06 Apr 2017

European cluster of cases of hepatitis A

Outbreaks of hepatitis A have been reported in Europe mostly affecting men who have sex with men (MSM) European cluster of cases of hepatitis A

Ahead of World Pride, which is taking place in Madrid, Spain from 23 June until 2 July 2017, NaTHNaC is reminding men who have sex with men (MSM) travelling to this event to seek early advice about travel related risks, including hepatitis A. 

Public Health England (PHE) has reported that linked outbreaks of hepatitis A, mainly among MSM are being investigated in several European countries, including the United Kingdom (UK). Some of the reported UK cases were in MSM who had travelled to Spain and other European countries [1]. Epidemiological and laboratory investigations indicate that these strains may have been imported several times from Spain, with secondary transmission in the UK [2].

Since February 2016, a total of 287 confirmed hepatitis A cases related to these outbreaks have been reported by 13 European countries: Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Italy, the Netherlands, Portugal, Spain, Sweden and the UK [3]. Most of these cases were reported in unvaccinated MSM, with only nine women affected. There is no indication of foodborne transmission and no cases of infected food handlers have been reported. Transmission by person-to person sexual contact is considered to be the most likely [3].  As of 29 March 2017, the Ministry of Health of Portugal have reported 115 cases in 2017 of which 97% were young men mainly residents in the Lisbon area and Vale do Teio (78 cases) [4]. 

Advice for travellers

Hepatitis A is a highly infectious virus that can cause inflammation of the liver. The virus is usually transmitted through food or water contaminated by human faeces or by contact with infected faeces during oral or anal sex. Information on avoiding sexual spread of hepatitis A is available from NHS Choices and a leaflet is available from PHE.

Take care with personal, food and water hygiene. Gay and bisexual men who have sex with multiple male partners may benefit from vaccination and should seek advice from their sexual health, GP or travel clinic prior to travelling. 

If you have returned from areas where hepatitis A infection is common and develop unexplained gastrointestinal symptoms, general malaise, jaundice (yellowing of the skin and whites of the eyes) and/or pale stools, you should seek medical advice from your GP or NHS 111. Remember to mention your travel history, so that appropriate measures and testing can be undertaken. 

Advice for health professionals

The main prevention measure in the context of the current outbreaks is offering hepatitis A vaccine to at-risk MSM [3]. Health professionals should inform MSM of risks of hepatitis A and about the need to maintain high standards of personal hygiene. Hepatitis A vaccine should be offered opportunistically to at-risk MSM (defined as having a new or casual sexual partner in the last three months), particularly during periods when outbreaks are occurring [5]. As part of the outbreak response in England, sexual health services are recommended to offer hepatitis A vaccine opportunistically to these MSM in areas where the outbreaks are occurring. Travel vaccination for at-risk MSM likely to have sexual contact with multiple contacts should also be considered.

If single hepatitis A vaccine is not available, sexual health and HIV services can offer combination hepatitis A/B vaccine, such as Twinrix®, to avoid delayed immunisation. Combination hepatitis A/B vaccine is also preferred for MSM who have no or incomplete hepatitis B immunisation.

When Twinrix® is used for pre-exposure immunisation, the standard schedule is 0, 1 and 6 months but an accelerated schedule: 0, 7, and 21 days, can be used for adults if rapid protection is needed, with a booster dose at one year [5].

There remains a risk of imported cases of hepatitis A to the UK. Health professionals should remain vigilant for recent travellers returning from the area affected by the virus who develop an unexplained gastrointestinal illness (with or without jaundice). Testing should be arranged through local virology laboratories and infected cases reported to your local Health Protection Team.

PHE have issued guidance to help public health professionals manage hepatitis A infection which includes recommendations on the use of human normal immunoglobulin and hepatitis A vaccine for post-exposure prophylaxis of contacts of cases. 

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