HIV Treatment Bulletin

UK hepatitis A outbreak in gay men: shortages of HAV and HBV vaccines escalated to ‘national incident’

HPE HAV graph to April 2017

Table 1. Hepatitis A cases in England to April 2017 (PHE)

Simon Collins, HIV i-Base

In May 2017, Public Health England PHE) published details of an ongoing investigation of an outbreak of hepatitis A (HAV) that had been occurring predominantly in MSM in London and other European cities for almost a year. [1]

Between July 2016 and 2 April 2017, 266 cases associated with the outbreak had been identified in England. At least 74% of these were among MSM, and 63% of cases were in London. Some cases in the wider population were linked to the outbreak. See Table 1.

The outbreak comprises three concurrently-circulating genotype 1a strains, previously not seen in England. Hepatitis A outbreaks caused by the same strains are concurrently occurring in 12 European countries and elsewhere in the UK outside of England. [2, 3]

This led to a joint recommendation from PHE, BHIVA and BASHH to offer vaccination to all at-risk gay men with one or more recent partners at GUM clinics in affected areas. [4]

Guidance was for all MSM attending GUM and HIV clinics should be opportunistically offered a single dose of adult monovalent hepatitis A vaccine, where available, unless they have documented evidence of two doses of hepatitis A vaccine or of previous hepatitis A illness.

Patients should not be asked to wait until results of HAV Ab levels.  In the event of a shortage of the monovalent vaccine, some alternative options have been proposed using paediatric vaccines or combined hepatitis A and B vaccines.  For example:

  • CD4 count <500 cells/mm3: two doses of paediatric hepatitis A vaccine.
  • CD4 count ≥500 cells/mm3: single dose of paediatric hepatitis A vaccine   Remaining hepatitis A and B doses can be given using either monovalent or combination vaccine.
  • For post exposure immunisation for HIV positive individuals schedules detailed in the Green Book and BHIVA should be followed.  [5, 6]

On 8 August 2017, a new joint statement was published from PHE, BHIVA and BASHH. [7]

This now expands the concern about the vaccine shortage for hepatitis B (HBV) and notes that shortages of both HAV and HBV vaccines have been escalated to a national incident. It also includes new guidance for vaccine allocation for people living with HIV.

It also notes in respect to the HBV vaccine: “as manufacturers have reduced maximum ordering quantities for NHS Trusts, GUM and HIV clinics will have further limits applied to their orders, while other customers (such as travel clinics and GPs) will not be receiving any adult vaccine until further notice”.

PHE has issued recommendations that include temporary dose sparing advice to preserve adult and paediatric monovalent hepatitis B vaccine stock for those at highest immediate need and with the greatest ability to benefit, and to sustain supplies over the period of shortage. [8]

A patient information leaflet has been developed for people who have been told that they wait for vaccine, although this leaflet makes no mention of HIV. [9]

Comment

Some London clinics with large HIV units are already reporting supply problems with both HAV and HBV monovalent vaccines.

Vaccine shortages are being reported in other European countries.

References:

  1. HPE Health Protection Report. Hepatitis A outbreak (England) investigation (2016-2017), 12 May 2017.
    https://www.gov.uk/government/publications/hepatitis-a-outbreak-england-investigation-2016-2017
  2. Beebeejaun K et al. Outbreak of hepatitis A ssociated with men who have sex with men (MSM), England, July 2016 to January 2017. Euro. Surveill. (2017):22(5). (2 February 2017).
    http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=22706
  3. ECDC Rapid Risk Assessment. Hepatitis A outbreaks in the EU/EEA mostly affecting men who have sex with men. (23 February 2017).
    https://ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/16-02-2017-RRA%20UPDATE%201-Hepatitis%20A-United%20Kingdom.pdf (PDF)
  4. PHE, BHIVA and BASHH. Classified memo to BHIVA members who are health professionals.
  5. Immunisation against Infections Disease Department of Health.  Hepatitis A Chapter 17.
    https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book 2015
  6. BHIVA. Guidelines on the use of vaccines in HIV-positive adults. (2015)
    http://www.bhiva.org/documents/Guidelines/Immunisation/consultation/BHIVA-Immunisation-Guidelines-2015-Consultation.pdf
  7. PHE/BHIVA/BASHH joint statement. Hepatitis B vaccine shortages: PHE and BASHH/BHIVA temporary guidance for management of patients in GUM and HIV services. 8 August 2017.
    http://www.bhiva.org/Hepatitis-B-vaccine-shortages.aspx
    http://www.bhiva.org/documents/News/170808/HepB-vaccine-shortages.pdf (PDF)
  8. Public Health England temporary recommendations on HBV immunisation:
    https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/631145/Hepb_vaccine_tem porary_recommendations_adults_and_children.pdf (PDF)
  9. Public Health England. What to do if you have to wait for a dose of hepatitis B vaccine: advice for patients. PHE publications gateway number: 2017260, August 2017.
    https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/636079/Hepb_vaccine_advice_for_patients.pdf (PDF)

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