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

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.

Provider-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.

Individual-level barriers

Socio-economic barriers

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.

Stigma

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.

Resources:

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.

References

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About the author(s)

Fozia Tanveer is CATIE’s Knowledge Broker, Immigrant and Newcomer Hepatitis C Community Health Programming. She has been working with CATIE’s Hepatitis C Ethnocultural Education and Outreach Program since 2011 and has a Master’s of Development Studies from the School of Oriental and African Studies, University of London.