Transcript Le point sur les protections solaire, vectorielle et

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
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
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
Objectives
 Prevalence (risk of disease?)
 Prevention in general (PPM)
 HBV Exposure Risk Factors
 Prevention with vaccines
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)
Immunization Categories
• Routine
– Childhood/adult immunizations
• Recommended
– According to specific risks
• Required
– To cross international borders
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
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
Hepatitis A Endemicity
Geographic Distribution of HAV Infection
Hepatitis B Endemicity
Geographic Distribution of Chronic HBV Infection
HBsAg Prevalence
8% - High
2-7% - Intermediate
<2% - Low
Hepatitis A Mortality
Age-specific Mortality Due to Hepatitis A
Age group
(years)
<5
5-14
15-29
30-49
>49
Total
Case-Fatality
(per 1000)
3.0
1.6
1.6
3.8
17.5
4.1
Source: Viral Hepatitis Surveillance Program, 1983-1989
Hepatitis B Mortality
Hepatitis B – Clinical Features
• Incubation period:
Average 60-90 days
Range 45-180 days
• Clinical illness
(jaundice):
<5 yrs, <10%
>5 yrs, 30%-50%
• Acute case-fatality rate:
0.5%-1%
• Chronic infection:
<5 yrs, 30%-90%
>5 yrs, 2%-10%
• Premature mortality from
chronic liver disease:
15%-25%
Risk Factors Associated with
Reported Hepatitis B, 1990-2000, United States
Other*
Injection drug use
14%
15%
Sexual contact with
hepatitis B patient
13%
Household contact of
hepatitis B patient
2%
Men who have
sex with men 6%
Unknown 32%
Blood transfusion
0%
Medical
Employee 1%
Multiple sex partners
Hemodialysis 0%
17%
*Other: Surgery, dental surgery, acupuncture, tattoo, other percutaneous injury
Source: NNDSS/VHSP
Hepatitis B
• Exposure risks
– sex contacts
– unexpected/planned health care (blood
products, nonsterile equipment, acupuncture)
– personal services (tattoo, body piercing,
manicures, hair cut/shave)
Hepatitis B Exposure Risks*
High travel risk**
Europeans
Americans
95% CI
8.3% (2000)
8% (2004/5)
18-40 yrs
1.9
0.8-4.9
Male
3.4
1.7-7.0
Single
2.4
1.2-5.0
Travel alone
2.0
1.0-4.2
>20 d duration
4.6
1.7-12.6
* 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
Sexual Risk Behaviour of Travellers*
• 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
* Croughs M, et al. J Travel Med 2008;15:6-12
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
Hutin, Y. J F et al. BMJ 2003;327:1075-1080
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
Hepatitis Vaccine Schedules
Hepatitis A
Twinrix®
Hepatitis B
1440 E.U.
50 Units
160 Ag Units
720 E.U.
20 mcg
10-20 mcg
0, 6-12 mo
0, 1, 6 mo
0, 1, 6 mo
1 mo
seroconversion
>95%
94% (HAV)
30% (HBV)
30%
80% (0,7,21d)
6 mo
seroconversion
>95%
>95%
>95%
>20 yrs
>20 yrs (HAV)
>15 yrs (HBV)
>15 yrs
Dose
Schedule
Duration
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
Hepatitis Prevention in Travellers
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
MERCI
THANK YOU