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Hepatitis B risks and immunisation coverage amongst Australians travelling to Southeast Asia and East Asia
Travel Medicine and Infectious Disease (2009) 7, 344e349
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
Hepatitis B risks and immunisation coverage amongst Australians travelling to Southeast Asia and East Asia Peter A. Leggat a,*, Nicholas A. Zwar b, Bernard J. Hudson a,c, on behalf of the Travel Health Advisory Group, Australiad a
School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Queensland 4811, Australia b School of Public Health and Community Medicine, University of New South Wales, Australia c MASTA (Australia), Sydney, Australia Received 20 March 2009; accepted 24 March 2009 Available online 9 May 2009
KEYWORDS Hepatitis B; Vaccination; Southeast Asia; Australia; Risk; Travel
Summary Background: Southeast Asia and East Asia are regarded as highly endemic regions for hepatitis B virus (HBV) and include many popular destinations for Australian travellers. The objectives of this survey were to evaluate the extent of pre-travel health advice, the prevalence of behaviours with HBV infection risks and the prevalence of HBV vaccination amongst Australian travellers to Southeast Asia and East Asia. Methods: In 2004, a telephone survey was conducted amongst Australians, who had travelled overseas to Southeast Asia and East Asia in the past three years for three nights or more. Results: Three hundred and nine travellers aged 14 years and over completed the interview, including 138 males (45%) and 171 females (55%). Respondents travelled for leisure (64%), business (20%), and visiting friends and relatives (VFR) (16%). The most common destinations were Indonesia (34%), Thailand (32%), and China (27%). About half of the travellers (54%) sought vaccination specific health advice before travel of which about half (56%) had sought this advice more than six weeks before travel. Just over one quarter of travellers reported receiving HBV vaccination (28%) of whom most (70%) were vaccinated at least three weeks before travel. About half of the travellers (49%) had participated in at least one activity with
* Corresponding author. Tel.: þ61 7 47816108; fax: þ61 7 47815254. E-mail address: [email protected] (P.A. Leggat). d Member organizations of the Australian Travel Health Advisory Group (and representatives) are Anton Breinl Center, James Cook University (Peter A. Leggat); Australian Federation of Travel Agents (Jayson Westbury); Faculty of Travel Medicine, The Australasian College of Tropical Medicine (Tony Gherardin); Jetset Travelworld (Karen Magee); MASTA (Australia) (Bernard Hudson); Royal Australian College of General Practitioners (Nicholas Zwar); Qantas Airways (Dr. Ian Cheng); Virgin Blue Airways (Ms. Bronwyn Claxton); and Youth Hostels Association (Julie Freeman). 1477-8939/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.tmaid.2009.03.008
Risks of hepatitis B in Australian travellers to Asia
345
HBV risk during their last overseas trip. Of those travellers aged 18 years and over who either had no HBV vaccination or who were unsure, about half (49%) had participated in at least one activity with HBV risk during their last overseas trip. Conclusions: Australian travellers to Southeast Asia and East Asia commonly undertake activities with a risk of exposure to HBV. Hepatitis B vaccination coverage amongst this group remains low. It is important that travellers to this region seek travel health advice from a qualified source, which will include a risk assessment for hepatitis B vaccination. ª 2009 Elsevier Ltd. All rights reserved.
Introduction About 4.5 million Australians travel abroad each year.1 These travellers are potentially exposed to infectious diseases for which they have no immunity, as well as other serious threats to well being, such as accidents and exacerbation of pre-existing medical and dental conditions. Conservatively, it is estimated that between 30 and 50% of travellers become ill or injured whilst travelling.2,3 Southeast Asia and East Asia are regarded as highly endemic regions for hepatitis B virus (HBV) (see Fig. 1) and include many popular destinations for Australian travellers.1 The monthly incidence rates of symptomatic and asymptomatic infection have previously been estimated to be 60 and 360, respectively, per 100,000 in travellers staying for various periods of time in Asia.4 Risky behaviours for HBV infection for travellers have traditionally included undergoing tattooing, piercing, acupuncture, accessing medical or dental care in circumstances of poor infection control, having casual
unprotected sex with locals, and sharing of needles for intravenous drug use.5 Accidents are another major area of risk for HBV exposure, particularly as they are one of the leading causes of morbidity and mortality amongst travellers. Further, an accidental injury or other medical emergency may result in the need for medical or dental treatment in circumstances of poor infection control, which may include a blood transfusion with contaminated blood products.5 It is important therefore that travellers seek pre-travel health advice concerning such risks and be immunised against HBV infection, particularly if the traveller is in a high risk occupational or recreational group.5 Little is known about HBV infection risks and immunisation coverage amongst Australians travelling to high risk areas. The objectives of this survey were to evaluate the extent of pre-travel health advice, the prevalence of behaviours with HBV infection risks and the prevalence of HBV vaccination amongst Australian travellers to Southeast Asia and East Asia.
Figure 1 Distribution map of HBV surface antigen prevalence by level of prevalence in 2006. Source: Centers for Disease Control and Prevention. URL: http://wwwn.cdc.gov/travel/yellowBookCh4-HepB.aspx [accessed 20 March 2009].
346
Methods
P.A. Leggat et al. Table 1
Age groups of sample.
Age groups
In 2004, a telephone survey was conducted amongst Australians aged 14 years and older by interviewers from Roy Morgan Research (Endemic Regions and Vaccinations Study, 2004, GSKV227/SEE), under the auspices of the Australian Travel Health Advisory Group. The sample of respondents was drawn from the Australian Roy Morgan Single Source survey, an ongoing survey which collects information through a combination of a face-to-face interview of over 50,000 people and approximately 25,000 self-completion surveys per annum with people aged 14 years and over. A re-contact sample of 1668 people was drawn from the Australian Roy Morgan Single Source survey, who met the following criteria: visited a disease endemic destination for business; visited a disease endemic destination for leisure; and/or intend to travel to a disease endemic destination for leisure. The sample was re-proportioned to ensure accurate representation of travellers by age, gender and place of residence, as ascertained from the Roy Morgan Single Source Holiday Tracking Survey for the year ending June 2004 which reflects Australian Bureau of Statistics (ABS) population estimates. This methodology enabled a highly targeted sample that has a low incidence in the population to be easily identified. From the available sample drawn a total of 1571 contacts were made (97 in the sample were not used). This included 309 completions and the remainder comprised 228 refusals, 110 terminations, 456 who were unobtainable (including 314 respondents who were tried three or more times to be contacted without success), and 69 general appointments, which were not required as all quotas had been filled. The balance failed the set quotas. Non-interlocking quotas by destination and reason for travel, which were representative of travel to Southeast Asia and East Asia, were applied. These quotas were ascertained from Roy Morgan Single Source and cross-referenced with Overseas Arrivals and Departures (OAD) data from the Australian Bureau of Statistics (ABS).6 At the conclusion of field work a total of 309 respondents met the set quotas and completed the entire survey. The data were re-proportioned to ensure accurate representation of travellers by age, gender and place of residence, as ascertained from the Roy Morgan Single Source Holiday Tracking Survey for the year ending June 2004. Using the travel and tourism information collected within the self-completion component of the survey respondents were identified and re-contacted. Inclusion criteria incorporated those who had travelled overseas or intended to travel to Southeast Asia and East Asia in the past three years for three nights or more. All respondents were re-screened on the travel behaviour criteria to identify their most recent trip, destination and where they spent the greatest number of nights. The proportion of sample per destination was representative of travellers to Southeast Asian and East Asian destinations as well as representative of the proportion of leisure (80%) and business travellers (20%). Demographic information was collected and travellers were also asked about whether they had sought pre-travel health advice, when they sought this advice, and whether they had received HBV vaccination. They were also asked about risk activities for HBV infection.
14e17 10
18e24 19
25e34 33
35e49 92
50e64 112
65þ 42
Missing data Z 1.
Results Demographic characteristics Three hundred and nine travellers aged 14 years and over, including 138 males (45%) and 171 females (55%), were interviewed. The age distribution is given in Table 1. Respondents travelled for leisure (64%), business (20%), and visiting friends and relatives (VFR) (16%) (see Table 2). Most common destinations (more than one destination possible) were Indonesia (34%), Thailand (32%), and China (27%) (see Table 2).
Pre-travel health advice Just over half of the travellers (54%) sought travel health advice before travel of which over half (56%) had sought this advice more than six weeks before travel. Travellers sought health advice from their family/regular/local doctor (45%), the Internet (17%), travel agent (17%), travel health clinic/ specialist (5%), family or friends (4%), travel guide book (3%) and a variety of other sources (7%). Male travellers were significantly more likely to have sought travel related health information primarily from a travel agent (p < 0.05). Table 3 gives the source of travel health advice for each category of traveller. Business travellers were significantly more likely to primarily seek travel related health advice from travel health clinic/travel health specialist (p < 0.01). Holiday/leisure travellers were significantly more likely to seek primarily travel related health advice from their family/regular/local doctor (p < 0.01). Those who visited friends and relatives primarily sought travel related health advice from family or friends (p < 0.01).
Hepatitis B vaccination Just over one quarter of travellers reported having HBV vaccination (28%) of which most (70%) had received the vaccination at least three weeks before travel. Almost one fifth (18%) reported receiving unspecified hepatitis Table 2
Reasons for travel by destination.
Country
Total (N Z 309)
Business (N Z 62)
VFR (N Z 44)
Leisure (N Z 200)
Indonesia Malaysia Philippines Thailand Vietnam China
105 65 22 97 46 84
21 13 8 14 5 24
8 12 10 11 6 18
74 39 4 73 36 42
VFR Z visiting friends and relatives.
Risks of hepatitis B in Australian travellers to Asia Table 3
347
Source of travel health advice by the type of traveller.
Source of health advice
Local/family/regular doctor Internet Travel agent Family/friend Travel health clinic/specialist Work/colleague Travel guide book The Government/health department Insurance company Airline Pharmacist Other
Type of traveller Business
Visiting friends and relatives
Holiday/leisure
Other non-business
40% 37% 19% 2% 21% 21% 4% 4% 2% e e 4%
63% 12% 25% 30% 5% e 4% 8% 2% e e e
70% 33% 29% 13% 6% 1% 5% 1% 2% 1% 1% 5%
35% 35% 65% 19% e e e 35% e e e e
vaccination and over half of travellers (55%) reported receiving no hepatitis vaccination. Travellers in the 18e24 years age group were significantly less likely than other age groups to be immunised against HBV or hepatitis unspecified (p < 0.01). High income travellers (>AUD120,000; AUD1 z USD0.67) were more likely to be immunised against hepatitis B or hepatitis unspecified than lower income travellers (p < 0.01).
At risk activities for hepatitis B Just under half of travellers (49%) had participated in at least one activity with an HBV risk during their last overseas trip (see Table 4). Almost half of the travellers aged 18 years and over (49%), who either had no HBV vaccination or who were unsure, had participated in at least one activity with an HBV risk during their last overseas trip. Male travellers and travellers in the 18e24 years age group were significantly more likely to participate in at least one activity with HBV risk during their last overseas trip, 58% and 77%, respectively (p < 0.01).
Discussion Demographic characteristics Large number of Australian travellers are travelling for leisure to Southeast Asia and East Asia, although business and VFR travellers make up about one third of travellers to this region. Middle and older age groups make up about two-third of these travellers. Indonesia, Thailand and China were the most popular destinations in this region.
Pre-travel health advice One of the biggest challenges for travel health professionals and the travel industry has been getting travellers to present for pre-travel health advice from a qualified source and in a timely manner. It has been found in previous studies that only 33e50% of travellers were seeking pre-
Table 4 Activities with HBV risk of Australian travellers aged 18 years. Activities with HBV risk
18 Participation on last overseas trip
Ride a motorcycle or drive an off road vehicle Participate in any water sports other than swimming Visit a health professional such as a doctor or nurse for any reason Participate in any contact sport such as football Receive any sort of injuries Have sexual contact using a condom with anyone who is not your regular partner Have any contact with anyone else’s blood or give first aid Require any dental procedures Require any medical or non-medical injections Have sexual contact without using a condom with anyone who is not your regular partner Have an ear or any other body piercing or tattoo Receive acupuncture Share a razor or toothbrush with a newly met person or a stranger Require a blood transfusion
24% 23% 16%
8% 9% 8%
5%
4% 2% 1%
1% 1% 0%
e
348 travel health advice.6e8 In this study, the results suggest that the proportion of travellers who had sought pre-travel health advice was similarly low and that the local/family/ regular doctor was the most likely source of health advice, especially for those travelling for leisure, which is similar to a previous studies summarised elsewhere.9 It is important that policies, which are being promoted by travel health groups in Australia,10 continue to advocate that travellers seek travel health advice early, preferably around sixe eight weeks before travel.
Hepatitis B vaccination Hepatitis B is a vaccine-preventable disease, which is routinely discussed as part of the travel health consultation, particularly for those travelling to Southeast Asia and East Asia, where the disease is considered endemic.5 The proportion of Australian travellers who did not receive hepatitis B vaccination prior to travel may be lower than suggested by previous Australian surveys,11,12 but higher than previous surveys of European13 and American travellers.14 Nonetheless, it is very important that travellers, who may be exposed to blood or body fluids (e.g. occupationally, at risk sporting activities, accidents), have sexual contact with the local population, or be exposed to medical or dental treatment in this region, be vaccinated for HBV. Indeed, HBV vaccination is also recommended for all travellers to areas with moderate to high risk of infection.5
At risk behaviours for HBV The proportion of Australian travellers at risk of HBV during their travel is substantially higher than what previous surveys have suggested.11e14 It is very important that travellers, who may be exposed to blood or body fluids (e.g. occupationally, at risk sporting activities, accidents), have sexual contact with the local population, or be exposed to medical or dental treatment in this region, be vaccinated for HBV. Indeed, HBV vaccination is recommended by the World Health Organization (WHO) for virtually all travellers to areas with moderate to high risk of infection.5 The Australian immunisation guidelines, which prevailed at the time of this study,15 are less prescriptive about vaccination for HBV than the WHO.5 The current Australian Immunisation Handbook recommends that ‘‘people travelling to regions of intermediate or high endemicity, either longterm or for frequent short terms, should be vaccinated’’(p. 159).16 The results of this study suggest that more public education is needed about the importance of pre-travel health advice and appropriate vaccination for HBV.
Limitations of the study This cross-sectional survey has some methodological limitations, including recall bias and the limited generalisability, in that it is focused on only 309 travellers to one area and from one country. The recruitment method employed and reproportioning applied attempted to minimise limitations of the survey. It should also be noted however that the Roy Morgan Single Source questionnaire is completed in English;
P.A. Leggat et al. hence there may be under-representation in the sample of people from non-English speaking backgrounds.
Conclusions Australian travellers to Southeast Asia and East Asia commonly undertake activities with a risk of exposure to HBV. Hepatitis B vaccination coverage amongst this group remains low. It is important that travellers to this region seek travel health advice from a qualified source, which will include a risk assessment for hepatitis B vaccination and advice should also be given on injury prevention.
Conflict of interest The activities of the Australian Travel Health Advice Group (THAG) are funded by GlaxoSmithKline, Australia. The sponsor had no role in the development of the study protocol, data analysis, or drafting of this article.
Acknowledgements We are grateful to all those who agreed to participate in our study.
References 1. Australian Bureau of Statistics. Australian resident departures 2005. In: Year book Australia 2007. Catalogue no. 1301.0; 2007. URL: [accessed 20 March 2009]. 2. Steffen R, Rickenbarh M, Wilhelm U, Helminger A, Scha ¨r M. Health problems after travel to developing countries. J Infect Dis 1987;156:84e91. 3. Cossar JH, Reid D, Fallon RJ, Bell EJ, Riding MH, Follett EA, et al. A cumulative review of studies on travellers, their experience of illness and the implications of these findings. J Infect 1990;21:27e42. 4. Steffen R. Risks of hepatitis B for travellers. Vaccine 1990; 8(Suppl.):S31e2. 5. World Health Organization. International travel and health. Geneva: WHO. URL: ; 2008 [accessed 11 February 2009]. 6. Australian Bureau of Statistics. 21.14 Australians travelling abroad. In: Year book Australia 2004. Catalogue no. 1301.0; 2004. URL: [accessed 20 March 2009]. 7. Leggat PA. Health advice provided to hostelers from Australia: influence of a travelers’ information evening. J Travel Med 2002;9:24e8. 8. Zwar N, Streeton CL, on behalf of the Travel Health Advisory Group. Pretravel advice and hepatitis A immunization among Australian travelers. J Travel Med 2007;14:31e6. 9. Leggat PA. Sources of health advice for travelers. J Travel Med 2000;7:85e8. 10. Travel Health Advisory Group. Objectives; 2009. URL: [accessed 20 March 2009]. 11. Zwar N, on behalf of the Australian Travel Health Advisory Group. Hepatitis risk and vaccination among Australian travellers overseas. Med J Aust 2003;178:469e70.
Risks of hepatitis B in Australian travellers to Asia 12. Streeton CL, Zwar N, on behalf of the Australian Travel Health Advisory Group. Risk of exposure to hepatitis B and other blood-borne viruses among Australians who travel abroad. J Travel Med 2006;13:345e50. 13. Zuckerman JN, Steffen R. Risks of hepatitis B in travellers as compared to immunization status. J Travel Med 2000;7: 170e4.
349 14. Connor BA, Jacobs RJ, Meyerhoff AS. Hepatitis B risks and immunization coverage among American travellers. J Travel Med 2006;13:273e80. 15. National Health and Medical Research Council. Australian immunisation handbook. 8th ed. Canberra: NHMRC; 2003. 16. National Health and Medical Research Council. Australian immunisation handbook. 9th ed. Canberra: NHMRC; 2008.
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
Hepatitis B risks and immunisation coverage amongst Australians travelling to Southeast Asia and East Asia Peter A. Leggat a,*, Nicholas A. Zwar b, Bernard J. Hudson a,c, on behalf of the Travel Health Advisory Group, Australiad a
School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Queensland 4811, Australia b School of Public Health and Community Medicine, University of New South Wales, Australia c MASTA (Australia), Sydney, Australia Received 20 March 2009; accepted 24 March 2009 Available online 9 May 2009
KEYWORDS Hepatitis B; Vaccination; Southeast Asia; Australia; Risk; Travel
Summary Background: Southeast Asia and East Asia are regarded as highly endemic regions for hepatitis B virus (HBV) and include many popular destinations for Australian travellers. The objectives of this survey were to evaluate the extent of pre-travel health advice, the prevalence of behaviours with HBV infection risks and the prevalence of HBV vaccination amongst Australian travellers to Southeast Asia and East Asia. Methods: In 2004, a telephone survey was conducted amongst Australians, who had travelled overseas to Southeast Asia and East Asia in the past three years for three nights or more. Results: Three hundred and nine travellers aged 14 years and over completed the interview, including 138 males (45%) and 171 females (55%). Respondents travelled for leisure (64%), business (20%), and visiting friends and relatives (VFR) (16%). The most common destinations were Indonesia (34%), Thailand (32%), and China (27%). About half of the travellers (54%) sought vaccination specific health advice before travel of which about half (56%) had sought this advice more than six weeks before travel. Just over one quarter of travellers reported receiving HBV vaccination (28%) of whom most (70%) were vaccinated at least three weeks before travel. About half of the travellers (49%) had participated in at least one activity with
* Corresponding author. Tel.: þ61 7 47816108; fax: þ61 7 47815254. E-mail address: [email protected] (P.A. Leggat). d Member organizations of the Australian Travel Health Advisory Group (and representatives) are Anton Breinl Center, James Cook University (Peter A. Leggat); Australian Federation of Travel Agents (Jayson Westbury); Faculty of Travel Medicine, The Australasian College of Tropical Medicine (Tony Gherardin); Jetset Travelworld (Karen Magee); MASTA (Australia) (Bernard Hudson); Royal Australian College of General Practitioners (Nicholas Zwar); Qantas Airways (Dr. Ian Cheng); Virgin Blue Airways (Ms. Bronwyn Claxton); and Youth Hostels Association (Julie Freeman). 1477-8939/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.tmaid.2009.03.008
Risks of hepatitis B in Australian travellers to Asia
345
HBV risk during their last overseas trip. Of those travellers aged 18 years and over who either had no HBV vaccination or who were unsure, about half (49%) had participated in at least one activity with HBV risk during their last overseas trip. Conclusions: Australian travellers to Southeast Asia and East Asia commonly undertake activities with a risk of exposure to HBV. Hepatitis B vaccination coverage amongst this group remains low. It is important that travellers to this region seek travel health advice from a qualified source, which will include a risk assessment for hepatitis B vaccination. ª 2009 Elsevier Ltd. All rights reserved.
Introduction About 4.5 million Australians travel abroad each year.1 These travellers are potentially exposed to infectious diseases for which they have no immunity, as well as other serious threats to well being, such as accidents and exacerbation of pre-existing medical and dental conditions. Conservatively, it is estimated that between 30 and 50% of travellers become ill or injured whilst travelling.2,3 Southeast Asia and East Asia are regarded as highly endemic regions for hepatitis B virus (HBV) (see Fig. 1) and include many popular destinations for Australian travellers.1 The monthly incidence rates of symptomatic and asymptomatic infection have previously been estimated to be 60 and 360, respectively, per 100,000 in travellers staying for various periods of time in Asia.4 Risky behaviours for HBV infection for travellers have traditionally included undergoing tattooing, piercing, acupuncture, accessing medical or dental care in circumstances of poor infection control, having casual
unprotected sex with locals, and sharing of needles for intravenous drug use.5 Accidents are another major area of risk for HBV exposure, particularly as they are one of the leading causes of morbidity and mortality amongst travellers. Further, an accidental injury or other medical emergency may result in the need for medical or dental treatment in circumstances of poor infection control, which may include a blood transfusion with contaminated blood products.5 It is important therefore that travellers seek pre-travel health advice concerning such risks and be immunised against HBV infection, particularly if the traveller is in a high risk occupational or recreational group.5 Little is known about HBV infection risks and immunisation coverage amongst Australians travelling to high risk areas. The objectives of this survey were to evaluate the extent of pre-travel health advice, the prevalence of behaviours with HBV infection risks and the prevalence of HBV vaccination amongst Australian travellers to Southeast Asia and East Asia.
Figure 1 Distribution map of HBV surface antigen prevalence by level of prevalence in 2006. Source: Centers for Disease Control and Prevention. URL: http://wwwn.cdc.gov/travel/yellowBookCh4-HepB.aspx [accessed 20 March 2009].
346
Methods
P.A. Leggat et al. Table 1
Age groups of sample.
Age groups
In 2004, a telephone survey was conducted amongst Australians aged 14 years and older by interviewers from Roy Morgan Research (Endemic Regions and Vaccinations Study, 2004, GSKV227/SEE), under the auspices of the Australian Travel Health Advisory Group. The sample of respondents was drawn from the Australian Roy Morgan Single Source survey, an ongoing survey which collects information through a combination of a face-to-face interview of over 50,000 people and approximately 25,000 self-completion surveys per annum with people aged 14 years and over. A re-contact sample of 1668 people was drawn from the Australian Roy Morgan Single Source survey, who met the following criteria: visited a disease endemic destination for business; visited a disease endemic destination for leisure; and/or intend to travel to a disease endemic destination for leisure. The sample was re-proportioned to ensure accurate representation of travellers by age, gender and place of residence, as ascertained from the Roy Morgan Single Source Holiday Tracking Survey for the year ending June 2004 which reflects Australian Bureau of Statistics (ABS) population estimates. This methodology enabled a highly targeted sample that has a low incidence in the population to be easily identified. From the available sample drawn a total of 1571 contacts were made (97 in the sample were not used). This included 309 completions and the remainder comprised 228 refusals, 110 terminations, 456 who were unobtainable (including 314 respondents who were tried three or more times to be contacted without success), and 69 general appointments, which were not required as all quotas had been filled. The balance failed the set quotas. Non-interlocking quotas by destination and reason for travel, which were representative of travel to Southeast Asia and East Asia, were applied. These quotas were ascertained from Roy Morgan Single Source and cross-referenced with Overseas Arrivals and Departures (OAD) data from the Australian Bureau of Statistics (ABS).6 At the conclusion of field work a total of 309 respondents met the set quotas and completed the entire survey. The data were re-proportioned to ensure accurate representation of travellers by age, gender and place of residence, as ascertained from the Roy Morgan Single Source Holiday Tracking Survey for the year ending June 2004. Using the travel and tourism information collected within the self-completion component of the survey respondents were identified and re-contacted. Inclusion criteria incorporated those who had travelled overseas or intended to travel to Southeast Asia and East Asia in the past three years for three nights or more. All respondents were re-screened on the travel behaviour criteria to identify their most recent trip, destination and where they spent the greatest number of nights. The proportion of sample per destination was representative of travellers to Southeast Asian and East Asian destinations as well as representative of the proportion of leisure (80%) and business travellers (20%). Demographic information was collected and travellers were also asked about whether they had sought pre-travel health advice, when they sought this advice, and whether they had received HBV vaccination. They were also asked about risk activities for HBV infection.
14e17 10
18e24 19
25e34 33
35e49 92
50e64 112
65þ 42
Missing data Z 1.
Results Demographic characteristics Three hundred and nine travellers aged 14 years and over, including 138 males (45%) and 171 females (55%), were interviewed. The age distribution is given in Table 1. Respondents travelled for leisure (64%), business (20%), and visiting friends and relatives (VFR) (16%) (see Table 2). Most common destinations (more than one destination possible) were Indonesia (34%), Thailand (32%), and China (27%) (see Table 2).
Pre-travel health advice Just over half of the travellers (54%) sought travel health advice before travel of which over half (56%) had sought this advice more than six weeks before travel. Travellers sought health advice from their family/regular/local doctor (45%), the Internet (17%), travel agent (17%), travel health clinic/ specialist (5%), family or friends (4%), travel guide book (3%) and a variety of other sources (7%). Male travellers were significantly more likely to have sought travel related health information primarily from a travel agent (p < 0.05). Table 3 gives the source of travel health advice for each category of traveller. Business travellers were significantly more likely to primarily seek travel related health advice from travel health clinic/travel health specialist (p < 0.01). Holiday/leisure travellers were significantly more likely to seek primarily travel related health advice from their family/regular/local doctor (p < 0.01). Those who visited friends and relatives primarily sought travel related health advice from family or friends (p < 0.01).
Hepatitis B vaccination Just over one quarter of travellers reported having HBV vaccination (28%) of which most (70%) had received the vaccination at least three weeks before travel. Almost one fifth (18%) reported receiving unspecified hepatitis Table 2
Reasons for travel by destination.
Country
Total (N Z 309)
Business (N Z 62)
VFR (N Z 44)
Leisure (N Z 200)
Indonesia Malaysia Philippines Thailand Vietnam China
105 65 22 97 46 84
21 13 8 14 5 24
8 12 10 11 6 18
74 39 4 73 36 42
VFR Z visiting friends and relatives.
Risks of hepatitis B in Australian travellers to Asia Table 3
347
Source of travel health advice by the type of traveller.
Source of health advice
Local/family/regular doctor Internet Travel agent Family/friend Travel health clinic/specialist Work/colleague Travel guide book The Government/health department Insurance company Airline Pharmacist Other
Type of traveller Business
Visiting friends and relatives
Holiday/leisure
Other non-business
40% 37% 19% 2% 21% 21% 4% 4% 2% e e 4%
63% 12% 25% 30% 5% e 4% 8% 2% e e e
70% 33% 29% 13% 6% 1% 5% 1% 2% 1% 1% 5%
35% 35% 65% 19% e e e 35% e e e e
vaccination and over half of travellers (55%) reported receiving no hepatitis vaccination. Travellers in the 18e24 years age group were significantly less likely than other age groups to be immunised against HBV or hepatitis unspecified (p < 0.01). High income travellers (>AUD120,000; AUD1 z USD0.67) were more likely to be immunised against hepatitis B or hepatitis unspecified than lower income travellers (p < 0.01).
At risk activities for hepatitis B Just under half of travellers (49%) had participated in at least one activity with an HBV risk during their last overseas trip (see Table 4). Almost half of the travellers aged 18 years and over (49%), who either had no HBV vaccination or who were unsure, had participated in at least one activity with an HBV risk during their last overseas trip. Male travellers and travellers in the 18e24 years age group were significantly more likely to participate in at least one activity with HBV risk during their last overseas trip, 58% and 77%, respectively (p < 0.01).
Discussion Demographic characteristics Large number of Australian travellers are travelling for leisure to Southeast Asia and East Asia, although business and VFR travellers make up about one third of travellers to this region. Middle and older age groups make up about two-third of these travellers. Indonesia, Thailand and China were the most popular destinations in this region.
Pre-travel health advice One of the biggest challenges for travel health professionals and the travel industry has been getting travellers to present for pre-travel health advice from a qualified source and in a timely manner. It has been found in previous studies that only 33e50% of travellers were seeking pre-
Table 4 Activities with HBV risk of Australian travellers aged 18 years. Activities with HBV risk
18 Participation on last overseas trip
Ride a motorcycle or drive an off road vehicle Participate in any water sports other than swimming Visit a health professional such as a doctor or nurse for any reason Participate in any contact sport such as football Receive any sort of injuries Have sexual contact using a condom with anyone who is not your regular partner Have any contact with anyone else’s blood or give first aid Require any dental procedures Require any medical or non-medical injections Have sexual contact without using a condom with anyone who is not your regular partner Have an ear or any other body piercing or tattoo Receive acupuncture Share a razor or toothbrush with a newly met person or a stranger Require a blood transfusion
24% 23% 16%
8% 9% 8%
5%
4% 2% 1%
1% 1% 0%
e
348 travel health advice.6e8 In this study, the results suggest that the proportion of travellers who had sought pre-travel health advice was similarly low and that the local/family/ regular doctor was the most likely source of health advice, especially for those travelling for leisure, which is similar to a previous studies summarised elsewhere.9 It is important that policies, which are being promoted by travel health groups in Australia,10 continue to advocate that travellers seek travel health advice early, preferably around sixe eight weeks before travel.
Hepatitis B vaccination Hepatitis B is a vaccine-preventable disease, which is routinely discussed as part of the travel health consultation, particularly for those travelling to Southeast Asia and East Asia, where the disease is considered endemic.5 The proportion of Australian travellers who did not receive hepatitis B vaccination prior to travel may be lower than suggested by previous Australian surveys,11,12 but higher than previous surveys of European13 and American travellers.14 Nonetheless, it is very important that travellers, who may be exposed to blood or body fluids (e.g. occupationally, at risk sporting activities, accidents), have sexual contact with the local population, or be exposed to medical or dental treatment in this region, be vaccinated for HBV. Indeed, HBV vaccination is also recommended for all travellers to areas with moderate to high risk of infection.5
At risk behaviours for HBV The proportion of Australian travellers at risk of HBV during their travel is substantially higher than what previous surveys have suggested.11e14 It is very important that travellers, who may be exposed to blood or body fluids (e.g. occupationally, at risk sporting activities, accidents), have sexual contact with the local population, or be exposed to medical or dental treatment in this region, be vaccinated for HBV. Indeed, HBV vaccination is recommended by the World Health Organization (WHO) for virtually all travellers to areas with moderate to high risk of infection.5 The Australian immunisation guidelines, which prevailed at the time of this study,15 are less prescriptive about vaccination for HBV than the WHO.5 The current Australian Immunisation Handbook recommends that ‘‘people travelling to regions of intermediate or high endemicity, either longterm or for frequent short terms, should be vaccinated’’(p. 159).16 The results of this study suggest that more public education is needed about the importance of pre-travel health advice and appropriate vaccination for HBV.
Limitations of the study This cross-sectional survey has some methodological limitations, including recall bias and the limited generalisability, in that it is focused on only 309 travellers to one area and from one country. The recruitment method employed and reproportioning applied attempted to minimise limitations of the survey. It should also be noted however that the Roy Morgan Single Source questionnaire is completed in English;
P.A. Leggat et al. hence there may be under-representation in the sample of people from non-English speaking backgrounds.
Conclusions Australian travellers to Southeast Asia and East Asia commonly undertake activities with a risk of exposure to HBV. Hepatitis B vaccination coverage amongst this group remains low. It is important that travellers to this region seek travel health advice from a qualified source, which will include a risk assessment for hepatitis B vaccination and advice should also be given on injury prevention.
Conflict of interest The activities of the Australian Travel Health Advice Group (THAG) are funded by GlaxoSmithKline, Australia. The sponsor had no role in the development of the study protocol, data analysis, or drafting of this article.
Acknowledgements We are grateful to all those who agreed to participate in our study.
References 1. Australian Bureau of Statistics. Australian resident departures 2005. In: Year book Australia 2007. Catalogue no. 1301.0; 2007. URL:
Risks of hepatitis B in Australian travellers to Asia 12. Streeton CL, Zwar N, on behalf of the Australian Travel Health Advisory Group. Risk of exposure to hepatitis B and other blood-borne viruses among Australians who travel abroad. J Travel Med 2006;13:345e50. 13. Zuckerman JN, Steffen R. Risks of hepatitis B in travellers as compared to immunization status. J Travel Med 2000;7: 170e4.
349 14. Connor BA, Jacobs RJ, Meyerhoff AS. Hepatitis B risks and immunization coverage among American travellers. J Travel Med 2006;13:273e80. 15. National Health and Medical Research Council. Australian immunisation handbook. 8th ed. Canberra: NHMRC; 2003. 16. National Health and Medical Research Council. Australian immunisation handbook. 9th ed. Canberra: NHMRC; 2008.