The risk of contracting hepatitis is a concern for travellers. The fact that the illness comes in several forms and has several routes of infection means that there is plenty of scope for confusion. So it is useful to know a little about hepatitis if only to understand what is vaccine preventable and what isn’t.
Hepatitis means inflammation of the liver. When this huge physiological sorting house becomes inflamed, the patient will often experience discomfort beneath the right side of the rib-cage and lack of appetite. If the inflammation is bad enough it fails to completely process waste products of protein metabolism, which results in yellow colouration.
First the whites of the eyes turn yellow and then the skin follows. Such yellowing or jaundice can be the result of a range of disease processes, including poisoning with drugs or alcohol or an infection involving the liver. Yellow fever is one severe viral infection that causes jaundice as the liver totally fails and death is a common consequence. Sensible travellers to yellow fever zones in Africa or tropical America, though, should be completely protected by immunisation.
Yellow fever is not usually classified with the other viruses which cause hepatitis. Medical researchers have labelled these others as hepatitis A, B, C, delta, E, G and TT. Four of these are relevant to travellers. Hepatitis A and E are common diseases in unhygienic environments, occurring in regions where human faecal contaminants get into peoples’ mouths. Someone with the hepatitis infection passes viruses out in their stools. Poor sanitary arrangements and sometimes a lack of understanding of how disease is transmitted via unwashed hands, allow an infective person to pass hepatitis on to others.
Fortunately these two forms of hepatitis, while unpleasant, rarely cause serious health problems. Most sufferers first experience feelings of tiredness, loss of appetite, and general puzzling non-specific symptoms. They then turn yellow and the reason for the original malaise becomes apparent; that’s when they can earn all the sympathy, although by this stage they usually feel much better. Even so, there is generally a period of up to several months of post-viral fatigue, although this settles completely with sensible pacing – such as not over-doing things and resting when tired.
While the liver is inflamed the sufferer finds that they cannot tolerate much alcohol or fat in the diet. This all recovers completely and – unlike with alcoholic liver disease – the liver returns to full capacity and there are no long-term health consequences. It is rare to get very ill with these infections, although hepatitis E can be serious in pregnant women. There is a vaccine against hepatitis A which protects for ten years. Efforts are being made to develop a hepatitis E vaccine but until this is launched, the disease is avoided by being careful about the foods that are eaten in countries with a high risk of filth-to-mouth disease transmission.
A study from Ron Behrens and Bernie Carroll of the London Hospital for Tropical Diseases, published in 2001, looked at travel-associated infections that were brought into Britain during the decade 1989-1999. They concluded that around 100 travel-associated cases of hepatitis A are imported into the UK annually out of eight million travellers at risk, 80% of whom visit the very risky Indian subcontinent.
Immunisation seems to have been responsible for a huge (eight-fold) reduction in the number of people returning from such high-risk destinations with the disease, but Dr Behrens said that doctors do immunise too many people, against both hepatitis A and typhoid. Many people going to low-risk regions like the Mediterranean are offered these vaccines when they are not really needed. Vaccine companies do quite a lot to encourage this over-immunisation of low-risk travellers.
The other two significant hepatitis viruses, B and C are spread in the same ways as the human immunodeficiency virus (HIV). These are acquired via contaminated hypodermic syringes (they are common in intravenous drug abusers), by way of unscreened blood products or transfusions, and by unsafe sex. Hepatitis B is vaccine-preventable although it is not routinely offered to ordinary travellers, because it should not be a significant risk unless the traveller is sharing needles while injecting recreational drugs or is promiscuous.
However, those living in a developing country in the long term are often advised to receive this vaccine. The reason for this is that in the case of a serious accident, they might be put at risk of infection through exposure to infected needles or blood. There is no vaccine for hepatitis C. Both hepatitis B and C are rather unpredictable diseases but both can cause very nasty, long-lasting disease resulting in permanent liver damage. Hepatitis B infection can also persist and go on to cause liver cancer. These two, then, are to be avoided.
Immunisation against hepatitis A is one of the four travel vaccines that are available free in the UK on the NHS. It is a ‘clean’ safe vaccine grown in tissue culture and unlikely to cause adverse reactions beyond a little soreness at the injection site. There are several effective vaccines for adults (Havrix and Avaxim) and a version for children (Havrix Junior) which can be given from the age of 12 months. Two injections give ten years’ protection. These supersede the somewhat uncomfortable gamma globulin jab in the bottom which, because the product is derived from human blood, carries some theoretical risk of diseases akin to CJD.
Unfortunately, during 2001 Aventis Pasteur MSD announced that there was a problem with one vaccine. They said that some patients who had recently been “vaccinated with the VAQTA, VAQTA paediatric or hepatitis A vaccine, purified, inactivated, may be insufficiently protected against hepatitis A”. There were technical problems, they explained, when they changed suppliers of syringes and they think that the hydrogen peroxide that was used to sterilise the syringes also sterilised the vaccine and completely inactivated it.
It happened to an unknown number of syringes and involves VAQTA products carrying expiry dates between May 1998 and February 2004; the products were withdrawn so that no further sub-standard doses have been offered in the last several months. When I phoned the company it played down the story and said that it was unable to estimate what proportion of the ampoules had been inactivated but thought that it was a very small number. It said that for ‘medico-legal’ reasons it needed to advise further immunisation. It tried to suggest that reimmunisation was only a precaution: “despite the potential for decreased potency, no cases of vaccine failure have been reported in recipients of the affected products in the UK.”
The company would not say whether there had been vaccine failures outside the UK. There has been no apology from the vaccine company to patients, nor a warning that reimmunisation could lead to an increased local reaction to the vaccine. Instead the vaccine company has merely asked GPs to go to the trouble of writing to those patients who received the immunisation and tell them that the problem “had come to their attention”.
Readers who have been immunised against hepatitis A and thought themselves protected might want to check with the GP or travel clinic who administered it and ask whether reimmunisation is necessary before any future trips. If reimmunisation is necessary, it should be with the SmithKline Beecham vaccine, Havrix.
The problem of these additional vaccines – fortunately – is not one of some dangerous (unproven) suggested link between them and some debilitating disease or syndrome, but merely of someone receiving an unnecessary jab – inconvenience and discomfort for no reason, and at the tax-payers’ expense.
And the problem is not only with the vaccine in the UK. I understand that travel clinics in Australia are also being told to reimmunise their clients and that they too are surprised that the vaccine company has not written to travellers themselves to explain. I guess what the company is hoping is that fingers won’t be pointed specifically at them if surgeries and clinics write bland letters implying failure of the system. In these times of mistrust of vaccines, it is a pity that the vaccine manufacturers cannot be a little more straightforward in owning up to a problem and apologising for it.
