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A previously asymptomatic carrier of hepatitis B virus receiving chronic hemodialysis developed acute delta hepatitis. The patient regularly received dialysis treatments on the same machine as a parenteral drug abuser with hepatitis B surface antigen (HBsAg)-positive chronic hepatitis whose serum was strongly positive for delta antibody. The drug abuser had a major bleeding episode that caused extensive environmental contamination 3 months before onset of illness in the index patient. No other patients receiving dialysis or staff members had evidence of delta infection. A surgeon previously infected with hepatitis B from the same parenteral drug abuser also had delta antibody. Testing for delta virus is indicated for both HBsAg-positive parenteral drug abusers and patients with hemophilia receiving chronic hemodialysis. All patients who are HBsAg- and delta-positive should receive dialysis separately from patients who are HBsAg-positive and delta-negative. Susceptible patients on dialysis and staff should receive hepatitis B vaccine to protect against both hepatitis B and delta virus infection.

Epidemic non-A, non-B hepatitis was diagnosed in three young Pakistani men during a 10-month period at the Los Angeles County-University of Southern California Medical Center. All three patients had recently visited or lived in Karachi, Pakistan. None had serologic markers of hepatitis B virus infection or IgM antibody (acute-phase) to hepatitis A virus. A liver biopsy from one patient showed marked cholestasis and cholangiolar transformation of hepatocytes, a pattern previously described in patients with epidemic non-A, non-B hepatitis. Immune electron microscopy of a stool specimen obtained from this patient 10 days after the onset of symptoms showed virus-like particles, 27 nm in diameter, that were specifically aggregated by antibody contained in acute-phase sera from the three Pakistani patients, from patients with non-A, non-B hepatitis in Burma and Nepal, and from an experimentally infected marmoset. Recognition of three separate cases of probable epidemic-type non-A, non-B hepatitis in patients at one institution during such a short time suggests that Pakistan is endemic for this infection and that the disease may be more commonly spread to the United States than is now presumed.

In a 2-month period four cases of hepatitis B occurred in hospital staff. Three months later two patients, hospitalized for open-heart surgery when the staff members had been infected, developed acute hepatitis B. Sera from all six ill individuals were subtype ayw and e-determinant positive. Epidemiologic investigation showed that the four staff had been exposed 3 months earlier to an asymptomatic hepatitis B surface antigen-positive (HBsAg) patient who was also e positive. To determine transmission from staff to patients study of 17 open-heart surgery patients was undertaken. Four of 17 were either HBsAg or anti-HBs positive. No correlation between infection and contact with three of four ill staff members or receipt of blood products was noted; however, 22 (46%) of 48 arterial blood gas specimens had been obtained from infected patients by one staff member, an inhalation therapist; this compared with seven (4%) of 157 specimens she obtained from control subjects (P less than 0.001). Furthermore, she handled indwelling arterial cannulae 25 (76%) of 33 times in infected patients compared with three (3%) of 95 times in control subjects (P less than 0.001). Transmission may have occurred via the arterial cannulae from a severe exudative dermatitis on the therapist's hands.

Sera of 103 carriers of hepatitis B surface antigen were assayed for e-antigen and anti-e. Twenty-four were e-antigen-positive, 31 anti-e-positive, and 48 had neither detectable (e-negative). Aminotransferases were elevated in 75% of the e-antigen-positive carriers compared with 25% of e-negative carriers (P less than 0.001) and 13% of anti-e-positive carriers (P less than 0.001). Serum DNA polymerase activity was significantly higher in the e-antigen-positive carriers than in carriers without e-antigen. Dane particles were shown in 10 of 12 carriers with e-antigen, compared with one of 12 e-negative carriers (P less than 0.0003) and none of 12 anti-e-positive carriers (P less than 0.00003). These results suggest that ongoing hepatitis B viral replication is more active in e-antigen-positive carriers than in carriers without e-antigen, a finding that may help explain the high prevalence of chronic active hepatitis described in these individuals.

Excerpt The availability of a safe and effective hepatitis B vaccine has stimulated debate about the most effective ways to use this product. Because the vaccine is costly and because tests for hep...

A randomized, double-blind, vaccine/placebo trial of the Merck 20-micrograms hepatitis B virus (HBV) vaccine was done among 1402 homosexual men attending venereal disease clinics in five American cities. Vaccination was followed by only minimal side effects. Two doses of vaccine induced antibody in 80% of vaccine recipients. A booster dose 6 months after the first dose induced antibody in 85% of recipients and markedly increased the proportion of recipients who produced high antibody titers. The incidence of HBV events was markedly less in the vaccine recipients compared to that in the placebo recipients (p = 0.0004). Between month 3 and 15 after the first dose, 56 more significant HBV events (hepatitis, or hepatitis B surface antigen positive, or both) occurred in the placebo group while only 11 occurred in the vaccine group. Ten of the 11 HBV events in the vaccine recipients occurred in hypo- or nonresponders to the vaccine. This vaccine appears to be safe, immunogenic, and efficacious in preventing infection with hepatitis B virus.

A nosocomial outbreak of fulminant hepatitis B infection at a medical center in Haifa, Israel, between 7 and 26 June 1986, involved five patients who had been hospitalized previously in the medical ward in late April and early May (first generation). This outbreak had an unusual clinical course, with fulminant hepatic failure associated with acute renal failure from acute glomerulonephritis, leading to death within a few days. The onset dates of hepatitis were tightly clustered temporally and incubation periods were short. Extensive laboratory and epidemiologic evaluation showed that the probable common-source vehicle of transmission was a multiple-dose vial of heparin and normal saline flush solution that may have been contaminated by blood of a known HBsAg carrier, who was positive for anti-HBe, hospitalized at the same time. A sixth patient died in August 1986 (second generation), after his initial admission in June that coincided with the terminal hospitalizations of three first-generation patients. Those patients had marked coagulopathies, and transmission to the sixth patient most probably occurred through environmental contamination by patients or through cross-contamination between patients through staff. The unusually high mortality rate (5 of 6) in this outbreak has not been definitely explained.

In September 1978, cases of hepatitis B in two patients treated by the same dentist led to investigation of a dental practice in Baltimore, Maryland. The dentist had had acute hepatitis B in June 1978 and had remained positive for hepatitis B surface antigen and hepatitis B e antigen over the ensuing 6 months. He had continued to work while infected, wearing surgical gloves to minimize the risk of transmitting infection. Serologic follow-up of 764 patients showed that a total of six patients, three of whom were symptomatic, had developed hepatitis B infection after dental treatment. All six were among a group of 395 patients treated before the dentist began wearing gloves. In this group, patients having highly traumatic dental work (attack rate 6.9%) were at significantly higher risk than patients having either less traumatic work (attack rate 0.5%) or nontraumatic work (attack rate = 0, p less than 0.02). None of 369 patients treated only when the dentist wore gloves became infected, suggesting that gloves could reduce the risk of virus transmission by the dentist.

For years patients hospitalized with viral hepatitis have been placed in two categories of isolation--enteric precautions and blood precautions. This strategy was based on the inability to differentiate between hepatitis A and B and on the assumption that feces and blood from patients with either type might be infective. It is now known that patients with hepatitis A do not pose a problem of disease transmission through direct contact with blood, and although blood of patients with hepatitis B may be infective, the virus is not transmitted via feces. The enteric route is the principal mode of transmission for hepatitis A, but maximal levels of hepatitis A virus excretion occur before the onset of jaundice. Non-A, non-B hepatitis is similar epidemiologically to hepatitis B. Thus, the major thrust for caring for patients hospitalized with viral hepatitis is toward blood precautions; the same precautions used when handling feces, urine, and excretions from all other hospitalized patients are appropriate for patients admitted with a diagnosis of hepatitis A.

Ten of sixty-one patients in a maintenance hemodialysis center seroconverted to hepatitis B surface antigen (HBsAg)-positive in August 1981. All but one were negative for antibody to hepatitis B core antigen, indicating early infection, and all received dialysis on the same days. Findings of case-control study showed that all "cases" received dialysis after the early morning shift, compared to 50% of controls (p = 0.01), and all cases used a multiple-dose vial of local anesthetic (bupivacaine), compared to 58% of controls (p = 0.03). At a common area used to prepare medications, an HBsAg carrier apparently stuck herself with a needle before drawing up bupivacaine, thus contaminating the vial that then served as the vehicle of transmission. Ten of eleven susceptible patients (those negative for antibody to HBsAg) who subsequently used bupivacaine and received dialysis seroconverted to HBsAg-positive, giving an attack rate of 91%. Serum samples from six of the ten cases were subtype Ad (or Adw), as was the implicated carrier's serum.

Excerpt The use of repeated infusions of adrenocorticotrophic hormone (ACTH) requiring 24-hour urine collections for 1 to 3 days has gained widespread acceptance in defining the functional integrit...