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Study of an epidemic of non-A, non-B hepatitis
Study of an Epidemic of Non-A, Non-B Hepatitis Possibility of Another Human Hepatitis Virus Distinct from Post-Transfusion Non-A, Non-B Type MOHAMMED
SULTAN KHUROO. M.D., D.M.
Srinogar. Kashmir, India
From the Department of Medicine, Medical College. Srinagar.Kashmir, India. Requests for reprintsshould be addressed to Dr. Mohammed Sultan Khuroo, Medical College, Srinagar. Kashmir, India 190910. Manuscript accepted December 5.1979.
818
June 1980
A common source waterborne epidemic of viral hepatitis was studied in Kashmir valley over the six month period from November 1978 to April 1979. Highly sensitive serologic tests for hepatitis B and hepatitis A failed to reveal either one as an etiologic agent of hepatitis. Of 16,620 inhabitants of the area screened four times in these six months, viral hepatitis developed in 1.65 per cent. In addition, 27.3 per cent of 126 persons who had contacts with patients who had viral hepatitis had biochemical features of anicteric hepatitis. The mode of spread of the epidemic, length of incubation, clinical features and biochemical test results of the patients studied resembled that of hepatitis A. These findings were in contrast to that of non-A, non-B hepatitis following transfusion, which closely resembles hepatitis B. The data strongly suggest the possibility of another human hepatitis virus and established the fecal oral route of its spread. The availability of sensitive serologic tests for hepatitis A virus and hepatitis B virus made definitive etiologic classification of viral hepatitis possible [l]. As a result, another variant of acute hepatitis has been discovered unrelated to either of these viral agents [2]. At present, 60 to 90 per cent of the post-transfusion cases of hepatitis in the United States is of this non-A, non-B type [3]. For a time it was thought that non-A, non-B hepatitis could be transmitted only parenterally [4,5], recent evidence shows that it can be spread by nonparenteral routes [6,7]. These findings can be explained by the existence of more than one agent-a possibility that appears to be borne out by the results of studies in patients who have had multiple episodes of apparent acute hepatitis [8]. We have carried out a detailed epidemiologic study of a common source waterborne epidemic of viral hepatitis. Highly sensitive serologic tests for hepatitis B virus and hepatitis A virus failed to incriminate either one as an etiologic agent. The length of incubation, clinical features and mode of spread of this epidemic of non-A, non-B hepatitis differed from those of the post-transfusion type, strongly suggesting the existence of a fourth human hepatitis virus. MATERIALS AND METHODS In the first week of November 1978. I was informed of an outbreak of hepatitis in the Baramulla district of the Kashmir valley. A team survey of the area was started within two weeks of the first report. Every house in the area was visited
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TABLE I
Age and Sex Dlstrlbutlon In 275 Cases of Viral HqWth
Rscorded Over SIX Months of Survey FUn8k
Mala
Population No.
viral Hapaiitb %
No.
O-10 1 l-20 21-30 31-40 41-50 51-60 60
2,754 1,955 1,270 1,152 774 502 233
17 52 41 34 7 1 1
0.61 2.66 3.15 2.99 0.69 0.20 0.42
2.615 1.a34 1.289 1,049 657 380 156
10 36 48 25 2 1
0.36 1.96 3.72 2.38 0.30 0 0.65
Total
8,640
153
1.77
7,980
122
1.52
Age(yr)
Ik.
by a Basic Health Worker and a Lady Health Visitor. The age and the sex of the inhabitants were recorded. A questionnaire was answered by the head of the family regarding (1) recent cases of jaundice in the house, (2) recent history of anorexia, vomiting, diarrhoea, fever, etc. in any family member, and (3) recent death in the house. All the household members were examined for the presence of jaundice by looking at the bulber conjectiva during daylight. All members with suspect viral hepatitis (those with positive answers to questionnaire or yellow tinge of the sclera) were examined either by me or the attending medical officer. The case histories were recorded with particular reference to the data of onset of present complaints, a history of prior jaundice or liver disease, and exposure to drugs, toxins, transfusions or needle pricks. A detailed physical examination was made. Ten milliliters of blood was collected in two containers from the patient. One blood sample was sent to the laboratory on the same day for liver function tests and the other was stored at -16’C. Blood samples from contacts of patients with viral hepatitis were also collected. In the six months between November 1978 and April 1979, we revisited every house three times. The time interval in between the visits was six to eight weeks. The purpose of these visits was to find further cases of suspected viral hepatitis and to determine the condition of the patients detected on prior visits. The criteria used for the diagnosis of viral hepatitis were [I) recent onset of jaundice in the absence of prior history of jaundice or chronic liver disease; (2) no other cause to account for jaundice, including drug hepatitis, severe infections, cholestatic jaundice of pregnancy, eclampsia. etc.. (3) serum bilirubin of 2.0 mg/dl or more, with an increase in transaminases two times above the upper limit of normal (serum glutamic oxaloacetic transaminase (SGOT) 6 to la W/liter; serum glutamic pyruvic transaminase (SGPT) 3 to 26 IU/liter). Fulminant hepatitis was defined as occurrence of hepatic encephalopathy in a patient with viral hepatitis within four weeks of onset of the disease. Fatal hepatitis meant death in a case of fulminant hepatitis. Liver biopsies, with informed consent, were performed with
a Travenol tru-cut needle in 31 cases of viral hepatitis. In a11 of these cases the patients were admitted to Medical Unit II of S.M.H.S. Hospital, Medical College, Srinagar. Liver function tests included the estimation of serum bilirubin, serum alkaline phosphatase, serum total proteins, SGOT and SGPT [9]. The presence of hepatitis B surface antigen (HBsAg) was tested by passive hemagglutination [lo]. The
serums with positive or indeterminable results for HBsAg were screened for antibody to the core antigen of hepatitis B by cross over electrophoresis [ll]. This was used as a confirmatory test for hepatitis B [u]. The presence of antibody to hepatitis A in serum samples was tested by radioimmunoassay 1131. The results were expressed as count ratio (i.e., number of counts per minute in the negative/the number of counts per minute in the test samples). These values give some idea of the amount of antibody present, although it cannot be strictly quantitated. The stool samples were tested for the presence of hepatitis A antigen by the same procedure. The presence of acute phase immunoglobulin M [IgM) type of antibody to hepatitis A (anti-hepatitis A virus IgM) was tested by recently developed radioimmunoassay [14]. The specific IgM assay is the most useful as it can indicate a recent infection on a single serum sample and obviated the need for serial determinations of anti-hepatitis A virus for diagnosis of hepatitis A. The test stays positive for approximately three months after infection with hepatitis A virus.
R3nJLTs Epidemiologic Data. The area studied consisted of 15 villages, with 1,435 houses in which 1,603 families were living. The total population was 16,620 in November 1978. In 11 villages, with a population of 12,900, the people were using drinking water from a local stream (Ningli Nallah). The remaining four villages, with a population of 3,720. had an alternative water supply from a water supply system. There is no system for sewage disposal, and there were only country type latrines in these villages. In the total population of 16,620 inhabitants, 275 cases of viral hepatitis were recorded, yielding a 1.65 per cent incidence of the disease. Age and sex breakdown in these cases is given in Table I. The majority of cases occurred in the age group from 11 to 40 years. The male to female ratio was 1:0.8.269 cases of v@al hepatitis were recorded in the villages whose drinking water supplied from Ningli Nallah giving an incidence of 2.83 per cent. In contrast, only six cases (0.16 per cent) were recorded in those villages whose water supply came from a water supply system (X2 = 26.4 P
June 1880 The American Journal of Medtctne
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EPIDEMIC NON-A. NON-B HEPATITIS-KHUROO
on
SEP
’ OCT
Ill
’ NOV
“l-l
’
DEC
MONTH
’
JAN
’
FEB
’ MAR
’ APR
’
OF SURVEY
Fiigure 1.
Weekly occurrence of 155 viral hepatitis c&es in six villages from September 1978 to April 1979.
from 18 to 180/dl (mean 127/d]). These data were suggestive of gross fecal contamination of the stream water. The weekly incidence of 155 cases recorded in six villages over an eight month period is shown in Figure 1. The majority of cases occurred over a seven week period from the second week of November 1978 to the last week of December 1978. These data led us to believe that the epidemic was of the common source waterborne type. In the majority of houses, a single case of viral hepatitis was recorded. However, two cases per house were recorded in 18 houses and three cases per house were recorded in two houses. This, in addition to the occurrence of new cases after the main epidemic was over, suggested that disease also spread by personal contact. However, this mode of spread appeared not to be of major consequence in the development of the epidemic. Twelve patients, including four male and eight female subjects, had fulminant hepatic failure. All four male patients with fulminant hepatitis died. One of them was a 10 year old child whereas the remaining three were between 30 and 40 years of age. Six of eight female patients with fulminant hepatitis died. All of these patients were pregnant (in the third trimester of pregnancy); their ages ranged from 20 to 35 years. None of the nonpregnant female patients had fulminant hepatitis. Thirty-nine cases of anicteric hepatitis were recorded in 128 contacts of patients with viral hepatitis. On follow-up four of these had icterus within three to 10 days. The incidence of anicterii: hepatitis in contacts was 27.3 per cent-32 per cent in male subjects and 23.4 per cent in female subjects. Patients. The clinical picture in the cases recorded was typical of viral hepatitis. In 60.5 per cent of the cases preicteric symptoms lasted from one to 10 days (mean 3.5 days). The symptoms recorded in addition to jaundice were anorexia (79 per cent), dark-colored urine (58 per cent). nausea and vomiting (46 per cent), fever (44 per cent) and epigastric pain (41 per cent). Most of the symptoms regressed or disappeared within one week
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of the onset of jaundice. Cholestatic symptoms, in the form of clay-colored stools and itching. were seen in 20 per cent of the cases. The physical signs, in addition to icterus, were hepatomegaly in 85.2 per cent of the cases (1 to 7 cm with mean of 2 cm below right costal margin) and splenomegaly in 8.6 per cent of the cases. The liver size was reduced in 4.5 per cent of the cases. In all the nonfatal cases, follow-up showed clinical recovery. Biochemical Tests. Bilirubin levels varied from 2 to 22.2 mg/lOO ml (mean 5.98 f 3.76 mg/lOO ml). SGOT and SGPT levels ranged from 70 to 182 W/liter (mean 98.1 f 23.8 W/liter) and 97 to 297 W/liter (mean 122 f 56.1 IU/liter), respectively. The levels of alkaline phosphatase ranged from 8.4 to 46 King-Armstrong (mean 26.5 f 6.0 King-Armstrong units]. Total proteins were from 5.8 to 7.6 g/l00 ml [mean 6.24 f 0.49 g/100 ml) with albumin levels of 2.9 to 3.8 g/100 ml (mean 3.18 f 0.33 g/100 ml) and globulin levels of 2.2 to 3.6 g/l00 ml (mean 2.15 f 0.56 g/100 ml). Serial determinations of liver function tests and serum enzymes were carried out in 30 patients. The biochemical test results returned to normal in all within two to six weeks. Viral Studies (Table II). Thirty-five serum samples (21 from patients with viral hepatitis and 14 from their contacts) and 10 stool samples (from patients with viral hepatitis collected during the first week of the illness) under code, were sent to Dr. Susan Skidmore and tested for hepatitis B virus and hepatitis A virus by the methods described. All 10 stool samples were negative for hepatitis A virus antigen. The reports on HBsAg, antibody to the core antigen of hepatitis B and hepatitis A, and antibody to hepatitis A virus IgM type are shown in Table II. Of 31 serum samples tested, one (sample 181 had evidence of hepatitis B virus. Antibody to hepatitis A virus IgM variety was detected only in sample 34. This suggested that the remaining patients did not have hepatitis A inthe preceding three months. Antibody to hepatitis A virus was present in all but two cases (samples 26 and 37).The mean antibody titers in patients with viral hepatitis (i-10.0) and in their contacts [+12.6) did not differ (t = 1.06 P >0.20). These data suggested that all the patients had been exposed to hepatitis A virus prior to the onset of the epidemic. In the majority of the patients with viral hepatitis tested, evidence of hepatitis B virus and hepatitis A virus as an etiologic agent was lacking. Histologic Data. Liver biopsy specimens were available in 31 cases (10 male and 21 female patients). Twenty-eight biopsy specimens were from patients with nonfulminant viral hepatitis; two patients underwent biopsy after recovery from fulminant hepatitis (two female patients) and one specimen was obtained from a female patient soon after death. Pathologic findings in the liver biopsy specimens consisted of portal inflammation, ballooning degeneration, binucleation of liver cells, hepatocytic and intracanalicular bile stasis and Kupffer cell hyperplasia. Liver cell necrosis varied from
single cell (focal or zonal) to more severe forms resulting
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TABLE II
Reports on Hepatltls B Burface Antigen (HB&Ag); Am to Core Antigen of Hepatitis B (Antl-HBc), Antibody to Hepatitis A (Anti-HAV) and Acuto Phase hnmunoolokrlln Wl(IgM) Type of Antibody to Hepatitis A (antl-HAV lgM) in 35 Cases (21 Patients wlth Viral Hepatitis and 14 Contacts) from the Epidemic Area
Interval
Case No.
Sample No.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
1 2 4 5 6 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 30 31 33 34 35 36 37 39 40 50
Age (yr) and Sex 25, 30. 25, 35, 28, 26, 24, 36, 24, 30, 36, 35, 22, 20, 18, 10, 35, 20, 14, 18. 22. 30, 12, 20, 32, 20, 25, 18, 25, 40, 27, 30, 35, 55, 60,
F F F M M M F F F M M M F F M M M M M M M F M F F F F M M M M F M M M
BetweenOnset of illnessand CollectIon01 Sample(days)
Clinical Status Contact VH Contact Contact Contact Contact’ Contact Contact VH Contact Contact VH VH Contact VH VH VH VH Contact’ VH Contact
l
l
Anti-HAV
‘
.
.
.
.
.
.
.
.
7
l
VH VH VH VH VH VH VH VH VH VH VH VH
22 8 . . 8 6 5 10 ‘10 ... ‘10 . . 7 8 10 7 10 4 3 42 10 10 15
HBsAg
Anti-HBc
Negative Negative Negative Negative Negative ND Negative Negative Negative Negative Negative ? ? ? ? ND ND ND Negative ?
ND ND ND ND ND ND ND ND ND ND ND Negative Negative Negative Positive ND ND ND ND Negative Negative
Negative ? ? ? Negative Negative Negative Negative Negative Negative Negative Negative ?
ND Negative Negative Negative ND ND ND ND ND ND ND ND Negative
An&HAV +18.5 +14.8 +24.1 +18.5 +15.6 +7.9 +15.2 +12.1 +24.9 +13.1 +6.8 +12.9 +5.1 +7.1 +19.5 +9.6 +9.7 +7.8 +14.5 +7.2 +12.1 +6.6 -2.6 +9.2 +13.3 +3.0 +11.9 +14.2 +12.1 +13.2 +16.7 -2.6 +10.6 +6.5 +8.8
f9N Negative Negative Negative Negative ND
Negative Negative
t t t ND ND ND
-t Negative t t t Negative Negative t Positive Negative Negative Negative
t Negative Negative
NOTE: V H = viral hepatitis; ND = test not done; ? = results indeterminable. Contact had anicteric hepatitis. t Results too low to be significant. l
in lobular scars, bridging and submassive hepatic necrosis (Figure 2). Fourteen biopsy specimens had features of classic viral hepatitis [16]. Biopsy specimens from 10patients conformed to the cholestatic form of viral hepatitis with intracanalicular bile stasis and rosette formation of hepatocytes as the dominent features [17]. Four patients with nonfulminant disease had severe viral hepatitis with bridging seen in the liver biopsy specimens. Two patients with nonfatal fulminant disease had similar changes in these liver biopsy specimens. The patient with fatal viral hepatitis showed submassive hepatic necrosis in the postmortem liver biopsy specimen. Liver biopsies were repeated in five cases on follow up. The
liver histology had essentially returned to normal in all cases. COMMENTS The clinical, biochemical and histologic findings in the
patients of this study were typical of viral hepatitis. Infectious mononucleosis was excluded as a cause of hepatitis by the absence of clinical, hematologic and serologic findings of the disease in patients admitted to the hospital [18]. Epidemics of toxic hepatitis can occur [19,20], however, the histologic findings in the liver biopsy specimens in these epidemics are distinctive and were not present in our patients. Moreover, in the present study, there was no epidemiologic clue to ex-
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HEPATITIS-KHLJROO
Figure 2. h patients with viral hepatitis in the epidemic area. A, intracanalicular bile stasis (arrows), binucleation of liver cells and mild lobular disarray (cholestatic viral hepatitis). B, heavy portal tract inflammation, with spilling of the inflammatory cells into the lobule, mild ballooning degeneration in the periportal region and active lobular scars. The biopsy was performed after six weeks of recovery from fulminant hepatitis. The patient has made complete clinical and biochemical recovery from hepatitis on follow up.
posure to any known hepatotoxin. There had been no vaccination or skin testing program in the area nor had the population been exposed to any other mass percutaneous procedure. Less than 2 per cent of the patients had received any kind of injections prior to the development of the disease, so that nonparenteral acquisition of the disease had to be assumed in most cases. The assumption that the stream, Ningli Nallah, was the source of infection was supported by evidence of gross fecal contamination of this water and the statistically higher incidence of the disease in the area of distribution of the particular water supply. Non-A, non-B hepatitis was first recognized as a disease associated with transfusion of blood [2,3] and then in units for long-term hemodialysis [4]. It is, however, clear that it must also exist in the general community, as Villarejos and co-workers [7] have found in Costa Rica, and may spread by other routes. Sporadic
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cases, representing about half of all patients with acute hepatitis admitted to the Los Angeles County Hospital over nine months were attributed to non-A, non-B hepatitis and most patients with the illness had no apparent parenteral exposure [6]. Occurrence of present common source water-borne epidemic is of significance, as it definitely establishes the nonparenteral mode of spread of non-A, non-B hepatitis, and also gives an important clue to fecal oral spread of the disease. Viral hepatitis in the present study occurred mainly in those in the second, third and fourth decade of life. The low attack rate in the infant and child population could have two explanations. The disease at this age may run an anicteric course in the majority, and we have not studied liver function tests of healthy contacts at this age to prove this point. It is also possible that non-A non-B hepatitis is commonly contacted very early in life, making this population immune to another attack. The mode of spread of the present epidemic resembled that of hepatitis A virus [2l]. Our inability to detect progression of any of the cases to chronic liver disease during six months of follow-up, and the high incidence of anicteric cases in the community also strengthened the resemblance of this epidemic to that of hepatitis A virus [22,23]. Although the exact length of incubation could not be found, a rough estimate could be made of 10 to 40 days (mean 15 days) with a maximal range of seven weeks. This was derived from the time lag of development of disease in contacts of the patients with viral hepatitis and also by the occurrence of a maximal number of cases within the seven week period from the second week of November 1978 to the last week of December 1978. Post-transfusion non-A, non-B hepatitis has an incubation period ranging from 18 to over 100 days, with a mode of spread akin to hepatitis B virus [24]. These observations argue strongly for the presence of more than one non-A, non-B agent. Now that we have an animal in which we can study the disease, assessment of cross immunity and rechallenge studies should determine whether this is the case [25,26]. A significant per cent of the patients in the present study had cholestatic features. The serum concentration of transaminases was not appreciably increased. In addition, the histologic finding of gland-like transformation of hepatocytes was distinctive and resembled the changes described in liver biopsy specimens from patients during the Delhi epidemic of viral hepatitis in 1955-1956 [17]. These variations in the manifestations of the disease in the present epidemic from those of hepatitis A virus or hepatitis B virus speak for an alternative agent in the pathogenesis of viral hepatitis. This belief was strengthened by the observation of Villarejos and his co-workers [7], who described a non-A, non-B hepatitis in Costa Rica, with infrafamilial, nonparenteral spread. The illness in the cases described was mild, and the serum concentration of transaminases was not appreciably increased.
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One hopeful, although surprising, observation has been the apparent beneficial effect of gamma globulin in preventing non-A, non-B hepatitis [27]. This suggested that sufficient antibody to this agent must have been present in the gamma globulin to prevent any infection, which suggests that non-A, non-B hepatitis must be common. The accurate diagnosis of non-A, non-B hepatitis has thus become important. At present, the only way to diagnose non-A, non-B hepatitis is by exclusion, and development of a direct serologic test for the disease is a matter of urgency. ACKNOWLEDGMENT
I am indebted to Susan Skidmore, Ph.D. at Virus Research Laboratory East Birmingham Hospital, Bordesley Green East, Birmingham B9 5ST for testing the samples for hepatitis B virus and hepatitis A virus infections. Work of Mohd. Ramzan Teli, M.D. and Ghulam Jeelani Samoon, M.D. is greatly appreciated. I am especially grateful to S. N. Ahmed Shah, FRCP, Principal and Dean of the Medical College, Srinagar, for allowing me to work in the field from November 1978 to April 1979. Thanks are also due to Khalid Muzaffar M.D., Deputy Director of Health Services, Kashmir province: Mohd Muzaffar, M.D., Block Medical Officer, Sopore; Ghulam Mohammad Qureshi, Chief Technician, Postgraduate Laboratory Medical College, Srinagar; and to the team of basic health workers and lady health visitors of Sopore block. ADDENDUM
Since this paper was submitted for publication, further observations were available and are important. One hundred forty-one serum samples (No. 51-192) collected during the field study were tested. Of these, 136 samples were found to be positive for antibody to hepatitis A. Forty-six patients had acute viral hepatitis, 28 were suffering from anicteric hepatitis and 67 sam-
NON-A,
NON-B
HEPATITIS-KHUROO
ples were from persons with no disease. The samples from patients with viral hepatitis were collected in the first two weeks of illness. Sixty-eight samples from patients with viral hepatitis and anicteric hepatitis were tested for antibody to hepatitis A IgM and all were found negative. William Duermeyer, at Organon Scientific Development Group Oss Holland, kindly agreed to test 57 coded serum samples for antibody to hepatitis A and antibody to hepatitis A IgM by ELISA [28,29]. During the field survey 24 serum samples from the epidemic area were cross-checked. Antibody to hepatitis A virus IgM was absent whereas antibody to hepatitis A was present in all 24 samples. All the samples were found to be negative for HBsAg. The remaining 33 samples were collected from 30 patients with acute viral hepatitis attending S.M.H.S. Hospital, Medical College, Srinagar between March 1979 to November 1979. Antibody to hepatitis A virus IgM was found in one serum sample, whereas none was found in the remaining samples. Antibody to hepatitis A virus was present in 30 of 33 samples tested. Seventeen samples were found to have HBsAg whereas the remaining 16 did not. These observations further strengthened the belief that the present epidemic was of non-A, non-B hepatitis. Hepatitis A and hepatitis B virus was detected in nearly all the samples tested including the samples from persons with no disease or those with hepatitis B. Hepatitis A was rarely found in the adult population tested during the field survey or in the inpatient population. Further, 13 of 14 cases of non-B hepatitis recorded in the hospital population were also of non-A type. This led us to believe that exposure to hepatitis A occurred early in childhood and that the majority of the adult population tested was immune. I am presently studying viral hepatitis in younger age groups to evaluate the role of hepatitis A in this population.
REFERENCES 1. Deinstag JL, PurcellRI+ Recentadvances in the identification
8. Mosley JW, Redeker AC, Feinstone SM. et al.: Multiple
of hepatitis viruses. Postgrad Med J 1977; 53: 364-373. 2. Feinstone S, Kapikian AZ, Purcell RH. Alter HJ, Holland PV: Transfusion associated hepatitis not due to viral hepatitis type A or B. N Engl J Med 1975; 292: 767-770. 3. Alter HJ. Purcell RH, Holland PV, Feinstone SM. Morrow AG, Morilsugn Y: Clinical had serological analysis of transfusion associated hepatitis. Lancet 1975; 2: 838-841. 4. Galbraith RM, Portmann B, Eddleston ALWWF, et al.: Chronic liver disease developing after outbreak of HBsAg-negative hepatitis in haemodialysis unit. Lancet 1975; 2: 886. 5. Craske J, Dilling H, Stern D: An outbreak of hepatitis associated with intravenous injection of factor VIII concentrate. Lancet 1975: 2: 221-223. 6. Deinstag JL, Alaama A, Mosle JW, Redeker AG, Purcell RH: Etiology of sporadic hepatitis B surface antigen negative hepatitis. Ann Intern Med 1977; 87: l-6. 7. Villarejos VM, Visona KA, Eduarte CA: Evidence for viral hepatitis other than type A or type B among persons in Costa Rica. N Engl J Med 1975; 293: 1350-1352.
hepatitis viruses in multiple attacks of acute viral hepatitis. N Engl J Med 1977; 296: 75-78. 9. King EJ, Wootton IDP: Microanalysis in medical biochemistry, 3rd ed. London: Churchill, 1959. 10. Vyas GN, Shulman NR: Haemagglutination assay for antigen and antibody associated with viral hepatitis. Science 1970; 170: 332-333.
11.
Huang SN. Groh V: A study on antibodies produced with liver tissue containing Australia antigen and virus like particles. Lab Invest 1973; 2% 743. 12. Hoofnagle JH, Gerely RJ. Barker LF: Antibody to hepatitis B core antigen. Am J Med Sci 1975; 270: 179-188. 13. Purcell RH, Wong DC, Morilsugu Y, Deinstag JL, Route&erg JA, Boggs, JD: A microhler solid phase radioimmuno assay for hepatitis A antigen and antibody. J Immunol1976; 316: 349-356. 14. Bradley DW, Maynard JF, Hindman SH, et al.: Serodiagnosis of viral hepatitis A-detection of acute phase immunoglobulin M j anti hepatitis A virus by radioimmunoassay. J Clin Microbial 1977; 5: 521-530.
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15. Examination of water and health criteria for water supplies. In: Park JE, Park K, eds. Textbook of preventive and social medicine. 5th ed. Jabalpur, India: Banarsidas Bhanot, publishers, 1976; 194-199. 16. Smetana HF: Pathology of hepatitis. In: Schiff L, ed. Diseases of the liver, 2nd ed. Philadelphia and Montreal: J. B. Lippincott Co., 1963; 369-424. 17. Guuta DN. Smetana HF: The histouatholonv of viral hepatitis seen in’the Delhi epidemic (1955-195g). Ind J Med Res 1957: 45 (suppl): 101-113. 16. Finch SC: Laboratory findings in infection mononucleosis. In: Carter RL, Penman HG, eds: Infections mononucleosis, 1st ed. Oxford and Edinburgh: Blackwell Scientific Publications, 1969. 19. Mohabbat D, Srivastava RN, Younos MS, et al.: Epidemic of hepatic veno-occlusive disease in North west Afghanistan. Lancet 1976; 2: 269. 26. Tandon BN, Krishnamurthv L, Koshv A. et al.: Study of an epidemic of Jaundice presumabiy due to toxic hepatitis in north west India. Gastroenteroloev-. 1977; 72: 488-494.
21.
a24
Viswanathan
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R: Epidemiology. Infectious hepatitis in Delhi
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(1955-1956). Ind J Med Res 1957; 45: l-29. 22. Mosley JW: The epidemiology of viral hepatitis an overview. Am 1Med Sci 1975; 270: 253-270. 23. Rekela J, Redeker AG, Edwards VM, et al.: Hepatitis A virus in fulminant hepatitis and chronic active henatitis. Gas1 troenterology 1978; 74: 879-882. 24. Non-A non-B hepatitis (editorial) Br Med J 1978; 1: 942944. 25. Alter HI, Purcell RH, Holland. PV. et al.: Transmissible aeent in non A non B hepatitis. Lancet 1978; 1: 459-463. v 26. Tabor E, Gerety RJ, Drucker JA, et al.: Transmission of non A non B hepatitis from man to chimpanzee. Lancet 1978; 1: 463-465. 27. Seeff LB, Zimmerman BJ. Wright EC, et al.: A randomized double blind controlled trial of the efficacy of immune serum globulin for the prevention of post transfusion hepatitis. Gastroenterology 1977; 72: 111-121. 28. Duermeyer W, Veen JVD, Koster B: ELISA in hepatitis A. Lancet 1978; 1: 823. 29. Duermeyer W. Veen JVD: Specific detection of IgM-antibodies by ELISA applied in hepatitis A. Lancet 1978; 2: 684.
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SULTAN KHUROO. M.D., D.M.
Srinogar. Kashmir, India
From the Department of Medicine, Medical College. Srinagar.Kashmir, India. Requests for reprintsshould be addressed to Dr. Mohammed Sultan Khuroo, Medical College, Srinagar. Kashmir, India 190910. Manuscript accepted December 5.1979.
818
June 1980
A common source waterborne epidemic of viral hepatitis was studied in Kashmir valley over the six month period from November 1978 to April 1979. Highly sensitive serologic tests for hepatitis B and hepatitis A failed to reveal either one as an etiologic agent of hepatitis. Of 16,620 inhabitants of the area screened four times in these six months, viral hepatitis developed in 1.65 per cent. In addition, 27.3 per cent of 126 persons who had contacts with patients who had viral hepatitis had biochemical features of anicteric hepatitis. The mode of spread of the epidemic, length of incubation, clinical features and biochemical test results of the patients studied resembled that of hepatitis A. These findings were in contrast to that of non-A, non-B hepatitis following transfusion, which closely resembles hepatitis B. The data strongly suggest the possibility of another human hepatitis virus and established the fecal oral route of its spread. The availability of sensitive serologic tests for hepatitis A virus and hepatitis B virus made definitive etiologic classification of viral hepatitis possible [l]. As a result, another variant of acute hepatitis has been discovered unrelated to either of these viral agents [2]. At present, 60 to 90 per cent of the post-transfusion cases of hepatitis in the United States is of this non-A, non-B type [3]. For a time it was thought that non-A, non-B hepatitis could be transmitted only parenterally [4,5], recent evidence shows that it can be spread by nonparenteral routes [6,7]. These findings can be explained by the existence of more than one agent-a possibility that appears to be borne out by the results of studies in patients who have had multiple episodes of apparent acute hepatitis [8]. We have carried out a detailed epidemiologic study of a common source waterborne epidemic of viral hepatitis. Highly sensitive serologic tests for hepatitis B virus and hepatitis A virus failed to incriminate either one as an etiologic agent. The length of incubation, clinical features and mode of spread of this epidemic of non-A, non-B hepatitis differed from those of the post-transfusion type, strongly suggesting the existence of a fourth human hepatitis virus. MATERIALS AND METHODS In the first week of November 1978. I was informed of an outbreak of hepatitis in the Baramulla district of the Kashmir valley. A team survey of the area was started within two weeks of the first report. Every house in the area was visited
The AmericanJournalof Medicine Volume 88
EPIDEMIC NON-A, NON-B HEPATITIS-KHUROO
TABLE I
Age and Sex Dlstrlbutlon In 275 Cases of Viral HqWth
Rscorded Over SIX Months of Survey FUn8k
Mala
Population No.
viral Hapaiitb %
No.
O-10 1 l-20 21-30 31-40 41-50 51-60 60
2,754 1,955 1,270 1,152 774 502 233
17 52 41 34 7 1 1
0.61 2.66 3.15 2.99 0.69 0.20 0.42
2.615 1.a34 1.289 1,049 657 380 156
10 36 48 25 2 1
0.36 1.96 3.72 2.38 0.30 0 0.65
Total
8,640
153
1.77
7,980
122
1.52
Age(yr)
Ik.
by a Basic Health Worker and a Lady Health Visitor. The age and the sex of the inhabitants were recorded. A questionnaire was answered by the head of the family regarding (1) recent cases of jaundice in the house, (2) recent history of anorexia, vomiting, diarrhoea, fever, etc. in any family member, and (3) recent death in the house. All the household members were examined for the presence of jaundice by looking at the bulber conjectiva during daylight. All members with suspect viral hepatitis (those with positive answers to questionnaire or yellow tinge of the sclera) were examined either by me or the attending medical officer. The case histories were recorded with particular reference to the data of onset of present complaints, a history of prior jaundice or liver disease, and exposure to drugs, toxins, transfusions or needle pricks. A detailed physical examination was made. Ten milliliters of blood was collected in two containers from the patient. One blood sample was sent to the laboratory on the same day for liver function tests and the other was stored at -16’C. Blood samples from contacts of patients with viral hepatitis were also collected. In the six months between November 1978 and April 1979, we revisited every house three times. The time interval in between the visits was six to eight weeks. The purpose of these visits was to find further cases of suspected viral hepatitis and to determine the condition of the patients detected on prior visits. The criteria used for the diagnosis of viral hepatitis were [I) recent onset of jaundice in the absence of prior history of jaundice or chronic liver disease; (2) no other cause to account for jaundice, including drug hepatitis, severe infections, cholestatic jaundice of pregnancy, eclampsia. etc.. (3) serum bilirubin of 2.0 mg/dl or more, with an increase in transaminases two times above the upper limit of normal (serum glutamic oxaloacetic transaminase (SGOT) 6 to la W/liter; serum glutamic pyruvic transaminase (SGPT) 3 to 26 IU/liter). Fulminant hepatitis was defined as occurrence of hepatic encephalopathy in a patient with viral hepatitis within four weeks of onset of the disease. Fatal hepatitis meant death in a case of fulminant hepatitis. Liver biopsies, with informed consent, were performed with
a Travenol tru-cut needle in 31 cases of viral hepatitis. In a11 of these cases the patients were admitted to Medical Unit II of S.M.H.S. Hospital, Medical College, Srinagar. Liver function tests included the estimation of serum bilirubin, serum alkaline phosphatase, serum total proteins, SGOT and SGPT [9]. The presence of hepatitis B surface antigen (HBsAg) was tested by passive hemagglutination [lo]. The
serums with positive or indeterminable results for HBsAg were screened for antibody to the core antigen of hepatitis B by cross over electrophoresis [ll]. This was used as a confirmatory test for hepatitis B [u]. The presence of antibody to hepatitis A in serum samples was tested by radioimmunoassay 1131. The results were expressed as count ratio (i.e., number of counts per minute in the negative/the number of counts per minute in the test samples). These values give some idea of the amount of antibody present, although it cannot be strictly quantitated. The stool samples were tested for the presence of hepatitis A antigen by the same procedure. The presence of acute phase immunoglobulin M [IgM) type of antibody to hepatitis A (anti-hepatitis A virus IgM) was tested by recently developed radioimmunoassay [14]. The specific IgM assay is the most useful as it can indicate a recent infection on a single serum sample and obviated the need for serial determinations of anti-hepatitis A virus for diagnosis of hepatitis A. The test stays positive for approximately three months after infection with hepatitis A virus.
R3nJLTs Epidemiologic Data. The area studied consisted of 15 villages, with 1,435 houses in which 1,603 families were living. The total population was 16,620 in November 1978. In 11 villages, with a population of 12,900, the people were using drinking water from a local stream (Ningli Nallah). The remaining four villages, with a population of 3,720. had an alternative water supply from a water supply system. There is no system for sewage disposal, and there were only country type latrines in these villages. In the total population of 16,620 inhabitants, 275 cases of viral hepatitis were recorded, yielding a 1.65 per cent incidence of the disease. Age and sex breakdown in these cases is given in Table I. The majority of cases occurred in the age group from 11 to 40 years. The male to female ratio was 1:0.8.269 cases of v@al hepatitis were recorded in the villages whose drinking water supplied from Ningli Nallah giving an incidence of 2.83 per cent. In contrast, only six cases (0.16 per cent) were recorded in those villages whose water supply came from a water supply system (X2 = 26.4 P
June 1880 The American Journal of Medtctne
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EPIDEMIC NON-A. NON-B HEPATITIS-KHUROO
on
SEP
’ OCT
Ill
’ NOV
“l-l
’
DEC
MONTH
’
JAN
’
FEB
’ MAR
’ APR
’
OF SURVEY
Fiigure 1.
Weekly occurrence of 155 viral hepatitis c&es in six villages from September 1978 to April 1979.
from 18 to 180/dl (mean 127/d]). These data were suggestive of gross fecal contamination of the stream water. The weekly incidence of 155 cases recorded in six villages over an eight month period is shown in Figure 1. The majority of cases occurred over a seven week period from the second week of November 1978 to the last week of December 1978. These data led us to believe that the epidemic was of the common source waterborne type. In the majority of houses, a single case of viral hepatitis was recorded. However, two cases per house were recorded in 18 houses and three cases per house were recorded in two houses. This, in addition to the occurrence of new cases after the main epidemic was over, suggested that disease also spread by personal contact. However, this mode of spread appeared not to be of major consequence in the development of the epidemic. Twelve patients, including four male and eight female subjects, had fulminant hepatic failure. All four male patients with fulminant hepatitis died. One of them was a 10 year old child whereas the remaining three were between 30 and 40 years of age. Six of eight female patients with fulminant hepatitis died. All of these patients were pregnant (in the third trimester of pregnancy); their ages ranged from 20 to 35 years. None of the nonpregnant female patients had fulminant hepatitis. Thirty-nine cases of anicteric hepatitis were recorded in 128 contacts of patients with viral hepatitis. On follow-up four of these had icterus within three to 10 days. The incidence of anicterii: hepatitis in contacts was 27.3 per cent-32 per cent in male subjects and 23.4 per cent in female subjects. Patients. The clinical picture in the cases recorded was typical of viral hepatitis. In 60.5 per cent of the cases preicteric symptoms lasted from one to 10 days (mean 3.5 days). The symptoms recorded in addition to jaundice were anorexia (79 per cent), dark-colored urine (58 per cent). nausea and vomiting (46 per cent), fever (44 per cent) and epigastric pain (41 per cent). Most of the symptoms regressed or disappeared within one week
620
June 1886 The American Journal of Medicine
of the onset of jaundice. Cholestatic symptoms, in the form of clay-colored stools and itching. were seen in 20 per cent of the cases. The physical signs, in addition to icterus, were hepatomegaly in 85.2 per cent of the cases (1 to 7 cm with mean of 2 cm below right costal margin) and splenomegaly in 8.6 per cent of the cases. The liver size was reduced in 4.5 per cent of the cases. In all the nonfatal cases, follow-up showed clinical recovery. Biochemical Tests. Bilirubin levels varied from 2 to 22.2 mg/lOO ml (mean 5.98 f 3.76 mg/lOO ml). SGOT and SGPT levels ranged from 70 to 182 W/liter (mean 98.1 f 23.8 W/liter) and 97 to 297 W/liter (mean 122 f 56.1 IU/liter), respectively. The levels of alkaline phosphatase ranged from 8.4 to 46 King-Armstrong (mean 26.5 f 6.0 King-Armstrong units]. Total proteins were from 5.8 to 7.6 g/l00 ml [mean 6.24 f 0.49 g/100 ml) with albumin levels of 2.9 to 3.8 g/100 ml (mean 3.18 f 0.33 g/100 ml) and globulin levels of 2.2 to 3.6 g/l00 ml (mean 2.15 f 0.56 g/100 ml). Serial determinations of liver function tests and serum enzymes were carried out in 30 patients. The biochemical test results returned to normal in all within two to six weeks. Viral Studies (Table II). Thirty-five serum samples (21 from patients with viral hepatitis and 14 from their contacts) and 10 stool samples (from patients with viral hepatitis collected during the first week of the illness) under code, were sent to Dr. Susan Skidmore and tested for hepatitis B virus and hepatitis A virus by the methods described. All 10 stool samples were negative for hepatitis A virus antigen. The reports on HBsAg, antibody to the core antigen of hepatitis B and hepatitis A, and antibody to hepatitis A virus IgM type are shown in Table II. Of 31 serum samples tested, one (sample 181 had evidence of hepatitis B virus. Antibody to hepatitis A virus IgM variety was detected only in sample 34. This suggested that the remaining patients did not have hepatitis A inthe preceding three months. Antibody to hepatitis A virus was present in all but two cases (samples 26 and 37).The mean antibody titers in patients with viral hepatitis (i-10.0) and in their contacts [+12.6) did not differ (t = 1.06 P >0.20). These data suggested that all the patients had been exposed to hepatitis A virus prior to the onset of the epidemic. In the majority of the patients with viral hepatitis tested, evidence of hepatitis B virus and hepatitis A virus as an etiologic agent was lacking. Histologic Data. Liver biopsy specimens were available in 31 cases (10 male and 21 female patients). Twenty-eight biopsy specimens were from patients with nonfulminant viral hepatitis; two patients underwent biopsy after recovery from fulminant hepatitis (two female patients) and one specimen was obtained from a female patient soon after death. Pathologic findings in the liver biopsy specimens consisted of portal inflammation, ballooning degeneration, binucleation of liver cells, hepatocytic and intracanalicular bile stasis and Kupffer cell hyperplasia. Liver cell necrosis varied from
single cell (focal or zonal) to more severe forms resulting
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EPIDEMIC NON-A, NON-B HEPATITIS-KHUROO
TABLE II
Reports on Hepatltls B Burface Antigen (HB&Ag); Am to Core Antigen of Hepatitis B (Antl-HBc), Antibody to Hepatitis A (Anti-HAV) and Acuto Phase hnmunoolokrlln Wl(IgM) Type of Antibody to Hepatitis A (antl-HAV lgM) in 35 Cases (21 Patients wlth Viral Hepatitis and 14 Contacts) from the Epidemic Area
Interval
Case No.
Sample No.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
1 2 4 5 6 8 9 10 11 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 30 31 33 34 35 36 37 39 40 50
Age (yr) and Sex 25, 30. 25, 35, 28, 26, 24, 36, 24, 30, 36, 35, 22, 20, 18, 10, 35, 20, 14, 18. 22. 30, 12, 20, 32, 20, 25, 18, 25, 40, 27, 30, 35, 55, 60,
F F F M M M F F F M M M F F M M M M M M M F M F F F F M M M M F M M M
BetweenOnset of illnessand CollectIon01 Sample(days)
Clinical Status Contact VH Contact Contact Contact Contact’ Contact Contact VH Contact Contact VH VH Contact VH VH VH VH Contact’ VH Contact
l
l
Anti-HAV
‘
.
.
.
.
.
.
.
.
7
l
VH VH VH VH VH VH VH VH VH VH VH VH
22 8 . . 8 6 5 10 ‘10 ... ‘10 . . 7 8 10 7 10 4 3 42 10 10 15
HBsAg
Anti-HBc
Negative Negative Negative Negative Negative ND Negative Negative Negative Negative Negative ? ? ? ? ND ND ND Negative ?
ND ND ND ND ND ND ND ND ND ND ND Negative Negative Negative Positive ND ND ND ND Negative Negative
Negative ? ? ? Negative Negative Negative Negative Negative Negative Negative Negative ?
ND Negative Negative Negative ND ND ND ND ND ND ND ND Negative
An&HAV +18.5 +14.8 +24.1 +18.5 +15.6 +7.9 +15.2 +12.1 +24.9 +13.1 +6.8 +12.9 +5.1 +7.1 +19.5 +9.6 +9.7 +7.8 +14.5 +7.2 +12.1 +6.6 -2.6 +9.2 +13.3 +3.0 +11.9 +14.2 +12.1 +13.2 +16.7 -2.6 +10.6 +6.5 +8.8
f9N Negative Negative Negative Negative ND
Negative Negative
t t t ND ND ND
-t Negative t t t Negative Negative t Positive Negative Negative Negative
t Negative Negative
NOTE: V H = viral hepatitis; ND = test not done; ? = results indeterminable. Contact had anicteric hepatitis. t Results too low to be significant. l
in lobular scars, bridging and submassive hepatic necrosis (Figure 2). Fourteen biopsy specimens had features of classic viral hepatitis [16]. Biopsy specimens from 10patients conformed to the cholestatic form of viral hepatitis with intracanalicular bile stasis and rosette formation of hepatocytes as the dominent features [17]. Four patients with nonfulminant disease had severe viral hepatitis with bridging seen in the liver biopsy specimens. Two patients with nonfatal fulminant disease had similar changes in these liver biopsy specimens. The patient with fatal viral hepatitis showed submassive hepatic necrosis in the postmortem liver biopsy specimen. Liver biopsies were repeated in five cases on follow up. The
liver histology had essentially returned to normal in all cases. COMMENTS The clinical, biochemical and histologic findings in the
patients of this study were typical of viral hepatitis. Infectious mononucleosis was excluded as a cause of hepatitis by the absence of clinical, hematologic and serologic findings of the disease in patients admitted to the hospital [18]. Epidemics of toxic hepatitis can occur [19,20], however, the histologic findings in the liver biopsy specimens in these epidemics are distinctive and were not present in our patients. Moreover, in the present study, there was no epidemiologic clue to ex-
June 1980
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EPIDEMIC
NON-A,
NON-B
HEPATITIS-KHLJROO
Figure 2. h patients with viral hepatitis in the epidemic area. A, intracanalicular bile stasis (arrows), binucleation of liver cells and mild lobular disarray (cholestatic viral hepatitis). B, heavy portal tract inflammation, with spilling of the inflammatory cells into the lobule, mild ballooning degeneration in the periportal region and active lobular scars. The biopsy was performed after six weeks of recovery from fulminant hepatitis. The patient has made complete clinical and biochemical recovery from hepatitis on follow up.
posure to any known hepatotoxin. There had been no vaccination or skin testing program in the area nor had the population been exposed to any other mass percutaneous procedure. Less than 2 per cent of the patients had received any kind of injections prior to the development of the disease, so that nonparenteral acquisition of the disease had to be assumed in most cases. The assumption that the stream, Ningli Nallah, was the source of infection was supported by evidence of gross fecal contamination of this water and the statistically higher incidence of the disease in the area of distribution of the particular water supply. Non-A, non-B hepatitis was first recognized as a disease associated with transfusion of blood [2,3] and then in units for long-term hemodialysis [4]. It is, however, clear that it must also exist in the general community, as Villarejos and co-workers [7] have found in Costa Rica, and may spread by other routes. Sporadic
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June 1666
The American Journal of Medicine
cases, representing about half of all patients with acute hepatitis admitted to the Los Angeles County Hospital over nine months were attributed to non-A, non-B hepatitis and most patients with the illness had no apparent parenteral exposure [6]. Occurrence of present common source water-borne epidemic is of significance, as it definitely establishes the nonparenteral mode of spread of non-A, non-B hepatitis, and also gives an important clue to fecal oral spread of the disease. Viral hepatitis in the present study occurred mainly in those in the second, third and fourth decade of life. The low attack rate in the infant and child population could have two explanations. The disease at this age may run an anicteric course in the majority, and we have not studied liver function tests of healthy contacts at this age to prove this point. It is also possible that non-A non-B hepatitis is commonly contacted very early in life, making this population immune to another attack. The mode of spread of the present epidemic resembled that of hepatitis A virus [2l]. Our inability to detect progression of any of the cases to chronic liver disease during six months of follow-up, and the high incidence of anicteric cases in the community also strengthened the resemblance of this epidemic to that of hepatitis A virus [22,23]. Although the exact length of incubation could not be found, a rough estimate could be made of 10 to 40 days (mean 15 days) with a maximal range of seven weeks. This was derived from the time lag of development of disease in contacts of the patients with viral hepatitis and also by the occurrence of a maximal number of cases within the seven week period from the second week of November 1978 to the last week of December 1978. Post-transfusion non-A, non-B hepatitis has an incubation period ranging from 18 to over 100 days, with a mode of spread akin to hepatitis B virus [24]. These observations argue strongly for the presence of more than one non-A, non-B agent. Now that we have an animal in which we can study the disease, assessment of cross immunity and rechallenge studies should determine whether this is the case [25,26]. A significant per cent of the patients in the present study had cholestatic features. The serum concentration of transaminases was not appreciably increased. In addition, the histologic finding of gland-like transformation of hepatocytes was distinctive and resembled the changes described in liver biopsy specimens from patients during the Delhi epidemic of viral hepatitis in 1955-1956 [17]. These variations in the manifestations of the disease in the present epidemic from those of hepatitis A virus or hepatitis B virus speak for an alternative agent in the pathogenesis of viral hepatitis. This belief was strengthened by the observation of Villarejos and his co-workers [7], who described a non-A, non-B hepatitis in Costa Rica, with infrafamilial, nonparenteral spread. The illness in the cases described was mild, and the serum concentration of transaminases was not appreciably increased.
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EPIDEMIC
One hopeful, although surprising, observation has been the apparent beneficial effect of gamma globulin in preventing non-A, non-B hepatitis [27]. This suggested that sufficient antibody to this agent must have been present in the gamma globulin to prevent any infection, which suggests that non-A, non-B hepatitis must be common. The accurate diagnosis of non-A, non-B hepatitis has thus become important. At present, the only way to diagnose non-A, non-B hepatitis is by exclusion, and development of a direct serologic test for the disease is a matter of urgency. ACKNOWLEDGMENT
I am indebted to Susan Skidmore, Ph.D. at Virus Research Laboratory East Birmingham Hospital, Bordesley Green East, Birmingham B9 5ST for testing the samples for hepatitis B virus and hepatitis A virus infections. Work of Mohd. Ramzan Teli, M.D. and Ghulam Jeelani Samoon, M.D. is greatly appreciated. I am especially grateful to S. N. Ahmed Shah, FRCP, Principal and Dean of the Medical College, Srinagar, for allowing me to work in the field from November 1978 to April 1979. Thanks are also due to Khalid Muzaffar M.D., Deputy Director of Health Services, Kashmir province: Mohd Muzaffar, M.D., Block Medical Officer, Sopore; Ghulam Mohammad Qureshi, Chief Technician, Postgraduate Laboratory Medical College, Srinagar; and to the team of basic health workers and lady health visitors of Sopore block. ADDENDUM
Since this paper was submitted for publication, further observations were available and are important. One hundred forty-one serum samples (No. 51-192) collected during the field study were tested. Of these, 136 samples were found to be positive for antibody to hepatitis A. Forty-six patients had acute viral hepatitis, 28 were suffering from anicteric hepatitis and 67 sam-
NON-A,
NON-B
HEPATITIS-KHUROO
ples were from persons with no disease. The samples from patients with viral hepatitis were collected in the first two weeks of illness. Sixty-eight samples from patients with viral hepatitis and anicteric hepatitis were tested for antibody to hepatitis A IgM and all were found negative. William Duermeyer, at Organon Scientific Development Group Oss Holland, kindly agreed to test 57 coded serum samples for antibody to hepatitis A and antibody to hepatitis A IgM by ELISA [28,29]. During the field survey 24 serum samples from the epidemic area were cross-checked. Antibody to hepatitis A virus IgM was absent whereas antibody to hepatitis A was present in all 24 samples. All the samples were found to be negative for HBsAg. The remaining 33 samples were collected from 30 patients with acute viral hepatitis attending S.M.H.S. Hospital, Medical College, Srinagar between March 1979 to November 1979. Antibody to hepatitis A virus IgM was found in one serum sample, whereas none was found in the remaining samples. Antibody to hepatitis A virus was present in 30 of 33 samples tested. Seventeen samples were found to have HBsAg whereas the remaining 16 did not. These observations further strengthened the belief that the present epidemic was of non-A, non-B hepatitis. Hepatitis A and hepatitis B virus was detected in nearly all the samples tested including the samples from persons with no disease or those with hepatitis B. Hepatitis A was rarely found in the adult population tested during the field survey or in the inpatient population. Further, 13 of 14 cases of non-B hepatitis recorded in the hospital population were also of non-A type. This led us to believe that exposure to hepatitis A occurred early in childhood and that the majority of the adult population tested was immune. I am presently studying viral hepatitis in younger age groups to evaluate the role of hepatitis A in this population.
REFERENCES 1. Deinstag JL, PurcellRI+ Recentadvances in the identification
8. Mosley JW, Redeker AC, Feinstone SM. et al.: Multiple
of hepatitis viruses. Postgrad Med J 1977; 53: 364-373. 2. Feinstone S, Kapikian AZ, Purcell RH. Alter HJ, Holland PV: Transfusion associated hepatitis not due to viral hepatitis type A or B. N Engl J Med 1975; 292: 767-770. 3. Alter HJ. Purcell RH, Holland PV, Feinstone SM. Morrow AG, Morilsugn Y: Clinical had serological analysis of transfusion associated hepatitis. Lancet 1975; 2: 838-841. 4. Galbraith RM, Portmann B, Eddleston ALWWF, et al.: Chronic liver disease developing after outbreak of HBsAg-negative hepatitis in haemodialysis unit. Lancet 1975; 2: 886. 5. Craske J, Dilling H, Stern D: An outbreak of hepatitis associated with intravenous injection of factor VIII concentrate. Lancet 1975: 2: 221-223. 6. Deinstag JL, Alaama A, Mosle JW, Redeker AG, Purcell RH: Etiology of sporadic hepatitis B surface antigen negative hepatitis. Ann Intern Med 1977; 87: l-6. 7. Villarejos VM, Visona KA, Eduarte CA: Evidence for viral hepatitis other than type A or type B among persons in Costa Rica. N Engl J Med 1975; 293: 1350-1352.
hepatitis viruses in multiple attacks of acute viral hepatitis. N Engl J Med 1977; 296: 75-78. 9. King EJ, Wootton IDP: Microanalysis in medical biochemistry, 3rd ed. London: Churchill, 1959. 10. Vyas GN, Shulman NR: Haemagglutination assay for antigen and antibody associated with viral hepatitis. Science 1970; 170: 332-333.
11.
Huang SN. Groh V: A study on antibodies produced with liver tissue containing Australia antigen and virus like particles. Lab Invest 1973; 2% 743. 12. Hoofnagle JH, Gerely RJ. Barker LF: Antibody to hepatitis B core antigen. Am J Med Sci 1975; 270: 179-188. 13. Purcell RH, Wong DC, Morilsugu Y, Deinstag JL, Route&erg JA, Boggs, JD: A microhler solid phase radioimmuno assay for hepatitis A antigen and antibody. J Immunol1976; 316: 349-356. 14. Bradley DW, Maynard JF, Hindman SH, et al.: Serodiagnosis of viral hepatitis A-detection of acute phase immunoglobulin M j anti hepatitis A virus by radioimmunoassay. J Clin Microbial 1977; 5: 521-530.
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15. Examination of water and health criteria for water supplies. In: Park JE, Park K, eds. Textbook of preventive and social medicine. 5th ed. Jabalpur, India: Banarsidas Bhanot, publishers, 1976; 194-199. 16. Smetana HF: Pathology of hepatitis. In: Schiff L, ed. Diseases of the liver, 2nd ed. Philadelphia and Montreal: J. B. Lippincott Co., 1963; 369-424. 17. Guuta DN. Smetana HF: The histouatholonv of viral hepatitis seen in’the Delhi epidemic (1955-195g). Ind J Med Res 1957: 45 (suppl): 101-113. 16. Finch SC: Laboratory findings in infection mononucleosis. In: Carter RL, Penman HG, eds: Infections mononucleosis, 1st ed. Oxford and Edinburgh: Blackwell Scientific Publications, 1969. 19. Mohabbat D, Srivastava RN, Younos MS, et al.: Epidemic of hepatic veno-occlusive disease in North west Afghanistan. Lancet 1976; 2: 269. 26. Tandon BN, Krishnamurthv L, Koshv A. et al.: Study of an epidemic of Jaundice presumabiy due to toxic hepatitis in north west India. Gastroenteroloev-. 1977; 72: 488-494.
21.
a24
Viswanathan
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R: Epidemiology. Infectious hepatitis in Delhi
The American Journal of Medicine
(1955-1956). Ind J Med Res 1957; 45: l-29. 22. Mosley JW: The epidemiology of viral hepatitis an overview. Am 1Med Sci 1975; 270: 253-270. 23. Rekela J, Redeker AG, Edwards VM, et al.: Hepatitis A virus in fulminant hepatitis and chronic active henatitis. Gas1 troenterology 1978; 74: 879-882. 24. Non-A non-B hepatitis (editorial) Br Med J 1978; 1: 942944. 25. Alter HI, Purcell RH, Holland. PV. et al.: Transmissible aeent in non A non B hepatitis. Lancet 1978; 1: 459-463. v 26. Tabor E, Gerety RJ, Drucker JA, et al.: Transmission of non A non B hepatitis from man to chimpanzee. Lancet 1978; 1: 463-465. 27. Seeff LB, Zimmerman BJ. Wright EC, et al.: A randomized double blind controlled trial of the efficacy of immune serum globulin for the prevention of post transfusion hepatitis. Gastroenterology 1977; 72: 111-121. 28. Duermeyer W, Veen JVD, Koster B: ELISA in hepatitis A. Lancet 1978; 1: 823. 29. Duermeyer W. Veen JVD: Specific detection of IgM-antibodies by ELISA applied in hepatitis A. Lancet 1978; 2: 684.
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