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Delta agent infection in Riyadh, Saudi Arabia
TRANSACTIONSOF THE ROYAL SOCIETYOF TROPICALMEDICINE AND HYGIENE (1987) 81, 317-318
Delta agent
infection
in Riyadh,
317
Saudi Arabia
A. F. EL-HAZMI’, PAMELA A.
VIVIAN~, DAVID K. WALLER~, ISA K. MUSHAHWAR~ GERT G. FR&NER~ Departments of Pathology’ and Biochemistr#, College of Medicine, King Saud University, Riyadh; ‘Virology Laboratory, Riyadh Armed Forces Hospital; 4Abbott Laboratories, North Chicago, Illinois, USA; ‘Max V. Pettenkofm-Institute, Munich University, German Federal Republic
SAMI RAMIA’*,
MOHSEN
AND
Abstract Blood samples from 186 HBsAg-positive Saudis and 42 HBsAg-positive Philippino blood donors were tested for anti-delta using the radioimmunoassay technique. The high prevalence of anti-delta in Saudis with liver disease (32%) contrasted sharply with that in Saudis with illness other than liver disease (13%) and in apparently healthy Saudis (5.4%). Together with the high prevalence of anti-delta in Philippino blood donors (9*5%), theseresults suggestthat foci of endemic delta infection other than Italy probably exist.
A transmissible agent capable of producing acute or chronic henatitis has been recentlv identified. This agent, named delta (a), has a low molecular weight RNA and cannot replicate without the help of hepatitis B virus (HBV) (RIZZETTOet al., 198Oa, b). Since hepatitis B surface antigen (HBsAg) carriers express 6 in the liver and do not circulate detectable 6 antigen in the blood, the development of sensitive serological techniques such as radioimmunoassay (RIA) for detection of antibody to this agent (anti-8) provided a tool for recognizing 6 infection and studying its epidemiology (RIZZETTO et al., 1979). Delta infection is worldwide but reported prevalences varied widely (RLZZETTO et al., 1980~;RAIMONDO et al., 1982; HOY et al., 1984; GOVINDARAJAN et al.., 1984). Recently we have shown that HBV is endemic in Saudi Arabia (RAMIA et al., 1984). It was of interest therefore to investigate the extent of 6 infection in this population. Blood samples from 186 HBsAg-positive Saudis (151 males, 35 females) from the Riyadh area (Central Province) and from 42 HBsAg-positive Philippino blood donors (35 males, 7 females) were tested for anti-8 using the RIA technique (Anti-delta test, Abbott Laboratories North Chicago, Illinois, USA). The prevalence of anti-6 correlated with sex and health is shown in the Table. The high prevalence of anti-~ (32%) in Saudi males and females with liver disease-contrasts sharply with the prevalence in Saudis with illnesses other than liver disease (13%) and with that in apparently healthy HBsAg Saudis (5.4%). There was no difference between males and females. A similar pattern, of a strong association between 6 agent infection and chronic liver disease due to HBV, has been reported by RIZZETTO et al. (1980~)and RAIMONDO et al. (1982). We are initiating a studv on the clinical sianiflcance of acute and chronic S infection in Saudi patients. Tests for the markers HBeAn and its antibodv (anti-Hbe) were done on only 17O~Bspositive serum samples(57 patients with or without liver diseaseand *Correspondenceto: Dr. Sami Ramia, Department of Pathology (32), College of Medicine, King Saud University, P.O. Box 2925 Riyadh 11461, Saudi Arabia.
113 blood donors). Among the 170 samples, 2 1 had HBeAe comnared to 125 with anti-HBe and 24 witho; eith& marker. None of the 21 HBe-Agpositive samples had anti-& Of the 125 which had anti-HBe, 12 samples had anti-6, and of the 24 samples with neither marker, 5 were anti-6 positive. This suggeststhat there is competition in replication between 6 agent and HBV. Studies on the epidemiology of HBV-associated 6 agent (RIZZETTO et al., 1980~; RAIMONDO et al., 1982) revealed that there are two patterns of 6 infection: (i) endemic and associated with nonparenteral spreadand (ii) sporadic and associatedwith parenteral transmission. The latter pattern predominatesin HBsAg carriers who received multiple transfusions and in drug addicts who receive their drugs by injection. Since these two routes are unlikely for the transmission of infection in our population (RAMIA et al., 1984; 1985), it seems that the non-parenteral route is the most probable in the Saudi population and that, like Italy, Saudi Arabia constitutes a reservoir of 6 infection. The remarkably high prevalence of anti-8 in Philippino blood donors suggests that foci of endemic infection other than Italy and Saudi Arabia are probable. It is interesting to note that, in spite of the high prevalence of HBsAg carriers in Taiwan, the prevalence of 6 infection in that population is low (GOVINDAIUJAN et al., 1984). References Hoy, J. F., Hansson, B. G., Dimitrakakis, M., Gust, I. & Lucas, C. R. (1984). Delta agent infection in Melbourne. 3oumal of Medical Virology, 13, 339-345. Govindarajan, S., Lee, S. D. & Tong, M. J. (1984). Prevalence of delta agent among Chinese in Taiwan and Los Angeles. Journal of Medical Virology, 14, 33-37. Raimondo, G., Gallo, L., Ponzetto, A., Smedile, A., Balbo, A. & Rizzetto, M. (1982). Multicenter study of prevalence of HBV-associated delta infection and liver disease in drug addicts. Lancet, i, 249-251. Ramia, S., Jabbar, F. A., Bakir, T. M. F. & Houssain, A. (1984). Vertical transmission of hepatitis B surface antigen in Saudi Arabia. Annals of Tropical Paediatrics, 4, 213-216. Ramia, S., Bakir, T. M. F., Houssain, A., Vivian, P. A. & Waller, D. K. (1986). Prevalence and subtype of hepatitis B surface antigen (HBsAg) in the Saudi
318 Table-Correlation
DELTA
AGENT
INFECTION
IN
SAUDI
ARABIA
of sex and health with the prevalence of anti-b in HBsAg-positive
Saudis Patients with liver disease (hepatitis, jaundice, chronic liver disease hepatomegaly, hepatoma) Patients without liver disease (nephrotic syndrome, gastroenteritis, hypertension, etc.) Healthy persons (blood donors, pregnant women, students)
Males
61107
Saudis and Phiippinos
Females
Total
216
609
33%
32%
l/7
5138
14%
13%
l/22
71129
5.6%
5%
5.4%
Total Saudis
14/151 9.3%
4135 11%
18/186 9.7%
Philippino blood donors
3135 8.6%
l/7 14.3%
4142 9.5%
population. Tropical and Geographical Medicine, 38, 63-69.
Rizzetto, M., Shih, J. W. K., Gocke, D. J. & Purcell, R. H. (1979). Incidence and significance of antibodies to delta antigen in hepatitis B virus infection. Lancer, ii, 986-990. Rizzetto, M., Canese,M. G., Gevin, J. L., London, W. T., Sly, D. L. & Purcell, R. H. (1980a). Transnussion of hepatitis B virus associateddelta agent to chimpanzees. Joumd of Infectious Diseases, 141, 590-602. Rizzetto, M., Hoyer, B., Canese, M. G., Shih, J. W. K.,
Purcell, R. H. & Gervin, J. L. (1980b). Delta antigen: the association of delta antigen with hepatitis B surface antigen and r&nucleic acid in the serum of delta infected chimpanzees. Proceedings of the National Academy of Sciences, USA, 27, 6124-6128. Rizzetto, H., Purcell, R. H. & Gervin, J. L. (198Oc). Epidemiology of HBV-associated delta agent: geographical distribution of anti-delta and prevalence of polytransfused HBsAg carriers. Lancer, i, 1215-1219. Accepted for publication 13 January 1986
Delta agent
infection
in Riyadh,
317
Saudi Arabia
A. F. EL-HAZMI’, PAMELA A.
VIVIAN~, DAVID K. WALLER~, ISA K. MUSHAHWAR~ GERT G. FR&NER~ Departments of Pathology’ and Biochemistr#, College of Medicine, King Saud University, Riyadh; ‘Virology Laboratory, Riyadh Armed Forces Hospital; 4Abbott Laboratories, North Chicago, Illinois, USA; ‘Max V. Pettenkofm-Institute, Munich University, German Federal Republic
SAMI RAMIA’*,
MOHSEN
AND
Abstract Blood samples from 186 HBsAg-positive Saudis and 42 HBsAg-positive Philippino blood donors were tested for anti-delta using the radioimmunoassay technique. The high prevalence of anti-delta in Saudis with liver disease (32%) contrasted sharply with that in Saudis with illness other than liver disease (13%) and in apparently healthy Saudis (5.4%). Together with the high prevalence of anti-delta in Philippino blood donors (9*5%), theseresults suggestthat foci of endemic delta infection other than Italy probably exist.
A transmissible agent capable of producing acute or chronic henatitis has been recentlv identified. This agent, named delta (a), has a low molecular weight RNA and cannot replicate without the help of hepatitis B virus (HBV) (RIZZETTOet al., 198Oa, b). Since hepatitis B surface antigen (HBsAg) carriers express 6 in the liver and do not circulate detectable 6 antigen in the blood, the development of sensitive serological techniques such as radioimmunoassay (RIA) for detection of antibody to this agent (anti-8) provided a tool for recognizing 6 infection and studying its epidemiology (RIZZETTO et al., 1979). Delta infection is worldwide but reported prevalences varied widely (RLZZETTO et al., 1980~;RAIMONDO et al., 1982; HOY et al., 1984; GOVINDARAJAN et al.., 1984). Recently we have shown that HBV is endemic in Saudi Arabia (RAMIA et al., 1984). It was of interest therefore to investigate the extent of 6 infection in this population. Blood samples from 186 HBsAg-positive Saudis (151 males, 35 females) from the Riyadh area (Central Province) and from 42 HBsAg-positive Philippino blood donors (35 males, 7 females) were tested for anti-8 using the RIA technique (Anti-delta test, Abbott Laboratories North Chicago, Illinois, USA). The prevalence of anti-6 correlated with sex and health is shown in the Table. The high prevalence of anti-~ (32%) in Saudi males and females with liver disease-contrasts sharply with the prevalence in Saudis with illnesses other than liver disease (13%) and with that in apparently healthy HBsAg Saudis (5.4%). There was no difference between males and females. A similar pattern, of a strong association between 6 agent infection and chronic liver disease due to HBV, has been reported by RIZZETTO et al. (1980~)and RAIMONDO et al. (1982). We are initiating a studv on the clinical sianiflcance of acute and chronic S infection in Saudi patients. Tests for the markers HBeAn and its antibodv (anti-Hbe) were done on only 17O~Bspositive serum samples(57 patients with or without liver diseaseand *Correspondenceto: Dr. Sami Ramia, Department of Pathology (32), College of Medicine, King Saud University, P.O. Box 2925 Riyadh 11461, Saudi Arabia.
113 blood donors). Among the 170 samples, 2 1 had HBeAe comnared to 125 with anti-HBe and 24 witho; eith& marker. None of the 21 HBe-Agpositive samples had anti-& Of the 125 which had anti-HBe, 12 samples had anti-6, and of the 24 samples with neither marker, 5 were anti-6 positive. This suggeststhat there is competition in replication between 6 agent and HBV. Studies on the epidemiology of HBV-associated 6 agent (RIZZETTO et al., 1980~; RAIMONDO et al., 1982) revealed that there are two patterns of 6 infection: (i) endemic and associated with nonparenteral spreadand (ii) sporadic and associatedwith parenteral transmission. The latter pattern predominatesin HBsAg carriers who received multiple transfusions and in drug addicts who receive their drugs by injection. Since these two routes are unlikely for the transmission of infection in our population (RAMIA et al., 1984; 1985), it seems that the non-parenteral route is the most probable in the Saudi population and that, like Italy, Saudi Arabia constitutes a reservoir of 6 infection. The remarkably high prevalence of anti-8 in Philippino blood donors suggests that foci of endemic infection other than Italy and Saudi Arabia are probable. It is interesting to note that, in spite of the high prevalence of HBsAg carriers in Taiwan, the prevalence of 6 infection in that population is low (GOVINDAIUJAN et al., 1984). References Hoy, J. F., Hansson, B. G., Dimitrakakis, M., Gust, I. & Lucas, C. R. (1984). Delta agent infection in Melbourne. 3oumal of Medical Virology, 13, 339-345. Govindarajan, S., Lee, S. D. & Tong, M. J. (1984). Prevalence of delta agent among Chinese in Taiwan and Los Angeles. Journal of Medical Virology, 14, 33-37. Raimondo, G., Gallo, L., Ponzetto, A., Smedile, A., Balbo, A. & Rizzetto, M. (1982). Multicenter study of prevalence of HBV-associated delta infection and liver disease in drug addicts. Lancet, i, 249-251. Ramia, S., Jabbar, F. A., Bakir, T. M. F. & Houssain, A. (1984). Vertical transmission of hepatitis B surface antigen in Saudi Arabia. Annals of Tropical Paediatrics, 4, 213-216. Ramia, S., Bakir, T. M. F., Houssain, A., Vivian, P. A. & Waller, D. K. (1986). Prevalence and subtype of hepatitis B surface antigen (HBsAg) in the Saudi
318 Table-Correlation
DELTA
AGENT
INFECTION
IN
SAUDI
ARABIA
of sex and health with the prevalence of anti-b in HBsAg-positive
Saudis Patients with liver disease (hepatitis, jaundice, chronic liver disease hepatomegaly, hepatoma) Patients without liver disease (nephrotic syndrome, gastroenteritis, hypertension, etc.) Healthy persons (blood donors, pregnant women, students)
Males
61107
Saudis and Phiippinos
Females
Total
216
609
33%
32%
l/7
5138
14%
13%
l/22
71129
5.6%
5%
5.4%
Total Saudis
14/151 9.3%
4135 11%
18/186 9.7%
Philippino blood donors
3135 8.6%
l/7 14.3%
4142 9.5%
population. Tropical and Geographical Medicine, 38, 63-69.
Rizzetto, M., Shih, J. W. K., Gocke, D. J. & Purcell, R. H. (1979). Incidence and significance of antibodies to delta antigen in hepatitis B virus infection. Lancer, ii, 986-990. Rizzetto, M., Canese,M. G., Gevin, J. L., London, W. T., Sly, D. L. & Purcell, R. H. (1980a). Transnussion of hepatitis B virus associateddelta agent to chimpanzees. Joumd of Infectious Diseases, 141, 590-602. Rizzetto, M., Hoyer, B., Canese, M. G., Shih, J. W. K.,
Purcell, R. H. & Gervin, J. L. (1980b). Delta antigen: the association of delta antigen with hepatitis B surface antigen and r&nucleic acid in the serum of delta infected chimpanzees. Proceedings of the National Academy of Sciences, USA, 27, 6124-6128. Rizzetto, H., Purcell, R. H. & Gervin, J. L. (198Oc). Epidemiology of HBV-associated delta agent: geographical distribution of anti-delta and prevalence of polytransfused HBsAg carriers. Lancer, i, 1215-1219. Accepted for publication 13 January 1986