Increasing incidence of viral hepatitis A outbreaks in Kerala due to contaminated water sources, unsafe handling of food or poor hand hygiene of food handlers, has once again reopened the discussion whether the State needs to introduce universal Hep A vaccination.
In the last decade or more, Kerala has been experiencing a sizeable number of hepatitis A outbreaks, majority of which are small outbreaks but which remain under-reported and under-investigated. The frequency of these outbreaks has been going up in recent years, with occasional deaths too.
The Health department’s Integrated Disease Surveillance Programme reports that this year as on March 3, there have been 1,743 probable cases of hepatitis A and 545 confirmed cases. There have been six suspected/probable hepatitis A deaths and one confirmed death.
What makes the hepatitis A outbreaks quite concerning is the fact that unlike in the rest of the country where the outbreaks are seen mostly in children, the susceptible population in the State is the older age group, especially adolescents and young adults. This epidemiological shift has been observed in the State for a decade or more
Hepatitis A presents as a self-limiting disease in children and is mostly asymptomatic or sub-clinical and the exposure at the young age lends them lifelong immunity to the disease. However, in Kerala, which boasts of better sanitation, good hygiene and standard of living, exposure to hepatitis A happens mostly in adulthood, when the disease might be severe and could have complications such as fulminant hepatic failure, which could be fatal or near-fatal, requiring liver transplantation, a public health expert pointed out.
According to the WHO, vaccination is the best way to prevent hepatitis A infections. The available vaccine’s immunogenic potential and efficacy is proven, with over 95% seroconversion sustained protection for at least two years.
Because hepatitis A virus is hyperendemic in the country, almost 95% of the infections are acquired in childhood itself, rendering children immune to the virus life-long. Thus, while hepatitis A vaccination might not be a priority or cost-effective for the rest of the country, for Kerala, universal hepatitis A vaccination could be justified, given the cost of care, morbidity and the increasing frequency of outbreaks.
In fact, a committee, headed by B. Ekbal, which was set up by the government in 2022 to formulate a vaccine policy for the State had recommended that hepatitis A vaccine at 12 months of age may be adopted to the UIP schedule of Kerala, of course, after considering feasibility, supply chain and logistical challenges.
But what Dr. Ekbal committee had recommended that the State implement on a short-term priority basis was that all food handlers and those who work in food processing units in Kerala be vaccinated against enteric fever and hepatitis A. It was suggested that a uniform mandatory vaccination card be issued to all food handlers.
Mandatory hepatitis A vaccination, at least for food handlers, is something the Health department would have to implement sooner than later, in the State’s current situation, wherein eateries have proliferated and a chunk of the population eats out frequently. The food business is also where a sizeable proportion of the migrant labourers in the State work.
Public health experts point out the State should focus better on evolving improved surveillance strategies for viral hepatitis outbreaks, public health measures and scientific outbreak investigations to pinpoint the source of contamination and create public awareness.
Raw onions, mint and coriander leaves used as garnish in many prepared foods and ice cubes (from water of dubious quality), when coupled with poor hand hygiene could become sources for major hepatitis A outbreaks.
