National hepatitis estimates

This transcript is the automated English captions in the recordings. The text may not align with the audio and there may be errors the transcript.

Marcus Wong: Hi everyone, my name is Marcus Wong. Thank you so much for joining the Public Health Agency of Canada's Communicable Diseases and Infection Control webinar series. We are pleased to have you join us today for today's webinar. 

Today we are meeting on a virtual platform, and I want to start off by acknowledging that from coast to coast , we each find ourselves on the unsurrendered and unceded territory of Inuit, Métis, and First Nations people. I, myself, am in Toronto, the land of many nations, including the Mississaugas of the Credit, the Anishnabeg, the Chippewa, the Haudenosaunee, and the Wendat peoples.  

As we move forward with today's discussions, let us remember our commitment to walking a path of partnership and friendship with Indigenous Peoples and remain mindful of the importance of person centered culturally safe care that honors the traditions, languages, cultures, and experiences of Indigenous People. 

A short disclaimer, today's webinar includes presentations from those external to the agency and may not reflect the views of the Public Health Agency of Canada. Following today's webinar, a copy of the presentation decks and the recording will be as well as a feedback form will be sent to you afterwards. And this webinar will be conducted in English. 

Simultaneous interpretation in French can be accessed through selecting the interpretation button in the menu at the bottom of your screen just like what you're seeing on this slide right now. A few technical notes as well. Your audio has been muted to reduce noise and video is disabled for this webinar. 

If you are having any technical problems and need help, you can reach us through the chat function. Please feel free to communicate in either English or French and we will get back to you. If you have a question for the presenters then please submit your questions using the Q&A function and we will look to answer them during the panel discussion which will happen at the end of this webinar. 

Note you may check send anonymously if you do not want your name attached to the questions in the Q&A part. And with that let me introduce our speakers for today's webinar.  

First up, we have Laurence Campeau who is an Epidemiologist with the Sexually Transmitted and Blood-Borne Infections (STBBI) Field Surveillance and Estimates section of the STBBI Surveillance Division at the Public Health Agency of Canada, where she contributes to the production of national estimates for viral hepatitis. She recently spent a year working with Doctors Without Borders in the Middle East, gaining valuable experience in field epidemiology and humanitarian response. Prior to joining the STBBI Surveillance Division, Laurence completed the Canadian Field Epidemiology Program, where she supported outbreak investigations across the country. 

Fozia Tanveer is the Manager of Multilingual Programming at CATIE and leads the Ontario Hepatitis C Immigrant and Newcomer Program. Since immigrating to Canada in 2011, Fozia has worked to advance health equity for immigrants and newcomers through multilingual education, culturally responsive programming, and community engagement. 

And last but certainly not least, Dr. Sofia Bartlett completed doctoral training in Australia at the University of New South Wales and a postdoctoral fellowship at the University of British Columbia (UBC). In 2021, she joined the BC Centre for Disease Control as a senior scientist and is currently the interim scientific director for Clinical Prevention Services. She is also an assistant professor (partner) in the School of Population and Public Health at UBC, leading a program of applied public health research aimed at identifying and understanding gaps in access to care and inequities related to sexually transmitted and blood-borne infections. 

So, they're going to be our three panelists today. And please join me in welcoming Laurence who will kick off the first presentation for today's webinar.  

Laurence Campeau: Okay. Hi everyone and thank you Marcus for the introduction. 

So as mentioned my name is Laurence and I am an epidemiologist working in the STBBI estimates and field surveillance section. So today I will be talking on behalf of both my own section as well as the STBBI enhanced surveillance section also known as the tracks team about the work we do to measure hepatitis B and C in Canada. So to start off with some background information, the WHO global health sector strategy set targets for the elimination of viral hepatitis as a public health threat and Canada has committed to meeting those targets. 

So this requires monitoring of epidemiological trends and disease burden. However, traditional surveillance systems relying on reported cases may underestimate the real burden of disease. So on this presentation, we will show how estimation methods and bio behavioral surveys can enhance traditional surveillance and offer a more comprehensive picture of the true burden of the disease. 

So here we're just going to start off with a little poll question for everyone. So the graph on the slide represent the cases of hepatitis C that were reported to the Canadian notifiable disease surveillance system between 2012 and 2021. So our question for you is what are some of the challenges of traditional surveillance systems to fully capture the true burden of disease? 

So I will give about 30 seconds for everyone to go through the list of options and select those that they think apply. So there's four options and you have to select those that you think are challenges of traditional surveillance systems to fully capture the burden of disease.  

Okay. 

So we have a few answers here. So most people selected the first option and then we also have quite a few people who selected the other ones. So we will look at the answers now. 

So if you selected the first three answers, you were correct. There's many reasons why traditional systems may not capture the full burden of disease. So this includes under reporting of cases since some diseases may be asymptomatic for many years. 

There's also a limited reach to key patients as they face more barriers in accessing health care. There's also a delay between infection, diagnosis, and reporting that can be up to many years for some diseases. And then the last point is also partly true in the sense that traditional surveillance systems typically only capture basic demographic information and without information on demographics and behaviors we cannot fully understand the burden of disease in all populations which is very important and we will talk more about this later. 

So I will start off with discussing the work that the STBBI field surveillance and estimates section does to measure Canada's progress toward viral hepatitis elimination. So first of all how do we generate estimates? So we use a method called the workbook method. 

This method incorporates both published and unpublished data from multiple sources. So I won't go into details about all the different sources that go into those estimates because of time constraints but here you can see them on the slide. So it include things like mathematical modeling, systematic literature reviews and data provided by partners such as the tracks team about which we will talk more later. 

So all of those things together allow us to triangulate the data and to generate estimates of the prevalence, incidence and awareness of infection as well as other indicators of elimination such as mortality related to hepatitis. And then finally we also collaborate with a group of experts which includes specialists such as hepatologist, epidemiologist and laboratory specialists from across Canada who provide support by reviewing our methodology and results. So now I will present some of the results that we've had from the latest set of estimates that we produced for the year 2021. 

So first of all we estimated the prevalence of chronic hep B at 0.7% which is equivalent to 262,000 people living with the disease. And then for chronic hep C the estimated prevalence was slightly lower at 0.6% or 214,000 people living with the disease. So the prevalence among the general population may seem low but we do know that some populations are disproportionately affected due to social and structural inequities. 

For this reason it is important for us at the Public Health Agency of Canada to adopt an equity approach. So on this slide we show the key preparations for which we were able to estimate the prevalence of hep B. So, hepatitis B is especially prevalent among immigrants from countries where the disease is common. 

We estimate that around 237,000 immigrants in Canada are living with the disease. The prevalence was also higher among gay, bisexual, and other men who have sex with men than for the general population with a prevalence of 1.4%. And finally, we estimated the prevalence among people incarcerated in federal prisons at 0.3%. 

As for hepatitis C, we were able to measure the prevalence among a total of eight key populations. So in this slide, we only included the three keys with the highest prevalence, but we invite you to have a look at our infographic on canada.ca for information on other key populations. And we will put the link in the chat for everyone to have a look if they wish. 

So the prevalence was highest among people who currently inject drug at about 37% followed by people who ever injected drug at 18% and then people incarcerated in provincial prisons had a prevalence of about 5%. We also estimated the proportion of people living with hepatitis B and C who are diagnosed which is one of the targets outlined in the global health sector strategy. We estimated that 58% of people living with chronic hepatitis B and 59% of people living with chronic hep C were diagnosed. 

So these estimates suggest that we very close to meeting the 60% target for 2025. However, the target for 2030 is 90%. So we still have work to do to improve awareness of viral hepatitis. 

Another indicator for elimination is the incidence. So we were only able to measure this for hepatitis C. Based on our estimates, the incidence in 2021 was 21 infections per 100,000 people. 

This is still quite a bit higher than the double usual target of 13 infections per 100,000. So this means that Canada still has work to do in order to lower the incidence of hepatitis C. Now we'll talk about the work done by the tracks team who does enhanced surveillance of STBBI among key populations in Canada. 

For anyone not familiar with the track surveys, it is a national system that monitors HIV, hepatitis and other STBBI along with related factors in key populations. So this is done through biobehavioral surveys. Participant complete a questionnaire with questions about behaviors, access to treatment and social determinants of health among other things. 

They also provide a biological sample usually through dried blood spot which is then tested for HIV and hepatitis. So recently tracks conducted two surveys. The first one was among people who inject drugs. 

Almost 2,300 participants were recruited through different venues such as harm reduction services across the country. This work was recently completed in May 2025. The second survey was with two spirit, gay, bisexual, queer, trans men, and non-binary people. 

Almost 5,000 people were recruited through different venues and events such as Pride festivals. And this work took place from June to September 2024. So the tracks team was able to share some preliminary results from this work. 

Among people who inject drugs, the proportion who said they had ever had hepatitis B was 2.4%. And the proportion who said they ever had hepatitis C was 54%. And then overall about 12% said they currently have hepatitis C. 

So currently this data is only self-reported which means it is likely an underestimate of the true prevalence and then once we have the testing results we will also be able to look into the proportion of people who have the disease but are not aware and then among those who reported having hepatitis C about 50% had a hepatitis C care provider and a bit more than a third had ever taken medication for hepatitis C. So this information allows us to identify people who are living with hepatitis but haven't received treatment and to look into some of their characteristics which can help us target interventions and policies. We also have self-reported data on the survey done among 2SGBTQ+people. 

So the results show that about 2.8%  reported ever having had hepatitis C and 0.3% said they were currently living with the disease. So once again, we will be able to validate this information once we get testing results which will provide insight into awareness and then we will also be able to link it with demographic characteristics and behaviors. And then finally, we also asked questions about vaccination status and about 30% of people said they had not been vaccinated and 26% didn't know, which suggests that vaccination coverage could be improved. 

So to conclude, we are able to measure progress toward elimination of viral hepatitis for eight of the 15 global targets. Based on our estimates, Canada has either met or is on track to meet six of these targets for 2025. 

However, progress is uneven. So, for instance, the incidence of hepatitis C is still too high, which highlights the need for more sustained and targeted interventions. We also saw that biobehavioral surveys are instrumental in measuring the burden of hepatitis among patients. 

However, there's still important gaps and additional data will be needed to fully assess Canada's progress towards elimination.  

Thank you.  

And I will be happy to take questions at the end. 

Fozia Tanveer: Okay. So, finally I'm able to now share my slide. So, good afternoon everyone. 

My name is Fozia Tanveer and I'm the manager of multilingual programming at CATIE. I will be presenting about CATIE's new social marketing campaign, routine practice. I'm excited to share how we use national data to inform this campaign that advances health equity for immigrants and newcomers. 

My presentation today will show the power of data in improving service providers awareness about hepatitis B and C screening among immigrants and newcomers from countries where hepatitis is common. But before I begin, I would like to acknowledge that I'm joining this webinar from Toronto, the traditional territory of the Mississaugas of the Credit First Nation, the Haudenosaunee, the Six Nations, and the Huron Wendat. I also want to acknowledge that CATIE's education and outreach work takes place on Indigenous lands across the country. 

We strive to honor the continued presence and resilience of the original peoples of these lands by approaching this work in a good way.  

So let's start with some basic facts. Hepatitis B and C are serious but preventable diseases. 

Hepatitis B can be prevented with a safe and effective vaccine. While there is no vaccine for hepatitis C, the infection can be prevented by avoiding contact with infected blood, primarily through safe injection practices and proper sterilization of medical, dental, and surgical equipment. The good news is that hepatitis C is now curable with an 8 to 12 week course of direct acting antivirals. 

Some immigrant groups in Canada, particularly those from countries where hepatitis B and C are common, are four times more likely to have hepatitis C and six times more likely to have hepatitis B compared to the Canadian born population. Despite these disparities, immigrants and newcomers are often missed in routine screening. Our campaign aims to change that by encouraging frontline healthcare providers to screen their immigrant and newcomer clients regularly. 

So when we begin developing this campaign, the most recent hepatitis B and C estimates from the Public Health Agency of Canada's 2021 surveillance data weren't yet publicly available. However, in CATIE's role as Canada's HIV and hepatitis C knowledge exchange broker, CATIE has a knowledge sharing agreement with the agency. So, we were able to access unpublished data which played a key role in shaping our campaign strategy and messaging. 

The compelling statistics that anchored the campaign and which I shared before showing that immigrants and newcomers are four times more likely to have hepatitis C and six times more likely to have hepatitis B were only possible through this collaboration.  

The partnership was essential as we were committed to grounding our campaign in the latest data and this is a point that I will speak to a little later in my presentation. The Public Health Agency of Canada released an infographic which Laurence mentioned in her presentation titled viral hepatitis Estimates among key populations in Canada 2021. 

We delayed the campaign launch until this infographic was public so we could link it to our campaign website. An important step in building trust and credibility with our audience. This infographic offers insights into where the burden of hepatitis is concentrated in Canada. 

Immigrants and newcomers from countries where hepatitis B and C are common are among the key populations. The data provided the evidence base we needed to encourage service providers to prioritize routine testing for immigrants and newcomers.  

If you would like to access this infographic, the link is in the chat. 

So that was the background information. Now let's turn to the campaign itself. As I mentioned earlier, routine practice is a social marketing campaign developed by CATIE in partnership with Pointlink Creative and funded by the Ontario Ministry of Health. 

The campaign aims to shift how frontline healthcare providers approach hepatitis B and C screening. Instead of relying on symptoms or risk disclosures, it promotes routine testing as standard practice, particularly for immigrants and newcomers from regions where viral hepatitis is common. So before finalizing the campaign's creative concept, we wanted to understand what kind of messaging would most effectively encourage healthcare providers to adopt routine testing.  

To ensure the campaign would resonate with the service providers we tested three different messaging approaches with a sample group of frontline workers in Ontario. The first approach was the just the facts approach which is the one we ended up choosing in this campaign. The second approach which we considered was cause and effect and the third option was personal stories. 

So when the results of the research came back the just the facts approach was the clear winner. Healthcare providers preferred straightforward, non-stigmatizing information that respected their time and expertise and helped them make clinical decisions. Interestingly, while personal stories were emotionally very powerful, they did not prompt action as effectively as data driven messaging. 

So from the same research we also learned that how we frame the issue matters a lot. Some messages unintentionally triggered anti-immigrant sentiment. So we were very intentional in avoiding language that frames immigrants as a risk group. 

Instead we focused on systemic and geographical gaps in screening. We also emphasized solutions rather than problems. This helped reduce bias and aligned with our hopeful and empowering approach. 

I would now like to show a short video from the campaign to give you a glimpse of our work.  

Actor portraying a doctor: They never tested you for Hep B. And yet you're immigrated from a high prevalence country. 

Actor portraying a patient: And my likelihood of testing positive is six times the Canadian average.  

Actor portraying a doctor: It's almost as if offering a test should be routine practice.  

Fozia: Okay. 

So that was one of the short videos.  

So within the first 3 months, this digital campaign generated 7.2 million ad impressions. On LinkedIn, we achieved a very high click-through rate, which was well above the industry average. 

More than 5,000 new users visited our campaign website showing strong engagement. These results indicate that healthcare providers and service organizations are not only interested in this information but also the campaign message was persuasive. So to watch the other two videos, please visit our campaign website and you can find the URLs in the chat. 

So before I wrap up my presentation, I would like to highlight some of CATIE's World Hepatitis Day resources. We have created a dedicated World Hepatitis Day web page with up-to-date information and resources on hepatitis C. The page can be accessed from the URLs in the chat. 

It includes downloadable infographics, social media toolkits, and multimedia files. These tools are designed to be user friendly and easy to share. So our latest hepatitis C resources are available free of charge from CATIE's ordering center. 

Again, the link is in the chat and you can order them for your World Hepatitis Day events or your regular education and outreach activities. So that concludes my presentation.  

Thank you so much for your attention and I hope this information about CATIE's new campaign and resources will be helpful in your work. 

Here are my contact details. If you need more information about our work, you can reach out to us. Thank you so much for your time and your commitment to health equity and I will also be happy to take the questions at the end. 

Sofia Barlett: Thanks Fozia.  

I am just going to share my screen.  

Okay so I'm now going to share a slightly different example of how the national hepatitis B and C estimates have been used.  

And I'll be speaking about how these estimates produced by the Public Health Agency of Canada can support community-led monitoring of progress towards viral hepatitis elimination. Before I go further into my presentation, I would like to begin by acknowledging that I am an uninvited occupier on the never ceded traditional and ancestral territories of the Musqueam, Squamish, and Tsleil-Waututh Nation. 

And I'm joining today from the office of the British Columbia Center for Disease Control in what's colonially known as Vancouver. And I acknowledge the title and the rights of the First Nations who've cared for and nurtured the lands, air, and waters around me for all time and whose territory we are occupying in what's colonially known as British Columbia. So, I'm going to talk a little bit about the hepatitis elimination strategies and targets that have been published and endorsed over the past few years. 

And the reason why I want to start with this background is because hepatitis elimination is actually a little bit of a moving target because over the past decade different strategies have actually included or endorsed slightly different targets. And the targets are important because that should shape the indicators that we monitor in order to determine if we are on or off track to achieve elimination. So, I'll start with that background and then I'll talk a little bit about Action Hepatitis Canada's reports that they've been producing over the past few years and sort of what the objectives of those are. And then how we've selected the indicators that are included in the Action Hepatitis Canada reports in order to monitor progress towards achieving hepatitis elimination across Canada and how the Public Health Agency of Canada national viral hepatitis Estimates have been used by Action Hepatitis Canada both within the indicators that they monitor as well as to inform some of the other work that they do. Okay. 

So, just starting off with a little bit of kind of context setting around viral hepatitis elimination and the monitoring indicators. So typically a lot of these very high level public health strategies like the goals to eliminate viral hepatitis as a public health threat by 2030. They follow a formula where they have an objective. 

So something that we want to achieve and then a goal is set that would help us achieve that objective. Then we identify and develop a strategy, a way that we're going to achieve that goal, and then measures that will help us to know whether our strategy is actually working or not. And this is often abbreviated as the OGSM framework. 

Depending on where we are in the world and maybe even the language that we're speaking, there are many ways to say the same thing. sometimes goal and target are used interchangeably. Sometimes measure, indicator or metric are also used interchangeably. 

And essentially these are all the same thing. The objectives and goals for the elimination of viral hepatitis as a public health threat by 2030, as I mentioned, have been set out in multiple different global and national strategies, frameworks, reports and statements and most of the objectives and goals are the same in all of these different strategies. 

However sometimes the measures or the indicators or the metrics that are proposed in one strategy or framework in order to gauge or measure progress towards achieving the goals, they actually change a little bit. And in many cases while the measures that have been proposed are very well thought through measures that would really help us to know if the strategy that we're employing is achieving the desired goal These measures are actually often very difficult to measure and especially you know thinking about what Laurence was sort of presenting earlier we actually often have to either do some modeling or other kind of ways to actually generate these measures and that they're actually estimates rather than an exact count. 

And so a lot of the time that depending on the framework or the strategy that we are trying to follow, it's actually not super clear exactly what we should be measuring to know whether something is on or off target. And just to maybe illustrate a little bit my point, I just want to take everybody through a little bit of a timeline of the different global and national viral hepatitis strategies that have are all aiming to get to that 2030 goal. So in 2010 the World Health Assembly, so this is the forum where all of the representatives from different countries that are part of the World Health Organization, they all go and they vote on different resolutions. 

And in 2010, there was a resolution on addressing viral hepatitis that was adopted by the World Health Assembly.  

And then in 2014, there was a very strong resolution adopted that was calling for the elimination of viral hepatitis as a public health threat by 2030.  

And the 2014 resolution is kind of what kicked off everything that that we're actually working towards at the moment. 

And so in 2016, the World Health Organization launched what they called the global health sector strategy on viral hepatitis. And this strategy was in aiming to put forward activities and actions that would be taken between 2016 and 2021 in order to start the movement towards eliminating viral hepatitis by 2030. And they set out some targets in that strategy. 

There was a preliminary targets for 2025 and then there was also the kind of overall objectives and the targets that would be met if those objectives were achieved for 2030. And this then launched the countries that had adopted or had had ratified that resolution from the World Health Assembly to begin starting to create their own strategies to align with this kind of global health sector strategy. And so the Public Health Agency of Canada developed this pan Canadian STBBI framework for action aiming to reduce the health impact of STBBIs in Canada by 2030. 

And they adopted all of the targets that were part of the health sector strategy on viral hepatitis in the pan Canadian STBBI framework for action. And then the WHO started to realize, ooh, we might need to give everybody a little bit more help to monitor and evaluate whether their hepatitis strategies are achieving the goals set out in the global health sector strategy. So they produced this consolidated strategic information guideline for viral hepatitis which set out these guidelines for how to monitor and evaluate what you're doing in terms of the viral hepatitis strategy. 

And very soon after that, the government of Canada 5-year action plan on STBBI was released. The first 5-year action plan which specified the Government of Canada's priorities under the STBBI framework for action. the Canadian Hepatitis C Network or CanHepC also produced a blueprint that was intended to guide the provinces and territories on producing their own strategies that would achieve the elimination of hepatitis C in Canada by 2030. 

Now the CanHepC blueprint actually took some slightly different turns compared to the way that the targets were laid out in for example the global health sector strategy on viral hepatitis. So that's sort of one of the first areas where we started to see a little bit of divergence. And then the global health sector strategy on viral hepatitis was refreshed in 2022. 

And this is intending to lay out the actions and activities from 2022 to 2030 in order for everywhere to achieve those goals by 2030. And they revised the targets for 2025 and 2030. Now when you first look at them they might seem they're basically the same but there are some key differences. 

And then of course the Government of Canada's STBBI action plan was also refreshed in 2024 which is highlighting the priorities for the government of Canada from 2024 to 2030. They have not changed the targets. They are the same but there are different act activities or priorities. 

And so, you know, again, thinking about how from a community perspective, how would we monitor and ensure that the actions that the government of Canada is taking are actually achieving the intended goals? 

And you know, obviously there are provincial and national efforts undertaken by provincial and national governments and government agencies to be able to monitor and evaluate progress towards these goals. But from the community perspective really being able to verify independently that the progress that you know we in public health or in the government are saying is being made that that is actually what the community sees as well. 

This is a very important part of community trust building as well as accountability. So community being able to hold the government and public health partners accountable for the commitments that they've made. It's very important part of sort of the overall strategies that we're employing and this is actually also something that is outlined in the global health sector strategy on viral hepatitis. 

This is the same information.  

Unfortunately, we weren't able to have both in French and English. So I'll leave this here for a moment for our francophone audience and this these slides will also be shared afterwards.  

So just to illustrate exactly how the targets have changed compared to the global health sector strategy on viral hepatitis that was first released in 2016 compared to the global health sector strategy that was released in 2022 and where we've had some divergence now which has resulted in us having to change our indicators. So the targets in the first strategy that was there was a interim target for 2030. 

There was a proportion of infections that were intended to be diagnosed. A proportional reduction in new cases for both hepatitis B and hepatitis C. And then there was also a global absolute number target for the number of people that would initiate treatment. 

And then for the 2030 ultimate targets, they flipped it.  

And so it was a proportional target for infections diagnosed, eligible persons treated, and then a reduction in new cases. And one of the key things that has caused confusion for folks who have been trying to look at monitoring targets for hepatitis elimination is that there was never any definition provided of what was intended to be eligible persons treated. 

Was that intended to be everybody who has a chronic viral hepatitis infection or is it everybody who has a chronic viral hepatitis infection who is also tested and diagnosed then is also treated. So the denominator that that we're intending to create that proportion out of it. It's actually quite important to know what the denominator is and in that initial strategy it wasn't defined. 

Then in the 2022 strategy the 2025 interim targets had been revised. So there are these proportional targets of infections diagnosed and people living with an infection who are treated. And so the wording has changed. 

Instead of being eligible persons treated, it's now people living with an infection who are treated. This is a much clearer denominator. We know exactly what is going to be in in the bottom of that proportion. 

And then we also have this different way of measuring the reduction in new cases. So we now have these absolute targets for crude incidence. So, a preliminary target for 2025 and then a target for 2030 of two new hepatitis B and five new hepatitis C cases diagnosed per 100,000 population members. 

So, if you if you imagine if you were putting out a report in 2021 where you were trying to measure targets towards hepatitis elimination, you would have been going off these targets. And then if you then subsequently start working on a new version of the report after 2022, you now have to change. So it's been challenging. 

There's maybe a little bit of disruption or less continuity. but still has been achievable. It's just important that we understand that like we're not measuring the exact same thing now. 

So this is where the Action Hepatitis Canada progress reports have come in. For those who aren't familiar, Action Hepatitis Canada is a national coalition of community based organizations who are responding to viral hepatitis. They aim to engage government policy makers and civil society across Canada to promote hepatitis prevention, improve access to care and treatment and increase knowledge and innovation creating public health awareness, supporting health professional capacity and supporting community based groups and initiatives.  

And in 2020, the Action Hepatitis Canada steering committee which is made up of representatives from the member organizations, they endorsed a plan to develop their own report which would be aiming to measure and track progress towards achieving hepatitis elimination targets across Canada in each of the provinces and territories.  

And that this would be a community-led monitoring and evaluation effort that then could be an advocacy tool and a planning tool that's used by organizations at the local level, whether they're in the provinces and territories and they're serving people across that region or if they're even at a local level in a city. 

They could then use this report for either planning, applying for funding, evaluating their own efforts or advocating with policy and decision makers. So the first report was published in 2021. So this inaugural report had a set of what we thought at the time was going to be standardized indicators that would be measured for each province and territory as well as areas of federal jurisdiction that were related to viral hepatitis elimination. 

So that was published in 2021. And the aim was to have a report published every 2 years and in between there would be a sort of more focused deep dive into a particular area. And the first special report that they published was focusing on prison health and looking at hepatitis C prevention, diagnosis and care in correctional settings across Canada. 

So then the 2023 report came out and if you remember back to that timeline that I was showing before, this was after the new global health sector strategy for hepatitis came out. And so this is where we actually had to update our standardized indicators in order to align them with those new WHO targets. So we kind of had to flip things around a little bit. 

And then there was the immigration health special report that was produced in 2024. And then that brings us to 2025. This was the third biannual progress toward viral hepatitis elimination in Canada report that's been prepared by Action Hepatitis Canada. 

And we'll be sharing the link for folks to be able to access this if you haven't already. So this then kind of brings back maybe a little bit of repressed kind of trauma for me. because in 2020 when I first started working with Jennifer van Gennip and Janet Butler McPhee on helping to put together this report, we were being guided by these targets that were in that 2016 strategy. 

And then we were also trying to align with the pan Canadian STBBI action plan and the CanHepC blueprint. And we started kind of bending ourselves around in pretzels trying to figure out ways that you know we could have targets that would be standardized that we could measure every 2 years that would help align between all of these things. It was very difficult to actually then balance that with what we had data on. 

So we then had to also interpret consider how interpretable the indicators would be and also if they were locally relevant. And so what we came up with and what we ended up putting in the report, it is not actually exactly aligned with any of the three of those strategies or blueprints. There's been compromises that we had to make based on what data was actually available. The Public Health Agency of Canada national hepatitis Estimates that have recently been published helped address some of the data gaps that we had. but we also then had to consider whether the indicators actually had any kind of meaning or relevance for local contexts. And so I think this is from my perspective as I work in public health and we do monitor some indicators and targets for British Columbia that are related to hepatitis elimination. 

We kind of have the targets that that we from the public health perspective are going to be measuring. We have our priorities. It's really important that community kind of then has the ability and the opportunity to be able to choose the targets that make sense for them. 

And so when you know the Public Health Agency of Canada can produce estimates like the viral hepatitis estimates that have recently been created that gives the tools to the community to then be able to actually take them and turn them into something that's meaningful for them. And it just means that, you know, when we're actually creating indicators and looking at them, there are always, as Laurence mentioned, there are always limitations in what we're measuring. And if we're measuring things from different perspective, it gives us the opportunity to triangulate the data. 

And being able to triangulate from different angles and different perspectives, that's probably how we're most likely to get an accurate idea about what's actually happening. And so it is it is really important that we don't just kind of have our public health kind of goal targets being measured. We also need to have the community being able to measure and monitor progress. 

So the metrics that we have most recently included in the hepatitis elimination progress report are these sort of six metrics here. The first one is the incidence of new hepatitis B and hepatitis C cases that are reported. These have been able to be pulled from provincial data reports and this target we changed the way that we were measuring it from the first report to then the subsequent two reports now it's being measured as that crude incidence and this one now hopefully won't change anymore some of these other metrics are actually more sort of like policy evaluation metrics so whether there's a hepatitis elimination plan or strategy in place in the particular jurisdiction, province, territory or federal, whether the recommended testing is available, whether the recommended treatments are available and who they're available to and how people have to access them. Then this very important one here which I highlighted in yellow, the annual hepatitis C treatment prescribing counts. Now, when the Action Hepatitis Canada report was first produced, they actually had to use private data that was purchased from IQVIA to be able to measure this indicator. 

However, the most recent Public Health Agency of Canada estimates that have been published actually provided national treatment prescribing counts. And so this is now what Action Hepatitis Canada is able to use to inform this metric. And then they also look at whether preventative measures are available. 

So just to give an example of exactly where we sort of see the national estimates being used. So, Laurence kind of explained this much better than I will, but you know, when we look at the number of cases of hepatitis B or hepatitis C that are actually being reported, this is sort of, you know, the tip of the iceberg. That doesn't necessarily represent actually how much transmission or how prevalent those infections are. 

And so the metric that that the Action Hepatitis Canada report currently includes that is just the reported cases. Whereas the new Public Health Agency of Canada estimates that they actually going to be much more inclusive of how many infections are actually in different jurisdictions and regions. And so, we're actually sort of going to be starting to think about, how the Action Hepatitis Canada biannual report indicators, can be shifted a little bit to use the PHAC indicators. 

And they those indicators are also being used a lot in the special reports that have been, produced by Action Hepatitis Canada, particularly the key population baseline estimates. And then as I mentioned before, the hepatitis C treatment initiation estimates, they've that's been essential for Action Hepatitis Canada, to be able to verify the treatment prescribing counts. And this is going to be a really important metric to be able to continue to monitor going forward. 

Some of the impact that Action Hepatitis Canada has been able to have through producing this report. They've been invited to present on the reports at the Global Hepatitis Summits both the one that happened this year and the one two years before. So really recognizing on the global stage how impactful this type of community-led national monitoring and surveillance is. 

They've been profiled by the coalition for global hepatitis elimination and featured in the country and regional elimination tracking dashboards. Canada is actually one of the only countries in the world that has a national community-led hepatitis elimination monitoring report. They've also been able to secure meetings with provincial and territorial ministers and assistant deputy ministers of health to be able to present the report to them and advocate for necessary actions that would help address what's being seen. 

And the indicators have also been informing and been used in hepatitis C elimination road maps that are being developed across Canada in different provinces and territories. I would like to acknowledge Jennifer van Gennip for her leadership of Action Hepatitis Canada. She is a steadfast community advocate, and she has really I think contributed enormously to the efforts towards hepatitis elimination across Canada. 

As well as Janet Butler McPhee who's the co-executive director of HIV legal network and she serves on the Action Hepatitis Canada steering committee.  

The two of them have done an excellent job of steering this progress monitoring report as well as all of the Action Hepatitis Canada member organizations and the steering committee members they are the people who came up with this idea so this wasn't my idea I have merely helped provide them the tools and the advice on how they could actually create these indicators and do this monitoring these are the people who are actually on the ground doing all of the work actually towards hepatitis elimination. So it would be remiss of me not to highlight that and I've just shared the link here and I think it's being put in the chat box as well to be able to see the most recent progress monitoring report. 

Thank you.  

Marcus: Okay, thank you so much Laurence, Fozia and Dr. Bartlett for your presentations. 

Really interesting to see how the information starts at the Public Health Agency of Canada and then gets utilized in so many different ways.  

This ship is running a tight schedule. So we have 3 minutes left for our Q&A. 

And just a reminder that you can go into the Q&A function to ask some questions. And I am going to ask our speakers to answer these questions a little bit quickly just based on our timeline here.  

And I'm going to start out with a question for Laurence which is how do you estimate the proportion of people living with hepatitis B or C who are aware of their infection? 

Laurence: Thank you Marcus for the question. So the most direct way to estimate awareness of infection is really through surveys where participants are asked whether they have hepatitis B or C and then they are tested and then among anyone who tests positive we can look into what is the proportion of people who were aware of their infection. So the track surveys are a good example of something like that. 

This is done mainly among key populations. But then to be able to do that for the general preparation, we also did a special project where we took samples that were collected as part of the Canadian Health Measure Survey which is a national survey done by Statistics Canada and then we tested those samples for hepatitis and then we were also able to measure the proportion of people who said that they were aware among those who tested positive and then you can weigh the results to make sure that there are represent relative of the population in Canada. And then we also work with modelers both here at the Public Health Agency and also externally to develop mathematical models that look into how the disease progress over time and then they're able to compare the number of people diagnosed with the total number of people the total number of infection. 

And then that allows us also to have estimates of how many people are aware of their infection. And then we really work on like triangulating all of that data to be able to have estimates that are as precise as possible.  

Marcus: Okay. 

Thank you so much, Laurence.  

A question from the audience related to the routine practice campaign. can you talk about any lessons learned in building out this campaign compared to the usual ones and Fozia over to you? 

Fozia: Yeah. So, I think this is a great question and a lesson learned which is a really important one for us was that if you know your target audience then investing in research pre-campaign research which I also mentioned in my presentation is really important and really helpful because then you can come up with the kind of messaging which resonates with them and that's what we did for this campaign. We did a pre-campaign research based on that we decided what kind of messaging we are going to use and yeah so that's an important lesson which we learned. 

Marcus: Okay thank you so much Fozia and unfortunately we are at time for this webinar. 

There was a lot of really important information that was being shared and of course this presentation once again will be sent to you over email as well as the recording and feel free to reach out if you have any additional questions and apologies that we were not able to get to all of them but thank you to everyone again who joined us today and a special thank you for Sofia, Fozia and Laurence for their time and insights and of course all of the staff making sure that the CDIC webinar can even happen. Once again, you will be receiving an email following the session with the recording, slides, and a short feedback form. 

We really value your input, so if you could fill out that feed feedback form, that would be amazing. On behalf of the Public Health Agency of Canada, thank you again for your participation. We look forward to seeing you at a future session in this series. 

Take care and enjoy the rest of your day.