REPORT NUMBER 59

Issued September 2004

DEPARTMENT OF HEALTH AND HUMAN SERVICES • Public Health Service

Centers for Disease Control and Prevention

CENTERS FOR DISEASE CONTROL AND PREVENTION

HEPATITIS

SURVEILLANCE
Suggested Citation

Centers for Disease Control and Prevention. Hepatitis Surveillance Report No. 59. Atlanta, GA: 

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 

2004 

The report is also available by Internet at: www.cdc.gov/hepatitis

Preface 

 Hepatitis Surveillance, No. 59 presents statistics and trends in viral hepatitis in the 

United States through 2002. This publication, which summarizes viral hepatitis case reports 

received from state health departments, is intended as a reference document for policy makers, 

program managers, health planners, researchers and others who are concerned with the public 

health implications of these diseases. Any comments and suggestions that would improve the 

usefulness of future publications are appreciated and should be sent to Chief, Surveillance Team, 

Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, 

Mailstop G37, Atlanta, GA 30333. 

Acknowledgments 

 

Publication of this report would not have been possible without the contributions of the State and 

Territorial Health Departments that provide state and local surveillance data to the Centers for 

Disease Control and Prevention. 

 This report was prepared by the following staff members of the Surveillance 

Team of the Epidemiology Branch of the Division of Viral Hepatitis, National Center for 

Infectious Diseases: Annemarie Wasley, Jeremy Miller, and Lyn Finelli.
 HEPATITIS SURVEILLANCE --- NUMBER 59 

i

Contents 

List of Figures................................................................................................................................. ii 

List of Tables .................................................................................................................................iii 

Methods........................................................................................................................................... 1 

Acute Hepatitis A, 2002................................................................................................................ 11 

Acute Hepatitis B, 2002................................................................................................................ 25 

Acute Hepatitis C/NANB Hepatitis, 2002.................................................................................... 39 

Future Directions .......................................................................................................................... 50 

Appendices.................................................................................................................................... 52 

References..................................................................................................................................... 54 

 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

ii

List of Figures 

Figure 1. Geographic Divisions of the United States ..................................................................... 5 

Figure 2: Incidence of reported viral hepatitis, 1966-2002............................................................ 6 

Figure 3: Incidence of Hepatitis A, 1966-2002 .......................................................................... 14 

Figure 4: Incidence of Hepatitis A, by Region, 1975-2002........................................................ 15 

Figure 5: Incidence of Hepatitis A, by County, 2002................................................................. 16 

Figure 6: Incidence of Hepatitis A, by Age, 1990-2002............................................................. 17 

Figure 7: Incidence of Hepatitis A, by Sex, 1990-2002 ............................................................. 18 

Figure 8: Incidence of Hepatitis A, by Age and Sex, 2002 ........................................................ 19 

Figure 9: Incidence of Hepatitis A, by Race and Ethnicity, 1990-2002..................................... 20 

Figure 10: Trends in Selected Epidemiologic Characteristics among Patients with Hepatitis A, 

by Year.................................................................................................................................. 23 

Figure 11: Incidence of Acute Hepatitis B, 1966-2002 ............................................................... 28 

Figure 12: Incidence of Acute Hepatitis B, by Region, 1975-2002............................................ 29 

Figure 13: Incidence of Acute Hepatitis B, by County, 2002..................................................... 30 

Figure 14: Incidence of Acute Hepatitis B, by Age, 1990-2002 ................................................ 31 

Figure 15: Incidence of Acute Hepatitis B, by Sex, 1990-2002 ................................................. 32 

Figure 16: Incidence of Acute Hepatitis B, by Age and Sex, 2002............................................ 33 

Figure 17: Incidence of Acute Hepatitis B, by Race and Ethnicity, 1990-2002......................... 34 

Figure 18: Trends in Selected Epidemiologic Characteristics among Patients with Acute 

Hepatitis B, by Year.............................................................................................................. 37 

Figure 19: Incidence of Acute Hepatitis C, 1982-2002 .............................................................. 41 

Figure 20: Incidence of Acute Hepatitis C/NANB, by Age, 1992-2002.................................... 42 

Figure 21: Incidence of Acute Hepatitis C/NANB, by Sex, 1992-2002..................................... 43 

Figure 22: Incidence of Acute Hepatitis C, by Age and Sex, 2002............................................ 44 

Figure 23 Incidence of Acute Hepatitis C/NANB, by Race and Ethnicity, 1992-2002 ............. 45 

Figure 24: Trends in Selected Epidemiologic Characteristics among Patients with Acute 

HepatitisC/NANB, by Year .................................................................................................. 48 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

iii

List of Tables

Table 1: Proportion of Reported Cases That Included Risk Factor Data, by State, 2002 ............. 2 

Table 2: Reported cases of acute viral hepatitis, by type and year, United States, 1966-2002 ..... 7 

Table 3: Incidence of reported acute viral hepatitis, by type, state and year, United States, 1990-

2002......................................................................................................................................... 8 

Table 4: Epidemiologic Characteristics of Patients with Hepatitis A, by Age, 2002 (Crude 

frequency) ............................................................................................................................. 21 

Table 5: Epidemiologic Characteristics of Patients with Hepatitis A, by Age, 2002(Mutually 

exclusive risk factor hierarchy)............................................................................................. 22

Table 6 : Clinical Characteristics of Patients with Hepatitis A, By Age, 2002 ........................... 24 

Table 7: Epidemiologic Characteristics of Patients with Acute Hepatitis B, by Age, 2002 (crude 

frequencies)........................................................................................................................... 35 

Table 8: Epidemiologic Characteristics of Patients with Acute Hepatitis B, by Age, 2002 

(mutually exclusive categories) ............................................................................................ 36 

Table 9: Clinical Characteristics of Patients with Acute Hepatitis B, by Age, 2002 ................. 38 

Table 10: Epidemiologic Characteristics of Patients with Acute Hepatitis C, by Age, 2002 

(Crude Frequency) ................................................................................................................ 46 

Table 11: Epidemiologic Characteristics of Patients with Acute Hepatitis C by Age, 2002 

(mutually exclusive categories) ............................................................................................ 47 

Table 12: Clinical Characteristics of Patients with Acute Hepatitis C by Age, 2002 ................. 49
 HEPATITIS SURVEILLANCE --- NUMBER 59 

iv
 HEPATITIS SURVEILLANCE --- NUMBER 59 

1

Methods 

Conditions under surveillance

 National surveillance is conducted for acute hepatitis A, acute hepatitis B, acute hepatitis 

C and acute non-A, non-B hepatitis (NANB). Case definitions for these conditions are below. 

Nationwide reporting of perinatal HBV infection was implemented in 2001. In addition, chronic 

hepatitis B virus (HBV) infection and hepatitis C virus (HCV) infection, past or present were 

added to the list of nationally notifiable conditions in January 2003. This publication 

summarizes information received about reported cases of acute disease. 

Sources of data

 Cases of acute hepatitis are reported to CDC by state and territorial health departments on 

a weekly basis via the National Notifiable Diseases Surveillance System (NNDSS). As of 

January 1, 2002, all reports are received electronically by CDC via NETSS (National Electronic 

Telecommunications System for Surveillance). However, for the period covered by this report, 

states could report data using hard-copy forms or by electronic means. The data used in this 

report are based on a combination of aggregated NETSS data and summary hardcopy reports 

received for the years 1990 through 2001. 

 Participation by states in the reporting of viral hepatitis cases to CDC is voluntary as it is 

for all nationally notifiable diseases. Currently, all states collect and report basic information 

(event date, source of report, demographic characteristics) about cases of acute viral hepatitis 

that are identified in their states. States are also asked to report additional information 

(laboratory test results, clinical information and exposure history) about investigated cases. 

Completeness of reporting of these additional data varies among and within states. Currently, 

approximately 30% of case reports received by CDC include extended data. See Table 1 for 

information on state-specific reporting profiles. 

Analyses

Incidence rate calculations 

 Crude incidence rates of new cases were calculated on an annual basis per 100,000 

population using Bureau of the Census estimates of the U.S. resident population. 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

2

Frequency analysis 

Analyses of risk factors and clinical characteristics were based on case reports that 

included information on symptoms and serologic test results to verify the presence of acute viral 

hepatitis. For individuals who report more than one risk factor, the assignment of a source of 

infection is based on a hierarchy of mutually exclusive categories that represents the relative 

efficiency of transmission by various routes. For example, based on the hierarchy used for 

hepatitis B risk factors, a case in which the individual’s reported exposures during the incubation 

period included injecting illegal drugs and having had multiple sex partners would be attributed 

to injection drug use. In the tables summarizing the analysis of mutually exclusive risk factors, 

the risk factors are listed according to their order in the hierarchy specific for that disease. For 

comparison, the crude frequencies of reported risk factors are included in separate tables. 

Table 1: Proportion of Reported Cases That Included Risk Factor Data, by State, 2002 

81%-100% 61% - 80% 41-60% 11-40% 0-10% 

Alabama 

D.C. 

Hawaii 

Kansas 

Maine 

Maryland 

Minnesota 

Nevada 

New York 

North Carolina 

Oklahoma 

Pennsylvania 

Rhode Island 

South Dakota 

Vermont 

Washington 

West Virginia 

Wisconsin 

Arkansas 

Colorado 

Florida 

Indiana 

Iowa 

Kentucky 

Montana 

Utah 

Wyoming 

Michigan 

Ohio 

Virginia 

Arizona 

Connecticut 

Illinois 

Louisiana 

Massachusetts 

Missouri 

Nebraska 

New Mexico 

North Dakota 

South Carolina 

Alaska 

California 

Delaware 

Georgia 

Idaho 

Mississippi 

New Hampshire 

New Jersey 

New York City 

Oregon 

Tennessee 

Texas 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

3

Data Limitations

There is considerable variability by state in terms of both the sensitivity of reporting (i.e. 

frequency of underreporting) and the completeness of individual case reports. Information to 

assess the degree of underreporting is not available. Only 30% of cases are reported with 

extended case investigation data (e.g., clinical characteristics, exposure history) and this 

percentage varies by state from 0 to 100% (see Table 1). Analyses of trends in the characteristics 

of reported cases are based on records for which this information is complete; it is not known if 

or how cases that are reported with complete data differ from those for which data are missing or 

from those that are not reported. 

As a result of widespread use of laboratory testing and implementation of laboratory reporting 

requirements, an increasing number of reports are being made to health departments on the basis 

of a laboratory test result alone. For many of these cases, information about symptoms or 

additional serologic testing is not available to distinguish case reports that are likely to represent 

cases of acute hepatitis from those representing chronic infection (in the case of infection with 

HBV or HCV), previous infections or false positive test results. To minimize the effect of 

including misclassified cases on assessments of epidemiologic trends, analysis of clinical 

characteristics and risk factors were restricted to those reports that included sufficient 

information to verify that the cases meet the definition for acute disease. 

Case definitions 

Reported cases must meet the clinical criteria and be serologically confirmed. 

Clinical case definition

An acute illness with a) discrete onset of symptoms and b) jaundice or elevated serum 

aminotransferase levels 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

4

Laboratory criteria for diagnosis: 

• Hepatitis A: 

o Immunoglobulin M (IgM) antibody to hepatitis A virus (anti-HAV) 

positive 

• Hepatitis B: 

o IgM antibody to hepatitis B core antigen (anti-HBc) positive or hepatitis B 

surface antigen (HBsAg) positive 

o IgM anti-HAV negative (if done)

• Hepatitis C: 

o Serum alanine aminotransferase levels greater than 7 times the upper limit 

of normal, and 

o IgM anti-HAV negative, and 

o IgM anti-HBc negative or if not done, HBsAg negative, and 

o One of the following:

 Antibody to hepatitis C virus (anti-HCV) screening-test-positive, 

verified by an additional more specific assay (e.g. RIBA for antiHCV or nucleic acid testing for HCV RNA) OR 

 Anti-HCV screening-test-positive with a signal to cut-off ratio 

predictive of a true positive as determined for the particular assay 

(e.g., >3.8 for the enzyme immunoassays). 

• Non-A, Non-B hepatitis: 

o Serum aminotransferase levels greater than 2.5 times the upper limit of 

normal, and 

o IgM anti-HAV negative, and 

o IgM anti-HBc negative (if done) or HBsAg negative, and 

o Anti-HCV negative (if done) 

Case classification 

 Confirmed: a case that meets the clinical case definition and is laboratory confirmed or, 

for hepatitis A, a case that meets the clinical case definition and occurs in a person who has an 

epidemiologic link with a person who has laboratory-confirmed hepatitis A (i.e., household or 

sexual contact with an infected person during the 15-50 days before the onset of symptoms) 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

5

Figure 1. Geographic Divisions of the United States 

West Midwest South Northeast 

Alaska 

Arizona 

California 

Colorado 

Hawaii 

Idaho 

Montana 

Nevada 

New Mexico 

Oregon 

Utah 

Washington 

Wyoming 

Illinois 

Indiana 

Iowa 

Kansas 

Michigan 

Minnesota 

Missouri 

Nebraska 

North Dakota 

Ohio 

South Dakota 

Wisconsin 

Alabama 

Arkansas 

Delaware 

District of Columbia 

Florida 

Georgia 

Kentucky 

Louisiana 

Maryland 

Mississippi 

North Carolina 

Oklahoma 

South Carolina 

Tennessee 

Texas 

Virginia 

West Virginia 

Connecticut 

Maine 

Massachusetts 

New Hampshire 

New Jersey 

New York 

Pennsylvania 

Rhode Island 

Vermont 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

6

Figure 2: Incidence of reported viral hepatitis, United States, 1966-2002 

0

5

10

15

20

25

30

35

1966196819701972197419761978198019821984198619881990199219941996199820002002

Year

Reported cases per 100,000 population

Hepatitis A

Hepatitis B

Hepatitis C/NANB
 HEPATITIS SURVEILLANCE --- NUMBER 59 

7

Table 2: Reported cases of acute viral hepatitis, by type and year, United States, 1966-2002 

Hepatitis A Hepatitis B Hepatitis C/NANB 

Year No. Rate** No. Rate No. Rate 

1966 32,859 16.8 1,497 0.8 *** *** 

1967 38,909 19.7 2,458 1.3 *** *** 

1968 45,893 23.0 4,829 2.5 *** *** 

1969 48,416 24.0 5,909 3.0 *** *** 

1970 56,797 27.9 8,310 4.1 *** *** 

1971 59,606 28.9 9,556 4.7 *** *** 

1972 54,074 26.0 9,402 4.5 *** *** 

1973 50,749 24.2 8,451 4.0 *** *** 

1974 40,358 19.5 10,631 5.2 *** *** 

1975 35,855 16.8 13,121 6.3 *** *** 

1976 33,288 15.5 14,973 7.1 *** *** 

1977 31,153 14.4 16,831 7.8 *** *** 

1978 29,500 13.5 15,016 6.9 *** *** 

1979 30,407 13.8 15,452 7.0 *** *** 

1980 29,087 12.8 19,015 8.4 *** *** 

1981 25,802 11.3 21,152 9.2 *** *** 

1982 23,403 10.1 22,177 9.6 2,629* 1.1 

1983 21,532 9.2 24,318 10.4 

** 

3,470* 1.5 

1984 22,040 9.3 26,115 11.1 3,871* 1.6 

1985H 23,257 10.0 26,654 11.5 4,192* 1.8 

1986H 23,430 10.0 26,107 11.2 3,634* 1.6 

1987 25,280 10.4 25,916 10.7 2,999* 1.2 

1988 28,507 11.6 23,177 9.4 2,619* 1.1 

1989 35,821 14.4 23,419 9.4 2,529* 1.0 

1990 31,441 12.6 21,102 8.5 2,553* 1.0 

1991 24,378 9.7 18,003 7.1 3,582* 1.4 

1992 23,112 9.1 16,126 6.3 6,010 2.4 

1993 24,238 9.4 13,361 5.2 4,786 1.9 

1994 26,796 10.3 12,517 4.8 4,470 1.8 

1995 31,582 12.0 10,805 4.1 4,576 1.7 

1996 31,032 11.7 10,637 4.0 3,716 1.4 

1997 30,021 11.2 10,416 3.9 3,816 1.4 

1998 23,229 8.6 10,258 3.8 3,518 1.3 

1999 17,047 6.3 7,694 2.8 3,111 1.1 

2000 13,397 4.8 8,036 2.9 3,197 1.1 

2001 10,615 3.7 7,844 2.8 1,640 I 0.7I

2002 8,795 3.1 8,064 2.8 1,223 

¥ 0.5¥

 Source: National Notifiable Diseases Surveillance System * Numbers and rates shown for hepatitis C/ Non-A, non-B hepatitis are unreliable -. ** Rate per 100,000 population. *** Not reported until 1982. ^ Excludes cases from New York City; data not available 

for 1985 or 1986.I Excludes cases from New Jersey and Missouri. ¥ Excludes cases from Missouri
 HEPATITIS SURVEILLANCE --- NUMBER 59 

8

Table 3: Incidence of reported acute viral hepatitis, by type, state and year, United States 

Hepatitis A (cases per 100,000 persons) 

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Alabama 2.4 1.1 1.3 1.4 3.3 2.2 5.1 2.0 1.9 1.4 1.3 1.8 0.9

Alaska 34.4 16.9 22.2 129.8 34.8 8.3 8.9 5.6 2.8 2.4 2.1 2.5 1.9

Arizona 53.8 29.7 31.7 37.4 52.1 31.6 39.9 51.2 39.5 14.6 9.0 7.7 5.6

Arkansas 25.7 10.9 6.5 3.1 10.3 26.7 20.0 8.8 3.2 3.2 5.4 2.7 2.7

California 21.4 16.5 16.0 18.2 21.1 21.5 20.9 20.0 12.8 10.4 8.8 5.3 4.1

Colorado 10.7 20.2 25.5 24.6 16.0 13.6 13.4 10.3 8.7 5.4 5.2 2.0 1.6

Connecticut 4.2 3.8 2.5 3.6 3.0 2.6 4.3 4.6 3.0 3.9 5.2 7.0 2.7

Delaware 14.3 1.9 8.1 1.7 3.1 1.7 2.9 4.2 0.8 0.3 1.9 2.0 1.9

District of Columbia 6.5 13.0 2.9 1.9 4.8 4.7 7.2 6.8 12.6 11.4 7.0 13.9 14.2

Florida 5.2 6.4 4.3 5.1 5.6 4.7 5.1 5.5 4.1 5.7 4.1 5.2 6.3

Georgia 5.8 3.7 3.4 2.1 0.6 1.2 5.6 10.2 11.5 6.2 4.6 11.1 5.9

Hawaii 9.5 7.9 14.9 5.9 4.9 14.0 10.1 12.4 4.5 2.0 1.1 1.4 2.0

Idaho 9.5 9.5 12.8 27.1 33.5 30.3 20.8 12.4 19.1 3.8 3.5 4.3 2.3

Illinois 15.1 12.2 6.7 8.7 5.2 5.6 6.4 7.2 6.8 7.0 5.6 3.5 2.1

Indiana 4.6 8.9 14.1 11.3 6.3 3.3 6.3 5.6 2.9 1.8 2.2 1.7 0.8

Iowa 10.1 1.7 1.9 2.1 2.3 3.8 11.7 17.2 14.0 5.6 2.3 1.2 2.2

Kansas 10.9 3.6 5.6 3.1 4.3 6.3 15.2 10.1 4.1 2.5 4.1 6.7 2.6

Kentucky 2.5 1.9 3.7 3.7 5.8 1.1 1.4 2.0 0.8 1.7 1.6 3.6 1.1

Louisiana 5.3 3.5 5.5 2.5 3.9 4.5 6.0 6.1 4.0 4.9 2.4 1.9 2.0

Maine 0.9 1.7 2.3 1.1 2.0 2.4 2.3 5.3 1.6 2.2 1.7 0.9 0.6

Maryland 19.8 5.6 5.2 3.2 4.0 4.4 5.1 3.7 8.1 5.9 4.0 5.5 5.5

Massachusetts 6.6 4.8 4.9 3.5 1.9 2.7 3.8 4.2 2.0 2.3 2.2 5.9 2.2

Michigan 4.1 3.1 1.6 2.2 3.7 3.8 5.2 14.0 21.7 12.7 4.9 3.3 2.2

Minnesota 7.4 10.9 19.8 11.0 5.7 4.3 3.8 5.2 3.1 2.7 3.7 0.9 1.1

Mississippi 1.8 1.3 1.6 2.3 2.9 8.3 8.3 3.5 2.5 4.6 5.0 1.3 2.2

Missouri 12.1 12.7 28.9 27.5 11.7 25.1 26.3 21.3 11.7 13.0 4.6 1.6 1.5

Montana 19.9 10.2 10.6 9.2 2.9 19.9 14.8 8.1 10.9 2.0 0.8 1.8 1.4

Nebraska 6.6 15.5 16.6 12.1 7.5 4.0 9.5 6.8 1.6 3.2 2.2 2.2 1.1

Nevada 26.3 24.2 8.3 12.6 17.4 21.9 28.0 26.0 13.0 8.1 4.5 3.3 2.5

New Hampshire 0.8 2.7 2.9 1.6 1.5 1.1 1.9 3.0 1.6 1.5 1.5 1.4 0.9

New Jersey 5.6 4.2 4.0 3.7 3.9 3.9 4.9 3.9 4.2 1.9 3.4 3.3 2.2

New Mexico 71.1 44.7 21.7 24.8 66.5 48.0 20.8 20.4 8.9 3.2 3.8 2.2 1.7

New York 11.9 8.4 3.3 4.3 5.0 4.8 4.1 3.7 3.5 2.7 2.4 3.0 1.7

New York City 10.8 13.9 12.1 9.9 12.8 13.7 8.3 12.3 8.0 5.4 6.6 5.5 5.5

North Carolina 9.7 2.4 1.6 1.4 2.1 1.5 2.8 2.8 1.7 2.2 1.9 2.9 2.5

North Dakota 5.2 10.4 22.5 12.6 0.9 3.6 21.8 2.2 0.6 0.5 0.6 0.5 0.6

Ohio 2.7 3.3 4.1 3.1 10.8 15.8 7.0 3.0 3.6 5.8 2.3 2.3 2.6

Oklahoma 19.3 9.0 6.8 6.6 12.9 43.6 78.5 43.5 19.9 15.9 7.9 3.3 1.5

Oregon 29.0 15.3 18.5 17.5 40.2 86.7 27.4 11.6 13.3 7.6 5.0 3.0 1.8

Pennsylvania 15.0 3.6 2.1 1.5 1.8 2.1 4.5 4.2 3.5 3.0 3.6 2.5 2.4

Rhode Island 5.2 11.4 17.0 7.7 3.0 3.5 2.6 13.3 1.8 3.5 3.0 7.1 3.2

South Carolina 1.3 1.2 0.6 0.5 1.1 1.2 1.5 2.9 1.4 1.2 2.4 2.1 1.6

South Dakota 70.8 118.3 30.1 2.5 5.3 13.5 5.8 3.7 5.4 1.4 0.4 0.4 0.4

Tennessee 4.4 3.2 2.3 2.0 6.7 37.3 14.7 7.8 4.3 2.7 2.7 3.3 2.1

Texas 16.0 15.4 10.3 15.5 15.7 16.1 18.2 23.3 17.9 12.6 9.2 2.6 3.9

Utah 35.3 16.2 38.2 44.2 38.8 34.9 53.1 26.6 9.3 3.0 3.2 2.9 2.4

Vermont 1.1 4.2 2.5 1.6 2.4 1.4 2.0 2.5 2.9 4.0 1.6 2.6 0.6

Virginia 4.9 3.0 2.6 2.4 3.0 3.6 3.3 3.7 3.3 2.7 2.3 2.3 2.2

Washington 28.1 12.1 16.8 17.6 21.0 17.2 18.1 18.1 18.2 8.8 5.0 3.1 2.7

West Virginia 1.3 1.2 0.6 1.6 1.3 1.3 1.0 0.7 0.5 2.6 3.1 1.6 1.3

Wisconsin 9.8 15.8 18.7 10.0 4.8 3.6 3.8 3.6 3.6 1.5 2.0 1.6 3.6

Wyoming 16.1 29.5 3.0 3.6 8.6 23.0 8.5 7.3 7.7 1.9 0.8 1.4 0.6
 HEPATITIS SURVEILLANCE --- NUMBER 59 

9

Hepatitis B (cases per 100,000 persons) 

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Alabama 4.1 4.2 3.3 2.6 2.1 2.7 1.8 1.9 1.7 2.0 1.6 2.0 2.3

Alaska 10.5 7.2 3.6 2.5 2.2 2.2 2.6 2.5 2.1 2.9 2.1 1.6 1.9

Arizona 13.2 4.7 5.1 2.4 2.5 2.8 5.3 4.4 4.0 2.9 4.2 3.1 4.6

Arkansas 5.2 6.5 4.5 3.7 2.4 3.3 3.7 4.2 4.5 3.8 4.1 4.0 4.4

California 9.8 8.6 9.2 6.0 6.5 5.5 5.4 5.1 4.4 3.7 3.2 2.5 1.7

Colorado 5.9 4.2 3.5 2.3 2.7 3.7 3.5 3.8 2.6 2.4 2.5 2.3 1.8

Connecticut 7.8 5.9 4.9 2.3 2.9 2.6 2.5 1.7 1.2 1.2 1.4 1.4 2.0

Delaware 14.6 7.9 30.3 2.6 2.0 1.3 1.2 1.0 0.5 0.1 1.9 3.6 1.7

District of Columbia 21.4 26.4 14.5 7.5 9.4 3.8 5.9 5.7 3.6 4.8 6.1 2.3 3.9

Florida 7.4 7.2 6.9 6.2 5.4 4.7 4.6 4.4 3.5 3.9 3.8 3.1 3.2

Georgia 8.3 8.9 4.7 9.7 7.9 1.4 0.8 3.0 2.7 3.0 4.3 5.2 5.7

Hawaii 9.5 4.4 1.6 1.9 2.4 2.7 1.2 0.9 1.5 1.3 1.0 1.8 1.0

Idaho 9.1 7.0 7.9 8.1 6.8 8.8 7.4 4.5 4.0 2.3 0.8 0.8 0.5

Illinois 5.2 3.6 3.4 2.9 2.7 2.5 2.8 2.4 1.9 1.7 1.4 1.7 1.5

Indiana 6.6 4.2 4.0 4.4 3.7 4.2 2.5 1.7 2.0 1.3 1.4 1.2 1.4

Iowa 1.9 1.5 1.2 1.3 1.0 1.6 2.6 1.5 1.9 1.5 1.3 0.8 0.7

Kansas 5.6 2.4 2.6 2.6 1.2 2.1 1.2 1.2 1.1 0.6 1.0 0.5 0.9

Kentucky 12.6 5.2 2.9 2.6 2.0 1.8 2.0 1.1 1.2 1.3 2.0 1.6 1.6

Louisiana 8.9 9.1 6.1 6.3 4.7 5.6 4.8 4.8 5.0 3.9 3.5 2.8 3.0

Maine 2.4 2.6 2.2 0.9 0.9 1.0 0.6 0.5 0.4 0.2 0.4 0.5 1.1

Maryland 11.8 8.0 8.2 5.4 7.1 5.2 3.3 3.4 2.8 2.9 2.5 2.6 2.4

Massachusetts 10.7 9.1 6.4 3.6 3.3 1.9 1.8 1.3 1.3 0.7 0.2 0.6 2.6

Michigan 6.9 6.5 6.2 4.1 4.5 4.1 4.3 4.7 4.8 5.2 4.3 6.2 3.3

Minnesota 2.8 2.3 2.1 2.1 1.8 2.0 2.0 1.3 1.5 1.7 1.2 0.9 1.0

Mississippi 4.8 2.9 13.1 14.8 . . 9.0 6.6 3.4 4.7 3.9 3.3 3.2

Missouri 12.3 10.6 10.3 11.2 10.2 8.2 6.1 6.7 4.6 4.2 2.7 2.3 2.1

Montana 9.4 8.7 4.9 3.3 2.5 2.8 2.4 1.4 0.9 2.4 0.9 0.3 1.1

Nebraska 2.1 2.5 2.8 1.2 1.9 2.4 2.4 1.6 1.4 1.3 2.6 2.0 1.8

Nevada 24.3 15.0 8.0 5.4 4.0 4.3 5.9 4.8 4.6 3.3 2.7 2.5 3.3

New Hampshire 3.7 3.0 4.5 2.4 2.5 2.0 1.8 1.5 1.8 1.4 1.5 1.3 2.0

New Jersey 7.0 6.3 6.5 5.2 5.2 4.6 3.5 3.1 2.5 1.7 2.1 3.4 4.0

New Mexico 15.5 13.3 13.2 13.3 13.2 19.1 24.4 14.9 17.9 12.4 7.9 7.4 7.9

New York 6.5 5.5 4.8 4.2 3.7 3.8 3.3 3.4 2.4 1.9 1.4 1.4 1.3

New York City 9.2 5.0 6.0 4.8 7.4 7.1 6.7 6.2 5.7 3.9 6.9 8.2 9.1

North Carolina 16.4 8.3 6.3 4.5 4.1 4.3 4.6 3.6 3.2 2.9 3.2 2.7 2.8

North Dakota 1.3 0.3 0.6 0.2 0.2 0.8 0.3 1.1 0.6 0.3 0.5 0.3 1.3

Ohio 3.6 3.7 2.1 1.7 1.5 1.0 1.1 0.8 0.7 0.8 0.9 0.8 1.0

Oklahoma 5.8 6.5 5.9 6.0 4.3 5.3 1.7 2.0 5.1 5.5 5.2 3.3 3.1

Oregon 14.7 10.6 10.3 7.3 5.1 4.1 4.0 3.7 6.1 3.5 3.6 4.8 3.6

Pennsylvania 6.2 4.2 4.1 3.0 3.4 2.4 2.4 2.9 3.0 2.4 2.2 2.7 2.8

Rhode Island 5.3 2.8 2.0 1.9 0.8 1.0 1.9 2.2 7.6 4.3 4.4 3.1 3.4

South Carolina 17.8 18.7 1.5 1.4 0.9 1.5 2.7 2.6 1.7 1.6 0.6 1.8 3.3

South Dakota 1.1 1.3 0.7 . 0.5 0.3 0.7 0.1 0.5 0.1 0.3 0.1 0.4

Tennessee 17.7 19.1 21.0 22.7 20.2 12.4 9.7 8.5 5.4 3.8 4.2 4.8 2.5

Texas 10.5 11.3 8.7 7.5 7.8 6.5 6.6 6.4 9.9 4.3 5.1 3.3 5.1

Utah 6.4 2.5 1.6 3.7 4.9 3.8 6.4 4.5 3.1 1.8 1.6 1.1 2.3

Vermont 9.0 3.4 3.0 1.7 2.1 1.2 2.4 1.9 1.7 0.8 1.0 0.8 1.1

Virginia 4.5 3.5 3.0 2.4 2.2 1.8 2.4 2.0 1.6 1.5 2.4 3.0 3.1

Washington 12.6 9.4 7.7 4.7 4.8 4.2 2.9 2.0 2.4 1.9 2.2 2.9 1.4

West Virginia 4.9 3.6 3.0 2.4 2.6 2.9 2.0 0.9 0.8 1.6 1.7 1.9 1.4

Wisconsin 9.1 9.7 9.6 6.3 1.9 1.6 1.7 10.9 9.8 0.6 0.8 0.9 0.9

Wyoming 5.1 7.2 4.7 7.2 5.1 6.9 9.4 5.2 2.3 2.9 0.6 0.6 3.4
 HEPATITIS SURVEILLANCE --- NUMBER 59 

10

Hepatitis C/NANB (cases per 100,000 persons) 

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Alabama 0.6 0.6 0.4 0.1 0.5 0.1 0.2 0.3 0.1 0.0 0.2 0.1 0.2

Alaska 1.6 2.3 1.2 2.0 . 0.5 0.5 . . . . . .

Arizona 2.0 0.5 0.9 0.3 0.7 1.4 1.7 0.6 0.4 1.0 0.4 0.2 0.1

Arkansas 0.8 0.2 0.2 0.2 0.3 0.3 0.3 0.6 1.2 1.2 0.4 0.6 0.4

California 2.1 1.3 3.4 1.8 1.8 1.6 1.5 2.7 2.6 0.6 0.3 0.3 0.2

Colorado 1.6 2.7 2.9 1.7 2.2 1.8 1.7 1.0 0.8 0.9 0.4 0.2 0.1

Connecticut 0.3 0.1 . . . . . . . . . . .

Delaware 1.3 0.7 29.6 0.1 0.3 . 0.1 . . . 0.3 1.4 .

District of Columbia 1.3 40.8 47.5 0.5 0.4 . . . . 0.2 0.5 . .

Florida 0.6 0.7 1.4 0.3 0.7 0.9 0.9 1.0 0.7 0.5 0.3 0.4 0.5

Georgia 0.2 1.5 2.0 6.5 3.1 0.4 . . 0.1 0.1 0.0 . 0.7

Hawaii 1.7 1.6 14.8 0.3 0.4 10.5 18.3 15.3 4.5 . 0.2 . 0.1

Idaho 0.8 0.6 . . 6.3 5.0 8.3 7.1 7.1 0.6 0.2 0.2 0.1

Illinois 0.7 0.9 1.0 0.9 0.7 0.7 0.8 0.7 0.3 0.4 0.2 0.1 0.2

Indiana 0.6 5.7 0.5 0.3 0.2 0.2 0.1 0.2 0.1 0.1 . 0.0 0.0

Iowa 0.5 0.4 0.2 0.3 0.5 0.5 1.9 1.0 0.3 . 0.1 . 0.0

Kansas 1.6 0.8 0.6 0.7 0.7 0.7 0.6 0.5 0.2 . 0.3 0.3 .

Kentucky 1.1 0.2 0.2 0.4 0.8 0.9 0.7 0.4 0.6 0.7 1.0 0.3 0.1

Louisiana 0.1 2.4 3.0 4.2 5.0 5.1 6.7 6.3 3.1 6.9 10.2 3.4 2.2

Maine 0.4 0.4 0.5 0.2 . . . . . 0.2 0.2 0.1 .

Maryland 0.9 1.0 0.7 0.8 0.4 0.1 0.1 0.2 0.4 0.4 0.3 0.2 0.3

Massachusetts 0.4 0.5 0.9 1.3 2.0 1.7 1.2 0.8 0.8 0.1 0.3 0.4 0.1

Michigan 0.5 1.5 5.1 4.2 2.1 2.5 3.6 4.0 4.8 8.3 2.0 1.4 0.9

Minnesota 0.8 0.4 0.6 0.3 0.4 0.1 0.2 0.1 0.4 0.5 0.3 0.7 0.3

Mississippi 0.6 0.4 0.0 0.4 . . 5.6 4.1 3.0 7.1 10.7 3.8 3.2

Missouri 0.8 0.7 0.5 0.5 0.6 0.4 0.4 0.2 0.3 5.8 10.8 19.8 10.8

Montana 0.9 4.1 3.4 0.4 1.5 2.1 2.3 2.7 0.9 0.6 0.6 0.1 0.1

Nebraska 0.3 0.1 5.6 0.7 0.9 1.4 0.5 0.2 0.3 0.2 0.3 0.6 0.9

Nevada 2.6 2.4 1.1 1.4 1.4 1.7 1.3 1.1 1.1 0.6 0.9 0.6 1.4

New Hampshire 0.8 0.8 2.2 0.7 1.0 1.2 0.6 . . . . . .

New Jersey 0.6 1.4 1.2 1.2 2.7 2.4 . . . . 6.7 14.3 0.1

New Mexico 1.8 1.6 3.4 6.6 2.7 3.1 4.5 3.5 5.6 2.0 0.9 0.7 0.2

New York 0.9 2.2 1.8 2.4 2.1 3.2 2.5 2.6 1.2 0.6 0.4 0.3 0.5

New York City 0.4 0.1 0.1 0.0 0.1 0.0 0.0 . . . . . .

North Carolina 2.2 1.7 1.3 1.2 0.8 0.9 0.6 0.7 0.3 0.4 0.2 0.3 0.3

North Dakota 0.3 0.8 0.6 0.5 0.2 1.1 . 0.6 . 0.2 0.2 . .

Ohio 0.9 1.5 0.9 0.3 0.2 0.1 0.3 0.2 0.1 0.0 0.1 0.1 0.0

Oklahoma 0.9 1.5 1.5 1.5 1.9 1.7 0.2 0.3 0.7 0.5 0.5 0.2 0.6

Oregon 2.1 4.5 2.9 1.8 1.5 1.2 0.3 0.1 0.6 0.7 0.8 0.4 0.4

Pennsylvania 0.7 0.4 0.3 0.3 0.4 0.5 0.5 0.7 1.0 0.6 0.4 1.2 0.5

Rhode Island . 1.2 0.7 1.3 2.0 0.8 0.6 0.8 0.4 0.3 0.7 . 0.1

South Carolina 0.4 1.1 0.0 0.1 0.3 0.6 0.9 1.1 0.5 0.6 0.1 0.3 0.1

South Dakota 0.6 0.1 . . . 0.1 . . . . . . 0.1

Tennessee 3.1 9.7 25.2 19.6 17.3 18.8 7.5 4.5 3.2 2.2 2.0 1.2 0.5

Texas 0.9 0.8 1.6 2.3 1.7 1.9 1.1 2.0 2.3 1.8 1.3 2.3 1.3

Utah 1.6 1.4 2.0 2.2 0.9 0.7 0.9 0.2 1.0 0.3 0.6 0.1 0.2

Vermont 1.4 1.2 3.0 1.0 2.8 2.4 4.4 0.7 1.0 1.2 0.8 1.1 2.4

Virginia 0.7 0.6 0.8 0.8 0.4 0.3 0.3 0.4 0.2 0.2 0.0 0.0 0.2

Washington 2.9 3.3 3.6 4.2 5.5 4.3 1.2 0.7 0.5 0.4 0.7 0.5 0.4

West Virginia 0.2 0.2 0.4 2.4 2.6 2.4 0.5 1.0 0.5 1.2 1.3 1.4 0.2

Wisconsin 0.3 2.0 2.0 0.8 . . . 0.5 2.8 0.3 . . 0.1

Wyoming 1.1 1.7 14.2 25.4 37.3 46.6 37.3 17.3 21.2 18.3 0.4 1.6 1.0
 HEPATITIS SURVEILLANCE --- NUMBER 59 

11

Acute Hepatitis A, 2002 

 Summary 

With an average of 28,000 cases per year (range: 23,112-35,821) during 1987-1997, hepatitis 

A has historically been one of the most frequently reported notifiable diseases in the United 

States. However, effective vaccines to prevent hepatitis A virus (HAV) infection have been 

available in the U.S. since 1995 for use in individuals at least two years of age. These vaccines 

have provided the opportunity to substantially reduce disease incidence and potentially eliminate 

transmission. 

Since 1996, hepatitis A vaccine has been recommended for individuals at increased risk of 

hepatitis A including international travelers, men who have sex with men, and injecting and noninjecting drug users 1

. In 1999, routine vaccination was also recommended for children living in 

11 states, ten of which are in the western region, with average hepatitis A rates during 1987-1997 

that were at least 20/100,000 and was suggested for children in an additional six states where 

rates were less than 20/100,000 but above 10/100,000 which was approximately the national 

average for the time period 2. 

Hepatitis A rates have declined steadily since the issuance of these recommendations, with 

the most dramatic decreases occurring in the age groups and regions for which routine childhood 

vaccination is recommended, suggesting that this strategy is reducing the transmission of HAV 

in the United States. The overall rate in 2002 is the lowest yet recorded. The declines in rates 

that have been observed in recent years have also been accompanied by substantial shifts in the 

epidemiologic profile of this disease in the United States with an increasing proportion of cases 

occurring among adults, particularly those in high risk groups such as international travelers and 

men who have sex with men. Further monitoring of disease rates is needed to determine if the 

current low rates are sustained and attributable to vaccination and to identify groups and areas 

where additional vaccination efforts are needed. 

• Historically, hepatitis A rates have varied cyclically with periodic nationwide increases. The 

national rate of hepatitis A has declined steadily since the last peak that occurred in 1995. 

With 8,795 cases reported for the year 2002, the national incidence of hepatitis A is now the 

lowest yet recorded (3.1/100,000). Figure 3
 HEPATITIS SURVEILLANCE --- NUMBER 59 

12

• In addition to temporal variation, hepatitis A rates have consistently varied geographically 

with higher rates in the West than elsewhere in the country. Following the 1999 issuance of 

recommendations for routine childhood vaccination that focused on states with consistently 

elevated rates of hepatitis A, incidence rates in the West have declined steadily and for the 

first time are approximately equal to those in other regions of the U.S. Figure 4, Figure 5

• Incidence of hepatitis A varies by age. Since the last nationwide increase, rates have 

declined among all age groups but the greatest decreases have been among children. 

Historically, the highest rates have been among children and young adults with the lowest 

rates observed among persons greater than 40 years of age. However, since 1997, rates 

among children have declined more rapidly than among adults and in 2002, the highest rates 

were in persons 25-39 years of age. Although the decline in rates was greatest in children 5-

14 years, the lowest rates in 2002 continue to be among persons <5 years of age and among 

persons 40+ years. However, asymptomatic infection is common among very young 

children and reported cases in children <5 represent only a small proportion of infections 

occurring in this age group. The low and relatively stable rates among persons 40+ years of 

age reflect the higher proportion of persons in this age group with immunity due to a 

previous infection; data from the Third National Health and Nutrition Examination Survey 

(NHANES IIII) conducted during 1988-1994 (CDC, unpublished data) indicated that 

approximately one third of the U.S. population have serologic evidence of immunity to HAV. 

Figure 6

• Rates of hepatitis A have historically been higher among males than females and the 

difference between them has increased over the decade. Although the ratio of male to female 

cases declined in 2002 relative to 2001, the 2002 rate among males (3.8/100,000) was 1.7 

times higher than that among females (2.3/100,000) Figure 7 The rate of hepatitis A is 

similar in males and females in age groups less than 19 years and in persons greater than 60 

but between ages 20-60, males had rates that were 1.6-3.1 times higher than among females 

with the greatest difference being observed for adults age 35-39. Figure 8
 HEPATITIS SURVEILLANCE --- NUMBER 59 

13

• Historically, hepatitis A rates have differed by race with the highest rates among American 

Indian/Alaska Natives and the lowest rates among Asians and by ethnicity with higher rates 

among Hispanics than non-Hispanics. However, rates among American Indians which were 

greater than 60/100,000 prior to 1995 have decreased dramatically following widespread 

vaccination in this group and in 2002, are approximately the same or lower than those in 

other races. Rates among Hispanics have also decreased since 1997 but remain higher than 

those for Non-Hispanics. Figure 9

• Among cases where information about exposures during the incubation period was 

determined, the most common risk factor for hepatitis A in 2002 continues to be sexual or 

household contact with another person with hepatitis A with 11.6% of cases attributed to this 

exposure. Over the decade, the proportion of cases attributed to male homosexual activity 

has increased from 1.5% starting in 1992 to 2.3% (1995) to 7.2% (1998) to 8.4% in 2002. 

Similarly, the proportion attributed to travel has increased from 1.3% (1992) to 2.8% (1995) 

to 5.6%(1998) to 9.4%(2002). The proportion of cases attributed to illegal drug use which 

had been declining steadily since 1996 when almost 10% of cases were associated with this 

risk factor increased from 3.6% in 2001 to 5.9% in 2002. In comparison, the proportion of 

cases attributed to either food- or water-borne outbreaks, or to being a child or employee in 

daycare declined from approximately 15% of cases in the years 1992-1995 to 5% of cases in 

2002. No risk factor was identified for approximately 50% of cases interviewed. Table 4, 

Table 5, Figure 10

• The clinical characteristics of hepatitis A cases reported in 2002 are similar to previous years 

with 72% of cases having jaundice, 25% requiring hospitalization for their illness and 0.5% 

resulting in death. The proportion of cases that were jaundiced was highest in persons 15-39 

years of age (80%) and lowest among persons older than 60 years (42%). The proportion of 

cases hospitalized increased with age from 5% among children <5 years of age to 34% 

among persons 60 years of age or older. Table 6
 HEPATITIS SURVEILLANCE --- NUMBER 59 

14

Figure 3: Incidence of Reported Hepatitis A, United States, 1966-2002 

0

5

10

15

20

25

30

35

1966196819701972197419761978198019821984198619881990199219941996199820002002

Year

Reported cases per 100,000 population
 HEPATITIS SURVEILLANCE --- NUMBER 59 

15

Figure 4: Incidence of Reported Hepatitis A, by Region, United States, 1975-2002 

See page 5 for regional categories 

0

5

10

15

20

25

30

35

40

19751977197919811983198519871989199119931995199719992001

Year

Reported cases per 100,000 population

Midwest

Northeast

Southeast

West
 HEPATITIS SURVEILLANCE --- NUMBER 59 

16

Figure 5: Incidence of Reported Hepatitis A, by County, United States, 2002 

rate per 100,000 0-4 5-9 10-19

>=20

 DC

 NYC
 HEPATITIS SURVEILLANCE --- NUMBER 59 

17

Figure 6: Incidence of Reported Hepatitis A, by Age, United States, 1990-2002 

0

5

10

15

20

25

1990199119921993199419951996199719981999200020012002

Year

Reported cases per 100,000 population

<5 yrs 

5 - 14 yrs 

15 - 24 yrs

25 - 39 yrs

40+ yrs 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

18

Figure 7: Incidence of Reported Hepatitis A, by Sex, United States, 1990-2002 

Note: The bars indicate the rate per 100,000 (the left y-axis) by gender; the line is the ratio (right 

y-axis) of the incidence rate among males to that among females.

0

2

4

6

8

10

12

14

16

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Reported Cases per 100,000 population

0

0.5

1

1.5

2

2.5

Ratio (Male/Female)

Female

Male

ratio
 HEPATITIS SURVEILLANCE --- NUMBER 59 

19

 

Figure 8: Incidence of Reported Hepatitis A, by Age and Sex, United States, 2002 

* A total of 8795 cases of Hepatitis A were reported. However, rates exclude patients with 

missing data for age and sex. 

Age Female Male

60+

55-59

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

<5 1.5 1.5

 3.2 2.7

 2.2 2.3

 1.9 2.6

 2.9 4.8

 2.6 5.5

 2.4 5.7

 2.0 6.1

 1.8 5.0

 1.8 4.1

 1.6 3.3

 2.1 2.8

 2.3 2.7

Rate per 100,000
 HEPATITIS SURVEILLANCE --- NUMBER 59 

20

Figure 9: Incidence of Reported Hepatitis A, by Race and Ethnicity, 

United States, 1990-2002 

0

5

10

15

20

25

30

35

40

45

50

1990199119921993199419951996199719981999200020012002

Year

Reported cases per 100,000 population

American Indian/Alaskan

Native 

Asian/Pacific Islander 

Black (non Hispanic) 

Hispanic 

0 White (non Hispanic) 

20

40

60

80

100

120

140

'90'92'94'96'98'00'02
 HEPATITIS SURVEILLANCE --- NUMBER 59 

21

 

Table 4: Epidemiologic Characteristics* of Patients Reported with Hepatitis A, by Age, 

United States, 2002 (Crude frequency) 

Age Groups 

<15 

(n=341) 

15-39 

(n=1437) 

40+ 

(n=1259) 

Total 

(n=3037) 

N % N % N % N % 

Sexual or Household Contact with hepatitis A patient 67 19.6 179 12.5 106 8.4 352 11.6

International travel† 110 32.3 122 8.5 84 6.7 316 10.4

Homosexual activity (Male) . . 198 13.8 104 8.3 302 9.9

Injection drug use 1 0.3 141 9.8 43 3.4 185 6.1

Child/employee in day-care center 29 8.5 15 1.0 16 1.3 60 2.0

Suspected food- or waterborne outbreak 10 2.9 27 1.9 29 2.3 66 2.2

Contact of day-care child/employee 31 9.1 83 5.8 42 3.3 156 5.1

Other Contact with hepatitis A patient¥ 99 29.0 274 19.1 170 13.5 543 17.9

Unknown 130 38.1 735 51.1 855 67.9 1,720 56.6

 *During the 2 to 6 weeks prior to illness 

† Of cases that reported travel to a region endemic for hepatitis A, 75% traveled to South/Central 

America, 15% to Asia/South Pacific, 4% to Africa and 6% to the Middle East. 

¥ Examples of other contact include playmate, drug sharing contact, or careprovider. 

Note 1: A total of 8,795 cases of hepatitis A were reported. This table includes case reports that 

contained sufficient information to verify the case definition (i.e. laboratory test results, clinical 

characteristics). 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

22

Table 5: Epidemiologic Characteristics* of Patients Reported with Hepatitis A, by Age, 

United States, 2002(Mutually exclusive risk factor hierarchy) 

Age Groups 

<15 15-39 yrs 40+ yrs Total 

N % N % N % N % 

Sexual or Household Contact with hepatitis A patient 67 19.6 179 12.5 106 8.4 352 11.6

International travel† 94 27.6 113 7.9 79 6.3 286 9.4

Homosexual activity (Male) ‡ . . 167 11.6 87 6.9 254 8.4

Injection drug use 1 0.3 114 7.9 35 2.8 150 4.9

Child/employee in day-care center 18 5.3 9 0.6 12 1.0 39 1.3

Suspected food- or waterborne outbreak 5 1.5 12 0.8 20 1.6 37 1.2

Contact of day-care child/employee 6 1.8 54 3.8 27 2.1 87 2.9

Other Contact with hepatitis A patient 20 5.9 54 3.8 38 3.0 112 3.7

Unknown 130 38.1 735 51.1 855 67.9 1,720 56.6

Total 341 100.0 1,437 100.0 1,259 100.0 3,037 100.0

*During the 2 to 6 weeks prior to illness 

† Of cases attributed to travel to a region endemic for hepatitis A, 74% traveled to South/Central 

America, 15% to Asia/South Pacific, 4% to Africa and 6% to the Middle East. 

‡ Among male cases, 13% were attributed to homosexual behavior and in males 15-39 years of age, 16% 

of cases were attributed to this risk factor. 

¥ Examples of other contact include playmate, drug sharing contact, or careprovider. 

Note 1: A total of 8795 cases of hepatitis A were reported. This table includes case reports that 

contained sufficient information to verify the case definition (i.e. laboratory test results, clinical 

characteristics). 

Note 2: For persons who reported multiple risk factors for hepatitis A, their source of infection is 

assigned to their reported risk factor that is highest in the order listed in the table above.
 HEPATITIS SURVEILLANCE --- NUMBER 59 

23

Figure 10: Trends in Selected Epidemiologic Characteristics among Patients Reported 

with Hepatitis A, by Year, United States, 1996-2002 

Sexual or Household Contact International Travel Homosexual Contact

Injection Drug Use Day Care Contact Food or Waterborne Outbreak

Percent of Cases

0

5

10

15

20

96 97 98 99 00 01 2002

0

5

10

15

20

96 97 98 99 00 01 2002

0

5

10

15

20

96 97 98 99 00 01 2002

Percent of Cases

0

5

10

15

20

96 97 98 99 00 01 2002

0

5

10

15

20

96 97 98 99 00 01 2002

0

5

10

15

20

96 97 98 99 00 01 2002

Note: This analysis is based on the assignment of cases to mutually exclusive risk categories 

with the source of infection for persons reporting more than one risk factor attributed to the 

reported risk factor that is highest in the table on the previous page.
 HEPATITIS SURVEILLANCE --- NUMBER 59 

24

Table 6 : Clinical Characteristics of Patients Reported with Hepatitis A, By Age, 

United States, 2002 

<5 

(n=122) 

5-14 

(n=400) 

15-39 

(n=1,740) 

40-59 

(n=1,078) 

60+ 

(n=492) 

All 

(n=3832) 

N % N % N % N % N % N % 

Died From Hepatitis 0 0.0 2 0.5 5 0.3 5 0.5 6 1.2 18 0.5

Hospitalized for Hepatitis 6 4.9 83 20.8 426 24.5 257 23.8 169 34.3 941 24.6

Jaundice 63 51.6 310 77.5 1,392 80.0 793 73.6 204 41.5 2,762 72.1

* A total of 8,795 cases of hepatitis A including 18 deaths were reported. Calculated percentages 

include patients with non-missing data for age, and for one or more outcomes of interest (i.e. jaundice, 

hospitalization or death) 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

25

Acute Hepatitis B, 2002 

Summary

During the past decade, a comprehensive strategy was developed and implemented for 

achieving the elimination of HBV transmission in the United States 3

. The primary elements of 

this strategy are: the screening of all pregnant women for HBV infection with the provision of 

post-exposure prophylaxis to infants born to infected women; the routine vaccination of all 

infants and children <19 years; and the targeted vaccination of individuals at increased risk of 

hepatitis B including health care workers, dialysis patients, household contacts and sex partners 

of persons with chronic HBV infection, recipients of certain blood products, persons with a 

recent history of having had multiple sex partners or a STD, men who have sex with men, and 

injecting drug users. 

As highlighted below, the incidence of hepatitis B has declined dramatically since 

implementation of the strategy, particularly among the younger age groups covered by the 

recommendation for routine childhood immunization. However, high rates of disease continue 

among adults, particularly males 25-39 years of age, and the high proportion of cases occurring 

among persons in identified risk groups (i.e. injection drug users, men who have sex with men 

and persons with multiple sex partners) indicate a need to strengthen efforts to reach these 

populations with vaccine. 

 

• With 8,064 cases reported nationwide, the overall incidence rate of reported acute hepatitis B 

in 2002 was 2.8/100,000. That rate was first achieved in 1999 and represents a decline of 

more than 70% since 1985 when incidence peaked at 11.5/100,000. However, the rate has 

remained approximately unchanged since 1999. Figure 11

• For the past decade, hepatitis B rates have been similar for all U.S. regions with rates in the 

West and Southeast only slightly higher than in the Northeast and Midwest (Figure 12, 

Figure 13). Rates in the Northeast have been increasing since 1999 while rates in the West 

have declined during the same period. 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

26

• Hepatitis B rates vary by age with the highest rates reported among persons 25-39 years of 

age (5.4/100,000 persons) and the lowest among persons less than 15 years of age 

(0.1/100,000). Rates have declined in all age groups with the greatest percent decline since 

1990 occurring among children <15 years of age (94%) and young adults 15-24 years of age 

(80% decline). Although less dramatic than the declines in the younger age groups, most of 

which are covered by the recommendations for routine hepatitis B vaccination, there have 

also been substantial decreases in the hepatitis B rates among older persons with a 65% and 

42% decrease in rates observed for 25-39 year olds and 40+ year old categories respectively. 

Figure 14

• As in previous years, the rate of acute hepatitis B in males (3.4/100,000) continues to be 

higher than in females (2.1/100,000). The ratio of cases occurring among males to those 

occurring among females increased slightly but steadily from 1990 to 2001 and although it 

dropped slightly in 2002, the rate in males is still 1.6 times higher than in females. (Figure 

15). This difference in hepatitis B rates by sex occurs only in persons more than 19 years of 

age and is greatest in persons more than 35 years of age where the ratio of male/female cases 

is approximately 2.0. Figure 15, Figure 16

• Rates of hepatitis B continue to decline among all racial and ethnic groups. Figure 17 

However, rates of hepatitis B remain highest among non-Hispanic blacks (3.9/100,000) and 

lowest (1.4/100,000) among non-Hispanic whites. The downward trend in the rate among 

Asians/Pacific Islanders continues and in 2002, is approaching the rate among non-Hispanic 

whites. In contrast, the rate among non-Hispanic blacks has remained unchanged since 

1999. 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

27

• Among cases for which information about exposures during the incubation period were 

determined, 25% of cases were attributed to sexual contact (including 5% sexual contact with 

a known hepatitis B case, 11% multiple sexual partners, and 9% male homosexual activity). 

Another 12% of cases were attributed to injection drug use. Receiving hemodialysis or a 

blood transfusion, both of which were previously major sources of infection, now account for 

<0.5% of cases (0.2% and 0.4% respectively), presumably as a result of the vaccination of 

dialysis patients, improvements in infection control and the required screening of donated 

blood for markers of HBV infection. Similarly, the percentage of cases attributable to 

occupational exposure to blood is approximately 0.5% following widespread hepatitis B 

vaccination of health care workers. In contrast, the role of male homosexual behavior as a 

source for infection has increased in recent years from 4.0% of cases in 1992 to 8.9% in 

2002. Table 7, Table 8, Figure 18

• Among cases of hepatitis B cases reported in 2002, 67% had jaundice, 31% were hospitalized 

because of their illness and 1.0% resulted in death. The proportion of cases that were 

jaundiced was approximately 62% in persons 5 years of age or older ranging from 57% 

among persons 60+ years to 71% among persons 15-39 years of age; less than half of cases 

occurring in children less than 5 years of age presented with jaundice (warning: number of 

cases in this age group extremely small). The proportion of cases hospitalized increased with 

age from 17% among children <5 years of age to 40% among persons 60 years of age or 

older. Table 9
 HEPATITIS SURVEILLANCE --- NUMBER 59 

28

Figure 11: Incidence of Reported Acute Hepatitis B, United States, 1966-2002 

0

2

4

6

8

10

12

14

1966196819701972197419761978198019821984198619881990199219941996199820002002

Year

Reported cases per 100,000 population
 HEPATITIS SURVEILLANCE --- NUMBER 59 

29

Figure 12: Incidence of Reported Acute Hepatitis B, by Region, United States, 1975-2002 

See page 5 for regional categories 

0

5

10

15

20

25

19751977197919811983198519871989199119931995199719992001

Year

Reported cases per 100,000 population

Midwest

Northeast

Southeast

West
 HEPATITIS SURVEILLANCE --- NUMBER 59 

30

Figure 13: Incidence of Reported Acute Hepatitis B, by County, United States, 2002 

Source: NNDSS

rate per 100,000 <4 4-<8 8-<12

>=12

 DC

 NYC
 HEPATITIS SURVEILLANCE --- NUMBER 59 

31

Figure 14: Incidence of Reported Acute Hepatitis B, by Age, United States, 1990-2002 

0

2

4

6

8

10

12

14

16

18

1990199119921993199419951996199719981999200020012002

Year

Reported cases per 100,000 population

<15 yrs 

15 - 24 yrs

25 - 39 yrs

40+ yrs 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

32

Figure 15: Incidence of Reported Acute Hepatitis B, by Sex, United States, 1990-2002 

Note: The bars indicate the rate per 100,000 (the left y-axis) by gender; the line is the ratio (right 

y-axis) of the incidence rate among males to that among females 

0

1

2

3

4

5

6

7

8

9

10

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Reported Cases per 100,000 population

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Ratio (Male/Female)

Female

Male

ratio
 HEPATITIS SURVEILLANCE --- NUMBER 59 

33

Figure 16: Incidence of Reported Acute Hepatitis B, by Age and Sex, United States, 2002 

Female Male Age

60+

55-59

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

<5 0.0 0.1

 0.0 0.0

 0.0 0.0

 1.3 0.9

 4.0 4.5

 4.4 6.2

 4.1 6.7

 3.7 7.1

 3.1 6.0

 3.0 4.6

 2.0 3.8

 1.5 2.9

 0.8 1.7

Rate per 100,000
 HEPATITIS SURVEILLANCE --- NUMBER 59 

34

Figure 17: Incidence of Reported Acute Hepatitis B, by Race and Ethnicity, 

United States, 1990-2002 

0

5

10

15

1990199119921993199419951996199719981999200020012002

Year

Reported cases per 100,000 population

American Indian/Alaskan

Native 

Asian/Pacific Islander 

Black (non Hispanic) 

Hispanic 

White (non Hispanic) 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

35

Table 7: Epidemiologic Characteristics* of Patients Reported with Acute Hepatitis B, by 

Age, United States, 2002 (crude frequencies) 

Age Groups 

<40 

(n=1483**)

40+ yrs 

(n=913) 

Total 

(n=2396) 

N % N % N % 

Injection drug use 229 15.4 46 5.0 275 11.5 

Sexual contact with hepatitis B patient 96 6.5 39 4.3 135 5.6 

Household contact of hepatitis B patient 27 1.8 21 2.3 48 2.0 

Homosexual activity 175 11.8 65 7.1 240 10.0 

Medical Employee with contact with Blood 5 0.3 4 0.4 9 0.4 

Hemodialysis 5 0.3 6 0.7 11 0.5 

Multiple sex partners† 349 23.5 141 15.4 490 20.5 

Blood transfusion 4 0.3 4 0.4 8 0.3 

Surgery 55 3.7 71 7.8 126 5.3 

Percutaneous injury (e.g. needlestick) 29 2.0 26 2.8 55 2.3 

Other reported exposures‡ 281 18.9 115 12.6 396 16.5 

None of the above 682 46.0 537 58.8 1,219 50.9 

*During the 6 weeks-6 months before illness onset 

** 56 (4%) of these cases were <19 years of age 

†More than 1 sex partner in the 6 weeks-6 months prior to illness onset 

‡Other includes: other (non-household and non-sexual) contact with a hepatitis B 

patient, dental /oral surgery, acupuncture, tattoo. 

Note 1: A total of 8,064 cases of hepatitis B were reported. However, calculated percentages are 

based on case reports that included sufficient information to verify the case definition (i.e. 

laboratory test results, clinical characteristics) and information on age and exposure history.
 HEPATITIS SURVEILLANCE --- NUMBER 59 

36

Table 8: Epidemiologic Characteristics* of Patients Reported with Acute Hepatitis B, by 

Age, United States, 2002(mutually exclusive categories) 

Age Groups 

<40 yrs** 40+ yrs Total 

N % N % N % 

Injection drug use 229 15.4 46 5.0 275 11.5

Sexual contact with hepatitis B patient 77 5.2 37 4.1 114 4.8

Household contact of hepatitis B patient 21 1.4 20 2.2 41 1.7

Homosexual activity§ 156 10.5 58 6.4 214 8.9

Medical Employee with contact with Blood 5 0.3 4 0.4 9 0.4

Hemodialysis 1 0.1 6 0.7 7 0.3

Multiple sex partners† 175 11.8 95 10.4 270 11.3

Blood transfusion 2 0.1 4 0.4 6 0.3

Surgery 24 1.6 52 5.7 76 3.2

Percutaneous injury(e.g. needlestick) 9 0.6 7 0.8 16 0.7

Other reported exposures‡ 102 6.9 47 5.1 149 6.2

None of the above 682 46.0 537 58.8 1,219 50.9

Total 1,483 100.0 913 100.0 2,396 100.0

* During the 6 weeks-6 months before illness onset. 

** 56 (4%) of these cases were <19 years of age 

§Among male cases, 14% were attributed to homosexual behavior and in males <40 years of 

age, 17% of cases were attributed to this risk factor. 

†More than 1 sex partner in the 6 weeks-6 months prior to illness onset 

‡Other includes: other (non-household and non-sexual) contact with a hepatitis B patient, 

dental /oral surgery, acupuncture, tattoo. 

Note 1: A total of 8,064 cases of hepatitis B were reported. However, calculated percentages are 

based on case reports that included sufficient information to verify the case definition (i.e. 

laboratory test results, clinical characteristics) and information on age and exposure history. 

Note 2: For persons who reported multiple risk factors for hepatitis B, their source of infection is 

assigned to their reported risk factor that is highest in the order listed in the table above.
 HEPATITIS SURVEILLANCE --- NUMBER 59 

37

Figure 18: Trends in Selected Epidemiologic Characteristics among Patients Reported 

with Acute Hepatitis B, by Year, United States 

Injection Drug Use Homosexual Activity Sexual Contact

Multiple Sex Partners Blood Transfusion Medical Employee

Percent of Cases

0

5

10

15

20

96 97 98 99 00 01 02

0

5

10

15

20

96 97 98 99 00 01 02

0

5

10

15

20

96 97 98 99 00 01 02

Percent of Cases

0

5

10

15

20

96 97 98 99 00 01 02

0

5

10

15

20

96 97 98 99 00 01 02

0

5

10

15

20

96 97 98 99 00 01 02

Note: This analysis is based on the assignment of cases to mutually exclusive risk categories 

with the source of infection for persons reporting more than one risk factor attributed to the 

reported risk factor that is highest in the table on the previous page.
 HEPATITIS SURVEILLANCE --- NUMBER 59 

38

Table 9: Clinical Characteristics of Patients Reported with Acute Hepatitis B, by Age, 

United States, 2002 

<5 

(n=12) 

5-14 

(n=12) 

15-39 

(n=1,856) 

40-59 

(n=1,013) 

60+ 

(n=200) 

All 

(n=3093) 

N % N % N % N % N % N % 

Died From Hepatitis 0 0.0 0 0.0 12 0.6 10 1.0 10 5.0 32 1.0

Hospitalized for Hepatitis 2 16.7 4 33.3 545 29.4 319 31.5 79 39.5 949 30.7

Jaundice 5 41.7 8 66.7 1,312 70.7 627 61.9 114 57.0 2,066 66.8

Note: A total of 8,064 cases of Hepatitis B including x deaths were reported. Calculated percentages 

include case reports with non-missing data for age and for one or more of the outcomes of interest (i.e., 

jaundice, hospitalization, or death). 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

39

Acute Hepatitis C/NANB Hepatitis, 2002 

Summary 

With an estimated 2.7 million chronically infected persons nationwide4

, hepatitis C virus (HCV) 

infection is the most common chronic bloodborne infection in the United States. No effective 

vaccine against this infection is available. National recommendations for prevention and control 

of HCV infection5 issued in 1998 rely on primary prevention activities to reduce the risk for 

HCV transmission. These activities include: screening and testing of blood donors, viral 

inactivation of plasma-derived products, risk-reduction counseling and services, and 

implementation and maintenance of infection control practices. 

Incidence of hepatitis C has been declining since the late 1980s. This decline is largely the result 

of a decrease in cases reported among injecting drug users (IDU) , the reasons for which are 

unknown. The majority of hepatitis C cases continue to occur in adult age groups (persons >25 

years of age) with injecting drug use the most commonly identified risk factor for infection. 

Transmission of HCV associated with transfusion, an important risk factor for infection in the 

past, is now rare. Ongoing surveillance is needed to ensure that any new cases of hepatitis C are 

identified and investigated to determine the source of infection and limit further spread of the 

virus. 

• 1837 cases of acute hepatitis C/NANB hepatitis were reported in 2002. However, 614 

(33%) of these were reported from a single state, Missouri; these reports were made on the 

basis of laboratory reports alone and the majority of them represent chronic rather than acute 

infection. Thus, all analyses excluded reports from Missouri. Based on the 1223 cases 

reported by all other states, the overall national rate of reported acute hepatitis C/NANB was 

0.5 per 100,000. Figure 19

• Historically, because of concerns about the quality of NNDSS data, national trends in 

hepatitis C/NANB have been monitored using data collected through the Sentinel Counties 

Study of Viral Hepatitis. However, in recent years, analysis of case reports meeting the 

definition for acute, symptomatic hepatitis C /NANB collected through NNDSS have yielded 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

40

similar results to those from the Sentinel Counties Study, suggesting that nationally reported 

cases can more reliably be used to monitor trends incidence and risk factors for acute 

hepatitis C. Figure 19

• Rates have been declining in all age groups since the mid-1990s. The greatest decline in 

incidence has been among 25-39 year olds which has historically been the age group with the 

highest rates of disease. In this age group, incidence has declined by 86% since 1992 to 

0.7/100,000 in 2002. Few cases are reported in persons <15 years of age. Figure 20 

• As in previous years, the rate of hepatitis C in 2002 is higher among males (0.5 per 100,000) 

than among females (0.3 /100,000). The ratio of cases occurring among males to those 

occurring among females has remained relatively stable with a range of 1.6-1.9 during the 

past 5 years. This difference in hepatitis C rates by sex is evident in persons 20 years of age 

and older. Figure 21, Figure 22 

• Incidence of hepatitis C/NANB varies by race and ethnicity. Rates have declined in all racial 

groups since 1995 but non-Hispanic blacks and American Indian/Alaska Natives continue to 

have higher incidence rates than other racial/ethnic groups. Rates among Hispanics have 

historically been higher than among non-Hispanic whites (but lower than for non-Hispanic 

blacks) but since 2000 have been lower than for any other racial/ethnic group except Asian or 

Pacific Islanders who continue to have the lowest incidence of hepatitis C/NANB. Figure 23 

• Among cases for which information about exposures during the incubation period was 

determined, the most common risk factor for hepatitis C in 2002 was injection drug use. The 

proportion of cases attributed to injection drug use has been increasing over the past decade 

from 4% in 1993 to 14% in 1996 to 17% in 1998 to 26% in 2002. Another 11% of cases 

were attributed to sexual exposure (5% to sexual contact with a known case and 6% to a 

history of multiple sex partners during the incubation period). Less than 2% of cases were 

attributed to occupational exposure to blood. A history of transfusion or dialysis, both of 

which were previously important sources of HCV infection now account together for <1% of 

cases. No risk factor was identified for 44% of cases interviewed. Table 10, Table 11
 HEPATITIS SURVEILLANCE --- NUMBER 59 

41

Figure 19: Incidence of Reported Acute Hepatitis C/NANB, United States, 1982-2002 

0

1

2

3

4

5

6

7

8

9

10

198219831984198519861987198819891990199119921993199419951996199719981999200020012002

Year

Reported cases per 100,000 population

NNDSS

Sentinel Counties
 HEPATITIS SURVEILLANCE --- NUMBER 59 

42

Figure 20: Incidence of Reported Acute Hepatitis C/NANB, by Age, 

 United States, 1992-2002 

 

0

1

2

3

4

5

6

19921993199419951996199719981999200020012002

Year

Reported cases per 100,000 population

<15 yrs 

15 - 24 yrs

25 - 39 yrs

40+ yrs 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

43

Figure 21: Incidence of Reported Acute Hepatitis C/NANB, by Sex, 

United States, 1992-2002 

Year 

0

0.5

1

1.5

2

2.5

3

3.5

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Reported Cases per 100,000 population

0

0.5

1

1.5

2

2.5

Ratio (Male/Female)

Female 

Male 

ratio 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

44

Figure 22: Incidence of Reported Acute Hepatitis C, by Age and Sex, United States, 2002 

 

Female Male Age

60+

55-59

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

<5 0.0 0.0

 0.0 0.0

 0.0 0.0

 0.2 0.2

 0.5 0.6

 0.4 0.8

 0.7 0.7

 0.9 1.4

 1.1 1.8

 1.0 2.0

 0.7 1.3

 0.4 0.6

 0.2 0.2

Rate per 100,000
 HEPATITIS SURVEILLANCE --- NUMBER 59 

45

 

Figure 23 Incidence of Reported Acute Hepatitis C/NANB, by Race and Ethnicity, 

United States, 1992-2002 

0

1

2

3

4

5

19921993199419951996199719981999200020012002

Year

Reported cases per 100,000 population

American Indian/Alaskan

Native 

Asian/Pacific Islander 

Black (non Hispanic) 

Hispanic 

White (non Hispanic) 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

46

Table 10: Epidemiologic Characteristics* of Patients Reported with Acute Hepatitis C, by 

Age, United States, 2002 (Crude Frequency) 

Age Groups 

<40 yrs 

(n=217) 

40+ yrs 

(n=164) 

Total 

(n=381) 

N % N % N % 

Injection drug use 81 37.3 19 11.6 100 26.2 

Employment in medical/dental field 3 1.4 4 2.4 7 1.8 

Hemodialysis 1 0.5 1 0.6 2 0.5 

Sexual contact with hepatitis C patient 12 5.5 12 7.3 24 6.3 

Household contact of hepatitis C patient 5 2.3 3 1.8 8 2.1 

Multiple sex partners† 36 16.6 21 12.8 57 15.0 

Blood transfusion . . 1 0.6 1 0.3 

Surgery 16 7.4 22 13.4 38 10.0 

Percutaneous injury (e.g. needlestick) 12 5.5 8 4.9 20 5.2 

Other reported exposures‡ 64 29.5 32 19.5 96 25.2 

Unknown 83 38.2 85 51.8 168 44.1 

*During the 6 weeks-6 months before illness onset 

**15(7%) of these cases were <19 years of age 

†More than one sex partner

‡ Other: Case reported one or more of the following exposures: other nonhousehold, non-sexual contact with another hepatitis case, dental or oral 

surgery, acupuncture, tattooing

Note: A total of 1,223 cases of hepatitis C/NANB were reported. However, calculated 

percentages are based on case reports that included sufficient information to verify the case 

definition (i.e. laboratory test results, clinical characteristics) and exposure information. 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

47

Table 11: Epidemiologic Characteristics* of Patients Reported with Acute Hepatitis C by 

Age, United States, 2002 (mutually exclusive categories) 

Age Groups 

<40 yrs 40+ yrs Total 

N % N % N % 

Injection drug use 81 37.3 19 11.6 100 26.2 

Employment in medical/dental field 2 0.9 4 2.4 6 1.6 

Hemodialysis 1 0.5 1 0.6 2 0.5 

Sexual contact with hepatitis C patient 8 3.7 11 6.7 19 5.0 

Household contact of hepatitis C patient 1 0.5 3 1.8 4 1.0 

Multiple sex partners† 12 5.5 10 6.1 22 5.8 

Blood transfusion . . 1 0.6 1 0.3 

Surgery 6 2.8 16 9.8 22 5.8 

Percutaneous injury (e.g. needlestick) 2 0.9 2 1.2 4 1.0 

Other reported exposures‡ 21 9.7 12 7.3 33 8.7 

Unknown 83 38.2 85 51.8 168 44.1 

Total 217 100.0 164 100.0 381 100.0 

*During the 6 weeks – 6 months before illness onset 

†More than one sex partner

‡Other: Case reported one or more of the following exposures: other nonhousehold, non-sexual contact with another hepatitis case, dental or oral 

surgery, acupuncture, tattooing.

Note 1: A total of 1,223 cases of hepatitis C/NANB were reported. However, calculated 

percentages are based on case reports that included sufficient information to verify the case 

definition (i.e. laboratory test results, clinical characteristics) and exposure information. 

Note 2: For persons who reported multiple risk factors for hepatitis C/NANB, their source of 

infection is assigned to their reported risk factor that is highest in the order listed in the table 

above.
 HEPATITIS SURVEILLANCE --- NUMBER 59 

48

Figure 24: Trends in Selected Epidemiologic Characteristics among Patients Reported 

with Acute Hepatitis C/NANB, by Year 

Injection Drug Use Medical Employee Sexual Contact

Multiple Sex Partners Blood Transfusion Hemodialysis

Percent of Cases

0

5

10

15

20

25

30

35

40

96 97 98 99 00 01 02

0

5

10

15

20

25

30

35

40

96 97 98 99 00 01 02

0

5

10

15

20

25

30

35

40

96 97 98 99 00 01 02

Percent of Cases

0

5

10

15

20

25

30

35

40

96 97 98 99 00 01 02

0

5

10

15

20

25

30

35

40

96 97 98 99 00 01 02

0

5

10

15

20

25

30

35

40

96 97 98 99 00 01 02

Note: This analysis is based on the assignment of cases to mutually exclusive risk categories 

with the source of infection for persons reporting more than one risk factor attributed to the 

reported risk factor that is highest in the table on the previous page. 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

49

Table 12: Clinical Characteristics of Patients Reported with Acute Hepatitis C by Age, 

United States, 2002 

Age Group Total 

5-14 

(n=1) 

15-39 

(n=281) 

40-59 

(n=189) 

60+ 

(n=23) 

All 

(n=501) 

N % N % N N % N % N 

Died From Hepatitis 0 0.0 0 0.0 3 1.6 1 4.3 4 0.8 

Hospitalized for Hepatitis 0 0.0 85 30.2 58 30.7 8 34.8 153 30.5 

Jaundice 0 0.0 147 52.3 95 50.3 10 43.5 254 50.7 

Note: A total of 1,223 cases of Hepatitis C/NANB were reported. Calculated 

percentages include patients with non-missing data for age and for one or more of the 

outcomes of interest (i.e., jaundice, hospitalization, and death). 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

50

Future Directions 

Surveillance for acute viral hepatitis

Hepatitis A: Continued monitoring of national and state-specific incidence rates is needed to 

determine if the dramatic decline in rates that has occurred following introduction of hepatitis A 

vaccines in this country is sustained and the extent to which it is attributable to vaccination. 

Enhanced investigation of cases reported in children living in states included in the 

recommendations for routine childhood hepatitis A vaccination and in other groups for which 

vaccination is recommended (e.g. travelers, men who have sex with men) is needed to determine 

if and why these individuals were not vaccinated so that additional cases can be prevented. 

Hepatitis B: The analysis of surveillance data will continue to provide critical information to 

assess the impact of the national strategy for eliminating HBV transmission in the United States. 

With ongoing vaccination of infants and children, it is expected that the number of cases 

occurring in young age groups will continue to decline. Enhanced investigation of cases 

reported in children and other groups for which vaccination is recommended (e.g. health care 

workers, men who have sex with men) is needed to determine if and why these individuals were 

not vaccinated so that additional cases can be prevented. In addition, the investigation of cases 

occurring in risk groups can identify settings in which these individuals might be reached with 

vaccine. The investigation of new cases identified in older persons or others who do not have 

typical risk factors (e.g., multiple sex partners, recent IDU) for HBV should be done to identify 

outbreaks associated with health care or other unusual settings. 

Hepatitis C/NANB: The incidence of acute hepatitis C continues to decline and outbreaks are 

rare. However, the investigation of any new infection is needed to identify and control ongoing 

sources of transmission. In particular, investigation of new cases occurring in persons who do 

not have typical risk factors (e.g., recent IDU) for HCV infection is needed to identify outbreaks 

associated with health care or other unusual settings. Case investigation efforts should be focused 

on the investigation of cases of acute disease or documented cases of seroconversion. 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

51

Surveillance for perinatal HBV infection: Reporting of perinatal HBV infection through NETSS 

began in 2001. In 2001, a total of 30 cases were reported by seven states; in 2002, the number of 

states reporting increased to 17 with a total of 63 cases reported. However, not all states have 

begun reporting through this mechanism. Based on estimations made using other data sources6

, 

approximately 1000 infants were infected with HBV in 2001 of whom 80% will remain 

chronically infected. Once reporting mechanisms are stabilized, analysis of reported cases will 

be included as part of this report. 

Surveillance for chronic hepatitis virus infections: To date, national surveillance has been 

conducted for cases of acute disease only. However, in June 2002, the Council of State and 

Territorial Epidemiologists voted to include chronic HBV infection and HCV infection (past or 

present) in the list of nationally notifiable diseases and approved a case definition for each of 

these conditions. Since January 2003, 20 states have begun reporting these cases electronically 

through NETSS to CDC. Once reporting mechanisms are stabilized, these reports will be 

evaluated and included as part of this report. The approved case definitions for chronic HBV 

infection and HCV infection (past or present) are available at www.cdc.gov/epo/dphsi/casedef/. 

The identification and reporting of chronically infected persons is needed to facilitate follow-up 

of these individuals to ensure that they are receiving appropriate interventions including 

counseling and referral for medical evaluation. In addition, it will allow states to determine the 

characteristics of persons being identified with chronic infection and provide data that can be 

used to describe the local burden of disease due to HBV and HCV infection. 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

52

Appendices 

Appendix I: State and Territorial Epidemiologists and Laboratory Directors

State and Territorial Epidemiologists and Laboratory Directors are acknowledged for their contributions 

to hepatitis surveillance programs. The epidemiologists and the laboratory directors listed below were in 

the positions shown as of July 2003. 

State/Territory State Epidemiologist State Laboratory Director 

Alabama J.P. Lofgren William J Callan 

Alaska John Middaugh Bernard Jilly 

Arizona Bob England Wesley Press 

Arkansas Frank Wilson Michael Loeffelholz 

California Gilberto Chavez Paul Kimsey 

Colorado Ned Calonge David Butcher 

Connecticut James Hadler Katherine Kelley 

Delaware A. LeRoy Hathcock Jane Getchell 

District of Columbia John Davies-Cole Maurice Knuckles 

Florida Landis Crocket Ming S Chan 

Georgia Paul Blake Elizabeth Franko 

Hawaii Paul Effler Vernon Miyamoto 

Idaho Christine Hahn Richard Hudson 

Illinois Mark Dworkin David Maserang 

Indiana Robert Teclaw David Nauth 

Iowa Patricia Quinlisk Mary Gilchrist 

Kansas Gianfranco Pezzino Duane Boline 

Kentucky Kraig Humbaugh George Graham 

Louisiana Raoult Ratard Henry Bradford Jr. 

Maine Kathleen Gensheimer John Krueger 

Maryland David Blythe Jack Deboy 

Massachusetts Alfred Demaria Jr. Ralph Timperi 

Michigan Matthew Boulton Francis P Downes 

Minnesota Harry Hull Norman Crouch 

Mississippi Mills McNeill Joe Graves 

Missouri Bao-Ping Zhu Eric Blank 

Montana Todd Damrow Michael Spence 

Nebraska Thomas Safranek Steve H Hinrichs 

Nevada Randall Todd L. Dee Brown 

New Hampshire Jesse Greenblatt Veronica C Malmberg 

New Jersey Eddy A Bresnitz Dennis Flynn 

New Mexico C. Mack Sewell David E Mills 

New York City Marci Layton 

New York State Perry Smith Lawrence Sturman 

North Carolina Jeff Engel Lou F Turner 

North Dakota Larry Shireley Bonna Cunningham 

Ohio Forrest Smith William Becker 

Oklahoma Kristy Bradley John J Mathewson 

Oregon Melvin Kohn Michael Skeels 

Pennsylvania James Rankin Bruce Kleger 

Rhode Island Utpala Bandy Gregory Hayes 

South Carolina James J. Gibson Harold Dowda 

South Dakota Lon Kightlinger Michael Smith 

Tennessee Allen Craig Michael W Kimberly 

Texas Dennis Perrotta Susan Neill 

Utah Robert Rolfs Charles Brokopp 

Vermont Cortland Lohff Mary Celotti 

Virginia John Marr James L Pearson 

Washington Jo Hofmann Romesh Gautom 

West Virginia Loretta Haddy Andrea Labik 

Wisconsin Jeffrey Davis Ronald H Laessig 

Wyoming Karl Musgrave Richard Harris 

American Samoa Joseph Tufa Joseph Tufa 

Federated States of Micronesia Jean-Paul Quez 

Guam Robert Haddock Peter John Camacho 

Marshall Islands Helen Jetnil 

Northern Mariana Island James Hosfschneider Joseph Villagomez 

Puerto Rico Francisco Alvarado-Ramy Jose L Molinaris 

Virgin Islands Mavis Matthew Norbert Mantor 

 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

53

Appendix II: Viral Hepatitis Case Report Form 
 HEPATITIS SURVEILLANCE --- NUMBER 59 

54

References 

1

 CDC. Prevention of hepatitis A through active or passive immunization. MMWR 1996; 

45(RR:15) 

2

 CDC. Prevention of hepatitis A through active or passive immunization. MMWR 1999; 

48(RR:12) 

3

 CDC. Hepatitis B virus: A comprehensive strategy for eliminating transmission in the United 

States through universal childhood vaccination. MMWR 1991; 40(RR:13) 

4

 Alter, MJ et al. The prevalence of hepatitis C virus infection in the United States. N Engl J 

Med 1999; 341:556-62. 

5

 CDC. Recommendations for prevention and control of hepatitis C virus (HCV) infection and 

HCV-related chronic disease. MMWR 1998; 47(RR:19) 

6

 U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. (Washington, 

DC: U.S. Government Printing Office, November 2000)