Cases of hepatitis A in Europe among men who have sex with men
15 March 2017
Europe is currently seeing three outbreaks of hepatitis A that are associated with sexual transmission. Since February 2016, 287 cases have been reported in a total of 13 countries – including Denmark. Vaccination provides effective protection against the condition.
In December, England, the Netherlands and Germany informed the international disease network about increases in the number of hepatitis A cases, primarily among men who have sex with men (MSM). Molecular biological typing of the hepatitis A virus has shown that three different variants of the genotype IA are causing the increase, which has subsequently been reported in another 10 countries.
The European Centre for Disease Prevention and Control (ECDC) monitors the situation and has recently issued a risk assessment about the outbreak
Furthermore, the outbreak has been described in Eurosurveillance:
Article from the Netherlands
Article from England
Article from Germany
At least one case in Denmark
In Denmark, typing has established that a case of hepatitis A from 2016 was linked to the outbreak in Germany. In addition, a total of three cases of hepatitis A in MSM have been recorded since October 2016. In these cases, subtyping of the patient sample was not possible. It is therefore unknown if these cases are linked to the current outbreaks. One of the affected persons has travelled to Germany and the two others are believed to have become infected in Denmark.
Denmark has previously witnessed an outbreak of hepatitis A among MSM in 2004, an outbreak that was associated with sauna visits in the Greater Copenhagen Area, EPI-NEWS 52/04.
The 2004-outbreak was also described in Eurosurveillance.
Infectious before you present with symptoms
Hepatitis A infection can be asymptomatic, but causes inflammation of the liver in adults. The symptoms are fever, nausea, abdominal pain and jaundice; yellowing of the skin and the whites of the eyes. The urine becomes dark coloured, and the stool becomes pale. Adults may present with symptoms for one or more weeks after which the infection recedes and they have gained life-long immunity.
Hepatitis A is transmitted faeco-orally, i.e. by ingestion of virus excreted from the stools of infected individuals. In the current outbreak, transmission is by sexual oral-anal contact (known as rimming), but more frequently transmission is by ingestion of faecally contaminated food or water.
The virus is excreted in the stool before the first symptoms present, which means that patients are infectious in the final weeks of the incubation period. The incubation period, i.e. the time that passes from a person is infected until he or she presents with symptoms, is rather long. Typically 3-4 weeks, but the period can vary from 15 to 50 days.
MSM who engage in rimming are at a special risk of becoming infected with hepatitis A, and the current international outbreaks may be explained by the presence of a large cross-European sex network among MSM. Statens Serum Institut therefore recommends that men who have sex with men receive hepatitis A vaccination to achieve life-long immunity against the disease. As combination vaccines are available that include both hepatitis A and hepatitis B, and as hepatitis B vaccine is also recommended for MSM, combination vaccines are recommended in persons who have not previously received hepatitis B vaccination. The vaccine as well as the doctor’s fee are paid by the person receiving the vaccination.
(L. Müller, S. Cowan, Department of Infection Epidemiology and Prevention)