Widespread outbreaks of hepatitis A across the United States
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, 23 states have publicly reported the following as of June 14, 2019
- Cases: 20,133
- Hospitalizations: 11,595 (58%)
- Deaths: 191
|States with an ongoing outbreak|
|Alabamaexternal icon||77||36 (47%)||NR||9/1/2018||6/12/2019|
|Arizonaexternal icon||374||295 (79%)||2||11/1/2018||6/13/2019|
|Arkansasexternal icon||343||NR (NR)||NR||2/7/2018||6/7/2019|
|Coloradoexternal icon||71||44 (62%)||0||10/1/2018||6/12/2019|
|Floridaexternal icon||1876||1353 (72%)||21||1/1/2018||5/31/2019|
|Georgiaexternal icon||416||280 (67%)||1||6/1/2018||6/7/2019|
|Illinois external icon||90||55(61%)||0||9/1/2018||6/12/2019|
|Indianaexternal icon||1581||851 (54%)||4||11/1/2017||6/14/2019|
|Kentuckyexternal icon||4695||2267 (48%)||58||8/1/2017||6/1/2019|
|Louisiana external icon||281||169 (60%)||1||1/1/2018||6/14/2019|
|Massachusettsexternal icon||360||296 (82%)||5||4/1/2018||6/7/2019|
|Michiganexternal icon||916||735 (80%)||28||8/1/2016||6/12/2019|
|Missouriexternal icon||314||158 (50%)||2||9/1/2017||6/11/2019|
|New Hampshireexternal icon||130||79 (61%)||1||11/1/2018||6/11/2019|
|New Mexicoexternal icon||124||99 (80%)||2||11/8/2018||6/13/2019|
|North Carolinaexternal icon||79||56 (71%)||1||1/1/2018||5/31/2019|
|Ohioexternal icon||3039||1821 (60%)||10||1/1/2018||6/10/2019|
|South Carolinaexternal icon||133||101 (76%)||1||11/1/2018||6/7/2019|
|Tennesseeexternal icon||1647||992 (60%)||9||12/1/2017||6/7/2019|
|Virginiaexternal icon||70||43 (61%)||0||1/1/2019||6/13/2019|
|West Virginiaexternal icon||2528||1249 (49%)||21||3/19/2018||6/7/2019|
|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
- “Outbreak-associated” status is currently determined at the state level in accordance with each state’s respective outbreak case definition.
- 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.
- 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, IL, IN, KY, LA, MA, MI, MO, NC, NH, OH, SC, TN, VA), or when a state declared a hepatitis A outbreak (NM, WV).
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 (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:
- Hepatitis A vaccine for people aged ≥12 months
- Hepatitis A virus-specific immunoglobulin (IG) for specific populations
- ACIP Recommendations for Use of Hepatitis A Vaccine for Postexposure Prophylaxis and for Preexposure Prophylaxis for International Travel
- Supplement 1. Provider Guidance on Risk Assessment and Clinical Decision-making for Hepatitis A Postexposure Prophylaxis
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.
State health departments wanting to submit specimens must contact CDC at email@example.com 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.
- Outbreak-specific considerations for hepatitis A vaccine administration
- MMWR – The dose of GamaSTAN™ S/D has recently been changed
- Current Vaccine Shortages & Delays – Information on Vaccine Supply
- For Immunization Managers – Information on Vaccines Purchased with 317 Funds
- Medscape Commentary: Hepatitis A: Breaking Out All Overexternal icon
- Archived webinar: Preventing and Controlling Hepatitis A in Jails and Prisons from the National Institute of Corrections, BOP and CDCexternal icon
- HAN: Update: Widespread Outbreaks of Hepatitis A among People Who Use Drugs and People Experiencing Homelessness across the United States – March 2019
- COCA Call On-Demand Webinar for Clinicians: Hepatitis A Outbreaks in Multiple States – CDC Recommendations and Guidance – Nov. 2018
- HAN: Outbreak of Hepatitis A Virus (HAV) Infections among Persons Who Use Drugs and Persons Experiencing Homelessness – June 2018
- MMWR: Hepatitis A Virus Outbreaks Associated with Drug Use and Homelessness — California, Kentucky, Michigan, and Utah, 2017
- Posters on how to clean up and disinfect to help prevent spread of hepatitis A virusexternal icon from Water Quality & Health Council
- Updated CSTE clinical case definition for acute viral hepatitis A
- CDC guidance on viral hepatitis surveillance and case management
- CDC training on hepatitis A serology
- Hepatitis A general FAQs for Health Professionals
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.
- One page visual fact sheets encouraging vaccination for:
- Two page visual fact sheet pdf icon[PDF – 615 KB] that includes information on hepatitis A prevention, transmission, symptoms and encourages multiple populations to get vaccinated
- Outbreak of hepatitis A Pocket Card pdf icon[PDF – 786 KB] to localize with organization information and outlines who should get vaccinated and the symptoms of hepatitis A
- Printing Instructions: These cards should be printed double-sided on 4.25” x 5.5” perforated postcard templates that print four double-sided cards per page. The print settings must be set to “Actual size” or “Custom Scale 100%” to ensure accurate alignment of the two sides of the cards.
- Get Vaccinated Pocket Card pdf icon[PDF – 455 KB] to localize with information where to go to get the vaccine and who should get vaccinated
- If You’re Sick Pocket Card pdf icon[PDF – 470 KB] to localize with information on where to go for medical care and the symptoms of hepatitis A
- Pocket Card Printing Instructions: These cards should be printed double-sided on business card templates that print six double-sided cards per page. The print settings must be set to “Actual size” or “Custom Scale 100%” to ensure accurate alignment of the two sides of the cards.
|Posters for people who use drugs encouraging hepatitis A vaccination|
|Poster for people at high risk of infection encouraging hepatitis A vaccination|
|Posters for people experiencing homelessness encouraging hepatitis A vaccination|
|Posters for men who have sex with men (MSM) encouraging hepatitis A vaccination|
|Poster pdf icon[PDF – 4 MB] outlining what Emergency Departments can do to help stop the hepatitis A outbreaks|
|Posters on how to clean up and disinfect to help prevent spread of hepatitis A virusexternal icon from Water Quality & Health Council|
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
- 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.
- 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.