Spring 1998 Volume 3, Number 1		Oklahoma mandates hepatitis A vaccination for school entry The State of Oklahoma has become the first state in the nation to mandate hepatitis A vaccination for school entry. Moving in response to a massive outbreak that began in 1994 and involved over 5,000 reported cases, the Oklahoma State Legislature enacted Senate Bill 1400, which adds hepatitis A vaccine to the list of vaccines required for entry into kindergarten and 7th grade. Final approval for the program came from the Oklahoma Board of Health on June 18, 1998. The requirement becomes effective on November 1, 1998. The state first considered mandatory vaccinations for Oklahoma schoolchildren in 1996. After discussions with the National Immunization Program and the CDC Hepatitis Branch in Atlanta, the state applied to CDC for permission to use the federal Vaccines for Children (VFC) entitlement for purchasing hepatitis A vaccine. CDC granted permission early in 1998. VFC will be used to purchase vaccine for all of the state's 77 counties. Over half of the vaccine cost will be covered by VFC, with the balance paid by private insurers, HMOs and the state government. Financing was made easier by Oklahoma's "first dollar coverage" law for childhood vaccines, which requires insurers to pay for all vaccines required for school entry in the state. In a story from the Associated Press, Laurie Smithee, an epidemiologist with the Oklahoma Health Department, said "The vaccination of younger people is one way to prevent another outbreak 10 years later." In the same story, Dr. Craig Shapiro, deputy epidemiology chief at the CDC Hepatitis Branch said, "I think it's actually a very reasonable approach to take, given the way hepatitis is occurring in Oklahoma." CDC staffers recently floated the idea of routine childhood vaccination against hepatitis A in 10 of the nation's highest-rate states. In a speech before the Spring Meeting of the American Academy of Pediatrics, Dr. Harold Margolis, CDC Hepatitis Chief, said, "I think something to be thinking about in the near future ÷ is to consider implementing a routine vaccination of children, namely pre-school children and school-age children in states with highest rates of hepatitis A." At its recent June meeting, ACIP heard presentations from CDC staff on wider use of hepatitis A vaccine. Speaking for the CDC Hepatitis Branch, Dr. Beth Bell suggested to the Committee that "states with average annual hepatitis rates over the past 10 years that are at least 2 (or 3) times the national average (that is, states with average annual rates of 20 [or 30] /100,000) should consider implementing routine hepatitis A vaccination programs statewide," including school entry requirements. States that meet this criterion are Arizona (average rate for 1987-97 of 48 per 100,000), Alaska (45), Oregon (40), New Mexico (40), Utah (33) Washington (30) Oklahoma (24), South Dakota (24), Idaho (21), Nevada (21), and California (20). Bell said that states with lower rates (such as Texas and Florida) should consider routine vaccination in counties or regions where rates have been consistently elevated or where epidemics have occurred. ACIP will reconsider the matter at its November meeting. ACIP Chairman Dr. John F. Modlin has announced that a working group will be formed to study the issue before the next meeting. Meanwhile, staff members at the Oklahoma Health Department are busy planning for the new requirement. Phyllis Brown, Director of the Oklahoma Immunization Division, said that "This has been the easiest vaccine to add to the school entry requirement, and I¼ve been around for a long time." She attributed the smooth addition to high community awareness of hepatitis A because of the outbreak, good publicity, and strong support from the health community and the legislature.