Acute Ffaemorrhagic Coniunctivitis (AHC) "Pink Eys-` n aar-

Acute FfaemorrhagicConiunctivitis
(AHC) "Pink Eys-' n aarSuru.wary
This stwd.yfocuses0n thefind.ings of atc
outbreah of acute baernonhagil
conjunctivitisin Mamelodi il a aennal
prartice en ly iru 1989.Age-sexiates are
giveru and. eruphasisisptaced.on tbe
,utLna.gewentand.preuention of the
spreadof this highly contagiousdisaase,
which hns sporadicalll' fficted millions
oJ
activepalpl( overtbepast
.economically
20 yearssinceit wasftrsi recognisedis a
cttntcAtc,ndtttqn.
S Afr Fam Pract 1989; l0: 634-9
Dr A Adam
!S_._l!91 MFGP(sA) MBBCh,DrM&H,
DPH (\,VrTS)
;
t
.t?
.J;
;1.'
Dept of National Hcalth & population
Delelopment, l)irectorate Epidemiology,
Private Bag X63
PRITORIA
000r
Curricuium vitae
Dr Anlir Adam first did a BSc at UCT and
then u.ent to \VITS rvhere he obtained rhe
MBChB in L964. After some Gp experience,
h e u ' r o r er h c M F G P t S A ) i n 1 9 2 3 . H e ' h a s b c c r r
i r r G e n e r a l P r a c r i c ef ' o r 2 5 r . e a r su i r h s p c c i a l
intercsts in infectior-rsdiseases,diabetei ar-rd
hlpertensior.r.In 1986 he obtaincd a DTM &
H and in 1988 a DPH at Wits, u,hich aq,akenecl
interest in epidemiology, and he is currently
engaged in epidemiological studies pertaining
to primarv and community health cari.
I(EYWORDS:
Conjunctivitis.
clinical condition in 1969. The
diseaseis causedby enterovirus Z0
(EV70) and coxsackievirus A24
variant QMal.
These two viruses
are distinguished either genericallyor
serologicallyfrom each other.
Flowever, the diseasesthev causeare
c l i n i c a l l yi n d i s r i n g u i s h a b a
l en d
constirute the AHC syndrome.r
The diseaseis very contagious and
spreadsrapidly, and its clinical
picture is so characteristicthat
difl-erentiation from other varieties of
viral conjunctivitis is possible.The
prognosis for the affetted vision is
fav^ourable
; rarely EV70 conjunctivitis
is followed by a polio-like nroror
paralvsis.t,5
World Overview
At the present time outbreaks of
acute haemorrhagic conjunctivitis are
occurring in pans of Sourh Africa.
Similar outbreaks of this diseaseu,ere
experiencedlrere in 1982 and \9g4.
As far as is known West Africa was
the first region of the World to be
affected by EV70 infection in 1969.
In succeedingyearsthe infection
rapidly spreadto various parts ofthe
easfern
hemisphere.Many parts of
This study fbcuseson 108 black
patients from the Mamelodi area seen the western hemispherewere
encompassedby tie diseasein the
at a generalpractice between
secondpandemic which occurred in
1989/ 02 / 09 and 1989/ OS/ 20 ; 7 3
1980 f982. AIIC outbreaks due to
patients were males and 35 females.
CA^2avwere first recognisedin 1970
During the period of study no
rn Srngaporeand probably Java.and
patlents were seenunder the ase of g
have
been localisedmainlv in
yearsand over the age of 49 yirs.
SoutheasrAsia and Indra until
Heaviest caseload oicurred between
recently. Today both aetiologic
89/ 03/ 23 and 89/ 05/02. Ase-sex
agents
are spreadalmost all over the
specific rates showed that males in
world.t
the age group 20.29 predominated.
Clinical fearuresin oidcr of hiehest
to lowesrfrequcncvare Iistcd aid
In 1984 epidemicsof AHC that
ernphasisis placed on management
occurredin Antigua, Grenada,and
and prevention ofthe spreadofthis
Trinidad and Tobago conrinuedinro
highly contagiousdiseasc.
1 9 8 5 .I n 1 9 8 5a n e p i d e m i co f A H C
occurred in Singapore with CA24v as
causatrveagent.A local outbreak of
Introduction
AHC from June to Aueust 19g6
Acute haemorrhagic conjunctivitis
occurred in Taiwan, also with CM4t.
(AHC) was firsr recognisedas a new
as the causativeagent.
634
SA F-amilyPracticeDeccmber l9g9
SAHuisansprakryk
Desember
l9g9
. . . Acute Haemorrhagic Conjunctivitis
Acute Haemorrhagic
Conjunctivitisin the Republic
of SouthAfrica
Outbreaks of AHC began in midMarch 1982, in Natal, KwaZulu,
Transkei and on the Witwatersrand,
mainly in Soweto.3'aFurther
outbreaks were reported from the
Eastern and Western CaPe and also
in the Temba-area,about 50km
north of Pretoria. Small foci of
infection remained in the black
townships on the Witwatersrand area
and the Northern Transvaal and
sporadic casesappeared until
1984-f985 when large outbreaks of
Acute Haemorrhagic
Conjunctivitis in the Mamelodi
area as studied from a general
practice near Mamelodi
and 88 460 females. Health services
for the residents of Mamelodi are
provided by the Mamelodi hospital,
fixed clinics and twelve private
medical practitioners in Mamelodi
and its outskirts. Most patients with
features of AHC would have received
medical attention from one of the
clinics and the hospital, although
some patients may have elected to
consult one of the private medical
practitioners.
Mamelodi is a blacktownshipwhich
lies about 2I km eastof Pretoria.It
hasan estimatedpopulation of
174332-ofwhich 85872 aremales
I. Methods
Between1989/ 02/ 09 and1989/
with
05/20,I08 blackpatients
the diseaseoccurredin manyparts of
the country.The incidencerate
declineduntil 1988 and the
beginningof 1989, when large
outbreakshavesweptseveralparts of
the country again.
TheGTeatNEOSPORIN*
r0
ofantibiotics
Thecombination
ophhalmic
,nNEOSP0BINT
B
preparations
isoneinheeye Polymyrin
conludivttis.
forbacterial
dayand l'leomvcin
IJsehesolutionby
for
byntght
theointnent
teatnent Gramicldin/
24hour
effective
Bacitnacin
NEOSPOBINPrescrrfu
*Trademark
today.
Gram-Negative
Pseudomonas
Haemophilus
Klehiella
Enterobacter
Escherichia
Proteus
Gram-Pqsitive
Corynebacterium
$aphylococcus
Sfeptococcus
Pneumococcus
Eachmlcontairs:
SOlr.moH@ Fd. No.H1111(Act101/1965)
OPTHAT-I'rC
NEOSPORIN
25 U'Ihiofl€rsal0'm1%m/v.
B Sulphd 50(x)U,Noo.nlEingrlphab lru U,GramicUin
Potyrnyxin
OPTHA|ITCOrn"reur@ R€f.No.Hl112(Act101/1965)
NEOSPORIN
PolynyxinB Sulphabsmo U,Znc Baciracin/t@ U,llefirydn Sulphab3400u.
Eachgramconoains:
mftNoA
8€IIFWAY
PaIk1620.
Kem@r
(Reg.
PO.Box653,
(Pty}
1'lo.
66/00480/04,
Limibd,
package
produc{
Wdcome
insert
orcorrbd
particulars,
consult
Forfu1presoibing
635
SA Family Practice December 1989
SA Huisartspraktyk Desember 1989
clinical features of AHC comine
from the Mamelodi areawere rtudi.d
at a nearby generalpractice.For the
purposes of this study, records were
kept ofnames and addressesof
Datients.The date ofonset of
iymptoms."nd datesof consultation
were noteo, as were sex, age,
household size and occuDationofthe
Datients.
T H E N U M B E RO F C A S E SO F A C U T E
HAEMORRHAGIC
CONJUNCTIVITIS
BY TWO-WEEKLY
PERIODS
19 8 9 - 0 2 - 0 9 T O 19 8 9 - 0 5 - 2 0
"Pink eye" was discovered
some 20 yearsago
Casedefinition was basedentirely on
the clinical diagnosismade by the
attending practitioner. The criteria
were pain, subconjunctival
haemorrhages('pink eye'), especially
well seenwhen the Datient looked
downwards; eye lidiwelling and
oedema,foreign body sensation and
irritation, photophobia, laterality and
discharge.
Note was also made of the presence
of pre-auricularlymphadenbpathy.
any unusual features and associated
upper respiratory symptoms, and the
presenceor absenceoffeatures
suggestiveof a polio-like motor
paralysis.5
g-22 FEB
25-8 MAR
9-22 tl|,AR
23-.+ ApR
of May 1989. This is shown in Fig l.
A total of 108 patientswere
examinedand treated for NIC;73 of
whom were males and 35 females,
giving a ratio of 2,08 males to I
female as illustrated in Fis 2. The
age-and sex-specificattaJ<ratesfor
the patients are reflected in Fig 3.
Very contagiousand spreads
rapidly
1S-2 gAy
3-,16 MAY
17-20 MAY
from households that had four
members per household, 17,60/ofrom
householdshavine 5 members in
each househ old, Il,,3o/o 23 ,Io/o and,
30,60/ofrom households having six,
sevenand eight members per
household respectivelv.This is
cleprctedln -brg41.
In 47 patients, symptoms had
commenced 2 days before date of
consultation: in 4I Datients
T H ES E X D I S T R I B U T I O F
NC A S E SO F
A C U T EH A E M O R R H A G
C IOCN J U N C T I V I T I S
1989-02-09TO 1989-05-20
2. Results
108 patients were analysedbetween
1989/ 02/ 09 and 1989/ 04,/20. No
patients in the age group under 8
years and over 49 years with clinical
features of AHC were seendurins
the period of study.Patientload per
two-weekly interval increased from 10
patientsin the secondweek to 75 by
the end of the tenth week of the
study. Thereafter, there was a steady
decline to the end of the third week
5-16 AtR
TWO-WEEKLY
PERIOD
Males showed a consistently higher
attack rate, being most marked in the
20-29 year age group (Table l). The
age-specificattack rates for both
sexesshow a similar age distribution,
peaking in the young adult age
groups and falling off with increasing
age.This largely correspondswith
the finding in the Soweto study.4
It was found rhat 7 ,4o/opatients came
636
SA Family Practice December 1989
SA HuisanspraktykDesember1989
. . . Acute Haemorrhagic Conjunctivitis
Fis.3
FJ9U64
T H E N U M B E RO F C A S E S P E R S I Z E O F H O U S E H O L D
O F A C U T EH A T M O R R H A GC
I CO N J U N C T I V I T I S
1989-02-09 TO 1989-05-20
AGE-SEX-SPECIFICATIACK RATESOF
ACUTE
CONJUNCTIVITIS
' 1 9 HAEMORRHAGIC
89-02-09
TO 19E9-05-20
t67A9
NUMBER OF MEMBERS IN HOUSEHOLD
symptoms had been present from the
day before consultation. A history of
onset ofpain of4 daysbefore
consultation was given by 7 patients,
whilst 13 patientswere not sure of
the date of onset of pain.
3. Clinical Features
All patients seen complained of eye
pain. In 27 patients pain commenced
unilaterally but became bilateral
subsequently. Subconjunctional
haemorrhages were seen in 102
patients. The other predominant
features were foreign body sensation
and irritation, eye lid swelling and
oedema,and discharge.In 63 patients
discharge was profuse and watery
from the start but in 45 patients the
discharge was seromucous initially.
This causedthe evelid stickiness but
cleared to a profuse watery discharge
after 2 days. In Ta6le 2 the clinical
features are tabulated, showing in
decreasing order the frequency of
clinical featurespresentedby the
panents.
4. Management
Specific treafinent and a vaccineare
not availablefor this self-limitine
Table l: Age-sexspecificattack ratesof Acute llaemorragic Conjunctivitis at a generalpractice
near Mamelodi, February I9B9 - May 1989
Age Group
Estimated
Population
Attack
Rate,/I0 000
No
Estimated
Population
09
t0 19
20.29
3039
40.49
1 98 8 8
21455
r5 834
12446
9276
JJ
6
1,5
8,9
20,8
9,6
6,4
TOTAL
78 889'
73'
9.3
L2
Attack
Rate,zl0 000
Females
Males
3
l9
No
20043
234LL
17327
t3 866
7 9L4
0
7
20
5
82 56ll
5J-
J
0,0
3,0
I1,5
3,6
3,8
4,2
Source: l. Estimated figures for Blacksin Mamelodi basedon the 1985-Census,for 1989
2. Clinical records of the author. Dr A Adam, General Practice,Silvenon, 1989
637
SA Family Practice December 1989
SA Huisartspraktyk Desember 1989
I
Acute F{aemorrhagicConjunctivitis
Table Clinical featuresin I0B parientswith AHC
Fcatures
No of Patients
rvith ftatures,/
No of Patients
examincd (studied)
I08
t02
94
B9
8l
63
45
34
27
Pain
Haemorrlt.rgcst subconjunctir',rl
)
Lid ocdcma & svelling
Irritarion & Forcign bodv scns.rriorr
Lateralin': Bihteral Dischargc
Watery
Seromucous
Pre-auricullr lvmphadcnopathl'
Lateralin': Unilareral
Unusual f'caturcs,(eg otitis rncclia
subcutancoushaemorrhages)
Upper respiraton' tract s\'mptoms
Complications
4
23
0
Percentage
r00,00
Q-44
87,0
82,4
75,0
58,3
43,5
11
A
J I,a
25,0
26,8
0,0
Sourcc:l: Clinical recordsofthc author Dr A Aclarn,gcncral practicc, Silverton,
1989.
viral disease.Subjectiverelief is
obtained by frcquent irrigation ofthe
eyeswith salinesolution and
instillationof anti-histamineeve
drops. Vasoconstrictor eye drops may
be used to reduce swelline and
oedema.Antibiotics shoJd be used
only ifsecondary bacterial infection is
present,ie, ifthere is evidenceof
purulent discharge.Topical
application of corticosteroidsis
contraindicatedbecauseof their u'ell
known side effects.6Preliminary trials
with human interfcron B eye drops
have shown no favourableinfluence
on the clinical course of AHC.'
Contact lensesshould not be worn
during rhe illncssas they may irritate
the eyes;damagc to soft lensescan
also be causedby instillation of eye
drops.' Spreadof the diseasesh<luld
,.ONE
WEEKEND
RIVER
RAFTING,
ANDAtLIGHTF
OTITIS
EXTERNAAND
AWETFILM"
@
ge{nsol"fi
l0 ml
638
SA Familv Practicc l)ecernber 1989
SA Huisartspraktyk
Desen-rber
1989
11iIilrtl.fl
"""
ll;,,'"'
Acute Haemorrhagic Conjunctivitis
be prevented by isolating patients
with AHC from school and place of
employment.The severityoflhe
diseaseshould determine the period
of isolation as the duration of the
infectious period is not known.
Usually isolation of patients lasts for
4 to 6 days.
Health education of the population at
risk as to the nature ofthe diseaseis
important. Emphasis should be
placed on the prevention of spreadof
the disease;personal hygiene needsto
be stressed:frequent washing ofeyes,
not using communal towels, not
sharing eye drops from the same
Millions of economicallyactive
people have been affected
bottle, and refraining from touching
and rubbing the eyes.The uninfected
should avoid contact with other'pink
eye' sufferers. Hostels and places of
work need not be closed as the course
of an outbreak will not be
significantly affected by this action.8
Discussion
All patients under discussion with
clinical features of AHC were seen at
the same general practice during the
period 89/ 02 / 09 and 89/ 05/ 20.
The patient load during this study
was reminiscentof the.19B4-f985
outbreak in Mamelodi. This view was
shared by three other general
practitionerswho also seepatients
from the Mamelodi area.e
During an outbreak it is not difficult
to make a diagnosis of AHC because
the clinical features ofthe diseaseare
so characteristic. School children and
the economically activegroup of
people were affected, with an attack
rate being higher in malesthan that
for females.
Crowdins is consideredto be a risk
factor in ihe soreadofacute
haemorrhagic conjunctivitis.'?
IJnfortunatelv- the distribution of
householdsby size of household was
unobtainable in resoectofthe
Mamelodi area.A proportional
distribution of 108 casesof AHC bv
sizeof householdis shown in Fie 4.
Although suggestive of a relatioiship
between incidence and crowding, this
argument clearly does not hold in
their case,becauseit may merely be a
reflection of the distribution of
household size in Mamelodi.
Conclusion
Twenty years have passedsince the
discovery that EV70 and CM4 are
aetiologic agentsofoutbreaks of
AHC. Millions of people were
affected by this diseasein the
pandemicsthat occurred. Sporadic
outbreaks all over the world continue
to affect large groups ofthe
economically active population. There
is a great need for education ofthe
generalpublic and health personnel
rn oroer to ensureproper
management and prevention of
spreadofthe disease.
Dr HGV lQisner, Director,Epifumiohgy
MissA van Middllhoop,Depwty-Director,
Epidmiologt
MissJ E van Wyk,'4ssistantBiomctrician,
Epidzmiology
Mrs SJ Moolman,for typing themanuscript
Dr C F Slobber,Director Generol,for granting
permission
for thepublicationof this atticle.
References
I. I(eizo Ishii, Yukio Uchida, Kikuko
Miyamura, Shudo Yamazaki. Preface.
In: Acute Haemorrhagic
Conjunctivitis. University of Tolcyo
Press, 1989.
2. Melnick |oseph L. Introduction. In:
Keizo Ishii, Yukio Uchida, Kikuuku
Miyamura, Shudo Yamazaki. Acute
Haemorrhagic Conj unctiviti s.
University of Tolcyo Press, 1989: xi-xiii
I(tistner H. Acute Haemorrhagic
Conjunctivitis. Epidemiological
Comments 1982; (4) 2 3.
I(iistner H. Acute Haemorrhargic
Conjunctivitis in South Africa.
Epidemiological Comment s L982 ; 9
(6):r-r7.
Leading Article. Neurovirulence of
enterovirus 70. Lancer 1982; i:373-4.
6. Hoffman M. Acute Haemorrhagic
Conjunctivitis. S Afr Med | 1982;62:
3rt 2.
Uchida Y. Clinical Features of AHC
due to Enterovirus 70. Universiw of
Tokyo Press, 1989.
8 . IGige F. Circular No 23 of 1989.
Vigilance as to the detection of
Management of Pink eye epidemics:
neurological complications associated
Information for Nurses (Communiry
with AHC is imoortant and should
Health), School Principals and Hostel
be borne in mind by the attending
Wardens. Deot of National Health and
practrtloner.
Population Development.
Acknowledgements
Sinceyethanlu nre rlue to thefollowing colleaguzs
and mewbersof the Directorate Epidzmiology,
Depatonznt of Nntional Heolth and. Population
Developmcnt,for their crwcial nntribution in the
prepnration of this article:
639
SA Family Practice December 1989
9. Personal communications with medical
practitioners.Drs MHH
Padayatchi, O Ebrahim.
Ismail, P
SA HuisanspraktykDesemberI9B9