What will it take to eliminate hepatitis B as a public health threat in the United States and Canada?

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HEPATITIS B ELIMINATION IN THE UNITED STATES AND CANADA

“If you don’t know where you are going, you might wind up someplace else.” Yogi Berra

This article examines the status of HBV elimination for the United States and Canada based on the World Health Organization (WHO) targets. It reviews both countries’ epidemiology and measurable progress toward specific goals, focusing on gaps and potential solutions to achieve elimination. Though both are high-income countries, hepatitis B receives little federal funding in the United States or Canada (Table 1). There are significant gaps in data and disparities in the implementation of elimination strategies. This article proposes solutions to bridge those gaps to achieve HBV elimination.

TABLE 1.

US and Canada public health funding and disease burden across HBV, HCV, and HIV

Virus	US disease burden (in persons)	US CDC National Center for HIV, Viral Hepatitis, STD and TB Prevention (NCHHSTP) 2022 budget: $1.3 Billion1	Canadian disease burden2 (in persons)	Canada public health funding3,4,5
HBV	580,000–2.49 million6,7	Division of Viral Hepatitis 2022 Budget: $41 Million 3% of NCHHSTP budget For all viral hepatitis, domestic/international	111,800–460,000	Government of Canada funding (2022): - $106.4M to address sexually transmitted and bloodborne infections (STBBI) across Canada, covers mostly HIV, hepatitis C and syphilis -Canadian Institutes of Health Research Catalyst Grant funding ($100K) available periodically to fund applications relevant to STBBI other than HIV and hepatitis C (general)
HCV	2.2 million8	Division of Viral Hepatitis 2022 Budget: $41 Million 3% of NCHHSTP budget For all viral hepatitis, domestic/international	204,000	—
HIV	1.2 million9	Division of HIV Prevention 2022 Budget: $986 Million 73% of NCHHSTP budget Only domestic, not including international HIV work	62,790	—

Abbreviations: CDC, Centers for Disease Control and Prevention; NCHHSTP, National Center for HIV, Viral Hepatitis, STD and TB Prevention, STBBI, Sexually Transmitted and Bloodborne Infections; STD, Sexually Transmitted Diseases; TB, Tuberculosis.

Target goals to eliminate hepatitis B and hepatitis C as global public health threats by 2030 were issued by the WHO in 2016.¹⁰ These were updated in 2022 with an integrated vision of ending the syndemic epidemics of viral hepatitis, HIV, and sexually transmitted infections within a framework of universal health coverage, primary health care, and access to high-quality care.¹¹ To assist countries applying for hepatitis elimination validation, WHO released guidance with criteria and tools, including a new Path to Elimination track for hepatitis B or C elimination.¹² For hepatitis B, validation can be conducted for just elimination of maternal-to-child transmission (EMTCT) or for HBV as a public health threat that includes EMTCT.¹³

HBV BURDEN AND EPIDEMIOLOGY IN CANADA AND THE UNITED STATES

Estimates in Canada indicate about 111,800–460,000 individuals have hepatitis B or 0.3%–1.1% of the population (Table 2). Rates do not differentiate between acute, chronic, and unspecified cases, leading to the inability to characterize the epidemic.

TABLE 2.

HBV burden and epidemiology in the United States and Canada

Characteristic	United States	Canada
Estimated prevalence	0.3%–0.35%6,14	0.3%–1.1%;2 13.45 per 100,000 (2019)15
Estimated no. people with chronic HBV infection	580,000–2,490,0006,7	111,800–460,000;2 Updated estimates are expected in 2024
Epidemiology or communities impacted	Foreign-born communities disproportionately burdened: >50% of people with HBV are Asian American Pacific Islander (AAPI)7 12%–15% are African16	No National Surveillance Data At tertiary referral clinics, patients with chronic HBV are 74% Asian, 11.6% Black/African/Caribbean; 11.6% White (0.8% Canadian born)17
	Mortality and disparities: Deaths due to HBV 10 times higher among AAPI and 2.6 times higher among non-Hispanic Blacks than non-Hispanic Whites18	No National Surveillance Data Liver cancer standard mortality for immigrants is 2.18–4.89 (males) compared to nonimmigrant population19
	Opioid crisis: In the past decade, acute HBV rates have increased from 56% to 175% in regions impacted by the opioid crisis20,21	No National Surveillance Data 5.1% of people in British Columbia HBV positive have history of i.v. drug use (2.6% HBV negative with the same history)22

Abbreviation: AAPI, Asian American Pacific Islander.

In the United States, there is a wide range of estimates for the number of people with chronic HBV infection (580,000–2,490,000)⁶,⁷ due to varied definitions and gaps in data collection. Historically, strict case definitions for acute versus chronic HBV have resulted in many unreported chronic cases. In 2023, new case definitions for reporting acute and chronic HBV were approved, which should improve surveillance.²³ In addition to these public health reporting gaps, surveys often underrepresent non-US–born persons and populations affected by recent outbreaks, such as people who use drugs (Table 2).

Better surveillance systems are needed for both countries to accurately assess HBV disease burden and to track elimination progress. Otherwise, both countries are at risk of inaccurate accounting for vulnerable populations, resulting in misleading estimates.

CURRENT HBV ELIMINATION PROGRESS

HBV elimination validation requires reaching incidence and mortality targets. Programmatic targets also ensure systems are in place to deliver key services.

In both the United States and Canada, estimated rates of diagnosis and treatment are below WHO 2030 targets. These measures, along with many other indicators, as shown in Table 3, are largely based on models or studies, not national surveillance. Some indicators are on track (ie, blood donation screening), but other measures such as antenatal screening and treatment are difficult to ascertain.

TABLE 3.

WHO HBV elimination targets and progress of United States and Canada

Characteristic	WHO elimination targets	United States	Canada
WHO impact indicators
Prevalence of HBsAg in children ≤5 y of age	≤0.1% HBsAg in ≤5-year-olds (≤100 cases/100,000 live births)	No National Surveillance Data 0.03% (modeled)24	No National Surveillance Data <0.1%–0.34% (modeled)25
Maternal-child transmission rate	≤2%	0.4%26	No National Surveillance Data 1%–2%27
Childhood 3-dose vaccine coverage	90%	92.1% coverage by 24 mo28	82.6% (79.7–85.1) of 2 y olds among 8 jurisdictions
Combined mortality attributable to HBV and HCV infection: Annual mortality rate from HCC, cirrhosis, and chronic liver diseases attributable to HBV and HCV infection	≤6 HCV-related and HBV-related deaths/100,000 population per year	HBV-related deaths 0.45/100,00018 HCV-related deaths 3.18/100,000 age-adjusted death rate for HCV (2017–2021)18	HBV-related deaths 1.3 deaths /100,00025 HCV-related deaths 7.2/100,000 per year25
WHO Program Indicators: Testing and Treatment of Infections
Proportion of people living with chronic hepatitis B who have been diagnosed	Elimination target: ≥90% Path to Elimination: Gold ≥80% Silver ≥70% Bronze ≥60%	No National Surveillance Data 32%–33%29,30	No National Surveillance Data 71% (modeled)24
Proportion of people diagnosed with chronic hepatitis B, who have been initiated on treatment	Elimination target: ≥80% of eligible Path to Elimination: Gold ≥70% Silver ≥60% Bronze ≥50%	No National Surveillance Data 18% treated of people diagnosed with HBV (from claims data*)31 60.4% treated of those eligible by AASLD guidelines (from claims data)32	No National Surveillance Data 23% treated of people with HBV (modeled)24
HBV prevention interventions (injection safety, blood screening, and harm reduction)
Proportion (%) of safe injections administered in health care setting	100%	No National Surveillance Data Legislated since 2000 through “Needlestick Safety and Prevention Act” (NSPA)	No National Surveillance Data Regulations exist for national standards
Proportion of devices with RUP or with SIP features procured at national (or health facility level if procurement is decentralized)	≥90%	No National Surveillance Data NSPA requires safety-engineered devices regulated by Occupational Safety and Health Administration (OSHA)	No National Surveillance Data Regulated requirements for safety devices exist among Provincial/Territorial but not nationally
Proportion (%) of blood units screened for bloodborne disease	100%	100% Blood safety regulated by FDA	100%
No. syringes and needles distributed per PWID per year	Elimination: ≥300 Path to elimination: Gold: 150% or 100% coverage increase in the past 2 y Silver: NSPA present in the country Bronze: NSPA present in the country	No National Surveillance Data 30 needle-syringes per PWID/y (modeled)30	Average 291 needle-syringes per PWID/year Range of 261–328 for 11 P/T having data (2016)33
Coverage (%) of opioid substitution therapy (OST) among PWID	Elimination: ≥40% Path to Elimination: Gold:>20% OAT coverage or doubling OAT coverage in past 2 y Silver: OAT present in the country	No National Surveillance Data State dependent	~94% in Federal Correctional Facilities (patients with opioid use disorder; March 2023) National average of 66% (2016)33

Abbreviations: AASLD, American Association for the Study of Liver Diseases; FDA, Food and Drug Administration; NSPA, Needlestick Safety and Prevention Act; OAT, Opioid Agonist Therapy; OSHA, Occupational Safety and Health Administration; OST, opioid substitution therapy; PWID, Persons Who Inject Drugs; RUP, Reuse Prevention; SIP, Sharps Injury Protection; WHO, World Health Organization.

Despite the availability of vaccines and treatment, HBV causes unacceptable disease burden in both countries. Canada’s universal health care does not cover pharmaceuticals. Its current government recently introduced the first phase of legislation for a single-payer public Pharmacare starting with contraception and diabetes medications. However, there are many uncertainties regarding how the plan will be eventually implemented.³⁴ HBV-related mortality rates for Asians and Blacks in the United States remain high.

In both countries, a tenuous patchwork of private, public, and employer benefits vary across state and provinces, leading to health inequity. Strengthening the HBV cascade of care from diagnosis to care and treatment will be critical for the implementation of HBV cure therapies once they become available.

HBV ELIMINATION OF MOTHER-TO-CHILD TRANSMISSION

Globally, HBV transmission largely occurs from mother to child at birth or through early childhood horizontal transmission.³⁵ However, with effective vaccines and antiviral treatments, EMTCT is achievable. Hepatitis B birth dose vaccination and infant HBV vaccine series are recommended by WHO for all infants, and HBV screening should be performed in each pregnancy. For women with HBV, antiviral treatment is recommended if HBV DNA exceeds 200,000 IU/mL.³⁶

Since 2021, HBV EMTCT has been a part of WHO’s global triple elimination efforts, along with HIV and syphilis, and countries can apply for HBV EMTCT for standalone validation.³⁷

Both countries appear on track for meeting the WHO indicators of MTCT rate and reduced prevalence of childhood HBV, yet there are still disparities (Table 4). The United States has a universal birth dose policy, but Canada does not, with most provinces and territories (P/T), providing hepatitis B birth dose only to infants of mothers with HBV. Canadian-born children receive the 3-dose vaccine series, but the timing inexplicably varies across Canada, with 3 P/T scheduling the hepatitis B birth dose while others are scheduled as late as preadolescence (Table 4). In the United States, an enhanced perinatal HBV program that follows mother-infant pairs occurs in limited jurisdictions but does not track maternal treatment. For both countries, there are significant gaps in tracking the cascade of care along the EMTCT pathway.

TABLE 4.

World Health Organization HBV elimination of mother-to-child transmission targets and progress of United States and Canada

Program indicator	Elimination target	United States	Canada
For countries with universal birth-dose vaccination
Coverage (%) of hepatitis B timely birth dose	Elimination: ≥90% Path to elimination: Gold ≥90% Silver ≥50%	81.5% infants received birth dose (2019–2020)28	—
Coverage (%) of 3-dose hepatitis B vaccine in infants	Elimination: ≥90% Path to elimination: Gold ≥90% Silver ≥90% Bronze ≥90%	92.1% coverage by 24 mo of age28	—
Coverage (%) of hepatitis B birth dose and HepB3 (3-dose HBV series) among infants at risk in all provinces or subnational areas	Elimination: ≥90% Path to elimination: NA	86% by 12 mo of age26
Coverage (%) of HBsAg testing among pregnant women	Elimination: ≥90% Path to elimination: Gold ≥30% Silver: NA	No National Surveillance Data 82% in claims assessment of 880,000 pregnancies38
Coverage (%) with antivirals among HBsAg-positive pregnant women eligible for prophylaxis or treatment	Elimination: ≥90% Path to elimination: NA	No National Surveillance Data 13% in study of 975 HBsAg+ pregnancies38
For countries without universal birth-dose coverage
Coverage (%) of 3-dose hepatitis B vaccine in infants	Elimination: ≥90% For path to elimination: Gold ≥90% Silver ≥90% Bronze ≥90%	—	Birth dose vaccination is not universal—only 3 P/T provide (representing 2.3% of Canadian population)(among 8 P/T in 2021), National Immunization Coverage Survey
Coverage (%) of HBsAg testing among pregnant women	Elimination: ≥90% Path to elimination: Gold ≥30% Silver: NA		No National Surveillance Data Estimated to be 80%–100% Reflex HBV DNA testing not routine on prenatal HBsAg positive39
Coverage (%) with antivirals among HBsAg-positive pregnant women eligible for prophylaxis or treatment	Elimination: ≥90% Path to elimination: NA		No National Surveillance Data All pregnant individuals with HBV DNA >200,000 IU/mL eligible for treatment

Abbreviations: NA, not applicable.

HBV ELIMINATION ENABLERS, BARRIERS, AND SOLUTIONS

Both enablers and challenges to HBV elimination exist in the United States and Canada, and along with proposed strategies to improve the care continuum, are shown in Table 5.

TABLE 5.

Enabler, barriers, and solutions to HBV elimination

Cascade of care	Enablers	Barriers	Proposed solutions
HBV screening
United States	CDC Universal Adult HBV screening recommendation40	• USPSTF (US Preventive Services Task Force) recommendation not universal, thus no guaranteed insurance coverage • Low awareness among providers • Need for blood draw, lack of point-of-care (POC) diagnostics	• Implementation of universal screening recommendations • USPSTF updated recommendation for universal adult HBV screening • National Coverage Determination from CMS should follow CDC universal HBV screening recommendation • Automated integration of screening panel into health system EMR (prompts and ordering sets, standing orders) • Expanded provider education (Extension for Community Health Care Outcomes, ECHO) • FDA Class 2 categorization for HBV diagnostic and licensing of point-of-care diagnostics • Electronic health record adult HBV screening prompts/care gaps • Quality metrics to include universal HBV screening (NCQA, NQF, Medicaid Core Set)
Canada	Recommendations for universal HBsAg screening of pregnant and HIV or HCV infected persons, otherwise risk-based screening suggested41	• Recommendations not widely circulated to all health care providers • Awareness of risk profile is narrow (drug use/sexual) such that persons at risk due to birth in an HBV endemic country may be missed • Late diagnoses- patients presenting first time with HCC and decompensated cirrhosis	• Improved education of frontline health care providers • Promotion of updated primary care guidelines/recommendations for Universal Screening and Vaccination of all Adults by the Canadian Task Force for Preventative Health Care (CTFPHC) • The College of Family Physicians of Canada should provide resources for practitioners • The Public Health Agency of Canada (PHAC) website and recommendations should be updated to Universal Screening instead of risk-based
Vaccination
United States	CDC/ACIP HBV vaccination recommendation for all children and adults < 60 y old42 Inflation coverage reduction act - no cost vaccine sharing with Medicaid	• Optional/risk-based vaccination for adults 60 y and older confusing for providers • No clear guidance on order of universal HBV vaccination and screening • Not all pharmacists can administer vaccine and vaccine not covered in all pharmacy settings • Many clinicians do not stock vaccine • Vaccine access/coverage challenges	• Automated integration into health system EMR with accompanied workflow and education • Education for providers and communities, focus on liver cancer prevention of vaccine • Programs to address vaccine hesitancy, partnering with trusted community organizations • Create vaccine demand among communities • Patient navigators to assist with vaccine completion • Updated state policies to allow pharmacy administration and reimbursement without prescription • NCQA’s proposal to add HBV adult vaccination to Measure Year 2025 as a quality metric
Canada	Covered under public health care plans for all childhood vaccines.	• Adult vaccination not covered and not recommended • Wide variation in timing of pediatric vaccination • Poor coverage of birth dose vaccination (discriminatory disadvantage for newcomer populations)	• Leverage engagement with Government decision makers (National Advisory Immunization Committee; Public Health Agency of Canada) and the general public by advocacy and stakeholder organizations to educate, promote awareness, and justify the implementation of universal birth dose vaccination • Leverage the updated national STBBI Action Plan (2024) recommending new innovation and uptake of vaccination (ie, universal birth dose vaccination)
Both countries		• Low awareness among providers and communities, vaccine hesitancy • Lack of National Vaccine registry	Wide dissemination of the recommendation through professional societies and awareness of newer vaccines
Treatment
Treaters
United States	• Any physician can write prescription for HBV antiviral • Primary care providers serving at risk communities are often HBV treaters (many at federally qualified health centers [FQHCs])	Barriers for nonspecialists treating • Primary care providers (PCP) with limited time per visit • Not familiar with hepatitis B management • Complex eligibility assessment by AASLD guidelines • PCPs not aware of simplified guidelines	Expand provider education on HBV care and treatment • Start in medical school • Include as core curriculum for family practice and internal medicine residency training • Expand ECHO and other professional training • AASLD partnership with family practice and internal medicine societies for training, training program for hepatitis B and C Create quality measures (National Quality Forum, HEDIS, Medicaid/Medicare) with payment incentives for HBV screening and treatment
Canada	Specialist can write prescription for HBV antiviral	• Nonspecialists cannot prescribe • Pharmacare reimbursement programs, lack of expertise, and shortage of primary care providers	Expand hepatitis B related services, including telehealth, in the provincial primary care and specialist pathways: Alberta: Specialist Link https://www.specialistlink.ca/ Ontario: Ontario eConsult https://otn.ca/patients/econsult/; VIRCAN - https://vircan.ca/ (Toronto area Viral Hepatitis network) Quebec: Réseau québécois de la télésanté HYPERLINK “https://telesantequebec.ca/”https://telesantequebec.ca British Columbia: RACE- http://www.raceconnect.ca/
Treatment Guidelines
United States	• Management and treatment guidelines published by AASLD (American Association for the Study of Liver Disease)43 • Simplified HBV management guidance for primary care providers available online44	• Largely specialist prescribing, specialty guidelines have high complexity • Simplified HBV management guidance not widely adopted	• Create and promote simplified management and treatment guidelines • Creation of HBV guidelines from internal medicine or family medicine societies or wider dissemination of already published simplified guidelines
Canada	Management and treatment guidelines published by CASL (Canadian Association for the Study of the Liver)45	Largely specialist prescribing	-Development of primary care version of CASL guidelines. -Work with primary care networks to create a shared care model with specialists.
Drug Access and Coverage
US	2 oral generics are available (entecavir, tenofovir disoproxil fumarate), can go through nonprofit pharmacies	• Inconsistent health insurance coverage of HBV drugs • HBV drugs are often high-tiered on formulary and require prior authorization • Can be very costly for patients • Pharmacy benefit managers have dropped tenofovir alafenamide (Vemlidy) coverage	HBV meds should be universally covered and generics should be in low tier formulary to reduce patient cost for insurance company (Single government leverage negotiation bulk pricing with pharmaceutical company)
Canada	2 oral generics are available (entecavir, tenofovir disoproxil fumarate)	• >100 public prescription drug plans and over 100,000 private plans—with a variety of premiums, copayments, deductibles and annual limits • Pharmacy coverage of entecavir and tenofovir as first-line therapies (remove current recommendations in some plans to use lamuvidine and adefovir)	National, universal, single-payer, public pharmacare program. First phase of Legislation introduced in Spring 2024
Patient engagement and representation Stigma and Discrimination Quality of life measures
US	Advocacy groups and patient-serving groups foster patient engagement and document quality of life impact Hepatitis B discrimination protected under Americans with Disabilities Act (ADA)46	• Little or no formal patient engagement/patient preference in treatment guidelines and national hepatitis efforts • Quality of life indicators not included in management and treatment guidelines • Discrimination continues to occur despite ADA47	• Enhanced medical society engagement with patients, create formal inclusion of patient perspective into guidelines • Develop PROs to assess quality of life on and off treatment, and integrate into clinical care/guidelines • Culturally appropriate messaging to reduce stigma • Continued efforts to decrease discrimination (Hepatitis B Foundation Discrimination Registry) • Patient/advocacy/community organizations and programming (Hepatitis B Foundation, Hep B United)
Canada	Advocacy groups and patient-serving groups foster patient engagement and document quality of life impact	• No formal patient engagement/patient preference in treatment guidelines • Quality of life indicators not included in management/treatment guidelines	• Recent studies to investigate barriers and quality of life outcome measures for Canadian patients48,49 • Canadian Charter of Rights and Freedoms provides equality rights and protection against discrimination • Patient/advocacy/community organizations (CATIE Canadian Liver Foundation, Action Hepatitis Canada)
HCC Surveillance Opportunities to address gaps in early detection and improve outcomes of liver cancer Other50
US and Canada	Tools for HCC surveillance are available (Imaging, AFP) Specialty recommendations for HCC surveillance	• Low implementation and adherence to HCC surveillance • Less than ideal sensitivity and specificity of currently available screening tools • Non-universal terminology and criteria for HCC screening methodologies • Limited data on effective strategies to improve implementation and adherence	• Increase use of current surveillance tools • Wider adoption of Ultrasound Liver Imaging Reporting and Data Systems (US LI-RADS) for HCC surveillance • Study and validate new screening strategies, including noninvasive biomarkers • Implement provider and patient education • Integrate automated algorithms and reminders into health systems EMR • Create quality metric for HCC screening • Support national coverage recommendations for HCC surveillance (Canadian Task Force on Preventive Healthcare, US Preventive Services Task Force)

Abbreviations: AASLD, American Association for the Study of Liver Diseases; ACIP, Advisory Committee on Immunization Practices; ADA, Americans with Disabilities Act; AFP, alpha fetoprotein; CASL, Canadian Association for the Study of the Liver; CDC, Centers for Disease Control and Prevention; CMS, Center for Medicare and Medicaid Services; CTFPHC, Canadian Task Force for Preventative Health Care; ECHO, Extension for Community Healthcare Outcomes; EMR, Electronic Medical Record; FDA, Food and Drug Administration; FQHC, federally qualified health centers; HEDIS, Healthcare Effectiveness Data and Information Set; NCQF, National Community for Quality Assurance; NQF, National Quality Forum; PCP, primary care providers; PHAC, Public Health Agency of Canada; POC, point of care; PRO, Patient Reported Outcomes; STBBI, Sexually Transmitted and Bloodborne Infection; US LI-RADS, Ultrasound Liver Imaging Reporting and Data Systems; USPSTF, US Preventative Services Task Force.

The United States has had a Viral Hepatitis National Strategic Plan and now Centers for Disease Control and Prevention (CDC) recommends universal adult hepatitis B screening and vaccination.⁴⁰,⁴²,⁵¹ If implemented effectively, these recommendations could have a tremendous impact. Considerable progress can also be achieved through:

• Updated recommendations from the US Preventative Services Task Force (USPSTF) to align with CDC screening and vaccination recommendations

• Improved federal and state policy for coverage of care and treatment

• Integration of the recommendations into health systems

• Addressing HBV-related stigma and misinformation

• Licensing of point-of-care diagnostic tests

• Funding of the national strategic plan

• Creating and implementing quality metrics to ensure health care delivery of key services, including HBV triple-panel screening and adult vaccination, and using HBV DNA as a measure for linkage to care of HBsAg-positive individuals.

In Canada, HBV screening is largely risk-based and does not capture all infected persons. Canada has a 5-year Action Plan on Sexually Transmitted and Bloodborne Infections (STBBI) (Action Plan), but it does not include recommendations for HBV universal screening or birth dose vaccination.

Strategies to improve HBV elimination in Canada include the following:

• Adopting universal birth dose and consistent adoption of an infant vaccine schedule

• Removing obstacles affecting prescribers and treatment coverage, such as:

  • Updating prescription governance to national pharmacare and ensuring first-line antiviral therapies are covered

  • Forging partnerships among specialists and primary care physicians

• Innovative screening that is nonstigmatizing

• Canada’s STBBI response should strengthen its support for HBV

For both countries, several strategies would help overcome challenges to HBV care and liver cancer surveillance (Table 5). Encouraging HBV management and treatment among primary care providers and implementing novel models of care (ie, virtual care) would help remove barriers. Decentralization and ECHO models of care (Extension for Community Healthcare Outcomes and increasing access to antivirals will be important as more people are diagnosed. Improving HCC surveillance will lead to earlier detection of HCC and better outcomes.

Increased engagement with affected communities is critical for improving programmatic uptake. Patients should be partners in all efforts and formally included in developing treatment guidelines and elimination planning. There are growing studies on the impact of HBV on quality of life and other patient-centered dimensions (Table 5), and such work should be expanded to promote whole person care.

EQUITY AND COMMUNITY ENGAGEMENT

Globally, HBV disproportionately affects countries in the global south. In the United States and Canada, communities from these countries bear the HBV burden. They face challenges with health care access, poor representation, stigma, and discrimination. Thus, health equity and community engagement are critical in elimination efforts.

Canada’s Action Plan promotes awareness of the stigma and discrimination associated with STBBI. Effective implementation needs to be culturally safe and empowering for affected communities, such as Indigenous, immigrant, and 2SLGBTQI (two-spirit, lesbian, gay, bisexual, transgender, queer, intersex and others) individuals. As described in Table 1, Canada’s STBBI response has focused on HIV, HCV, and other sexually transmitted infections, with little support for HBV.

The US government has made efforts to engage communities in the national strategic plan but would benefit from a formal process for ongoing engagement. Of note, there is a proposed White House Hepatitis C Elimination Plan, but not one for hepatitis B, a reflection of the lack of HBV prioritization in the elimination agenda.

CONCLUSIONS

The tools for eliminating hepatitis B—diagnostics, vaccines, and treatments—have been long available in the United States and Canada but are not widely implemented or accessible to all. Despite being citizens of resource-rich nations, too many people are not diagnosed and treated for HBV, driving premature deaths and preventable morbidity due to HBV.

Available data show that both the United States and Canada need to make significant improvements to reach HBV elimination. To be validated for elimination, better surveillance systems for HBV are needed to track the true disease burden, people living with hepatitis B on treatment, and pregnancies at high risk of transmission. In both countries, policies and program adoption are needed to address the challenges at every step of the care cascade. While barriers and resource limitations exist, multisector advocacy and commitment can lead to incremental changes and progress.

Hepatitis B elimination is achievable in the United States and Canada with the implementation of tools, enabling policies, and the collaboration of health care providers, public health, and the affected community. However, prioritization of HBV and resource commitment are needed if elimination is to be reached by 2030