Hepatitis A Among Homosexual Men -- United States, Canada, and Australia

Although male homosexual activity has been reported as a risk factor for hepatitis A, the frequency with which homosexual activity was reported by persons with hepatitis A was less than 10% during 1982-1989 (CDC unpublished data, 1990). However, in June of 1991, CDC received reports from several cities in the United States, Canada, and Australia of an increase in hepatitis A among homosexual men during the first 6 months of 1991. This report summarizes data from each of these cities.

UNITED STATES Denver

From January through June 1991, 24 cases of hepatitis A were reported among homosexual and bisexual men in Denver; in comparison, 0-3 cases were reported during the first 6 months each of 1986-1990. During the first 6 months of 1991, 59 cases of hepatitis A were reported among heterosexual adults and children; although this represents an increase in the number of reported cases for these groups for the same period over previous years (1990: 28 cases, 1989: 34 cases, 1988: 23 cases, 1987: 31 cases, and 1986: 14 cases), the rate of increase is less than that for homosexual/bisexual men. Of the 24 homosexual/bisexual men with hepatitis A, 16 lived in one central urban neighborhood. Four (17%) had commonly recognized risk factors for hepatitis A, compared with eight (57%) among 14 adult heterosexual men with hepatitis A.

New York City

From January through June 1991, 631 cases of hepatitis A were reported in New York City, a 42% increase over the number of cases reported during the same period in 1990. Most cases (80%) occurred in Brooklyn (254) and Manhattan (253). In Brooklyn, an ongoing outbreak of hepatitis A associated with person-to-person transmission within a traditional ethnic/religious community began in 1990, with the number of reported cases remaining relatively stable during the past 18 months. In contrast, hepatitis A increased more than fourfold in Manhattan during January-June 1991 over the same period in 1990 (58).

Of the 253 cases in Manhattan, 221 (87%) occurred among men. Analysis of the total number of cases by ZIP code of residents indicated that 115 (45%) patients resided in six ZIP code areas corresponding to two Manhattan neighborhoods with large homosexual populations, compared with 17 cases reported from these ZIP code areas in the first half of 1990. Of 189 persons for whom both age and sex were known, 154 (81%) were men aged 20-49 years; this is a 5.5-fold increase over the number of cases reported among this group during the same period in 1990. Race/ethnicity information was available for 102 (40%) of the 253 cases; 85 (83%) occurred among white non-Hispanics.

In May 1991, the New York City Department of Health surveyed 50 persons with hepatitis A. Hepatitis A was diagnosed in each person during January 1-April 15; these persons resided in a Manhattan neighborhood with a large homosexual male population. Telephone interviews were completed for 32 (64%) persons. Twenty-seven (84%) were men; 26 (96%) of these were aged 20-49 years (median: 30 years; range: 22-55 years). Twenty-one (78%) of the 27 men identified themselves as homosexual or bisexual, three (11%) as heterosexual, and three (11%) did not state sexual preference. Male respondents reported a median of one sex partner (range: 0-7) during the 2-6 weeks before onset of illness. Eleven (41%) had no risk factors for hepatitis A other than being homosexual or bisexual. Seven (26%) of the 27 men reported contact with a person with hepatitis A during their incubation periods; two of the seven reported sexual contact with a person with hepatitis

These trends continued through the second half of 1991. As of mid-December, 1116 cases of hepatitis A were reported in New York City, with 79% occurring in Manhattan (429) and Brooklyn (452). Of the cases reported from Manhattan, 370 (86%) occurred among men. Of 339 cases for which both age and sex were known, 270 (80%) occurred among men aged 20-49 years.

San Francisco

From January through November 1991, 350 cases of hepatitis A were reported to the San Francisco City Department of Public Health, compared with 254 for the same period in 1990. Of the 350 persons with hepatitis A, 293 (84%) were male, and 186 (78%) of 237 men interviewed identified themselves as homosexual or bisexual. Of the 254 hepatitis A cases reported in 1990, 189 (74%) occurred among men, and 64 (68%) of 94 men interviewed identified themselves as homosexual or bisexual.

CANADA Toronto

From January through September 1991, 274 cases of hepatitis A were reported to the City of Toronto Department of Public Health, representing a fourfold increase over the number of cases reported during the same period in 1990, when 68 cases were reported (Figure 1). The number of hepatitis A cases reported in Toronto have increased annually, from 36 in 1985 to 86 in 1990. Of the 274 cases in 1991, 234 (85%) were among men aged 20-49 years. Risk-factor information collected on 169 male hepatitis A patients aged 20-49 years in 1991 identified homosexual behavior in 94 (56%) persons, compared with eight of 37 (22%) for the same period in 1990.

Montreal

From January through mid-November 1991, 389 cases of hepatitis A were reported in metropolitan Montreal, an incidence rate of 20.7 per 100,000 population; this represents a fourfold increase in the incidence rate for 1984-1989 of less than 5.0 per 100,000 population. The rate for men was 36.4 per 100,000 compared with 6.3 per 100,000 for women. Two hundred thirty-four (60%) of the cases were among men aged 20-39 years, and the highest attack rate was among men aged 25-29 years (82.9 per 100,000).

Among 107 persons with hepatitis A interviewed by telephone and for whom a risk factor could be identified, 45 (42%) were homosexual, compared with six (8%) of 72 persons in 1990. No increases were observed for other possible risk factors.

AUSTRALIA

From January through July 1991, 134 cases of hepatitis A were reported to the Health Department of Victoria (which includes the city of Melbourne), compared with 41 cases of hepatitis A reported for all of 1990, 14 for 1989, 31 for 1988, and 72 for 1987. Of the cases in 1991, 102 (76%) occurred among men, and 35 (34%) of those were homosexual.

From January through June 1991, 342 cases of hepatitis A were reported to the New South Wales Health Department (which includes the city of Sydney), compared with 34 cases for all of 1990. Of the 326 persons for whom age and sex information were available, 133 (41%) were aged 20-29 years, and 115 (86%) of these were men. Of the total cases, 131 (38%) were clustered in the eastern suburbs of Sydney, and 60% of these were identified by telephone interview of the attending physician as occurring in homosexual men.

Reported by: K Schomer, JM Douglas, MD, DL Cohn, MD, FN Judson, MD, Denver Disease Control Svc. R Roman, MPH, E Bell, KR Ong, MD, Commission on Disease Intervention, New York City Dept of Health. F Taylor, MD, San Francisco Dept of Health. L Yuan, MD, B Yaffe, MD, P Kendall, MBBS, City of Toronto Dept of Public Health; RS Remis, MD, L Bedard, R Dion, MD, Association of Community Health Depts of Montreal. W Manning, M Stokes, MBBS, New South Wales Health Dept, Sydney; T Stewart, MD, Macfarlane Burnet Center for Medical Research, Melbourne, Australia. Div of Field Epidemiology, Epidemiology Program Office; Hepatitis Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Hepatitis A virus (HAV) is transmitted by the fecal-oral route and has traditionally been associated with crowding, poor personal hygiene, improper sanitation, and contamination of food or water. The prominent risk factors for HAV infection include close contact with a hepatitis A patient, travel to developing countries, contact with children in day care centers, and intravenous drug use.

Although studies consistently have found an increased prevalence of hepatitis B virus infection among homosexual men (1), studies of the prevalence of HAV infection among homosexual men have shown conflicting results. Studies in New York and Copenhagen in the late 1970s did not indicate a prevalence of HAV infection among homosexual men higher than that among matched controls (2,3). However, a study in Seattle during the same period found a 30% prevalence of HAV infection among homosexual men, compared with 12% (p less than 0.01) among heterosexual men (4). A second study conducted in Copenhagen found a prevalence of HAV infection of 36% among homosexual men, compared with 20% in heterosexual men (p less than 0.01) (5). HAV infection among homosexual men was correlated with an increased number of sex partners, an increased frequency of oral-anal contact, and multiple episodes of syphilis (4,5).

The age and sex distribution of persons with hepatitis A reported to CDC's Viral Hepatitis Surveillance Program indicates that approximately 50% of cases occur among persons 20-39 years of age, and 15% occur among children aged less than 10 years. The male-female ratio is generally 1:1. Data presented in this report indicate a substantial shift in the sex distribution of and risk factors for hepatitis A in several cities throughout the world. This is in contrast to recent trends showing a decline in the incidence of gonorrhea and hepatitis B among homosexual men as a result of educational efforts targeted at reducing high-risk sexual behavior (6,7). The increase in hepatitis A among homosexual men may be a reflection of 1) a population of susceptible homosexual men who have recently become sexually active with an increase in the number of sex partners; 2) a return to unsafe sexual practices that might promote fecal contamination (e.g., oral-anal contact); and/or 3) misperceptions among the homosexual community regarding the relative safety of certain sexual behaviors in the transmission of sexually transmitted diseases (STDs) other than human immunodeficiency virus.

Early recognition of increases in hepatitis A among homosexual men should prompt public health officials to collect detailed information concerning behaviors that would place homosexual men at increased risk for acquiring hepatitis A and to promote behavior that prevents further spread of the virus. A public education campaign in Denver to disseminate information about routes of transmission of HAV, with emphasis on those associated with sexual activity, was initiated in May 1991. Written material was posted in areas frequented by homosexuals, and information was communicated through area media outlets. Although the effectiveness of the Denver campaign is difficult to assess, hepatitis A patients stated during subsequent interviews that, as a result of the information campaign, they recognized early symptoms and sought medical attention.

In addition to disseminating information on hepatitis A prevention, educational efforts should continue to be directed toward changing behaviors that would place homosexual men at risk of acquiring any STD.

References

1. Szmuness W, Much M, Prince A, et al. On the role of sexual behavior in the spread of hepa titis B. Ann Intern Med 1975;83:489-95.

2. Szmuness W, Dienstag JL, Purcell RH, Harley EJ, Stevens CE, Wong DC. Distribution of antibody to hepatitis A antigen in urban adult populations. N Engl J Med 1976;295:755-9.

3. Hentzer B, Skinhoj P, Hoybye G, Nielsen AO, Kvorning SA, Faber V. Viral hepatitis in a venereal clinic population. Scand J Infect Dis 1980;12:245-9.

4. Corey L, Holmes KK. Sexual transmission of hepatitis A in homosexual men. N Engl J Med 1980;302:435-8.

5. Kryger P, Pederson NS, Mathiesen L, Nielsen JO. Increased risk of infection with hepatitis A and B viruses in men with a history of syphilis: relation to sexual contacts. J Infect Dis 1982;145:23-6.

6. Gershman KA, Rolfs RT. Diverging gonorrhea and syphilis trends in the 80s: are they real? Am J Public Health 1991;81:1263-7.

7. Alter MJ, Hadler SC, Margolis HS, et al. The changing epidemiology of hepatitis B in the United States. JAMA 1990;263:1218-22.

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