The Wall Street Journal - May 6, 1997
Marilyn Chase

"In the U.S., we don't do a good job of getting people to go to travel medicine clinics and get their vaccines," says Hal Margolis, director, hepatitis branch of the U.S. Centers for Disease Control and Prevention.

In a 1995 survey of international travelers, only 26% of people bound for affected countries had taken steps to prevent the disease.

The good news is even if you're going overseas next month, you still have four weeks -- just enough time -- to get preventive immunization against hepatitis A.

Of course, travelers need all vaccinations recommended for their destination. But consider this: Hepatitis A strikes travelers 100 times more often than typhoid fever and 1,000 times more often than cholera.

Travelers formerly had only one shield against hepatitis A; now we have two. The old way was a shot of immune globulin (aka gamma globulin), which consists of antibodies harvested from the plasma of former hepatitis A sufferers. "IG" is given before travel for preventive immunization lasting three to five months. It's also given to people exposed to hepatitis A, like the schoolchildren recently served tainted strawberries in several states. Like any blood-derived product, it has sparked some safety concerns, and shortages.

The new and more lasting form of protection is a preventive Hepatitis A vaccine made from killed virus. One shot, taken four weeks before traveling, offers more than 90% protection, and a booster shot six to 12 months later extends your immunity for at least 10 years. The vaccines are sold by SmithKline Beecham Biologicals as Havrix, and by Merck & Co. as Vaqta. (They're not recommended for babies under age two, however, who still need to take IG.)

HEPATITIS A IS a virus that attacks the liver, resulting in nausea, vomiting, jaundice and fatigue. It is spread mainly by contaminated food, water and person-to-person contact. (Hepatitis B, which is spread through sexual contact, infected blood and unclean needles, requires another vaccine.)

Regions hardest-hit with hepatitis A include Africa, Asia (except Japan), Latin America, the Middle East, Eastern Europe, the Mediterranean basin and parts of the Caribbean. Most of Western Europe, like the U.S. is deemed low-risk; but Spain and Italy are classed as "intermediate risk," so your doctor may recommend the vaccine. "Travelers don't think about this when they're going for that Mediterranean beach holiday, eating all that frutta di mare (seafood) or going swimming," says Elaine Jong, co-director of the Travel Medicine Service at the University of Washington at Seattle.

The hepatitis A shots aren't cheap. They cost $50 to $75 each, or up to $150 for the series. But Dr. Jong argues, "If you like to travel and eat out, you can't afford to come down with a disease that sends you to bed for several weeks."

Michele Barry, director of the Office of International Health at Yale University, adds, "I think this is a great vaccine. In my experience there are very few side effects" beyond a sore arm. Severe allergic reactions are extremely rare.

Consider the alternative. Adults with hepatitis A can lose a month from work. Moreover, severe hepatitis A kills 100 to 150 Americans a year -- usually older adults and people with chronic liver disease. Even after recovering from the acute misery, sufferers may experience months of malaise.

OF COURSE, as last month's headlines made clear, you needn't leave home to get hepatitis A. In April, a school-lunch program featuring tainted strawberries sickened 170 students and employees of a Michigan school district. Thousands of exposed schoolchildren in several states received immune globulin for "post-exposure prophylaxis" against the disease. Separately, an outbreak at a suburban Maryland steakhouse last December sickened about two dozen diners.

Overall, 80,000 cases of hepatitis A strike the U.S. each year, officials say. Of these, about 6% of cases stem from travel experiences, 2% from food or water, 26% from person-to-person contact and 16% from day-care contacts. In the remaining half, the source wasn't identified. Hardest hit are areas where populations are living in poor, overcrowded conditions, including towns on the Mexican border, American Indian reservations and native Alaskan communities, says Dr. Margolis.

In the future, CDCP's approach will shift from fighting individual outbreaks, to overall prevention. "We'd like to lower the incidence of disease, and ultimately, to eradicate it," says Dr. Margolis.

While the future may hold a national vaccination program for hepatitis A, the present strategy is to target hardest-hit communities. In San Antonio, Texas, Public Health Director Fernando A. Guerra says he's vaccinating 13,000 schoolchildren this year in the most vulnerable census tracts to lower the community's infection rate.

But a major obstacle to universal immunization is the lack of a preventive vaccine for infants. "If we had an infant vaccine right now, we'd be moving more toward more routine vaccination nationally," says Dr. Margolis.

For now, travelers should consider their own protection. Not only will their vacations be safer, he says, "A vaccinated traveler becomes protected in his own country."

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