| Abstract|| |
Context: Hepatitis A is one of the most common causes of hepatitis in the pediatric age group and the most common cause of fulminant hepatic failure (FHF) among children in India. Hepatitis A is a waterborne disease. High endemicity obviates the need for vaccine in the community. Aims: We studied 116 children in the outpatient department (OPD) to know the seroprevalence of hepatitis A virus (HAV), total antibodies, and the effect of various demographic and water sanitation variables on it. Settings and Design: Children attending the pediatric OPD with minor problems in a medical college hospital were chosen for this study. It is a descriptive, cross-sectional, and seroepidemiologic investigative study. Materials and Methods: Blood samples of randomly selected children were collected and competitive enzyme-linked immunosorbent assay (ELISA) test was done for the detection of total anti-HAV antibodies, [both immunoglobulin M (IgM) and immunoglobulin G (IgG)], using a commercially available ELISA kit. "Dia.Pro" (Diagnostic Bioprobes srl via Columella n° 31 20128 Millano, Italy). Statistical Analysis Used: Statistical analysis was performed by the chi-square test using Epi Info software 3.5.4 version (2012) [Center for disease control and prevention (CDC), Atlanta, Georgia (USA)]. Results: Seroprevalence in children from the upper social class was 54.5% versus 87.2% in the lower social class (P = 0.00075). 90.9% of the children with rural background were seropositive compared to 77.1% of children with urban background. The mother's education above and below secondary level had a seropositivity for HAV in children up to 69.23% and 87.1%, respectively. The method of water treatment using boiled water, mechanical filtration, filtration plus ultraviolet (UV) light treatment, and no treatment had a seropositivity of 50.0%, 83.33%, 37.5%, and 84%, respectively, (P = 0.0036). Seropositivity was the highest when the water source was municipal bore well pipeline (88.88%), followed by municipal dam water through pipeline (79.16%), and personal bore well (68.16%) (P = 0.026). Conclusion: Children of this geographical area have high seroprevalence for HAV antibodies at a younger age with a significant difference between their social classes, water sources, and water treatment methods.
Keywords: Hepatitis A virus (HAV), seroprevalence, water sanitation
|How to cite this article:|
Verma YS, Rajput N, Rajput SS. Seroprevalence of hepatitis A virus infection in different age groups of children. Ann Trop Med Public Health 2014;7:223-6
|How to cite this URL:|
Verma YS, Rajput N, Rajput SS. Seroprevalence of hepatitis A virus infection in different age groups of children. Ann Trop Med Public Health [serial online] 2014 [cited 2020 Feb 27];7:223-6. Available from: http://www.atmph.org/text.asp?2014/7/5/223/154825
| Introduction|| |
Hepatitis A virus (HAV) is a major cause of disease throughout the world, with an estimated 1.5 million cases reported annually.  HAV is endemic in many developing countries, where its prevalence reaches nearly 100% in children by 5 years of age. 
HAV is an enterically transmitted virus and is the major cause of acute viral hepatitis in children. The water source has a very important effect on seroprevalence.  In areas of high endemicity, most of the children are exposed to the virus and the consequent acquisition of antibodies against it confers lifelong immunity. Most infections in children of a younger age are asymptomatic or have mild, nonspecific manifestations (e.g., fever) that are indistinguishable from other viral infections. With increasing age, symptomatic acute infection becomes more common while chronic HAV infection does not occur. 
In India, limited epidemiology data are available on HAV infection, with a seroprevalence of antibody to HAV exceeding 90% in adults. However, there have been recent reports of decreasing prevalence of HAV infection in this country, suggesting that the seroprevalence of HAV antibodies is becoming similar to that of the industrialized world.  Consequently, HAV vaccination has been recommended for schoolchildren and adults. From the data, it appears that the population is no longer homogenous in seroprevalence. The difference in exposure may be due to the different levels of socioeconomic status of the families and the stage of development of that place of residence. ,, Monitoring the population would also provide information on enlarging the cluster of susceptible older children and adults.
Hepatitis A is a major cause of fulminant hepatic failure (FHF) in children. In India, it contributes to approximately 50-60% of the cases of FHF in children in contrast to <10% in the developed world. ,
Clearly, seroprevalence data relating to healthy pediatric population are necessary in order to assess the need for routine or mass vaccination. Moreover, in India, the indication for HAV vaccination is not clear due to the contradictory seroepidemiology data on children. 
The data collected from India suggested that there are some pockets that show evidence of epidemiological shift from high hepatitis A immunoglobulin G (IgG) prevalence to a low prevalence. Further, epidemic outbreak in Kerala compels us to identify other geographical regions that have the potential for epidemic outbreaks through cyclical epidemiological surveys. ,,
Hence, a study in this region of India is required.
| Materials and Methods|| |
This study was carried out in the outpatient department (OPD), Department of Pediatrics of a medical college hospital over a period of 1 year, from July 2011 to June 2012. It is a descriptive, cross-sectional, and seroepidemiologic investigative study. The participants were children belonging to the same district from both urban and rural areas, between 1 and 15 years, attending the pediatric OPD with minor problems. The children who received HAV vaccination were excluded from the study. Clearance and approval were obtained by the Ethical Committee of the institution.
A total of 116 children fulfilling the inclusion criteria were recruited for the study, after taking written informed consent from the parents or guardians of the children.
Competitive enzyme-linked immunosorbent assay (ELISA) test was done for the detection of total anti-HAV antibodies [both IgM and IgG], using the commercially available ELISA kit "Dia.Pro" (Diagnostic Bioprobes srl via Columella n° 31 20128 Millano-Italy). Statistical analysis was performed by the chi-square test using the Epi Info software 3.5.4 version (2012) [Center for disease control and prevention (CDC), Atlanta, Georgia, USA]. The differences were regarded as significant when P < 0.05.
| Results|| |
A total of 116 children were studied, divided into three age groups; 35 children were 1-5 years of age (30.17%), 39 children were 6-10 years of age (33.62%), and 42 children came from the age group of 11-15 years (36.21%). Genderwise distribution consisted of 72 males (53.45%) and 54 females (46.55%) [Table 1].
According to their socioeconomic class, the study subjects were categorized into five groups by the modified Kuppuswamy scale. Out of the 116 subjects, 10 belonged to the upper class (I), 12 belonged to the upper middle class (II), 36 belonged to the lower middle class (III), 32 belonged to the upper lower class (IV), and 26 belonged to the lower class (V) 'Environmental distribution included 33 (28.44%) children from the rural areas and 83 (71.55%) from the urban areas. Seropositivity rose with an advancement in age. Up to 5 years of age, almost half of the subjects were susceptible to HAV infection, whereas in the higher age group almost all the children acquired anti-HAV antibodies.
In this study, the difference of positivity for anti-HAV antibody among males and females (62 and 54 respectively) was not statistically significant (P = 0.362).
Out of 33 children from the rural background, 30 (90.9%) were seropositive for HAV antibody compared to 64 (77.10%) out of 83 children from the urban or semi-urban background. The difference of positivity for HAV antibody among urban and rural children was statistically significant (P = 0.043).
Significantly lower seroprevalence of 69.23% (27/39) was observed in children with maternal education up to secondary and higher levels compared to 87.10% (67/77) in children with maternal education below secondary level, or those whose mothers were uneducated. Father's education was not significantly associated with seropositivity [Table 2].
Out of the total positive cases, a majority (87.23%) belonged to the modified Kuppuswamy scale class III, class IV, and class V, suggesting a higher incidence of subclinical infection among the lower middle and lower socioeconomic strata groups. Out of 22 children belonging to the upper socioeconomic class, 12 (54.50%) were seropositive for anti-HAV antibody compared to 82 (87.2%) out of 94 children belonging to the lower socioeconomic class; this difference was statistically significant with a P value of 0.00075 [Table 3].
|Table 3: Correlation of Seropositivity of anti-HAV antibodies with socioeconomic class (SEC)|
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The children whose water source was a pipeline supply of water had a higher seropositivity in comparison to those with a personal bore well in their own household [Table 4].
|Table 4: Correlation of source of water supply with seropositivity of anti-HAV antibodies|
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Study of the water treatment methods reveals that seropositivity was 50.0% when the children had boiled water at home, 83.33% when the children had mechanically filtrated water at home, and 37.5% when the children had filtrated combined with ultraviolet (UV) light treated water. A majority of the children were not using any method of water treatment and 85.71% of them were seropositive for HAV antibodies [Table 5].
|Table 5: Correlation of seropositivity with method of water treatment at home|
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| Discussion|| |
Prevalence of positivity for HAV antibody increases with age and a majority of the subjects above the age of 5 years were positive for HAV antibodies; it is because of subclinical infections in an early age. Compared to other studies, seroprevalence in all the age groups was relatively high in this study, except the one by Rakesh et al. from Northern India, which showed high endemicity in Northern India. Improvement of hygiene and socioeconomic conditions has undoubtedly contributed to the intermediate endemicity in our population. In contrast to the present study finding, a recent study done by Rath et al. showed low seroprevalence in all age groups, which reflects the impact of living standards and environmental hygiene on the prevalence of infection. This study also showed a significant transition of positivity for anti-HAV IgG in the age group of 3-4 years, similar to our study in which significant transition of seropositivity was observed in the age group of 3-5 years.
In this study, difference between the urban and rural areas was statistically significant; this finding suggests an improved hygiene, sanitation, and socioeconomic condition of the urban children who are more prone to the clinical disease of hepatitis A. Findings on the parents' education reflect that a higher educated mother has more impact on the prevention of infection in her child as compared to the father, because mothers are more involved with food hygiene and water sanitation of the children.
Statistically, lower seroprevalence in the higher socioeconomic class is similar to those reported by Rath et al.  and Ahmad et al.  It is a reflection of the fact that higher socioeconomic groups have better access and affordability to food hygiene and water sanitation. This finding emphasizes the fact that food and water sanitation is still very far off in the lower social class.
Finding higher seroprevalence in children receiving pipeline supply of water probably suggests a contamination while carrying water from an outside source to the house. In this area of the country, personal bore well is significantly less associated with seroprevalence, a fact that reflects poor standard of pipelines and their maintenance. Contamination with household drainage and sewage systems may be one of the facts. Water treatment at the household is emphasized by the fact that seroprevalence was significantly less in those using any method of water treatment (85.7% vs 55.5%). UV light water treatment is the best, although it needs to be studied in a greater number of cases.
| Conclusion|| |
It can be concluded that Children of this geographical area have high seroprevalence for HAV antibodies at a younger age with a significant difference between their social classes, water sources, and water treatment methods.
Looking at the vast variation over the different parts of the country, we recommend that HAV seroprevalence of every small geographical area should be assessed in order to evaluate the need for mass immunization.
| References|| |
Hepatitis A vaccines. Wkly Epidemiol Rec 2000;75:38-44.
Poovorawan Y, Chatchatee P, Chongsrisawat V. Epidemiology and prophylaxis of viral hepatitis: A global perspective. J Gastroenterol Hepatol 2002;17(Suppl):S155-66.
Salama II, Samy SM, Shaaban FA, Hassanin AI, Abou Ismail LA. Seroprevalence of hepatitis A among children of different socioeconomic status in Cairo. East Mediterr Health J 2007;13:1256-64.
Gust ID, Feinstone SM, Hepatitis A. In: Popper H, Schaffner F, editors. Progress in Liver Diseases. Philadelphia: WB Saunders Co.; 1998. p. 371-8.
Aggarwal R, Naik S, Yachha SK, Naik SR. Seroprevalance of antibodies to Hepatitis A virus among children in Northern India. Indian Pediatr 1999;36:1248-50.
Rath CP, Akki A, Patil SV, Kalyanshettar SS. Seroprevalence of hepatitis A virus antibody in Bijapur, Karnataka. Indian Pediatr 2011;48:71-3.
Mohanavalli B, Dhevahi E, Menon T, Malathi S, Thyagarajan SP. Prevalence of antibodies to Hepatitis A and Hepatitis E virus in urban school children in Chennai. Indian Pediatr 2003;40:328-31.
Jacobsen KH, Koopman JS. The effects of socioeconomic development on worldwide hepatitis A virus seroprevalence patterns. Int J Epidemiol 2005;34:600-9.
Jindal M, Rana SS, Gupta RK, Das K, Kar P. Serological study of hepatitis A virus infection amongst the students of a medical college in Delhi and evaluation of the need of vaccination. Indian J Med Res 2002;115:1-4.
Bendre SV, Bavdekar AR, Bhave SA, Pandit AN, Chitambar SD, Arankalle VA. Fulminant hepatic failure: Etiology, viral markers and outcome. Indian Pediatr 1999;36:1107-12.
Batra Y, Bhatkal B, Ojha B, Kaur K, Saraya A, Panda SK, et al
. Vaccination against hepatitis A virus may not be required for schoolchildren in Northern India: Results of a seroepidemiological survey. Bull World Health Organ 2002;80:728-31.
Murhekar MV, Sehgal SC, Murhekar KM, Padbhidri SP, Chitambar SD, Arankalle VA. Changing scenario of hepatitis A virus and hepatitis E virus exposure among the primitive tribes of Andaman and Nicober Islands, India over the 10-years period 1989-99. J Viral Hepat 2002;9:315-21.
Ahmed M, Munshi SU, Nessa A, Ullah MS, Tabassum S, Islam MN. High prevalence of hepatitis A virus antibody among Bangladeshi children and young adults warrants pre-immunization screening of antibody in HAV vaccination strategy. Indian J Med Microbiol 2009;27:48-50.
Dr. Yogendra Singh Verma
Kamathipura, Madhoganj, Jinci Road-4, Roxypul, Gwalior - 474 001, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]