So, Is It Time to Give This a Shot?

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.

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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.

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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.

* While children are the target of vaccination, it is adults who are at higher risk for getting sick from the disease. Children usually get only mildly ill when infected or have no symptoms but can transmit the virus to others for about six weeks. The virus, which travels in feces, spreads easily when children don’t wash their hands after using the bathroom. The virus also travels in food and water. Adults who get the disease can become very ill for several weeks with flu-like symptoms and can remain actively infected for up to a year.

* Hepatitis A vaccination is not the same thing as the hepatitis B vaccine, which was recommended for all infants, children and teenagers in 1992. While there is research on a combined vaccine, so far each immunization requires a separate series of shots.

* There is a treatment to prevent the disease after exposure. But the medicine, called immune globulin, builds only a temporary immunity against infection and will not protect against future outbreaks. Some people may mistakenly think that immune globulin provides long-term vaccination.

* Insurance coverage of hepatitis A vaccine has been spotty; only roughly 40% of insurers cover it now, according to one manufacturer of the vaccine. The shot, costing about $75, isn’t covered by insurance because the federal guidelines for who should receive it remain vague. (Should the CDC recommend the vaccine routinely in childhood, however, it is expected that insurers would cover the costs. The vaccine is also included in the federal Vaccines for Children Program, ensuring that any child not covered by insurance or whose family cannot afford the shot would receive it.)

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Unlike other vaccinations that prevent childhood diseases or prevent extremely dangerous illness later in life (such as with the hepatitis B vaccine), the hepatitis A vaccine fits neither description. It would be given to children to prevent what can be a very uncomfortable, but rarely dangerous, illness in adults.

That might make the vaccine a tougher sell, Thiel admits.

“If we can immunize the kiddies, they can prevent this chain reaction,” she says. “But it’s a matter of educating people to show them how serious a problem this is.”

“Children are usually silent carriers of hepatitis A and get rid of it. But adults can get very ill and miss a lot of work,” says Dr. Melissa Palmer, a liver specialist in Long Island, N.Y., who has a large hepatitis practice. “It makes sense to immunize children because you have a group there who is going to the doctor for other reasons.”

One state, Oklahoma, has acted. Oklahoma legislators voted in June to require hepatitis A vaccination for kindergarten and seventh-grade schoolchildren after cases in that state quadrupled during the last decade. The infection rate in Oklahoma is still not as high as in California.

The vaccine, which is usually recommended to be given with a booster shot at six to 12 months after the initial immunization, is believed to be effective for up to 20 years, according to studies.

California health officials have begun discussions about widespread hepatitis A vaccination, says Dr. Natalie Smith, immunization branch chief for the Department of Health Services.

“We’re still in the early discussion phase. One problem is that there is no clear consensus about where to fit in the immunization [in the childhood immunization schedule]. People were hoping we’d have a combined vaccine for hepatitis A and B to make it easier to vaccinate children routinely.”

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A Closer Look at Hepatitis

Government officials soon will consider a proposal to vaccinate children for hepatitis A in states with high rates of the disease, including California. If approved, it would be the second hepatitis vaccine recommended for children. The three primary hepatitis viruses--A, B and C--have different characteristics, but all can cause liver damage.

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HEPATITIS A

How It Is Spread: Transmitted from fecal matter through food, water and person-to-person contact.

U.S. cases per year: 125,000 to 200,000.

Who’s at High Risk: Travelers to foreign countries, military personnel, day care and institutional workers, food handlers, and certain ethnic and geographical groups with history of outbreaks.

Effects: Vomiting, abdominal pain, diarrhea, fever, jaundice. Can also cause acute liver disease and, in rare cases, death.

Prevention: Vaccine is recommended for high-risk groups. Government committee has proposed vaccinating children in several high-risk states, including California.

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HEPATITIS B

How It Is Spread: Transmitted through direct contact with the blood or bodily fluids of an infected person by having unprotected sex, injecting drugs, receiving blood transfusions before 1972, and during childbirth from infected mother to baby.

U.S. Cases Each Year: 128,000 to 320,000.

Who Is at Higher Risk: People who are exposed to blood on the job, live with infected person, have sex with infected person or carrier (infected people who have no symptoms), use IV drugs, work or live in prison, travel to countries with high hepatitis B rates.

Effects: Loss of appetite, nausea and vomiting, fever, weakness and fatigue, abdominal pain, dark urine, jaundice. Chronic infection can damage liver and cause death.

Prevention: Vaccine recommended for all newborns, infants and teenagers. People exposed to blood at work and those who live with an infected person.

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HEPATITIS C

How It Is Spread: Through blood exchanges, such as using intravenous drug and having unprotected sex with an infected partner.

U.S. Cases Each Year: 28,000 to 180,000.

Who Is at Higher Risk: Health care workers, people with multiple sex partners, intravenous drug users, anyone who has had a tattoo or body piercing and may have been exposed to contaminated needles, and received a blood transfusion before 1992.

Effects: Flulike symptoms, headache and decreased appetite. Can cause liver damage. Hepatitis C is leading cause of liver transplants.

Prevention: No vaccine. Prevention can be practiced by washing hands after using the bathroom, not injecting or snorting drugs, avoiding unprotected sex with an infected person or multiple partners.

Source: American Liver Foundation