Bridging the gap in viral hepatitis care for immigrants and newcomers in Canada

Prevention in Focus PiF 2025 Fall

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Viral hepatitis is the second leading infectious cause of death globally.1 In Canada, it is a major cause of morbidity and mortality,2 contributing significantly to serious health outcomes, such as liver disease and liver cancer. Immigrants and newcomers in Canada are disproportionately impacted by both hepatitis B and C, making them a priority population in viral hepatitis response efforts. This article explores the impact of viral hepatitis on immigrants and newcomers in Canada, including the prevalence of hepatitis B and C, common transmission routes, and the barriers these populations face in accessing prevention, testing and treatment services.

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What is viral hepatitis?

Hepatitis is a condition characterized by inflammation of the liver. When this inflammation is caused by a virus, it is referred to as viral hepatitis. Among the various types of viral hepatitis, hepatitis B and C are particularly concerning because of their potential to cause long-term liver damage. These infections are often asymptomatic, meaning that people can live for years without knowing they have hepatitis. As a result, the virus can damage the liver over time, leading to chronic liver disease, which in turn can potentially lead to liver cancer and death. While hepatitis B and C have many similarities, they also have some key differences. 

Hepatitis B can be transmitted through contact with bodily fluids containing the virus; this usually happens through blood, but transmission is also possible through semen and vaginal fluids. About 95% of healthy adults who get hepatitis B clear the virus on their own shortly after infection (during the acute infection stage);3 after this, they have immunity against the virus and cannot get hepatitis B again. However, some people with hepatitis B develop a chronic hepatitis B infection. This is more likely to happen for babies and children. Many people will require lifelong treatment for a chronic hepatitis B infection. There is a vaccine to prevent hepatitis B. Since babies are at highest risk of developing a chronic (lifelong) infection if they are exposed to the virus, the World Health Organization recommends vaccination of all babies as soon as possible after birth.4

Hepatitis C is primarily transmitted through blood-to-blood contact. About 25% of people will spontaneously clear the virus shortly after infection (during the acute infection stage). People who do not clear the virus on their own will need treatment. Unlike hepatitis B, hepatitis C is curable. Treatment for hepatitis C is highly effective and involves taking one to three pills daily for eight or 12 weeks with few, if any, side effects. There is no vaccine to prevent hepatitis C.

How does viral hepatitis impact immigrants and newcomers?

Immigrants and newcomers are an essential part of Canada’s cultural fabric and economic growth; each year, Canada accepts approximately 400,000 new permanent residents, in addition to many more temporary residents.5 In 2021, approximately 23% of the population of Canada (8.3 million people) was made up of immigrants and newcomers from many parts of the world.6 

Many immigrants and newcomers acquire hepatitis B or C in their home countries before coming to Canada. This is because infection rates are often higher in other countries because of inconsistent access to safe medical procedures and infection control practices in healthcare settings and a lack of universal infant hepatitis B vaccine programs. Countries with higher infection rates — particularly parts of Africa, Asia, and Eastern or Southern Europe — are also important sources of immigration to Canada.7 As a result, immigrants and newcomers may be up to six times more likely to have hepatitis B and up to four times more likely to have hepatitis C than the general population of Canada.8

Immigrants and newcomers face unique barriers to viral hepatitis care

Immigrants and newcomers face multiple, interconnected barriers when accessing and navigating hepatitis B and C testing and care in Canada. These barriers often result in significant delays in diagnosis — on average, six to seven years after arrival in Canada — allowing infections to go undetected during this time.9–11 Delayed diagnoses increase the risk for serious liver-related complications, including liver disease and liver cancer.12 In fact, many immigrants have already developed liver-related complications by the time they are diagnosed or seek care.12 However, research shows that once immigrants and newcomers are engaged in care for hepatitis B or C, they often progress through the care cascade more effectively than Canadian-born people.10,11,13 Taken together, these facts indicate that addressing the barriers that prevent early testing and successful linkage to care and treatment is essential to improving hepatitis-related health outcomes for this population.

Barriers may exist at multiple levels, including at the system, organizational or provider, and individual levels. It is important to acknowledge that systemic and structural factors (i.e., racism, colonialism) shape barriers at the organizational, provider and individual levels. This influences access to viral hepatitis care and creates health inequities for immigrants and newcomers. Understanding how these interconnected barriers impact access to viral hepatitis care for immigrants and newcomers can inform practices to better support their engagement in care.

System-level barriers

  • Lack of routine screening: A lack of routine screening before or after arrival14 may contribute to missed or delayed diagnoses. 
  • Public health insurance: The variable eligibility for and accessibility of health insurance across immigration pathways, including the potential for long wait periods before being eligible for coverage (e.g., up to three months for permanent residents), creates barriers to care for hepatitis B and C.15–17 These barriers may be further compounded for people with precarious legal status (e.g., pending refugee claimants).15,18
  • National hepatitis B vaccine policy: A lack of a universal birth dose vaccine policy for hepatitis B can leave infants and children vulnerable to infection. 

Organizational- and provider-level barriers

  • Knowledge and awareness of risk factors: Providers may lack awareness about risk factors specific to immigrants and newcomers19,20 and thus not offer screening to those who would benefit.
  • Cultural barriers: Cultural differences, including different religious beliefs and cultural health practices, may lead to misunderstandings between service providers and patients, discouraging engagement in care. 12,21 These barriers to accessing health services are compounded when providers lack cultural competency.21–23
  • Racism and discrimination: When immigrants and newcomers experience racism and discrimination by providers (e.g., unfair treatment, racial bias) they are discouraged from seeking or continuing in care.21
  • Availability of culturally responsive services: Culturally responsive services are limited in availability21,23 and are often overstretched where they do exist.23

Individual-level barriers

  • Lack of awareness and knowledge of viral hepatitis: Variable knowledge of risk factors for viral hepatitis transmission12,20,24,25 leads to delays in testing and engagement in care. 
  • Lack of health literacy: Limited health literacy affects individuals’ understanding of health information, including the importance of testing and how to navigate health services.21
  • Fears of diagnosis: The stigma related to blood-borne viruses in some communities, alongside misconceptions about how viral hepatitis is spread, can lead to fears of diagnosis,26 affecting uptake of testing and treatment.12,20,26
  • Immigration status: Individuals who are undocumented may fear deportation if they access care.18
  • Communication challenges: Language barriers can impede navigation of the healthcare system and communication with providers.21 A lack of interpretive services may lead some to rely on informal interpreters (i.e., family members), potentially resulting in miscommunications, breaches of confidentiality, omission of sensitive medical information and difficulties advocating for health needs.21
  • Socioeconomic barriers: The risk of losing wages and a lack of paid sick days may make it difficult to take time off work for appointments.12 Out-of-pocket costs associated with seeking care, like childcare or transportation, further increase the financial burden.12,21,27

What can frontline service providers do to improve engagement in viral hepatitis care?

In Canada, immigrants and newcomers are disproportionately impacted by hepatitis B and C. As this population is expected to continue to grow, engaging them in testing and care can help with timely diagnosis to prevent adverse health outcomes like liver disease and liver cancer. 

Many immigrants and newcomers would benefit from understanding transmission risk factors for hepatitis B and C, as well as the importance of testing even in the absence of symptoms. Service providers can provide tailored, culturally sensitive education about hepatitis B and C, including transmission routes, testing and treatment options for hepatitis B and C, that is non-judgmental and mindful of potential stigma around blood-borne pathogens. 

Facilitating navigation of the healthcare system and communication with service providers can improve access to viral hepatitis testing and treatment. Where possible, service providers can take advantage of professional interpretation services or offer culturally relevant resources (e.g., information in immigrant and newcomer languages) to reduce language barriers. Incorporating culturally sensitive health navigators can help immigrants and newcomers connect to and access systems of care. 

Engaging immigrants and newcomers in timely testing and linkage to care is critical to prevent worsening liver health and adverse outcomes. Service providers can offer or link immigrants and newcomers to screening for hepatitis B and C if wanted. For immigrants and newcomers with chronic hepatitis B or C, service providers can offer treatment or link clients to providers offering these services.

Vaccination against hepatitis B is a key strategy to help prevent transmission of the virus. For immigrants and newcomers from regions where hepatitis B is common, it is recommended to vaccinate individuals who are not immune to hepatitis B and all household contacts.28 Service providers can offer vaccination as appropriate or link individuals to providers who offer this service.

Access to culturally responsive or tailored services can improve engagement in care. Service providers can learn more about local organizations serving immigrants and newcomers (e.g., settlement services, newcomer health services) and develop partnerships to establish referral pathways or facilitate access to services. Where possible, service providers can participate in training opportunities to improve cultural competency and reduce cultural barriers while engaging with immigrants and newcomers.

Resources

CATIE multilingual website

CATIE Ordering Centre

Hepatitis C and Immigrants and Newcomers

References

  1. World Health Organization. Global hepatitis report 2024: action for access in low- and middle-income countries. Geneva (Switzerland): World Health Organization; 2024 Apr. Available from: https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hepatitis/overview#:~:text=The%20disease%20is%20the%20second,tuberculosis%2C%20a%20top%20infectious%20killer
  2. Government of Canada. Canada’s progress towards eliminating viral hepatitis as a public health threat, 2021. 2024 Oct 13. Available from: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/progress-towards-eliminating-viral-hepatitis-threat-2021.html
  3. Ganem D, Prince AM. Hepatitis B virus infection — natural history and clinical consequences. New England Journal of Medicine. 2004 Mar 11;350(11):1118-29.
  4. World Health Organization. Hepatitis B vaccines: WHO position paper. Weekly Epidemiological Record. 2017 Jul 7;(92):369-92. Available from: https://www.who.int/publications/i/item/WER9227 
  5. Government of Canada. Canada’s immigration levels. 2024 Nov 4. Available from: https://www.canada.ca/en/immigration-refugees-citizenship/corporate/mandate/corporate-initiatives/levels.html
  6. Statistics Canada. Canada at a glance, 2023: immigration and ethnocultural. 2024 Sep 4. Available from: https://www150.statcan.gc.ca/n1/pub/12-581-x/2023001/sec2-eng.htm
  7. Risdon J. Top 10 source countries of new permanent residents of Canada in 2024. 2024 Oct 2. Available from: https://immigration.ca/top-10-source-countries-of-new-permanent-residents-of-canada/
  8. Government of Canada. Viral hepatitis estimates among key populations in Canada, 2021. 2025 Jan 17. Available from: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/viral-hepatitis-estimates-key-populations-2021.html
  9. Passos-Castilho AM, Murphy DG, Blouin K et al. A population-based study of reported hepatitis C diagnoses from 1998 to 2018 in immigrants and nonimmigrants in Quebec, Canada. Journal of Viral Hepatitis. 2023 Aug 1;30(8):656-66.
  10. Yasseen AS, Kwong JC, Feld JJ et al. Viral hepatitis C cascade of care: a population-level comparison of immigrant and long-term residents. Liver International. 2021 Aug 1;41(8):1775-88.
  11. Yasseen AS, Kwong JC, Feld JJ et al. The viral hepatitis B care cascade: a population-based comparison of immigrant groups. Hepatology. 2022 Mar 1;75(3):673-89.
  12. Greenaway C, Makarenko I, Tanveer F et al. Addressing hepatitis c in the foreign-born population: a key to hepatitis C virus elimination in Canada. Canadian Liver Journal. 2018 Mar 1;1(2):35-50.
  13. Passos-Castilho AM, Murphy DG, Blouin K et al. Ongoing gaps in the hepatitis C care cascade during the direct-acting antiviral era in a large retrospective cohort in Canada: a population-based study. Viruses. 2024 Mar 1;16(3):389.
  14. Government of Canada. Canadian panel member guide to immigration medical examinations 2020. 2020. Available from: https://www.canada.ca/en/immigration-refugees-citizenship/corporate/publications-manuals/panel-members-guide.html#hepatitis
  15. Action Hepatitis Canada. Immigration health is public health. Toronto (ON): Action Hepatitis Canada; 2024 May. Available from: https://www.actionhepatitiscanada.ca/immigrationhealth.html
  16. Government of Canada. Interim Federal Health Program: who is eligible. 2025 Feb 19. Available from: https://www.canada.ca/en/immigration-refugees-citizenship/services/refugees/help-within-canada/health-care/interim-federal-health-program/eligibility.html
  17. Government of Canada. Health care in Canada: access our universal health care system. 2025 Feb 6. Available from: https://www.canada.ca/en/immigration-refugees-citizenship/services/settle-canada/health-care/universal-system.html
  18. Hacker K, Anies M, Folb BL et al. Barriers to health care for undocumented immigrants: a literature review. Risk Management and Healthcare Policy. 2015 Oct 30;8:175-83.
  19. Ha S, Timmerman K. Awareness and knowledge of hepatitis C among health care providers and the public: a scoping review. Canada Communicable Disease Report. 2018 Jul 5;44(7-8):157.
  20. Vedio A, Liu EZH, Lee ACK et al. Improving access to health care for chronic hepatitis B among migrant Chinese populations: a systematic mixed methods review of barriers and enablers. Journal of Viral Hepatitis. 2017 Jul 1;24(7):526-40.
  21. Tsai PL, Ghahari S. Immigrants’ experience of health care access in Canada: a recent scoping review. Journal of Immigrant and Minority Health. 2023 Jun 1;25(3):712-27.
  22. Alghazali IS, Ahmed R. The role of cultural competence in health care to improve communication between immigrant patients and health-care providers in Ottawa, Canada. International Journal of Migration, Health and Social Care. 2024 Feb 5;21(1):132-48.
  23. Lane G, Vatanparast H. Adjusting the Canadian healthcare system to meet newcomer needs. International Journal of Environmental Research and Public Health. 2022 Apr 1;19(7):3752.
  24. Mendlowitz AB, Mandel E, Capraru CI et al. Factors associated with knowledge and awareness of Hepatitis B in individuals of Chinese descent: results from a mass point of care testing and outreach campaign in Toronto, Canada. Canadian Liver Journal. 2024 Feb 1;7(1):28.
  25. Zibrik L, Huang A, Wong V et al. Let’s talk about B: barriers to hepatitis B screening and vaccination among Asian and South Asian immigrants in British Columbia. Journal of Racial and Ethnic Health Disparities. 2018 Dec 15;5(6):1337-45.
  26. Shehata N, Austin T, Ha S et al. Barriers to and facilitators of hepatitis C virus screening and testing: a scoping review. Canada Communicable Disease Report. 2018 Jul 5;44(7-8):166.
  27. Tu T, Block JM, Wang S et al. The lived experience of chronic hepatitis B: a broader view of its impacts and why we need a cure. Viruses. 2020 May 7;12(5):515.
  28. Government of Canada. Immunization of persons new to Canada: Canadian immunization guide. 2023 Feb 7. Available from: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-3-vaccination-specific-populations/page-10-immunization-persons-new-canada.html

Externally reviewed by: Katie Bryan, Dr. Carla Coffin, Genevieve Isshak & Amy Visser

About the author(s)

Madison Kennedy is CATIE's knowledge specialist in hepatitis C. She has a Master of Public Health degree in Health Promotion and previously worked in sexual and reproductive health service delivery and research.