Indian Journal of Medical Microbiology, (2013) 31(3): 261-265

Original Article

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

Abstract
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 GradeI viral diagnostic laboratory over a 1year period. Subjects and Methods: Samples were tested
for hepatitis B surface antigen, antiHCV total antibodies, antiHAV immunoglobulin M(IgM) and antiHEV IgM by
the enzymelinked immunosorbent assay. PCR for nucleic acid detection of HBV and HCV was also carried out. Those
positive for HBV infection were tested for antiHDV antibodies. Statistical Analysis Used: Fishers 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%). Coinfections with more than one virus were present in 34cases;
HAVHEV coinfection being the most common. HEV was the most important cause of acute hepatic failure followed by
coinfection 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.
Key words: Acute viral hepatitis, epidemiological shift, hepatitis A virus, North India, prevalence

Introduction

Subjects and Methods

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 NewDelhi[13]
and Chandigarh[4,5] 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.

Over a 1year period from July 2011 through June

2012, total 267cases of AVH were referred to the GradeI
viral diagnostic laboratory. The samples from hospitalised
patients of both sexes and all ages, who did not have a
known coexisting 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).

*Corresponding author(email: <amita602002@gmail.com>)

Department of Microbiology, K.G. Medical University,
Lucknow, Uttar Pradesh, India
Received: 18102012
Accepted: 25042013
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PMID:
***
DOI:
10.4103/0255-0857.115631

An AVH case was defined as a person having an

acute illness of<15days 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>100IU/L documented
at least twice at a 1week interval without any history
of preexisting liver disease.[6] Patients who developed
encephalopathy after the onset of icterus were considered to
have acute hepatic failure.[7]
Approximately 5 ml blood sample was collected from
all cases, serum was separated and stored at 20C until

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Indian Journal of Medical Microbiology

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]).
Laboratory investigations
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 enzymelinked immunosorbent assay(ELISA) as per
the manufacturers 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.[8] and Bukh et al.[9] respectively. PCR products were
visualised after electrophoresis on 2% agarose gel.
Samples that tested positive for HBsAg or HBV DNA
were also tested for antiHDV total antibodies by ELISA
(DSI, SRL, Italy).
Statistical methods
The prevalence of hepatitis viruses were analysed by
Fishers exact test. Two tailed tests were used and a P<0.05
was considered to be statistically significant.

Viral
etiology

vol. 31, No. 3

Results
Of 267cases 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[Table1]. 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%)[Table1].
The percentage positivity of antiHAV 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 antiHEV IgM(27.42%), HBsAg(23.38%) and
antiHCV 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 34cases, the most common being HAV and HEV
coinfection in 23cases; 15 of which presented as AVH
alone while 8cases developed Acute Hepatic Failure.
Coinfection of HBV with other viruses was present in
10cases(1 with E, 3 with C and 6 with A).
In cases that developed AHF
disease, HEV was found in the
cases(25.80%, 16/62) followed by
and HEV(12.90%, 9/62), followed

during the course of

maximum number of
coinfection with HAV
by HBV (9.67%, 6/62)

Table1: Prevalence of causative agents of acute viral hepatitis and fulminant hepatic failure
AVH(205)
AHF(62)
Total(267)
Children
Adults
Total
Children
Adults
Total
Children
Adults
(n=97)
(n=108)
(n=205)
(n=46)
(n=16)
(n=62)
(n=143)
(n=124)
33(34.02) 31(28.70) 64(31.21) 6(13.04) 2(12.50) 8(12.90) 39(27.27) 33(26.61)
9(9.27) 28(25.92) 37(18.04) 5(10.86) 1(6.25)
6(9.67) 14(9.79) 29(23.38)
9(9.27) 23(21.29) 32(15.61)
0(0)
0(0)
0(0)
9(6.29) 23(18.54)
7(7.21) 25(23.14) 32(15.61) 7(15.21) 9(56.25) 16(25.80) 14(9.79) 34(27.42)
6(6.18)
9(8.33)
15(7.31) 6(13.04) 2(12.5) 8(12.90) 12(8.39) 11(8.87)

Total
(n=267)
72(26.96)
43(16.10)
32(11.98)
48(17.97)
23(8.61)

HAV
HBV
HCV
HEV
HAVHEV
coinfection
HBVHCV
1(1.03)
2(1.85)
3(1.46)
0(0)
0(0)
0(0)
1(0.69)
2(1.61)
3(1.12)
coinfection
HBVHEV
0(0)
0(0)
0(0)
1(2.17)
0(0)
1(1.61)
1(0.69)
0(0)
1(0.37)
coinfection
HBVHAV
4(4.12)
1(0.92)
5(2.43)
1(2.17)
0(0)
1(1.61)
5(3.49)
1(0.81)
6(2.24)
coinfection
HCVHAV
1(1.03)
0(0)
1(0.48)
0(0)
0(0)
0(0)
1(0.69)
0(0)
1(0.37)
coinfection
Aetiology
46(47.42) 95(87.96) 141(68.78) 10(21.74) 10(62.50) 20(32.26) 56(39.16) 105(84.67) 161(60.29)
confirmed
cases
AVH: Acute viral hepatitis, FHF: Fulminant hepatic failure, HAV: Hepatitis A virus, HBV: Hepatitis B virus, HCV: Hepatitis C virus,
HEV: Hepatitis E virus, AHF: Acute hepatic failure
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July-September 2013

Jain, etal.: Acute viral hepatitis in North India

[Table1]. No case of AHF had HCV or isolated HAV

infection.
Results of ELISA and PCR were compared for HBV
and HCV[Table2]. PCR could detect 2 additional HBV
cases and 6 additional HCV cases while ELISA could detect
2additional 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%), rightupperquadrant pain
with tenderness (59.02%), anorexia(26.82%), vomiting
(24.63%), nausea (23%), malaise(22.43%), diarrhoea
(18.21%) and headache(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 222.88IU/L, 155.67IU/L,
475.07 KAU/L and 6.68mg/dl respectively.
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[Figure1].
Discussion
Several studies on AVH are available from India
and abroad that have reported varying prevalence of
Table2: Comparison of ELISA and PCR results for
HBV and HCV in 267 AVH cases
Virus
Only
Only
PCR and
Total
positive
PCR
ELISA
ELISA both
positive
positive
positive
HBV
2
0
41
43
HCV
6
2
24
32
PCR: Polymerase chain reaction, ELISA: Enzyme linked
immunosorbent assay, HBV: Hepatitis B virus, HCV: Hepatitis C virus

Figure1: Seasonality of hepatitis A virus/hepatitis E virus positive cases

263

hepatotropic viruses: HAV (1.767%), HBV (7.342%),

HCV (1.1610.6%) and HEV (16.366.3%)[15,10] [Table3].
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 Table3.
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 1.13.1% in children
and 2.0210.6% 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[11](26.61% presently vs. 8% previously)
combined with a decreased percentage in children[12]
(27.27%presently vs. 37.564% previously) along with
a paradoxical increase in the overall incidence of HAV
infection. With improvement in the socioeconomic
conditions of the communities, a shift in the age of
acquiring HAV infection has been seen from childhood
to older age groups in India[13] and globally;[12] this shift
is known as epidemiological shift. Several studies from
different parts of India[12,13] 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.[12,13] 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(16.366.3%). 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.[14]
Few studies have shown an epidemiological shift based
upon age specific immunoglobulin G (IgG) prevalence
levels.[15] This study has a limitation of not studying the
IgG levels. To further confirm the epidemiological shift,
population based studies for detection of antiHAV and
antiHEV 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

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Indian Journal of Medical Microbiology

studies from India[4,6,8,16,17][Table4]. 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[Table4]. It could
not be determined whether these were coinfections or
superinfections. But, it is known that both coinfection
and superinfection usually cause complications leading
to high morbidity and mortality.[18] It is in contrast to
the findings of a study done earlier at Lucknow, which
states that coinfection does not produce a more severe
disease.[19]
In this study, 0.75%(2/267) HBsAg negative cases
were positive for HBVDNA by PCR and 2.25%(6/267)
antiHCV negative cases were positive for HCVRNA by
PCR. Detection of nucleic acid by amplification technique
serves as an important supplementary tool besides
serology[20] for diagnosis of AVH, when false negative
serology results may occur in early stage acute disease.
Total 0.75%(2/267) cases had only antiHCV detectable in
blood. Both these patients had low titres of antiHCV and
therefore may represent false positive results as has been
noticed earlier. True positive was predicted in 95% of
cases with antiHCV signalto cutoff ratio of 3.8 when
Abbott secondgeneration HCV or Ortho thirdgeneration
HCV kits were used.[21] The definite diagnosis of these
2cases could not be made because of unavailability of
Recombinant immunoblot assay. Lower sensitivity and
specificity of domestic ELISA kits as compared to the

Year of
study
1984
2002
2002
2006
2007
2010
2012

vol. 31, No. 3

Abbott confirmation kits is reported.[22] 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[23] or a peak in summer and monsoon months of the
year.[24]
To conclude, AVH is a significant problem in North
India. Coinfection 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, NewDelhi
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.

Table3: Prevalence of agents of acute viral hepatitis from different parts of India
Place of
Total samples
HAV
HBV
HCV
HEV
Comments
study
studied
% positive
NewDelhi
100
14
42
Adults
78
67
9
Children
NewDelhi
177
1.7
19.8
3.4
51.4
Adults
129
3.1
8.6
3.1
66.3
Children
Chandigarh
172
64.5
7.6
1.16
16.3
Children(<14years)
NewDelhi
1932
11.4
16.61
2.02
26.24
Adults
Chandigarh
685
17.5
7.3
2.8
38.6
Individuals aged 1070years
NewDelhi
74
8.1
12.3
10.6
25.3
Adults
Lucknow
124
26.61
23.38
12.90
27.42
Adults
143
27.27
9.79
11.18
6.99
Children

References
3
2
4
10
5
1

HAV: Hepatitis A virus, HBV: Hepatitis B virus, HCV: Hepatitis C virus, HEV: Hepatitis E virus

Year
1984
1996
2002
2003
2007
2012

Place of study
NewDelhi
Indore
NewDelhi
Kashmir
Chandigarh
Lucknow

Table4: Etiology of AHF from different studies in India

No of cases
HAV
HBV
HCV
HEV
Mixed infections
93
12
33

ND
95
4
27
2
41
4
458
4
11
4
23
6
180
2.1
13.9
7.2
43.9
ND
70
4.3
22.9
15.7
41.4
ND
62
12.90
9.67
4.83
17.94
14.51

AHF: Acute hepatic failure

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References
3
14
7
15
5

July-September 2013

Jain, etal.: Acute viral hepatitis in North India

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How to cite this article: Jain P, Prakash S, Gupta S, Singh KP,
Shrivastava S, Singh DD, et al. 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.
Source of Support: The Indian Council of Medical Research,
NewDelhi, India, Conflict of Interest: None declared.

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