Rodriguez and colleagues describe five patients, four of whom were previously healthy and between the ages of 26 and 55 years, who required liver transplantation for fulminant hepatitis A. Under the current guidelines, vaccine would not have been recommended for these patients [1]. These cases, which occurred sporadically (not during an epidemic), underscore the fact that hepatitis A in the industrialized world is not an asymptomatic disease of childhood but rather a potentially life-threatening disease of adults.

Haznedaroglu and colleagues report a case of severe hepatitis A complicated by the acute respiratory distress syndrome and death in a 16-year-old girl. This is an example of the unexpected extrahepatic manifestations that may occur with hepatitis A, and it also supports more widespread use of vaccination.

Drs. Yende and Lancaster report another unusual complication of hepatitis A. Although the patient had a good outcome, some morbidity resulted and considerable expense was incurred by the health care system. A cost–benefit analysis of the Memphis series may be helpful in analyzing costs associated with this epidemic in comparison to universal vaccination.

Vento and colleagues [2] have reported that superinfection with hepatitis A virus in patients with underlying chronic hepatitis C can result in fulminant hepatitis and death. Keefe and associates [3] found that patients with chronic hepatitis C, hepatitis B, and other chronic liver disease do have a satisfactory immune response to hepatitis A virus vaccination.

These letters highlight some of the points we made in our series and reemphasize that as more of the population becomes susceptible to hepatitis A virus, we should anticipate more outbreaks with serious complication, including death and the need for liver transplantation. We urge more widespread use of vaccination and consideration of adding hepatitis A virus vaccine to the routine immunization given universally in children.