Hepatitis C in Canadian immigrants and newcomers: Why are hepatitis C rates higher in these populations?
The face of hepatitis C in Canada is diverse, with a significant proportion of the burden carried by Canadians from countries where hepatitis C is endemic. This article will explore why hepatitis C rates are higher among Canadian immigrants and newcomers, including common modes of transmission, and barriers related to testing.
Hepatitis C in Canadian immigrants and newcomers
Hepatitis C is a virus that affects the liver. Although there is a cure, treatment is not accessible to everyone. Hepatitis C disease progresses slowly – sometimes over 20 or 30 years – and if left untreated can lead to cirrhosis, liver cancer and death.
Immigrants bear a large burden of the hepatitis C epidemic in Canada. Recent data estimate that just over one in three people who are antibody positive for hepatitis C in Canada are foreign-born.1 It is estimated that 1.9% of Canadian immigrants are positive for hepatitis C antibodies, which is higher2 than the Canadian national prevalence of 1% or less.2
Canada has a large foreign-born population that could be living with hepatitis C. In 2011, about 21% of people living in Canada (6.7 million) were foreign-born, compared to 25.6 million people who were born in Canada.Statistics Canada.3 Every year, Canada admits about 250,000 permanent residents,4 and a much larger number of people with temporary status (such as students, temporary foreign workers, and people with work permits).
Four countries are the major sources of immigration to Canada – China, India, Pakistan and the Philippines.5 These countries either have high prevalence rates for hepatitis C or a large number of people living with hepatitis C. Table 1 shows the prevalence and absolute number of people living with hepatitis C in these countries compared to Canada. Of these countries, China has the highest number of people living with hepatitis C, followed by India. The Indian prevalence of 1.5% is higher than that in Canada (1.0 %), but it is much less than in the other three countries. However, India accounts for a substantial number of hepatitis C infections due to its population size.
Table 1: Comparison of hepatitis C prevalence and population between Canada and the four major source countries for immigration6
Hepatitis C prevalence
Population living with hepatitis C (estimated)
1.0 % (antibody positive)
0.6–0.7 % (chronic infection)
221,000 – 246,000
Source: Clinical Microbiology and Infection 2011
Before immigrating to Canada, applicants must undergo a medical examination that includes screening for HIV, active tuberculosis and some other conditions.7 Many immigrants believe that this medical examination includes screening for any potential viruses they might be at high risk for, including hepatitis C, and assume they are in good health if they are not diagnosed with any of the conditions that are screened for.8 However, people can immigrate to Canada without knowing their hepatitis C status because there is no mandatory screening for hepatitis C9 as part of the immigration process. Physicians performing the Immigration Medical Examination are instructed to screen for risk factors or signs of liver disease10 and test for hepatitis C antibodies as appropriate.
How is hepatitis C spread among Canadian immigrants and newcomers?
There are a number of risk factors for hepatitis C infection in immigrants and newcomers, and it is important for service providers to understand them. In Canada, the primary mode of hepatitis C transmission is injection drug use.11 However, Canadian immigrants usually acquire hepatitis C in their home countries before coming to Canada. Modes of transmission include the use of unsterilized or inadequately sterilized medical, dental and surgical equipment; unsafe injections and the transfusion of unscreened blood and blood products.12 The transmission from re-used needles, blood and blood products is on the decline due to increased awareness and the targeted campaigns launched by the World Health Organizations in the 2000s to address this problem. However, globally, a significant proportion of hepatitis C transmissions continue to occur in medical settings.13
In addition to medical modes of transmission, there are other less common modes of hepatitis C transmission unique to immigrants and newcomers. Practices used by traditional healers like wet cupping (which involves making a small skin incision with a scalpel and drawing out a small amount of blood) and acupuncture may be a risk factor for transmission if unsterilized scalpels or needles are reused. Wet cupping is common in many Muslim countries and acupuncture is common in China. Shaving at community barber shops (common in Pakistan and India) where razors are re-used without sterilization can also lead to the transmission of hepatitis C.14 In Pakistan, there is also some evidence of the potential role of potash alum (barber’s salt) in hepatitis C transmission at barber shops. 15 Alum has traditionally been used as an antiseptic aftershave. A study on the role of potash alum in hepatitis C virus transmission in Pakistan noted that the majority of barbers were rubbing potash alum stone on facial shaving cuts and reusing the stone on many people.15 Laboratory studies have shown that the blood spots on the alum could carry the virus even when dry.15 Some other modes of transmission include non-medicalized male penile circumcision using unsterilized equipment;14,16 and a very high rate of therapeutic injection with unsterilized syringes, mostly by unqualified medical professionals. This practice is based on a common misperception that intravenous medication works more quickly and helps speed up healing.17
Screening and testing for hepatitis C among Canadian immigrants and newcomers
Screening among immigrants and newcomers is crucial because hepatitis C is a slowly progressing disease, which can be life threatening when left untreated. Immigrants and newcomers are particularly at risk due to poorer health outcomes. One Quebec study,18 found that it took an average of 10 years after arriving in Canada before immigrants were diagnosed with hepatitis C. This study also found that immigrants with hepatitis C were more likely to be diagnosed at an older age than non-immigrants. People who are diagnosed with hepatitis C later are more at risk of having more serious complications, such as cirrhosis or liver cancer, left untreated. Immigrants have higher mortality associated with both viral hepatitis and liver cancer, which are estimated to be two- to three-fold higher and two- to four-fold higher, respectively, than that of the Canadian-born population.19 Earlier diagnosis and treatment of hepatitis C could reduce the risk of health complications related to the virus.
Currently, the Public Health Agency of Canada (PHAC) recommends a risk-based screening approach for hepatitis C among immigrants and newcomers. Based on PHAC recommendations, “birth or residence in a region where hepatitis C is more common (prevalence greater than 3%), including Central, East and South Asia; Australasia and Oceania; Eastern Europe; Sub-Saharan Africa; and North Africa/Middle East” 20 is a risk factor. The Canadian Collaboration on Immigrant and Refugee Health (CCIRH) also recommends screening immigrants originating from a country with a prevalence of greater than 3%.21 CCIRH has comprehensive and easy-to-use on-line tools to guide service providers about regions and country-of-origin-specific screening and testing needs of immigrants. Other provincial and regional guidelines may provide further direction regarding hepatitis C screening and testing.
What are the barriers to testing and diagnosis?
Canadian immigrants and newcomers face multiple barriers in accessing the care and services they need to stay healthy. There are both provider-level barriers and individual-level barriers.
The testing process itself may pose a barrier to immigrants and newcomers seeking screening. Hepatitis C testing is a two-step process to confirm a hepatitis C diagnosis. The first step is a hepatitis C antibody test. Antibodies are present in anyone who has ever been exposed to hepatitis C. If this test comes back positive, a second test needs to be done to confirm if the infection is still active. A positive result on the second test means the person has chronic hepatitis C.
It is estimated that approximately 50% of people who test positive for hepatitis C antibodies in the United States don’t receive follow-up testing or care.8 While this study did not look specifically at immigrants, they are likely to be over-represented among people who don’t receive follow-up testing or care due to the multiple barriers they face. These barriers include socio-economic, linguistic and cultural barriers, which will be further examined in the section on individual-level barriers9 below.
Lack of testing sites at newcomer health services
The current high incidence and prevalence of hepatitis C in people who inject drugs22 in Canada means that testing for hepatitis takes place in many sexual health or harm reduction clinics. However, immigrants and newcomers may not access care from these clinics due to their different risk profiles23 and may not be screened through these clinics.
Clinics for newcomers that often offer hepatitis C testing, such as clinics for refugees or uninsured people, may not be able to offer care to all immigrants, in particular permanent residents because their mandate is to serve the uninsured. More testing sites need to be established at health services accessed by all immigrants to increase hepatitis C detection at earlier stages of the disease.
Knowledge and awareness about risk factors
Studies in the U.S. have shown that frontline workers and primary care providers may lack a good understanding and knowledge of hepatitis C risk factors.22,24,25 The situation in Canada may be similar, especially when it comes to understanding the unique risk factors for hepatitis C transmission and acquisition in immigrants and newcomers. Frontline workers and primary care providers may not recognize immigrants as an important risk group for chronic hepatitis C screening.26 Therefore, hepatitis C diagnosis in immigrants may happen long after their arrival, when symptoms begin to appear. The occurrence of late diagnosis may be reflected in the higher prevalence of hepatocellular carcinoma (HCC) in immigrants at diagnosis.18
Readiness to work with immigrants
Frontline workers and physicians in health, community and social services may find themselves less than prepared27 to work with the changing Canadian demography. This lack of preparedness can be attributed to lack of training opportunities to develop the skills needed to serve diverse groups of immigrants and newcomers.
Some frontline workers and physicians may lack the skills required to work with people who are new to Canada27 who are not fluent in Canada’s official languages or belong to a different culture. Medical literature has shown that this lack of cultural competence can impact the detection of diseases,28 and this is true for hepatitis C diagnosis as well. In addition, risk-based screening requires frontline workers and physicians to ask sensitive or personal questions related to hepatitis C acquisition and transmission. The skills needed to ask these questions in a culturally competent way may be lacking.
Canadian newcomers and recent immigrants have high rates of unemployment and are over-represented in precarious and vulnerable employment.29 This can affect their ability to access care,30,31 including hepatitis C testing and care.
Provincial health plans do not cover the cost of prescription drugs and with higher levels of unemployment and precarious jobs many people do not have extended health benefits like drug plans.32 The risk of losing their wages, which are extremely important for their survival, means that Canadian immigrants, and particularly newcomers, use the healthcare system infrequently or only when they are too sick to work because of the lack of paid sick days.33 Immigrants’ ability to access care is also compromised by a number of other complex socio-economic factors like precarious employment, lack of transportation and child care.
Linguistic and cultural barriers
There are a number of linguistic and cultural barriers to medical care for immigrants and newcomers. Immigrants and newcomers may hesitate to engage with the system due to language barriers and cultural unfamiliarity.34 Immigrants and newcomers mostly settle in areas that are largely inhabited by their community.35,36 This may facilitate access to ethno-specific services; however, it can result in a huge pressure on the few ethno-specific physicians and services available in those neighbourhoods.34 Those who cannot be accommodated by these service providers either do not access services at all or have to travel long distances to see a healthcare provider who is familiar with their culture or understands their language.
In some immigrant communities, there is a strong stigma attached to blood-borne diseases, including hepatitis C. Stigma is primarily linked with the fear of contagion, which results from a lack of understanding about hepatitis C transmission. Stigma can reduce the likelihood of accessing testing and care.37 People might also hesitate to share all of their risk factors for hepatitis C22 with a provider due to stigma. This can affect their access to appropriate screening for hepatitis C.
Stigma can also be related to one’s immigration status, which can have a direct bearing on one’s ability to access care. People who are medically uninsured due to their immigration status, like undocumented persons or refugees whose appeals have been rejected, find it difficult to get the care they need37 not only because of the associated stigma but also fear of being reported to the authorities.
What can frontline services do to improve newcomers' access to hepatitis C testing and diagnosis?
Changing Canadian demographics and the high prevalence of hepatitis C in immigrants and newcomers requires frontline workers and service providers to shift their understanding of hepatitis C. Here are some practical ideas.
Frontline service providers can:
- Offer or refer immigrants and newcomers from hepatitis C endemic countries to screening. The CCHIR tool can help determine if screening is appropriate.
- Learn more about hepatitis C in Canadian immigrants and newcomers and access both service provider and client resources from CATIE’s website. A number of culturally tailored multilingual client resources are available here for clients to get information on hepatitis C in their own languages.
- Know more about local settlement services, newcomer health services, translation and interpretation services and link up their clients with them.
- Work in partnerships with public health, settlement and newcomers services, and immigrant health organizations to create culturally safe services.
- Be sensitive to the presence of stigma related to hepatitis C in many newcomer communities.
Clinical Guidelines Checklist for New Immigrants and Refugees (Canadian Collaboration for Immigrants and Newcomers) – an eLearning knowledge translation tool designed for primary care practitioners to help integrate the Canadian Immigrant Health Guidelines into practice
Hepatitis C and Immigrants and Newcomers (CATIE) – hepatitis C resources for service providers working with immigrants and newcomers from countries where hepatitis C virus is endemic.
- 1. Greenaway C, Thu Ma A, Kloda L, et al. The seroprevalence of hepatitis C antibodies in immigrants and refugees from intermediate and high endemic countries: A systematic review and meta-analysis. PLoS ONE. 2015;10(11):e0141715. Available from http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0141715
- 2. a. b. Trubnikov M, Yan P, Archibald C. Estimated Prevalence of Hepatitis C Virus infection in Canada, 2011. Canada Communicable Disease Report: Volume 40-19, December 18, 2014. Available at: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/14vol40/dr-rm40-19/surveillance-b-eng.php
- 3. Immigration and Ethnocultural Diversity in Canada. National Household Survey, 2011. Ministry of Industry, 2013. Available from: https://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-010-x/99-010-x2011001-eng.cfm
- 4. Immigration, Refugees and Citizenship Canada. Facts and figures 2014 – Immigration overview: Permanent residents. Canada – Permanent residents by source category. Government of Canada, 2015. Available from: http://www.cic.gc.ca/english/resources/statistics/facts2014/permanent/02.asp
- 5. Immigration, Refugees and Citizenship Canada. Facts and figures 2013 – Immigration overview: Permanent residents. Canada – Permanent residents by source country. Government of Canada, 2015. Available from: http://www.cic.gc.ca/english/resources/statistics/facts2013/permanent/10.asp
- 6. Lavanchy D. Evolving epidemiology of hepatitis C virus. Clinical Microbiology and Infection. 2011 February;17(2): 107–115. Available from: http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)61648-7/fulltext
- 7. Immigration, Refugees and Citizenship Canada. Panel Members’ Handbook 2013. Government of Canada, 2013. Available from: http://www.cic.gc.ca/ENGLISH/resources/publications/dmp-handbook/index.asp
- 8. a. b. CATIE. Hepatitis C’s impact on Canadian newcomers [webinar]. CATI E, 2016. Available from: http://www.catie.ca/en/webinars/hepatitis-c-impact-canadian-immigrants-and-newcomers
- 9. a. b. Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted Infections: Section 6 – Specific populations, Revised July 2013. Ottawa: PHAC; 2013. Available from: http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-6-1-eng.php
- 10. Immigration Medical Examination Instructions: Hepatitis/liver disease. Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, 2013. Available from: http://www.cic.gc.ca/english/department/partner/pp/pdf/IMEI_Hepatitis.pdf
- 11. Payne E, Totten S, Archibald C. Hepatitis C surveillance in Canada. Canada Communicable Disease Report. 2014 Dec 18;40(19). Available from: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/14vol40/dr-rm40-19/surveillance-a-eng.php
- 12. Hepatitis C. World Health Organization. 2017. Available from: http://www.who.int/mediacentre/factsheets/fs164/en/
- 13. Waheed Y, Shafi T, Safi SZ, Qadri I. Hepatitis C virus in Pakistan: A systematic review of prevalence, genotypes and risk factors. World Journal of Gastroenterology. 2009 Dec 7;15(45):5647-5653. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2789216/
- 14. a. b. Waheed Y, Safi SZ, Qadri I. Role of Potash Alum in Hepatitis C virus Transmission at Barber's Shop. Virology Journal. 2011;8:211. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3112445/
- 15. a. b. c. Wazir MS, Mehmood S, Ahmed A, Jadoon HR. Awareness among barbers about health hazards associated with their profession. Journal of Ayub Medical College Abbottabad. 2008 Apr-Jun;20(2):35–38.
- 16. Khan AA, Saleem M, Qureshi H, et al. Comparison of need and supply of syringes for therapeutic injections in Pakistan. Journal of Pakistan Medical Association. 2010 November. Available from: http://jpma.org.pk/full_article_text.php?article_id=3793
- 17. Kamstra R, Azoulay L, Steele R, Klein M, Greenaway C. Hospitalizations in Immigrants and Nonimmigrants Diagnosed With Chronic Hepatitis C Infection in Québec. Clinical Infectious Diseases. 2016;63(11):1439–1448.
- 18. a. b. Pottie K, Greenaway C, Feightner J, et al. Evidence-based clinical guidelines for immigrants and Refugees. Canadian Medical Association Journal. 2011 September 6;183(12):E824–E925. Available from: http://www.cmaj.ca/content/183/12/E824
- 19. Ha S, Totten S, Pogany L, et al. Hepatitis C in Canada and the importance of risk-based screening. Canada Communicable Disease Report. 2014 Mar 3;42–3:57-62. Available from: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/16vol42/dr-rm42-3/assets/pdf/16vol42_3-ar-02-eng.pdf
- 20. Greenaway C, Wong D, Assayag D, et al. Screening for hepatitis C infection: evidence review for newly arriving immigrants and refugees. Canadian Medical Association Journal. 2011; 183(12):E861–E864.
- 21. Shah HA, Heathcote J, Feld JJ. A Canadian screening program for hepatitis C: Is now the time? Canadian Medical Association Journal. 2013 Oct 15;185(15):1325–1328. Available from: http://www.cmaj.ca/content/185/15/1325
- 22. a. b. c. Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Recommendations for the public health response to hepatitis C in Ontario. Toronto, ON: Queen’s Printer for Ontario; 2014. Available from: http://www.publichealthontario.ca/en/eRepository/Recommendations_Public_Health_Response_Hepatitis_C.pdf
- 23. Institute of Medicine (US) Committee on the Prevention and Control of Viral Hepatitis Infection. Knowledge and Awareness About Chronic Hepatitis B and Hepatitis C. In: Colvin HM, Mitchell AE, (eds.) Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C. Washington, DC: National Academies Press (US); 2010. Available from: https://www.ncbi.nlm.nih.gov/books/NBK220038/
- 24. Ferrante JM, Dock G, Winston DG, Chen P-H.de la Torre AN. Family Physicians’ Knowledge and Screening of Chronic Hepatitis and Liver Cancer. Family Medicine. 2008 May;40(5): 345–351. Available from: https://www.stfm.org/fmhub/fm2008/May/Jeanne345.pdf
- 25. Greenaway C. Hepatitis C in migrants: An underappreciated group at increased risk [webinar]. CATIE, 2015. Available from: http://www.catie.ca/en/hepatitis-c-migrants-underappreciated-group-increased-risk
- 26. Yan MC, Chan S. Are social workers ready to work with newcomers? Canadian Social Work. 2011;12:16–23.
- 27. a. b. Primary Health Care Section, Nova Scotia Department of Health. A Cultural Competence Guide for Primary Health Care Professionals in Nova Scotia; 2005. Available from: http://healthteamnovascotia.ca/cultural_competence/Cultural_Competence_guide_for_Primary_Health_Care_Professionals.pdf
- 28. Identifying Vulnerable Workers and Precarious Work. In: Vulnerable Workers and Precarious Work: Final Report. Law Commission of Ontario, Toronto, ON; December 2012. Available from: http://www.lco-cdo.org/en/vulnerable-workers-interim-report-sectionii
- 29. Premji S, Shakya Y, Spasevski M, et al, Precarious work experiences of racialized immigrant women in Toronto: A community-based study. Just Labour. 2014; 22: 122–143. Available from: http://www.justlabour.yorku.ca/volume22/pdfs/08_premji_et_al_press.pdf
- 30. Social and Economic Factors that Influence Our Health and Contribute to Health Inequalities. In: The Chief Public Health Officer's Report on the State of Public Health in Canada 2008. Government of Canada, 2008. Available from: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2008/fr-rc/cphorsphc-respcacsp07i-eng.php
- 31. Asanin J, Wilson K. “I spent nine years looking for a doctor”: Exploring access to health care among immigrants in Mississauga, Ontario, Canada. Social Science & Medicine. 2008 Mar;6:1271–1283.
- 32. Strengthening employment legislation in Ontario: Upstream policies to help promote health and well being. Association of Ontario Health Centres. 2015. Available from: https://www.aohc.org/sites/default/files/documents/2015-06-18%20-%20Final%20AOHC%20Submission%20Changing%20Workplaces%20Review.pdf
- 33. Addressing Inequalities – Where are we in Canada. In: The Chief Public Health Officer's Report on the State of Public Health in Canada 2008. Government of Canada, 2008. Available from: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2008/fr-rc/cphorsphc-respcacsp07i-eng.php http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2008/fr-rc/cphorsphc-respcacsp11-eng.php#397
- 34. a. b. Housing, Family and Social Statistics Division, Statistics Canada. Immigrants’ choice of destination. In: Longitudinal Survey of Immigrants to Canada: Process, progress and prospects. Ministry of Industry, 2003. Available from: http://www.statcan.gc.ca/pub/89-611-x/4152881-eng.htm
- 35. Murdie RA. Diversity and concentration in Canadian immigration. Centre for Urban & Community Studies Research Bulletin. 2008 Mar;42. Available from: http://www.urbancentre.utoronto.ca/pdfs/researchbulletins/CUCSRB42-Murdie-Cdn-Immigration3-2008.pdf
- 36. Cotler SJ, Cotler S, Xie H, et al. Characterizing hepatitis B stigma in Chinese immigrants. Journal of Viral Hepatitis. 2012 Feb;19(2):147–152.
- 37. a. b. Caulford P. Health care for Canada’s medically uninsured immigrants and refugees. Whose problem is it? Canadian Family Physician. 2012 Jul;58(7):725–727. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3395500/