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An outbreak of hepatitis B in men who have sex with men but identify as heterosexual
  1. Ananda Giri Shankar1,
  2. Sema Mandal2,
  3. Samreen Ijaz2
  1. 1 Health Protection Team, Public Health England, East of England, Thetford, UK
  2. 2 National Infection Service, Public Health England, London, UK
  1. Correspondence to Dr Ananda Giri Shankar, Health Protection Team, Public Health England, East of England, Thetford IP24 1JD, UK; giri.shankar{at}

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We investigated an unusual cluster of acute hepatitis B (HBV) infection among middle-aged men in East of England. Between January and August 2015, five cases of acute, symptomatic HBV cases were seen in men (median age 55 years: range 39–72), four of whom were white. All described themselves as married heterosexual men. Sequencing data showed four cases were genotype A2. Additional phylogenetic analysis showed that three were A2 (prisoner variant). First described in prisoners,1 this stable virus circulates widely in England and is commonly associated with transmission among men who have sex with men (MSM).

In-depth, confidential, face-to-face interviews were undertaken with five cases who initially denied any MSM behaviour. Three admitted to having regular casual, unprotected, anonymous sex with men at a truck stop off a regional motorway, a well-known cruising ground. Two of the cases reported up to 15 sexual encounters over a fortnight, mainly on weekday evenings. Encounters had occurred within the known incubation period for acute HBV infection. Working with local GUM services, the outbreak control team developed health promotion initiatives aimed at men visiting the site. These included the provision of condoms and advice on sexually transmitted infections (STIs) and blood-borne viruses infection prevention including the importance of hepatitis B immunisation. Since the interventions were implemented in August, two new cases with the same strain have been identified from a neighbouring area.

This cluster highlights the sexual health risks being taken by married men who do not self-identify as gay or bisexual. The group does not access sexual health services and appears to be unaware of the risks of acquiring HBV, HIV and other STIs. In-depth interviews were invaluable to effective incident management. However, the interventions need to be prioritised and sustained if the sexual health needs of this potential bridging population are to be addressed.



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  • Contributors All authors have contributed equally to the preparation of this letter.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.