EBV & Socioeconomic Status

From: Viral Infections of Humans. Third Edition, Plenum Publishing Corp. 1991. Alfred S Evans, editor. Chapter 10, Epstein-Barr virus. AS Evans, JC Niederman.

"Infection with EBV is worldwide. Antibody to EBV has been demonstrated in every population thus far tested, including very isolated tribes in Brazil, Alaska, and other remote areas where measles and influenza antibody are often lacking. Infection occurs earlier in life in developing countries. A recent study of 94 children in the Republic of China revealed that 78.6% had EBV-VCA IgG antibody by the end of the first year of life and 80.7% were positive by the age of three.

"Clinical infectious mononucleosis occurs most commonly in those hygienic and socioeconomic areas where exposure to and infection with EBV are delayed until older childhood and young adult life. These include Australia, Canada, England, many European countries, New Zealand, Scandinavian countries, and the United States. In contrast, at the University of the Philippines, not a single case was recorded among 5000 admissions to the college infirmary, where laboratory facilities existed; EBV antibody determinations in this college population revealed a very high level of prior immunity. The disease is now being recognized with more careful clinical and diagnostic scrutiny in developing countries. The prevalence of EBV antibody had been found to vary in young adults entering the U.S. Military Academy from different areas of the United States. The highest rate of 81.5% was found in cadets resident for 6 years or more in the East South Central States, and the lowest prevalence rate of 51.9% in the West North Central States. Since admission to the academy is based on competitive academic, athletic, and achievement values rather than on any social or economic considerations, a broad range of backgrounds would be expected.

"Epstein-Barr virus infection occurs in all ethnic groups, and no evidence of differential susceptibility has been found. Infectious mononucleosis in developed countries has been rare in blacks, but this probably reflects sociohygienic factors and earlier acquisition of infection rather than any difference in susceptibility. The incidence of the disease in whites in Atlanta, Georgia was 30 times higher than in blacks. Antibody prevalence to EBV among entering black cadets at the U.S. Military Academy was 85% as compared with 65% among whites. In an analysis of prevalence rates among different ethnic groups in Hawaii, higher rates were observed in Hawaiians and Filipinos than in Caucasians of the same age. However, socioeconomic levels, hygienic habits, and varying cultural practices in the home cannot be separated from the ethnic backgrounds.

"Socioeconomic settings influence the incidence of both EBV infection and infectious mononucleosis, but in opposite directions. Low socioeconomic groups have high rates of EBV infection early in life but little clinical infectious mononucleosis; high socioeconomic groups have low levels of EBV infection early in life but a high rate of clinical disease that occurs in the 15- to 25-year-old group. Two examples illustrate this effect on infection rates. At the U.S. Military Academy at West Point, the EBV-antibody prevalence rate was 77.1% in cadets coming from families earning under $6000 and only 58.6% among those from families with incomes over $30,000. In New Haven, the antibody prevalence among first graders in three schools serving a low socioeconomic group was 84.8%, and in three schools serving a high socioeconomic group, it was 37.8% (T Shope, AS Evans, and DM Horstmann, unpublished data, 1973). A second serum sample collected from these same children 4-5 years later revealed an EBV seroconversion rate of 50% among susceptible childen from lower socioeconomic areas and only 2.4% in susceptible children in the higher socioeconomic group."

Other Studies

South Asian ethnicity and material deprivation increase the risk of Epstein-Barr virus infection in childhood Hodgkin's disease. KJ Flavell, JP Biddulph, JE Powell, SE Parkes, D Redfern, M Weinreb, P Nelson, JR Mann, LS Young, PG Murray. Br J Cancer 2001 Aug;85(3):350-356. "62% of cases were Epstein-Barr virus-positive. Ethnic group was the strongest predictor of Epstein-Barr virus-positivity, with South Asians having a more than 20-fold risk of being Epstein-Barr virus-positive compared with non-South Asians.... The relative risk of Epstein-Barr virus-positivity showed a gradient with increasing Townsend score; the risk being 7-times higher in the most deprived quartile compared with the least deprived group.... In addition, cases having 2 or more siblings were 5-times as likely to be Epstein-Barr virus-positive as those from smaller families."

Flavell - Br J Cancer 2001 abstract / PubMed

Herpesvirus reactivation and socioeconomic position: a community-based study. RP Stowe, MK Peek, NA Perez, DL Yetman, MP Cutchin, JS Goodwin. J Epidemiol Community Health 2010 Aug;64(8):666-671. 1457 adults aged 25-90. "Individuals were significantly more likely to have higher antiviral antibodies (ie, reactivation) to both EBV and HSV-1 than one virus alone. Individuals in the lowest age group had less reactivation, whereas greater reactivation was observed in women and those with the least education. Compared to white non-Hispanics, Hispanics and black non-Hispanics experienced more viral reactivation. These relationships remained strong after controlling for sociodemographic factors as well as smoking status, body mass index and physical activity."

Stowe - J Epidemiol Community Health 2010 abstract / PubMed

Seroepidemiology of Epstein-Barr virus and cytomegalovirus among Israeli male young adults. H Levine, RD Balicer, V Rozhavski, T Halperin, M Shreberk, N Davidovitch, M Huerta-Hartal, OE Ankol. Ann Epidemiol 2012 Nov;22(11):783-788. "Overall seroprevalence rates were 87% for EBV and 59% for CMV. An association between the seroprevalence of EBV and CMV was observed. Seroconversion was 56% for EBV as compared with 31% for CMV. Lower paternal education was found to be associated with both EBV and CMV seroprevalence. Lower socioeconomic status, North African origin, and urban residence were found to be associated with CMV seropositivity, as was smoking for EBV seropositivity."

Levine - Ann Epidemiol 2012 abstract / PubMed

Seroprevalence of Epstein-Barr Virus Infection in U.S. Children ages 6-19, 2003-2010. JB Dowd, T Palermo, J Brite, TW McDade, A Aiello. PLoS One 2013 May 22;8(5):e64921. 8417 children aged 6-19 from U.S. National Health and Nutrition Examination Survey (NHANES). "Seroprevalence increased with age, ranging from 54.1% (95% CI 50.2%–57.9%) for 6–8 year olds to 82.9% (95% CI 80.0%–85.9%) for 18–19 year olds." Mexican American children had the highest seroprevalence (85.4%), followed by non-Hispanic blacks (83.1%), and whites (56.9%). "Large differences were also seen by family income, with children in the lowest income quartile having 81.0% (95% CI 77.6%-84.5%) seroprevalence compared to 53.9% (95% CI 50.5%-57.3%) in the highest income quartile, with similar results for parental education level. These results were not explained by household size, BMI, or parental smoking. Among those who were seropositive, EBV antibody titers were significantly higher for females, Non-Hispanic Blacks and Mexican-Americans, with no association found for socioeconomic factors."


Figure 2. Mean EBV Seroprevalence by age and income quartile, National Health and Nutrition Examination Survey, 2003–2010.

Dowd - PLoS One 2013 full article / PubMed Central
Dowd / PLoS One 2013 full article

Coprevalence of Epstein-Barr Virus, Cytomegalovirus, and Herpes Simplex Virus Type-1 Antibodies Among United States Children and Factors Associated With Their Acquisition. AS Delaney, W Thomas, HH Balfour Jr. J Pediatric Infect Dis Soc 2015 Dec;4(4):323-329. From NHANES 2003-2004. "Overall, 36% of children had antibody against 2 or more of the viruses. Coprevalence with EBV, CMV, and HSV-1 was higher in females, in non-Hispanic blacks, and Mexican Americans, compared with non-Hispanic whites, and in those without health insurance. Antibody prevalence was associated with (1) lower household income and education and (2) greater crowding. Nearly all children with CMV antibody or HSV-1 antibody had been infected with EBV."

Delaney - J Pediatric Infect Dis Soc 2015 abstract / PubMed

Predictors of Epstein-Barr virus serostatus in young people in England. JR Winter, GS Taylor, OG Thomas, C Jackson, JEA Lewis, HR Stagg. BMC Infect Dis 2019 Nov 28;19(1):1007. Current smoking 4.29 (2.13-8.65), p < 0.001. "A series of studies have demonstrated that EBV is generally acquired pre-adulthood, and that this varies between settings. Our findings regarding smoking fit with the prevailing narrative that there is an association between EBV and socioeconomic status, rather than smoking being an independent risk factor. Unfortunately, we did not have a good measure of socioeconomic status in our analysis; the NS-SEC does not account for familial socioeconomic status during childhood, which is probably more relevant to EBV seroprevalence than individual occupational status in young adults, and we were unable to measure socioeconomic status in children at all."

Winter - BMC Infect Dis 2019 full article / PubMed Central
Winter / BMC Infect Dis 2019 full article

See also:

Epstein-Barr Virus Causes Nasopharyngeal Cancer
Epstein-Barr Virus Causes Lymphomas
Epstein-Barr Virus Causes Gastric Carcinoma
Epstein-Barr Virus Causes Lymphoepithelioma-Like Lung Cancer
EBV Causes Interstitial Lung Disease
EBV and Other Diseases
EBV Causes Mental Impairment in Children
Confounding By Infection
EBV Causes Lupus
EBV Causes Multiple Sclerosis
Epstein-Barr Virus Causes Sjogren’s Syndrome


cast 12-17-19