Vaccination and safe sex: addressing hepatitis A outbreaks among men who have sex with men in Europe

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Since June 2016, 16 European countries are experiencing hepatitis A outbreaks with 1 500 reported cases involving three separate clusters that mainly affect men who have sex with men. On the occasion of World Hepatitis Day, ECDC stresses the importance of hepatitis A vaccination and safe sex practices including the use of condoms to avoid new infections. As several EU/EEA countries experience hepatitis A vaccine shortages, targeting of vaccination to groups at higher risk of infection is suggested.

The on-going hepatitis A (HAV) outbreaks across Europe have most likely not reached their peak yet. On the contrary: confirmed cases from April 2017 onwards have not yet been reported from some of the affected countries, notably Spain and Italy, which reported a large proportion of the overall number of confirmed cases up to March 2017.

So far, most cases are reported among unvaccinated men who have sex with men (MSM) but there is evidence of secondary cases among other groups. Countries reporting outbreak-related cases are Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, the Netherlands, Norway, Portugal, Slovenia, Spain, Sweden and the United Kingdom.

Interrupting the transmission chain

“As suggested in our latest rapid risk assessment, further transmission may be prevented by vaccination of men who have sex with men and post-exposure prophylaxis among contacts of those infected”, says ECDC Acting Director Andrea Ammon, “limited vaccine availability in some countries may however have an impact on the implementation of such control measures.”
 

Austria, Denmark, Italy, Portugal, Spain and Sweden are facing hepatitis A vaccine shortages while others have reported no shortages. As outlined in the ECDC risk assessment, countries should interact directly with marketing authorisation holders to enquire about supplies at national level as early as possible, i.e. create forecasts of the number of doses required and make procurement arrangements. Any changes in current hepatitis A vaccination policies and supplementary immunisation activities should be planned early.

Where hepatitis A vaccination is not universally offered to MSM, the following groups could be prioritised for vaccination, in line with the national vaccine recommendations: 

  • MSM living in areas where there are ongoing outbreaks;
  • MSM travelling to destinations reporting outbreaks of hepatitis A among MSM;
  • MSM attending Pride festivals this summer, where the likelihood of contact with HAV-infected people could be elevated (provision of vaccination at Pride festival venues could be considered);
  • MSM at risk of severe outcome as a result of hepatitis A, for example those with chronic liver disease, hepatitis B and/or hepatitis C and those who inject drugs

A systematic review by ECDC showed that about 90% of EU and EEA residents have moderate to very high susceptibility to HAV infection indicating the need to reconsider specific prevention and control measures across Europe, such as national vaccination strategies.