The Calgary Refugee Health Clinic (CRHC) operates an innovative program in Calgary that provides screening and care for chronic hepatitis B to newly arrived refugees using a shared care model. The primary care team at CRHC conducts screening and baseline assessments and then provides ongoing management with support from local hepatologists. Between 2011 and 2020, a total of 171 people were identified and managed for chronic hepatitis B, of whom 139 were followed for more than a year. Rates were high for the completion of baseline testing (approximately 98% for bloodwork and 84% for ultrasound) and follow-up testing (approximately 88% for bloodwork and 71% for ultrasound).
Program description
Refugees are disproportionately impacted by hepatitis B and face numerous barriers to care, including access to specialist care, which is typically required for those with chronic hepatitis B. To address this, the primary care team at CRHC developed a shared care model, in partnership with local hepatologists, to screen all newly arrived refugees for hepatitis B and to manage the care of those with chronic hepatitis B. Once someone is diagnosed with chronic hepatitis B, a multidisciplinary team provides wraparound hepatitis B care at CRHC in consultation with two hepatologists and connects them to services in the community. The multidisciplinary team includes family physicians, nurses, visiting specialist physicians, dietitians, pharmacists, psychologists, social workers, patient navigators and administrative staff.
An approach was established for diagnosing and monitoring chronic hepatitis B. To track these assessments and follow-up, a patient registry was created, which was later transitioned to an electronic medical record (EMR) database.
Clinical assessments and intake
The CRHC is an interdisciplinary healthcare clinic that provides primary care for refugees in Calgary, Alberta. All new patients at the CRHC, operating as the Mosaic Refugee Health Centre (MRHC) at the time of publication, attend an initial intake appointment, where they complete screening bloodwork that includes hepatitis B testing. Patients diagnosed with chronic hepatitis B receive their results at a follow-up visit, where the primary care team discusses the diagnosis, provides education about hepatitis B transmission and explains the importance of lifelong monitoring to prevent complications such as liver disease and liver cancer. Following this discussion, the patient completes additional bloodwork and other baseline clinical assessments (e.g., ultrasound). The primary care team also works with the patient and local public health authorities to identify close contacts (i.e., household members, sexual partners) to encourage them to be screened and vaccinated.
To support patients and reduce barriers to care, the program offers several key supports. A telephone interpretation service helps clinic staff communicate effectively with patients in their preferred language, reducing cultural and language barriers. In addition, a dedicated health navigator assists with coordinating follow-up care and managing administrative tasks, ensuring that patients receive seamless and timely support throughout their care journey.
Ongoing management and monitoring
A plan for ongoing management of a patient’s chronic hepatitis B infection is established during a quarterly consultation between the lead family physician at MHRC and a local hepatologist for all new cases. Existing cases are also discussed when the family physician identifies a need for additional management, such as when a patient requires treatment or additional monitoring or needs to transition to specialist care. Each patient is monitored every six months by the primary care team, with auto-reminders set up in the EMR, or as often as recommended by the hepatologist. Monitoring includes follow-up bloodwork and/or ultrasound screening to monitor for liver disease progression and cancer, respectively. When a patient transitions to a community-based primary care clinic, the CRHC primary care team reviews the patient’s chart and provides a detailed care plan to the accepting family physician. Patients who require specialist care are referred to an outpatient hepatology clinic at a local hospital.
Results
Between January 1, 2011, and December 31, 2020, 171 patients with hepatitis B were identified and seen in the program, representing 2.6% (171/6511) of the total number of adult patients seen at the CRHC during this time. Patients were excluded if they were seen only for an intake visit or were already under specialist care at intake. Among the 171 patients in the cohort, 28 countries of origin were identified, with 60% of patients originating from either Eritrea (27%), Ethiopia (14%), Sudan/South Sudan (9%), Myanmar (6%) or Syria (5%). Most were male (66%) and aged 40 years or older (64%). The majority (65%) requested interpretation services for their appointments.
Clinical assessments and outcomes
Completion rates of baseline clinical assessments were high, with approximately 98% of patients completing their baseline bloodwork and approximately 84% completing their baseline ultrasound. Baseline bloodwork results showed that most patients had a long-standing chronic hepatitis B infection, probably acquired as an infant or child. Bloodwork results also suggested that most infections were relatively stable (i.e., were not causing significant liver damage at the time of diagnosis). Of the 171 people in the cohort, three had cirrhosis. No cases of liver cancer were diagnosed at intake or at any point in the study.
Follow-up monitoring and outcomes
Among the 171 patients in the cohort, 139 (81%) were followed for more than 12 months at the CRHC. It was recommended that 112 of these patients receive liver cancer screening every six months. Approximately 88% of patients met the acceptable/optimal target for completing follow-up bloodwork and approximately 71% of patients met the acceptable/optimal target for completing ultrasound screening.
Among the patients who transitioned out of the shared care program:
- 123 transitioned to a community-based primary care provider with a care plan (non-MHRC)
- 27 transitioned to outpatient hepatology for specialist care
- 27 moved out of Calgary
- 25 were lost to follow-up
- 1 cleared their infection
What does this mean for service providers?
The shared care program at CRHC offers an accessible model of care for hepatitis B screening and management among refugees. This population is disproportionately impacted by the virus but often lacks access to appropriate care, putting them at increased risk for complications from the infection such as liver disease and liver cancer. Given the need for lifelong monitoring for hepatitis B, enabling primary care providers to manage routine follow-up is key to engaging and retaining refugees in care.
Results demonstrate that with adequate guidance and support from specialists, primary care teams are well positioned to manage chronic hepatitis B monitoring and follow-up. The program had high rates of adherence to the recommended follow-up screening.
These results suggest that a multidisciplinary team with a dedicated health navigator can reduce barriers to care for refugees, ensuring they remain engaged in care. A large proportion of the patients in the study were transitioned into community-based care, suggesting that the shared care model can ensure continuity of care as the patient transitions.
Note: As a result of recent changes to the CRHC funding structure, staffing for the program model has been adapted and some of the details in this article may not reflect the current model of care.
Related resources
Understanding viral hepatitis in immigrant and newcomer communities – CATIE webinar
Bridging the gap in viral hepatitis care for immigrants and newcomers in Canada – CATIE Prevention in Focus article
Hepatitis B – CATIE fact sheet
Reference
Talavlikar R, Hull AR, Marlinga J et al. A shared care program for the management of patients with chronic hepatitis B in a Canadian primary care refugee clinic. Public Health. 2025 Oct 1;247:105894.