International Journal of Infectious Diseases 34 (2015) 41–45

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High prevalence of anti-toxoplasma antibodies and absence of Toxoplasma gondii infection risk factors among pregnant women attending routine antenatal care in two Hospitals of Addis Ababa, Ethiopia Woyneshet Gelaye a,b,*, Tadesse Kebede a, Asrat Hailu a a b

Department of Medical Microbiology, Immunology and Parasitology, Faculty of Medicine, Addis Ababa University, Ethiopia Regional Health Research Laboratory Center, Bahir Dar, Ethiopia

A R T I C L E I N F O

Article history: Received 14 August 2014 Received in revised form 2 February 2015 Accepted 3 March 2015 Corresponding Editor: Eskild Petersen Keywords: Toxoplasma gondii congenital Ethiopia.

S U M M A R Y

Objective: Toxoplasmosis is an infection caused by the protozoan parasite Toxoplasma gondii. It is acquired mainly by eating raw or undercooked meat containing Toxoplasma gondii tissue cyst, eating food or water contaminated with oocyst, and acquiring congenital infection through the placenta. This study was conducted to determine the prevalence of toxoplasmosis and assess possible risk factors associated with the infection among pregnant women in Addis Ababa, Ethiopia. Method: Cross sectional study was designed, and 288 serum samples were collected from November 1st 2010 to January 2011. The serum samples were tested for anti- Toxoplasma gondii antibodies using latex agglutination test. The risk factors were tested for significance using Bivariate and multivariate analysis. P-value 35 Residence Addis Ababa Out of Addis Ababa Education status Illiterate Read and write only Grade 1-8 Grade 8-12 >12+ Marital status Married Single Occupation Government employee House wife Private sector employee Other Gestational period 1st trimester 2nd trimester 3rd trimester

Total n(%)

Seroprevalence Negative n(%)

Positive n(%)

8 (19) 32 (14.7) 2 (7.1)

34 (81) 186 (85.3) 26 (92.9)

42 (14.6) 218 (75.7) 28 (9.7)

288 (85.4) 0 (0)

288 (85.4) 0 (0)

23 3 53 101 66

24 3 63 120 78

0 (0) 0 (0) 1 0 10 19 12

(4.2) (0) (15.9) (15.8) (15.4)

(95.8) (100) (84.1) (84.2) (84.6)

(8.3) (1) (21.9) (41.7) (27.1)

40 (14.5) 2 (16.7)

236 (85.5) 10 (83.3)

276 (95.8) 12 (4.2)

4 23 13 2

28 129 74 15

32 152 87 17

(12.5) (15.1) (14.9) (11.8)

4 (22.2) 7 (11.9) 31 (14.7)

(87.5) (84.9) (85.1) (88.2)

14 (77.8) 52 (88.1) 180 (85.3)

(11.1) (52.8) (30.2) (5.9)

18 (6.2) 59 (20.5) 211 (73.3)

W. Gelaye et al. / International Journal of Infectious Diseases 34 (2015) 41–45

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Table 2 Factors associated with T. gondii infection among pregnant women (n = 288), Addis Ababa, Ethiopia 2011. Characteristics Age group (Years) 15-24 25-34 >35 Education status Illiterate Read and write only Grade 1-8 Grade 8-12 >12+ Marital status Married Single Occupation Government employee House wife Private sector employee Other Gestational period 1st trimester 2nd trimester 3rd trimester Raw meat eating habit Yes No Raw vegetable eating habit Yes No Owning cat Yes No Blood transfusion Yes No History of abortion Yes No HIV status Positive Negative

Negative n(%)

Positive n(%)

COR (95% CI)

AOR (95% CI)

P Value

8 (19) 32 (14.7) 2 (7.1)

34 (81) 186 (85.3) 26 (92.9)

0.327 (0.064 - 1.671) 0.447 (0.101 - 1.977) 1

0.334 (0.061 - 1.827) 0.457 (0.100 - 2.099) 1

0.206 0.314 -

1 0 10 19 12

23 3 53 101 66

4.182 0.968 0.964 0.967 1

5.222 1.201 1.200 1.002 1

0.139 0.998 0.735 0.996 -

(4.2) (0) (15.9) (15.8) (15.4)

(95.8) (100) (84.1) (84.2) (84.6)

(0.515 (0.442 (0.386 (0.440

-

33.961) 2.112) 2.403) 2.122)

(0.586 (0.416 (0.418 (0.410

-

46.572) 3.242) 3.440) 2.454)

40 (14.5) 2 (16.7)

236 (85.5) 10 (83.3)

0.847 (0.179 - 4.012) 1

0.896 (0.181 - 4.441) 1

0.835 -

4 23 13 2

28 129 74 15

(87.5) (84.9) (85.1) (88.2)

0.933 (0.153 - 5.700) 0.748 (0.160 - 3.491) 0.759 (0.155 - 3.717) 1

1.174 (0.161 - 8.582) 0.678 (0.134 - 3.424) 0.696 (0.127 - 3.825) 1

0.875 0.638 0.677 -

4 (22.2) 7 (11.9) 31 (14.7)

14 (77.8) 52 (88.1) 180 (85.3)

0.603 (0.186 - 1.951) 1.279 (0.533 - 3.073) 1

0.519 (0.142 - 1.893) 1.331 (0.540 - 3.279) 1

0.320 0.534 -

2 (16.1) 37 (14.4)

26 (83.9) 220 (85.6)

0.875 (0.316 - 2.422) 1

0.868 (0.297 - 2.534) 1

0.795 -

26 (14) 16 (15.7)

160 (86) 86 (84.3)

1.145 (0.587 - 2.250) 1

1.362 (0.645 - 2.877) 1

0.418 -

5 (9.1) 37 (15.9)

50 (90.9) 196 (84.1)

1.888 (0.706 - 5.051) 1

2.011 (0.725 - 5.576) 1

0.180 -

2 (18.2) 40 (14.4)

9 (81.8) 237 (85.6)

0.759 (0.158 - 3.645) 1

0.632 (0.122 - 3.272) 1

0.584 -

9 (12.7) 33 (15.2)

62 (87.3) 184 (84.8)

1.236 (0.56 - 2.726) 1

1.195 (0.505 - 2.826) 1

o.686 -

3 (13.6) 39 (14.7)

19 (86.4) 227 (85.3)

1.088 (0.307 - 3.852) 1

0.925 (0.237 - 3.606) 1

0.910 -

(12.5) (15.1) (14.9) (11.8)

Key to Abbreviation: COR = Crude odds ratio, AOR = Adjusted odds ratio, CI = Confidence interval

3.3. Factors associated with T. gondii infection Among the participants; 14.6% were between age groups of 15 24, 75.7% were between 25 - 34, and 9.7% were above 35. The infection prevalence among age groups 15 -24, 25 - 34, and  35 was 81% (CI: 0.064 - 1.671), 85.3% (CI: 0.101 - 1.977), 92.9% respectively. However; no significant association was observed between seroprevalence and age. There was no significant association between seroprevalence of infection and level of education, occupation, and gestational period of the participant (Table 2). None of the pregnant women had history of organ transplantation; whereas 3.8% had a history of blood transfusion in their life time. Among those who had blood transfusion 81.8% (CI: 0.158 3.645) were seropositive. From the participants 19.1% had domestic cat at home and had experience of cleaning litter. Among the pregnant mothers who had cats at home, 90.9% (CI: 0.706 - 5.051) were seropositive. Assessment of raw meat eating habit revealed only a minority (10.8%) had the experience of eating raw meat; 89.2% had no experience of raw meat eating habit throughout their life time. Among those with raw meat eating habit the seroprevalence of Toxoplasma infection was 83.9% (CI: 0.316 - 2.422). Similarly, 64.6% had experience of eating uncooked vegetables. The seroprevalence of Toxoplasma infection among those who had

experience of raw vegetable eating habit was 86% (CI: 0.587 2.250). From the total of 288 pregnant women tested for HIV, 7.6% were positive. Comparable prevalence of Toxoplasma infection was observed between HIV positive (86.4%) and HIV negative (85.3%) pregnant women with CI: 0.307 - 3.852. 4. Discussion The current study is one of the few studies carried out in Ethiopia to explore the seroprevalence of T. gondii infection among pregnant women in Addis Ababa. If a woman gets infection with T. gondii for the first time in her life during pregnancy, she may pass infection to the fetus; a situation that ultimately could lead to a very serious fetal damage. A wide variability in the prevalence of toxoplasmosis among pregnant women has been reported worldwide [2]. The present study demonstrates that prevalence of anti-Toxoplasma gondii antibodies in pregnant women in Addis Ababa was 85.4%. The high prevalence of anti-T. gondii antibodies observed in this study was in agreement with seroprevalence data from previous studies conducted in Ethiopia: 90% from HIV infected and HIV uninfected individuals [17]; 75% from a survey carried out in general population [18]; 83.6% among pregnant women in Jimma town [19], and 81.4% among women of child bearing age [20]. However, our findings as well as those of previous

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W. Gelaye et al. / International Journal of Infectious Diseases 34 (2015) 41–45

works in Ethiopia are substantially higher than results which were reported from other countries; 34.1% in Sudan [15], 25.3% in Burkina Faso [16], 47.1% in Jordan [22]. This variation might be attributed to climate, cultural differences in hygienic and feeding habits. We found no significant association between age and seroprevalence. This finding is in agreement with previous results reported from Ethiopia [20] and Saudi Arabia [23]. Other studies in Ethiopia found significant association between age and seroprevalence [19]. In this study, absence of significant association between age and seroprevalence among pregnant women might be due to the incidence of infection seems at their childhood since we found high prevalence at the younger age groups. No significant difference was observed between the different occupations and levels of education. This is in agreement with results from Ethiopia [19,20]. The highest seroprevalence of Toxoplasma antibodies we found (88.1%) was in those pregnant women at the second trimester. However, there was no statistically significant association between gestational age of the fetus and seropositivity. This result is in agreement with a study in Saud Arabia [23]. Consumption of raw vegetable was identified as a risk factor in other study [20]. In our study no significant association was observed between seroprevalence and ingestion of raw meat (OR = 0.875, CI: 0.316 - 2.422, P = 0.795) or ingestion of raw vegetable (OR = 1.145, CI: 0.587 - 2.250, P = 0.418). Similar findings were reported by other studies [17,23,24]. The absence of statistically significant association between seroprevalence and food habits, especially consumption of raw meat and vegetables should prompt future studies to identify other routes of Toxoplasma transmission among pregnant women in Addis Ababa. Notwithstanding, the results are indicative that most of the pregnant women were probably exposed to Toxoplasma infection already in their childhood, ending up with high seroprevalence in their adulthood. Other studies in Ethiopia indeed showed that children aged 1-5 years had relatively high seroprevalence (41%) of anti-toxoplasma antibodies (25). This phenomenon, i.e., the high prevalence rate, obviously will have a masking effect, and makes the exercise of identifying the risk factors during pregnancy a daunting task. The seroprevalence of Toxoplasma antibodies in our study population is very high and comparable to the high rates already reported in the general Ethiopian population [18]. Given this, the absence of association between consumption of raw meat or vegetables and toxoplasma infection may not be surprising, and cannot rule out the role these food habits could have in toxoplasma transmission. The general food and environmental hygiene of a community is an important factor that drives the transmission of toxoplasma infection. In addition, contact with soil, consumption of unwashed fruits (not investigated herewith), drinking unpotable water are common events and practices, if not overwhelming, in our communities; as a result toxoplasma transmission can take place widely and in various vehicles. In Ethiopia, consumption of raw or undercooked meat takes place in many different ways and widely, with the exception of those who consider eating raw meat a taboo. Clearly, the role this habit plays in toxoplasma transmission cannot be underestimated, and is likely to explain the high rate of toxoplasma infection in many Ethiopian communities. Addressing this issue might require an adapted comparative study design on a large scale. Although cats are the definitive hosts that shed oocysts, ownership of cat was not found to be significantly associated with T. gondii infection (OR = 1.888, CI: 0.706 - 5.051, P = 0.180). This finding is in agreement with other results reported from Ethiopia [17], Jordan [22], Saudi Arabia [23], and Turkey [24]. In relation to experience of blood transfusion, no significant difference was observed (OR = 0.759, CI: 0.158 - 3.645, P = 0.584) among pregnant women who had or did not have

blood transfusion. HIV has been significantly associated with seroprevalence of T. gondii antibodies in other studies [16,17]. On the contrary, in this study significant difference in seropositivity of T. gondii was not observed between HIV positive and negative pregnant women (OR = 1.088, CI: 0.307 - 3.852, P = 0.910). The reason for this might be the small number of HIV positive pregnant women found in the study. This study also showed that there was no significant difference in prevalence between women who had and did not have a history of abortion (OR = 1.236, CI: 0.56 - 2.726; P = 0.686). This finding is in agreement with other results [23,24]. Conclusion and recommendations In conclusion, this study demonstrates that the prevalence of T. gondii infection among pregnant women in Addis Ababa Ethiopia is very high; and is likely to be a reflection of the overall high prevalence among adult Ethiopians. In this study, our attempts to draw an association between seroprevalence of toxoplasmosis and age, gestational age of the fetus, educational status, occupation, history of abortion, consumption of raw meat, consumption of unwashed raw vegetable, cat ownership, and blood transfusion could not be revealing. Similarly, no significant difference in prevalence of toxoplasmosis was found between HIV positive and HIV negative individuals. The high prevalence of anti-toxoplasma antibodies among adult Ethiopians reported by other authors [17– 20] is likely to mask the incidence of infections during pregnancy. Efforts to describe risk factors for toxoplasma infection among Ethiopians should focus on children. Author’s contribution WG designed the study and performed the laboratory procedures, and drafted the manuscript. TK and AH were involved in the study design. WG and AH revised the manuscript. All the authors read and approved the final manuscript. Acknowledgement The authors would like to thank the study participants for their participation in the study, Addis Ababa University and Amhara National Regional State Health Bureau for their financial support. Debark Hospital availed laboratory supplies We are thankful to Professor Getachew Tilahun and Dr. Simegnew Tesfa for their unreserved support; and The managements of Tikur Anbesa General Specialized and Gandhi Memorial Hospitals’ gynecology and obstetrics departments and the nursing staff are thanked for the permission to use their facilities and for accessing pregnant women. Simegne Terefe and Woyneshet Mekonen, staff members of the Microbiology and Parasitology laboratories are thanked for their valuable support and encouragement. Competing interest: The authors declare that they have no competing interest. References [1] Dubey JP, Lindsay DS, Speer CA. Structures of Toxoplasma gondii tachyzoites, bradyzoites, and sporozoites and biology and development of tissue cysts. Clin Microbiol Rev. 1998;11:267–99. [2] Dubey JP. Toxoplasmosis – a waterborne zoonosis. Vet. Parasitol. 2004;126(1– 2):57–72. [3] Jones JL, Muccioli C, Belfort RJ, Holland GN, Roberts JM, Silveira C. Recently acquired Toxoplasma gondii infection, Brazil. Emerg Infect Dis. 2006;12(4): 582–7. [4] Joyner LP. Host and site specificity. In: Long PL, editor. The Biology of the Coccidia. Baltimore, Maryland: University Park; 1982. p. 35–62. [5] Rorman E, Zamir CS, Rilkis I, Ben-David H. Congenital toxoplasmosis–prenatal aspects of Toxoplasma gondii infection. Reprod Toxicol. 2006;21(4):458–72.

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