Att 6_GuidelinesVHSurveillance

GUIDELINES FOR

VIRAL HEPATITIS SURVEILLANCE

AND CASE MANAGEMENT

January 2005

Guidelines for Viral Hepatitis Surveillance and Case Management

Ordering information
To order a copy of this manual, write to:
Division of Viral Hepatitis
Centers for Disease Control and Prevention
Mailstop G37
1600 Clifton Road
Atlanta, GA 30333

Suggested citation

Centers for Disease Control and Prevention. Guidelines for Viral Hepatitis Surveillance and
Case Management. Atlanta, GA 2005

CONTENTS
SUMMARY.…………………………………...………………..…………………………………………1

BACKGROUND............................................................................................................................2

Hepatitis A .................................................................................................................................4

Hepatitis B .................................................................................................................................6

Hepatitis C .................................................................................................................................9

Non-ABC Hepatitis...................................................................................................................11

GENERAL SURVEILLANCE GUIDELINES...............................................................................12

Case Ascertainment ................................................................................................................12

Case Reporting........................................................................................................................13

Databases of persons chronically infected with HBV or HCV..................................................16

Monitoring the Quality of Surveillance Data.............................................................................17

Data Analysis and Dissemination ............................................................................................17

DISEASE-SPECIFIC SURVEILLANCE GUIDELINES...............................................................18

Acute Hepatitis A .....................................................................................................................18

Acute Hepatitis B .....................................................................................................................22

Perinatal HBV Infection............................................................................................................27

Chronic HBV Infection .............................................................................................................31

Acute Hepatitis C .....................................................................................................................35

Hepatitis C Virus Infection, (Past or present)..........................................................................39

OTHER SURVEILLANCE METHODS........................................................................................42

Serologic Surveys....................................................................................................................42

Chronic Liver Disease Surveillance .........................................................................................42

Viral Hepatitis Surveillance Guidelines – page 1

Summary
Surveillance for viral hepatitis is needed to direct and evaluate prevention
and control activities. CDC recommends that all states and territories
conduct surveillance for acute viral hepatitis, including hepatitis A, B, C,
and non-ABC hepatitis. In addition, states and territories should consider
establishing computerized databases of persons who test positive for
hepatitis B surface antigen (HBsAg) or antibody to hepatitis C virus (antiHCV) to facilitate the notification, counseling and management of persons
with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections.
The purpose of this document is to 1) provide guidance to clinicians, state
and local health departments, and other health agencies regarding case
ascertainment, reporting, investigation, and follow-up of persons with
acute viral hepatitis; and 2) provide a framework for the development of
systems for identifying and following up persons who may have chronic
HBV or HCV infections. These guidelines describe the essential
elements and best practices for conducting surveillance for viral hepatitis,
and were developed based on consultation with representatives from
state and local health departments who met in Atlanta in January 1999.

Viral Hepatitis Surveillance Guidelines – page 2

BACKGROUND

In 2000, there were
approximately 25,000
cases of acute viral
hepatitis reported
nationwide, including
14,000 cases of
hepatitis A and 8,000
cases of hepatitis B.
In addition, 1.25
million persons are
chronically infected
with HBV and 2.7
million are
chronically infected
with HCV.

The primary goals of conducting surveillance for viral hepatitis are
to direct prevention and control activities for these diseases and to
evaluate the impact of these activities. In 2000, there were
approximately 25,000 cases of acute viral hepatitis reported nationwide,
including 14,000 cases of hepatitis A and 8,000 cases of hepatitis B. In
addition, 1.25 million persons are chronically infected with HBV and 2.7
million are chronically infected with HCV. Any person with a hepatitis
virus infection is a potential source of infection to others. The
investigation of infected persons can prevent further transmission by
identifying contacts who require vaccination or other preventive
interventions and by detecting outbreaks, determining the cause, and
implementing appropriate control and prevention measures. Aspects of
the epidemiology and prevention specific for each type of viral hepatitis
need to be considered in developing surveillance systems for these
diseases. Surveillance overall helps to accomplish these goals by
providing information to:
• Monitor trends in incidence of and risk factors for disease
• Assess burden of disease
• Identify infected persons requiring counseling and medical follow-up
• Identify contacts of infected persons requiring counseling and/or post
exposure prophylaxis
• Identify and control outbreaks
Information on cases of viral hepatitis reported nationally has been
maintained at CDC in two surveillance systems. Information collected by
the National Notifiable Disease Surveillance System (NNDSS) includes
diagnosis, event dates (e.g., illness onset), and basic demographic data
(e.g., state, county, age, race, ethnicity). Additional information collected
by the Viral Hepatitis Surveillance Program (VHSP) includes clinical
features, serologic test results, and risk factors for infection. This
information is needed to confirm the diagnosis, determine a source of
infection, and identify others at risk of infection that would benefit from
preventive intervention.
In 1989, a consolidation of VHSP and NNDSS was initiated with
efforts to have all acute viral hepatitis surveillance data reported
electronically to a single system, the National Electronic
Telecommunications System for Surveillance (NETSS). Data entry
screens are available in NETSS that include all of the information
requested for both NNDSS and the VHSP.
Not all states have participated in VHSP, and among states that have
participated in VHSP, the proportion of cases reported to both NNDSS
and VHSP has been variable. In addition, several participating states
have continued to report data only on the paper copy of the VHSP form,
rather than electronically. Paper reporting via VHSP was discontinued as
of January 2002. Thus, all information on reported cases of acute viral

Viral Hepatitis Surveillance Guidelines – page 3

hepatitis are now received and maintained through a single unified
electronic reporting system. Improving the completeness of case reports
made through this system will require further efforts by CDC and state
health departments.
As an element of the planned National Electronic Data
Surveillance Systems (NEDSS), substantial changes in the structure and
function of NETSS are expected. The development of a person-based
system that collects and stores public health information according to
widely used, standardized definitions and formats and that uses unique
identifiers to link information from different disease reports and other
health data sources will significantly enhance the capacity to conduct
surveillance for viral hepatitis.
To date, nationwide surveillance efforts for viral hepatitis have
focused on cases of newly acquired clinically apparent disease, and
historically, most cases of acute viral hepatitis have been identified on the
basis of a clinician’s report of a patient with an illness compatible with
acute hepatitis. With the implementation of laboratory reporting
requirements in many states, laboratory-based reporting of serologic
markers for viral hepatitis is an increasingly common route by which
suspected cases are identified to state and local health departments.
Although laboratory-based reporting can increase the completeness and
timeliness of case identification, it also identifies asymptomatic individuals
with newly acquired infections, individuals with chronic infection, and
individuals for whom there is insufficient information to verify the
diagnosis based on laboratory testing alone.
Although asymptomatic individuals with newly acquired infections
represent incident infections, they have not been included as reportable
conditions. However, as the incidence of all types of acute viral hepatitis
declines, the ascertainment and reporting of all persons testing positive
for serologic markers of recent infection with hepatitis viruses will be
necessary to monitor their incidences. When the definitions and
categories for reporting cases of acute viral hepatitis are expanded to
include those identified by laboratory test results alone, it will be important
to distinguish symptomatic from asymptomatic individuals. This is
because the numbers of asymptomatic persons identified can be highly
variable depending on testing practices, and result in artificial differences
in incidence both temporally and geographically. In addition, the ability to
identify such individuals is primarily limited to HAV and HBV infections, for
which IgM antibody assays specific for acute infection are available. No
serologic marker is available for acute HCV infection, thus, the incidence
of HAV or HBV infections relative to HCV infection would not accurately
reflect their true relationships. The full implications of expanding
surveillance case definitions to include asymptomatic individuals will not
be known until these strategies are implemented.
Laboratory-based reporting also identifies HBV or HCV infected

Viral Hepatitis Surveillance Guidelines – page 4

persons with chronic infection. Although previously not included among
nationally notifiable conditions, the public health importance of chronic
viral hepatitis infections dictates that they be added. Several states and
counties have established viral hepatitis infection databases for persons
testing positive for HBsAg or anti-HCV, but their experience indicates that
managing large numbers of HBsAg positive and anti-HCV positive
laboratory reports has the potential to overwhelm a surveillance system
and divert scarce resources into data management rather than disease
prevention. The expected integration of functions and standards in
NEDSS that facilitate the implementation of such databases will enhance
capacity to manage and monitor these reports. Further assessment at the
state and local level is needed to determine the most feasible and useful
approaches for establishing these types of systems and linking them to
prevention activities.

Hepatitis A
Rates of hepatitis A
are now the lowest
ever recorded.
Nevertheless,
hepatitis A remains
one of the most
frequently reported
vaccine preventable
diseases in the United
States

Epidemiologic characteristics
Periodic epidemics of hepatitis A have occurred in the United States
approximately every decade; the last nationwide epidemic occurred in
1995 1. Since then, rates of hepatitis A have declined precipitously and
are now the lowest ever recorded. Nevertheless, hepatitis A remains one
of the most frequently reported vaccine preventable diseases in the
United States. In 2000, a total of 13,397 cases of hepatitis A were
reported to CDC1, which, when corrected for underreporting and
asymptomatic infections, represents an estimated 57,000 cases and
143,000 infections.
Historically, incidence of hepatitis A has varied by race/ethnicity with
the highest rates among American Indians/Alaska Natives and rates
among Hispanics that were higher than among non-Hispanics. However,
rates among American Indians/Alaska Natives have dropped dramatically
since the implementation of widespread routine hepatitis A vaccination in
high rate Native American communities and are now the same as for
other races. Rates among Hispanics remain higher than among nonHispanics. The highest rates of reported disease have been among
children 5-14 years of age, and although disease rates in this group have
decreased substantially in recent years and are similar to those among
adults, $25 percent of reported cases are in persons <20 years of age.
Asymptomatic or unrecognized infections occurring in young children are
often a source of infection to others. Most cases of hepatitis A result from
person-to-person transmission during community-wide epidemics in
which children play a critical role in sustaining hepatitis A virus (HAV)
transmission.
Prevention strategies
Hepatitis A vaccine has been licensed in the United States
since 1995, and in 1996 routine childhood hepatitis A vaccination was
recommended in communities with the highest hepatitis A rates, which

Viral Hepatitis Surveillance Guidelines – page 5

included American Indian, Alaskan Native and selected Hispanic, migrant
and religious communities. Coincident with the implementation of
hepatitis A vaccination of children in those communities, there have been
dramatic reductions in hepatitis A rates in those areas.
In 1999, the recommendations for routine vaccination of children
were extended to include children living in states or counties with rates at
least twice the 1987-1997 national average (i.e. #20 cases per 100,000
population) 2. It was suggested that vaccination also be considered for
children living in states or counties with average rates that exceeded the
1987-1987 national average (i.e., $10-#20 cases per 100,000).
Reductions in hepatitis A rates in these areas since 1999 suggest that
routine vaccination is having an impact but further monitoring is needed to
determine whether these decreased rates are sustained and attributable
to vaccination. Pre-exposure vaccination is also recommended for
persons at high risk for hepatitis A including illegal drug users, men who
have sex with men, persons traveling to countries where HAV is endemic,
and persons with occupational risk of infection (i.e., persons who work
with HAV-infected primates or with HAV in a research laboratory), as well
as for persons with chronic liver disease. However, since as many as
50% of reported cases do not belong to one of these identified risk
groups, vaccination of persons in these groups has little effect on national
disease rates and does not prevent the majority of cases.
Surveillance
Because no chronic infection develops after hepatitis A, reported
cases of acute disease provide a valid measure of ongoing transmission
and the overall burden of disease due to HAV. Investigation of reported
cases to determine their characteristics and source for infection provides
the best information for monitoring trends in transmission patterns.
Monitoring changes in overall and age-specific disease rates is the only
means available to assess the effectiveness of hepatitis A vaccination
programs.
Demographic and risk factor information collected through
surveillance can be used to direct ongoing prevention efforts by
identifying new target groups or areas in which vaccination programs
should be initiated. Missed opportunities for vaccination can be assessed
by investigating cases occurring in persons belonging to a group for
which vaccination is recommended to determine where they have
received health care and other recommended vaccinations. Intensive
investigation of cases occurring in persons who received hepatitis A
vaccine may be used to evaluate the frequency and causes of vaccine
failure.
Timely identification of persons with acute hepatitis A allows
exposed contacts to receive effective prophylaxis to prevent secondary
spread of HAV. This is important in preventing outbreaks associated with
day care centers or infected food handlers and to prevent person-toperson transmission in households and extended family settings and

Viral Hepatitis Surveillance Guidelines – page 6

among sexual contacts.
Hepatitis A often occurs in the context of community wide
epidemics, but outbreaks also occur among persons reporting certain
behaviors (e.g., men having sex with men, illicit drug use) or exposures
(e.g., food contaminated with HAV). By investigating reported cases for
risk factors and recent exposures, groups at increased risk for infection
can be identified for targeted prevention activities or a potential common
source can be identified that might have placed additional persons at risk.

Hepatitis B

The estimated
number of new
infections in 2000
was 81,000, a
decrease of 70% from
a peak of
approximately
280,000 in the mid1980’s

Epidemiologic characteristics
Acute and chronic HBV infections are a major cause of morbidity
and mortality in the United States. Acute hepatitis B is one of the most
commonly reported vaccine preventable diseases; in 2000, 8036 cases
were reported 1. However, because most newly infected persons are
asymptomatic 3, and because even symptomatic persons are
underreported 4, reported hepatitis B cases markedly underestimate the
incidence of HBV infection. Based on catalytic modeling of data from the
second and third National Health and Nutrition Examination Surveys, the
estimated number of new infections in 2000 was 81,000, a decrease of
70% from a peak of approximately 280,000 in the mid-1980’s. In addition
to acute disease, approximately 1.25 million persons in the United States
have chronic HBV infection. These persons are at increased risk for
chronic liver disease, including cirrhosis and hepatocellular carcinoma,
and they are the major reservoir of ongoing HBV transmission.
The incidence of HBV infection differs significantly by race and
ethnicity with the highest rates among blacks; rates are higher among
Hispanics than non-Hispanics. Incidence also varies by age with the
highest rates reported among persons 20-39 years of age. Less than 5%
of the HBV infections that occur among children are reported as cases of
acute hepatitis B to CDC because HBV infections that occur in infants
and children rarely produce signs or symptoms of disease. Furthermore,
chronic HBV infection develops in approximately 90% of children infected
at birth and 30%-60% of children infected between 1 to 5 years of age
compared with 2%-6% of older children and adults; thus, prior to routine
immunoprophylaxis of infants and children, cases occurring in children
accounted for a disproportionate amount of the disease burden due to
chronic infection.
In addition to infections occurring in childhood, CDC estimates that
20,000 (95% confidence interval, 15,000 to 32,000) infants are born to
HBsAg positive mothers each year 5. Post-exposure prophylaxis is highly
effective in preventing transmission of HBV from mother to infant.
However, an estimated 1000 of these infants become chronically infected
with HBV each year because not all infected mothers are identified and
not all infants receive appropriate post-exposure prophylaxis. Although
perinatal HBV infections have been nationally notifiable since 1995,

Viral Hepatitis Surveillance Guidelines – page 7

Enhanced
surveillance for cases
occurring in age
groups for which
routine vaccination is
recommended (i.e.,
children <18 years of
age) to determine
their characteristics
and vaccination
history provides
information to
monitor and evaluate
the operation of
childhood vaccination
programs.

reported cases have not been reliable for monitoring the number of
perinatal infections that are occurring in the United States because of a
lack of follow-up serologic testing of infants born to infected mothers.
Prevention strategies/recommendations
Hepatitis B vaccine has been available in the United States since
1982. A comprehensive immunization strategy to eliminate HBV
transmission in the United States includes 1) preventing perinatal HBV
transmission by screening all pregnant women for HBsAg and providing
immunoprophylaxis to infants of HBV-infected women; 2) routine
immunization of all infants; 3) catch-up vaccination of all previously
unvaccinated children aged <19 years, with priority for vaccination at 11
to 12 years of age; and 4) vaccination of adolescents and adults at high
risk for infection including persons with a history of multiple sex partners
(>1 partner/6 months) or a sexually-transmitted disease; men who have
sex with men; injecting drug users; incarcerated persons; household and
sex contacts of persons with chronic HBV infection; health care and
public safety workers who have exposure to blood in the workplace; and
hemodialysis patients.
Surveillance
To accomplish the goals of conducting surveillance for hepatitis B,
multiple types of surveillance activities are needed, including surveillance
for acute hepatitis B, surveillance for perinatal HBV infection, and
surveillance for persons who test positive for HBsAg to identify those
with chronic HBV infections.
Surveillance for acute hepatitis B—newly acquired symptomatic
infections – is needed to monitor ongoing transmission of HBV, and
investigation of these cases to determine their characteristics and risk
factors provides the information needed for monitoring trends in
transmission patterns and targeting prevention activities. Enhanced
surveillance for cases occurring in age groups for which routine
vaccination is recommended (i.e., children <18 years of age) to determine
their characteristics and vaccination history provides information to
monitor and evaluate the operation of childhood vaccination programs.
Additional information on reported cases of acute hepatitis B is useful to
identify settings in which hepatitis B vaccine could have been offered.
Analysis of cases of acute hepatitis B reported during 1996-1998
indicated that more than half had previously received care in settings
where hepatitis B vaccine is recommended (i.e. STD clinics, correctional
facilities) 6. Furthermore, 40% of persons who report no recognized risk
factor for infection during their exposure period reported high-risk
characteristics or behaviors that place them in groups for which hepatitis
B vaccine is recommended (past history of MSM activity, IDU or treatment
for a STD). Monitoring changes in the incidence of acute disease
provides data to assess the impact of hepatitis B vaccination programs.
National hepatitis B disease reduction objectives for the year 2010
include reducing the incidence of acute hepatitis B among persons <19

Viral Hepatitis Surveillance Guidelines – page 8

Surveillance for
perinatal HBV
infection depends
upon the
identification of
HBV-infected
mothers by screening
pregnant women for
HBsAg and the postvaccination testing of
infants born to HBVinfected mothers.
including their
mothers.

Many states currently
have regulations
requiring laboratories
to report all HBsAg
positive results to
local health
departments. These
results can be used to
identify persons with
chronic HBV
infection who need
counseling and
referral for medical
follow-up and whose
contacts require
immunization.

years of age by >99% and reducing hepatitis B incidence in adult high
risk groups by >75% 7. The effect of routine infant and adolescent
vaccination can already be seen in the declining rate of disease in
persons <19 years of age. Similarly, the impact of a 1992 OSHA rule
requiring employers to offer hepatitis B vaccine to at risk employees is
demonstrated by vaccine coverage levels of >65% and a decrease of
>70% in the number of cases occurring among health care workers since
1993. In contrast, the continued high incidence among persons in other
risk groups for which vaccination is recommended such as injection drug
users and persons engaging in high risk sexual behaviors indicates that
programs for reaching these populations with vaccine need to be
developed or strengthened.
The timely identification of persons recently infected with HBV
provides the opportunity not only to counsel the infected individual but
also to identify susceptible contacts requiring post-exposure prophylaxis
early enough to prevent further transmission. Fifteen to 20% of acute
hepatitis B cases are acquired from a known infected contact and could
have been prevented by timely pre- or post-exposure prophylaxis (JID,
submitted). By monitoring the exposures of recently infected persons,
surveillance for acute disease also provides the information critical for
identifying outbreaks of hepatitis B that, while uncommon, do occur.
Nosocomial outbreaks involving patient-to-patient transmission have
occurred in association with a variety of transmission vehicles including
multidose medication vials, reusable fingerstick devices, and other
contaminated medical equipment 8, 9, 10, 11, 12. Although cases of
provider-to-patient transmission of HBV are rare in the United States
continued vigilance is needed to detect these cases should they occur.
Surveillance for perinatal HBV infection is needed to evaluate the
effectiveness of the perinatal HBV prevention program by monitoring the
incidence of these infections and to identify HBV-infected infants for
referral for medical management and treatment if appropriate.
Surveillance for perinatal HBV infection depends upon the identification of
HBV-infected mothers by screening pregnant women for HBsAg and the
post-vaccination testing of infants born to HBV-infected mothers. Postvaccination testing also identifies uninfected infants who did not respond
to vaccination and require re-vaccination because of ongoing exposure to
infected household contacts including their mothers.
Intensive investigation of infected infants is needed to assess and
reduce missed opportunities for providing post-exposure
immunoprophylaxis and to assess the frequency and risk factors for
failure of immunoprophylaxis. Although rare, possible reasons for failure
of immunoprophylaxis include incomplete vaccination, in utero infections,
delayed vaccination doses, and infection with an HBV variant 13, 14, 15, 16, 17
Surveillance for chronic HBV infection: HBsAg can be detected in virtually
all persons with chronic HBV infection. Many states currently have

Viral Hepatitis Surveillance Guidelines – page 9

regulations requiring laboratories to report all HBsAg positive results to
local health departments. These results can be used to identify persons
with chronic HBV infection who need counseling and referral for medical
follow-up and whose contacts require immunization.
Determining the frequency and characteristics of persons reported
as HBsAg-positive also describes who and where infected persons are
being identified. Although dependent upon testing practices, this
information can help in developing minimum estimates of infection burden
and is useful for identifying gaps in current testing practices. Further
investigation of chronically infected persons (or a sample of them) to
determine why they were identified and what actions (e.g. medical
evaluation, vaccination of contacts) resulted from being identified
provides information to direct and evaluate prevention activities.

Hepatitis C

There are an
estimated 3.9 million
Americans who have
been infected with
HCV. Approximately
75% of these persons
are chronically
infected and may not
be aware of their
infection because
they are not clinically
ill

Epidemiologic characteristics
Hepatitis C virus (HCV) infection is the most common chronic
bloodborne infection in the United States. Although the annual number of
new infections has declined since 1989 by more than 80% to 36,000 in
2000, data from the Third National Health and Nutrition Examination
Survey 18 conducted during 1988-1994 indicate that there are an
estimated 3.9 million Americans who have been infected with HCV.
Approximately 75% of these persons are chronically infected and may not
be aware of their infection because they are not clinically ill. These
persons serve as a source of transmission to others and are at risk for
chronic liver disease or other HCV-related chronic diseases.
HCV infection occurs among persons of all ages, but the highest
incidence of acute hepatitis C is found among persons 20-39 years.
African Americans and whites have similar incidence rates of acute
disease with higher rates in persons of Hispanic ethnicity.
Prevention strategies
With no effective vaccine or post-exposure prophylaxis, reducing
the burden of HCV infection and HCV-related disease in the United
States requires implementation of primary prevention activities to reduce
the risk of contracting the infection and secondary prevention activities to
reduce the risk of liver disease and other HCV-related chronic diseases
among HCV-infected persons 19.
Surveillance
Hepatitis C surveillance is a critical component of a comprehensive
strategy to prevent and control HCV infection and HCV-related chronic

Viral Hepatitis Surveillance Guidelines – page 10

Surveillance for
newly acquired
symptomatic hepatitis
C is needed to
monitor ongoing
transmission of HCV,
and investigation of
these cases to
determine their
characteristics and
risk factors provides
the best information
for monitoring trends
in transmission
patterns

liver disease. To accomplish the goals of hepatitis C surveillance,
activities are needed to identify persons with acute hepatitis C, as well as
persons with chronic HCV infection.
Surveillance for acute hepatitis C –newly acquired symptomatic
infection- is needed to monitor ongoing transmission of HCV, and
investigation of these cases to determine their characteristics and risk
factors provides the best information for monitoring trends in transmission
patterns. The collection of this information for reported cases is useful for
characterizing groups at risk of infection and targeting prevention
activities. Monitoring changes in acute disease incidence and in the risk
factors for infection can be used to assess the effectiveness of prevention
programs.
By monitoring the exposures of recently infected persons,
surveillance for acute hepatitis C also provides the information needed to
detect outbreaks that, while uncommon, do occur. Although rarely
reported in the United States except in the chronic hemodialysis setting,
nosocomial outbreaks of HCV involving patient-to-patient transmission
can occur if infection control techniques or disinfection procedures are
inadequate and contaminated equipment is shared among patients. The
risk of HCV transmission from an infected health care worker to patients
appears to be very low but vigilance is needed to detect these cases
should they occur.
Conducting surveillance for acute hepatitis C on a nationwide
basis has been difficult because a) no serologic marker for acute infection
is available; b) cases are usually reported on the basis of a positive
laboratory report and most health departments do not have the resources
to conduct investigations to determine if these reports represent acute
infection, chronic infection, repeated testing of a person who was
previously reported, or a false-positive result; and c) it can be difficult to
differentiate acute infection from exacerbation of chronic infection based
on clinical features of disease. Thus, the cases reported as acute
hepatitis C to the National Notifiable Disease Surveillance System have
been unreliable to date. Instead acute disease incidence and
transmission patterns have been monitored using reported cases from
CDC’s Sentinel Counties Study of Acute Viral Hepatitis, in which all
patients with signs and symptoms of viral hepatitis are investigated to
ascertain cases of acute hepatitis C.
However, reliable state-specific data are needed to direct and
evaluate hepatitis C prevention and control programs. In addition to
expanding the use of strategies such as sentinel surveillance or serial
serologic surveys to address local needs for hepatitis C surveillance data,
the implementation of methods that facilitate the management and
evaluation of case reports of suspected hepatitis C can enhance the
capacity of state or local health departments to conduct surveillance for
acute hepatitis C. For example, the revision of the case definition for
acute hepatitis C to include a higher ALT threshold provided a more

Viral Hepatitis Surveillance Guidelines – page 11

Although limitations
exist to the use of
anti-HCV positive
laboratory reports to
conduct surveillance
for HCV infection,
these reports can be
an important source
from which state and
local health
departments can
identify HCV-infected
persons who need
counseling and
medical follow-up.

efficient and specific criterion to determine which reports require further
investigation to distinguish anti-HCV positive individuals with acute
disease from those with remote or chronic infection.
Surveillance for HCV-Infection. Many states currently have
regulations requiring laboratories to report all anti-HCV positive results to
local health departments. Although limitations exist to the use of antiHCV positive laboratory reports to conduct surveillance for HCV infection,
these reports can be an important source from which state and local
health departments can identify HCV-infected persons who need
counseling and medical follow-up.
Determining the frequency and characteristics of persons reported
as anti-HCV-positive also describes who and where infected persons are
being identified. Although dependent upon testing practices, this
information can help in developing minimum estimates of infection burden
and is useful for identifying gaps in current testing practices. Further
investigation of chronically infected persons (or a sample of them) to
determine why they were identified and what actions (e.g. medical
evaluation) resulted from being identified provides information to direct
and evaluate prevention activities.

Non-ABC Hepatitis
HAV, HBV and HCV are the etiologic agents of >95 % of acute viral
hepatitis in the United States. However, a small percentage of persons
with signs and symptoms typical of acute viral hepatitis do not have
serologic markers of infection with these viruses, and may be infected
with other viruses. Hepatitis D (delta) virus (HDV) is an incomplete virus
that requires the helper function of HBV to replicate. HDV can be
acquired either as a coinfection with HBV or as a superinfection in
persons with chronic HBV infection. The incidence of delta hepatitis
cannot be directly calculated from national surveillance data because this
disease is not reportable in the United States; however, in prevalence
studies among patients with acute hepatitis B, 1.5-7.2% had serologic
evidence of HBV-HDV coinfection 20.
Hepatitis E is rare in the United States and most reported cases
have been associated with travel to HEV-endemic countries 21, 22.
However, several cases of acute hepatitis E have been reported in
persons with no recent history of travel outside the United States 23, 24 and
HEV infection should be considered in patients with non-ABC hepatitis.
Additional candidate hepatitis viruses that have been isolated from
patients with posttransfusion hepatitis include hepatitis G virus (also
called GB virus C), TTV, and SENV 25, 26, 27, 28; however, none of these
viruses has been demonstrated to be a cause of acute or chronic
hepatitis 27, 29.

Viral Hepatitis Surveillance Guidelines – page 12

GENERAL SURVEILLANCE GUIDELINES
Case Ascertainment
Methods to improve the timeliness and completeness of reporting include
a) implementing laboratory reporting laws, b) ensuring that all patients
who have signs and symptoms of acute viral hepatitis are appropriately
tested and reported; and c) ensuring that all patients with chronic
hepatitis, or who have risk factors for HBV or HCV infection are
appropriately tested and reported if positive.
Laboratory reporting rules. All states should implement rules or
regulations requiring laboratories to promptly report test results positive
for any of the following serologic markers of acute or chronic hepatitis:
• IgM antibody to HAV (IgM anti-HAV);
• Hepatitis B surface antigen (HBsAg);
• IgM antibody to hepatitis B core antigen (IgM anti-HBc); and
• Antibody to HCV (anti-HCV).

The clinical features
of acute disease
caused by hepatitis
viruses are similar.
Thus, serologic
testing is necessary to
establish a diagnosis
in persons with
jaundice or other
signs and/or
symptoms of acute
hepatitis.

Computerized data systems are maintained by many clinical
laboratories. The establishment of information management systems for
receiving data electronically from laboratories can facilitate surveillance
for viral hepatitis by increasing timeliness and completeness of case
identification. State regulations for laboratory reporting of serologic
markers of viral hepatitis should include requirements to report available
information which could facilitate case identification and investigation,
including contact information for the patient and for the patient’s
physician. Reports of positive test results should also include the results
for other serologic markers of viral hepatitis that were evaluated on the
same individual, and serum aminotransferase (e.g. ALT) levels, if
available. In addition, pregnancy status should be reported if testing was
done as part of a prenatal test panel.
Testing of patients with signs and/or symptoms of acute viral
hepatitis. The clinical features of acute disease caused by hepatitis
viruses are similar. Thus, serologic testing is necessary to establish a
diagnosis in persons with jaundice or other signs and/or symptoms of
acute hepatitis (e.g., anorexia, nausea, malaise, vomiting, dark urine, clay
colored or light stools, and abdominal pain). Appropriate diagnostic
testing of such patients is crucial to ensure complete case ascertainment.
To facilitate accurate testing, laboratories, managed care organizations
and payors should encourage implementation and use of standardized
diagnostic panels for testing patients with signs and symptoms of acute
hepatitis which should include all of the serologic markers that are
included in state laboratory reporting requirements (e.g., IgM anti-HAV,
HBsAg, IgM anti-HBc, and anti-HCV). In addition, educational efforts
should be developed and promoted in conjunction with professional

Viral Hepatitis Surveillance Guidelines – page 13

organizations to increase awareness of appropriate testing algorithms
and reporting laws among clinicians.

Most persons with
chronic HBV or HCV
infection are
asymptomatic. Thus,
testing programs for
persons with risk
factors for infection
and/or elevated liver
enzymes (e.g., ALT,
AST) are required to
identify chronically
infected persons.

Testing of patients with chronic hepatitis, or risk factors for chronic
HBV or HCV infection. Most persons with chronic HBV or HCV infection
are asymptomatic. Thus, testing programs for persons with risk factors for
infection and/or elevated liver enzymes (e.g., ALT, AST) are required to
identify chronically infected persons. Routine screening of pregnant
women for HBsAg is done to identify infants of infected women who
require post-exposure prophylaxis. High risk populations for chronic
HBV infection (e.g., STD and drug treatment patients, inmates of
correctional facilities, immigrants from countries with a HBsAg prevalence
>2%) might benefit from routine HBsAg testing, but the feasibility and cost
effectiveness of such testing in various clinical settings has not been
determined. Recommendations have been developed for routine antiHCV testing for persons at high risk of HCV infection (i.e., persons who
have ever injected illegal drugs, persons who received a blood
transfusion or organ transplant before July 1992, persons ever on chronic
hemodialysis, persons who received clotting factor concentrates made
before 1987, persons with abnormal liver enzyme levels) 30.
The specificity of HBsAg or anti-HCV testing is high when used to
evaluate persons with signs or symptoms of hepatitis. However, as with
any test, the positive predictive value of these tests when used to screen
asymptomatic persons depends on the prevalence of the condition
among the persons being tested, and the likelihood of a false-positive test
result increases when the tests are used in low-risk populations.
Confirmation of a positive test result for HBsAg or anti-HCV by an
additional more specific assay is needed to rule out a false-positive result,
especially in persons with no identified risk factor for infection. The
presence of other serologic markers of HBV infection (i.e. total anti-HBc
or IgM anti-HBc) can be used to evaluate the likelihood that an HBsAg
positive test result is a true positive but isolated HBsAg positive test
results should be verified by a confirmatory assay (e.g. neutralization
assay). Anti-HCV positive results by enzyme immunoassay (EIA) should
be verified by a supplemental antibody assay (e.g., RIBA™). If
supplemental test results are not available, a positive EIA test can also be
confirmed by calculating the signal to cutoff ratio (S/CO) for the specimen.
If the S/CO is $3.8, the likelihood that the specimen would be positive by
supplemental assay is >95%. Detection of HCV RNA by RT-PCR
verifies HCV infection, but the absence of detectable RNA in a single
serum specimen does not exclude the possibility of HCV infection.

Case Reporting
Data elements
The collection of a minimum set of standardized data elements

Viral Hepatitis Surveillance Guidelines – page 14

(Table I) on all reported cases of viral hepatitis ensures that information
collected can be effectively used at the local, state and national level.
These minimum data elements should conform wherever possible to the
definitions and formats specified for NEDSS. In addition to locators (e.g.,
state, county of report) and demographic descriptors (e.g., age, race,
ethnicity, sex), the following information, required for classifying the case
as acute or chronic and for determining appropriate follow-up should be
reported for every case:
• Presence of symptoms consistent with acute hepatitis and the
date of onset for those symptoms
Confirmation of a
• Presence of jaundice
positive test result for
• Results and date of serum aminotransferase testing, if available.
HBsAg or anti-HCV
• Serologic test results for any markers of viral hepatitis (see Case
by an additional more
Ascertainment)

specific assay is
needed to rule out a
false-positive result,
especially in persons
with no identified risk
factor for infection

Unique Identifiers. Patient name and other identifying information (e.g.
birthdate/social security number) are typically maintained as part of state
surveillance databases. A unique identifier is essential for appropriate
patient follow-up, distinguishes newly identified cases from previously
reported individuals and allows linkage to related health-care data.
Efforts are underway by CDC and its’ public health partners to develop a
unique identifier composed of standardized data elements that are used
throughout the health-care and public health sectors. Policies for ensuring
patient privacy and security of data should be in place for any system
maintaining unique patient identifiers.
In addition to these core elements, information including recent
exposures should be collected and reported as part of the recommended
case investigation of cases of acute viral hepatitis or perinatal HBV
infection. The information to be collected and reported for investigations
of different types of viral hepatitis are described in the virus specific
guidelines below. Recommendations regarding the types of information
that might be collected in a chronic infection database also are included in
the disease specific sections below; however, further evaluation is
needed to determine the types of information that will be most useful.

Viral Hepatitis Surveillance Guidelines – page 15

Table I: Information elements to be collected for case reports of viral hepatitis
Information Collected
Locator Information
• State, county, ZIP code
Demographic Information
• Date of birth, age, sex, race, ethnicity
Clinical Data
• Date of illness onset
• Presence of symptoms of acute
hepatitis
• Presence of jaundice
• ALT level
• Hospitalization for hepatitis
• Death from hepatitis
Diagnostic Testing Results
• IgM anti-HAV, HBsAg, IgM anti-HBc,
anti-HCV, anti-HDV

•

Date of diagnosis

Other
• Pregnancy Status
•

Origin of report

Comments

Core variables (NEDSS standards)
Core variables (NEDSS standards)
First sign or symptom of hepatitis
Verifies case definition
Verifies case definition
Verifies case definition
If yes, verify dates of hospitalization
If yes, review death certificate and medical records
to rule out other potential causes of death and to
confirm acute liver failure as cause of death
Verifies case definition. Determine all results
(positive and negative). HBsAg and anti-HCV
positive test results require confirmation by an
additional more specific assay or for anti-HCV, a
S/CO ratio $ 3.8.
Date of test result confirming infection

If pregnant, infants of HBV or HCV infected women
should be tested for infection (see disease specific
guidelines)
Site requesting viral hepatitis testing

Reporting cases to CDC
With the implementation of NEDSS, which will include standards
for electronic transfer of data, all reporting of viral hepatitis case data,
including risk factor information, will occur electronically. States that
currently transmit VHSP data electronically via NETSS should discontinue
paper-based reporting. CDC is committed to working with those states
that rely on paper-based reporting to overcome barriers to electronic
reporting of hepatitis surveillance data.

Viral Hepatitis Surveillance Guidelines – page 16

Databases of persons chronically infected with HBV or HCV
Computerized databases of HBsAg positive and anti-HCV positive
persons can facilitate the notification, counseling and medical
management of persons chronically infected with HBV or HCV. These
databases can be used to:
• distinguish newly reported cases of infection from previously identified
cases;
• facilitate and track the follow-up of chronically infected persons; and
• provide local, state, and national estimates of the proportion of
persons with chronic HBV or HCV infection who have been identified.

Computerized
databases of HBsAg
positive and antiHCV positive persons
can facilitate the
notification,
counseling and
medical management
of persons
chronically infected
with HBV or HCV.

The specific information elements to be maintained in a database of
chronically infected persons will depend upon the objectives of
establishing the database and the feasibility of collecting that information.
At a minimum, sufficient information should be collected to distinguish
newly identified persons from previously reported individuals including
information to establish a unique identifier (e.g. name, race, date of birth)
and serologic test results to confirm chronic infection with HBV or HCV.
Information about the clinical characteristics of the individual (e.g.
presence of symptoms consistent with acute viral hepatitis, date of
symptom onset, results of liver enzyme testing) and why they were
identified can help to distinguish persons with chronic infection from those
with acute disease. The collection of the minimum demographic
information that is required for reporting of acute cases is also
recommended for cases of chronic infection as these data can be used to
describe the population of infected persons that has been identified,
information useful for allocating public health resources and directing and
evaluating prevention programs. The collection of additional information
for a sample of persons in these databases can be useful to further
characterize the infected population (e.g. past exposures or risk factors)
or to assess the impact of public health follow-up of these persons (e.g.
did they receive medical evaluation, did their susceptible contacts receive
appropriate follow-up). The recommended information to be collected in
databases of persons with chronic HBV or HCV infection is included in
the disease specific sections below.
When any type of database is established, the confidentiality of
individual identifying information should be ensured according to
applicable laws and regulations. Guidelines that clarify how and when
line-listed data with or without personal identifiers are transmitted and
used can facilitate the protection of confidential data.
Methods for accomplishing the follow-up of persons identified in
chronic infection databases include contacting health care practitioners
and/or patients individually by telephone, mail or in person. Mechanisms
such as automated systems for the mailing of follow-up educational
materials might be useful. Such systems require relatively few health
department resources and involve little or no interaction with patients or

Viral Hepatitis Surveillance Guidelines – page 17

their health care practitioner; however, the effectiveness of such systems
should be evaluated. Effective mechanisms for delivering follow-up to
mobile and hard-to-reach individuals such as injection drug users need to
be identified.

Monitoring the Quality of Surveillance Data
Periodic, regular evaluations of surveillance data for quality,
completeness, and timeliness are essential to identify specific aspects of
surveillance and case investigation that need improvement. The
completeness of surveillance data is assessed by determining the
frequency with which individual data elements are reported with nonmissing data. The quality or validity of the data is measured by the
proportion of each data element that is reported with a correct or valid
answer. Timeliness of surveillance data can be measured by determining
the average length of time in days required for each of the steps in the
surveillance process.
The use of standardized indicators to assess the completeness (e.g.
proportion of cases that are reported with risk factor information) or
timeliness (e.g. time between date of diagnostic testing and date reported
to health department) of surveillance data will allow more accurate
interpretation and comparison of data reported at different times or by
different sources. The development of data quality indicators to measure
the completeness of case-investigation and follow-up activities (e.g.,
proportion of at-risk contacts immunized) also might be useful.

Data Analysis and Dissemination
Periodic summaries of analyzed surveillance data that are
accompanied by a concise interpretation can be useful to a variety of
audiences including public health decision makers, clinical case
reporters, and other health professionals. Health department should
consider developing specialized communications for dissemination of
annual reports of case rates analyzed by person, place and time to
different audiences. These communications might also include: reports to
data providers identifying providers’ specific contribution to surveillance
efforts, newsletters or bulletins providing concise data interpretation and
advice to clinicians and laboratory directors, and press release/reports for
general public releases. In addition to dissemination via printed media,
other dissemination mechanisms such as the internet should be explored
In addition to summarized data, line listed data should be provided
to local health departments to ensure complete and accurate description
of identified cases and to highlight those cases that require further followup. The regular (at least quarterly) provision of summarized state specific
surveillance data by CDC can be useful to state and local health
departments in monitoring the reporting of cases to CDC and in providing
feedback to local health departments and other public health partners.

Viral Hepatitis Surveillance Guidelines – page 18

DISEASE-SPECIFIC SURVEILLANCE GUIDELINES
Acute Hepatitis A
Case Definition (*)
Clinical criteria
An acute illness with
• discrete onset of symptoms (e.g. fatigue, abdominal pain, loss
of appetite, intermittent nausea, vomiting), and
• jaundice or elevated serum aminotransferase levels
Laboratory criteria
• IgM antibody to hepatitis A virus (anti-HAV) positive
Case Classification
• Confirmed. A case that meets the clinical case definition and
is laboratory confirmed or 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).
*This case definition was approved by CSTE in September, 1996. 31
To date, asymptomatic individuals who are IgM anti-HAV positive
have not been included as reportable cases. However, these cases do
represent incident infections and it is expected that as rates of acute
disease continue to decline, the case definition will be expanded to
include newly infected individuals identified on the basis of laboratory
results alone. When the case definition is expanded to include
asymptomatic HAV infections, these cases will need to be distinguished
from symptomatic cases to ensure accurate interpretation of surveillance
data.

Case Ascertainment
The primary methods to ascertain suspected acute hepatitis A cases are
• Laboratory reporting of all persons who test IgM anti-HAV positive to
state and/or local health departments; and
• Reporting by health care practitioners of persons with symptoms of
acute hepatitis who are IgM anti-HAV positive. Persons reported as
suspected cases of viral hepatitis on the basis of clinical criteria
alone should be followed up to ensure that appropriate diagnostic
testing for acute viral hepatitis is done.

Viral Hepatitis Surveillance Guidelines – page 19

Case Investigation
Confirmed or suspected cases of acute hepatitis A should be reported
and investigated as soon as possible after the case is identified to ensure
adequate time to implement preventive measures, including the provision
of post-exposure prophylaxis to contacts. To report a case as confirmed,
it should be verified that the case meets both the serologic and clinical
criteria of the case definition. The components of a case investigation
should include:
• Clinical features. Determine date of illness onset, whether jaundice
was present and results of testing for aminotransferase levels.
• Serologic test results. For suspected cases, confirmation by IgM
anti-HAV testing is ideal but if not done, a potential case of acute
hepatitis A can be reported as confirmed if the person has an
epidemiologic link.
• Risk factors for infection. (Table II) All confirmed cases of acute
hepatitis A should be interviewed to identify a potential source or risk
factor for infection during the 2-6 weeks prior to illness onset.
Because IgM antibodies persist for up to 6 months after infection, it is
not possible to define the appropriate exposure period for
asymptomatic IgM anti-HAV positive persons. Therefore, risk
histories for these persons may be unreliable for determining a source
of infection.
• Identification of contacts requiring post exposure prophylaxis.
Immunoprophylaxis with immune globulin (IG) should be provided to
persons recently exposed to a person with acute hepatitis A including
close personal contacts and others in selected settings according to
existing recommendations of the Advisory Committee on
Immunization Practices32. IG should be given as soon as possible but
not >2 weeks after the last exposure. Post-exposure prophylaxis is
not recommended for contacts of persons with asymptomatic HAV
infection because the period of exposure is unknown.

Reporting to CDC
Case reports of acute hepatitis A should be transmitted weekly by
state health departments to CDC via NETSS. Symptomatic cases
need to be distinguished from asymptomatic cases to accurately
assess changes in incidence. See Appendix X for CDC hepatitis A
case report form.

Viral Hepatitis Surveillance Guidelines – page 20

Table II. Components of Acute Hepatitis A Case Investigations
Information Collected

Risk factors (2-6 weeks prior to illness onset)

• Close contact with a person w/confirmed
or suspected acute hepatitis A
•
•
•
•

Employment or attendance of nursery,
day care center or preschool
Household contact of a child or employee
in a nursery, day care center or preschool
Travel outside of the United States or
Canada
Illicit drug use

• No. of male sex partners
• No. of female sex partners
Detection and prevention of common source
outbreaks
• Employment as a foodhandler

•

Part of recognized common-source
foodborne outbreak

Vaccination history
• Hepatitis A vaccination status
Results of case investigation and follow-up
• Date reported to health department
responsible for case investigation
• Date case investigation initiated
•

At-risk contacts identified

Missed Opportunities for
Prevention/Vaccination
• Household or sex contact of person with
acute hepatitis A
• Sought medical care prior to foreign
travel
•

Ever in treatment for illicit drug use

•

Child living in area/state where routine
childhood vaccination is recommended

Comments/Action
If yes, type of contact (sexual/household).
Evaluate missed opportunities to receive
immunoprophylaxis
If yes, notify and investigate facility to
determine if others are at risk for transmission
If yes, where and how long?
If yes, notify contacts of need for post-exposure
prophylaxis
If yes, notify contacts of need for post-exposure
prophylaxis

If yes, notify and investigate food handler and
establishment
Enhance case finding among persons eating at
establishment
If yes, determine if other cases linked to same
source and report to CDC foodborne outbreak
surveillance system
If vaccinated, number of vaccine doses, date(s)
of vaccination

Date of first contact with patient and/or health
care practitioner
Specify type of contact and whether postexposure prophylaxis was received

If yes, notify health care practitioner and assess
barrier(s) to timely administration of IG
If yes, notify health care practitioner and assess
barrier(s) to timely administration of preexposure prophylaxis (hepA vaccine and/or IG)
If yes, determine date of most recent treatment,
notify facility, and assess barrier(s) to receiving
HepA vaccine
If yes, identify child’s source of health care and
assess reason(s) for failure to receive HepA
vaccine.

Viral Hepatitis Surveillance Guidelines – page 21

Uses of Surveillance Data
Monitoring trends in disease incidence and determining risk factors
for infection. Hepatitis A surveillance data should be analyzed at weekly
intervals by time, place and person to monitor disease incidence. Cases
reported in adults provide a valid measure of trends in incidence and the
overall burden of disease in those age groups. Because most children
with HAV infection are asymptomatic, reported cases represent only a
small proportion of the overall burden of HAV infection in young age
groups. Nevertheless, trends in the incidence of cases reported in
children do reflect changes in the frequency of HAV transmission among
children and can be used to estimate the impact of prevention strategies.
The proportion of cases reporting specific risk factors should be
determined to monitor disease transmission patterns.
Identifying community-wide epidemics. Significant increases in
hepatitis A incidence can indicate that a community-wide epidemic is
developing and requires further investigation. Surveillance data should be
analyzed to determine the areas (e.g., rates by county or zipcode) and
groups (e.g., age-specific incidence rates and frequencies of reported risk
factors ) affected.
Identifying common-source outbreaks. The identification of clustering
of hepatitis A cases should prompt an investigation to determine if a
common-source outbreak is occurring. This investigation should include
collection of additional information from reported cases regarding
potential common exposures (e.g., restaurants, community gatherings,
child day care centers) and enhancement of prospective surveillance to
identify additional cases that might be associated with a common source
of transmission.
Amplification and sequencing of viral isolates using nucleic acid
based methods can help to identify cases that might share a common
source. Therefore, when investigating a possible common source
outbreak, efforts should be made to collect sera from cases for possible
sequence analysis. Public health professionals who need information
regarding use of nucleic acid based methods for the investigation of
hepatitis A outbreaks can contact CDC’s Division of Viral Hepatitis,
National Center for Infectious Diseases at (404) 371-5910.
Assessing missed opportunities for prevention. Case-patients whose
source for infection was reported as household or sexual contact with a
suspected or confirmed hepatitis A case should be investigated to
determine if the case-patient received post-exposure prophylaxis when
the source case was identified. The health care practitioners for these
persons should be contacted to determine why the patient did not receive
timely post-exposure prophylaxis (e.g., late identification of the source
case or of the contact) so potential barriers to administering postexposure prophylaxis to patients at risk of hepatitis A can be identified
and resolved.

Viral Hepatitis Surveillance Guidelines – page 22

Missed opportunities for vaccination should be assessed among
cases occurring in persons for whom hepatitis A vaccination is
recommended (e.g., adults in high risk groups such as MSM, and illicit
drug users, or children in selected high rate states/communities) by
inquiring about their history of previous contact with health care
practitioners or other settings in which vaccination could have been given
(e.g., drug treatment centers, STD clinics). These facilities and health
care practitioners should be contacted to determine why the case-patient
did not receive hepatitis A vaccine so potential barriers to vaccinating
patients at risk of hepatitis A can be identified and resolved.
Assessing the impact of vaccination programs. Age-specific
hepatitis A rates for the target groups and the community as a whole can
be compared to historical rates for the same age groups to assess the
impact of routine vaccination programs.

Acute Hepatitis B
Case Definition (*)
Clinical criteria
An acute illness with:
• discrete onset of symptoms (e.g. fatigue, abdominal pain, loss
of appetite, intermittent nausea, vomiting), and
• jaundice or elevated serum aminotransferase levels
Laboratory criteria
• IgM antibody to hepatitis B core antigen (anti-HBc) positive or
Hepatitis B surface antigen (HBsAg) positive
• IgM anti-HAV negative (if done)
Case classification
• Confirmed. A case that meets the clinical criteria and is
laboratory confirmed
To date, asymptomatic individuals who are IgM anti-HBc positive
have not been included as reportable cases. However, it is expected that
as rates of acute disease continue to decline, the case definition will be
expanded to include newly infected individuals identified on the basis of
laboratory results alone. In expanding surveillance to include
asymptomatic HBV infections, these cases will need to be distinguished
from symptomatic cases to ensure accurate interpretation of surveillance
data.

Viral Hepatitis Surveillance Guidelines – page 23

Case Ascertainment
The primary methods to ascertain suspected acute hepatitis B cases are:
• Laboratory reporting of all IgM anti-HBc positive and HBsAg positive
test results to state and/or local health departments;
• Reporting by health care practitioners of persons with confirmed acute
hepatitis B. Follow-up with providers reporting persons testing
HBsAg-positive who have signs and/or symptoms of acute viral
hepatitis to ensure testing for IgM anti-HBc;
• Follow-up with providers reporting persons as suspected cases of
acute viral hepatitis on the basis of clinical criteria alone to ensure
appropriate diagnostic testing for acute viral hepatitis.

Case Investigation
Confirmed and suspected cases of acute hepatitis B should be reported
and investigated as soon as possible after the case is identified to ensure
adequate time to implement preventive measures including postexposure prophylaxis of contacts. To report a case as confirmed, it
should be verified that the case meets both the serologic and clinical
criteria of the case definition. The components of a case investigation
should include:
• Clinical features. Determine date of illness onset, whether jaundice
was present and results of testing for elevated aminotransferase
levels.
• Serologic test results. Serologic confirmation of acute hepatitis B
requires a positive IgM anti-HBc test result. Individuals meeting the
clinical criteria who test positive for HBsAg but who were not tested
for IgM anti-HBc should be classified as suspected cases.
• Risk factors for infection. (Table III) All confirmed or suspected
cases of acute hepatitis B should be interviewed to identify a source
or risk factor(s) for infection during the 6 weeks to 6 months prior to
illness onset. Because IgM antibodies persist for up to 6 months after
infection, it is not possible to define the appropriate exposure period
for asymptomatic IgM anti-HAV positive persons. Therefore, risk
histories for these persons may be likely to be unreliable for
determining a source of infection.
• Vaccination history. Obtain a complete history of all doses of
hepatitis B vaccine received including dates of vaccination and the
results and dates of post-vaccination testing if such testing was
performed.

Viral Hepatitis Surveillance Guidelines – page 24

• Identification of contacts who require post exposure prophylaxis.
Immunoprophylaxis following exposure to a person with acute
hepatitis B (HBsAg positive) should be provided according to existing
recommendations of the Advisory Committee on Immunization
Practices 33. At-risk contacts requiring post-exposure prophylaxis
include infants whose primary caretaker has acute hepatitis B, sexual
partners, and other contacts who have had a blood exposure to the
index patient (e.g., needle sharing contacts of injection drug users,
non-sexual household contacts who may have had inapparent
exposure to the blood of the index patient through exposures such as
sharing toothbrushes or razors). The vaccination status of children
and adolescents in the household of a person with acute hepatitis B
should be assessed to ensure that they receive vaccine if not
previously vaccinated.
• Referral for medical evaluation. Persons with acute hepatitis B
should be evaluated for the development of chronic infection. The
detection of HBsAg >6 months after illness onset indicates the
presence of chronic infection.

Reporting to CDC
Case reports of acute hepatitis B should be transmitted weekly by
state health departments to CDC via NETSS. In reporting,
symptomatic cases need to be distinguished from asymptomatic cases
to accurately assess changes in incidence. See Appendix X for CDC
Hepatitis B case report form.

Viral Hepatitis Surveillance Guidelines – page 25
Table III. Components of Acute Hepatitis B Case Investigations
Information Collected
Risk factors (6 wks-6 mo prior to illness
onset)
• Contact with a person w/confirmed or
suspected HBV infection
• Employment involving contact with human
blood
• Receipt of blood transfusion or blood
products
• Dialysis or kidney transplant patient
• Injecting drug use
• Number of different male sex partners
• Number of different female sex partners

Comments/Action

Type of contact (sexual, household, casual)
Degree of blood contact (several times weekly/infrequent)
Product(s) administered, date(s) received
Notify and investigate facility; assess barriers to vaccination
Notify at risk contacts of need for hepatitis B
vaccination -- (and HBIG, if it can be administered
within 14 days of last contact)

•
•

Hospitalization and/or surgery
Intravenous infusions or injections received
in outpatient settings
• Residence in a long term care facility (e.g.
nursing home)
• Dental work/oral surgery
• Acupuncture/tattooing/body piercing
• Puncture with a needle or other object
contaminated w/blood
Vaccination History
• Hepatitis B vaccination status
Results of Case Investigation and Follow-up
• Date reported to health department
responsible for case investigation
• Date case investigation initiated
• At risk contacts identified
•
•

At risk contacts initiating prophylaxis
Date referred for medical evaluation

Missed Opportunities for Hepatitis B
Vaccination
• Household or sex contact of HBV-infected
person
• Ever in correctional facility
• Ever treated for a sexually-transmitted

disease

• Ever in treatment for injecting drug use

Determine if additional cases are linked to same facility; assess
need for investigation for a nosococomial source of infection

Determine post-exposure prophylaxis history: date(s) of HBIG
administration, date(s) of vaccination
If vaccinated, number of vaccine doses, date(s) of vaccination,
and post-vaccination test results (if available)

Date of first contact with patient and/or health care practitioner
Sexual contacts, household contacts, and
needle-sharing contacts
Need to assure completion of 3-dose HepB vaccine series
Evaluate for development of chronic infection including testing
for HBsAg >6 months after illness onset

Notify health care practitioner and assess barrier(s) to providing
HepB vaccine
Determine date of most recent incarceration, notify facility and
assess barrier(s) to providing HepB vaccine
If yes, determine date of most recent treatment, notify facility,
and assess barrier(s) to providing HepB vaccine

Viral Hepatitis Surveillance Guidelines – page 26

Uses of Surveillance Data
Identifying outbreaks. Identification of any of the following risk factors
among persons with acute hepatitis B should prompt an investigation to
determine if additional cases are associated with a common source of
transmission:
Receipt of blood or blood products. When cases are identified in
persons who received a blood transfusion during the incubation period,
the transfusion service and the blood collection establishment should be
notified. For patients who have no other recognized risk factors for
infection, the blood collection establishment should identify and retest the
donor(s) for evidence of HBV infection (HBsAg, anti-HBc). For persons
who received plasma-derived products during the incubation period, the
specific product name and lot number should be obtained.
Hemodialysis. The patient’s dialysis unit should be contacted to
determine if additional cases have been detected. Current policies of the
unit should be determined regarding vaccination and routine serologic
testing of patients as well as infection control practices. The unit should
be provided with appropriate recommendations to prevent transmission of
HBV and other bloodborne pathogens in the facility34.
Hospitalization, surgery, other medical or dental procedures.
Additional information should be obtained regarding the specific medical
care provider(s) and setting (e.g., hospital, clinic) involved. The
occurrence of at least two cases associated with the same medical care
provider or setting or one case with no other recognized risk factors for
infection should prompt an investigation to determine if there is a
nosocomial source of infection.
Monitoring trends in disease incidence and determining risk factors
for infection. Acute hepatitis B surveillance data should be analyzed at
regular intervals (e.g., weekly) by time, place, and person to monitor
disease incidence. The proportion of cases with specific risk factors
should be determined to monitor disease transmission patterns and to
identify high risk groups that need to be targeted by vaccination
programs.
Assessing missed opportunities for prevention. Case-patients whose
source for infection was reported as household or sexual contact with a
person with acute or chronic HBV infection should be investigated to
determine if the case-patient should have been immunized when the
source case was identified. The health care practitioners for these
persons should be contacted to determine why the case-patient did not
receive hepatitis B vaccine so barriers to vaccinating at-risk contacts of
identified cases can be identified and resolved.
Missed opportunities for pre-exposure vaccination should be
assessed among cases of acute hepatitis B occurring in persons for

Viral Hepatitis Surveillance Guidelines – page 27

whom hepatitis B vaccination is recommended (e.g.,MSM, injecting drug
users) by inquiring about their history of previous contact with health care
practitioners or other settings in which vaccination could have been given
(e.g., STD clinics, correctional facilities, drug treatment centers). These
facilities/health care practitioners should be contacted to determine why
the case-patient did not receive hepatitis B vaccine so barriers to
vaccinating persons belonging to groups at increased risk of HBV
infection can be identified and resolved. Missed opportunities for
vaccination should also be assessed among cases occurring in children
less than 18 years of age to determine the frequency and characteristics
of these cases so that the effectiveness of routine childhood vaccination
programs can be monitored and any barriers to vaccinating children can
be identified and resolved.
Assessing the frequency and causes of immunization failure. The
frequency of cases occurring in vaccinated persons should be determined
to monitor the efficacy of vaccination and to detect possible cases of
vaccine failure. Additional investigation is needed to identify causes for
these potential breakthrough infections (e.g., waning of vaccine induced
immunity, infection with viral variants). Health care professionals who
need information regarding investigation of these cases can contact
CDC’s Division of Viral Hepatitis, National Center for Infectious Diseases
at (404) 371 5910.

Perinatal HBV Infection
Case Definition (*)
Clinical description
Perinatal HBV infection in the newborn can range from asymptomatic to
fulminant hepatitis.
Laboratory criteria
Hepatitis B surface antigen (HBsAg) positive
Case classification
HBsAg positivity in any infant >1-24 months old who was born in the
United States or in U.S. territories to an HBsAg-positive mother.
Comment: Infants born to HBsAg-positive mothers should receive
hepatitis B immune globulin (HBIG) and the first dose of hepatitis B
vaccine within 12 hours of birth, followed by the second and third doses of
vaccine at 1 and 6 months of age, respectively. Postvaccination testing
for HBsAg and anti-HBs (antibody to HBsAg) is recommended from 3 to 6
months following completion of the vaccine series. If HBIG and the initial
dose of vaccine are delayed for >1 month after birth, testing for HBsAg
may determine if the infant is already infected.
*This case definition was adopted by CSTE in March 1995 31.

Viral Hepatitis Surveillance Guidelines – page 28

Case Ascertainment
Virtually all infants who are infected with HBV are asymptomatic.
The primary method for identifying such infants is to test pregnant women
for HBsAg and test the infants born to infected women for HBsAg at 9-15
months of age.
To facilitate identification of HBV-infected infants:
• consider laws or regulations to require prenatal HBsAg screening of
all pregnant women;
• ensure that all birthing hospitals have appropriate written standing
orders and/or administrative procedures for determining the HBsAg
status of all pregnant women during each pregnancy and prior to
delivery;
• ensure that all birthing hospitals have appropriate written standing
orders and/or procedures to test mothers with an unknown HBsAg
status at the time of delivery;
• make HBsAg-positive test results in pregnant women a reportable
condition;
• establish links with hospitals and infection control practitioners for
reporting of all births to HBsAg-positive women;
• consider requirements to document maternal HBsAg status on the
newborn metabolic screening card or birth certificate;
• assure that health care practitioners, health care organizations, and
perinatal HBV prevention programs have appropriate policies and
procedures for active tracking and/or case-management of infants
born to HBsAg-positive mothers;
• assure testing of all infants born to HBV-infected women for HBsAg
and anti-HBs at 9 to 15 months of age; and
• establish routine reporting as part of health department casemanagement of all HBsAg and anti-HBs test results (positive and
negative) from infants born to HBsAg-positive women.

Case Investigation
Case investigations of suspected cases of perinatal HBV infection
should be conducted promptly. Information to be collected includes (Table
IV):
• Serologic test results: Obtain documentation of positive HBsAg
test results for both the mother and the infant, the age of the child,
and the child’s country of birth.
• Post-exposure prophylaxis history. Ascertain the date and
dosage of HBIG and the date and dosage of all doses of hepatitis B
vaccine given to the child.

Viral Hepatitis Surveillance Guidelines – page 29

•

•

Referral for medical evaluation. Children with HBsAg positive test
results should be evaluated (by referral or consultation, if
appropriate) to:
• verify the presence of chronic HBV infection;
• assess for biochemical evidence of chronic liver disease; and
• assess for severity of disease and possible treatment according
to current practice guidelines in consultation with, or by referral
to, a specialist knowledgeable in this area.
Revaccination of susceptible infants: Ensure that children who
test negative for HBsAg and anti-HBs at 9-15 months of age are
revaccinated.

Viral Hepatitis Surveillance Guidelines – page 30

Table IV. Components of Perinatal HBV Infection Case Investigations
Information Collected for Infant
Demographic Information
• Sex, date and place of birth, age,
race/ethnicity
Diagnostic Test Results
• HBsAg, anti-HBs

Comments/Action

Testing should be done at 9-15 months of
age
If HBsAg positive , refer for medical
evaluation
If HBsAg negative and anti-HBs negative,
revaccinate

• Date of diagnosis
Immunization History
• Date and dosage of HBIG administered
• Date(s) and dosage of hepatitis B vaccine
administered
Information Collected for Mother
Demographic information
• Age, date of birth, race/ethnicity, country
of birth
Diagnostic Test Results
• HBsAg
• Date of diagnosis
Results of Case Investigation and Followup
• Date reported to health department
responsible for case investigation
• Date case investigation initiated
•

At
 risk contacts identified

•

At
 risk contacts initiating hepatitis B
vaccination
Date referred for medical evaluation

•

Date of positive HBsAg test

Date of first contact with patient and/or health
care practitioner
Sexual and household contacts, and needlesharing contacts of injecting drug users
Need to assure completion of 3-dose HepB
vaccine series
Evaluate for chronic liver disease, eligibility
for treatment

Viral Hepatitis Surveillance Guidelines – page 31

Reporting to CDC
Confirmed cases of perinatal HBV infection should be reported to health
departments as specified by local regulations. Case reports should be
transmitted weekly by state health departments to CDC using the
separate NETSS category established for reporting cases of perinatal
HBV infection. See Appendix for CDC perinatal HBV case report form.

Uses of Surveillance Data
Monitoring the operation and effectiveness of perinatal HBV
prevention programs:
The following indicators can be used to monitor the operation and
effectiveness of perinatal HBV prevention programs and should be
determined for all infants born to HBV-infected women:
• The proportion of cases that received the first hepatitis B vaccine

dose <12 hours after birth;

• The proportion of cases that received the third hepatitis B vaccine

dose <8 months after birth;

• The proportion of cases that received HBIG <12 hours after birth; and
• The proportion of cases that received > 3 hepatitis B vaccine doses.
Assessing the frequency and causes of immunization failure.
The frequency of cases occurring in infants who received post exposure
prophylaxis should be determined to monitor its efficacy. Investigation of
cases of perinatal HBV infection should be done to evaluate causes of
possible breakthrough infections and should include obtaining sera from
the infant and mother to test for the presence of HBV variants. Health
care professionals who need information regarding testing infants with
perinatal HBV infection for HBV variants can contact the Perinatal
Hepatitis B Prevention Program in their state health department or
CDC’s Division of Viral Hepatitis, National Center for Infectious Diseases
at 404-371-5910.

Chronic HBV Infection
The objectives and activities of existing state-based databases of
persons who test positive for HBsAg vary considerably and have not been
standardized. The following case definition, case ascertainment
methods, and case investigation and follow-up methods are provided as a
guide for management of persons who test HBsAg positive. Further
assessment is needed to determine the most feasible and useful
approaches to establish these types of systems.

Viral Hepatitis Surveillance Guidelines – page 32

Case Definition (*)
Clinical description
Persons with chronic hepatitis B virus (HBV) infection may be asymptomatic.
They may have no evidence of liver disease or may have a spectrum of
disease ranging from chronic hepatitis to cirrhosis or liver cancer.
Laboratory criteria
•

Hepatitis B surface antigen (HBsAg) positive, total anti-HBc positive (if
done) and IgM anti-HBc negative, OR

•

HBsAg positive two times at least 6 months apart

Case classification
• Confirmed. A case that is laboratory confirmed
*Note: This case definition was approved by CSTE in June 2002. This is the

first published case definition for chronic HBV infection.

Comment:

HBsAg positive test results by enzyme immunoassay (EIA) that are not

supported by positive test results for total anti-HBc or IgM anti-HBc

should be confirmed by an additional more specific assay (e.g.

neutralization assay)

Case Ascertainment
The primary methods to ascertain cases of chronic HBV infection are:
• Laboratory reporting of all HBsAg-positive results to state and/or

local health departments

• Make HBsAg-positive test results a reportable condition. All positive

HBsAg test results should be followed-up to determine if the person

has chronic HBV infection (see case definition above). Particular

efforts should be made to follow-up women of reproductive age.

Case Investigation and Follow-up
Case investigation and follow-up should be conducted for persons with
HBsAg-positive laboratory results and should include (Table V.):
• Serologic test results. A single HBsAg positive and total anti-HBc

positive test result in an asymptomatic person that is simultaneously

negative for IgM anti-HBc confirms chronic infection. Chronic HBV

infection can also be verified by two or more HBsAg positive test

results separated by at least 6 months. The results of prior hepatitis

test results should be reviewed if available.

• Pregnancy status for women of childbearing age. All HBsAgpositive pregnant women should be reported to the Perinatal

Hepatitis B Prevention Program Manager to ensure that infants born

Viral Hepatitis Surveillance Guidelines – page 33

to these women receive appropriate postexposure management
according to existing ACIP recommendations 33.
•
Immunoprophylaxis and counseling to prevent transmission.
HBsAg-positive persons should be advised regarding how to reduce
their risk of transmitting HBV to others, including notifying their
sexual, household, and other (e.g., needle-sharing contacts of IDUs)
contacts at risk of the need to get vaccinated against hepatitis B. 35
• Counseling and referral. HBsAg-positive persons should be
advised regarding how to reduce their risk of liver injury and referred
for medical evaluation and management 35.

Viral Hepatitis Surveillance Guidelines – page 34

Table V. Components of case investigations of persons testing HBsAg-positive
Information Collected
Clinical data
• Pregnancy status (if female)
Risk factors (lifetime history)*
• Hemodialysis
• Injection drug use
• Number of sex partners
• Contact with a person who had hepatitis
•

Employment involving contact with human
blood
• Incarceration
Results of Case Investigation and Follow-up
• Date reported to health department
responsible for case investigation
• Date case investigation initiated
•

At
 risk contacts identified

•

 At risk contacts initiating hepatitis B
vaccination
Date referred for medical evaluation

•

Comments/Action
If yes, report to State Perinatal Hepatitis B
Prevention Program

If yes, type of contact (sexual, household,
casual)
If yes, degree of blood contact (several
time weekly/infrequent)

Date of first contact with patient and/or
health care practitioner
Sexual contacts, household contacts, and
needle-sharing contacts of injecting drug
users
Need to assure completion of 3-dose
HepB vaccine series
Evaluate for chronic liver disease,
eligibility for treatment

*The collection of risk factor information is not recommended for individuals belonging to groups
in which most chronic HBV infections are attributable to perinatal or early childhood infection
with HBV (e.g. emigrants from countries endemic for HBV). The routine collection of risk factor
information for other individuals is not required but may provide useful information for the
development and evaluation of programs to identify and counsel HBV-infected persons.

Reporting to CDC
Cases of chronic HBV infection should be reported to CDC through the
NNDSS. Inclusion of chronic HBV infection in the list of nationally
reportable conditions is pending CSTE approval.

Uses of Surveillance Data.
Databases of HBsAg-positive persons should be established to
distinguish newly reported cases of chronic HBV infection from previously
identified cases. Periodic analyses of the cumulative number of persons
with HBV infection included in these databases could be used to provide
local, state and national estimates of the proportion of persons with HBV
infection who have been identified.

Viral Hepatitis Surveillance Guidelines – page 35

Acute Hepatitis C
Case Definition(*)
Clinical criteria
An acute illness with
• discrete onset of symptoms consistent with acute viral
hepatitis, and
• jaundice or elevated serum aminotransferase levels
Laboratory criteria
• Serum alanine aminotransferase levels >7 times the upper
limit of normal, and
• IgM anti-HAV negative (if done), and
• IgM anti-HBc negative , or if not done, HBsAg negative and
• Antibody to hepatitis C virus (anti-HCV) positive (repeat
reactive) by EIA, verified by an additional more specific assay
(e.g. RIBA™ for anti-HCV or nucleic acid testing for HCV RNA)
OR
Anti-HCV positive (repeat reactive) by screening immunoassay
with a signal to cut-off ratio predictive of a true positive as
determined for the particular assay (e.g., >3.8 for enzyme
immunoassay).

Case classification
Confirmed: A case that meets the clinical case definition and is
laboratory confirmed.

Comment
1) Up to 10% of cases of acute hepatitis C will be anti-HCV negative
when tested initially because some have not yet seroconverted and
others (<3%) remain negative even with prolonged follow-up.
2) Available serologic tests for anti-HCV do not distinguish between
acute and chronic or past infection. Thus, other causes of acute
hepatitis should be excluded for anti-HCV positive patients who have
an acute illness compatible with hepatitis.
3) The diagnosis of HCV infection can be made by detecting HCV RNA
using gene amplification techniques (e.g. RT-PCR). However, a
negative HCV RNA test result does not exclude the possibility of HCV
infection.
*This case definition was approved by CSTE in June, 2003. It has been
updated from the previously published case definition.

Viral Hepatitis Surveillance Guidelines – page 36

Case Ascertainment
The primary method to ascertain suspected cases of acute
hepatitis C is by follow-up of reported clinical cases of hepatitis C and
non-A, non-B hepatitis. This includes:
• Serologic testing of patients with signs/symptoms of acute viral
hepatitis, according to an appropriate algorithm (see section on case
ascertainment).
• Repeat anti-HCV testing, or testing for HCV RNA by RT-PCR, of
persons with suspected acute viral hepatitis who test negative for IgM
anti-HAV, IgM anti-HBc, and anti-HCV at the time the case is
reported.
Laboratory reporting of anti-HCV positive results is encouraged as
a method to identify persons with HCV infection. However, most HCVinfected persons who are identified on the basis of anti-HCV positive
laboratory reports have chronic, rather than acute, infections. Thus, the
investigation of these reports is not likely to be an efficient mechanism to
identify acute hepatitis C cases unless additional clinical information is
obtained with the serologic result. Routine reporting of ALT levels with
anti-HCV positive laboratory results might be useful to identify persons
who are most likely to have acute disease, and would enhance the
usefulness of laboratory reporting in conducting surveillance for acute
hepatitis C.

Case Investigation
Case investigations should be conducted of suspected cases of acute
hepatitis C and should include (Table VI):
• Clinical features. Determine the date of illness onset, whether
jaundice or other symptoms consistent with acute viral hepatitis
were present and the results of testing for aminotransferase
levels. If possible, evaluate previous medical history for evidence
of past infection to assess likelihood that current symptoms are
due to a newly acquired infection.
• Diagnostic test results: Serologic confirmation of acute hepatitis
C requires negative test results for IgM anti-HAV and IgM antiHBc and a positive test result for anti-HCV by EIA verified by a
positive test result from an additional more specific assay (e.g.,
RIBA™ for anti-HCV or RT-PCR for HCV RNA), or by an average
EIA signal to cutoff ratio of >3.8.
• Risk factors for infection. (Table VI) All confirmed cases of
acute hepatitis C should be interviewed to identify a risk factor(s)
for infection during the 2 weeks to 6 months prior to illness onset.
• Pregnancy status of HCV-infected women of childbearing
age. No post-exposure prophylaxis is available to prevent
perinatal transmission of HCV. Children born to anti-HCV positive
women should be tested for infection.19

Viral Hepatitis Surveillance Guidelines – page 37

•

Counseling and referral for follow-up Persons with acute
hepatitis C should be advised regarding how to reduce their risk of
transmitting HCV to others and the need for follow-up to
determine the outcome of their infection 19.

Table VI. Components of Acute Hepatitis C Case Investigations
Risk factors
(in 2 wks-6 mo prior to illness
onset)
• Contact with a person w/
confirmed or suspected HCV
infection
• Employment involving contact
with human blood
• Receipt of blood transfusion or
blood products
• Dialysis or kidney transplant
• Injecting drug use

Type of contact (sexual, household, casual)

Assess degree of blood contact
(frequent/infrequent)
Determine product(s) received, date(s) of
administration, notify transfusion service
Notify and investigate facility
Refer injecting drug use contacts for counseling
and testing

•

Number of different male sex
partners
• Number of different female sex
partners
• Hospitalization and/or surgery
• Intravenous infusions or
injections received in an
outpatient setting

• Residence in long-term care
facility (e.g. nursing home)
• Dental work/oral surgery
• Acupuncture/tattooing/body
piercing
• Puncture with a needle or other
object contaminated w/ blood
Case Investigation and Follow-up
• Date reported to health
department responsible for case
investigation
• Date case investigation initiated
•

At-risk contacts identified and
referred for counseling and
testing

Refer all sex contacts for counseling and testing

Determine if additional cases are linked to same
facility; assess need for investigation for a

nosocomial source of infection

Date of first contact with patient and/or health care
practitioner
Sex partners, injecting drug use contacts

Viral Hepatitis Surveillance Guidelines – page 38

Reporting to CDC
Case reports of acute hepatitis C are transmitted weekly by state health
departments to CDC via NETSS. See Appendix X for CDC case report
form.

Uses of Surveillance Data
Identifying outbreaks Identification of any of the following risk factors in
persons with acute hepatitis C should prompt an investigation to
determine if additional cases are associated with a common source of
transmission:
• Receipt of blood or blood products. When cases are identified in
persons who received a blood transfusion during the incubation
period, the transfusion service and the blood collection
establishment should be notified. For those patients who have no
other recognized risk factors for infection, the blood collection
establishment should identify and retest the donor(s) for evidence of
HCV infection. For persons who received plasma-derived products
during the incubation period, the specific product name and lot
number should be obtained.
• Hemodialysis. The patient’s dialysis unit should be contacted to
determine if additional cases have been detected. Current policies
of the unit should be determined regarding routine testing of patients
for ALT and anti-HCV as well as infection control practices. The unit
should be provided with appropriate recommendations to prevent
transmission of HCV and other bloodborne pathogens in the facility34
.
• Hospitalization, surgery, other medical or dental procedures. For
persons who report a history of hospitalization, surgery, and/or
dental procedures, and who have no other recognized risk factors
for infection, additional information should be obtained regarding the
specific medical care provider(s) and setting (e.g., hospital, clinic)
involved. The occurrence of at least two cases associated with the
same medical care provider or setting or one case with no other risk
factors should prompt an investigation to determine if there is a
nosocomial source of infection.
Monitoring trends in disease incidence and determining risk factors
for infection Acute hepatitis C surveillance data should be analyzed at
regular intervals by time, place and person to monitor disease incidence.
The proportion of cases with specific risk factors should be determined to
monitor disease transmission patterns.

Viral Hepatitis Surveillance Guidelines – page 39

Hepatitis C Virus Infection, (Past or present)
The objectives and activities of existing state-based databases of
persons reported as anti-HCV positive vary considerably and have not
been standardized. The following case definition, case ascertainment
methods, and case investigation and follow-up methods are provided as a
guide for management of persons who test anti-HCV positive. However,
further evaluation is needed to determine the most feasible and useful
approaches to establish these types of systems.

Case Definition (*)
Clinical description
Most HCV-infected persons are asymptomatic. However, many
have chronic liver disease, which can range from mild to severe
including cirrhosis, and liver cancer.

Laboratory criteria
• Anti-HCV positive (repeat reactive) by EIA, verified by an
additional more specific assay (e.g. RIBA for anti-HCV or nucleic
acid testing for HCV RNA)
Or
• Anti-HCV positive (repeat reactive) by EIA 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 is laboratory confirmed.
Probable. A case that is anti-HCV positive (repeat reactive) by
EIA and has alanine aminotranferase (ALT or SGPT) values
above the upper limit of normal, but the anti-HCV EIA result has
not been verified by an additional more specific assay or the
signal to cut-off ratio is unknown.
*Note: This case definition was approved by CSTE in June 2002
and is the first published for HCV infection.

Case Ascertainment
The primary method to ascertain cases of HCV infection is by reporting of
all anti-HCV positive laboratory results to state and/or local health
departments.

Viral Hepatitis Surveillance Guidelines – page 40

Case Investigation and Follow-up
Case investigation and follow-up should be conducted for persons with
anti-HCV positive laboratory results and should include (Table VII.)
• Serologic test results. The diagnosis of HCV infection in a person
testing positive for anti-HCV by EIA should be confirmed by an
additional more specific assay (e.g., RIBA for anti-HCV or RT-PCR
for HCV RNA). However, if test results by an additional more specific
assay are not available, a person who tests positive for anti-HCV by
EIA with an average signal to cut-off ratio >3.8 can also be reported
as confirmed. An anti-HCV positive person who has elevated liver
enzyme levels but for whom additional confirmatory data are
unavailable should be reported as a probable case.
• Counseling and referral for medical management. HCV-infected
persons should be advised regarding how to reduce their risk of
transmitting HCV to others and how to reduce further liver injury.
They should also be referred for medical evaluation and
management19.

Reporting to CDC
Cases of Hepatitis C virus infection should be reported to CDC
through the NNDSS. Inclusion of HCV infection, chronic or resolved in
the list of nationally reportable conditions is pending CSTE approval.

Uses of Surveillance Data
Periodic analyses of the cumulative number of persons
enrolled in HCV infection databases could be used to provide local, state
and national estimates of the proportion of persons with HCV infection
who have been identified. Recommended information elements to be
maintained in such databases are described in Appendix.

Viral Hepatitis Surveillance Guidelines – page 41

Table VII. Components of HCV Infection Case Investigations
Information Collected
Clinical data
• Pregnancy status (if female)

• Reason for testing
Diagnostic Test Results
• Anti-HCV (EIA)
• Anti-HCV (RIBA™)
• HCV RNA
• Date of diagnosis
Risk factors (lifetime history)*
• Blood transfusion prior to 1992
• Organ transplant prior to 1992
• Receipt of clotting factor
concentrates made prior to
1987
• Hemodialysis
• Injection drug use
• Number of sex partners
• Contact with a person who had
hepatitis
• Employment involving contact
with human blood
Case Investigation and Followup
• Date reported to health
department responsible for
case investigation
• Date case investigation
initiated
• Date referred for medical
evaluation

Comments/Action
If yes, provide counseling regarding risks of
transmission from mother to infant. Arrange follow-up
of infant to test for infection. Consider testing other
children for infection

Obtain most recent and prior diagnostic test results
for HCV infection (if available), including dates of
testing
Date of first positive anti-HCV test

If yes, type of contact (sexual, household, casual)
If yes, degree of blood contact (several times
weekly/infrequent)

First contact with patient and/or health care
practitioner
Evaluate for chronic liver disease, eligibility for
treatment

*Routine collection of risk factor information for persons who test HCV positive is not required.
However, collection of risk factor information for such persons may provide useful information
for the development and evaluation of programs to identify and counsel HCV-infected persons

Viral Hepatitis Surveillance Guidelines – page 42

Acute non-ABC hepatitis
Surveillance for non-ABC hepatitis is needed to identify and
monitor the frequency of disease that may be associated with other
known agents of viral hepatitis (HDV and HEV) and to detect new
etiologic agents. Individuals with signs and symptoms of acute viral
hepatitis who are negative for serologic markers of acute hepatitis A (IgM
anti-HAV), acute hepatitis B (IgM anti-HBc) and hepatitis C (anti-HCV)
should be reported via the state health department to CDC and further
investigation to describe the characteristics of the case and to identify a
causal agent may be considered. Health-care professionals who need
information on additional testing of persons with acute non-ABC hepatitis
may contact CDC’s Division of Viral Hepatitis, National Center for
Infectious Diseases at (404) 371-5910.

OTHER SURVEILLANCE METHODS
Serologic Surveys
Many persons with new HAV, HBV, and HCV infections,
particularly young children, are asymptomatic and many cases of
symptomatic disease are not reported to the Nationally Notifiable Disease
Surveillance System. Thus, serosurveys are needed to assess the extent
of the disease burden associated with viral hepatitis and to monitor the
impact of prevention and control programs. National seroprevalence data
for HAV, HBV, and HCV infections are provided by the CDC National
Health and Nutrition Examination Survey (NHANES), a periodic survey of
a sample of the civilian, non-institutionalized U.S. population. However,
NHANES can provide only regional seroprevalence estimates and the
survey does not have an adequate sample size for some population
groups that are at high risk of viral hepatitis. Thus, selected serosurveys
conducted at the state and local level and of specific population groups
are needed to measure the effectiveness of prevention and control
programs.
Chronic Liver Disease Surveillance
Surveillance for HBV and HCV-related chronic liver disease can provide
information to measure the burden of disease, determine natural history
and risk factors, and develop and evaluate the effect of therapeutic and
prevention measures on incidence and severity of disease. Recently, a
sentinel surveillance pilot program for physician-diagnosed chronic liver
disease was established which will provide baseline data and a template
for a broader surveillance system for chronic liver disease. As the primary
source of data regarding the incidence and natural history of chronic liver
disease, this network will be pivotal for monitoring the effects of
education, counseling, other prevention programs, and newly developed
therapies on the burden of the disease.

References
1

CDC. Summary of notifiable diseases, United States, 1999. MMWR 2001; 48: 46

2

CDC. Prevention of hepatitis A through active or passive immunization. MMWR 1999; 48(RR12).

3

McMahon BJ, Alward WLM, Hall DB et al. Acute hepatitis B virus infection: relation of age to
the clinical expression of disease and subsequent development of the carrier state. J Inf Dis
1985; 151: 599-603.

4

Alter MJ, Mares A, Hadler SC et al. The effect of underreporting on the apparent incidence
and epidemiology of acute viral hepatitis. Am J Epi 1987; 125(1): 133-139.

5

CDC. Hepatitis Surveillance Report No. 56 , 1995, pp9-14.

6

Khan A, Goldstein S, Williams I et al (abstract). Opportunities for hepatitis B prevention in
correctional facilities and sexually transmitted disease treatment settings. Antiviral Therapy
2000; Vol 5(Supp 1): 21 –submitted JID, 2002

7

U.S. Department of Health and Human Services. Tracking Healthy People 2010. Washington,
DC: U.S. Government Printing Office, 2nd ed.

8

Alter MJ, Ahtone J and Maynard JE. Hepatitis B virus transmission associated with a multipledose vial in a hemodialysis unit. Ann Inter Med 1983; 99(3):330-333

9

Oren I, Hershow RC, Ben-Porath E et al. A common-source outbreak of fulminant hepatitis B
in a hospital. Ann Inter Med 1989; 110(9): 691-698

10

Polish LB, Shapiro CN, Bauer F et al. Nosocomial transmission of hepatitis B virus
associated with the use of a spring-loaded finger-stick device. NEJM 1992; 326: 721-725.

11

Kent GP, Brondum J, Kenlyside RA, LaFazia LM and Scott HD. A large outbreak of
acupuncture-associated hepatitis B. Am J Epi 1988; 127(3):591-598

12

Slater PE, Ben-Ishai P, Leventahal A et al. An acupuncture-associated outbreak of hepatitis
B in Jerusalem. Eur J Epi 1988; 4(3): 322-5.

13

Del Canho R, Grosheide PM, Schalm SW, de Vries RRP et al. Failure of neonatal hepatitis
B vaccination: the role of HBV-DNA levels in hepatitis B carrier mothers and HLA antigens in
neonates. J Hepatol 1994; 20: 483-486

14

Boxall EH, Harrison TJ, Whelley, HBV DNA levels in hepatitis B carrier mothers: relationship
with protection against perinatal transmission by vaccine. In: Hollinger FB, Lemon SM, Margolis
HS eds. Viral hepatitis and liver disease/ Baltimore. Williams and Wilkins 1991: 757-759

15

Carman WF, Zanetti AR, Karayiannis P et al. Vaccine-induced escape mutant of hepatitis B
virus. Lancet 1990; 336:325-329

16

Harrison TJ, Hopes E, Oon CJ, Zanetti AR, Zuckerman AJ. Independent emergence of a
vaccine-induced escape mutant of hepatitis B virus. J Hepatol 1991; 13: S105-S107

17

Oon CJ and Chen WN. Current aspects of hepatitis B surface antigen mutants in Singapore.

J Viral Hep 1998; 5(Supp 2): 17-23
18

Alter MJ, Kruszon-Moran D, Nainan OV, McQuillan GM et al. The prevalence of hepatitis C
virus infection in the United States, 1988 through 1994. NEJM 1999; 341:556-562

19

CDC. Recommendation for prevention and control of hepatitis C virus (HCV) infection and
HCV-related chronic disease. MMWR 1998; 47: RR19

20

Alter MJ, Hadler SC. Delta hepatitis and infection in North America. In: Hadziyannis SJ,
Taylor JM, Bonino F (eds): Hepatitis Delta Virus: Molecular Biology, Pathogenesis, and Clinical
Aspects. New York, Wiley-Liss, 1993, 243-250

.21 De Cock KM, Bradley DW, Sandford NL et al. Epidemic non-A, non-B hepatitis in patients
from Pakistan. Ann Intern Med 1987; 106:227-230
22

CDC. Hepatitis E among U.S. travelers, 1989-1992. MMWR 1993; 42:1-4.

23

Kwo PY, Schlauder GG, Carpenter HA et al. Acute hepatitis E by a new isolate acquired in
the United States. Mayo Clinic Proceeding 1997; 72(12):1133-1136

24

Tsang THF, Denison EK, Williams HV et al. Acute hepatitis E infection acquired in California.
Clin Inf Dis 2000; 30:618-619.

25

Linnen J, Wages J Jr, Zhang-Keck ZY, et al. Molecular cloning and disease association of
hepatitis G virus: a transfusion-transmissible agent. Science 1996;271:505-8

26

Simons JN, Leary TP, Dawson GJ, et al. Isolation of novel virus-like sequences associated
with human hepatitis. Nat Med 1995;1:564-9.
27

Okamoto H, Nisizawa T, Kato N, et al. Molecular cloning and characterization of a novel DNA
virus (TTV) associated with posttransfusion hepatitis of unknown etiology. Hepatol Res
1998;10:1-16

28

Tanaka Y, Primi D, Wang RY, et al. Genomic and molecular evolutionary analysis of a newly
identified infectious agent (SEN virus) and its relationship to the TT virus family. J Infect Dis
2001 Feb 1;183(3):359-67

29

Alter MJ, Gallagher M, Morris TT, et al. Acute non-A-E hepatitis in the United States and the
role of hepatitis G virus infection. N Engl J Med 1997;336:741-6

30

CDC. Recommendations for prevention and control of hepatitis C virus (HCV) infection and
HCV-related chronic disease. MMWR 1998; 47: RR19

31

CDC. Case definitions for infectious conditions under public health surveillance. MMWR
1997; 46: RR10

32

CDC. Prevention of hepatitis A through active or passive immunization: Recommendations of
the Advisory Committee on Immunization Practices (ACIP). MMWR 1996; 45:RR-15

33

CDC. Hepatitis B virus: A comprehensive strategy for eliminating transmission in the United
States through universal childhood vaccination. MMWR 1991; 40(RR-13)).

34

CDC. Updated U.S. Public Health Service guidelines for the management of occupational
exposures to HBV, HCV and HIV and recommendations for postexposure prophylaxis. MMWR
2001; 50(RR-5)).

35

CDC. Public Health Service inter-agency guidelines for screening donors of blood, plasma,
organs, tissues, and semen for evidence of hepatitis B and hepatitis C. MMWR 1991; Vol
40(RR-4)

DRAFT COPY

DRAFT COPY

U.S. DEPARTMENT OF
HEALTH & HUMAN SERVICES
PUBLIC HEALTH SERVICE

CDC

VIRAL HEPATITIS CASE REPORT

Centers for Disease Control
and Prevention
Hepatitis Branch, (G37)
Atlanta, Georgia 30333

The following questions should be asked for every case of viral hepatitis
Prefix: (Mr. Mrs. Miss Ms. etc) ______

Last: ______________________________

Preferred Name (nickname): _________________________________

First: _________________________

Middle: _________________

Maiden: _________________________________________________________

Address: Street: ________________________________________________________________________________________________________________
City: ________________________________________________

Phone: (

) -

Zip Code: ___ ___ ___ ___ ___ -- ___ ___ ___ ___

SSN # (optional) ___ ___ __ - ___ ___ - ___ ___ ___ ___
Only data from lower portion of form will be transmitted to CDC
State: _______________

County: ______________________________________________ Date of Public Health Report__ __ / __ __ / __ __ __ __

Was this record submitted to CDC through the NETSS system?

Yes

No

If yes, please enter NETSS ID NO.

If no, please enterSTATE CASE NO.

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667788
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678
DEMOGRAPHIC INFORMATION
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678
RACE (check all that apply):
Amer Indian or Alaska Native
Asian
SEX:

Male

Female

Black or African American
Native Hawaiian or Pacific Islander

Unk

White
Other Race, specify: ___________

PLACE OF BIRTH:

USA

Other:____________

ETHNICITY:
Hispanic ....................
Non-hispanic .............
Other/Unknown .........

__ __
__ Y
__ __
__
AGE: ___ ___ (years)
( 00= <1yr , 99= Unk )
DATE OF BIRTH: __
M __
M/D
D /Y
YY
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678
CLINICAL & DIAGNOSTIC DATA
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REASON FOR TESTING: (Check all that apply)
Symptoms of acute hepatitis
Screening of asymptomatic patient with reported risk factors
Screening of asymptomatic patient with no risk factors (e.g., patient requested )
Prenatal screening
Unknown
CLINICAL DATA:
Diagnosis date:

DIAGNOSTIC TESTS: CHECK ALL THAT APPLY
__ M
__
M

/ __
__ / Y
__ Y
__ Y
__ Y
__
DD
Yes

No

Unk

Is patient symptomatic? ...........................................
if yes, onset date: M
__ M
__ / __
__ / Y
__ Y
__ __
__
DD
YY
Was the patient

•
•

Jaundiced? ...............................................................
Hospitalized for hepatitis? ....................................
Was the patient pregnant ? .......................................
due date :

M
__ M
__ / D
__ D
__

•
•
•
•
•
•

LIVER ENZYME LEVELS AT TIME OF DIAGNOSIS

Yes

No

Unk

Total antibody to hepatitis B core antigen [total anti-HBc] .....
IgM antibody to hepatitis B core antigen [IgM anti-HBc] .........
Antibody to hepatitis C virus [anti-HCV] ...................................
anti-HCV signal to cut-off ratio __________

Supplemental anti-HCV assay [e.g., RIBA] ..............................

HCV RNA [e.g., PCR] .....................................................................
Antibody to hepatitis D virus [anti-HDV] ...................................
Antibody to hepatitis E virus [anti-HEV] ...................................
If this case has a diagnosis of hepatitis A that has not been

Upper limit normal_______

serologically confirmed, is there an epidemiologic link between

AST [SGOT] Result ______

Upper limit normal_______

this patient and a laboratory-confirmed hepatitis A case? ............

Date of AST result

Unk

Hepatitis B surface antigen [HBsAg] .............................................

ALT [SGPT] Result ______

Date of ALT result

Neg

IgM antibody to hepatitis A virus [IgM anti-HAV] .....................

•
•
•
•
•

Pos
Total antibody to hepatitis A virus [total anti-HAV] ................

-

Y __
Y __
Y __
Y
/ __

Did the patient die from hepatitis? ..........................
__ M
__ / D
__ D__ / __
__
• Date of death: M
Y __
Y __
YY

•
•
•
•

Evaluation of elevated liver enzymes
Blood / organ donor screening
Follow-up testing for previous marker of viral hepatitis
Other: specify: ____________

M
M / __
D D__ /Y
Y __
Y __
Y
__ __
__ __
M
M / __
D D__ /Y
Y __
Y __
Y
__ __
__ __

DIAGNOSIS: (Check all that apply)
Acute hepatitis A
Acute hepatitis B
Chronic HBV infection
Acute hepatitis C
HCV infection (chronic or resolved)

Acute hepatitis E

Acute non-ABCD hepatitis

Perinatal HBV infection

1
C:\My Documents\Projects\Hepatitis\VHSPW.p65

Hepatitis Delta (co- or super-infection)

DRAFT COPY

Patient History- Acute Hepatitis A

NETSS ID NO.
STATE CASE NO. _________________________________________

During the 2-6 weeks prior to onset of symptoms­
Yes
Was the patient a contact of a person with confirmed or suspected
hepatitis A virus infection? .................................................................................................
If yes, was the contact (check one)

•
•
•
•
•
•

household member (non-sexual) ...................................................................................

•
•

a child or employee in a day care center, nursery, or preschool ? ..........................

No

Unk

sex partner ......................................................................................................................
child cared for by this patient .......................................................................................
babysitter of this patient ...............................................................................................
playmate ..........................................................................................................................

other _____________________________________
Was the patient
a household contact of a child or employee in a
day care center, nursery or preschool ? ....................................................................
If yes for either of these, was there an identified hepatitis A case
in the child care facility? ............................................................................................

Please ask both of the following questions regardless of the patient’s gender.
0 1
2-5
In the 2- 6 weeks before symptom onset how many
• male sex partners did the patient have? ....................................................

•

Unk

female sex partners did the patient have? ................................................

In the 2- 6 weeks before symptom onset
Yes
Did the patient inject drugs not prescribed by a doctor? .............................................
Did the patient use street drugs but not inject? ............................................................
Did the patient travel outside of the U.S.A. or Canada .............................................

•

If yes, where?

1) _________________ 2) _________________

(Country)

3) _________________

In the 3 months prior to symptom onset
Did anyone in the patient’s household travel outside of the U.S. A. or Canada?
• If yes, where? 1) _________________ 2) _________________
(Country)
3) _________________
Is the patient suspected as being part of a common-source outbreak? ..........................
If yes, was the outbreak
Foodborne- associated with an infected food handler ................................................
Foodborne - NOT associated with an infected food handler ....................................

• specify

food item

_____________________________________

Waterborne ......................................................................................................................
Source not identified .......................................................................................................
Was the patient employed as a food handler during the TWO WEEKS
prior to onset of symptoms or while ill? ..............................................................................

VACCINATION HISTORY
Yes

No

Unk

Has the patient ever received the hepatitis A vaccine ?
1

•

If yes, how many doses? ................................................

•

In what year was the last dose received? ..................

≥≥2

Y Y
Yes

Y Y
No

Unk

Has the patient ever received immune globulin ? ...........

•

>5

If yes, when was the last dose received? ...................... ______ / _____
mo
yr

2

No

Unk

DRAFT COPY

STATE CASE NO. _________________________________________
NETSS ID NO.

Patient History- Acute Hepatitis B
During the

6 weeks- 6 months prior to onset of symptoms

was the patient a contact of a person with confirmed or
suspected acute or chronic hepatitis B virus infection? Yes

Ask both of the following questions regardless of the patient’s gender.
0 1 2-5 >5 Unk
In the 6 months before symptom onset how many
No

Unk

If yes, type of contact

•
•
•

Sexual .........................................................................

•
•

male sex partners did the patient have? ...............
female sex partners did the patient have? ...........

Was the patient EVER treated for a sexually­

Household [Non-sexual] ..........................................
Other: _______________________________

•
•
•

6 weeks- 6 months

prior to onset of symptoms
Yes
Did the patient­
• undergo hemodialysis? ...................................................
• have an accidental stick or puncture with a needle
or other object contaminated with blood? ...............
• receive blood or blood products [transfusion] ............
• if yes, when? M M / D D / Y Y Y Y

•
•

No

Unk

have other exposure to someone else’s blood ............
specify: ____________________________________

•

During the 6 weeks- 6 months prior to onset of symptoms
• Did the patient have any part of their body pierced
(other than ear)?
where was the piercing performed? (select all that apply)
commercial
correctional
other ________________
parlor / shop
facility
Yes No Unk
Did the patient have dental work or oral surgery? .............
Did the patient have surgery ? (other than oral surgery) ..
Was the patient- Check all that apply

•
•
•

6 weeks - 6 months prior to onset of symptoms

Was the patient employed in a medical or dental field

(fire fighter, law enforcement or correctional officer)
having direct contact with human blood? ..........................
If yes, frequency of direct blood contact?
Frequent (several times weekly)
Infrequent

Yes
1

Y

incarcerated for longer than 24 hours ? ..........................

incarcerated for longer than 6 months ? ...........................

•

Did the patient receive a tattoo? ...................................

In what year was the last shot received? ..................

a resident of a long term care facility ? ...........................

During his/her lifetime, was the patient EVER

•

No
2

Y

Y

If yes,

YY
__Y__
__
what year was the most recent incarceration ? ....................__ Y

where was the tattooing performed? (select all that apply)
commercial
correctional
other ________________
parlor / shop
facility

•

hospitalized ? .............................

if yes, what type of facility (check all that apply)
prison ..............................................................
jail ....................................................................
juvenile facility ..............................................

• Was the patient employed as a public safety worker

Did the patient ever receive hepatitis B vaccine?
If yes, how many shots? ...........................................

6 weeks- 6 months prior to onset of symptoms

use street drugs but not inject? .......................................

involving direct contact with human blood ? ...............
If yes, frequency of direct blood contact?
Frequent (several times weekly)
Infrequent

•

Unk

inject drugs not prescribed by a doctor? ........................

•
•
•

receive any IV infusions and/or injections in the outpatient setting...

During the

No

YY
If yes, in what year was the most recent treatment ? __
__ Y
__Y
__

During the

During the

Yes

transmitted disease? ...............................................................

for how long ? ..................................................................... __ __ __ mos

Unk
Was the patient tested for antibody to HBsAg
3+ (anti-HBs) within 1-2 months after the last dose? .......
• If yes, was the serum anti-HBs ≥≥10mIU/ml? ....................
(answer ‘yes’ if the laboratory result was reported as .....
Y
‘positive’ or ‘reactive’)

3

Yes

No

Unk

DRAFT COPY
Perinatal Hepatitis B Virus Infection

NETSS ID NO.
STATE CASE NO. _________________________________________

RACE OF MOTHER:
Amer Ind or Alaska Native
Asian

Black or African American
Native Hawaiian or Pacific Islander

White
Unknown
Other Race, specify: ______________
Yes

No

Unk

Was Mother born outside of United States? .................................................................

If yes, what country?___________________

Was the Mother confirmed HBsAg positive prior to or at time of delivery ? ...

•

If no, was the mother confirmed HBsAg positive after delivery? ....................

Date of HBsAg positive test result ....................................................................................

M M / D D / Y Y Y Y

How many doses of hepatitis B vaccine did the child receive ? ..................................
0

•
•
•
•

1

2

No

Unk

3

When?

MM/DD/YYYY
MM/DD/YYYY
Dose 3- M M / D D / Y Y Y Y
Dose 1Dose 2-

Yes

Did the child receive hepatitis B immune globulin (HBIG)? .......................................

•

If yes, on what date did the child receive HBIG? .................................................

5

ETHNICITY OF MOTHER:
Hispanic ....................
Non-hispanic .............

Other/Unknown .........

M M / D D / Y Y Y Y

DRAFT COPY

NETSS ID NO.

Patient History- Acute Hepatitis C
During the

STATE CASE NO. _________________________________________

2 weeks- 6 months prior to onset of symptoms

Ask both of the following questions regardless of the patient’s gender.
1
2-5 >5 Unk
In the 6 months before symptom onset how many 0

was the patient a contact of a person with confirmed or
suspected acute or chronic hepatitis C virus infection?

Yes

No

•
•

Unk

If yes, type of contact

•
•
•

Sexual .........................................................................

2 weeks- 6 months

prior to onset of symptoms
Yes

•
•

inject drugs not prescribed by a doctor? ........................
use street drugs but not inject? .......................................

During the
No

Unk

•

•
•
•

have other exposure to someone else’s blood ............
specify: ____________________________________

•

Was the patient employed in a medical or dental field

prior to onset of symptoms

Did the patient have dental work or oral surgery? .............
Did the patient have surgery ? (other than oral surgery) ..
Was the patient- Check all that apply

•
•
•

2 weeks - 6 months prior to onset of symptoms

2 weeks- 6 months

Did the patient have any part of their body pierced
(other than ear)?
where was the piercing performed? (select all that apply)
commercial
correctional
other ________________
parlor / shop
facility
Yes No Unk

involving direct contact with human blood ? ...............
If yes, frequency of direct blood contact?
Frequent (several times weekly)
Infrequent

hospitalized ? .............................
a resident of a long term care facility ? ...........................
incarcerated for longer than 24 hours ? ..........................
if yes, what type of facility (check all that apply)
prison ..............................................................
jail ....................................................................
juvenile facility ..............................................

• Was the patient employed as a public safety worker
(fire fighter, law enforcement or correctional officer)
having direct contact with human blood? ..........................
If yes, frequency of direct blood contact?
Frequent (several times weekly)
Infrequent

•

No Unk

Y __
YY
• If yes, in what year was the most recent treatment ? __
__ Y
__
During the 2 weeks- 6 months prior to onset of symptoms

receive any IV infusions and/or injections in the outpatient setting...

During the

Yes

transmitted disease? ....................................................................

•
•
Did the patient­
• undergo hemodialysis? ...................................................
• have an accidental stick or puncture with a needle
or other object contaminated with blood? ...............
• receive blood or blood products [transfusion] ............
• if yes, when? M M / D D / Y Y Y Y

female sex partners did the patient have? ...........

Was the patient EVER treated for a sexually

Household [Non-sexual] ..........................................
Other: _______________________________

During the

male sex partners did the patient have? ...............

During his/her lifetime, was the patient EVER

•

incarcerated for longer than 6 months ? ...........................

•

Did the patient receive a tattoo? ...................................

If yes,

YY
__Y__
__
what year was the most recent incarceration ? ....................__ Y

where was the tattooing performed? (select all that apply)
commercial
correctional
other ________________
parlor / shop
facility

for how long ? ..................................................................... __ __ __ mos

3

DRAFT COPY
NETSS ID NO.

Patient History- Hepatitis C Virus Infection (chronic or resolved)
STATE CASE NO. _________________________________________
The following questions are provided as a guide for the investigation of lifetime risk factors for HCV infection. Routine collection of risk factor

information for persons who test HCV positive is not required. However, collection of risk factor information for such persons may provide useful

information for the development and evaluation of programs to identify and counsel HCV-infected persons.

•
•
•
•
•

Yes
Did the patient receive a blood transfusion prior to 1992? ...................

Did the patient receive an organ transplant prior to 1992? .............................

Did the patient receive clotting factor concentrates produced prior to 1987?

No

Was the patient ever on long-term hemodialysis? ..........................................

Has the patient ever injected drugs not prescribed by a doctor
even if only once or a few times? ............................................................

• How many sex partners has the patient had (approximate lifetime) ? _________
• Was the patient ever incarcerated? .............................................................

• Was the patient ever treated for a sexually transmitted disease? .............

• Was the patient ever a contact of a person who had hepatitis ? ..........
If yes, type of contact

•
•
•

Sexual .........................................................................................................

Household [Non-sexual] ............................................................................

Other: ____________________________________

Unk

•

Yes
No
Was the patient ever employed in a medical or

dental field involving direct contact with human
blood? ....................................................................

Unk