Epidemiologic Notes and Reports Non-A, Non-B Hepatitis -- Illinois

From November 15, 1988, through June 30, 1989, 17 cases of non-A, non-B (NANB) hepatitis were reported to the Wabash County (Illinois) Health Department. In Wabash County, a small rural county in southern Illinois (estimated 1987 population: 13,800), only one other case of NANB hepatitis had been reported since 1982.

Of the 17 reported cases, 14 met a case definition for NANB hepatitis: an acute illness with symptoms and signs of hepatitis, elevated serum alanine aminotransferase (ALT) levels greater than 2.5 times the upper limit of normal, and negative serologic markers for acute hepatitis A and B. Interviews with local physicians and review of the county hospital's medical records and emergency room log books detected no other cases among Wabash County residents since September 1988, but three cases were identified in neighboring counties (Figure 1). Based on cases reported from January through June 1989, the annual rate of NANB hepatitis for Wabash County was 87.0 per 100,000 population, more than 100 times higher than the rate for all of Illinois during 1988 (0.7 per 100,000). Of the 17 cases in Wabash and neighboring county residents, six (35%) were male; 16 (94%) were white, and one was American Indian; and the median age was 28 years (range: 14-36 years). Nine (53%) patients were clinically jaundiced, and nine (53%) required hospitalization for their acute illness. Peak ALT values at onset of illness ranged from 201 to 3950 (median: 1493).

Patients were contacted to identify potential risk factors for acquiring NANB hepatitis. For 12 patients, information was obtained by interview, and for five, from medical chart review. Seven (41%) patients admitted to intravenous (IV)-drug use, and five (29%) were suspected IV-drug users. Of the seven who admitted IV-drug use, four used heroin and/or cocaine; one used heroin, cocaine, and methamphetamine; one used only methamphetamine; for one, the drug was unknown. Three of the 12 patients reported drinking greater than 55 ounces of alcohol per week. None of the patients reported blood transfusion within 6 months before onset of illness; none reported employment in a health-care setting with frequent blood exposure; and none reported sexual contact within 6 months before onset of illness with a person known to have had NANB hepatitis.

Blood specimens were obtained in late May and in June from 12 of the patients and 28 of their household, sexual, and needle-sharing contacts. All contacts denied symptoms of hepatitis. However, four had abnormal ALT values: three with histories of IV-drug use (elevations of 57-91 units/liter (upper limits of normal range from 36 to 53)) and a 6-year-old boy (ALT of 430) whose mother was a case-patient. All contacts were negative for IgM antibody to hepatitis B core antigen; of those with elevated ALT values, all were negative for IgM antibody to hepatitis A virus. Serologic testing of patients and contacts using a new assay for a parenterally transmitted NANB hepatitis virus is pending (1). Efforts will be made to obtain follow-up specimens to determine the extent of transmission to household and sexual contacts.

IV-drug use has existed in the county for many years; most drug users are thought to reside within the community and to have limited interaction with drug users from other areas. However, the apparent index patient was an IV-drug user who had lived intermittently in other states; he had recently returned to the area and became ill 1 week after arrival in November. Before his illness, he shared needles with another person who became ill 4 weeks later. Among the cases in March and April, two distinct clusters occurred that involved persons who were both friends and known or suspected IV-drug users. During the New Year holiday, some of these persons attended parties at which IV drugs were reportedly used. One IV-drug user reported that, because the area's needle supply had been scarce during the past year, needle-sharing had increased. Reported by: MR Lynn, MP Henry, MA, Wabash County Health Dept, Mount Carmel; JM Ottolini, CW Langkop, MSPH, JD Roder, RJ Martin, DVM, Div of Infectious Diseases, Illinois Dept of Public Health. Hepatitis Br, Div of Viral and Rickettsial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Parenterally transmitted NANB hepatitis accounts for 20%-40% of acute viral hepatitis in the United States. Although it has traditionally been considered a transfusion-associated disease, studies of community-acquired NANB hepatitis and data from the CDC national surveillance system have shown that 23%-42% of NANB hepatitis cases are associated with IV-drug use (2,3); in addition, 8%-11% are attributed to blood transfusion and 4%-8% to health-care occupational exposure. However, for as many as 57%, no source of infection can be identified (3). In this outbreak, the high proportion of ill persons who were confirmed or suspected IV-drug users and the lack of an identifiable common hepatotoxic chemical or drug suggest that the etiologic agent is parenterally transmitted NANB hepatitis virus.

Community-based outbreaks of parenterally transmitted NANB hepatitis have not been reported previously in the United States. Large outbreaks of NANB hepatitis occur in developing countries (4); however, in these settings, the disease is transmitted enterically and is caused by an agent distinct from that causing paren terally transmitted NANB hepatitis (5). This enterically transmitted form of disease is not believed to occur in the United States except for occasional imported cases (6).

The role of person-to-person contact in the transmission of NANB hepatitis in the United States has not been well defined. Transmission between spouses has been observed (7). In addition, a recent case-control study of patients with acute NANB hepatitis showed that contact with multiple heterosexual partners and household or sexual contact with a person who had had hepatitis were associated with risk for disease (8).

A portion of the genome of a virus that is probably a major cause of parenterally transmitted NANB hepatitis was recently cloned and a candidate serologic assay was developed (1,9). The assay should assist with studies of the mechanisms and extent of transmission of NANB hepatitis outside the transfusion setting, such as transmission by household and sexual contact. Previous studies of household and sexual transmission of NANB hepatitis using ALT testing have been limited by the lack of specificity of ALT values and the possibility of asymptomatic, biochemically silent transmission.

IV-drug use traditionally has been considered a problem of urban areas. The recognition of a high prevalence of drug use and an associated epidemic of a bloodborne disease in this rural community and the increased recognition of outbreaks of hepatitis A and B among drug users in rural settings (10-12) emphasize that IV-drug use is not limited to urban areas. This recognition also underscores the need for prevention and treatment programs in many geographic areas.

References

1. Kuo G, Choo Q-L, Alter HJ, et al. An assay for circulating antibodies to a major etiologic virus of human non-A, non-B hepatitis. Science 1989;244:362-4.

2. Alter MJ, Hadler SC, Francis DP, Maynard JE. The epidemiology of non-A, non-B hepatitis in the United States. In: Dodd RY, Barker LF, eds. Infection, immunity, and blood transfusion. New York: Alan R. Liss, 1985:71-9.

3. CDC. Hepatitis surveillance report no. 52. Atlanta: US Department of Health and Human Services, Public Health Service, 1989:25-7.

4. Ramalingaswami V, Purcell RH. Waterborne non-A, non-B hepatitis. Lancet 1988;1:571-3.

5. Krawczynski K, Bradley DW. Enterically transmitted non-A, non-B hepatitis: identification of virus-associated antigen in experimentally infected cynomolgus macaques. J Infect Dis 1989;159:1042-9.

6. De Cock KM, Bradley DW, Sandford NL, Govindarajan S, Maynard JE, Redeker AG. Epidemic non-A, non-B hepatitis in patients from Pakistan. Ann Intern Med 1987;106:227-30.

7. Guyer B, Bradley DW, Bryan JA, Maynard JE. Non-A, non-B hepatitis among participants in a plasmapheresis stimulation program. J Infect Dis 1979;139:634-40.

8. Alter MJ, Coleman PJ, Alexander WJ, et al. Importance of heterosexual activity in the transmission of hepatitis B and non-A, non-B hepatitis. JAMA 1989;262:1201-5.

9. Choo Q-L, Kuo G, Weiner AJ, Overby LR, Bradley DW, Houghton M. Isolation of a cDNA clone derived from a blood-borne non-A, non-B viral hepatitis genome. Science 1989; 244:359-62.

10. CDC. Hepatitis B--New Bern, North Carolina. MMWR 1979;28:373-4.

11. CDC. Fulminant hepatitis B among parenteral drug abusers--Kentucky, California. MMWR 1984;33:70,76-7.

12. Harkess J, Gildon B, Istre GR. Outbreaks of hepatitis A among illicit drug users, Oklahoma, 1984-87. Am J Public Health 1989;79:463-6.

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