When you think of hepatitis B, what comes to mind? An infection you can acquire while travelling? A virus that can be passed through sex or sharing needles? An infection that is mostly preventable with a two-dose vaccine? While all of these are true, the epidemiological realities of hepatitis B in Canada are changing. More and more Canadians with hepatitis B are immigrants and newcomers from countries where hepatitis B is endemic, and where transmission mostly occurs during pregnancy and childbirth.
A recent study from the University of Waterloo suggests that under current strategies for diagnosis, vaccination and treatment, Canada and other high-income countries with high immigration rates will not be able to eliminate hepatitis B as a public health threat by 2030, a commitment made at the World Health Assembly.
What could we be doing differently to achieve our elimination goals?
Implement birth dose vaccination
Even in countries like Canada with low prevalence of hepatitis B, the World Health Organization recommends that all infants receive a first dose of the hepatitis B vaccine as soon as possible after birth, also known as birth dose vaccination. However, this recommendation is not consistently implemented in all Canadian provinces and territories. Only New Brunswick, the Northwest Territories and Nunavut offer hepatitis B birth dose vaccination, while Alberta, British Columbia, Prince Edward Island, Quebec and the Yukon offer vaccination starting at two months after birth. The remaining five provinces provide vaccines to adolescents between the ages of nine and 12.
The birth dose is vital because it can prevent parent-to-child transmission during pregnancy and childbirth, as well as the development of chronic infection in infants. The birth dose is followed by additional vaccine doses, which are given at specific intervals to ensure long-term protection. It is important that provinces and territories that do not currently offer birth dose vaccination change their policies to account for the changing epidemiology of hepatitis B in Canada.
Expand screening for hepatitis B
In Canada, there are no national hepatitis B screening guidelines outside of prenatal care. Guidelines could help frontline workers and healthcare providers identify people who could benefit from hepatitis B testing. Prompt diagnosis is a crucial first step in preventing further transmission of the virus, and can link individuals to treatment and care.
Recently, the U.S. Centers for Disease Control and Prevention updated its hepatitis B screening guidelines to recommend testing of all adults at least once in their lifetime. Likewise, Canada could offer one-time screening to all adults and make hepatitis B testing more widely available to reduce stigma and testing barriers, especially for priority populations.
Increase culturally appropriate awareness and education efforts
In Canada, hepatitis B is most prevalent among populations that are also at greater risk for other sexually transmitted and bloodborne infections, including people who inject drugs, Indigenous people, immigrants and newcomers, gay, bisexual and other men who have sex with men, people who are street-involved or homeless, as well as people who have been incarcerated.
These are all highly marginalized communities that face multiple barriers to accessing healthcare, requiring culturally appropriate and trauma-informed approaches to education and awareness. Prevalence is also higher among Canadians born in countries where hepatitis B is endemic – mostly in Africa, Asia and the Caribbean – making language and cultural barriers an additional challenge for effective awareness and education efforts.
Strengthen surveillance and monitoring
A recognized challenge of working in the hepatitis B response is working with epidemiological data that are often years old. The availability of real-time, centralized and accurate data may be a game changer for the elimination of hepatitis B as a public health threat by 2030. Improvements to surveillance and monitoring could help us better understand and track trends at the national and regional level, as well as to implement interventions that are informed by and responsive to real-time information.
May 11 will mark the second Canadian Viral Hepatitis Elimination Day. On this day, we call for immediate action from all levels of government, working together with healthcare and service providers and communities affected by viral hepatitis, to meet Canada’s commitments to the WHO’s first global health sector strategy to eliminate viral hepatitis as a public health threat by 2030.
Fozia Tanveer is CATIE’s manager of immigrant and newcomer hepatitis C programming. She has been working with CATIE since 2011 and has a master’s degree in development studies from the School of Oriental and African Studies, University of London.