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Hepatitis B infection status & vaccine coverage among under five children in Mayurbhanj district, Eastern India
#Equal contributions
For correspondence: Dr Debdutta Bhattacharya, Department of Microbiology & One Health, ICMR- Regional Medical Research Centre, Bhubaneswar 751 023, Odisha, India e-mail: drdebdutta.bhattacharya@yahoo.co.in
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Received: ,
Accepted: ,
Abstract
Background & objectives
Hepatitis B virus (HBV) infection continues to pose a major public health challenge, especially among rural and tribal communities where access to healthcare services is often limited. The present study aimed to assess the status of HBV infection among children between 1 to 5 yr of age and to evaluate vaccination coverage in the Mayurbhanj district of Odisha.
Methods
A cross-sectional study was conducted among children aged 1–5 yr. Blood samples were tested for Hepatitis B surface antigen (HBsAg), antibody to Hepatitis B surface antigen (anti-HBs) and other serological markers to determine infection status and vaccination coverage.
Results
HBsAg seropositivity, indicating active HBV infection, was detected in 0.6 per cent [95% confidence interval (CI): 0.3–0.9] of the samples. Similarly, anti-HBc was tested positive in 0.4 per cent (95% CI: 0.2–0.8) of children. The combined prevalence of HBV infection—based on positivity for either HBsAg or anti-HBc—was 0.8 per cent (95% CI: 0.5–1.2). Vaccination data were collected for 2,647 (98.0%) children of which 90.9 per cent received the birth dose of Hepatitis B vaccine. A total of 98.1 per cent received pentavalent 1 (Penta 1), whereas 97.3 per cent and 96.1 per cent of children received Penta 2 and Penta 3. However, 72.6 per cent (1,961) had protective levels of antibody (anti-HBs) above the threshold, signifying adequate immune protection and 27.4 per cent had sub-protective anti-HBs levels (<10 IU/mL), indicating insufficient immunity.
Interpretation & conclusions
The results of this study highlighted the need for targeted interventions—such as improving timely administration of the birth dose, enhancing follow-up for subsequent doses including digital or paper-based tools, implementing a robust tracking and reminder system to ensure HBV vaccination series and increasing awareness through community-based health education—to strengthen acceptance of HBV vaccination in rural and tribal communities.
Keywords
anti-HBs
HBsAg
HBV
prevalence
vaccination coverage
Globally, Hepatitis B virus (HBV) affects over 240 million people, and each year, more than one million deaths are attributed to complications arising from this chronic infection1. India documented high HbsAg positive rates ranging between 1 per cent to 12 per cent, with an average of 3 per cent to 4 per cent2. A previous study among particularly vulnerable tribal groups of Odisha documented the weighted HBsAg seropositivity to be 5.7 per cent3.
The global prevalence of Hepatitis B infection among children under five years varies, with estimates ranging between 0.5 per cent and 1 per cent4. In areas of high endemicity, such as regions of sub-Saharan Africa, East Asia, and the Pacific, the prevalence can be much higher, reaching 5-10 per cent due to perinatal transmission from mothers with chronic Hepatitis B5. In India, HBsAg-positivity ranges between 2.14–2.25 per cent under five years of age and 4.3 per cent –7.2 per cent among the entire paediatric population up to 12 yr of age6. More than 10 lakh infants born in India each year are at risk of developing chronic Hepatitis B in their lifetime7. The global HBV immunization program began in the 1980s, and in 2006, World Health Organization (WHO) recommended it in the universal immunization schedule8. India introduced the vaccine under the Universal Immunization Program in 2002 and added the birth (zero) dose in 2011 to prevent mother-to-child transmission and if given within 24 h of birth, the vaccine offers over 95 per cent protection8,9. Despite over two decades of inclusion of the Hepatitis B vaccination in the UIP, only half of Indian children were fully vaccinated against HBV by 201810. Hepatitis B birth dose vaccine coverage increased from ∼40 per cent in 2015 to ∼60 per cent in 2019, while coverage for all three doses remained higher, peaking near 90 per cent in 2018 before a slight decline11. Birth dose uptake was higher in institutional deliveries, with 56 per cent in private hospitals compared to 29 per cent in government health facilities12-15. In 2015, Odisha introduced the pentavalent vaccine into its routine immunization program, replacing DPT and covering Hepatitis B16. As per National Family Health Survey (NFHS) 2019–21, the Hepatitis B vaccine coverage reached 98.4 per cent in urban and 93.7 per cent in rural areas, with an overall state coverage of 94.4 per cent and in Mayurbhanj district, coverage improved to 88 per cent from 83.2 per cent reported in 2015–1617.
Investigating HBV infection in children under five is crucial, as they are more prone to chronic disease via perinatal transmission, often linked to maternal HBsAg positivity. Limited data in Mayurbhanj district hampers understanding of the disease burden in this age group. This study aims to estimate the prevalence of HBV infection among children aged 1–5 yr in Mayurbhanj district and also to assess the hepatitis B vaccination coverage as well as the levels of protective antibodies (anti-HBs) post-vaccination.
Materials & Methods
This cross-sectional study was undertaken by the department of Microbiology and One Health, ICMR – Regional Medical Research Centre, Bhubaneswar, Odisha, India, after obtaining the ethical clearance from the Institutional Ethics Committee. The study has adhered to the National Ethical Guidelines for Biomedical Research involving Human Participants issued by the Indian Council of Medical Research in 2017. Written informed consent was obtained from all parents before blood sample collection. The study prioritised confidentiality, freedom, anonymity, benefits, and safety of participants and the blood samples were anonymised with unique identification numbers.
Study design and settings
This cross-sectional study was carried out in Mayurbhanj district, a tribal dominated district in Odisha, a landlocked area spanning 10,418 sq. km, located in northern Odisha. Mayurbhanj has a subtropical climate with hot summers and cold winters, with an average annual rainfall of 1648.20 mm. It has a population of 2.5 million people, with over 58 per cent of the population belonging to scheduled tribes, and the overall literacy rate is around 63.17 per cent, with tribal literacy rate being lower at 53.1 per cent18. The headquarters of Mayurbhanj is Baripada. Healthcare in the district is almost under the government sector and is provided by the Directorate of Health Services, Government of Odisha and a few private hospitals scattered across Baripada, Karanjia, Rairangpur, and Udhala blocks. The network of government healthcare facilities comprises one district headquarters hospital, three sub-divisional hospitals, 28 community health centres (CHC), 89 primary health centres (PHC), and 589 sub-centres. This district was selected due to the absence of district-specific data on Hepatitis B prevalence and vaccination coverage, especially among children.
Study subjects and sampling methods
Information on the number of children was collected from the chief district medical office. This study serves as the sampling frame for the selection of subjects to estimate the prevalence of HBV among children aged between 1 to 5 yr. Since past studies related to HBV were unavailable in the Mayurbhanj district, the sample size was calculated with estimated prevalence 2.1 per cent and the desired margin of error 0.055 per cent requiring a minimum sample size of 2,620 participants6. Detailed methodology has been described in a previously published protocol19.
The sample was initially collected using multistage sampling. Forty subcentres were selected based on the population proportional to sample size (PPSS), from the 589 subcentres present in the Mayurbhanj district. From each sub-centre, 68 children were chosen randomly for the study and only one eligible child was recruited per household (Fig. 1). A total of 2,720 children were contacted, of which approximately 20 selected children could not be contacted, primarily due to their absence during household visits.
- Sampling and recruitment process.
Data collection and sample collection
The data were collected between September 2024 and December 2024. Data collection was carried out in phases, systematically covering the entire district to ensure comprehensive and representative data20. Vaccination status was categorised based on the number of hepatitis B vaccine doses received. Children who received all four doses were classified as fully vaccinated; those who received either one or more but not all four doses were considered partially vaccinated; and those who received none were considered unvaccinated.
In the study, the children’s ages were categorized into five groups: Group 1 (12 months), Group 2 (13–24 months), Group 3 (25–36 months), Group 4 (37–48 months) and Group 5 (49–60 months) and the monthly family income was classified based on the BG Prasad scale21. Vaccination information was primarily collected from the child’s vaccination card, maintained by the parents. If the card was unavailable, records from the local anganwadi centre or PHC were used for verification. Two rounds of field surveys were conducted in the selected subcentres to understand the local context. The chief district medical officer, the village chiefs, and healthcare workers were informed about the study, and their cooperation was sought to facilitate smooth data collection and ensure community support. Consent was obtained from the respective parents prior to data collection, after which 2 mL of venous blood was drawn from each child under aseptic conditions. The blood sample was transported to the nearest PHC for serum separation. The serum samples were labelled and stored at -20°C. For lab investigation, the samples were transported to ICMR-Regional Medical Research Centre, Bhubaneswar weekly, maintaining cold chain conditions once and stored at -80°C until processing3.
Laboratory Investigations
The initial screening focused on detecting the HBsAg (J. Mitra& CO. Pvt. Ltd. India, sensitivity 100%; specificity 100%), which indicates an active HBV infection and serves as a key marker for prevalence. To assess the HBV status among the study participants, additional tests were conducted, including the detection of Hepatitis B core antibody (anti-HBc; DIAPRO, Diagnostics Bio probes, ITALY; sensitivity 100%; specificity 100%) and Hepatitis B surface antibody (Anti-HBs; DIAPRO, Diagnostics Bio probes, ITALY; sensitivity 100%; specificity 100%)3.
Participants were classified as hypo-responders, hyper-responders, or non-responders based on their post-vaccination anti-HBs antibody titres. Non-responders were defined as people with anti-HBs levels less than 10 mIU/mL, hypo-responders as those with anti-HBs levels between 10 and 100 mIU/mL, and hyper-responders as people with levels greater than 100 mIU/mL22.
Statistical analysis
Data analysis was conducted using IBM SPSS Statistics version 2323. To describe the demographic and clinical features of the participants, descriptive statistics such as frequencies, percentages, mean and standard deviation were calculated. For inferential statistics, associations between categorical variables were evaluated using the chi-square test and Fisher’s exact test. Statistical significance was determined at P< 0.05.
Results
Demographic details
A total of 2,700 samples were collected from 40 sub-centres during the study period. The mean age of the children was 36.1±14.4 months, which included 46.6 per cent females and 53.4 per cent males. The majority (90.8%) resided in rural areas and belonged to the Class II income group (84.4%), with a mean monthly income of 6,276.5 INR (SD±1,789.6). Other details are shown in table I.
| Characteristics | N (%) |
|---|---|
| Child’s age (in months) | |
| 12 | 42 (1.6) |
| 13-24 | 642 (23.8) |
| 25-36 | 707 (26.2) |
| 37-48 | 625 (23.1) |
| 49-60 | 684 (25.3) |
| Gender | |
| Female | 1258 (46.6) |
| Male | 1442 (53.4) |
| Monthly family income (BG Prasad scale) | |
| Class I | 35 (1.3) |
| Class II | 2280 (84.4) |
| Class III | 374 (13.9) |
| Class IV | 11 (0.4) |
| Residence | |
| Urban | 249 (9.2) |
| Rural | 2451 (90.8) |
| Caste | |
| General | 329 (12.1) |
| Other Backward Caste | 506 (18.7) |
| Scheduled Caste | 319 (11.8) |
| Scheduled Tribe | 1546 (57.3) |
Vaccination data were available for 2,647 (98%) children, with data missing for 53 (2.0%). Among these 2647 participants, 90.9 per cent (n=2,407) received the Hepatitis B birth dose, while 9.1 per cent (n=240) were unvaccinated. For the subsequent vaccination, 98.1 per cent (n=2,596) received the first dose (Penta 1), 97.3 per cent (n=2,575) received the second dose (Penta 2), and 96.1 per cent (n=2,545) received the third dose (Penta 3). The proportions of unvaccinated children were 1.9 per cent (n=51) for Penta 1, 2.7 per cent (n=72) for Penta 2, and 3.9 per cent (n=102) for Penta 3.
Prevalence of hepatitis B infection
The serological results for Hepatitis B surface antigen (HBsAg) are presented in table II. HBsAg was tested positive among 0.6 per cent (15/2700) (95% CI; 0.3-0.9), indicating the presence of active Hepatitis B infection whereas 99.4 per cent (2685) was tested negative. Similarly, 0.4 per cent (12/2700) (95 % CI; 0.2-0.8) children showed the presence of anti-HBc, whereas 99.5 per cent (2688) were found negative for the antibody. Combined prevalence of HBsAg and anti-HBC was 0.8 per cent (22/2700) (95% CI; 0.5-1.2).
| Parameters | HBsAg, n (%) | Anti HBc, n (%) | Anti-HBs, n (%) | |||
|---|---|---|---|---|---|---|
| Positive | Negative | Positive | Negative | Positive | Negative | |
| Completely vaccinated (n=2266) | 10 (0.4) | 2256 (85.2) | 8 (0.3) | 2258 (85.3) | 1677 (63.4) | 580 (21.9) |
| Incompletely vaccinated (n=381) | 5 (0.2) | 376 (14.2) | 3 (0.1) | 378 (14.3) | 276 (10.4) | 114 (4.3) |
| Total (n=2647) | 15 (0.6) | 2632 (99.4) | 11 (0.4) | 2636 (99.6) | 1953 (73.8) | 694 (26.2) |
Association between vaccination status, HBsAg positivity, and anti-HBc positivity are shown in table III. Children who were vaccinated had about 70 per cent lower odds of being HBsAg positive compared to those who were not vaccinated.
| Hepatitis B vaccination status | HBsAg positive (n=15), n (%) | HBc Ag positive (n=11), n (%) | OR (95% CI) | P value |
|---|---|---|---|---|
| Completely vaccinated (n=2266) | 10 (0.4) | 8 (0.4) | 0.3 (0.11-0.97) | 0.036 |
| Incompletely vaccinated (n=381) | 5 (1.3) | 3 (0.8) | 0.2 (0.05-1.06) | 0.10 |
Anti HBs results
Around 27.4 per cent (739/2700) of children showed anti-HBs titre below 10IU/ml and 72.6 per cent (1961/2700) had anti-HBs titre ≥10 IU/mL (38.9% were hypo responders with anti-HBs titre 10-99.99 IU/ml and 33.7per cent were hyper responder with ≥100 IU/mL anti-HBs titre).
Among completely vaccinated (n=1997), the mean anti-HBs titre was 1.8, which was highest in the age group of 1-yr-old children. Similar results were observed among the 2-yr-old and 3-yr-old children. The anti-HBs titre was observed to be relatively stable in the age groups of 2 yr and 3 yr age groups (1.8±0.7 and 1.8±0.6, respectively). A gradual decline of anti-HBs titre was observed in the age group of 4 yr (1.7±0.7) and 5 yr (1.5±0.7), with an overall mean of 1.7 (±0.7). In comparison, incompletely vaccinated children (N=329) showed slightly lower anti-HBs titres across all age groups from 1 yr to 4 yr. A sharper decline of antibody titres was observed in the 5-yrage group (1.4±0.8), resulting in an overall mean titre of 1.6±0.6 (Fig. 2).
- Anti-HBs titre values among study participants.
Among the 15 HBsAg-positive children, 10 (66.7%) were completely vaccinated; of these, 3 (30%) were non-responders with anti-HBs titres below 10 mIU/mL, and 7 (70.0%) were responders, including 4 (57.1% of responders) who also tested positive for anti-HBc, indicating prior exposure or an ongoing immune response. The remaining 5 (33.3%) children were incompletely vaccinated; of these, 2 (40%) had low or undetectable anti-HBs titres and were anti-HBs negative, while 3 (60.0%) had titres above the protective threshold and were anti-HBs positive.
Discussion
Worldwide, the prevalence of HBV infection in children under five years of age has declined significantly from approximately 5 per cent before the introduction of the HBV vaccine to an estimated 1 per cent24. The present study documented HBsAg and anti-HBc seroprevalence 0.6 per cent (95% CI: 0.3–0.9%) and of 0.4 per cent (95% CI: 0.2–0.8%) respectively, among children aged 1 to 5 years in Mayurbhanj district, Odisha, with a combined seroprevalence of 0.8 per cent (95% CI: 0.5–1.2%). These findings are similar to the previously reported studies in Odisha, which showed higher HBsAg prevalence rates, like 1.16 per cent to 3 per cent of children aged 6–15 years. They were identified as HBV carriers in a State wide sero survey study spanning seven districts24-26. The global prevalence of HBV infection in children under five has consistently decreased, from 4.4 per cent to 1.2 per cent in 2015 since 1990 and further to 1 per cent by 201927. This finding highlighted the progress of reduced burden of chronic infection due to routine Hepatitis B vaccination, with low HBsAg and anti-HBc prevalence in children, suggesting a declining transmission rate in line with global and national trends28.
Previous studies by Zhu et al29 and Wong et al30 highlight that vaccinated infants can still get infected if exposed to high maternal HBV DNA levels, particularly when anti-HBs titres are low. Among the 10 participants with anti-HBs titres above 10 mIU/mL, five were anti-HBc positive, indicating prior exposure to HBV. Although this profile usually suggests chronic infection, the negative HBV DNA results may indicate a resolved or inactive infection, a scenario documented in chronic Hepatitis B studies31. The serological profile of five individuals who were HBsAg positive, anti-HBs positive, and anti-HBc negative presents an intriguing scenario. Typically, HBsAg positivity indicates active Hepatitis B infection and reflects ongoing viral replication or carrier status. However, the concomitant presence of anti-HBs is unexpected, as this usually indicates immunity from vaccination or previous infection. Several possibilities could explain this unusual combination: First, anti-HBs positivity could indicate passive immunity from an external source, such as immunoglobulin therapy32, although this is unlikely in this case, since the children did not receive such treatment. Another possible explanation is the presence of escape mutants, where viral mutations cause the virus to persist despite antibodies. Individuals with high viral exposure or weakened immune systems may also be more susceptible to breakthrough infections, in which the immune response is not sufficient to control the infection33.
Twenty-seven percent (739/2700) of children in this study did not exhibit adequate levels of anti-HBs protection. Vaccine non-responders have been documented in earlier studies, where the reason was mainly from either genetic or environmental factors or other like non as non-development of the antibodies34-36. These findings reinforce that vaccine non-responsiveness is a well-recognised phenomenon, attributable to a mix of genetic, immunological and environmental factors. A multi-centre study from Zhejiang, China, involving children aged 7 to 24 months born to HBsAg-positive mothers, reported that while 99.3 per cent of children achieved protective anti-HBs titers (≥10 mIU/mL), only 86.48per cent had adequate levels (≥100 mIU/mL), indicating that ⁓13.5 per cent had an inadequate immune response despite immunoprophylaxis37.
An antibody titre of ≤10 mIU/mL does not necessarily signify a loss of immunity. The anti-HBs results also indicate that complete vaccination is associated with higher anti-HBs titres across all ages, while incomplete vaccination leads to lower titres38. The percentage of children with protective titres (≥100 mIU/mL) decreases progressively with age39. Vaccine-induced protection often persists even when antibody levels fall below the seroprotective threshold, and the persistence of anti-HBs at a concentration of ≥ 10 mIU/mL is not necessary for protection because it is immune memory that matters38-40. In contrast, no large-scale Indian study has definitively established the age for a booster dose vaccination and those who don’t respond to the vaccine despite adhering to the schedule.
The study has a few limitations. As this was a cross-sectional study, it only provides a snapshot of HBV prevalence and vaccination status at one point in time, limiting the ability to establish causal relationships or assess temporal changes in immunity and infection. Although HBsAg, anti-HBc and anti-HBs were tested, other serological and molecular markers such as HBV DNA or HBeAg were not assessed, which may underestimate the true burden of infection. The study was restricted to one tribal-dominated Mayurbhanj district, which may limit the generalizability of findings to other districts or states with different socio-demographic and healthcare contexts.
This study provides valuable data on the prevalence of Hepatitis B among children aged 1–5 yr in Mayurbhanj district, highlighting both the successes and challenges of immunisation efforts in tribal areas. Timely administration of the birth dose of the hepatitis B vaccine within 24 h of birth, as well as a strong monitoring system of follow-up for subsequent doses, must be prioritised to strengthen the immunisation service at institutional deliveries and mobile health worker teams trained in safe vaccine administration in case of home deliveries or deliveries in remote areas could help bridge the gap. Multifaceted and community-engaged approaches are essential in achieving universal vaccination coverage, as well as a key step in eliminating Hepatitis B infection among children.
Acknowledgement
This manuscript is part of the doctoral thesis of Dr. K. DivyasreeBhat, which was submitted to The Tamil Nadu Dr. M.G.R. Medical University and the Nurturing Clinical Scientists Fellowship from the Indian Council of Medical Research
Financial support & sponsorship
None.
Conflicts of Interest
None.
Use of Artificial Intelligence (AI)-Assisted Technology for manuscript preparation
The authors confirm that there was no use of AI-assisted technology for assisting in the writing of the manuscript and no images were manipulated using AI.
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