Hepatitis C Testing in the Hepatitis C Testing in the Muslim CommunityMuslim Community

Hasnain JafferbhoyHasnain JafferbhoyGrampian Hepatitis Stakeholder Conference Grampian Hepatitis Stakeholder Conference

16 16 th th June 2011June 2011

BackgroundBackground Hepatitis C(HCV) is a leading cause of Liver disease Hepatitis C(HCV) is a leading cause of Liver disease

W.H.O estimates 2.2% of the world population is infected W.H.O estimates 2.2% of the world population is infected

Vast geographic variations in prevalence Vast geographic variations in prevalence

Major risk factors are blood transfusion and injecting drug use (IDU)Major risk factors are blood transfusion and injecting drug use (IDU)

Since the advent of routine blood screening and identification of this Since the advent of routine blood screening and identification of this reservoir reservoir

This has led to a shift in epidemiology of HCV over the last two decadesThis has led to a shift in epidemiology of HCV over the last two decades

Currently IDU is the cardinal risk factor in the western world Currently IDU is the cardinal risk factor in the western world

Migration means society is not homogenousMigration means society is not homogenous

In UK 0.4 % of the population is infected with HCV In UK 0.4 % of the population is infected with HCV

Scotland estimates are higher at 1% Scotland estimates are higher at 1%

Pakistanis are the largest ethnic minority in Scotland as per 2001 census Pakistanis are the largest ethnic minority in Scotland as per 2001 census estimates estimates

Two main periods for economic migration from Pakistan are 1950-1960 and Two main periods for economic migration from Pakistan are 1950-1960 and another wave in 1990-2000another wave in 1990-2000

Dundee in East of Scotland has third largest Pakistani sub population of Dundee in East of Scotland has third largest Pakistani sub population of 1700 1700

In Pakistan the prevalence is estimated at 6% In Pakistan the prevalence is estimated at 6%

Work done in England on south Asian populationWork done in England on south Asian population Found 2.7% Pakistanis to be Anti HCV positiveFound 2.7% Pakistanis to be Anti HCV positive

Testing and treating HCV is cost effective Testing and treating HCV is cost effective

HypothesisHypothesisImmigrant Pakistanis retain higher level of Immigrant Pakistanis retain higher level of

HCV infectivity as compared to native HCV infectivity as compared to native population of their adopted homelandpopulation of their adopted homeland

AimAim

We intended to investigate this sub populationWe intended to investigate this sub population

MethodMethod Collaborated with community representatives to organise Collaborated with community representatives to organise

HCV awareness programHCV awareness program Spoke at city's Mosques on Friday just prior to prayers Spoke at city's Mosques on Friday just prior to prayers

and Pakistan women's associationand Pakistan women's association Message was delivered bilingually (English & Urdu)Message was delivered bilingually (English & Urdu) Thereafter we set up outreach testing clinics in three Thereafter we set up outreach testing clinics in three

Mosques and a women’s centre on consecutive weeksMosques and a women’s centre on consecutive weeks Venous blood samples were taken for testing of HCV IgG Venous blood samples were taken for testing of HCV IgG

and HBsAg, using the Abbott Architect systemand HBsAg, using the Abbott Architect system Relevant medical, family ,travel history was recorded as Relevant medical, family ,travel history was recorded as

well as history of risk factors for HCVwell as history of risk factors for HCV Consent obtained regarding results being mailed to Consent obtained regarding results being mailed to

address provided address provided

ResultsResults

177 Individuals were tested,7 were excluded from calculation because country of ancestral origin 177 Individuals were tested,7 were excluded from calculation because country of ancestral origin was not Pakistanwas not Pakistan

Only 11 were born in U.K (6.5 %)Only 11 were born in U.K (6.5 %)

They were predominantly males 145 (85.2%) They were predominantly males 145 (85.2%)

Average age and SD was 45.11 (16.7)Average age and SD was 45.11 (16.7)

74.5% have been resident in UK for >5 years74.5% have been resident in UK for >5 years

Length of residency varied from a minimum of 1 to a maximum of 59 Length of residency varied from a minimum of 1 to a maximum of 59 yearsyears

A minority 29 (17%) had not re visited the country of originA minority 29 (17%) had not re visited the country of origin

Most (86 %) had visited the General Practice in the preceding two Most (86 %) had visited the General Practice in the preceding two yearsyears

None admitted to using in IDUNone admitted to using in IDU

All males had circumcision performed and 31 had this as the only All males had circumcision performed and 31 had this as the only risk factor identifiedrisk factor identified

Risk categoryRisk category

GenderGender TransfusionTransfusion SurgerySurgery Family Family historyhistory

HCVHCV

Dental Dental carecare

Child Child birthbirth

Injection Injection therapytherapy

CircumcisionCircumcision

onlyonly

MaleMale

(145)(145)

55 1818 2121 2525 N/AN/A 4545 3131

FemaleFemale

(25)(25)

11 22 44 22 44 1212 N/AN/A

Total %Total % 3.53.5 11.711.7 14.714.7 15.815.8 2.32.3 33.533.5 18.218.2

Seven males tested anti HCV positive (4%)Seven males tested anti HCV positive (4%)

Average age and SD was 40 (18.7)Average age and SD was 40 (18.7)

The length of residency varied from 3 to 49 years with average of 21 The length of residency varied from 3 to 49 years with average of 21 yearsyears

Risk factors profile shows all underwent circumcision, two had Risk factors profile shows all underwent circumcision, two had injections and one had a family history of HCVinjections and one had a family history of HCV

Five tested HCV RNA PCR positive (2.9%)Five tested HCV RNA PCR positive (2.9%) PCR positive patients were Genotype 3 with elevated PCR positive patients were Genotype 3 with elevated ALT none were found to be cirrhoticALT none were found to be cirrhotic

All have been started on treatment All have been started on treatment

DiscussionDiscussion We have tested 10% of the Pakistani population of Dundee We have tested 10% of the Pakistani population of Dundee

(census estimates)(census estimates)

The project demonstrates high risk population can be target tested by The project demonstrates high risk population can be target tested by outreach clinicsoutreach clinics

Our results are lower than prevalence reported in Pakistan and could be Our results are lower than prevalence reported in Pakistan and could be secondary to the healthy migrant effectsecondary to the healthy migrant effect

Guidelines from SIGN need to be updated to encompass Pakistani origin as Guidelines from SIGN need to be updated to encompass Pakistani origin as risk factor and to offer testingrisk factor and to offer testing

Our project has selection bias as we chose sites to test and also individuals Our project has selection bias as we chose sites to test and also individuals self selected by volunteering self selected by volunteering

Female and UK born Pakistani participation was low hence it is difficult to Female and UK born Pakistani participation was low hence it is difficult to infer the prevalence in these two groups infer the prevalence in these two groups