Preventable Deaths in the U.S. Hepatitis A Outbreaks, 2016–2022

Hepatitis A spreads by the fecal-oral route and is prevented by a safe, highly effective vaccine. It is usually mild and clears on its own, but it can kill — especially older adults. Since 2016, outbreaks spread person to person have been reported in 37 states, with approximately 44,900 cases, 27,450 hospitalizations and 423 deaths as of October 6, 2023. They have hit hardest among people who use drugs and people experiencing homelessness, who may face poor access to sanitation, crowded living and other barriers to hygiene. Nearly twice as many hepatitis A–related deaths occurred in 2016–2022 as in 2009–2015.

Who died

CDC studied 315 outbreak-related deaths in 27 states from August 1, 2016, to October 31, 2022 — approximately 75% of all publicly reported outbreak deaths.

• Deaths peaked in 2019 and fell every year through 2022.
• Median age at death was 55; 73% were men and 84% non-Hispanic white.
• Death came a median of 17 days after symptoms began. 91% had been hospitalized, 77% had jaundice, and one had a liver transplant.

Dates of hepatitis A outbreak-related deaths in 27 states. Image from CDC’s report.

Missed chances to vaccinate

63% of those who died had at least one documented reason to have been vaccinated under national recommendations:

Yet only 12 (4%) had any evidence of previous hepatitis A vaccination. The authors call these substantial missed opportunities to prevent deaths.

Undercounted on death certificates

Death certificates were available for 272 people. Hepatitis A was not listed on 108 (40%) of them. On the 164 that did mention it, it was listed as a cause of death on 142 and as a contributing condition on 26. So national death statistics likely underestimate hepatitis A deaths — though the 60% reporting rate is far higher than for hepatitis B and C, which appeared on only 19% of death certificates in earlier studies.

Preventing future deaths

• Raise vaccination coverage among adults at higher risk of infection or severe disease — including people who use drugs, people experiencing homelessness, and people with other liver disease.
• Offer integrated services — vaccination, harm reduction, substance use treatment, and hygiene and sanitation — to medically underserved people.

Limits: states used different definitions of a hepatitis A–related death; such deaths are not reportable, so some may have been missed; risk factors were self-reported; vaccination records were missing for nearly half of those who died; and the 27 states may not represent every outbreak death.

Sources

Based on Hofmeister MG, Gupta N, and the Hepatitis A Mortality Investigators, "Preventable Deaths During Widespread Community Hepatitis A Outbreaks — United States, 2016–2022," MMWR Vol. 72, No. 42, CDC; a work of the United States government in the public domain.