Viral Hepatitis Surveillance Report 2018 — Hepatitis A

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HEPATITIS A, 2018. 12,474 New cases reported. 3.8 Reported cases per 100,000 population. 24,900 Acute infections estimated
* 95% Bootstrap Confidence Interval: (17,500–27,400)

AT A GLANCE: Hepatitis A in 2018

Hepatitis A incidence increased 850% from 2014 to 2018. The increase in 2018 was primarily due to unprecedented person-to-person outbreaks reported in 24 states among people who use drugs and people experiencing homelessness.

Groups Most Affected by Hepatitis A in 2018

By Age†
20–29 years: 6.1 cases per 100,000 people
30–39 years: 9.8 cases per 100,000 people
40–49 years: 6.6 cases per 100,000 people

By Sex†
Males: 4.7 cases per 100,000 people

By Race/ Ethnicity†
White, Non-Hispanic: 4.3 cases per 100,000 people

By Risk
Injection Drug Use (IDU): Among the 8,471 reported cases with IDU information available, 4,247 (50%) report IDU

† Indicates groups above the national average in 2018
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Figure 1.1. Number of reported hepatitis A cases and estimated infections* — United States, 2011–2018

Figure 1.1. Number of reported hepatitis A cases and estimated infections – United States, 2011-2018. From 2011 – 2015, the number of reported cases and estimated hepatitis A infections generally remained constant, followed by an increase each year from 2016 through 2018.

Hepatitis A 2011 2012 2013 2014 2015 2016 2017 2018
Number of reported hepatitis A cases and estimated infections* — United States, 2011–2018
Reported acute cases 1,398 1,562 1,781 1,239 1,390 2,007 3,366 12,474
Estimated acute infections 2,800 3,100 3,500 2,500 2,800 4,000 6,700 24,900
Source: CDC, National Notifiable Diseases Surveillance System.
* The number of estimated viral hepatitis infections was determined by multiplying the number of reported cases by a factor that adjusted for under-ascertainment and under-reporting(7). The 95% bootstrap confidence intervals for the estimated number of infections are shown in the Appendix.

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Table 1.1. Number and rate* of reported cases† of hepatitis A, by state or jurisdiction ― United States, 2014–2018

Table 1.1
State 2014
No.		 2014
Rate*		 2015
No.		 2015
Rate*		 2016
No.		 2016
Rate*		 2017
No.		 2017
Rate*		 2018
No.		 2018
Rate*
Alabama 15 0.3 23 0.5 19 0.4 23 0.5 38 0.8
Alaska 1 0.1 4 0.5 2 0.3 — — 1 0.1
Arizona 29 0.4 54 0.8 32 0.5 59 0.8 77 1.1
Arkansas 2 0.1 10 0.3 13 0.4 7 0.2 254 8.4
California 142 0.4 179 0.5 229 0.6 947 2.4 189 0.5
Colorado 23 0.4 25 0.5 22 0.4 65 1.2 31 0.5
Connecticut 23 0.6 9 0.3 16 0.4 17 0.5 15 0.4
Delaware 1 0.1 2 0.2 1 0.1 6 0.6 7 0.7
District of Columbia U U U U 4 0.6 3 0.4 11 1.6
Florida 90 0.5 108 0.5 115 0.6 261 1.2 548 2.6
Georgia 24 0.2 30 0.3 44 0.4 24 0.2 84 0.8
Hawaii 5 0.4 6 0.4 285 20.0 8 0.6 4 0.3
Idaho 7 0.4 9 0.5 7 0.4 4 0.2 5 0.3
Illinois 82 0.6 57 0.4 71 0.6 73 0.6 93 0.7
Indiana 20 0.3 19 0.3 18 0.3 21 0.3 964 14.4
Iowa 12 0.4 16 0.5 16 0.5 9 0.3 10 0.3
Kansas 7 0.2 7 0.2 5 0.2 6 0.2 14 0.5
Kentucky 19 0.4 16 0.4 9 0.2 71 1.6 3,560 79.7
Louisiana 5 0.1 5 0.1 12 0.3 8 0.2 37 0.8
Maine 8 0.6 8 0.6 8 0.6 7 0.5 9 0.7
Maryland 27 0.5 19 0.3 37 0.6 29 0.5 52 0.9
Massachusetts 43 0.6 34 0.5 64 0.9 52 0.8 364 5.3
Michigan 45 0.5 51 0.5 112 1.1 670 6.7 299 3.0
Minnesota 19 0.3 21 0.4 15 0.3 30 0.5 16 0.3
Mississippi 3 0.1 2 0.1 2 0.1 3 0.1 13 0.4
Missouri 20 0.3 9 0.1 16 0.3 27 0.4 243 4.0
Montana 5 0.5 2 0.2 3 0.3 3 0.3 — —
Nebraska 9 0.5 6 0.3 21 1.1 4 0.2 6 0.3
Nevada 5 0.2 11 0.4 14 0.5 19 0.6 41 1.4
New Hampshire 5 0.4 2 0.2 8 0.6 7 0.5 12 0.9
New Jersey 59 0.7 59 0.7 74 0.8 71 0.8 70 0.8
New Mexico 8 0.4 6 0.3 4 0.2 4 0.2 23 1.1
New York 84 0.4 123 0.6 99 0.5 218 1.1 165 0.8
North Carolina 38 0.4 45 0.4 52 0.5 29 0.3 103 1.0
North Dakota 9 1.2 5 0.7 2 0.3 — — — —
Ohio 32 0.3 36 0.3 36 0.3 45 0.4 1,687 14.4
Oklahoma 17 0.4 11 0.3 11 0.3 9 0.2 5 0.1
Oregon 13 0.3 28 0.7 15 0.4 20 0.5 23 0.5
Pennsylvania 48 0.4 43 0.3 62 0.5 69 0.5 99 0.8
Rhode Island 8 0.8 4 0.4 4 0.4 6 0.6 7 0.7
South Carolina 6 0.1 16 0.3 21 0.4 21 0.4 30 0.6
South Dakota 3 0.4 2 0.2 1 0.1 1 0.1 1 0.1
Tennessee 12 0.2 14 0.2 7 0.1 6 0.1 654 9.7
Texas 124 0.5 147 0.5 139 0.5 129 0.5 88 0.3
Utah 8 0.3 8 0.3 12 0.4 159 5.1 135 4.3
Vermont 1 0.2 3 0.5 5 0.8 2 0.3 3 0.5
Virginia 27 0.3 50 0.6 190 2.3 46 0.5 82 1.0
Washington 26 0.4 26 0.4 31 0.4 28 0.4 35 0.5
West Virginia 12 0.6 8 0.4 15 0.8 6 0.3 2247 124.4
Wisconsin 7 0.1 9 0.2 7 0.1 16 0.3 15 0.3
Wyoming 1 0.2 3 0.5 — — 18 3.1 5 0.9
Total 1,239 0.4 1,390 0.4 2,007 0.6 3,366 1.0 12,474 3.8
Source: CDC, National Notifiable Diseases Surveillance System.
* Rate per 100,000 population.
† For the case definition, see https://wwwn.cdc.gov/nndss/conditions/hepatitis-a-acute/.
—: No reported cases. The reporting jurisdiction did not submit any cases to CDC.
N: Not reportable. The disease or condition was not reportable by law, statue, or regulation in the reporting jurisdiction.
U: Unavailable. The data are unavailable.

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Figure 1.2. Rates of reported hepatitis A, by state — United States, 2017–2018

Figure 1.2. The horizonal bar chart shows the distribution of rates of reported hepatitis A by state for 2017 and 2018 compared to the 2018 US average rate of 3.8 cases per 100,000 population. West Virginia and Kentucky had the highest rates of hepatitis A in 2018.

Source: CDC, National Notifiable Diseases Surveillance System.

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Figure 1.3. Rates of reported hepatitis A, by state or jurisdiction — United States, 2018

Figure 1.3. This map displays rates of reported hepatitis A by state or jurisdiction for 2018. States are grouped and shaded based on hepatitis A rates (cases per 100,000 population). States with no reported cases are grouped separately.

Color
Key		 Cases/100,000
Population		 States
Color Key Table
0-0.3 AK, HI, ID, IA, MN, NE, OK, SD, TX, WI
>0.3-0.7 CA, CO, CT, DE, IL, KS, ME, MS, OR, RI, SC, VT, WA
>0.7-0.9 AL, GA, LA, MD, NH, NJ, NY, PA, WY
>0.9-3.9 AZ, DC, FL, MI, NV, NM, NC, VA
>3.9-9.7 AR, MA, MO, TN, UT
>9.7-124.4 IN, KY, OH, WV
No reported cases MT, ND

Source: CDC, National Notifiable Diseases Surveillance System.

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Figure 1.4. Rates of reported hepatitis A, by age group — United States, 2003–2018

Figure 1.4. This line graph shows trends in the rates of hepatitis A by age groups (0 – 9 years, 10 – 19 years, 20 – 29 years, 30 – 39 years, 40 – 49 years, 50 – 59 years, and 60 years and older) for 2003 through 2018. For all age groups the reported rates of hepatitis A declined from 2003 through 2009, remained stable from 2009 through 2015, and increased from 2016 through 2018. A large increase occurred between 2017 and 2018 for persons aged 20-29 years, 30-39 years, and 40-49 years. Over 55% of hepatitis A cases submitted to CDC in 2018 were among persons aged 30-49 years.

Age (years) 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Data points for Figure 1.4.
0-9 1.8 1.9 1.4 1.1 0.7 0.5 0.3 0.3 0.2 0.2 0.1 0.1 0.1 0.1 0.1 0.1
10-19 2.2 2.0 1.6 1.3 0.9 0.8 0.6 0.5 0.4 0.4 0.3 0.3 0.2 0.3 0.2 0.6
20-29 3.5 2.3 2.0 1.6 1.4 1.0 1.0 0.8 0.6 0.7 0.7 0.5 0.6 0.9 1.4 6.1
30-39 2.8 1.8 1.5 1.2 1.2 0.9 0.8 0.6 0.5 0.5 0.7 0.5 0.6 0.9 2.1 9.8
40-49 2.7 1.6 1.3 1.2 1.0 0.9 0.6 0.5 0.4 0.5 0.6 0.3 0.4 0.8 1.5 6.6
50-59 2.6 1.7 1.4 1.1 0.9 0.9 0.6 0.5 0.4 0.6 0.6 0.4 0.5 0.7 1.3 3.5
60+ 2.6 2.1 1.4 1.0 0.9 0.9 0.7 0.6 0.5 0.6 0.7 0.5 0.5 0.6 0.7 1.4
Source: CDC, National Notifiable Diseases Surveillance System.

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Figure 1.5. Rates of reported hepatitis A, by sex — United States, 2003–2018

Figure 1.5. The line graph shows trends in rates of hepatitis A for males and females from 2003 through 2018. Rates for males and females declined from 2003 through 2011 and remained constant through 2015. Rates increased from 2016 through 2018, with the largest increase from 2017 to 2018. Rates for males were higher than rates for females for all years except 2012 through 2014, when the rates were equal.

Sex 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Data points for Figure 1.5.
Male 2.8 2.1 1.7 1.3 1.1 0.9 0.7 0.6 0.5 0.5 0.6 0.4 0.5 0.7 1.4 4.7
Female 2.4 1.8 1.3 1.1 0.9 0.8 0.6 0.5 0.4 0.5 0.6 0.4 0.4 0.5 0.7 3.0
Source: CDC, National Notifiable Diseases Surveillance System.

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Figure 1.6. Rates of reported hepatitis A, by race/ethnicity — United States, 2003–2018

Figure 1.6. The line graph shows rates of reported hepatitis A by race/ethnicity for 2003 through 2018. The race/ethnicity classifications are American Indian/Alaska Native, Asian/Pacific Islander, Black non-Hispanic, White non-Hispanic, and Hispanic. Rates for White, non-Hispanic and Black, non-Hispanic increased in 2018. The largest increase was for White, non-Hispanics (330% increase). Rates for American Indian/Alaska Natives remained constant and rates for Asian/Pacific Islanders and Hispanics decreased.

Race/
Ethnicity		 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Data points for Figure 1.6.
American Indian/ Alaska Native 1.5 0.8 0.6 0.5 0.7 0.8 0.3 0.2 0.7 0.2 0.3 0.2 0.2 0.1 0.5 0.5
Asian/Pacific Islander 1.9 2.9 1.7 1.5 1.1 1.3 1.1 1.0 0.9 0.6 0.6 0.7 0.6 1.5 0.6 0.5
Black, Non-Hispanic 1.5 1.0 0.8 0.6 0.4 0.4 0.4 0.3 0.3 0.2 0.2 0.2 0.2 0.3 0.7 1.2
White, Non-Hispanic 1.5 1.1 0.9 0.7 0.7 0.6 0.4 0.4 0.3 0.4 0.5 0.3 0.3 0.4 1.0 4.3
Hispanic 2.7 2.7 2.7 2.3 1.4 1.0 0.8 0.7 0.5 0.5 0.5 0.4 0.4 0.5 0.8 0.7
Source: CDC, National Notifiable Diseases Surveillance System.

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Table 1.2. Number and rate* of reported cases† of hepatitis A, by demographic characteristics — United States 2014–2018

Table 1.2
State 2014
No.		 2014
Rate*		 2015
No.		 2015
Rate*		 2016
No.		 2016
Rate*		 2017
No.		 2017
Rate*		 2018
No.		 2018
Rate*
Total§ 1,239 0.4 1,390 0.4 2,007 0.6 3,366 1.0 12,474 3.8
Age group (years)
0–9 41 0.1 48 0.1 47 0.1 40 0.1 54 0.1
10–19 114 0.3 97 0.2 131 0.3 86 0.2 231 0.6
20–29 246 0.5 287 0.6 392 0.9 659 1.4 2,763 6.1
30–39 207 0.5 233 0.6 391 0.9 893 2.1 4,268 9.8
40–49 139 0.3 164 0.4 333 0.8 621 1.5 2,658 6.6
50–59 182 0.4 205 0.5 297 0.7 554 1.3 1,509 3.5
60+ 304 0.5 353 0.5 409 0.6 509 0.7 987 1.4
Sex
Male 645 0.4 726 0.5 1,107 0.7 2,209 1.4 7,497 4.7
Female 591 0.4 662 0.4 897 0.5 1,149 0.7 4,952 3.0
Race/ethnicity
American Indian/Alaskan Native 4 0.2 5 0.2 3 0.1 13 0.5 15 0.5
Asian/Pacific Islander 135 0.7 114 0.6 299 1.5 124 0.6 104 0.5
Black, Non-Hispanic 82 0.2 71 0.2 137 0.3 303 0.7 508 1.2
White, Non-Hispanic 566 0.3 701 0.3 865 0.4 1,979 1.0 8670 4.3
Hispanic 211 0.4 219 0.4 293 0.5 471 0.8 413 0.7
HHS Region
Region 1 88 0.6 60 0.4 105 0.7 91 0.6 410 2.8
Region 2 143 0.5 182 0.6 173 0.6 289 1.0 235 0.8
Region 3 115 0.4 122 0.4 309 1.0 159 0.5 2,498 8.1
Region 4 207 0.3 254 0.4 269 0.4 438 0.7 5,030 7.6
Region 5 205 0.4 193 0.4 259 0.5 855 1.6 3,074 5.9
Region 6 156 0.4 179 0.4 179 0.4 157 0.4 407 1.0
Region 7 48 0.3 38 0.3 58 0.4 46 0.3 273 1.9
Region 8 49 0.4 45 0.4 40 0.3 246 2.1 172 1.4
Region 9 181 0.4 250 0.5 560 1.1 1,033 2.0 311 0.6
Region 10 47 0.4 67 0.5 55 0.4 52 0.4 64 0.5
Source: CDC, National Notifiable Diseases Surveillance System.
* Rate per 100,000 population.
† For the case definition, see https://wwwn.cdc.gov/nndss/conditions/hepatitis-a-acute/.
§ Numbers reported in each category may not add up to the total number of reported cases in a year due to cases with missing data or, in the case of race/ethnicity, cases categorized as “Other”.
¶ Health and Human Services Regions were categorized according to the grouping of states and U.S. Territories assigned under each of the ten Department of Health and Human Services regional offices (https://www.hhs.gov/about/agencies/iea/regional-offices/index.html). For the purposes of this report, regions with U.S. territories (Region 2 and Region 9) contain data from states only.

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HEPATITIS A – RISK BEHAVIORS AND EXPOSURES

Figure 1.7. Availability of information on risk behaviors/exposures* associated with reported cases of hepatitis A — United States, 2018

Color Key with three items listed. Risk identified*, No risk identified, and Risk data missing
Figure 1.7. The pie chart provides information on the availability of risk behaviors/exposures information for reported cases of hepatitis A for 2018. At least one risk behavior/exposure was identified for 26% of cases, no risk was identified for 34% of cases, and risk data were missing for 40% of cases.

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Table 1.3. Reported risk behaviors/exposures† among reported cases of hepatitis A — United States, 2018

Risk behaviors/exposures Risk identified* No risk identified Risk data missing
Table 1.3
Injection drug use 4,247 4,224 4,003
Sexual contact § 299 4,728 7,447
Household contact (non-sexual) § 260 4,767 7,447
Other contact § 312 4,715 7,447
Men who have sex with men 194 1,362 5,941
International travel 114 6,896 5,464
Source: CDC, Nationally Notifiable Diseases Surveillance System.
* Case reports with at least one of the following risk behaviors/ exposures reported 2–6 weeks prior to symptom onset: 1) injection drug use; 2) sexual, household, or other contact; 3) men who have sex with men; 4) travel to hepatitis A-endemic region.
† Reported cases may include more than one risk behavior/exposure.
§ Cases with more than one type of contact reported were categorized according to a hierarchy: 1) sexual contact; 2) household contact (non-sexual); and 3) other contact with hepatitis A case
¶ A total of 7,497 hepatitis A cases were reported among males in 2018.

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Table 1.4. Number and rate* of deaths with hepatitis A listed as a cause of death† among U.S. residents, by demographic characteristic and year — United States, 2014–2018

Table 1.4
Demographic
characteristic		 2014
No.		 2014
(95% CI)		 2015
No.		 2015
(95% CI)		 2016
No.		 2016
(95% CI)		 2017
No.		 2017
(95% CI)		 2018
No.		 2018
(95% CI)
Age group (years)
0–44 4 UR§ 5 UR§ 6 UR§ 9 UR§ 33 0.02
(0.01-0.02)
45–64 35 0.04
(0.03-0.06)		 25 0.03
(0.02-0.04)		 33 0.04
(0.03-0.06)		 35 0.04
(0.03-0.06)		 72 0.09
(0.07-0.11)
65+ 37 0.08
(0.06-0.11)		 37 0.08
(0.05-0.11)		 31 0.06
(0.04-0.09)		 47 0.09
(0.07-0.12)		 66 0.13
(0.10-0.16)
Race/ethnicity
White,
Non-Hispanic		 51 0.02
(0.02-0.03)		 45 0.01
(0.00-0.01)		 50 0.02
(0.01-0.02)		 69 0.02
(0.02-0.03)		 150 0.06
(0.05-0.07)
Other 25 S 22 S 20 S 22 S 21 S
Sex
Male 42 0.02
(0.01-0.03)		 38 0.02
(0.01-0.03)		 38 0.01
(0.01-0.02)		 63 0.03
(0.02-0.03)		 115 0.07
(0.06-0.08)
Female 34 0.01
(0.01-0.02)		 29 0.01
(0.00-0.01)		 32 0.01
(0.01-0.02)		 28 0.00
(0.00-0.00)		 56 0.02
(0.02-0.03)
Overall 76 0.02
(0.02-0.03)		 67 0.01
(0.01-0.02)		 70 0.01
(0.00-0.02)		 91 0.02
(0.02-0.03)		 171 0.05
(0.04-0.06)
Source: CDC, National Center for Health Statistics, Multiple Cause of Death 1999–2018 on CDC WONDER Online Database. Data are from the 2014–2018 Multiple Cause of Death files and are based on information from all death certificates filed in the vital records offices of the fifty states and the District of Columbia through the Vital Statistics Cooperative Program. Deaths of nonresidents (e.g., nonresident aliens, nationals living abroad, residents of Puerto Rico, Guam, the Virgin Islands, and other U.S. Territories) and fetal deaths are excluded. Numbers are slightly lower than previously reported for 2013–2016 due to NCHS standards which restrict displayed data to US residents. Accessed at http://wonder.cdc.gov/mcd-icd10.html on February 14, 2020. CDC WONDER dataset documentation and technical methods can be accessed at https://wonder.cdc.gov/wonder/help/mcd.html#.
* Rates for race/ethnicity, sex, and the overall total are age-adjusted per 100,000 U.S. standard population in 2000 using the following age group distribution (in years): <1, 1–4, 5–14, 15–24, 25–34, 35–44, 45–54, 55–64, 65–74, 75–84, and 85+. For age-adjusted death rates, the age-specific death rate is rounded to one decimal place before proceeding to the next step in the calculation of age-adjusted death rates for NCHS Multiple Cause of Death on CDC WONDER. This rounding step may affect the precision of rates calculated for small numbers of deaths. Missing data are not included.
† Cause of death is defined as one of the multiple causes of death and is based on the International Classification of Diseases, 10th Revision (ICD-10) codes B15 (hepatitis A).
UR§ Unreliable rate: Rates where death counts were less than 20 were not displayed due to the instability associated with those rates.
S¶ Suppressed: CDC WONDER did not have the functionality to calculate rates for the “Other” race/ethnicity group.

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