The health of the UK has been improving steadily for most diseases over recent decades. This is partly due to investment in resources to tackle diseases such as cardiac disease. Liver disease has not followed this trend and has in fact significantly increased in its prevalence. The Lancet Commission (2014) identifies that standard mortality rates have increased 400 percent from 1970 to 2010, and most of these patients die in working age (Figure 1.) The Office of National Statistics identifies liver disease as the third largest cause of premature mortality after ischaemic heart disease and self harm.
Liver diseases Figure 1: Demonstrating percentage change in standardised mortality rates where 1970 is regarded as 100 percent
In England, liver disease causes approximately 2 percent of all deaths and the total number is rising, from 15.8 per 100,000 in 2001 to 2003 to 17.8 per 100,000 in 2012 to 2014.
In 2012/13, an estimated 1 million hospital admissions in England were for an alcohol related disease or injury as the primary reason for admission or a secondary diagnosis. There were 15,785 deaths specifically resulting from alcohol from 2010 to 2012.
In 2012/13, there were 305,048 recorded crimes in England related to alcohol and 881,000 violent incidents in England and Wales where the victim believed the perpetrator was under the influence of alcohol. (National Institute for Health and Care Excellence, 2015.) The Nuffield Trust (2015) show that Accident and Emergency attendances likely due to alcohol poisoning doubled from 2008/09 to 2013/14. Over a longer time period (2005/06 to 2013/14), alcohol-specific inpatient admissions increased by 64 percent, with emergency admissions increasing by 53 percent and elective admissions increasing by 143 percent.
Obesity rates in the UK almost doubled between 1993 and 2011, from 13 percent to 24 percent in men and 16 percent to 26 percent in women. (National Institute for Health and Care Excellence, 2014.) Obesity is directly linked to multiple chronic diseases including type 2 diabetes mellitus, non-alcoholic fatty liver disease, hypertension, gallstones and gastro-oesophageal reflux disease.
In 2014, a total of 488 acute or probable acute cases of hepatitis B were reported for England. This is an annual incidence of 0.91 per 100,000 population, higher than the incidence of 0.77 per 100,000 reported for 2013. 95 percent of new chronic hepatitis B infections seen in the UK occur in migrant populations following vertical transmission in the country of birth. 90 percent of those with chronic hepatitis C infections inject drugs or have done so in the past. (Public Health England, 2015.)
Hepatitis C is primarily acquired through injecting drugs with shared needles. 70 percent of those with acute infection will develop chronic hepatitis. National estimates suggest that around 214,000 individuals are chronically infected with hepatitis C.
Wokingham’s Liver disease profile
Between 2001 to 2003 and 2010 to 2012, the average number of people who died each year with an underlying cause of liver disease increased from 15 to 23. The under 75 mortality rate from liver disease was 12.8 per 100,000 population, which was significantly better than the England rate in 2012 to 2014. This was similar to the comparator group of local authorities from the same deprivation decile (Figure 2). Under 75 mortality rates for men were also significantly better in Wokingham, compared to England, at 14.1 per 100,000 population. Rates for women are not published for Wokingham, due to the low numbers.
Figure 2: Under 75 mortality rate for liver disease (persons) in Wokingham
Source: Public Health Outcomes Framework (2015.)
In 2013/14 there were 95 hospital admissions due to liver disease, a rate of 63.9 per 100,000 compared to the rate for England of 115.8 per 100,000.
There were 200 alcohol specific hospital admissions in Wokingham in 2013/14 (125 male and 75 female). The rate of alcohol specific hospital admissions in Wokingham was significantly lower than the England average. Between 2010 and 2012, an average of 5 men and 2 women aged under 75 died each year in Wokingham from alcoholic liver disease. (Public Health England, 2015.)
Between 2006 and 2015 in Wokingham, alcoholic liver disease was the greatest cause of death in those dying from liver disease aged under 69 years. This is shown in Figure 3.
Figure 3: Deaths from lived disease in Wokingham by age group (2006-2015)
Source: Primary Care Mortality Database (2015.)
The proportion of Year 6 children classified as overweight or obese in Wokingham was 26 percent in 2014/15, which was significantly better than the England average of 33 percent. The proportion of adults classified as overweight or obese in 2012 to 14 was 62 percent, which was similar to the England average of 65 percent. (Public Health Outcomes Framework, 2015.)
In 2012/13, 84 percent of people injecting drugs, who were in their latest treatment episode at specialist drug services, took up the hepatitis C test they were offered. In 2012, it was estimated that 33 percent of those who inject drugs have been infected with hepatitis C. The estimated total infected with hepatitis C in Wokingham is 254. (Public Health England, 2015.)
In 2012/13, 82 percent of babies born to mothers infected with hepatitis B received a complete course of hepatitis B vaccination. In the same year, the proportion of people in their latest treatment journey at specialist drug services, being offered and completing a course of hepatitis B vaccine was 28 percent. (Public Health England, 2015.)
What is this telling us?
Mortality from liver disease is increasing in the UK, whilst mortality from other major diseases is decreasing. Disease of the liver is largely caused by preventable lifestyle behaviours, the 3 main causes being alcoholic liver disease, non-alcoholic fatty liver disease and viral hepatitis. Whilst these 3 factors are all significant contributors to liver disease, excessive alcohol consumption represents the most serious burden. Alcohol consumption continues to rise rapidly and following this trend closely is a rise in alcohol related Accident and Emergency attendances, alcohol related hospital admissions to hospital, alcohol related mortality and a rise in alcohol related crime and loss of productivity.
Attendances at Accident and Emergency and rates of premature death are increasing secondary to these causes and this represents an opportunity for preventative measures to be implemented to stem the rise. Although there is no national framework to combat liver disease, Public Health England recognises it as a public health priority and recommendations are being made by a variety of interested organisations aimed at tackling liver disease. A preventative approach will alleviate an increasing pressure on primary and secondary care providers.