Hepatitis B

Hepatitis B is a viral infection of the liver spread by direct contact with the blood or body fluids of an infected person. It occurs worldwide with highest rates reported in parts of East Asia and Sub Saharan Africa. Higher rates of infection are also found in the Amazon, southern parts of Eastern and Central Europe, the Middle East and the Indian subcontinent. The rates of infection in Western Europe and North America are low.

Risk for travellers is low although certain behaviours or activities put individuals at higher risk, particularly when these occur in areas where hepatitis B is more common. These behaviours and activities include:

unprotected sex
exposure to blood or blood products through occupation, such as healthcare work
exposure to contaminated needles through injecting drug use, or as a result of accessing medical or dental care, because of needing emergency treatment or those travelling specifically for medical treatment
participation in contact sports
adoption of children from risk countries
long-stay travel

In the majority of cases of hepatitis B symptoms do not occur. Symptoms more commonly occur in adults than children and may include: jaundice (yellowing of the skin and eyes), loss of appetite, fever and abdominal pain. Persistent hepatitis B infection develops in 80 to 90 percent of those infected in the first year of life and in only five percent of those infected in adult years. Persistent infection may lead to liver failure or liver cancer.

Prevention

All travellers should avoid contact with blood and bodily fluids by:

avoiding unprotected sexual intercourse.
using appropriate protective precautions where contact is unavoidable e.g. due to occupation
avoiding tattooing, piercing and acupuncture (unless sterile equipment is used)
not sharing needles or other injection equipment.
not sharing shaving equipment

Any traveller can be at risk of an accident or require emergency treatment. Travellers should be aware that using precautions will also help protect against other blood and body fluid-borne viruses, such as HIV and hepatitis C, for which there are currently no vaccines. A sterile medical equipment kit may be helpful when travelling to resource poor areas.

Hepatitis B vaccine

Several well-tolerated inactivated hepatitis B vaccines, including combined hepatitis A/B products, are available and vaccination is recommended for all travellers considered at risk.

Vaccine schedules

Vaccine and antigen component	Schedule	Age range
Ambirix® Combined hepatitis A (720 ELISA units) and B (20mcg)	2 dose schedule given 6-12 months apart	Children from 1 to 15 years
Engerix B® Monovalent hepatitis B (20mcg/1ml)	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; a 4th dose at 12 months can be considered for those in certain risk categories
	Very rapid schedule of 4 doses: 0, 7 and 21 days; 4th dose at 12 months	Very rapid schedule: Adults, 18 years and above (can consider '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)	3 doses: 0, 1 and 6 months	From birth to 15 years
Engerix B® Monovalent hepatitis B (10mcg/0.5ml)	Accelerated schedule: 0, 1 and 2 months; a 4th dose at 12 months can be considered for those in certain risk categories	From birth to 15 years
Infanrix hexa® Diphtheria, tetanus, pertussis (acellular), hepatitis B, poliomyelitis (inactivated) (IPV) and Haemophilus influenzae type b (Hib) conjugate vaccine (0.5ml)	3-dose There should be an interval of at least 1 month between primary doses The booster dose should be given at least 6 months after the last priming dose and preferably before 18 months of age 2-dose There should be an interval of at least 2 months between primary doses The booster dose should be given at least 6 months after the last priming dose and preferably between 11 and 13 months of age	Full term infants
	3-dose There should be an interval of at least 1 month between primary doses The booster dose should be given at least 6 months after the last priming dose and preferably before 18 months of age	Pre-term infants born after at least 24 weeks of gestational age
HBVAXPRO Paediatric® Monovalent hepatitis B (5mcg/0.5ml)	3 doses: 0, 1 and 6 months	From birth to 15 years
HBVAXPRO Paediatric® Monovalent hepatitis B (5mcg/0.5ml)	Accelerated schedule: 0, 1 and 2 months; a 4th dose at 12 months can be considered for those in certain risk categories	From birth to 15 years
HBVAXPRO Adult® Monovalent hepatitis B (10mcg/ml)	3 doses: 0, 1 and 6 months	16 years and older
HBVAXPRO Adult® Monovalent hepatitis B (10mcg/ml)	Accelerated schedule: 0, 1 and 2 months; a 4th dose at 12 months can be considered for those in certain risk categories	16 years and older
Twinrix Adult® Combined hepatitis A (720ELISA units) and B (20mcg)	3 doses: 0, 1 and 6 months	Adults and children from 16 years of age
	Very rapid 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)	3 doses: 0, 1 and 6 months	Children from 1 to 15 years

Length of protection

The WHO has concluded that although knowledge about the duration of protection against infection and disease is still incomplete, studies demonstrate that, among successfully vaccinated immunocompetent individuals, protection against chronic infection persists for 20-30 years or more. Therefore there is no compelling evidence for recommending a booster dose of hepatitis B vaccine in routine immunisation programmes (WHO 2017) [5].

Those who have received a primary course of immunisation, including children vaccinated according to the routine childhood schedule and individuals at high risk of exposure, do not require a reinforcing dose of hepatitis B-containing vaccine, except:

healthcare workers (including students and trainees), who should be offered a single booster dose of vaccine, once only, around five years after primary immunisation
patients with renal failure. Antibody levels should be monitored annually and a booster given to those who have responded to vaccine previously and whose antibody levels fall below 10mlU/ml. A booster dose should be offered to any haemodialysis patients who are intending to visit high risk countries and who have previously responded to the vaccine, particularly if they are to receive haemodialysis and have not received a booster in the last 12 months.
at the time of a significant exposure

A blood test to check immunity (hepatitis B surface antibody levels) is only recommended for people with kidney failure or those at risk of occupational exposure particularly healthcare and laboratory workers