Health Professionals

Travel Health Information Sheets

Hepatitis B

Key messages:

Hepatitis B is a viral infection of the liver transmitted by contact with the blood or body fluids of an infected person.


Infants who are infected with the virus in their first year of life are more likely to develop persistent hepatitis B infection and chronic (long-term) liver disease.


The risk of contracting hepatitis B infection for most travellers is low. The risk can be reduced by avoiding unprotected sex with new partners abroad and avoiding sharing drug injection equipment, public shaving, acupuncture, skin piercing and tattoos (unless sterile equipment is used).  


Hepatitis B vaccination is recommended for all travellers considered to be at risk and can be given to adults and children from birth.   


Those who need to seek urgent medical or dental care in resource poor countries should consider the risks from contaminated equipment or blood/blood products. Travel health insurance may help travellers access better facilities if urgent care abroad is required.  A sterile medical equipment pack may also be helpful when travelling to some countries.

          

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 worldwide more than 240 million have chronic (persistent) liver infections [1]. Approximately 780,000 people die annually due to the acute or chronic consequences of 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 prevalence is highest in parts of East Asia and Sub Saharan Africa where between five and ten per cent of the adult population are estimated to have persistent  hepatitis B infection [1]. High seroprevalence is also found in the Amazon and the southern parts of eastern and central Europe [1]. In the Middle East and Indian subcontinent, an estimated two to five per cent of the general population is persistently infected. Less than one per cent of the population in western Europe and North America is persistently infected [1].

Figure 1. World Health Organization map of countries or areas with moderate to high prevalence (>2% of the population) of hepatitis B infection, 2012

 

 Figure 1.World Health Organization map of countries or areas with moderate to high prevalence (>2% of the population) of hepatitis B infection, 2012

View larger image (opens in new window)

 

Hepatitis B in travellers in England

In 2013, 414 acute or probable acute cases of hepatitis B were reported in England, of which 60% (249) had reported risk factor information.  There were 18 health care related exposures including surgery, dental treatment, blood transfusion and dialysis (of which five cases were reported to have been exposed 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 intermediate to high (>2% of the population) prevalence.  

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 (see Vaccine Information section below for further details).

 

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 [4, 5]. Risk of sexual transmission of HBV is high for individuals who change partners frequently, particularly men who have sex with men [2] and commercial sex workers.

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 by perinatal transmission or from person to person during childhood [1].

 

Signs and symptoms

In the majority of cases, hepatitis B is a sub-clinical illness, with less than 10 per cent of children and between 30 to 40 per cent 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 of infection is approximately 1 per cent in adults [6].

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

 

Treatment

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

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

 

Prevention

All travellers should avoid contact with blood and bodily fluids to reduce their risk, this includes:

 - avoiding unprotected sexual intercourse,

 - avoiding tattooing, piercing and acupuncture (unless sterile equipment is used)  

 - not sharing needles or other injection equipment.

 - following universal precautions if working in a medical/dental/high risk setting.

Hepatitis B vaccination is recommended for all travellers considered to be at risk of HBV (see vaccine 

information below).

A sterile medical kit should be carried if travelling to resource poor areas.

Travel health insurance may help travellers access better medical facilities if they need urgent medical or dental care abroad.

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. For the single antigen vaccines, the accelerated pre-exposure vaccine schedule given at zero, one and two months should be used for most adults and children at risk (see vaccine table below).

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 or travel plans place them at risk and include those who:

  • may have unprotected sex
  • may be directly exposed to blood or blood products through their occupation, such as healthcare professionals
  • may be exposed to contaminated needles through injecting drug use, or as a result of accessing medical or dental care e.g. those with pre-existing medical conditions and those travelling for medical care
  • intend to undergo renal dialysis whilst overseas
  • are participating in contact sports
  • are adopting children from a country
  • are long stay travellers

Hepatitis B vaccine is listed in the Country Information Pages of the NaTHNaC website for countries where two per cent or more of the population are known or presumed to be persistently infected with the hepatitis B virus (intermediate/high prevalence).

 

Availability of vaccine

Several monovalent (single antigen) hepatitis B recombinant vaccines are licensed for use in the UK. Combined hepatitis A and B vaccines are also available.

In addition, Fendrix® and HBVAXPRO 40mcg® vaccines have been developed to prevent HBV in patients with renal insufficiency, including high risk groups such as haemodialysis and pre-haemodialysis patients (these vaccines are not listed below).

All hepatitis B vaccines available in the UK are inactivated.

Vaccines (listed alphabetically) [8-13]

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

For pre-exposure prophylaxis with the single antigen vaccine for most adult and childhood risk groups, an accelerated schedule should be used, with vaccine given at zero, one and two months. Public Health England’s ‘Green Book’ Immunisation against infectious disease states that for infants who are at continued risk, a fourth dose is recommended at 12 months. A fourth dose at 12 months is not recommended for others travellers following this schedule. An alternative schedule at zero, one and six months should only be used where rapid protection is not required and there is a high likelihood of compliance [4].

Vaccine and antigen component

Manufacturer

Schedule

Age range

Ambirix®

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

GlaxoSmith

Kline

2 dose schedule given 6-12 months apart

Children from 1 to 15 years

Engerix B®

Monovalent

hepatitis B (20mcg/1ml)

GlaxoSmith

Kline

3 doses: 0, 1 and 6 months

From 16 years

(dose 20mcg)

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

Accelerated schedule: 0;1 and 2 months

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

Super accelerated schedule: Adults, 18 years and above (can conbsider 'off license' for 16 -17 year olds [4].

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

Engerix B®

Monovalent

hepatitis B (10mcg/0.5ml)

GlaxoSmith

Kline

3 doses: 0, 1 and 6 months

From birth to 15 years

Accelerated schedule: 0;1 and 2 months (with a 4th dose at 12 months for infants at continued risk)

From birth  to 15 years

HBvaxPRO Paediatric®

Monovalent hepatitis B (5mcg/0.5ml)

Sanofi Pasteur MSD

3 doses: 0, 1 and 6 months

From birth to 15 years

Accelerated schedule: 0;1 and 2 months (with a 4th dose at 12 months for infants at continued risk)

HBVaxPRO®

Monovalent hepatitis B (10mcg/ml)

Sanofi Pasteur MSD

3 doses: 0, 1 and 6 months

16 years and older

Accelerated schedule: 0;1 and 2 months

Twinrix Adult®

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

GlaxoSmith

Kline

3 doses: 0, 1 and 6 months

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

Children from 1 to 15 years.

 

Length of protection

There is no evidence that further reinforcing doses of hepatitis A vaccine are needed in immunocompetent individuals following completion of the primary course [14]. The duration of protection from a completed course of hepatitis A vaccine can be expected to be at least 25 years and probably indefinite. However, until further evidence is available, a further booster of hepatitis A vaccine is indicated at 25 years for those at ongoing risk of infection [15]. However, specific advice should be sought for individuals with altered immune responses.

The Public Health England (PHE) currently advises that post vaccination hepatitis B surface antibody levels should only be checked in those with renal failure and those at risk of occupational exposure particularly healthcare and laboratory workers [4]. Following the completion of a full course, PHE recommend that a single booster dose of vaccine at five years is  required for travellers only if they are considered to be at continuing risk of infection (see page 178) [4].

 

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 [16].

It is good practice to continue a course of hepatitis B with the same product. However, should this not be possible, monovalent (single antigen) vaccine products may be used interchangeably, with the exception of Fendrix and HBVAXPRO40 for those with renal insufficiency.

 

 

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  2014. [Accessed 24 September 2014]. Available at: http://www.who.int/mediacentre/factsheets/fs204/en/index.html

2. Public Health England, Acute hepatitis B (England): annual report for 2013. Health Protection Report. 8:33, 22 August 2014. [Accessed 24 September 2014].  Available at: https://www.gov.uk/government/uploads/system/uploads/

attachment_data/file/348576/hpr3314_hbv13.pdf

3. Health Protection Agency. Foreign travel-associated illness. England, Wales, and Northern Ireland – Annual Report. London: HPA, 2005. [Accessed 24 September 2014].  Available at:http://www.hpa.org.uk/Publications/InfectiousDiseases/Trave

lHealth/0511Foreigntravelassociatedillness2005/

4. Department of Health. Immunisation against Infectious Disease. Chapter 18 – Hepatitis B. Updated 4 December 2013 [Accessed 24 September 2014]. Available at: https://www.gov.uk/government/uploads/system/uploads/

attachment_data/file/263311/Green_Book_

Chapter_18_v2_0.pdf

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. Vaccine and vaccine preventable diseases: Hepatitis B. International Travel and Health. WHO: Geneva, 2014. pg14-15. [Accessed 24 September 2014]. Available online at:  http://www.who.int/ith/ITH_chapter_6.pdf?ua=1

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.  June 2013 [Accessed 24 September 2014]. Available at: http://guidance.nice.org.uk/CG165

8. GlaxoSmithKline UK. Summary of Product Characteristics – Ambirix. Updated 27 August 2014. [Accessed 24 September 2014]. 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 24 September 2014].  Available at: http://www.medicines.org.uk/emc/medicine/24844/SPC/

Engerix+B+20+micrograms+1+ml/

10. Sanofi Pasteur MSD Ltd. Summary of Product Characteristics – HBVAXPRO 5mcg. Updated 5 June 2014. [Accessed  24 September 2014]. Available at: http://www.medicines.org.uk/emc/medicine/9850/SPC/HBV

AXPRO+5mcg/

11. Sanofi Pasteur MSD Ltd. Summary of Product Characteristics – HBVAXPRO 10mcg. Updated 5 June 2014. [Accessed  24 September  2014].  Available at: http://www.medicines.org.uk/emc/medicine/9847/SP

C/HBVAXPRO+10mcg/

12. GlaxoSmithKline UK. Summary of Product Characteristics – Twinrix Adult. Updated 19 January 2012. [Accessed 24 September 2014]. Available at: http://www.medicines.org.uk/emc/medici

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

or+injection+in+pre-filled+syringe/

13. GlaxoSmithKline UK. Summary of Product Characteristics – Twinrix Paediatric. Updated 31 January 2012. [Accessed 24 September 2014]. Available at: http://www.medicines.org.uk/emc/medicine/2062/SPC/

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

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

15. Department of Health. Immunisation against Infectious Disease. Chapter 17 – Hepatitis A. Updated 4 December 2013 [Accessed 24 September 2014]. Available at: https://www.gov.uk/government/publications/hepatitis-a-the-green-book-chapter-17

16.  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 24 September 2014