Evolving trends in hepatitis A epidemiology: Shifting patterns, emerging risks, and future strategies

Table 3 Global variation in hepatitis A vaccine provision and access

Vaccine policy	Cost coverage	Equity/operational notes	Ref.
Routine childhood vaccination; targeted adult vaccination (VFC program)	Free under VFC; OOP for adults without insurance	Outbreaks in PEH and drug-using adults; gaps in adult uptake	Nelson et al[41], United States
Targeted (indigenous, travelers, PEH)	Provincial programs; partial coverage	Uneven uptake across provinces	Palaisy[42], Canada
Universal childhood vaccination (≥ 12 months)	Government-funded	High coverage; regional disparities in remote areas	Brito and Souto[43], Brazil
Integrated in national schedule (since 2023)	Free public sector	Rapid rollout post-urban outbreaks	Guzman-Holst et al[44], Mexico
Universal single-dose schedule	Government-funded	Successful herd immunity; sustained low incidence	Flichman et al[45], Argentina
Targeted (travelers, men who have sex with men, PEH)	National Health Service covers high-risk groups	Limited adult awareness	Johnson et al[46], United Kingdom
Recommended (travelers, men who have sex with men, laboratory staff)	Reimbursed by insurance	Stable low incidence; high cost limits universal rollout	Szucs[47], Germany
Universal since 2003 in several regions	Government-funded	Decline in hepatitis A virus cases; regional autonomy causes inconsistency	Bechini et al[48], Italy
Targeted vaccination	Regional funding	Good outbreak response; inequity across regions	Urbiztondo et al[49], Spain
Included in routine childhood schedule in 2008	Government-funded	High coverage; rare outbreaks	Ryani[50], Saudi Arabia
Universal childhood (since 2011)	Fully subsidized	Excellent coverage nationwide	Yigit and Kalayci[51], Turkey
Targeted vaccination (private market)	Mostly OOP	High-cost limits uptake; growing private sector use	Shah et al[52], India
Targeted; not yet universal	OOP except high-risk groups	Declining seroprevalence; debate on adding to National Immunisation Programme	Poovorawan et al[53], Thailand
Universal childhood vaccination since 2008	Government-funded	Dramatic incidence decline; urban-rural gap remains	Yan et al[54], China
Targeted (travelers, men who have sex with men)	OOP	Low uptake; periodic import-linked outbreaks	Kanda et al[12], Japan
Targeted (travelers, laboratory staff)	OOP	Low uptake due to cost; increasing adult outbreaks	Patterson et al[55], South Africa
Not routine; private market only	OOP	High endemicity; vaccine not prioritized	Ahmed and Nashwan[56], Pakistan

OOP: Out of pocket; PEH: People experiencing homelessness; VFC: Vaccines for Children.