Low Hepatitis B vaccination coverage in New Delhi, India: urgent call for Universal Adult Hepatitis B vaccination (2025)

Introduction

Eliminating Hepatitis B by 2030 is achievable through vaccination. However, despite the safety of the Hepatitis B vaccine, vaccination coverage among adults in India is suboptimal.

Methods

From April 2021 to August 2022, a study in New Delhi, India assessed Hepatitis B vaccination status, willingness to be vaccinated, and awareness of vaccination importance among adults.

Results

7,097 participants (mean age ± SD = 43.3 ± 14 years; range = 18–99 years) were screened. 93.3% of participants reported not receiving even a single dose of the Hepatitis B vaccine. Only 4.4% of the participants were completely vaccinated for Hepatitis B. On Binomial Logistic Regression, we found that as the age increase [Exp(b) = 4.09; 95% CI = 2.061–8.148; p < 0.001], females [Exp(b) = 1.327; 95% CI = 1.056–1.667; p = 0.015], married [Exp(b) = 5.891; 95% CI = 4.610–7.528; p < 0.001], illiterate [Exp(b) = 30.085; 95% CI = 13.307–68.020; p < 0.001], employed [Exp(b) = 1.966; 95% CI = 1.471–2.629; p < 0.001], Muslim population [Exp(b) = 3.031; 95% CI = 1.552–5.917; p = 0.001], monthly salary < 10,000 INR [Exp(b) = 9.580; 95% CI = 6.172–14.872; p < 0.001] are significantly less likely to have completed Hepatitis B vaccination. Most respondents (85.5%) were willing to receive Hepatitis B vaccination, whereas only 25% knew that Hepatitis B vaccination was an effective way to prevent and control Hepatitis B.

Conclusion

Targeted policies and programs are needed to improve low vaccination rates among older adults in India. The Advisory Committee on Immunization Practices recommends Universal Adult Hepatitis B vaccination, which can eliminate the need for risk factor screening, increase vaccination coverage, and reduce Hepatitis B cases.

With an estimated 296million people living with chronic hepatitis B virus (HBV) infection and approximately 8,87,000 deaths each year due to complications such as cirrhosis and hepatocellular carcinoma (HCC), HBV infection continues to be a significant global public health concern [1]. Hepatitis B and C infections account for 96% of all viral hepatitis deaths [2].

India is in the intermediate endemic zone for HBV infection worldwide, with 40million HBV carriers and a prevalence of 3-4.2 per cent of HBsAg [3]. There was population heterogeneity, with the point prevalence of HBV in India estimated to be 2.4% (95% confidence interval [CI]: 2.2-2.7%) and in tribal areas as high as 15.9% (95% CI: 11.4‐20.4%). Clusters of HBV infection have been noted in regions such as Lahaul and Spiti (10.6%) [4], where a high prevalence (17.2%) of HBV was recorded in Spiti Valley but not in Lahaul Valley (3.1%), Ladakh (12.7%), Arunachal Pradesh (21.2%) [5], and the Nicobarese (23.3%), Shompen (37.8%), and Jarawa (65%) tribes of the Andaman and Nicobar Islands [6].

The Global Health Sector Strategy (GHSS) on viral hepatitis (2022–2030) called for eliminating viral hepatitis as a public health threat by 2030. The target is to reduce new HBV and Hepatitis C virus (HCV) infections annually from 20 per 100,000 to 2 per 100,000 and 5 per 100,000, respectively, by 2030 [2]. HBV is 50–100 times more infectious than human immunodeficiency virus, but Hepatitis B (Hep B) is a vaccine-preventable disease. Hep B vaccines have demonstrated safety, immunogenicity, and efficacy during the past four decades [7, 8]. A marked reduction in chronic Hep B virus infection and hepatocellular cancer prevalence has been observed in several countries since the introduction of Hep B vaccination [9, 10].

The Hep B vaccination program was initially launched in 14 metropolitan cities in India in June 2002, and an additional 33 rural districts were included for vaccination in October 2003. The Hepatitis B vaccine was introduced in the Universal Immunization Program (UIP) of 10 states in India in the year 2007-08 [11]. The national policy in India recommends that children receive three doses of the Hep B vaccine, administered concurrently with diphtheria, pertussis, tetanus (DPT), and trivalent oral polio vaccine at 6, 10, and 14 weeks. In addition, a birth dose is recommended for all new-borns (within 24h of delivery) for all institutional deliveries. The percentage of Indian children aged 12–23 months who have received three doses of Penta or Hep B vaccine (%) increased from 62.8% in NFHS 4 to 83.9% in NFHS 5 [12].

However, guidelines are needed to scale up any data to report Hep B vaccination coverage among adults in India. According to GHSS [2], critical strategic and operational shifts are required to eliminate HBV and HCV as public health threats by 2030. This includes scaling up universal access to Hep B birth-dose vaccines and improving services for testing pregnant women to prevent the vertical (mother-to-child) transmission of Hep B. This study aimed to assess Hep B vaccination coverage in the general population, the factors associated with vaccination, and the awareness and willingness of Hepatitis B among the general population.

Study design and population

This community-based, cross-sectional study was conducted between April 2021 and August 2022 among participants aged >/=18 years in Delhi. The city of Delhi is urban, with 75% of its total area (1483 sq km) falling in urban jurisdiction, and the population density in urban areas is as high as 14,698 persons per sq. km as per the 2011 Census. 16.37million Population, i.e. 98% of the total population (16.79million) of Delhi is residing in urban areas. The Health & Family Welfare Department of the Government of the National Capital Territory (NCT) of Delhi is dedicated to offering comprehensive health care services, including preventive, promotive, and curative care, to the citizens of Delhi. In 2015, the healthcare delivery system in Delhi was restructured into several key components Mohalla Clinics, Multi-Specialty Clinics (Polyclinics), Multi-Specialty Hospitals (previously known as Secondary Level Hospitals), and Super Specialty Hospitals (formerly Tertiary Level Hospitals).

As of March 31, 2023, the Government of NCT of Delhi provides health services through a network that includes 38 Multi-Specialty and Super Specialty Hospitals, 174 Allopathic Dispensaries, 60 Seed Primary Urban Health Centres, 521 Aam Aadmi Mohalla Clinics, 30 Polyclinics, 55 Ayurvedic Dispensaries, 25 Unani Dispensaries, 117 Homeopathic Dispensaries, and 46 School Health Clinics. These facilities collectively offer a wide range of preventive, promotive, and curative health care services to the population of Delhi.

Sampling strategy: two stage sampling strategy

In first phase, primary health clinics across Delhi, known as ‘Mohalla Clinics,’ were selected, and people who resided in the catchment areas around the clinics were targeted. Delhi is divided into 11 districts and two zones were chosen from these districts based on convenience ( the viability of referring patients to government tertiary care hospitals.) In the second phase, mohalla clinics were selected from each zone using proportionate stratified sampling, considering the percentage of mohalla clinics in a specific zone. The selected 22 clinics were visited in a randomly generated order.

A mobile screening vehicle was positioned at each site for two–three weeks, and research staff with training enrolled the local population of general residents. As the study allowed the public to participate voluntarily, all participants who provided informed consent were included.

We obtained permission from the DGHS, GNCTD, and the Institutional Ethics Committee for Human Research to conduct the study at the health camps. Study adhered to the Declaration of Helsinki to this effect in the ‘Ethics approval and consent to participate’ section or appropriate national guidelines. Participants in the study provided written informed consent in the language they could understand, and participant confidentiality was maintained. The sample comprised 7,097 adults in the urban area of New Delhi, the capital of India. A self-administered, pre-tested, semi-structured interview questionnaire was administered to the general population. Participants understood the questions and provided helpful information for the study. The questionnaire collected sociodemographic information, such as age, gender, education, marital status, religion, family income, and occupation. Participants were also asked about their Hepatitis B vaccination history, number of doses they received, and vaccination status.

Having received at least three vaccine doses, this was established as the operational definition for an individual with a complete vaccination schedule. Participants’ willingness to receive vaccinations and whether they planned to do so during the upcoming vaccination campaign. Information regarding the Hep B vaccine was included in the questionnaire. To determine each person’s level of awareness regarding Hepatitis B and vaccination, questions were asked concerning the disease, its spread, the responsible agent, and the current vaccination schedule. This information was gathered during the institute’s regular liver health screening programs. Participants were familiar with the goals and objectives of the study. Participants could choose not to participate or answer questions, and participation was voluntary, anonymous, and confidential. It was impossible to determine who had not received the HBV vaccination because of the survey’s anonymity and confidentiality. Still, participants were verbally urged to visit the camps to request vaccination.

Data analysis

Microsoft Excel (version 13) was employed to input and refine the participant data. Subsequently, SPSS Version 29 was utilized to export and analyze the data from Excel. Frequencies and proportions were applied to describe the demographic features of categorical data, while the mean and standard deviation were used to characterize continuous variables. The calculated frequencies and proportions were used to indicate the immunisation status of the participants. To investigate the potential relationships between vaccination status and sociodemographic characteristics, bivariate logistic regression was performed, with a significant association being defined as a p-value of less than 0.05.

Of the 7,097 participants, women comprised the majority (51.4%), and more than half (49.9%) were aged 30- 49-year-old age range. Only 14.5% of the participants had completed high school. As shown in Tables1 and 88.1% of the population (88.1%) had a family income of less than Rs. 50,000, and half (53%) were employed in the private sector.

Only 311 (4.4%) study participants had received all recommended doses of the Hep B vaccine, as shown in Fig.1. 52 (0.7%) patients received a single dose, 116 (1.6%) received two doses, and 6619 (93.3%) did not receive a single dose.

Table2 elaborates that as compared to females (56.3%), males (55.3%) received more vaccinations, but still 48.3% received no shots. Ages 18–29 had the highest vaccination rate (41.2%), while age groups 30–49 had almost half of the population (50.5%) without vaccination. Of the private employees, only 19.9% had received all the recommended vaccinations, and over half (54.7%) had not received any shots. The government workforce had the lowest vaccination rate (5.3%). Compared with joint families, nuclear households had a higher vaccination coverage rate (68.5%).

Table3 gives results on bivariate logistic regression; there was a significant association (p < 0.05) between all factors and vaccination status, except for family type. As age increased, the likelihood of being vaccinated decreased. Possibility of being vaccinated also decreased with education level. Males were 1.32 times more likely to be immunised than females. Participants with a family income of 50,000 were 9.58 times more likely to be vaccinated than participants with a family income of more than 50,000.

According to our survey, when the participants were asked about their willingness to receive a vaccination during the next vaccination campaign, most respondents (85.5%) expressed their desire to receive a Hepatitis B vaccination. On the other hand, 6.8% of the respondents stated that they would not be vaccinated, and 7.7% were unsure about their decision to get vaccinated.

According to this survey, many people have inadequate knowledge of Hepatitis B. When asked about the agent responsible for causing Hepatitis B, 74.6% of the respondents were unaware of it. Similarly, 64.5% of respondents needed to learn when asked about immunisation schedules. This lack of awareness can be a significant risk factor for the transmission of Hepatitis B. Furthermore, the survey also revealed that 71.2% of participants were unaware of the transmission methods of Hepatitis B. This is particularly concerning as Hepatitis B is a highly contagious disease that can be transmitted through various means, such as sharing needles, unprotected sex, and from an infected mother to her newborn child during delivery. This lack of awareness can lead to the spread of disease, which can have serious consequences. The survey found that 25% of people recognize vaccination’s effectiveness in preventing Hepatitis B, which is encouraging. However, more awareness and educational programs are needed to increase this percentage.

Our research indicates that the Hep B vaccination coverage among adults aged 18 years and above in the Indian adult population is inadequate. Our findings reveal that the majority of the adult population in New Delhi, amounting to 93.3%, have not received the Hepatitis B vaccination despite the World Health Organization’s global hepatitis strategy. Lu et al.‘s study in the United States showed data from the National Health Interview Survey (NHIS), where 30% of adults over 19 years reported receiving at least three doses of Hep B vaccination in 2018. Adults aged 19–49 years had a vaccination coverage of 40.3% (≥ three doses) against Hep B, while adults aged 50 years and older had a coverage of 19.1% [13]. In another study that presented data from the United States, HepB vaccination coverage among adults aged ≥ 19 years was low. In 2018, the self-reported HepB vaccination coverage (≥ three doses) among adults aged ≥ 19 years was 30%. The study also recommended a call for a universal recommendation for HepB vaccination, which could increase the number of persons who receive vaccination before the onset of chronic liver disease and other comorbidities (e.g., obesity or diabetes) that might make vaccination less effective [14].

Adults aged 19–59 and those above 60 with risk factors for Hepatitis B should receive the vaccine. Even those above 60 without risk factors can get vaccinated. Earlier, patients requested the vaccine, but now healthcare providers offer it to adults above 60.

Over the past four decades, Hep B vaccines have demonstrated safety, immunogenicity, and efficacy. There is no evidence that additional doses are harmful, but individuals who have already received all required doses or have a history of Hep B infection should not receive additional vaccinations. However, certain situations may warrant revaccination, such as non-responder infants born to HBsAg-positive individuals and patients receiving haemodialysis, as stated in the 2018 ACIP recommendation. Providers should only rely on dated records as proof of vaccination. Revaccination against HBV in individuals who are already immune due to past or present infection or vaccination does not increase the risk of adverse effects. Kumar et al. [15] studied 3,545 adults, and only 22.7% of respondents said that they received all three doses of the Hep B vaccine, 8.6% had only partial vaccination, 18.5% did not receive any vaccinations, and 50.3% were unsure of their vaccination status. Males received more vaccinations than females; only 16.9% of people over 60 received all vaccination doses. Sex and education level were significantly associated. The vaccination rates increased with educational attainment. These findings align with those of our study, where it was observed that males were more vaccinated than females, and as the level of education increased, vaccination rates also increased.

Our recent survey on public attitudes toward the Hepatitis B vaccine revealed that 85.5% of participants are willing to get vaccinated during the next campaign, indicating strong community acceptance. However, 6.8% of respondents would not choose to get vaccinated, and 7.7% remain uncertain. This highlights a need for additional information and reassurance for some individuals. To enhance participation rates, healthcare professionals should address these concerns by clarifying misconceptions and providing details on the vaccine’s safety and efficacy. Ultimately, targeted communication strategies are essential for encouraging informed vaccination choices and fostering a healthier public. This information can provide valuable insights into the public’s acceptance of vaccinations and help healthcare professionals tailor their campaigns and messages accordingly. The survey revealed that 25% of people are aware of the effectiveness of vaccination in preventing and controlling Hepatitis B. This is a positive finding, as vaccination is among the most effective methods for preventing the transmission of Hepatitis B. However, there is still a need for increased awareness and educational programs to raise the percentage of people informed about this vaccination and other preventive measures.

This study’s significant strength is its large sample size, which bolsters the generalizability of its findings. The outcomes are valuable in raising awareness about the preventable nature of hepatitis B. However, the study’s sole reliance on self-reported data for data collection is a limitation because self-reported responses may be subject to recall biases.

Catch up on Hepatitis B adult vaccination [16]

Getting vaccinated against hepatitis B is a crucial step toward eliminating the disease and the liver problems and cancer it causes. The vaccine is safe and can be administered to adults of all ages. If you’ve missed a dose or have yet to be vaccinated, there is still time to start. Figure2 outlines key considerations for adult Hepatitis B vaccination.

Limitations

The limitations of convenience sampling in our study may have led to bias, as participants are not randomly selected, potentially limiting the generalizability of the findings. The selection of participants may also fail to represent diverse sociodemographic groups, affecting the applicability of results to broader populations with varying access to healthcare. This skewed representation according to religion could limit the applicability of the results to the broader demographic. Stratifying the data based on income or education levels could provide valuable insights into the variations in vaccination coverage and help identify specific barriers within different socio-economic strata. Therefore, the study’s findings may not fully represent all population groups in Delhi. Factors such as the cost of the Hepatitis B vaccine and issues with compliance (e.g., forgetting appointments, financial constraints, or vaccine hesitancy) can significantly impact vaccine uptake. If not properly addressed, these barriers can undermine the study’s conclusions and real-world applicability, particularly in populations with limited resources or awareness.

New Delhi, the capital city of India, exhibits a low adult Hepatitis B vaccination rate. To address this issue, a targeted initiative is necessary to enhance awareness and improve accessibility of the vaccination process for the general population. The Advisory Committee on Immunization Practices (ACIP) recommends that all adults aged 19–59 and those aged 60 and above, irrespective of their risk factors, should receive the Hepatitis B vaccine. However, despite this recommendation, adult vaccination rates in India remain low. One contributing factor to low vaccination rates is the requirement for risk factor disclosure and screening, which can present a barrier for adults seeking vaccination. Several additional factors also contribute to low vaccination rates. A significant issue is the lack of awareness about the disease, particularly since most cases of transmission are perinatal. Adherence to the vaccination schedule can also be challenging, as individuals may fail to remember appointments or encounter difficulties in maintaining the required dosage regimen. The cost of the vaccine presents another obstacle, especially for families from lower socio-economic strata. In certain areas, there is limited access to healthcare. Consequently, a universal adult Hepatitis B vaccination program that eliminates the requirement for risk factor disclosure and screening could potentially increase vaccination rates and reduce the incidence of cases.

Further research is necessary to ensure the efficacy of such programs. This investigation should focus on serological evidence of Hepatitis B vaccination, vaccine accessibility, vaccine hesitancy, and communication channels for senior citizens and their healthcare providers. By addressing these issues, significant progress can be made toward reducing the burden of Hepatitis B infection in India.

Authors and Affiliations

1. Clinical Research and Epidemiology, Institute of Liver and Biliary Sciences, New Delhi, India

   Kanica Kaushal

2. Clinical Research and Epidemiology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, India

   Kanica Kaushal,Sumridhi Gautam&Priyanka Aggarwal

3. ILBS, New Delhi, India

   Guresh Kumar,Shantanu Dubey&Shiv Kumar Sarin

Contributions

KK: Conceptualization, Methodology, Formal Analysis, Writing - Original Draft, Writing - Review & Editing, SG: Data Curation, Analysis, Writing - Review & EditingPA: Writing - Review & EditingGK: Software, AnalysisSD: Resources, Project Administration, SupervisionSKS: Resources, Visualization, Supervision, Review & Editing.

Corresponding author

Correspondence to Kanica Kaushal.

Ethics approval and consent to participate

Ethical permission was taken from ILBS’s Institutional Ethics Committee as IEC/2021/83/MA11 via letter number F.37/(1)/9/ILBS/DOA/2020/20217/22; dated 16th January 2021.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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