Case scenario

This educational activity was independently developed by PSA, with funding from GSK.

Serena has her hands full with cosmetics, sunscreen, electrolytes and medicine for mild pain relief. She asks for help finding something for diarrhoea, stating that she and her friends are travelling to Thailand for her 40th birthday in a month. She also hands you a prescription for the parenteral monovalent typhoid vaccine and the combination hepatitis A/hepatitis B vaccine. She is unsure whether she really needs these vaccines, as she recalls having her childhood vaccinations and is up to date with influenza and COVID-19 vaccination. This will be the first time Serena has been out of Australia.

Learning objectives

​​After reading this article, pharmacists should be able to:

  • Outline the Three R’s framework for guiding vaccine recommendations
    for travellers
  • Explain factors which may influence a traveller’s health-related risk
  • Describe common pre-travel vaccines that may be recommended to travellers
  • Discuss hepatitis B vaccination in relation to travel health.
  • Competency standards (2016) addressed: 1.1, 1.4, 1.5, 3.5, 3.6

Accreditation number: CAPSYP2412ND

Accreditation expiry: 30/11/2027

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Introduction

As international travel resumes to pre-COVID levels,1 many travellers delay vaccinations due to low disease risk perceptions, costs, and access issues.2–4

Pharmacists are highly trusted and accessible health professionals and play a vital role in providing preventive care and advice. In Australia, the role of pharmacists in vaccination has evolved significantly, and continues to evolve.5–7

This article will explore the role of pharmacists in travel vaccination, with a focus on hepatitis B.

Vaccination in adults

Many travellers make spontaneous decisions or underestimate health risks. For example, a 2022 cross-sectional study revealed that risk for travel-related conditions, including vaccine-preventable illnesses, was often significantly under-estimated by travellers when compared to expert-assessed risk.8 When a traveller believes their destination is safe, they are often unlikely to seek travel-health advice.8,9 Identifying these travellers presents an opportunity to discuss health risks. Factors listed in the ‘This person, this trip, this time’ framework can help assess individual risk during travel (see Table 1),10 while the Three R’s (Required-Routine-Recommended) guide vaccine recommendations.9,10

  1. Determine which, if any, vaccines are REQUIRED to cross international borders under international health regulations or as specific requirements for the country or destination.
  2. Confirm the traveller is up to date with ROUTINE vaccinations. For example, standard ‘childhood’ vaccines included in the National Immunisation Program (NIP)
    and other applicable vaccines routinely recommended for
    certain populations.
  3. Determine which vaccinations should be RECOMMENDED based on factors such as the traveller’s itinerary, risk of exposure and current immune status.

In addition to factors listed in Table 1, other traveller and itinerary-specific risks that are important to consider include factors such as pregnancy or breastfeeding status, prior travel history, prior travel-related illness, stopover/transit destinations and time until departure.9

Common pre-travel vaccines

Table 2 outlines common pre-travel vaccines that may be recommended to travellers.

It is important to consider a range of individual factors when recommending pre-travel vaccines. For example, although hepatitis B vaccination is now considered routine and part of the NIP from birth,11 individuals aged ≥40 years may be less likely to have received the hepatitis B vaccine due to previous funding gaps.12 Given hepatitis B virus (HBV) transmission risks, pharmacists can be crucial in assessing vaccination needs for travellers. For more information about hepatitis B, see below, and refer to Box 1 for hepatitis B vaccination recommendations for travellers.

What is Hepatitis B?

Hepatitis B is an infection caused by the hepatitis B virus (HBV), which impacts the liver. HBV is highly infectious and can remain infectious for up to 7 days outside the body.16,17

After acute HBV infection, some individuals may develop chronic infection. Up to 25% of adults with chronic HBV may develop cirrhosis or liver cancer.13 In those whose infection resolves, the virus can remain latent in liver cells and may reactivate later.
Who can get hepatitis B, and how common is it?

Anyone in contact with an infected individual is at risk of contracting HBV. It is transmitted when non-intact skin or mucosal membranes come into contact with infected body fluids (such as through sexual contact or blood exposure).9 It can also be transmitted from mother to child at birth.13,18 Certain occupational, behavioural, and living conditions can further increase the risk of exposure to contaminated body fluids.13,18

Chronic HBV infection is a significant public health concern. Hepatitis B surface antigen serologic prevalence varies by region.19 Areas with ≥8% prevalence, including regions in Africa and East Asia, are highly endemic, and infections are often acquired perinatally or in early childhood.20–22 In Australia in 2017, there were approximately 234,000 people living with chronic hepatitis B, with the condition primarily affecting Aboriginal and Torres Strait Islander peoples and those born overseas.23
Who should receive a hepatitis B vaccine and why?

Hepatitis B vaccination is recommended for13:

  • infants (hepatitis B vaccines are offered under the NIP) and children/adolescents who have not previously received hepatitis B vaccines†
  • Aboriginal and Torres Strait Islander peoples
  • people who are immunocompromised or have medical risk factors (e.g. patient
    with human immunodeficiency virus (HIV), severely impaired renal function, chronic liver disease, people who receive blood products)
  • people with increased occupational risk (e.g. healthcare workers, funeral workers/embalmers, tattooists/body-piercers)
  • people with increased circumstantial risk (e.g. men who have sex with men, sex workers, people who inject drugs)
  • travellers going to HBV-endemic areas who may be at increased risk (see Box 1 below).

Refer to the Australian Immunisation Handbook13 for the complete and comprehensive list of population groups with increased risk of exposure to HBV or severe hepatitis B disease for whom vaccination is recommended.
What is the efficacy and tolerability of hepatitis B vaccines?

Hepatitis B vaccines are considered safe, with adverse events typically being minor and transient.24–26 Among adults, common reactions include injection site soreness (5%), low-grade fever (2–3%), nausea, dizziness, myalgia, and arthralgia.13,27

A standard three-dose schedule generates protective antibody levels against HBV in
over 90% of healthy adults.24 Seroconversion occurs in 30–55% after the first dose and increases to 75% after the second. The third dose enhances the response and ensures
long-term protection.13,24,28

†Hepatitis B vaccination has been available from birth on the NIP since 2000. At present, NIP funds catch-up vaccinations for people under 20 years of age who have not received certain vaccines in the NIP schedule. For refugees and humanitarian entrants, catch-up vaccinations are available even if they are older than 20 years.29

Some vaccines require multiple doses over a defined period, and it can take some time after completing the course to reach optimal effectiveness. For some vaccines, accelerated dosing schedules may be considered for those at imminent risk of exposure. For example, for hepatitis B, most schedules require multiple doses across a 6–12-month period. An accelerated dosing schedule is available for those with limited time to departure. Refer to the Australian Immunisation Handbook for further information.13 It’s never too late to vaccinate before a trip, especially for longer travel where some immunity may develop, benefiting future travel as well.10

Box 1 –  Hepatitis B vaccination recommendations for travellers
Travellers are advised to receive the hepatitis B vaccine if they are visiting areas with intermediate or high endemicity and meet any of the following criteria:

  • Travelling for an extended period or making frequent short trips.
  • Engaging in activities that may increase their risk of exposure to the hepatitis B virus.

The combined hepatitis A/hepatitis B vaccine may be suitable for travellers who are not immune to either virus and are also travelling to a region with high hepatitis A endemicity.

Reference: Australian Technical Advisory Group on Immunisation13

Yellow fever vaccination

Another travel vaccine to consider is yellow fever. Proof of vaccination (International Certificate of Vaccination or Prophylaxis [ICVP]) or a valid exemption letter, may be a condition of entry (or transit requirement) to some destinations after visiting areas with risk of yellow fever transmission.9 In Australia, the yellow fever vaccine can only be administered at state/territory authority-approved yellow fever vaccination centres.9 Further information about where to refer travellers who may require yellow fever vaccination can be found on relevant state or territory health department websites.

Knowing when to refer

Pharmacists should follow legislative requirements and recognise their individual scope of practice and level of training when providing travel health advice. If any of the traveller’s intended trip, current health status or medical history is beyond a pharmacist’s capability to provide an appropriate standard of travel health advice, the patient should be referred on for GP or travel specialist consultation.10

Conclusion

Pharmacists are uniquely positioned to assist in travel vaccination, particularly for critical immunisations like hepatitis B. With their accessibility, expertise, and patient relationships, pharmacists can deliver essential vaccination services that meet the needs of travellers. Through effective communication and patient education, they can promote healthier travel experiences. The role of pharmacists in travel vaccination is vital not only for individual health but also for public health, contributing to the prevention of infectious diseases on a global scale.

Case scenario continued

After responding to Serena’s request and providing advice about products that could be helpful for her upcoming trip, you take the opportunity to confirm and ask more about her trip itinerary, medical history, proposed activities and her vaccination history (including hepatitis B vaccination).

You provide further advice regarding the benefits of these vaccines to help protect against illnesses not covered by her childhood vaccinations, that she may be at risk of during her trip.

As you are a pharmacist immuniser and working in a jurisdiction that allows you to vaccinate against all three illnesses for the purpose of travel, you offer to administer the vaccines. Serena is very happy with this offer and agrees to start receiving these today.

To ensure the best possible protection in her limited time before departure, you recommend the accelerated dosing schedule for the combination hepatitis A/hepatitis B vaccine. She books in with you for her next dose in 7 days.

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Key points

  • It is important to opportunistically recognise potential travellers. Many travellers will not seek out specific travel health advice.
  • Travellers often underestimate the risk of exposure or the risks that they might take. Strategies such as the Three R’s framework can be applied to determine appropriate immunisation recommendations.
  • Hepatitis B is a significant public concern with prevalence varying by region worldwide. While the estimated prevalence is low in Australia, those most affected within Australia are Aboriginal and Torres Strait Islander peoples and those born overseas. Although hepatitis B vaccination is now on the NIP from birth, some people may not have previously received the hepatitis B vaccine.

References

  1. Australian Bureau of Statistics. Number of Aussies travelling overseas reaches pre-COVID levels. 2024. At: www.abs.gov.au/media-centre/media-releases/number-aussies-travelling-overseas-reaches-pre-covid-levels
  2. Kain D, Findlater A, Lightfoot D, et al. Factors affecting pre-travel health seeking behaviour and adherence to pre-travel health advice: a systematic review. J Travel Med 2019;26(6).
  3. McGuinness SL, Spelman T, Johnson DF, et al. Immediate recall of health issues discussed during a pre‐travel consultation. J Travel Med 2015;22(3):145–51.
  4. Heywood AE, Zwar N. Improving access and provision of pre-travel healthcare for travellers visiting friends and relatives: a review of the evidence. J Travel Med 2018;25(1).
  5. Pharmaceutical Society of Australia. Pharmacist administered vaccinations. 2024. At: www.psa.org.au/state-vaccination-regulations/
  6. Kc B, Alrasheedy AA, Leggat PA, et al. Types and outcomes of pharmacist-managed travel health services: A systematic review. Travel Med Infect Dis 2023;51:102494.
  7. Bascom CS, Rosenthal MM, Houle SK. Are pharmacists ready for a greater role in travel health? An evaluation of the knowledge and confidence in providing travel health advice of pharmacists practicing in a community pharmacy chain in Alberta, Canada. J Travel Med 2015;22(2):99–104.
  8. Piché-Renaud P-P, Hoang Nguyen J, Pell LG, et al. Underestimation of travel-associated risks by adult and paediatric travellers compared to expert assessment: a cross-sectional study at a hospital-based family pre-travel clinic. Travel Medicine and Infectious Disease 2022;47:102315.
  9. Pharmaceutical Society of Australia. Travel health – Essential CPE. 2023. At: https://my.psa.org.au/s/training-plan/a110o00000KVhisAAD/travel-health-essential-cpe
  10. New South Wales government. Travel vaccination advice for pharmacists. 2024. At: www.health.nsw.gov.au/travel/Pages/pharmacist-vax-guide.aspx
  11. Australian Government Department of Health and Aged Care. National immunisation program schedule. 2024. At: www.health.gov.au/sites/default/files/2024-07/national-immunisation-program-schedule.pdf
  12. National Centre for Immunisation Research and Surveillance (NCIRS). History of immunisation in Australia – hepatitis B. 2022. At: https://ncirs.org.au/sites/default/files/2022-11/Hepatitis-B-history-November%202022.pdf
  13. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. 2024. At: https://immunisationhandbook.health.gov.au/
  14. Centers for disease control and prevention.  CDC Yellow Book 2024: Health Information for International Travel. 2024. At: wwwnc.cdc.gov/travel/yellowbook/2024/table-of-contents
  15. Freedman DO, Chen LH, Kozarsky PE. Medical considerations before international travel. N Engl J Med 2016;375(3):247–60.
  16. Bond WW, Favero MS, Petersen NJ, et al. Survival of hepatitis B virus after drying and storage for one week. Lancet 1981;1(8219):550–1.
  17. World Health Organization (WHO). Hepatitis B. 2024. At: www.who.int/news-room/fact-sheets/detail/hepatitis-b
  18. National Centre for Immunisation Research and Surveillance (NCIRS). Hepatitis B vaccines for Australians – Fact sheet. 2023. At: https://ncirs.org.au/sites/default/files/2023-06/Hepatitis%20B%20factsheet%20June%202023.pdf
  19. World Health Organization. Hepatitis B vaccines: WHO position paper, July 2017 – Recommendations. Vaccine 2019;37(2):223–5.
  20. Ott JJ, Stevens GA, Groeger J, et al. Global epidemiology of hepatitis B virus infection: new estimates of age-specific HBsAg seroprevalence and endemicity. Vaccine 2012;30(12):2212–9.
  21. Schweitzer A, Horn J, Mikolajczyk RT, et al. Estimations of worldwide prevalence of chronic hepatitis B virus infection: a systematic review of data published between 1965 and 2013. Lancet 2015;386(10003):1546–55.
  22. World Health Organization (WHO). Guidelines for the prevention, diagnosis, care and treatment for people with chronic hepatitis B infection. 2024. At: www.who.int/publications/i/item/9789240090903
  23. Kirby Insititute. HIV, viral hepatitis and sexually transmissible infections in Australia: Annual surveillance report 2018. 2018. At: www.kirby.unsw.edu.au/sites/default/files/documents/KI_Annual-Surveillance-Report-2018.pdf
  24. André FE. Summary of safety and efficacy data on a yeast-derived hepatitis B vaccine. Am J Med 1989;87(3a):14s–20s.
  25. McMahon BJ, Helminiak C, Wainwright RB, et al. Frequency of adverse reactions to hepatitis B vaccine in 43,618 persons. Am J Med 1992;92(3):254–6.
  26. Niu MT, Salive ME, Ellenberg SS. Neonatal deaths after hepatitis B vaccine: the vaccine adverse event reporting system, 1991-1998. Arch Pediatr Adolesc Med 1999;153(12):1279–82.
  27. Schillie S, Vellozzi C, Reingold A, et al. Prevention of hepatitis B virus infection in the United States: Recommendations of the advisory committee on immunization practices. MMWR Recomm Rep 2018;67(1):1–31.
  28. Zajac BA, West DJ, McAleer WJ, et al. Overview of clinical studies with hepatitis B vaccine made by recombinant DNA. J Infect 1986;13 Suppl A:39–45.
  29. Australian Government Department of Health and Aged Care. Catch-up immunisations. 2024. At: www.health.gov.au/topics/immunisation/immunisation-information-for-health-professionals/catch-up-immunisations

Our author

NATASHA DEAN (she/her) BSc(Hon) is a Senior Medical Writer with over 20 years’ experience in medical education and medical communications. She is a
CPD representative with the RACGP CPD Program and regularly accredits activities
for other organisations including ACCRM, PSA and ACN.

DISCLAIMER

Vaccine administration should be in accordance with relevant legislation, the Australian Immunisation Handbook, and state-based conditions specific to the vaccine.

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