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Hepatitis B

Dr George Kassianos shares his insights gained from working as a GP and expert on immunisation and travel medicine

Dr George Kassianos shares his insights gained from working as a GP and expert on immunisation and travel medicine

1 Exposure

The hepatitis B virus can remain active for up to a week in dried blood so tattoos and piercing, plus sharing of personal items such as toothbrushes, razors and ear-rings can all lead to exposure to infected blood and therefore infection.

2 High-risk activities

When discussing immunisation needs with travellers, ask about high-risk activities, such as adventure holidays, extreme and contact sports.

3 Vaccine schedule

The typical immunisation schedule for hepatitis B consists of three injections at 0, one and six months.

All available vaccines in the UK are licensed for all ages for an accelerated course at 0, one and two months, but a fourth dose is required at 12 months.

However, where an adult traveller (over 18 years) needs to travel within a month, an exceptional schedule is available at 0, seven and 21 days with a fourth dose at 12 months (this is true for both the monovalent Engerix B vaccine and the combined hepatitis A and B vaccines Twinrix)

4 Reimbursement

Hepatitis B vaccines are not reimbursed in England and Wales under the 'personal dispensing of vaccines' for travel purposes and travellers would need to pick up this cost.

However, the hepatitis A and B combination vaccine is reimbursed due to the hepatitis A component.

5 Antibody titres

There is no need to check antibody titres in travellers after a vaccination course unless the patient: has renal impairment and is undertaking dialysis; is immunosuppressed; an infant born to a mother carrier or who had HBV infection during pregnancy; is a sexual contact of a carrier; or is a health care worker at high risk of percutaneous or per mucosal exposure to HBV.

6 Boosters

For people who are immunocompetent there appears to be little need for hepatitis B vaccine boosters. Indeed many countries do not routinely administer boosters unless the individual is immunocompromised.

The official advice is that individuals at continuing risk of infection should be offered a single booster dose of vaccine, only once, around five years after primary immunisation.

7 Contraindications

There is one contraindication and that is anaphylaxis, either with a previous dose of the yeast hepatitis B vaccine or its excipients.

8 Seroconversion

Around 10-15 per cent of adults fail to seroconvert after a full course of hep B vaccine ­ as we get older, fewer of us seroconvert. Try another course of vaccine (three doses).

9 Changes to the Green Book

Draft changes published last month recommend travellers who place themselves at risk when visiting countries with high and intermediate prevalence (ie India) be vaccinated.

10 Carriers

Individuals positive for HBsAg are chronic carriers. If they are also positive for HBeAg, they are highly infectious. HBeAg persists throughout chronic infection but between 8-15 per cent of patients develop anti-HBe antibodies each year ­ such patients are carriers but of low infectivity.

George Kassianos is a GP in Bracknell, Berkshire, and honorary secretary of the British Travel Health Association ­ he is spokesperson on immunisation for the RCGP

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