ACIP hepatitis A guidelines finalized (Atlanta) The Advisory Committee on Immunization Practices (ACIP) of the federal CDC has completed its revised recommendations for prevention of hepatitis A in the United States. A draft of the document was distributed to members at a meeting of ACIP in October and a subsequent final draft was distributed recently. Publication has been delayed because of a long queue of articles at the Morbidity and Mortality Weekly Report (MMWR), but is expected in early- to mid-1996. The recommendations become official when they are published in MMWR. The new document, called "Prevention of Hepatitis A Through Active or Passive Immunization," covers use of the newly licensed inactivated hepatitis A vaccine. One vaccine, HavrixĈ (SmithKline Beecham Biologicals) was licensed in February 1995 and another, VAQTAĈ (Merck & Co., Inc.), is expected to be licensed in the near future. Vaccination philosophy In the past few years, CDC officials and other experts have adopted the philosophy that universal infant vaccination is the best public health strategy against hepatitis A. In its draft document, the Committee stuck to that philosophy, writing that "the most effective means of achieving control of HAV infection would be to add hepatitis A vaccine as a routine vaccine to the childhood vaccination schedule. However, several obstacles must be overcome before making this recommendation . . . ." The Committee cited the lack of data supporting "the appropriate dose and timing of vaccination in the first or second year" and the need for combination vaccines. As an "interim strategy," ACIP recommended pre-exposure vaccination for the following groups that are at increased risk for hepatitis: a travelers to countries with high or intermediate endemicity of infection; b children living in communities with high rates of HAV infection and periodic epidemics (i.e., Alaskan Natives, American Indians on reservations, selected Hispanic communities, selected religious groups); c men who have sex with men; d injecting and noninjecting street drug users, if local epidemiologic data demonstrate current or past outbreaks; e HAV-exposed research workers. In addition, ACIP recommended vaccine for persons with chronic liver disease, in whom HAV infection may be severe. Additionally, because of recent reports in the U.S. concerning HAV infection among persons receiving clotting factor concentrate for hemophilia (MMWR, Jan. 16, 1996), vaccine is recommended for "susceptible persons who receive clotting factor concentrates, especially solvent-detergent treated preparations." Communitywide outbreaks The Committee separated communitywide hepatitis A outbreaks into two types based on attack rate, anti-HAV prevalence, and other characteristics. "Highrate communities" were defined as areas that experience periodic outbreaks with reported annual attack rates of 700-1,000 per 100,000, such as Alaskan Native areas and American Indian reservations. For high-rate communities, ACIP recommended routine vaccination of all young children, plus accelerated implementation of catch-up vaccinations in older children. "Intermediate-rate communities" were defined as areas with reported annual rates of 50-200 per 100,000 population. In such areas, ACIP pointed out that vaccination "has the potential" to control outbreaks, but that "widespread vaccination may not be feasible." The Committee also said that "targeting vaccinations among subpopulations or groups with the highest rates of disease may be more feasible," but that the effectiveness of using vaccine in these settings has not yet been determined. "Local surveillance and epidemiologic data should be used to define populations . . . with the highest rates of disease." Factors to consider in deciding whether to vaccinate include the feasibility of delivery to high-risk groups, cost, and the ability to "sustain ongoing vaccination." In areas where day care centers play a role in sustaining communitywide outbreaks, the Committee said that "consideration should be given to adding hepatitis A vaccine to the immunoprophylaxis regimen for children and staff in the involved center or centers . . . ." The Committee also said that "evaluation of the effectiveness of vaccination should be an essential element of programs in these settings." Foodhandlers, too? At its June 1995 meeting, the Committee wrestled with the issue of vaccinating foodhandlers in outbreak areas. The draft says, "Persons who work as foodhandlers may contract hepatitis A and potentially transmit HAV to others. To decrease the frequency of evaluations of foodhandlers with hepatitis A and the need for postexposure prophylaxis of patrons, consideration may be given to vaccination of these employees in areas where state and local health authorities determine that such vaccination is cost-effective."