WHO also recommended that the national decision to introduce hepatitis A vaccine as part of the routine immunization programme be weighed against competing priorities in terms of burden of disease and the capacity of immunization systems to integrate new and underutilized vaccines, including hepatitis B, Haemophilus influenzae type B, rubella and yellow fever. In terms of recommendations, the position paper differentiated high, intermediate and low endemicity settings. In high endemicity settings, WHO did not recommend large-scale vaccination as almost all persons are asymptomatically infected with HAV during childhood. In intermediate endemicitWHO recommended that large-scale childhood vaccination may be considered as a supplement to health education and improved sanitation as a relatively large proportion of the adult population remains susceptible leading to a substantial hepatitis A public health burden. In low endemicity settings, WHO only recommended vaccination against hepatitis A for individuals with increased risk of infection (e.g., travellers to areas of intermediate or high endemicity).