Hepatitis A
	Know before you go!
	Disease profile
	Transmission
	Geographic distribution
	Symptoms
	Treatment
	Vaccines
	Prevention & precautions
	Recommendations
	Some things to think about

Hepatitis A

April 2001

Know before you go!

Infectious diseases not necessarily common in Canada can occur and may even be widespread in other countries. Standards of hygiene and medical care may differ from those at home. Before departure, you should learn about the health conditions in the country or countries you plan to visit, your own risk of disease and the steps you can take to prevent illness.

The risk is yours
Your risk of acquiring a disease depends on several factors. They include: your age, gender, immunization status and current state of health; your itinerary, duration and style of travel (e.g., first class, adventure) and anticipated travel activities (e.g., animal contact, exposure to fresh water, sexual contact); as well as the local disease situation.

Risk assessment consultation
The Public Health Agency of Canada strongly recommends that your travel plans include contacting a travel medicine clinic or physician 6 to 8 weeks before departure. Based on your individual risk assessment, a health care professional can determine your need for immunizations and/or preventive medication (prophylaxis) and advise you on precautions to avoid disease. We can help you locate a travel medicine clinic closest to your home.

Some facts from the experts
The information below has been developed and is updated in consultation with Public Health Agency of Canada's Committee to Advise on Tropical Medicine and Travel (CATMAT). The recommendations are intended as general advice about hepatitis A prevention for Canadians travelling internationally.

Disease profile

Hepatitis A, formerly called infectious hepatitis, is a viral infection of the liver that varies in severity and duration of illness. The hepatitis A virus (HAV) causes an individual to become ill with flu-like symptoms, abdominal pain and jaundice (i.e., yellowing of skin and eyes). An individual may be ill or in convalescence for a long period, but complete recovery occurs in the vast majority of cases.

Transmission

Hepatitis A is acquired indirectly through water or food contaminated with human feces. Inadequately treated water, or polluted fresh or sea water can cause infection. Shellfish, such as oysters and mussels, are frequently carriers. Milk, cold meats and other food contaminated during preparation can also be sources.

Hepatitis A is also transmitted directly through oral-fecal contact with an infected individual; though person-to-person exposure is unlikely when good hygiene practices (e.g., hand washing) are in place. Person-to-person transmission is particularly common between children, and between sexual partners. Children, who are frequently asymptomatic, are a major cause of infection in older family members.

Geographic distribution

Hepatitis A occurs sporadically worldwide and is endemic throughout the developing world. People born and raised in developing countries, and people born in developed countries before 1945 (when hepatitis A was still common here), have usually been infected in childhood with an asymptomatic or mild case of HAV, and are likely now immune to the disease. Individuals from developed countries born after 1945 are at risk for acquiring hepatitis A, especially when travelling to endemic areas. While travellers to rural areas of developing countries are at a higher risk of infection, many cases of HAV do occur among people staying in resorts or other standard-level or 'five-star' tourist accommodations.

In Canada, 558 cases of HAV were reported in 1998, and 397 cases of HAV were reported in 1999. For the year 2000, provisional reports indicate a total of 484 reported cases of HAV. Due to current provincial reporting practices, the national statistics on HAV cases do not distinguish between domestic exposure and travel-related exposure, or imported cases, of HAV..

Symptoms

HAV has an incubation period of 3 to 5 weeks. The symptoms of hepatitis A include the sudden onset of fever, malaise, loss of appetite, nausea and abdominal pain, followed within a few days by jaundice. The disease is usually mild, lasting 10 to 30 days. Recovery from a severe case can last months, and while fatalities due to liver damage do occur, they are rare. Infection usually causes illness in adults and school-age children, but is often asymptomatic in younger children and may be mistaken for the flu and general malaise.

Treatment

There is no specific treatment for hepatitis A, but supportive treatment is given to address the symptoms. Full recovery is common. Hepatitis A infection confers lifelong immunity in individuals who have been infected.

Vaccines

There are four hepatitis A vaccines licensed in Canada. The vaccines are safe, provide long-lasting protection and are interchangeable. They are all given in two doses, with the second dose administered 6 months after the first. There are also two 'combined' hepatitis A and hepatitis B vaccines (one for adults and one for children) licensed in Canada, given in three doses over 6 months.

For infants under 1 year of age and those few individuals for whom the vaccine is not advised, immune serum globulin (ISG) may still be used. ISG provides protection from hepatitis A for 4 to 6 months.

A travel health clinic or family physician will recommend which immunization is appropriate for individual circumstances.

Prevention and personal precautions

Most travellers are at low risk of acquiring HAV infection. However, cases of hepatitis A have occurred in travellers to developing countries who stay in rural areas or in standard-level tourist accommodations where the hygienic quality of the food and water supply may be inadequate. Taking food and water precautions (see below: Recommendations) is the best means of preventing hepatitis A infection. Moreover, hepatitis A is a vaccine-preventable disease.

Recommendations

Because hepatitis A is spread through contaminated food and water, Public Health Agency of Canada strongly recommends that travellers to developing countries where hepatitis A is known to occur exercise general food and water precautions to minimize their risk of exposure. The key principles to remember are: boil it, cook it, peel it or leave it!

• Eat only food that has been well-cooked and is still hot when served.
• Drink only purified water that has been boiled or disinfected with chlorine or iodine, or commercially bottled water in sealed containers.
• Carbonated drinks without ice, including beer, are usually safe.
• Avoid ice, unless it has been made with purified water.
• Boil unpasteurized milk.
• Avoid unpasteurized dairy products and ice cream.
• Avoid uncooked foods -- especially shellfish -- and salads. Fruit and vegetables that can be peeled are usually safe.
• Avoid food from street vendors.
• Wash hands before eating or drinking.

Protection against hepatitis A through immunization with a vaccine
is recommended for travellers to, and people planning to live in, developing countries, especially in rural areas, HAV-endemic areas or areas where the hygienic quality of food and water supply is likely to be poor.

Some things to think about...

By taking a few food and water precautions and emphasizing personal hygiene while travelling, you can protect yourself against hepatitis A. Remember: boil it, cook it, peel it, or forget it!

If you should develop nausea, stomach cramps or jaundice during travel to an hepatitis A-endemic area or after returning, seek medical attention and report your recent travel history.

For more information...

• For more information on hepatitis A worldwide, visit the World Health Organization's (WHO)
• Communicable Disease Surveillance and Response page on hepatitis at: www.who.int/csr/disease/hepatitis/en/
• For general information about immunizations recommended for travel outside of Canada, click here.
• For more Know before you go! information, click here.

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• For health care practitioners, visit the Committee to Advise on Tropical Medicine and Travel (CATMAT) statement on "Fever in the International Traveller: Initial Assessment Guidelines".
• For health care practitioners, information about immunizations for travellers, click here.