ORIGINAL ARTICLE
Stephen J. Liu, MPH, Umid Sharapov, MD, MSc, and Monina Klevens, DDS, MPH
Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention,
Division of Viral Hepatitis, Epidemiology and Surveillance Branch, Atlanta, GA, USA
DOI: 10.1111/jtm.12186
Published 2015. This article is a U.S. Government work and is in the public domain in the USA. 1195-1982
Journal of Travel Medicine 2015; Volume 22 (Issue 3): 174178
Patient Awareness of Hepatitis A Vaccination Before Travel 175
Methods patients who did not provide data about travel were not
included.
During 1982 to 2006, the Centers for Disease Con- All activities were part of the public health surveil-
trol and Prevention (CDC) supplemented routine lance efforts and were determined as non-research
surveillance with the Sentinel Counties Study of Acute and exempt from Institutional Review Board at
Viral Hepatitis.1 Methods for the Sentinel Coun- the CDC.
ties Study have been previously described.1 Briefly,
the population-based study collected information on
patients with acute viral hepatitis (A, B, and C) who Results
reported to one of the seven county health depart-
ments as follows: Contra Costa County, CA (1996 During 1996 to 2006, a total of 2,181 cases of HAV
only); San Francisco County, CA (20002006); Mult- infection were reported from the seven sites. There
nomah County, OR (19962006); Jefferson County, were 2,002 persons with available travel history, of
AL (19962006); Denver County, CO (19962006); which 300 (15%) reported travel outside the United
Pinellas County, FL (19962006); and Pierce County, States during the incubation period, 1,702 reported
WA (19962006). no international travel during the incubation period,
Serum specimens from patients were collected and and 179 patients did not provide information about
travel. These travelers with HAV infections were more
Table 1 Demographic characteristics of hepatitis A patients by international travel history, Sentinel Counties, United States,
1996 to 2006
Table 2 Regions/countries visited by hepatitis A patients so to Mexico, and, while hepatitis A is endemic in
during the 2 to 6 weeks before illness, Sentinel Counties, Mexico, hepatitis A vaccination is not routine there.15
1996 to 2006 In countries of high and intermediate endemicity, there
is a greater chance for children to be exposed and
WHO region Frequency (%)
develop asymptomatic infection.3 In addition, the sero-
Africa 6 (2.0) prevalence of anti-HAV among adults decreased slightly
Americas (total) 243 (79.2 ) in the United States from 1988 to 2006.16 Patients in
Caribbean 2 (0.7) this study could have been either unvaccinated Ameri-
Central America 33 (10.8) can tourists or unexposed (those unvaccinated and not
Mexico 189 (61.6) exposed to prior HAV infection) Mexican-Americans
South America 19 (6.2) who traveled from the United States to Mexico, where
Eastern Mediterranean 7 (2.3) they became infected with HAV.
Europe 30 (9.8)
There is a large amount of traffic between the
Southeast Asia 14 (4.6)
United States and Mexico, due in part to its prox-
Western Pacific 7 (2.3)
Total 307
imity and land border access. According to the US
Department of Transportation, about 164 million peo-
Results from WHO regions are shown in bold.
ple crossed a USMexico port of entry via truck, train,
WHO = World Health Organization.
bus, personal vehicle, or by pedestrian travel in 2012.17
According to one study, which analyzed data from the
option at the time. There is also a possibility that some Border Infectious Disease Surveillance (BIDS), there
medical providers are simply not recommending vac- are more than three times more cases of hepatitis A
cine to at-risk patients. A sample of patients with chronic in Mexican jurisdictions than in the US counties.15
liver disease showed that only 63% were recommended In another study, almost one-half of the US patients
hepatitis A vaccine by their care provider.14 traveled across the border during their incubation
The CDC and other researchers have been recom- periods.8
mending hepatitis A vaccine for persons traveling to In this analysis, Hispanics encompassed the highest
or working in countries that have high or intermedi- percentage of persons to have traveled before the onset
ate endemicity of infection since the vaccine became of illness than those of other race/ethnicities. This is
available in 1996.3,10 Hepatitis A vaccination coverage consistent with the large number of persons of Mexican
among US travelers to endemic countries is twice as and Hispanic descent who may be visiting friends and
high as coverage for non-travelers (26.6% vs 12.7%), relatives.
but is still low overall and needs to be improved.11 Females and persons aged less than 18 years were
Most (61.6% or 189 of the 307 countries visited more likely to be HAV-infected travelers. This could
by the travelers) hepatitis A patients who traveled did be because women may travel more frequently with
Table 3 Reasons HAV patients reported for not receiving hepatitis A vaccination before international travel, Sentinel
Counties, 1998 to 2006
Reason for no vaccine/ Did not know could or should get shots
immune globulin Did not know could get shots 62 (70) 17 (50) 2 (6) 81 (53)
Did not know it was needed 19 (61) 19 (12)
Too late to receive shot 1 (1) 1 (3) 0 2 (1)
Too expensive 1 (1) 0 0 1 (1)
Did not know where to get shots 1 (1) 1 (3) 0 2 (1)
MD did not recommend 7 (20) 1 (3) 8 (5)
Do not believe in shots 1 (3) 0 1 (1)
Never got around to it 2 (6) 2 (1)
Other 24 (27) 7 (20) 7 (26) 38 (25)
Total 89 34 31 154
HAV = hepatitis A virus.
*Time periods were grouped based on questionnaire responses.
of Health and Human Services, CDC; 2010. Available at: 13. Alter MJ, Coleman PJ, Alexander WJ, et al. Importance of
http://www.cdc.gov/hepatitis/Statistics/2010Surveillance/ heterosexual activity in the transmission of hepatitis B and
PDFs/2010HepSurveillanceRpt.pdf. (Accessed 2013 non-A, non-B hepatitis. JAMA 1989; 262:12011205.
Mar 1) 14. Thudi K, Yadav D, Sweeney K, Behari J. Physicians
7. Bunn WB. Risk and burden associated with the acquisition infrequently adhere to hepatitis vaccination guidelines for
of viral hepatitis A and B in the corporate traveler. Occup chronic liver disease. PLoS One 2013; 8:e71124.
Environ Med 2008; 50:935944. 15. Waterman S, Cortes Alcala R, Spradling P. Crossing
8. Spradling PR, Xing J, Phippard A, et al. Acute viral borders. Viral hepatitis in the United States, Mexico, and
hepatitis in the United States-Mexico border region: the United States-Mexico border region. Clin Infect Dis
data from the Border Infectious Disease Surveillance 2012; 55:vvi.
(BIDS) Project, 20002009. J Immigr Minor Health 2013; 16. Klevens RM, Kruszon-Moran D, Wasley A, et al. Sero-
15:390397. prevalence of hepatitis A virus antibodies in the U.S.:
9. Askling HH, Rombo L, Andersson Y, et al. Hepatitis A results from the National Health and Nutrition Exami-
risk in travelers. J Travel Med 2009; 16:233238. nation Survey. Public Health Rep 2011; 126:522532.
10. Wu D, Guo CY. Epidemiology and prevention of hepatitis 17. U.S. Department of Transportation. Border Cross-
A in travelers. J Travel Med 2013; 20:394399. ing/Entry Data: Query Detailed Statistics 2012
11. Lu PJ, Byrd KK, Murphy TV. Hepatitis A vaccination [4/11/2013]. Available at: http://transborder.bts.gov/
coverage among adults 1849 years traveling to a country programs/international/transborder/TBDR_BC/TBDR_
of high or intermediate endemicity, United States. Vaccine BCQ.html. (Accessed 2013 Apr 1)