CENTERS FOR DISEASE CONTROL AND PREVENTION

HEPATITIS 

 SURVEILLANCE 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service

REPORT NUMBER 60 

Issued September 2005
Suggested Citation

Centers for Disease Control and Prevention. Hepatitis Surveillance Report No. 60. Atlanta, GA: 

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

2005 

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

Preface 

 Hepatitis Surveillance, No. 60 presents statistics and trends in viral hepatitis in the 

United States through 2003. 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 60 

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Contents 

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

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

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

Acute Hepatitis A, 2003................................................................................................................ 11 

Acute Hepatitis B, 2003................................................................................................................ 25 

Acute Hepatitis C, 2003................................................................................................................ 39

Future Directions .......................................................................................................................... 49

References..................................................................................................................................... 53

 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

 ii

List of Figures

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

Figure 2: Incidence of viral hepatitis, United States, 1966-2003 .................................................. 6 

Figure 3: Incidence of Hepatitis A, 1966-2003 ........................................................................... 15 

Figure 4: Incidence of Hepatitis A, by Region, 1975-2003......................................................... 16 

Figure 5: Incidence of Hepatitis A, by County, 2003.................................................................. 17 

Figure 6: Incidence of Hepatitis A, by Age, 1990-2003.............................................................. 18 

Figure 7: Incidence of Hepatitis A, by Sex, 1990-2003 .............................................................. 19 

Figure 8: Incidence of Hepatitis A, by Age and Sex, 2003 ......................................................... 20 

Figure 9: Incidence of Hepatitis A, by Race and Ethnicity, 1990-2003 ...................................... 21 

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

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

Figure 11: Incidence of Acute Hepatitis B, 1966-2003 ................................................................ 28 

Figure 12: Incidence of Acute Hepatitis B, by Region, 1975-2003............................................. 29 

Figure 13: Incidence of Acute Hepatitis B, by County, 2003...................................................... 30 

Figure 14: Incidence of Acute Hepatitis B, by Age, 1990-2003 ................................................. 31 

Figure 15: Incidence of Acute Hepatitis B, by Sex, 1990-2003 .................................................. 32 

Figure 16: Incidence of Acute Hepatitis B, by Age and Sex, 2003............................................. 33 

Figure 17: Incidence of Acute Hepatitis B, by Race and Ethnicity, 1990-2003.......................... 34 

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

Hepatitis B, by Year.............................................................................................................. 36 

Figure 19: Incidence of Acute Hepatitis C/NANB, 1992-2003................................................... 41

Figure 20: Incidence of Acute Hepatitis C/NANB, by Age, 1992-2003..................................... 42

Figure 21: Incidence of Acute Hepatitis C/NANB, by Sex, 1992-2003...................................... 43

Figure 22: Incidence of Acute Hepatitis C, by Age and Sex, 2003............................................. 44

Figure 23 Incidence of Acute Hepatitis C/NANB, by Race and Ethnicity, 1992-2003 .............. 45

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

Hepatitis C/NANB, by Year ................................................................................................. 47
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 iii

List of Tables

Table 1: Proportion of Reported Cases That Included Risk Factor Data, by State, 2003 ............. 2 

Table 2: Reported cases of acute viral hepatitis, by type and year, United States, 1966-2003 ..... 7 

Table 3: Incidence of reported acute viral hepatitis, by type, state and year, United States ......... 8 

Table 4: Epidemiologic Characteristics of Patients with Hepatitis A, by Age, 2003 ................ 22 

Table 5 : Clinical Characteristics of Patients with Hepatitis A, By Age, 2003 ............................ 24 

Table 6: Epidemiologic Characteristics of Patients with Acute Hepatitis B, by Age, 2003 ....... 35 

Table 7: Clinical Characteristics of Patients with Acute Hepatitis B, by Age, 2003 .................. 37 

Table 8: Epidemiologic Characteristics of Patients with Acute Hepatitis C, by Age, 2003 ....... 46

Table 9: Clinical Characteristics of Patients with Acute Hepatitis C by Age, 2003 ................... 48

 HEPATITIS SURVEILLANCE --- NUMBER 60 

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Methods 

Conditions under surveillance

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

hepatitis C. 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). 

 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 60 

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Frequency analysis 

The percentage of cases reporting a specific risk factor is determined using the number of 

cases reporting any information, positive or negative, about that exposure as the denominator. 

Depending on the type of hepatitis, the percentage of cases reported with any risk factor 

information ranges from 30-40%. Multiple risk factors can be reported by a single case. 

Consequently, the percentages associated with the specific risk factors may sum to >100%. 

Table 1: Proportion of Reported Cases That Included Risk Factor Data, by State, 2003 

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

Alabama 

Arkansas 

Florida 

Kansas 

Maine 

Maryland 

Minnesota 

Nevada 

North Carolina 

Ohio 

Oklahoma 

Pennsylvania 

Rhode Island 

South Dakota 

Vermont 

Washington 

West Virginia 

Colorado 

Iowa 

Kentucky 

Montana 

New York 

North Dakota 

Utah 

Wisconsin 

Hawaii 

Michigan 

Nebraska 

New Mexico 

Wyoming 

Arizona 

Connecticut 

Illinois 

Louisiana 

Massachusetts 

Missouri 

Virginia 

Alaska 

California 

Delaware 

District of 

Columbia 

Georgia 

Idaho 

Indiana 

Mississippi 

New Hampshire 

New Jersey 

New York City 

Oregon 

South Carolina 

Tennessee 

Texas 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

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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. 

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 

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 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

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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). 

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 60 

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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 60 

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Figure 2: Incidence of reported viral hepatitis, United States, 1966-2003 

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 60 

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Table 2: Reported cases of acute viral hepatitis, by type and year, United States, 1966-2003 

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¥

2003 7,653 2.6 7,526 2.6 891¥ 0.4¥

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 60 

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

Hepatitis A 

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Alabama 2.4 1.1 1.3 1.4 3.3 2.2 5.0 2.0 1.8 1.4 1.3 1.8 0.9 0.5

Alaska 34.3 16.8 22.1 129.3 34.6 8.3 8.9 5.5 2.7 2.4 2.1 2.5 1.9 1.5

Arizona 53.7 29.5 31.3 36.7 50.9 30.8 38.5 49.2 37.7 13.9 9.0 7.7 5.6 5.0

Arkansas 25.6 10.9 6.4 3.0 10.1 26.1 19.4 8.6 3.1 3.1 5.4 2.7 2.7 1.4

California 21.4 16.5 15.9 18.2 21.0 21.3 20.8 19.8 12.7 10.3 8.8 5.3 4.1 3.2

Colorado 10.7 20.0 25.3 24.3 15.7 13.3 13.1 10.0 8.4 5.2 5.2 2.0 1.6 1.4

Connecticut 4.2 3.8 2.5 3.5 3.0 2.6 4.2 4.4 2.9 3.8 5.2 7.0 2.7 2.6

Delaware 14.3 1.9 8.1 1.7 3.1 1.6 2.8 4.1 0.8 0.3 1.9 2.0 1.9 1.1

District of Columbia 6.4 12.8 2.8 1.8 4.6 4.5 6.8 6.3 11.7 10.3 7.0 13.9 14.2 7.6

Florida 5.2 6.4 4.3 5.1 5.4 4.6 4.9 5.3 3.9 5.4 4.1 5.2 6.3 2.3

Georgia 5.8 3.7 3.3 2.1 0.6 1.1 5.5 9.9 11.2 6.0 4.6 11.1 5.9 9.1

Hawaii 9.5 7.8 14.8 5.9 4.9 13.9 10.0 12.2 4.4 2.0 1.1 1.4 2.0 1.0

Idaho 9.5 9.5 12.7 26.9 33.2 30.0 20.5 12.2 18.8 3.7 3.5 4.3 2.3 1.3

Illinois 15.1 12.1 6.7 8.7 5.2 5.5 6.3 7.1 6.7 6.9 5.6 3.5 2.1 1.5

Indiana 4.6 8.8 14.1 11.3 6.2 3.2 6.2 5.5 2.9 1.7 2.2 1.7 0.8 1.2

Iowa 10.1 1.7 1.9 2.1 2.2 3.7 11.6 16.9 13.8 5.5 2.3 1.2 2.2 1.4

Kansas 10.9 3.6 5.6 3.1 4.3 6.2 15.0 9.9 4.1 2.5 4.1 6.7 2.6 1.0

Kentucky 2.5 1.9 3.7 3.7 5.7 1.1 1.4 2.0 0.8 1.7 1.6 3.6 1.1 0.9

Louisiana 5.3 3.5 5.5 2.4 3.9 4.5 5.9 6.0 3.9 4.8 2.4 1.9 2.0 1.1

Maine 0.9 1.7 2.3 1.1 2.0 2.4 2.2 5.3 1.6 2.1 1.7 0.9 0.6 1.6

Maryland 19.8 5.6 5.2 3.2 3.9 4.4 5.0 3.6 8.0 5.8 4.0 5.5 5.5 3.2

Massachusetts 6.6 4.8 4.8 3.5 1.8 2.6 3.7 4.1 2.0 2.2 2.2 5.9 2.2 3.4

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 2.0

Minnesota 7.4 10.9 19.7 10.9 5.7 4.2 3.7 5.1 3.0 2.6 3.7 0.9 1.1 1.0

Mississippi 1.8 1.3 1.6 2.3 2.9 8.2 8.2 3.5 2.5 4.5 5.0 1.3 2.2 0.6

Missouri 12.1 12.6 28.8 27.4 11.6 24.9 26.0 21.0 11.5 12.8 4.6 1.6 1.5 1.1

Montana 19.9 10.1 10.5 9.1 2.9 19.7 14.7 8.0 10.8 2.0 0.8 1.8 1.4 0.9

Nebraska 6.6 15.5 16.5 12.0 7.4 3.9 9.3 6.7 1.6 3.1 2.2 2.2 1.1 0.8

Nevada 26.3 24.0 8.2 12.3 16.9 21.1 26.9 24.8 12.2 7.5 4.5 3.3 2.5 2.3

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

New Jersey 5.6 4.2 3.9 3.7 3.8 3.9 4.8 3.8 4.1 1.8 3.4 3.3 2.2 2.4

New Mexico 71.0 44.5 21.5 24.4 65.4 47.0 20.3 19.8 8.6 3.0 3.8 2.2 1.7 1.3

New York 11.4 10.6 6.8 6.5 8.0 8.3 5.6 7.0 5.2 3.7 4.2 4.1 3.3 3.1

North Carolina 9.7 2.4 1.6 1.3 2.0 1.5 2.7 2.8 1.6 2.1 1.9 2.9 2.5 1.5

North Dakota 5.2 10.4 22.4 12.5 0.9 3.6 21.5 2.2 0.6 0.5 0.6 0.5 0.6 0.3

Ohio 2.7 3.3 4.1 3.0 10.8 15.7 7.0 2.9 3.5 5.8 2.3 2.3 2.6 1.5

Oklahoma 19.2 8.9 6.8 6.5 12.8 43.1 77.4 42.8 19.6 15.5 7.9 3.3 1.5 0.8

Oregon 29.0 15.3 18.4 17.4 39.8 85.5 26.9 11.4 13.0 7.4 5.0 3.0 1.8 1.7

Pennsylvania 15.0 3.5 2.1 1.5 1.8 2.0 4.5 4.1 3.4 3.0 3.6 2.5 2.4 8.2

Rhode Island 5.2 11.3 16.8 7.6 3.0 3.4 2.5 12.8 1.7 3.4 3.0 7.1 3.2 1.6

South Carolina 1.3 1.1 0.6 0.5 1.1 1.2 1.5 2.8 1.4 1.2 2.4 2.1 1.6 1.4

South Dakota 70.7 118.9 30.2 2.5 5.3 13.4 5.8 3.6 5.4 1.3 0.4 0.4 0.4 .

Tennessee 4.4 3.1 2.3 2.0 6.6 36.6 14.4 7.6 4.2 2.6 2.7 3.3 2.1 3.5

Texas 16.0 15.3 10.3 15.4 15.5 15.8 17.9 22.9 17.6 12.2 9.2 2.6 3.9 2.8

Utah 35.2 16.1 37.8 43.6 38.5 34.6 51.9 25.9 9.0 2.9 3.2 2.9 2.4 1.7

Vermont 1.1 4.2 2.4 1.6 2.4 1.4 2.0 2.5 2.8 4.0 1.6 2.6 0.6 1.0

Virginia 4.9 3.0 2.6 2.4 2.9 3.6 3.2 3.7 3.3 2.6 2.3 2.3 2.2 1.9

Washington 28.1 12.1 16.7 17.5 20.8 17.1 18.0 17.9 18.0 8.6 5.0 3.1 2.7 1.2

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 2.1

Wisconsin 9.8 15.7 18.6 10.0 4.8 3.5 3.8 3.6 3.5 1.5 2.0 1.6 3.6 0.8

Wyoming 16.1 29.4 3.0 3.6 8.5 22.7 8.4 7.2 7.5 1.8 0.8 1.4 0.6 0.4
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Hepatitis B

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Alabama 4.1 4.1 3.3 2.5 2.1 2.7 1.8 1.8 1.7 1.9 1.6 2.0 2.3 2.1

Alaska 10.5 7.2 3.6 2.5 2.2 2.2 2.6 2.4 2.1 2.9 2.1 1.6 1.9 1.2

Arizona 13.2 4.7 5.1 2.4 2.4 2.7 5.2 4.3 3.8 2.7 4.2 3.1 4.6 5.1

Arkansas 5.2 6.5 4.5 3.7 2.4 3.3 3.6 4.1 4.4 3.7 4.1 4.0 4.4 3.3

California 9.8 8.6 9.2 6.0 6.5 5.5 5.3 5.1 4.4 3.7 3.2 2.5 1.7 1.9

Colorado 5.9 4.2 3.5 2.2 2.6 3.6 3.4 3.7 2.5 2.3 2.5 2.3 1.8 1.8

Connecticut 7.8 5.9 4.8 2.3 2.9 2.6 2.5 1.7 1.1 1.2 1.4 1.4 2.0 2.8

Delaware 14.6 7.9 30.1 2.5 2.0 1.2 1.2 0.9 0.5 0.1 1.9 3.6 1.7 1.7

District of Columbia 21.3 26.1 14.2 7.2 9.0 3.6 5.6 5.3 3.4 4.4 6.1 2.3 3.9 2.3

Florida 7.4 7.1 6.8 6.1 5.3 4.6 4.5 4.3 3.3 3.7 3.8 3.1 3.2 3.7

Georgia 8.3 8.9 4.7 9.6 7.8 1.4 0.8 2.9 2.7 2.9 4.3 5.2 5.7 7.7

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 2.1

Idaho 9.1 7.0 7.8 8.0 6.7 8.7 7.3 4.4 3.9 2.3 0.8 0.8 0.5 0.6

Illinois 5.2 3.6 3.4 2.9 2.6 2.4 2.8 2.3 1.9 1.6 1.4 1.7 1.5 1.0

Indiana 6.6 4.1 4.0 4.3 3.7 4.1 2.4 1.7 2.0 1.3 1.4 1.2 1.4 1.1

Iowa 1.9 1.5 1.2 1.3 0.9 1.6 2.6 1.5 1.9 1.5 1.3 0.8 0.7 0.6

Kansas 5.6 2.4 2.6 2.5 1.2 2.0 1.2 1.2 1.1 0.6 1.0 0.5 0.9 0.7

Kentucky 12.6 5.2 2.9 2.6 2.0 1.8 1.9 1.1 1.2 1.2 2.0 1.6 1.6 2.3

Louisiana 8.9 9.1 6.1 6.2 4.7 5.5 4.8 4.7 4.9 3.9 3.5 2.8 3.0 2.6

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 0.5

Maryland 11.8 8.0 8.2 5.3 7.0 5.2 3.3 3.3 2.7 2.8 2.5 2.6 2.4 2.4

Massachusetts 10.7 9.1 6.4 3.5 3.3 1.9 1.8 1.2 1.3 0.7 0.2 0.6 2.6 3.3

Michigan 6.9 6.5 6.2 4.1 4.5 4.1 4.3 4.7 4.8 5.1 4.3 6.2 3.3 2.2

Minnesota 2.8 2.3 2.1 2.1 1.8 2.0 2.0 1.3 1.5 1.6 1.2 0.9 1.0 1.1

Mississippi 4.8 2.9 13.1 14.7 . . 8.9 6.5 3.4 4.6 3.9 3.3 3.2 3.9

Missouri 12.3 10.6 10.3 11.1 10.1 8.1 6.0 6.6 4.6 4.1 2.7 2.3 2.1 4.3

Montana 9.4 8.6 4.8 3.3 2.4 2.7 2.4 1.3 0.9 2.3 0.9 0.3 1.1 1.7

Nebraska 2.1 2.5 2.8 1.2 1.9 2.4 2.3 1.5 1.4 1.3 2.6 2.0 1.8 1.8

Nevada 24.2 14.9 7.9 5.2 3.9 4.1 5.7 4.5 4.4 3.0 2.7 2.5 3.3 3.9

New Hampshire 3.7 3.0 4.5 2.4 2.5 2.0 1.8 1.5 1.7 1.4 1.5 1.3 2.0 1.9

New Jersey 7.0 6.2 6.5 5.1 5.1 4.6 3.4 3.0 2.5 1.7 2.1 3.4 4.0 2.1

New Mexico 15.4 13.2 13.1 13.1 13.0 18.7 23.8 14.5 17.3 11.9 7.9 7.4 7.9 1.9

New York 7.6 5.2 5.2 4.4 5.1 5.1 4.6 4.4 3.7 2.6 3.7 4.3 4.6 1.6

North Carolina 16.4 8.3 6.2 4.5 4.0 4.2 4.5 3.5 3.1 2.8 3.2 2.7 2.8 1.9

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 0.3

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 1.4

Oklahoma 5.7 6.5 5.9 6.0 4.3 5.2 1.7 2.0 5.1 5.4 5.2 3.3 3.1 2.2

Oregon 14.7 10.5 10.2 7.2 5.1 4.1 4.0 3.6 6.0 3.4 3.6 4.8 3.6 3.4

Pennsylvania 6.2 4.2 4.1 2.9 3.3 2.4 2.3 2.8 2.9 2.4 2.2 2.7 2.8 2.4

Rhode Island 5.3 2.8 2.0 1.9 0.8 1.0 1.9 2.1 7.3 4.1 4.4 3.1 3.4 2.0

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 4.8

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 0.5

Tennessee 17.7 19.0 20.9 22.4 19.9 12.1 9.5 8.3 5.3 3.7 4.2 4.8 2.5 3.9

Texas 10.5 11.3 8.6 7.5 7.7 6.4 6.5 6.3 9.7 4.2 5.1 3.3 5.1 4.4

Utah 6.4 2.5 1.6 3.6 4.9 3.7 6.2 4.4 3.0 1.8 1.6 1.1 2.3 2.2

Vermont 9.0 3.3 3.0 1.7 2.1 1.2 2.4 1.8 1.7 0.8 1.0 0.8 1.1 0.6

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 3.1

Washington 12.6 9.4 7.7 4.7 4.7 4.1 2.8 2.0 2.4 1.9 2.2 2.9 1.4 1.5

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 2.4

Wisconsin 9.1 9.6 9.6 6.3 1.9 1.6 1.7 10.7 9.7 0.6 0.8 0.9 0.9 0.9

Wyoming 5.1 7.2 4.7 7.2 5.0 6.8 9.2 5.1 2.2 2.8 0.6 0.6 3.4 6.2
 HEPATITIS SURVEILLANCE --- NUMBER 60 

 10

Hepatitis C/NANB

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

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 0.1

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

Arizona 2.0 0.5 0.9 0.3 0.7 1.3 1.7 0.5 0.4 1.0 0.4 0.2 0.1 0.1

Arkansas 0.8 0.2 0.2 0.2 0.3 0.3 0.3 0.6 1.1 1.2 0.4 0.6 0.4 0.1

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 0.1

Colorado 1.6 2.7 2.9 1.7 2.1 1.8 1.6 0.9 0.8 0.9 0.4 0.2 0.1 0.3

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

Delaware 1.3 0.7 29.4 0.1 0.3 . 0.1 . . . 0.3 1.4 . .

District of Columbia 1.3 40.3 46.5 0.5 0.3 . . . . 0.2 0.5 . . .

Florida 0.6 0.7 1.4 0.3 0.7 0.9 0.8 1.0 0.6 0.4 0.3 0.4 0.5 0.4

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

Hawaii 1.7 1.6 14.7 0.3 0.4 10.4 18.0 15.0 4.4 . 0.2 . 0.1 0.3

Idaho 0.8 0.6 . . 6.2 4.9 8.2 7.0 6.9 0.6 0.2 0.2 0.1 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 0.2

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

Iowa 0.5 0.4 0.2 0.3 0.5 0.5 1.8 1.0 0.3 . 0.1 . 0.0 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 0.6

Louisiana 0.1 2.4 3.0 4.1 4.9 5.1 6.6 6.2 3.1 6.8 10.2 3.4 2.2 2.3

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

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 0.2

Massachusetts 0.4 0.5 0.9 1.3 2.0 1.7 1.2 0.7 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 1.0

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 0.5

Mississippi 0.6 0.4 0.0 0.4 . . 5.6 4.0 3.0 6.9 10.7 3.8 3.2 1.5

Missouri 0.8 0.7 0.5 0.5 0.6 0.4 0.4 0.2 0.3 5.7 10.8 19.8 10.8 4.5

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 0.4

Nebraska 0.3 0.1 5.5 0.7 0.9 1.4 0.5 0.2 0.3 0.2 0.3 0.6 0.9 0.2

Nevada 2.6 2.4 1.1 1.4 1.3 1.6 1.3 1.1 1.1 0.5 0.9 0.6 1.4 1.2

New Hampshire 0.8 0.8 2.1 0.7 1.0 1.2 0.6 . . . . . . .

New Jersey 0.6 1.4 1.2 1.2 2.6 2.3 . . . . 6.7 14.3 0.1 .

New Mexico 1.8 1.5 3.3 6.5 2.7 3.1 4.4 3.4 5.4 1.9 0.9 0.7 0.2 .

New York 0.7 1.4 1.1 1.4 1.3 1.8 1.5 1.5 0.7 0.4 0.2 0.2 0.3 0.1

North Carolina 2.2 1.7 1.3 1.1 0.8 0.9 0.6 0.7 0.3 0.4 0.2 0.3 0.3 0.2

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 0.1

Oklahoma 0.9 1.5 1.5 1.5 1.9 1.6 0.2 0.3 0.7 0.5 0.5 0.2 0.6 0.2

Oregon 2.1 4.5 2.8 1.8 1.5 1.2 0.2 0.1 0.6 0.7 0.8 0.4 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 0.9

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

South Carolina 0.4 1.1 0.0 0.1 0.3 0.6 0.9 1.0 0.5 0.6 0.1 0.3 0.1 0.6

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

Tennessee 3.1 9.6 25.1 19.3 17.1 18.5 7.4 4.4 3.1 2.2 2.0 1.2 0.5 0.4

Texas 0.9 0.8 1.6 2.3 1.7 1.8 1.1 1.9 2.3 1.8 1.3 2.3 1.3 0.2

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

Vermont 1.4 1.2 3.0 1.0 2.7 2.4 4.4 0.7 1.0 1.2 0.8 1.1 2.4 2.1

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

Washington 2.9 3.3 3.6 4.1 5.5 4.3 1.2 0.7 0.5 0.4 0.7 0.5 0.4 0.3

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 1.1

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

Wyoming 1.1 1.7 14.2 25.2 36.9 46.0 36.7 17.0 20.8 17.9 0.4 1.6 1.0 .
 HEPATITIS SURVEILLANCE --- NUMBER 60 

11

Acute Hepatitis A, 2003 

 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 2003 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 7653 cases reported for the year 2003, the national incidence of hepatitis A is now the 

lowest yet recorded (2.6/100,000). Figure 3
 HEPATITIS SURVEILLANCE --- NUMBER 60 

 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 since 

2001 have been approximately equal to those in other regions of the U.S. Figure 4, Figure 5. 

In 2003, the increase in the rate in the Northeast was attributable to a single large food-borne 

outbreak in a Pennsylvania county which resulted in more than 500 cases of hepatitis A. The 

implicated food-product, imported green onions, was also linked to increased numbers of 

cases in Georgia and Tennessee. 

• 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 2003, rates were 

similar for all age groups 5 years of age or older ranging from 2.3/100,000 among children 5-

14 years to 3.1/100,000 among persons 25-39 years . Since 2001, the lowest rates have been 

among persons <5 years of age. 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 in large part reflect the higher proportion of persons in this age group with 

immunity due to previous infection; data from the Third National Health and Nutrition 

Examination Survey (NHANES III) 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 during the 

late 1990s through 2001, the difference in the gender-specific rates increased until there were 

almost 2 male cases for each female case. However, since 2001, rates have declined more in 

males than females and the rates are now similar for both genders (2.8/100,000 for males vs. 

2.4/100,0000 for females) Figure 7 Nevertheless, although overall rates are now similar for 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

13

males and females, the difference remains apparent for persons aged 30-49 where rates 

among males are 33-73% higher than for similarly aged females. Figure 8

• 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 2003, 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 frequently identified risk factor for hepatitis A in 2003 was commonsource outbreaks which was reported by 16% of cases up from an average of 4% during the 

previous 5 years. Many of these outbreak-associated cases were part of a group of related 

outbreaks in Pennsylvania, Tennessee and Georgia associated with the consumption of 

contaminated green onions. International travel was also a commonly identified risk factor 

reported by approximately 11% of cases overall and by more than 25% of cases <15 years of 

age. 75% of these travel-related cases were associated with travel to Central/South America 

including Mexico while 12% reported travel to Asia/South Pacific, 6% to Africa and 10% to the 

Middle East. The percentage of cases reporting sexual and household contact with another 

hepatitis A case which has historically always been among the most frequently identified risk 

factors was smaller than previous years but still was reported by approximately 11% of cases. 

Similarly, of all cases reported, the proportion (and also the absolute number) reporting male 

homosexual behavior which, since 1999, has been reported by 14-23% of cases declined to 

10%. When calculated for male cases only, 16% reported homosexual behavior. The proportion of 

cases in persons reporting illegal drug use was 7% in 2003 which is similar to previous years. 

Table 4, Figure 10

• The clinical characteristics of hepatitis A cases reported in 2003 are similar to previous years 

with 80% of cases having jaundice, 25% requiring hospitalization for their illness and 0.6% 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

14

resulting in death. The proportion of cases that were jaundiced was highest in persons 5-39 

years of age (86%) and lowest among persons older than 60 years (58%). The proportion of 

cases hospitalized increased with age from 14% among children <5 years of age to 45% 

among persons 60 years of age or older. Table 5
 HEPATITIS SURVEILLANCE --- NUMBER 60 

15

Figure 3: Incidence of Reported Hepatitis A, United States, 1966-2003 

0

5

10

15

20

25

30

35

1966196819701972197419761978198019821984198619881990199219941996199820002002

Year

Reported cases per 100,000 population
 HEPATITIS SURVEILLANCE --- NUMBER 60 

 16

Figure 4: Incidence of Reported Hepatitis A, by Region, United States, 1975-2003 

See page 5 for regional categories 

0

5

10

15

20

25

30

19901991199219931994199519961997199819992000200120022003

Year

Reported cases per 100,000 population

Midwest

Northeast

Southeast

West
 HEPATITIS SURVEILLANCE --- NUMBER 60 

17

Figure 5: Incidence of Reported Hepatitis A, by County, United States, 2003 

Source: NNDSS

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

>=20

 DC

 NYC
 HEPATITIS SURVEILLANCE --- NUMBER 60 

 18

Figure 6: Incidence of Reported Hepatitis A, by Age, United States, 1990-2003 

0

5

10

15

20

25

19901991199219931994199519961997199819992000200120022003

Year

Reported cases per 100,000 population

<5 yrs 

5 - 14 yrs 

15 - 24 yrs

25 - 39 yrs

40+ yrs 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

19

Figure 7: Incidence of Reported Hepatitis A, by Sex, United States, 1990-2003 

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 2003

Reported Cases per 100,000 population

0

0.5

1

1.5

2

2.5

Ratio (Male/Female)

Female

Male

ratio
 HEPATITIS SURVEILLANCE --- NUMBER 60 

 20

Figure 8: Incidence of Reported Hepatitis A, by Age and Sex, United States, 2003 

* A total of 7653 cases of Hepatitis A were reported. However, rates exclude patients with 

missing data for age and sex. 

1.12

2.12

2.08

2.25

3.52

4.05

3.42

3.27

3.4

3.36

2.91

2.8

2.69 2.65

1.24

2.70

2.42

2.21

3.06

2.07

2.27

2.58

1.94

3.23

2.57

2.30

<5

 5-9

 10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60+

age groups

rate per 100,000 persons

Female Male 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

21

 

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

United States, 1990-2003 

0

5

10

15

20

25

30

35

40

45

50

19901991199219931994199519961997199819992000200120022003

Year

Reported cases per 100,000 population

American Indian/Alaskan

Native 

Asian/Pacific Islander 

Black (non Hispanic) 

Hispanic 

White (non Hispanic) 

0

20

40

60

80

100

120

'90'92'94'96'98'00'02
 HEPATITIS SURVEILLANCE --- NUMBER 60 

 22

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

United States, 2003 

Age Groups 

Exposure during the 2-6 weeks <15 15-39 40+ Total 

prior to illness onset n N % n N % n N % n N % 

Sexual or Household Contact 79 378 20.9 104 1,042 10.0 76 998 7.6 259 2,418 10.7

International travel 122 440 27.7 118 1,155 10.2 60 1,103 5.4 300 2,698 11.1

Male Homosexual activity ‡ 1 21 4.8 39 402 9.7 34 358 9.5 74 781 9.5

Injection drug use 2 264 0.8 95 672 14.1 19 652 2.9 116 1,588 7.3

Child/employee in day-care center 52 435 12.0 29 1,170 2.5 22 1,144 1.9 103 2,749 3.7

Suspected food- or waterborne outbreak 52 316 16.5 159 744 21.4 85 790 10.8 296 1,850 16.0

Contact of day-care child/employee 35 412 8.5 63 1,106 5.7 38 1,072 3.5 136 2,590 5.3

Other Contact with hepatitis A patient¥ 65 378 17.2 137 1,042 13.1 61 998 6.1 263 2,418 10.9

No risk factor identified 192 488 39.3 678 1,295 52.4 915 1,249 73.3 1,785 3,032 58.9

No risk factor data submitted . 679 . . 1,699 . . 2,126 . . 4,504 .

TOTAL . 1,167 . . 2,994 . . 3,375 . . 7,536 .

‡ When calculated for male cases only, 16% reported homosexual behavior. 

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

 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

23

 

Figure 10: Trends in Selected Epidemiologic Characteristics among Patients Reported 

with Hepatitis A, by Year, United States, 1996-2003 

Note: The percentage of cases reporting a specific risk factor was calculated based on the total 

number of cases reporting any information for that exposure. Multiple risk factors can be 

reported for a single case. 

0

5

10

15

20

25

1997 1998 1999 2000 2001 2002 2003

International travel 

0

5

10

15

20

25

1997 1998 1999 2000 2001 2002 2003

Percent of cases

Child/employee in day-care

center 

0

5

10

15

20

25

1997 1998 1999 2000 2001 2002 2003

Injection drug use 

0

5

10

15

20

25

1997 1998 1999 2000 2001 2002 2003

Percent of cases

Sexual or Household Contact 

0

5

10

15

20

25

1997 1998 1999 2000 2001 2002 2003

Homosexual activity (Male) 

0

5

10

15

20

25

1997 1998 1999 2000 2001 2002 2003

Food- or waterborne outbreak 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

 24

Table 5 : Clinical Characteristics of Patients Reported with Hepatitis A, By Age, 

United States, 2003 

<5 yrs 5-14 yrs 15-39 yrs 40-59 yrs 60+ yrs All 

n N % n N % N N % n N % n N % n N % 

Died From 

Hepatitis 0 85 0.0 2 341 0.6 1 1,133 0.1 6 713 0.8 6 397 1.5 15 2,669 0.6

Hospitalized 

for Hepatitis 11 79 13.9 74 332 22.3 342 1,117 30.6 228 692 32.9 172 382 45.0 827 2,602 31.8

Jaundice 54 80 67.5 319 367 86.9 1,058 1,244 85.0 635 785 80.9 216 373 57.9 2,282 2,849 80.1

A total of 7653 cases of hepatitis A including 15 deaths were reported. Percentages are calculated based 

upon the number of cases reported with non-missing data for age, and for outcome of interest (i.e. 

jaundice, hospitalization or death) 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

25

Acute Hepatitis B, 2003 

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 7,526 cases reported nationwide, the overall incidence rate of reported acute hepatitis B 

in 2003 was 2.6/100,000. This is the lowest rate yet recorded and represents a decline of 

more than 75% since 1985 when incidence peaked at 11.5/100,000. However, the decline in 

rates has slowed and since 1999, the overall rate has changed by only 7%. 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). In 2003, rates were similar in the West, Midwest and Northeast but remained 

higher in the Southeast. 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

26

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

age (5.1/100,000 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 (95%) and young adults 15-24 years of age 

(83% 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 67% and 

43% 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 (3.2/100,000) continues to be 

higher than in females (2.0/100,000). The ratio of cases occurring among males to those 

occurring among females increased from 1990 to 2001 and although it has dropped slightly 

since then, the rate in males is remains 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 45 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 Rates 

of hepatitis B remain highest among non-Hispanic blacks (3.5/100,000) and are now lowest 

(1.1/100,000) among Hispanics whose rates in 2003 dropped below that of non-Hispanic 

whites for the first time. The downward trend in the rate among Asians/Pacific Islanders 

continues and in 2003, the rate in this group is approaching the rate among non-Hispanic 

whites. 

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

determined, 36% of cases reported at least one sexual risk factor (11% reported sexual 

contact a known hepatitis B case, 30% multiple sexual partners, and 13% male homosexual 

activity). Injecting drug use was reported by 18% of cases. Receiving hemodialysis or a 

blood transfusion, both of which were previously major sources of infection, were reported 

by only 0.7% and 0.4% of cases 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 where occupational 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

27

exposure to blood is now approximately 0.5% following widespread hepatitis B vaccination 

of health care workers. Table 6, Figure 18

• Among cases of hepatitis B cases reported in 2003, 79% had jaundice, 40% were hospitalized 

because of their illness and 1.3% resulted in death. The proportion of cases that were 

jaundiced was approximately 79% in persons 5 years of age or older ranging from 67% 

among persons 5-14 years of age to 82% among persons 15-39 years of age; less than 25% 

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 25% among children <5 years of age to 45% among persons 60 

years of age or older. Table 7
 HEPATITIS SURVEILLANCE --- NUMBER 60 

 28

Figure 11: Incidence of Reported Acute Hepatitis B, United States, 1966-2003 

0

2

4

6

8

10

12

14

1966196819701972197419761978198019821984198619881990199219941996199820002002

Year

Reported cases per 100,000 population
 HEPATITIS SURVEILLANCE --- NUMBER 60 

29

Figure 12: Incidence of Reported Acute Hepatitis B, by Region, United States, 1975-2003 

See page 5 for regional categories 

0

5

10

15

20

25

19751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003

Year

Reported cases per 100,000 population

Midwest

Northeast

Southeast

West
 HEPATITIS SURVEILLANCE --- NUMBER 60 

 30

Figure 13: Incidence of Reported Acute Hepatitis B, by County, United States, 2003 

Source: NNDSS

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

>=12

 DC

 NYC
 HEPATITIS SURVEILLANCE --- NUMBER 60 

31

Figure 14: Incidence of Reported Acute Hepatitis B, by Age, United States, 1990-2003 

0

2

4

6

8

10

12

14

16

18

19901991199219931994199519961997199819992000200120022003

Year

Reported cases per 100,000 population

<15 yrs 

15 - 24 yrs

25 - 39 yrs

40+ yrs 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

 32

Figure 15: Incidence of Reported Acute Hepatitis B, by Sex, United States, 1990-2003 

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 2003

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 60 

33

Figure 16: Incidence of Reported Acute Hepatitis B, by Age and Sex, United States, 2003 

3.9

6.2

6.3

6.0

6.2

5.1

3.8

2.6

1.7

0.1

0.0

0.1

0.7

0.1

0.0

0.1

1.1

0.8

1.3

2.0

2.7

3.6

4.4

4.0

4.2

3.1

<5

 5-9

 10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60+

age groups

rate per 100,000 persons

Female Male 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

34

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

United States, 1990-2003 

0

5

10

15

19901991199219931994199519961997199819992000200120022003

Year

Reported cases per 100,000 population

American Indian/Alaskan Native

Asian/Pacific Islander

Black (non Hispanic)

White (non Hispanic)

Hispanic
 HEPATITIS SURVEILLANCE --- NUMBER 60 

35

Table 6: Epidemiologic Characteristics of Patients Reported with Acute Hepatitis B, by 

Age, United States, 2003 

Age Groups 

Exposure during the 6 weeks-6 months <40* 40+ Total 

before illness onset n N % n N % n N % 

Injection drug use 254 1,135 22.4 110 895 12.3 364 2,030 17.9

Sexual contact with hepatitis B patient 85 842 10.1 79 689 11.5 164 1,531 10.7

Household contact of hepatitis B patient 27 842 3.2 17 689 2.5 44 1,531 2.9

Male homosexual activity§ 120 819 14.7 61 565 10.8 181 1,384 13.1

Medical Employee with contact with Blood 5 1,136 0.4 6 917 0.7 11 2,053 0.5

Hemodialysis . 893 . 10 624 1.6 10 1,517 0.7

More than one sex partner 364 1,006 36.2 186 813 22.9 550 1,819 30.2

 Heterosexual 321 909 35.3 170 764 22.3 491 1,673 29.3

 Male homosexual or bisexual 43 97 44.3 16 49 32.7 59 146 40.4

Blood transfusion 1 1,124 0.1 7 884 0.8 8 2,008 0.4

Surgery 67 1,072 6.3 79 879 9.0 146 1,951 7.5

Percutaneous injury 29 992 2.9 40 802 5.0 69 1,794 3.8

No risk factor identified 645 1,342 48.1 601 1,053 57.1 1,246 2,395 52.0

No risk factor data . 2,729 . . 2,301 . . 5,030 .

TOTAL . 4,071 . . 3,354 . . 7,425 .

* 151 (4%) of these cases were <19 years of age 

§When determined for male cases only, 22% reported homosexual or bisexual behavior and in 

male cases <40 years of age, the proportion was 26% 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

 36

Figure 18: Trends in Selected Epidemiologic Characteristics among Patients Reported 

with Acute Hepatitis B, by Year, United States 

Note: The percentage of cases reporting a specific risk factor was calculated based on the total 

number of cases reporting any information for that exposure. Multiple risk factors can be 

reported for a single case. 

0

5

10

15

20

25

1997 1998 1999 2000 2001 2002 2003

Medical Employee with blood

contact

0

5

10

15

20

25

1997 1998 1999 2000 2001 2002 2003

Sexual contact 

0

5

10

15

20

25

1997 1998 1999 2000 2001 2002 2003

Homosexual activity 

0

5

10

15

20

25

1997 1998 1999 2000 2001 2002 2003

Injection drug use 

0

5

10

15

20

25

1997 1998 1999 2000 2001 2002 2003

Blood transfusion 

25

30

35

1997 1998 1999 2000 2001 2002 2003

Multiple sex partners 

Year 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

37

Table 7: Clinical Characteristics of Patients Reported with Acute Hepatitis B, by Age, 

United States, 2003 

<5 5-14 15-39 40-59 60+ All 

n N % n N % n N % n N % n N % n N % 

Died From 

Hepatitis 0 4 0.0 0 11 0.0 14 1,556 0.9 9 1,012 0.9 12 194 6.2 35 2,777 1.3

Hospitalized 

for Hepatitis 1 4 25.0 4 11 36.4 593 1,491 39.8 367 967 38.0 91 201 45.3 1,056 2,674 39.5

Jaundice 1 5 20.0 6 9 66.7 1,205 1,473 81.8 695 914 76.0 129 178 72.5 2,036 2,579 78.9

Note: A total of 7526 cases of Hepatitis B including 35 deaths were reported. Percentages are calculated 

based upon the number of cases reported with non-missing data for age, and for outcome of interest (i.e. 

jaundice, hospitalization or death). 

 HEPATITIS SURVEILLANCE --- NUMBER 60 

39

Acute Hepatitis C/NANB Hepatitis, 2003 

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. 

• 1150 cases of acute hepatitis C were reported in 2003. However, 259 (23%) 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 891 cases reported by all other 

states, the overall national rate of reported acute hepatitis C was 0.4 per 100,000. 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 90% since 1992 to 

0.5/100,000 in 2003. Few cases are reported in persons <15 years of age. Figure 20 

• As in previous years, the rate of hepatitis C in 2003 is higher among males (0.4 per 100,000) 

than among females (0.3 /100,000) but this differential has declined gradually over the 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

40

decade and is now the smallest it has ever been. In 2003, this difference in hepatitis C rates 

by sex is evident only in persons 20 years of age and older. Figure 21, Figure 22 

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

since 1995. In 2003, the rates are increasingly similar across racial/ethnic groups and range 

from 0.3/100,000 among non-Hispanic whites, non-Hispanic blacks and American 

Indian/Alaska Natives to 0.1/100,000 among Asian/Pacific Islanders. Hispanics who 

historically have had rates higher than among non-Hispanic whites (but lower than for nonHispanic blacks) have since 2000 have had rates lower than for any other racial/ethnic group 

except Asian or Pacific Islanders. Figure 23 

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

determined, the most common risk factor for hepatitis C in 2003 was injection drug use. The 

proportion of cases reporting injection drug use has increased over the past decade from 

31% in 1994 to 38% in 1999 to 45% in 2003. Another 14% reported sexual contact with a 

known case and 25% of cases reported having had multiple sexual partners during the 

incubation period. 2% of cases reported occupational exposure to blood. A history of 

transfusion or dialysis, both of which were previously important sources of HCV infection 

are now reported by only 0.4% and 1.5% of cases respectively. Table 8
 HEPATITIS SURVEILLANCE --- NUMBER 60 

41

Figure 19: Incidence of Reported Acute Hepatitis C/NANB, United States, 1992-2003 

0

0.5

1

1.5

2

2.5

199219931994199519961997199819992000200120022003

Year

Reported cases per 100,000 population
 HEPATITIS SURVEILLANCE --- NUMBER 60 

42

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

 United States, 1992-2003 

 

0

1

2

3

4

5

6

199219931994199519961997199819992000200120022003

Year

Reported cases per 100,000 population

<15 yrs 

15 - 24 yrs

25 - 39 yrs

40+ yrs 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

43

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

United States, 1992-2003 

Year 

0

0.5

1

1.5

2

2.5

3

3.5

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Reported Cases per 100,000 population

0

0.5

1

1.5

2

2.5

Ratio (Male/Female)

Female 

Male 

ratio 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

44

Figure 22: Incidence of Reported Acute Hepatitis C, by Age and Sex, United States, 2003 

Female Male 

0.2

0.6

0.5

0.5

0.6

0.7

0.7

0.7

0.3

0.2

0.0

0.0

0.0

0.5

0.5

0.4

0.5

0.5

0.5

0.2

0.1

0.1

0.3

<5 -0.1

 5-9

 10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60+

age groups

rate per 100,000 persons
 HEPATITIS SURVEILLANCE --- NUMBER 60 

45

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

United States, 1992-2003 

0

1

2

3

4

5

199219931994199519961997199819992000200120022003

Year

Reported cases per 100,000 population

American Indian/Alaskan Native 

Asian/Pacific Islander 

Black (non Hispanic) 

Hispanic 

White (non Hispanic) 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

46

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

Age, United States, 2003 

Age Groups 

Exposures during the 6 weeks-6 months <40* 40+ Total 

before illness onset 

n N % n N % n N % 

Injection drug use 93 152 61.2 26 110 23.6 119 262 45.4

Employment in medical/dental field 2 141 1.4 4 113 3.5 6 254 2.4

Hemodialysis . 114 . 3 87 3.4 3 201 1.5

Sexual contact with hepatitis C patient 11 86 12.8 13 83 15.7 24 169 14.2

Household contact of hepatitis C patient 3 86 3.5 7 83 8.4 10 169 5.9

More than one sex partner 22 97 22.7 22 74 29.7 44 171 25.7

Blood transfusion . 139 . 1 106 0.9 1 245 0.4

Surgery 11 126 8.7 22 100 22.0 33 226 14.6

Percutaneous injury (e.g. needlestick) 11 106 10.4 5 88 5.7 16 194 8.2

No risk factor identified 75 191 39.3 57 129 44.2 132 320 41.3

No risk factor data reported . 265 . . 304 . . 569 .

TOTAL . 456 . . 433 . . 889 .

 *38(4%) of these cases were <19 years of age 

 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

47

Figure 24: Trends in Selected Epidemiologic Characteristics among Patients Reported 

with Acute Hepatitis C/NANB, by Year 

Note: The percentage of cases reporting a specific risk factor was calculated based on the total 

number of cases reporting any information for that exposure. Multiple risk factors can be 

reported for a single case. 

0

5

10

15

20

25

30

35

40

45

50

1997 1998 1999 2000 2001 2002 2003

Percent of cases

Injection drug use 

0

5

10

15

20

25

30

35

40

45

50

1997 1998 1999 2000 2001 2002 2003

Percent of cases

Medical employee

0

5

10

15

20

25

30

35

40

45

50

1997 1998 1999 2000 2001 2002 2003

Percent of cases

Sexual contact 

0

5

10

15

20

25

30

35

40

45

50

1997 1998 1999 2000 2001 2002 2003

Percent of cases

Multiple sex partners 

0

5

10

15

20

25

30

35

40

45

50

1997 1998 1999 2000 2001 2002 2003

Percent of cases

Blood transfusion 

0

5

10

15

20

25

30

35

40

45

50

1997 1998 1999 2000 2001 2002 2003

Percent of cases

Hemodialysis 

Year 
 HEPATITIS SURVEILLANCE --- NUMBER 60 

48

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

United States, 2003 

<15 15-39 40-59 60+ All 

n N % n N % n N % n N % n N % 

Died From 

Hepatitis 0 9 0.0 1 282 0.4 1 263 0.4 4 29 13.8 6 583 1.0

Hospitalized for 

Hepatitis 1 6 16.7 84 219 38.4 56 149 37.6 9 20 45.0 150 394 38.1

Jaundice 4 5 80.0 116 207 56.0 98 145 67.6 12 19 63.2 230 376 61.2

A total of 891 cases of Hepatitis C were reported. Percentages are calculated based upon 

the number of cases reported with non-missing data for age, and for outcome of interest (i.e. 

jaundice, hospitalization or death).
 HEPATITIS SURVEILLANCE --- NUMBER 60 

49

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 60 

50

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 and in 2003, 80 cases were 

reported by 15 states. 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 60 

51

Appendix I: Viral Hepatitis Case Report Form 

PATIENT'S LAST NAME (please print clearly) (12-26) FIRST AND MIDDLE NAME (or initials) OCCUPATION

STREET ADDRESS TOWN OR CITY STATE (Zip Code) COUNTY (27-36) COUNTY FIPS CODE (37-40)

AGE (yrs) (41-42) DATE OF (43-48) SEX (49) RACE (50) 1 American Indian or Alaskan Native 2 Asian or Pacific Islander

 ___ ___ BIRTH __ __ / __ __ / __ __ 1 Male 3 Black 5 White 9 Unk

00 =  1yr Mo Day Yr 2 Female

99 = Unk 9 Unk ETHNICITY (51) 1 Hispanic 2 Non-Hispanic 9 Unk

Reporting physician's diagnosis (52-53) 1 Hepatitis A 2 Hepatitis B 3 Non-A, Non-B 4 Hepatitis D 5 Hepatitis

 DO NOT REPORT CASES OF CHRONIC HEPATITIS OR CHRONIC CARRIERS!! Hepatitis (Delta) Unspecified

 CLINICAL DATA LABORATORY RESULTS

 Mo Day Yr Pos Neg Not Tested/Unk

Date of first symptom (54-59) ___ ___ / ___ ___ / ___ ___ IgM Hepatitis A antibody (IgM anti-HAV) (69) 1 2 9

Date of diagnosis (60-65) ___ ___ / ___ ___ / ___ ___ Hepatitis B surface antigen (HBsAg) (70) 1 2 9

Was the patient jaundiced? (66) 1 Yes 2 No IgM Hepatitis B core antibody (IgM anti-HBc) (71) 1 2 9

Was the patient hospitalized for hepatitis? (67) 1 Yes 2 No Antibody to Delta (anti-HDV) (72) 1 2 9

Did the patient die from hepatitis? (68) 1 Yes 2 No

For purposes of National Surveillance, ASK ALL OF THE FOLLOWING QUESTIONS FOR EVERY CASE OF HEPATITIS. These questions may help determine where the

patient acquired his/her infection. Please refer to the work sheet on the back of the last page for additional questions.

During the 2-6 weeks prior to illness Yes No Unk

 1. was the patient a child or employee in a nursery, day care center, or preschool? . . . . . . . . . . . . . . . . . . . . . (73) 1 2 9

 2. was the patient a household contact of a child or employee in a nursery, day care center, or preschool? . . . . . . . . . . . . (74) 1 2 9

 3. was the patient a contact of a confirmed or suspected hepatitis A case? . . . . . . . . . . . . . . . . . . . . . . . . . (75) 1 2 9

If yes, type of contact: (76) 1 Sexual 2 Household (non-sexual) 3 Other

 4. was the patient employed as a food handler? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(77) 1 2 9

 5. did the patient eat raw shellfish? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (78) 1 2 9

 6. was the patient suspected as being part of a common-source foodborne or waterborne outbreak? . . . . . . . . . . . . (79) 1 2 9

 7. did the patient travel outside of the U.S. or Canada? . . . . . . . . . . . . . . . . . . . . . . . . . . . (80) 1 2 9

If yes, where: (81) 1 So./Central America (including Mexico) 2 Africa 3 Caribbean 4 Middle East

 5 Asia/So. Pacific 6 Australia/New Zealand 7 Other_____________________

Duration of stay: (82) 1 1-3 Days 2 4-7 Days 3 More than 7 Days

During the 6 weeks-6 months prior to illness

 8. was the patient a contact of a confirmed or suspected acute or chronic hepatitis B or non-A, non-B case? . . . . . . . . . . . (83) 1 2 9

If yes, type of contact: (84) 1 Sexual 2 Household (non-sexual) 3 Other

 9. was the patient employed in a medical, dental or other field involving contact with human blood? . . . . . . . . . . . . . . (85) 1 2 9

If yes, degree of blood contact: (86) 1 Frequent (several times weekly) 2 Infrequent

10. did the patient receive blood or blood products (transfusion)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (87) 1 2 9

If yes, specify date(s) received: (88-93) From ___ ___/___ ___/___ ___ to ___ ___/___ ___/___ ___ (94-99)

11. was the patient associated with a dialysis or kidney transplant unit? . . . . . . . . . . . . . . . . . . . . . . . . . . (100) 1 2 9

If yes, (101) 1 Patient 2 Employee 3 Contact of patient or employee

12. did the patient use needles for injection of street drugs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(102) 1 2 9

13. what was the patient's sexual preference? (103) 1 Heterosexual 2 Homosexual 3 Bisexual 9 Unk

14. how many different sexual partners did the patient have? (104) 1 None 2 One 3 2-5 4 More than 5 9 Unk

15. did the patient have

dental work or oral surgery? (105) 1 Yes 2 No 9 Unk tattooing? . . . . . . . . . . .(108) 1 2 9

other surgery? (106) 1 Yes 2 No 9 Unk an accidental stick or puncture with a needle

acupuncture? (107) 1 Yes 2 No 9 Unk or other object contaminated with blood? (109) 1 2 9

Has this patient ever received the three dose series of Hepatitis B vaccine? . . . . . . . . . . . . . . . . . . . (110) 1 2 9

If yes, what year? (111-112) ___ ___ AND was the patient tested for antibody within 1-6 months after the last dose? . . .(113) 1 2 9

If yes, was the antibody test: (114) 1 Pos 2 Neg 3 Unknown

Comments:

_______________________________________________________________________________________

_______________________________________________________________________________________

Investigator's Name

Date

STATE GEOGRAPHIC CODE

 (1) (2) (3) (4) (5)

STATE CASE N0.

 (8) (9) (10) (11)

CDC CASE NO.

 (8) (9) (10) (11)

VIRAL HEPATITIS CASE RECORD

FOR REPORTING OF PATIENTS WITH SYMPTOMATIC ACUTE VIRAL HEPATITIS

(SEE CASE DEFINITION ON REVERSE)

DEPARTMENT OF HEALTH AND HUMAN SERVICES

PUBLIC HEALTH SERVICE

Centers for Disease Control and Prevention

Hepatitis Branch, (G37)

Atlanta, Georgia 30333

CDC 53.1 Rev. 6-93 Form Approved This questionnaire is authorized by law (Public Health Service Act, 42 USC 241). Although response to the questions is voluntary, cooperation of the patient is necessary for the study and control OMB No. 0920-0009 of the disease. Public burden for this collection of information is estimated to average 25 minutes per response. Send comments regarding this burden estimate or any other aspect of this collection

of information, including suggestions for reducing this burden to PHS Reports Clearance Officer; ATTN: PRA; Hubert H. Humphrey Bg, Rm 721-H; 200 Independence Ave. SW; Washington,

DC 20201, and to the Office of Management and Budget; Paperwork Reduction Project (0920-0009); Washington, DC 20503.
WORK SHEET

CASE DEFINITION FOR REPORTING OF ACUTE VIRAL HEPATITIS

Illness with: 1) discrete onset of symptoms and

2) jaundice or elevated serum aminotransferase levels.

Hepatitis A: IgM anti-HAV positive.

Hepatitis B: IgM anti-HBc positive if done or HBsAg positive and IgM anti-HAV negative if done.

Non-A, Non-B Hepatitis: 1) IgM anti-HAV negative, and

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

3) serum aminotransferase levels greater than 2 1/2 times the upper limit of normal.

Delta Hepatitis: 1) HBsAg or IgM anti-HBc positive and

2) Anti-HDV positive.

FOR USE BY LOCAL HEALTH DEPARTMENTS TO DETERMINE THE PATIENT'S MOST PROBABLE SOURCE OF INFECTION

Patient's name_____________________________ Home phone____________ Employed by______________________ Work phone_____________

Reporting physician's name, address, and phone #_________________________________________________________________________________

___________________________________________________________________________________________________________________________

If patient was hospitalized for hepatitis, give name of hospital_________________________________________________________________________

Results of liver function tests: SGOT (AST)___________ SGPT (ALT)____________ Bilirubin___________

FURTHER INFORMATION FOR ADMITTED RISK FACTORS AND SOURCES LISTED ON FRONT PAGE

IF APPLICABLE:

1. Name, address, and phone # of child care center____________________________________________________________________________

2. Name and address of school, grade, classroom attended______________________________________________________________________

3. Name, address, and phone # of restaurant where food handler worked (HEPATITIS A ONLY)________________________________________

 ____________________________________________________________________________________________________________________

4. Food history of patient for the 2-6 wks prior to onset: (HEPATITIS A ONLY)

 a. name and location of restaurants______________________________________________________________________________________

 b. name and location of food stores______________________________________________________________________________________

 c. name and location of bakery__________________________________________________________________________________________

 d. group meals attended (e.g., reception, church, meeting, etc.)________________________________________________________________

 e. location raw shellfish purchased_____________________________________________________________________________________ __

5. Name, address, and phone # of known hepatitis A or hepatitis B contact__________________________________________________________

 _________________________________________________________________________ Relationship_______________________________

6. CONTACTS REQUIRING PROPHYLAXIS FOR HEPATITIS A OR HEPATITIS B

 Name Age Relationship to case IG HBIG Vaccine

 ___________________________________________________________________________________________________________________

 ___________________________________________________________________________________________________________________

 ___________________________________________________________________________________________________________________

 ___________________________________________________________________________________________________________________

 ___________________________________________________________________________________________________________________

7. If transfused, NOTIFY BLOOD CENTER! Name of blood center_______________________________________________________________

 a. number of units of whole blood, packed RBC or frozen RBC received_________________________________________________________

 b. specify type of blood product (e.g., albumin, fibrinogen, factor VIII, etc.)________________________________________________________

8. IF DONOR, name, address, and phone # of donor or plasmapheresis center_______________________________________________________

 ______________________________________________________________________________________ Date________________________

9. Name, address, and phone # of dialysis center______________________________________________________________________________

 10. Name, address, and phone # of dentist or oral surgeon_______________________________________________________________________

 11. If other surgery performed, name, address, and phone # of location_____________________________________________________________

 ____________________________________________________________________________________________________________________

 12. Name, address, and phone # of acupuncturist or tattoo parlor__________________________________________________________________

 13. Is patient currently pregnant?___________ If yes, give obstetrician's name, address and phone #_____________________________________

 ____________________________________________________________________________________________________________________

 a. estimated date and location of delivery_________________________________________________________________________________

Comments:__________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

___________________________Investigator's Name and Title___________________________________________Date of Interview_______________

CDC 53.1 Work sheet REV. 6-93 Work sheet

Ist Copy  Local Health Department 2nd Copy  Centers for Disease Control 3rd Copy  State Health Department

52




 HEPATITIS SURVEILLANCE --- NUMBER 60 

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)