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Hepatology Hepatitis


This excludes children under one year of age, as they have a low risk of disease and the vaccines are not licensed for use at this age. As clinical HAV disease has greater severity in elderly individuals, it is imperative that non-immune elderly tavellers be immunised. Following administration of HAV vaccine, antibody is detectable in the majority of vaccinees within two weeks.129–131


The


long HAV incubation period (mean 28 days) allows for vaccination any day up to departure and development of protective immunity against subsequent exposure to HAV.132


Therefore, even in last-minute


travellers, HAV vaccination has largely superseded the use of immune globulin. If it is available, immune globulin may be given (at a separate anatomical site) together with vaccine to ensure immediate protection in elderly travellers, immunocompromised persons, and persons with CLD or other chronic medical conditions planning to depart in less than two weeks (guidelines for the US and Ireland).127,128 In individuals who have completed the two-dose vaccination schedule, antibodies are thought to persist for 25 years or more, thus further booster doses are not recommended.19, 81


In unvaccinated adults, HAV seroprevalence shows a direct correlation with age.23


Thus, older adults are likely to be seropositive


This can be determined through serological testing for anti-HAV seropositivity. Pre-vaccination testing of travellers >40 years of age should be considered if the cost of screening (laboratory test and office visit) is less than the cost of the vaccine series and will not hamper immunisation in adequate time before travel. Pre-vaccination testing may also be considered for adults who were born in or have resided for an extensive period in an area of high or intermediate HAV prevalence, or fall into high-risk groups such as IDUs. However, vaccination of an immune individual is not contraindicated.134


HBV vaccination is recommended for non-immune travellers to areas with intermediate to high levels of endemic HBV transmission who are likely to be at risk while abroad.19,31,126–128


All elderly travellers to these


destinations should be offered HBV vaccination, according to WHO recommendations.19


Completion of the vaccine series according to


the licensed schedule is necessary for long-term protection against HBV. For immunisation on the standard schedule, this requires that the vaccine series be commenced six months prior to departure. However, patients often wait until close to their departure date to ascertain the immunisation requirements of their destination country.5,135


for HAV and not require vaccination in order to confer protection against HAV.133


Despite the availability of clear guidelines for vaccination against HAV for travel to HAV endemic countries, a considerable proportion of hepatitis A cases reported in the EU and the US are travel-related,137,138 suggesting that many travellers undertake journeys without immunisation against HAV.8 European travellers8,12


and travellers from the US,139


This was confirmed in surveys of which revealed


that considerable proportions of international travellers to countries of intermediate or high HAV/HBV prevalence had not sought travel health advice and immunisation against these infections. Those visiting friends and relatives were least likely to do so. The surveys highlight the lack of traveller awareness about the risk of exposure to HAV and HBV, and their non-adherence with vaccination guidelines. Immunisation of travellers needs to be emphasised in order to reduce HAV or HBV importation into low endemicity countries with the potential for outbreaks among the highly susceptible population.2 Further studies in elderly persons are needed to provide more information and guidance for immunisation against HAV and HBV in this most vulnerable group.


Conclusion


As some protection is conferred by one or two doses, the vaccine series should be commenced, even if it cannot be completed prior to departure, and the traveller should be advised to return for


1. Lavanchy D, Hepatitis B virus epidemiology, disease burden, treatment, and current and emerging prevention and control measures, J Viral Hepat, 2004;11:97–107.


2. Shouval D, Zanetti A, Viral Hepatitis, Viral Hepatitis Prevention Board (VHPB), 2009;18:1–28.


3. Davis JP, Experience with hepatitis A and B vaccines, Am J Med, 2005;118(Suppl. 10A):7S–15S.


4. Hewlett AT, Combined hepatitis A and B vaccine: providing a bright future for preventing hepatitis, Expert Opin Biol Ther, 2009;9:1235–40.


5. Steffen R, Banos A, deBernardis C, Vaccination priorities, Int J Antimicrob Agents, 2003;21:175–80.


6. Nothdurft HD, Dahlgren AL, Gallagher EA, et al., The risk of acquiring hepatitis A and B among travelers in selected Eastern and Southern Europe and non-European Mediterranean countries: review and consensus statement on hepatitis A and B vaccination, J Travel Med, 2007;14:181–7.


Adults from countries that have low prevalence of hepatitis A and hepatitis B are highly susceptible to infection when travelling to areas of high HAV or HBV endemicity. Vaccination against HAV is recommended for all travellers to areas of intermediate or high prevalence of HAV, and HBV vaccination is recommended for travellers to areas of intermediate or high HBV prevalence who are likely to be at risk. Elderly individuals are at particular risk from the complications of clinical disease from HAV or HBV infection, a fact compounded by the remodelling of the immune system that occurs with ageing, potentially decreasing the protective response to immunisation. Nevertheless, analyses of data in older adults indicate that the monovalent and combined vaccines for HAV and HBV are safe, well-tolerated and immunogenic in this vulnerable group. Data on seroprotection for HAV and HBV in the elderly are limited and further studies are needed to elucidate how optimal protection in the elderly can be achieved. n


7. World Tourism Organization.International Tourist Arrivals up 7% in the First Half of 2010: Asia Leads Growth Available at


www.unwto.org/media/news/en/press_det.php?id=6561&idi oma=E (accessed 1 January 2011).


8. Van Herck K, Van Damme P, Castelli F, et al., Knowledge, attitudes and practices in travel-related infectious diseases: the European airport survey, J Travel Med, 2004;11:3–8.


9. Loscher T, Keystone JS, Steffen R, Vaccination of travelers against hepatitis A and B, J Travel Med, 1999;6:107–14.


10. Steffen R, Risks of hepatitis B for travellers, Vaccine, 1990;(Suppl. 8):S31–2, discussion S41–3.


11. Mutsch M, Spicher VM, Gut C, et al., Hepatitis A virus infections in travelers, 1988–2004, Clin Infect Dis, 2006;42:490–7.


12. Zuckerman JN, Hoet B, Hepatitis B immunisation in travellers: poor risk perception and inadequate protection,


Travel Med Infect Dis, 2008;6:315–20.


13. Urhausen J, Tourism in Europe: does age matter?, Eurostat: statistics in focus. Industry, trade and services, 2008;1–7.


14. Eurostat. Tourism statistics in the European Statistical System – 2008 data, 2010. Available at


http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-RA- 10-010/EN/KS-RA-10-010-EN.PDF (accessed January 2011).


15. Poland GA, Jacobson RM, Ovsyannikova IG, Trends affecting the future of vaccine development and delivery: the role of demographics, regulatory science, the anti-vaccine movement, and vaccinomics, Vaccine, 2009;27:3240–4.


16. Brown GR, Persley K, Hepatitis A epidemic in the elderly, South Med J, 2002;95:826–33.


17. Hepatitis B, Available at


www.cdc.gov/vaccines/pubs/pinkbook/downloads/hepb.pdf (accessed 1 February 2011).


18. Sawabe M, Arai T, Esaki Y, et al., Fulminant hepatic failure in


Guidelines for Hepatitis A/B Vaccination of Travellers National and international guidelines recommend HAV vaccination for travellers to countries with intermediate- or high-prevalence of HAV.2,19,31,126–128


the remaining dose(s) when possible. Alternative schedules have been explored in order to meet the requirement for rapid protection such as in last-minute travellers. The monovalent HBV vaccine Engerix-B™ can be used at 0, seven and 21 days,91


with a booster


dose recommended 12 months after the start of the series to confer long-term immunity. For travellers with dual HAV or HBV risk, the combined HAV/HBV vaccine may be considered. An accelerated schedule of zero, seven and 21 days with Twinrix™ was shown to be highly immunogenic and tolerable.108,136


If the accelerated schedule is


applied, a booster dose should be given at 12 months to provide long-term immunity.


90


EUROPEAN GASTROENTEROLOGY & HEPATOLOGY REVIEW


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