ECDC NORMAL

SURVEILLANCE REPORT

Hepatitis A
Annual Epidemiological Report for 2022

Key facts
• In 2022, 30 EU/EEA countries reported 4 548 cases of hepatitis A.
• The EU/EEA notification rate was one case per 100 000 population. Twenty EU/EEA countries had
notification rates below one case per 100 000 population. The countries with the highest notification
rates were Hungary (5.5), Croatia (5.3) Romania (4.8), and Bulgaria (4.4).
• The reported number of cases and the EU/EEA notification rate in 2022 were similar to 2020 and 2021, but
remained lower than the years preceding the COVID-19 pandemic.
• Similar to previous years, children between 5–14 years of age accounted for a large proportion of cases
(20%) and had the highest notification rate (2.0 cases per 100 000 population).
• In 2022, six multi-country clusters of hepatitis A were reported to EpiPulse. Five clusters were caused
by hepatitis A sub-genotype IB virus and one cluster was caused by hepatitis A sub-genotype IA virus.

Introduction
Hepatitis A is an inflammation of the liver caused by the hepatitis A virus. In children, hepatitis A virus infection is
often asymptomatic or mild. In adults, the onset of illness is usually abrupt, characterised by fever, malaise, and
abdominal discomfort. Jaundice is the predominant symptom. Very severe disease is unusual, but the infection can
lead to acute liver failure and death, particularly in the elderly and patients with liver disease. Symptoms may last
from one or two weeks or for months.
The hepatitis A virus is highly transmissible and has an average incubation period of four weeks, ranging from two
to six weeks. Transmission most often occurs via the faecal–oral route through contaminated food and water or via
person-to-person contact (e.g. among household contacts, sexual contacts, daycare centres or schools). A vaccine
against Hepatitis A infection is available.

Methods
This report is based on data for 2022 retrieved from The European Surveillance System (TESSy) on 11 October
2023. TESSy is a system for the collection, analysis and dissemination of data on communicable diseases.
For a detailed description of methods used to produce this report, please refer to the Methods chapter [1].
An overview of the national surveillance systems is available online [2].

Suggested citation: European Centre for Disease Prevention and Control. Hepatitis A. In: ECDC. Annual Epidemiological Report
for 2022. Stockholm: ECDC; 2024.

Stockholm, February 2024

© European Centre for Disease Prevention and Control, 2024. Reproduction is authorised, provided the source is acknowledged.
SURVEILLANCE REPORT Annual epidemiological report for 2022

A subset of the data used for this report is available through ECDC’s online Surveillance atlas of infectious diseases [3].
For 2022, 30 EU/EEA countries reported hepatitis A data to ECDC. Twenty-five countries used EU case definitions:
15 countries used the EU 2018 case definition; three countries used the EU 2012 case definition, and six countries
used the EU 2008 case definition. The remaining four reporting countries used unspecified or other case
definitions. The only difference between the three case definitions is that the 2018 case definition considers
laboratory confirmation as sufficient for a confirmed case when information on clinical symptoms is missing.
Reporting hepatitis A was compulsory in all 30 reporting countries. Twenty-nine countries have a comprehensive
surveillance system, and Belgium has a sentinel surveillance. In 29 countries, surveillance was based on either
laboratory or physician reporting or a combination of the two. Romania reported only hospitalised cases. Twenty-
eight countries reported case-based data and two countries (Belgium and Bulgaria) reported aggregated data [2].
In 2020, Spain did not receive data from all regions that normally report cases, and case numbers were therefore
lower than expected, with the rate not calculated. No data for 2020–2022 were reported by the United Kingdom
due to its withdrawal from the EU on 30 January 2020.
In addition to TESSy reporting, information from event-based surveillance for hepatitis A clusters or outbreaks with
a potential EU dimension was collected through the European surveillance portal for infectious diseases (EpiPulse).

Epidemiology
In 2022, 30 EU/EEA countries reported 4 548 cases of hepatitis A (Table 1). The EU/EEA notification rate was one
case per 100 000 population. In 2022 the EU/EEA notification rate and the number of reported cases were
considerably lower than the years preceding the COVID-19 pandemic (Table 1). This is similar to 2020 and 2021.
Hungary reported 5.5 cases per 100 000 population - the highest notification rate - followed by Croatia (5.3),
Bulgaria (4.4), and Romania (4.8). Romania reported the highest number of cases overall followed by Germany
and Hungary. Two thirds of EU/EEA countries (20 out of 30; 67%) had a notification rate of less than one case per
100 000 population (Figure 1).
In the 23 countries reporting information on travel history for all or part of their cases, 16.7% (564 of 3 375 cases
with available information) were travel-associated in 2022. France (n=185), Germany (n=120) and Spain (n=54)
accounted for two thirds (63.7%) of all travel-related cases. Among 527 cases with available information, the most
commonly reported countries cases visited were Morocco (50 cases; 9.5%), Pakistan (48 cases; 9.1%) and Algeria
(28 cases; 5.3%). Among cases with available information, 55.2% (1 065 out of 1 928) were hospitalised and ten
deaths were reported.
Table 1. Confirmed hepatitis A cases and rates per 100 000 population by country and year, EU/EEA,
2018–2022
Country 2018 2019 2020 2021 2022
Number Rate Number Rate Number Rate Number Rate Number Rate
Austria 80 0.9 76 0.9 35 0.4 32 0.4 65 0.7
Belgium 241 2.1 219 1.9 124 1.1 121 1.0 133 1.1
Bulgaria 1 347 19.1 1 512 21.6 1 297 18.7 723 10.5 303 4.4
Croatia 96 2.3 9 0.2 5 0.1 5 0.1 206 5.3
Cyprus 9 1.0 0 0.0 1 0.1 4 0.4 6 0.7
Czechia 209 2.0 240 2.3 183 1.7 210 2.0 70 0.7
Denmark 65 1.1 34 0.6 53 0.9 22 0.4 23 0.4
Estonia 15 1.1 20 1.5 30 2.3 7 0.5 19 1.4
Finland 27 0.5 18 0.3 12 0.2 15 0.3 15 0.3
France 1 525 2.3 1 375 2.0 411 0.6 423 0.6 448 0.7
Germany 1 038 1.3 871 1.0 558 0.7 587 0.7 705 0.8
Greece 104 1.0 28 0.3 8 0.1 7 0.1 7 0.1
Hungary 177 1.8 104 1.1 28 0.3 75 0.8 533 5.5
Iceland 1 0.3 2 0.6 1 0.3 2 0.5 1 0.3
Ireland 35 0.7 51 1.0 33 0.7 71 1.4 64 1.3
Italy 1 077 1.8 528 0.9 130 0.2 167 0.3 112 0.2
Latvia 67 3.5 37 1.9 21 1.1 15 0.8 13 0.7
Liechtenstein NDR NRC NDR NRC NDR NRC 2 5.1 0 0.0
Lithuania 13 0.5 8 0.3 9 0.3 5 0.2 24 0.9
Luxembourg 2 0.3 4 0.7 11 1.8 10 1.6 5 0.8
Malta 4 0.8 11 2.2 2 0.4 9 1.7 7 1.3

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Country 2018 2019 2020 2021 2022

Number Rate Number Rate Number Rate Number Rate Number Rate
Netherlands 180 1.0 146 0.8 38 0.2 68 0.4 81 0.5
Norway 32 0.6 37 0.7 14 0.3 33 0.6 31 0.6
Poland 1 440 3.8 1 054 2.8 110 0.3 92 0.2 233 0.6
Portugal 82 0.8 42 0.4 20 0.2 13 0.1 30 0.3
Romania 4 527 23.2 3 351 17.3 1 010 5.2 873 4.5 917 4.8
Slovakia 173 3.2 99 1.8 11 0.2 12 0.2 61 1.1
Slovenia 16 0.8 12 0.6 4 0.2 11 0.5 68 3.2
Spain 2 294 4.9 974 2.1 189 NRC 208 0.4 304 0.6
Sweden 123 1.2 90 0.9 57 0.6 97 0.9 64 0.6
EU/EEA 14 999 3.3 10 952 2.4 4 405 1.0 3 919 0.9 4 548 1.0
(30
countries)
United 681 1.0 418 0.6 NDR NRC NA NA NA NA
Kingdom
EU/EEA 15 680 3.0 11 370 2.2 4 405 1.0 NA NA NA NA
(31
countries)

Source: Country reports.

NDR: No data reported.
NRC: No rate calculated.
NA: Not applicable.
For 2020–2022, no data were reported by the United Kingdom due to its withdrawal from the EU on 31 January 2020.
Figure 1. Confirmed hepatitis A cases per 100 000 population by country, EU/EEA, 2022

Source: Country reports.

The average number of cases per month in the EU/EEA noticeably decreased from a peak of 1 128 cases per
month in 2018 to 257 cases per month in 2020 (Figure 2). Between 2020 and 2022, the average number of cases
was stable at 285 cases per month.

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Figure 2. Confirmed hepatitis A cases by month, EU/EEA, 2018–2022

Source: Country reports from Austria, Belgium, Cyprus, Czechia, Denmark, Estonia, Finland, France, Germany, Greece, Hungary,
Iceland, Ireland, Italy, Latvia, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden.
Hepatitis A typically has a seasonal pattern of transmission in EU/EEA countries, with cases frequently peaking
between September and November. In 2022, a slight increase in case numbers was evident in September.
However, the monthly number of cases reported were consistently lower for each month when compared to the
mean number of cases reported between 2018–2021 (Figure 3).
Figure 3. Confirmed hepatitis A cases by month, EU/EEA, 2022 and 2018–2021

Source: Country reports from Austria, Belgium, Cyprus, Czechia, Denmark, Estonia, Finland, France, Germany, Greece, Hungary,
Iceland, Ireland, Italy, Latvia, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden.
Gender was reported for 4 541 (99.8%) hepatitis A cases; 57.3% were males and 42.7% were females, with a
male-to-female ratio of 1.3:1. Almost one-third of cases (30%) were aged 45 years and above. Similar to previous
years, children between the ages of 5–14 years accounted for a large proportion of cases (20%) and the highest
notification rate (2.0 cases per 100 000 population). Males had slightly higher notification rates than females in all
age groups, particularly in the age groups 15–24 years and 25–44 years (Figure 4).

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Figure 4. Confirmed hepatitis A cases per 100 000 population, by age and gender, EU/EEA, 2022

Source: Country reports from Austria, Belgium, Bulgaria, Croatia, Cyprus, Czechia, Denmark, Estonia, Finland, France, Germany,
Greece, Hungary, Iceland, Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, the Netherlands, Norway, Poland,
Portugal, Romania, Slovakia, Slovenia, Spain, Sweden.

Microbial surveillance
In 2022, information on sub-genotype was reported by four countries (Hungary, Ireland, Norway and Sweden) for
236 cases (5.1%) in the EU/EEA. Ten cases were of sub-genotype IA, 207 cases were of sub-genotype IB, and 19
cases were of sub-genotype IIIA.

Outbreaks and other threats

Six multi-country clusters of hepatitis A virus infection were reported through EpiPulse in 2022. Phylogenetic
analysis of the sequences and information submitted are presented in Figure 5.
One cluster (Cluster 1 in Fig. 5) involved cases infected with four closely-related hepatitis A sub-genotype IB virus
strains. Epidemiological and microbiological data suggested human-to-human transmission, and possibly also
transmission via contaminated food (frozen berries). The signal was initially reported by Hungary in EpiPulse in
February 2022 [4]. Over 160 Hungarian cases (86% males) were reported between December 2021 and
September 2022, a number of which were hospitalised. Several cases identified themselves as men who have sex
with men (MSM), indicating likely sexual transmission. Foodborne transmission was also suspected as a proportion
of cases were linked to consumption of a cold soup made with frozen berries at a restaurant in Hungary. By
September 2022, over 300 cases with identical or closely-related virus strains were identified in six EU/EEA
countries, and the UK [5].
Two further clusters, both caused by hepatitis A sub-genotype IB virus, were also linked to consumption of frozen
fruit, possibly berries. One cluster (Cluster 2 in Fig. 5) was reported in two EU/EEA countries and was involved in at
least nine cases in 2022. Additional historical cases possibly linked to this cluster were also identified in 2019 in
four other countries. The other cluster (Cluster 5 in Fig. 5) was reported in five EU/EEA counties and involved at
least 24 cases.
The source of infection for two multi-country clusters of hepatitis A sub-genotype IB virus infections was not
identified, but foodborne transmission was suspected. These included one cluster (Cluster 3 in Fig. 5) of 38
hepatitis A cases in four countries, and a second cluster (Cluster 4 in Fig. 5) of four hepatitis A cases in two
countries.

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Another cluster (Cluster 6 in Fig. 5) involving at least 23 hepatitis A sub-genotype IA virus infections in one EU/EEA
country and New Zealand was reported. Information from patient interviews and traceback investigations identified
frozen berries as the suspected vehicle of infection.
Figure 5. Phylogenetic analysis of hepatitis A sub-genotype IA- and IB virus clusters reported in
EpiPulse during 2021

The phylogenetic tree was constructed using information reported by countries in EpiPulse during 2022 on sequences matching
the VP1/2A outbreak sequences with the Neighbour-joining method in MEGA11, using the Tamura Nei as evolutionary model, and
a bootstrapping approach for the statistical analysis (1 000 replicates). The scale bar indicates the number of nucleotide
substitutions per site.

Discussion
In 2022, hepatitis A was the fifth most commonly reported infectious disease in the EU/EEA [3]. Despite this, the
number of reported hepatitis A cases in 2022 remained as low as the numbers reported during the COVID-19
pandemic years of 2020 and 2021. The number of hepatitis A cases in the EU/EEA has remained stable between
2020 and 2022. Measures implemented during the COVID-19 pandemic, such as improved hand hygiene and
reduced international travel, notably impacted hepatitis A surveillance data resulting in considerably fewer cases
reported. Other factors contributing to the reduced number of cases in 2020–2022 include the increased natural
immunity in at-risk groups following the large multi-country outbreak of hepatitis A genotype IB in 2017 and 2018
which disproportionally affected MSM [6, 7].

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This is in addition to heightened awareness of hepatitis A transmission and preventive measures such as practising
good hygiene, and increased vaccine uptake among at-risk groups [6, 7]. It should also be noted that data for the
UK has not been reported since 2019, and case numbers are not complete for Spain in 2020 as data were not
received from all regions.
In 2022, the highest notification rates were reported by Hungary (5.5 cases per 100 000 population), Croatia (5.3
cases per 100 000 population), Romania (4.8 cases per 100 000 population) and Bulgaria (4.4 cases per 100 000
population); these countries accounted for slightly more than one third (36%) of all cases reported that year. In
Croatia, there was a notable increase in the notification rate and the reported number of cases in 2022 compared
to previous years. Most cases were reported among males, in those ages 25–44 years and occurred in the first four
months of 2022. This is linked to a prolonged hepatitis A sub-genotype IA outbreak between January and October
2022 in the population of MSM living with HIV and those who use pre-exposure prophylaxis (PrEP)[8]. The
outbreak report highlights that MSM, including individuals living with HIV and MSM PrEP users, are vulnerable to
hepatitis A virus infection and may be a potential source for more widespread virus transmission [8]. The increase
in cases reported in Hungary in 2022 relates to a multi-country outbreak of hepatitis A genotype IB virus infections
(see above section Outbreaks and other threats). Even though Romania reported one of the highest notification
rates among all reporting countries in 2022, it was one of the lowest ever reported by Romania since 2007 (when
the EU-level surveillance in the country began) [3].
The proportion of travel-associated cases observed in 2022 (16.7%) represented an increase compared to 2020
(11.7%) and 2021 (8.4%) but was consistent with numbers reported in 2019 (14.6%). This trend appears
correlated to the withdrawal of travel restrictions implemented during the COVID-19 pandemic. As travel
restrictions were gradually withdrawn during 2021 and 2022 there was a resumption of international travel,
resulting in a greater number of travel-related hepatitis A cases.
Similar to previous years, children aged 5–14-years accounted for 20% of all cases in 2022 and also had the
highest notification rate. Compared to adults, children are more likely to develop mild or very mild disease.
Therefore, it can be difficult to capture the true number of cases in this population group, possibly leading to an
underestimation [9]. In 2022, adults older than 44 years of age accounted for almost one-third of cases in the
EU/EEA. Older adults are at increased risk of severe disease, hospitalisations and, rarely, death [10].
In 2022, 236 cases were reported with information on sub-genotype. Most cases were sub-genotype IB (59%);
this is related to the outbreak of hepatitis A cases in Hungary and other countries in the spring and summer of
2022. Indeed, molecular characterisation and sharing of sequences at the international level offers the opportunity
to rapidly link seemingly sporadic cases and detect diffuse cross-border outbreaks. ECDC recommends that
molecular characterisation of hepatitis A viruses and sharing of sequences at the European level is prioritised.

Public health implications

The World Health Organization (WHO) sets out the following vaccination recommendations to reduce the incidence
of hepatitis A towards its eventual elimination. In countries at very low and low hepatitis A virus endemicity, like
most EU/EEA countries, WHO recommends vaccinating MSM, travellers to endemic areas and people who inject
drugs [11]. The same groups should be targeted by communication campaigns to increase awareness of the
infection and on the mode(s) of transmission. In very low and low hepatitis A virus endemicity areas, WHO also
recommends vaccinating susceptible individuals at risk of a severe outcome (i.e. immunocompromised individuals
and the elderly). In countries of intermediate endemicity (seroprevalence ≥50% by age 15 years, with <90% by
age 10 years), WHO recommends universal childhood vaccination [11].
Measures aiming to improve hygiene and sanitation, and rapid implementation of outbreak response are essential
to reduce hepatitis A virus transmission. This includes timely contact tracing to reduce the likelihood of secondary
and tertiary transmission. Further, collaboration between the public health and food safety sectors is important to
help reduce food-borne infections.

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References
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ECDC; 2022. Available from: https://www.ecdc.europa.eu/en/publications-data/surveillance-systems-
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genotype-ib-several-eu-countries-and-united-kingdom
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hepatitis A. Update 2019. Geneva: WHO; 2019. Available at:
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Available at: https://www.who.int/publications/i/item/who-wer8728-29-261-276