Despite global efforts to eliminate viral hepatitis by 2030, hepatitis B remains a persistent and underestimated public health challenge in India. A recent editorial published in the Indian Journal of Gastroenterology—penned by eminent gastroenterologists Dr Shekhar Swaroop, Dr Shalimar, and Dr Subrat Kumar Acharya—serves as a clarion call to policymakers and public health authorities. It underlines the concerning stagnation in combating this preventable and treatable disease
The global burden: Alarming statistics
According to the World Health Organisation’s (WHO) Global Hepatitis Report 2024, an estimated 254 million people were living with hepatitis B virus (HBV) infection worldwide in 2022. That marks only a marginal drop from the 257 million in 2015. Even more disturbingly, hepatitis B was responsible for 83% of the 1.3 million global deaths due to viral hepatitis that year
Despite WHO setting ambitious interim targets—including 90 per cent vaccine coverage, 90% reduction in incidence among children under five, 100 per cent screening of blood donations, and 80% treatment coverage—the world is nowhere near achieving these goals. By 2022, only 13% of HBV-infected individuals globally were diagnosed, and a paltry 3 % were receiving antiviral treatment.
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Regional disparities: India and its neighbours
Geographic disparities further underscore the challenge. Africa continues to report the highest prevalence of HBV at 7.5%, followed by the Western Pacific region (5.9%), while South-East Asia—home to India—has a prevalence of about 3 %. India, specifically, reported 29.8 million people living with HBV in 2022, placing it among the countries with the highest disease burden
India also recorded around 98,305 HBV-related deaths in 2022. It remains the third leading cause of cirrhosis in the country, following alcohol-induced liver disease and metabolic dysfunction-associated steatotic liver disease. Alarmingly, about 25% of individuals with chronic HBV are at risk of developing hepatocellular carcinoma, a deadly form of liver cancer. Furthermore, HBV reactivation contributes to acute-on-chronic liver failure in nearly 8% of cases in South-East Asia.
A patchwork of data: Prevalence across India
India lacks comprehensive nationwide data on HBV prevalence. Historical data from 1996 estimated a 4% prevalence—approximately 36 million cases—based primarily on hospital studies, which are prone to selection bias. Later studies, including the National Family Health Survey-4 (NFHS-4) conducted between 2015 and 2016, estimated a national prevalence of 0.95%. However, considerable regional variation persists: Andhra Pradesh and Telangana recorded the highest prevalence at 2.39%, while states like Jammu & Kashmir and Himachal Pradesh reported less than 0.5%.
Significantly, rural (1.03%) and tribal populations (1.84%) showed higher prevalence compared to urban areas (0.81%), highlighting the role of socioeconomic and healthcare disparities
National response: Progress and pitfalls
To combat hepatitis, India launched the National Viral Hepatitis Control programme (NVHCP) in 2018. The programme targets prevention through immunisation, safe blood transfusions, and maternal-infant transmission control. Some successes are worth noting: third-dose hepatitis B vaccination coverage reached 93% in 2023, and the proportion of children receiving all three doses rose from 62.8% in NFHS-4 to 83.9% in NFHS-5
However, key metrics remain disappointing. Birth dose vaccination coverage is still only at 63%, while just 2.4% of HBV-infected individuals are diagnosed, and shockingly, treatment coverage is at 0%. These gaps point to systemic weaknesses in surveillance, diagnostics, and treatment infrastructure
A case study: Rural Puducherry
A recent community-based study, conducted in four villages in Puducherry, provides an insightful lens into ground realities. With a commendable 94% participation rate among adults aged 18 and above, the study reported an adjusted HBV prevalence of 2.5% —much higher than NFHS-4 estimates.
The researchers observed that younger adults had a higher infection rate and that a history of blood transfusion remained a significant risk factor. These findings suggest ongoing lapses in infection control and public awareness.
Yet, the study had limitations: it excluded children, who are a crucial focus group for vertical (mother-to-child) transmission interventions. Also, while the Alere Determine™ diagnostic kit used is highly sensitive, reliance on participant recall for assessing risk factors introduces bias. Moreover, the 6% of adults who declined to participate may belong to high-risk groups, potentially underestimating the actual prevalence.
Diagnostics and treatment: Barriers and gaps
Despite the disease’s large footprint, HBV diagnostics in India remain expensive and inaccessible. For instance, HBV DNA quantification—essential for disease staging and treatment eligibility—is still cost-prohibitive for most patients. Affordable antivirals, although available generically, are not widely distributed through public health facilities. Inadequate infrastructure, a shortage of trained personnel, and fragmented surveillance systems further exacerbate the crisis.
The WHO’s 2024 updated guidelines aim to simplify diagnosis and treatment protocols, broadening the treatment eligibility criteria and pushing for better access. However, India’s implementation of these recommendations is still in its infancy.
Why is progress so slow
Several factors contribute to India’s lag in hepatitis B control.
Fragmented surveillance: There is no centralised national HBV registry. State-level reporting is inconsistent, and data collection is not harmonised.
Low public awareness: Many people are unaware of hepatitis B, its transmission routes, or the availability of vaccination and treatment.
Stigma: Social stigma surrounding hepatitis B leads to delays in diagnosis and treatment, especially among women and rural communities.
Private sector disconnect: A large portion of India’s population seeks care in the private sector, which often functions outside government surveillance and reporting systems.
Inconsistent vaccination protocols: Although vaccination is included in the Universal Immunisation Programme, birth dose delivery remains patchy, especially in home deliveries and low-resource settings.
Resource constraints: Many states lack adequate funding and trained health workers to implement and monitor HBV programs effectively.
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The way forward: A call to action
As the editorial rightly stresses, the time for complacency is over. To accelerate progress toward hepatitis elimination, India must adopt a multi-pronged strategy.
Enhance data collection: Invest in large-scale, population-based seroprevalence studies and build a robust, unified HBV surveillance system.
Strengthen public health infrastructure: Ensure all health centres are equipped for early diagnosis, linkage to care, and regular follow-up.
Universal screening: Introduce mandatory screening for pregnant women, high-risk groups (e g , healthcare workers, intravenous drug users), and family members of infected individuals.
Improve vaccination coverage: Ensure 100 per cent birth dose vaccination through institutional deliveries, outreach programme, and incentivised immunisation drives.
Affordable diagnostics and drugs: Negotiate with manufacturers for price reductions on HBV DNA tests and ensure free or subsidised antiviral availability across all public health systems.
Engage the private sector: Bring private hospitals, labs, and clinics under the purview of NVHCP through reporting mandates and incentive-based partnerships.
Awareness campaigns: Launch nationwide campaigns using mass media, schools, and community networks to spread awareness about hepatitis B prevention and treatment.
Leverage technology: Utilise telemedicine platforms and AI-based patient monitoring tools to reach underserved areas and improve follow-up compliance.
