Views from the frontline: Hepatitis B vaccination

Prevention in Focus PiF 2026 Fall

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Vaccination for hepatitis B is the most important strategy to prevent transmission of the virus. However, the implementation of vaccine policies and rates of vaccine coverage vary across the country, preventing this strategy from realizing its potential toward eliminating hepatitis B as a public health concern in Canada. CATIE asked three experts about what policy and practice changes are required to increase vaccine coverage and uptake and what service providers can do to promote vaccine uptake in their practice. 

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  • Jennifer van Gennip is the executive director of Action Hepatitis Canada 
  • Ève Dubé is a professor of anthropology at Laval University and a researcher at the Centre de recherche du CHU de Québec–Université Laval & Dominique Gagnon is a research professional affiliated with the Centre de recherche du CHU de Québec–Université Laval 

See more in this article: Protection is prevention: The importance of hepatitis B vaccination 

Jennifer van Gennip, executive director, Action Hepatitis Canada 

What policy change would have the biggest impact on increasing hepatitis B vaccine coverage in Canada? 

The single most impactful policy change would be implementing universal birth-dose hepatitis B vaccination across all provinces and territories. Canada currently has a patchwork approach, with five provinces relying on school-based vaccination programs delivered years after birth. We are generally much more successful as a country at reaching babies through routine infant immunization systems than we are at consistently reaching older children and adolescents through school programs. 
 
This matters because hepatitis B infection acquired in infancy or early childhood carries a much higher risk of becoming chronic and leading to serious long-term health consequences, including cirrhosis and liver cancer. Preventing infection early in life is therefore especially important. A universal birth dose is also a highly equitable intervention. It protects infants regardless of whether hepatitis B infection has been identified in the birth parent during pregnancy and helps reduce risks associated with gaps in prenatal care, testing or follow-up. If Canada is serious about hepatitis B elimination, preventing infection at the very beginning of life should be a cornerstone strategy. 

What systemic or policy barriers impact why a person may not have been vaccinated for hepatitis B? 

There are many reasons someone in Canada may not have received hepatitis B vaccination, and many of them are systemic rather than individual. Some people may have been born in countries where hepatitis B vaccination was not routinely offered in infancy or childhood at the time they were growing up. Others may have moved between jurisdictions with different vaccine schedules or eligibility criteria. Still others may have been born before childhood hepatitis B vaccination was routinely offered in their province or territory. 
 
In Canada, reliance on school-based vaccination programs can also create gaps. A student may have been absent on clinic days, changed schools, experienced housing instability or faced other barriers that interrupted access. The COVID-19 pandemic further exposed the fragility of these systems. In Ontario, school-based vaccination rates dropped dramatically during the pandemic, at one point reaching approximately 17% coverage in some programs. Many young people may still not have caught up. 
 
There are also broader systemic issues, including inconsistent public awareness, fragmented adult catch-up programs and limited access to vaccination for people without regular primary care. These gaps underscore the need for an equitable strategy for hepatitis B vaccination delivered through strong, universal, routine immunization systems that do not rely heavily on individuals navigating complex access pathways. 

Why is hepatitis B vaccination such an important cornerstone in efforts to eliminate hepatitis B? 

Hepatitis B vaccination is foundational to elimination efforts because it prevents new infections before they occur. Unlike some infectious diseases, hepatitis B is not yet curable. Treatments can effectively manage the virus and reduce complications, but prevention remains far better than lifelong clinical management. Vaccination also provides an important public health benefit: when fewer people acquire hepatitis B, transmission declines across the population. Preventing infection protects both individual health and the broader health system. 

Vaccination is particularly important because of the way hepatitis B affects young children. Infants and young children who acquire hepatitis B are far more likely than adults to develop chronic infection, often without symptoms for many years. You could even say that every new pediatric hepatitis B infection in jurisdictions that delay vaccination is a policy failure. 

Elimination will require improvements in testing, linkage to care, access to treatment, and public awareness. But vaccination remains the intervention that can stop transmission before it starts, and that makes it one of the most powerful tools we have. 

Ève Dubé is a professor of anthropology at Laval University and a researcher at the Centre de recherche du CHU de Québec–Université Laval. She holds a Canadian Institutes of Health Research Applied Public Health Chair on the Anthropology of Vaccination and chairs the Social Science and Humanities Network of the Canadian Immunization Research Network.  

Dominique Gagnon is a research professional affiliated with the Centre de recherche du CHU de Québec–Université Laval and a member of the research team of the Applied Public Health Chair on the Anthropology of Vaccination. 

What practice or policy change would have the biggest impact on increasing hepatitis B vaccine coverage in Canada?   

The implementation of a standardized universal infant vaccination strategy across all provinces and territories is the approach that will have the biggest impact on coverage in Canada. Although hepatitis B vaccination is publicly funded nationwide, differences in delivery models persist, with some provinces relying on infant schedules while others continue school-based programs.1 This variability contributes to differences in age at protection, missed opportunities and inequities in coverage. 

Universal infant vaccination must be complemented by targeted interventions to improve coverage among adolescents and adults who remain under-immunized or at increased risk of exposure. Catch-up vaccination programs delivered through pharmacies, schools, public health clinics, primary care offices, harm reduction services, correctional facilities and outreach initiatives could help reach populations of people who may face barriers to routine care or who missed earlier vaccination opportunities.2–5 Tailored communication, culturally safe services and low-barrier access to vaccination would also be important to improve equitable uptake among underserved and higher risk groups.5,6

What individual- and provider-level barriers impact why a person may not have been vaccinated for hepatitis B? 

Among the general population of Canadian adults, the main barriers for vaccination are related to lack of awareness and difficulties accessing services rather than strong ideological opposition to vaccines. Adults commonly report insufficient information about the vaccine, concerns about side effects, cost-related barriers and limited awareness of vaccine availability. Furthermore, lower socioeconomic status, not having a regular healthcare provider and limited engagement with preventive healthcare are associated with lower initiation and completion of the hepatitis B vaccine series.7,8

For equity-deserving populations, barriers are often shaped by broader structural and systemic factors rather than individual attitudes alone. Some of the barriers related to hepatitis B screening and vaccination include cultural mistrust, lack of culturally appropriate communication, language barriers, religious concerns, accessibility issues (e.g., inaccessible sites, identification requirements, online booking systems), housing instability and exclusion from mainstream healthcare systems.9,10 

Stigma may also reduce vaccine uptake, as shown in evaluation of other targeted campaigns, with individuals reporting concerns about being identified when seeking vaccination and perceiving eligibility messaging as stigmatizing.11,12

At the provider level, missed opportunities for recommending vaccination, limited time during consultations, insufficient knowledge of adult hepatitis B vaccination recommendations, and challenges identifying eligible patients may also contribute to under-vaccination.13–15 

What approaches are effective in addressing vaccine hesitancy?  

Trust-building interventions are most likely to influence the small proportion of individuals who are genuinely hesitant about vaccination. Provider recommendation and proactive engagement remain among the strongest predictors of vaccine uptake.16 Person-centred communication approaches that emphasize empathy, autonomy and collaborative decision-making are more effective for individuals who are uncertain or hesitant about vaccination; however, strategies combining tailored communication, provider engagement, reminders and low-barrier access are generally more effective than passive information provision alone.17-20

For many equity-deserving groups, interventions focused primarily on hesitancy are unlikely to substantially increase coverage because the main barriers to vaccination are structural. Vaccine uptake improves when services are delivered directly within trusted and accessible community settings (e.g., supervised consumption services, sexual health services, low-barrier housing programs) rather than through referral-based models.21-22 Trusted staff, non-stigmatizing environments and immediate access are consistently identified as key facilitators.22–25 Peer navigators, community ambassadors, trusted messengers and culturally tailored outreach programs can strengthen trust, improve access and reduce inequities, particularly when embedded within existing community organizations.26–28 Improving hepatitis B vaccine uptake requires combining person-centred communication approaches with structural interventions that reduce access barriers and strengthen trust within communities. 

References

  1. Government of Canada. Provincial and territorial routine and catch-up vaccination schedule for infants and children in Canada. 2026. Available from: https://www.canada.ca/en/public-health/services/immunization-vaccines/provincial-territorial-routine-vaccination-programs-infants-children.html
  2. Burson RC, Buttenheim AM, Armstrong A et al. Community pharmacies as sites of adult vaccination: a systematic review. Human Vaccines & Immunotherapeutics. 2016;12(12):3146-59. Available from: https://doi.org/10.1080/21645515.2016.1215393 
  3. Gregorio GEV, Velasco-Aro SJG. HBV catch-up vaccination in children and adults with incomplete or unknown vaccination to reduce hepatitis B-related morbidity: a systematic review. Acta Medica Philippina. 2025;59(12):68-76. Available from: https://doi.org/10.47895/amp.vi0.9874 
  4. Palmateer NE, Goldberg DJ, Munro A et al. Association between universal hepatitis B prison vaccination, vaccine uptake and hepatitis B infection among people who inject drugs. Addiction. 2018;113(1):80-90. Available from: https://doi.org/10.1111/add.13944 
  5. Picchio C. Closing hepatitis B vaccination gap: barriers and solutions for underserved groups. European Journal of Public Health. 2025;35(Supplement_4):ckaf161.325. Available from: https://doi.org/10.1093/eurpub/ckaf161.325 
  6. Zovich B, Block SJ, Borondy-Jenkins F et al. The role of culturally appropriate mediated communication strategies to reduce hepatitis B and liver cancer disparities. Journal of Health Communication. 2024;29(7):440-9. Available from:  https://doi.org/10.1080/10810730.2024.2362882
  7. Okoli GN, Grossman Moon A, Soos AE et al. Hepatitis B vaccination initiation and vaccination series completion: an in-depth systematic evidence review, with meta-analysis of associations with individual socioeconomic and health-related factors. Vaccine. 2025;55:127051. Available from: https://doi.org/10.1016/j.vaccine.2025.127051 
  8. Stratoberdha D, Gobis B, Ziemczonek et al. (2022). Barriers to adult vaccination in Canada: a qualitative systematic review. Canadian Pharmacists Journal. 2022;155(4):206-18. Available from: https://doi.org/10.1177/17151635221090212 
  9. Li C, Thapa D, Mi Q et al. Disparities in hepatitis B virus healthcare service access among marginalised poor populations: a mixed-method systematic review. Infectious Diseases of Poverty. 2024;13(1):58. Available from: https://doi.org/10.1186/s40249-024-01225-0 
  10. Tiwana MH, Smith J. Structural determinants of vaccine access: an integrated review of the Canadian literature. Vaccine. 2026;76:128324. Available from: https://doi.org/10.1016/j.vaccine.2026.128324 
  11. Muncaster K, Masterman C, Barnett T et al. A retrospective chart review and thematic analysis of patients seeking mpox vaccination during the initial outbreak in 2022–2023: evaluation of access, motivations, and stigma. BMC Public Health. 2024;24(1):3436. Available from: https://doi.org/10.1186/s12889-024-20948-1 
  12. Omame A, Iyaniwura SA, Ebenezer A et al. Pre-exposure vaccination in the high-risk population is crucial in controlling mpox resurgence in Canada. BMC Infectious Diseases. 2025;26(1):14. Available from: https://doi.org/10.1186/s12879-025-12172-y 
  13. Chitnis AS, Wong RJ. Review of updated hepatitis B vaccine recommendations and potential challenges with implementation. Gastroenterology & Hepatology (NY). 2002;18(8):447-51. 
  14. Daley MF, Hennessey KA, Weinbaum CM et al. Physician practices regarding adult hepatitis B vaccination: a national survey. American Journal of Preventive Medicine. 2009;36(6):491-6. Available from: https://doi.org/10.1016/j.amepre.2009.01.037 
  15. Thorpe S, Larkin A. P-984. Assessment of clinical practice gaps negatively impacting vaccination rates for hepatitis B. Open Forum Infectious Disease. 2025;12(Supplement_1):ofae631.1174. Available from: https://doi.org/10.1093/ofid/ofae631.1174 
  16. Ceccarelli A, Munafò G, Sintoni F et al. Effectiveness of general practitioners’ involvement in adult vaccination practices: a systematic review and meta-analysis of international evidence. Vaccines (Basel). 2024;12(12):1438. Available from: https://doi.org/10.3390/vaccines12121438 
  17. Jaca A, Mathebula L, Malinga T et al. Interventions to improve vaccination uptake among adults: a systematic review and meta-analysis. Vaccines (Basel). 2025;13(8):811. Available from: https://doi.org/10.3390/vaccines13080811 
  18. Jarrett C, Wilson R, O’Leary M et al. Strategies for addressing vaccine hesitancy – a systematic review. Vaccine. 2015;33(34):4180-90. Available from: https://doi.org/10.1016/j.vaccine.2015.04.040 
  19. Ortiz E, Scanlon B, Mullens A et al. Effectiveness of interventions for hepatitis B and C: a systematic review of vaccination, screening, health promotion and linkage to care within higher income countries. Journal of Community Health. 2020;45(1):201-18. Available from: https://doi.org/10.1007/s10900-019-00699-6 
  20. Pennisi F, Lunetti C, Barbati C et al. Interventions addressing vaccine hesitancy in the WHO European Region and in North America (United States and Canada): a systematic review. Public Health Reviews. 2026;47:1609375. Available from: https://doi.org/10.3389/phrs.2026.1609375 
  21. Des Jarlais DC, Fisher DG, Newman JC et al. Providing hepatitis B vaccination to injection drug users: referral to health clinics vs on-site vaccination at a syringe exchange program. American Journal of Public Health. 2001;91(11):1791-2. Available from: https://doi.org/10.2105/ajph.91.11.1791 
  22. Malik S, Plesons M, Faraldo M et al. Perspectives on hepatitis A and B screening and immunization at a syringe services program: a mixed-methods study. Harm Reduction Journal. 2026;23(1):23. Available from: https://doi.org/10.1186/s12954-025-01391-w 
  23. Emery H, Evans C, Jack K et al. A qualitative systematic review of barriers and facilitators to hepatitis B and C programmes in prisons. Journal of Viral Hepatitis. 2025;32(2):e14049. Available from: https://doi.org/10.1111/jvh.14049 
  24. Griffin R, Wilkinson T, Hoff GL. Hepatitis vaccination of men-who-have-sex-with-men by taking the vaccine into the community. Journal of Men's Health & Gender. 2007;4(1):39-43. Available from: https://doi.org/10.1016/j.jmhg.2006.11.001  
  25. Schick V, Grace A, Quan FT et al. Optimizing community-based hepatitis B and C care for engaging housing-insecure individuals. Cancer Control. 2025;32:10732748251374419. Available from: https://doi.org/10.1177/10732748251374419 
  26. Etowa J, Hyman I, Unachukwu U. Use of a peer equity navigator intervention to increase access to COVID-19 vaccination among African, Caribbean and Black communities in Canada. International Journal of Environmental Research and Public Health. 2025;22(8):1195. Available from: https://www.mdpi.com/1660-4601/22/8/1195 
  27. Bhatti S, Pham J, Rayner J. Using trusted relationships and community-led approaches to promote COVID-19 vaccine confidence and uptake across Ontario. Healthcare Quarterly. 2022;25(3):25-9. https://www.longwoods.com/content/26945/healthcare-quarterly/using-trusted-relationships-and-community-led-approaches-to-promote-covid-19-vaccine-confidence-and
  28. Tam T. Lessons learned from COVID-19: harnessing community insights for better vaccination outcomes. Canada Communicable Disease Report. 2024;50(10):335-7. Available from: https://doi.org/10.14745/ccdr.v50i10a01