1. Hepatitis Prevention in Travellers Dr. Pierre J. Plourde Medical Officer of Health Medical Director, Travel Health and Tropical Medicine Winnipeg Regional Health Authority Associate Professor, Departments of Medical Microbiology and Community Health Sciences, University of Manitoba Chair, Committee to Advise on Tropical Medicine and Travel Public Health Agency of Canada

2. What You Don’t Know Can Hurt You Dr. Pierre J. Plourde Medical Officer of Health Medical Director, Travel Health and Tropical Medicine Winnipeg Regional Health Authority Associate Professor, Departments of Medical Microbiology and Community Health Sciences, University of Manitoba Chair, Committee to Advise on Tropical Medicine and Travel Public Health Agency of Canada

3. Hepatitis Prevention in Travellers Hepatitis Prevention in Travellers DISCLOSURE Honoraria from GSK for presentations on travel health and tropical medicine (Twinrix ® ) Honoraria from sanofi pasteur for presentations on travel health and tropical medicine

4.  Prevalence (risk of disease?)  Prevention in general (PPM)  HBV Exposure Risk Factors  Prevention with vaccines Objectives

5. Risks of Vaccine-Preventable Diseases Hepatitis A (1:1000/month) Hepatitis B (1:2000/month) Yellow fever (1:4000/week endemic; 1:300/week epidemic) JE (1:5000/month) Typhoid (1:30,000/month) Cholera (1:300,000/month)

6. Immunization Categories Routine –Childhood/adult immunizations Recommended –According to specific risks Required –To cross international borders

7. Algorithm for Travel Immunizations Childhood immunizations UTD? (Routine) –If no; administer Td, aP, Polio(?), MMR, HBV Food/water risk? (Recommended) –If yes; HAV, Typhoid, ETEC vaccine(?) Long-term stay? (Recommended) –If yes; HBV, rabies Border crossing? (Required) –If yes; Yellow fever, meningococcal

8. Hepatitis Prevention Summary HAV –Food and water precautions, especially raw shellfish –Vaccine HBV –Safer sex; avoid skin piercing activities –Vaccine HCV –Avoid skin piercing activities; ?safer sex HDV (rare) –Avoid skin piercing activities –HBV vaccine HEV (relatively rare) –Food and water precautions

9. Hepatitis A Endemicity

10. Hepatitis B Endemicity

11. Hepatitis A Mortality

12. Hepatitis B Mortality

14. Hepatitis B Exposure risks –sex contacts –unexpected/planned health care (blood products, nonsterile equipment, acupuncture) –personal services (tattoo, body piercing, manicures, hair cut/shave)

15. Hepatitis B Exposure Risks* * Zuckerman JN, et al. J Travel Med 2000;7:170-174; Connor BA, et al. J Travel Med 2006;13:273-280) ** invasive medical intervention, dental, tattoo, body piercing, acupuncture, sex contact

16. Sexual Risk Behaviour of Travellers* * Croughs M, et al. J Travel Med 2008;15:6-12 Of ~2000 travellers, 5% reported casual sexual contact with a new partner from the destination country 52% did not expect this to happen (75% in women) 31% did not always use condoms 41% were not protected against hepatitis B

17. Hutin, Y. J F et al. BMJ 2003;327:1075-1080 Fig 2 Number of injections per person and per year and proportion of these administered with injection equipment reused in the absence of sterilisation, by region, 2000

18. Hepatitis B Exposure risks –sex contacts –unexpected/planned health care (blood products, nonsterile equipment, acupuncture) –personal services (tattoo, body piercing, manicures, hair cut/shave) Potential benefits –vaccine efficacy >95% after 3 doses –vaccine adverse events minimal –“catch up” universal immunization

19. Hepatitis Vaccine Schedules

20. Hepatitis Vaccine Costs Hepatitis A vaccine –$110 for vaccine –$65 for visit fees HAV/HBV vaccine (Twinrix ® ) –$180 for vaccine –$85 for visit fees Incremental cost of ~$90

21. Conclusions Pre-travel risk assessment for HAV and HBV in all travellers Food and water precautions, safer sex, avoidance of skin piercing activities All non-immune travellers should receive HAV and HBV vaccines –Vaccines are very efficacious and safe Immune globulin (Ig) rarely indicated Stay tuned for CATMAT Statement Hepatitis Prevention in Travellers

22. MERCI THANK YOU Hepatitis Prevention in Travellers