Correspondence

Vaccination against Hepatitis A

N Engl J Med 1999; 341:293July 22, 1999

Article

To the Editor:

Koff states in his editorial on childhood vaccination against hepatitis A (Feb. 25 issue)1 that “a strategy of universal early-childhood immunization beginning at the age of two should . . . be implemented immediately.” Both the justification for and the implementation of such a strategy are open to serious question.

Efforts during the past decade have focused on immunization of infants by the age of 18 months, with booster doses administered at the time of entry into school (4 to 6 years of age). Because hepatitis A vaccine can be given only after the age of two years, imposing a separate immunization schedule (presumably two doses) after this age would require two visits to health care facilities in addition to those for which compliance is already difficult. Because hepatitis A infection is usually occult during the first four years of life, protection of children in this age group does not have great urgency. The only justification might be to prevent their bringing the virus home to adult household members.

The increasing complexity of the childhood immunization schedule and its costliness are important considerations. This relates not only to the vaccines themselves but also to the infrastructure for their administration. Funds for immunization were greatly reduced in the 1999 federal budget. Federal assistance to state and municipal programs under section 317 of the Public Health Service Act was reduced from $228 million to $195 million in 1998, despite the addition to the childhood immunization schedule of vaccines for varicella and rotavirus infection and the substitution of inactivated poliovirus vaccine for oral poliovirus vaccine.

Absent from Koff's recommendation are any comments on the cost–benefit analysis of the program he recommends for universal early-childhood immunization. Other vaccines that may be licensed in the coming months include a childhood pneumococcal conjugate preparation to which most pediatricians would assign higher priority than a vaccine against hepatitis A. For the present, the recommendations of the Advisory Committee on Immunization Practices for hepatitis A vaccination in counties with rates of 20 or more cases per 100,000 population are well conceived, and the results of this strategy should be awaited before any universal program is attempted.

Samuel L. Katz, M.D.
Duke University Medical Center, Durham, NC 27710

1 References

1. 1

   Koff RS. The case for routine childhood vaccination against hepatitis A. N Engl J Med 1999;340:644-645
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Koff replies:

To the Editor: Although I understand Dr. Katz's concerns, acute liver failure due to hepatitis A is not rare in young children.1 A polyvalent combination vaccine that incorporates immunization against hepatitis A and could be given to infants without additional injections or visits would be the ideal approach to hepatitis A prevention. However, until such a preparation is available, immediate implementation of universal early-childhood immunization at the age of two years with the current hepatitis A vaccines could reduce hepatitis A–associated illnesses and deaths, not only in those who receive the vaccine but also in older children and adults at risk because of exposure to infected youngsters. Given the failure to identify risk factors in nearly 50 percent of patients with hepatitis A, a targeted approach to immunization is likely to have little effect on overall morbidity and mortality in this country. Others have also suggested that reducing the incidence of hepatitis A will require ongoing vaccination of infants or young children.2 Although I agree that cost–benefit analysis may be a helpful tool in determining the allocation of health care resources and that such studies should be undertaken in assessing early routine immunization with hepatitis A vaccine, the role of cost–benefit analysis in decision making remains murky.

The fact that federal funding for immunization is diminishing is a disgrace. This decline should be addressed by better education of the budget planners, Congress, and the public about the value of immunization programs. Rationing immunization and limiting consideration of new programs in response to reduced federal aid is not in the public interest. Finally, although I salute the efforts of the Advisory Committee on Immunization Practices, its recommendation of a targeted approach to the use of hepatitis B vaccines may have wasted a decade in the effort to control that disease. Will we have to repeat that experience with hepatitis A immunization?

Raymond S. Koff, M.D.
MetroWest Medical Center, Framingham, MA 01702

2 References

1. 1

   Debray D, Cullufi P, Devictor D, Fabre M, Bernard O. Liver failure in children with acute hepatitis A. Hepatology 1997;26:1018-1022
   CrossRef | Web of Science | Medline

2. 2

   Bell BP, Shapiro CN, Alter MJ, et al. The diverse patterns of hepatitis A epidemiology in the United States -- implications for vaccination strategies. J Infect Dis 1998;178:1579-1584
   CrossRef | Web of Science | Medline