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Dagan R, Leventhal A, Anis E, Slater P, Ashur Y, Shouval D. Incidence of Hepatitis A in Israel Following Universal Immunization
of Toddlers. JAMA. 2005;294(2):202–210. doi:10.1001/jama.294.2.202
Author Affiliations: Pediatric Infectious Disease
Unit, Soroka University Medical Center and the Faculty of Health Sciences,
Ben-Gurion University of the Negev, Beer-Sheva, Israel (Dr Dagan); Public
Health Services (Dr Leventhal) and Departments of Infectious Diseases (Dr
Anis) and Epidemiology (Dr Slater), Ministry of Health, Jerusalem, Israel;
Liver Unit, Hadassah-Hebrew University, Jerusalem (Drs Ashur and Shouval).
Context In Israel, the mean annual incidence of hepatitis A disease was 50.4
per 100 000 during 1993-1998. A 2-dose universal hepatitis A immunization
program aimed at children aged 18 and 24 months (without a catch-up campaign)
was started in 1999.
Objective To observe the impact of toddlers-only universal vaccination on hepatitis
A virus disease in Israel.
Design and Setting Ongoing passive national surveillance of hepatitis A cases in Israel
has been conducted since 1993 by the Ministry of Health. An active surveillance
program in the Jerusalem district in 1999-2003 provided validation for the
Main Outcome Measure Incidence of reported hepatitis A disease, 1993-2004.
Results Overall vaccine coverage in Israel in 2001-2002 was 90% for the first
dose and 85% for the second dose. A decline in disease rates was observed
before 1999 among the Jewish but not the non-Jewish population. After initiation
of the program, a sharp decrease in disease rates was observed in both populations.
The annual incidence of 2.2 to 2.5 per 100 000 during 2002-2004 represents
a 95% or greater reduction for each year with respect to the mean incidence
during 1993-1998 (P<.001). For children aged 1
through 4 years, a 98.2% reduction in disease was observed in 2002-2004, compared
with the prevaccination period (P<.001). However,
a sharp decline was also observed in all other age groups (84.3% [<1 year],
96.5% [5-9 years], 95.2% [10-14 years], 91.3% [15-44 years], 90.6% [45-64
years], and 77.3% [≥65 years]). Among the Jewish population in the Jerusalem
district, in whom the active surveillance program was successfully conducted,
a more than 90% reduction of disease was demonstrated. Of the 433 cases reported
nationwide in 2002-2004 in whom vaccination status could be ascertained, 424
(97.9%) received no vaccine and none received 2 doses.
Conclusion This universal toddlers-only immunization program in Israel demonstrated
not only high effectiveness of hepatitis A vaccination but also marked herd
protection, challenging the need for catch-up hepatitis A vaccination programs.
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