CEYLON J. MED. SCI. Vol. 18 N o . 2 , (December) 1969 Spread o f Infectious Hepatitis in the Family Group;f a report o f biochemical investigations by N . NAGARATNAM* A N D D A W N F. DE SILVA Government Hospital, ICegalle, Ceylon and S. SENTHESHANMUGANATHAN, H . R. PE1RIS A N D N . NAGARAJAH Medical Research'Institute, Colombo, Ceylon. .The epidemiology of infectious hepatitis is poorly understood. Although the gastro? intestinal tract is the principal pathway of infection in this widespread disease, parenteral transmission is known to occur in a variety of ways. The possibility of the respiratory route has been indicated by MacCallum, MacFarlan, Miles, Pollock & Wilson (1951) from their epidemiological studies. There are in addition several reports of epidemics caused by food (Ballance, 1954), water (Roos, 1956) and milk. An important method of spread appears to be person to person contact. This is facilitated under conditions where people congregate such as in military camps and institu? tions for mental defectives (Leading Article, 1964). Other factors which favour the spread of this disease has been found to be household congestion, together with poor sanitation and hygiene which are prevalent among the lower economic groups. In the endemic as well as in the epidemic situations, anicteric and asymptomatic cases of infectious hepatitis may be present widely in the population at risk. The importance of such cases in the epidemiology of the disease is becoming well recognised. Anicteric and asymptomatic cases are not uncommon (Paul, 1957), and the only abnormalities seen are in the liver function tests (Goldberg and Campbell, 1962). The importance of these cases as potent sources of infection is obvious. In Ceylon, as in other countries there is an increasing incidence of infectious hepatitis. Epidemics are uncommon but sporadic cases abound. With the above in view it was thought worthwhile to investigate the families of patients admitted to hospital with infectious hepatitis, to map out the incidence of infection in the household and to evaluate the common liver function tests under such a situation. Tests used in the study of patients with liver and biliary tract diseases can be classified according to the specific function of the liver involved. These include abnormalities of pigment metabolism, tests based on the liver's part in carbohydrate metabolism, tests based on changes in plasma protein, tests based on abnormalities of plasma lipids, determination t Paper reacj at the Annual Session of the Ceylon Ass. A d v m f Sci., Dec. 1969 * Present address, Government Hospital, Gampaha, W . P. Ceylon. T A B I E I. B I O C H E M I C A L F I N D I N G S I N T H E T H I R T Y (30) P O S I T I V E C A S E S O F I N F E C T I O U S H E P A T I T I S Serum Bilirubin Zinc Sulphate Turbidity Alkaline Phosphatase Scrum Glutamic Oxal? Acetic Transaminase Serum Glutamic Pyruvic Transaminase Normal Values Range Mean S D 0.8 mg % 1 . 2 - 2 2 . 5 m g % 5.77 5.2 2.0 ? 8 . 0 units 9.0 ? 35.0 24.97 7.18 3 ? 13 KA units 13.0 ? 58.0 35.0 14.32 23 ? 1 0 7 units 130 ? 500 326.8 90.3 25 ? 110 units 120 ? 430 333.7 14.3 Values 0.9?3.0 > 3 . 1 9?12 13?16 > 1 7 14?21 22?29 > 3 0 108?158 159? 258 > 2 5 9 111? 161 162? 261 > 2 6 2 Percentage of Total 36.7 63.3 6 13 81 13 17 70 6.6 13.3 80.1 6.6 10.0 83.4 > > H > > C O K S P R E A D O F I N F E C T I O U S H E P A T I T I S I N T H E F A M I L Y G R O U P S 3 of serum, enzyme activities and several others. In the present investigation wc determined the abnormalities of pigment metabolism (serum bilirubin), changes in plasma proteins (zinc sulphate turbidity) and serum enzyme levels (alkaline phosphatase and the transa? minases, serum glutamicpyruvic transaminase, (SGPT) and serum glutamic oxaloacetic transaminase, (SGOT). These tests are carried out as a routine in liver diseases in most of the Institutions in Ceylon. The samples of blood were drawn from household members of patients with infec? tious hepatitis, warded at the Government Hospital, Kegalle, which is situated about forty miles from the Medical Research Institute where the biochemical tests were carried out. In view of the transport difficulties encountered and in order to maintain a uniformity, all tests were carried out within four days of collection of samples of blood, unless stated to the contrary. The serum bilirubin (Dyke, 1951), zinc sulphate turbidity (Kunkel, 1947), alkaline phosphatase (King and Jegadieesan, 1959), serum glutamic oxalacatic transaminase and serum glutamic pyruvic transaminase (King, 1958) were estimated in all cases except when the samples were found to be haemolysed. R E S U L T S The normal values for serum bilirubin, zine sulphate turbidity, alkaline phosphatase and the transaminases are provided in Table I which also shows die biochemical findings in thirty positive cases of infectious hepatitis. For purposes of recording and analysis of the findings the values were arbitrarily divided into various groups viz: Zinc sulphate turbidity 9-12,13-16 and> 17 units; alkaline phosphatase 14-21, 22-30 and > 30 KA units; SGOT 108-158, 159-258 and > 259 units; SGPT 1 1 1 - 1 6 T , 162-261 and > 262 units. The age and sex distribution of the 140 contacts subjected to the present investigation are provided in Table II. The subjects were found to be equally distributed among the sexes and about 50% were below the age of 19 years. T A B U II A G E A N D S E X D I S T R I B U T I O N I N F A M I L Y C O N T A C T S Age group Male Female Total 11 4 15 5?9 18 10 28 10?14 7 8 15 15?19 9 7 16 20?24 4 8 12 25?29 3 5 8 30?34 1 6 7 35?39 3 9 12 40?44 6 8 14 45 above 7 6 13 69 71 140 5 4 N . NAGARATNAM A N D OTHERS TABLE III SIZE OF FAMILIES Number of occupants Families 3 3 4 8 5 7 6 4 7 6 8 0 9 and more 2 30 Table III shows the size of the families; little less than half of the families having six or more members in their households. Bilirubin: Of the positive cases of infectious hepatitis investigated all of them had biliru? bin values above 1.2 mg% (Table I) and in 63.3% it was above 3.1 mg%. The picture was quite different in the case of the contacts, all had values within the limits of normality. TABLE IV BIOCHEMICAL ABNORMALITIES IN RELATION T O FAMILY SIZE. Family size 3?4 5?6 > 7 Members Members Numbers of families 11 11 . 8 Zinc sulphate turbidity 22 48 47 Alkaline phosphatase 11 28 34 SGOT 8 9 9 SGPT 8 10 6 TABLE V F A M I L Y D I S T R I B U T I O N O F C O N T A C T S W I T H A B N O R M A L B I O C H E M I C A L D A T A . Numbers of members Zinc sulphate Alkaline SGOT SGPT affected in each turbidity phosphatase Family. 1 1 8 7 10 2 5 9 5 5 3 8 4 2 1 4 7 4 1 1 5 5 3 0 0 6 and > 6 2 1 0 0 Zinc sulphate turbidity : Among the positive cases of infectious hepatitis, all of them had values ranging from 9.0 to 35.0 units (Table I) while 83% of the contacts possessed abnormal values viz: 42% between 9-12, 35% between 13-16 and the balance having values > 16 units. Abnormal values were distributed almost equally among the sexes. SPREAD OF INFECTIOUS HEPATITIS IN THE FAMILY GROUP 5 5 In Table IV and V we have also provided the biochemical abnormalities in relation to the family size and family distribution respectively. The number showing abnormal zinc sulphate turbidity in families with five or more members was more than four times as much as those families who had less than five mem? bers. In two families, (Table V) six or more members, had abnormal values. Alkaline phosphatase: Elevated levels of alkaline phosphatase were observed in all positive cases of infectious hepatitis (Table I) and in 50% of the contacts (Table VI). In 40.8% of the contacts the values were found to lie between 14-21 ; in 32.4% between ' 22-30 and in the balance > 30 units of activity. The younger age groups showed a consi? derable increase in the phosphatase activity. Transaminase: Raised transaminase levels were found in all the positive cases of infectious hepatitis (Table I). The values ranged from a low value of 130 units to a high value of 500 units. But among the contacts the pattern was quite different. Thus 22.3% had raised SGPT activity, 51.9% between 108-158 units; 24.1% between 159-258 units and the same with values over 259 units (Table VII). A higher incidence in this abn? ormality was once again seen in the younger age groups; the highest values being in the 10-14 year group. The SGPT levels among the contacts also showed a similar pattern. The incidence of the increased SGOT and SGPT activity (Tables IV and V) appear to have no relation to the family size and the greatest number showing abnormal activity were in families with 1-2 members per family. In many cases the SGPT values were found to be raised while the SGOT remained within normal limits. These will be discussed at the end of this paper. TABLB VI CONTACTS WITH ELEVATED ALKALINE PHOSPHATASE IN RELATION TO AGE Age Number of contacts groups. with elevated levels % ! o f alkaline phosphatase . 0?4 15 100 5?9 23 79 i 10?14 15 100 I 15?19 9 56 I 20?24 2 f - . 17 ! 25?29 0 ' 0 30?34 0 , 0 35?39 3 23 4 0 - 4 4 3 21 45 and above 1 8 DISCUSSION Biochemical investigations: The importance of anicteric and asymptomatic cases have been stressed and their detection presents very many difficulties. This is mainly due to the non-availability of a technique to isolate the causal viral agent and to find a suscep? tible host animal for the infection. This difficulty has been overcome to a great extent by the introduction of serum enzyme studies. 56 N . NAGARATNAM AND OTHERS T A B U VII SGOT ACTIVITY IN RELATION T O OTHER BIOCHEMICAL. DATA A N D S G O T ACTIVITY WITH NORMAL SGOT LEVELS. SGOT units/ml. SGPT units/ml. Zinc Sulphate Alkaline turbidity (units) Phosphatase KA?units Contacts showing SGOT activity of 259 or more units. 460 350 9 15 380 320 16 36 320 275 10 37 280 387 11 35 Contacts showing SGOT activity of 158-258 units. 230 245 23 30 220 150 10 19 200 120 .11 6 200 128 13 50 210 120 9 19 180 30 16 28 166 130 15 Contacts showing SGOT activity o f 108-157 units. 150 135 17 15 150 120 10 15 150 78 13 8 140 49 8 25 140 123 18 11 144 67 12 8 130 75 8 13 124 90 27 26 122 60 19 14 120 185 24 22 120 67 11 50 110 18 19 20 110 52 15 7 110 67 11 33 Contacts showing elevated SGPT activity but normal SGOT 90 135 11 10 60 230 15 36 86 142 12 16 80 150 9 19 40 120 9 26 100 112 16 19 60 136 12 13 In the present investigation we have observed that in all positive cases of infectious hepatitis the bilirubin values were all raised above the limits of normality while among the contacts none had values above the normal limits. Therefore, the determination of the serum bilirubin would not throw any light when investigating an outbreak of infec? tious hepatitis. While the flocculation and turbidity tests employed in liver and biliary diseases depend to a large extent on the alterations in gamma-globulin, other factors are also involved. Kunkel (1947) described a zinc sulphate turbidity test which he claimed gives an index of the amount of gamma-globulin present. Discombe et at. (1954) also reported a close corrcla- SPREAD OP INFECTIOUS HEPATITIS IN THE FAMILY GROUP 57 tion with gamma-globulin as measured by electrophoresis. The normal range was found . to lie between 2 and 9 units for Ceylon subjects but results of up to 60 units have been obtained in our laboratories (unpublished data, 1968) in cases with liver disease. Kunkel (1947) also observed delayed rise in gamma-globulin in infectious hepatitis with subsequent prolonged high levels and suggested that this might reflect the production of antibodies rather than a disturbance in liver function. He claimed that the zinc sulphate test is the most sensitive for the detection of residual hepatitis. However, the present studies show that among the contacts abnormal values were obtained in 8 3 % of cases. Therefore, the determination of zinc sulphate turbidity might give a better indication of the presence of infectious hepatitis in the early stages of the disease. The present findings are therefore contrary, to the observations made by Kunkel (1947). W e are not in a position to provide a suitable explanation for such variation. It might be that the Ceylonese are more suscep? tible to infection than the European subjects. This needs further study. An analysis of serum enzyme levels among the contacts showed that 50% of them had an elevated serum alkaline phosphatase and a greater percentage of this abnormality was seen; in the younger age group. These findings are in close agreement with those of Harris and Beveridge (1967). The latter investigators found that the alkaline phospha? tase levels in growing children are on the higher side of normal. This test becomes very valuable ; when taken in conjunction with zinc sulphate turbidity test. It lias been shown by several workers that among the enzymes the transaminase esti? mation yields a better index of liver function especially in the detection'of subclinical cases. Both the transaminases SGOT and SGPT are found in most tissues but the relative amounts vary. Thus the liver is rich in SGPT while the heart in SGOT (Wrpblcwski, 1958). In infectious hepatitis the rise in SGOT generally preceded the appearance of other abnormal clinical aiid laboratory criteria and therefore served as an important and useful criterion in the diagnosis of this illness (Bodansky et al, 1954). In induced hepatitis, in an asymp? tomatic and anicteric patient Krugman et al. (1959) found that the only indication of liver involvement was an increase in the serum transaminase when all other conventional tests were within normal limits. But in the majority of their cases of anicteric hepatitis both the enzymes and the usual biochemical tests were abnormal. According, to them the serum trahsaminase activity though not specific, may be the most sensitive test for hepatitis in a patient who is thought to be incubating the disease. In art outbreak of infectious hepatitis in West Germany where 70% were anicteric, Schoen ahdWust (1961) concluded that the measurement of-SGPT was the most sensitive test for diagnosis and epidemiological purposes. Similarly, Goldberg and Campbell (1962) reported that the SGPT is the most reliable index of infectivity in all forms of the disease. The rise of SGOT precedes that of SGPT but the relative rise in the latter is gene? rally greater than that of SGOT though SGPT enzyme is less stable (Bodansky et al., 1954). In our series, contacts who showed a marked or moderate rise in SGOT activity also showed similar rise in SGPT activity (Table VII) but those who had minimum SGOT activity often had normal SGPT activity and vice versa. It is therefore not possible to conclud 58 N . NAGARATNAM A N D OTHERS from our series as to which is the more sensitive test for the detection of anicteric asympto? matic or subclinical cases. Using the transaminase activity as an index of infectivity approxi? mately 20% of the household members were infected. Epidemiology: The high infectivity of infectious hepatitis is well known. In the Bristol outbreak, Bothwell etah (1963) found that 10.3% of the adults and 39.6% of the children in the infected households had the illness. Out of a total of 2107 cases in 2 years, 790 (37%) were members of a family with one or more other cases. In Leicester (Burns, 1967) 9.6% of the adults and 36.2% of the children were affected. Case tocase infections and multiple cases within a household are frequent. The high infectivity accounts for the high incidence of anicteric and asymptomatic cases. The high incidence of these cases in the epidemic as well as in the endemic situation is well established. According to Capps et ah (1948) the non-icteric forms may represent 90% of the cases in a given epidemic. Capps et ah (1952) in a study of endemic hepatitis in an infant orphanage found that 90% of the patients who had the disease were without jaundice or hypcrbilirubinaemia, anicteric hepatitis is twice as common as the icteric in the endemic situation. Krugman et ah (1959) and MacCallum (1961) estimate the ratio of anicteric to icteric as 10:1. In an out-break of hepatitis in a bakery in which 41 persons had jaundice one was ill but without jaundice and 5 of the remaining 34 had abnormal liver function tests, the remainder being apparently well (Thorling, 1954). Schneider and Mosley (1959) studied families with hepatitis and control families in two situations; one where infectious hepatitis was epidemic and the other where it occurred as sporadic cases. Two to five measurements of SGOT activity were performed over a period of 1-3 months. In the former situation they found that 46% had abnormal SGOT as compared with only 6% in the controls. In the latter situation 39% of the families had abnormal SGOT activity while only 8% were affected among the controls. The anicteric and asymptomatic cases are potent sources of infection and present diffi? culties as to the control of the illness and their detection. Where the disease is endemic there are thus many sources as well as many ways of spread. Bothwell et ah (1963) in the Bristol outbreak has referred to the roles played in the illness by housing type, population density, sanitary provision, standards of hygiene in the social class, play situation, dental decay and shedding of teeth in children. In the Leices? ter outbreak, Burns (1967) found a significant association between the high incidence of the disease and domestic overcrowding and poor living standards and further the large part played by anicteric cases in the spread of the disease. Person to person contact is a common mode of spread, contact history according to Bothwell (1963) implies ingestion or inhalation of the virus material on the hands, clothing or bodily contact or exhalation on its recipient. 43% of 4341 patients with infectious hepatitis admitted to the hospital gave a history of contact with infection (Boughton, 1967). SPREAD OF INFECTIOUS HEPATITIS IN THE FAMILY GROUP 5 9 In the endemic situation large families household congestion and social class were some of the factors noted in the increasing incidence in Ceylon (Nagaratnam and Sikkander, 1969). The greater incidence in the wet zones were attributed by them to the increased popula? tion density in these areas. SUMMARY Thirty Ceylonese families of patients with infectious hepatitis consisting of 140 con? tacts were investigated. Of these, 80% had raised zinc sulphate turbidity levels, 50% had raised alkaline phosphatase levels and about 20% had raised transaminase levels (SGOT and SGPT). The index of infectivity as determined by these biochemical tests would have been higher, had more frequent estimations been done at regular intervals over a longer period. It was noticed that those who showed a moderate increase in SGOT activity also showed an increased SGPT activity as well. On the other hand, a minimal increase in SGOT activity was more often unaccompanied by a rise in SGPT activity and the converse was also found to be true. W e are unable to conclude from this series as to which is the more sensitive test under these conditions. The epidemiology of this illness has been briefly discussed and the importance of anicteric and asymptomatic cases stressed. The importance of large families with the accompaniment of poverty, overcrowding, unhygienic living conditions and increased avenues for person to person contact has been stressed in regard to the high incidence of the infection in such families.. The prevention of this illness therefore, to a large extent is purely a problem of hygiene and on the individual level where faccal-oral contamination is responsible. Personal cleanliness should be emphasised in the home. ACKN OWLEDGEMEN TS W e are grateful to Dr. N . M. P. 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