Do we need to consider universalising the hepatitis A vaccine in Kerala, India?

Kerala, a state in southern India, has made impressive improvements in its population’s conditions of living. Despite having a low per capita income, its indicators of social development—such as the human development index (0.84), infant mortality rate (12/1000 live births), sex ratio (1084 females to 1000 males), and female literacy rates (92.07%)—are comparable to those of many developed countries.[1]

However, several outbreaks of hepatitis A have occurred in Kerala state in recent years [2 3 4 5], with outbreaks involving more than 100 people at a time reported from almost all districts of Kerala in the past decade.[5 6 7 8 9] According to the state’s official disease surveillance system, there were at least 22 deaths due to hepatitis A over the past two years and the majority of these deaths were in the age group of 30-45 years.[5]

Although hepatitis A is a self limiting viral disease, it causes significant morbidity. People affected with hepatitis A virus (HAV) may take a few months to return to work, school, or daily life. Consequently, being infected with hepatitis A can lead to economic losses and have social consequences in the community setting. A report showed that the average out of pocket expenditure to a family in Kerala due to one of its members being affected with hepatitis A is 24 025 rupees.[10]

Presentation of hepatitis A disease is determined by the age at exposure, which tends to be asymptomatic or subclinical during childhood, but usually symptomatic among older children, adolescents, and adults. Those infected in childhood do not experience any noticeable symptoms, but will develop lifelong immunity. In Kerala, with its comparatively better sanitation and hygiene and improved standards of living, children often escape infection in early childhood. Ironically, these improved economic and sanitary conditions seem to lead to a higher susceptibility in older age groups and higher disease rates, as infections occur in adolescents and adults.

The HAV antibody seroprevalence rates reported from Kerala were <10% in children aged 5 years and under, compared with 60-80% from many other parts of the country.[11 12 13 14] These findings, along with the age distribution of cases during hepatitis A outbreaks in the state, suggest that a substantial proportion of individuals in Kerala will not be exposed to HAV until adulthood. These findings reiterate the conclusion that huge outbreaks of hepatitis A may be expected in the state in coming years.

The World Health Organization (WHO) recommends vaccinating against hepatitis A as the best way to prevent the virus.[15] Several studies have demonstrated the immunogenic potential of the hepatitis A vaccine and its excellent efficacy in pre-exposure prophylaxis against HAV.[16] Many other countries’ experiences have shown that the disease incidence, not only in the vaccinated cohorts but also in the whole population, has decreased within a few years of the start of mass vaccination. There is also convincing evidence that the vaccine confers herd immunity if the main spreaders of the virus are targeted for immunisation.[17]

Currently, there is no government recommendation for the use of the hepatitis A vaccine in India. But the disease’s epidemiological transition should force Kerala to modify its views in relation to use of the hepatitis A vaccine.

Cost is a major concern for universalising the vaccine. Yet considering the out of pocket expenditure hepatitis A inflicts on patients and families, the cost to the health system from treating patients, and the cost to the public health system to deal with outbreaks, the cost for universalising the hepatitis A vaccine in Kerala might be justified. Whether Kerala chooses to implement universal vaccination to all children as part of routine immunisation or opts for a selective immunisation strategy to avoid outbreaks of HAV among susceptible populations needs to be decided, based on cost factors and seroprevalence patterns.

We think that it is time for Kerala to consider rolling out hepatitis A vaccination. Filling in the data gaps on its seroprevalence and cost effectiveness will be important in guiding policy decisions, and studies investigating the cost effectiveness of HAV prevention strategies to determine the feasibility of vaccination programmes in Kerala will need to be carried out. Vaccination efforts should continue to be supplemented by public health initiatives to improve sanitation, hygiene practices, water quality, and food safety.

Rakesh PS, Kesavan Rajasekharan Nayar, Muhammed Shaffi, Chitra Grace

Rakesh PS, MD, department of community medicine, Amrita Institute of Medical Science, Amrita Vishwa Vidhyapeetham, Kochi, Kerala, India. 

Kesavan Rajasekharan Nayar MCH, PhD, professor and head, Global Institute of Public Health, Ananthapuri Hospitals, Chacka, Trivandrum, Kerala, India.

Muhammed Shaffi MBBS, MPH, assistant professor, Global Institute of Public Health, Ananthapuri Hospitals, Chacka, Trivandrum, Kerala, India. 

Chitra Grace MSc, MPH, PhD, associate professor, Global Institute of Public Health, Ananthapuri Hospitals, Chacka, Trivandrum, Kerala, India.

Competing interests: None declared.

Note: An earlier version of this article was published with the Journal of Health Systems.


[1] Government of Kerala. Economic Review 2014. State Planning Board, Thiruvananthapuram, Kerala, India. March 2015. Available from:
[2] Kumar T, Shrivastava A, Kumar A, Laserson KF, Narain JP, Venkatesh S et al. Viral Hepatitis Surveillance—India, 2011–2013. Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. July 24, 2015 / 64(28);758-762. Available from:
[3] Arankalle VA, Sarada Devi KL, Lole KS, Shenoy KT, Verma V, Haneephabi M. Molecular characterization of hepatitis A virus from a large outbreak from Kerala, India. Indian J Med Res. 2006;123(6):760–9. Available from:
[4] Rakesh PS, Sherin D, Sankar H, Shaji M, Subhagan S, Salila S. Investigating a Community-Wide Outbreak of Hepatitis A in India. J Glob Infect Dis. 2014;6(2):59-64. Available from:
[5] Directorate of Health Services. Data on Communicable diseases. Kerala State. Available from:
[6] Health dept. pulls up family for hepatitis A outbreak. The Hindu. 2015 10 Dec. Available from
[7] Radhakrishnan Kuttoor. Concern over prevalence of hepatitis A. The Hindu. 2014 31 Oct. Available from
[8] Mini Muringatheri. Steps to contain hepatitis A in Thrissur. The Hindu. 2015 14 Nov. Available from
[9] Steps to check hepatitis A in Kozhikode. The Hindu. 2009. Available from
[10] Rakesh PS. Out of pocket expenditure due to hepatitis A in Kollam district. Centre for Public health Protection. 2015 Dec. Report No: 84/2015.
[11] Mall ML, Rai RR, Philip M, Naik G, Parekh P, Bhawnani SC,et al. Seroepidemiology of hepatitis A infection in India: Changing pattern. Indian J Gastroenterol. 2001;20:132-5. Available from
[12] Mathew P, Bobba R, Zacharias P. Hepatitis A seroprevalence in Kerala. Indian J Gastroenterol. 1998;17:71-2.
[13] Mittal SK, Rastogi A, Rastogi A, Kumar N, Talukdar B, Kar P. Seroprevalence of hepatitis A in children – Implications for hepatitis A vaccine. Trop Gastroenterol. 1998;19:120-1. Available from
[14] Dutta AK, Aggarwal A, Kapoor AK, Ray GN, Batra S. Seroepidemiology of hepatitis A in Delhi. Indian J Pediatr. 2000;67:77-9. Available from
[15] World Health Organization. WHO position paper on hepatitis A vaccines – June 2012. Wkly Epidemiol Rec. 2012;87:261-76.
[16] Ott JJ, Irving G,Wiersma ST. Long-term protective effects of hepatitis A vaccines. A systematic review. Vaccine. 2012 Dec 17;31(1):3-11. Available from
[17] André FE. Universal mass vaccination against hepatitis A. Current Topics in Microbiology and Immunology. 2006, 304:95-114.