Widespread contamination of groundwater sources, huge gaps in sanitation and generally poor environmental public health have been responsible for explosive outbreaks of hepatitis A in Kerala in the past few years.
This is compounded by epidemiological factors such as the shift in the age group susceptible to infection from early childhood to adolescence and young adulthood in Kerala, which means there could be more outbreaks, increased mortality and morbidity.
The recent outbreaks of hepatitis A in Kerala are not random, isolated events, but appear to be part of a pattern, particularly in northern districts that experience repeated outbreaks. Almost all Hep A outbreaks in the state over the past decade have been in rural areas where provision of safe drinking water is nil and people are supplied by local water supply systems that may not be scientifically designed and regular monitoring of water quality would be poor.
It is indeed a shame for a state that is very proud of its achievements in public health, universal health infrastructure and provision of advanced medical care that it is still unable to provide people with the most basic public health requirement, which is safe drinking water, public health experts warn.
In the last two years, the mortality and morbidity caused by Hep A in the state has multiplied several times. In 2023, Kerala reported a total of 4,581 Hep A cases (including probable cases) and 15 deaths.
As of 30 December 2025, Kerala reported a total of 31,536 confirmed and probable hepatitis A cases and 82 deaths, the highest to date.
In 2024, the state also reported a total of 28,412 cases of hepatitis A and 96 deaths due to the infection.
“There are huge areas in the state that do not receive treated tap water and in many rural water systems, the chlorination may not be correct, the process may not be properly monitored and we often find water pipes that run too close to the sewer pipes. In some areas, people refuse to drink boiled water, saying the water is ‘dead,'” says a senior health official.
Widespread use of commercially purchased ice to serve cold drinks in juice parlors or during events, contamination of cut fruit and salads are also other ways of spreading the virus.
Once a Hep A outbreak occurs in an area, it usually takes months for the outbreak to be brought under control because person-to-person transmission is rapid and the virus spreads among close contacts. Transmission takes place via the fecal-oral route and hand hygiene becomes paramount.
In an outbreak in Ernakulam in 2016 that affected nearly 400 people, the health department traced the infection to a hotel in the locality and specifically to a grocer who had been hired to make lime juice.
While Hep A is usually a self-limiting disease, the disease can have significant morbidity and occasional death when it affects the adult population. Studies conducted in Kerala indicate that the average out-of-pocket cost incurred by a family when one adult member is infected with Hep A is nearly ₹25,000.
Due to the age shift, adolescents and people in the 20-40 age group were most vulnerable in all outbreaks in the last decade.
While vaccination with two doses of inactivated hepatitis A vaccine or one dose of live attenuated hepatitis A vaccine is an effective method of preventing Hep A infection, cost considerations may have hindered the inclusion of these vaccines in state health budgets.
A June 2024 study in Kerala (Cost-Effectiveness Analysis of Hepatitis A Vaccination in Kerala by Gurav YK et.al.) reported that for individuals aged 15 years, a vaccination program with live attenuated hepatitis A vaccine or inactivated hepatitis A vaccine would be a cost-effective intervention.
However, nothing can replace the importance of the state’s investments in ensuring a safe supply of drinking water, proper sewage systems and consistent supervision of water quality. Superchlorination of water sources during outbreaks is only a stopgap measure, according to experts.
Published – 03 Jan 2026 19:59 IST
