Hepatitis B

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Protection against hepatitis B has gained greater importance for all types of travellers who may be exposed to hepatitis B by virtue of many risk activities as well as destination. It has been estimated that there are 2 billion people infected with hepatitis B and more than 350 million carriers of disease throughout the world. The risks of infection to travellers has been estimated to be 80-240 cases per 100 000 travellers per month of stay for long-term travellers and 2-10 times lower among short-term travellers. Therefore, hepatitis B is the second most common vaccine-preventable disease in travellers. The risk factors which may lead to subsequent infection with hepatitis B include sexual behaviour, medical or dental intervention, which may follow an accident or an adventure sports activity, acupuncture, tattooing, body piercing, haircuts, sharing razors and toothbrushes; all of these may result in transmission of bloodborne viruses. Travel health care professionals should consider vaccination against hepatitis B for those travelling outside northwestern Europe, North America, Australia and New Zealand, including long- and short-term travellers, those at occupational risk, e.g. aid/health care workers including expatriates, missionaries and the military, those with preexisting medical conditions who may require medical attention while abroad, and young children who may be in contact with other young children in an endemic area.

Hepatitis B vaccine is licensed for administration by the intramuscular route by several different schedules and is also available following the use of the combination hepatitis A and B vaccine (see above, Hepatitis A). Monovalent hepatitis B vaccine may be administered by the following schedules:

• 0, 1 and 6 months with a booster at 5-yearly intervals for those at continued high risk.

• 0, 12 and 24 months (licensed schedule in the United States).

• Days 0, 7 and 21, with a booster at 12 months only for those over 18 years of age. The levels of seroprotection achieved are 65% within 1 week of the course and 98% 1 month after the booster dose. This schedule of immunisation is ideal for those travelling at short notice. It is currently only licensed for use in Europe.

The combined hepatitis A and B vaccine may be administered as follows:

Nonresponse to hepatitis B vaccine occurs in approximately 10-15% of adult vaccinees and is associated with several factors, including incorrect administration, male sex, increasing age ( > 40 years), body mass index and haplotype. Hepatitis B vaccine must be administered intramuscularly in the deltoid muscle or anterolateral aspect of the thigh (see above, Route of Administration). Consequently, it is advisable to check the hepatitis B antibody response following vaccination with the primary course as well as boosters in the older traveller to ensure that adequate levels of protection have been achieved. The use of booster doses remains controversial, but for those at continued high risk, e.g. aid/health care professionals and expatriates deployed to areas of high endemicity, the administration of booster doses of hepatitis B vaccine is recommended at 5-yearly intervals. Travellers who have been exposed to a risk of infection with hepatitis B and are nonresponders or poor respon-ders to hepatitis B vaccine should receive hepatitis B specific hyperimmune globulin as well as a booster dose of hepatitis B vaccine under specific medical guidance (see below, Immunoglobulins).

Universal immunisation against hepatitis B has been successfully implemented in more than 100 countries throughout the world, with the objective of eliminating this disease. Introduction of such programmes will ensure protection against infection for all high-risk groups, including those of travellers, both present and future. Dual and concurrent protection against both hepatitis A and B by use of the combination vaccine may be recognised in future universal immunisation programmes.

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