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Communicating the risks of hepatitis B to travellers

Norma Evans
RN BSc FPCert
DipTravMed
Independent Travel Health and Immunisations Nurse Specialist

It never ceases to amaze me the different types of holiday that people choose to take these days, from mountain climbing in Nepal to bungee jumping in Zambia. And there is no particular type of traveller - I meet retired people going on active holidays, youngsters going backpacking during a gap year, and business travellers who once would only travel to cities but now seem to be doing deals in more remote parts of the world.
Never has travel health and vaccination been more important. It is vital that travellers are made aware of the risks of all infectious diseases they might encounter. This article focuses on hepatitis B.

Implications for travellers
Many travellers unwittingly expose themselves to the risk of hepatitis B infection by travelling to areas of high or intermediate endemicity, without seeking or receiving sufficient travel health advice. A recent European telephone survey of over 5,000 travellers showed that 67% exposed themselves to the risk of hepatitis B infection while travelling to areas of moderate and high endemicity (high risk = 8.3%; potential risk = 58.3%).(1) This is further endorsed by visits abroad by UK residents to areas of high risk of hepatitis B infection, which rose by 27% during the 12 months ending June 2005.(2)
So where are these areas of endemicity? Figure 1 shows the areas highlighted in green by the World Health Organization that have moderate-to-high prevalence of hepatitis B.(3)
To put this in context, you may find your patients travelling to holiday destinations such as the Maldives, Dubai and the Gambia. These hugely popular destinations are areas with a moderate-to-high prevalence of hepatitis B, so travellers must be made aware of the disease, how they could be at risk of being infected, and interventions to minimise this risk.

[[NIP29_fig1_52]]

Symptoms and health implications
Hepatitis B is often called a silent disease because many of those who have it have no symptoms. However, others experience a flu-like illness including a sore throat, tiredness, joint pains and a loss of appetite. Other symptoms include nausea and vomiting, while acute infection can be severe, causing abdominal discomfort and jaundice.(4) Acute hepatitis B is a liver inflammation lasting one to six months. Failure to clear the disease after six months is defined as chronic carrier status, a lifelong infection characterised by liver inflammation and damage that can lead to morbidity and in some cases mortality from cirrhosis and liver cancer.(5)
The facts outlined below demonstrate the worldwide impact of the disease:(6-8)

  • Hepatitis B is a major public health problem in approximately 30% of the world's population - this means that one-third of the world's population have been exposed to hepatitis B at some point in their lives.
  • Hepatitis B kills between 500,000 and one million people each year from liver cancer or liver cirrhosis.
  • Hepatitis B is in importance second to tobacco as a human carcinogen, causing 50% of all liver cancers.

How does hepatitis B transmit?
Transmission of hepatitis B takes place through contact with blood or body fluids of an infected person, and the disease can be spread by routes that include:(4,9)

  • Contaminated equipment used in medical or dental procedures in a country where hygiene standards are not as high as they should be, such as needles for syringes for injections, blood or blood product transfusion.
  • Skin-penetrating procedures, including acupuncture, piercing and tattooing.
  • Sexual contact.
  • Sharing earrings, razors or toothbrushes with an infected person.
  • Close contact, through contact sports, day-to-day activities with locals (ie, work, public transport, sharing homes), and so on.

How to communicate the risks
It is essential for travellers to understand the disease and how it is transmitted, but nurses often feel it can be challenging within the tight time constraints of a travel consultation to convey the potential risks of an infection.
There is also a misunderstanding by the general public that hepatitis B can only be contracted by sexual contact or by those who take drugs for recreational purposes. In essence, the task of educating travellers could prove daunting, but it need not be, and the following three steps may be helpful.

1. Increase disease awareness
If travellers do not understand the risks they face when they travel to an area of high or moderate hepatitis B endemicity, then they are not in a position to avoid situations associated with risk of exposure. It is important that travellers understand that the intended destination is a high- or moderate-risk area (reference to the WHO map is very useful and communicates the point in a straightforward and visual manner). As travellers frequently lack awareness of the routes of transmission of hepatitis B, it is advisable to outline how risk of exposure can occur - for example, through medical treatment required in a hepatitis B endemic country, perhaps following a car or adventure sports accident or unexpected illness, emergency dental work, or through close contact with the local population.(1)

2. Accidental risk of exposure
It is well documented that accidents while abroad are one of the most common causes of morbidity and mortality in travellers. Just a small amount of hepatitis B-infected material can lead to infection, so even the most minor medical or dental procedure can lead to risk. All it could take is the use of equipment that has been inadequately sterilised or the use of blood products that may not have been screened for the presence of bloodborne viruses in some developing countries.(1)

3. Risk behaviour
Today's travellers are more likely to pursue adventure holidays or take part in extreme sports that are potentially hazardous.(10) Close contact with locals living in areas of high endemicity also presents an increased risk. There is also the sensitive subject of sexual transmission.(9) Introducing advice on the risk of sexual transmission of hepatitis B is often easier if the discussion of other methods of transmission, such as risks from medical intervention,(4) leads on to advice about avoiding sexual transmission.

Recommendations
Immunisation against hepatitis B is the most effective means of preventing infection and its consequences.(11) Hepatitis B vaccination has an outstanding record of safety and effectiveness and has been available for 20 years (see Table 1).(6,9) The Department of Health Green Book recommends that the following groups of travellers are offered immunisation against hepatitis B (guidance/draft guidance is scheduled for publication this summer):(12)

  • Those travelling to areas of high or intermediate prevalence who place themselves at risk when travelling abroad.
  • Those travelling to areas of high or intermediate prevalence who are likely to require medical or dental attention in these areas. These include:
  1. Those who plan to remain for lengthy periods.
  2. Those visiting friends and relatives who may require medical care while abroad.
  3. Those with chronic medical conditions  who may require hospitalisation while  abroad.
  4. Those travelling for medical care.

[[NIP29_table1_55]]

It is important to note that new guidance recommends those travelling to areas of both high and intermediate prevalence to be immunised against hepatitis B. Previously it was only countries with high prevalence.(12)
Supporting the Case for Immunisation Against Hepatitis B is a recent position paper from the British Medical Association (BMA), which states that as destinations become more diverse, with people increasingly travelling outside Europe, the opportunity for hepatitis B transmission is much greater. As such, vaccination should also be considered for a wider range of travellers, including:(13)

  • Those who may travel to areas endemic for hepatitis B.
  • Those who may be exposed by virtue of their sexual practices.
  • Those who may be exposed to unscreened or inadequately screened blood or blood products or inadequately sterilised medical and surgical equipment.

The future
The UK remains one of the few industrial nations who do not offer universal vaccination to hepatitis B at birth or in childhood, despite the 1991 WHO recommendation that hepatitis B vaccination be included in all countries' national immunisation programmes,(9) and despite the BMA calling for all children in the UK to be immunised against hepatitis B as it can cause potentially fatal liver disease.(13)
As people's taste for adventure holidays in exotic locations grows, and as air travel becomes more accessible, it is vital that healthcare professionals provide a travel health service that matches their patients' travel health needs.

References

  1. Zuckerman JN, Steffen R. Risks of hepatitis B in travellers as compared to immunization status. J Travel Med 2000;7:170-4. Available from: http://journals.bcdecker.com/pubs/JTM/
  2. GSK Data On File. VCG/DOF/05/23350/1. Source: International Passenger Survey, Visits by UK residents to hepatitis B high risk areas. Contact GSK for further details.
  3. Health Protection Agency. Available from: http://www.hpa.org.uk/infections/topics_az/hepatitis_b/data_not_region.htm
  4. Health Protection Agency. Available from: http://www.hpa.org.uk/infections/topics_az/hepatitis_b/gen_info.htm
  5. Ganem D, Prince AM. Hepatitis B virus infection - natural history and clinical consequences. N Engl J Med 2004;350:1118-29.
  6. Steffen R, Connor BA. Vaccines in travel health: from risk assessment to priorities. J Travel Med 2005;12:26-35.
  7. Foundation For Liver Research.Hepatitis B: out of the shadows.  Available from: http://www.britishlivertrust.org.uk/content/diseases/hepatitis_b_overvie...
  8. WHO. Hepatitis B immunization. Available from: http://www.who.int/vaccines-documents/DocsPDF01/www598.pdf
  9. WHO. Hepatitis B fact sheet No 204. Available from: http://who.int/mediacentre/factsheets/fs204/en/print.html
  10. Jones N. Mind the gap. Practice Nurse 2005; March: 55-60.
  11. WHO. Communicable disease surveillance and response. Available from: http://www.who.int/csr/disease/hepatitis/whocdscsrlyo20022/en/index.html
  12. Department of Health.Immunization against infectious diseases 1996 (The Green Book). Available from: http://www.dh.gov.uk/PublicationsAndStatistics/Publications/Publications...
  13. British Medical Association. Hepatitis B vaccination in childhood. London: BMA; 2005. Available from: http://www.bma.org.uk/ap.nsf/Content/Hepbchildhood#EpidemiologicaldataWo...