National Profile of Viral Hepatitis

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National overview

This annual publication, available exclusively online, is intended as a reference document for policymakers, program managers, health planners, researchers, and others who are concerned with the public health implications of viral hepatitis. The figures and tables in this report are based on data available as of MMWR Week 1, 2024 (ending on January 6, 2024) and supersede data in earlier publications.

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 from three different data sources: 1) reported cases of hepatitis A, hepatitis B, and hepatitis C from CDC’s NNDSS; 2) deaths listing hepatitis A, hepatitis B, or hepatitis C as a cause of death in CDC’s National Vital Statistics System (NVSS); and 3) outcome data for a birth cohort of infants born to a gestational parent with hepatitis B virus (HBV) infection from the CDC Perinatal Hepatitis B Prevention Program (PHBPP).

These surveillance data are used by public health partners to focus prevention efforts, plan services, allocate resources, develop policy, and detect and respond to clusters of viral hepatitis cases. These actions support the goal of CDC’s 2025 Strategic Plan1 for establishing comprehensive national viral hepatitis surveillance for public health action.

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Investment for comprehensive national viral hepatitis surveillance

In May 2021, CDC awarded new funding to 59 US states, territories, and large cities to support viral hepatitis surveillance activities. The five-year funding award is intended to strengthen surveillance for viral hepatitis; increase partner engagement in elimination planning; and improve access to diagnosis, treatment, and prevention among populations most at risk for viral hepatitis. This represents near national coverage, up from 14 sites funded for surveillance activities during May 2017–April 2021. The 2022 Viral Hepatitis Surveillance Report represents the first full year of funding for these 59 jurisdictions.

Impact of COVID-19

The global COVID-19 pandemic began in March 2020 and continued to cause disruptions in access to medical care and routine public health activities in 2021 and 2022. Pandemic-related stay-at-home orders suspended or delayed many routine health care visits, patients avoided seeking medical and preventative services,2 and a decline in testing for hepatitis C was identified.3 Furthermore, many health department staff routinely assigned to viral hepatitis case investigation and surveillance activities were reassigned to respond to the COVID-19 pandemic during 2020–2022, which may have affected a health department’s capacity to detect, investigate, and report all hepatitis cases in their jurisdiction.4 The COVID-19 pandemic also had a profound impact on mortality with the overall age-adjusted death rates increasing during 2020 and 2021 compared to 2019.5,6 Provisional mortality data in 2022 suggest that while the impact of COVID-19 on overall mortality decreased, COVID-19 remained a leading cause of death.7 For these reasons, the numbers and rates of viral hepatitis cases and deaths associated with viral hepatitis during 2020–2022 presented in this report should be interpreted with caution.

- Hepatitis A

During 2022, a total of 2,265 hepatitis A cases were reported to CDC by 50 states and the District of Columbia, corresponding to 4,500 estimated infections (95% confidence interval [CI]: 3,200–5,000) after adjusting for case underascertainment and underreporting (see Technical Notes).8 The reported case count corresponds to a rate of 0.7 cases per 100,000 population, a 59% decrease from the reported rate of 1.7 cases per 100,000 during 2021. A continued decrease in the reported rates of hepatitis A in 2022 follows a period of several years of increasing rates that peaked in 2019 due to widespread and prolonged hepatitis A outbreaks associated with person-to-person transmission, primarily occurring among persons who use drugs and those experiencing homelessness.9 During 2022, 14 out of 23 states with ongoing outbreaks declared an end to their outbreaks.

Approximately half of all hepatitis A cases reported to CDC during 2022 occurred among persons aged 30–49 years, and 58% occurred among non-Hispanic White persons. Among the 927 (41%) reported cases in 2022 that included risk information for injection drug use, 299 (32%) reported injection drug use, which is the most commonly reported risk factor for hepatitis A. A total of 901 patients with hepatitis A were hospitalized (60% hospitalization rate among the 1,513 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 2022 among US residents was 0.02 deaths per 100,000 population, a decrease from the rate reported in 2021 of 0.03 per 100,000 population.

- Hepatitis B

The rate of reported cases of acute hepatitis B declined by 14% between 2020 and 2021 and has remained steady through 2022. During 2022, a total of 2,126 acute hepatitis B cases were reported to CDC by 47 states and the District of Columbia, resulting in 13,800 estimated infections (95% CI: 7,900–33,800) after adjusting for case underascertainment and underreporting (see Technical Notes).8 The reported case count corresponded to a rate of 0.6 per 100,000 population in 2022, which is unchanged from 2021 (0.6 cases per 100,000 population).

Half (52%) of all acute hepatitis B cases reported to CDC during 2022 occurred among persons aged 40–59 years, and 23% occurred among persons aged 60 years and older. The rates of reported cases of acute hepatitis B among persons aged 0–29 years remained low, in part because of the implementation of childhood hepatitis B vaccine recommendations first issued in 1991. The rate of acute hepatitis B was highest among non-Hispanic Black persons (1.0 cases per 100,000 population), compared with other race and ethnicity groups. Among the 976 (46%) reported cases that included risk information for injection drug use, 239 (24%) reported injection drug use, which is the most commonly reported risk factor for acute hepatitis B. A total of 775 patients with acute hepatitis B were hospitalized (58% hospitalization rate among 1,340 cases with hospitalization information available).

A total of 16,729 newly reported cases of chronic hepatitis B were reported to CDC by 43 states and the District of Columbia during 2022, corresponding to a rate of 5.8 cases per 100,000 population; 89% 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 non-Hispanic Asian/Pacific Islander (A/PI) persons (20.1 cases per 100,000 population), which was 11.2 times the rate among non-Hispanic White persons (1.8 cases per 100,000 population). The rate of newly reported chronic hepatitis B cases in urban areas (6.2 per 100,000 population) was double the rate reported in rural areas (3.1 per 100,000 population).

A total of 13 perinatal hepatitis B cases were reported through NNDSS to CDC from nine states during 2022, four fewer cases than reported in 2021. Data from the PHBPP (see Table 4.1 and Figure 4.1) from 64 jurisdictions reported 7,102 infants born to persons with HBV infection during 2021, 95% of whom had received recommended prophylaxis at birth, 88% had completed 3 doses of vaccine by age 12 months, and 65% had received recommended post-vaccination serologic testing. Among 4,631 infants in the 2021 PHBPP cohort with post-vaccination testing, 17 (0.4%) were cases of perinatal hepatitis B transmission.

Data from death certificates demonstrated that the age-adjusted death rate associated with hepatitis B during 2022 among US residents was 0.44 deaths per 100,000 population, remaining stable with the rate during 2021 (0.44 deaths per 100,000 population). The death rate was highest among non-Hispanic A/PI persons (2.3 deaths per 100,000 population), 8.5 times the rate among non-Hispanic White persons (0.27 deaths per 100,000 population).

- Hepatitis C

After over a decade of consecutive annual increases in acute hepatitis C, the number of acute hepatitis C cases declined for the first time in 2022. A total of 4,848 acute hepatitis C cases were reported to CDC in 2022 from 46 states and the District of Columbia, corresponding to 67,400 estimated infections (95% CI: 53,300–229,800) after adjusting for case underascertainment and underreporting (see Technical Notes).8 The acute hepatitis C case count corresponds to a reported rate of 1.5 cases per 100,000 population, a 6% decrease from the reported rate during 2021 (1.6 per 100,000 population). This decrease was observed despite a change to the acute hepatitis C case definition beginning in 2020, which was designed to improve sensitivity in identifying acute hepatitis C cases (see Technical Notes/Case Definitions).

Approximately 70% of acute hepatitis C cases reported to CDC during 2022 were among persons aged 20–49 years, with the highest rate among persons aged 30–39 years (3.6 cases per 100,000 population). The rate among persons aged 20–29 years declined for the fourth consecutive year, from 3.0 per 100,000 population in 2018 to 2.2 per 100,000 population in 2022. The rate of reported cases of acute hepatitis C was highest among non-Hispanic American Indian/Alaska Native (AI/AN) persons (2.9 cases per 100,000 population), compared with other race and ethnicity groups. Although the rate of reported cases of acute hepatitis C decreased among non-Hispanic White persons, the rates increased among non-Hispanic AI/AN, non-Hispanic Black, and Hispanic persons.

Prevention initiatives, such as syringe service programs, might be driving some of the overall decrease in acute hepatitis C observed in 2022; however, decreases were not observed equally across all age and race and ethnicity groups. Other factors, such as difference in drug use practices (for example, transitioning from injecting to smoking opioids10,11 or delaying injection debut), treatment access or coverage, or overdose deaths might explain some of these age or race- and ethnicity-related differences. Further research is needed to investigate and characterize these inequities.

Among the 1,595 (33%) reported acute hepatitis C cases that included risk information for injection drug use, 834 (52%) reported injection drug use, which is the most commonly reported risk factor for acute hepatitis C. A total of 632 patients with acute hepatitis C were hospitalized (31% hospitalization rate among 2,050 cases with hospitalization information available).

During 2022, 93,805 cases of newly reported chronic hepatitis C were reported to CDC from 43 states and the District of Columbia, corresponding to a rate of 40.2 cases per 100,000 population. The rate of newly reported chronic hepatitis C was highest among persons aged 30–39 years (80.2 cases per 100,000 population), followed by persons aged 40–49 years (64.9 cases per 100,000 population).12 The rate of newly reported chronic hepatitis C cases was highest among non-Hispanic AI/AN persons (104.8 cases per 100,000 population), compared with other race and ethnicity categories. The rate of newly reported chronic hepatitis C cases was higher in rural areas (58.5 cases per 100,000 population), compared with urban areas (37.1 cases per 100,000 population).

A total of 197 perinatal hepatitis C cases were reported to CDC from 28 states during 2022, similar to the 199 cases reported in 2021.

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 associated with hepatitis C during 2022 was 2.89 deaths per 100,000 population, a 9% decrease compared to the rate during 2021 (3.18 deaths per 100,000 population) and a 43% decrease from a peak mortality rate during 2013 (5.03 deaths per 100,000 population; data not shown). Since 2013, highly effective, well-tolerated curative treatments have been available for hepatitis C. In 2022, the death rate among non-Hispanic AI/AN persons (9.08 deaths per 100,000 population) was 3.3 times the rate among non-Hispanic White persons (2.72 deaths per 100,000 population). The age-adjusted death rate for hepatitis C decreased for all race and ethnicity categories during 2021–2022, but disparities by race and ethnicity persist.

References

  1. Centers for Disease Control and Prevention (CDC). Division of Viral Hepatitis 2025 Strategic Plan. CDC 2020.
  2. 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.
  3. Kaufman HW, Bull-Otterson L, Meyer WA, et al. Decreases in Hepatitis C Testing and Treatment During the COVID-19 Pandemic. Am J Prev Medicine 2021;61:369–376.
  4. Silk BJ, Scobie HM, Duck WM, et al. COVID-19 Surveillance After Expiration of the Public Health Declaration – United States, May 11, 2023. MMWR Mob Mortal Wkly Rep 2023;72:523–528.
  5. 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.
  6. Xu J, Murphy SL, Kochanek KD, Arias E. Mortality in the United States, 2021. NCHS Data Brief, no 456. Hyattsville, MD: National Center for Health Statistics 2022.
  7. Ahmad FB, Cisewski JA, Xu J, Anderson RN. Provisional Mortality Data – United States, 2022. MMWR Morb Mortal Wkly Rep 2023; 72:488–492.
  8. 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.
  9. Centers for Disease Control and Prevention (CDC). Person-to-person outbreaks of hepatitis A across the United States. Atlanta, GA: US Department of Health and Human Services, CDC 2022.
  10. Kingston S, Newman A, Banta-Green C, Glick S. Results from the 2021 WA State Syringe Service Program Health Survey. Seattle, WA: Addictions, Drug & Alcohol Institute, Department of Psychiatry & Behavioral Sciences, University of Washington, March 2022.
  11. Kral AH, Lambdin BH, Browne EN, Wenger LD, Bluthenthal RN, Zibbell JE, Davidson PJ. Transition from injecting opioids to smoking fentanyl in San Francisco, California. Drug Alcohol Depend. 227 (2021). doi: 10. 1016/j.drugalcdep.2021.109003.
  12. 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.