NCHS Data Brief ■ No. 27 ■ March 2010

u.s. department of health and human services

Centers for Disease Control and Prevention

National Center for Health Statistics

Viral Hepatitis

Geraldine M. McQuillan, Ph.D.; Deanna Kruszon-Moran, M.S.; Maxine M. Denniston, M.S.P.H.;

and Rosemarie Hirsch, M.D., M.P.H.

Key findings

•	 The prevalence of hepatitis 

A antibody, which is indicative 

of immunity to hepatitis A 

virus, increased among U.S. 

born persons aged 6–19, but 

decreased among persons aged 

40 years and over. 

•	 Hepatitis B virus (HBV) 

infection among persons aged 

6–19 has decreased in recent 

years. By 2003–2006, over 

90% of children had received 

at least one dose of the recommended three-dose series of 

hepatitis B vaccine.

•	 Prevalence of infection 

with hepatitis C virus (HCV) 

decreased among those at 

highest risk of infection 

including males and MexicanAmerican and non-Hispanic 

black populations. Despite this 

decrease, the prevalence of 

infection remains higher in 

the non-Hispanic black population. The peak prevalence 

of HCV infection has shifted 

over time from persons aged 

30–39 years (3.9%) to those 

aged 40–49 years (4.3%).

Viral hepatitis is a disease of major public health significance in the United

States with most infection caused by three viruses, hepatitis A virus (HAV), 

hepatitis B virus (HBV), and hepatitis C virus (HCV) (1). Although unrelated, they share a similar symptomatology (2). HBV and HCV can produce 

chronic infection that is associated with chronic liver disease and liver cancer. 

Because 70–85% of those acutely infected with HCV become chronically 

infected, HCV is the most common chronic bloodborne infection in the 

United States (3).

The vaccine for HAV has been recommended for travelers since 1995; 

children and others at risk since 2006 (4). The vaccine for HBV has been 

recommended for infants, older children and adolescents not previously vaccinated since 1991, and adults at risk since the early 1980s (5,6). No vaccine 

currently exists for HCV. Effective antiviral treatments are available for HBV 

infection to halt progressive liver damage (7) and for hepatitis C to achieve 

“sustained virologic response” (i.e., virologic cure). 

Keywords: hepatitis • liver disease • National Health and Nutrition Examination Survey

Has there been a change in the prevalence of HAV antibody 

among the U.S. born population?

0

20

40

60

80

1988–1994 1999–2002 2003–2006 2007–2008

Mexican American1,2

Non-Hispanic black1

Non-Hispanic white1 All1

1 p<0.05 for a test of an increasing linear trend with time for the total population and all race/ethnic groups.

2 p<0.05 when comparing the Mexican-American population with the non-Hispanic white and the non-Hispanic black 

populations for all time periods.

NOTES: HAV is hepatitis A virus. All estimates are age adjusted. All includes race/ethnic groups not reported separately. 

Figure 1. HAV antibody prevalence among U.S. born persons aged 6–19 years: NHANES 

1988–1994, 1999–2002, 2003–2006, and 2007–2008 Percent

Survey years
NCHS Data Brief ■ No. 27 ■ March 2010

■  2  ■

The prevalence of HAV antibody among persons aged 6–19 years increased steadily over the four 

time periods from 8.0% in 1988–1994 to 35.3% in 2007–2008 (Figure 1). Among persons aged 

20–29 years, the prevalence of HAV antibody increased overall from 8.9% in 1988–1994 to 17.1 

in 2003–2006 (Figure 2, HAV antibody was not measured among persons aged 19 years and over 

in 2007–2008). There was no change over time in HAV antibody among persons aged 30–39 

years. Among adults aged 40 years and over, there was a decline in the HAV antibody prevalence 

from 1988–1994 to 2003–2006. 

Are there differences in HAV antibody prevalence by race/ethnicity and 

were they consistent over time?

For all time periods, the Mexican-American population had a significantly higher prevalence of

HAV antibody compared with the non-Hispanic white and non-Hispanic black populations among 

both children aged 6–19 years (Figure 1) and adults aged 20 years and over (Figure 2).

Has the prevalence of HBV infection changed over time? 

The overall prevalence of HBV infection among persons of all ages decreased from 1988–1994 

to 2007–2008 (Figure 3). The decrease in the prevalence of HBV infection from 1988–1994 to 

2007–2008 was significant for all age groups except for persons aged 40–59 years.

1 Estimates are age adjusted. 

2 p<0.05 for test of linear trend decreasing with time among the total, non-Hispanic white, non-Hispanic black, and MexicanAmerican populations; and age groups 40–49, 50–59, and 60 years and over.

3 p<0.05 for test of linear trend increasing with time among those aged 20–29 years.

4 p<0.05 when comparing the non-Hispanic white population with the non-Hispanic black population, all time periods.

5 p<0.05 when comparing the non-Hispanic white population with the Mexican-American population, all time periods. 

6 p<0.05 when comparing the non-Hispanic black population with the Mexican-American population, all time periods.

NOTES: HAV is hepatitis A virus. All includes race/ethnic groups not reported separately .

Figure 2. HAV antibody prevalence among U.S. born persons aged 20 years and over: NHANES 

0 10 20 30 40 50 60 70

 60 and

over2

 50–592

 40–492

 30–39

 20–293

Mexican

American1,2,5,6

Non-Hispanic

black1,2,4,6

Non-Hispanic

white,1,2,4,5

All1,2

Years of age

Percent

32.5

51.5

24.9

19.5

28.2

26.7

15.919.3

17.2

17.1

18.8 8.9

35.2

41.3

37.3

23.8 29.7

29.3

47.3

50.9

61.5

63.3

58.4 68.2

67.2

33.5

26.7

2003–2006

1999–2002

1988–1994
NCHS Data Brief ■ No. 27 ■ March 2010

■  3  ■

Did HBV infection vary by race/ethnicity, sex or place of birth, and how did 

prevalence change over time in these population subgroups?

Survey years

Percent

1 p<0.05 for test for linear decreasing trend with time for age groups 6–19, 20–39, 60 years and over, and all ages combined.

2 estimates are age adjusted.

r estimate may be unstable because the relative standard error is greater than 30%.

p estimate may be unstable because it is based on less than 10 positive persons.

NOTE: HBV is hepatitis B virus.

Figure 3. HBV infection prevalence, by age group and survey cycle: NHANES 1988–1994, 1999–2002, 2003–2006,

and 2007–2008 

0

2

4

6

8

10

All ages1,2

60 and over1

40-59 years

20-39 years1

6-19 years1

1988–1994 1999–2002 2003–2006 2007–2008

p

r r 

2003–2006

1999–2002

2007–2008

1988–1994

Percent

5.5 4.0

3.9

4.5

3.7

3.2

3.0

13.8

16.0

12.3

12.2 10.1

5.4

4.8

4.6

3.6

12.7

11.8 9.1

5.1

2.83.0

3.9

3.6

3.4 2.4

2.7

3.0

2.6 1.8

5.7

6.4

1 p<0.05 for test of linear decreasing trend with time among all groups.

2 p<0.05 when comparing the non-Hispanic black population with both the non-Hispanic white and Mexican-American populations, all time periods.

3 p<0.05 when comparing the non-Hispanic white population with the Mexican-American population, 1988–1994.

4 p<0.05 when comparing U.S. born persons with foreign born persons, all time periods.

5 p<0.05 when comparing males with females, 1988–1994, 1999–2002, and 2003–2006.

NOTES: HBV is hepatitis B virus. All estimates are age adjusted. All includes the race/ethnic groups not reported separately.

Figure 4. HBV infection prevalence among persons aged 6 years and over: NHANES

0369 12 15 18

Foreign born1,4

U.S. born1,4

Mexican

American1,2,3

Non-Hispanic

black1,2

Non-Hispanic

white1,2,3

Female1,5

Male1,5

All1
NCHS Data Brief ■ No. 27 ■ March 2010

■  4  ■

For all four time periods, the non-Hispanic black population had a higher prevalence of HBV infection compared with the non-Hispanic white and Mexican-American populations. Persons born 

outside the United States had a higher prevalence of infection compared with those that were U.S. 

born (Figure 4). For the three time periods from 1988–2006, males also had higher prevalence of 

infection than females. HBV infection prevalence decreased from 1988–1994 to 2007–2008 for 

all racial/ethnic and demographic groups. 

What percentage of the population aged 6–19 years reported vaccination 

with the HBV vaccine?

HBV vaccination (at least one dose) was reported for 73% of the population in 1999–2002. This 

increased to 90% and 91% in 2003–2006 and 2007–2008, respectively (data not shown).

Did HCV infection vary by race/ethnicity or sex, and how did prevalence 

change over time in these population subgroups?

The overall prevalence of HCV infection decreased from 1988–1994 to 2007–2008 (Figure 5). 

The non-Hispanic black population had significantly greater prevalence of HCV infection compared with both the non-Hispanic white and Mexican-American populations across all survey 

cycles from 1988–2008. Among three subgroups, non-Hispanic black and Mexican-American 

persons and males, decreases in prevalence of HCV infection were observed from 1988–1994 

to 2003–2006. Among Mexican-American persons and males decreases were observed from 

1988–1994 to 2007–2008. In contrast, there was no change over time in prevalence among nonHispanic white persons or among females.

2003–2006

1999–2002

2007–2008

1988–1994

Percent

2.5

2.6

2.3

2.4

1.7

1.4

1.1r

1.8

1.6

1.3

1.3

3.2

3.4

2.1

1.7

1.6

1.2

1.1

1.1

1.0

1.5

1.5

1.2

1.3

1 p<0.05 for test of decreasing linear trend with time from 1988–1994 through 2007–2008 among the total, male, and Mexican-American populations.

2 p<0.05 for test of decreasing linear trend with time from 1988–1994 through 2003–2006 among the male, non-Hispanic black , and Mexican-American populations.

3 p<0.05 when comparing males with females, NHANES 1988–1994, NHANES 1999–2002, and NHANES 2003–2006.

4 p<0.05 when comparing the non-Hispanic white population with the non-Hispanic black population, all survey cycles.

5 p<0.05 when comparing the non-Hispanic white population with the Mexican-American population, 1988–1994 only.

6 p<0.05 when comparing the non-Hispanic black population with the Mexican-American population, all survey cycles.

r estimate may be unstable because the relative standard error is greater than 30%.

NOTES: HCV is hepatitis C virus. All estimates are age adjusted. All includes race/ethnic groups not reported separately.

Figure 5. HCV infection prevalence among persons aged 6 years and over: NHANES

0 1234

Mexican

American1,2,5,6

Non-Hispanic

black2,4,6

Non-Hispanic

white4,5

Female3

Male1,2,3

All1
NCHS Data Brief ■ No. 27 ■ March 2010

■  5  ■

Did the prevalence of HCV infection by age group change over time? 

For 1988–1994, persons aged 30–39 years had the highest prevalence of HCV infection (3.9%) 

(Figure 6). By 1999–2002, the peak of infection had shifted to persons aged 40–49 years (4.3%). 

Peak infection remained among persons aged 40–49 years in 2003–2006 and 2007–2008.

Summary 

There was a significant increase in the prevalence of HAV antibody among U.S. born persons

aged 6–19 years from 1988–1994 to 2007–2008 most likely reflecting increasing HAV immunization of children and others. Among U.S. born adults (aged 40 years and over), HAV antibody 

prevalence decreased from 1988–1994 and 2003–2006. This may reflect lower rates of infection

due to reduced exposure to the virus, resulting from higher rates of immunization among the

younger age groups. Surveillance data also have recently demonstrated a decrease in incidence 

over the past 50 years to historic lows with the release of the HAV vaccine and changes in vaccination policy (4,8). 

The significantly higher prevalence of HAV antibody among U.S. born Mexican-American

children and adults may reflect not only higher rates of vaccination within this subgroup, but also

continued greater exposure to natural infection from travel to or visitors from Mexico where the 

disease is endemic. 

There was a significant decrease from 1988–1994 to 2007–2008 for the total population and

for most age groups (6–19, 20–39, and 60 years and over) including the youngest age groups 

that were targeted for vaccination. Disparities continued with significantly higher HBV infection prevalence among non-Hispanic black persons, males, and foreign born persons for most 

time periods. Reported vaccination coverage among persons aged 6–19 years was over 70% by 

1999–2002 and increased to over 90% by 2003–2006. 

Overall prevalence of HCV decreased from 1988–1994 to 2003–2006, but remained constant 

from 2003–2006 to 2007–2008. The decreases in HCV prevalence were observed among the 

subgroups at highest risk, which suggest a positive impact of prevention efforts (9). Despite these 

apparent gains, rates remained high among non-Hispanic black persons compared with other Percent

Age

r estimate may be unstable because the relative standard error is greater than 30%.

p estimate may be unstable because it is based on less than 10 positive persons.

NOTE: HCV is hepatitis C virus.

Figure 6. HCV infection prevalence, by age and time periods: NHANES

0

1

2

3

4

5

2007–2008

2003–2006

1999–2002

1988–1994

6–29 years 30–39 years 40–49 years 50–59 years 60 and over

r, p

r

r
NCHS Data Brief ■ No. 27 ■ March 2010

■  6  ■

race/ethnicity populations. The peak in age-specific prevalence shifted from aged 30–39 years in

1988–1994 to aged 40–49 years by 1999–2002 and continued through 2007–2008. This shift in 

peak age group suggests younger cohorts in the later time periods are not being infected at the 

same rate as those in earlier time periods.

Limitations

National Health and Nutrition Examination Surveys (NHANES) do not include groups that may 

be considered at higher risk for hepatitis infection (i.e., those institutionalized, incarcerated, those

in nonhospital based long-term care facilities, injection drug using homeless populations, etc.). 

Therefore, these data provide conservative estimates of disease prevalence.

Definitions

Prevalence of HAV antibody: Presence of HAV antibody reflects immunity due to vaccination or

due to natural infection transmitted by close personal contact or ingestion of fecal contaminated 

food or drink. All analyses for HAV are restricted to those U.S. born because prevalence of HAV 

antibody is much higher among those not born in the U.S., possibly reflecting infection early in

life prior to immigration.

Prevalence of HBV infection: Presence of HBV core antibody, a measure of lifetime infection 

transmitted through sexual contact, sharing contaminated needles, or from an infected mother 

to her newborn. HBV core antibody alone does not distinguish between history of infection and 

chronic active infection.

Prevalence of HCV infection: Presence of antibody to HCV, a measure of lifetime infection 

transmitted by contact with the blood of an infected person primarily through sharing contaminated needles.

Data source and methods 

NHANES data were used for these analyses. NHANES is a cross-sectional survey designed to 

monitor the health and nutritional status of the civilian, noninstitutionalized U.S. population (10).

The survey consists of interviews conducted in participant’s homes, standardized physical examinations conducted in specially outfitted mobile examination centers, and laboratory tests utilizing

blood provided by participants during the physical examination. 

The NHANES sample design is a complex, multistage design that includes oversampling in 

order to obtain reliable estimates of health and nutritional measures for population subgroups. In 

NHANES III conducted from 1988 to 1994, children under age 5 years, persons aged 60 years 

and over, Mexican-American persons and non-Hispanic black persons were oversampled. In 

1999–2006, non-Hispanic black persons, Mexican-American persons, persons with low-income, 

persons aged 12–19 years, and persons aged 60 years and over were oversampled. In 2007–2008, 

adolescents were no longer oversampled. In 1999, NHANES became a continuous survey, fielded

on an ongoing basis. Public use data files are released in 2-year cycles.

Sample weights, which account for the differential probabilities of selection, nonresponse and 

noncoverage, are incorporated into the estimation process. Standard errors of the estimates were 

calculated and tests of significance were conducted incorporating the sample weights and sample

design (11). Prevalence estimates were age adjusted by the direct method to the projected 2000 

U.S. Census population for comparisons across population subgroups and between surveys (12). 
NCHS Data Brief ■ No. 27 ■ March 2010

■  7  ■

Tests for linear trends with time were examined using orthogonal contrast matrices (13). All data 

analyses were performed using SAS System for Windows (release 9.2; SAS Institute Inc, Cary 

N.C.) and SUDAAN (release 10.0; Research Triangle Institute, Research Triangle Park, N.C.). 

Serum samples for persons aged 6 years and over (aged 6–19 years only for HAV testing in 

NHANES 2007–2008) were sent to the Division of Viral Hepatitis, National Center for HIV/

AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention for 

HAV, HBV, and HCV antibody testing.

About the authors

Geraldine McQuillan, Deanna Kruszon-Moran, and Rosemarie Hirsch are with the Centers for

Disease Control and Prevention’s National Center for Health Statistics, Division of Health and 

Nutrition Examination Surveys. Maxine Denniston is with the Centers for Disease Control and 

Prevention’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division 

of Viral Hepatitis.

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Health and Nutrition Examination Survey. http://www.cdc.gov/nchs/nhanes.htm (accessed 

December, 2008). 
NCHS Data Brief ■ No. 27 ■ March 2010

11. Centers for Disease Control and Prevention. National Center for Health 

Statistics. National Health and Nutrition Examination Surveys Analytic 

Guidelines. http://www.cdc.gov/nchs/nhanes/nhanes2003-2004/analytical_guidelines.htm. 2006.

12. Klein RJ, Schoenborn CA. Age adjustment using the 2000 projected 

U.S. population. Healthy People Statistical Notes, no. 20. Hyattsville, MD: 

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Suggested citation

McQuillan GM, Kruszon-Moran D, Denniston MM, Hirsch R. Viral hepatitis. NCHS 

data brief, no 27. Hyattsville, MD: National 

Center for Health Statistics. 2010.

Copyright information

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the public domain and may be reproduced 

or copied without permission; citation as to 

source, however, is appreciated.

National Center for Health 

Statistics

Edward J. Sondik, Ph.D., Director

Jennifer H. Madans, Ph.D., Associate 

 Director for Science

Division of Health and Nutrition

Examination Surveys

Clifford L. Johnson, M.S.P.H., Director

U.S. Department of

Health & Human Services

Centers for Disease Control and Prevention

National Center for Health Statistics

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