|Year : 2020 | Volume
| Issue : 3 | Page : 379-384
Prevalence of torch infections and its associated poor outcome in high-risk pregnant women of Central India: Time to think for prevention strategies
HV Manjunathachar1, Kavita N Singh2, Vivek Chouksey1, Ravindra Kumar3, Ravendra K Sharma4, Pradip V Barde5
1 Division of In vivo Research, ICMR-National Institute of Research in Tribal Health, Jabalpur, Madhya Pradesh, India
2 Department of Obstetrics and Gynaecology, NSCB Medical College, Jabalpur, Madhya Pradesh, India
3 Division of Genetic Disorder, ICMR-National Institute of Research in Tribal Health, Jabalpur, Madhya Pradesh, India
4 Division of Social Science and Ethnomedicine, ICMR-National Institute of Research in Tribal Health, Jabalpur, Madhya Pradesh, India
5 Division of Virology and Zoonoses, ICMR-National Institute of Research in Tribal Health, Jabalpur, Madhya Pradesh, India
|Date of Submission||31-Mar-2020|
|Date of Decision||09-Jul-2020|
|Date of Acceptance||17-Aug-2020|
|Date of Web Publication||4-Nov-2020|
Dr. Pradip V Barde
Division of Virology and Zoonoses, ICMR-National Institute of Research in Tribal Health, Jabalpur - 482 003, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: The TORCH infections during pregnancy are associated with adverse congenital abnormalities, poor foetal outcome and subsequent reproductive failures. The absence of baseline data on status of TORCH infections and associated foetal outcomes prompted us to conduct the current study in Central India. Materials and Methods: A total of 144 high-risk pregnant women attending tertiary care unit, suspected for TORCH infections were enrolled from August 2017 to December 2018. All the participants were tested for the presence of IgM and IgG antibodies and followed up to record the foetal outcome. Results: The overall TORCH infection (IgM positivity) positivity rate was 61.1% (88/144). Rubella was the most prevalent infection (46.5%) followed by herpes simplex virus (HSV) 1 and 2 (41%) and cytomegalovirus (CMV) (34.7%). The highest IgG sero-positivity was recorded against CMV (88.6%), followed by Rubella (86.8%), HSV 1 and 2 (28.4%), and toxoplasmosis (15.2%). Follow-up of IgM TORCH positive pregnant women revealed that majority of the neonates/infants are having congenital cardiac abnormalities (39.2%), followed by microcephaly/hydrocephaly (25%), low birth weight (10.7%), and deafness (3.6%). Thirty-two percent of neonatal mortality was associated to multiple TORCH infections. Conclusion: A high prevalence of IgM seropositivity of TORCH infection was noted in the present study with the increased rate of poor foetal outcome warrants the need of proper prenatal counselling, universal immunisation and nutritional supplements during pregnancy.
Keywords: Bad obstetric history, Central India, congenital malformations, pregnancy, TORCH infections
|How to cite this article:|
Manjunathachar H V, Singh KN, Chouksey V, Kumar R, Sharma RK, Barde PV. Prevalence of torch infections and its associated poor outcome in high-risk pregnant women of Central India: Time to think for prevention strategies. Indian J Med Microbiol 2020;38:379-84
|How to cite this URL:|
Manjunathachar H V, Singh KN, Chouksey V, Kumar R, Sharma RK, Barde PV. Prevalence of torch infections and its associated poor outcome in high-risk pregnant women of Central India: Time to think for prevention strategies. Indian J Med Microbiol [serial online] 2020 [cited 2020 Nov 24];38:379-84. Available from: https://www.ijmm.org/text.asp?2020/38/3/379/299814
| ~ Introduction|| |
The maternal infections that are transmissible in-utero at the different stages of pregnancy caused by many pathogens, of which TORCH complex acronym comprises of Toxoplasma gondii, Rubella virus (RV), cytomegalovirus (CMV) and herpes simplex virus (HSV) type 1 and 2, contributes majorly in neonatal and infant deaths globally. Most of these pathogens causes asymptomatic or mild maternal morbidity but have serious adverse effects on foetal outcomes. The primary TORCH infection during the different stages of pregnancy has life-threatening serious consequences on fetus in comparison to recurrent infections and may cause spontaneous abortions, congenital malformations, intrauterine growth restriction, still births, prematurity and chronic postnatal infections., As per the estimate, TORCH infections are the foremost cause of stillbirths and accounting for approximately half of them, reported especially in developing countries. On an account, almost 7.5 lakhs neonatal deaths recorded in India in 2013, and it is highest for any country in the world., In India, child-bearing women belonging to low socio-economic group or residing in rural/tribal areas, comes under high-risk pregnancy group since, they exposed to a range of infections due to poor environmental condition and lack of good hygienic practices. The high-risk pregnancy, where mother or developing fetus or both are prone for high- risk complications during or after pregnancy and birth., Toxoplasmosis, a protozoan infection caused by T. gondii, causes life-threatening events in pregnant women when infection acquired during the first or second trimester of pregnancy as a primary infection and pose major threat to the fetus.,, The infection is transmitted through handling infected cat feces, consumption of contaminated vegetables, fruits and milk., RV is transmitted by droplets between person to person and vertical transmission occurs between mother to child. Rubella infection in the first trimester of pregnancy is responsible for congenital malformations in infants referred as congenital rubella syndrome (CRS)., CMV is considered as one of the leading cause for congenital deafness, loss of vision and cognitive impairment in infants., Herpes viral infections are the most common infections spreads through oral or genital contact in humans. Genital herpes caused by HSV type-2 spreads mainly through sexual contact and the infection during the last trimester of pregnancy leads to neonatal herpes with reported 80% case fatality rate.,,
Among all states in India, Madhya Pradesh reported highest neonatal mortality rate.,, TORCH infection in pregnancy may be a major cause of high neonatal mortality. In the absence of national level screening programme for TORCH, serological detection of infections during the pregnancy is the only means of revealing such infections and may help obstetrician to counsel the couple to avoid poor pregnancy outcome. However, meager studies have been conducted from the different parts of the country and reported huge variation in the infection status from the region to region owing to changes in the life style pattern, socio-economic status and availability of diagnostic facilities.,,,, Even though, Madhya Pradesh recorded high neonatal mortality, to the best of our knowledge, no studies have been conducted to evaluate the TORCH infections in pregnant women and their teratogenic effects on the foetal development from the Central part of India. Therefore, the aim of the present study is evaluate the status of TORCH infections in high-risk pregnant women attending a tertiary care antenatal unit at Jabalpur and their deleterious effect on foetal outcome.
| ~ Materials and Methods|| |
Study area and design
This follow-up study was conducted between August 2017 and December 2018 at the ICMR-National Institute of Research in Tribal Health. Pregnant women aged between 18 and 40 years from different districts of Madhya Pradesh attending Obstetrics and Gynaecology department of NSCB Medical College and Hospital, Jabalpur were recruited at different gestational phases of pregnancy.
The pregnant women suspected of TORCH infection, namely(1) Pregnant women with signs and symptoms suggestive of infection, (2) Pregnant women suspected to be complicated with congenital malformations in fetal growth, (3) pregnant women with previous bad obstetric history (BOH) were included in the study. Women with other known issues which affect the current pregnancy such as Rh incompatibility, eclampsia, preeclampsia, gestational diabetes or reproductive organ defects were excluded from the study. After briefing about the study aim to participants properly, informed written consent was obtained. The study was carried out under establishment of virology research and diagnostic laboratory (VRDL) network had Institutional Ethical Committee (IEC) approval (No. NIRTH/IEC/1157/2017 dated 7th July 2017).
The sample size was calculated using standard statistical tool. Epi Info™, Division of Health Informatics & Surveillance (DHIS), Center for Surveillance, Epidemiology & Laboratory Services (CSELS), USA and the five year TORCH sero-positivity rate (toxoplasmosis - 24.2%, Rubella - 9.2%, CMV -53.8% and HSV 1 and 2%–11.7%) reported by Nirmal et al. Keeping the 9.2% sero-positivity rate of Rubella with accepting the 5% Type I error rate and study power of 80%, the minimum required sample size of 130 was calculated.
Clinical data collection and laboratory investigations
Clinical history such as previous obstetric history and general conditions such as anaemia and gestational age were recorded using a predesigned questionnaire from each recruited individual.
Two millilitres of venous blood was collected aseptically and sera was separated by centrifugation at 3500 rpm and stored at −20°C until testing. All the samples were tested for the detection of IgM and IgG antibodies against the T. gondii, Rubella, CMV, HSV 1 and 2 by enzyme-linked immunosorbent assay using commercially available kits (ChemuxBioScience, Inc., USA) following manufacturer's protocol. Assay validity was evaluated as per the manufacturer's recommended method.
The reports of TORCH infection status were distributed to patients and based on the positive result of the reports, obstetrician counseled patients/couple about possible outcomes, prevention and available treatment measures. Further, information about fetal outcomes and child health status was recorded telephonically by follow-up of IgM-positive cases.
Collected data were entered in Microsoft Excel-2007 for the primary analysis. The statistical analyses were carried out using the SPSS software version 20 (SPSS Inc., IBM Corp., Armonk, USA). Possible associations with each variable were studied using the Fisher's exact test. Odd ratios (ORs) were computed with 95% confidence interval for each of the TORCH components in the all the participants. A two-tailed P < 0.05 was considered as statistically significant.
| ~ Results|| |
A total of 144 pregnant women aged between 18 and 40 years belong to Jabalpur and 10 adjacent districts of Madhya Pradesh were investigated. The mean age of the pregnant women was 24 ± 3.9 years. The overall TORCH, IgM positivity rate in high-risk pregnant women was 61.1% (88/144). Based on the IgM positivity, Rubella is the most prevalent infection (46.5%) followed by HSV 1 and 2 (41%), CMV (34.7%), and toxoplasmosis (6.3%) in high-risk pregnant women having rash or any clinical signs. On the whole, highest IgG seropositivity was recorded against CMV (88.6%), followed by Rubella (86.8%), HSV 1 and 2 (28.4%), and toxoplasmosis (15.2%). The combined infection status is presented in [Table 1]. The IgM seropositivity TORCH participants showed statistically significant differences with age. Whereas, there was no substantial shifts in IgM and IgG seropositivity of participants in relation to trimester and BOH [Table 2]. The rate of IgM positivity was more in 1st and 2nd trimesters as compared to the last trimester of pregnancy; however, the differences were statistically insignificant (P > 0.05). Relationship of TORCH infections in pregnant women along with the foetal outcome was recorded [Table 3]. Follow-up of TORCH IgM-positive pregnant women revealed that, majority of mothers had more than one TORCH infection and the neonates/infants are having congenital cardiac abnormalities (39.2%), followed by microcephaly/hydrocephaly (25%), low-birth weight (10.7%) and deafness (3.6%). Besides, 32% of neonates were died within two weeks after birth. Majority of the neonatal deaths were observed in pregnant women affected with mixed TORCH infections.
|Table 1: Serological status of IgG and IgM antibodies against oxoplasmosis, Rubella, Cytomegalovirus, and Herpes Simplex Virus type 1 and 2 infections in pregnant women|
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|Table 2: Status of IgM and IgG sero-positivity in pregnant women based on different variables such as age, bad obstetric history, and trimester|
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|Table 3: Association of fetal outcome Toxoplasmosis, Rubella, Cytomegalovirus, and Herpes Simplex Virus 1 and 2 infection in pregnant women|
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| ~ Discussion|| |
In present study, IgM positivity of TORCH infections in pregnant women was found to be 61.1%, which is in contrast with the seropositivity rate of 13.8% reported by Padmavathy et al. from Bangalore. The variation in seropositivity rate depicts the geographic variation of infection rate and risk factors. Further, Tiwari et al. reported 45.56% IgM positivity in pregnant women of New Delhi. Subsequently, Nirmal et al. reported the increasing trend of TORCH infections, i.e., 98.8% of TORCH positivity from same region, highlighting the need of the antenatal TORCH screening in pregnant women and immunization strategy to evade the adverse foetal outcome.
In India, the reported seroprevalence rate of toxoplasmosis is up to 80%., In the present study, 15.2% and 6.3% pregnant women showed anti-toxoplasma IgG and IgM antibodies, respectively whereas Shrivastava et al. reported 9.37% and 29.68% toxoplasma IgG and IgM antibodies respectively in pregnant women from Indore, Madhya Pradesh. The seroprevalence of toxoplasmosis in different countries ranges between 7.7% and 76.7%.,, The varying prevalence status between the geographical regions may be due to climate variability, hygiene and sanitization practices, and life standards of the people,,, Toxoplasmosis is a completely treatable infection in pregnancy with antibiotic therapy; hence, early antenatal detection and prompt treatment of infection may prevent the foetal complications. Further, several studies reported that encysted forms of T. gondii activate in subsequent pregnancy and may lead to infection in the first trimester of pregnancy and often leads to spontaneous abortions.,,, Hence, the pregnant women showing seroconversion should be monitored during their subsequent pregnancies and advised to avoid handling infected cat litter material, consumption of raw vegetables, fruits, meat and milk products. Further, in the absence of vaccination against toxoplasmosis, the prevention of infection in pregnant mother can be achieved through hygiene, sanitisation and proper education by health-care authorities.
The World Health Organization (WHO) reported that 103,000 infants were born with CRS globally and 50% of CRS cases are reported from South-East Asia region, illustrates the burden of CRS. To overcome this situation, the WHO South-East Asia region committed to control Rubella and CRS by 2020. In India, several studies reported 5%–50% CRS cases following maternal infection of Rubella and the severity is much more, if infection acquired at first trimester of pregnancy.,, In the current study, it was observed that 86.8% and 46.5% pregnant women were showing anti-rubella IgG and IgM antibodies respectively. However, the antibodies titre level was less, depicts the absence of vaccination programme and silent transmission of infection to susceptible population in Madhya Pradesh. Earlier, Kori et al. demonstrated 61.8% immuno-protection to Rubella in pregnant women. In line with our results, several studies from different parts of India reported Rubella seropositivity ranging from 68.4% to 90.8%, thus leaving another one third population susceptible to infection.,,, Based on the study, it clears that the participants were not protected against Rubella. This may be due low socio-economic status, poor education in the community, lack of universal vaccination and health-care facilities in this rural/tribal dominated region.
Recently, the Government of India also launched nationwide measles-rubella vaccination campaign in 2017 targeting children aged 9 months to 14 years in five states or union territories with the objective to reduce the burden of CRS.,
Globally, the reported prevalence of CMV infection is ranging from 45% in developed countries to 100% in developing countries, whereas in India, recorded 80%–90% CMV IgG antibodies in women of child-bearing age.,,, Our results are also in similar line, where anti-CMV IgG antibodies were observed in 88.8% pregnant women. Our results of IgG antibodies against CMV infection are in parallel with the reported 85.93% and 96.4% seropositivity from Indore, Madhya Pradesh, and Turkey, respectively., High seropositivity in the current study may be due to primary infection or reinfection of variant strain in this population. Hence, conducting prenatal CMV detection may help obstetrician regarding the status of infection and possible outcome of pregnancy. Thus, proper counselling and treatment of infected children may be considered timely to overcome the complications. Centers for Disease Control and Prevention also recommended prenatal counselling for pregnant women about hand washing, reducing exposure to body fluids of young children's in preventive aspect.
Disseminated herpes infection is quite severe, and it is associated with a high rate of neonatal morbidity and mortality. About 80% of this infection is acquired during birth process and associated mortality was >75% in untreated cases. In the present study, the prevalence of HSV 1 and 2 infection in pregnant women of <24 years age group was 57.7%. Interestingly, 71.6% pregnant women in the study area are susceptible to infection due to the lack of immunity against the same. A study by Prasoona et al. from South India reported highest seropositivity (61%) of HSV-II associated with bad obstetric outcome. In contrast, we have noticed there was no statistically significant association between BOH with the HSV infection. Other studies conducted in North India reported seropositivity rate of 16.8% and 53.12% from different regions, and our results are in line with the mentioned studies., To avoid the horizontal transmission between mother to new-born, the Federation of Obstetric and Gynaecological Societies of India, Good Clinical Practice Recommendations suggests, offering a caesarean section to avoid the risk of transmission. It was noticed that, infection rate in ≤24 years' age group pregnant women was statistically higher, and the results were in analogous with earlier reports from Delhi, Hyderabad, Bengaluru and Varanasi.,,, TORCH pathogens usually cause a primary maternal viremia which pass through the placenta and have teratogenic effects on fetus, except HSV-1 or 2 where, ascending type of infection through the genital tract to foetal membranes and then to the foetus is more common. Owing to type of infection in different stages of pregnancy, significant morbidity and mortality may be noticed in the developmental stages of neonate/infant. Several studies reported that, the incidence of congenital malformation and preterm deliveries probability will be more in toxoplasma positive pregnant women, on the other hand, the incidence of spontaneous abortion, cardiac, hearing and ocular problems are more associated with Rubella, CMV, and HSV-positive cases.,,, Follow-up of IgM positive pregnant women cases recorded, high neonatal mortality, other congenital abnormalities in neonates/infants. RV is known for its teratogenicity and may cause intrauterine growth retardation, cardiac, ocular, and hearing defects. Since, mixed TORCH infections in pregnant women having worst adverse outcome on foetal development so, obstetrician should keep in mind while counselling and treating the patient.
Conducting the study in constricted socioeconomic group, i.e., tribes/rural regions where lack of basic amenities, including connectivity, low education level in community hinders the documentation of the foetal outcome are few limitations recorded in the study. Hence, in the absence of previous reports from this constricted socioeconomic region, the present data will be helpful for planning and designing the preventive strategies in this geographic location.
| ~ Conclusion|| |
The prevalence of TORCH infections was very high in this geographic region, and these infections probably associated with high neonatal mortality rate recorded in Madhya Pradesh. Further, the present study illustrates the importance of prenatal diagnosis of TORCH infections in high-risk pregnant women for proper counselling in states where higher neonatal mortalities recorded. Since pregnant women in tribal/rural regions are more vulnerable to these infections, health authorities should think and implement strategies to provide vigorous pre-pregnancy Information, Education and Communication regarding do or don't during pregnancy period through local health-care workers in local language, regular health check-up, nutritional supplements, implementation of universal immunisation schemes and monitoring, strengthening diagnostic facilities for antenatal screening of pregnant women to prevent adverse fetal outcomes.
Financial support and sponsorship
This study was financially supported by the Indian Council of Medical Research, New Delhi, for financial support.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]