A CAJM survey on the prevalence of Australia Antigen in the blood of Zimbabweans (formerly Rhodesians)Consequently a more comprehensive survey was undertaken to determine the general prevalence of the antigen in Rhodesia by testing African and European blood donors as examples of urban populations and, in contrast, certain African tribal groups as examples of rural populations. The results are presented here together with the findings in cases of hepatitis and leprosy which have come to hand subsequent to the pilot survey

Cruickshank, J.G.

Lowe, R.F

Moore, H.

Robertson, T.

Swanepoel, R.

Central African Journal of Medicine

English

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The Central African Journal of Medicine
Editor: y
MICHAEL GELFAND, C.BE., M.D., F.JjLC.P.
!
Assistant Editor:
JOSEPH RITCHKEN, M.D.
Volume Eighteen 
JANUARY - DECEMBER 
1972
Salisbury Rhodesia
Vol. 18. No. 6; June, 1972.
Australia Antigen — Rhodesia
2. SURVEY OF URBAN BLOOD DONORS 
AND RURAL POPULATIONS
BY
J. G. CRUICKSHANK
AND
R. SWANEPOEL,
Department of Medical Microbiology, University of 
Rhodesia,
R. F. LOWE,
T. ROBERTSON,
AND
H. MOORE,
Salisbury and District Blood Transfusion Service.
I ntroduction
A recent pilot survey indicated that there was a 
high incidence of Australia antigen (Aid) in the 
serum of African patients with hepatitis in Rho­
desia (Cruickshank and Swanepoel, 1971). Else­
where in Southern Africa the antigen was 
demonstrated in 3,4 per cent, of a random sample 
of an apparently normal African 'population 
(Grobbelaar, 1970). An incidence as high as this 
implies a real risk in circumstances where blood 
or blood products are handled or administered as 
in transfusion, renal dialysis, surgical and haema­
tology units.
Consequently a more comprehensive survey was 
undertaken to determine the general prevalence of 
the antigen in Rhodesia by testing African and 
European blood donors as examples of urban 
populations and, in contrast, certain African 
tribal groups as examples of rural populations. 
The results are presented here together with the 
findings in cases of hepatitis and leprosy which 
have come to hand subsequent to the pilot survey.
Materials and Methods 
Urban blood donors
Serum samples were obtained from all donors 
bled in Salisbury over a four-month period. The 
African donors were almost exclusively young men 
apparently in good health.
African donors were generally bled in groups 
and were drawn from individual industrial firms, 
the labour exchange, prisons, police, air force, 
secondary schools, training colleges and the 
university. A few donors from non-defined 
sources were bled at community centres and Red 
Cross clinics.
The European donors were drawn from a rota 
of individuals.
For comparative purposes the Bulawayo and 
District Blood Transfusion Service supplied three 
batches of serum samples from unselected African 
donors drawn from sources similar to those in 
Salisbury.
Rural populations
The screening of rural African populations was 
opportunist, the blood samples being collected 
from three areas in the course of other surveys:—
(a) Randomly selected men, women and 
children were bled in villages at Ohisunga and 
Chitsungo in the Dande, Angwa and Hunyani 
river areas of the Zambesi Valley in a survey into 
the incidence of malaria, filariasis and trypano­
somiasis.
(lb) Randomly selected men, women and 
children from villages in1'the Kariba area of the 
Zambesi Valley were bled in a survey of filariasis.
(c) Staff and patients — mainly healthy 
women in maternity wards — at the Regina Coeli 
Mission Hospital in the Nyamaropa tribal trust 
lands beyond Inyanga, were bled following a 
report of typhoid fever in the area.
Lepers
Mr. B. P. B. Ellis, Leprosy Control Officer of 
the Ministry of Health, supplied sera from cases of 
leprosy additional to those included in the pilot 
survey. Patients came from a variety of tribal 
groups — principally Manyika and Ndau from 
Manicaland, Mazezuru and Kore Kore from 
Mashonaland and Tonga from the Binga area.
Patients with liver disease
Sera were obtained from 32 African patients at 
Harari Hospital and from three Europeans. The 
clinical diagnoses are presented with the results in 
Table IV.
Australia antigen tests
All sera were examined for Aul by the orossed- 
over immunoelectrophoretic method detailed pre­
viously (Cruickshank and Swanepoel, 1971) using 
anti-Aul serum prepared in baboons at the Natal 
Institute of Immunology.
T h e  Central African
J ournal of Medicine
113
J u ne , 1972. AUSTRALIA ANTIGEN IN RHODESIA T h e  Cen tra l  A frican
J ou rn al  of M ed ic in e
T1
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Results
The results are presented in tables I—IV. 
Table I
T he I ncidence of Aui in  Urban Blood 
D onors
Origin
No.
:xamined
No.
positive
%
positive
(a) African donors in Salis­
bury:
Community centres and 
clinics .. ... .. ... ... 101 1 1,0
Educational institutions 1 006 27 2,7
Prisons ............ . _ ... 1 731 55 3,2
Industry ... .„ „ ... ... 761 32 4,2
Forces (Police and Air 
Force) f ... 387 28 7,2
(b) European donors in Salis­
bury ........................  „ ..
3 986 
1 275
143
2
Av. 3,6 
0,2
(c) African donors in Bula-
wayo ............ . ... ... 228 10 4,4
Table II
T he I ncidence of A ui in  Rural African 
Populations
Origin
No.
examined
No.
positive
%
positive
Regina Coeli Mission, Inyanga 71 0 ----
Chitsungo, Zambezi Valley ... 652 10 1,5
Chttsunga, Zambezi Valley ... 169 9 4,7
Kariba, Zambezi Valley ....... 144 8 5,6
1 036 26 Av. 2,5
Table III
T he I ncidence of Aui in  Lepers
Type
No.
examined
No.
positive
%
positive
Lepromaitous leprosy ............. 85 1 1,2
Tuberculoid leprosy ............. 101 1 1,0
186 2 Av. 1,1
Table IV
T he I ncidence of A ui in  Patients with  
L iver D isease
Clinical diagnosis
No.
examined
No.
positive
%
positive
Serum hepatitis _ ... „ 1 1 100
Infeotious hepatitis .. ... _. 22 8 36,3
Undiagnosed jaundice ............. 10 1 10
Hepatoma ..................  „ „. 1 1 100
Ca panoreas and liver failure 1 0
Total: 6 746 specimens
D iscussion
The results of the present survey of the inci­
dence of Aui in Rhodesia are best considered in 
relation to findings elsewhere. A selection of t'he 
surveys carried out over the last five years on 
apparently healthy populations are summarised in 
Table V. Most studies were performed on blood 
donors, but early work involving a search for a 
familial trait (Blumberg, Altar & Visnich, 1965) 
included more random population groups.
It is apparent that by and large the less sophis­
ticated the population the higher is the incidence 
of Aui. The rate among Europeans in Rhodesia 
is comparable to the lowest in Europe and North 
America, while that among Africans is high by the 
standards of the developed countries.
Though some studies attempt to relate the 
antigen to certain genetic traits, the evidence that 
it is a transferable infectious agent is now irre­
futable and the variations in incidence are pro­
bably best related to the environment and ways of
Rig. 1—Particles of Australia antigen from a Rhodesian 
blood donor. Serum was centrifuged at 105 000 
xg for two hours and the resulting pellet re­
suspended in distilled water. An aliquot was 
transferred to  a copper grid, stained with 
phosphotungstate ph 7,4 and examined in a 
Hitachi HU 11 electron microscope using a 
50 kV voltage.
114
June, 1972. AUSTRALIA ANTIGEN IN  RHODESIA T h e  Central African
J ournal of M edicine
Table V
Surveys of the I ncidence of A ui over the 
Last F ive Years
% Reference
Country Source positive
EUROPE
Lowest: Norway .......  _ ... Blood donors 0,16 Solaas, 1970
Highest: Greece _ _ _ _ Blood donors 1,8 Blumberg, et al, 1970
N. AMERICA
General .......  _ „ „ _ _ General population 0,1 Shulman, et al, 1970
New York .................. . _ ... Blood donors 0,75 Gocke, et al, 1969
S. AMERICA
Peru ... ... ... ... _ ... _ „ Cashinahua Indians 20,2 Blumberg, et al, 1966
Mexico _ .......  ... „ _ ... Indians 0,4 Blumberg, et al, 1966
PACIFIC
Australia _ _. ... _ ... _ ... Aborigines 5,1 Blumberg, et al, 1966
New Guinea ............. _ „ _ Melanesians 3,6 Blumberg, et al, 1966
Bora Bora ... „ ... _ „ ... Polynesians 2,5 Blumberg, et al, 1966
ASIA l •
Japan _ _ _ _ _ _ _ _ Blood donors (male) 1,23 Okochi & Murakami, 1968
Japan ........... . ............. „ ... Blood donors (female) 0,19 Okochi & Murakami, 1968
Phillipines ... _ ... ....... Filipinos 4,7 Blumberg, et al, 1970
Israel _ _ _ _ _ _ _  ... General population 1,2 U Blumberg, et al, 1970
AFRICA
Tanzania ■ _ ■ _ „ ... General population 0,8 ' Blumberg, et al, 1970
Ghana _ _ _ _ _ _  ... General population 9,5 1. Blumberg, et al, 1970
Kenya _ ... _ _• „ „ ... Blood donors 6,0 ! Bagshawe, et al, 1971
Natal „ _ .......  „ _ _ ... Blood donors 3,4 Grobbelaar, 1970
Rhodesia _ _ „ „ _ _ ... Blood donors (African) 3,6 This survey
Rhodesia _ ................. . ....... Blood donors (European) 0,2 This survey
life of the different groups. Opportunities in tribal 
life for parental transfer of the agent inolude 
tribal markings and tattoos, circumcision and 
other minor surgical procedures undertaken 
.without sterilisation of instruments. The uneven 
, distribution of the antigen in rural populations 
suggests that careful epidemiological investigation 
might uncover parenteral transfer mechanisms of 
this nature at work in villages.
Urbanisation presents its own hazards and cer­
tain batches of donors have been found to have 
a strikingly high incidence of the antigen suggest­
ive of small epidemics. This occurs in the young 
adult age group known to have the highest attack 
rate of hepatitis and involves particularly highly 
institutionalised groups such as those in the forces 
or training colleges and prisons. Accepting now 
that serum hepatitis is transmissible occasionally 
by the faecal-oral route (as iby food handlers), 
common factors in each group include the sharing 
of bath and toilet facilities and even perhaps 
razors. It is most unlikely in the age of disposable 
syringes and needles that official inoculation pro­
grammes in such groups play a role in disseminat­
ing the antigen, but one throw-off of the disposable
era is that it facilitates the work . of the do-it- 
yourself medicine man. In two urban cases of 
Aul-positive hepatitis clear histories were obtained 
of repeated injections performed by unqualified 
persons known to be in the habit of treating 
people (Dr. T. Stamps, personal communication).
Since people in the survey were apparently well, 
it must be assumed that Aul-positive donors were 
in the throes of low-grade hepatitis of were carri­
ers following frank or low-grade hepatitis. It is 
estimated that anicteric hepatitis occurs in 99 per­
cent. of antigen positive infections (Hampers, 
Prager & Senior, 1964) and, therefore, most 
people who become carriers are probably unaware 
of antecedent disease. Long term carriers follow­
ing hepatitis are reported to occur in the order of 
seven per cent, of cases (Wright, et al, 1969). 
One apparently healthy donor in this survey 
continues to carry the antigen after four months, 
and a patient remains positive a year after an 
attack of hepatitis. This patient’s liver function 
tests are still abnormal (Dr. E. Taube and Dr. 
K. G. Gadd, personal communication).
The risk of hepatitis following transfusion with 
Aul-positive blood is difficult to assess as the
115
June, 1972. AUSTRALIA ANTIGEN IN RHODESIA T h e  Central African
J ournal of Medicine
majority of cases are anicteric. Out of 40 persons 
who were transfused with • Aul-positive blood, 
Gocke & Kavey (1969), found that 70 per cent, 
developed hepatitis, while only four out of 69 
transfused with Au I-negative blood acquired the 
disease. Thus, though eliminating Aul-positive 
blood, by no means eliminates post-transfusion 
hepatitis, it is estimated that this procedure will 
reduce the incidence by 37 per cent, or more 
(Ghailmers and Alter, 1971). The case of serum 
hepatitis reported in this paper is the second post- 
transfusion fatality recorded this year in Rhodesia. 
In both instances Aul was present in high con­
centration in the serum of the recipient, but only 
in the case reported in the pilot survey (Cruick- 
shank and Swanepoel, 1971) was the antigen 
detected in a donor.
On the basis of the present survey, replacing 
Aul -positive blood adds four per cent, to the total 
cost of African blood in Rhodesia. It may be 
possible to reduce this figure by eliminating known 
positive donors, but the high rate of turnover of 
the donor population may militate against it. Only 
the continued testing of Salisbury donors will 
show whether or not any appreciable reduction 
can be achieved.
Pressure is now being brought to screen food 
handlers, medical personnel and others who may, 
in the course of their work, be in a position to 
transmit the agent, so that those who turn out 
to be positive may be found safer work during the 
time they remain potentially infectious (Chalmers 
& Alter, 1971). Further, in their own interests, 
carriers - should undergo liver function tests to 
detect any active hepatitis. A recent study reported - 
finding evidence of acute or chronic hepatitis by 
liver biopsy in 22 out of 25 Aul antigen carriers 
(Singleton, et al., 1971).
The findings in the lepers and in the hepatitis 
cases reinforce those published earlier that lepers
here unlike those in the Antipodes do not have a 
high incidence of Aul carriage and that many 
cases diagnosed as infectious hepatitis are in fact 
of the more serious serum variety.
Su m m a r y
Australia antigen was found in the sera of 3,6 
per cent of African blood donors from Salisbury 
and in 4,4 per cent, from Bulawayo and in 0,2 per 
cent, of European donors in Salisbury.
The incidence in rural African groups varied 
from nil to 5,6 per cent.
The epidemiology and significance of these find­
ings are discussed.
The low incidence among lepers in Rhodesia is 
confirmed.
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Acknowledgments
We are grateful to the Secretary for Health 
for permission to publish certain of the data.
116
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