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Subject: Hepatitis A

From: Christos


I am planning to go to Greece. I was told that I have to be careful of
hepatitis A.  Is there any danger in contracting hepatitis A in Greece and second do I need to immunize myself and my family form hepatitis A? Any other travel advice about Greece is also welcome.

Reply from Dr. Bazos: (See Addendum update)

Hepatitis A is a liver disease caused by the hepatitis A (Hep-A) virus. Some Greeks refer to this as the "A-HEP-A" virus. Other synonyms for this disease include "infectious hepatitis" and "short-incubation hepatitis".

It usually causes symptoms in children and adults but often has no symptoms (asymptomatic) in younger children.

The virus is spread (transmitted) almost exclusively via interpersonal feces-mouth (fecal-oral) contact or ingestion of contaminated water. Although HAV can affect anyone, it almost always occurs in areas with inadequate sewage facilities and contaminated water. Eating contaminated food (e.g. shellfish) may also place you at risk.

Last year over 3,000 cases of Hepatitis A were reported in Canada. The real incidence is actually much higher because the disease is frequently asymptomatic.

Symptoms begin anywhere from 2 to 6 weeks after exposure and contact with the virus. These symptoms typically include fever, fatigue, loss of apetite, nausea, abdominal pain, diarrhea and jaundice (greenish skin and yellowish eyeballs). One usually recovers completely from the illness within 2 months after symptoms. Severe liver damage, necrosis and death are very rare, but have been reported. Once infected then you are protected from recurrence (e.g. life long immunity).

High Risk Groups in Canada include:

1. Household or sexual contacts of already infected persons with Hep A; 
2. International travellers (especially travellers to Africa, Asia, Southeast Asia, Central and South America, eastern and southern Europe, Greenland and the Middle East);
3. Persons living in high incidence locations (endemic areas) such as Native Canadian Indian reservations, correctional facilities, and those for developmentally challenged persons; 
4. During Community outbreaks: daycare center employees or children;
5. Homosexually active men involving anal contact, IV drug users

This disease usually occurs in outbreaks every decade or so. The last epidemic occured in 1989.

Good hygiene and sanitation will prevent transmission. Careful attention to thorough handwashing after toileting (with a separate towel) will prevent most household and institutional spread. If you're traveling, then avoid ingesting untreated water, iced drinks, uncooked shellfish, and uncooked fruits and vegetables in which you yourself have not supervised personally.

Follow the old Greek expression, "If you can't peel it or boil it, then don't eat it (and don't marry it)." Hep A virus is inactivated, dead and becomes non contagious with only 1 minute of heating food at 85 degree C. 

Yes, there are effective vaccines available to prevent acquiring the virus and provide life-long immunity. These vaccines are currently only recommended for the High Risk Groups mentioned above. In Canada there are 2 vaccines available: HAVRIX (SmithKline Beecham Pharma) and VAQTA (Merck Frosst). Both are given by deep injection into the shoulder (deltoid) muscle. There are 2 doses of vaccines given, initially and 6 months afterwards. 

Vaccination is recommended for travelers to and planning to live in developing countries stated above, especially in rural areas where the food and water supply is likely to be poor, and hence a haven area for Hepatitis A. The safety of these vaccines during pregnancy and breast-feeding (lactation) have not been established and are best left to decide by the patient and her treating physician.

So Christos, if you have been exposed to the Hep A virus less than 4 weeks, then you may also be given an additional Immune globulin (IG) vaccine. IG stimulates your immune system to work in overdrive and hence (hopefully) start creating antibodies to Hep A to prevent infection and disease and liver damage. Close contacts of infected persons should receive IG in a single dose within 2 weeks (preferably 72 hours) after exposure. Unlike the above active 2 vaccines, IG is passive in nature and hence safe to give during pregnancy. In Ontario, IG is not easy to acquire. It requires a doctors prescription and is available only in certain hospital pharmacies or alternatively in the Red Cross Blood Bank Central Pharmacy.

Now, what about Greece? In 1999 the World Health Organization (W.H.O) and Health Canada reported that hepatitis A and typhoid fever "can occur" in Greece. They did not mention any specific outbreak or cause for any alarm. To protect themselves they both recommended that any individual risk assessment be made by a travel medicine provider prior to departure. Christos, I have been to Greece several times and am not aware of any outbreak or vaccine endemic areas. I suspect the above reports were prompted during Greece's involvement in Kossivo when there was a significant influx of Albanian refugees in Greece suffering from infectious communicable diseases due to the aversities they were facing.

Therefore, I see no reason for either you or your family to warrant any hepatitis A vaccination.

Personally, if you are planning to go to Greece this summer, than Hep A should be a far distant priority to the following:

1. Safety and Crime: Pay careful attention to your personal valuables as petty theft is prevalent in Greece, especially in urban areas. Tourists are particularly targetted to pickpocketing, purse snatching, luggage theft, and muggings at tourist sites. Recently, some of these robberies have involved the use of violence.

Tips: Travel with your passports, tickets, and money separate in case of theft/loss.

Only carry enough money for anticipated expenses. Carry traveller's cheques.

2. MVA'S: Greece has the highest fatality traffic accidents in Europe. Driving is considered extremely dangerous (even by French Canadaian standards!) I have seen many tragedies and fatalities to my patients while vacationing in Greece. Hazardous terrain and heavy traffic make it very difficult and risky for tourists. Motorcycles are particularly dangerous, especially on the islands, and tourists who rent them are often not covered by insurance.

Tips: Drive defensively, as road conditions are very different from Canada.

Avoid isolated areas. Do not travel alone.

Only visit unknown areas with official guidance.

So Christos, if I have managed to infect you with some of my above germinal pearls, then you and your family will hopefully be singing "OPAH!!" this summer and not crying "A-HEP-A!!" at some travel clinic in Greece.

"Yiassou" Christos!

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