National Profile of Viral Hepatitis
National Overview
Staff at health departments routinely submit case reports of viral hepatitis to CDC through the National Notifiable Diseases Surveillance System (NNDSS). The Centers for Disease Control and Prevention (CDC) collects, analyzes, and disseminates viral hepatitis surveillance data.
The annual surveillance report, published by CDC, summarizes information about reported cases of hepatitis A, hepatitis B, and hepatitis C, and deaths with any of these hepatitides listed as a cause of death in CDC’s National Vital Statistics System (NVSS).
These surveillance data are used by public health partners to help focus prevention efforts, plan services, allocate resources, develop policy, and detect and respond to clusters of viral hepatitis infection. These actions support the goal of CDC’s Division of Viral Hepatitis 2020 – 2025 Strategic Plan1 for establishing comprehensive national viral hepatitis surveillance for public health action. The 2020 Viral Hepatitis Surveillance Report is published exclusively online.
Impact of COVID-19
During 2020, the COVID-19 pandemic caused major disruptions in access to medical care and routine public health activities. Stay-at-home orders suspended or delayed many routine health care visits, patients avoided seeking medical and preventative services in a health care setting2, and many health department staff routinely assigned to viral hepatitis case investigation and surveillance activities were reassigned to respond to the COVID-19 pandemic.
To illustrate the potential magnitude of the impact of the COVID-19 pandemic on viral hepatitis testing and subsequently on surveillance data, a study of national reference clinical laboratory data reported an approximate 60% decline in positive hepatitis C test results during the first months of the pandemic in 2020, relative to the prior non-pandemic months3. In addition, the COVID-19 pandemic had a profound impact on mortality. In the United States, during 2020 the overall age-adjusted death rate increased by 16.8% compared to 20194.
For these reasons, the number and rates of viral hepatitis cases and deaths associated with viral hepatitis for 2020 included in the 2020 Viral Hepatitis Surveillance Report should be interpreted with caution.
Updated Hepatitis C Screening Recommendations
In April 2020, CDC published updated recommendations for hepatitis C screening5, which broadened the previous recommendations. The updated CDC guidance recommends:
- Hepatitis C screening at least once in a lifetime for all adults 18 years and older.
- Hepatitis C screening for all pregnant persons during each pregnancy.
The recommendation for HCV testing that remains unchanged is that all persons with risk factors (regardless of age or setting prevalence) should be tested for hepatitis C, with periodic testing while risk factors persist.
The updated guidance is designed to increase the number of persons tested and diagnosed with HCV infection, which will subsequently increase the number of reported cases of acute or chronic HCV infection.
Hepatitis A
During 2020, a total of 9,952 hepatitis A cases were reported to CDC by 49 states and the District of Columbia, corresponding to 19,900 estimated infections (95% confidence interval [CI]: 13,900 – 21,900) after adjusting for case underascertainment and underreporting (see Technical Notes).6 The reported case count corresponds to a rate of 3.0 cases per 100,000 population, a 47% decrease from the reported rate of 5.7 cases per 100,000 population during 2019.
The decrease in 2020 follows four successive years of increasing rates due to widespread and prolonged hepatitis A outbreaks associated with person-to-person transmission, primarily occurring among persons who use drugs and those experiencing homelessness7. During 2020, several states declared an end to their outbreaks, while only two states had outbreaks begin4.
Monthly reductions in hepatitis A case counts occurred during the last 6 months of 2019 and continued throughout 2020. Approximately 58% of all hepatitis A cases reported to CDC during 2020 occurred among persons aged 30–49 years, and 84% occurred among non-Hispanic White persons. Among the 4,816 (48%) reported cases that included risk information for injection drug use, 2,339 (49%) reported injection drug use. A total of 4,399 patients were hospitalized (65% hospitalization rate among the 6,739 cases with hospitalization information available).
Data from death certificates filed in the vital records offices of the 50 states and the District of Columbia revealed that the age-adjusted death rate associated with hepatitis A during 2020 among US residents was 0.04 deaths per 100,000 population, which is the same rate as reported in 2019, but 4 times the rate during 2015 (0.01 deaths per 100,000 population).
Hepatitis B
Reported cases of acute hepatitis B virus infection decreased after routine vaccination of children was recommended in 1991, and the rates of reported cases of acute hepatitis B were relatively stable during 2010–2019. During 2020, a total of 2,157 acute hepatitis B cases were reported to CDC by 44 states, resulting in 14,000 estimated infections (95% CI: 8,000–34,300) after adjusting for case underascertainment and underreporting (see Technical Notes).6
The reported case count corresponded to a rate of 0.7 per 100,000 population, a 30% decrease from the rate during 2019 (1.0 case per 100,000 population). After many years of stable rates, the sudden decline observed in 2020 is most likely attributed to 1) disruptions in health care access resulting from COVID-19 pandemic reducing the number of persons tested for hepatitis B virus infection, and 2) reassignment of viral hepatitis surveillance staff in health departments to work on the COVID-19 pandemic, thus limiting their ability to investigate laboratory reports and conduct medical provider follow-up and medical record review required to accurately determine acute case status.
Approximately 76% of all acute hepatitis B cases reported to CDC during 2020 occurred among persons aged 30–59 years. The rate of acute hepatitis B was highest among non-Hispanic White and non-Hispanic Black persons (0.7 cases per 100,000 population for each), compared with other race/ethnicity groups. Among the 1,115 (52%) reported cases that included risk information for injection drug use, 402 (36%) reported injection drug use. A total of 877 patients with acute hepatitis B were hospitalized (63% hospitalization rate among 1,403 cases with hospitalization information available).
A total of 11,635 newly identified cases of chronic hepatitis B were reported to CDC by 39 states during 2020, corresponding to a rate of 5.0 cases per 100,000 population; 88% of all chronic hepatitis B cases occurred among persons aged 30 years and older. The rate of newly reported chronic hepatitis B cases was highest among Asian/Pacific Islander persons (17.6 cases per 100,000 population), which was 12 times the rate among non-Hispanic White persons (1.5 cases per 100,000 population).
A total of 10 perinatal hepatitis B cases were reported through NNDSS to CDC from 9 states during 2020, 7 fewer than the 17 cases reported in 2019. Data from CDC’s Perinatal Hepatitis B Prevention Program from 64 jurisdictions reported 9,055 infants born to persons with hepatitis B virus infection during 2019, 96% of whom had received recommended prophylaxis at birth; 85% had completed 3 doses of vaccine by age 12 months; and 64% had received recommended post-vaccination serologic testing. Among infants with post-vaccination testing (5,759), 16 (0.3%) were cases of perinatal hepatitis B transmission.
Data from death certificates filed in the vital records offices of the 50 states and the District of Columbia demonstrated that the age-adjusted death rate associated with hepatitis B during 2020 among US residents was 0.45 deaths per 100,000 population, approximately the same as the rate during 2019 (0.42 deaths per 100,000 population).
Hepatitis C
During 2020, a total of 4,798 acute hepatitis C cases were reported to CDC from 44 states, corresponding to 66,700 estimated infections (95% CI: 52,700–227,400) after adjusting for case underascertainment and underreporting (see Technical Notes).6
The acute hepatitis C case count corresponds to a reported rate of 1.5 cases per 100,000 population, a 50% increase from the reported rate during 2016 (1.0 cases per 100,000 population), and a 15% increase from the reported rate during 2019 (1.3 cases per 100,000 persons).
While the COVID-19 pandemic disrupted health care access and reduced the number of persons tested for hepatitis C virus infection3 anticipated reductions in the number or reported acute hepatitis C cases was offset by a change to the acute hepatitis C case definition in 2020.
The new case definition was designed to better characterize the number of cases classified as acute hepatitis C (see Case Definitions). Approximately 57% of acute hepatitis C cases reported to CDC during 2020 were among persons aged 20–39 years. The rate of reported cases of acute hepatitis C was highest among American Indian/Alaska Native persons (2.1 cases per 100,000 population), compared with other racial/ethnicity groups.
Among the 1,540 (32%) reported acute cases that included risk information for injection drug use, 1,017 (66%) reported injection drug use. A total of 640 patients with acute hepatitis C were hospitalized (34% hospitalization rate among 1,904 cases with hospitalization information available).
A total of 107,300 new identified cases of chronic hepatitis C were reported to CDC from 41 states during 2020, corresponding to a rate of 40.7 cases per 100,000 population. The rate of newly reported chronic hepatitis C was highest among persons aged 30–39 years (73.6 cases per 100,000 population), followed by persons aged 50–59 years (54.4 cases per 100,000 population), compared with other age categories.
These rates are consistent with the previously reported bimodal distribution of newly reported chronic hepatitis C affecting multiple generations8. The rate of newly reported chronic hepatitis C cases was highest among American Indian/Alaska Native persons (66.8 cases per 100,000 population), compared with other racial/ethnicity categories.
A total of 165 perinatal hepatitis C cases were reported to CDC from 25 states during 2020, a 24% decrease from the 217 cases reported in 2019. 2020 is the third year that standardized surveillance for perinatal hepatitis C was conducted by states and case notifications submitted to CDC.
Data from death certificates filed in the vital records offices of the 50 states and the District of Columbia indicated that the age-adjusted death rate for hepatitis C during 2020 was 3.45 deaths per 100,000 population, a 4% increase compared to the rate during 2019 (3.33 deaths per 100,000 population). The age-adjusted death rate for hepatitis C during 2020 represents a 22% decrease from the rate during 2016 (4.42 deaths per 100,000 population).
References
- Centers for Disease Control and Prevention (CDC). Division of Viral Hepatitis 2025 Strategic Plan, CDC; 2020.
- Czeisler MÉ, Marynak K, Clarke KE, et al. Delay or Avoidance of Medical Care Because of COVID-19–Related Concerns — United States, June 2020. MMWR Morb Mortal Wkly Rep 2020;69:1250–1257.
- Kaufman HW, Bull-Otterson L, Meyer WA, at el. Decreases in Hepatitis C Testing and Treatment During the COVID-19 Pandemic. Am J Prev Medicine 2021; 61:369-376.
- Murphy SL, Kochanek KD, Xu JQ, Arias E. Mortality in the United States, 2020. NCHS Data Brief, no 427. Hyattsville, MD: National Center for Health Statistics. 2021.
- Schillie S, Wester C, Osborne M, Wesolowski L, Ryerson AB. CDC recommendations for hepatitis C screening among adults—United States, 2020. MMWR Recomm Rep 2020; 69:(No. RR-2).
- Klevens RM, Liu, S, Roberts H, et al. Estimating acute viral hepatitis infections from nationally reported cases. Am J Public Health 2014;104:482. PMC3953761.
- Centers for Disease Control and Prevention (CDC). Widespread person-to-person outbreaks of hepatitis A across the United States. Atlanta, GA: US Department of Health and Human Services, CDC; 2022.
- Ryerson AB, Schillie S, Barker L, et al. Vital signs: newly reported acute and chronic hepatitis C cases—United States, 2009–2018. MMWR Morb Mortal Wkly Rep 2020;69:399–404.