Hepatitis outbreaks warrant new strategies

State’s epidemiology similar to that of developed countries

Kerala has always stood apart from the rest of India because of its better socio-economic status, access to clean water, good hygiene, and improved sanitation.

It is thus a strange paradox that it is precisely these indicators of good health which have made the State more vulnerable to increasing incidence of food and waterborne disease outbreaks such as hepatitis A in recent times.

The State has a sizeable number of hepatitis A cases occurring annually and majority of these are small outbreaks. The actual number of cases would be several times over the official figures.

But while the hepatitis A outbreaks which occur in rest of the country are mostly in children less than five years old (when the disease is mild and unsymptomatic), in Kerala, almost all those affected are those in the 15 to 45 year age group. A few deaths are also reported annually in the State. “The age profile of those affected clearly shows that the State’s epidemiology is different from the rest of the country and that our situation more or less mimics the picture in developed countries. Because of better socio-economic situation, improved sanitation and hygiene, today our children may grow well into adulthood, never having contracted chicken pox or hepatitis A. In adulthood, as soon as they are exposed to a lesser environment, these infections manifest with evident symptoms,” points out K. Vijayakumar, former Professor of Community Medicine and a public health professional.


The increase in the average age at infection or the late exposure to viral infections has thus been leaving a significant chunk of adolescents and adults in the State at risk of contracting hepatitis A virus (HAV). As the severity of the infection and the associated risks increase with age, many Western nations have adopted the strategy of vaccination against HAV, especially for adolescents and adults. However, vaccination is not a cost-effective or suitable option from a public health perspective for low-resource settings. “From a clinical perspective though, it might be advisable to protect your adolescent son or daughter who may be proceeding for higher studies to other parts of the country or to hostels for the first time, against hepatitis A through vaccination. Even though the mortality profile is low, it can lead to significant morbidity, prolonged convalescence, and thus loss of several work days,” a paediatrician said.

Better surveillance

Public health experts also point out that it is time the health authorities opted for more scientific disease surveillance and outbreak investigations. It spreads through the faecal-oral route either by direct contact with the infected person or through the ingestion of contaminated food and water. “ We should consider the fact that food – especially uncooked food – raw onions or coriander and mint leaves which are used in salads or to garnish food, could be a major agent in the outbreaks. It is time that the Health and the Food Safety wing conducted investigations,” a public health expert pointed out.

Hepatitis A is a hardy virus and survives well on the surfaces of fruits and vegetables which may be contaminated due to the contaminated irrigation water or water used to wash the produce or when handled by an infected person. “Several outbreaks in Kozhikode and Malappuram in recent times were traced to the “welcome drink” or fruit punch which is typically served to guests in these parts of the State during celebrations – it could be the contaminated ice cubes or even the mint leaves floating on top of the drink.

Another strong suspect is the uncooked chutneys — mint or coriander – which are often served with fried chicken, ” he says. While universal vaccination is not an option, it might be time the Health and Food Safety wing insisted on compulsory vaccination for all those in the business of handling food.

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