1. Section 1: Introduction Dr Somen Banerjee, Director of Public Health London Borough Tower Hamlets

2. Liver disease mortality in Tower Hamlets nearly twice English average Http://hna.londonhp.nhs.uk/documents/PHOF/Tower%20Hamlets%20Regional%20PHOF.pdf This is Public Health Outcomes Framework baseline data (June 2012) showing the high mortality rate from liver disease for persons aged under 75 (per 100 000 population)

3. Liver disease in Tower Hamlets AreaTower Hamlets Performance Liver disease mortality in under 75 year oldsOne of highest in England Rate of admission for cirrhosisHighest in England Rate of primary liver cancer mortality in under 75 year oldsHighest in England Incidence of acute hepatitis BFifth highest in England Hospital admissions with chronic hepatitis BHighest in London Chronic hepatitis C prevalence rateFourth highest in England Trend in hospital admissions for liver disease attributable to alcohol over past 5 years Increasing

4. Four causes of liver disease all result in cirrhosis, cancer & mortality Mortality Cirrhosis and Cancer Liver diseaseHepatitis BHepatitis C Alcoholic liver disease Non Alcoholic Fatty Liver Disease

5. Number of people in Tower Hamlets with each disease (GP diagnosis)

6. The 4 diseases in Tower Hamlets, London and England Hepatitis BFifth highest incidence in England Hepatitis CHighest prevalence in London Alcoholic Liver DiseaseHigher than London average for alcohol admissions Non-Alcoholic Fatty Liver Disease Comparable data not available, but likely to be high

7. Hepatitis B disease burden in Tower Hamlets 765 chronic hepatitis B cases Royal London: highest number of cases of chronic hepatitis B of any London hospital in 2011 (1,069 cases) Incidence of new, acute hepatitis B: – 2.2 / 100,000 (2011) –Fifth highest in London 7

8. Who gets Hep B in Tower Hamlets? Chronic cases detected and treated in Tower Hamlets are usually: –People from south Asia –Men –Detected between ages 25-44 –People who have acquired it during childhood in country of high prevalence (e.g. Bangladesh) New infections within Tower Hamlets are usually people who: –Change sexual partners frequently, or –Inject drugs, or –Recently travelled to an area of high prevalence

9. Chronic Hepatitis C disease burden in Tower Hamlets 647 diagnosed cases However HPA estimates 1813 cases –The fourth highest rate nationally So nearly two thirds undiagnosed We don’t currently know the number of new cases each year Admissions increased from 12.7 to 19.3 per 100,000 from 2007-2012

10. Who gets Hep C in Tower Hamlets? Mostly men Predominantly report White ethnicity Usually diagnosed in adulthood Usually they are from one of the following at risk groups: –Injecting drug users –People who change sexual partners frequently –Men who have sex with men

11. Alcoholic liver disease background 9000 high risk drinkers. 68% of migrants drink harmfully. 110 in-patient admissions for ALD in 2013/14 (total cost= £285,000) Prevalence of ALD= 458  15 deaths from ALD in 2012

12. 3) Alcoholic liver disease Tower Hamlets rates of admissions to hospital for liver disease related to alcohol per 100,000 population TH hospital admissions between 2007-2012 increased from 31.6 to 54.6 per 100,000 population. 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.

13. Non alcoholic fatty liver disease (NAFLD) background Estimated prevalence in Tower Hamlets= 2546 Fat depositions in the liver potentially leading to cirrhosis and death Risk factors= obesity, diabetes Prevention and treatment= weight loss and exercise. High risk group= Bangladeshi 109 in-patient admissions in 2013/14 (total cost= £160,000)

14. Tackling liver disease - preventian and early intervention is key NHS Liver Care (2013) NHS Atlas of Variation in Healthcare for People with Liver Disease

15. Growing up Education on sexual health, alcohol and drugs Early identification and prevention of harmful alcohol consumption and drug use Encourage physical activity and healthy eating Addressing Liver Disease – A life course narrative Disease Hepatitis B Hepatitis C Alcoholic Liver Disease Non-Alcoholic Fatty Liver Disease (NAFLD) Early years Screening mothers Child Vaccinations Screening mothers Young Adults Screening and vaccinating Sexual health, drug and alcohol services Encourage physical activity and healthy eating Middle age Older adults High quality services for people with liver disease Early identification and treatment of complications: Cirrhosis Liver Cancer Income, Housing, Environment, Social networks, Community, Health Behaviours, High Quality Services

16. Where we are now Health & Wellbeing Board have identified this as a priority area Completed needs assessment Mapped care pathways CCG appointed a clinical lead Stakeholder event – July 14

17. Where we are now cont’d Primary care liver function testing has been unbundled – this will save the CCG up to £300K in 3 years’ time. CEG clinical guidelines for the treatment of liver disease to be released September 2015 - for Tower Hamlets, Waltham Forest and Newham. A universal vaccination has been approved for Hepatitis B - NHSE are leading on this. The British liver Trust are having a “love your liver” event on the 26 th of May. People will be able to have a fibroscan and increase their understanding of liver disease PLT Continue to explore issues in the secondary care pathway Launch of the liver disease page on the CCG intranet with all relevant information updated.

18. Summary Tower Hamlets has one of the highest levels of liver disease and mortality in the country The cost on secondary care is high Intervening early is more beneficial and can save money