Eriskinde Epstein-Barr virus enfeksiyonunun seroprevalansi ve risk faktorleri/Seroprevalence and risk factors for Epstein-Barr virus infection in adults.
Amac: Insan herpes virus 4 olarak da bilinen Epstein-Barr virus, infeksiyoz mononukleoz hastaliginin etkenidir. EBV infeksiyonlari cok sayida malignitelerle de iliskilendirilmektedir. Bu calismanin amaci, eriskinde EBV seroprevalansini ve risk faktorlerini belirlemektir.
Gerec-Yontem: Bu calisma, Istanbul'da Haydarpasa Numune Egitim ve Arastirma Hastanesi'nde Agustos 2012 ve Ekim 2012 tarihleri arasinda yapildi. 500 olguda ELISA yontemiyle EBV VCA IgG testi yapildi. Yas, cinsiyet, meslek, egitim durumu, gelir duzeyi, yasanilan yer, yasanilan ev ve kronik hastalik durumlari irdelendi. Risk gruplari arasindaki farklilik istatistiksel olarak arastirildi.
Bulgular : Calismaya katilan 500 olguda ortalama yas 47.7 [+ or -] 19.1 (15-87 yas arasi) idi ve 292 olgu erkekti. Ortalama EBV seropozitifligi %96.4 idi. %90.8 olguda, 15 yasina gelene kadar sezopozitiflik olusmaktaydi.Yas, cinsiyet, meslek, egitim durumu, gelir duzeyi, yasanilan yer, yasanilan ev ve kronik hastalik durumlari acisindan istatistiksel olarak anlamli farklilik saptanmadi.
Sonuc: EBV seropozitifligi oldukca yuksekti ve 15 yasina kadar olgularin %96'si seropozitif hale gelmekte idi. EBV seroprevalansi ve risk faktorleri arasinda anlamli bir baglanti saptanmadi.
Anahtar kelimeler: Epstein-Barr virus enfeksiyonlari, seroprevalans, risk faktorleri
Introduction: Epstein-Barr virus (EBV), also known as human herpesvirus 4, is the causative agent of infectious mononucleosis. Infection with EBV is associated with multiple malignancies. The aim of this study was to determine the seroprevalence and risk factors for seropositivity.
Materials and Methods: This study was conducted in Haydarpasa Numune Training and Research Hospital in Istanbul between August 2012 and October 2012. EBV VCA IgG antibody was measured using commercial ELISA in 500 cases. Age, gender, occupation, education level, family income, the area and type of residence, and chronic illness of the participants were also evaluated. Differences between risk groups were statistically analylzed.
Results: The participants' mean age was 47.7 [+ or -] 19.1 years (15-87 years) and 292 of the 500 participants were male. Mean EBV seropositivity was 96.4%, and 90.8 % of the cases become seropositive for EBV by 15 years of age. No significant associations with age, gender, occupation, education level, family income, area and type of residence, and chronic illness were detected.
Conclusions: EBV seropositivity rates were very high and about 91% of the cases become seropositive for EBV by 15 years of age. There was no significant relationship between risk factors and seroprevalence of EBV.
Key Words: Epstein-Barr virus infections, seroprevalence, risk factors
Epstein-Barr Virus (EBV) is a latent virus from the family Herpesviridae which is transmitted via the oropharyngeal secretions, blood, and contaminated belongings of infected individuals. EBV is the causative agent of infectious mononucleosis, which is a generally self-limiting condition characterized by fever, sore throat, and lymphadenopathy. However, the virus is known to be associated with Burkitt lymphoma, lymphoproliferative diseases, nasopharyngeal carcinoma, Hodgkin's lymphoma, primary central nervous system lymphoma in AIDS patients, and autoimmune diseases such as multiple sclerosis ().
The serologic profile of EBV infection is determined using specific antibodies against the major antigens of the virus including EBV nuclear antigen (EBNA), early antigen (EA), and viral capsid antigen (VCA) (). VCA IgM is found in the serum for 4-8 weeks during the active phase of the disease. In contrast, EBV VCA IgG appears early in acute infection and remains positive for the lifetime of the patient. Therefore EBV VCA IgG is commonly used in epidemiologic studies (). EBV seropositivity rates in adults in Turkey have been reported as 80-99.4% ([3,4]).
Due to the oncogenic potential of EBV and its known role as an etiologic factor for many idiopathic diseases, determining EBV seropositivity is important for identifying individuals at risk (). The present study was conducted with individuals over the age of 15 living in Istanbul, which receives immigrants from many regions of Turkey. The aim was to determine EBV seroprevalence and identify any significant differences in seroprevalence based on age, sex, occupation, education level, economic status, chronic diseases, and place and type of residence.
Materials and Methods
This study was performed between August and October 2012 in Haydarpasa Numune Training and Research Hospital. A total of 500 individuals aged 15 years and over who presented to the Haydarpasa Numune Hospital Infectious Diseases Polyclinic and Blood Bank were included. Previously prepared standard questionnaires were filled in during face-to-face interviews. The study participants were asked about their age, sex, occupation, education level, economic status, chronic diseases, area and type of residence, and underlying diseases. Individuals with history of blood transfusion or surgery and immunosuppressed individuals were excluded. Ethics committee approval was obtained from the Haydarpasa Numune Training and Research Hospital Ethical Council (decision number HNEAH.KA.EK-2012/50). A venous blood sample of about 5 cc was obtained from the participants and the serum samples were preserved at -20[degrees]C until analysis. Micro-ELISA was used to measure EBV VCA IgG antibody levels (NovoTec NovaLisa EBV VCA IgG ELISA (Dietzenbach, Germany) as per the manufacturer's instructions. The formula n=[t.sup.2]pq/[d.sup.2] was used to calculate the sample size required to determine the EBV VCA IgG seroprevalence in the adult Turkish population. Statistical analyses were done using the NCSS (Number Cruncher Statistical System) 2007 Statistical Software (Utah, USA) package. Data were analysed using descriptive statistics (mean, standard deviation) and categorical data were compared using chi-square and Fisher's exact test. The results were evaluated at a significance level of p<0.05.
The mean age of the 500 study participants was 47.7[+ or -]19.1 (15-87) years and 292 (58.4%) were males. EBV VCA IgG positivity was found in 479 (96.4%) of the participants. No statistically significant differences emerged in the age and gender distribution of EBV VCA IgG-positive participants (p>0.05, p=0.748) (Tables 1 and 2). There was no statistically significant difference in the gender distribution of the participants according to age groups (p>0.05) (Table 3).
Analysis of seropositivity rates in terms of participants' occupation, education level, and income levels revealed no statistically significant differences (p>0.05 for all) (Tables 4-6). There were no statistical differences in seropositivity according to the participants' place of and type of residence (p>0.05) (Table 7). The presence of a chronic disease was also not significantly associated with EBV VCA IgG positivity (p>0.05) (Table 8).
EBV is present in the saliva of asymptomatic seropositive individuals and is easily transmitted between people. It is known that socioeconomic level, hygiene habits, and crowded living conditions influence EBV seroprevalence, and higher seropositivity rates are seen in developing countries (). In our study, the overall EBV seroprevalence was 96.4%. Our findings are consistent with those of other seroprevalence studies conducted in our country ([3,7]). Customary Turkish behaviors showing love and respect, such as hand kissing, hugging and kissing the cheeks in greeting, are believed to facilitate the transmission of EBV through saliva and may cause this high seroprevalence.
It is known that having an EBV infection at an early age has harmful effects. Burkitt lymphoma is more common among infants who have primary EBV infection at very early ages and the accompanying high EBV viremia (). Many studies have shown that EBV seroprevalence increases with age ([7,9-11]). In our study, presence of EBV IgG antibodies was analysed in individuals aged 15 years and over. The EBV IgG positivity rate was 90.77% in the 15-25 years group and 97.78% in participants over 75 years old, with no statistically significant differences between age groups. This lack of significant age-related differences in seropositivity may be due to the participants having encountered a large number of viruses before the age of 15.
We also analyzed sex differences in EBV seropositivity and found that seropositivity rates were higher in males than in females. However, the difference was not statistically significant. In a study conducted with students of Edinburg University, Higgins et al. () determined seropositivity rates of 68.1% in males and 78.5% in females, which was a statistically significantly difference. In another study of children between 6-19 years of age, EBV seroprevalence was found to be higher in girls than in boys (68.9%, 64.2%) (). A study by Ozkan et al. () demonstrated that women had similar rates to men.
In the present study, we investigated the relationship between EBV seropositivity and education level. The participants were classified as illiterate, literate without formal education, primary school graduate, secondary school graduate, high school graduate, and university graduate/postgraduate. No statistically significant association was found between educational level and seroprevalence. This result is consistent with that reported by Ozkan et al. (). In contrast, Balfour et al. () analyzed the relationship between family education level and seropositivity and found that seropositivity was 72% for those who did not attend high school, 63% for high school graduates, and 56% for those with education beyond high school. Another study showed that EBV seropositivity in individuals with education below high school, at the high school level, and beyond high school was 83.5%, 69.5%, and 59%, respectively (). As suggested by these studies, higher education level has been linked to better hygiene habits and consequently a lower risk of virus transmission. High levels of transmission in childhood indicated the importance of family education. Contamination with EBV is known to be affected by socioeconomic status (). A study analyzing the correlation between income level and EBV seropositivity reported rates of 81% in the low-income group, 75% in the mid-level income group, and 54% in the high-income group (). In a seroprevalence study including 283 individuals in Brazil, it was reported that EBV seropositivity increases with decreasing socioeconomic level of the families (). However, the findings of our study indicate that EBV seropositivity does not change significantly according to income level.
A limitation of our research is that our analysis only included adults, and did not include children. Therefore, we were unable to identify differences in seroprevalence among children, among whom EBV exposure is the highest and general manifests with subclinic infection, and we could not determine the risk factors that affect seropositivity in this age group.
In conclusion, this study based on the adult population of Istanbul has shown that EBV seropositivity reaches 90% by the age of 15. Due to the high seropositivity rate, there were no significant differences between groups with regard to risk factors. Because EBV infection early in life increases its oncogenicity, it is vitally important to prevent transmission to the very young. The lack of an effective vaccine against EBV increases the importance of protective measures. Identifying and eliminating the risk factors for virus transmission will lead to a reduction in EBV seroprevalence.
Ethics Committee: This study was approved by a Local Ethics Committee
Informe Consent: A consent form was filled out by all participants
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Jale Altintas (1), Serpil Erol (1), Derya Ozturk Engin (1), Seyfi Ozyurek (1), Seniha Senbayrak (1), Asuman Inan (1), Zeynel Abidin Demir (1)
Haydarpasa Numune Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
Sorumlu yazar: Derya Ozturk Engin, Haydarpasa Numune Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey Mobile phone: +90 50575126 55
Table 1. EBV VCA IgG positivity distribution by age group EBV VCA IgG (+) EBV VCA IgG (-) n = 479 n = 21 P value Age (years) n % n % 15-25 years 59 90.77 6 9.23 0.052 26-35 years 104 98.11 2 1.89 0.327 36-45 years 78 92.86 6 7.14 0.201 46-55 years 62 100 0 0.00 0.169 56-65 years 69 97.18 2 2.82 0.957 66-75 years 63 94.03 4 5.97 0.595 >75 44 97.78 1 2.22 0.804 Table 2. EBV VCA IgG positivity distribution by sex EBV VCA IgG (+) EBV VCA IgG (-) n = 479 n = 21 P Sex n % n % Female 198 95.19 10 4.81 Male 278 96.19 11 3.81 0.748 Table 3. EBV VCA IgG positivity distribution by age and sex EBV VCA IgG (+) EBV VCA IgG (-) n = 479 n = 21 P value n % n % Female 27 90 3 10 15-25 years Male 32 91.40 3 8.60 0.843 Female 33 97.10 1 2.90 26-35 years Male 68 95.80 3 4.20 0.748 Female 25 89.30 3 10.70 36-45 years Male 51 91.10 5 8.90 0.793 Female 23 100 0 0.00 46-55 years Male 37 97.40 1 2.60 0.433 Female 23 95.80 1 4.20 56-65 years Male 44 95.70 2 4.30 0.972 Female 37 97.40 1 2.60 66-75 years Male 25 86.20 4 13.80 0.085 Female 29 93.50 2 6.50 >75 Male 14 100 0 0.00 0.331 Table 4. EBV VCA IgG positivity distribution by occupation EBV VCA IgG (+) EBV VCA IgG (-) n = 479 n = 21 P value Occupation n % n % Unemployed 89 92.71 7 7.29 0.131 Homemaker 126 95.45 6 4.55 0.927 Worker 45 93.75 3 6.25 0.633 Civil servant of 34 100 0 0.00 0.432 officer Retired 82 97.62 2 2.38 0.592 Doctor/Nurse 23 100 0 0.00 0.643 Self-employed/ 80 96.39 3 3.61 0.833 freelance worker Table 5. EBV VCA IgG positivity distribution by education level EBV VCA IgG (+) EBV VCA IgG (-) n = 479 n = 21 P value Education level n % n % Illiterate 63 94.03 4 5.97 0.595 Literate without 25 100 0 0.00 0.597 formal education Elementary school 139 96.53 5 3.47 0.880 Middle school 71 94.67 4 5.33 0.762 High school 97 96.04 4 3.96 0.968 University/Graduate 84 95.45 4 4.55 0.788 school Table 6. EBV VCA IgG positivity distribution by monthly income level EBV VCA IgG (+) EBV VCA IgG (-) n = 479 n = 21 P value n % n % <500 TL 116 96.67 4 3.33 0.859 500-1000 TL 220 94.42 13 5.58 0.164 1000-2000 TL 104 97.20 3 2.80 0.654 >2000 TL 39 97.50 1 2.50 0.925 Table 7. EBV VCA IgG positivity distribution by area of type of residence EBV VCA IgG (+) EBV VCA IgG (-) n = 479 n = 21 P value N % n % Area of Rural 29 96.67 1 3.33 0.841 residence Suburban 20 95.24 1 4.76 0.862 Urban 430 95.77 19 4.23 0.795 Type of Separate 112 94.12 7 5.88 0.366 residence house Apartment 361 96.52 13 3.48 0.436 Other 6 85.71 1 14.29 0.673 Table 8. EBV VCA IgG positivity distribution according to chronic diseases EBV VCA IgG (+) EBV VCA IgG (-) n = 479 n = 21 P value n % n % DM 68 97.14 2 2.86 0.834 CKD 37 94.87 2 5.13 0.717 CHF 37 92.50 3 7.50 0.458 COPD 26 92.86 2 7.14 0.734 Hypo- 10 100.00 0 0.00 0.513 /Hyperthyroidism Liver disease 16 94.12 1 5.88 0.693 Malignancy 13 100 0 0.00 0.973 HT 50 98.04 1 1.96 0.677 Other 6 100 0 0.00 0.614 DM: Diabetes mellitus, CKD: Chronic kidney disease, CHF: Chronic heart failure, COPD: Chronic obstructive pulmonary disease, HT: Hypertension
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|Author:||Altintas, Jale; Erol, Serpil; Engin, Derya Ozturk; Ozyurek, Seyfi; Senbayrak, Seniha; Inan, Asuman;|
|Publication:||Mediterranean Journal of Infection, Microbes and Antimicrobials|
|Date:||Jan 1, 2017|
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