Hepatitis Control Notes 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 purchase of hepatitis A vaccine. CDC granted permission in early 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, "Something to be thinking about in the near futureäis 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." 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. Furthermore, she said, vaccination of single age cohorts, linked to school entry requirements, may be the most feasible way to accomplish routine vaccination. 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. End of the IMIG shortage is in sight The nation's shortage of intramuscular immune globulin (IMIG) may end next year, according to Dr. Beth Bell, epidemiologist at the CDC Hepatitis Branch, in a presentation before the ACIP on June 24, 1998. The IMIG shortage began in 1994, when the U.S. Department of Defense purchased the entire year's production from Armour, an IMIG manufacturer. Civilian orders were immediately backordered. Later on, the civilian supply of IMIG was further reduced by product withdrawals, product discontinuations, and interruptions in production. Currently, only two manufacturers make IMIG. Both are government entities: the Massachusetts Public Health Biologic Laboratories and the Michigan Biologics Products Institute. Bell said that the IMIG shortage is likely to ease next year as Centeon (which acquired the Armour operation) resumes production. Additionally, another manufacturer, Bayer, is planning to enter regular production, and the Massachusetts Laboratories expect to increase their production capacity. An estimated 275,000 2ml vials were distributed nationwide in 1997. In the six month period, June to December 1998, an estimated 200,000 2ml vials will be distributed, a sizeable increase from previous levels, Bell said. CDC has worked closely with the nation's only IMIG distributor, FFF Enterprises of Temecula, California, to locate large quantities of IMIG when needed by states and localities. According to Bell, there have been no circumstances when CDC could not locate sufficient quantities of IMIG for postexposure hepatitis A prophylaxis. In January and February 1998, the nation's IMIG supply was completely depleted. CDC recommended tetanus immune globulin as a substitute, and it was used in some cases (see HCR, Fall 1997 issue). Although the shortage of IMIG is expected to improve next year, production is still hampered by an uncertain and shrinking market, competition with other products for precursor materials, and off-label uses, Bell said. The IG shortage continues to hold the attention of the House Committee on Government Reform and Oversight, chaired by Rep. Chris Shays of Connecticut. Shays held hearings on the problem in early May. In his opening statement, he said "Public health officials need quick access to adequate supplies of intramuscular IG to meet disease outbreaks, as in 1997 when hundreds of school children were exposed to hepatitis A from contaminated strawberries. If that outbreak occurred today, there would not be enough medicineä".