Prevalence of hepatitis-D virus in hepatitis B surface antigen-positive patients of India: A meta-analysis (research on behalf of ESGVH)

doi:10.3748/wjg.v32.i21.115964

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World Journal of Gastroenterology

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1007-9327

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Meta-Analysis

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Gastroenterol. Jun 7, 2026; 32(21): 115964
Published online Jun 7, 2026. doi: 10.3748/wjg.v32.i21.115964

Prevalence of hepatitis-D virus in hepatitis B surface antigen-positive patients of India: A meta-analysis (research on behalf of ESGVH)

Nitu Mishra, Anish Gupta, Ashutosh K Singh, Juhi Nagar, Ashish K Vyas, Vikas Yadav, Greeshma C Ravindran, Megha K Pandey, Irfan F Corovic, Uday Mandal, Rajnarayan R Tiwari, Pradyumna K Mishra, Sumit K Rawat, Ram K Nema

Nitu Mishra, Multidisciplinary Research Unit, Bundelkhand Medical College Sagar, Sagar 470001, Madhya Pradesh, India

Anish Gupta, Department of Oral Pathology and Microbiology, People’s University, Bhopal 462025, Madhya Pradesh, India

Ashutosh K Singh, Juhi Nagar, Division of EBGMB, ICMR-National Institute for Research in Environmental Health, Bhopal 462030, Madhya Pradesh, India

Ashish K Vyas, Amrita Research Center Delhi NCR, Amrita Vishwa Vidyapeetham, Faridabad Campus, Faridabad 110070, Haryāna, India

Vikas Yadav, Uday Mandal, Department of Environmental Health and Epidemiology, ICMR-National Institute for Research in Environmental Health, Bhopal 462030, Madhya Pradesh, India

Greeshma C Ravindran, Division of Biostatistics, ICMR-National Institute for Research in Environmental Health, Bhopal 462030, Madhya Pradesh, India

Megha K Pandey, Department of Translational Medicine, All India Institute of Medical Sciences, Bhopal 462020, Madhya Pradesh, India

Irfan F Corovic, Center for Molecular Medicine and Stem Cell Research, Faculty of Medical Sciences, University of Kragujevac, Kragujevac 34000, Serbia

Rajnarayan R Tiwari, ICMR-National Institute for Research in Environmental Health, Bhopal 462030, Madhya Pradesh, India

Pradyumna K Mishra, Ram K Nema, Division of Environmental Biotechnology, Genetics and Molecular Biology, ICMR-National Institute for Research in Environmental Health, Bhopal 462030, Madhya Pradesh, India

Sumit K Rawat, Department of Microbiology, Bundelkhand Medical College Sagar, Sagar 470001, Madhya Pradesh, India

Co-corresponding authors: Irfan F Corovic and Ram K Nema.

Author contributions: Mishra N, Singh AK, Nagar J and Vyas AK were involved in data curation, investigation, and methodology; Yadav V, and Ravindran GC contributed to data analysis and visualization; Pandey MK, and Mandal U participated in the investigation and methodology; Rawat SK and Gupta A contributed to writing review and editing; Tiwari RR contributed to project administration, provided resources, and participated in writing, review, and editing; Nema RK and Corovic IF contributed to the conceptualization, methodology, and project administration, wrote the first draft of the manuscript, and they are co-corresponding authors; Mishra N, Gupta A, Singh AK, Nagar J, Vyas AK, Yadav V, Ravindran GC, Pandey MK, Corovic IF, Mandal U, Tiwari RR, Mishra PK, Rawat SK, Nema RK and ESCMID Study Group for Viral Hepatitis (ESGVH) members commented on previous versions of the manuscript, read and approved the final manuscript.

AI contribution statement: AI tools (ChatGPT and Grammarly) were used solely for linguistic refinement and formatting assistance. No AI tool was involved in the generation of research data, interpretation of results, or formulation of conclusions. All AI-generated outputs were critically reviewed and revised by the authors.

Conflict-of-interest statement: The authors declare that they have no conflict of interest.

PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.

Corresponding author: Ram K Nema, PhD, Scientist, Division of Environmental Biotechnology, Genetics and Molecular Biology, ICMR-National Institute for Research in Environmental Health, Bhopal Bypass Road, Bhopal 462030, Madhya Pradesh, India. ramkumarnema@gmail.com

Received: October 31, 2025
Revised: December 16, 2025
Accepted: March 20, 2026
Published online: June 7, 2026
Processing time: 207 Days and 17.1 Hours

Abstract

BACKGROUND

Hepatitis D virus (HDV) infection accelerates liver disease progression in individuals with hepatitis B virus (HBV) infection, yet its true burden in India remains unclear. HDV depends on HBV for replication and is associated with rapid fibrosis, early cirrhosis, and increased hepatocellular carcinoma risk, making accurate prevalence estimates essential for clinical management and public health planning in endemic settings.

AIM

To estimate the pooled prevalence of HDV among hepatitis B surface antigen (HBsAg)-positive individuals in India and assess regional and methodological variations to inform national hepatitis control strategies.

METHODS

We systematically searched PubMed, Scopus, and Web of Science from inception to December 31, 2024 for studies reporting HDV prevalence in HBsAg-positive individuals in India, using laboratory-confirmed diagnosis. Eligible cross-sectional, cohort, or case-control studies were assessed for methodological quality using the Joanna Briggs Institute checklist. Pooled prevalence was calculated using a random-effects generalized linear mixed model with logit transformation. Heterogeneity was quantified with I² statistics, and publication bias was assessed by funnel plot inspection, Begg’s, and Egger’s tests.

RESULTS

Thirty studies, comprising a total of 5365 HBsAg-positive participants from multiple regions in India, met inclusion criteria. The pooled HDV prevalence was 5.05% (95% confidence interval: 2.37-10.41; I² = 93.5%, P < 0.0001), with reported rates ranging from 0% to 91.7%. Heterogeneity appeared related to study setting, population risk profile, diagnostic method, and geographic location. Begg’s test showed no significant asymmetry (P = 0.57), while Egger’s test indicated possible small-study effects (P = 0.006).

CONCLUSION

HDV co-infection affects approximately 5% of HBV carriers in India, representing a significant public health concern. Routine HDV screening, prioritization of high-burden regions, expansion of diagnostic capacity, and sustained HBV vaccination coverage are critical to reducing disease impact. Regional and population-based variation demands urgent implementation of standardized HDV testing protocols and targeted public health interventions in high-burden areas.

Keywords: Hepatitis D virus; Hepatitis B surface antigen; Prevalence; Co-infection; Epidemiology; Public health; Risk factors

Core Tip: This systematic review and meta-analysis provides the first comprehensive national estimate of hepatitis D virus (HDV) prevalence among hepatitis B surface antigen-positive individuals in India. Analyzing 30 studies with 5365 participants, the pooled HDV prevalence was 5.05%, highlighting substantial regional and methodological variability. The study identifies key drivers of heterogeneity, including diagnostic methods and population risk profiles, and underscores the urgent need for routine HDV screening, standardized testing protocols, and region-specific public health interventions to mitigate the burden of hepatitis B virus-HDV co-infection in India.