Centers for Disease Control and Prevention (CDC)

Dear Colleagues:

Thank you for your efforts to help end the ongoing widespread person-to-person hepatitis A outbreaks. The risk for person-to-person transmission of hepatitis A virus (HAV) continues during the COVID-19 pandemic. As new tools and resources are available, we at the Centers for Disease Control and Prevention (CDC) will share them with you in the form of a newsletter, such as this one. We hope you find this information useful in supporting your activities and as you communicate with others about the hepatitis A outbreaks. 

Recently, CDC and the Advisory Committee on Immunization Practices (ACIP) published Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020. The hepatitis A vaccine is the best way to prevent HAV infection. CDC recommends routine vaccination of children aged 12–23 months and catch-up vaccination for children and adolescents aged 2–18 years who have not previously received hepatitis A vaccine at any age. CDC also recommends vaccination of adults at risk for acquiring HAV infection (such as people who use drugs, people experiencing homelessness, and men who have sex with men) or developing serious complications from HAV infection (such as people with HIV infection and people with chronic liver disease). These individuals should be prioritized to receive the hepatitis A vaccine as soon as it is possible to do so safely. Learn more about safe administration of vaccines during the COVID-19 pandemic by reading CDC’s Interim Guidance for Immunization Services During the COVID-19 Pandemic

Low adult hepatitis A vaccination coverage and high population susceptibility to HAV infection allow outbreaks to continue to occur. A recent analysis of 2007–2016 data from the National Health and Nutrition Examination Survey (NHANES), Susceptibility to Hepatitis A Virus Infection in the United States, 2007–2016, showed that approximately 70% of US born adults remained susceptible to hepatitis A, including those at highest risk (people who use non-injection drugs [79%], people who use injection drugs [73%], men who have sex with men [68%], and people with chronic viral hepatitis [55%]). Implementation of the expanded hepatitis A recommendations is critical to reduce HAV incidence and prevent future outbreaks.  

A high proportion of patients in these hepatitis A person-to-person outbreaks have been hospitalized. A recent study, Hepatitis A Hospitalization Costs, United States, 2017, used Healthcare Cost and Utilization Project data to show that the overall estimated average cost per hepatitis A-related hospitalization in the United States in 2017 was $16,232 (SD $602; 95% CI $15,052–$17,411). Alternatively, the highest manufacturer-reported private sector price per single-antigen adult hepatitis A vaccine dose was $69.58 as of June 1, 2020. The costs associated with hepatitis A hospitalization far exceed the cost of providing a highly efficacious vaccine. 

As jurisdictions seek to end the ongoing person-to-person hepatitis A outbreaks, vaccination strategies targeting the populations at highest risk (i.e., people who use drugs, people experiencing unstable housing or homelessness, men who have sex with men, and people who are or were recently incarcerated) remain the cornerstone of effective public health response. While outbreaks associated with restaurants often attract media attention, vaccinating food handlers without identified risk factors will not mitigate the current risk for person-to-person outbreaks and may prompt health departments to divert limited vaccine resources away from at-risk populations. A survey of 26 state health departments impacted by person-to-person hepatitis A outbreaks, as explained in the recently published Notes from the Field: Assessing the Role of Food Handlers in Hepatitis A Virus Transmission — Multiple States, 2016–2019, showed that among almost 23,000 hepatitis A outbreak cases, <4% occurred among food handlers and secondary infections among patrons accounted for only 0.2% of outbreak cases. 

We are dedicated to keeping you well informed of the latest news about the person-to-person outbreaks of hepatitis A. CDC recognizes that many of you are supporting efforts to respond to COVID-19 and are not able to maintain ongoing viral hepatitis activities at a normal pace. We appreciate your efforts to stay committed to viral hepatitis in the midst of responding to the COVID-19 pandemic. Your hard work does not go unnoticed. 


Laura A. Cooley, MD, MPHTM 
CDR, U.S. Public Health Service
Incident Manager, Hepatitis A Outbreak Response
Division of Viral Hepatitis
Centers for Disease Control and Prevention