No 10 - 2017

Cases of hepatitis A in Europe among men who have sex with men
Update on yellow fever in Brazil
Phasing-put of the temporary vaccination programme

Cases of hepatitis A in Europe among men who have sex with men

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)

Update on yellow fever in Brazil

Since December of 2016, a large outbreak of yellow fewer has developed in Brazil. The outbreak occurs primarily in the eastern part of the country. Link to EPI-NEWS 6/2017

The outbreak of yellow fever continues to evolve.

Several yellow fever cases are being reported from the Espirito Santo region of Brazil, a region located immediately to the north of the State of Rio. However, at present no cases have been reported in the Cities of Rio de Janerio or Sao Paulo.

As per 2 March 2017, a total of 1,369 cases have been reported, including 326 laboratory-confirmed cases.
In all, 220 deaths have been reported, including 109 among the confirmed cases, corresponding to a 33% mortality among the confirmed cases.

The confirmed cases are from the three states of Minas Gerais (269), Espirito Santo (53) and São Paulo (4). A downward trend is being observed for Minas Gerais, but it is essential to continue monitoring the occurrence closely to assess if the decrease continues.

In Espirito Santo, the period from 2 to 24 February 2017 has seen a total of 120 reported cases (both confirmed and suspected cases).

Yellow fever vaccination is recommended for all travellers over 9 month age going to areas in Brazil with a risk of yellow fever transmission, i.e. nearly all of Brazil, including the Iguaçu Falls. The coastal cities of Rio de Janeiro, Sao Paulo, Salvador, Recife and Fortaleza, are not currently yellow fever risk areas.

At present, there is no yellow fever vaccination requirement for entry into Brazil, but vaccination and mosquito bite prophylaxis are strongly recommended for all travellers to the current risk areas.

The vaccine may be given as from 9 months of age. Protection becomes effective 10 days after vaccination.

The vaccine is administered as a single dose. A single vaccination provides lifelong protection. This also applies to persons who have previously been vaccinated against yellow fever.

Phasing-put of the temporary vaccination programme

Since Week 7/8 2016, the childhood vaccination programme has temporarily employed the Hexyon vaccine®, which - in addition to protecting against the same conditions as the DTaP-IPV/Act-Hib® - also protects against hepatitis B, EPI-NEWS 3/16 and 5/16.

The temporary vaccination programme starts the phase-out on 3 April 2017.

All children who initiate the vaccination programme as from that date will therefore receive the DTaP-IPV/Act-Hib®.
Children who have started vaccination under the temporary vaccination programme with Hexyon® are offered to conclude their vaccination with this vaccine.

In an upcoming issue of EPI-NEWS, we will bring more detailed information about the phase-out.

(Department of Infection Epidemiology and Prevention)

Link to previous issues of EPI-NEWS

8 Marts 2017