Kerala Hepatitis A Outbreak: Adults Bear Brunt as Deaths Rise, Experts Demand Vaccination

Kerala is witnessing an alarming shift in Hepatitis A infections, with the disease now striking adults with severe complications and a rising death toll, prompting public health experts to call for universal vaccination and assured safe drinking water.

Once considered a mild childhood illness, Hepatitis A has become a significant health threat in the State. According to official data, Kerala reported 31,536 confirmed and probable cases and 82 deaths last year. In 2024, the State recorded 28,412 cases and 96 deaths. This year, the numbers have surged further, with 12,437 cases and 125 deaths reported so far, of which 69 have been confirmed as Hepatitis A-related.

The Malappuram-Kozhikode belt continues to be the epicentre of water-borne infectious diseases, including Hepatitis A and shigellosis. Clinicians are increasingly observing severe manifestations of the disease, including a dysregulated inflammatory response, often described as a cytokine storm, which requires treatment with steroids.

“This cytokine storm is something we have been seeing in many infectious diseases now, especially post-Covid,” said Dr. R. Aravind, head of infectious diseases at Thiruvananthapuram Government Medical College.

The epidemiological profile of Hepatitis A in Kerala has changed dramatically. Traditionally, most Indians acquire the infection in childhood, which confers lifelong immunity. However, improved sanitation and better socio-economic conditions in Kerala have reduced childhood exposure, leaving many young adults immunologically naive and vulnerable to severe adult hepatitis.

“The age shift is very evident, with 90% of patients in the 18–40 age group, for whom eating out, especially from wayside shops and exotic juice shops, is a way of life,” said Dr. V.K. Shameer, assistant professor of general medicine at Kozhikode Government Medical College.

Doctors report atypical and severe symptoms in these adult patients. These include a prolonged phase of elevated liver enzyme levels, extra-hepatic complications such as bone marrow suppression, and a significant number progressing to fulminant hepatitis requiring liver transplantation.

“Over the last two years, the Hepatitis A case load has been huge, and we see a lot of complications. In about 1% of cases, patients developed acute liver failure and died, while some others required liver transplantation,” Dr. Shameer noted.

Some patients with acute liver failure have been saved through plasmapheresis, a procedure now incorporated into the State’s Hepatitis A management protocols over the past two years. However, rare complications persist. Dr. Shameer recounted the case of a young patient who developed bone marrow suppression following Hepatitis A, progressing to hepatitis-associated aplastic anaemia, which required a bone marrow transplant. In several other seemingly recovered patients, bilirubin levels remained elevated for three to six months, a condition known as relapsing or cholestatic hepatitis.

These clinical observations are supported by a recent multicentre study across six tertiary care hospitals in Kerala (2024–25), titled ‘Clinicopathological Profile and Outcomes of Severe Hepatitis A Outbreak in India: A Multicenter Cross-sectional Study’. The study, which examined 324 adults with a mean age of 32 years, reported that Kerala is witnessing a paradigm shift in Hepatitis A—from a benign childhood illness to a multisystem disease in adults, characterised by immune dysregulation, extra-hepatic organ involvement, and higher mortality.

Public health experts argue that while safe drinking water is the ultimate preventive measure, the government must also act immediately to protect the population through universal Hepatitis A vaccination. “If the government cannot ensure safe drinking water for everyone, the least it can do is protect people through universal immunisation,” they assert.

As Kerala continues to battle these outbreaks, the message from clinicians is clear: Hepatitis A is no longer a simple disease in the State. Urgent action is needed to safeguard public health.