Chronic hepatitis B in Canada: Challenges, insights and pathways forward

Hepatitis B is a liver infection caused by the hepatitis B virus (HBV), which can result in either acute or chronic infection. Most HBV infections are transmitted from mother to child at birth, shortly after birth, or during early childhood. Research shows that infections in babies and young children are more likely to become long-term, so vaccination at birth is crucial to prevent transmission.

Other modes of transmission include exposure to infected body fluids like blood, saliva, vaginal fluids and semen. The main transmission routes include injection drug use, vaginal, anal and oral sex, being born to a mother with HBV, and exposure to blood or blood products in HBV endemic regions or medical equipment that isn’t properly sterilized.

HBV is a major public health threat worldwide, with an estimated 257 million people (3.2% of the global population) living with HBV infection in 2022, and approximately 1.5 million new cases per year. Untreated HBV results in high rates of liver-related complications, such as cirrhosis, liver cancer and mortality. Available data in Canada show a higher rate of liver-related mortality among those living with HBV compared to those without the infection. This underscores the urgent need for comprehensive HBV prevention and management strategies to mitigate its impact on public health. That said, not every patient with hepatitis B will go on to develop these complications and it is important to consider who will benefit from treatment and offer it to them in line with current HBV management guidelines.

In Canada, priority populations for HBV interventions include Indigenous people, people who inject drugs, immigrants, gay, bisexual and other men who have sex with men, street-involved youth, and people who are or have been incarcerated. Developing targeted interventions for these populations is crucial if we are to address the specific needs and challenges of each group.

Epidemiology of HBV in Canada

Hepatitis B virus infection is a serious public health issue in Canada. Although there is limited data on prevalence in Canada, we know that there were an estimated 250,000- 460,000 individuals living with HBV infection in 2018. We also know that less than 25% of eligible people received treatment. This treatment gap represents a significant challenge in our efforts to manage HBV and prevent its complications.

In 2021, British Columbia had the highest provincial rate of reported HBV (16.2 per 100,000 people), which was close to twice the national rate (8.9 per 100,000 people). HBV rates in Canada may rise further with increasing immigration, which is expected to make up to 34% of the overall population by 2041. This demographic shift highlights the need for culturally sensitive and accessible HBV services to ensure equitable healthcare for all Canadians.

For most adults HBV is a short-term infection, but recent studies in Canada have shed light on the demographics of chronic HBV (CHBV), an infection that lasts over six months. A nationwide analysis of 9,380 individuals living with CHBV from eight healthcare jurisdictions revealed that most were older (with a median age of 48), male and of Asian backgrounds. Another study of 1,539,869 first-time Canadian blood donors from 2005 to 2022 revealed similar findings, including prevalence in ethnoculturally diverse neighbourhoods and among lower-income backgrounds due to marginalization and lack of access to information/treatment. These findings emphasize the importance of tailoring HBV interventions to address the specific needs of diverse communities across Canada.

Challenges in HBV prevention and management in Canada

Despite the high burden of CHBV, many individuals are not linked to care or receiving treatment, including those who meet the criteria outlined in the Canadian Association for the Study of the Liver’s treatment guideline. For example, our recent work found that in British Columbia, only 52% of people diagnosed with CHBV and cirrhosis were receiving treatment. Several factors may contribute to low treatment rates, including difficulties reaching groups who have been historically underserved in Canada, such as racialized people, people who are institutionalized or underhoused, people who use drugs and people with mental health needs. In addition, immigrants experience multifaceted barriers to accessing healthcare, including cultural, linguistic and socioeconomic factors, for example, not being able to take time off work for healthcare. Patients may also refuse treatments with interferon due to adverse side effects.

The low treatment rates in the treatment eligible group are alarming given that CHBV can lead to severe complications, such as cirrhosis, liver cancer and mortality, particularly in those with comorbidities such as HIV infection, non-alcoholic fatty liver disease, or hepatitis C virus co-infection. This situation not only impacts individual health outcomes but also places a considerable strain on our healthcare system.

Moreover, there is a paucity of data on the HBV care cascade in Canada. A care cascade is a useful tool for evaluating the delivery of care for chronic infections from diagnosis to viral suppression, which can inform resource allocation and service planning. Significant gaps in the HBV care cascade were highlighted in an Ontario study comparing the HBV care cascade among immigrants and long-term residents. Although this study revealed that immigrants had slightly higher rates of diagnosis and slightly better measures in subsequent cascade stages, it nonetheless called for better screening efforts and linkage to care strategies. After all, it indicated that in both immigrants and long-term residents, only 4% of individuals continued HBV treatment after initiation. This underscores the urgent need for improved strategies to engage and retain patients in HBV care across all populations.

Pathways for improving HBV prevention and management

Here are some of the ways we can strengthen the HBV care cascade and improve linkage to services:

1. Collect and analyze data on gaps in the care cascade across all provinces and territories. This information is crucial to inform service programming, particularly for priority populations, as different groups experience different healthcare barriers.
2. Decentralize and integrate HBV testing, treatment and care into other existing services and settings. Locating these services in more accessible health settings has shown promise in improving care cascade outcomes, such as local health centers and district hospitals, where general practitioners and nurses can prescribe anti-HBV drugs and follow up without requiring specialist approval. In our recent work in Rwanda, this strategy was employed and we saw an increase of individuals enrolling in care, initiating HBV treatment and remaining in care after decentralization of HBV services.
3. Align Canadian HBV management strategies with the latest international guidelines. The World Health Organization (WHO) published updated guidelines on hepatitis B in March 2024, which provide new recommendations for testing, care, and treatment of people with chronic hepatitis B infection. These guidelines represent a significant shift in HBV management strategies globally and could have important implications for Canada. The Canadian Association for the Study of the Liver (CASL) is currently reviewing these guidelines and the updated Canadian HBV management recommendations will be published in 2025. These forthcoming guidelines are expected to enhance the HBV care cascade in Canada, ensuring alignment with international best practices.
4. Collaborate with community organizations and people with lived experience to help inform optimal interventions and services and effectively engage and retain priority groups in testing, treatment and care. This approach ensures that interventions are culturally appropriate and address the specific needs of diverse communities.
5. Learn from strategies that have been highly effective with other chronic viral infections, such as HIV and hepatitis C. These include empowering community-based organizations and increasing support for peer-led initiatives. The crucial roles of community education and outreach programs in engaging people in care have been highlighted by both healthcare providers and community members.
6. Ensure that healthcare providers, as well as other professionals who work with priority populations, have up-to-date and culturally sensitive training on HBV and treatment options. Peer educators can play an important role in education as well as supporting individuals through the HBV care cascade.
7. Increase access to affordable testing and treatment options, particularly for underserved communities. This may require advocating for increased funding and resources to support comprehensive HBV initiatives at both provincial and federal levels.

Learning from hepatitis C

Daryl Luster, a long-time peer navigator, community health educator and advocate on viral hepatitis, shared his insights:

Based on my experience with hepatitis C (HCV) and the ongoing struggle to adequately inform people of the health risks of living with viral hepatitis, it is evident that more must be done to address HBV, especially in high-risk populations. The lack of community and peer-led advocacy in Canada for HBV care and treatment access, much like the initial efforts for HIV and HCV, has hindered progress.

In conclusion, to effectively address CHBV, it is imperative that we adopt a multifaceted approach. This includes elaboration of the HBV care cascade and addressing gaps across all provinces and territories, prioritizing interventions for populations facing the highest barriers to care, as well as implementing and scaling up HBV prevention and management services. Data on gaps in the care cascade are necessary for all provinces and territories to inform service programming, particularly for priority populations, as different groups experience different healthcare barriers.

By implementing these strategies and learning from successful approaches used for other chronic viral infections, we can improve HBV management and reduce its impact on public health in Canada. These efforts align with the WHO’s global health strategy to eliminate viral hepatitis as a public health threat by 2030. Continued research, data collection and evaluation of interventions will be crucial in guiding our future efforts in paving the way for better health outcomes for all affected populations in Canada.

 

Dr. Jean Damascene Makuza is a medical doctor with a master’s degree in epidemiology and is currently a PhD candidate at the School of Population and Public Health at the University of British Columbia and trainee with the Canadian Network on Hepatitis C (CanHepC). In his 12 years of experience as public health professional, he has led programs in HIV, sexually transmitted infections, viral hepatitis and cervical cancer prevention and control in Rwanda. At the BC Centre for Disease Control (BCCDC), under the supervision of Dr. Naveed Janjua, his research looks at care cascade and treatment outcome for patients screened for hepatitis B and C in Rwanda.

Daryl Luster uses his experience as a person who lived with HCV to work as an advocate and educator with patients, caregivers, legislators, drug companies and healthcare professionals. He is an advocate for a greater commitment on the part of payers, whether public or private, and speaks with patients regularly. He also has experience as a presenter, peer navigator and blogger, and brings a broad understanding of issues faced by people living with chronic disease. Supporting improved quality of life for all patients is at the center of his work. He is part of multiple organizations such as the Canadian Institutes of Health Research’s HIV/AIDS and STBBI Research Advisory Committee and Institute of Infection and Immunity Community Advisory Committee, as well as the Canadian Network on Hepatitis C (CanHepC).

Dahn Jeong is a PhD candidate at the School of Population and Public Health at the University of British Columbia. Her doctoral research examines the benefits of direct-acting antiviral treatment for HCV infection, specifically in relation to extrahepatic manifestations (EHMs), and ethnic disparities in EHMs. Dahn is a PhD trainee with the Canadian Network on Hepatitis C (CanHepC) and is also supported by the Canadian Institutes of Health Research.