Behind the science: Understanding Canada’s new hepatitis B guidelines
Hepatitis B is a liver infection caused by the hepatitis B virus. Without proper care, hepatitis B can lead to serious health problems like liver failure, liver cancer and early death. In 2025, the Canadian Association for the Study of the Liver (CASL) and the Association of Medical Microbiology and Infectious Disease Canada (AMMI) released new guidelines for the management of chronic hepatitis B.
Madison Kennedy, CATIE’s knowledge specialist in hepatitis, spoke with Dr. Hin Hin Ko, Clinical Professor of Medicine at University of British Columbia and member of the chronic hepatitis B guideline committee, to understand how these guidelines can improve patient care.
Why were new Canadian hepatitis B guidelines developed?
The previous guidelines were published in 2018. Since then, a lot has changed in terms of what we know about the hepatitis B virus. We also wanted to align with the World Health Organization (WHO) targets to eliminate viral hepatitis by 2030. To reach these targets, we wanted the new guidelines to increase engagement in screening and vaccination, expand treatment indications, and include recommendations for patient-centred care. Around the same time the Canadian guidelines were published, both European and American ones were released with similar recommendations.
How did the committee approach developing the guidelines?
The whole guideline committee looked at the latest evidence on hepatitis B, trying to improve awareness and care of hepatitis B among service providers in Canada. We tried to write in a way that would raise awareness of screening among family doctors and frontline workers, because everyone can play a role. The guidelines are also written to try to simplify treatment, so any kind of healthcare provider—if they feel comfortable—can treat hepatitis B. We know that there’s only a limited number of specialists, so expanding the number of hepatitis B care providers would make treatment more accessible for people living with hepatitis B.
What are the main changes from the 2018 guidelines?
The first change is about screening. The 2018 guidelines were more focused on risk-based screening. To reduce stigma and ensure no one gets missed, we recommend that any adult over 18 years should have one-time screening. So, we shifted from risk-based to one-time universal screening to increase the number of people getting diagnosed.
There’s also more of a prevention focus in the 2025 guidelines. If someone doesn’t have hepatitis B, but screening shows they’re not protected from the virus, we can offer the vaccine. In other words, we broadened our vaccine recommendations. Even though provinces may have different vaccine programs, we emphasized the importance of universal infant vaccination. Ideally this would happen at birth, across all provinces and territories. Also, if people missed their childhood vaccinations, we recommend universal adult catch-up vaccinations.
We also touched more on hepatitis D. In the 2025 guidelines, we recommend people with chronic hepatitis B to have one-time universal reflex testing for hepatitis D. This is because hepatitis D is the most severe form of viral hepatitis. Even though it is rare, having hepatitis B and D significantly increases the risk of liver cancer compared to just having hepatitis B.
In terms of treatment, there’s also a major change. Everyone with chronic hepatitis B needs ongoing monitoring, but not everyone needs treatment. In 2018, there were some gray areas where a person didn’t fall into the treatment category but might have benefitted from treatment to reduce their risk of health complications. We didn’t specify what care they needed. Now, we think they might benefit from taking a proactive approach. We recommend offering treatment to an expanded group of people with chronic hepatitis B, to prevent complications.
We also expect that in the next couple of years new hepatitis B treatment options may become available in addition to the therapies currently in use. These new treatments suppress the virus better and improve the body’s immune response to the virus. This means there’s a higher chance people might be able to achieve functional cure and not need to stay on treatment forever. Since the last guidelines, we also rely on newer diagnostic markers to guide when a person can stop treatment. So, in anticipation of new treatments, we touch on diagnostic tools and who might benefit from future treatments.
We also focus more on special populations because we felt that some communities have not been getting equitable access to hepatitis B care. These include immigrants and newcomers from where hepatitis B is common, pregnant women and Indigenous communities. We emphasize that lots of different healthcare providers are needed to diagnose and manage care for patients who face barriers to testing and care.
Finally, an overarching theme in our guidelines that is different from before is the focus on patient-centred care. Many of our recommendations focus on involving patients in discussions about treatment. We realize that healthcare isn’t just what healthcare providers tell patients – it’s about patients themselves being partners in decision-making. They have to feel comfortable with their care plan.
Why are these changes important and what impact do you hope they will have?
These changes are essential for reaching the WHO targets to eliminate viral hepatitis. I think they’re very important because Canada is still behind in achieving elimination targets. We’re really trying to change how people see viral hepatitis. Our goal is to prevent people from getting hepatitis B through vaccination and to hopefully diagnose more people who are living with chronic hepatitis B, preventing liver complications.
Hepatitis B is a silent condition, so if people don’t have symptoms, they may not seek medical care. However, even without symptoms, they’re at risk of liver cirrhosis and liver cancer. Many people with hepatitis B feel really stigmatized and because of that, they’re worried about being on treatment. We hope with wider screening recommendations we can destigmatize hepatitis B.
We also hope to see broad policy changes. Hepatitis B is very preventable, so we should start by doing a much better job with vaccination. Of course, it’s hard to show to governments that vaccination can prevent healthcare costs by just using modelling studies. They often want to see real-world data to support any policy changes. It will be years before we see the real economic benefits, but hopefully they can see that it’s worthwhile to invest upfront to see these benefits down the road.
Finally, universal coverage of medications would make a big impact to improve patient care across the country. Right now, each province does slightly different things. If all provincial and territorial governments were more aligned, we could provide universal coverage of medications and a consistent vaccination schedule. To help advocate for these changes, we need to keep making our voice bigger. That’s why we have the Canadian Hepatitis B Peer Support Group and other partners like Action Hepatitis Canada. We need the voice of patients, not just physicians. Hopefully, through a combined effort we see some changes.
Dr. Hin Hin Ko is a clinical professor of medicine in the Division of Gastroenterology at the University of British Columbia. She is a fellow of both the American Association for the Study of Liver Diseases (FAASLD) and American Gastroenterology Association (AGAF). She is a hepatologist and gastroenterologist at St. Paul’s Hospital in Vancouver.
Madison Kennedy is CATIE’s knowledge specialist in hepatitis C. She has a master’s degree of public health in health promotion and previously worked in sexual and reproductive health service delivery and research.