|Year : 2020 | Volume
| Issue : 5 | Page : 2253-2257
Seroprevalence of Toxoplasma, Rubella, CMV and HSV infection at a teaching hospital: A 7 year study from North India
Anju Dinkar1, Jitendra Singh2
1 Department of Microbiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Medicine, Narayana Medical College, Sasaram, Bihar, India
|Date of Submission||29-Jan-2020|
|Date of Decision||13-Mar-2020|
|Date of Acceptance||26-Mar-2020|
|Date of Web Publication||31-May-2020|
Dr. Jitendra Singh
Department of Medicine, Narayana Medical College, Sasaram, Post Jamuhar, Distt Rohtas, Bihar . 821 115
Source of Support: None, Conflict of Interest: None
Objectives: The present study was aimed to find seroprevalence in different age group population to explore the burden of TORCH (toxoplasma, rubella virus, cytomegalovirus [(CMV] and herpes simplex virus [HSV]) infection in the North Indian Population. Materials and Methods: It is a retrospective study carried out in the Microbiology Department, Institute of Medical Science, Banaras Hindu University (IMS, BHU), a tertiary care centre of North India. The blood samples of the suspected population of either sex or age group from different departments were analysed over a period of 7 years. The samples were tested for TORCH infections by the IgM ELISA kit following the manufactures instruction. Results: Out of total 4044 samples, 1353 (33.46%) cases were seropositive with maximum cases from the obstetrics and gynaecology department 39.46%. The highest seropositivity of TORCH (43.15%) was in the age group 15–25 years followed by 36.33% in the age group 25–35 years. This study revealed an overall male and female ratio of the total positive cases as 0.12 while it was 2.2 for pediatric cases (0–15 years). The overall seroprevalence was contributed as toxoplasma 1.38%, rubella 1.14%, CMV 13.63% and herpes 17.43%. The overall seropositivity (IgM) contributed as toxoplasma gondii with 4%, rubella with 3%, cytomegalovirus with 41% and herpes simplex virus with 52%. The coinfection of HSV with CMV was most abundant with 246 cases. Conclusions: The seropositivity of toxoplasma and rubella were comparatively more in infants while CMV and herpes were more prevalent in adults. Though, the incidence of TORCH has reduced over the past few years. Furthermore, knowing the epidemiology is an important aspect to develop strategies and appropriate implementation for the prevention of infection.
Keywords: Congenital malformations, epidemiology, high-risk pregnancy, seroprevalence, TORCH infection
|How to cite this article:|
Dinkar A, Singh J. Seroprevalence of Toxoplasma, Rubella, CMV and HSV infection at a teaching hospital: A 7 year study from North India. J Family Med Prim Care 2020;9:2253-7
|How to cite this URL:|
Dinkar A, Singh J. Seroprevalence of Toxoplasma, Rubella, CMV and HSV infection at a teaching hospital: A 7 year study from North India. J Family Med Prim Care [serial online] 2020 [cited 2020 Sep 19];9:2253-7. Available from: http://www.jfmpc.com/text.asp?2020/9/5/2253/285083
| Introduction|| |
The TORCH pathogens (toxoplasma, rubella virus, cytomegalovirus [(CMV] and herpes simplex virus [HSV]) generally cause asymptomatic or mild infections in the mother,, but may result in a serious sequel and congenital malformations in the foetus or years after birth such as spontaneous abortions, intrauterine foetal death, congenital anomalies, intrauterine growth retardation, prematurity, stillbirth and live born infants with the evidence of disease.,, Due to poor environmental and hygiene conditions, pregnant women may be exposed to a variety of these infections. Infection with TORCH pathogens may lead to significant morbidity and mortality in the health, especially in developing countries. It is challenging to diagnose TORCH aetiology clinically, therefore diagnosis is usually established by seroconversion in paired sera or by the presence of specific antibody. The prevalence of these infections varies with the geographical area. Data for seroprevalence of TORCH agents in north India are very meager. With this background, the present study was carried out on a larger sample size to assess the prevalence to explore the burden of TORCH infection in this region.
| Material and Methods|| |
Settings and design
It is a retrospective study conducted in the Microbiology Department, Institute of Medical Science, Banaras Hindu University (IMS, BHU), a tertiary care centre of North India.
Study sample and population
The samples belonged to patients for antenatal screening and clinically suspected of all age groups and either sex were sent in the serology laboratory as a part of routine diagnostic services from various departments of the institution from January 2011 to December 2017. A total of 4,044 samples were collected under aseptic conditions from the patients of outdoor and indoor. BHU is serving as a referral tertiary care centre for the patients of whole eastern Uttar Pradesh, nearby states such as Bihar, Madhya Pradesh and Nepal country also.
Sample collection and processing
The serum was used for serological evaluation for TORCH infections. Sera were properly labelled and stored at 2–8°C for up to 7 days. IgM antibodies for the TORCH infections were detected by the ELISA test kit (NovaTec Immundiagnostica GmbH, Germany). The manufacturer instructions were followed in the performance and interpretation of the tests.
As it was a retrospective study, informed consents and clearance from the institutional ethical committee were not taken. Though, care was taken not to disclose patients’ identity in any form.
| Results|| |
Out of 4,044 samples of either sex collected from various departments, 1,353 (33.46%) cases were seropositive. Most of the cases and positivity were reported from the obstetrics and gynecology department followed by paediatrics as 2,846 (1123) 39.46% and 1,095 (194) 17.72%, respectively. During 7 years, there were increasing trends in sample size except for a dip in the year 2012. On the other hand, the positivity of cases was reported highest in year 2011 (50.29%), followed by decreasing continuously till year 2016 [Table 1]. In a total of 4,044 samples, the highest TORCH seropositive 598 (43.15%) cases were in the age group 15–25 years followed by 530 (36.33%) cases in the age group 25–35 years. Out of 1,353 seropositive cases, 146 (10.79%) cases were male and 1207 (89.21%) cases were female. The male and female ratio was 0.12, on the other hand, it was 2.2 for pediatric cases (0–15 years). Males were predominant in the age group up to 15 years while most of the females were positive in age 15–25 followed by 25–35 years, age group. Maximum cases of toxoplasma were seen in age 15–25 years, rubella in the age group 0–15 years, cytomegalovirus and herpes in age 15–25 followed by 25–35 years [Table 2]. The overall seroprevalence was revealed as toxoplasma 1.38%, rubella 1.14%, CMV 13.63% and herpes 17.43% [Table 3]. During 7 years, total seropositivity was contributed with herpes as 52%, cytomegalovirus as 41%, toxoplasma as 4% and rubella as 3% [Figure 1]. In the year 2011, maximum positive cases were reported as 263 and lowest cases (127) in the year 2016. During the study period, HSV cases followed by CMV were most prevalent each year. Rubella was highest with 13 cases in the year 2014 and lowest with two cases in 2012. Toxoplasma was reported on the peak with 12 cases in the year 2012 while only two cases in the year 2016 [Figure 2]. Coinfection of HSV with CMV was most abundant with 246 cases and highest cases of 46 in each year 2011 and 2013 while HSV with toxoplasma was the second most common coinfection as 11 cases [Table 4]. Male sex was predominant in TORCH agents among paediatric age group [Figure 3].
|Figure 1: Overall contribution of seropositivity of TORCH (toxoplasmosis, rubella virus, cytomegalovirus [(CMV], and herpes simplex virus [HSV]) for 7 years|
Click here to view
|Figure 3: Sex-wise distribution among seropositive paediatric cases (up to 15 years)|
Click here to view
| Discussion|| |
In the present study, we had analysed retrospective data over the 7 years for TORCH agents (Toxoplasma, rubella, CMV and herpes) in a tertiary care hospital of North India. It is important, however to aware of the variation in the incidence of various TORCH infections in different parts of the country. The exact prevalence of TORCH agents is largely unknown.
Toxoplasma gondii, an intracellular protozoan parasite that is transmitted through contaminated food or water and undercooked meat. An infected person is usually asymptomatic, but during pregnancy, it can cause pregnancy loss, stillbirth and intrauterine malformations in the foetus.,, The incidence of congenital toxoplasmosis varies from country to country and estimated around 1–2 per 1,000 live births in the UK while 1–10 per 10,000 newborns in Europe and other countries., Previous literature had shown seroprevalence of toxoplasma in different countries between 7.7 and 76.7% as as UK 9.1–17.8%, Norway 10.9%, Sweden 14–25.7%, India 45%, Iran 51.8%, France 71% and Brazil 50–76%., Few Indian studies had been reported a seroprevalence of toxoplasma as 14.66% in cases having a bad obstetric history of Nagpur, 2.73% in reproductive age group females of Ludhiana. Fortunately, the present study revealed low toxoplasma seroprevalence as 1.38% in whole population while 1.36% in infants.
Rubella causes asymptomatic or mild viral illness commonly in children and less common in adults. It is transmitted from person to person by tiny droplets in air and mother-to-child through the placenta. Primary virus infection during pregnancy may lead to miscarriage, foetal death, or an infant with serious birth defects including hearing impairment, cataracts and cardiac defects collectively called congenital rubella syndrome. The prevalence of Rubella infection in pregnant women from the different country were reported as 87% in the USA, 93.3–94% in Saudi Arabia, 95–96% in Turkey, 98% in Spain., In the present study, rubella was prevalent as 1.14% and infant with 1.96% which is comparatively low as reported in previous studies. A study from Chandigarh reported rubella as 2.8% in children, 4.66% in cases having bad obstetric history (BOH) in Nagpur, and 5.66% in females of the reproductive age group of Ludhiana.
Human cytomegalovirus (CMV), otherwise known as human herpes virus 5 is transmitted by direct contact with saliva, urine and genital secretions., It can cause intrauterine growth retardation, microcephaly with intracranial calcification, hepatosplenomegaly, jaundice, chorioretinitis, thrombocytopenic purpura and anaemia in neonates while the loss of vision, hearing and cognitive impairment in childhood age. In CMV infection, the fetus is affected in all stages of pregnancy but more severe damage is reported during the first half of the pregnancy. It is highly prevalent in both developed and developing countries and remains the most common congenital infection worldwide with an estimated incidence of 0.2–2.2% with seroprevalence ranging between 45% and 100%. Studies reporting seropositivity of CMV in pregnant women are 56.8% in Australia, 84% in Spain, 39–94.7% in the USA and 84.5–95% in Turkey. The seroprevalence in Indian adult population ranges 80%–90% with some states of India reporting 15.98% CMV IgM in Kashmir and 12.9% in Delhi and 22.03% for CMV IgM in Punjab,, 5.33% in cases with BOH in the study of Nagpur, 12.5% in children of Chandigarh and 19.91% infertile females of Ludhiana. The present study revealed CMV prevalence in infants as 7.4% while overall it was 13.63% which is near to previous studies.
Herpes is categorised into herpes type 1 (HSV-1 or oral herpes) and herpes type 2 (HSV-2 or genital herpes). Worldwide, HSV is the most common sexually transmitted viral disease. HSV2 is always transmitted by sexual contacts causing genital herpes, while HSV1 is transmitted by non-sexual contacts causing mucocutaneous disease largely involves the mouth and oral cavity., Primary genital HSV infection remains asymptomatic or unrecognized in more than 75% of cases but during pregnancy, it may lead to spontaneous abortion, prematurity, congenital and neonatal herpes., Primary HSV infection during the first half of pregnancy is associated with increased frequency of neonatal morbidity and mortality while infection during the third trimester is associated with the highest risk of neonatal transmission. Congenital malformations (organomegaly, bleeding and CNS abnormalities) are reported in the fetus due to infection of both herpes virus as 30–50% due to HSV-1 and 50–70% to HSV-2., A recent study of the United States assessed the epidemiological association between herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) infections from 1999 to 2016, and revealed a strong declining trend for at least two decades, for both sexes and for the different ethnicities. The prevalence rate of HSV IgM in the present study was 17.43% in the whole study population and 5.14% in infants, while the study conducted in central India had reported a variation of prevalence as 1.56% in pregnant women, 8.66% among BOH in Nagpur, 24.84% in Ludhiana among studying females, 9.46% in women of Hyderabad, Telangana. Though, the incidence of herpes has reduced over the past few years as shown in studies conducted on different population groups. This is possibly due to improvements in hygiene level, better living standard and safer sexual contact.
The positive serology for toxoplasma (1.36%) and rubella (1.96%) were comparatively more in infants while CMV with 14.84% and herpes with 19.84% were more prevalent in adults. Among confections in this study, the highest rate with 90.8% of CMV and HSV, followed by toxoplasma and HSV with 4.1% was reported. Besides this, maximum cases of herpes (52%) followed by CMV (41%), toxoplasma (4%) and rubella (3%) were distributed among overall TORCH seropositivity.
TORCH infections are a very annihilating group of infections. Its prevalence varies with different socioeconomic statuses on two different patient populations. Some of them can be preventable or curable if diagnosed on a regular basis of primary care. Thus, it is paramount to prevent TORCH and its associated serious sequels in mothers and infants by health promotion and better counselling of their patients by primary care physicians.
| Conclusion|| |
In summarising context, TORCH pathogens have potentially devastating clinical manifestations. Hence, serological screening before pregnancy and early diagnosis of TORCH can diminish morbidity and mortality in both child and mother. Furthermore, knowing the epidemiology is an important aspect to develop strategies and appropriate implementation for the prevention of infection.
We thank our junior residents for patient care and the staff of the microbiology department for data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Prasoona KR, Srinadh B, Sunitha T, Sujatha M, Deepika MLN, Vijaya Lakshmi B, et al
. Seroprevalence and influence of torch infections in high risk pregnant women: A large study from South India. J Obstetr Gynecol India 2015;65:301-9.
Stegmann BJ, Carey JC. TORCH infections Toxoplasmosis, other (syphilis, varicella-zoster, parvovirus B19), Rubella, cytomegalovirus (CMV), and herpes infections. Curr Women Health Rep 2002;2:253-8.
Kaur K, Oberoi A. Prevalence of various torch infections among females of reproductive age group. J Evol Med Dent Sci 2015;4:11391-6.
Maruyama Y, Sameshima H, Kamitomo M, Ibara S, Kaneko M, Ikenoue T, et al
. Fetal manifestations and poor outcomes of congenital cytomegalovirus infections: Possible candidates for intrauterine antiviral treatments. J Obstet Gynaecol 2007;33:619-23.
Shrivastava G, Bhatambare GS, Patel KB. Seroprevalance of toxoplasma, rubella, CMV and HSV infection in pregnant women in central India. Int J Health Syst Disaster Manage 2014;2:166-9. [Full text]
Surpam RB, Kamlakar UP, Khadse RK, Qazi MS, Jalgaonkar SV. Serological study for TORCH infections in women with bad obstetric history. J Obstet Gynecol India 2006;56:41-3.
Singh MP, Arora S, Das A, Mishra B, Ratho RK. Congenital rubella and cytomegalovirus infections in and around Chandigarh. Indian J Pathol Microbio 2009;52:46-8.
Montoya JG, Remington JS. Toxoplasma gondii. In: Mandel GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennetts’ Principles and Practice of Infectious Diseases. 5th
ed. Philadelphia: Churchill Livingstone; 2000. p. 2858-88.
Greenough A. The TORCH screen and intrauterine infections. Arch Dis Child Fetal Neonatal Ed 1994;70:F163-5.
Singh S, Pandit AJ. Incidence and prevalence of toxoplasmosis in Indian pregnant women: A prospective study. Am J Reprod Immunol 2004;52:276-83.
Pedranti MS, Adamo MP, Macedo R, Zapata MT. Prevalence of anti-rubella and anti-parvovirus B19 antibodies in pregnant women in the city of Córdoba, and in women of fertile age in the city of Villa Mercedes, province of San Luis. Rev Argent Microbiol 2007;39:47-50.
Kumar M, Nizam MB, Mugunthan M. Seroprevalence of cytomegalovirus infection in antenatal women in a tertiary care center in Western India. J Mar Med Soc 2017;19:51-4. [Full text]
Berry V, Lal M. Primary cytomegalovirus infection during pregnancy. Int J Life Sci Pharm Res 2012;2:L5-7.
Anzivino E, Fioriti D, Mischitelli M, Bellizzi A, Barucca V, Chiarini F, et al
. Herpes simplex virus infection in pregnancy and in neonate: Status of art of epidemiology, diagnosis, therapy and prevention. Virol J 2009;6:40.
Brown ZA, Selke S, Zeh J, Kopelman J, Maslow A, Ashley RL, et al
. The acquisition of herpes simplex virus during pregnancy. New Engl J Med 1997;337:509-15.
Biswas D, Borkakoty B, Mahanta J, Walia K, Saikia L, Akoijam BS, et al
. Seroprevalence and risk factors of herpes simplex virus type-2 infection among pregnant women in Northeast India. BMC Infect Dis 2011;11:325.
Haider M, Rizvi M, Khan N, Malik A. Serological study of herpes virus infection in female patients with bad obstetric history. Biol Med 2011;3:284-90.
Shandera WX, Dima Dandachi D. Viral and rickettsial infections. In: Papadakis MA, McPhee SJ, Rabow MW, editors. Current Medical Diagnosis and Treatment Treatment. 58th
ed. United States of America: The McGraw-Hill Companies, Inc.; 2011. p. 1377-447.
Corey L. Herpes simplex virus infections. In: Kasper DL, Hauser SL, Jameson JL, Fauci AS, Longo DL, Loscalzo J, editors. Harrison's Principles of Internal Medicine. 19th
ed. New York: McGraw-Hill Education; 2015. p. 1175-83.
Chemaitelly H, Nagelkerke N, Omori R, Abu-Raddad LJ. Characterizing herpes simplex virus type 1 and type 2 seroprevalence declines and epidemiological association in the United States. PLoS One 2019;14:e0214151.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]