discuss
Data from 27 states were analyzed to describe the epidemiology of 315 hepatitis A outbreak-related deaths between August 1, 2016, and October 31, 2022. Deaths occurred primarily among men, non-Hispanic whites and people over 50 years old. Nearly two-thirds of the decedents had at least one documented sign of hepatitis A vaccination, including drug use, homelessness, or co-infection with hepatitis B virus or hepatitis C virus; however, only 12 of the decedents had previous vaccination There is evidence that hepatitis A vaccines have been passed, suggesting that they are missing out on preventing hepatitis A deaths. Lack of stable housing and substance use disorders are often associated with viral hepatitis (3,4) and interact to increase disease incidence and health disparities. Although hepatitis A is typically a self-limiting and preventable disease, it can have fatal consequences when introduced into populations with limited access to preventive care, unstable housing, inadequate health services, or coexisting liver disease. These findings underscore the importance of comprehensive, integrated services, including vaccination, harm reduction, substance use disorder treatment, and hygiene and sanitation, to improve the health of medically underserved populations.
Of the 272 outbreak-related deaths for which death certificate data were available, only 60% listed hepatitis A as the cause of death or an important condition contributing to death, suggesting that hepatitis A deaths associated with outbreaks in humans Rates of human-to-human transmission are significantly underestimated in U.S. national vital statistics data. The reporting rate of hepatitis A outbreak-related deaths was 60%, which is much higher than the reporting rate for hepatitis B and hepatitis C; in a previous death certificate analysis of a cohort of patients with chronic hepatitis B and chronic hepatitis C, only 19% of decedents had hepatitis B or C reported on their death certificates (8,9).
limitation
The findings in this report are subject to at least five limitations. First, states did not use a standardized definition of hepatitis A-related death, which may have resulted in different classifications of hepatitis A-related deaths. Second, hepatitis A deaths are not a reportable disease, and health departments may not be able to identify all hepatitis A deaths that are outbreak-related. Third, risk factor data are self-reported and subject to social desirability, recall bias, and deletion. Therefore, information on other deceased persons with indications for hepatitis A vaccination was not available. Fourth, vaccination information was missing for nearly half of the deceased; however, given the high immunogenicity of the vaccine, HAV infection after vaccination or appropriately timed post-exposure prophylaxis is rare.3). Finally, although the analysis included nearly three-quarters of publicly reported outbreak-related deaths, the results may not be generalizable to all outbreak-related deaths in the United States.
Implications for public health practice
Hepatitis A is a vaccine-preventable disease; safe and effective vaccines have been available for decades (3). Through the health department’s vigorous efforts, including expanding vaccination access through mobile vans and walking teams, non-traditional vaccination clinics at jails and homeless shelters, and working with the Sheriff’s Association and other community partners, control Substantial progress has been made in coverage of the recent epidemic. As of October 2023, 34 states have declared the epidemic over; however, many vulnerable adults, particularly drug users, homeless individuals, and those with chronic liver disease, are infected with HAV or develop severe illness from HAV infection. The risk of disease remains higher.5,10). Improving hepatitis A vaccination coverage is critical to sustaining the progress made and preventing future hepatitis A deaths.