Elsevier

Journal of Hepatology

Volume 59, Issue 6, December 2013, Pages 1177-1183
Journal of Hepatology

Research Article
Targeted vaccination programme successful in reducing acute hepatitis B in men having sex with men in Amsterdam, The Netherlands

https://doi.org/10.1016/j.jhep.2013.08.002Get rights and content

Background & Aims

In the Netherlands, transmission of hepatitis B virus occurs mainly within behavioural high-risk groups, such as in men who have sex with men. Therefore, a vaccination programme has targeted these high-risk groups. This study evaluates the impact of the vaccination programme targeting Amsterdam’s large population of men who have sex with men from 1998 through 2011.

Methods

We used Amsterdam data from the national database of the vaccination programme for high-risk groups (January 1, 1998 to December 31, 2011). Programme and vaccination coverage were estimated with population statistics. Incidence of acute hepatitis B was analyzed with notification data from the Amsterdam Public Health Service (1992–2011). Mathematical modelling accounting for vaccination data and trends in sexual risk behaviour was used to explore the impact of the programme.

Results

At the end of 2011, programme coverage was estimated at 41% and vaccination coverage from 30% to 38%. Most participants (67%) were recruited from the outpatient department for sexually transmitted infections and outreach locations such as saunas and gay bars. Incidence of acute hepatitis B dropped sharply after 2005. The mathematical model in which those who engage most in high-risk sex are vaccinated, best explained the decline in incidence.

Conclusions

Transmission of hepatitis B virus among Amsterdam’s men who have sex with men has decreased, despite ongoing high-risk sexual behaviour. Vaccination programmes targeting men who have sex with men do not require full coverage; they may be effective when those who engage most in high-risk sex are reached.

Introduction

Worldwide, an estimated two billion people are infected with hepatitis B virus (HBV). More than 240 million have chronic liver infections, and approximately 600,000 die each year from HBV-associated cirrhosis or hepatocellular carcinoma [1]. The endemicity of HBV differs greatly by geographical region; depending on the prevalence of HBV surface antigen (HBsAg) in the population, countries may be classified endemically as high (>8%), intermediate (2–8%), or low (<2%) [2]. In high- and intermediate-endemic countries, HBV transmission occurs mainly perinatally or in early childhood, whereas in low-endemic areas, HBV is more often contracted later in life, either through sexual contact or use of contaminated needles. In 1982 a safe, effective vaccine became available, and many countries have since implemented a national infant immunization programme. In the Netherlands, HBV prevalence in the general population is very low (HBsAg = 0.2%; 95% confidence interval (95% CI) 0.1–0.4%) [3]. Since 1983, vaccination programmes have been implemented for health care workers (1983), newborns of HBsAg-positive mothers (1989), and newborns with at least one parent from a high- or intermediate-endemic country (2003) [3]. In addition, in 2002, as transmission occurred mainly within behavioural high-risk groups (injecting drug users, men who have sex with men (MSM), and commercial sex workers), a vaccination programme targeting behavioural high-risk groups was implemented nationally, after a pilot programme from 1998 to 2000 in several regions, including Amsterdam [4], [5]. Because more recent insights have shown that vaccination of the general population is cost-effective and more beneficial in the long term than those only in the high-risk groups, a nationwide infant vaccination programme was initiated in August, 2011 [6]. As no catch-up campaign will be instituted, the ‘high-risk group’ policy must be continued for at least another 20–30 years. In this study, we describe trends in the incidence of acute HBV in the MSM population in Amsterdam from 1992 through 2011 and evaluate the impact of the HBV vaccination programme targeting MSM that began in 1998. The Dutch capital, with about 800,000 inhabitants, is a popular residence for MSM from the world all over, totalling at least 26,000 [7]. We used a mathematical model, taking into account vaccination data, demographic aspects, and changes in sexual risk behaviour, to explore potential explanations for these trends.

Section snippets

Population statistics

Yearly age- and gender-specific population data were obtained from the Research and Statistics Department of Amsterdam. The number of MSM residing in Amsterdam was estimated as 10% of the male population aged 15–69 years as registered on December 31 of each calendar year [8], [9]. The differential effect of migration in and out of the population was accounted for; however, the changing proportions of immune, vaccinated, or susceptible MSM were unknown.

Targeted vaccination programme MSM

To evaluate the programme targeting MSM in

Targeted vaccination programme MSM

From 1998 to 2012, a total of 12,273 MSM in Amsterdam participated in the targeted HBV vaccination programme. Table 1 shows the programme coverage per calendar year, which increased from 2% in 1998 to 41% in 2011. The median age at inclusion was 34 years (interquartile range [IQR] 27–41 years, range 14–83 years). Most participants were born in the Netherlands (71%) or other low-endemic countries (9%). Fifty-one percent of the participants (6306) were recruited from the outpatient department for

Discussion

From 2004 to 2012, the incidence rate of HBV infection in MSM in Amsterdam decreased by 78% (from 75 to 17/100,000), indicating that transmission among MSM has decreased [22]. As in the past eight years, high-risk sexual behaviour among MSM has stabilized, and the reduced transmission is a probable effect of the targeted MSM risk-group vaccination programme started in 1998 [17]. Earlier evaluations of the programme (up until 2006) did not find evidence that this programme had an impact, partly

Financial support

This study was conducted within the Sarphati Initiative: Academic Collaborative Center on Public Health of Noord-Holland and Flevoland, the Netherlands. The Sarphati Initiative is financially supported by the Netherlands Organization for Health Research and Development (ZonMw; grant number 125010001).

Conflict of interest

The authors who have taken part in this study declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.

Acknowledgements

The authors would like to thank Mark Rutherford for his comments on the statistical procedures regarding the age-period-cohort (APC) model; and Sally Hebeling for editing the final manuscript. Furthermore the authors would like to thank the nurses of the Public Health Services in Amsterdam for their data collection on HBV.

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