Clinical  

Statistics show that travel to tropical destinations by UK residents continues to rise each year.1 Travellers can tailor their own itineraries, often to remote areas, and participate in high-risk activities.

Hepatitis B is one of the most prevalent viruses across the globe and, as a serious but often silent disease, is given a low profile by travel health advisers. The virus is transmitted by exposure to the blood or body fluids of an infected person. Although the risk of acquiring the disease is considered low for travellers, exposure can be dependent on activity and the prevalence of the disease at the destination.

Risk and vaccination

Hepatitis B virus (HBV) can cause inflammation of the liver, asymptomatic infection or chronic liver disease. Chronic infection can lead to cirrhosis and liver cancer.2

In 1991, the WHO recommended that a universal childhood hepatitis B vaccination programme should be introduced globally, but some countries including Britain chose to adopt an at-risk policy.

A recent review has revisited this issue. The author states: 'Global efforts to control and prevent hepatitis B are of crucial importance.'3

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.4 The Green Book highlights certain types of behaviour that can put travellers at risk of infection (see box, below).5

Tattoos and body-piercing are commonly done by travellers abroad, and medical tourism for cosmetic surgery is on the increase, placing such people at risk of hepatitis B infection. Many of these activities are voluntary, but the risk of acquiring hepatitis B through participation may be unknown to the traveller.

Every year, around 20,000 Muslim travellers from the UK perform the hajj or the umrah, joining nearly 2 million pilgrims from across the globe. One ritual performed on the hajj is shaving the head, sometimes using shared razors, which can expose men to the risk of acquiring hepatitis B.6,7 Travellers should be informed of the risks of sharing personal grooming items or jewellery.

In the UK between 1995 and 2000, about one acute hepatitis B infection in eight was associated with travel to areas of high/intermediate disease prevalence.8 Of all those travelling to a hepatitis B-endemic country, 24 per cent were at increased risk of exposure to the virus because of situations in which blood-borne viruses could be transmitted.9

Travellers to areas of moderate-to-high endemicity for hepatitis B should be considered at increased risk of exposure to the disease.

To raise awareness of travellers' risk of acquiring hepatitis B, nurses must be knowledgeable about global epidemiology and the prevalence of the disease at the destination in question.

The prevalence of hepatitis B, which is vaccine-preventable, varies throughout the world (see table)10 and the WHO provides maps showing global distribution.

Pre-travel risk assessment

A pre-travel risk assessment consists of thorough information-gathering. It is fundamental to promoting travellers' health, and forms the basis of advice and recommendations for travellers.

In the recent competency document produced by the RCN travel health forum, pre-travel risk assessment for individual travellers is given high priority as part of the consultation process.11 The guidance recommends that sufficient time is allocated to conduct a thorough risk assessment. To demonstrate best practice, it would be unsafe to conduct the consultation in less than 20 minutes.

A recent report from the Health Protection Agency has highlighted the lack of a travel history when gathering information on those who contracted illnesses abroad.12

To assess the risk of contracting hepatitis B accurately, the travel health consultation should concentrate on three main areas: the traveller, the trip, and future travel plans (see box, below).

While all identifiable risk factors must be noted, a study has pointed out that up to 75 per cent of hepatitis B occurs in individuals with no such identifiable risk factors,13 showing that the provision of hepatitis B vaccination based on these factors alone is no longer sufficient.

Young travellers are especially likely to alter their itineraries - behaviour and peer pressure among travellers abroad cannot always be identified in advance. New-found freedom and alcohol use can lead to a change in behaviour and to increased risk-taking.

Offering vaccination

Travel health advisers are there to educate travellers about the health risks posed by diverse destinations.

While the UK at-risk policy on hepatitis B vaccination remains in place, a key consideration in every pre-travel consultation and risk assessment should be to identify, advise and protect travellers considered likely to be exposed to risk. Hepatitis B vaccine can be offered to those travellers, along with further information on key risk factors and preventive measures.

However, current usage rates show that, despite WHO recommendations, for every 10 travellers given the hepatitis A vaccine, only one receives hepatitis B vaccine.

The WHO recommends hepatitis B vaccine because of increased risk during travel and the severity of the disease. Among vaccine-preventable diseases, immunisation against hepatitis A and B saves the most lives.14

Sandra Grieve RGN, RM, BSc (Hons),DTM, MFTM (RCPSG), is an independent travel health specialist nurse based in Stratford-upon-Avon, Warwickshire.

References

1. Office for National Statistics. Travel trends: a report on the 2005 International Passenger Survey. London: HMSO; 2006.

2. National Travel Health Network and Centre (NaTHNaC). Hepatitis B. Travel health information sheet. August 2007. Available from: www.nathnac.org/pro/factsheets/hep_b.htm.

3. Zuckerman J, et al. Lancet Infect Dis 2007;7:410-9.

4. WHO. Vaccine-preventable diseases and vaccines. In: WHO. International travel and health. Geneva: WHO; 2007. Available from: http://whqlibdoc.who.int/publications/2007/9789241580397_6_eng.pdf.

5. Salisbury D, et al (eds.). Immunisation against infectious disease - the Green Book. London: HMSO; 2007.

6. Shafi S, et al. Euro Surveill 2005;10:EO51215.2.

7. Gatrad A R, Sheikh A. BMJ 2005;330:133-7.

8. Hahne S, et al. J Clin Virol 2004;29:211-20.

9. Zuckerman J. Understanding the risk of hepatitis B and travellers: findings of a 2006 survey in Europe. Presented at the Northern European Conference on Travel Medicine in Edinburgh, 2006.

10. WHO. Hepatitis B Factsheet No 204. October 2000. Available from: http://who.int/mediacentre/factsheets/fs204/en/print.html.

11. RCN. Competencies: an integrated career and competency framework for nurses in travel health medicine. 2007.

12. Health Protection Agency (HPA). Foreign travel-associated illness, England, Wales, and Northern Ireland. 2007 report. August 2007.

13. Jilg W. Vaccine 1995;13 Suppl 1: S44-6.

14. Steffen R, Connor BA. J Travel Med 2005; 12: 26-35.