IMMUNOPARASITOLOGICAL STUDY IN BILHARZIAL PATIENTS WITH OR WITHOUT HEPATITIS C VIRUS IN EL-BEHEIRA GOVERNORATE

Hepatitis C virus infection and schistosomiasis are common in Egypt. Coinfection is not uncommon. Little and quite controversial data are known about biochemical profile in these patients. This study was designed to study IL-2 production as a marker of lymphocyte activity in patients suffering from schistosomiasis with or without hepatitis C virus infection. This work enrolled 513 patients (239 females and 274 males) of Damanhour Teaching Hospital. Study sample included 120 subjects to form 4 groups: gp I (30 normal subjects as control), gp II (30 patients +ve for S. mansoni only), gp III (30 patients seopositive for HCV only), and gp IV (30 patients with mixed S. mansoni and HCV infection). The intensity of schistosomiasis was estimated by Kato-Katz technique. ELISA was used to detect anti HCV, HBs Ag and to estimate interleukin 2 (IL 2) in serum of selected groups. Indirect haemagglutination test was used to detect schistosomiasis among pure HCV. Complete blood picture and liver function tests were also done. Out of 513 samples examined, 89 (17.3%) were +ve for Schistosoma mansoni and 7 (1.4%) +ve for Schistosoma heamatobium. The overall prevalence rate among males was almost double that among females (21.9% versus 12.1%). The risk of HCV infection increased 7 times with the presence of S. mansoni infection. Focusing on the risk factors for S. mansoni infection it was found that gender, water contact, low education, and low socioeconomic status were the most important factors affecting prevalence of S. mansoni infection which in turn increased the risk of HCV infection. In the selected studied groups the results of heamatological and biochemical parameters showed significant decrease in group IV (schistosomiasis + HCV) than that of normal controls, schistosomal, and HCV patients groups. On the other hand, there were an increase in serum bilirubin and aminotransferase enzymes in the group of mixed infections. It has been shown that, in patients with mixed infections, IL2 level was lower than that of the other 3 groups. In conclusion S. mansoni was the predominating species in the present study. History of water contact, low education, and low socioeconomic status were the most important determinant factors of schistosomiasis. The risk of HCV infection increased with the presence of schistosomiasis. INTRODUCTION Schistosomiasis is still endemic in 74 tropical and subtropical countries. It ranks second behind malaria in terms of socio-economic and public health importance. Despite control efforts in a number of countries, still an 691 Bull High Inst Public Health Vol.37 No.3 [2007] estimated 200 million people are infected and about 600 million are at risk.(1) WHO reported that 120 million are symptomatic and 20 million have severe consequences of the infection.(2) In Egypt, the total number of infected individuals with schistosomiasis are in the range of 5-6 million which means that Egypt is one of the most highly endemic areas in the world(3). The prevalence of S. mansoni ranged between 17.5% to 42.9% among both sexes aged 5-50 years in ElBehira Governorate.(4,5) Hepatitis C virus infection is a global health problem. WHO estimates that 3% of the world’s population has been infected with HCV and that more than 170 million persons are chronic carriers.(6) Recently, HCV infection was concluded to be the main cause of chronic liver diseases in Egypt, where this infection is largely associated with schistosomiasis which has been claimed to be an important risk factor for HCV infection(7). However, The immunologic aspects of this pattern of coninfection have never been reported because of the absence of small animal model that can support both infections(8). A cytokine (IL2), is one of the peptide mediators which up and down regulate immunologic, inflammatory, and reparative host responses to injury.(9) Thelper lymphocytes are separated into Thelper 1 (Th1) and T-helper 2 (Th2) cells depending on their cytokine secretion pattern. Th1 cytokines; (interferon γ (IFN-γ), IL2, and tumour necrosis factor) promote cellular immune responses. Th2 cytokines (IL-4, IL-5, IL-6, and IL-10) regulate the humoral immune responses. Cytokines produced by each subset inhibit the production and activities of the opposing subset.

Bull High Inst Public Health Vol.37 No.3 [2007]   estimated 200 million people are infected and about 600 million are at risk. (1)WHO reported that 120 million are symptomatic and 20 million have severe consequences of the infection. (2) Egypt, the total number of infected individuals with schistosomiasis are in the range of 5-6 million which means that Egypt is one of the most highly endemic areas in the world (3) .The prevalence of S.
mansoni ranged between 17.5% to 42.9% among both sexes aged 5-50 years in El-Behira Governorate. (4,5)patitis C virus infection is a global health problem.WHO estimates that 3% of the world's population has been infected with HCV and that more than 170 million persons are chronic carriers. (6)Recently, HCV infection was concluded to be the main cause of chronic liver diseases in Egypt, where this infection is largely associated with schistosomiasis which has been claimed to be an important risk factor for HCV infection (7) .However, The immunologic aspects of this pattern of coninfection have never been reported because of the absence of small animal model that can support both infections (8) .A cytokine (IL2), is one of the peptide mediators Cytokines produced by each subset inhibit the production and activities of the opposing subset.
The type of T-helper cell that predominates in a parasitic infection influences the course of the disease. (10)though concomitant schistosomiasis and HCV infection is common in Egypt and other developing countries, yet little information is available on the immunological factors that may be affected due to pathogenesis of these diseases (11,12) .However, this pattern of

MATERIAL AND METHODS
The Samples were processed using: -Formol ether sedimentation technique to detect intestinal helminthes. (9)ato Katz technique was also applied to estimate Intensity of infection of S.
-Anti HCV using 3 rd generation ELISA technique. (17)sed upon stool analysis, a total of 513 screening patients, enrolled in this study were divided into 3 categories: -The first includes 89 S. mansoni cases.Two groups (II and IV) were selected from this category.

Liver function tests including biochemical investigations ALT,
AST, serum total bilirubin, plasma prothrombin activity, total protein, and albumin (19) .

Statistical Analysis
Data collected were coded, tabulated, and analyzed using SPSS software package version 10 to compare the risk of schistosomiasis and hepatitis virus infection among groups, Chi-square was used to study the association between two qualitative variables.A one-way analysis of variance (ANOVA) was used for comparison between more than 2 groups of means.Odds ratio together with its 95% confidence interval were used.

RESULTS
Table The impact of schistosomiasis on the risk of HCV infection is presented in major public health problem especially as a risk factor for HCV and chronic liver diseases. (21)In Egypt, many investigators have documented a high prevalence of schistosoma infection in rural areas population. (22,23)HCV represents a health problem affecting an estimated 170 million people world wide and 10%-31% of the population in some countries, such as Egypt. (24,25)e present study was designed to study the immune status of the patients suffering from schistosomiasis with and without HCV in El-Beheira Governorate which is considered as one of the highly endemic areas for schistomiasis.
It was observed that bad sanitary conditions stand beyond the existing high rate of helminthic infection among rural population.Thus, communities with basic amenities of safe water supply, proper sewage and refuse disposal have lower prevalence (26,27) than those with one or none of these amenities.
In agreement with the present data, the risk of schistosomiasis for males was found to be greater than that for females in the Republic of Yemen.Gray et al., 1999 (30) suggested that sex difference could be attributed to the role of male in farming.
The current study revealed that individuals exposed to canal water were 4 times at risk of infection compared to non-exposed individuals.This is consistent with what revealed by previous studies (31,32) .
In accordance with our results, it has been reported that prior treatment of schistosomiasis was a risk for infection (26,27) , meanwhile, the associated risk was statistically significant.
Inspite of the fact that blood in stools is not a direct indicator for intestinal schistosomiasis, (25) the present study revealed that it was frequent symptom among S. mansoni infected cases.
On the contrary, there was no association between history of abdominal pain and S. mansoni infection which is consistent with what has been stated by Nooman et al., (2000) (4) .
A significantly higher prevalence of S. mansoni infection was found among those with the lower educational level.
This was against previous studies (28) .
Bull High Inst Public Health Vol.37 No.3 [2007]   They found that both illiterates and literates had high levels of infection (33,34) .
This finding was also confirmed by Abdel-Aty et al., (2000) (35) who reported that there was no relation between education and schistosomiasis.
The obtained results indicated that, S.
mansoni infection rate increased with low income and high crowding index.The significant effect of the income on parasitic infection was reported by Shehata (1995) (34) .
Epidemiological studies in Egypt demonstrated that the highest risk of hepatitis C virus (HCV) infection occurred among patients infected with schistosomiasis (36)(37)(38) .HCV-antibody prevalence was reported to be 70% in adults suffering from schistosmiasis without a history of blood transfusion (39) .Some authors showed that patients with concomitant HCV and schistosomiasis infection had a higher incidence of cirrhosis and hepatocellular carcinoma (HCC) (40,41) .
The obtained results showed that, out of 513 examined, 81 were anti-HCV seropositive with overall prevalence (15.8%), using third generation ELISA test.This prevalence nearly coincides with that reported among Egyptian population where the prevalence of HCV infection was 10%-31% (25,42) .
Haemomarkers pattern of the mixed infection (S. mansoni associated with HCV) Th1 responses might play a role in progression of HCV disease (43) .
Several biochemical parameters were used to assess liver dysfunction.Serum total proteins were significantly lower in the mixed infection (S. mansoni with HCV) when compared to healthy control group while in contrast serum bilirubin which showed higher mean values in mixed group than individuals of other three groups.This reflects the impairment of the hepatic synthetic capability. (44)he serum due to the increasing pressure from the growing mass when integrity of the hepatocytes are compromised.Some reports showed +ve relationship between high levels and advanced liver damage, while other reports failed to prove this relationship (45,46) .
As regard immunological change associated with S. mansoni with or without HCV infection, the present data showed that, in patients with mixed infections, IL-2 level was lower than that of the other 3 group.
This could be explained by the fact that schistosomiasis down regulates Th1.
T-lymphocytes, in turn, reduces serum IL-2 production which is very important for the stimulation of mononuclear cells and fibroblasts to produce IFN-γ which is thought to be involved in the control of the virus. (47)ull High Inst Public Health Vol.37 No.3 [2007]   This is in line with findings of previous reports demonstrating that alterations of cytokine patterns in the form of insufficient intrahepatic Th1 responses or augmented Th2 responses enhance progression of fibrosis (43) .Collectively, Th2 immunologic Finally, recent studies illustrated that derangement of certain cytokine genes might make some patients more susceptible to the development of HCC (48) .
viral/parasitic coinfection offers a unique opportunity to study the evolution and kinetics of human immune responses toward HCV in a setting of prevailing Th2 immune response.(8)The aim of the present work was to cross sectional study was carried out among out-and in-patients attending Internal Medicine Department of Damnhour Teaching Hospital in El-Behira Governorate.Study population included 513 patients; 239 females and 274 males.Their age ranged from 3-63 years.Data Collection All the study population enrolled in the present study were subjected to the following:a-A specially designed questionnaire was filled for every patient.Personal, demographic, and socioeconomic data were collected, including profession, e.g., farming, fishing,…, etc., the use of canal water in Bull High Inst Public Health Vol.37 No.3 [2007] washing, bathing.b-Laboratory investigation 1. Stool samples were collected in clean tight proof plastic containers.
prevalence in our study could be explained on the grounds that our studied groups have lower levels of agricultural, recreational, and domestic exposure to canal water.The present study revealed that children below the age of 5 years had the lowest prevalence.The peak prevalence and intensity of infection were observed among those aged 10-<15 years.Young children might get infection while accompanying their mothers Eassa et al., 698 to canals for washing utensils or clothes.The prevalence and intensity of infection increases as the children grow and become able to frequent water bodies and by spending a longer time swimming, bathing, and washing.This finding matched with what previously reported in communitybased studies in the Nile Delta and Upper Egypt; children particularly, around 10-<15 years, have been associated with the highest prevalence and intensity of S.
other 3 groups.This has been confirmed and explained by an inverse relationship between cytotoxic Tlymphocytes (CTL) responses and viral load hypothesis.That HCV-specific CTL limits viral replication but in co-infected patients selective deterioration of HCV specific aminotransferases which are indicators of hepatocellular necrosis showed minimal elevation in HCV infection.Kamal et al., (2001) (8) stated that ALT levels could not predict the outcome of HCV infection.The elevation of serum activity levels of amino transferases, ALT and AST are mostly owing to the release of the enzymes from the surrounding liver cells; bias characteristic of S. mansoni infection could modulate the outcome and course of HCV infection as CD4 + Th1 responses are associated with either viral clearance of or slower disease progression.On the other hand, none of coinfected patients achieved viral clearance (8) .In conclusion, the data presented in the current study have demonstrated the importance of cellular immune responses in preventing the progression of liver disease and may have implications for development of immunotherapy.

Table ( 5): Heamatological finding among the studied four groups
the comparison between patients studied groups against healthy control group P= probability value for the comparison between the studied groups against healthy control group