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Hepatitis and travel: who is most at risk?

Sandra Grieve
RGN RM BSc(Hons) DTM FFTM RCPS(Glasg)
Independent Travel Health Specialist Nurse

Some diseases have a low prevalence in the UK with citizens unlikely to have natural immunity, leaving them more susceptible to infection when travelling abroad.

With better disease surveillance methods now available, nurses have access to more accurate and current information. They should be aware of the endemnicity of communicable diseases globally, now more identifiable with excellent map resources and country-specific information (see Resources).

Pre-travel risk assessment
Travellers often assume hygiene and medical standards will be similar to those at home; but the reality can be different. No travel health consultation should take place without a comprehensive pre-travel risk assessment.1 This will provide information on the individual and identify the destination, length of stay, trip's purpose, accommodation, transport and proposed activities, highlighting potential risks and forming the basis for recommendations and advice. General travel health advice is suggested in Box 1. Travellers should also take responsibility for their health and be directed to specialist websites for information (see Resources).

[[Box 1 trav]]

Hepatitis
The term "hepatitis" comes from the Greek "hepato" and means inflammation of the liver. Six hepatitis viruses have been identified, but risks for travellers are mainly hepatitis A (HAV), B (HBV), C (HCV) and E (HEV).2 Only HAV and HBV are vaccine preventable. Travellers should be provided with information on the diseases, transmission and avoidance, carriage rates within the local population and the likelihood of risk for their itinerary.

The Health Protection Agency (HPA) publishes data on foreign travel-associated illness imported to the UK but acknowledges that this information is flawed due to the lack of a travel history.3 Nurses should elicit and report this information alongside requests for laboratory tests when assessing travellers who return ill from abroad.

HAV and HEV are transmitted through the faecal-oral route. Advice on food and water borne diseases should be provided for travel to endemic areas.

Hepatitis A (HAV)
HAV is an acute liver infection caused by an entero virus (Picornaviridae), endemic to varying degrees worldwide with around 1.5 million cases a year globally (probably an underestimate).4 It is associated with poor sanitation, and poor personal and food hygiene practices. HAV is transmitted through:

  • The faecal-oral route.
  • Person to person contact (poor personal hygiene or sexually).
  • Sharing contaminated drug-injecting equipment.
  • Blood/plasma products.
  • Contaminated food and water (shellfish is a
  • particular culprit).

Hepatitis A outbreaks have been reported among men having sex with men and significant numbers of HAV infections have occurred in injecting drug users.5,6 People are most infectious during incubation when the virus is shed in faeces. The most reported travel areas for UK-imported cases are India and Pakistan. The fatality rate in travellers is generally low, but risk increases with age.7

Infection is more severe in adults and causes a range of illnesses from mild non-specific illness to more severe illness with jaundice. The disease can be mild and transient in children who are often a source of outbreaks in endemic areas. Recovery is slow and treatment supportive, but infection results in lifelong immunity.

In the UK, the incidence of hepatitis A is low, with small numbers of the population exposed to the disease and likely non-immune, leaving them at risk of exposure when visiting an endemic area. Good personal hygiene and using potable drinking water can aid prevention, especially in areas of poor socio-economic conditions in the developing world. Good-quality hotel accommodation is no guarantee of avoidance as food hygiene practices by staff may be poor.
A HPA report focused on foreign travel-associated illness in those visiting friends and relatives (VFRs). This group constitutes 18% of travellers from the UK and their destinations included countries with a high prevalence of hepatitis A.8 These travellers are more likely to travel without seeking health advice and the report makes recommendations aimed at reducing the burden of imported disease in this group.

Hepatitis A is one of the most common vaccine-preventable diseases linked to travel.9 Vaccination is recommended for travel to endemic areas and two doses, six to 12 months apart, confers longlasting immunity. A booster dose at 20 years is indicated for those at ongoing risk.10 Advice should be based on the individual's risk factors and DH guidance (Box 2).

[[Box 2 trave]]

Hepatitis E (HEV)
HEV is prevalent worldwide and is endemic in regions where sanitation is poor, particularly Asia, Mexico and Central America and Africa.

Transmission is similar to hepatitis A by the faecal-oral route through contaminated food and water. The disease has a particularly high mortality rate in pregnant women, especially in the third trimester.3 The overall mortality rate is 1-4%, but can be 20% in pregnant women.11 In the UK, on average 33 cases of hepatitis E are reported annually. Enhanced surveillance has seen a rise in reported cases. In 2005, 162 cases were reported, compared to 39 in 2004. Where a travel history was recorded most had travelled to the Indian sub-continent, especially Bangladesh. 

The virus has caused epidemics in several resource-poor countries. In indigenous cases transmission is thought to be zoonotic with pigs and domestic livestock implicated.12 HEV is transmitted through the ingestion of even microscopic amounts of faecal matter. Outbreaks are associated with poor sanitation and water supplies contaminated with sewage following heavy rain and flooding. Person-to-person transmission is uncommon. HEV infections are most common in children and a self-limiting sub-clinical illness followed by complete recovery. Symptomatic hepatitis E infection is more common in those aged 15-49 years and in pregnant women.13 There is no vaccine.
HCV and HBV are transmitted through blood and body fluids. Information on blood-borne viruses should be provided for travel to endemic areas.

Hepatitis C (HCV)
HCV is found worldwide, with a prevalence of up to 15% in some countries of Africa and Asia, and over 15% in Egypt.13 HCV was identified in the 1980s and a UK screening process introduced in 1991. It is estimated that 200,000 people in the UK have chronic HCV, with half of these undiagnosed. Many infected people are asymptomatic, but where infection exists over many years, acute hepatitis, cirrhosis, liver failure and hepatocellular carcinoma can result, with the virus also affecting other body systems. HCV is mostly transmitted in relation to activities resulting in the exchange of infected blood.

The risk to travellers is generally low and can be assessed through the possibility of direct contact with blood (injecting drug users/tattoos/body piercing) and activities which may lead to injury requiring medical treatment involving blood transfusions in countries where blood is not screened for the virus. More travellers are going abroad for health-related procedures where contaminated medical equipment (dental/surgical) may expose them to risk. No vaccine is available, and drug treatments have significant side-effects and are not suitable for everyone.

Hepatitis B (HBV)
HBV is a major problem worldwide but with varying degrees of endemnicity. The virus is transmitted by exposure to the blood or body fluids of an infected person in the same way as HIV, but HBV is 50 to 100 times more infectious than HIV.14 HBV can remain active in dried blood for a week or more.15 Main routes of transmission are:

  • Perinatal (mother to baby at birth).
  • Person-to-person contact in childhood (playground activities where the skin is broken).
  • Sexual contact.
  • Infected medical equipment or unscreened blood. 

The World Health Organization (WHO) estimates that over two billion people worldwide have been infected with HBV, of whom 360 million have lifelong infection.16 HBV can cause hepatitis, asymptomatic infection or chronic liver disease. People with chronic HBV infection may be asymptomatic and unaware that they are infectious to others. Chronic infection can lead to cirrhosis and liver cancer and each year 500,000-700,000 people die of these diseases worldwide. In most cases, hepatitis B is a sub-clinical illness, with under 10% of children and 30-50% of adults experiencing symptoms.

When clinical hepatitis results from infection, the onset is gradual with anorexia, abdominal pain, nausea and vomiting and occasionally mild fever followed by jaundice and a case fatality rate of 1% in adults.16 Although the risk of acquiring the disease is considered low for travellers, exposure can depend on activity, lifestyle, occupation, behaviour and the prevalence of the disease in the destination. It is important to assess the risk of exposure for the individual before recommending vaccination. Travellers should be made aware of the means of transmission and advised on preventive measures, especially if their lifestyle puts them at risk.

In England and Wales (1995-2000), 12% of reported cases of hepatitis B were associated with foreign travel, often to countries with high or intermediate endemnicity (see Box 3).17 In 1991, the WHO recommended that a universal childhood hepatitis B vaccination programme should be introduced globally. Britain adopted an "at-risk" policy. A review in The Lancet revisited this issue and stated, "Global efforts to control and prevent hepatitis B are of crucial importance."18

[[Box 3 trave]]

Another review readdressed the Department of Health (DH) document, Getting Ahead of the Curve, and noted that increasing migration of people from areas of intermediate and high HBV prevalence has been reflected in the UK and exposes the unimmunised population to risk of infection. It estimates that 325,000 people in the UK have chronic HBV infection.19

The British Medical Association (BMA) called on the DH to introduce the hepatitis B vaccine to the UK childhood schedule without delay.20 The Joint Committee on Vaccination and Immunisation (JCVI) had the issue on a recent agenda, but the influenza AH1N1 pandemic took precedence and it was postponed. The WHO advises that hepatitis B vaccination should be considered for virtually all non-immune travellers to areas of moderate to high risk of infection because of the increased risk during travel, coupled with the severity of disease. Tattoos and body piercing are commonly undertaken by travellers abroad. Medical tourism for dental and surgical procedures is increasing. Sex tourists and Hajj pilgrims are at risk of exposure to hepatitis B infection abroad. Many of these activities are voluntary, but the risk of acquiring hepatitis B through participation may be unknown to the travellers (Box 4).

[[Box 4 trave]] 

Hepatitis B vaccination is the most effective form of prevention. Information regarding vaccination in the UK is contained in Immunisation against Infectious Disease (the Green Book).10 In the 2006 edition, the advice on hepatitis B vaccination changed to recommending vaccination for travellers to areas of intermediate or high endemnicity who place themselves at risk when abroad. These inactivated vaccines include single antigen vaccines and a combined hepatitis A and B vaccine. Several schedule options are available, offering flexibility for administration depending on risk assessment and timescale before departure.

Following a full pre-exposure course, the DH advises a single booster dose five years after the primary course for those at continuing risk. Hepatitis B vaccine is often not considered as a travel vaccine but should be provided by the NHS if clinically indicated.16 Three doses of vaccine within six months constitutes the complete series. Ideally, the course should be completed before departure, but time constraints can make this difficult. It is worthwhile starting the course and completing on return, especially if future travel is envisaged, but individuals should be aware that they are not fully protected if the course is incomplete. Behaviour and lifestyle abroad may contribute to risk of exposure, so information on blood-borne infections should be reinforced to travellers.

Conclusion
Exposure to viral hepatitis can be limited by travellers' awareness, behaviour and lifestyle when visiting or residing in endemic areas. Hepatitis is not always vaccine preventable, so to minimise the risk of infection, individuals should be made aware of the routes of transmission and provided with appropriate information and resources. Knowledge of the global distribution and interpretation of the traveller's risk factors is essential for health professionals advising travellers.

References
1. Chiodini J, Boyne L, Grieve S, Jordan A. Competencies: an integrated career and competency framework for nurses in travel health medicine. London: RCN; 2007. Available from: http://www.rcn.org.uk/publications/pdf/travel_health_medicine.pdf
2. Zuckerman JN (ed). Principles and Practice of Travel Medicine. Chichester: Wiley; 2001: 40-52.
3. Health Protection Agency (HPA). Foreign travel-associated illness: England, Wales, and Northern Ireland - 2007 report. London: HPA; 2007. Available from: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1204186182561
4. World Health Organization (WHO). Hepatitis A vaccines: WHO position paper. Weekly Epidemiological Record 2000;5:38-44.
5. Bell A, Neube F, Hansell A et al. An outbreak of hepatitis A among young men associated with having sex in public places. Commun Dis Public Health 2001;4(3): 163-70.
6. Health Protection Agency (HPA). Shooting Up: Infections among injecting drug users in the United Kingdom 2006. An Update: 2007. London: HPA; 2007.
7. Steffen R. Changing travel-related global epidemiology of hepatitis A. Am J Med 2005;118:46S-9S.
8. Health Protection Agency (HPA). Foreign travel-associated illness - a focus on those visiting friends and relatives: 2008 report. London: HPA; 2008. Available from: http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1231419801008?...
9. Steffen R. Hepatitis A and hepatitis B: risks compared with other vaccine preventable diseases and immunization recommendations. Vaccine 1993;11(5):518-20.
10. Salisbury D, Ramsay M, Noakes K (eds). Immunisation Against Infectious Diseases (The Green Book). London: The Stationery Office; 2006. Available from: http://www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Green...
11. Zuckerman JN. Hepatitis E and the traveller. Travel Med Infect Dis 2003;1:73-6.
12. Teo CG. Hepatitis E indigenous to economically developed countries: to what extent a zoonosis? Curr Opin Infect Dis 2006;19(5):460-6.
13. Centres for Disease Control and Prevention (CDC). Health Information for International Travel 2010. Atlanta: CDC; 2009: 335-7.
14. World Health Organization (WHO). International Travel and Health 2009. WHO: Geneva; 2009.
15. Chiodini J. Understanding travellers risk of hepatitis B. Practice Nurse 2008;36(4):46-52.
16. World Health Organization. International Travel and Health 2009. WHO: Geneva, 2009: 106-7. 
17. Hahné S, Ramsay M, Balogun K, Edmunds WJ, Mortimer P. Incidence and routes of transmission of hepatitis B virus in England and Wales, 1995-2000: Implications for immunisation policy. J Clin Virol 2004;29(4):211-20.
18. Zuckerman J, van Hattum J, Cafferkey M. Should hepatitis B vaccination be introduced into childhood immunisation programmes in northern Europe? Lancet Infect Dis 2007;7(6):410-9.
19. Department of Health. Getting ahead of the curve: A strategy for combating infectious diseases. London: DH; 2002.
20. Pollard AJ. Hepatitis B vaccination. BMJ 2007;335(7627):950.
 
Resources
Fit for Travel
W: www.fitfortravel.nhs.uk

Foreign and Commonwealth Office
W: http://fco.gov.uk

Malaria Hotspots
W: www.malariahotspots.co.uk

British Liver Trust
W: www.britishlivertrust.org.uk

NHS Choices - Hepatitis C
W: www.nhs.uk/hepatitisc/Pages/default.aspx

Hepatitis C Trust
W: www.hepctrust.org.uk

Department of Health
W: www.dh.gov.uk/travellers

National Travel Health Network and Centre
information sheets
W: www.nathnac.org/pro/factsheets/hep_c.htm/
www.nathnac.org/pro/factsheets/hepE.htm