In a development experts say they have anticipated with apprehension, significant numbers of homosexual men in the Los Angeles area are starting to contract a newly recognized variety of hepatitis--a type more severe, disabling and more frequently fatal than the two major common strains.
The situation is complex and the number of cases of the new, virulent form of hepatitis is still comparatively small. Hepatitis authorities in other parts of the country are still tentative on whether the newly recognized variety, called delta virus hepatitis, has the potential to sweep through homosexual populations as Acquired Immune Deficiency Syndrome (AIDS) already has.
But a nationally known USC researcher says a total of nearly 150 cases of the potentially catastrophic new hepatitis strain have been identified in the Los Angeles area recently--especially during the last three years. And, since 1981, the incidence among homosexuals has begun to accelerate markedly, according to the USC expert. The local cases of the new hepatitis strain are producing a death rate more than double that of the conventional disease.
Other experts agree that the spread of delta virus into the homosexual population--which would defy earlier observations that incidence in that group was lower than others--could mark the beginning of a dangerous and potentially deadly trend. Victims who die of the new type of hepatitis either succumb quickly in a super-acute first phase of the disease or linger when the strain turns into a chronic affliction, eventually dying of cirrhosis of the liver.
The volume of the cases and the increasing proportion of them that involve homosexuals--as opposed to drug addicts, who are still the highest risk group--have convinced the USC expert, Dr. Allan Redeker, that "the time (for the widespread dissemination of delta virus into the homosexual community) is already here."
"We feel the time has come," he continued, "at least in this community."
Experts across the country emphasized that delta virus is probably not technically a new entity. In fact, cases have been clearly identified in the United States as long as 40 years ago. But it has become recognized as a potentially widespread problem only within the last three to 10 years, most researchers agree.
Redeker, who holds professor rank at the USC Medical School, heads the liver unit at Rancho Los Amigos Hospital in Downey. Redeker is the nation's top expert on the ramifications of delta virus hepatitis for homosexual populations, according to Dr. Stephen Hadler, a hepatitis specialist at the federal government's National Centers for Disease Control in Atlanta.
Redeker discussed the local delta virus situation last week after publication in the New England Journal of Medicine of a study organized by Italian researchers in which scientists examined the emergence and possible spread of the new hepatitis type. The Rancho Los Amigos unit contributed some of the data to the worldwide analysis, headed by a team in Turin, Italy.
Publication of the study in the journal was accompanied by an editorial warning that, unless ways are found to control the spread of delta virus, it could become--in the United States or, more likely, in Asia--"a new scourge."
The co-author of the editorial, Dr. Jules L. Dienstag of Massachusetts General Hospital in Boston, said it is already widely known that delta virus cases are on the increase in Los Angeles and on the East Coast. Dienstag said he was unaware of the still unpublished data on involvement of homosexuals in the spread, but he said that development is one many hepatitis experts fear.
"What worries us," he said in a telephone interview, "is that once it (delta virus) gets through the homosexual community, it could spread like wildfire."
Redeker's detailing of the spread of delta virus to local homosexuals came in response to questions posed last Friday by The Times. He was asked about American data included in the worldwide summary. Redeker's disclosures also follow by several months extensive press coverage of an outbreak of delta virus in Worcester, Mass., which has so far involved more than 200 people since late 1983.
Most of the Worcester victims have been addicts who inject drugs, and sexual partners of those addicts. Nine persons have died in the Worcester outbreak, which is believed to be the first major instance in which a significant number of cases has occurred in a comparatively short time in the United States.
Redeker said, however, that delta virus cases in Los Angeles have been traced to the late 1960s and early 1970s and that the total incidence here may be higher than the Worcester caseload, although the large numbers in Massachusetts in less than two years clearly constitute a significant development.
"I don't think that (a confined outbreak) like Worcester is going on (in Los Angeles) or has yet," Redeker said. "But I think it could occur and I know of no reason why it could not." Redeker was reluctant to divulge some details of a recently completed USC study of the spread of delta virus here because a formal scientific report on the research is still awaiting publication.
Mainstream scientists normally refrain from describing in detail the findings of major research studies in the lay press before such reports are scrutinized by colleagues who make up review boards that evaluate manuscripts for medical and scientific journals.
Redeker did say, however, that:
--Nearly 150 cases of the delta variety hepatitis have been discovered by the USC team, mainly among patients seen at Rancho Los Amigos and at County-USC Medical Center. Nearly a dozen of those cases have been discovered since the team's formal data-gathering process ended in January.
--Slightly more than half of the total have involved known intravenous drug users--a proportion similar to that discovered in other studies of delta virus.
--Slightly more than 10% of the cases, however, have proven to involve male homosexuals and almost exactly 10% include victims who are both homosexual and intravenous addicts. The cases also included fewer than five people who had had blood transfusions--identified as a far more significant risk factor in studies elsewhere. The rest of the cases either led to no identifiable risk factor or could not be completely evaluated.
--The mix of cases--while Redeker has been gathering data since 1967, most of the cases studied have been reported in the last three years--has been slowly changing in proportion so that homosexuals are more heavily represented in recent cases than they have been in the past. Drug users still constitute the largest single group of delta virus victims here, though Redeker said the trend toward ever greater involvement of homosexuals is unmistakable.
--The death rate for local delta virus cases is running between 21% and 23%--or a factor more than double that of normal hepatitis B.
The delta strain is a variation on hepatitis that can only be contracted by someone who has already been infected by the virus that causes hepatitis B, one of the two major, common types. Hepatitis B can be spread by use of contaminated needles and blood products or sexual contact. In 1980, 19,015 people contracted hepatitis B nationwide and 29,087 got hepatitis A, a less virulent strain transmitted through food and personal contact.
In 1983, the most recent year for which figures are available, 24,300 people contracted hepatitis B. Symptoms include severe jaundice, nausea and stomach pain. Most people recover within four to eight weeks, but, at the very least, delta virus victims normally experience more acute symptoms that last far longer than normal. In some high-risk groups, mortality rates can be as high as 10% or 15% for hepatitis B. But for the delta virus strain, rates nationally, as well as here, have been reported as high as 25% or more.
Delta virus does not affect people with hepatitis A. But for victims of hepatitis B, addition of the delta virus to the existing organism can often mean that any ensuing hepatitis can progress far more swiftly and be much more severe than if the delta organism is not present. Often, delta virus begins with a fulminant phase in which the disease is so acute death occurs within a few days.
If a person survives the initial episodes but then develops chronic hepatitis B aggravated by the delta virus factor, the disease can easily develop into cirrhosis. Cirrhosis is the type of total liver deterioration that often kills alcoholics. Cirrhosis, Redeker said, is the most common cause of death for delta virus victims. Once a person is infected by the hepatitis B virus, there is no protection known to prevent addition of the delta virus component. Not all people who become infected with the hepatitis B virus develop the disease.
Hepatitis B can be prevented by vaccination, but the recently developed three-shot series is comparatively expensive--the total cost is about $100--and immunization campaigns have so far met with only limited success. An attempt to vaccinate large numbers of drug addicts in Worcester, Mass., has failed, according to the Centers for Disease Control's Hadler, and scientists are not optimistic about the prospect of attracting large numbers of homosexual men to immunization campaigns.
Even if homosexuals can be drawn into vaccination programs, there are only limited prospects for success in stamping out delta virus infection. The immunization has no effect if a person has already been exposed to the hepatitis B virus and there is no effective way to prevent addition of the delta virus strain alone, Hadler and other experts said.
Dienstag speculated that the only potentially effective way to prevent the spread of delta virus in the homosexual community is to identify young men and immunize them before they become extensively sexually experienced. "It is a very difficult group to target," said Dienstag of homosexuals in general, "because most people have been sexually active for a while.
"By that time, they have a high likelihood of being already infected. The difficulty is to get to them early in their sexual activities while they are still quite young.
"The Worcester outbreak is so worrisome because the possibility exists for it (delta virus) to get into populations such as homosexual men who have a very high risk, yet they have so far been spared."
The CDC's Hadler said data he has reviewed on the possibility of widespread involvement of homosexual men in delta virus infection has so far been equivocal. "I'd reserve judgment," Hadler said in a telephone interview from Atlanta. While Hadler said "there's no doubt that delta virus is moving" into new populations, he hesitated to say it has epidemic potential specifically among homosexuals yet--though he agreed that the incidence of delta virus is increasing at an alarming rate. Hadler, however, had not seen the new data gathered in Los Angeles.
All of the experts were cautious and chose their words carefully, but Dienstag noted that the incidence of delta virus can be expected to be greatest in populations already high in exposure to hepatitis B. That includes drug addicts and homosexual men, as well as large numbers of people in Southern Europe and Central and South America. Some of the worst outbreaks recorded so far, said Dienstag, have occurred in Colombia, Brazil and Venezuela.
Dienstag was not aware of completion of the USC study here in Los Angeles and has not seen any of the data gathered by the Redeker team, which includes Drs. Sue Govindarajan and Kevin DeCock. Dienstag said his greatest fear at the moment is for countries in Asia where delta virus has so far been only infrequently reported, but where indigenous hepatitis B infection rates run as high as 10% or 20%.
In Asia, said Dienstag, all of the elements exist to make possible development of a fast-moving and deadly international delta virus epidemic. It was Asian countries that Dienstag was talking about when he warned in an editorial in the journal publishing the Italian results that "unless additional, intensive investigation of this novel agent and its properties provides clues to its control, we may be confronted with a new scourge."
The Italian research team, led by Dr. Mario Rizzetto, did not focus extensively on the potential delta virus problem among homosexuals. Instead, after analysis of data on 262 delta virus patients in Italy, Greece, Brazil, Australia, England, Austria, West Germany and the United States (including about a dozen of the ones seen at Rancho Los Amigos), the Italian team warned that blood and blood products--particularly plasma--are a potential source of delta virus transmission.
Among Blood Donors
The Italian researchers noted that on the East and West coasts of the United States, the incidence of blood donors with possible susceptibility to delta virus infection is "among the highest recorded to date."
The Italian team warned patients at risk of hepatitis to use only plasma products made by gene-splitting techniques or from individual donors or small groups of donors. Plasma derived from large groups of donors should be avoided by high-risk groups, the team warned.