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Hwang YM, Wei Q, Piekos SN, Vemuri B, Molani S, Mease P, Hood L, Hadlock JJ. Maternal-fetal outcomes in patients with immune mediated inflammatory diseases, with consideration of comorbidities: a retrospective cohort study in a large U.S. healthcare system. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.07.23293726. [PMID: 37609126 PMCID: PMC10441487 DOI: 10.1101/2023.08.07.23293726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Background Immune-mediated inflammatory diseases (IMIDs) are likely to complicate maternal health. However, literature data on patients with IMIDs undergoing pregnancy is scarce and often overlooks the impact of comorbidities. Methods We investigated 12 selected IMIDs: psoriasis, inflammatory bowel disease, rheumatoid arthritis, spondyloarthritis, multiple sclerosis, systemic lupus erythematosus, psoriatic arthritis, antiphospholipid syndrome, Sjögren's syndrome, vasculitis, sarcoidosis, systemic sclerosis. We characterized patients with IMIDs prior to pregnancy (IMIDs group) based on pregnancy/maternal characteristics, comorbidities, and pre-pregnancy/prenatal immunomodulatory medications (IMMs) prescription patterns. We 1:1 propensity score matched the IMIDs cohort with people who had no IMID diagnoses prior to pregnancy (non-IMIDs cohort). Outcome measures were preterm birth (PTB), low birth weight (LBW), small for gestational age (SGA), and cesarean section. Findings The prevalence rate of pregnancy occurring with people with a previous IMID diagnosis has doubled in the past ten years. We identified 5,784 patients with IMIDs. 17% of the IMIDs group had at least one prenatal IMM prescription. Depending on the type of IMM, from 48% to 70% of the patients taking IMMs before pregnancy continued them throughout pregnancy. Patients with IMIDs had similar but slightly increased risks of PTB (Relative risk (RR)=1·1[1·0, 1·3]), LBW (RR=1·2 [1·0,1·4]), SGA (RR=1·1 [1·0,1·2]), and cesarean section (RR=1·1 [1·1,1·2]) compared to a matched cohort of people without IMIDs. Out of the 12 selected IMIDs, three for PTB, one for LBW, two for SGA, and six for cesarean section had results supporting increased risk. Interpretation The association between IMIDs and the increased risk of adverse pregnancy outcomes depend on both the nature of the IMID and the presence of comorbidities.
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Affiliation(s)
- Yeon Mi Hwang
- Institute for Systems Biology, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Qi Wei
- Institute for Systems Biology, Seattle, WA, USA
| | | | - Bhargav Vemuri
- Institute for Systems Biology, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | | | | | - Leroy Hood
- Institute for Systems Biology, Seattle, WA, USA
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Sim SY, Choi HY, Jung MH, Lee SY, Rhim JW, Kang HM, Jeong DC. Catch-up growth of infants born to mothers with autoimmune rheumatic disorders. Pediatr Rheumatol Online J 2022; 20:7. [PMID: 35109877 PMCID: PMC8812023 DOI: 10.1186/s12969-022-00667-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 01/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In women with autoimmune rheumatic disorders (ARD), pregnancy complications or postpartum events are more frequent compared to the general population. Transplacental autoantibodies or cytokines influence various fetal and neonatal outcomes. We compared the growth patterns of babies born to mothers with ARD versus healthy mothers to assess the long-term growth outcomes of children born to women with ARD. METHODS This was a retrospective age-matched cohort analyses of babies born to mothers with ARD from the hospitals belonging to the Catholic University of Korea between 2010 and 2017. Demographic and autoimmune laboratory test data of the mothers and newborns were assessed. Neonatal growth was measured in terms of height and weight, measured at birth and follow-up examinations. RESULTS We enrolled 142 infants from mothers with ARD and 149 infants from healthy mothers. There was no significant difference between mothers with ARD and healthy mothers in terms of delivery age, parity, abortion, and premature delivery history. The mothers with ARD were diagnosed with systemic lupus erythematosus (81%), Sjogren syndrome (6%), and other autoimmune phenomena (11%). The groups were significantly different in terms of neonatal characteristics such as prematurity, gestational age, birth weight, and height, but not in Apgar score and delivery type. For most neonates, autoimmune laboratory results were normalized within 1 year, except for anti-La/SSB antibody, which remained high in some. The height and weight for age z-score were lower than the normal age groups at birth but showed catch-up growth by 2 years of age. CONCLUSIONS Low birthweight and prematurity at birth for neonates born to mothers with ARD could be caught up by 2 years of age, and maternal ARD does not affect the growth of their offspring.
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Affiliation(s)
- Soo Yeun Sim
- grid.411947.e0000 0004 0470 4224Department of Pediatrics, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222, Banpodaero, Seocho-gu Seoul, 06591 Republic of Korea
| | - Hye Yeon Choi
- grid.411947.e0000 0004 0470 4224Department of Pediatrics, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222, Banpodaero, Seocho-gu Seoul, 06591 Republic of Korea
| | - Min Ho Jung
- grid.411947.e0000 0004 0470 4224Department of Pediatrics, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222, Banpodaero, Seocho-gu Seoul, 06591 Republic of Korea
| | - Soo Young Lee
- grid.411947.e0000 0004 0470 4224Department of Pediatrics, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222, Banpodaero, Seocho-gu Seoul, 06591 Republic of Korea
| | - Jung Woo Rhim
- grid.411947.e0000 0004 0470 4224Department of Pediatrics, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222, Banpodaero, Seocho-gu Seoul, 06591 Republic of Korea
| | - Hyun Mi Kang
- grid.411947.e0000 0004 0470 4224Department of Pediatrics, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222, Banpodaero, Seocho-gu Seoul, 06591 Republic of Korea
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, 222, Banpodaero, Seocho-gu, Seoul, 06591, Republic of Korea.
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Rahmati A, Farhat AS, Boroumand-Noughabi S, Soleymani F, Keramati M. Retrospective analysis of direct antiglobulin test positivity at tertiary academic hospital over 10 years. Transfus Apher Sci 2022; 61:103358. [DOI: 10.1016/j.transci.2022.103358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/16/2021] [Accepted: 01/17/2022] [Indexed: 10/19/2022]
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Erazo-Martínez V, Nieto-Aristizábal I, Ojeda I, González M, Aragon CC, Zambrano MA, Tobón GJ, Arango J, Echeverri A, Aguirre-Valencia D. Systemic erythematosus lupus and pregnancy outcomes in a Colombian cohort. Lupus 2021; 30:2310-2317. [PMID: 34874750 DOI: 10.1177/09612033211061478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Pregnant women with SLE have higher probabilities of maternal complications. SLE during pregnancy has alternating patterns of remission and flare-ups; however, most pregnant SLE patients tend to worsen with associated poor obstetric and perinatal outcomes. This study aimed to describe obstetric outcomes in pregnant women with SLE. METHODS This retrospective study was performed between 2011 and 2020 at a highly complex referral health center in Cali, Colombia. Pregnant women with a diagnosis of SLE were included. Demographic, clinical, and laboratory features and obstetric and fetal outcomes, including intensive care unit (ICU) characteristics, were evaluated. RESULTS Forty-eight pregnant women with SLE were included. The median age was 29 (25-33.7) years. The SLE diagnosis was made before pregnancy in 38 (79.1%) patients, with a median disease duration of 46 (12-84) months. Thirteen (27.1%) patients had lupus nephritis. Preterm labor (34, 70.8%), preeclampsia (25, 52%), and preterm rupture of membranes (10, 20.8%) were the most common obstetric complications. A relationship between a greater systemic lupus erythematosus pregnancy disease activity index (SLEPDAI) and the development of hypertensive disorders during pregnancy was established (preeclampsia = p < 0.0366; eclampsia = p < 0.0153). A relationship was identified between lupus nephritis (LN) and eclampsia (p < 0.01), preterm labor (p < 0.045), and placental abruption (p < 0.01). Seventeen (35.4%) patients required ICU admission; 52.9% of them were due to AID activity, 17.6% for cardiovascular damage, 11.7% for septic shock, and 5.8% for acute kidney failure. Fetal survival was 89.5% (N = 43/48). Among the live births, two (4.2%) newborns were diagnosed with neonatal lupus, and two (4.2%) were diagnosed with congenital heart block. One maternal death was registered due to preeclampsia and intraventricular hemorrhage. CONCLUSIONS This study is the first to describe SLE during pregnancy in Colombia. SLE was the most prevalent AID in this cohort, and complications included preterm labor, preeclampsia, and postpartum hemorrhage. A higher SLEPDAI and lupus nephritis predicted adverse maternal outcomes.
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Affiliation(s)
| | | | - Isabella Ojeda
- Facultad de Ciencias de la Salud, 28012Universidad Icesi, Cali, Colombia
| | - Michelle González
- Facultad de Ciencias de la Salud, 28012Universidad Icesi, Cali, Colombia
| | - Cristian C Aragon
- CIRAT: Centro de Investigación en Reumatología, 28012Universidad Icesi, Autoinmunidad y Medicina Traslacional, Cali, Colombia
| | - María Andrea Zambrano
- Centro de Investigaciones Clínicas, 67597Fundación Valle del Lili, Cali, Colombia.,CIRAT: Centro de Investigación en Reumatología, 28012Universidad Icesi, Autoinmunidad y Medicina Traslacional, Cali, Colombia
| | - Gabriel J Tobón
- CIRAT: Centro de Investigación en Reumatología, 28012Universidad Icesi, Autoinmunidad y Medicina Traslacional, Cali, Colombia.,Unidad de Reumatología, 67597Fundación Valle del Lili, Cali, Colombia
| | - Johanna Arango
- Unidad de Gineco-obstetricia, 67597Fundación Valle del Lili, Cali, Colombia
| | - Alex Echeverri
- Unidad de Reumatología, 67597Fundación Valle del Lili, Cali, Colombia
| | - David Aguirre-Valencia
- Facultad de Ciencias de la Salud, 28012Universidad Icesi, Cali, Colombia.,Unidad de Reumatología, 67597Fundación Valle del Lili, Cali, Colombia
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Seppälä LK, Madanat‐Harjuoja L, Troisi R, Sampson JN, Leinonen MK, Vettenranta K. Maternal autoimmune disease is not associated with cancer in the offspring. Acta Paediatr 2021; 110:2259-2266. [PMID: 33638889 DOI: 10.1111/apa.15821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 12/22/2022]
Abstract
AIM Autoimmune disease and its medication are associated with increased cancer risk in adults, but it is unknown whether maternal autoimmune disease and/or medication use in pregnancy are associated with increased cancer risk in offspring. METHODS In this case-control study, we identified all patients under 20 years of age with their first cancer diagnosis in 1996-2014 from the Finnish Cancer Registry (n = 2029) and 1:5 population-based controls (n = 10,103) from the Medical Birth Register. We obtained information on maternal autoimmune disease and its medication from the relevant Finnish registries and used conditional logistic regression to analyse the risk of offspring cancer after maternal autoimmune disease exposure. RESULTS The odds ratio (OR) for cancer in offspring following maternal autoimmune exposure was 0.76 (95% confidence interval [CI] 0.47-1.23). Individual ORs for inflammatory bowel and connective tissue diseases were 1.08 (95% CI 0.56-2.01) and 0.50 (95% CI 0.23-1.08), respectively. The OR for maternal autoimmune medication was 0.95 (95% CI 0.80-1.14) overall and similar by drug subtype. There was an increased risk with medication in late pregnancy but the ORs were unstable owing to small numbers. CONCLUSION Our study does not support an increased cancer risk among offspring of women with autoimmune disease or its medication during pregnancy.
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Affiliation(s)
- Laura K. Seppälä
- Pediatrics University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Laura‐Maria Madanat‐Harjuoja
- Pediatrics University of Helsinki and Helsinki University Hospital Helsinki Finland
- Finnish Cancer Registry Helsinki Finland
| | - Rebecca Troisi
- Division of Cancer Epidemiology and Genetics Transdivisional Research ProgramNational Cancer Institute Rockville United States
| | - Joshua N. Sampson
- Biostatistics Branch Division of Cancer Epidemiology and Genetics National Cancer Institute Rockville United States
| | - Maarit K. Leinonen
- Unit of Data and Analytics Information Services Department Finnish Institute of Health and Welfare Helsinki Finland
| | - Kim Vettenranta
- Pediatrics University of Helsinki and Helsinki University Hospital Helsinki Finland
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Multidisciplinary Unit Improves Pregnancy Outcomes in Women with Rheumatic Diseases and Hereditary Thrombophilias: An Observational Study. J Clin Med 2021; 10:jcm10071487. [PMID: 33916674 PMCID: PMC8038315 DOI: 10.3390/jcm10071487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/19/2021] [Accepted: 03/31/2021] [Indexed: 01/03/2023] Open
Abstract
Rheumatic diseases (RD) and hereditary thrombophilias (HT) can be associated with high-risk pregnancies. This study describes obstetric outcomes after receiving medical care at a multidisciplinary consultation (MC) and compares adverse neonatal outcomes (ANOs) before and after medical care at an MC. This study is a retrospective observational study among pregnant women with RD and HT treated at an MC of a university hospital (southern Spain) from 2012 to 2018. Absolute risk reduction (ARR) and number needed to treat (NNT) were calculated. A total of 198 pregnancies were registered in 143 women (112 with RD, 31 with HT), with 191 (96.5%) pregnancies without ANOs and seven (3.5%) pregnancies with some ANOs (five miscarriages and two foetal deaths). Results previous to the MC showed 60.8% of women had more than one miscarriage, with 4.2% experiencing foetal death. MC reduced the ANO rate by AAR = 60.1% (95%CI: 51.6-68.7%). The NNT to avoid one miscarriage was 1.74 (95%CI: 1.5-2.1) and to avoid one foetal death NNT = 35.75 (95CI%: 15.2-90.9). A total of 84.8% of newborns and 93.2% of women did not experience any complication. As a conclusion, the follow-up of RD or HT pregnant women in the MC drastically reduced the risk of ANOs in this population with a previous high risk.
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Luciano R, Bersani I, Mancini G, Vento G, Mercuri E. Cranial ultrasound evaluation in term neonates. Early Hum Dev 2020; 143:104983. [PMID: 32113074 DOI: 10.1016/j.earlhumdev.2020.104983] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 02/08/2020] [Accepted: 02/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Term neonates (TN) are not routinely submitted to cranial ultrasound scan (CUS), since they are not considered at high risk for developing cerebral lesions. AIMS To investigate the prevalence of cerebral abnormal findings in term neonates (TN), to identify the associated clinical features and to better target neonatal CUS investigations. STUDY DESIGN Prospective observational study. SUBJECTS A total number of 1805 healthy TN underwent CUS. 1181 neonates had clinical features supposed to increase the risk for cerebral abnormal findings (study cohort), 624 were controls. OUTCOME MEASURES Prevalence of minimal, minor, and major cerebral abnormal findings was analyzed in six different categories of low-risk TN and compared to controls. RESULTS Variations from normality at the neonatal CUS were observed in 402 TN (22.27%). In half of the cases the ultrasound findings were minimal abnormal findings, while minor abnormal findings were found in 179 TN (9.92%). About 1% of the studied neonates showed major cerebral abnormal findings potentially compromising neurodevelopmental outcome. The prevalence of the observed abnormal findings varied significantly in the different low-risk categories. CONCLUSIONS The clinical features significantly increasing the risk for cerebral anomalies in healthy TN were microcrania, macrocrania, mild neurologic signs, and the detection of mild variations from normal cerebral aspect at the antenatal ultrasound evaluation.
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Affiliation(s)
- R Luciano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Division of Neonatology; Catholic University of Sacred Heart, Rome, Italy.
| | - I Bersani
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Division of Neonatology.
| | - G Mancini
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Division of Neonatology.
| | - G Vento
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Division of Neonatology; Catholic University of Sacred Heart, Rome, Italy.
| | - E Mercuri
- Catholic University of Sacred Heart, Rome, Italy; Fondazione Policlinico Universitario A. Gemelli IRCCS Rome, Italy, Department of Pediatric Neurology, Catholic University, Rome, Italy.
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Ulrich P, Blaich G, Baumann A, Fagg R, Hey A, Kiessling A, Kronenberg S, Lindecrona RH, Mohl S, Richter WF, Tibbitts J, Crameri F, Weir L. Biotherapeutics in non-clinical development: Strengthening the interface between safety, pharmacokinetics-pharmacodynamics and manufacturing. Regul Toxicol Pharmacol 2018; 94:91-100. [PMID: 29355662 DOI: 10.1016/j.yrtph.2018.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/14/2018] [Indexed: 12/29/2022]
Abstract
Biological drugs comprise a wide field of different modalities with respect to structure, pharmacokinetics and pharmacological function. Considerable non-clinical experience in the development of proteins (e.g. insulin) and antibodies has been accumulated over the past thirty years. In order to improve the efficacy and the safety of these biotherapeutics, Fc modifications (e.g. Fc silent antibody versions), combinations (antibody-drug conjugates, protein-nanoparticle combinations), and new constructs (darpins, fynomers) have been introduced. In the last decade, advanced therapy medicinal products (ATMPs) in research and development have become a considerable and strongly growing part of the biotherapeutic portfolio. ATMPs consisting of gene and cell therapy modalities or even combinations of them, further expand the level of complexity, which already exists in non-clinical development strategies for biological drugs and has thereby led to a further diversification of expertise in safety and PKPD assessment of biological drugs. It is the fundamental rationale of the BioSafe meetings, held yearly in the EU and in the US, to convene experts on a regular basis and foster knowledge exchange and mutual understanding in this fast growing area. In order to reflect at least partially the variety of the biotherapeutics field, the 2016 EU BioSafe meeting addressed the following topics in six sessions: (i) In vitro Meets in vivo to Leverage Biologics Development (ii) New developments and regulatory considerations in the cell and gene therapy field (iii) CMC Challenges with Biologics development (iv) Minipigs in non-clinical safety assessment (v) Opportunities of PKPD Assessment in Less Common Administration Routes In the breakout sessions the following questions were discussed: (i) Cynomolgus monkey as a reprotoxicology Species: Impact of Immunomodulators on Early Pregnancy Maintenance (ii) Safety Risk of Inflammation and Autoimmunity Induced by Immunomodulators (iii) Experience with non-GMP Material in Pivotal Non-clinical Safety Studies to Support First in Man (FiM) Trials (iv) Safety Assessment of Combination Products for Non-oncology.
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Affiliation(s)
| | | | | | | | - Adam Hey
- Novartis Pharma, Basel, Switzerland
| | | | - Sven Kronenberg
- Roche Pharmaceutical Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center, Basel, Switzerland
| | | | - Silke Mohl
- Roche Pharmaceutical Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center, Basel, Switzerland
| | - Wolfgang F Richter
- Roche Pharmaceutical Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center, Basel, Switzerland
| | | | - Flavio Crameri
- Roche Pharmaceutical Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center, Basel, Switzerland
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Zarei AE, Redwan EM. Antibodies prevalence against Haemophilus influenzae type b in Jeddah population, Saudi Arabia. I. Total antibodies. Hum Antibodies 2018; 26:225-235. [PMID: 29945350 DOI: 10.3233/hab-180342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In this national comprehensive seroprevalence study, indirect ELISA test was used to evaluate Haemophilus influenzae type b (Hib) anti-polyribosyl-ribitol phosphate (PRP) total antibodies (IgM, IgG, IgA) in 1,003 sera samples from routine medical check-up of healthy individuals attending the local medical facility in Jeddah, Saudi Arabia in the period from February 2014 to January 2016. Serum anti-CPS antibodies confer immunity against invasive Hib disease. An anti-CPS concentration of ⩾ 0.15 μg/mL is believed to be a serological indication for short-term immunity protection against invasive Hib disease, while a concentration of ⩾ 1.0 μg/mL is believed to be long-term protective. Results showed higher level of anti-Hib IgG (2.41 μg/ml average geometric mean concentration (GMC) regardless of age and gender, followed by levels of IgM (0.91 μg/ml) and IgA (0.34 μg/ml), reflecting the community immunity against Hib. Low anti-Hib level (< 0.15 μg/ml of anti-PRP IgG) in elderly people (males aged 57-91 years and females aged 35-64 years) may indicate a need for a booster dose of Hib vaccine to elderly people in the community. The IgG prevalence over IgM, and IgM prevalence over IgA indicate the major role of IgG over IgM and IgA in keeping immunity in the track against Hib. Low level of IgM and IgA comparing to IgG may indicate the absence of Hib acute infections in the population.
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Affiliation(s)
- Adi Essam Zarei
- Biological Sciences Department, Faculty of Science, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Main Medical Laboratory, Medical Services, Saudi Airlines, Jeddah 21231, Saudi Arabia
| | - Elrashdy M Redwan
- Biological Sciences Department, Faculty of Science, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Main Medical Laboratory, Medical Services, Saudi Airlines, Jeddah 21231, Saudi Arabia
- Therapeutic and Protective Proteins Laboratory, Protein Research Department, Genetic Engineering and Biotechnology Research Institute, City for Scientific Research and Technology Applications, Alexandria 21934, Egypt
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