Shifting epidemiology and disease severity: Rethinking India's hepatitis A strategy in the context of acute liver failure.

India is, at present, witnessing a significant epidemiological transition in hepatitis A virus (HAV) infection, shifting from high to intermediate endemicity. This transition, primarily driven by improvements in sanitation and socioeconomic conditions, has paradoxically delayed the acquisition of natural immunity, resulting in a growing pool of susceptible adolescents and young adults. This has, in turn, led to the re-emergence of HAV as a major cause of acute liver failure (ALF) in India, particularly among adolescents and young adult populations, with high mortality rates, particularly in settings with limited access to liver transplantation. This is a critical public health and epidemiological paradox: while sanitation has reduced early-life exposure, it has increased the risk of severe disease at older ages. In this context, we synthesize evidence from serosurveys, surveillance systems, and clinical cohorts to highlight the rising burden and severity of HAV infection in India. We propose a comprehensive, stratified public health strategy encompassing phased vaccination, targeted protection of high-risk groups, strengthened surveillance, improved clinical preparedness, and enhanced sanitation and food safety measures to align India's public health response with the evolving epidemiology of HAV.