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So, Is It Time to Give This a Shot?

Vaccinations Federal officials join the debate about immunizing children for hepatitis.


Federal health officials are mulling a mass immunization program for elementary-school students to prevent the type of hepatitis A outbreak that threatened thousands of Los Angeles schoolchildren in March 1997.

Whether parents--and health insurers--would get behind such a proposal is uncertain, officials concede. While frightening outbreaks are on the rise in California, many people don't understand the differences among the family of hepatitis viruses and how vaccination can help.

"People are very confused about the variety of hepatitis viruses," says Thelma King Thiel, chairwoman of Hepatitis Foundation International, an advocacy group. "Some are transmitted through food and water and others through blood. Some people think that the vaccination for hepatitis B covers all the hepatitis viruses. And it doesn't." Hepatitis Foundation International, based in Cedar Grove, N.J., and several other public health education groups have launched an intensive campaign to teach Americans about hepatitis in advance of a government decision, expected early next year, on who should be tested for hepatitis A.

Last month, an advisory committee to the Centers for Disease Control and Prevention recommended that children living in states or communities with high hepatitis A rates--defined as double the national average--be vaccinated against hepatitis A. This would include California and most other Western states.

According to the CDC, about one-third of Americans have already been exposed to hepatitis A. Among adults who are exposed for the first time, three out of four will become ill. And the disease can be miserable, causing vomiting, fatigue and jaundice. One study put the cost of hepatitis A infection in the United States at $450 million annually. It is also the most surreptitious of the hepatitis viruses because it spreads through food and water and is highly contagious.


About 100 to 150 people a year die of the disease, mostly because of complications. In people with underlying liver disease, the virus can cause serious complications. About 12% to 15% of infected adults are hospitalized each year from hepatitis A infection, often because of dehydration from vomiting.

The national hepatitis A rate is 10.8 cases per 100,000 people. California's rate last year was 21 per 100,000. There are about 125,000 to 200,000 hepatitis A cases per year in the United States.

A vaccine for hepatitis A has been available since 1995 and has been recommended for travel to some countries, including Mexico, for gay men, people with liver disease and hemophiliacs. In December, the Food and Drug Administration recommended that all food handlers also receive the vaccine. Several counties with outbreaks have also begun programs to vaccinate children.

But these efforts have not been enough, says Dr. Harold Margolis, chief of the hepatitis branch at the CDC.

"When we look at areas where there has been a large outbreak, what we have found is that unless you have a communitywide effort, it's hard to achieve high enough rates of vaccination to stop the disease. If you can get high coverages--over 70% to 80% of the community immunized--hepatitis A goes away," he says.


While there is no "huge problem" with hepatitis A in this country, "the whole area of hepatitis has come under much greater scrutiny and focus because we have gathered so much more data in the past five years," says Dr. Karen Lindsay, director of the Hepatitis Research Center at USC.

Public health officials are troubled by an increase in hepatitis A outbreaks from tainted imported produce. For example, in 1997, as many as 9,000 Los Angeles schoolchildren were exposed to the virus through frozen fruit in the school lunch program.

Several studies have shown that periodic outbreaks of hepatitis A continue until a community undertakes widespread vaccination. The previous strategy of targeting certain groups of people for hepatitis A vaccination, such as travelers and gay men, has not kept the virus in check.

The strategy of targeting certain groups hasn't worked in the past because too many people in those groups fail to get vaccinated, Lindsay says. A better strategy, she says, "is to vaccinate a certain population group at a certain age. That is the theory behind moving toward [childhood immunization for hepatitis A]."

The reasons for the difficulty in eradicating hepatitis A are many. Among them:

* There is no effective vaccine yet for infants. Only individuals age 2 or older can be vaccinated, which makes a mass immunization campaign more difficult because parents are less likely to take older children to the doctor.

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