Sporadic Transmission Of Hepatitis C

By P.E. Newman, 10 rue Anatole de la Forge, 75017 Paris, France

Abstract--At the present time, people having contracted hepatitis C are not warned about the possible ways in which they can transmit this disease to others. This greatly increases the risk of sporadic transmission of the virus. Public health and medical authorities should institute programs to inform all such afflicted persons how to avoid communicating the disease to others.

Introduction:

Hepatitis C is usually thought of as a blood-transmitted disease, blood transfusions, parenteral drug use, injections of human- blood- derive dimmunoglobin, hemodialysis, tattooing, acupuncture and ear-piercing have all been indicted. Transmission by dental therapy, surgical intervention and needle-stick accidents have also been reported. However, in the USA and Europe, only about 50% of the cases of hepatitis C can be related to the above (1).

Sporadic transmission, defined as conveying the disease by means other than blood or blood derivatives, must therefore account for the other 50% in the Western world. In many of the developing countries in Africa and Asia, hepatitis C infection is much more widespread. As many of theabove-described blood transmittal vectors are simply not available to their citizens, sporadic transmission in these regions must represent a fargreater proportion of the total, and accordingly of the total cases world-wide.

A recent study in Egypt (2) found antibodies to hepatitis C virus, anti-HCV,in 18.1% of the residents of a rural village and in 22.1% of the armyrecruits. The number of those infected rises with age and reaches aproportion of 41% of persons over 50 years old in this rural community. The vast majority must represent sporadic transmission.

In many of these countries, cirrhosis following chronic viral hepatitis is amajor cause of death. In addition, hepatocellular carcinoma is the mostimportant cancer in these areas and probably 75% of these can be attributed to hepatitis C (3).

A recent estimate has projected the number of persons in the world who will have hepatitis C in the year 2000 at 500 million. As the majority of these cases will be found in developing countries, sporadic transmission will have been responsible for well over 50% of these infections (4). It has been estimated that the number of persons infected with hepatitis C is between nine and 35 times the number of persons having acquired immune deficiency syndrome (AIDS) (5). This focuses on the fact that hepatitis C and not AIDS is proably the most important public health problem in the world, although not recognized as such. Despite some interesting work done with interferon alpha, hepatitis C, like AIDS, is considered to be incurable.

HOMOSEXUAL TRANSMISSION:

Gasparini et al (6) researched a large group of apparently healthy homosexuals in gay clubs in Italy and found an incidence of seropositivity for anti-HCV of 18.9%. This is about 15 times the incidence of anti-HCV inthe population as a whole in the same region. Intravenous drug-users were excluded from this group. A definite correlation was found between incidence of infection and frequency of intercourse.

Another group of homosexual men in Australia were found to have an anti-HCV positivity of 34.1% (7). From these examples and other articles not cited but giving high percentages of hepatitis C in homosexuals, it can be concluded that homosexual and bisexual intercourse is an important factor in the sporadic transmission of hepatitis C.

HETEROSEXUAL TRANSMISSION:

There have been many papers published concerning the heterosexual transmission of hepatitis C. Some of these articles deal with spouse- to- spouse infection and others with rates of infection of female prostitutes and their customers. Although varying percentages of infection have been found, one fact is common to all these studies: namely, an increase in the total number of contacts with an infected person or persons leads to a higher infection rate. The number of years in prostitution or the number of years in marriage are the most important variables.

Although infection rates as high as 58% of the wives of anti-HCV husbands and 44% of the husbands of anti-HCV wives have been reported, an average of nine recent studies would put the spouse- to- spouse infection rate at 20.%%. Certain studies have found that female- to- male transmission was more important and others have found the reverse. However, it is clear that sexual transmission is an important vector of sporadic transmission of hepatitis C between the sexes (8-11).

INTRAFAMILIAL, OTHER-THAN-HETEROSEXUAL TRANSMISSION:

In a recent review in Japan of 96 patients with hepatitis C, 5% of the children and 9% of persons other than spouses living in the same household were anti-HCV positive (12). In a much smaller sample in Italy, 11 men and 10 women who had cirrhosis and were anti-HCV positive had 11.3% of their offspring and 48.8% of their siblings who were household contacts were anti-HCV-positive (13). Direct transmission of the virus from mother to infant has been shown to exist (14,15). Many other studies have shown that children, siblings and other persons living in the household of persons having liver disease caused by hepatitis C are anti-HCV positive in percentages largely higher than that of control populations. It is generally accepted that being a family member in which one or more persons has hepatitis C liver disease carries a serious risk of becoming contaminated by the virus.

OTHER TRANSMISSION:

Ngatchu et al (16) researched the incidence of anti-HCV in an urban childpopulation in Cameroon. They found a seroprevalence of 14.4% in 696children ranging in age from 4 to 14 years. The seroprevalence increaseswith age. The social class of the family had a risk effect, with the lowest class having a 2.2 risk factor. They hypothesized that the transmission was from child to child, but with the parameter of social class it appears to me that intrafamilial transmission might also have had an influence. Nevertheless, this shows that close association with persons having hepatitis C is a transmission risk.

There has been a well-documented case of transmission of a chronic hepatitis C infection by a man who was bitten by another man in a bar-room fight (17). Experiemental transmission of the virus by saliva to chimpanzees had also been demonstrated. (18).

SUGGESTED WAYS OF SPORADIC TRANSMISSION:

With regard to homosexual transmission, as a relationship between incidence of infection and frequency of intercourse has been found, this strongly implicates the transfer of seminal fluid by unprotected anal and oral sex as being the main vector of virus transmission. Saliva transfer by oral osculation or by other means such as drinking from the same glass can also be envisaged as possibilities, but probably to a lesser degree.

Unprotected vaginal, anal and oral sex can all be implicated in heterosexual hepatitis-C transmission. The existence of genital lesions, ulcers or other open sores obviously adds to the transmission risk. In regions where excision of the clitoris is practiced, the transmission risk for both AIDS and hepatitis C is heightened. Saliva transfer by mouth- to- mouth kissing also presents a risk.

Intrafamilial transmission can be envisaged by saliva transmission through mouth- to- mouth kissing, utilization of the same utensils, drinking cups and glasses without washing, and using the same toothbrush. A lack of basic hygiene with respect to all body fluids could also be a cause. The simple act of a mother sucking or kissing a child's would could be envisaged as a possible method of communicating the virus. Unthinking introduction of saliva into foodstuffs, for example, could be a cause.

CONCLUSION:

Sporadic transmission of hepatitis C is the major way of spreading thisvirus to uninfected persons. Not only does this serious liver disease cause great suffering, particularly in its terminal phases,as decompensated cirrhosis or hepatocellular cancer, but the care of such afflicted persons is very costly.

At the present time, there is no apparent effort being made by public health or medical authorities to inform persons afflicted of the possible methods of transmission. This would permit taking the necessary precautions to prevent its transmission, such as using condoms for sex, proscribing oral sex and osculation and, in general, assuring the necessary hygiene with respect to all body fluids.

I recomment that public health authorities publish a succinct document setting forth, firstly, a list of the body fluids which can contain thevirus and secondly, methods in which its transmission could be envisaged. This document would be mandatorily given to all persons testing positive for hepatitis C either by the laboratory or by the physician communicating the analysis. The small cost involved would be negligible in terms of potential savings in costs of caring for persons who otherwise might become infected. Furthermore, a great deal of needless suffering could be avoided.

REFERENCES:

1. Kao J H, Chen P J. Yand P M et al, Intrafamilial transmission of hepatitis C virus: the important role of infection between spouses. J Infect Dis 1992; 166: 900-903

2. Farid A Q, Zakaria S, Kamel M et al. High seropositivity of hepatitis C among risk groups in Egypt. Am J Trop Med Hyg 1994; 51(5):563-567

3. Ogawa M. Okuyama Y, Abe M et al, Study on the clinical background to hepatocellular carcinoma.. Nichidai, Igaku Zasshi 1994; 53(9); 710-716

4. Elsenburg J. Gelbsucht durch Blutkonserven-bald schlimmer als AIDS. Blick, 26 January 1993

5. Newman P E, Retaarding the eventual development of liver cirrhosis and hepatocellular carcinoma by persons having hepatitis C, Med Hypotheses 1993; 40:351-354

6. Gasparini V, Chiaramonte M Maschen M E et al, Hepatitis C virus infection in homosexual men. Eur J Epidemiol 1991; 7(6); 665-669

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11. Nakashima K, Kashiwagi S, Hayashi J et al, Sexual transmission of hepatitis C virus among female prostitutes and patiens with sexually transmitted diseases in Fukuoka, Hyusu, Japan Am J Epidemiol 1992; 136(9): 1132-1137

12. Oshita M, Hayashi N, Kasahara A et al. prevalence of hepatitis C virus in family members of patients with hepatitis C J Med Virol 1993; 41: 251-255

13. Mondello P, Patti S, Vitale M G et al. Anti-HCV antibodies in household contacts of patients with cirrhosis of the liver. Infection 1992; 20(1); 51-52

14. Wejstal R, Hermodsson S, Iwarson S, Norhans G, Mother to infant transmission of hepatitis C virus infection. J Med Virol 1990; 30: 178-180

15. Thaler M M, Park C K, Landers D V et al. Vertical transmission of hepatitis C virus, Lancet 1991; 338: 17-18

16. Ngatchu T, Stroffolini M, et al. Seroprevalence of anti-HCV in an urban child population. J Trop Med Hyg 1992; 95(1): 57-61

17. Dusheiko G M, Smith M, Scheuer P J, Hepatitis C virus transmitted by human bite. Lancet 1990; 336: 503-504

18. Abe K, Kurata T, Sugitini M, Oda T. Experimental transmittal of a non-A, non-B hepatitis by saliva. J Infect Dis 1987; 155: 1078-1079

19. Liou T C, Chang T T, Young K C et al. Detection of HCV RNA in saliva, urine, seminal fluid and ascites. J Med Virol 1992; 37: 197-202

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