medical Royal College UK recently stated that the obesity related illnesses are causing many needless deaths from avoidable disease and costing the NHS an estimated £5.1 bn a year (10). Majority of obese patients suffers from NASH which may lead to cirrhosis and HCC. There is a complex bi-directional relationship between obesity and mental disorders (11) which needs to be analyzed more closely in order to break this bi-directional flow. Obesity is to be dealt on an MDT basis. Highlighting the importance of healthy eating, physical activity and harms of drug/alcohol misuse as preventative measures in educational settings at an appropriate age can be very helpful.
Chronic hepatitis B and C cluster is another “Iceberg” inflicting a heavy burden to the liver disease pool. Hepatitis “infection rate” can be reduced by adhering to various preventive measures. However, availability of a safe and efficacious vaccine and adoption of appropriate immunization strategies is the most effective means to prevent HBV infection and its consequences. In 2010, 179 countries have included the hepatitis B vaccine into their national infant immunization programs but United Kingdom hasn’t done it so far. Instead, vaccination of only the high risk individual against hepatitis B is the adopted policy (Department of Health, 2006). Although the UK is considered as a low prevalence area of chronic hepatitis B infection(12) the hepatitis B notifications in Wales and England is increasing (13), probably due to migration(14). Both C and B viruses can stay viable at room temperature at least for a few days. Hence the danger of inapparent transmission to anyone even by simple cosmetic procedures like pedicure cannot be ruled out. Up to 90% of infants infected with Hep B virus during the first year of life and 30%-50% of children infected between one to four years of age develop Chronic Infections (15). These aspects underline the importance of implementing mandatory Hepatitis B vaccination. Their immunity has been shown to be long-lasting. No booster is required in healthy vaccinated individuals to sustain protection. One of the best example is “The hepatitis B vaccination program” implemented since 20 years in Italy. It demonstrates what universal immunization is able to provide in the medium-long-term when health care authorities are so wise as to invest in prevention(16,17). With its relatively modest costs and high benefits, HBV immunization continues to be one of the best values for public health investment today. Introducing mandatory vaccination of infants and increasing HBV vaccination coverage in high-risk groups, including households of HBsAg carriers as well as immigrants, remain a priority for the future.
Early detection of the extent of liver damage is very important in all the above mentioned instances . The cost effectiveness of including recent non invasive technologies like transient elastography for liver screening is worth considering.
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2.Rohit Loomba, Hwai-I Yang, Jun Su et al Synergism Between Obesity and Alcohol in Increasing the Risk of Hepatocellular Carcinoma: A Prospective Cohort Study. Am. J. Epidemiol. (2013) 177(4):333-342.
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4.Gerard Hastings, Nick Sheron, Alcohol marketing: grooming the next generation
BMJ2013;346doi: http://dx.doi.org/10.1136/bmj.f1227(Published 1 March 2013)
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5. Cheers?Understanding the relationship between alcohol and mental health: Mental Health Foundation, April 2006.
6. Epidemiologic Catchment Area Study, in Regier et al (1990). Co-morbidity of mental disorder withalcohol and other drug abuse: results from the Epidemiological Catchment Area (ECA) study. Journal ofthe American Medical Association, vol. 264, pp 2511-2518 [quoted in chapter 32 of Heather N, Peter TJ,Stockwell T (eds) International Handbook Alcohol Dependence and Problems. Wiley 2001. Mueser KT and Kavanagh D, Treating co-morbidity of alcohol problems and psychiatric disorder]
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8. Hawkes N. Minimum price for alcohol is proposed for England and Wales. BMJ 2012;345:e8140.
9. “The likely impacts of increasing alcohol price: a summary review of the evidence base”; Home Office, January 2011.
10.Royal College call for “duty”on sugary drinks in action plan against obesity.BMJ 2013;346:f1146.
11. Document by “noo”; National Obesity Observatory ,Obesity and mental health.March 2011.
12. Caley M, Fowler T, Greatrex S, Wood A. Differences in hepatitis B infection rate between ethnic groups in antenatal women in Birmingham, United Kingdom, May 2004 to December 2008 . Euro Surveill. 2012;17(30):pii=20228.
Available online:http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20228
13. Health Protection Agency (HPA). Hepatitis B. Notifications for England and Wales 1990-2003. London: HPA. [Accessed 22 Jun 2012]. Available from: http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/HepatitisB/...
14. Janet JunQuing Chu, Tanja Wormann, Johann Popp et al. Changing epidemiology of Hepatitis B and migration-a comparison of six Northern and North-Western European countries . The Europian Journal of Public Health Advance Access. June 8 2012 (1-6).
15.WHO. Expanded Programme on Immunization Hepatitis B Vaccine. Available from: http://www.who.int/vaccines-documents/DoxNews/updates/updat31e.pdf.
Hum Vaccin Immunother.
16. Boccalini S, Taddei C, Ceccherini V, et al. Economic analysis of the first 20 y of universal hepatitis B vaccination program in Italy: An a posteriori evaluation and forecast of future benefits. Hum Vaccin Immunother 2013 Feb 1;9(5). [Epub ahead of print]
17. Luisa Romanò, Sara Paladini, Alessandro R. Zanetti. Twenty years of universal vaccination against hepatitis B in Italy: achievements and challenges. (2012) Vol No.2.
Competing interests :
The authors disclose no competing interests.
Competing interests: No competing interests