Liver disease

There is no national strategy on combating the rising level of liver disease. Specific advice can be found in Public Health England’s (2015) ‘Liver Disease in the South West: a health needs assessment’, and while this is based on South West England the recommendations can be generalised nationally. These include prevention strategies for the 3 main preventable causes of liver disease, which include identification and brief advice for alcohol misuse, needle and syringe programmes, immunisation for hepatitis B prevention and healthy lifestyles to reduce obesity and its impact on health. Additional advice includes education for health care professionals, specifically improving expertise in primary care, and public health campaigns. Finally this document recommends a minimum unit price for alcohol, which is also included in the All-Party Parliamentary Hepatology Group (2014) Inquiry into Improving Outcomes in Liver Disease.

The All-Party Parliamentary Hepatology Group’s Inquiry outlines 20 recommendations which focus on prevention of liver disease and the provision of national guidance for a coordinated approach to combating liver disease. As well as the recommendation that the government implements a minimum unit price of alcohol to 50p, it also endorses universal hepatitis B vaccination, elimination of hepatitis C in 15 years and the promotion of obesity reduction programs in the context of liver disease. It also recommends that Liver Function Tests should become part of the health check for over 40s.

The British Society of Gastroenterology has outlined key recommendations regarding alcohol related disease. Chief among these are for multidisciplinary ‘alcohol care team’ led by a consultant to be accessible to a typical district general hospital. Additional recommendations include the instigation of coordinated policies on detection and management of alcohol-use disorders in Accident and Emergency with access to brief interventions and appropriate services within 24 hours of diagnosis, 7 day alcohol specialist nurses and link workers, addiction psychiatrists with specific responsibility for screening for depression, the establishment of an outreach alcohol service, integrated alcohol treatment pathways and integrated modular training in alcohol and addiction for relevant members of staff. Further research targeting alcohol-use disorders is also called for.

The Lancet Commission provide 10 recommendations, again these largely focus on the detection, screening and prevention of liver disease with the provision of a 7 day specialist alcohol unit in district general hospitals. Their other recommendations mirror those already mentioned above.

National Institute for Health and Care Institute guidance includes

• PH43: Hepatitis B and C testing (2012) - aims to ensure more people at increased risk of hepatitis B and C infection are tested

• CG189: Obesity identification, assessment and management (2014) - evidence-based advice on the care and treatment of obesity

• QS83: Alcohol – preventing harmful use in the community (2015)

Alcohol

The national cost of alcohol consumption can be measured financially, but there is also a cost to society in terms of crime, lost productivity, and morbidity and mortality. The financial cost of treating alcohol-related conditions is 3 percent of the NHS annual budget (Government’s Alcohol Strategy. Third Report of Session 2012-2013). 70 percent of the cost to the NHS of alcohol-related services is spent on hospital treatment, largely for chronic conditions related to alcohol consumption. Restructuring this service to favour preventative measures represents an opportunity to achieve better outcomes for both individual patients and society. The estimated cost to society is £21 billion annually - £3.5 billion for NHS England, £11 billion for crime in England and £7.3 billion for lost productivity. (National Institute for Health and Care Excellence, Local Government Briefing 6.)

Data provided by the Health and Social Care Information Centre (2014) describes the nation’s current consumption of alcohol trends.

Most pertinently

• Between 2005 and 2012 the proportion of men and women who drank alcohol in the week before being interviewed fell from 72 percent to 64 percent and 57 percent to 52 percent respectively

• Among adults who had drunk alcohol in the last week, 55 percent of men and 53 percent of women drank more than the recommended daily amounts, according to previous guidance of no more than 4 units per day form men and three for women. New guidance as of 2016 does not recommend a daily limit, but now suggests a maximum recommended weekly limit of 14 units.

Although the first statement suggests that alcohol consumption is falling, those who were drinking were doing so to excessive levels. With the re-classification of alcohol limits in 2016, we may see a sharp rise in apparently excessive alcohol consumption.

Obesity

The cost of being overweight and obese to society was estimated at £16 billion in 2007. This has been predicted to increase according to the department of health, possibly to £50 billion by 2050 if current trends continue, (National Institute for Health and Care Excellence, 2014.)

Hepatitis

Greater optimism exists with regards to chronic viral hepatitis, as both vaccination and drug therapy continue to advance. Whilst initially expensive, new hepatitis C drugs represent long term cost-effective prevention of chronic liver disease. However, a barrier to this potential success is the underutilisation of the hepatitis B vaccination and the forecast increase in immigration of infected individuals from high prevalence countries, both causing pools of infection within the population. 

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.

Source: The Lancet Commission (2014.)

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.

Alcohol

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 

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.

Hepatitis

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.

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.

Alcohol

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. 

Source: Primary Care Mortality Database (2015.)

Obesity

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.)

Hepatitis

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.

Liver disease disproportionately affects the younger age groups - 90 percent of people who die from liver disease are under 70 years old and 10 percent of deaths of people in their 40s are from liver disease. (Public Health England, 2014.)

Alcoholic liver disease accounts for 37 percent of liver disease deaths and there are 3 times as many deaths from alcoholic liver disease in the most deprived areas of England compared to the least deprived. Mortality rates from liver disease for people aged 75 and under also vary significantly by geographical location, being generally higher in the north than the south of England. Part of this variation may be explained by underlying deprivation-related variation in liver disease incidence and mortality. Wokingham is classified within the least deprived decile in the country.

Deaths from liver disease in males exceed those in females for all age groups, apart from those aged 80 and over. Wokingham’s under 75 mortality rate from liver disease for all persons and men were significantly better than the England rate in 2012 to 2014. Rates for women were not available for women, as the numbers were too small to publish.

Nationally, hospital admission rates due to liver disease are also higher for men at 145.9 per 100,000, compared to 87.6 per 100,000 for women. Hospital admission rates for alcoholic liver disease also reflect this difference with 44.0 admissions per 100,000 for men, compared to 20.3 per 100,000 for women.

Over 70 percent of those dying with liver disease do so in hospital.