An outbreak of Hepatitis A in Cuba

According to news reports, the Cuban Ministry of Public Health has issued a health alert regarding hepatitis A, a common viral disease of low and low middle-income countries. The current outbreak probably started in May last year.

Hepatitis A is transmitted through contaminated food or water and is common in areas where water and environmental sanitation is poor.

Most adults in low and low middle-income countries have already acquired the disease in childhood and are immune for life. They are usually unaware of exposure, as the disease can have no symptoms in young children. The illness is likely to be more severe as an adult with some studies showing a 3% mortality rate over 40 years. It can take many months to fully recover from the effects of the disease.

Should travellers consider Hepatitis A vaccination?

Travellers from countries like Australia and New Zealand are unlikely to have natural immunity to the disease and are generally advised to consider vaccination if travelling to risk areas. Vaccination is a recommended childhood immunisation in the United States.

In Australia it is recommended and funded for Aboriginal and Torres Strait islands children living in the Northern Territory, Queensland, South Australia and Western Australia but not for the wider childhood immunisation program. Hopefully this will change in the future.

The hepatitis A vaccine has been available in Australia since 1994. It should not be confused with Hepatitis B vaccination which was first offered in the 1980’s.

Two doses of hepatitis A vaccine given 6 months apart will provide good protection for many years. The first dose is often given prior to a trip and then the booster dose 6 to 12 months later.

The vaccine can be given from 12 months of age, but consideration might also be offered to children aged 6-12 months visiting high risk locations (Africa, Indian subcontinent etc). While the disease is likely to be mild (not all) in this age group, there is a possibility they can return infected and start an outbreak in a childcare centre or school.

The vaccine is also available as a combination with hepatitis B. This vaccine is called Twinrix. This is usually given as a course 0, 1 and 6 months. If the traveller is intending to be away for a lengthy period, a rapid course of the vaccine can be given at 0,1 and 3 weeks. A booster dose should be given after 12 months for long term protection.

Hepatitis B is now an included childhood vaccine in the first year of life but previously given as a childhood catch up vaccine in high school. Most children born from 1985 would have been offered 2 or 3 doses of hepatitis B in high school.

Increasing cases in Australia - most acquired overseas

More than 200 cases of hepatitis A have been notified in Australia over the past 12 months. Most of these would have been acquired overseas.

Only 19 cases were recorded for a similar period in November 2021 – when Australia’s borders were closed!

A large outbreak is also being reported in northern India (Darjeeling) and Sikkim.

The Indian subcontinent has always been considered high risk for hepatitis A and many older travellers might remember the very uncomfortable gammaglobulin injection given into the buttocks prior to the introduction of the vaccine.

Gammaglobulin was not a vaccine, just antibody, providing 3-6 months short term protection for travellers. It would have prevented many cases of hepatitis A in backpackers travelling in India and Nepal. It was still being used in the late 90’s and should not be confused with vaccination.