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Medical Journal, Armed Forces India logoLink to Medical Journal, Armed Forces India
. 2015 Feb 16;71(2):135–138. doi: 10.1016/j.mjafi.2014.12.009

Seroprevalence of TORCH infections in antenatal and HIV positive patient populations

Lavan Singh a,, Siddhartha Mishra b, S Prasanna c, MP Cariappa d
PMCID: PMC4388965  PMID: 25859075

Abstract

Background

The TORCH (Toxoplasma gondii, Rubella, Cytomegalovirus (CMV) and the Herpes Simplex Virus) cause range of diseases in pregnant women and HIV patients and lead to adverse fetal outcomes when not treated on time, in HIV positive can cause life threating infections. There is inadequate data available of these infections in India.

Methods

A retrospective study was undertaken to determine the seroprevalence of the TORCH infections in antenatal and HIV/AIDS patients at a tertiary care centre. The laboratory data pertaining to the period Jan 2012–May 2014 was analyzed. The study population involved 162 antenatal cases and 729 HIV/AIDS patients under review at an ART centre. Laboratory testing was done for the presence of IgM and IgG antibodies against the TORCH infections by ELISA method.

Results

Among the antenatal cases, 30 (18.52%) samples were found to be seropositive for Toxoplasma IgM, CMV IgM antibodies were found in 47 (29.01%) samples, HSV IgM antibodies were found in 12 (7.40%) samples, Rubella IgM antibodies were found in 13 (8.02%) samples, indicating recent infection. Among the HIV/AIDS cases, indicative of recent or current infection, 160 (21.94%) samples were positive for Toxoplasma IgM, CMV IgM was found in 99 (13.58%), HSV IgM antibodies were found in 98 (13.44%) and Rubella IgM in 47 (6.44%).

Conclusions

The study showed a high seroprevalence of the infections caused by the TORCH complex amongst pregnant women and HIV/AIDS patients despite improved hygiene conditions and health awareness. Maximum seroprevalence for CMV was observed followed by Rubella and HSV infection.

Keywords: TORCH seroprevalence, Pregnant women, HIV patients

Introduction

TORCH, which includes Toxoplasmosis, Rubella, Cytomegalovirus (CMV), and Herpes infection are grouped together because they may result in similar clinical and pathological manifestations and lead to latent infections and recurrence of diseases whenever immunity is lowered.

Perinatal infections account for 2%–3% of all congenital anomalies. TORCH infections, are some of the most common infections associated with congenital anomalies. Most of the TORCH infections cause mild maternal morbidity but have serious fetal consequences and treatment of maternal infection frequently has no impact on fetal outcome. Therefore, recognition of maternal disease and fetal monitoring once disease is recognized are important for all clinicians. The knowledge of these diseases will help the clinician appropriately counsel mothers on preventive measures to avoid these infections, and will aid in counseling parents on the potential for adverse fetal outcomes when these infections are present.1

Toxoplasmosis, CMV and HSV infections are also very frequent in HIV positive patients with progressively lowered immunity and require to be diagnosed as such at an early stage. Hence treating physicians are to investigate the patients accordingly to modify their treatment regimens and prophylaxis as required. From the healthcare provider safety perspective, TORCH infections in pregnant women are also a hazard to attending nurses.2

The diagnosis of these infections depends mainly on serology as these are initially asymptomatic or causes minor illness in healthy individuals and are difficult to diagnose clinically. The detection of the IgM and IgG antibodies against TORCH is currently the best approach for the identification of these infections. Diagnosis can also be done by using various molecular techniques. PCR based methods have actually revolutionized the approach to diagnose, manage and later on to follow up the cases. There is a not much current data regarding TORCH infections during pregnancy and in patients with HIV infection. This study was undertaken to detect the seroprevalence of TORCH infections in two population groups, viz pregnant women with BOH and HIV positive patients, by detection of the IgM and IgG antibodies. These two groups were considered of interest as the highest seroprevalence has been noted to be in these discrete populations. Further periodic analysis of seroprevalence is necessary for cost effective management of these cases.

Materials and methods

At the laboratory of a tertiary care hospital, over a two and a half year period, subsets of 891 sera samples collected from patients for the detection of the IgM and IgG for TORCH and were analyzed qualitatively by commercially available ELISA kits. 162 samples belonged to antenatal cases being screened for TORCH and 729 to HIV/AIDS cases. The study population included pregnant women who were in the first trimester of their pregnancy and had BOH. All the confirmed HIV positive patients were under follow up in the STD Clinic and were under review by a physician.

The sera were assayed according to the manufacturer's instructions and the results were calculated on the basis of the cut off Activity Index (AI). Results are presented as positive or negative for the antibody, indicating the presence or absence of IgG and IgM antibodies. Presence of IgM antibodies indicates a current or recent infection and presence of IgG antibodies indicates past infection. We did not use kits to differentiate between HSV Type I and II, as this was a screening test. No antibody titration was done for anti-toxoplasma antibody.

Results

Results obtained are presented in Figs. 1 and 2. All the tests have been evaluated against the reference range in the reports of the laboratory. The normal result would be normal levels of IgM antibody in the serum samples.

Fig. 1.

Fig. 1

Seroprevalence of TORCH in antenatal cases (n = 162).

Fig. 2.

Fig. 2

Seroprevalence of TORCH in HIV positive cases (n = 729).

Among the antenatal cases, 30 (18.52%) samples were found to be seropositive for Toxoplasma IgM, CMV IgM antibodies were found in 47 (29.01%) samples, HSV IgM antibodies were found in 12 (7.40%) samples, Rubella IgM antibodies were found in 13 (8.02%) samples, indicating recent infection.

Among the HIV/AIDS cases, indicative of recent or current infection, 160 (21.94%) samples were positive for Toxoplasma IgM, CMV IgM was found in 99 (13.58%), HSV IgM antibodies were found in 98 (13.44%) and Rubella IgM in 47 (6.44%).

Discussion

Pregnant women and immunocompromised patients are the two major risk groups affected by the TORCH infections. TORCH infection in pregnancy does not harm the patient but affects the outcome of the pregnancy leading to BOH. Infections caused by TORCH are considered to be a major cause of BOH. The incidence of preterm deliveries, and congenital malformation has been reported to be more in patients with Toxoplasma positive titers, while the incidence of spontaneous abortion has been reported to be more in patients with Rubella, CMV, and HSV-positive titers.3 Sero-epidemiological studies have shown that a high percentage of women in the childbearing ages in India, are susceptible to Rubella infection.4 The seroprevalence of the TORCH microorganisms varies greatly in different populations. A comparison of seroprevalence in different population of antenatal cases is given in the Table 1. In our study Toxoplasma IgM positivity was similar to study done by Sen et al.5 But we there was marked difference with the study by Turbadkar et.al6 where Toxoplasma IgG positivity was much higher 42.10% as compared our study 9.70%. But we had higher positivity for IgM 18.25% as compared to 10.5% in their study. Their study have shown higher positivity for Rubella IgM and IgG 26.8% & 61.3% respectively, while we had lower positivity IgM (08.02%) and IgG (38.88%). There were marked difference in positivity rates for HSV serpositivity as depicted in table.7,8 In one older studied done by Seth et al observed Rubella serpositivity in female populations.9 Seroepidemiologic survey done by Seth P et al showed serpositivity of 80% of women of childbearing age (15–34 years) in three cities of northern India, 56.8% of such women in Calcutta in eastern India and 100% in Delhi.10

Table 1.

The seroprevalence of IgM and IgG Antibodies against TORCH infections in antenatal cases.

Study Sample size Toxoplasma
Rubella
CMV
HSV
IgM IgG IgM IgG IgM IgG IgM IgG
Present Study 162 18.25% 09.73% 08.02% 38.88% 29.01% 22.22% 07.40% 10.49%
Sen et al5 380/414
374/450
19.4% 30.4% 34.7% 33.5%
Turbadkar et al6 380 10.5% 42.10% 26.8% 61.3% 08.4% 91.05% 03.6% 33.58%
Rathore et al7 200 07.5%
Kaur et al8 120 11.6% 08.3% 20.8% 70%

HIV infected patients are always at risk of developing illness due to infection with opportunistic microorganisms such as CMV and HSV and often have recurrent attacks of illness and complications. Opportunistic Infections (OIs) are signs of a declining immune system. Most life-threatening OIs occur when CD4 count is below 200 cells/cu.mm. OIs are known to be the most common cause of death for people with HIV/AIDS. In the HIV/AIDS cases, Toxoplasma IgM and IgG antibodies were found in 21.94% and 11.11% respectively (total of 33.05%) which was similar to the seroprevalence in a study in Nigeria (38.7%).11

Routine prophylaxis with co-trimoxazole is provided under the National AIDS Control Programme.12 Co-trimoxazole Preventive Therapy (CPT) is effective against several organisms, including Toxoplasma. Recent evidence has shown that CPT helps prevent morbidity and mortality in adults with both early and advanced HIV disease. In our study, Toxoplasma IgM seroprevalence indicating current or recent infection was 21.94%. It indicates that once patient is HIV positive he is at high risk of acquiring Toxoplasma at any time and thus needs to be monitored for seroconversion. In our study we found higher positivity for Toxoplasma both IgM (21.94%) and IgG (11.11%) as compared to other study group.13 Herpes Simplex having a sexual mode of transmission, in a high risk group like HIV positive patients, is amenable to secondary prevention. With a seroprevalence for HSV IgM and IgG being 13.44% and 25.51% respectively, it is indicative of the scope for interventions (Prevention among Positives).14 HSV Type II IgG positivity is seen about 10.10% in a small survey conducted by sample size of 2546.15 Rubella antibodies both IgM (6.44% and IgG (28%) were positive and prevalence rates was not higher for IgG antibodies in our study when compared in antenatal cases. Prevalence of CMV IgG antibodies in blood donors is found to be 70% which is much higher than in our cases positivity of IgG 33.33% only.9 More studies are required to understand this phenomenon.

Conclusion

TORCH infections are very important group of infection in day today clinical practice. Some of them are preventable and some are curable to some extent. These carry different socioeconomic effects on two different patient's population. We studied and analyzed the current situation in our patients. Our study revealed wide and highly variable seroprevalence when compared with other studies. There has been significant number of cases who have acquired recent infection (IgM positivity) during antenatal as well as HIV/AIDS cases and thus emphasized the need of very close monitoring. A significant number of antenatal cases were found to be having no serpositivity for any of the infection. Low positivity for Rubella, only 46%, gives a different message. An increased level of immunization coverage for Rubella will result in increased seroprevalence and consequently lowered morbidity in the antenatal group in the long term. There is thus, a need to develop public health policies to prevent TORCH infections among these groups especially for immunization programs targeting young women before they become pregnant.

TORCH study in HIV/AIDS cases decreases the overall morbidity and mortality during follow up. This data does correlate well with clinical experience. Thus immune profile of TORCH in HIV infected patients has a good prognostic significance. The high level of seroprevalence for HIV indicates the need for Prevention with Positives approach to educate patients to protect their sexual partners.14

Conflicts of interest

All authors have none to declare.

References

  • 1.Stegmann B.J., Carey J.C. TORCH Infections. Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes infections. Curr Women's Health Rep. 2002;2:253–258. PubMed PMID: 12150751. [PubMed] [Google Scholar]
  • 2.Young A.B., Reid D., Grist N.R. Is cytomegalovirus a serious hazard to female hospital staff? Lancet. 1983;1:975–976. doi: 10.1016/s0140-6736(83)92092-5. PubMed PMID: 6132279. [DOI] [PubMed] [Google Scholar]
  • 3.Sharma P., Gupta I., Ganguly N.K., Mahajan R.C., Malla N. Increasing toxoplasma seropositivity in women with bad obstetric history and in newborns. Natl Med J India. 1997 Mar–Apr;10:65–66. [PubMed] [Google Scholar]
  • 4.Singla N., Jindal N., Aggarwal A. The seroepidemiology of Rubella in Amritsar (Punjab) Indian J Med Microbiol. 2004;22:61–66. [PubMed] [Google Scholar]
  • 5.Sen M.R., Shukla B.N., Tuhina B. Prevalence of serum antibodies to TORCH infection in and around Varanasi, Northern India. J Clin Diagn Res. 2012;9:1483–1485. doi: 10.7860/JCDR/2012/4550.2538. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Turbadkar D., Mathur M., Rele M. Seroprevalence of torch infection in bad obstetric history. Indian J Med Microbiol. 2003;21:108–110. http://www.ijmm.org/text.asp?2003/21/2/108/7985 [serial online] [cited 2014 Jun 8] Available from: [PubMed] [Google Scholar]
  • 7.Rathore S., Jamwal A., Gupta V. Herpes simplex virus type 2: seroprevalence in antenatal women. Indian J Sex Transm Dis. 2010;31:11–15. doi: 10.4103/2589-0557.68994. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Kaur R., Gupta N., Nair D., Kakkar M., Mathur M.D. Screening for TORCH infections in pregnant women: a report from Delhi. Southeast Asian J Trop Med Public Health. 1999 Jun;30:284–286. PubMed PMID: 10774696. [PubMed] [Google Scholar]
  • 9.Radhiga S.T., Kalpana S., Natarajan Mayil Vahanan. Screening of cytomegalo virus (CMV) among blood donors – can we include CMV in Transfusion Transmitted Infection? Ann Biological Res. 2012;3:5420–5422. [Google Scholar]
  • 10.Seth P., Manjunath N., Balaya S. Rubella infection: the Indian scene. Rev Infect Dis. 1985 Mar–Apr;7(suppl. 1):S64–S67. doi: 10.1093/clinids/7.supplement_1.s64. [DOI] [PubMed] [Google Scholar]
  • 11.Ogoina D., Onyemelukwe G., Musa B., Obiako R. Seroprevalence of IgM and IgG antibodies to toxoplasma infection in healthy and HIV-positive adults from Northern Nigeria. J Infect Dev Ctries. 2013;7(5):398–403. doi: 10.3855/jidc.2797. http://www.jidc.org/index.php/journal/article/view/23669429 Available at: Accessed 09.06.14. [DOI] [PubMed] [Google Scholar]
  • 12.NACO . 2013. ART Guidelines for HIV Infected Adults and Adolescents.http://naco.gov.in/ Accessed 09.06.14. [Google Scholar]
  • 13.Nissapatorn V., Lee C., Quek K.F. Toxoplasmosis in HIV/AIDS patients : a current situation. Jpn J Infect Dis. 2004 Aug;57:160–165. [PubMed] [Google Scholar]
  • 14.International HIV/AIDS Alliance. Positive Prevention Draft Background Paper. http://www.cdc.gov/hiv/topics/prev_prog/ahp/resources/other/pdf/Positive_Prevention_IHA_Marked.pdf Accessed 09.06.14.
  • 15.Sgaier S.K., Mony P., Jayakumar S. Prevalence and correlates of Herpes Simplex Virus-2and syphilis infections in the general population in India. Sex Transm Infect. 2011 Mar;87:94–100. doi: 10.1136/sti.2010.043687. [DOI] [PubMed] [Google Scholar]

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