IARY 25, 1978

ilotte's Hospiral,
The Lancet ' SaturdaY 4 March 1978
Snancy.

. Rowlands: I're

WlP 2AR
'$t
nent of Common TRANSMISSIBLE AGENT IN NON-A, NON-B in the 4 patients with P.r.H. The peak alanine amino- rf,r
HEPATITIS transfera;e (a.r.r.) levels in the 5 chimpanzees were
265, 212, 219, 70, and 62 I.u./. Histoiogical changes
iu
n Fields, London Har.vrv J. Ar-tsn* RosERt H. Puncnrlf ranged from mild to conspicuous hepatitis and generally ,h
n Human Breast P,cuL \'. Hort-axo* Hnus PonpEnf, cor;elated $'ith the degree of a.l.T. elevation' There was
no evidence of clinical disease and all animals went on ::,
Banh Dcpart ne nt, Cli nical C en ttr, N otional I ns titutes
rplasia and Nce 'Bl,rtLl
to biochemical and histological recovery There 'nvas no qi
e.) of Hcalth, Rethcsdtt, Mdr)tlaild;
f rhe Skin, I-isle Institute s oJ serological evidence of type A or type R hepatitis' Hepa-
r1.df(r/(rr0r'1r of Infcctiotts 1)t.sea-sc-r, National
Allergl and Infectious Disease, National Institutes of Health, titis r'vas transmitted by serum derived from patients \r
lpndon WCIN B e t hes da, M ar1 land ; and with chronic as well as acute hepatitis' stronglv suggest- ldh

'$uatton LaborttLLrqr'/or Srrldl' of I'iz'er Diseases, Mount ing a chronic carrier state for the agent responsible for
lism of Ammonia
Sinri Srloo/ ry'rl{rrlicine of the Citv Uniz'ersitv of New York, nJn-A, non-B hepatitis. Non-A, non-B hepatitis thus 8t
Nctr Yorlt Crrl', N.I'.' U S.l. seems to be due to a transmissible agent which can per- \rt
Psychiarric and sist and remain inf ectious for long periods. fl:t
dy Relationship.
Summary Plasma or serum from 4 patients with
WIN6AD acute or chronic non-A' non-B post- Introduction
rransfusion hepatitis (n.r.H.) and from a blood-donor
d Tibia.
rdon SE5 implicated in two cases of P.r.H. was inoculated
into 5 IupncrtoN due to human hepatitis viruses A and B
nce from Patho Biochemical and histological evidence of can be identified by assays for various serological and
enzymatic markers.l 5 At present, 60-90qc of post-
chrmpanzees.
hepairtis developed in these 5 chimpanzees but-not in a
control anrmal. The mean incubation period in the
transfusion hepatitis is serologically unreiated to either
chimpanzees was 13'4 rveeks, compared with 7'7 weeks
of these viral agents.6-e Neither cytomegalovirus nor the
TO CHIMPANZEES
Disease. (Hony- CI-INICAL DATA ON PAT1ENTS PROVIDING INOCULA ADMINISTERED

Incubation period Wk after transfusion Chimp

to first e.t.T. over inoculum obtained* Volume of receiving
Clinrcai inoculum (no.)
t00 I.u.,4 (wk) (e.r.r. at that wk) inoculum
Subject course

4 (i0) 4.5 ml 165

I Acute non A,
6 (22) serum
non-B p.t.H.
8 (3e0)
progresslng
10 (1000)
lo c.A.H.
1 1 (520)

_t
978/256 42 (.228) /) ml
,\cute non-A plasma
non-B LT.H.
ian and pryneco progressrng
R.H.A. to c.P,H.
tant radiologtsr,
6 (153)
:consultanl psy
7 (618)
m Forest A.H.A.
th Easr-fhames 8 (e06)

turgeon with an N.e. (474)

reater Glasgow

reral physician,
t.u.a., Northern

ant psychiatrisr,
non-B p.t. tt
rhing).
ally rransmirred
k Street Clinic, 35 (l 80) ;'--l-
plasma
* -
___1_
I

sultant psvche
n Forest A.u.n.,
ro c.A.H
Newham healrh injection'
,\\.hen morc than one $,eek indrcated, 0. 5-1 ml samples from each week were pooled and the total volume was given as a-single
ttepatitis; c.r.u.-chronic persistent hepatitis; N'a
:not applicable;
tanr radiologisr, p T.H.=p.sr-rransfusion h"putirrr; c.,i.i.-.iion;. ui,iu.
t .t. jfrl". , r.o.".r'); a s r':aspartate aminotransferase (s c o r')'
' "..",runri..ur.
8062 O'I he l-ancet Lld, 1978
 --

460 THE LANCET, MARCH 4, 1978

IJpstein-Barr virus has becn implicated in such cases,6

?
5j ofthem (nos. 165, 186, and 189) had heen
years old. Three
and the cxistence ofat least one additional human hepa- experimcntally inlccred with thc hepatitis-B virus prevrouslt
and had anti-HBs and anti-HB. at the beginning of the study
titis virus is suspectcd. No serological marker of this All were negative for HB.Ag and all had normal hepatic'
"non A, non-B" virus has been delined, no viral particle enzyme levels. 'I'wo of the animals (191' 196) had not pre-
has been observed, and no agcnt has been isolated in tis- viously bcen used in experiments and each rvas negative l0I
sue culture. We have investigated the blood of patients HB.Ag, anti-Hl}., and anti-HB.. All chimpanzees had anli'
with acute or chronic non-A, non-B hepatitis for the H.A.v. al the beginning of the studl'.
presence ofan agent transmissible to chimpanzees' 'l he five chimpanzees wcre housed in a single roomJ a\\'a)-
from other chimpanzces at L.Il.r\1.S.I.P. A sixth uninoculated
control was housed in a separatc room. Each chimpanzec lras
Materials and Methods kept rn an isolation cage suspended from the rvall and separ-
Hunatt Inocula
'l he samples came from subjects identified rn a continuing
360 Chimp No. 165
investigation of post-transfusion hepatitis among patients hav-
ing opcn heart surgcry.6 Four u'erc patients; the fifth was a 320
280 lnoculum: 4.Scc
blood{onor (sec accompanying table). All thc patients had Acute Phase
received volunteer-donor blood prescreened for hepatitis-B sur- 240
Serum
face antigen (HB"Ag) by solid-phase radioimmunoassay. 200
Blood-samplcs rvere obtaincd rveekly or biweekly during thc 160
first threc months aftcr translusion and then monlhll' for a 120
lurther three months. Additional samples were obtained when 80
livcr enzvmes lverc raised; rvhenever possible, plasmapheresis 40
'"vas perlbrmed on paticnts rvith suspccted acute or chronic 5
non A, non-B hepatitis.
l'ost-transfusir-.n hcpatitis rvas diagnosed when, between 2 280 Chimp No. 186
o_
and 26 r.veeks aficr transfusion, alanine aminotransferase F 240
(a.r.r.) rose to 2] rimes the upper limit of normal (112 r.u.A) (J 200 lnoculum: 75cc 212)
U 63)
and rvhen a second sample, alter at least a week, was over 160 Chronic Phase 1

Plasma
twice the uppcr limit of normal (90 r.u.4). Icteric hepatitis was 120
diagnosed when the serum-bilirubin exceeded 2'5 mg/dl. Con-
4cr
1
80
TIJ
gestive Iailurc, toxic hepatitis, and other causes of raised hepa- F 40 B
+
tic cnzvmes rvere excluded as far as possible. Diagnosis of FJ
non A, non-B hepatitis was contingent upon thc absence of O(/)-. PRE.2 O
(9F
HB.Ag and the absencc of antibod.v seroconversion to HI3.Agr
l-rcpatitrs R corc antigen (HIl"Ag), hepatitis A virus (u.n.v.)'
9= 280
Fl 240
cytomegalovirus (c.,u.v.), and the Flpstein-Barr virus (r.n.v.). u)) 200
Livcr biopsy specimens were not obtained in the acute phase
of the disease, but rvere obtained when enzyme abnormalities ^z
T^
t:i
160
120
persisted lor more than six months. dF
80
Subject no. 4 was a blood-donor. Her blood had been givcn
to two paticnts in r.vhom non A, non-B hepatitis developed. In ^z
FCC
40
the morc recent casc she rvas the only donor who proved, on o- uJ
(j)F
recall, to have raised aminotransferase values. She had no his u1 z
torl' of previous hepatitis or other medical discase, was not on Chimp No. 191
medication, and denied use of narcotics or heavy intake of F
J
alcohol. Her e.l.t. on first recall was 79 r.u.,4 and it fluctuated lnoculum: 75cc
160
bctr.veen 56 and ,174 during the next six months. She com- It Chronic Phase
120 Plasma
plained of nausca and incrcased fatigue at the time her hepatic
80
cnzymcs \\,crc a{ their maximum levei, but generally shc was
40 D
+
svmptomlcss. Liver biopsy has not yet becn done.

Study in Cltintpanzccs
Chimp No. 196
Selcctcd samplcs ol plasma or scrum lrom thc lour patients
and lion thc blood donor rvcre inoculated intravenously into lnoculum; 75cc
five chin.rpanzees in volumcs ranging frorp 3 to 75 ml (see 160 Chronic Phase
rabic). -l'ie chimpanzees \\'ere thcn motliinrcd s'eeklv for 120 Plasma
A.r-.T.) aspartate aminotranslerase (a.s.r.), gamma-glutam-vl 80
transpepridasc (c.c.r.p.), and HRrAg. Pre infusion and six- 40
month post-infusion samples rvere also tested lor antibod.v to
IIIS.Ag (anri-IIR"), antibodv to HB.Ag (anti-HB.)' and anti-
10 15

body to the hepatitis A virus (anti-H.A.v.). When enzyme ab- WEEKS

normalities were detected, the animals were plasmapheresed
on one or more occasions and serial liver biopsy specimens
were obtained.
'I'he chimpanzecs were kept at thc I-abttratory' for Experi-
mcntal Medicir.re ancl Surgcrv in l'rimates (L.B.M.S.I.P.) in
Stcrling Irorest, Nerv York. Each of the animals had been ivild-
caught in Sicrra l-eone, Africa, but hacl been housed at
L.Ir.M.S.I.l'. tbr at least 2 vears rvhen this study rvas started.
At thc tine o1'thc study, the chimpanzccs were belrveen 4 and
Fig. l-Serial determinations of alanine aminotransferase,
aspartate aminotransferase, and ganma-glutamyl transpep'
tidase in five chimpanzees inoculated on day 0 with serum or
plasna from patients with acute or chronic non-4, non'B
hepatitis,
A - mean and rangc of 18 sanrples in preceding 6 mol B = mean
and rangc of 17 samples in prccccling 6 mo; O - mean and rangeol
9 samplcs in preccding '1 mo; I) - mcan and range of 13 samples in
prccccling 6 mo: li mcan antl range of 1 3 samples in preceding 6 mo,
 4, 1978 461
{RcH 4, 1978 THI r ANcFr, MrRCH

l89l had bccn ,rrcd lrom adlaccnt cages b.v a 'Plexiglass' barrier. The animals parcd from the AD 169 strain of human c.,1t.v.15 l'aired sera
'us previouslv i0uld not touch each other or transfer secretions or excretions rverc titralcd in duplicate lbr anti-s.s.v. bv immunofluores-
lrom one cage to another. Excreta fell on to plasric mats which
cencg.t6 Liver biopsl' specimens were obtained percutaneously
i of the srud!'. with'Trucut' disposable needles (1'ravenol). Biopsi' specimens
rmal hepatic- were discarded daily. For inoculation, venepuncture' plasma-

had not prc lhrresis. or liver bropsl', the animals were anrsthetised in therr
were placed in formalin, embedded in parafin, sectioned'
cagt wirh intravenous ketamine h1'drochloride and then trans- stained with hrmatoxylin and eosin, and read under code by
i nellatiVc li)r
ported t0 an adiacent treatment room rvhich was used only for H. P.
ees had anti 'l'here rvas no contact between animals in the
these animals.

g roorlt. f,\\'av lrrarment room and all equipment was disposable. Attendants Results
uninocul atccl \r0rr go\\'ns, masks, surgical gloves, and surglcal shoe covers
riere experienced in isolation techniques.
Chinp 165 had had 18 blood-samples takcn in the six
impanze e s as
months bcfore inoculation with 4 5 ml of acute-phase
and

all ancl scpar

Test it/lethods
serum from subicct 1. In onlv onc sample did thc a.l.r.
excecd 25 r.u./l (value of '12) ancl the A.s.r. was never
Aminotransferases were measured in chimpanzees by the
higher than 27 t.rt.A. A mild rise in e.L.r. began rhree FI
method
'fhe range of normal values in iuvenile
of Henry.r0 hr
weeks alter inoculation an.i pcrsisted through week I 1
chimpanzees wa; 6-38 l.u./4 for A.L.r. and 6-35 I.u.,rl lbr
(11g i). c.c.t.p. lbllorved a similar pattern but did not
r.s.T: c.c,T.P. was assayed by the method of Szasz'11 with ;,'tl
n0rnal values in juvenile chimpanzees ranging between 8 and risc ur-rtil rvcek five. 'l'hcre rvere no significant changes
.llr I L in R.s.r. during this carly pcriod. A.L.T. began a stecp .dl
HB,Ag anrl anti-HBs were tested by solid-phase radioim- rise during week twelve, peaked al 265 r.u.l during st
munoas;\' i'Ausria II' and 'Ausab" respectively' Abbott weck lburtccn and returncd to normal by rveek seven-
l.rboratories . Anti-IIR. was tested bv a nervl-v developed solid- teen. c.c.r.P. fbllo'"ved a similar, but slightly dclal'ed i{i
phlsc radioimmunoassavi2 \\'hich employs radio-labelled anti- pattcrn, rcaching a peak of 3'13 r.u./ dr.rring week lifteen
#ca I{ll. and is bascd on conlpctitive inhtbition.* A reduction in
and returning to normal bv u'eck twent-v-one' A.s.T. par-
',,|!l
,",1,
25 r:Jnlctive counts of more than 50(i compared rvith negative
alleled a.r-.r. and c.c.T.P., but the magnitude of change
lnrrols r rs takcn as a positive result. -I-he animal remalned HBrAg
,\ntibodr to hepatrtrs A ar.rtigen rvas determined by immune was considerably less.
r.lhcrcncc htmagglutination assav.ll Antibody to c'M.v. was negative throughout this time and was positiv. for
2I
3) nclsurcd br conrplemcnt lixation;ra c.M.v. antigen was pre- antiHB., anti-HB., and anti-H.A.v. before the study
began. tiver biopsy specimens obtained at the time of
'hrnJlr bi I)r [-rcv Orerbv ofAbbott Laboratorics peak increases in hepatic enzymes (weeks thirteen and
'upplicJ
\\ fourteen) showed a moderately severe acute hepatitis
'<+ri\. " a W .W, u ts
if,g. 2).There was 'r'ariation in the size and staining
I
"\
+*&, quality of hepatocyte nuclei and the cytopiasm was irre-
& * &*,
25 . itl
%! gularlv clurnpcd. Sorne hcpatocvtcs \verc replaccd bv
t{
&,;. 8,..+ 6'+ ou1 inflammatorv cclls ifbcal necrosis) and-l'herc therc rverc ,1
modcratc numbers ol acidophilic bodies. rvas a )[
uu4
.r6f{$ distinct increase in sinusoidal lining cells. l hc portal
tracrs \verc denselv infiltrated bv mononuclear cells. In tlt
,w ^:N
& gcncral, thc bordcr benvcen portal tracts and the sur- j[i
d+o6 "
8,4 \ w4 roundirrg parenchf lna u'as sharp, but in places the limit- jlil
* u* ''.e ing plate u'as crodecl and cellular exudate spilled into the
25
. s-@ w - oK parcnchyma. 'l'u'o months latcr (rveck twent\ -t\\'t) r, ',t
:,.
" * r*# rvhen A.L.t., A.s.T., and c"c.T.P, were normal) the liver ,l
,N{ *& - 2

rvas histologicallv normal.

a

' ** e pW
,-& Chinp 186 had had 17 blood-samples taken in the six .

%&q months bcfore thc beginning of this study; the highest

I E
A.L.r. was 25 r.u./1 and the highcsr A.s.r.20 I.u.'4. As
., r " Fw secn in fig. 1, therc was a slight and fluctuant increase
a-4+{ , h"e dl w
25 s of a.l.r. beginning three rvceks after the animal received
t' & /4, I rs W* 75 ml of chronic-phasc plasma from subiect 2. Delinite
i :ai ,e, & increases ol hepatic cnzvmes did not appear until weeks

t&
" 3& "' .,,
tcn to eleven. 'fhe animal remained HBrAg negatrvc
't # ) - 4t ..
throughout and rvas positive for anti-HBr, alrti-HBc'
ee and anti-s.R.v. 'nvhen thc study began. I-iver biopsy
b
specimens obtaincd during rveeks thirteen and fourteen
sho."ved an acute hcpatitis rvhich was histologically simi-
Es.G
25
lar to that seen in chimpanzee 165, but less consptcttous'
Subsequent biopsies (rveeks sixteen and eighteen)
shorved considerable improvement, but a specimen takcn
lotransferase, cluring rveek twenr-v-two sho"vcd increascd portal-tract
ryl transpep- inflammation and fbcal necrosis, despite improving
rith serum or
ton-A, non-B Fig. 2-Biopsy specimen of liver from chimpanzee 165 at the values lirr a.l.t. and c.c.T.P.
time alanine aminotransferase was 163 I' U.4 (week 14). Chimp 189 had 9 blood-samples taken in the four
no; Ii nrcall lhmrtorrlin and eosin. :250. Notc nuclear variation, lobular dis- months before it
received 3 m1 of acute-phase serum
I anrl ranqc (Jl rrrl nrrh "rnu.1giqg". increased sinusoidal lining cclls, acidophilic lrom subiect 3. 'l'hc highest A.L.r. during this time was
13 sanrf,lcs in ",'l1g'. lircrl nccrosrs. and portal-tract inflanrration rvirh some infil-
:.rtron oi parcnchvrna.
27 and the highest A.s.r. was 20. Unlike chimps 165 and
recedinq 6 rnrr.
 _-

162 THE LANCET, MARCH 4, 1978

THE

186, this animal did not show an elevation in e.r-.r. and 'uvhether thc inoculum rvas non-infectious or the particu- toc
G.c.T.P. three to fbur weeks after inoculation. There lar chimpanzccs wcre immune could not be ascertained, to br
was, however, a delinite rise in R.r-.r., beginning at week Lately, Hollinger et a1.rE have recorded modest increases F
12 (fig. 1). c.c.r.n. and a.s.r. fbllowed a similar pattern, in a.r.r. (maximum 75 t.u.A) in 4 of 5 chimpanzeesin- funr
lbut the increases rvere considerably smaller. HB"Ag was oculated with material either from donors implicared in the
.not detected and anti-I{8", anti-HB,., and anti-n.a.v. a case of non-A, non-B hepatitis or from recipients rvirh four
rvcrc alrcadv prcscnt rvhen the str,rdy' began. Histologi- non-A, non-B post-transfusion hepatitis. Minimal hrsro. G.G.
callv the liver r,"'as vcry similar to that of chimp 186, logical changes, primarily Kupffer-cell hyperplasia and
shorving an acLlte hepatitis rvith acidophilic bodies, focal
in or
swelling of hepatocytes, were noted in relation to e.l.r, levcl
necrosis, and a conspicuous portal-tract inllammatory elevations, but were not absolutely diagnostic of hepa A.I-.:
rcaction. Subscquent biopsv specimens shorved striking titis. the I
improvcrncnt. In thc studv dcscribed here, chimps 165, 196, and 189
f,,
t-)ltintp 191 hacl haci 13 blooclsamples taken iir the 6 shou'ed uncquivocal enzvmatic and histological evidence fluer
months befbrc receiving 75 ml of plasma fiom subicct 4 of hepatitis. In chin"rps 191 and 196 rhe diagnosis of threr
(thc blootl-dorror). -l'hc highest A.L.r. during this time hepatitis was less certain; ho'"vcver, the a.r.r. rcached than
rvas 22 l.u.l and the highest a.s.r.,20 Lu.,4.'l'he enzv- distinctlv highcr levels alier inoculation than in rhr the
matic resporlsc \\'as not great and r.vas later than that in baseline period, and higher, too, than those in the unino men'
thc othcr animals (lig. 1). Neither A.s.r. nor c.c.'r.p. culatecl control chimpanzcc. In addrtion, enzvme abnor- the s
bccarne abnormal. HBrAg, anti-H13,, and anti-[{13. rvere nralitics pcrsisted for at least tr.vo u,eeks and the a.l,r, bioor
not cletectcd. I-iver biopsv shou,ed onlv borderline rcachecl a pcak at a post-inocLllation interval sinrilar to courl
changes including acti\ration ot'sinusoidal lining cells, a that in thc three chir-npanzees u'ith unequivocal hepa had
fcrv arcas of focal necrosis, and a minimal portal inflarn- titis. l,astlv, in chimp 196, although cnzvme abnormali- mals
matorY rcaction. ties rvere minor, bropsv shorved delinite hepatitrs.
\\I
In 13 blood-samples frctm chintp 196 in the six 'l hcre rr,ere several additional observations ofintcresl,
appa
months belore inoculation the highest a.L.t. rvas 25 First, thc incubation period in thc chimpanzees, as
able
r.u./ and thc highcst A.s.r. 20 r.u./. 'l'he enzvme re- judged b1' the first A.L.r. over 50 r.u./, rvas soncu'har
mal r
sponse 10 translusion rvith 75 ml of chronic-phase longcr than that in the human bcings lrom u'hom thern- tion ,
plasnra lrom subject 5 ri'as also small, but it n'as dcfinite ocula cilme 113.4 r','eeks in the chimpanzees comparrd
asses
and the temporal relation to transfusion rvas verv simi u,ith 7 7 rvccks in the four patienrs rvith post-transfusron
non-,
lar to that in chimps 165, 186, and 189 (fig. 1). a.l.r. hcpatitis), though in one patient/chimp pair the rncuba-
detec
reached a maximum at rveck thirtccn and there rvas a rion pcriods rvcrc almost idcntical.
mate
sccondarv rise during rveek eighteen. 'l-here \\'as no con- Second, the thrcc chimpanzees s,ith thc greatrst
non-l
comitant rise in a.s.r. or c.c.T.p. In this anirnal HB"Ag, enzvnlc riscs r,'ere the ones that had been pr*'iouslr,ur.
anti-HBs, and anti-Hilc were never detected. l-iver lcctetl u,ith ti,pc 13 hepatitis. \\'e do not f'eel rhar rhrs \\'c
biopsv during rveck eightcen revealed a mild diffuse rcprcsents rccrudesence of the tvpe B inlectron sina I ILrdso

hepatitis; although thc cnzymc abnormalities were much cach had had repeatcdlv normal enzvmes f'or at least ll. cc1

less than in chimp 186, the histological lesions rvere verv four months before entry inro this studv and becausr tulCs (
I1a rr'lr
similar. I'artial rcsolution had occurred b1' rveek twent_v- each was persistently HBrAg negative. In addirron,
two. beibre the present study rvas started, each chimpanzee
Chintp 183 was an uninoculated control. During the had acquircd anti HBc and anti-HB,-rvhich generalli
trvcnty-six week follo'"v-up the highest A.r-.r., e.s.T., and dcnotc comple te rccover,v lrom tvpe B virus infection, It l. I'rin
t.;\lnr
c.c.T.p. rvcrc 20, 19, and 22 t.u.A. HBrAg was not de- is rrorc plausible that these three anirnals received a J. i-,rn
tectablc. Antr-FIR., anti-HBc, and anti-n.a.v. were pres- mort' r'irulcnt inoculum or that their host response \\,as {. lrcin
ent before the study began. Ncither the uninoculated such as to induce more sevcre hepatic dcstruction, Such i. Kap
S
control nor anv ol the inoculated animals trecame clini- variabilitl" of host responsc has been clearll demon- 6. r\lrc
cally il1. strarcd in type 13 r'iral jntecrions of borh rnanro and (i
-. I'r in
chimpanzccs.20 l)iverse human responses to rdentical R
Discussion non-A, r.ron-Il inocula have also been demonstrated rna ll. I loll
Indirect evidence that an infectious agent is respon- rclrospcctive, serologtcal ar-ralvsis of Volunteer studies 9. Sc(',1
siblc for non-A, non-B hepatitis has been threefold: (1) pcrformed in thc earlv 19-50s.21
a variable, but defined incubation period intermediate Third, non-A, non-B hepatitis rvas transmirted l0 I Icnr
br
I l Szas
bctrveen that of type A anrl tvpe B hepatitis rgqgerally serum or plasma obtained either in the acute or in the Il. Orcr
six to trvelve weeks); (2) hepatic histologv rv'liibh by chronic phase of the disease. 'l'his provides good evr. li
I l. It'll(
hematoxylin and eosin stain is virtually indistinguish- dence for a chronic carrier state. Only the existence of
able from that of type A or type B viral hepatitis; and such a carrier state can account for the large numberof 1.1. I)urc
( it
(3) a positive correlation between the development of non-A, non-B hepatitis cases which derive from seem- l \. Itou r

non-A, non-R hepatitis and the source ofdonor blood ingly heaithy donors. Indeed, this is a key observationrn
16. I Ienl
likc t1'pe ts hepatitis, non-A, non-B hepariris is about ten this study.
I'. I'urc,
times nrore commoll after rcceipt of paid-donor blooci Fourth, the hisrological lesion in these chimpanzees 18. llolli
than after receipt ofvolunteer-donor blood.7 rvas identical to rhar seen in tvpe B hepatitis, in that the Sr
ca
\\'e chosc the chimpanzee as an indicator of a trans* ',vhole lobule '"1'as involved. and in that streaks of local I9. Bark
missible inlectious agent because this animal is suscep- necrosis cxtended into the central zone. In contrast, the
20. Ilark
K.
tible to both hepatitis A and hepatitis B virus infection. changes seen in hcpatitis A are primarilv periponal. 13
Scveral previous attempts to transmit non-A, non-B These histological differenccs mav account for the tend- 21. Iiool
hepatitis to chimpanzees have been unsuccessful,rT but encv of tvpe B and non-A, non B hepatitis to progre$ l,u
12. l)icnl
MARCH 4,1g7g THE LANCET, MARCTJ 4 , 1978 463

Dr the parricu- liver disease '"vhereas type A

E ascertained_
to chronrc seems TRANSMISSION OF NON-A, NON-B HEPATITIS
lo be aselflimited acute disease.22 FROM MAN TO CHIMPANZEE
ldest increases Fifth, u,e employed rhree tests of hepatocellular dys-
impanzees in- function, of rvhich e.r.r. was the most consistent: it was -fasoR
Lloweno RosEnr J. (innrrv
,implicared in raised in all five chimpanzees, and in
pcipients with
the onlv enzvme
.|ncquEs A.I)nucrln LooNaRo B. SrErr
[inimal histo-
lour of them \\'as thc one showing greatest abnormality.
Jav H. FloorNaclr I)aNrrr_ R. JacxsoN
c.c.r.r. had a verv similar pattern to rhat of a.l.r. and Mrr.roN Apnrr I-rwnrlvs F. BRnrln
perplasia and
in one chtmpanzee reached a higher and more sustained (itnoNLne P INr oa-TR,r.roNooNc
Itlon to A.L.T. lelel. Holvever, in the rlr'o chimpanzees with the mildesr
lstic of hepa- rl.L.T. increases, the c.c.T.p. remained normal. A.s.T. was
Diz'ision o.fBlood and Blootl Products and Diztisiort of
I'athologl, Btrreau o.f Biologics, P-ood and l)rug
the least reliable ofthe tests.
,196, and 189 A tlnin i s tr ation, B e t he s da, M arll dn d ;
Lastly, the volume of inoculum did not seem to in- Departtncttt of Medicine, teruns Adniristratiott Hospital,
fical evidence fluence of the ensuing disease; two of the
the severity
Ve

i diagnosis of
Washington, D.C.;
three chimpanzees with severe disease had received less ()corgetoutt Unircrsity School of Lledicinc, Washington,
fr.r. reached
than 4 ml of infectious material, whereas the two with D.C.:
ithan in rht:
the mildest hepatitis received 75 ml. In future experi- and Amarican National Red Cross, Washington, D.C., U.S.A.
fn the unino- ments, therefore, smaller inocula can be used. Similarly,
me abnor-
the stage of human non-A, non-B hepatitis at which the Surnntar1 Non-A, non-B heparitis was transmitted
the e.l.r.
blood was obtained did not seem to influence the disease to four colony-born chimpanzees by in-
I similar ro
course: one animal which received chronic-phase plasma tra\renous inoculation of human sera. Two chimpanzees
vocal hcpa-
almost identical to those of the two ani-
had a response werc inoculated rvith serum from a patienr with a clini-
abnormali-
mals receiving acute-phase
serum. cal and serological diagnosis of chronic non-A, non-B
\\'e havc shorvn that blood from human beings rvith hcpatitis u,hosc blood appeared to transmit this disease
of intcrest.
nzees, as
apparent non-A, non-B hepatitis contains an agent cap- to a nurse follorving accidenral needle-stick, and the
abie of causrng similar disease in chimpanzees. This ani- other t\l'o chimpanzees were inoculated with serum from
some.ryhat
mal model may now permit more definitive characterisa- either of t\\'o former blood-donors whose HB.Ag-nega-
thc in-
lion ofnon-A, non-B inocula, including infectivity titres; tive blood appeared to rransmir clinically recognisable
compared
anslusion
assessment of cross immunity to determine whether hepatitis, and who were found to have raised serum-
q
non-A, in more than one varietyl
non-B hepatitis exists aminotransferase levels ij and 5 years later. Serum-
the tncuba-
detection of virus material in liver; and the use of such aminotransferase levels rose in al1 four chimpanzees, {
greatesl
material in development of a serological test for non-A, beginning 2-4 weeks afrer inoculation: peak alanine- :l
non-B hepatitis. aminotransferase values were 210 to 328 t.u.A. Evidence
iouslv in-
I rhat this \\c thrnk l)clorcs Koziol, \lax Shapiro, l)ana James, ancl I_enira
of hepatitis was present in liver biopsy specimens fronl
tion since Ilrrjnn lirr crpcrt technical assistance. all four chimpanzees, beginning 8-10 weeks after inocu-
at least Rcqurrtr lirr rcprinls should be addrcsscd 1o H. J. A., National Insti
lation. None sho.,ved serological evidence of infection
because rul$ 0lll.rlrh Olinical Ocnter, lllood Uank Departmenr, I3ethesda, with hepatitis A virus, hepatitis B virus, cyromegalo-
Ihnhn,l ll)01.{, t .S.r\. virus, or Epstein-Barr virus.
.addition,
rmpanzee
generalIv REI]D Rts NCE S Introduction
fecrion. Ir I Itin.c. Il.
I'rnt. iltlt)t.;1rul. .Scr tI..9.ul. 19611, 60, lll4.
A.
Strqcn the discoverv of hepatitis B surface antigen
L\lnciLh. I. J . l{ubcnsrcin, I)., Sron. lr. J.1,arcci, 1971. ii, 1225.
ved a i LrnJrr. f ..f .,\itcr, I L l., I)urcell. R. H. J. I n n u n. 1 97 1, 106, 1 t 66. (I{B.Ag)l and hepatitis A virus (u.e.v.),2 hepatitis types
nse \t'as 1 licrnlore, S. ,\1.. Kepikian, A. 2.. Ihrccll, R. H. Scrcrcc, 1973, lS2,1026. A and B have become distinguishable by specific serolo-
t.Kaphn, I'. I1.. (;rcenman. R. I.., (icrin, f. L., I,urcel1. R. H.. Robinson. \\,.
n. Such \iI 1lq-r.12,u-. gical tests. A further type of heparitis, in '"vhich no agenr
demon- 6,\h.r. il. J., I)urcell. R. IJ.. Holland. l'. \'., Feinsrone, J. tr1., Nlorrow. A. has vet been identified, has been designated "non-A,
nle and r;.\1'r.r rf .\ /.rr.i.lq-'.rr.l.
- I'rincc.,\.11.. llrotman, 8., Gradr. (i. non-B hepatitis".3'a r.r-on-A, non-B hepatitis represents a
F., Kuhns, \\,. .J., Hazz, (i., I_eoine,
idenrical R \\ . Ilillian, S. .f. rfrJ. I 9l-1, ii, 24 I high proportion of the cases of post-rransfusion hepatitis
tecl in a s.llLrllingcr. l:. B., r\ach. R. I).. (iirnick, (i. F'., Roche, J. K.,,\,telnick,
I,;r 1:rr1 /..11rd. I973. 289, 38 j.
J. I_. in thc tinited Stares, no'"v that HB,Ag-positive donor
st udies
'l Seitl. 1.. Il., limurerman. ll. f., \\,righr, l:. O., ,\1c(iollunr, R. \\r. ,4nr. J. blood is excluded.a'5 -I-he association of a transmissible
rlJ.ll.1915.270,355. agcnt with this disease has been suggested by invesriga-
tted by l1) llcnrr. R. I.;1ar../. rJirr. 1,rrl. 1 960. 34, 3 8 1
ll 5rriz.(i.(lhr. Clrrrr. 1969, 15, 12,1.
.
tion of stored scrum specimens taken in studies of volun-
ll (\crbr. L R., Ling. (.. ,\1. ll/rrr 1)rdslal.ndn,St. Ltrhc's ned. lJutt. 1976,
15, ll ,\9Frs in the i95{)s.6 Horvever, investigation of the disease
ll \1illcr. \\'..J.. I'rolosl.1,. J., r\,lcAlccr, \\/..J., Iirenson, O. l_., Villarejos,
has becn hampered bv the lack of a serum marker and
of \.'L. tlrllcnru.ll. 1rroc. Soc. c:7. 8iol.r11cd. 1975, 149,254. of an animal model. \\re have tried to demonstrare a
of l1 I'uricLl. R IL, \\'alrh. J. H., IIoiland, I). \'., Morrorv, A. G., \\,ood, S.,
(.hrnock. R. \1./. rrrlccr. 1)ro. I 97 1, 123,,106.
transmissible agenr bv inoculating human sera into
seem- 1j RwL. \\. 1'j. Ilrnlcr'. l. \\'.. \\'arcrild11, S., 'l urncr, ll. (i., Hucbner, R. J. young chimpanzees born in captiviry.
tion in 1",'i J,,i. rrro. lJro/. JIcr.t. 1956, 92, 4 1 8.
16. Ilcnlt. (i.. Ilcnlc. \\ ..1. Bact. 1966,9I,1248.

l' l\r' Lll ll,lr,rl.-.1.Ll1r.,'nrl.,,rlnunrLJrrun. Methods

anzees 18. Hollinger, F. B., Aach, R. D., I-ander, J., cirnick, G. L., Szmuness, W.,
that the Stevens, C.,,\losley, J. W., Perers, R., V'einer, J., Personal communr- Inocula
cation.
of focal 19. Barker, I-. F., Murray,R. An. J. ned. S ci,197 2,26J,27 . lnoculum I u'as obtained fiom a patient with aplastic
st, the 10.Barker, [.. F., Maynard, J. C., l'jurcell, R. H., Hoofhagle, J. H., Berquist, anamia at thc Veterans Administration Hospiral, Vrashington,
K. R., London, \\'. f., Gerety, R. J., Krushak, D. H. J. infen. Dri. 1975, I).C. Hepatitis developed alter transtusion and aminotransfer-
portal t12,451.
tend- (ieretv, R. J.,'labor, Fi., Fcinstonc, S. M., llarker, I-. tr., ase levels remained high for more than.{ years. 6 weeks alter
ll.Ilfttnrglt. J. IL.
I'urerll, R. ll.,.l rz. ;rtrrn. M ed. 1977,87,11. the onset of his disease, a nurse caring for him injured herself
11 l)icnstrg. J. l.., lbppcr, H., ['urcel], R. ll. A nt. J. l'a t h. 1976, 85, 1 3 1. rvith a broken capillar-v pipette contamir-rated rvith his blood.