Shona Arora

BACKGROUND: The age standardised mortality rate per 100 000 population for all causes of liver tumours (International Classification of Disease 9 (ICD-9) 155) has almost doubled in England and Wales during the period 1979-1996. We further analysed the mortality statistics to determine which anatomical subcategories were involved. METHODS: Mortality statistics for liver tumours of ICD-9 155, 156, and subcategories, and for tumours of the pancreas (ICD-9 157), in England and Wales were investigated from the Office for National Statistics, London, from 1968 to 1996 inclusive. Data for 1997 and 1998 were also available on intrahepatic cholangiocarcinomas. RESULTS: There has been a marked rise in age standardised mortality rates for intrahepatic cholangiocarcinoma. Since 1993, it represents the commonest recorded cause of liver tumour related death in England and Wales. This is evident in age groups older than 45 years. In contrast, mortality trends from other primary liver tumours, including hepatocellular carcinoma, were unremarkable. CONCLUSIONS: The observed increase in mortality from intrahepatic cholangiocarcinoma may represent better case ascertainment and diagnosis due to improved diagnostic imaging, use of image guided biopsies, or increased use of ERCP. However, the trend started before ERCP was introduced nationally, mortality rates have continued to increase steadily thereafter, and there is no clear evidence that diagnostic transfers easily explains the findings. Alternatively, these observations may represent a true increase in intrahepatic bile duct tumours. Epidemiological studies are required to determine whether there is any geographical clustering of cases around the UK.

INTRODUCTION: The UK Health Security Agency's (UKHSA) Health Protection Teams (HPTs) provide specialist public health advice and operational support to NHS, local authorities and other agencies in England. The development of a three-year UKHSA Health Equity strategy creates a unique opportunity for HPTs to reduce health inequities within their work. AIMS: This study aimed to understand current health equity activities and structures within HPTs, and to propose future HPT-led health equity activities. METHODS: Between November 2021 - March 2022, HPT staff from the nine UKHSA regions were invited to participate in a semi-structured interview or focus group. RESULTS: Twenty-seven participants covering all nine UKHSA regions took part in a total of 18 interviews and two focus groups. There was enthusiasm to address health inequity, and many reported this as their motivation for working in public health. All HPTs routinely engaged in health equity work including, variously: liaising with other organisations; advocacy in case and outbreak management meetings; developing regional HPT health equity action plans; and targeting under-served populations in day-to-day work. HPT staff discussed the challenge of splitting their time between reacting to health protection incidents (e.g., COVID as the main priority at the time) and pro-active work (e.g., programmes to reduce risk from external hazards for vulnerable populations). Although COVID had raised awareness of health inequities, knowledge of health equity among the professionally diverse workforce appeared variable. Limited evidence about effective interventions, and lack of clarity about future ways of working with other organisations were also shared as barriers to tackling health inequities. CONCLUSION: HPTs welcomed the development of UKHSA's health equity strategy, and through this study identified opportunities where HPTs can influence, support and lead on tackling health inequities. This includes embedding health equity into HPTs' acute response activities, stakeholder working, and staff management. This study also identified a need for health equity training for HPTs to improve knowledge and skills, utilising evidence-based approaches to health equity. Finally, we have identified areas where HPTs can lead, for example using brief advice interventions and through developing resources, such as standard operating procedures that focus on vulnerable populations. These findings will support a more integrated approach to addressing health equity through health protection work.