A study of hepatitis B infection in a Montana insititution for the mentally retarded
by Bradford Oldham Brooks
A thesis submitted in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE
in Microbiology
Montana State University
© Copyright by Bradford Oldham Brooks (1976)
Abstract:
A test population of 524 patients in residence at Boulder River School and Hospital was assayed for the
prevalence of both anti-HBs and HBsAg. 16.8% of the test population were found to be positive for
either of these markers indicating Hepatitis B infections are endemic to this institution. Correlations
were observed between the prevalence of these markers and the following: Sex, Institutional Location,
Degree of Ambulation, Feeding Skills, and Drinking from Faucets, Sinks and Bathtubs.
Cohorting, Routine Admission Screening, Environmental Surface Testing, and Immune Competence
testing were proposed in an endeavor to lower the prevalence of Hepatitis B at Boulder River School
and Hospital. STATEMENT OF PERMISSION TO COPY
In p re s e n tin g t h i s th e s is in p a r t i a l
f u l f i l l m e n t , o f th e
re q u ire m e n ts f o r an advanced degree a t Montana S ta te U n iv e r s it y ,
I agree t h a t th e L ib r a r y s h a ll make i t
in s p e c tio n .
f r e e l y a v a ila b le f o r
I f u r t h e r agree t h a t perm ission f o r e x te n s iv e copying
o f t h is th e s is f o r s c h o la r ly purposes may be gran ted by my m ajor
p ro fe s s o r, o r , in h is absence, by th e D ir e c t o r o f L ib r a r ie s .
It
is
understood t h a t any copying o r p u b lic a tio n o f t h is th e s is f o r fin a n c ia l
g ain s h a ll no t be a llo w e d w ith o u t my w r it t e n p e rm is s io n .
S ig n a tu re
Date
A STUDY OF HEPATITIS B INFECTION IN A MONTANA
INSTITUTION FOR THE MENTALLY RETARDED
by
BRADFORD OLDHAM BROOKS
A th e s is s u b m itted in p a r t i a l f u l f i l l m e n t
o f th e re q u ire m e n ts f o r th e degree
of
MASTER OF SCIENCE
in
M ic ro b io lo g y
Approved:
C h a irp e rs o n , G raduate Committee
Head, M a jo r Departm ent
'=T v -
G rad u ate flDean
MONTANA STATE UNIVERSITY
Bozeman, Montana
May, 1976
iii
ACKNOWLEDGMENTS
I thank D r. A. G. Fiscus and D r. N. D. Reed f o r c o n s u lta tio n and
re v ie w o f th e m a n u s c rip t.
I a ls o thank D r. M a rtin D. S k in n e r f o r his
guidance thro u g h o u t t h is re s e a rc h .
T h is re se a rch was supported in p a r t by th e Boulder R iv e r School
and H o s p ita l, th e Montana S ta te H e a lth Lab, and A bb o tt L a b o ra to rie s .
TABLE OF CONTENTS
Page
V IT A .............................................. .................................................. ....................................
ii
ACKNOWLEDGMENTS . ................................................................. ...................... ....
LIST OF TABLES. . . ...................................................................................... .
iii
. .
vi
ABSTRACT..................................... .... ...................................................................................
v ii
INTRODUCTION............................ .... .............................................................................. .... ■
I
MATERIALS AND METHODS................................. ...
5
............................ ....
S e r a ............................................................................................ ...........................
5
HBgAg A s s a y . .......................................................
5
Chronic C a r r ie r D e te rm in a tio n ............................................................
.
7
A n ti-H B g Assay .................................................................................................
7
Data Form at................................................................................................
8
S t a t i s t i c a l T reatm ent o f D a ta .
9
. .................................
.
. . .
RESULTS ............................................................................................................................
10
Age C o r r e la tio n w ith A n ti-H B gand HBgAg............................................
10
Sex C o r r e la tio n w ith A n ti-H B gand HBgAg.............................................
14
D u ra tio n o f I n s t i t u t i o n a l i z a t i o n C o r r e la tio n
w ith A n ti-H B g and HBgAg
.. ' ........................................................
14
I n s t i t u t i o n a l L o c atio n C o r r e la tio n w ith
A n ti-H B g and HBgA g . .......................
19
H a b its and A b i l i t i e s C o r r e la tio n w ith
A n ti-H B g and HBgAg....................................
25
A d m ittin g D iagnosis C o r r e la tio n w ith
A n ti-H B g and HBgAg. ....................................................
29
DISCUSSION
CONCLUSION
APPENDIX
REFERENCES CITED.
vi
LIST OF TABLES
TABLE
Page
L
R e s u lts o f A n tirH B s and HBgAg Radioimmunoassay . . . . . .
11
II.
A n ti-H B g A s s o c ia tio n w ith Age G roupings....................................
12
HBgAg A s s o c ia tio n w ith Age G r o u p in g s ......................
13
A n ti-H B g A s s o c ia tio n w ith Sex...................................
15
V.
HBgAg A s s o c ia tio n w ith S e x ................................................................
16
V I.
A n ti-H B A s s o c ia tio n w ith D u ra tio n o f
I n s t i t u t i o n a l i z a t i o n . ' . . . . ........................................................
17
HB Ag A s s o c ia tio n w ith D u ra tio n o f
I n s t i t u t i o n a l i z a t i o n ..............................................
18
III.
IV .
V II.
V IiI..
IX .
X.
. . . . . .
A n ti-H B g A s s o c ia tio n w ith L o c a tio n . ....... ............. ....................
20
HBgAg A s s o c ia tio n w ith L o c a tio n ........................................
21
A n ti-H B g A s s o c ia tio n w ith L o c a tio n ................................
. . .
23
X I.
HBgAg A s s o c ia tio n w ith L o c a tio n .......................................................
24
X II.
A n ti-H B g A s s o c ia tio n w ith H a b its and A b i l i t i e s . ..................
26
X III.
HBgAg A s s o c ia tio n w ith H a b its and A b i l i t i e s ............................
27
A n ti-H B g A s s o c ia tio n w ith A d m ittin g D ia g n o s is .
30
X IV .
XV.
. . . . .
HBgAg A s s o c ia tio n w ith A d m ittin g Diagnosis ............................
31
v ii
ABSTRACT
A t e s t p o p u la tio n o f 524 p a tie n ts in re sid e n c e a t B oulder R iv e r
School and H o s p ita l was assayed f o r th e p re v a le n c e o f both a n ti-H B _
and HB Ag. '1 6 .8 % o f th e t e s t p o p u la tio n were found to be p o s it iv e 5
f o r e i t h e r o f th ese m arkers in d ic a tin g H e p a titis B in fe c t io n s are
endemic to t h i s i n s t i t u t i o n .
C o rre la tio n s were observed between th e
p re v a le n c e o f th ese m arkers and th e fo llo w in g :
Sex, I n s t i t u t i o n a l
L o c a tio n , Degree o f A m b u la tio n , Feeding S k i l l s , and D rin k in g from
F a u c e ts , Sinks and B ath tu b s.
C o h o rting, R outine Admission S c re e n in g , Environm ental S urface
T e s tin g , and Immune Competence te s t in g were proposed in an endeavor
to lo w er th e p re v a le n c e o f H e p a titis B a t Boulder R iv e r School and
H o s p ita l.
INTRODUCTION
V ir a l
d is e a s e .
h e p a t i t i s has c l a s s i c a l l y been a m ysterious and in t r a c t a b le
It
has long been reco g n ized th a t, symptoms a r is e from two
d i s t i n c t types o f in f e c t i o n .
H e p a t it is A, a ls o c a lle d in fe c tio u s
h e p a t i t i s , s h o rt in c u b a tio n h e p a t i t i s , o r MS-I h e p a t i t i s ,
is thought
to be tr a n s m itte d p r im a r ily by f e c a l - o r a l c o n ta m in a tio n .
H e p a titis B,
a ls o c a lle d serum h e p a t i t i s , long in c u b a tio n h e p a t i t i s , o r MS-2
h e p a t i t i s , is thou g h t to be tr a n s m itte d p a r e n t e r a lly ( I ) .
U n t il
r e c e n tly l i t t l e
e ls e was known about v i r a l
h e p a titis .
A
m ajo r b reakthrough o ccurred in 1964 when D r. Baruch S. Blumberg e t a l .
(2 ) d is co v e red a new a n tig e n in th e p e rip h e ra l blood o f an A u s tr a lia n
A b o rig in e .
A n tig e n ."
T h is a n tig e n was subsequently la b e le d th e
" A u s tr a lia
I t was thoug ht to be im p lic a te d w ith lym p h o cytic leu k e m ia ,
leprom atous le p ro s y , H odgkiris's d is e a s e , and Down's syndrome ( 3 - 6 ) .
In
1 96 8 , P rin c e e t a l . (7 ) observed a s im i l a r substance in th e blood o f
p a tie n ts w ith , h e p a t i t i s B.
C lo s e r la b o r a to ry o b s e rv a tio n re v e a le d
t h a t t h is substance and th e " A u s tr a lia A n tig en " were i d e n t i c a l .
F u rth e r
in v e s t ig a t io n has re v e a le d th e c o r r e la t io n o f t h is a n tig e n w ith
h e p a t i t i s B in fe c t io n s
(3 , 5, 7 -1 2 ).
T h is o r ig in a l a n tig e n , now c a lle d th e h e p a t it is B s u rfa c e a n tig e n
(HBcA g ), served as th e f i r s t s e r o lo g ic a l m arker f o r h e p a t i t i s B.
It
is
both a means f o r diag n o sin g th e presence o f h e p a t it is B and an
in s tru m e n t w ith which to in v e s tig a te th e n a tu re o f th e d is e a s e .
HBgAg
is c h a r a c te riz e d as a s m a ll, s p h e ric a l p a r t i c l e a p p ro x im a te ly 22 nm in
2
d ia m e te r.
The predom inant form is a s p h e ric a l p a r t i c l e , alth o u g h f i l a ­
ments 22nm in d ia m e te r and v a ry in g le n g th a re a ls o observed.
p r o te in substance c o n ta in in g some l i p i d
It
is a
components, b u t devoid o f
n u c le ic a c id s . . I t has a m o le c u la r w e ig h t o f 3 X 10® and a buoyant
d e n s ity o f 1 .2 1 .
It
is s ta b le a t 56°C o v e r n ig h t, r e s is t a n t to tre a tm en t
w ith p r o t e o ly t ic enzymes and w ith s ta n d s s to ra g e a t -2 0 °C f o r up to 20
y e a rs
(1 3 , 1 4 ).
A ll
h e p a t it is B s u rfa c e a n tig e n s
d e te rm in a n t d e s ig n a te d a (1 5 , 1 6 ) .
e x c lu s iv e a n tig e n ic d e te rm in a n ts
(HBgAg) have a common a n tig e n ic
In a d d it io n , two p a irs o f m u tu a lly
(<f and y , and w and r )
have been
d e s c rib e d ( 1 6 , 1 7 ) .
T h e re fo re , th e re a re fo u r p o s s ib le HBgAg subtypes
adw, a d r , ayw, a y r .
Subtypes o f HBgAg a re u s efu l m a in ly as epidem io­
lo g ic a l m arkers.
E p id e m io lo g ic a lly r e la t e d cases o f v i r a l
ty p e B have th e same HBgAg subtype (1 8 , 1 9 ) .
h e p a t it is
The subtype o f i n d i - .
v id u a !s , w ith acu te o r c h ro n ic h e p a t i t i s o r those who a re symptom -free
c a r r i e r s , alm o st alw ays rem ains th e same w h ile th e y a re HBgAg p o s itiv e
(1 9 , 2 0 ) .
ty p e s .
There is an unequal g e o g rap h ic a l d i s t r i b u t i o n o f HBgAg sub-
In th e U .S .A . th e subtype observed in p a tie n ts w ith c h ro n ic .
h e p a t it is and c h ro n ic symptom^free c a r r ie r s
is n o rm a lly ad.
Subtype ay
is most o fte n found in p a tie n ts s u ffe r in g a tta c k s o f a c u te h e p a t i t i s .
T h is is r e a d ily seen among drug a d d ic ts
going re n a l d i a l y s i s .
(1 8 , 21) and p a tie n ts under­
S tu d ie s on th e r e la t i o n between subtype and
l i v e r a b n o rm a lity have y ie ld e d in c o n c lu s iv e r e s u lts
(2 2 ).
3
Recent in v e s t ig a t io n has re v e a le d t h a t th e HBgAg is m erely a
fragm ent o f an e x tre m e ly complex a n tig e n system. . Dane e t a l . (2 3 )
f i r s t re p o rte d la r g e p a r t ic le s 4 0 -4 2 nm in d ia m e te r w ith a double
w a ll and in n e r core resem bling a v i r a l
p a tie n ts w ith h e p a t it is B a n tig e n e m ia .
n e u c le o id in th e sera o f
These p a r t ic le s
(Dane p a r t ic le s )
were found to have h e p a t it is B a n tig e n ic d e te rm in a n ts on t h e i r s u rfa ce s .
They a ls o showed a d i s t i n c t in n e r co re a p p ro x im a te ly 27 nm in d ia m e te r.
Dane e t a l . (2 4 ) proposed t h a t th e s e la r g e r p a r t ic le s c o n s t itu te th e
com plete h e p a t i t i s B v ir io n and t h a t th e o th e r more abundant morpho­
lo g ic a l forms (2 5 ) o f serum HBgAg p a r t i c l e s denote excess v iru s co at
p r o te in .
D ane's hypothesis was enchanced when Alm eida (2 6 ) discovered
a new a n tig e n system in th e 27 nm in n e r co re o f th e Dane p a r t i c l e .
In v e s tig a to r s have been a b le to d e te c t and d i f f e r e n t i a t e human a n t i ­
body d ir e c te d a g a in s t s u rfa c e a n tig e n ic components (HBgAg) o f th e Dane
p a r t i c l e and a n tib o d y d ir e c te d a g a in s t th e core a n tig e n ic components o f
th e Dane p a r t i c l e
(HBgAg) ( 2 7 ) .
th e DNA-polymerase a c t i v i t y
Kaplan e t a l . (2 8 ) have dem onstrated
is a s s o c ia te d w ith th e Dane c o re , le n d in g
f u r t h e r credence to Dane's o r ig in a l
h y p o th e s is .
In f e c t io n w ith h e p a t it is B is no t always accompanied by o v e rt
c lin ic a l
symptoms ( 2 9 ) .
Some a p p a re n tly h e a lth y c a r r i e r s o f the
in f e c t io n may be d e te c te d by assaying f o r th e presence o f HBgAg in th e
p a tie n ts ' serum.
A number o f tech n iq u es have been developed and u t i l ­
iz e d to d e te c t HBsAg in th e sera o f in fe c te d p a t ie n t s .
One s e n s itiv e
4
te c h n iq u e is t h a t o f radioimmunoassay ( 3 0 ) .
The s o lid phase sandwich
radioimmunoassay developed by Ling and Overby (3 1 ) is both s e n s itiv e
and s p e c i f i c , p e r m ittin g a h ig h e r freq u en cy o f d e te c tio n o f HBgAg ( 3 2 ) .
An e le v a te d in c id e n c e o f HBgAg c h ro n ic c a r r ie r s has been found
among th e re s id e n ts o f c e r t a in
in s titu tio n s
i n s t i t u t i o n s f o r th e m e n ta lly re ta rd e d
(3 3 ).
E s p e c ia lly those
(4 , 5 , 34, 3 5 ).
Boulder R iv e r
School and H o s p ita l, B o u ld e r, M ontana, is an i n s t i t u t i o n o f t h is ty p e .
It
has been plagued w ith re c u r r in g o u tb reaks o f h e p a t i t i s B s in ce 1970.
The r i s k o f in f e c t io n w ith h e p a t i t i s B t h a t a p a t ie n t encounters a t
B oulder R iv e r School and H o s p ita l is not w e ll d e fin e d .
T h is r i s k needs
to be more a c c u r a te ly assessed in a c o n tr o lle d s u rv e y , and th e e p i­
d e m io lo g ic p a tte rn s o f h e p a t i t i s B in fe c t io n s w ith in t h i s
need to be in v e s tig a te d .
in s titu tio n
Such a survey would c o n tr ib u te to a b e t t e r
u n d erstand ing o f th e mechanisms o f th e tra n s m is s io n o f th e v iru s and
its
r e la t i o n to environm ental and g e n e tic f a c t o r s .
Such a study could
a ls o be used to e lu c id a te s p e c if ic c o n tro ls f o r h e p a t it is B a t t h is
in s titu tio n .
MATERIALS AND METHODS
Sera
Serum samples were o b ta in e d from both re s id e n ts
B oulder R iv e r School and H o s p ita l
and s t a f f o f th e
(BRSH)9 an i n s t i t u t i o n
m e n ta lly re ta rd e d lo c a te d in B o u ld e r, Montana.
f o r the
Samples were s to re d a t
-2 0 °C f o r v a rio u s p e rio d s o f tim e ra n g in g from fo u r weeks to 14 months.
Ths sample draw ing p e rio d extended from August 1974 to June 1975.
HBgAg Assay
The te c h n iq u e used to d e te c t h e p a t it is
B s u rfa c e a n tig e n (HBgAg)
was radioim m unoassay, th e A u s r i a - I I 125 system produced by A bbott
L a b o r a to rie s .
T h is is a s o lid phase radioimmunoassay em ploying an
A n tib o d y -A n tig e n -A n tib o d y sandwich (3 1 , 3 2 , 3 7 - 4 0 ).
The procedure c o n s is te d o f th e a d d itio n o f 0 .2 ml o f serum sample
to w e lls c o n ta in in g a n t i -HBg coated (g u in e a p ig ) beads.
serum were then in c u b ated f o r two hours a t 45°C .
Beads and
Beads were washed
w ith a t o t a l o f 1 0 .0 ml o f s t e r i l e w a te r using a Cornw all s y rin g e and
I or
an a s p ir a tin g c a n u la .
0 .2 ml o f
added to th e washed beads.
! - la b e le d a n tib o d y ( a n t i HBg) was
The beads and th e ra d io la b e le d a n tib o d y
were in cu b ated f o r one hour a t 4 5°C .
and t r a n s fe r r e d to co u n tin g tu b e s .
gamma s c i n t i l l a t i o n
c o u n te r.
The beads were washed as b e fo re
Samples were counted in a w e ll-t y p e
The n o n -s p e c ific f a ls e p o s itiv e s th a t
n o rm a lly r e s u l t from cross re a c tio n s in th e sandwich te c h n iq u e o f r a d io ­
immunoassay were circum vented by using a h eterolo gous a n tib o d y system
*
ipr
(Guinea Pig a n ti-H B g coated beads and
! - la b e le d human a n t i -HBg ) .
6
N e g a tiv e human c o n tro l
in th e A u s r i a - I I system c o n s is te d o f r e c a l­
c if ie d
human plasma n o n re a c tiv e f o r h e p a t it is B s u rfa c e a n tig e n
or its
corresponding a n tib o d y ( a n t i -HBg ) .
as a p r e s e r v a t iv e .
P o s it iv e human c o n tro l
(HBgAg)
0.1% sodium a z id e was added
in t h i s system c o n sis te d o f
human plasma r e a c tiv e f o r h e p a t i t i s B s u rfa c e a n tig e n (HBgAg) in a 0.01
M TRIS b u f f e r c o n ta in in g 4% bovine serum album in and 0.1% sodium a z id e
as p r e s e r v a t iv e .
a t 60°C .
T h is c o n tro l
had been h e at in a c tiv a te d f o r 10 hours
^ I - a n t i - H B g (human) in t h i s system was s u p p lie d in a 0 .0 0 5
M TRIS ami nomethane b u f f e r c o n ta in in g 50% c a l f serum, 2% normal human
serum, 0.5% bovine serum a lb u m in , and 0.1% sodium a z id e as p r e s e r v a tiv e .
A n ti-H B g (g u in e a p ig ) in t h i s system was adsorbed onto th e s u rfa c e o f
p o ly s ty re n e beads and used in t h a t form .
R e s u lts o f t h i s assay were d eterm ined by r e la t i n g n e t counts per
m inute o f th e unknown serum sample to n e t counts per m inute o f the
n e g a tiv e c o n tro l mean tim es th e f a c t o r 2 . 1 .
T h is f a c t o r has been s e le c te d in o rd e r to decrease th e t o t a l number
o f n o n -re p e a ta b le p o s itiv e s
(4 7 ).
Serum samples whose n e t counts per
m inute were h ig h e r than th e mean c u t o f f v a lu e e s ta b lis h e d w ith th e
n e g a tiv e c o n tro l mean were co nsidered p re s u m p tiv e ly r e a c t iv e f o r HBgAg.
The mean v a lu e f o r th e p o s it iv e c o n tro l samples had to be a t le a s t f i v e
tim es th e v a lu e o f th e n e g a tiv e c o n tro l mean.
Samples t h a t were found
to be p re s u m p tiv e ly p o s it iv e were, assayed a second tim e .
Serum samples
7
whose counts per m inute were re p e a ta b le above th e e s ta b lis h e d c u t o f f .
v a lu e were con sid ered p o s it iv e w ith re s p e c t to HBsA g ..
C hronic C a r r ie r D e te rm in a tio n
C hronic C a r r ie r s o f th e HBgAg were determ ined by s e q u e n tia l te s tin g
o f HBgAg p o s it iv e p a t ie n t s .
P a tie n ts determ ined, to be HBgAg p o s itiv e
(3 1 , 3 2 , 3 7 -4 0 ) were te s te d ag ain a t s ix months and ag ain a t one y e a r .
Those p a tie n ts who were determ ined to be HBgAg p o s it iv e on a l l
th re e
occasions were c o n sid ered to be c h ro n ic c a r r ie r s o f th e HBgAg.
A n ti-H B g Assay
A n ti-H B 0 d e te c tio n in t h i s study was accom plished through an o th er
sandwich ty p e radioim m unoassay, th e AUSAB system produced by Abbott
L a b o ra to rie s
(3 1 , 3 2 , 4 1 - 4 4 ) . .
The procedure c o n s is te d o f th e a d d itio n o f 0 .2 ml o f serum sample
in to a w e ll c o n ta in in g a n tig e n (HBgAg) coated beads.
were in c u b ated f o r 18 hours a t 25°C .
Beads and serum
Beads were washed in th e w e lls
w ith a t o t a l o f 1 0 .0 ml o f s t e r i l e w a te r using a Cornw all s y rin g e and
an a s p ir a t in g c a n u la .
to th e w e lls .
hours a t 25°C .
0 .0 2 ml o f ^ ^ I - l a b e l e d a n tig e n (HBgAg was added
Beads and ra d io la b e le d a n tig e n were in c u b ated f o r fo u r
Beads were washed w ith a t o t a l o f 1 0 .0 ml o f s t e r i l e
w a te r as b e fo re and tr a n s fe r r e d to c o u n tin g tu b e s .
using a w e ll- t y p e gamma s c i n t i l l a t i o n
c o u n te r.
Samples were counted
N e g a tiv e human c o n tro l
in t h i s system c o n s is te d o f r e c a l c i f i e d normal human s era n o n re a c tiv e
f o r h e p a t i t i s B s u rfa c e a n tig e n
(HBgAg) o r i t s c orresponding a n tib o d y
8
(a n ti-H B s ) .
0.1% sodium a z id e served as a p r e s e r v a tiv e .
^ I-Ia b e le d
HBgAg was s u p p lie d in a 0.01 M TRIS aminemehtane b u f f e r c o n ta in in g 20%
r e c a l c i f i e d normal human plasm a, 1% bovine serum album in and 0.1%
sodium a z id e as p r e s e r v a t iv e .
A ll
HBgAg s u p p lie d in t h i s
system con­
ta in e d both ad and ay subtypes.
R e s u lts o f t h i s assay were determ ined by r e la t i n g n e t counts per
m inute o f th e n e g a tiv e c o n tro l mean tim es th e f a c t o r 2 . 1 .
Samples
whose n e t counts p e r m inute were h ig h e r than th e c u t o f f v a lu e e s ta b ­
lis h e d w ith th e n e g a tiv e c o n tro l mean were co nsidered p re s u m p tiv e ly
r e a t iv e f o r a n t i -HBg .
P res u m p tiv ely r e a t iv e serum samples were re te s te d
to v a lid a t e th e presence o f a n t i -HBg in th e specimen.
Thdse samples
found to be re p e a te d ly r e a c tiv e f o r a n t i -HBg were con sid ered to be
p o s it iv e w ith re s p e c t to a n t i -HBg
Data Format
M edical h is t o r ie s were review ed f o r each r e s id e n t in v o lv e d in th e
h e p a t it is B study a t BRSH f o r th e fo llo w in g in fo rm a tio n :
2.
Sex, 3 .
In th e l a t t e r c a te g o ry , a b i l i t i e s
in fo rm a tio n concerning th e p a t i e n t 's r e l a t i v e s k i l l s
(2 ) A m b u la tio n , (3 ) Feeding.
ta in s to b e h a v io r such as:
fe c e s , 3 .
5.
Age,
BRSH lo c a t io n , 4 . D u ra tio n o f i n s t i t u t i o n a l i z a t i o n , 5.
H a b its and A b i l i t i e s .
T r a in in g ,
I.
I.
P la y in g in u r in e , 4 .
in
p e rta in s to
(I)
T o ile t
H a b its in t h i s c a te g o ry p e r­
P la y in g in th e t o i l e t , 2 .
P la y in g in
P la c in g fo r e ig n o b je c ts in mouth,
E a tin g /S u c k in g c lo th e s , and 6 .
D rin k in g from t o i l e t s , s in k s .
9
and b a th tu b s .
These d a ta were c o r r e la te d to th e presence o f a n t i -HBs ,
HBgAg o r b o th .
S t a t i s t i c a l Treatm en t o f Data
S t a t i s t i c a l a n a ly s is o f these data was c a r r ie d o u t by making use
o f th e ODDS-RATIO t e s t , a commonly used e p id e m io lo g ic a l approach to
d a ta a n a ly s is
(4 5 , 4 6 ) .
Data were an aly ze d on a o n e -to -o n e basis as
w e ll as o v er a s im u lta n e o u s ,c o n fid e n c e i n t e r v a l .
r e p o rte d using th e o n e -to -o n e com parison.
Data a n a ly s is was
M a in ta in in g an a r b i t r a r y p
v a lu e o f 0 .0 5 as th e m inim al level, o f s ig n if ic a n c e , a l l
s c r u t in iz e d f o r i n t r i n s i c d iffe r e n c e s .
d a ta were
Comparisons haying p values o f
< 0 .0 5 were co nsidered to be s ig n if ic a n t and re p o rte d as such.
RESULTS
Upon th e c o m p letio n o f radioimmunoassays f o r both HB5Ag and a n t i HBg among th e 524 p a tie n ts te s te d a t BRSH, 66 p a tie n ts were found to be
p o s itiv e f o r a n t i -HBg and 22 p a tie n ts were found to be HBgAg p o s it iv e .
These d a ta in d ic a t e t h a t o v er 16% o f th e t e s t p o p u la tio n were in fe c te d
w ith h e p a t i t i s B w ith in th e tim e fram e o f t h i s study (T a b le I ) .
In
a d d it io n , fo u r p a tie n ts w ith in th e t e s t p o p u la tio n were found to be
c h ro n ic c a r r i e r s o f th e HBgAg.
Age C o r r e la tio n w ith A n ti-H B g and HBgAg
Standard e p id e m io lo g ic a l age groupings were a n a ly ze d in o rd e r to
d e te rm in e i f th e re i s , in t h i s i n s t i t u t i o n , a c o r r e la t io n between th e
age o f a p a t ie n t and th e presence o f e i t h e r a n t i -HBg o r HBgAg.
r e s u lt s
(T a b le s I I ,
III)
The
re v e a l t h a t th e o ld e r age groups in th e i n s t i ­
t u t io n have h ig h e r le v e ls o f a n t i -HBg p re v a le n c e than age groups 15
y e a rs o f age and younger.
Age groups 4 0 -4 4 y ea rs and 2 0 -2 4 y ea rs were
observed to have th e h ig h e s t le v e ls o f a n t i -HBg p re v a le n c e .
I t was
in t e r e s t in g t h a t th e 2 0 -2 4 y e a r age group c o n ta in ed 38% o f th e 66 a n t i HBg p o s it iv e p a tie n ts i d e n t i f i e d in t h i s s tu d y .
The p re v a le n c e o f HBgAg p o s itiv e s a ls o was h ig h e r in th e 4 0 -4 4
y e a r age group.
The 2 5 -2 9 y e a r age group was a ls o observed to have
h ig h e r le v e ls o f HBgAg p re v a le n c e than th e younger age groups a n a ly ze d .
The 2 5 -2 9 y e a r age group co n ta in ed 27.3% o f th e 22 HBgAg p o s itiv e
p a tie n ts i d e n t i f i e d
in th e t e s t p o p u la tio n .
I t was noted t h a t no
a n t i -HBg p o s itiv e s and o n ly one HBgAg p o s it iv e p a t ie n t were found in
age groups below 10 y e a rs o f age.
O f th e c h ro n ic c a r r i e r s o f HBgAg
11
Table I .
Results o f A nti-H B5 and HB5Ag Radioimmunoassays
Group
No.
P a tie n ts
524
% o f T o ta l P a tie n ts
100
A n ti-H B S(+ )
66
1 2 .6
HBsA g(+)
22
4 .2
P a tie n ts (+ ) f o r
both HB Ag and
A n ti-H B 5
4
.7
Chronic c a r r ie r s
o f HB5Ag
4
.7
84
1 6 .8
P a tie n ts (+ ) f o r
e i t h e r A n ti-H B o r
HB5Ag
12
Table I I .
A n ti-H B g (+ )
%
.
Chronic C a r r ie r
(HBsAg)
0 .0
0
1 -4
0 /1 0
0 .0
0
5 -9
0 /2 6
1 0-14
4 /5 5
7 .3
0
15-19
1 0 /9 8
1 6 .2b
0
2 0-24
2 5 /1 2 9
1 9 .4 *
3
2 5 -2 9
1 4 /9 2
1 5 .2 *
I
3 0-34
5 /5 5
9,1
0
3 5-39
4 /2 6
1 5 .4
0
4 0 -4 4
3 /1 2
2 5 .0
0
45
1 /2 3
4 .3
0
O
I
Cr
0 /0
O
Age Group
(y e a rs )
A nti-H B g A ssociation w ith Age Groupings
0
a , b ’ P e rc e n ta g e s t h a t d i f f e r in s u p e rs c rip t a re s i g n i f i c a n t l y
d i f f e r e n t using th e O dds-R atio t e s t (4 5 , 4 6 ) p £ 0 . 0 5 .
13
Table I I I .
HBgAg A ssociation w ith Age Groupings
HBsAg (+ )
Age Group
(y e a rs )
%*
. . Chronic C a r r ie r
(HBsAg)
0 /0
0 .0
0
1 -4
0 /1 0
0 .0
0
5 -9
1 /2 6
3 .8
0
1 0-14
2 /5 3
3 .8
0
1 5-19
1 /9 8
1.1
0
5 /1 2 9
3 .9
3
2 5 -2 9
6 /9 2
6 .5
I
3 0 -3 4
2 /5 5
3 .8
3 5 -3 9
1 /2 6
3 .8
0
4 0 -4 4
1 /1 2
8 .3
0
45
0 /2 3
0 .0
0
I
2 0 -2 4
.
.
0
*P e rc e n ta g e not having s u p e rs c rip ts were not found to be s i g n i f ­
ic a n t using th e O dds-R atio t e s t (4 5 , 4 6 ) .
14
id e n tifie d
in t h i s s tu d y , th r e e were lo c a te d in th e 2 0 -2 4 age group and
one was lo c a te d in th e 2 5 -2 9 y e a r age group;
Sex C o r r e la tio n w ith A n ti-H B c and HBcAg
The sex o f p a tie n ts was an aly ze d in o rd e r to d e te rm in e i f th e re i s ,
in t h i s
i n s t i t u t i o n , a c o r r e la t io n between th e sex o f a p a t ie n t and th e
presence o f e it h e r a n ti-H B s o r HBgAg.
The r e s u lts Tables IV , V) re v e a l
t h a t th e r e is a h ig h e r le v e l o f p re v a le n c e in both a n t i -HBg and HBgAg
in th e male segment o f th e t e s t p o p u la tio n .
15.9% o f th e males were
found to be a n t i -HBg p o s it iv e as compared to 7.4% o f th e fe m a le s .
HBgAg
a ls o fo llo w e d a male predominance p a tte r n w ith 5.5% o f th e males in
th e t e s t p o p u la tio n i d e n t i f i e d as p o s it iv e compared w ith 2.3% o f th e
fem ales i d e n t i f i e d as HBgAg p o s it iv e .
I t was noted t h a t 74.3% o f th e
66 a n t i -HBg p o s itiv e s i d e n t i f i e d were m ale and 77.3% o f th e 22 HBgAg
p o s itiv e s were m ale.
3 :1 .
Chronic c a r r ie r s o f HBgAg were male predom inant
These d a ta im p lic a te a s tro n g male predominance in th e p re va len ce
o f both a n t i -HBg and HBgAg among th e p a tie n ts o f BRSH.
D u ra tio n o f I n s t i t u t i o n a l i z a t i o n C o r r e la tio n
w ith A n ti-H B g and HBgAg
The le n g th o f a p a t i e n t 's
i n s t i t u t i o n a l i z a t i o n was observed in
o rd e r to d e term in e i f th e r e is in t h i s
i n s t i t u t i o n , a c o r r e la t io n
between a p a t i e n t 's le n g th o f s ta y and th e presence o f e i t h e r a n t i -HBg
o r HBgAg.
The r e s u lts
(T a b le s V I , V I I )
re v e a l t h a t th e p re va len ce o f
a n ti-H B gis h ig h e s t in th e 1 0-14 y e a rs and 3 0-39 y e a rs d u ra tio n groups.
15
Table IV .
Sex
Female
Unknown
A n t i-HBs (+ )
4 9 /3 0 7
1 7 /2 1 6
0 /1
% .
Chronic C a r r ie r
(HBsAg)
1 5 .9a
3
7 .4 b
I
O
O
O
Male
A nti-H B g A ssociation w ith Sex
0
a ’ ^ P e r c e n t a g e s t h a t d i f f e r in s u p e rs c rip t a re s i g n i f i c a n t l y
d i f f e r e n t using th e O dds-R atio t e s t (4 5 , 4 6 ) p £ 0 .0 5 .
16
HBgAg A ssociation w ith Sex
Sex
HBgA gf+)
%
Chronic C a r r ie r
(HBgAg)
Male
1 7 /3 0 7
5 .5 *
3
Female
5 /2 1 6
CO
CM
' I
Unknown
0/1
O
O
O
Table V.
0
a , k , c Percentages t h a t d i f f e r in s u p e rs c rip t a re s i g n i f i c a n t l y
' d i f f e r e n t using th e O dds-R atio t e s t (4 5 , 4 6 ) p £ 0 . 0 5 .
17
T a b le V I.
A n ti-H B g A s s o c ia tio n w ith D u ra tio n o f I n s t i t u t i o n a l i z a t i o n
D u ra tio n
(y e a rs )
A n ti-H B c (+ )
I
0 /2
1 -4
5/41
%
Chronic C a r r ie r
(HBgAg)
0 .0
0
1 2 .2
0
. 1 3 /1 7 5
7 .4 a
I
1 0-14
2 4 /1 1 6
2 0 . 6b
3
1 5-19
1 6 /1 1 3
1 4 .2
0
1 0 .0
0
5 -9
2 0 -2 4
3 /3 0 .
2 5 -2 9
2 /2 4
8 .3
0
3 0 -3 9
3 /1 8
1 6 .6
0
4 0 -4 9
0 /5
0 .0
0
a ’ bPercentages th a t d i f f e r in s u p e rs c rip t are s ig n if ic a n t ly
d if f e r e n t using th e Odds-Ratio t e s t (4 5 , 46) p<0.0 5 .
18
Table V I I .
D u ra tio n
(y e a rs )
HBgAg A ssociation w ith Duration o f I n s t it u t io n a liz a t io n
HBgAg(+ )
%*
Chronic C a r r ie r
(HBgAg)
0 /2
0 .0
0
1 -4
1/41
2 .4
0
5 -9
6 /1 7 5
3 .4
I
10-14
6 /1 1 6
5 .2
3
15-19
5 /1 1 3
4 .4
0
2 0 -2 4
0 /3 0
0 .0
0
2 5 -2 9
1 /2 4
4 .2
0
3 0 -3 9
2 /1 8
11.1
0
4 0 -4 9
1 /5
2 0 .0
0
I
*Percentages th a t have no s u p e rs c rip t do not d i f f e r enough to be
s ig n ific a n t (p £ 0 .0 5 ) using th e Odds-Ratio t e s t (4 5 , 4 6 ).
19
I t was noted t h a t 61% o f th e 66 a n t i -HBg p o s itiv e s were in d u ra tio n
groups between 5 and 15 y e a rs .
The HBgAg p re va len ce le v e ls p re se n t a
more equal d i s t r i b u t i o n among th e d u ra tio n groups in d ic a tin g th a t
h ig h e r le v e ls o f HBgAg p re v a le n c e may n o t be a s s o c ia te d w ith lo n g e r
d u ra tio n s o f i n s t i t u t i o n a l i z a t i o n .
These d a ta im p lic a te a v e ry lim it e d
degree o f a s s o c ia tio n between a p a t i e n t 's le n g th o f s ta y a t BRSH and
th e presence o f e i t h e r a n t i -HBg o r HBgAg.
Of th e fo u r c h ro n ic c a r r ie r s
o f th e HBgAg i d e n t i f i e d , one was lo c a te d in th e 5 -9 y e a rs group and
th r e e were lo c a te d in th e 1 0 -1 4 y e a rs group.
Each y e a r o f adm ission o f each p a t ie n t was a ls o an aly ze d f o r th e
o ccu rren ce o f s p e c i f i c a l l y "hot" y e a rs in which th e p re v a le n c e o f
e i t h e r a n t i -HBg o r HBgAg reached s i g n i f i c a n t l y high l e v e l s .
This
approach p ro vid ed a c o n s is te n t and equal d i s t r i b u t i o n th rough out th e
range o f y e a rs o f adm ission.
I n s t i t u t i o n a l L o c atio n C o r r e la tio n w ith
A n ti-H B g and HBgAg
The i n s t i t u t i o n a l
d e te rm in e i f th e r e i s ,
lo c a tio n o f p a tie n ts was an aly ze d in o rd e r to
in t h i s
i n s t i t u t i o n , a c o r r e la t io n between a
p a t i e n t 's lo c a tio n and th e presence o f a n t i -HBg and HBgAg.
The r e s u lts
(T a b le s V I I I , IX ) re v e a l a h ig h e r p re v a le n c e o f both a n t i -HBg and
HBgAg in th e male segregated c o tta g e s than th e r e s t o f th e p o p u la tio n .
T h is o b s e rv a tio n f u r t h e r supports th e sex c o r r e la t io n r e s u lt s observed
e a r lie r .
To a llo w f o r t h i s observed sexual p r e d is p o s itio n a t BRSH,
20
Table V I I I .
A nti-H B 5 A ssociation w ith Location
L o c atio n
(c o tta g e )
A n ti-H B 5 (+ )
3
(m ale)
8 /3 6
4
(m a le)
5
%
C hronic C a r r ie r
(HB5Ag)
2 2 .0
0.
1 5 /3 4
4 4. Oa
I
(fe m a le )
2 /2 4
8 .3
0
6a
(m a le)
6/31
1 9 .4 ^
0
6b
(fe m a le )
2 /2 0
1 0 .0 .
I
10
(m a le)
4 /3 0
1 3 .3 ^
I
11
(fe m a le )
1 /3 2
3.1
0
12
(m a le)
6 /1 7
3 5 .3
0
13
(fe m a le )
1 /2 4
4 .2
0
14
(c o -e d )
1 /1 8
5 .5
0
15
(c o -e d )
2 /1 8
1 1 .0
0
16ab
(c o -e d )
1 /3 2
3.1
0
16c
(c o -e d )
3 /5 3
5 .7
I
(m a le)
0 /8
0 .0 b
0
104c
^ '^ P e rc e n ta g e s t h a t d i f f e r in s u p e rs c rip t a re s i g n i f i c a n t l y
d i f f e r e n t using th e O dds-R atio t e s t (4 5 , 4 6 ) p < 0 .0 5 .
'
21
Table IX .
HBgAg A ssociation w ith Location
L o c atio n
(c o tta g e )
HBgA gf+)
%*
Chronic C a r r ie r
(HBgAg)
3
(m a le)
4 /3 6
11.1
0
4
(m ale)
4 /3 4
1 1 .8
I
5
(fe m a le )
1 /2 4
4 .2
0
6a
(m a le )
0/31.
0 .0
0
6b
(fe m a le )
1 /2 0
5 .0
I
10
(m ale)
1 /3 0
3 .3
I
11
(fe m a le )
0 /3 2
0 .0
0
12
(m ale)
0 /1 7
0 .0
0
13
(fe m a le )
0 /2 4
0 .0
0
14
(c o -e d )
1 /1 8
5 .5
0
15
(c o -e d )
2 /1 8
1 1 .0
0
16ab
(c o -e d )
0 /3 2
0 .0
0
16c
(c o -e d )
3 /5 3
5 .7
I
(m ale)
1 /8
1 2 .5
0
104c
^P ercentages t h a t have no s u p e rs c rip t do not d i f f e r enough to be
s ig n if ic a n t (p < 0 .0 5 ) using th e O dds-R atio t e s t ( 4 5 , 4 6 ) .
22
c o tta g e s were s e p a ra te d in to male s e g re g a te d , fem ale s e g re g a te d , and
co-ed l i v i n g groups.
Each group was a n aly ze d f o r i t s '
l a t i o n w ith th e presence o f e i t h e r a n t i -HBg o r HBgAg.
p o s s ib le c o rre ­
Even a f t e r
a llo w in g f o r t h i s p r e d is p o s itio n , d iffe r e n c e s in th e le v e ls o f p re ­
v ale n c e o f both a n t i -HBg and HBgAg were found to each group.
A n ti-H B g
p re v a le n c e was found to reach h ig h e r le v e ls in c o tta g e s 4 and 12 than
in th e r e s t o f th e male seg reg ated c o tta g e s .
C ottages 5 and 6b had
h ig h e r le v e ls o f a n t i -HBg p re v a le n c e than th e r e s t o f th e fem ale s eg re­
gated c o tta g e s .
Levels o f a n t i -HBg p re v a le n c e were observed to be
h ig h e r in c o tta g e 15 than in th e r e s t o f th e co-ed c o tta g e s .
HBgAg
p re v a le n c e le v e ls were found to be h ig h e r in c o tta g e s 3 and 4 than in
th e r e s t o f th e male seg regated c o tta g e s .
Cottages 5 and 6b were
observed to have h ig h e r le v e ls o f HBgAg p re va len ce than th e r e s t o f
th e fem ale seg reg ated c o tta g e s .
C ottag e 15 was found to have a h ig h e r
le v e l o f HBgAg p re v a le n c e than th e r e s t o f th e co-ed c o tta g e s .
c a r r ie r s o f th e HBgAg i d e n t i f i e d in t h i s
Chronic
study were lo c a te d in c o tta g e s
4 , 6b , 1 0 , and 16c.
A nother segment o f th e t e s t p o p u la tio n is lo c a te d o u ts id e o f th e
in s titu tio n a l
grounds (T a b le s X , X I ) .
T h is segment c o n s is ts o f those
p a tie n ts who have f o r one reason o r a n o th e r been p laced in Nursing
Homes, F o s te r Homes, O th e r I n s t i t u t i o n s , Home P lacem en t, o r have been
c o m p le te ly d is c h a rg e d .
Also in c lu d e d in t h i s segment a re those members
o f th e t e s t p o p u la tio n who have d ie d d u rin g th e tim e span o f t h i s study.
23
T a b le X.
L o c a tio n 3
A n ti-H B s A s s o c ia tio n w ith L o c atio n
A n ti-H B S(+ )
%*
Chronic C a r r ie r
(HBsAg)
NHP
5 /6 4
7 .8
0
FHP
6 /4 9
1 2 .0
0
OI
0 /4
0 .0
0
HP
2 /1 4
1 4 .2
0
DIS
1 /1 0
1 0 .0
0
EX
0 /6
0 .0
0
.
aNHP=Nursing Home Placement
FHP=Foster Home Placement
OI= Placement in O ther I n s t i t u t i o n s
HP= Home Placement
DIS=D ischarged
EX= Died d u rin g th e study p e rio d
*Percentages th a t have no s u p e rs c rip t do not d i f f e r enough to be
s ig n ific a n t ( P<0.0 5 ) using the Odds-Ratio te s t (4 5 , 4 6 ).
24
Table X I.
L o c a tio n 9
HBgAg A ssociation w ith Location
HBSAG(+)
%*
Chronic C a r r ie r
(HBsAg)
NHP
2 /6 4
9.1
0
FHP
1 /4 9
2.1
■ 0
OI
0 /4
0 .0
0
HP
0 /1 4
0 ,0
0
DIS
1 /1 0
0 .0
0
EX
0 /6
0 .0
0
a NHP=Nursing Home Placement
FHP=Foster Home Placement
OI= Placement in O ther I n s t i t u t i o n s
HP= Home Placement
D IS=Discharged
EX= Died d u rin g study p e rio d
*Percentages th a t have no s u p e rs c rip t do not d i f f e r enough to be
s ig n ific a n t (p < 0 .0 5 ) using th e Odds-Ratio t e s t (4 5 , 4 6 ).
25
S in ce in n e a r ly e v e ry in s ta n c e , placem ent o u ts id e th e i n s t i t u t i o n
in v o lv e s a co-ed l i v i n g gro u p , t h i s group was n o t a n aly ze d w ith a llo w ­
ance f o r th e sexual p r e d is p o s itio n as th e c o tta g e l i v i n g groups w ere.
In t h i s segment, h ig h e s t le v e ls o f a n t i -HBs p re va len ce were observed
in th e F o s te r Home Placement and Home Placement groups.
The h ig h e s t
le v e ls o f HBgAg p re v a le n c e were found in th e Nursing Home Placement and
D ischarged groups.
There were no HBgAg c h ro n ic c a r r ie r s
in t h i s segment
o f th e t e s t p o p u la tio n .
H a b its and A b i l i t i e s C o r r e la tio n w ith
A n ti-H B g and HBgAg
S e le c te d h a b its and a b i l i t i e s
o f p a tie n ts in BRSH were analyzed
in o rd e r to d e te rm in e i f th e r e i s ,
in t h i s
between th e s e h a b its and a b i l i t i e s
and th e presence o f e it h e r a n t i -HBg
o r HBgAg.
The r e s u lt s
(T a b le s X I I , X I I I )
i n s t i t u t i o n , a c o r r e la t io n
re v e a l a number o f i n t e r ­
e s tin g a s s o c ia tio n s w ith in th e segments o f t h i s c o r r e l a t i o n .
Among th e T o i l e t T r a in in g o b s e rv a tio n s , th e segment o f p a tie n ts
t h a t were c o m p le te ly t o i l e t t r a in e d had th e h ig h e s t le v e ls o f a n t i HBg p re v a le n c e .
m ed iate in i t s
The " p a r t i a l l y " t o i l e t t r a in e d segment was i n t e r ­
le v e ls o f a n t i -HBg p re v a le n c e , w ith th e segment o f
p a tie n ts w ith no t o i l e t t r a i n i n g having th e lo w es t le v e ls o f a n t i -HBg
p re v a le n c e .
p a tte rn .
HBgAg p re v a le n c e d id n o t fo llo w th e p re v io u s a n t i -HBg
The h ig h e r le v e ls o f HBgAg p re v a le n c e were found in both th e
"c o m p le te ly " t o i l e t t r a in e d segment and t h a t segment o f p a tie n ts
26
Table X I I .
Anti-HBs A ssociation w ith Habits and A b il it ie s
H a b its /A b ilitie s
A n t i-HBs (+ )
I
Chronic C a r r ie r
(HBsAg)
T o i l e t T ra in in g
com plete
2 9 /1 6 0
1 8 .1
I
p a r tia l
1 5 /1 0 2
1 4 .7
I
7 /1 0 3
6 .8
2
1 6 .I a
4
none
A m bulation
4 6 /2 8 5
no
3 /6 3
0
com plete
1 8/7 7
2 3 .8a
2
p a r tia l
2 9 /2 2 6
1 0 .9b .
I
2 /5 2
9 .6 b
I
■d-
JD
CO
yes
Feeding S k i l l s
1 2 .5
0
P lays in T o i l e t
2 /1 6
P lays in Feces
3 /5 6
Plays in U rin e
2 /1 7
1 1 .8
2
F o reig n O b jects
in Mouth
9 /7 2
1 2 .5a
0
C lo th es in Mouth
0 /2 0
%
none
0
2 9 .5b
2
D rin k s from F a u c e ts ,
S in k s , and Tubs
1 3 /4 4
O
5 /4 a
2
a ^ P e rc e n ta g e s t h a t d i f f e r in s u p e rs c rip t a re s i g n i f i c a n t l y
d i f f e r e n t using th e O dds-R atio t e s t (4 5 , 4 6 ) p < 0 .0 5
27
Table X I I I .
HBgAg A ssociation w ith Habits and A b il it ie s
HBgAG(+ )
%
Chronic C a r r ie r
(HBgAg)
com plete
8 /1 6 0
5 .0
I
p a r tia l
3 /1 0 2
2 .9
I
none
6 /1 0 3
5 .8
2
yes
1 6 /2 8 5
5 .6
4
no
1 /6 3
1 .6
0
3 /7 7
3 .9
2
1 2 /2 2 6
5 .3
I
none
2 /5 2
3 .8
I
P lays in T o i l e t
0 /1 6
0 .0
0
Plays in Feces
4 /5 6
7.1
2
P lays in U rin e
3 /1 7
1 7 .Gf
2
F o re ig n O b jects
in Mouth
1 /7 2
1 .4 b
0
C lo th e s in Mouth
0 /2 0
0 .0
0
D rin k s from F a u c e ts ,
S in k s , and Tubs
4 /4 4
9.1
2
H a b its /A b ilitie s
T o i l e t T ra in in g
A m bulation
Feeding S k i l l s
com plete
p a r tia l
^ P e r c e n t a g e s t h a t d i f f e r in s u p e rs c rip t a re s i g n i f i c a n t l y
d i f f e r e n t using th e O dds-R atio t e s t (4 5 , 4 6 ) p £ 0 . 0 5 .
28
having no t o i l e t t r a i n i n g s k i l l s , as compared w ith th e lo w er le v e ls o f
p re v a le n c e found in t h a t segment o f p a tie n ts c la s s i f ie d as being
" p a r t i a l l y " t o i l e t t r a in e d .
O b servations on th e am bulato ry a b i l i t y o f p a tie n ts re v e a le d th e
h ig h e s t le v e ls o f both a n t i -HB5 and HBgAg p re v a le n c e were to be found
in t h a t segment o f p a tie n ts t h a t were c la s s i f ie d as being a m b u lato ry.
Those p a tie n ts c la s s i f ie d as n on-am bulatory had lo w er le v e ls o f a n t i HBg and HBgAg p re v a le n c e .
O b servatio n s on th e fe e d in g s k i l l s o f p a tie n ts re v e a le d t h a t th e
h ig h e s t le v e ls o f a n t i -HBg p re v a le n c e were to be found among those
p a tie n ts possessing "com plete" fe e d in g s k i l l s as opposed to those
p a tie n ts possessing " p a r t i a l " fe e d in g s k i l l s and no fe e d in g s k i l l s .
HBgAg p re v a le n c e p a tte rn s d id n o t fo llo w th e a n t i -HBg p re v a le n c e
p a tte r n s seen above.
The h ig h e s t le v e ls o f HBgAg p re v a le n c e were found
among th e s e p a tie n ts possessing "com plete" fe e d in g s k i l l s and those
p a tie n ts possessing no fe e d in g s k i l l s .
O b servatio n s o f s e le c te d p a t ie n t h a b its y ie ld e d complex asso- .
c ia t io n s w ith th e presence o f a n t i -HBg and HBgAg.
A n a ly s is o f those
p a tie n ts known to p la y in th e t o i l e t on a r e g u la r b a sis showed a r e l a ­
t i v e l y high le v e l o f a n t i -HBg .
P a tie n ts known to p la y in u rin e and
p la c e fo r e ig n o b je c ts in t h e i r mouths a ls o had r e l a t i v e l y high le v e ls
o f a n t i -HBg p re v a le n c e .
The h ig h e s t le v e ls o f a n t i -HBg p re va len ce
were found in p a tie n ts known to d r in k from fa u c e t s , s in k s , and bathtubs
29
w ith in th e i n s t i t u t i o n .
The h ig h e s t HBgAg le v e ls o f p re v a le n c e were
found among those p a tie n ts known to p la y in u rin e on a r e g u la r b a s is .
Those p a tie n ts who d rin k from th e fa u c e t s , s in k s , and bathtubs o f th e
i n s t i t u t i o n a ls o were found to have e le v a te d le v e ls o f HBgAg p re v a le n c e .
The r e s t o f th e c a te g o rie s in t h i s segment were observed to have low
le v e ls .
A d m ittin g D iagnosis C o r r e la tio n w ith
A n ti-H B g and HBgAg
The a d m ittin g d ia g n o s is o f each p a t ie n t was an aly ze d in o rd e r to
d e term in e i f th e re i s ,
in t h i s
i n s t i t u t i o n , a c o r r e la t io n between th e
a d m ittin g d ia g n o s is assigned each p a t ie n t and th e presence o f e it h e r
a n t i -HBg o r HBgAg.
The r e s u lts
(T a b le s X IV , XV) re v e a l t h a t s ev e ral
o f th e d ia g n o s is groups show r e l a t i v e l y high le v e ls o f both a n t i -HBg
and HBgAg p re v a le n c e .
R e la t iv e ly high le v e ls o f a n t i -HBg p re va len ce
were observed in groups IV , V and V I .
Groups I , V I I , V I I I and th e
undiagnosed p a tie n ts were found to have in te rm e d ia te le v e ls o f a n t i HBg p re v a le n c e .
R e la t iv e ly low le v e ls o f a n t i -HBg p re v a le n c e were
observed in groups I I
and I I I .
HBgAg p re va len ce was a ls o found to be
e le v a te d in some d ia g n o s is groups.
However, th e e le v a te d le v e ls o f
HBgAg d id no t c lo s e ly fo llo w those p re v io u s ly observed f o r a n t i -HBg
in th e same d ia g n o s is c l a s s i f i c a t i o n s .
R e la t iv e ly high le v e ls o f
HBgAg p re v a le n c e were observed in groups I I I ,
V , and V I I I .
In te r ­
m ed iate le v e ls o f HBgAg p re v a le n c e were found in groups I and V I.
30
Table XIV .
A nti-H B g A ssociation w ith A dm itting Diagnosis
D ia g n o s is 3
(c la s s )
A n t i-HBg (+ )
I
5 /4 3
II
%
Chronic C a r r ie r
(HBgAg)
1 1 .6
0
0 /6
0 .0
0
III
1 /4 9
2 .I b
.1
IV
1 6 /1 0 6
1 5 .I c
I
5 0 .Oc
0
V
2 /4
VI
2 9 /2 0 0
1 4 .5C
2
V II
. 7/61
1 1 .5
0
V III
4 /3 7
1 0 .8
0
Unknown
3 /1 8
1 6 .7
0
.
a I=M ental r e t a r d a t io n due to In f e c t io n
II= M e n ta l r e ta r d a tio n due to In t o x ic a t io n
III= M e n t a l r e t a r d a t io n due to Trauma o r P h ysical Agents
IV=M ental r e t a r d a t io n due to D is o rd e rs in M e ta b o lism , Growth,
o r N u t r it io n
V=Mental r e t a r d a t io n due to New Growth
V I=M ental r e t a r d a t io n due to Unknown P re n a ta l In flu e n c e
V II= M e n ta l r e t a r d a t io n due to U n c e rta in cause w ith A ssociated
S tr u c tu r a l R eaction
V III= M e n ta l r e t a r d a t io n due to U n c e rta in cause w ith A ssociated
F u n c tio n a l R eaction
k ,c Percentages t h a t d i f f e r in s u p e rs c rip t a re s i g n i f i c a n t l y
d i f f e r e n t using th e O dds-R atio t e s t (4 5 , 4 6 ) p < 0 .0 5 .
31
Table XV.
D ia g n o s is 9
(c la s s )
HBgAg A ssociation w ith A dm itting Diagnosis
HBgAg(+ )
%
C hronic C a r r ie r
(HBgAg)
I
3 /4 3
6 .9
0
II
0 /6
0 .0
0
III
5 /4 9
1 0 ,2
I
IV
2 /1 0 6
V
2 /4
1 .9 b
50. Oc
I
_ .
.
o
VI
1 0 /2 0 0
5 . Ob
2
V II
0/61
0 .0 b
0
V III
2 /3 7
9.1
0
Unknown
0 /1 8
0 .0
0
a I=M ental r e t a r d a t io n due to In fe c t io n
II= M e n ta l r e t a r d a t io n due to In t o x ic a t io n
III= M e n t a l r e t a r d a t io n due to Trauma o r P h ysical Agents
IV=M ental r e t a r d a t io n due to D is o rd e rs in M e ta b o lism ,
G row th, o r N u t r it io n
V=Mental r e t a r d a t io n due to New Growth
V I=M ental r e t a r d a t io n due to Unknown P re n a ta l In flu e n c e s
V II= M e n ta l r e t a r d a t io n due to U n c e rta in causes w ith A ssociated
S tr u c tu r a l R eactions
V III= M e n ta l r e t a r d a t io n due to U n c e rta in causes w ith A ssociated
F u n c tio n a l R eactions
^ '^ P e rc e n ta g e s t h a t d i f f e r in s u p e rs c rip t a re s i g n i f i c a n t l y
d i f f e r e n t using th e O dds-R atio t e s t (4 5 , 4 6 ) p < 0 .0 5
32
Groups I I ,
IV , V I I and th e undiagnosed p a tie n ts were found to . have
r e l a t i v e l y low le v e ls o f HBgAg p re v a le n c e .
A more thorough e x p la n a tio n
o f th e s e M ental R e ta rd a tio n c la s s i f ic a t i o n s appears in th e appendix o f
t h i s t h e s is .
DISCUSSION
The d is c o v e ry o f th e h e p a t i t i s B s u rfa c e a n tig e n (HBgAg) and th e
subsequent developm ent o f s p e c if ic and s e n s itiv e te s ts
id e n tific a tio n
th is
(R IA ) f o r i t s
have p ro vid ed th e te c h n o lo g y needed to f u r t h e r study
i n t r a c t a b le d is e a s e ( 3 0 - 4 6 ) .
The p a t ie n t in an i n s t i t u t i o n
f o r th e m e n ta lly and p h y s ic a lly
handicapped who harbors HBgAg re p re s e n ts a complex p u b lic h e a lth
problem .
Evidence o f th e h is to r y o f h e p a t it is B a t B oulder R iv e r
School and H o s p ita l
(BRSH) dates back to 1970 ( 4 7 ) .
S ince 1970, th e re
have been re p e a te d o u tb reaks o f h e p a t it is B, in d ic a tin g th e r e may be a
p o p u la tio n o f p a tie n ts who do harb o r th e h e p a t it is B v ir u s .
The
d e te c tio n o f e i t h e r a n t i -HBg o r HBgAg in 16.8% o f th e 524 p a t ie n t t e s t
p o p u la tio n a t BRSH in d ic a te s t h a t h e p a t i t i s B is endemic th e r e .
As each i n s t i t u t i o n
presen ts a unique e p id e m io lo g ic a l s e t t in g ,
e p id e m io lo g ic a l s tu d ie s a t BRSH a re c r i t i c a l
o f r e la t e d i n s t i t u t i o n s s tu d ie d to d a te .
in s p ite o f th e numbers
Data o b ta in e d from t h is
stu d y lends credence to th e uniqueness o f each i n s t i t u t i o n a l
s e ttin g
and p re se n ts new im p lic a tio n s as to th e r i s k o f in f e c t io n w ith
h e p a t i t i s B.
The prolonged presence o f HBgAg seems to be r e la t e d to age a t th e
tim e o f in f e c t io n
(3 4 ).
Of th e fo u r HBgAg c h ro n ic c a r r i e r s
id e n tifie d
in t h i s s tu d y , th re e o f th e s e were found in th e 2 0-24 y e a rs o f age
group.
The fo u r th c h ro n ic c a r r i e r o f th e HBgAg was found in th e 2 5 -2 9
y e a rs o f age group.
These d a ta d i f f e r from o th e r i n s t i t u t i o n a l
studies
34
which im p ly t h a t c h ro n ic c a r r i e r r a te s predom inate in younger age
d is tr ib u tio n s .
The f a c t t h a t th e HBgAg c h ro n ic c a r r i e r r a t e is o n ly
0.7% a t BRSH is rem arkab le c o n s id e rin g p re vio u s s tu d ie s a t o th e r
in s titu tio n s
have re p o rte d c h ro n ic c a r r i e r ra te s as high as 25-30% ( 3 4 ) .
The p re s e n t s tu d y a t BRSH in d ic a te s t h a t a high pe rce n ta g e o f both th e
a n t i -HBg p o s it iv e p a tie n ts and th e HBgAg p o s it iv e p a tie n ts a re found in
age ranges <20 y e a rs o f age.
HB
S
These p a tie n ts re p re s e n t 74% o f th e a n t i -
p o s itiv e s and 64% o f th e HB Ag p o s itiv e s found in th e e n t i r e study
.
S
(T a b le s I I ,
III).
Based on s t a t i s t i c a l
a n a ly s is , th e e le v a te d le v e ls
o f a n t i -HBg p re v a le n c e seen in th e 2 0 -2 4 and 2 5-29 y e a r age groups is
s ig n if ic a n t (p < 0 .0 5 ) when compared w ith th e 5 -9 and 1 5 -1 9 y e a r age
groups.
There is th e n , in BRSH, a c o r r e la t io n w ith a lim it e d degree
o f a s s o c ia tio n between th e p re v a le n c e o f a n t i -HBg and c e r t a in age
groups.
An in t e r e s t in g f a c t to note is t h a t both th e 2 0 -2 4 and 2 5 -2 9
y e a r age groups were found to h arbor a l l
id e n tifie d
o f th e HBgAg c h ro n ic c a r r ie r s
in t h i s s tu d y .
P revious s tu d ie s on th e prolonged presence o f HBgAg in v ario u s
in s titu tio n s
im p ly a m ale p r e d is p o s itio n occurs in th e c h ro n ic c a r r i e r
r a te s
The HBgAg c h ro n ic c a r r ie r s
(4 8 ).
male predom inant ( 3 : 1 ) .
i d e n t i f i e d in t h i s study were
T h is male predominance p a tte r n is a ls o seen
in th e g en eral p re v a le n c e le v e ls o f both a n t i -HBg and HBgAg seen
th ro u g h o u t th e i n s t i t u t i o n
(T a b le s IV , V ).
S t a t i s t i c a l a n a ly s is
35
s u b s ta n tia te s t h a t , a t BRSH, th e re is a s ig n if ic a n t male p re d is p o s itio n
in th e p re v a le n c e o f both a n t i -HB5 and HBgAg.
In view o f th e many v a r ia b le s t h a t m ight a f f e c t th e tra n s m is s io n
o f h e p a t it is B and i t s
p e rs is te n c e w it h in BRSH, th e d u ra tio n o f each
p a tie n ts s ta y a t BRSH was a s s o c ia te d w ith th e presence o f e it h e r a n t i HBg o r HBgAg.
The d a ta (T a b le s V I , V I I )
in d ic a te th e r e were d iffe re n c e s
between th e a n t i -HBg and HBgAg le v e ls o f p re va len ce o f th e d u ra tio n
groups.
However, a s t a t i s t i c a l a n a ly s is o f th ese d a ta does not
s u p p o rt a s ig n if ic a n t c o r r e la t io n .
These data in d ic a te t h a t t h is
d is e a s e may not be a " p a rt" o f th e i n s t i t u t i o n
fu n c tio n o f th e p a tie n ts housed a t BRSH.
i t s e l f , b u t more a
I t was not found t h a t any
s in g le y e a r had any s ig n if ic a n t le v e ls o f a n t i -HBg o r HBgAg p re va len ce
on a co m p arative b a sis w ith o th e r le n g th s o f i n s t i t u t i o n a l s ta y .
In o rd e r to o b ta in a b e t t e r understan d in g o f th e tra n s m is s io n o f
h e p a t i t i s B and i t s
in s titu tio n a l
subsequent p e rs is te n c e p a tte rn s a t BRSH, th e
lo c a tio n o f each p a t ie n t was a s s o c ia te d w ith th e p re v ­
a le n c e o f a n t i -HBg and HBgAg (T a b le s X I I I ,
X IV ) .
In an a tte m p t to
compensate f o r th e male p re d is p o s itio n d e sc rib e d e a r l i e r in t h is
s tu d y , comparison o f i n s t i t u t i o n a l
lo c a tio n was c a r r ie d o u t w ith in
each s eg re g a te group (M a le , Fem ale, and C o -e d ).
A f t e r compensating
f o r t h i s p r e d is p o s itio n s ig n if ic a n t d iffe r e n c e s in a n t i -HBg p re va len ce
were observed in th e male segregated c o tta g e s .
C ottag e 4 s i g n i f i c a n t l y
d i f f e r e d from o th e r m ale segregated c o tta g e s 6 a , 1 0 , and 104c.
A
36
p o s it iv e c o r r e la t io n between c o tta g e 4 and a n t i -HB5 was th e r e fo r e
o b ta in e d .
It
is in t e r e s t in g to note t h a t c o tta g e 4 c o n ta in s a c h ro n ic
HBgAg c a r r i e r .
Although th e HBgAg p re v a le n c e data o b ta in e d f o r c o tta g e
4 do not d i f f e r s i g n i f i c a n t l y from o th e r male seg regated c o tta g e s i t
does r e f l e c t a h ig h e r le v e l o f HBgAg p re v a le n c e .
Levels o f a n t i -HBg
and HBgAg p re v a le n c e in fem ale seg regated c o tta g e s d id no t d i f f e r
s ig n if ic a n tly .
P rev a le n c e o f a n t i -HBg and HBgAg in co-ed c o tta g e s was
not found to d i f f e r s i g n i f i c a n t l y .
I t was in t e r e s t in g to note th a t
in g en eral th e male c o tta g e had th e h ig h e s t le v e ls o f a n t i -HBg and
HBgAg p re v a le n c e ,
th e co-ed c o tta g e s had in te rm e d ia te le v e ls o f p re v ­
a le n c e , and th e fem ale segregated c o tta g e s had th e lo w e s t le v e ls o f
p re v a le n c e .
The la c k o f a c c u ra te d a ta on th e freq u en cy and lo c a tio n
o f p a t ie n t r e lo c a tio n w ith in th e c o tta g e s hampers a more vig orous
c o r r e la t io n between high a n t i -HBg and HBgAg p re va len ce in. c o tta g e s and
th e presence o f a HBgAg c h ro n ic c a r r i e r .
These d a ta in d ic a te th e re
may be an e n v iro n m e n ta l/e c o lo g ic a l c o n ta c t aspect o f th e tra n s m is s io n
o f h e p a t it is
B w ith in t h i s
in s titu tio n .
should prove in t e r e s t in g to i n i t i a t e
Because o f t h i s p o s s i b i l i t y i t
environm ental s u rfa c e te s tin g f o r
HBgAg as w e ll as s tu d ie s on th e fre q u e n cy o f sewer b a c k -u p , amount o f
s u p e rv is io n in th e c o tta g e , m o b ilit y o f p a tie n ts in th e c o tta g e , e tc .
A t an i n s t i t u t i o n
such as BRSH th e modes o f tra n s m is s io n o f
h e p a t i t i s B can be v a rie d and numerous.
Because o f th e poor s a n ita r y
h a b its o f most o f th e p a tie n ts an o ra l tra n s m is s io n o f th e disease is
37
q u ite p o s s ib le .
The la c k o f p h y s ic a l c o n tro l
in v a ry in g degrees by
p a tie n ts can a ls o c o n tr ib u te to am a e r-o s o l ty p e o f tra n s m is s io n , both
r e s p ir a t o r y and u r in a r y .
A lso a t BRSH th e re occur a c c id e n ta l p a re n te ra l
forms o f tra n s m is s io n such as b i t e s , s c ra tc h e s , b u rn s , and o th e r a c c i­
d e n ta l i n j u r i e s a l l
o f which could serv e to tra n s m it h e p a t i t i s B.
Because o f th e v a rie d and numerous modes o f tra n s m is s io n encountered in
BRSH, a c a te g o ry was e s ta b lis h e d in o rd e r to a tte m p t p r e lim in a r y c o rre ­
la t io n s between a n t i -HBg and HBgAg. p re v a le n c e and many o f th e h a b its
and a b i l i t i e s
(Tables X I I ,
common to th e i n s t i t u t i o n a l i z e d m e n ta lly re ta rd e d
X III).
T o i l e t T r a in in g a n a ly s is re v e a le d t h a t th e group o f p a tie n ts
c la s s i f i e d as "com pletely" t o i l e t t r a in e d was t h a t group having th e
h ig h e s t le v e ls o f a n t i -HBg p re v a le n c e .
The " p a r t i a l l y " t o i l e t tr a in e d
group a ls o had r e l a t i v e l y high le v e ls o f a n t i -HBg p re v a le n c e .
The
group having no t o i l e t t r a i n i n g s k i l l s were observed to have r e l a t i v e l y
low le v e ls o f a n t i -HBg p re v a le n c e .
HBgAg p re va len ce remained r e l a t i v e l y
c o n s ta n t among th e th r e e t o i l e t t r a i n i n g groups.
S t a t i s t i c a l a n a ly s is
o f t h i s d a ta does n o t support a s ig n if ic a n t (p £ 0 .0 5 ) d iffe r e n c e in
a n t i -HBg and HBgAg p re v a le n c e le v e ls among th e t o i l e t t r a i n i n g groups.
However, because th e "c o m p le te ly " t o i l e t tr a in e d in d iv id u a l
is probably
more m o b ile in th e f i r s t p la c e and a ls o w i l l re c e iv e th e le a s t super­
v is io n d u rin g t o i l e t a c t i v i t i e s , th e chances o f t h is
in d iv id u a l encoun­
t e r in g f e c a l - o r a l c o n ta m in a tio n a re g r e a t e r than th e in d iv id u a l w ith the
38
lo w e s t le v e l o f t o i l e t t r a i n i n g .
T h is l i n e o f reasoning may account
f o r th e high le v e ls o f p re v a le n c e seen in th e more s k i l l e d p a tie n ts .
These d a ta , when viewed in th e i n s t i t u t i o n a l c o n te x t, may support a
n o n p a re n te ra l mode o f tra n s m is s io n o f h e p a t it is B a t BRSH.
Each p a t i e n t 's am bulato ry a b i l i t i e s were a ls o c o n s id e re d .
There
was found to be a s ig n if ic a n t (p <%05) d iffe r e n c e in th e le v e ls o f
a n t i -HBs and HBgAg p re v a le n c e between th e am bulato ry and non-am bulatory
p a t ie n t s .
T h is a g a in , lends credence to th e key concept t h a t th e
m o b ilit y o f a p a t ie n t is h e a v ily a s s o c ia te d w ith th e p re v a le n c e o f th e
d is e a s e .
Because o f th e p o s s i b i l i t y o f o ra l tra n s m is s io n o f h e p a t it is B
( 4 9 ) , a r b i t r a r y le v e ls o f fe e d in g s k i l l s were con sid ered in t h is s tu d y .
Groups c la s s i f ie d as possessing "com plete" and " p a r t i a l " were found to
have h ig h e r le v e ls o f a n t i -HBg p re v a le n c e than th e group o f p a tie n ts
c la s s i f ie d as having no fe e d in g s k i l l s .
S ta tis t ic a l
a n a ly s is sub­
s t a n t ia t e s t h i s d if f e r e n c e as being s ig n if ic a n t (p < 0 . 0 5 ) .
Although
h o t s t a t i s t i c a l l y s i g n i f i c a n t , th e same p a tte r n can be observed in th e
le v e ls o f HBgAg p re v a le n c e .
T h is may support th e th e o ry t h a t th e more
ad ep t a p a t ie n t is a t using h is u t e n s i ls , th e le s s s u p e rv is io n he is
l i k e l y to r e c e iv e d u rin g m eals.
Those p a tie n ts who have no fe e d in g
s k i l l s a re hand fe d by p a t ie n t c a re te c h n ic ia n s .
The unsupervised
p a t ie n t may t h e r e fo r e drop h is u t e n s i ls , e a t o f f th e f l o o r , e a t o f f
o f o th e r p a t ie n t s ' p la te s and g e n e r a lly e ncou nter more o f a r i s k o f
39
o ra l c o n ta m in a tio n d u rin g e a tin g a c t i v i t i e s .
These d a ta may support
a p o s s ib le n o n p a re n te ra l tra n s m is s io n o f h e p a t it is
In a d d itio n to th e v a rio u s a b i l i t i e s
B a t BRSH.
observed e a r l i e r , an a r b i ­
t r a r y s e t o f h a b its were observed f o r t h e i r a s s o c ia tio n w ith th e
p re v a le n c e o f a n t i -HB5 and HBgAg.
These h a b its were some o f the
c la s s ic examples o f b e h a v io r e x h ib ite d by th e .m e n ta lly re ta rd e d a t
in s titu tio n s
(T a b le s X I I , X I I I ) .
p resen ted sound s t a t i s t i c a l
Of th e s e h a b its th e o n ly h a b it th a t
s ig n if ic a n c e upon comparison w ith th e
o th e r groups was t h a t group o f p a tie n ts t h a t d rin k from th e fa u c e ts ,
s in k s , and tubs o f th e i n s t i t u t i o n .
Viewed w ith in th e i n s t i t u t i o n a l
c o n te x t, th e s e d a ta may sup p o rt n o n p a re n te ra l forms o f tra n s m is s io n
o f h e p a t i t i s a t BRSH.
Blumberg e t a l . (3 4 ) emphasize
and th e p e rs is te n c e o f HBgAg.
th e a s s o c ia tio n between mongolism
Krugman e t a l . (3 5 ) were n o t a b le to
su p p o rt t h i s o b s e rv a tio n w ith t h e i r w ork.
Because o f t h i s apparent
d is c re p a n c y , an a tte m p t to a s s o c ia te a d m ittin g d ia g n o s is w ith th e
p re v a le n c e o f a n ti-H B g and HBgAg was made (T ab les X IV , IV , A ppendix).
Data from BRSH do in d ic a t e t h a t th e re a re high le v e ls o f a n t i -HBg in
groups IV , V, and V I .
However, a s t a t i s t i c a l a n a ly s is re v e a ls th a t
th e s e groups d i f f e r s i g n i f i c a n t l y w ith o n ly one o th e r group ( I I I )
th e re b y l i m i t i n g th e degree o f a s s o c ia tio n o f t h is p o s it iv e c o r r e la tio n .
HBcAg p re v a le n c e , a lth o u g h p ro v id in g a s ig n if ic a n t d if f e r e n c e between
S
40
group B and groups IV , V I , and V I I , a ls o is lim it e d
in i t s degree o f
a s s o c ia tio n due to th e sm all sample s iz e o f group V.
The r e s u lt s o f t h i s s tu d y , a lth o u g h in t e r e s t i n g , would have no
meaning w ith o u t a p p lic a t io n .
P o s s ib le s o lu tio n s to th e problem o f
h e p a t it is B a t BRSH should be in c lu d e d in c u rre n t i n s t i t u t i o n a l
p o lic ie s .
One p o s s ib le s o lu tio n m ight be to employ th e te c h n iq u e o f
" c o h o r tin g ."
T h is in v o lv e s th e placem ent o f a l l
p a tie n ts in th e same re s id e n c e a r e a .
HBgAg p o s it iv e
Nb o th e r p a tie n ts would be placed
in t h i s a re a unless th e y dem onstrated a d e te c ta b le t i t e r o f a n t i -HBg .
Personnel should be a le r t e d to th e p o s s ib le danger th e s e p a tie n ts
p re s e n t to o th e r p a tie n ts as w e ll as to th e s t a f f .
C ottages t h a t have been shown to have an ab n o rm ally high prevalen ce
o f e it h e r a n t i -HBg o r HBgAg should be s tu d ie d in d e t a il
in o rd e r to
e lim in a te any e nvironm ental a s p e c t.o f th e tra n s m is s io n o f h e p a t it is B.
E nvironm ental s u rfa c e te s t in g f o r HBgAg in tr o u b le a rea s could be.used
to e lim in a te t h i s ty p e o f tra n s m is s io n ( 5 0 ) .
A nother p o lic y o f im portance is th e r o u tin e s cre e n in g o f incoming
p a tie n ts and s t a f f f o r both a n t i -HBg and HBgAg.
th e e n t i r e
i n s t i t u t i o n could be u s e fu l
An annual screen o f
in th e c o n tro l o f th e disease
a t th is in s t it u t io n .
S ince th e course o f h e p a t it is B has been shown to be dependent
upon th e immune s ta tu s o f th e in fe c te d in d iv id u a l
(6 2 ) a study o f th e
immune competence o f p a tie n ts a t BRSH could prove v a lu a b le in
41
p in p o in tin g high r i s k p a tie n ts l i k e l y to develop f a t a l
d is e a s e such as c h ro n ic a g g re s s iv e h e p a t i t i s .
could prove to be h e lp fu l
forms o f t h is
A study o f t h i s type
in th e c o n tro l o f o th e r d is e a s e processes as
w e ll.
I t is p ro b a b le t h a t h e p a t it is B w i l l never be c o m p le te ly e lim in a te d
from BRSH.
However, one o f th e purposes o f t h i s study was to more
a c c u r a te ly d e te rm in e th e r i s k a p a t ie n t encounters a t BRSH.
O ther
g o als were to e lu c id a te problem areas w ith in th e i n s t i t u t i o n and to
make suggestions as to p o s s ib le s o lu tio n s to lo w er th e p re v a le n c e o f
th e d is e a s e .
CONCLUSION
The B oulder R iv e r School and H o s p ita l H e p a titis B Study c o n s is te d .
o f s cre e n in g 524 p a tie n ts o f t h a t i n s t i t u t i o n f o r th e presence o f th e
h e p a t i t i s B s u rfa c e a n tig e n (HB Ag) and th e a n tib o d y to t h i s a n tig e n
(a n ti-H B s ) , using a ra d io im m inoassay te c h n iq u e .
16.8% o f th e t e s t
p o p u la tio n (16 to 32 tim es th e normal in c id e n c e in .th e USA) were found
to be p o s it iv e f o r e i t h e r o f th e s e m arkers o f h e p a t it is B in f e c t io n .
C o r r e la tio n s were a ttem p ted between th e s e m arkers and th e p a tie n ts a g e,
s e x , le n g th o f s ta y in th e i n s t i t u t i o n ,
and a b i l i t i e s , and a d m ittin g d ia g n o s is .
i n s t i t u t i o n a l l o c a t io n , h a b its
S t a t i s t i c a l l y s ig n if ic a n t
c o r r e la tio n s were found in th e s e c a te g o r ie s .
By e lu c id a tin g s p e c ific
areas o f high r i s k , more a c c u ra te d e te rm in a tio n s a re o b ta in e d as to
th e r i s k o f a c q u irin g h e p a t i t i s B a t BRSH.
Suggestions
c o n tro l o f t h i s d is e a s e a t BRSH were in c lu d e d .
concerning th e
APPENDICES
APPENDIX I
S im p lifie d M edical C l a s s if ic a t io n o f M ental R e ta rd a tio n
code
I
MENTAL RETARDATION ASSOCIATED WITH DISEASES
AND CONDITIONS DUE TO INFECTION
11
E ncephalopathy, c o n g e n ita l, a s s o c ia te d w ith p re n a ta l
12
Encephalopathy due to p o s tn a ta l.c e r e b r a l
in fe c t io n
in f e c t io n
II
MENTAL RETARDATION ASSOCIATED WITH DISEASES AND CONDITIONS
DUE TO INTOXICATION
21
E ncephalopathy, c o n g e n it a l, a s s o c ia te d w ith toxem ia o f
pregnancy
22
E ncephalopathy, c o n g e n ita l, a s s o c ia te d w ith o th e r m aternal
in to x ic a tio n s
23
B i l i r u b i n encephalopathy (K e r n ic te ru s )
24
P o s t-im m u n iza tio n encephalopathy
29
E ncephalopathy, o th e r , due to in t o x ic a t io n
MENTAL RETARDATION ASSOCIATED WITH.DISEASES AND CONDITIONS
DUE TO TRAUMA OR PHYSICAL AGENT
31
Encephalopathy due to p re n a ta l
i n ju r y
32
Encephalopathy due to m echanical i n ju r y a t b i r t h
33
Encephalopathy due to anoxemia a t b ir t h
34
E ncephalopathy due to p o s tn a ta l
i n ju r y
45
Appendix I
(c o n tin u e d )
MENTAL RETARDATION ASSOCIATED WITH DISEASES AND CONDITIONS DUE
TO DISORDER OF METABOLISM, GROWTH OR NUTRITION
40
C e re b ra l l i p o id o s i s , i n f a n t i l e
(T a y -S a c h 1s d is e a s e )
41
Encephalopathy a s s o c ia te d w ith o th e r d is o rd e rs o f l i p i d
m etabolism
42
P h e n y lk e to n u ria
43
Encephalopathy a s s o c ia te d w ith o th e r d is o rd e rs o f p ro te in
m etabolism
44
G alactosem ia
45
Encephalopathy a s s o c ia te d w ith o th e r d is o rd e rs o f c arb o h y d ra te
m etabolism
46
A ra ch n o d ac tly
47
H ypothyroidism
48
G argoylism (L ip o ch o n d ro d ystro p h y)
49
E ncephalopathy, o th e r , due to m e ta b o lic , g ro w th , o r n u t r i ­
t io n a l d is o rd e r
V
MENTAL RETARDATION ASSOCIATED WITH DISEASES AND CONDITIONS
DUE TO NEW GROWTHS
51
N e u ro fib ro m a to s is (Von R e c klin g h a u se n 's d is e a s e )
/
.
52
T rig e m in a l c e re b ra l angiom atosis (S tu r g e -W e b e r -D im itr i's
d is e a s e )
53
Tuberous s c le r o s is
59
In t r a c r a n i a l neoplasm, o th e r
46
Appendix I
(c o n tin u e d )
^
MENTAL RETARDATION ASSOCIATED WITH DISEASES AND CONDITIONS
DUE TO (UNKNOWN) PRENATAL INFLUENCE
61
C e reb ra l d e f e c t , c o n g e n ita l
62
C e reb ra l d e f e c t , c o n g e n ita l, a s s o c ia te d w ith p rim a ry c r a n ia l
anomaly
63
Laurence-M oon-B iedl syndrome
64
Mongolism
69
O th e r, due to unknown p re n a ta l in flu e n c e
.
V II
MENTAL RETARDATION ASSOCIATED WITH DISEASES AND CONDITIONS DUE
TO UNKNOWN OR UNCERTAIN CAUSE WITH STRUCTURAL REACTIONS MANIFEST
71
Encephalopathy a s s o c ia te d w ith d if f u s e
72
Encephalopathy a s s o c ia te d w ith c e r e b e lla r d e g e n e ra tio n
78
Encephalopathy a s s o c ia te d p re m a tu rity
79
E ncephalopathy, o th e r , due to unknown.or u n c e rta in causes w ith
s t r u c t u r a l re a c tio n s m a n ife s t
'
s c le r o s is o f th e b ra in
V III
MENTAL RETARDATION DUE TO.UNKNOWN (OR PRESUMED PSYCHOLOGIC)
CAUSE WITH FUNCTIONAL REACTION MANIFEST
81
C u l t u r a l - f a m i l i a l mental r e t a r d a t io n
82
Psychogenic mental r e ta r d a tio n a s s o c ia te d w ith
d e p r iv a tio n
83
environm ental
Psychogenic mental r e t a r d a t io n a s s o c ia te d w ith em otional
. d is tu rb a n c e
47
Appendix I
(c o n tin u e d )
84
Mental r e ta rd a tio n associated w ith psychotic (o r o th e r major
p e rs o n a lity ) d iso rd er
89
M ental r e t a r d a t io n , o th e r , due to u n c e rta in cause w ith th e
fu n c tio n a l r e a c tio n a lo n e m a n ife s t
S im p lifie d Supplem entary Term L is tin g
1
W ith G e n e tic Component
2
W ith Secondary C ra n ia l Anomaly
3
W ith Im pairm ent o f S p e c ia l Senses
4
W ith C o n vu lsive D is o rd e r
5
W ith p s y c h ia tr ic Im pairm ent
6
W ith M otor D y s fu n c tio n
anti-HBs
(Guinea Pig)
L
HBsAg _
(patient)
(human)
RADIOIMMUNOASSAY DIAGRAM
Anti-HBs
RIA
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Blumberg, B. S . , A. I . S u tn ic k , and W. T . London.
1968.
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B u ll. N .Y .A c a d .M e d ., 4 4 :1 5 6 6 -1 5 8 6 .
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