By Author
  By Title
  By Keywords

August 1988, Volume 38, Issue 8

Original Article


M Shuaib Quraishi  ( Army Medical College and Armed Forces Institute of Pathology, Rawalpindi. )
Manzoor Ahmad  ( Army Medical College and Armed Forces Institute of Pathology, Rawalpindi. )
Haroon ul Rashid  ( Army Medical College and Armed Forces Institute of Pathology, Rawalpindi. )
Sajid Mushtaq  ( Army Medical College and Armed Forces Institute of Pathology, Rawalpindi. )
S. Azhar Ahmed  ( Army Medical College and Armed Forces Institute of Pathology, Rawalpindi. )


An outbreak of hepatitis was reported from a military unit. An investigation to determine the type and the cause of outbreak revealed that the maximum number of cases occurred in a barrack which shared a common water supply contaminated from an overflow from a septic tank. Another barrack which had separate supply from the same source was unaffected.
Seromarker study in 8 cases showed immunity to Hepatitis A and no evidence for recent HBV infection.
The disease was self limited in nature. No chronic sequelae were documented. In view of the spread a public health education plan is necessary (JPMA 38: of this disease through contaminated water supply 203, 1988).


Hepatitis Non A Non B has emerged as the major type of hepatitis in Pakistan and other developing countries. There has been evidence that more than one virus is responsible1,2


An outbreak of viral hepatitis was repor­ted from a Military Unit over a short period of time. An investigation team visited the area, and inspected living arrangements, cook houses, water supply, latrines and sewage disposal. Water samples were taken from the water points for evidence of pollution. The occurrence of cases, their location and sequence was charted.
An cases were hospitalised and clinical complaints recorded on a proforma. The patients were discharged after becoming clinically and biochemically normal. They were re-examined after 3 months. The liver function tests included Serum bilirubin, alkaline phosphatase and SGPT. Serum was also taken for Anti HAy, 1gM and IgG, Anti HBS. 1gM antibodies to HBC were also deter­mined. Two hundred clinically normal individuals living in the same accommodation were examined for clinical complaints and hepatomegaly and their serum tested for serum transaminase leveis.


Living Accommodation Water Supply and Sewage Disposal
The affected personnel lived in barracks (Figure)

in sub-unit groupings (Company) each comprising 200 persons. A new set of barracks had been provided next to the old ones. The water supply of both areas was from a tube well, distributed from a central overhead tank and carried through G. I. pipes to different water points. The water for cooking was taken from the tap near the cook house. The pipe was found cracked. The latrine was a modified water carriage type with a septic tank nearby. There was seepage and over-flow from the septic tank which was in commu­nication with cracked pipe. The examination of water samples showed that the tubewell water and that from central overhead tank were free from contamination.
The first case occurred in August followed by 6 in September and 13 in October. About 10 percent of those exposed developed jaundice. There were scattered cases in the adjacent barracks but the maximum cases (21) occurred in one company which had water point near the polluted area. No case occurred in the nearby new barracks. No history of vaccination/inoculation was elicited in the previous six months.
The clinical features and biochemical features are shown in Table-I-II.

The average stay in hospital was 20.4 days (range 10-35). None of the patients had any residual symptoms or raised transaminase levels on follow up ex­ amination. The seromarkers could be carried out in 8 cases. All cases showed IgG antibodies to Hepatitis A. No antibodies indicating recent B virus infection were present.


Hepatitis Non A Non B is the commonest type of sporadic hepatitis in adult population in Pakistan3. Unlike disease in the western countries, history of parenteral exposure is uncommon. There is suggestive evidence that it may be water-borne. The present study documents a water borne outbreak of this disease. The conclusion is based on the following evidence:
1. The cases were confined to the barrack which shared a common water supply.
2. This water supply was contaminated by overflow from the septic tank.
3. No cases occurred in the adjacent barracks which got water from the same overhead tank.
4. The occurrence of cases stopped after the pipe was repaired.
5. All cases showed immunity to Hepatitis A virus. None showed serological evidence of recent B virus infection.
It is difficult to estimate incubation period in these cases. Others, however, have suggested that the incubation period may vary from 3540 days4.
Only a proportion of cases which were exposed developed jaundice. Why others did not develop jaundice can only be speculated upon. It is possible that they received a smaller dose of the infective agent. On the other hand the possibility that these persons may have been immune needs looking into. Hepatitis A is also an enteric transmitted disease. The adults in Pakistan, however, have almost universal immunity against it. It appears that immunity against Non A Non B agent, if present, is only partial. It is interesting to note that none of the contacts showed any rise in the transaminase level. It could indicate that the persistence of virus in subclinical form is uncommon, unlike-B virus which persists for long time in liver. The self limited nature of the disease is also shown by the fact that all cases on follow up did not show any elevation of enzymes or clinical evidence of chronic hepatitis. There are however, reports which suggest that the disease is not always benign. It has been reported to have caused fulminant hepatitis5 and death in pregnant women6.
Waterborne NANB hepatitis has been reported from many countries including India7, Nepal8, Burma9, Algeria10 and the Central Asian republics of Soviet Union11. It is perhaps a major public health problem for the developing countries. In Pakistan safe water supply and sewage disposal leave much to be desired. In view of the water-borne nature of the disease, it is imperative that a public health education programme be under­taken. Purification of water or even simple boiling of water may help in preventing the disease.


We are grateful to Major Redfield and Dr Perine of Uniformed Services University of Health Sciences, USA, for carrying out seromarkers studies on hepatitis cases.


1. Bradley, D.W. The agents of non-A. non-B viral hepatitis. J. Viral. Methods, 1985; 10 : 307.
2. Bradley, D.W. and Maynard, J.E. Etiology and natural history of Post Transfusion and enterically transmitted Non A Non B hepatitis. Semin. Liver Dis., 1983; 1148:254.
3. Quraishi, M.S., Manzoor, A., Khan, F.A. Acute sporadic viral hepatitis - A sero.marker study in 50 consecutive cases. JPMA., 1987; 37:231.
4. Cock, D.E., Bradley, K.M., Sandford, D.W. et al. Epidemic non-A, non-B hepatitisin patients from Pakistan. Ann. Intern. Med., 1987; 106:227.
5. Tandon, B.N., Gandhi, B.N., Joshi, Y.K.,lrshad, M. and Gupta, H. Hepatitis virus non-A, non-B; the cause of a major public health problem in India. Bull. WHO., 1985; 63:931. Khuroo, M.S. Study of epidemic of non-A, non-B hepatitis.
6. Possibility of another human hepatitis virus distinct from post-transfusion non-A, non-B, type. Am. J. Med., 1980; 68 :818.
7. Wong, D.C., Purcell, R.H., Sreenivasan, M.A., Prasad, S.R. and Pari, K.M. Epidemic and endemic hepatitis in India. Evidence for a non-A, non-B hepatitis virus aetiology. Lancet, 1980; 2: 876.
8. Kane, M.A, Bradley, D.W., Shrestha, S.M., Maynard, J.E., Cook, E,H., Mishra, R.P. and Joshi, DD. Epidemic non-A, non-B hepatitis in Nepal. Recovery of a possible etiological agent and transmission studies in marmosets. JAMA., 1984; 252: 3140.
9. Shwe, S. and Soe, M.M. Epidemiological criteria as indication of Non-A, Non-B hepatitis in a community. Lancet, 1985; 2 : 828.
10. Belabbes, E.H., Bouguermouth, A., Ahmad Benatallah, A. and Illoul, G. Epidemic non-A, non-B viral hepatitis in Algeria; strong evidence for its spreading by water. J.Med. Viral., 1985; 16: 257.
11. Balayan, M.S., Andjaparidze, A.G., Savinskaya, S.S., Ketlladze, E.S., Braginsky, D.M., Savinov, A.P. and Poleschuk, V.F. Evidence for a virus in non-A, non-B hepatitis transmitted via the facal-oral route. Intervirology, 1983; 20:23.
12. Sreenivasan, M.A., Sehgal, A., Parsad, S.R. and Dhorje, S.A. Seroepidemiologic study of a waterborne epidemic of viral hepatitis in Kotha­ pur city India. J. Hyg. Camb., 1984; 93 :113.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: