Outbreak of Hepatitis A among Men Who Have Sex with Men:
Implications for Hepatitis A Vaccination Strategies
The Journal of Infectious Diseases 2003;187:1235-1240
Suzanne M. Cotter,1,a Stephanie Sansom,2,a Teresa Long,3 Elizabeth
Koch,4 Scott Kellerman,1,a Forrest Smith,4 Francisco Averhoff,2,a
and Beth P. Bell1 1Division of Viral Hepatitis, National Center for
Infectious Diseases, and 2National Immunization Program, Centers for
Disease Control and Prevention, Atlanta, Georgia; 3Columbus
Department of Health and 4Ohio State Department of Health, Columbus
"...in some MSM communities, the majority of hepatitis A cases
cannot be attributed to specific high-risk sex practices.... could
have resulted from other contact by which fecal-oral transmission
can occur, such as nonsexual close personal contact or consumption
of contaminated food... Although it was not specifically evaluated,
our investigation suggests that hepatitis A vaccination coverage
among MSM was low. Few participants were aware of the availability
of hepatitis A vaccine or had ever been recommended it..... similar
findings with respect to hepatitis B vaccination have been reported
in this population..... Our findings also suggest that many MSM
could be readily accessed for vaccination in private providers'
offices.... To improve hepatitis A and hepatitis B vaccination
coverage among MSM, providers should be made aware of the importance
of vaccinating their MSM patients, and patients should be made aware
of the vaccine's availability and the importance of requesting it
when they seek routine health care"
Between November 1998 and May 1999, 136 cases of hepatitis A were
reported in Columbus, Ohio, a 325% increase over the average of 32
cases reported annually during the same period for the each of the
previous 5 years. The median age of case patients was 33 years
(range, 585 years), 108 (80%) were white, and 118 (87%) were male.
Incidence among men was higher than that among women (24.6
cases/100,000 population vs. 3.5 cases/100,000 population).
Twenty-six (19%) patients were hospitalized, and 1 case patient died
of fulminant hepatic failure secondary to acute hepatitis A.
Despite the licensure of hepatitis A vaccine in 1995, hepatitis A
remains one of the most frequently reported diseases in the United
States that is preventable by vaccine. Most cases occur in the
context of community-wide outbreaks, during which infection is
transmitted primarily from person to person in households and
extended family settings. Recognized risk factors include contact
with an infected person, contact with a day care center, the use of
illicit drugs, being a man who has sex with men (MSM), and
international travel. However, 40%50% of reported cases do not
involve a recognized risk factor.
Periodic hepatitis A outbreaks among MSM have been reported during
the past 3 decades in the United States, Canada, Europe, and
Australia. In 1996, the Advisory Committee on Immunization Practices
(ACIP) recommended hepatitis A vaccination for sexually active MSM
[2]. Between January and March 1999, the Columbus city and Franklin
County, Ohio, health departments noted an increase in hepatitis A
cases, compared with previous years. Preliminary investigation
indicated that MSM were disproportionately affected. We studied this
community-wide hepatitis A outbreak, evaluated the risk factors for
hepatitis A among MSM, and looked for potential opportunities to
deliver the hepatitis A vaccine to MSM.
Eighty-nine (65%) case patients were reinterviewed. Of 74 male case
patients, 47 (66%) were men who have sex with men (MSM). These 47
MSM were compared with 88 MSM control subjects, to identify risk
factors for infection and potential opportunities for vaccination.
During the exposure period, 6 (13%) case patients reported contact
with a person who had hepatitis A, compared with 2 (2%) control
subjects (odds ratio, 6.15; 95% confidence interval, 1.0448.02);
neither number of sex partners nor any sex practice was associated
with illness.
Household or sexual contact with a hepatitis A case in the 26 weeks
before onset of illness (i.e., the referent exposure period) was the
only risk factor associated with hepatitis A (OR, 6.15; 95% CI,
1.0448.02) but was reported by only 6 (13%) case patients. There was
no association between hepatitis A and other recognized risk
factors, including international travel, contact with day care, or
illicit drug use (data not shown). There also was no association
between hepatitis A and reporting of anonymous sex, visiting the
local or any bathhouse, or specific sex practices, such as having
digital-anal or oral-anal sex.
Most case patients and control subjects (68% and 77%, respectively)
saw a health care provider at least annually, and 93% of control
subjects reported a willingness to receive hepatitis A vaccine. MSM
are accessible and amenable to vaccination; increased efforts are
needed to provide vaccination, regardless of reported sex practices.
Potential access points for vaccination. The majority of case
patients and control subjects reported having health insurance,
having a regular health care provider, and seeing their health care
provider at least once a year. Case patients were more likely than
control subjects to have informed their health care provider of
their sexual preference (P < .001). The majority of case patients
and control subjects reported having ever visited a human
immunodeficiency virus (HIV) testing site, and approximately
one-third reported ever visiting a sexually transmitted disease
(STD) clinic.
Knowledge of hepatitis A and willingness to pay for vaccine. Among
control subjects recruited from social settings (bars and coffee
houses), 54 (78%) had heard of hepatitis A. However, only 21 (31%)
were aware of the hepatitis A vaccine. Fifty-six (93%) control
subjects said they would get the vaccine if their health care
provider recommended it, and most (74%) expressed a willingness to
pay $25 per dose of vaccine .
Discussion by authors
Among MSM, household or sexual contact with a hepatitis A case
patient was the only risk factor associated with hepatitis A, but
this exposure accounted for a small proportion of cases. We did not
identify any sex practices associated with hepatitis A, and the
majority of case patients reported 1 or no sex partner during the
referent exposure period. In studies of other outbreaks among MSM,
specific sex practices, including >1 anonymous sex partner, group
sex, oral-anal or digital-anal sex, or visiting darkrooms (similar
to bathhouses) and saunas, were associated with illness. In
seroprevalence studies, a greater number of sex partners , longer
duration of sexual activity, frequent oral-anal contact, and
serological evidence of other STDs were associated with HAV
infection. The results of our investigation and those of other
studies suggest that risk factors that promote the transmission of
HAV among MSM may vary and that, at least in some MSM communities,
the majority of hepatitis A cases cannot be attributed to specific
high-risk sex practices [24, 25]. Unlike many other infections that
disproportionately affect MSM, HAV infection from sexual contact
results from fecal-oral transmission. Thus, infections could have
resulted from other contact by which fecal-oral transmission can
occur, such as nonsexual close personal contact or consumption of
contaminated food. We attempted, but ultimately were unable, to
evaluate the possible contribution of nonsexual potential sources of
HAV transmission, such as foodborne exposures. The role of
unrecognized person-to-person and other nonsexual transmission of
HAV among close social networks during hepatitis A outbreaks among
MSM merits further investigation.
ALL INFORMATION, DATA, AND
MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION
PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS
OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR
LEGAL ADVICE. THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND
COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH
YOUR HEALTH CARE PROVIDER.
"A foolish faith in authority is the worst enemy of truth."
-- Albert Einstein, letter to a friend, 1901
"I know of no safe depository of the ultimate powers of the society but the people themselves, and if we think them not enlightened enough to exercise control with a wholesome discretion, the remedy is not to take it from them, but to inform their discretion by education."
-- Thomas Jefferson, letter to William C. Jarvis, September 28, 1820
"What's the point of vaccination if it doesn't protect you from the unvaccinated?"
-- Sandy Gottstein
"Who gets to decide what the greater good is and how many will be sacrificed to it?"
