Health Professionals

Travel Health Information Sheets

Hepatitis B

Introduction

The hepatitis B virus (HBV) is one of the most prevalent blood-borne viruses worldwide and is a major cause of chronic liver disease and hepatocellular carcinoma. It is estimated that two billion people worldwide have been exposed to the hepatitis B virus and more than 240 million have chronic (long term) liver infections [1]. Approximately 600 000 people die annually due to hepatitis B infection [1]. HBV is a DNA virus of the Hepadnavirus family, consisting of a core antigen surrounded by a surface antigen.

Epidemiology

Global epidemiology

Hepatitis B is endemic in parts of Asia and Africa where greater than 8% of the adult population are estimated to have chronic hepatitis B infection. High rates of chronic infections are also found in the Amazon and the southern parts of eastern and central Europe [1]. In the Middle East and Indian subcontinent, an estimated 2–7% of the general population is chronically infected. Less than 1% of the population in western Europe and North America is chronically infected [1].

See NaTHNaC Country Information Pages for prevalence of hepatitis B in each country.

 Figure 1. Map of prevalence of hepatitis B virus chronic infection, 2012

View larger image (opens in new window)

 

Hepatitis B in travellers in England

In 2012, 554 acute or probable acute cases of hepatitis B were reported in England, of which 60% (332) had reported risk factor information.  There were 33 health care related exposures reported of which five were acquired abroad [2].

Risk for travellers

The risk of HBV for tourists and short term travellers is low. However, as risk is associated with particular behaviours, it will increase with certain activities particularly in areas of high endemnicity.

Sexual transmission is an important factor in travel related cases. In 2003, 48% of travel-related cases in England, Wales and Northern Ireland had reported heterosexual exposure as a risk factor. Asia, in particular Thailand, was the most common destination [3].

Frequent, long-term and expatriate travellers and those travelling for medical reasons or with medical conditions can be at higher risk if they need medical treatment whilst overseas. Those at occupational risk, including healthcare and humanitarian aid workers are also at increased risk.

Transmission

HBV is transmitted by exposure to infected blood or bodily fluids contaminated with infectious blood, vertically from mother to child, and percutaneously.

Unprotected sexual intercourse, body piercing, tattoos, acupuncture, injecting drug use and contact sports are behavioural risk factors. Risk of sexual transmission of HBV is high for individuals who change partners frequently, particularly men who have sex with men and commercial sex workers [4, 5].

The percutaneous route of transmission also includes the use of contaminated medical, dental or other instruments and transfusion of infected blood products.

In areas of high endemnicity, infection is predominantly acquired during childhood by perinatal transmission or from child-to-child [1].

Signs and symptoms

In the majority of cases, hepatitis B is a sub-clinical illness, with less than 10% of children and between 30% to 40% of adults experiencing symptoms. Following an incubation period of 40 to 160 days, symptomatic patients  will experience symptoms which may include anorexia, abdominal pain, nausea and vomiting and occasionally fever. Dark urine and pale stools may also be apparent. During the acute stage of infection cases may develop jaundice.  The case fatality rate during the acute stage if infection is approximately 1% in adults [6].

Chronic infection develops in 80-90% of children infected in the first year of life and 30-50% in those infected before the age of 6 years [1].  Of those adults infected in childhood who become chronically infected, 15-25% die from hepatitis B related liver cancer or cirrhosis [1]. Chronic infection develops in less than 5% of adults infected in adulthood.

 

Treatment

There is no specific treatment for acute hepatitis B, but rather supportive intervention.

The aim of treatment of chronic hepatitis B is to prevent liver cirrhosis or hepatocellular carcinoma and to reduce  infectiousness. Treatment options for chronic hepatitis B infection include interferon, tenofovir and entecavir. Treatment should be initiated by a specialist and follow national guidelines [7].

Prevention

All travellers should receive the following advice to reduce their risk:

  • Avoid unprotected sexual intercourse.
  • Avoid tattooing, piercing and acupuncture.
  • Do not share needles.
  • Follow universal precautions if working in a medical/dental/high risk setting.
  • Carry a sterile medical kit.

Travellers should be aware that using precautions against HBV will prevent other blood and body fluid-borne viruses, such as HIV and hepatitis C, for which there are no available vaccines.

 

 Vaccine information

 

Vaccine is recommended for all travellers considered to be at risk of HBV.

Any traveller can be at risk of an accident or require emergency treatment. Travellers to areas of moderate or high endemnicity can be at increased risk [6].

Hepatitis B vaccine is recommended for travellers whose behaviours place them at risk and include:

  • Those who may be exposed to blood or blood products through their occupation, e.g. healthcare professionals, aid workers and public service workers such as police and fire-fighters
  • Those who intend to stay for long periods in areas of moderate or high endemnicity areas
  • Those travellers who change sexual partners frequently
  • Those travellers who are participating in contact sports
  • Children who may require medical care while travelling to visit families or relatives
  • Those with pre-existing medical conditions such as renal failure, chronic liver disease, or pregnant women, who may require hospitalisation and invasive medical procedures abroad
  • Those travelling for medical care including those receiving renal dialysis overseas
  • Families adopting children from countries of moderate or high endemnicity

Availability of vaccine

Several monovalent hepatitis B recombinant vaccines are licensed for use in the UK.

In addition, Fendrix® and HBVaxPRO 40® vaccines have been developed to prevent HBV in patients with renal insufficiency, including high risk groups such as haemodialysis and pre-haemodialysis patients.

Combined hepatitis A and B vaccines are also available.

All hepatitis B vaccines available in the UK are inactivated.

Vaccines (listed alphabetically) [8-15]

Vaccine and antigen component

Manufacturer

Schedule

Length of protection

Age range

Ambirix®

Combined hepatitis A (720 ELISA units) and B (20mcg)

GlaxoSmith

Kline

2 dose schedule given 6-12 months apart

Hepatitis B: see ‘Length of protection’ below

Hepatitis A: at least 10 years*

Children from 1 to 15 years

Engerix B®

Monovalent

hepatitis B (20mcg/ml)

GlaxoSmith

Kline

3 doses: 0, 1 and 6 months

See ‘Length of protection’ section below

From 16 years

(dose 20mcg)

Note 10mcg dosage for children up to and including 15 years of age.

Accelerated schedule of 4 doses: 0, 1 and 2 months; 4th at 12 months

See ‘Length of protection’ section below

Super accelerated schedule of 4 doses: 0, 7 and 21 days; 4th dose at 12 months

Super accelerated schedule: Adults, 18 years and above.

In children aged 11-15 years, 2 doses of the adult dose at 0 and 6 months

Engerix B®

Monovalent

hepatitis B (20mcg/ml)

0.5ml dose (10mcg)

GlaxoSmith

Kline

3 doses (10mcg) : 0, 1 and 6 months

See ‘Length of protection’ section below

From birth to 15 years

Accelerated schedule of 4 doses (10mcg): 0, 1 and 2 months; 4th at 12 months

See ‘Length of protection’ section below

From birth  to 15 years

Fendrix

Monovalent hepatitis B (20mcg/0.5ml); with adjuvant

GlaxoSmith

Kline

4 doses: 0, 1, 2 and 6 months.

See ‘Length of protection’ section below

For adults and children aged 15 years and older with renal insufficiency, including pre-haemodialysis and haemodialysis patients

HBvaxPRO Paediatric®

Monovalent hepatitis B (5mcg/0.5ml)

Sanofi Pasteur MSD

3 doses: 0, 1 and 6 months

See ‘Length of protection’ section below

From birth to 15 years

Accelerated schedule of 4 doses: 0, 1 and 2 months; 4th dose at 12 months

HBVaxPRO®

Monovalent hepatitis B (10mcg/ml)

Sanofi Pasteur MSD

3 doses: 0, 1 and 6 months

See ‘Length of protection’ section below

16 years and older

Accelerated schedule of  4 doses: 0, 1 and 2 months; 4th dose at 12 months.

HBVaxPRO40®

Monovalent hepatitis B (40mcg/ml)

Sanofi Pasteur MSD

3 doses: 0, 1 and 6 months

See ‘Length of protection’ section below

For adults with renal insufficiency, including pre-haemodialysis and haemodialysis patients

Twinrix Adult®

Combined hepatitis A (720ELISA units) and B (20mcg)

GlaxoSmith

Kline

3 doses: 0, 1 and 6 months

See ‘Length of protection’ section below

Hepatitis A: at least 10 years*

Adults and children from 16 years of age.

Super accelerated schedule of 4 doses: days 0, 7 and 21; 4th dose at 12 months.

Adults, 18 years and above.

Twinrix Paediatric®

Combined hepatitis A (360ELISA units) and B (10mcg)

GlaxoSmith

Kline

3 doses: 0, 1 and 6 months

See ‘Length of protection’ below

Hepatitis A: at least 10 years*

Children from 1 to 15 years.

 

* There is no evidence that further reinforcing doses of hepatitis A vaccine are needed in immunocompetent individuals following completion of the primary course [16]. The duration of protection from a completed course of Hepatitis A vaccine can be expected to be at least 25 years and probably indefinite. A further booster of Hepatitis A vaccine can be considered for those at ongoing risk of infection after 25 years [17]. However, specific advice should be sought for individuals with altered immune responses.

The vaccine Summary of Product Characteristics (SPC) should be consulted prior to administration of any vaccine.

It is good practice to continue a course of hepatitis B with the same product. However, should this not be possible, monovalent vaccine products may be used interchangeably, with the exception of Fendrix and HBVaxPRO40 in those with renal insufficiency.

 

Length of protection

The Department of Health (DH) currently advises that post vaccination hepatitis B surface antibody levels should only be checked in those with renal failure or healthcare workers at risk of occupational exposure [18]. Following the completion of a full course, the DH recommends that travellers who have completed a primary course of vaccination, a single booster dose of vaccine at five years is not required, unless they are considered to be at continuing risk of infection [18].

 

Interrupted courses

It is not necessary to repeat doses if the hepatitis B course has been interrupted. Longer than recommended intervals between doses do not appear to reduce the final antibody level or efficacy, however vaccine doses for each schedule should be given at the correct interval[19].

 

Contraindications

Known hypersensitivity to any components of the vaccine, or to a previous dose.

Vaccination should be delayed in acute febrile illness.

 

Adverse events

Adverse reactions following hepatitis B vaccine tend to be mild and transient. They include soreness, erythema and induration at the vaccine site. Less commonly fatigue, fever, malaise and influenza-like symptoms have been reported.

References

1. World Health Organization. Hepatitis B fact sheet. July  2013. [Accessed 4 April 2014]. Available at: http://www.who.int/mediacentre/factsheets/fs204/en/index.html

2. Health Protection Agency. Acute hepatitis B in England, annual report for 2012. Health Protection Report. 7:35, 2013. [Accessed 4 April 2014].  Available at:  http://www.hpa.org.uk/hpr/archives/2013/hpr3513.pdf

3. Health Protection Agency. Foreign travel-associated illness. England, Wales, and Northern Ireland – Annual Report. London: HPA, 2005. [Accessed 4 April 2014].  Available at: http://www.hpa.org.uk/Publications/InfectiousDiseases/Trave

lHealth/0511Foreigntravelassociatedillness2005/

4. Health Protection Agency. General Information on Hepatitis B. [Accessed 4 April 2014]. Available at: http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ

/HepatitisB/GeneralInformationHepatitisB/hepbGeneralInfo/

5. Kordi R, Wallace WA. Blood borne infections in sport: risks of transmission, methods of prevention, and recommendations for hepatitis vaccination. Br J Sports Med 38:678-84, 2004.

6. World Health Organization. International Travel and Health. Hepatitis B. 2012. WHO: Geneva, 2012.14-15. Available online at:  http://www.who.int/ith/chapters/ith2012en_chap6.pdf

7. National Institute for Health and Clinical Excellence. Hepatitis B (chronic): diagnosis and management of chronic hepatitis B in children, young people and adults draft guideline. [Accessed 4 April 2014]. Available at: http://guidance.nice.org.uk/CG165

8. GlaxoSmithKline UK. Summary of Product Characteristics – Ambirix. Updated 22 August 2012. [Accessed 4 April 2014]. [Accessed 4 April]. Available at: http://www.medicines.org.uk/emc/medicine/20491/SPC/

Ambirix+suspension+for+injection/

9. GlaxoSmithKline UK. Summary of Product Characteristics – Engerix B. Updated 23 October 2013. [Accessed 4 April 2014].  Available at: http://www.medicines.org.uk/emc/medicine/24844/SPC/Eng

erix+B+20+micrograms+1+ml/

10. GlaxoSmithKline UK. Summary of Product Characteristics – Fendrix. Updated 3 January 2014. [Accessed 4 April 2014].  Available at: http://www.medicines.org.uk/emc/medicine/16906/SPC/Fendrix/

11. Sanofi Pasteur MSD Ltd. Summary of Product Characteristics – HBVAXPRO 5mcg. Updated  26 September 2011. [Accessed 4 April 2014]. Available at: http://www.medicines.org.uk/emc/medicine/9850/SPC/HBV

AXPRO+5mcg/

12. Sanofi Pasteur MSD Ltd. Summary of Product Characteristics – HBVAXPRO 10mcg. Updated 26 September 2011. [Accessed 4 April 2014].  Available at: http://www.medicines.org.uk/emc/medicine/9847/SPC/HBVAXP

RO+10mcg/

13. Sanofi Pasteur MSD Ltd. Summary of Product Characteristics – HBVAXPRO 40mcg. Updated 26 September 2011. [Accessed 4 April 2014].  Available at: http://www.medicines.org.uk/emc/medicine/9848/SP

C/HBVAXPRO+40mcg/

14. GlaxoSmithKline UK. Summary of Product Characteristics – Twinrix Adult. Updated 19 January 2012. [Accessed 4 April 2014]. Available at: http://www.medicines.org.uk/emc/medici

ne/2061/SPC/Twinrix+Adult+Vaccine%2c+suspension+for

+injection+in+pre-filled+syringe/

15. GlaxoSmithKline UK. Summary of Product Characteristics – Twinrix Paediatric. Updated  31 January 2012. [Accessed 4 April 2014]. Available at: http://www.medicines.org.uk/emc/medicine/2062/SPC/T

winrix+Paediatric+Vaccine+suspension+for+injection+in+pre-filled+syringe/

16. Ott JJ, Irving G, Wiersma ST. Long-term protective effects of hepatitis A vaccines. A systematic review. Vaccine 31; 3–11, 2012

17. Department of Health. Immunisation against Infectious Disease. Chapter 17 – Hepatitis A. [Accessed 4 April 2014]. Available at: https://www.gov.uk/government/uploads/system/upload

s/attachment_data/file/263309/Green_Book_Chapter

_17_v2_0.pdf

18. Department of Health. Immunisation against Infectious Disease. Chapter 18 – Hepatitis B. [Accessed 4 April 2014]. Available at: https://www.gov.uk/government/uploads/system/uploads

/attachment_data/file/263311/Green_Book_Chapter_

18_v2_0.pdf

19.  Middleman A, Kozinetz C, Robertson L, et al. The effect of late doses on the achievement of seroprotection and antibody titre levels with hepatitis B immunisation among adolescents. Pediatrics. 107:1065-9, 2001

 

Link

Health Protection Agency Hepatitis B information

Advice current at 4 April 2014