Screening migrant patients for viral hepatitis in a primary care setting is effective if clinicians are given incentive and support, according to study results published in the Lancet Gastroenterology & Hepatology.

The results also indicated that community care and bespoke invitation letters for screening do not result in any added benefit in this population.

The study included adults aged ≥18 years receiving primary care services who had been identified as a first- or second-generation migrant from a high-risk country. Each participating general practice was randomly assigned (1:2:2:2:2) to an opportunistic screening (control) group or to 1 of 4 targeted screening (intervention) groups: standard (hospital-based) care and a standard invitation letter, standard care and an enhanced invitation letter, community care and a standard invitation letter, or community care and an enhanced invitation letter.

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During control screenings, general practitioners underwent a 1-hour teaching seminar on viral hepatitis and were asked to test all registered migrants. In the intervention groups, general practitioners were paid a nominal fee to set up searches of records, given a prompt to evaluate eligible patients, reimbursed for signed consent forms, and supported by a dedicated trainee clinician.

The study’s primary outcomes were the percentage of patients eligible for screening at primary care practices, the percentage of patients eligible who were sent an invitation letter in the intervention groups, the percentage of eligible patients who presented for viral hepatitis screening, the percentage of patients who tested positive for viral hepatitis, the percentage who complied with treatment, and the cost-effectiveness of the intervention.

A total of 58 practices were randomly assigned in the study: 8 practices to the control group and 50 to an intervention.

In the control practices, 38.4% (26,046 of 67,820) of participants who were registered were eligible for testing. In the intervention practices, that percentage was 43.3% (152,321 of 351,710).

Of 51,773 randomly-selected participants from intervention practices, 84.2% (n=43,585) were sent letters.

Of control participants, 1.7% (543/31,738) of eligible participants took up screening compared with 19.5% (11,386/58,512) of intervention participants (incidence rate ratio 3.70; 95% CI 1.30–10.51; P=.014). The researchers also found that the intervention was cost-effective.

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In participants who received letters, 4.5% (720/15,844) of participants who received the standard letter were tested compared with 3.7% (1032/28,095) of participants who received the enhanced letter.

“The finding that only 20% of patients attended screening, even with the interventions in this trial, indicates that further measures will be required to eliminate viral hepatitis as a healthcare concern,” the researchers concluded.


Flanagan S, Kunkel J, Appleby V, et al. Case finding and therapy for chronic viral hepatitis in primary care (HepFREE):  a cluster-randomised controlled trial [published online November 23, 2018]. Lancet Gastroenterol Hepatol. doi:10.1016/S2468-1253(18)30318-2