The cost-effectiveness of hepatitis B vaccine

We evaluated the cost-effectiveness of different strategies for use of hepatitis B vaccine. For populations with high prevalences of immunity and high attack rates, screening for prior immunity and vaccinating susceptibles is the lowest cost strategy. For populations with low prevalences of immunity but with high attack rates, vaccination without screening is most cost-saving. For populations with low prevalences of immunity and low attack rates, a non-vaccination policy is least costly. Vaccination will be cost-saving for populations with annual attack rates of five per cent, if direct medical costs only are considered or, for populations with annual attack rates on the order of one per cent, if indirect medical costs are included.

Elevated thyroxine levels due to increased thyroxine-binding globulin in acute hepatitis

Two patients are presented who had unexpected increases in serum thyroxine concentration due to acquired thyroxine-binding globulin excess associated with asymptomatic hepatitis. Serum hormone concentrations were also analyzed retrospectively in 10 outpatients with viral hepatitis. Acute hepatitis is associated with an increase in serum thyroxine and thyroxine-binding globulin concentrations and a corresponding decrease in the triiodothyronine resin uptake. In five patients, serum thyroxine concentration (mean +/- SD) was elevated at 21.08 +/- 5.86 micrograms/dl during illness, and decreased to 10.18 +/- 2.96 micrograms/dl during full recovery (p less than 0.05); serum thyroxine-binding globulin concentration was elevated at 2.14 +/- 0.36 mg/dl during illness, and decreased to 1.18 +/- 0.16 mg/dl during recovery (p less than 0.01). Interpretation of thyroid function test results can be difficult in patients with hepatitis. When serum thyroxine is elevated, careful attention to a decrease in the triiodothyronine resin uptake is essential to avoid the incorrect diagnosis of hyperthyroidism. Occasionally, this change in the triiodothyronine resin uptake may be the first evidence of occult hepatic inflammation.

Aplastic anemia and non-A, non-B hepatitis

Severe aplastic anemia is a rare but important complication of hepatitis. The agent(s) responsible for the hepatitis in these cases have not been well defined. Sixteen patient with hepatitis-associated aplastic anemia were studied for evidence of recent infection with hepatitis A virus, hepatitis B virus, cytomegalovirus, Epstein-Barr virus, and Toxoplasma. Results were compared with data from 10 randomly selected patients with aplastic anemia unassociated with hepatitis. Of the 16 patients, recent acute hepatitis A infection could be excluded in at least 14 patients. Hepatitis B surface antigen (HBsAg) was present in only one patient. A diagnosis of recent hepatitis B infection could not be excluded with confidence in two others. Tests for cytomegalovirus, Epstein-Barr virus, and Toxoplasma gave negative results. No patient with aplasia unassociated with hepatitis had evidence of recent hepatitis A infection, and the frequency of hepatitis B antibodies in this group was indistinguishable from that in patients with hepatitis. These data indicate that most cases of hepatitis that preceded aplastic anemia were not caused by hepatitis A virus or hepatitis B virus; non-A, non-B agents were probably involved in at least 13 of the 16 cases studied.

Hepatitis B immune complex glomerulonephritis: simultaneous glomerular deposition of hepatitis B surface and e antigens

A case of a 29-year-old homosexual male with chronic hepatitis B infection, cryoglobulinemia, and glomerulonephritis is described. The glomerular lesions were not readily classified, but exhibited features consistent with immune complex deposits, in both peripheral loop (predominantly epimembranous) and mesangial sites. Immunofluorescence studies, which included the use of a monoclonal antibody, showed that HBsAg was present in mesangial deposits but not in peripheral loop deposits. Immunoperoxidase studies employing HRP-conjugated anti-HBc and anti-HBe provided evidence that the epimembranous deposits contained HBe. Studies of the patient's serum revealed high titers of HBsAg, low titers of HBeAg, as well as anti-HBe and anti-HBc. The cryoglobulins contained small amounts of HBsAg, HBeAg, and anti-HBc, but anti-HBe and anti-HBs antibodies were not found. The possible mechanisms accounting for accumulation of HBsAg and HBeAg in glomeruli are discussed. In addition, the literature concerning the nature of hepatitis B antigens found in glomerular deposits is reviewed.

Circulating immune complexes in primary biliary cirrhosis: interactions with lymphoid cells

To evaluate the interactions between circulating immune complexes (CIC) and lymphoid cells in primary biliary cirrhosis (PBC), we determined (1) whether antibodies to lymphocytes in PBC serum, independent of CIC, could account for binding in the Raji cell assay for CIC and (2) whether CIC or other humoral factors in PBC serum could interact with lymphoid cells to alter their function. We found that three quarters of CIC positive PBC sera bound specifically to Raji cells via complement receptors, while only one quarter had antibodies to lymphoid cells or Raji cells devoid of complement receptors. We also demonstrated factors which inhibited cell-mediated cytotoxicity and suppressor cell activity in PBC sera; however, we found no correlation between the level and presence of CIC or of lymphocyte antibodies and the level or presence of these serum inhibitory factors. Thus, although the detection of CIC in PBC is not artifactual, the contribution of CIC and other serum factors to the other immunological aberrations in PBC remains to be elucidated.

Indications for use of hepatitis B vaccine, based on cost-effectiveness analysis

To formulate indications for the use of hepatitis B vaccine, we examined the cost effectiveness of three strategies: vaccinating everyone; screening everyone and vaccinating those without evidence of immunity; and neither vaccinating nor screening, but passively immunizing those with known exposure. Estimates of the hepatitis attack rate, prevalence of immunity, and frequency of known exposure were made for three representative populations: homosexual men, surgical residents, and the general population of the United States. Screening followed by vaccination of homosexual men and vaccination without prior screening of surgical residents would result in savings of medical costs. Neither screening nor vaccination is the lowest-cost strategy for the general population. Vaccination of susceptible persons will save medical costs for populations with annual attack rates above 5 per cent. Vaccination may be considered cost effective (or cost saving when indirect costs are included) for populations with attack rates as low as 1 to 2 per cent.

Hepatitis A and non-A, non-B viral hepatitis in São Paulo, Brazil: epidemiological, clinical and laboratory comparisons in hospitalized patients

During a 33-month period, 295 patients with acute viral hepatitis were admitted to a state hospital for civil servants and their dependents in São Paulo, Brazil. Seventy-nine per cent (232) were HBsAg negative. To define the contribution of non-A, non-B viral hepatitis to hepatitis morbidity in this population, further serological studies were performed in 147 confirmed HBsAg-negative patients. One hundred and twelve (76%) were serologically classified as hepatitis A based on identification of IgM antibody to hepatitis A virus. Thirty patients (20%) without IgM antibody to hepatitis A virus, HBsAg, or anti-HBc were categorized as the non-A, non-B hepatitis group. The remaining five patients had probable hepatitis B (IgM antibody to hepatitis A virus negative, HBsAg negative, anti-HBs negative but anti-HBc positive). These data suggest that all three etiological forms of viral hepatitis are endemic in São Paulo. Epidemiological, clinical, and laboratory features were compared to the hepatitis A and non-A, non-B hepatitis groups. Patients with non-A, non-B hepatitis were significantly older than patients with hepatitis A (mean age +/- S.D.: 30 +/- 22 years vs. 9 +/- 9 years, p less than 0.001). Contact with hepatitis or jaundice was recognized in 26 (23%) of 112 hepatitis A patients and 3 (10%) of 30 non-A, non-B patients, a difference which was not statistically significant. Parenteral exposures were identified in 13 (43%) of 30 patients with non-A, non-B hepatitis and 23 (21%) of the 112 hepatitis A patients. Blood transfusion in the 2 months preceding onset of illness was reported in 5 (17%) of the 30 non-A, non-B patients and in none of the hepatitis A group (p less than 0.001). Although prodromal symptoms and fever were more common in patients with hepatitis A, neither these nor other clinical features appeared to be distinguishing characteristics. Similarly, mean peak SGPT levels, peak SGPT levels of greater than or equal to 1,000 IU/per liter, and the mean duration of SGPT elevations for each group were not significantly different. Mean peak serum bilirubin levels were slightly higher in the non-A, non-B group than in the hepatitis A group (7.6 +/- 8.0 mg per dl vs. 5.1 +/- 2.7, p less than 0.01) and peak bilirubin levels greater than or equal to 10 mg per dl were found in 27% of the non-A, non-B group and 5% of the hepatitis A group (p less than 0.001). Whether the higher bilirubin levels reflect an agent-related phenomenon or an older population of affected patients is uncertain.

Hepatitis B vaccine administered to chronic carriers of hepatitis b surface antigen

We administered up to 6 monthly doses of hepatitis B vaccine to 16 chronic carriers of hepatitis B surface antigen (HBsAg) in an attempt to eliminate the antigen. The HBsAg in this vaccine differs from native antigen. No patients had elimination of HBsAg, but one of 10 no longer carried hepatitis B e antigen (HBeAg), Of 13 patients without preexisting antibody to HBsAg (anti-HBs), none acquired the antibody; two of three patients with preexisting heterotypic anti-HBs had transient, low-level increases in anti-HBs titers. Serum alanine aminotransaminase (ALT) levels fell in eight patients, remained unchanged in six, and increased transiently in two. Decreased ALT and HBeAg clearance, however, did not seem to be related to vaccination, and the transient ALT elevations appeared to represent sporadic, acute non-A, non-B hepatitis. No adverse effects other than sore arm and joint pain were seen. Immunization of chronic HBsAg carriers with hepatitis B vaccine, although ineffective in eliminating HBsAg, appeared to be safe. Such safety, if confirmed, would simplify the design of hepatitis B vaccination programs.

Alterations of T-cell subsets in primary biliary cirrhosis

To determine whether abnormalities of immunoregulatory T cells are associated with primary biliary cirrhosis, we characterized peripheral blood mononuclear cells in 16 patients with primary biliary cirrhosis and compared them with 30 normal controls. For this analysis we used monoclonal antibodies to the surface antigens on helper/inducer (T4+) and suppressor (T8+) T cell subsets and to a common T cell antigen (T3+). In contrast to normal persons, patients with primary biliary cirrhosis had reduced percentages of T3+ cells. More importantly, there was a relative decrease in helper/inducer (T4+) cells in 9/16 patients and a decrease in suppressor (T8+) cells in 5/16 patients. Furthermore, clinical studies indicated that patients with a decreased suppressor cell population (increased T4+ : T8+ ratio) had more advanced disease, as reflected by serum bilirubin levels (P less than 0.05) and histological changes in the liver (P less than 0.001), than those patients with a reduced helper T cell population (decreased T4+ : T8+ ratio). These data suggest that abnormalities of immune responsiveness in primary biliary cirrhosis may have a more complex origin than a uniform alteration in one immunoregulatory T-cell subset and that these immunoregulatory cell changes vary according to the severity of the disease.

Occupational exposure to hepatitis B virus in hospital personnel: infection or immunization?

In a seroepidemiologic survey of 624 health workers representing a spectrum of exposure to blood and patients, the authors detected serologic markers of hepatitis B virus infection in 16%, significantly greater than the 5% prevalence in 462 volunteer blood donors (p less than 0.001). Frequency of hepatitis B serologic markers increased as a function of contact with blood, previous hepatitis history, years in occupation, and age but not as a function on contact with patients, years of education, previous needlestick, transfusion or globulin injection. The inclusion of testing for antibody to hepatitis B core antigen (anti-HBc) enhanced the sensitivity of surveillance by identifying an additional 3% of hospital personnel with hepatitis B exposure and proved to be a better indicator of intense exposure to blood and hepatitis B than antibody to hepatitis B surface antigen (anti-HBs). In addition, anti-HBc testing discriminated between the 47 (62%) of the 76 anti-HBs-positive health workers, predominantly those most intensely exposed to blood, who had anti-HBc and the 29 (38%), predominantly those with low-intensity blood contact, who did not. The association of the anti-HBs-positive/anti-HBc-negative pattern with infrequent blood contact suggests that in the setting of continuous, low intensity exposure to hepatitis B, health workers may become naturally immunized with hepatitis B surface antigen rather than infected with hepatitis B.

Interpretation of various serological profiles of hepatitis B virus infection

Serial serum specimens from 149 patients with clinically diagnosed hepatitis were tested for five hepatitis B serological markers: hepatitis B surface antigen and its antibody (anti-HBs); hepatitis B e-antigen and its antibody (anti-HBe); and antibody to hepatitis B core antigen (anti-HBc). The times of appearance, disappearance, and persistence of these markers were used to differentiate various serological profiles obtained from the study. Four distinctive profiles were found to be associated with acute hepatitis B followed by recovery, and three with chronic hepatitis. These serologic profiles were assessed as diagnostic and prognostic guides for clinical management of the disease.

Hepatitis A virus: virologic, clinical, and epidemiologic studies

The last decade has borne witness to accelerated expansion of our understanding of hepatitis A virus. The agent of type A hepatitis is an RNA virus with a mean diameter of 27 nm. and biochemical-biophysical properties of an enterovirus. A variety of sensitive specific serologic techniques have been developed with which to identify hepatitis A virus and antibody, and both chimpanzees and marmosets have been studied extensively as experimental animal models. As a result of these studies, in vitro cultivation of hepatitis A virus has finally been accomplished, and a commercial radioimmunoassay for IgM antibody to hepatitis A virus has been developed for the rapid diagnosis of hepatitis A virus infection during acute illness. Clinically the illness caused by hepatitis A virus is relatively mild, often subclinical, and of limited duration and does not progress to chronic liver disease. This relative clinical benignity is reflected, according to preliminary histologic observations, in the sparing of the centrozonal area of the liver lobule. Rarely, however, hepatitis A virus can cause fulminant hepatitis. Type A hepatitis is transmitted almost exclusively by the fecal-oral route, and its spread is enhanced by epidemiologic settings favoring dissemination of enteric infections. Hepatitis A virus does not contribute to transfusion associated or other types of percutaneously transmitted hepatitis. Exposure to the virus increases as a function of age and decreasing socioeconomic class, but the incidence of hepatitis A virus infection in urbanized societies is decreasing. There is no evidence for the existence of chronic hepatitis A virus carriage; natural perpetuation of hepatitis A virus in urban communities appears to depend on a reservoir of nonepidemic, clinically inapparent cases. Until a vaccine, now being developed, becomes available, prevention of hepatitis A virus infection will continue to depend on maintenance of high standards of environmental and personal hygiene and on timely administration of immune serum globulin. Such prophylaxis may confer long lasting passive-active immunity but more frequently prevents infection entirely.

Impact of hepatitis on renal transplantation

In order to delineate the incidence, etiology, and impact of liver disease in renal transplant patients, we reviewed 405 consecutive transplants performed between 1970 and 1980. Hepatic dysfunction of at least 2 weeks' duration was diagnosed in 42 patients (10.4%). Of 28 patients acquiring hepatitis in the first post-transplant year, 26 (92.8%) developed chronic hepatitis; of 14 acquiring hepatitis after the first year, 9 (64.2%) developed chronic hepatitis. Of the 42 patients, 19 (45.2%) died, as compared with 16% of the nonhepatitis patients (P less than 0.001). Only one of these patients died of liver failure, with 15 of the 19 (78.9%) dying of extrahepatic infection. In addition, 12 of the 23 survivors (52.1%) suffered life-threatening infections from which they recovered, as compared with 20% of the nonhepatitis patients (P less than 0.01). Conversely, graft survival was significantly increased among the hepatitis patients (73% 1-year cadaveric allograft survival as compared with 50% for the nonhepatitis patients (P less than 0.01)). The etiology of the liver disease was identified in the minority of patients: 5 (11.9%) with hepatitis B, with none occurring since 1973; 10 (23.8%) with evidence of cytomegalovirus infection; and 1 (2.3%) with azathioprine toxicity. We conclude that the major cause of liver disease in renal transplant patients is non-A, non-B hepatitis, and furthermore, that this disease has a marked immunosuppressing effect resulting in increased allograft survival and a marked increase of life-threatening extrahepatic infection.

Therapy for acute and chronic hepatitis

Review of therapy for acute and chronic hepatitis indicates no available medication is effective in acute, severe acute, or fulminant hepatitis. Management should include observation in acute hepatitis and meticulous medical care in severe acute and fulminant hepatitis. The only patients with chronic active hepatitis in whom steroid therapy has been shown effective are those who are hepatitis B surface antigen (HBsAG) negative and have symptomatic disease with morphologically severe lesions. Insufficient data have been generated to determine the need for and response to therapy in patients with asymptomatic or mild HBsAG-negative or HBsAG-positive disease or symptomatic, severe HBsAG-positive disease. Among the more novel therapies being evaluated, transfer factor and levamisole do not hold great promise. In contrast, antiviral chemotherapy with interferon and vidarabine may benefit patients with chronic hepatitis B, but this remains to be better defined. Finally, it has become apparent how crucial to objective evaluation is the properly executed randomized controlled trial. In the future, we can look forward to new therapy modes based on a better understanding of the immunopathogenesis of acute and chronic hepatitis.

Cutaneous vasculitis associated with acute and chronic hepatitis

We encountered 11 patients who had rashes associated with hepatitis. Five of six acute hepatitis cases, but only one of five chronic hepatitis cases, were related to hepatitis B. Nine of the 11 patients had rash in the absence of clinically overt liver disease. Skin biopsy specimens showed histologic evidence of cutaneous vascular injury; specimens of urticarial and maculopapular rashes, which were seen in this series only with acute hepatitis, showed a primarily lymphocytic venulitis with focal necrosis, while palpable purpura, which was seen in this series only in chronic hepatitis, showed a primarily neutrophilic necrotizing vasculitis involving small vessels. One patient had lichen planus-like lesions. Demonstration of vascular deposits of immunoglobulins, complement, and fibrin in skin, as well as hypocomplementemia, circulating immune complexes, and mixed cryoglobulinemia, in these patients suggests that cutaneous lesions associated with liver disease resulted from immune complex-mediated vascular injury.

In vitro studies of enhanced IgG synthesis in severe alcoholic liver disease

Elevated serum immunoglobulin levels are a frequent finding in patients with severe alcoholic liver disease. We measured in vitro peripheral blood lymphocyte IgA synthesis by radioimmunoassay in 13 patients with severe alcoholic liver disease and hypergammaglobulinaemia and in normal control subjects. We found an increase in spontaneous IgA synthesis compared to controls (P greater than 0.001). On the other hand, there was no difference between groups in percentage stimulation of IgG production by B cells exposed to pokeweed mitogen. We also searched for defects in concanavalin A (Con A) induced suppressor T cell activity. There was no difference between patients with alcoholic liver disease and controls in the capability of such suppressor T cells to inhibit the response of allogeneic cells to a T cell mitogen. Similarly, we examined the capability of Con A-induced suppressor T cells to inhibit pokeweed mitogen-stimulated IgG synthesis by both autologous and allogeneic responder cells and observed no difference between alcoholic patients and controls. Thus these measured suppressor T-T and T-B cell interactions appeared no different from those in control subjects. Our studies suggest, therefore, that B cell IgG synthesis in vitro is enhanced in alcoholic liver disease. Furthermore, the capability to induce suppressor T cells which affects both T and B cell function appears intact; a finding in contrast to our previous observation in chronic active hepatitis. The investigations suggest that enhanced spontaneous IgG synthesis in vitro may result from intense antigenic stimulation in vivo.

Use of IgM-hepatitis A antibody testing. Investigating a common-source, food borne outbreak

An outbreak of hepatitis, type A, affecting 30 employees of a large metropolitan department store was investigated using traditional case findings, a food preference questionnaire, and case-control methods. In addition, the new serological tests for IgM and IgG antibody to hepatitis A virus (anti-HAV) were employed to establish a serological diagnosis of hepatitis A infection, to define the control group, and to identify the index case, an asymptomatic food handler. Twenty-five of 25 cases tested had IgM anti-HAV, whereas none of 73 controls and one of 46 food handlers were IgM anti-HAV positive. This test eliminated three suspect cases that were diagnosed as hepatitis but that had atypical epidemiologic features. Epidemiologic and serological analysis confirmed the association of illness with eating in the employees' cafeteria and eating cold sandwiches.

Non-A, non-B hepatitis after experimental transmission of malaria by inoculation of blood

In a 1969 prisoner volunteer study of malaria transmission by blood inoculation, six persons were subinoculated sequentially, and acute hepatitis occurred in the last four (sequential study). Subsequently, another 15 volunteers receiving malaria-rich blood from 14 different donors were followed prospectively (prospective study), and hepatitis developed in six. Incubation periods were shorter but serum transaminase levels were higher for the cases of hepatitis occurring in the sequential study than in the prospective study. Although the illnesses were clinically mild, elevations in transaminase levels persisted for more than six months in five and fluctuating transaminase activities were observed in nine of the 10 affected persons. In addition, an 11th prisoner developed sporadic hepatitis. Neither known human hepatitis viruses nor malaria could be implicated in these cases, which were classified as non-A, non-B (NANB) hepatitis. The data suggested that the viremia of short-incubation NANB hepatitis may begin within the first week after inoculation, confirmed that NANB hepatitis may be transmitted either percutaneously or nonpercutaneously, and provided further evidence that there is more than one NANB agent.

Hepatitis B as an immune complex disease

Evidence has accumulated which indicates that several of the extrahepatic syndromes associated with HBV infection--the prodromal arthritis-dermatitis syndrome, systemic necrotizing vasculitis, and glomerulonephritis--result from immune complex-mediated injury; however, our understanding of their pathogenesis remains incomplete. Other disorders--essential mixed cryoglobulinemia and polymyalgia rheumatica--have also been linked to HBV, but these associations are more controversial. In most patients with HBV infection, circulating immune complexes are of no pathogenetic importance, but may reflect normal mechanisms for immune clearance of viral antigens. Little insight has been gained into the factors which predispose to immune complex-mediated tissue injury in only a small proportion of patients with type B hepatitis, and few options are available for the management of patients with these extrahepatic disorders. Finally, circulating immune complexes do not appear to contribute to the pathogenesis of liver disease associated with HBV infection.

Serodiagnosis of viral hepatitis A by a solid-phase radioimmunoassay specific for IgM antibodies

A solid-phase radioimmunoassay for detecting specific IgM antibodies to hepatitis A virus (HAV) was developed and characterized. The test utilized microtiter plates coated with anti-IgM to specifically absorb the IgM antibodies from the test serum. The anti-hepatitis A IgM antibodies are measured by the specific consecutive binding of hepatitis A antigen and radiolabelled anti-hepatitis A antibodies (anti-HA). In 6 chimpanzees infected with HAV, IgM anti-HA was detected from about the first date of elevated transaminases and was positive for about 3 months. The usefulness of the test was confirmed by testing acute phase sera of 30 patients from a common source outbreak of epidemic hepatitis, and negative sera from 2 control groups. A collection of serum specimens from 190 patients with sporadic HBsAg-negative hepatitis in Brazil was also tested and an etiologic association with HAV was confirmed in the majority of these cases.