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 and provides up to 95% seroprotection in healthy individuals for up to 11 years.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.

Since the outbreaks were first identified in 2016, 30 states have publicly reported the following as of November 15, 2019

  • Cases: 28,269
  • Hospitalizations: 17,078 (60%)
  • Deaths: 285

State-Reported Hepatitis A Outbreak Cases as of November 15, 2019
Data illustrated in this map can be found in the table found directly below
State-Reported Hepatitis A Cases and Clinical Outcomes
State Case Total Hospitalizations n (%) Deaths Outbreak Start Date Data Current Through
Total 28269 17078 (60%) 285    
States with an ongoing outbreak
Alabamaexternal icon 163 90 (55%) NR 9/1/2018 10/2/2019
Arizonaexternal icon 597 472 (79%) 8 11/1/2018 11/14/2019
Arkansasexternal icon 439 228 (52%) 3 2/7/2018 11/15/2019
Coloradoexternal icon 249 182 (73%) 2 10/1/2018 11/13/2019
Floridaexternal icon 3446 2444 (71%) 51 1/1/2018 10/31/2019
Georgiaexternal icon 789 532 (67%) 8 6/1/2018 11/9/2019
Idahoexternal icon 66 33 (50%) 0 1/1/2019 11/15/2019
Illinoisexternal icon 169 113 (67%) 1 9/1/2018 11/13/2019
Indianaexternal icon 2219 1223 (55%) 4 11/1/2017 11/15/2019
Kentuckyexternal icon 4966 2395 (48%) 61 8/1/2017 11/2/2019
Louisianaexternal icon 633 354 (56%) 1 1/1/2018 11/15/2019
Massachusettsexternal icon 528 417 (79%) 7 4/1/2018 11/1/2019
Michiganexternal icon 920 738 (80%) 30 8/1/2016 11/6/2019
Minnesotaexternal icon 49 35 (71%) 0 12/16/2018 11/8/2019
Mississippiexternal icon 82 54 (66%) 0 4/1/2019 11/14/2019
Missouriexternal icon 529 301 (57%) 2 9/1/2017 11/12/2019
Nevadaexternal icon 99 86 (87%) 1 11/1/2018 11/11/2019
New Hampshireexternal icon 264 161 (61%) 2 11/1/2018 11/5/2019
New Jerseyexternal icon 517 340 (66%) 6 12/1/2018 11/9/2019
New Mexicoexternal icon 155 118 (76%) 2 11/8/2018 11/14/2019
North Carolinaexternal icon 124 80 (65%) 1 1/1/2018 11/12/2019
Ohioexternal icon 3381 2068 (61%) 16 1/1/2018 11/12/2019
Pennsylvaniaexternal icon 681 522 (77%) 10 1/1/2018 11/9/2019
South Carolinaexternal icon 585 357 (61%) 1 11/1/2018 11/11/2019
Tennesseeexternal icon 2704 1633 (60%) 21 12/1/2017 11/8/2019
Virginiaexternal icon 236 148 (63%) 0 1/1/2019 11/14/2019
Washingtonexternal icon 113 56 (50%) 0 4/1/2019 11/14/2019
West Virginiaexternal icon 2577 1282 (50%) 23 3/19/2018 10/15/2019
States with a declared end to their outbreak
Californiaexternal icon 708 464 (66%) 21 11/1/2016 4/11/2018
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, UT), the left censor date for which cases are considered part of the outbreak based on the state outbreak case definition (AL, CA, CO, 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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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. 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;150(7):733-739.
  2. 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;17(11):e939-944.