Hepatitis, from the. Health Clinic. Prevention and control of viral hepatitis at home and abroad. Travel

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1 sciencephotolibrary The hepatitis viruses are important causes of morbidity worldwide. Sandra Grieve looks at the global epidemiology of hepatitis and the value of raising public awareness to prevent widespread infection Supported by Master mastertravel.co.uk and control of viral hepatitis at home and abroad Sandra Grieve is an independent travel health specialist nurse Submitted 27 April 2014; accepted for publication following peer review 3 May 2014 Key words: Hepatitis, traveller, risk assessment, communicable diseases Hepatitis, from the Greek Hepato, means inflammation of the liver. The five main recognized hepatitis viruses hepatitis A (HAV), B (HBV), C (HCV), D (HDV) and E (HEV) are important causes of morbidity and mortality worldwide (Zuckerman, 2013). lers from the UK visiting countries where hepatitis is endemic may be at risk of exposure. Raising awareness of how the various hepatitis viruses are transmitted and how travellers can protect themselves is important to prevent infection in the individual and for public health in the UK. Risk assessment Practice nurses conducting a risk assessment for travellers going abroad should be alert to the endemicity of communicable diseases globally (Chiodini et al, 2012). Access to current resources and national Raising awareness of prevention of hepatitis is critical for public health databases with countryspecific information and maps are important tools for establishing disease prevalence in the traveller s destination(s) before offering advice to minimize the risk of infection. Global disease surveillance provides access to accurate, current information, with literature and research also essential for providing evidence to inform practice. Some diseases have a low prevalence in the UK and travellers are unlikely to have acquired natural immunity, leaving them more susceptible to infection abroad. The practice nurse should gather information about the individual and the following aspects of the journey: Destination Purpose of trip Length of stay Accommodation Transport Proposed activities. Table 1. Key areas in travel health advice Food, water and personal hygiene lers diarrhoea Blood-borne diseases Sexually transmitted infections Insect and animal bite avoidance malaria, rabies Accidents Sun and heat protection Air travel deep vein thrombosis Altitude Insurance From: Field et al, 2010 Going through the key areas in travel health (Table 1) with the traveller will highlight potential risks. These form the basis for recommendations and advice, and should be tailored to the individual (Chiodini et al, 2012). lers should also be advised to take responsibility for their health and safety. Practice nurses should provide individuals with leaflets and direct them to specialist websites for information. Links to relevant websites and online resources have been included at the end of this article. Hepatitis A Hepatitis A is an acute liver infection caused by an entero virus (Picornaviridae). The hepatitis A virus is transmitted by the faecal-oral route and associated with poor sanitation, as well as poor personal and food hygiene practices. Nonimmune travellers to endemic areas are at risk of infection. Hepatitis A is one of the most vaccine-preventable infections in travellers (Keystone, 2013). Endemicity varies worldwide, with 1.5 million cases annually (World Health Organization (WHO), 2010). Hepatitis A is uncommon in the UK and mostly associated with certain groups, including men who have sex with men (MSM) and injecting drug users (Department of Health (DH), 2013a). Practice Nursing 2014, Vol 25, No 6 276

2 Supported by Master mastertravel.co.uk Overseas travel is another common factor in sporadic outbreaks (DH, 2013a). However, as a travel history is not always recorded, data is limited. For UK travellers, the highest risk is in the Indian subcontinent, the Far East and Eastern Europe (DH, 2013a). Following natural disasters where infrastructure and sanitation sources break down, outbreaks can occur, exposing the population, including humanitarian aid workers, to infection. As food hygiene practices may be poor, high-starred hotel accommodation does not guarantee avoidance. In low-income countries, where infection is acquired in childhood, many adults are immune. With improved sanitation and hygiene, many who have not been infected in childhood are at higher risk of symptomatic infection in adolescence and adulthood. The disease is more severe in adults, with a fatality of over 2% in those over 40 years of age and 4% for those 60 years or over. (WHO, 2014a). lers should be aware of the importance of following food, water and personal hygiene advice. People are most infectious during incubation, when the virus is shed in faeces (children take 6 months to shed the virus). Hepatitis A is mild and transient in children but those under 15 years visiting friends and relatives (VFRs) are at highest risk. These travellers seldom seek advice and visit countries with a high prevalence of hepatitis A, hepatitis B, typhoid and malaria (Keystone, 2014). Although the incidence of Hepatitis A is declining, a risk remains for non-immune travellers visiting areas of intermediate or high endemicity. Vaccination is recommended for travel to high risk areas. (British Medical Association (BMA), 2013). Vaccines are available as either monovalent, or combined with either typhoid or hepatitis B (DH, 2013a). Two doses administered 6 12 months apart confer long-lasting immunity. This period can be extended depending on the product used (National Health Network and Centre (NaTHNaC), 2014a). There is also a booster dose at 25 years for those at ongoing risk. Advice should be based on the individual s risk factors and national guidance (Table 2). Hepatitis B The hepatitis B virus (Hepadnaviridae) is one of the most prevalent blood-borne viruses worldwide. Hepatitis B is a major cause of chronic liver disease and hepatocellular carcinoma (NaTHNaC, 2014b). Over 2 billion people worldwide have been infected with hepatitis B (WHO, 2013a). Of these, more than 240 million people have chronic liver infections and approximately people die annually as a result of the virus (WHO, 2013a). In developed countries, transmission is mainly through sexual activity and injecting drug use. Support programmes are available in the UK (National Institute for Health and Care Excellence (NICE), 2014) but uptake of diagnostic testing for blood-borne viruses and hepatitis B vaccine is low (Hope et al, 2013). The hepatitis B virus is transmitted through exposure to the of an infected person, in the same way as HIV. However, hepatitis B is 50 to 100 times more infectious and can remain active in dried blood for a week or more and still cause infection in individuals who have not been immunized (Chiodini, 2008). The main routes of hepatitis B transmission are: Perinatally, predominant in areas of high endemicity Person-to-person in childhood, e.g. playground activities, home contacts Behavioural choices, e.g. unprotected sexual intercourse, tattoos, body piercing, invasive medical treatment Infected medical equipment or unscreened blood. In England, 554 acute cases of hepatitis B were reported, including health care-related exposures acquired abroad (Public Health England (PHE), 2013a). In London, the incidence rate is estimated at twice the national rate and higher than in any other region, mostly transmitted through heterosexual or MSM exposure (PHE, 2013b). In almost three fifths of cases, these individuals were born overseas (PHE, 2013b). PHE (2013b) further reports that 19 out of 20 antenatal women found to be positive for hepatitis B were born abroad, with almost half born in Africa, and increasing numbers of women from eastern Europe are hepatitis B positive. Hepatitis B is an occupational risk for health-care workers (NaTHNaC, 2014b). Illness is mostly subclinical, most adults recover but infants and children infected during their first year or before the age of 6 years will often develop chronic infections (WHO, 2013a). Less than 5% of infected adults develop chronic infection but 15 25% of those chronically infected during childhood die from hepatitis B-related liver cancer or cirrhosis (WHO, 2013a). Most people do not experience any symptoms during the acute infection phase and are unaware they are infectious to others (WHO, 2013a). Endemicity varies globally and categories are based on the prevalence of the hepatitis B Table 2. Patient groups recommended to receive pre-exposure vaccination for hepatitis A People travelling to or intending to reside in areas of high or moderate prevalence, e.g. those visiting friends and relatives (VFRs), long-term travellers and those visiting or working in areas of poor sanitation People with chronic liver disease or haemophilia People whose sexual behaviour is likely to put them at increased risk, e.g. men who have sex with men Injecting drug users People at occupational risk, e.g. laboratory or sewage workers From: Department of Health, 2013a 278 Practice Nursing 2014, Vol 25, No 6

3 Supported by Master mastertravel.co.uk virus in the general population, as shown below (DH, 2013b): High endemicity (over 8%) sub-saharan Africa, most of Asia and the Pacific Islands Intermediate endemicity (2 8%) the Amazon, southern parts of Eastern and Central Europe, the Middle East and the Indian sub-continent Low endemicity (under 2%) most of Western Europe and North America (Figure 1). Generally, for short-term travellers, the risk is low but associated with behaviour or activities, especially sexual activity, in endemic areas. Risk is higher for long-term travellers, those seeking medical treatment abroad or with preexisting medical conditions, especially if hospitalized in endemic areas. People living long-term in risk areas, such as humanitarian workers or expatriates are at increased risk (NaTHNaC, 2014b). Several vaccines are available as either monovalent or combined with hepatitis A, with schedule options offering flexibility (DH, 2013b). Postvaccination hepatitis B surface antibody levels should only be checked in those with renal failure or at occupational risk. A single booster dose is recommended for those at continuing risk 5 years after a primary course, with no need to measure anti-hepatitis B levels before or after (DH, 2013b). The hepatitis B vaccine should be offered to travellers at risk, and is an NHS provision if Figure 1. Prevalence of hepatitis B virus infection among adults. From: World Health Organization, 2014a clinically indicated (BMA, 2012) (Table 3). NaTHNaC (2014b) also recommends that all travellers should receive the following advice in order to reduce their risk of infection from bloodborne viruses: Avoid unprotected sexual intercourse Avoid tattooing, piercing and acupuncture when abroad Do not share needles Follow universal precautions if working in a medical, dental or high risk setting Carry a sterile medical kit. Hepatitis C Hepacivirus is a blood-borne virus found worldwide, with over 185 million people infected (WHO, 2014b). Of the million people who have chronic infection, many will develop liver cirrhosis or liver cancer, and evidence shows that people die from hepatitis C-related liver disease each year (WHO, 2014c). Table 3. Patient groups recommended to receive pre-exposure vaccination for hepatitis B People travelling to or intending to reside in areas of high or moderate prevalence, e.g. expatriates, military personnel, humanitarian aid workers Children and others who may require medical care while travelling to visit families or relatives in high- or moderate-endemicity countries Pregnant women or those with chronic medical conditions who may require hospitalization overseas Those travelling for medical or dental care People whose sexual behaviour is likely to put them at increased risk, e.g. individuals who participate in unprotected sex and/or change sexual partners frequently Those participating in contact sports Families adopting children from countries with a high or moderate prevalence of hepatitis B From: Department of Health, 2013b There are multiple hepatitis C genotypes and distribution varies by region. Prevalence is up to 15% in countries such as Africa and Asia, and is highest in Egypt (Johnson et al, 2013). Hepatitis C is transmitted by contact with infected blood, mainly through injecting drug use, equipment sharing, tattoos or body piercing. It is less commonly transmitted through sex or being exposed to infected body fluids at work. Unsafe health care practises such as the use of unsterilized medical equipment and unscreened blood pose risks as well (WHO, 2014c). PHE et al (2013) estimates that people have chronic hepatitis C infection, although asymptomatic figures may be underestimated (Figure 2). Early diagnosis is rare, and in those who go on to develop chronic infection many remain undiagnosed, 280 Practice Nursing 2014, Vol 25, No 6

4 Number of reports 12,000 10,000 8,000 6,000 4,000 2, often until serious liver damage has developed (WHO, 2014c). UK hospital admissions and deaths from hepatitis C-related, end-stage liver disease and hepatocellular carcinoma continue to rise (PHE et al, 2013). lers risk is generally low and related to activities and behaviour in endemic areas. However, the number of citizens going abroad for treatment, also referred to as medical tourism, is increasing and poses a risk (Johnson et al, 2013). Injecting drug use remains the most important risk factor, and information on the provision of needle and syringe programmes aimed at reducing equipment sharing levels has recently been updated (NICE, 2014). The hepatitis C virus can cause acute and chronic infection, and ranges from mild, limited illness to serious lifelong disease (WHO, Year Figure 2. Number of laboratory reports of hepatitis C infection from England: c). Unlike hepatitis A and B, there is no vaccine for hepatitis C (PHE et al, 2013; NICE, 2014). Antiviral treatments that successfully clear hepatitis C are recommended, and new treatments, although expensive and not always without side effects, are becoming available. Hepatitis D Hepatitis D is a rare bloodborne virus that affects people already infected with hepatitis B. Two forms of hepatitis D are recognized, as shown below: A susceptible person is co-infected with both hepatitis B and D, often resulting in more severe acute hepatitis from the hepatitis B virus A person chronically infected with hepatitis B becomes superinfected with hepatitis D, accelerating the course of chronic liver disease. As healthy individuals immunized with the hepatitis B vaccine cannot be co-infected with hepatitis D, immunizing those at risk of hepatitis B aids prevention (Zuckerman, 2013). Hepatitis E Hepeviridae is found worldwide and endemic in regions where sanitation and food hygiene is poor. The virus has caused epidemics in resource-poor countries. of the hepatitis E virus is by the faecal-oral route through contaminated food and water. The hepatitis E virus is also thought to be zoonotic, mostly through ingesting undercooked or raw pig and deer meat (PHE, 2012). In the UK, reported infections are more common than hepatitis A (PHE, 2012). Many cases are acquired within the UK, although specific transmission routes are undefined (PHE, 2012). Person-to-person spread is uncommon, but the ingestion of raw or uncooked shellfish has been identified as the source of sporadic cases in endemic areas (WHO, 2013b). Disease from blood transfusion has been reported, although rare (Teo, 2014). Clinical attack rates are highest in those aged years (Teo, 2014). Pregnant women who are at greater risk of miscarriage and premature delivery may present with or progress to liver failure (Teo, 2014). Infections in the immunocompromised have been linked with aggressive chronic hepatitis and cirrhosis (PHE, 2012). No vaccine is available, nor are drugs for preventing infection (Teo, 2014). lers should be advised to avoid drinking unboiled or unchlorinated water and should eat only thoroughly cooked food, especially seafood, meat and offal. Conclusions lers may have limited or no knowledge of their risk of exposure to hepatitis in their destination or the part their behaviour plays in that risk. Many UK-imported cases occur in those born overseas. Such travellers are likely to return to their home country in endemic areas to visit family without seeking medical advice. The number of travellers seeking health care abroad is increasing and in order to minimize the risk of infection, Practice Nursing 2014, Vol 25, No 6 281

5 Supported by Master mastertravel.co.uk travellers should be made aware of the routes of transmission and provided with appropriate information and resources (Table 4). Knowledge of the global distribution of hepatitis and careful interpretation of the traveller s risk factors is essential for practice nurses advising travellers (Table 5). Raising awareness of risk and prevention is critical for the wider public health as not all hepatitis is vaccine-preventable. Conflict of interest: The author is an invited speaker for Sanofi Pasteur MSD and Glaxo SmithKiline at travel health events. British Medical Association (2012) Focus on hepatitis B immunisations guidance for GPs. British Medical Association (2013) Focus on vaccines and immunisations guidance for GPs. Chiodini J (2008) Understanding travellers risk of hepatitis B. Practice Nurse 36(4): Chiodini J, Boyne L, Stillwell A et al (2012) Health Nursing: Career and Competence Development RCN Guidance. Royal College of Nursing, London Dawood R (2012) lers Health: How to Stay Healthy Abroad. 5th edn. Oxford University Press, Oxford Department of Health (2013a) Hepatitis A. In: Immunisation Against Infectious Disease. [The Green Book.] Chapter 17: Department of Health (2013b) Hepatitis B. In: Immunisation Against Infectious Disease. [The Green Book.] Chapter 18: Field V, Ford L, Hill DR, eds (2010) Health Information for Overseas. National Health Network and Centre, London Hope VD, McVeigh J, Marongiu A et al (2013) Prevalence of, and risk factors for, HIV, hepatitis B and C infections among men who inject image and performance enhancing drugs: a cross-sectional study. BMJ Open 3(9): e doi: /bmjopen Johnson DF, Leder K, Torresi J (2013) Hepatitis B and C Table 4. Online resources for travellers The National Health Network and Centre (NaTHNaC) provides health information on various aspects of travel, including rabies, insect bite avoidance and ongoing outbreaks. Further information is available at: Fitfortravel is a public access website that provides health information for people travelling abroad from the UK. Further information is available at: The UK Foreign and Commonwealth Office provides a comprehensive checklist of foreign travel advice and Know Before You Go information at: The NHS Choices website is a useful online resource that provides practical advice on travel illnesses and vaccinations. Further information is available at: infection in international travelers. J Med 20(3): doi: /jtm Keystone JS (2013) Medicine. 3rd edn. Elsevier, Canada Keystone JS (2014) Immigrants returning home to visit friends and relatives (VFRs). In: Centers for Disease Control and. CDC Health Information for International Chapter 8. kg3u68f National Institute for Health and Care Excellence (2014) Needle and syringe programmes. NICE public health guidance tinyurl.com/mchzb2g (accessed 12 May 2014) National Health Network and Centre (2014a) Hepatitis A. hep_a.htm (accessed 14 May 2014) National Health Network and Centre (2014b) Hepatitis B. Public Health England (2012) Public health operational guidelines for hepatitis E. tinyurl.com/kjqonrn (accessed 14 May 2014) Public Health England (2013a) Acute hepatitis B (England): annual report for q5pjytp (accessed 14 May 2014) Public Health England (2013b) Hepatitis B epidemiology in London 2012 data. k625az5 (accessed 14 May 2014) Public Health England, Health Protection Scotland, Public Health Wales et al (2013) Hepatitis C in the UK 2013 report. mq5gcgy (accessed 14 May 2014) Teo C (2014) Infectious diseases related to travel hepatitis E. In: Centers for Disease Control and. CDC Health Information for International Chapter 3. tinyurl.com/kzn8gcy (accessed 12 May 2014) World Health Organization (2010) The global prevalence of hepatitis Key Points Raising awareness of how hepatitis is transmitted is important to prevent infection in the individual and the wider public Practice nurses conducting risk assessments for travellers should be alert to the endemicity of communicable diseases globally Table 5. Viral hepatitis: supporting signs, prevention and action to be taken Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Incubation Signs and symptoms Treatment Average: 28 days Range: days Average: 75 days Range: days 2 weeks to 6 months Co-infection with hepatitis B Average: 6 weeks. Range: 2 8 weeks Children often asymptomatic Abrupt onset Malaise, anorexia, nausea, fever, jaundice Commonly asymptomatic Abdominal pain, anorexia, nausea, fatigue, jaundice Many asymptomatic Abdominal pain, anorexia, nausea, fatigue, jaundice Similar to hepatitis B but more severe Can be asymptomatic Acute hepatitis, fever, malaise, nausea, jaundice can last up to 4 weeks From: Field et al, 2010; Dawood, 2012; World Health Organization, 2013c, Zuckerman, 2013 Vaccine Food and water hygiene Personal hygiene Vaccine Food and water hygiene Personal hygiene Avoid raw meat Slow recovery No chronic carrier status Antivirals for chronic disease, longterm expensive therapy Antivirals or interferon for chronic disease A virus infection and susceptibility: a systematic review. World Health Organization (2013a) Hepatitis B. d3okjx2 World Health Organiztion (2013b) Hepatitis E. mgmbqy World Health Organization (2014a) Vaccine-preventable diseases and vaccines. oh55bkg World Health Organization (2014b) Guidelines for the screening, care and treatment of persons with hepatitis C infection. com/kp5qlgh World Health Organization (2014c) Hepatitis C Zuckerman AJ (2013) Virus infections in travellers. In: Zuckerman JN, ed. Principles and Practice of Medicine. 2nd edn. Blackwell, Oxford: Practice Nursing 2014, Vol 25, No 6