Widespread person-to-person outbreaks of hepatitis A across the United States

When hearing about hepatitis A, many people think about contaminated food and water. However, in the United States, hepatitis A is more commonly spread from person to person. Since March 2017, CDC’s Division of Viral Hepatitis (DVH) has been assisting multiple state and local health departments with hepatitis A outbreaks, spread through person-to-person contact.

The hepatitis A vaccine is the best way to prevent HAV infection

  • The following groups are at highest risk for acquiring HAV infection or developing serious complications from HAV infection in these outbreaks and should be offered the hepatitis A vaccine in order to prevent or control an outbreak:
    • People who use drugs (injection or non-injection)
    • People experiencing unstable housing or homelessness
    • Men who have sex with men (MSM)
    • People who are currently or were recently incarcerated
    • People with chronic liver disease, including cirrhosis, hepatitis B, or hepatitis C
  • One dose of single-antigen hepatitis A vaccine has been shown to control outbreaks of hepatitis A.1,2
  • Pre-vaccination serologic testing is not required to administer hepatitis A vaccine. Vaccinations should not be postponed if vaccination history cannot be obtained or records are unavailable.

CDC has provided outbreak-specific considerations for hepatitis A vaccine administration and has updated its overall recommendations on the prevention of hepatitis A virus infection in the United States.

Since the outbreaks were first identified in 2016, 34 states have publicly reported the following as of October 23, 2020

  • Cases: 35,628
  • Hospitalizations: 21,782 (61%)
  • Deaths: 336

Vaccination Guidance During the COVID-19 Pandemic

The risk for person-to-person transmission of HAV continues during the COVID-19 pandemic. The hepatitis A vaccine is the best way to prevent HAV infection. People at risk for acquiring HAV infection or developing serious complications from HAV infection during the current hepatitis A outbreaks should be prioritized to receive the hepatitis A vaccine as soon as it is possible to do so safely.

Learn more about safe administration of vaccines during the COVID-19 pandemic:
Learn how COVID-19 impacts people with viral hepatitis:
State-Reported Hepatitis A Outbreak Cases as of October 23, 2020
Data illustrated in this map can be found in the table found directly below
State-Reported Hepatitis A Outbreak Cases and Clinical Outcomes
State Case Total Hospitalizations n (%) Deaths Outbreak Start Date Data Current Through
Total 35628 21782 (61%) 336    
States with an ongoing outbreak
Alabamaexternal icon 838 565 (67%) NR 9/1/2018 8/31/2020
Arkansasexternal icon 482 256 (53%) 3 2/7/2018 3/6/2020
Coloradoexternal icon 405 288 (71%) 2 10/1/2018 9/30/2020
Delawareexternal icon 38 22 (58%) 1 8/1/2019 9/23/2020
Floridaexternal icon 4592 3221 (70%) 70 1/1/2018 8/31/2020
Georgiaexternal icon 1370 884 (65%) 8 6/1/2018 10/17/2020
Idahoexternal icon 74 37 (50%) 0 1/1/2019 8/13/2020
Illinoisexternal icon 195 132 (68%) 1 9/1/2018 6/23/2020
Indianaexternal icon 2393 1335 (56%) 4 11/1/2017 7/3/2020
Kansasexternal icon 124 95 (88%) 0 5/15/2020 10/23/2020
Kentuckyexternal icon 5001 2411 (48%) 62 8/1/2017 2/8/2020
Louisianaexternal icon 1303 769 (59%) 4 1/1/2018 10/16/2020
Michiganexternal icon 920 738 (80%) 30 8/1/2016 2/5/2020
Minnesotaexternal icon 124 86 (69%) 1 12/16/2018 10/16/2020
Mississippiexternal icon 187 129 (69%) 0 4/1/2019 2/26/2020
Missouriexternal icon 697 403 (58%) 2 9/1/2017 3/14/2020
New Hampshireexternal icon 319 198 (62%) 2 11/1/2018 2/11/2020
New Jerseyexternal icon 623 408 (65%) 7 12/1/2018 2/22/2020
New York (excluding New York City)external icon 394 266 (68%) 0 6/1/2019 10/17/2020
North Carolinaexternal icon 346 223 (64%) 2 1/1/2018 10/7/2020
Ohioexternal icon 3691 2296 (62%) 16 1/1/2018 10/19/2020
Pennsylvaniaexternal icon 866 669 (77%) 14 1/1/2018 10/17/2020
South Carolinaexternal icon 1660 875 (53%) 5 11/1/2018 10/9/2020
Tennesseeexternal icon 3036 1839 (61%) 28 12/1/2017 5/8/2020
Vermontexternal icon 14 6 (43%) 0 1/1/2019 7/11/2020
Virginiaexternal icon 443 277 (63%) 2 1/1/2019 10/23/2020
Washingtonexternal icon 366 212 (58%) 5 4/1/2019 6/22/2020
West Virginiaexternal icon 2702 1366 (51%) 23 3/19/2018 2/28/2020
States with a declared end to their outbreak
Arizonaexternal icon 598 484 (81%) 8 11/1/2018 4/16/2020
Californiaexternal icon 708 464 (66%) 21 11/1/2016 4/11/2018
Massachusettsexternal icon 563 442 (79%) 9 4/1/2018 5/29/2020
Nevadaexternal icon 107 94 (88%) 1 11/1/2018 6/18/2020
New Mexicoexternal icon 168 127 (76%) 2 11/8/2018 6/10/2020
Utahexternal icon 281 152 (54%) 3 5/8/2017 2/12/2019

NR: not publicly reported

  1. “Outbreak-associated” status is currently determined at the state level in accordance with each state’s respective outbreak case definition.
  2. Outbreak-related hepatitis A deaths are defined at the state level in accordance with each state’s respective hepatitis A-related death definition. Some states are reviewing death certificates on a regular basis to actively find hepatitis A-related deaths, while other states are utilizing passive surveillance.
  3. Outbreak start date is defined at the state level and may represent the earliest onset date of an outbreak case (AR, AZ, KS, UT), the left censor date for which cases are considered part of the outbreak based on the state outbreak case definition (AL, CA, CO, DE, FL, GA, ID, IL, IN, KY, LA, MA, MI, MN, MO, MS, NV, NH, NJ, NC, OH, PA, SC, TN, VA, WA), or when a state declared a hepatitis A outbreak (NM, WV).

CDC’s Response

In response to all hepatitis outbreaks, CDC provides ongoing epidemiology and laboratory support as well as support on vaccine supply and vaccine policy development. When requested, CDC sends “disease detectives” to affected areas to evaluate and assist in an outbreak response. CDC alerts other public health jurisdictions of any increases in disease. All jurisdictions are encouraged to be watchful for increases in hepatitis A cases. CDC also works with state and local health officials to ensure hepatitis A vaccine is targeted to the correct at-risk populations and that supply is adequate.

Postexposure Prophylaxis

Postexposure prophylaxis (PEP) is recommended for unvaccinated people who have been exposed to hepatitis A virus (HAV) in the last 2 weeks; those with evidence of previous vaccination do not require PEP.

PEP consists of:

PEP Recommendations:

NOTE: CDC recommends that all children be vaccinated against hepatitis A at age 1 year. Parents or caregivers who are unsure if a child has been vaccinated should consult the child’s health-care provider to confirm vaccination status.

HAV Specimen Requests

State health departments wanting to submit specimens must contact CDC at hepaoutbreaklab@cdc.gov for approval before shipping specimens to CDC.  Only specimens that that have tested positive for anti-hepatitis A IgM and meet any of the following criteria will be considered.

  • Specimen from a case patient in a county that has not yet reported a hepatitis A case in an at-risk population;
  • Specimen from a case patient who doesn’t report any known risk factors or contact with at-risk populations (e.g., household or sexual contact, volunteering at a homeless shelter);
  • Specimen from a case patient suspected to be associated with foodborne transmission;
  • Archived/stored specimen from a patient who has died, and whose classification as an outbreak-related death requires nucleic acid testing beyond anti-HAV IgM-positivity; or
  • Other patient specimens not meeting the above criteria that require nucleic acid testing or molecular characterization (to be discussed on a case-by-case basis).

Dear Colleague Letter pdf icon[PDF – 6 MB] from CDC Division of Viral Hepatitis Director regarding Submission of Patient Specimens to CDC for Hepatitis A Testing.

Educational Resources

CDC is developing educational materials to support the outbreak at the state and local levels. Most materials include an area where local information can be inserted. Your organization’s contact information can be typed into the blue colored rectangle. To upload your logo, click on the white space below the blue colored rectangle. In the pop-up box, select browse and upload a PDF version of your logo.

Fact Sheets

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For people who use drugs

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For gay and bisexual men

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For people experiencing unstable housing or homelessness

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For people who are or were recently in jail or prison

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Two page visual fact sheet

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Pocket Cards

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Outbreak hepatitis A Pocket Card – to localize with organization information and outlines who should get vaccinated and the symptoms of hepatitis A
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These cards should be printed double-sided on business card templates that print six double-sided cards per page. Settings must be set to “Actual size” or “Custom Scale 100%” to ensure accurate alignment.

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Get Vaccinated  Pocket Card – to localize with information where to go to get the vaccine and who should get vaccinated

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These cards should be printed double-sided on business card templates that print six double-sided cards per page. Settings must be set to “Actual size” or “Custom Scale 100%” to ensure accurate alignment.

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If You’re Sick  Pocket Card – to localize with information on where to go for medical care and the symptoms of hepatitis A

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These cards should be printed double-sided on business card templates that print six double-sided cards per page. Settings must be set to “Actual size” or “Custom Scale 100%” to ensure accurate alignment.

Posters

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Poster for people who use drugs encouraging hepatitis A vaccination

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Poster for people who use drugs encouraging hepatitis A vaccination

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Poster for people who use drugs encouraging hepatitis A vaccination

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Poster for people at high risk of infection encouraging hepatitis A vaccination

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Poster for people experiencing homelessness encouraging hepatitis A vaccination

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Poster for people experiencing homelessness encouraging hepatitis A vaccination

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Poster for men who have sex with men (MSM) encouraging hepatitis A vaccination

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Poster for men who have sex with men (MSM) encouraging hepatitis A vaccination

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Poster for men who have sex with men (MSM) encouraging hepatitis A vaccination

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Poster outlining what Emergency Departments can do to help stop the hepatitis A outbreaks

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Posters on how to clean up and disinfect to help prevent spread of hepatitis A virus from Water Quality & Health Council

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Digital Image

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Information relating to the Hepatitis A Outbreak. To download the image, right-mouse-click on the link below and select the “save …” menu item to save the file to your own folder.

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Information for the Public
For Additional Information

If you are a state or local health department with questions about outbreak investigation, management, and/or specimens, please email DVH staff.

If you are a practicing clinician with a concern about a potential case of hepatitis A virus infection, please contact your local or state health department.

For all other inquiries, please contact CDC-INFO at 800-CDC-INFO (800-232-4636), TTY: 888-232-6348 or Email CDC-INFO

References
  1. Ott JJ, Wiersma ST. Single-dose administration of inactivated hepatitis A vaccination in the context of hepatitis A vaccine recommendations. Int J Infect Dis. 2013 Nov;17(11):e939-44. doi: 10.1016/j.ijid.2013.04.012. Epub 2013 Jun 21. Review. PubMed PMID: 23791857.
  2. McMahon BJ, Beller M, Williams J, Schloss M, Tanttila H, Bulkow L. A program to control an outbreak of hepatitis A in Alaska by using an inactivated hepatitis A vaccine. Arch Pediatr Adolesc Med. 1996 Jul;150(7):733-9. PubMed PMID: 8673200.