|Year : 2013 | Volume
| Issue : 3 | Page : 261-265
Prevalence of hepatitis A virus, hepatitis B virus, hepatitis C virus, hepatitis D virus and hepatitis E virus as causes of acute viral hepatitis in North India: A hospital based study
P Jain, S Prakash, S Gupta, KP Singh, S Shrivastava, DD Singh, J Singh, A Jain
Department of Microbiology, K.G. Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||18-Oct-2012|
|Date of Acceptance||25-Apr-2013|
|Date of Web Publication||25-Jul-2013|
Department of Microbiology, K.G. Medical University, Lucknow, Uttar Pradesh
Source of Support: The Indian Council of Medical Research, New Delhi, India, Conflict of Interest: None
Context: Acute viral hepatitis (AVH) is a major public health problem and is an important cause of morbidity and mortality. Aim: The aim of the present study is to determine the prevalence of hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV) and hepatitis E virus (HEV) as causes of AVH in a tertiary care hospital of North India. Settings and Design: Blood samples and clinical information was collected from cases of AVH referred to the Grade I viral diagnostic laboratory over a 1-year period. Subjects and Methods: Samples were tested for hepatitis B surface antigen, anti-HCV total antibodies, anti-HAV immunoglobulin M (IgM) and anti-HEV IgM by the enzyme-linked immunosorbent assay. PCR for nucleic acid detection of HBV and HCV was also carried out. Those positive for HBV infection were tested for anti-HDV antibodies. Statistical Analysis Used: Fisher's exact test was used and a P < 0.05 was considered to be statistically significant. Results: Of the 267 viral hepatitis cases, 62 (23.22%) patients presented as acute hepatic failure. HAV (26.96%) was identified as the most common cause of acute hepatitis followed by HEV (17.97%), HBV (16.10%) and HCV (11.98%). Co-infections with more than one virus were present in 34 cases; HAV-HEV co-infection being the most common. HEV was the most important cause of acute hepatic failure followed by co-infection with HAV and HEV. An indication towards epidemiological shift of HAV infection from children to adults with a rise in HAV prevalence was seen. Conclusions: To the best of our knowledge, this is the first report indicating epidemiological shift of HAV in Uttar Pradesh.
Keywords: Acute viral hepatitis, epidemiological shift, hepatitis A virus, North India, prevalence
|How to cite this article:|
Jain P, Prakash S, Gupta S, Singh K P, Shrivastava S, Singh D D, Singh J, Jain A. Prevalence of hepatitis A virus, hepatitis B virus, hepatitis C virus, hepatitis D virus and hepatitis E virus as causes of acute viral hepatitis in North India: A hospital based study. Indian J Med Microbiol 2013;31:261-5
|How to cite this URL:|
Jain P, Prakash S, Gupta S, Singh K P, Shrivastava S, Singh D D, Singh J, Jain A. Prevalence of hepatitis A virus, hepatitis B virus, hepatitis C virus, hepatitis D virus and hepatitis E virus as causes of acute viral hepatitis in North India: A hospital based study. Indian J Med Microbiol [serial online] 2013 [cited 2015 May 22];31:261-5. Available from: http://www.ijmm.org/text.asp?2013/31/3/261/115631
| ~ Introduction|| |
Acute viral hepatitis (AVH) is a major public health problem in India and other developing nations having inadequate sanitary conditions. Few studies describing the pattern of hepatitis viruses are available from New Delhi ,, and Chandigarh , in North India, but to our knowledge no recent study is available from other parts of North India. Therefore, this study was undertaken to determine the prevalence of hepatotropic viruses among individuals presenting as AVH in Northern India so that appropriate management of cases as well as preventive strategies for this part of the country could be planned.
| ~ Subjects and Methods|| |
Over a 1-year period from July 2011 through June 2012, total 267 cases of AVH were referred to the Grade-I viral diagnostic laboratory. The samples from hospitalised patients of both sexes and all ages, who did not have a known co-existing illness were only included. Known alcoholics and patients on hepatotoxic drugs were excluded from the study. Written informed consent was taken from patients or guardians, in case patient was a child or was not able to consent. The study was approved by the institutional ethics committee. The patients were tested for five hepatitis viruses, hepatitis A virus (HAV), hepatitis B virus (HBV) hepatitis C virus (HCV), hepatitis D virus (HDV) and hepatitis E virus (HEV).
An AVH case was defined as a person having an acute illness of <15 days duration with a discrete onset of any sign or symptom (e.g., fever, headache, malaise, anorexia, nausea, vomiting, diarrhoea and abdominal pain) and either a) jaundice or b) elevated serum alanine aminotransferase (ALT) levels > 100 IU/L documented at least twice at a 1-week interval without any history of pre-existing liver disease.  Patients who developed encephalopathy after the onset of icterus were considered to have acute hepatic failure. 
Approximately 5 ml blood sample was collected from all cases, serum was separated and stored at −20C until tested. Relevant clinical information was collected from the laboratory database and clinical case sheets that included history of jaundice, physical signs and symptoms and biochemical results (aspartate aminotransferase [AST], ALT, serum bilirubin and alkaline phosphatase [ALP]).
Serum was assessed for anti HAV immunoglobulin M (IgM) (DSI, SRL Italy), hepatitis B surface antigen (HBsAg) (Erba Transasia), anti HCV total antibodies (Erba Transasia) and anti HEV IgM (DSI, SRL Italy). All analyses were performed using commercial kits based on the enzyme-linked immunosorbent assay (ELISA) as per the manufacturer's instructions. To decrease the rate of false positivity, the initially reactive samples were retested.
The samples were also tested for HBV deoxyribonucleic acid (DNA) and HCV RNA by conventional PCR. For the detection of HBV DNA and HCV RNA, extracted nucleic acid samples were amplified using methods of Olioso et al.  and Bukh et al.  respectively. PCR products were visualised after electrophoresis on 2% agarose gel.
Samples that tested positive for HBsAg or HBV DNA were also tested for anti-HDV total antibodies by ELISA (DSI, SRL, Italy).
The prevalence of hepatitis viruses were analysed by Fisher's exact test. Two tailed tests were used and a P < 0.05 was considered to be statistically significant.
| ~ Results|| |
Of 267 cases enrolled in the study, 143 were children and 124 were adults. Males (62.54%) outnumbered females (37.45%). Total 23.22% (62/267) cases developed encephalopathy during their illness and were therefore labelled as acute hepatic failure [Table 1]. The viral aetiology was confirmed in 161 (60.29%) cases while in 106 (39.70%) cases no hepatitis virus could be detected. Hepatitis A virus was found in the maximum number of cases (26.96% cases), followed by HEV (17.97% cases), HBV (16.10% cases) and HCV (11.98%) [Table 1].
|Table 1: Prevalence of causative agents of acute viral hepatitis and fulminant hepatic failure |
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The percentage positivity of anti-HAV IgM was similar in children (27.27%) and adults (26.61%) (P = 0.109). On the other hand, a much larger proportion of adults were positive for anti-HEV IgM (27.42%), HBsAg (23.38%) and anti-HCV total antibodies (18.54%) compared with children (9.79%, 9.79%, and 6.29% respectively) (P = 0.001 and 0.001, P = 0.001 respectively).
Infection with more than one virus could be detected in 34 cases, the most common being HAV and HEV co-infection in 23 cases; 15 of which presented as AVH alone while 8 cases developed Acute Hepatic Failure. Co-infection of HBV with other viruses was present in 10 cases (1 with E, 3 with C and 6 with A).
In cases that developed AHF during the course of disease, HEV was found in the maximum number of cases (25.80%, 16/62) followed by co-infection with HAV and HEV (12.90%, 9/62), followed by HBV (9.67%, 6/62) [Table 1]. No case of AHF had HCV or isolated HAV infection.
Results of ELISA and PCR were compared for HBV and HCV [Table 2]. PCR could detect 2 additional HBV cases and 6 additional HCV cases while ELISA could detect 2 additional HCV cases. No case was positive only for HBsAg. For these discordant results, the tests were repeated with fresh blood samples to rule out any technical errors or sample degradation. Both these cases were immunocompetent adults and none had alcoholic or autoimmune liver disease.
All patients were icteric at the time of enrolment in the study. Fever (64.87%), right-upper-quadrant pain with tenderness (59.02%), anorexia (26.82%), vomiting (24.63%), nausea (23%), malaise (22.43%), diarrhoea (18.21%) and head-ache (11.46%) were the most common clinical signs and symptoms, in that order of frequency. Hepatomegaly and Splenomegaly were found in 22 and one patients, respectively. The mean AST, ALT, serum ALP and total serum bilirubin values were 222.88 IU/L, 155.67 IU/L, 475.07 KAU/L and 6.68 mg/dl respectively.
|Table 2: Comparison of ELISA and PCR results for HBV and HCV in 267 AVH cases |
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Seasonal distribution of HAV and hepatitis E virus was studied. Although cases are seen throughout the year, maximum number of cases was seen from February through June that is autumn and summer seasons in this part of the country [Figure 1].
|Figure 1: Seasonality of hepatitis A virus/hepatitis E virus positive cases|
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| ~ Discussion|| |
Several studies on AVH are available from India and abroad that have reported varying prevalence of hepatotropic viruses: HAV (1.7-67%), HBV (7.3-42%), HCV (1.16-10.6%) and HEV (16.3-66.3%) ,,,,, [Table 3]. In the present study, HAV (26.96%) was identified to be the most common cause of acute hepatitis followed by HEV (17.97% cases), HBV (16.10% cases) and HCV (11.98%). The overall prevalence of hepatitis viruses is in accordance with that of other studies mentioned in [Table 3].
|Table 3: Prevalence of agents of acute viral hepatitis from different parts of India |
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In our study, a high prevalence of HCV was seen in both children (6.29%) and adults (18.54%) while other studies have reported HCV prevalence of 1.1-3.1% in children and 2.02-10.6% in adults. This raises an alarm that HCV is circulating at a high frequency in North India and thus large population based studies in the general population are required for studying the prevalence of hepatitis C in this part of the country.
Though we do not have the background data of HAV infection in our population; comparing our present data with that of the studies done previously in North India show an increased percentage of HAV induced AVH in adults  (26.61% presently vs. 8% previously) combined with a decreased percentage in children  (27.27% presently vs. 37.5-64% previously) along with a paradoxical increase in the overall incidence of HAV infection. With improvement in the socio-economic conditions of the communities, a shift in the age of acquiring HAV infection has been seen from childhood to older age groups in India  and globally;  this shift is known as epidemiological shift. Several studies from different parts of India , have reported a change in the age pattern of HAV infection that indicates an evolving epidemiological shift; though no such studies are available from North India except Delhi. , To the best of our knowledge, this is the first report indicating a similar epidemiological shift from Uttar Pradesh, the most populous state of India. Data may be helpful while formulating HAV vaccine policy recommendations for this region.
In our study, the HEV prevalence in children (9.79%) is lower than that reported by other studies (16.3-66.3%). The lower HEV prevalence combined with an indication towards epidemiological shift of HAV suggests an improvement in living standards of the North Indian population. Previous studies have shown that age specific prevalence of HAV and HEV may remained unchanged over a period of time thereby indicating that the epidemiological factors involved in the spread of these viruses have remained unchanged.  Few studies have shown an epidemiological shift based upon age specific immunoglobulin G (IgG) prevalence levels.  This study has a limitation of not studying the IgG levels. To further confirm the epidemiological shift, population based studies for detection of anti-HAV and anti-HEV IgG antibodies may be undertaken.
In this study, HEV was found to be the major cause of acute hepatic failure (25.80%) as indicated by other studies from India ,,,, [Table 4]. Other studies have found Hepatitis B as the next most important cause of AVH, mixed infections ranked second as the causative agent of AHF in our study [Table 4]. It could not be determined whether these were co-infections or super-infections. But, it is known that both co-infection and super-infection usually cause complications leading to high morbidity and mortality.  It is in contrast to the findings of a study done earlier at Lucknow, which states that co-infection does not produce a more severe disease. 
In this study, 0.75% (2/267) HBsAg negative cases were positive for HBV-DNA by PCR and 2.25% (6/267) anti-HCV negative cases were positive for HCV-RNA by PCR. Detection of nucleic acid by amplification technique serves as an important supplementary tool besides serology  for diagnosis of AVH, when false negative serology results may occur in early stage acute disease. Total 0.75% (2/267) cases had only anti-HCV detectable in blood. Both these patients had low titres of anti-HCV and therefore may represent false positive results as has been noticed earlier. True positive was predicted in ≥95% of cases with anti-HCV signal-to cut-off ratio of ≥3.8 when Abbott second-generation HCV or Ortho third-generation HCV kits were used.  The definite diagnosis of these 2 cases could not be made because of unavailability of Recombinant immunoblot assay. Lower sensitivity and specificity of domestic ELISA kits as compared to the Abbott confirmation kits is reported.  There is always an issue of comparability between publications when standard/same tests/kits are not used. Other publications, with which the present study has been compared, have also used domestic ELISA kits.
HAV and HEV infections are endemic in North India and infections occur throughout the year, though 2 peaks were seen, one in the month from February to May and the second in December. Since this is a hospital based data the true seasonal distribution in the community could not be assessed. Earlier studies have found either no seasonal peaks  or a peak in summer and monsoon months of the year. 
To conclude, AVH is a significant problem in North India. Co-infection of hepatitis viruses is not infrequent and detected in many cases. The reduced incidence of HEV infection together with an evolving epidemiologic shift of hepatitis A infection may indicate the improvement in living standards of the North Indian population. More extensive studies are required to further justify the findings of this study.
| ~ Acknowledgment|| |
We thank the Indian Council of Medical Research, New Delhi for financial support, staff of Grade I diagnostic viral laboratory for technical support and most of all, patients who helped us in completing this study.
| ~ References|| |
|1.||Irshad M, Singh S, Ansari MA, Joshi YK. Viral hepatitis in India: A Report from Delhi. Glob J Health Sci 2010;2:96-103. |
|2.||Kaur R, Gur R, Berry N, Kar P. Etiology of endemic viral hepatitis in urban North India. Southeast Asian J Trop Med Public Health 2002;33:845-8. |
|3.||Tandon BN, Gandhi BM, Joshi YK. Etiological spectrum of viral hepatitis and prevalence of markers of hepatitis A and B virus infection in north India. Bull World Health Organ 1984;62:67-73. |
|4.||Poddar U, Thapa BR, Prasad A, Singh K. Changing spectrum of sporadic acute viral hepatitis in Indian children. J Trop Pediatr 2002;48:210-3. |
|5.||Kumar S, Ratho RK, Chawla YK, Chakraborti A. The incidence of sporadic viral hepatitis in North India: A preliminary study. Hepatobiliary Pancreat Dis Int 2007;6:596-9. |
|6.||United States Centers for Disease Control and Prevention. 2012 National Notifiable Diseases and Conditions and Current case Definitions. Available from: http://www.cdc.gov/nndss/document/2012_Case%20Definitions.pdf. [Last accessed on 2012 May 16]. |
|7.||Acharya SK, Batra Y, Hazari S, Choudhury V, Panda SK, Dattagupta S. Etiopathogenesis of acute hepatic failure: Eastern versus Western countries. J Gastroenterol Hepatol 2002;17:S268-73. |
|8.||Olioso D, Boaretti M, Ligozzi M, Lo Cascio G, Fontana R. Detection and quantification of hepatitis B virus DNA by SYBR green real-time polymerase chain reaction. Eur J Clin Microbiol Infect Dis 2007;26:43-50. |
|9.||Bukh J, Purcell RH, Miller RH. Importance of primer selection for the detection of hepatitis C virus RNA with the polymerase chain reaction assay. Proc Natl Acad Sci U S A 1992;89:187-91. |
|10.||Hussain Z, Das BC, Husain SA, Murthy NS, Kar P. Increasing trend of acute hepatitis A in north India: Need for identification of high-risk population for vaccination. J Gastroenterol Hepatol 2006;21:689-93. |
|11.||Batra Y, Bhatkal B, Ojha B, Kaur K, Saraya A, Panda SK, et al. Vaccination against hepatitis A virus may not be required for schoolchildren in northern India: Results of a seroepidemiological survey. Bull World Health Organ 2002;80:728-31. |
|12.||Kunasol P, Cooksley G, Chan VF, Isahak I, John J, Loleka S, et al. Hepatitis A virus: Declining seroprevalence in children and adolescents in Southeast Asia. Southeast Asian J Trop Med Public Health 1998;29:255-62. |
|13.||Mathur P, Arora NK. Epidemiological transition of hepatitis A in India: Issues for vaccination in developing countries. Indian J Med Res 2008;128:699-704. |
|14.||Arankalle VA, Tsarev SA, Chadha MS, Alling DW, Emerson SU, Banerjee K, et al. Age-specific prevalence of antibodies to hepatitis A and E viruses in Pune, India, 1982 and 1992. J Infect Dis 1995;171:447-50. |
|15.||Cho HC, Paik SW, Kim YJ, Choi MS, Lee JH, Koh KC, et al. Seroprevalence of anti-HAV among patients with chronic viral liver disease. World J Gastroenterol 2011;17:236-41. |
|16.||Jaiswal SB, Chitnis DS, Asolkar MV, Naik G, Artwani KK. Aetiology and prognostic factors in hepatic failure in central India. Trop Gastroenterol 1996;17:217-20. |
|17.||Khuroo MS, Kamili S. Aetiology and prognostic factors in acute liver failure in India. J Viral Hepat 2003;10:224-31. |
|18.||Arora NK, Nanda SK, Gulati S, Ansari IH, Chawla MK, Gupta SD, et al. Acute viral hepatitis types E, A, and B singly and in combination in acute liver failure in children in north India. J Med Virol 1996;48:215-21. |
|19.||Kumar A, Yachha SK, Poddar U, Singh U, Aggarwal R. Does co-infection with multiple viruses adversely influence the course and outcome of sporadic acute viral hepatitis in children? J Gastroenterol Hepatol 2006;21:1533-7. |
|20.||Stramer SL, Zou S, Notari EP, Foster GA, Krysztof DE, Musavi F, et al. Blood donation screening for hepatitis B virus markers in the era of nucleic acid testing: Are all tests of value? Transfusion 2012;52:440-6. |
|21.||Seo YS, Jung ES, Kim JH, Jung YK, Kim JH, An H, et al. Significance of anti-HCV signal-to-cutoff ratio in predicting hepatitis C viremia. Korean J Intern Med 2009;24:302-8. |
|22.||Wu X, Zhou C, Huang WJ, Qi ZB, Liang ZL, Li HM, et al. Sensitivity and specificity of 4 domestic ELISA kits for detection of hepatitis B virus markers. Zhonghua Liu Xing Bing Xue Za Zhi 2008;29:915-8. |
|23.||Mathur P, Arora NK, Panda SK, Kapoor SK, Jailkhani BL, Irshad M. Sero-epidemiology of hepatitis E virus (HEV) in urban and rural children of North India. Indian Pediatr 2001;38:461-75. |
|24.||Singh J, Prakash C, Gupta RS, Bora D, Jain DC, Datta KK. Epidemiology of endemic viral hepatitis in an urban area of India: A retrospective community study in Alwar. Bull World Health Organ 1997;75:463-8. |
[Table 1], [Table 2], [Table 3], [Table 4]
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