Volume 95, Issue 4
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Sri Lanka is one of the intermediate-endemic areas for hepatitis A virus (HAV), and concerns exist about the increasing HAV-susceptible population. In fact, Sri Lanka recorded a large hepatitis outbreak, possibly hepatitis A, around the end of the Sri Lankan war. It included more than 14,000 patients consisting of local residents, internally displaced personnel, and military personnel in the main combat zone. The outbreak had slowed down by October 2009; however, acute viral hepatitis continued to occur sequentially among military personnel. We obtained clinical information and serum samples from 222 patients with acute hepatitis who visited the Military Hospital Anuradhapura between January and September 2010. Samples were subjected to laboratory testing including HAV-immunoglobulin M and genotyping. Most patients (98.2%) were confirmed as having hepatitis A belonging to two subgenotypes: IA and IIIA. We did not observe any differences in clinical or biochemical features among patients with subgenotypes IA and IIIA except for pale stools and upper abdominal discomfort. During the investigation period, we observed a serial outbreak caused by identical HAV strains with an interval in line with that of typical HAV incubation periods. Most patients in the first outbreak were found in the training center, and patients in the second outbreak were found in multiple places where soldiers were assigned after the training center. These findings indicate that a strain of HAV diffused from one place to another along with movement of infected persons among the HAV-susceptible population. HAV vaccination for high-risk groups, such as young soldiers, is necessary.


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  1. Hollinger FB, Emerson SU, Knipe DM, Howley PM, , 2007. Hepatitis A virus. , eds. Fields Virology, 5th edition. Philadelphia, PA: Lippincott Williams and Wilkins, 911947.
  2. World Health Organization, 2000. Department of Communicable Disease Surveillance and Response Hepatitis A. Available at: http://www.who.int/csr/disease/hepatitis/whocdscsredc2007/en/index.html. Accessed September 28, 2015.
  3. Lemon SM, Jansen RW, Brown EA, , 1992. Genetic, antigenic and biological differences between strains of hepatitis A virus. Vaccine 10: S40S44.[Crossref]
  4. Koff RS, , 1992. Clinical manifestations and diagnosis of hepatitis A virus infection. Vaccine 10: S15S17.[Crossref]
  5. World Health Organization, 2012. WHO position paper on hepatitis A vaccine: June 2012. Wkly Epidemiol Rec 87: 261276.
  6. Jacobsen KH, Koopman JS, , 2005. The effects of socioeconomic development on worldwide hepatitis A virus seroprevalence patterns. Int J Epidemiol 34: 600609.[Crossref]
  7. Jacobsen KH, Wiersma ST, , 2010. Hepatitis A virus seroprevalence by age and world region, 1990 and 2005. Vaccine 28: 66536657.[Crossref]
  8. Wasley A, Fiore A, Bell BP, , 2006. Hepatitis A in the era of vaccination. Epidemiol Rev 28: 101111.[Crossref]
  9. Xu ZY, Li ZH, Wang JX, Xiao ZP, Dong DX, , 1992. Ecology and prevention of a shellfish-associated hepatitis A epidemic in Shanghai, China. Vaccine 10: S67S68.[Crossref]
  10. Fiore AE, , 2004. Hepatitis A transmitted by food. Clin Infect Dis 38: 705715.[Crossref]
  11. Bordi L, Rozera G, Scognamiglio P, Minosse C, Loffredo M, Antinori A, Narciso P, Ippolito G, Girardi E, Capobianchi MR, GEAS Group, , 2012. Monophyletic outbreak of hepatitis A involving HIV-infected men who have sex with men, Rome, Italy 2008–2009. J Clin Virol 54: 2629.[Crossref]
  12. Askling HH, Rombo L, Andersson Y, Martin S, Ekdahl K, , 2009. Hepatitis A risk in travelers. J Travel Med 16: 233238.[Crossref]
  13. Moritsugu Y, Miyamura K, Utagawa E, Kono R, de la Motte PU, Forbes CA, , 1979. Prevalence of antibody to hepatitis A virus in Sri Lanka. Asian J Infect Dis 3: 3336.
  14. de Silva KS, Weerasuriya DC, Peelawattage M, Fernando S, , 2005. Seroprevalence of hepatitis A antibodies in relation to social factors: a preliminary study. Ceylon Med J 50: 5458.
  15. Dahanayaka NJ, Kiyohara T, Agampodi SB, , 2013. Massive hepatitis A outbreak in Sri Lanka in 2009: an indication of increasing susceptibility and epidemiological shift? Sri Lankan J Infect Dis 3: 2830.
  16. Kiyohara T, Sato T, Totsuka A, Miyamura T, Ito T, Yoneyama T, , 2007. Shifting seroepidemiology of hepatitis A in Japan, 1973–2003. Microbiol Immunol 51: 185191.[Crossref]
  17. Kiyohara T, Ouchi Y, Hasegawa Y, Sato T, Yoneyama T, Ishii K, Ito T, Wakita T, , 2009. An in-house-anti-hepatitis A virus (HAV)-specific immunoglobulin M capture enzyme-linked immunosorbent assay: evaluation and application to an HAV outbreak. J Med Virol 81: 15131516.[Crossref]
  18. Ishii K, Kiyohara T, Yoshizaki S, Wakita T, Shimada T, Nakamura N, Nakashima K, Tada Y, Noda M, , 2012. Epidemiological and genetic analyses of a diffuse outbreak of hepatitis A in Japan, 2010. J Clin Virol 53: 219224.[Crossref]
  19. Ishii K, Nukuzuma S, , 2015. Notice regarding possible false negative results for HAV using the recommended real-time PCR method [in Japanese]. Infect Agent Surv Rep 36: 78.
  20. Robertson BH, Jansen RW, Khanna B, Totsuka A, Nainan OV, Siegl G, Widell A, Margolis HS, Isomura S, Ito K, Ishizu T, Moritsugu Y, Lemon SM, , 1992. Genetic relatedness of hepatitis A virus strains recovered from different geographical regions. J Gen Virol 73: 13651377.[Crossref]
  21. Thompson JD, Higgins DG, Gibson TJ, , 1994. Improving the sensitivity of progressive multiple sequence alignment through sequence weighting, position-specific gap penalties and weight matrix choice. Nucleic Acids Res 22: 46734680.[Crossref]
  22. Kimura M, , 1980. A simple method for estimating evolutionary rates of base substitutions through comparative studies of nucleotide sequences. J Mol Evol 16: 111120.[Crossref]
  23. Hussain Z, Das BC, Husain SA, Asim M, Chattopadhyay S, Malik A, Poovorawan Y, Theamboonlers A, Kar P, , 2005. Hepatitis A viral genotypes and clinical relevance: clinical and molecular characterization of hepatitis A virus isolates from northern India. Hepatol Res 32: 1624.[Crossref]
  24. Yun H, Lee HJ, Jang JH, Kim JS, Lee SH, Kim JW, Park SJ, Park YM, Hwang SG, Rim KS, Kang SK, Lee HS, Jeong SH, , 2011. Hepatitis A virus genotype and its correlation with the clinical outcome of acute hepatitis A in Korea: 2006–2008. J Med Virol 83: 20732081.[Crossref]
  25. Yoo SH, Kim IH, Jang JW, Choi CH, Moon JC, Park JK, Lee SY, Kim SH, Kim SW, Lee SO, Lee ST, Kim DG, Cho EY, Jung GM, , 2014. Clinical features and risk factors for severe complications among patients with acute hepatitis A virus infection in the Jeonbuk Province of Korea. Korean J Gastroenterol 63: 2531.[Crossref]
  26. Moon HW, Cho JH, Hur M, Yun YM, Choe WH, Kwon SY, Lee CH, , 2010. Laboratory characteristics of recent hepatitis A in Korea: ongoing epidemiological shift. World J Gastroenterol 16: 11151118.[Crossref]

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  • Received : 18 Mar 2016
  • Accepted : 30 May 2016

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