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Traveler Summary

Key Points

  • Hepatitis B is a potentially serious viral infection of the liver acquired through contact with infected blood or bodily fluids. Hepatitis B virus (HBV) infection is prevalent in most developing countries.
  • Risk is high for travelers going to developing countries who are likely to have a new sex partner; engage in tattooing, body piercing, or acupuncture; require medical or dental care in local facilities; or are health care workers (HCWs).
  • Symptoms vary by age and when present include fever, fatigue, loss of appetite, nausea, vomiting, stomach pain, dark urine, clay-colored stools, joint pain, and jaundice (yellow eyes and skin).
  • Consequences of infection include possible progression to a chronic carrier state (virus remains in the body) as well as liver damage or liver cancer.
  • Prevention includes avoiding risk behaviors.
  • Hepatitis B (HepB) killed vaccine is routinely given as 3 doses: 1 each at 0, 1 and 6 months. Accelerated dosing schedules for travelers are also available.
  • Vaccine side effects are most commonly injection-site reactions, headache, and nausea.
  • Duration of vaccine protection following a completed series is at least 30 years.
  • Postexposure prevention with immune globulin (IG), HepB vaccine, or both may be recommended as soon as possible after exposure (preferably within 24 hours).

Introduction

Hepatitis B is a serious, potentially chronic liver infection caused by HBV. Infection can be acute (short-term) or chronic, resulting in liver damage and cancer. More than 2 billion people worldwide have been infected with HBV and more than 240 million people have chronic, lifelong infections.

Risk Areas

HBV infection prevalence is low in the general population in northern and western Europe, North America, and northern South America and in Mexico; intermediate in northern, central, and southern Africa, Asia, eastern and southern Europe, and the Middle East (including Israel) and in Japan and Russia; and high in all socioeconomic groups in West Africa.

Transmission

HBV is transmitted from an infected person to a noninfected person via blood (through a transfusion or minor breaks in the skin and mucous membranes), bodily fluids (e.g., semen or vaginal secretions), or from other bodily secretions contaminated with infected blood during close contact. Transmission may also occur from mother-to-child before or after birth, via exposure to contaminated objects (such as needles, sharp instruments [dental, surgical, tattoo, acupuncture], and unsterile medical supplies), interpersonal contact (e.g., sharing contaminated toothbrushes, razors), and contaminated surfaces (because HBV can survive outside the human body for a prolonged period).

Risk Factors

Risk is highest for travelers going to countries with intermediate or high prevalence of HBV infection who engage in risk behaviors (such as unprotected sex with a new partner, injection-drug use, tattooing, body piercing, acupuncture) or who require a blood transfusion or medical/dental care in local facilities.

Symptoms

Symptoms most commonly appear about 90 days (range, 2-5 months) following exposure. Children younger than 5 years and newly infected immunocompromised adults may not have symptoms (compared to persons 5 years and older). When present, symptoms include fever, fatigue, loss of appetite, nausea, vomiting, stomach pain, dark urine, clay-colored stools, joint pain, and jaundice.

Consequences of Infection

Complications of HBV infection can be acute (short-term) or chronic. Acute disease, which may last up to 3 months, is more severe among adults older than 60 years, but nearly all recover completely, with a death rate of less than 1.5%.

The chronic phase, following the acute phase, may result in some persons (infants, children 5 years and younger and immunocompromised persons are at highest risk) becoming "chronic carriers," with HBV remaining in the liver and blood. Persons with chronic infection may not have symptoms or evidence of liver disease until onset of liver damage or cancer, leading to premature death in 25% of chronic carriers infected in childhood and 15% of chronic carriers infected after childhood. The risk of acute liver failure is increased in pregnant women, with consequences to the fetus including premature delivery, suffocation, and death.

Need for Medical Assistance

Travelers who develop symptoms of or who have been exposed to HBV should seek medical attention for evaluation of the need for postexposure treatment.

Prevention

Nonvaccine

Avoid the risk behaviors described above.

Vaccine

HepB vaccine is given as a routine childhood vaccination and to adults in certain risk groups. Following receipt of a complete series, most persons will be protected for at least 30 years. A combined hepatitis A-hepatitis B (HepA-HepB) vaccine is also available for persons 18 years and older in the U.S. and for all ages elsewhere.

HepB vaccination is recommended for unvaccinated travelers going to:

  • Areas with high risk of HBV infection, including:
    • Travelers with prolonged stays
    • Travelers with frequent, short stays in the same or other high-risk areas
    • Travelers likely to have a new sexual partner during their stay
    • Travelers more likely to require medical or dental care in local facilities, including
      • Those with underlying medical illness
      • Those traveling for medical or dental care or consultation
      • Adventure travelers
      • Those who anticipate extensive use of local or public transportation
    • Travelers likely to engage in tattooing, body piercing, or acupuncture
    • HCWs
    • Any short-stay traveler wishing to be protected against HBV infection, in case medical care from local facilities might be required
  • Areas of lower risk of HBV infection, including:
    • Those with any likelihood of a new sexual partner during the stay
    • HCWs
    • Risk-averse travelers desiring maximum pretravel protection

Persons with underlying medical conditions or who have concerns about the vaccine should speak to their health care provider before vaccine administration.

Side Effects

The most common vaccine side effects are injection-site reactions (pain, redness, itching) and fever. Headache and nausea also occur.

Timing

HepB vaccine (Engerix-B or Recombivax HB) is given as follows:

  • Routine, regardless of travel: 3 doses, 1 each at 0, 1, and 6 months. Infants should receive the first dose at birth. Ideally the series should be completed before travel, but even 1 or 2 doses confer some protection; however, the series should be completed upon return.
  • Several accelerated schedules are available:
    • 4 doses total: 1 each at 0, 1, and 2 months, plus a final dose at 12 months
    • 4 doses total: 1 each at 0, 7, and 21 to 30 days, plus a final dose at 12 months
    • 4 doses total: 1 each at 0, 7, and 14 days, plus a final dose at least 6 months after the first dose

HepB vaccine (Heplisav-B), approved for use in persons 18 years and older, is given as 2 doses 1 month apart.

HepA-HepB vaccine is given as follows:

  • Persons 18 years and older: 3 doses, 1 each at 0, 1, and 6 months.
  • Completion of 3 doses protects more than 90% of vaccinated persons. For departures occurring in less than 6 months, an accelerated schedule may be given: 4 doses, 1 each on days 0, 7, and 21 to 30, and the final dose at 12 months. This regimen should not be started unless at least 2 doses can be given prior to departure.

Postexposure prevention with either IG, HepB vaccine, or both may be indicated as soon as possible after exposure (preferably within 24 hours), depending on the exposure setting and the person's vaccination status.