Hepatitis B and C infection in international travelers

A systematic review and meta-analysis of sexually transmitted infections and blood-borne viruses in travellers

BACKGROUND

Sexually transmitted infections (STIs) and blood-borne viruses (BBVs) impose a global health and economic burden. International travellers facilitate the spread of infectious diseases, including STIs. Hence, this review assessed the prevalence/proportionate morbidity of travellers with STIs and sexually transmitted BBVs and factors associated with the infection in this population.

METHODS

PubMed, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase and Cochrane Library were searched from inception of the databases until November 2022. Published analytical observational studies reporting the prevalence/proportionate morbidity of travellers with STIs and factors associated with STIs by type of traveller [i.e. tourists, business travellers, students, visiting friends or relatives (VFRs), international truck drivers, backpackers, expatriates and men who have sex with men (MSM)] were included. The selection of articles, data extraction and risk of bias assessment were conducted by two independent reviewers. Meta-analyses were conducted for each STI by clinical presentation and type of traveller.

RESULTS

Thirty-two studies (n = 387 731 travellers) were included; 19 evaluated the proportionate morbidity of STIs among symptomatic travellers, while 13 examined the prevalence of STIs in asymptomatic travellers. The highest proportionate morbidity was found among VFRs (syphilis, 1.67%; 95% CI: 1.03-2.81%), backpackers (Chlamydia trachomatis, 6.58%; 95% CI: 5.96-7.25%) and MSM (HIV [2.50%;95% CI: 0.44-12.88%], gonorrhoea [4.17%; 95% CI: 1.1.5-13.98%], lymphogranuloma venereum [4.17%;95% CI: 1.1.5-13.98%] and HAV [20.0%; 95% CI: 14.99-26.17%]). The highest prevalence of STIs among asymptomatic were found in MSM (HIV [25.94%; 95% CI: 22.21-30.05%] and HBV [24.90%; 95% CI: 21.23-28.96%]) and backpackers (C. trachomatis, 3.92%; 95% CI: 2.72-5.32%). Short duration of the trip (<1 month), not having pre-travel consultation, travelling to Southeast Asia and being unvaccinated for HBV were identified as risk factors for STIs.

CONCLUSION

Strategies to prevent STIs and sexually transmitted BBVs should be discussed at pre-travel consultations, and recommendations should be prioritized in high-risk groups of travellers, such as backpackers, VFRs and MSMs. Additionally, healthcare providers should tailor recommendations for safe sex practices to individual travellers' unique needs.

HBV S antigen evolution in the backdrop of HDV infection affects epitope processing and presentation

INTRODUCTION

HBV can evolve under selection pressure exerted by drugs and/or host immunity, resulting in accumulation of escape mutations that can affect the drug or the immune activity. Hepatitis delta virus (HDV) coinfection is also known to exert selection pressure on HBV, which leads to selective amplification of certain mutations, especially in genes that are required for HDV pathogenesis, such as HBsAg. However, little is known about the function of these mutations on HBV or HDV life cycle. The purpose of this study is to determine mutations selectively amplified in the backdrop of HDV, and how these mutations affect processing of CD4- and CD8-T cell epitopes.

METHODS

HBsAg was successfully amplified from 49/50 HBV mono- and 36/50 coinfected samples. The sequences were used to identify mutations specific to each study group, followed by an in silico analysis to determine the effect of these mutations on (1) proteasomal degradation, (2) MHC-I and MHC-II biding, and (3) processing of T-cell epitopes.

RESULTS

HBV-HDV coinfected sequences exhibited certain unique mutations in HBsAg genes. Some of these mutations affected the generation of proteasomal sites, binding of HBsAg epitopes to MHC-I and -II ligands, and subsequent generation of T- cell epitopes.

CONCLUSION

These observations suggest that HBV selectively amplifies certain mutations in the backdrop of HDV coinfection. Selective amplification of these mutations at certain strategic locations might not only enable HBV to counteract the inhibitory effects of HDV on HBV replication but also facilitate its survival by escaping the immune response.

Surveillance of Vaccination Coverage Among Adult Populations -United States, 2018

PROBLEM/CONDITION

Adults are at risk for illness, hospitalization, disability and, in some cases, death from vaccine-preventable diseases, particularly influenza and pneumococcal disease. CDC recommends vaccinations for adults on the basis of age, health conditions, prior vaccinations, and other considerations. Updated vaccination recommendations from CDC are published annually in the U.S. Adult Immunization Schedule. Despite longstanding recommendations for use of many vaccines, vaccination coverage among U.S. adults remains low.

REPORTING PERIOD

August 2017-June 2018 (for influenza vaccination) and January-December 2018 (for pneumococcal, herpes zoster, tetanus and diphtheria [Td]/tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap], hepatitis A, hepatitis B, and human papillomavirus [HPV] vaccination).

DESCRIPTION OF SYSTEM

The National Health Interview Survey (NHIS) is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population. In-person interviews are conducted throughout the year in a probability sample of households, and NHIS data are compiled and released annually. NHIS's objective is to monitor the health of the U.S. population and provide estimates of health indicators, health care use and access, and health-related behaviors. Adult receipt of influenza, pneumococcal, herpes zoster, Td/Tdap, hepatitis A, hepatitis B, and at least 1 dose of HPV vaccines was assessed. Estimates were derived for a new composite adult vaccination quality measure and by selected demographic and access-to-care characteristics (e.g., age, race/ethnicity, indication for vaccination, travel history [travel to countries where hepatitis infections are endemic], health insurance status, contacts with physicians, nativity, and citizenship). Trends in adult vaccination were assessed during 2010-2018.

RESULTS

Coverage for the adult age-appropriate composite measure was low in all age groups. Racial and ethnic differences in coverage persisted for all vaccinations, with lower coverage for most vaccinations among non-White compared with non-Hispanic White adults. Linear trend tests indicated coverage increased from 2010 to 2018 for most vaccines in this report. Few adults aged ≥19 years had received all age-appropriate vaccines, including influenza vaccination, regardless of whether inclusion of Tdap (13.5%) or inclusion of any tetanus toxoid-containing vaccine (20.2%) receipt was measured. Coverage among adults for influenza vaccination during the 2017-18 season (46.1%) was similar to the estimate for the 2016-17 season (45.4%), and coverage for pneumococcal (adults aged ≥65 years [69.0%]), herpes zoster (adults aged ≥50 years and aged ≥60 years [24.1% and 34.5%, respectively]), tetanus (adults aged ≥19 years [62.9%]), Tdap (adults aged ≥19 years [31.2%]), hepatitis A (adults aged ≥19 years [11.9%]), and HPV (females aged 19-26 years [52.8%]) vaccination in 2018 were similar to the estimates for 2017. Hepatitis B vaccination coverage among adults aged ≥19 years and health care personnel (HCP) aged ≥19 years increased 4.2 and 6.7 percentage points to 30.0% and 67.2%, respectively, from 2017. HPV vaccination coverage among males aged 19-26 years increased 5.2 percentage points to 26.3% from the 2017 estimate. Overall, HPV vaccination coverage among females aged 19-26 years did not increase, but coverage among Hispanic females aged 19-26 years increased 10.8 percentage points to 49.6% from the 2017 estimate. Coverage for the following vaccines was lower among adults without health insurance compared with those with health insurance: influenza vaccine (among adults aged ≥19 years, 19-49 years, and 50-64 years), pneumococcal vaccine (among adults aged 19-64 years at increased risk), Td vaccine (among all age groups), Tdap vaccine (among adults aged ≥19 years and 19-64 years), hepatitis A vaccine (among adults aged ≥19 years overall and among travelers aged ≥19 years), hepatitis B vaccine (among adults aged ≥19 years and 19-49 years and among travelers aged ≥19 years), herpes zoster vaccine (among adults aged ≥60 years), and HPV vaccine (among males and females aged 19-26 years). Adults who reported having a usual place for health care generally reported receipt of recommended vaccinations more often than those who did not have such a place, regardless of whether they had health insurance. Vaccination coverage was higher among adults reporting ≥1 physician contact during the preceding year compared with those who had not visited a physician during the preceding year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts during the preceding year, depending on the vaccine, 20.1%-87.5% reported not having received vaccinations that were recommended either for all persons or for those with specific indications. Overall, vaccination coverage among U.S.-born adults was significantly higher than that of foreign-born adults, including influenza vaccination (aged ≥19 years), pneumococcal vaccination (all ages), tetanus vaccination (all ages), Tdap vaccination (all ages), hepatitis B vaccination (aged ≥19 years and 19-49 years and travelers aged ≥19 years), herpes zoster vaccination (all ages), and HPV vaccination among females aged 19-26 years. Vaccination coverage also varied by citizenship status and years living in the United States.

INTERPRETATION

NHIS data indicate that many adults remain unprotected against vaccine-preventable diseases. Coverage for the adult age-appropriate composite measures was low in all age groups. Individual adult vaccination coverage remained low as well, but modest gains occurred in vaccination coverage for hepatitis B (among adults aged ≥19 years and HCP aged ≥19 years), and HPV (among males aged 19-26 years and Hispanic females aged 19-26 years). Coverage for other vaccines and groups with Advisory Committee on Immunization Practices vaccination indications did not improve from 2017. Although HPV vaccination coverage among males aged 19-26 years and Hispanic females aged 19-26 years increased, approximately 50% of females aged 19-26 years and 70% of males aged 19-26 years remained unvaccinated. Racial/ethnic vaccination differences persisted for routinely recommended adult vaccines. Having health insurance coverage, having a usual place for health care, and having ≥1 physician contacts during the preceding 12 months were associated with higher vaccination coverage; however, these factors alone were not associated with optimal adult vaccination coverage, and findings indicate missed opportunities to vaccinate remained.

PUBLIC HEALTH ACTIONS

Substantial improvement in adult vaccination uptake is needed to reduce the burden of vaccine-preventable diseases. Following the Standards for Adult Immunization Practice (https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/index.html), all providers should routinely assess adults' vaccination status at every clinical encounter, strongly recommend appropriate vaccines, either offer needed vaccines or refer their patients to another provider who can administer the needed vaccines, and document vaccinations received by their patients in an immunization information system.

Impact of HIV and chronic kidney disease comorbidities on hepatitis C treatment choices, drug-drug interactions and hepatitis C cure

Background Human immunodeficiency virus (HIV) co-infection and chronic kidney disease add challenges to hepatitis C virus treatment. Objective To conduct a comparative study of treatment choices, drug–drug interactions and clinical outcomes in hepatitis C mono-infected patients, or those with HIV or chronic kidney disease comorbidities. Setting Hepatitis C treatment centers of West Midlands England, United Kingdom. Method An observational study was conducted analyzing datasets of all hepatitis C patients that were referred to a large tertiary liver unit in the West Midlands, UK between July 2015 and January 2018. Patients aged ≥ 18 years with diagnosis of hepatitis C alone or co-infected with HIV or comorbid with chronic kidney disease were eligible. Main outcome measures The treatment choices, relevant potential drug–drug interactions and sustained virologic response 12 weeks post end of treatment were assessed. Results Out of 313 patients, 154 (49.2%) were hepatitis C mono-infected, 124 (39.6%) hepatitis C/HIV co-infected and 35 (11.2%) were hepatitis C/chronic kidney disease comorbid. There were 151 (98.1%) of hepatitis C mono-infected, 110 (88.7%) of hepatitis C/HIV and 20 (57.1%) of hepatitis C/chronic kidney disease patients treated with 1st line regimens. Significantly more patients who had co-morbidity with either HIV or chronic kidney disease were prescribed 2nd line regimens (8.1% and 37.1% respectively), compared to patients with hepatitis C mono-infection (1.9%) (P value < 0.05). Comorbid patients (12.1% of HIV and 25.8% of chronic kidney disease) were more likely to required drug–drug interactions advice (grade 5) than hepatitis C mono-infected (1.8%). Higher cure rates were observed in hepatitis C mono-infected (95.33%), hepatitis C/HIV (96.1%) compared to hepatitis C/chronic kidney disease patients (90.3%). Conclusion This study shows that treatment pathways permitting access to individual treatment adjustments in accordance with comorbidities and with consideration of drug–drug interaction in a multi-disciplinary team, provides successful outcomes in hepatitis C patients co-morbid with HIV or chronic kidney disease.

Travel-associated STI amongst HIV and non-HIV infected travellers

BACKGROUND

The incidence of sexually transmitted infections (STI) is increasing in Western countries whilst travel plays a major role in STI dissemination worldwide. However, there is no study distinguishing HIV-positive and HIV-negative travellers.

METHODS

We retrospectively evaluated the epidemiological, clinical and biological characteristics of the patients diagnosed with a travel-related STI between 2008 and 2016. We describe and compare the spectrum of STI diagnosed amongst HIV-positive and negative travellers.

METHODS

Overall, 163 travel-related STI were identified in 140 patients (89% male, 54% men having sex with men, 40% HIV-positive). Symptoms occurred during travel in 39% of them, otherwise the median time between return and symptoms' onset was 13 days. Amongst the 84 HIV-negative travellers, the main STI were primary HIV infections (n = 36, 38%), Neisseria gonorrhoeae (NG) infections (17%) and primary herpes infection (14, vs 1.5% amongst HIV-positive travellers, P = 0.01). The regions of exposure to HIV were concordant with the known geographical distribution of HIV subtypes. Amongst the 56 HIV-positive travellers, the main STI were syphilis (43, vs 6% amongst HIV-negative travellers, P = 0.01), Chlamydia trachomatis (CT) infections (22, vs 13% amongst HIV-negative travellers, P = 0.08), NG infections (13%) and acute hepatitis C (12, vs 1% amongst HIV-negative travellers, P = 0.01), with a predominance of anal forms for both CT and NG infections.

CONCLUSIONS

The spectrum of STI diagnosed in returning travellers is broad with important differences according to HIV status. In our setting, primary HIV infection was the leading STI in non-HIV infected patients, which suggests that pre-exposure prophylaxis may have a role in HIV prevention in at-risk travellers.

Vaccines for International Travel

The pretravel management of the international traveler should be based on risk management principles. Prevention strategies and medical interventions should be based on the itinerary, preexisting health factors, and behaviors that are unique to the traveler. A structured approach to the patient interaction provides a general framework for an efficient consultation. Vaccine-preventable diseases play an important role in travel-related illnesses, and their impact is not restricted to exotic diseases in developing countries. Therefore, an immunization encounter before travel is an ideal time to update all age-appropriate immunizations as well as providing protection against diseases that pose additional risk to travelers that may be delineated by their destinations or activities. This review focuses on indications for each travel-related vaccine together with a structured synthesis and graphics that show the geographic distribution of major travel-related diseases and highlight particularly high-risk destinations and behaviors. Dosing, route of administration, need for boosters, and possible accelerated regimens for vaccines administered prior to travel are presented. Different underlying illnesses and medications produce different levels of immunocompromise, and there is much unknown in this discipline. Recommendations regarding vaccination of immunocompromised travelers have less of an evidence base than for other categories of travelers. The review presents a structured synthesis of issues pertinent to considerations for 5 special populations of traveler: child traveler, pregnant traveler, severely immunocompromised traveler, HIV-infected traveler, and traveler with other chronic underlying disease including asplenia, diabetes, and chronic liver disease.

Clinicoepidemiological characteristics of viral hepatitis in migrants and travellers of the +Redivi network

BACKGROUND

Continuous growth of mobile populations has influenced the global epidemiology of infectious diseases, including chronic and acute viral hepatitis.

METHOD

A prospective observational multicentre study was performed in a Spanish network of imported infections. Viral hepatitis cases from January 2009 to September 2017 were included.

RESULTS

Of 14,546 records, 723 (4.97%) had imported viral hepatitis, including 48 (6.64%) acute cases and 675 (93.36%) chronic cases. Of the 48 acute cases, 31 were travellers and immigrants returning from visiting friends or relatives (VFR), while 19 (61%) were acute Hepatitis A or Hepatitis B. Only 18.2% of VFR immigrants and 35% of travellers received pre-travel advice. Acute hepatitis was more frequent in VFR immigrants (AOR 2.59, CI95% 1.20-5.60) and travellers (AOR 2.83, CI95% 1.46-5.50) than immigrants. Of the 675 Chronic cases, 570 were immigrants, and 439 (77%) had chronic Hepatitis B. Chronic hepatitis was more frequent in immigrants (AOR 20.22, CI95% 11.64-35.13) and VFR immigrants (AOR 11.12, CI95% 6.20-19.94) than travellers.

CONCLUSIONS

Chronic viral hepatitis was typical of immigrants, acute viral hepatitis was common among travellers, and VFR immigrants had mixed risk. Improving pre-travel consultation and screening of immigrants may contribute to preventing new cases of viral hepatitis and avoiding community transmission.

Hepatitis B vaccination coverage among adults aged ≥18 years traveling to a country of high or intermediate endemicity, United States, 2015

BACKGROUND

Persons from the United States who travel to developing countries are at substantial risk for hepatitis B virus (HBV) infection. Hepatitis B vaccine has been recommended for adults at increased risk for infection, including travelers to high or intermediate hepatitis B endemic countries.

PURPOSE

To assess hepatitis B vaccination coverage among adults ≥18 years traveling to a country of high or intermediate endemicity from the United States.

METHODS

Data from the 2015 National Health Interview Survey (NHIS) were analyzed to determine hepatitis B vaccination coverage (≥1 dose) and series completion (≥3 doses) among persons aged ≥18 years who reported traveling to a country of high or intermediate hepatitis B endemicity. Multivariable logistic regression and predictive marginal analyses were conducted to identify factors independently associated with hepatitis B vaccination.

RESULTS

In 2015, hepatitis B vaccination coverage (≥1 dose) among adults aged ≥18 years who reported traveling to high or intermediate hepatitis B endemic countries was 38.6%, significantly higher compared with 25.9% among non-travelers. Series completion (≥3 doses) was 31.7% and 21.2%, respectively (P < 0.05). On multivariable analysis among all respondents, travel status was significantly associated with hepatitis B vaccination coverage and series completion. Other characteristics independently associated with vaccination (≥1 dose, and ≥3 doses) among travelers included age, race/ethnicity, educational level, duration of US residence, number of physician contacts in the past year, status of ever being tested for HIV, and healthcare personnel status.

CONCLUSIONS

Although travel to a country of high or intermediate hepatitis B endemicity was associated with higher likelihood of hepatitis B vaccination, hepatitis B vaccination coverage was low among adult travelers to these areas. Healthcare providers should ask their patients about travel plans and recommend and offer travel related vaccinations to their patients or refer them to alternate sites for vaccination.

Hepatitis B vaccination coverage among adults aged ≥ 18 years traveling to a country of high or intermediate endemicity, United States, 2015

BACKGROUND

Persons from the United States who travel to developing countries are at substantial risk for hepatitis B virus (HBV) infection. Hepatitis B vaccine has been recommended for adults at increased risk for infection, including travelers to high or intermediate hepatitis B endemic countries.

PURPOSE

To assess hepatitis B vaccination coverage among adults ≥ 18 years traveling to a country of high or intermediate endemicity from the United States.

METHODS

Data from the 2015 National Health Interview Survey (NHIS) were analyzed to determine hepatitis B vaccination coverage (≥1 dose) and series completion (≥3 doses) among persons aged ≥ 18 years who reported traveling to a country of high or intermediate hepatitis B endemicity. Multivariable logistic regression and predictive marginal analyses were conducted to identify factors independently associated with hepatitis B vaccination.

RESULTS

In 2015, hepatitis B vaccination coverage (≥1 dose) among adults aged ≥ 18 years who reported traveling to high or intermediate hepatitis B endemic countries was 38.6%, significantly higher compared with 25.9% among non-travelers. Series completion (≥3 doses) was 31.7% and 21.2%, respectively (P < 0.05). On multivariable analysis among all respondents, travel status was significantly associated with hepatitis B vaccination coverage and series completion. Other characteristics independently associated with vaccination (≥1 dose, and ≥ 3 doses) among travelers included age, race/ethnicity, educational level, duration of U.S. residence, number of physician contacts in the past year, status of ever being tested for HIV, and healthcare personnel status.

CONCLUSIONS

Although travel to a country of high or intermediate hepatitis B endemicity was associated with higher likelihood of hepatitis B vaccination, hepatitis B vaccination coverage was low among adult travelers to these areas. Healthcare providers should ask their patients about travel plans and recommend and offer travel related vaccinations to their patients or refer them to alternate sites for vaccination.

Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices

HEPATITIS B VIRUS (HBV) IS TRANSMITTED VIA BLOOD OR SEXUAL CONTACT. PERSONS WITH CHRONIC HBV INFECTION ARE AT INCREASED RISK FOR CIRRHOSIS AND LIVER CANCER AND REQUIRE MEDICAL CARE. THIS REPORT UPDATES AND SUMMARIZES PREVIOUSLY PUBLISHED RECOMMENDATIONS FROM THE ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP) AND CDC REGARDING THE PREVENTION OF HBV INFECTION IN THE UNITED STATES. ACIP RECOMMENDS TESTING ALL PREGNANT WOMEN FOR HEPATITIS B SURFACE ANTIGEN (HBSAG), AND TESTING HBSAG-POSITIVE PREGNANT WOMEN FOR HEPATITIS B VIRUS DEOXYRIBONUCLEIC ACID (HBV DNA); ADMINISTRATION OF HEPB VACCINE AND HEPATITIS B IMMUNE GLOBULIN (HBIG) FOR INFANTS BORN TO HBV-INFECTED WOMEN WITHIN 12 HOURS OF BIRTH, FOLLOWED BY COMPLETION OF THE VACCINE SERIES AND POSTVACCINATION SEROLOGIC TESTING; UNIVERSAL HEPATITIS B VACCINATION WITHIN 24 HOURS OF BIRTH, FOLLOWED BY COMPLETION OF THE VACCINE SERIES; AND VACCINATION OF CHILDREN AND ADOLESCENTS AGED <19 YEARS WHO HAVE NOT BEEN VACCINATED PREVIOUSLY. ACIP RECOMMENDS VACCINATION OF ADULTS AT RISK FOR HBV INFECTION, INCLUDING UNIVERSAL VACCINATION OF ADULTS IN SETTINGS IN WHICH A HIGH PROPORTION HAVE RISK FACTORS FOR HBV INFECTION AND VACCINATION OF ADULTS REQUESTING PROTECTION FROM HBV WITHOUT ACKNOWLEDGMENT OF A SPECIFIC RISK FACTOR. THESE RECOMMENDATIONS ALSO PROVIDE CDC GUIDANCE FOR POSTEXPOSURE PROPHYLAXIS FOLLOWING OCCUPATIONAL AND OTHER EXPOSURES. THIS REPORT ALSO BRIEFLY SUMMARIZES PREVIOUSLY PUBLISHED AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASEST GUIDELINES FOR MATERNAL ANTIVIRAL THERAPY TO REDUCE PERINATAL HBV TRANSMISSION.

Hepatitis B Vaccination Status among Japanese Travelers

This study clarified the characteristics of travelers who received hepatitis B vaccinations. Subjects were 233 Japanese travelers who visited our clinic prior to travel. We summarized the characteristics of the clients and performed two comparative studies: first, we compared a hepatitis B-vaccinated group with an unvaccinated group; second, we compared a group that had completed the hepatitis B vaccine series with a group that did not complete the series. The hepatitis B vaccine was administered to 152 clients. Factors positively associated with the hepatitis B vaccination (after adjusting for age and sex) included the following: travel for business or travel as an accompanying family member; travel to Asia; travel for a duration of a month or more; and, inclusion of the vaccine in a company or organization's payment plan. Meanwhile, factors negatively associated with the vaccination were travel for leisure or education, and travel to North America or Africa. Among 89 record-confirmed cases, only 53 completed 3 doses. The completion rate was negatively associated with the scheduled duration of travel if it was from a month to less than a year (after adjusting for age and sex). The present study provides a basis for promoting vaccination compliance more vigorously among Japanese adults.

Hepatitis B vaccination for international travelers to Asia

There is a wide range in prevalence of hepatitis B virus (HBV) infection and HBV immunization programs between different regions. Hepatitis B is a vaccine preventable disease yet is still endemic in the majority of countries in Asia. Despite the decreasing global prevalence of chronic HBV infection, there is still considerable risk of HBV infection among international travelers to high endemic areas. Numbers of international travelers are expected to increase year by year; thus immunization among this cohort is a crucial preventive measure. Among international travelers to Asia, HBV immunization should be recommended for those without previous HBV vaccination who plan to travel to countries with intermediate to high prevalence of HBV, and especially for those individuals at greater risk of HBV infection; including travelers engaging in casual sex, getting a tattoo or piercing, and those having dental surgery or other medical procedures. Longer duration of travel is also associated with a greater risk of HBV infection. Travelers from low HBV prevalence countries, especially those born before implementation of universal HBV vaccination, might benefit from HBV vaccination during long-term traveling to HBV intermediate to high endemic country.

Hajj vaccinations-facts, challenges, and hope

Vaccination is an effective preventive measure that has been used in the unique Hajj pilgrimage setting to control the transmission of infectious diseases. The current vaccination policy applied during Hajj is reviewed herein, highlighting the effectiveness of the approaches applied and identifying research gaps that need to be filled in order to improve the development and dissemination of Hajj vaccination strategies.

HAV & HBV vaccination among travellers participating in the National Health and Wellness Survey in five European countries

BACKGROUND

A main cause of hepatitis A and B infections in European countries is travel to endemic countries. Most research on hepatitis vaccination among travellers from Europe has been conducted in airports or travel clinics, samples which potentially overrepresented frequent travellers.

METHODS

2102 respondents across France, Germany, Italy, Spain, and UK completed an internet-based questionnaire. Vaccination status, travel to endemic countries, and other characteristics were compared across frequent, occasional, and non-travellers. Logistic regressions tested association between vaccination and travel adjusting for potential confounders.

RESULTS

Most respondents were occasional travellers (61%) and 24% were frequent travellers. Frequent travellers had 2.3-2.4 times the odds of being vaccinated relative to non-travellers, and odds of vaccination were 2.5-3.1 times higher among travellers to endemic areas relative to others (all p < .05). Frequent travellers were more aware of their vaccination status (HAV: 80% vs. 72%; HBV: 82% vs. 74%), though many who were vaccinated could not identify the number of injections to complete the series (47% vs. 29%) (all p < .05).

CONCLUSION

Travel frequency and destination endemicity are associated with increased hepatitis A and B vaccination. The number of unvaccinated travellers and the lack of recall for the dosing schedule suggest the need to improve travellers' awareness and adherence to recommendations.

Immunogenicity and safety of concomitant administration of a combined hepatitis A/B vaccine and a quadrivalent meningococcal conjugate vaccine in healthy adults

BACKGROUND

This phase 3b randomized, open-label study evaluated the immunogenicity and safety of coadministration of a hepatitis A and/or B vaccine with a quadrivalent oligosaccharide meningococcal CRM197 -conjugate vaccine (MenACWY-CRM), in the context of an accelerated hepatitis A and/or B immunization schedule.

METHODS

A total of 252 healthy adult subjects were randomized to three groups to receive hepatitis A/B only (HepA/B), hepatitis A/B coadministered with MenACWY-CRM (HepA/B+MenACWY-CRM), or MenACWY-CRM only (MenACWY-CRM). Hepatitis A and/or B vaccination was administered in the form of a single booster dose or a primary three-dose series, depending on the hepatitis A and/or B vaccination history of subjects. Antibody responses to hepatitis A/B vaccination were assessed 1 month following the last hepatitis A and/or B dose. Serum bactericidal activity with human complement (hSBA) against meningococcal serogroups A, C, W-135, and Y was assessed 1 month post-MenACWY-CRM vaccination. Safety was monitored throughout the study.

RESULTS

At 1 month following the final hepatitis A and/or B vaccination, concomitant administration of hepatitis A/B and MenACWY-CRM was non-inferior to administration of hepatitis A/B alone in terms of geometric mean concentrations of antibodies against the hepatitis A and B antigens. One month post-MenACWY-CRM vaccination, the percentages of subjects achieving hSBA titers ≥8 for serogroups A, C, W-135, and Y in the HepA/B+MenACWY-CRM group (76, 87, 99, and 94%, respectively) were comparable to those in the MenACWY-CRM group (67, 82, 96, and 88%, respectively). The percentages of subjects reporting adverse events (AEs) were similar across study groups and a majority of the reported AEs were mild to moderate in nature. There were no study vaccine-related serious AEs.

CONCLUSIONS

MenACWY-CRM can be administered concomitantly with a hepatitis A and/or B vaccine in the context of an accelerated hepatitis A and/or B immunization schedule without increasing safety concerns or compromising the immune responses to any of the vaccine antigens. [NCT01453348].

Vaccine-preventable travel health risks: what is the evidence--what are the gaps?

BACKGROUND

Existing travel health guidelines are based on a variety of data with underpinning evidence ranging from high-quality randomized controlled trials to best estimates from expert opinion. For strategic guidance and to set overall priorities, data about average risk are useful. The World Health Organization (WHO) plans to base future editions of "International Travel and Health" on its new "Handbook for Guideline Development."

METHODS

Based on a systematic search in PubMed, the existing evidence and quality of data on vaccine-preventable disease (VPD) risks in travelers was examined and essentials of vaccine efficacy were briefly reviewed. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to evaluate the quality of the data.

RESULTS

Moderate-quality data to determine the risk of VPD exist on those that are frequently imported, whereas in most others the level of confidence with existing data is low or very low.

CONCLUSIONS

In order for the WHO to produce graded risk statements in the updated version of "International Travel and Health," major investment of time plus additional high-quality, generalizable risk data are needed.

Travel-associated infection presenting in Europe (2008-12): an analysis of EuroTravNet longitudinal, surveillance data, and evaluation of the effect of the pre-travel consultation

BACKGROUND

Travel is important in the acquisition and dissemination of infection. We aimed to assess European surveillance data for travel-related illness to profile imported infections, track trends, identify risk groups, and assess the usefulness of pre-travel advice.

METHODS

We analysed travel-associated morbidity in ill travellers presenting at EuroTravNet sites during the 5-year period of 2008-12. We calculated proportionate morbidity per 1000 ill travellers and made comparisons over time and between subgroups. We did 5-year trend analyses (2008-12) by testing differences in proportions between subgroups using Pearson's χ(2) test. We assessed the effect of the pre-travel consultation on infection acquisition and outcome by use of proportionate morbidity ratios.

FINDINGS

The top diagnoses in 32 136 patients, ranked by proportionate morbidity, were malaria and acute diarrhoea, both with high proportionate morbidity (>60). Dengue, giardiasis, and insect bites had high proportionate morbidity (>30) as well. 5-year analyses showed increases in vector borne infections with significant peaks in 2010; examples were increased Plasmodium falciparum malaria (χ(2)=37·57, p<0·001); increased dengue fever (χ(2)=135·9, p<0·001); and a widening geographic range of acquisition of chikungunya fever. The proportionate morbidity of dengue increased from 22 in 2008 to 36 in 2012. Five dengue cases acquired in Europe contributed to this increase. Dermatological diagnoses increased from 851 in 2008 to 1102 in 2012, especially insect bites and animal-related injuries. Respiratory infection trends were dominated by the influenza H1N1 pandemic in 2009. Illness acquired in Europe accounted for 1794 (6%) of all 32 136 cases-mainly, gastrointestinal (634) and respiratory (357) infections. Migration within Europe was associated with more serious infection such as hepatitis C, tuberculosis, hepatitis B, and HIV/AIDS. Pre-travel consultation was associated with significantly lower proportionate morbidity ratios for P falciparum malaria and also for acute hepatitis and HIV/AIDS.

INTERPRETATION

The pattern of travel-related infections presenting in Europe is complex. Trend analyses can inform on emerging infection threats. Pre-travel consultation is associated with reduced malaria proportionate morbidity ratios and less severe illness. These findings support the importance and effectiveness of pre-travel advice on malaria prevention, but cast doubt on the effectiveness of current strategies to prevent travel-related diarrhoea.

FUNDING

European Centre for Disease Prevention and Control, University Hospital Institute Méditerranée Infection, US Centers for Disease Control and Prevention, and the International Society of Travel Medicine.

Hepatitis B surface antigen positivity after twinrix vaccination: a case report

Travelers might have an increased risk of hepatitis B virus (HBV) infection. We report a case of prolonged transient hepatitis B surface antigenemia in a healthy Canadian female 8 days after administration of a combined hepatitis A and hepatitis B vaccine. Travel health providers providing hepatitis B vaccines need to be aware of this phenomenon and educate their patients accordingly.

Hepatitis B screening in travelers: a retrospective analysis

BACKGROUND

Non-immune travelers are at risk of acquiring hepatitis B (HB) in high prevalence countries.

METHOD

At the Institut Pasteur Vaccination Center in a retrospective study we retrieved hepatitis B serological data from the vaccination database between 2008 and 2012. Serology (HBsAg, HBsAb and HBcAb) is proposed to travelers who have no information about their previous HB vaccination status if they travel to countries of high or intermediate prevalence of HB, for long or frequent trips.

RESULTS

Of 1093 people 53.1% were men, mean age was 39.6 ± 13.0 years. Prevalence of chronic HBV infection was 5.86% (64 subjects). Their mean age was 36.2 ± 7.3 years, 65.6% were men. Seroprevalence of people of sub-Saharan African origin was 9.2%, higher than the other geographic groups. Past, resolved HB infection was found in 320 subjects, 29.3% of the population; 90.3% were of sub-Saharan African origin. A subgroup of the "Past, resolved HB infection": 73 people (6.7% of the population) had isolated HB core antibodies. Vaccine induced immunity was found in 286 subjects (26.17% of the total population), 40% of people born in France. All three markers of HB were negative at 38.7% of our total population (423 people), and 54% of people of French origin.

CONCLUSIONS

HB seroprevalence was higher than in general French and European population, due to our large number of individuals with immigrant background. Pre-travel counseling allows screening and vaccination of non-immune travelers and detection of chronic HB infection cases.

Hepatitis B virus reactivation in HBsAg-positive patients with rheumatic diseases undergoing anti-tumor necrosis factor therapy or DMARDs

OBJECTIVE

The aim of this study was to assess the effects of anti-tumor necrosis factor (TNF) agents or disease-modifying antirheumatic drugs (DMARDs) on hepatitis B virus (HBV) reactivation in hepatitis B surface antigen (HBsAg)-positive patients with rheumatic diseases.

METHODS

Evidence of HBV reactivation after anti-TNF therapy or DMARDs in HBsAg-positive patients with rheumatic disease was summarized by performing a systematic review.

RESULTS

A total of 122 HBsAg-positive rheumatic disease-positive patients undergoing treatment with an anti-TNF agent or with DMARDs were identified in nine studies. In eight of the studies, the anti-TNF agents used were etanercept in 56 cases, adalimumab in 25 cases and infliximab in 14 cases. Follow-up periods ranged from 6 to 52 months. Antiviral prophylaxis was administrated in 48 of the 122 patients (39.3%). HBV reactivation in HBsAg-positive patients taking an anti-TNF agent or DMARD was reported in 15 cases (15/122 = 12.3%). Ten of the 15 patients provided individual data on HBV reactivation: four patients had rheumatoid arthritis, four had ankylosing spondylitis and two had psoriatic arthritis; four received etanercept, and two received infliximab. In one of the four etanercept-treated cases in which the patient had elevated HBV-DNA levels, antiviral prophylaxis was also administered. Antiviral treatment was also administered in seven patients receiving other treatments: lamivudine in one, adefovir in one and entecavir in five. Clinical outcomes were satisfactory in all 10 cases of HBV reactivation.

CONCLUSIONS

Hepatitis B virus reactivation was found in 15 (12.3%) patients among the 122 HBsAg-positive patients with rheumatic diseases treated with anti-TNF agents or DMARDs.

Rapid detection of hepatitis B virus in blood plasma by a specific and sensitive loop-mediated isothermal amplification assay

BACKGROUND

Hepatitis B virus (HBV) is an important blood-borne pathogen that causes hepatic inflammation and can lead to liver cirrhosis and hepatocellular carcinoma. Conventional methods of HBV detection are time consuming and require highly trained personnel and elaborate equipment. This report describes the development of a rapid, simple, specific, and sensitive loop-mediated isothermal amplification assay (LAMP) for detection of HBV genotypes A, B, C, D, E, and F in blood samples.

METHODS

HBV standard plasma panels and clinical donor plasma specimens were used for the development and validation of the LAMP assay. Amplification was performed at 60°C for 60 minutes using extracted DNA or heat-treated plasma specimens without DNA extraction. The assay was evaluated for its ability to detect various HBV genotypes and for its sensitivity, specificity, and time-point of detection.

RESULTS

The LAMP assay detected HBV genotypes A-F and demonstrated a sensitivity of 10-100 IU per reaction of HBV DNA. The assay also detected 69 of 75 (92%) HBV-positive donor plasma specimens tested and demonstrated a specificity of 100%.

CONCLUSIONS

These results demonstrate that our HBV-LAMP assay is rapid, sensitive and specific, and capable of detecting the major HBV genotypes. This assay could be used in clinical point-of-care settings, mainly in endemic and resource-limited environments for HBV diagnostics, donor screening, epidemiological studies, and therapeutic monitoring of patients undergoing antiviral treatment.

Dengue fever, tuberculosis, human immunodeficiency virus, and hepatitis C virus conversion in a group of long-term development aid workers

BACKGROUND

Development and humanitarian aid workers are a diverse group of travelers who, because of the nature of their travel, may have specific travel-related health risks. The main objective of this study was to quantify the risk of dengue fever virus (DFV), tuberculosis (TB), human immunodeficiency virus (HIV), and hepatitis C virus (HCV) infections in a group of long-term development aid volunteers.

METHODS

Medical files of Volunteer Service Abroad (VSA) volunteers and their accompanying family/partner/spouse serving over 17 years (1995-2011) were reviewed. Demographics, destination, months spent in-country, and, where available, results of pre- and post-assignment testing for DFV, TB, HCV and HIV infections were extracted.

RESULTS

Results from 652 assignments were audited. Conversion rates were calculated when both pre- and post-assignment results were available. Evidence of dengue fever seroconversion was found in 6.3% of 205 volunteers [at a rate of 3.4 per 1,000 person months (pm) on assignment], with assignments in Southeast Asia having the highest risk. Evidence of TB during assignment was found in 2.9% of 336 volunteers converting at a rate of 1.4 per 1,000 pm. There were no HIV or HCV infections detected. On post-assignment questioning, 6.7% of volunteers reported unprotected sex with someone other than their regular partner and 9.8% reported a potential exposure to blood and/or blood products.

CONCLUSIONS

Infection with DFV and TB occurred in this group at rates similar to that seen in other groups of long-term travelers, and screening would appear to be warranted. While none contracted HIV or HCV infection, reported behavior did put them at risk of blood- and body fluid-borne diseases. It is important that pre-assignment travel health preparation in this group focuses on strategies to minimize these risks.