Fall 1998 Volume 3, Number 3		ACIP considers expansion of hepatitis A vaccination recommendation (Atlanta) CDCıs Advisory Committee on Immunization Practices (ACIP) is considering an expansion in its recommendation for control of hepatitis A that would make vaccination routine for children in many high-incidence states. The Committee considered the issue at its last two meetings, in June and October 1998. At the October meeting, CDC staff proposed the following updated recommendations: 1. "In states where the average annual hepatitis A rate during 1987-97 was at least 20/100,000 population (i.e., approximately 2 times the national average), hepatitis A vaccination should be routine for children living in these states." These states include Arizona (average annual 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). 2. "In states where the average annual hepatitis A rate during 1987-97 was less than 20/100,000 populationŠ, hepatitis A vaccination should be routine for children living in communities or counties where the average annual rate during 1987-97 was at least 20/100,000."< br> The current ACIP statement on hepatitis A calls for routine childhood vaccination only in areas designated as "high-rate," such as Native American communities, certain religious groups, selected Hispanic communities (such as areas along the U.S.-Mexico border), and in certain "intermediate rate" areas (CDC. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1996;45 (No. RR-15)). But CDC staffers now want to move beyond this "interim strategy" toward more aggressive control of the disease. In a statement released at the October ACIP meeting, they said "to achieve a sustained reduction in hepatitis A incidence in [high-incidence or epidemic] areas, a comprehensive strategy of sustained vaccination of children and ultimately of infants is necessary." Under the current strategy, only a few states have instituted routine vaccination in high-incidence or epidemic areas. Oklahomaıs is the only statewide program. Regional programs have begun in Texas, Arizona, and a few other states (for a description of a program in El Paso, Texas, see the Hepatitis Control Report, Summer 1998 issue). CDC staffers have been particularly concerned about Hispanic communities on the U.S.-Mexico border, where hepatitis A rates are typically two to three times the national average. ACIP recommended routine vaccination of children there in 1996, but programs have started only in Texas (which plans to make hepatitis A vaccination mandatory for school entry in 32 border counties). No comprehensive programs have begun in the vast border areas of the southwest and southern California. The states have been hesitant to start routine hepatitis A vaccination programs in part because of budgetary concerns (see lead story in this issue of the Hepatitis Control Report), in part because of the burden of adding yet another vaccine to the school entry requirement, and in part because of fear that amending school entry vaccination laws will expose existing requirements to attack from anti-vaccine groups. A few states are waiting for combination vaccines or simply do not view hepatitis A as a very serious disease. But three developments in 1997 and 1998 convinced CDC that it is time to move more aggressively. First, the old three-dose pediatric series was replaced by a two-dose series, dropping the cost of vaccination by about 30%. Second, Oklahoma, after experiencing a huge statewide communitywide outbreak in 1994-97, stepped forward to make hepatitis A vaccination mandatory for school entry. Third, it became clear that hepatitis A can be controlled in many communities by long-term vaccination of all children in one or two age cohorts (over age two), depending on the local epidemiology. At ACIPıs October 24th meeting, Dr. Beth Bell, who is now leading CDCıs hepatitis A efforts, told members that "to have an impact on overall hepatitis A rates, high levels of childhood vaccination must be achieved. The experience to date indicates this has best been accomplished through extensive professional and public education and the use of school entry mandates." Bell proposed a switch from ACIPıs current "epidemic intervention strategy," which she said was "unlikely to result in a sustained reduction in incidence," to a strategy that will "focus on sustained vaccination of all children in at least a single age cohort to prevent communitywide outbreaks and to eventually lower disease incidence in states or communities with the highest rates of hepatitis A." At the same meeting, CDC economist Dr. Martin Meltzer presented the preliminary results of a cost-effectiveness study of hepatitis A vaccination in children. The analysis shows a cost per case prevented "in the same ballpark as other new vaccines for children" like rotavirus and varicella vaccines, he said. An ACIP working group, headed by ACIP member Dr. Mary P. Glode, a professor of pediatrics at Childrenıs Hospital in Denver, has been meeting with CDC staff to revise the ACIP recommendation. Final action is expected at ACIPıs meeting in February 1999.