Preventable Deaths During Widespread Community Hepatitis A Outbreaks United States, 20162022 | MMWR – CDC

Data from 27 states were analyzed to characterize the epidemiology of 315 hepatitis A outbreakrelated deaths during August 1, 2016October 31, 2022. Deaths occurred predominantly among males, non-Hispanic White persons, and persons aged 50 years. Nearly two thirds of decedents had at least one documented indication for hepatitis A vaccination, including drug use, homelessness, or coinfection with hepatitis B virus or hepatitis C virus; however, only 12 decedents had evidence of previous hepatitis A vaccination, indicating substantial missed opportunities to prevent hepatitis A deaths. Lack of stable housing and substance use disorder are commonly associated with viral hepatitides (3,4) and interact to increase disease incidence and health disparities. Although hepatitis A is usually a self-limited and preventable disease, it can have lethal consequences when introduced into populations with limited access to preventive care, unstable housing situations, inadequate access to sanitary services, or coexisting liver disease. These findings underscore the importance of integrated, comprehensive services, including vaccination, harm reduction, substance use disorder treatment, and hygiene and sanitation, to improve the health of medically underserved populations.

Among 272 outbreak-related decedents with available death certificate data, hepatitis A was listed as a cause of death or significant condition contributing to death on only 60% of death certificates, suggesting a substantial underestimation of hepatitis A mortality related to the outbreaks associated with person-to-person transmission in U.S. national vital statistics data. The 60% reporting rate for hepatitis A outbreakrelated deaths is substantially higher than reporting rates for hepatitis B and hepatitis C; in previous death certificate analyses of cohorts of patients with chronic hepatitis B and chronic hepatitis C, only 19% of decedents had hepatitis B or hepatitis C reported on their death certificates (8,9).

The findings in this report are subject to at least five limitations. First, states did not use a standardized hepatitis Arelated death definition, which might have resulted in differential classification of deaths as being related to hepatitis A. Second, death from hepatitis A is not a reportable condition and health departments might not have identified all outbreak-related hepatitis A deaths. Third, risk factor data were self-reported and subject to social desirability and recall biases and missingness. Consequently, information about additional decedents with indications for hepatitis A vaccination was unavailable. Fourth, vaccination information was missing for nearly one half of decedents; however, HAV infection after vaccination or appropriately timed postexposure prophylaxis is rare given the documented high immunogenicity of the vaccine (3). Finally, although the analysis captured nearly three quarters of publicly reported outbreak-related deaths, the results might not be generalizable to all outbreak-related deaths in the United States.

Hepatitis A is a vaccine-preventable disease; safe and highly effective vaccines have been available for decades (3). Substantial progress has been made in controlling the recent outbreaks through intensive efforts by health departments, including outreach through mobile vans and foot teams, nontraditional vaccination clinics in jails and homeless shelters, and partnerships with sheriffs associations and other community-based partners to expand vaccination coverage. As of October 2023, 34 states have declared ends to their outbreaks; however, many susceptible adults, particularly among persons who use drugs, persons experiencing homelessness, and persons with chronic liver disease, remain at increased risk for HAV infection or severe disease from HAV infection (5,10). Increased hepatitis A vaccination coverage is critical to maintain the progress that has been made and prevent future hepatitis A deaths.

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Preventable Deaths During Widespread Community Hepatitis A Outbreaks United States, 20162022 | MMWR - CDC