July 28 Is World Hepatitis Day

World Hepatitis Day, July 28, provides an opportunity to raise awareness of the global burden of viral hepatitis. Incarcerated people are disproportionately affected by viral hepatitis, so the Centers for Disease Control and Prevention is leveraging this year’s World Hepatitis Day to address this critical disparity.

Compared with the general population in the United States, the prevalence of hepatitis B virus (HBV) infection is 5 times higher and hepatitis C virus (HCV) infection is 10 times higher among people who are incarcerated. People infected with hepatitis A virus (HAV) infection during community-based outbreaks often spend time in prisons or jails, and congregate living environments can facilitate HAV transmission. Social and economic factors; mental health and substance use disorders; and a history of homelessness, sex work, and injection drug use contribute to the increased prevalence of viral hepatitis in correctional settings.

To address these risks, CDC recently released At-A-Glance: CDC Recommendations for Correctional and Detention Settings, compiling recommendations for testing, vaccination, and treatment of viral hepatitis. The document also includes recommendations for addressing HIV, TB, and STIs.

The information below summarizes the current state of viral hepatitis in correctional settings, the risks, and CDC’s recommendations to help reduce the impact of viral hepatitis on people who are incarcerated.

Hepatitis A 
An estimated 37,700 new HAV infections occurred in the United States in 2019.  HAV is found in the stool and blood of people who are infected and is spread through close person-to-person contact, including sexual contact, or ingestion of contaminated food or water. Groups who experience higher risk for infection include people who use injection or noninjection drugs, men who have sex with men, and people experiencing unstable housing or homelessness.

Large hepatitis A outbreaks associated with person-to-person transmission were first detected in the United States in 2016 and remain ongoing in many states today. People with chronic liver disease, including cirrhosis, hepatitis B, or hepatitis C, and those with HIV, experience increased risk for severe disease from hepatitis A. 

Vaccination Recommendations
Hepatitis A vaccination in correctional settings can help control transmission inside facilities as well as community outbreaks. A recent survey of 25 health departments found that 11% of outbreak-associated HAV cases (up to 30% in some jurisdictions) were among people who had been incarcerated during their exposure or infectious period, and some of them were likely infected while incarcerated.

The hepatitis A vaccine series should be given to

• Youths (≤ 18 years)
• Adults at risk for HAV infection (see risk factors above)
• People at risk for severe adverse outcomes of HAV infection (i.e., people with chronic liver disease and those with HIV)

Hepatitis B
An estimated 880,000 to 1.89 million people in the United States have chronic hepatitis B. HBV is a bloodborne infection, and routes of transmission in correctional settings can include sharing needles/syringes; sharing personal items contaminated with blood, like razors and tattooing equipment; and having sex with someone with HBV infection. HBV is highly infectious, can be transmitted in the absence of visible blood, and remains viable on environmental surfaces for at least seven days.

Hepatitis B is preventable with vaccination and treatable with antiviral medications. Providing vaccination, testing, and treatment can prevent people from developing liver cirrhosis and liver cancer.

Testing and Vaccination Recommendations
All people should be screened for HBV infection at intake, to include hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and hepatitis B core antibody (anti-HBc). See chart to assist in interpreting test results.

The hepatitis B vaccine series should be started for all people at intake unless documentation shows completion of the series or serologic evidence of immunity or infection. Those found to have chronic hepatitis B should be managed according to the AASLD 2018 hepatitis B guidance.

People with ongoing risk factors, those with potential HBV exposures, and those serving long sentences should be routinely retested. Staff who are unvaccinated should also be given the hepatitis B vaccine series if their duties involve possible exposure to blood or other infectious body fluids. This will help to prevent and control HBV infection.

Hepatitis C
An estimated 2.4 million adults in the United States have chronic hepatitis C. HCV is a bloodborne infection, and routes of transmission in correctional settings can include sharing needles/syringes and sharing personal items contaminated with blood, like razors and tattooing equipment. Sexual transmission is less common.

Approximately 30% of all people with HCV infection in the United States spend at least part of the year in a correctional or detention facility. Twenty to 55% of incarcerated people have a history of IDU, which is the most common mode of HCV transmission. If someone with hepatitis C continues to inject drugs while incarcerated and after release, further spread is likely not only in the prison or jail, but in the community as well.  

Chronic hepatitis C often causes no symptoms, and people can spread the virus to others without knowing it. Liver cirrhosis and liver cancer can also occur, over time, in a person without symptoms.

There is no vaccine to prevent HCV infection, but antiviral medications can cure it. These medications have high cure rates and few side effects. Providing testing and curative treatment can prevent people from developing liver cirrhosis and liver cancer and can prevent new HCV infections. Comprehensive testing and treatment in correctional settings have contributed to hepatitis C micro-elimination efforts in several countries.

Testing and Treatment Recommendations
All people should be tested for HCV infection at intake to a correctional or detention facility. Someone who has been cured can be reinfected, so people with ongoing risk factors should be offered periodic retesting. Management of chronic HCV infection should follow the AASLD/IDSA Recommendations for Testing, Managing, and Treating Hepatitis C.

Correctional and detention facilities should also offer counseling on preventing hepatitis B and hepatitis C transmission, as well as evidence-based treatment for substance use disorders, to help reduce the chance of reinfection and ongoing IDU.

CDC and partners at Stanford University have developed a corrections-specific online tool to help facilities plan for expanded HCV testing and treatment, and pilot tested it in 2021 with two state Departments of Corrections. Users can input their own population size, estimated hepatitis C prevalence, and testing and treatment costs, and the tool will estimate the 1-year and 3-year cost and population health outcomes associated with a range of hepatitis C testing and treatment strategies.

For More Information
CDC’s At-A-Glance document is an easy-to-understand guide to help reduce viral hepatitis in correctional settings. Testing, vaccination, and treatment of people who are incarcerated plays an important role in their individual health, in reducing the burden of viral hepatitis, and ultimately in its elimination.

Please join us on this World Hepatitis Day to renew our commitment to protecting the health of all people from viral hepatitis, including those in our criminal justice system.

About the authors: Emily J. Cartwright, MD, is medical officer in the Division of Viral Hepatitis, Centers for Disease Control and Prevention. Liesl Hagan, MPH, is senior scientist for correctional health in the Office of the Deputy Director for Infectious Diseases, Centers for Disease Control and Prevention. Carolyn Wester, MD, MPH, is director of the Division of Viral Hepatitis, Centers for Disease Control and Prevention.