Infectious Diseases: Prevention and Control

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Immune Response 2019: Hepatitis E Virus Seroprevalence and Putative Risk Factors by a Cross -Sectional Study Among The General Population in West Bank, Palestine - Dr. Ouadi Ibtissem - Badji Mokhtar University


Our aim in this study was to evaluate the specificity of Anti-Aquaporin-4 antibodies detected by indirect immunofluorescence (IIF)



Hepatitis E virus (HEV) infection is a major public health concern in developing countries. HEV transmission occurs primarily by the oral-fecal route. This could progress to an acute self-limiting disease. Severe cases are more common among pregnant and immune-compromised patients, leading to a high mortality rate in these populations.

Objectives: This study aimed to evaluate whether the rate of seroprevalence of IgG anti-HEV and IgM anti-HEV are associated with sociodemographic variables, clinical history, personal hygiene, and other related risk factors among the general population in West Bank, Palestine.

Neuromyelitis optica (NMO) is a severe inflammatory demyelinating disease

that predominantly affects the optic nerve and spinal cord. NMO has been considered for a

long time as a subtype of multiple sclerosis (MS). The presence of a highly specific serum

autoantibody marker (NMO-IgG) further differentiates NMO from MS and has helped to

define a neuromyelitis optica spectrum of disorders. NMO-IgG reacts with the water channel

aquaporin 4 (AQP4)

Since the discovery of a specific serum marker for NMO in2004, and its subsequent

identification as an antibody to AQP-4 , various methods have been developed to test for

The antibodies in patients’ serum.

When it Comes to Other Infectious and Non-infectious diseases : Historically, Infectious diseases were the main cause of death in the world and, indeed, in some developing regions this may still be the case. With the development of antibiotics and vaccination programs, infectious disease is no longer the leading cause of death in the western world. Non-infectious disease is now responsible for the leading causes of death in both developed and some developing countries.


Hepatitis and Its types


An inflammatory condition of the liver is Hepatitis. It’s commonly caused by a viral infection,there are other possible causes of hepatitis. These include auto immune hepatitis and hepatitis that occurs as a secondary result of medications, drugs, toxins, and alcohol. When your body makes antibodies against your liver tissue Autoimmune hepatitis occurs. Viral infections of the liver that are classified include hepatitis A, B, C, D, and E. Taking a sample of tissue from your liver is an invasive procedure called liver biopsy which allows your doctor to determine how infection or inflammation has affected your liver. In the early treatment of autoimmune hepatitis  corticosteroids, like prednisone or budesonide, are extremely important.


Prevalence of Cryoglobulinemia in Chronic Hepatitis C Virus Infection

Hepatitis C virus–related chronic hepatitis may be associated with various immunological disorders.We have assessed the prevalence of cryoglobulinemia in patients with chronic HCV infection. Forty four patients with chronic liver disease associated with HCV infection were included. Cryoglobulins were sought in the serum. All patients were examined carefully for clinical manifestations of cryoglobulinemia (e.g., palpable purpura, Raynaud's syndrome, arthritis, peripheral neuropathy, glomerulonephritis). Our patients were older (mean age, 56±14), consisted of 22 women and 22 men. Cryoglobulins were detected in 22,7% of patients with a mean concentration of 0,38 g/l (range 0.15-1.2 g/l), most of these patients were asymptomatic.The cryoglobulinemia were of type III in 91% and of type II in 9% .


This seroepidemiological cross- sectional study conducted from October 2016 to March 2017 include 432 participants from all governorates of West Bank, Palestine. Participants answered the questionnaire regarding the sociodemographic, clinical and personal hygiene characteristic. Blood samples were tested for IgG and IgM to HEV by an enzyme linked immunosorbent assay (ELISA). All serum samples positive for total anti-HEV were also assayed for IgM anti-HEV by ELISA.


We tested 118 sera of patients with NMO, high-risk

syndrome of NMO (hr NMO), MS, clinically isolated syndrome suggestive of MS and

miscellaneous diseases, for AQP4 antibody, with indirect immunofluorescence (IIF)

using human AQP4-transfected cell.



The overall seroprevalevce of anti-HEV was 3.7% (16/432). There was a significant association between anti-HEV seropositivity and levels of education.  Anti-HEV reactivity among subjects with less than Tawjihi level (93.75% 15 out of 16) was higher than other group with high education level. Other associated factor with anti- HEV seropositivity, place of distract (P< 0.0107), the incidence rates of HEV seropositivity subjects were the highest in Ariha and Salfit (2/ 8= 0.25), but most cases of HEV seropositive subjects came from Al-Khalil populations 31.3% (5/16). Although participants aged >= 40 years had the highest prevalence, but there was no significant difference between the age groups. However, no significant relationship was observed between positive anti-HEV and other sociodemographic variables, travel, clinical history (such as surgical procedures, dental procedures, and contact with hepatitis patients), and personal hygiene (such as type of sewage systems and history of animals contact).

Among the 118 patients, 06(5%) were AQP4 antibody–positive. We found

that the presence of serum anti-AQP4 reactivity is almost exclusively restricted to

patients with NMO and hrNMO. Seroprevalence and sensitivity was 23%, and the

specificity was 100%. Seropositive patients were found to be predominantly female ,

to more often have signs of co-existing autoimmunity, and to experience more

severe clinical attacks.


Although this study revealed low seroprevalence of HEV infection in the study population, the results showed that the HEV virus is circulating among the West Bank population of Palestine. This study points out the need for further studies to define the clinical and epidemiological importance of HEV infection and to identify additional risk factors involved in the epidemiology and pathogenesis of HEV infection.

In conclusion, hepatitis C virus‐related chronic hepatitis may be associated with immunological abnormalities, one of theme, immune complex–mediated disease, mainly represented by mixed cryoglobulinemia that, in rare cases, may be associated with symptoms of vasculitis.

  • NMO-IgG against aquaporin-4 (AQP4) is a specific marker for NMO.
  • The newly developed assay represents a highly specific and easily reproducible

detection method.

  • Detection of anti-AQP4 antibodies may represent a valuable tool to assist neurologists in the differential diagnosis between patients with NMO, hrNMO, or MS and other inflammatory diseases.

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