This year, the Canadian Association for the Study of the Liver (CASL) hosted a single topic conference from September 29th to Oct 1st, bringing together a group of national and international experts in Hepatitis B research and practice in Calgary to discuss the Progress towards Hepatitis B elimination in Canada.
Acute Hepatitis B is an initial infection that can lead to immediate symptoms such as fever, vomiting, jaundice, joint pain, etc., or remain asymptomatic. Most adults recover fully from acute Hepatitis B within a few months, with the immune system successfully fighting off the virus. Chronic Hepatitis B, on the other hand, occurs when the virus remains in the body for six months or longer. Often asymptomatic in its early stages, chronic Hepatitis B can lead to serious health issues like liver cirrhosis, liver failure, or liver cancer over time. The risk of chronic infection is higher in individuals infected at a young age, and it requires ongoing medical management to monitor liver health and prevent disease progression.
It is estimated that over 250 million people are living with hepatitis B, many of whom are in regions that have limited access to quality healthcare and vaccination programs. Hepatitis B is a global health concern, with some of the highest prevalence being reported in Africa and the Eastern Mediterranean region. The primary mode of Hepatitis B transmission globally is from mother to child during childbirth. In adults, Hepatitis B is commonly transmitted through condomless sex and sharing needles or equipment for injection drug use. Additionally, challenges such as limited access to screening and immunization, high cost of treatment, lack of awareness, and multilayered stigma make Hepatitis B a complex public health issue.
Canada, like many other countries, is experiencing changes in the demographics of Hepatitis B cases. The shift is largely attributed to immigration from regions where Hepatitis B is endemic, it is therefore important to understand the global challenges of hepatitis B elimination. Additionally, the Indigenous people are disproportionately affected by HIV.
Testing
Some of the data shared at the conference suggested that nearly 50-70% of people living with Hepatitis B in the US and Canada remain undiagnosed. Many individuals may carry the virus without knowing it, leading to delayed treatment and potential transmission. Factors such as stigma, lack of awareness, and limited health literacy around healthy liver contribute to the problem. Screening for Hepatitis B is the most important step for early diagnosis and treatment. Since Canada lacks a nationwide guideline for testing and treatment while people living with hepatitis B remain undiagnosed, many speakers and participants recommended broad screening strategies such as universal one-time testing for chronic infection. Meanwhile, some participants also highlighted the considerations for such a policy such as feasibility, and available resources to handle increased screening, immunization, and treatment.
Treatment
Unlike Hepatitis C, hepatitis B lacks a complete cure, with treatments focused mainly on virus suppression. Effective management of Hepatitis B often involves long-term or lifelong antiviral therapy. The evolving nature of the chronic infection is influenced by factors such as alcohol use, and Metabolic Associated Liver Diseases (MAFLD). Additionally, challenges around properly diagnosing and managing coinfections with Hepatitis C, D, and HIV, particularly in resource-limited settings, add layers of complexity to treatment. These coinfections can accelerate liver damage, requiring regular monitoring of treatment approaches and for the detection of liver cancer. Furthermore, the stigma associated with these coinfections can further complicate the challenges with linkage to care and adherence to the treatment.
Vaccination
Vaccinating infants against Hepatitis B is the most effective strategy to prevent transmission and long-term complications as over 90% of infants who become infected will develop chronic Hepatitis B, while only 5% of adults will develop Hepatitis B. For infants born to Hepatitis B surface antigen-positive mothers, vaccination within the first 24 hours of birth is crucial. Few Canadian healthcare jurisdictions have implemented birth dose vaccinations, some provinces start their vaccination at two months, and others rely on school-based vaccination programs that start at a later age. This disparity in vaccination schedules across healthcare jurisdictions indicates a lack of a unified national approach to Hepatitis B vaccination in Canada.
Map of Canada showing the age the first dose of HBV vaccine is offered. Note: Alberta changed from 10y to 2m in 2019. Picture Source – Action Hepatitis Canada
In the conference there were additional discussions around adult vaccination for key population groups, including immigrants from endemic regions, Indigenous population, people who use drugs, and those that are at increased risk of sexual transmission. The lack of specific guidelines for adult vaccination led to a debate on the need for triple panel testing before vaccination and the cost-effectiveness of such program.
Additional Considerations
Efforts to eliminate Hepatitis B greatly benefit from strengthening healthcare providers’ capacity through tailored education that promotes client-centered and culturally safer care and services. The education program should highlight the need for not only early detection and treatment but also vaccination, other prevention strategies, and adherence to the treatment.
Community-based organizations and peer groups play a critical role in this elimination effort by creating programs and services to increase public and provider awareness, address stigma, create safe and supportive space, link people to testing and care, provide wraparound services, and advocate for effective policy change.
Additionally, researchers, evaluators, and knowledge users need to work together to create a collaborative space to deepen the understanding of hepatitis B, understand trends and patterns of the infection, develop prevention strategies, and monitor and evaluate the effectiveness of the interventions.
Resources
World Health Organization – Hepatitis B
Relevant literature
Chahal, D., Lee, J. G., Yoshida, E. M., Lowe, C., Ho, F., Sum, V., & Kwan, P. (2022). Seroprevalence of hepatitis B in previously undiagnosed patients: A community screening study. Canadian liver journal, 5(2), 144–151. https://doi.org/10.3138/canlivj-2021-0008
Coffin, C. S., Fung, S. K., Ma, M. M., & Canadian Association for the Study of the Liver (2012). Management of chronic hepatitis B: Canadian Association for the Study of the Liver consensus guidelines. Canadian journal of gastroenterology = Journal canadien de gastroenterologie, 26(12), 917–938. https://doi.org/10.1155/2012/506819
Joshi, S. S., & Coffin, C. S. (2020). Hepatitis B and Pregnancy: Virologic and Immunologic Characteristics. Hepatology communications, 4(2), 157–171. https://doi.org/10.1002/hep4.1460
O’Brien, S. F., Reedman, C. N., Osiowy, C., Bolotin, S., Yi, Q. L., Lourenço, L., Lewin, A., Binka, M., Caffrey, N., & Drews, S. J. (2023). Hepatitis B Blood Donor Screening Data: An Under-Recognized Resource for Canadian Public Health Surveillance. Viruses, 15(2), 409. https://doi.org/10.3390/v15020409
Osiowy, C., Giles, E., Trubnikov, M., Choudhri, Y., & Andonov, A. (2015). Characterization of Acute and Chronic Hepatitis B Virus Genotypes in Canada. PloS one, 10(9), e0136074. https://doi.org/10.1371/journal.pone.0136074
Terrault, N. A., Lok, A. S. F., McMahon, B. J., Chang, K. M., Hwang, J. P., Jonas, M. M., Brown, R. S., Jr, Bzowej, N. H., & Wong, J. B. (2018). Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology (Baltimore, Md.), 67(4), 1560–1599. https://doi.org/10.1002/hep.29800
World Health Organization. (2017). Global Hepatitis Report 2017. Geneva: Author. Licence: CC BY-NC-SA 3.0 IGO.
For more information, please contact PAN’s Manager of Research and Evaluation Jennifer Demchuk at [email protected]