Survey of obstetrician-gynecologists in the United States about toxoplasmosis

Hygiene measures as primary prevention of toxoplasmosis during pregnancy: A systematic review

Background Hygiene measures are recommended to prevent toxoplasmosis during pregnancy, although screening for seroconversion in pregnant women currently are debated and practices vary among countries. Objectives The purpose of this systematic literature review was to assess the effectiveness of hygiene measures during pregnancy to prevent toxoplasmosis infection. Search Strategy We followed the standard MOOSE and PRISMA criteria when conducting this systematic review and reporting the results. Selection criteria A systematic literature search was conducted for studies focused on congenital toxoplasmosis prevention, toxoplasmosis prevention during pregnancy, toxoplasmosis prevention and hygiene measures, which were published between 1970 and August 2020, using the databases of PubMed, Scope Med, EMBASE, and the Cochrane library. Data collection and analysis Our literature search identified 3964 articles, 3757 were excluded after review of title or abstract and 67 studies were considered relevant to the subject. We reviewed risk factors for toxoplasmosis infection during pregnancy and for congenital toxoplasmosis, preventive measures for toxoplasmosis during pregnancy, including: dietary recommendations, pet care measures, environmental measures, knowledge of risk factors and ways to control toxoplasmosis infection, knowledge of risk factors for infection by health professionals, knowledge of primary prevention measures by pregnant women. Conclusion: Hygiene measures are effective and applicable primary prevention to reduce toxoplasmosis and avoid congenital toxoplasmosis and its consequences. Funding No.

Toxoplasmosis in pregnancy: a clinical, diagnostic, and epidemiological study in a referral hospital in Rio de Janeiro, Brazil

Toxoplasmosis in pregnant women can cause significant morbidity and mortality in the fetus, which may be mitigated by early diagnosis and treatment. Social factors have also been related to the risk of developing the congenital form of toxoplasmosis, since some of these factors interfere directly in the quality of prenatal care. This study aimed to describe the clinical, laboratory, and epidemiological data of pregnant women diagnosed with toxoplasmosis and their newborns followed up at a referral hospital in Rio de Janeiro, Brazil. This was descriptive cohort study of 334 pregnant women with toxoplasmosis followed from May 2014 to December 2017. We conducted interviews to assess knowledge about the disease and its preventive measures, analyzed clinical and laboratory data during antenatal visits, and collected data from the newborns’ medical charts.

Results

This was a predominantly low-income women cohort study, with little schooling, mainly referred from public health services late in pregnancy (178; 53.3%), in the second and third trimesters (286; 85.6%). Diagnosis of acute toxoplasmosis had not been confirmed in 171 cases (51.2%). Out of 183 (54.9%) women who had initiated treatment at the original health services, 45 (24.6%) received an incorrect prescription. Seventy-two amniocenteses were performed, with positive real-time polymerase chain reaction (qPCR) in the amniotic fluid in two cases (2.8%). Congenital toxoplasmosis at birth was identified in eight newborns (5.4%).

Conclusion

Late referral to specialized medical services, inadequate toxoplasmosis management at the original prenatal care services, and social vulnerabilities are contributing factors to the persistent occurrence of congenital toxoplasmosis cases.

The first report of the evaluation of the knowledge regarding toxoplasmosis among health professionals in public health centers in Rabat, Morocco

Background

The assessment of the knowledge of Toxoplasma gondii infection among health professionals is essential to design an effective management strategy. The current study was conducted to assess the knowledge and perception of health professionals working in urban public health centers of different parts of Rabat in Morocco.

Methods

A cross-sectional study was conducted from March 15 to June 15, 2017, in urban public health centers selected in the prefecture of Rabat in Morocco. A structured questionnaire was completed by participants and included questions on the epidemiology and diagnosis of toxoplasmosis and clinical issues related to the infection.

Results

Ninety-six health professionals participated, including medical doctors, nurses, midwives, and laboratory technicians. Most of them were female (86, 89.58%). The mean age was 40.51 ± 10.26 years, and the mean length of time working in the field of healthcare was 15.92 ± 8.55 years. Eighty one percent (86, 81.25%) of health professionals knew the agent of toxoplasmosis, and 62 (64.5%) knew the definitive host of the parasite. Regarding clinical symptoms, 55 (57.29%) of the respondents knew that toxoplasmosis is an asymptomatic disease in immunocompetent persons. More than half of the respondents correctly identified the main routes of transmission: eating raw or undercooked meats, unwashed fruits and vegetables, and having direct contact with cats. However, only 29 (30.21%) of them believed that water can be a risk factor for the transmission of toxoplasmosis. Regarding diagnosis, only 14 (14.58%) health professionals knew about the avidity test.

Conclusions

The implementation of educational interventions is recommended to raise awareness of toxoplasmosis among health professionals who provide prenatal care in public health centers.

High burden and low awareness of toxoplasmosis in the United States

Toxoplasmosis, a disease with diverse clinical manifestations, caused by infection with the Apicomplexan parasite, Toxoplasma gondii (T. gondii), is a major source of morbidity and mortality in the United States. Although toxoplasmosis prevalence and mortality have declined over the past two decades, the CDC considers this disease a neglected parasitic infection requiring public health action. Here, we overview the literature to bring attention to the prevalence of the disease in the United States, and high economic burden associated with the disease. The conclusions to be drawn are clear: there is low awareness and underestimation of the disease burden amongst healthcare professionals; a high economic burden associated with the disease; relapse rates to treatment represent additional mortality and morbidity and further costs for the healthcare system; and better treatments are necessary to combat this public health threat.

Spatial and simultaneous representative seroprevalence of anti-Toxoplasma gondii antibodies in owners and their domiciled dogs in a major city of southern Brazil

Toxoplasmosis, caused by Toxoplasma gondii, has traditionally been considered an important water and foodborne protozoonosis with important public health considerations. Although felids play a well-established role as definitive hosts, canine epidemiological involvement in the parasite's life cycle remains questionable and controversial. The increasing closeness of the human-dog bond, particularly seen in urban settings, has been recognized as a historically unprecedented worldwide movement. Sharing daily lives in the same households, dogs may be exposed to similar associated risks of T. gondii infection as their owners. Thus, epidemiological assessment of the intra-domiciled environment, especially among socio-economically different human populations, may provide novel information regarding the actual role of dogs in animal and human toxoplasmosis. Despite spatial approaches being recently used for other water and foodborne diseases, no study has been conducted on the simultaneous spatial seroprevalence of both human and animal IgG anti-T. gondii antibodies in urban areas of major cities. Accordingly, the aim of the present study was to assess the seroprevalence and associated variables of Toxoplasma infection in owners and their domiciled dogs in Londrina, southern Brazil. Human and canine seroprevalence rates and variables associated with seroprevalence were investigated through representative random sampling among 564 households, which included 597 owners and 729 dogs. Overall, statistically significant differences between the seroprevalence of human and dog anti-T. gondii antibodies were found by Immunofluorescence Antibody Testing in 248/597 (41.54%) owners and 119/729 (16.32%) dogs. Through multiple analysis, significant concomitant variables for seropositivity of household individuals (people and dogs) were determined, including public sewer service, yard cleaning frequency, and having a dirty yard. Although no statistically significant multiple logistic model was observed among owners, univariate analysis detected associations with monthly income, soil contact, and occupation. Among dogs, the absence of other dogs and the absence of a dirty yard were concomitant significantly protective associated factors. Age differences between seropositive and seronegative individuals was significant only for human beings, with the median age of negative individuals significantly higher than positive individuals. Although no spatial clusters were identified for humans or residences, a significant cluster was identified for dogs. In conclusion, characteristics of urban toxoplasmosis may include significantly higher owner seroprevalence than their owned dogs, with canine seroprevalence directly associated with having more dogs and a dirty backyard, and spatial differences in both human and dog exposures. Although not a good indicator for human foodborne diseases, dogs may be a reliable sentinel for environmental infection. Moreover, such a holistic approach may provide crucial information for more focused prevention and monitoring programs, particularly in households with multiple pets and trash-filled backyards.

Survey of obstetrician-gynecologists in the United States about toxoplasmosis: 2012 update

PURPOSE

Toxoplasmosis, caused by the parasite Toxoplasma gondii, can have serious impacts on fetal development in the setting of acute maternal primary infection. The American College of Obstetricians and Gynecologists (ACOG) sought to determine current knowledge, practices, opinions, and educational preferences regarding T. gondii infection in pregnancy among ACOG members practicing prenatal care.

METHODS

ACOG sent a survey to 1,056 members chosen by stratified random sampling from membership lists, including 370 participants and 686 non-participants in the Collaborative Ambulatory Research Network (CARN). Mailings were sent up to four times to nonresponders.

RESULTS

Survey minimum response rates were 40.3% (CARN) and 19.7% (non-CARN); response rates adjusted for imputed non-eligibility were 59.7% (CARN) and 22.6% (non-CARN). Among providers, 80.2% had diagnosed no acute maternal T. gondii infections in the past 5 years, 12.7% correctly identified the screening role of the Toxoplasma avidity test, 42.6% performed serologic T. gondii screening for at least some asymptomatic pregnant women, and 62.1% of those who so did used appropriate approaches. Providers in the northeastern United States were 2.02 times more likely to routinely screen than those in the west (p = 0.025) and female providers were 1.48 times more likely than male providers (p = 0.047). The potential educational interventions considered useful by the most practitioners were updated ACOG guidelines on screening (81.4%) and management (71.7%) for acute T. gondii infection in pregnancy.

CONCLUSIONS

ACOG members would benefit from educational efforts targeted at risk factor counseling and screening approaches.

Toxoplasmosis preventive behavior and related knowledge among Saudi pregnant women: an exploratory study

INTRODUCTION

Many cases of congenital toxoplasmosis can be prevented provided that pregnant women following hygienic measures to avert risk of infection and to reduce severity of the condition if primary prevention failed.

OBJECTIVES

This descriptive exploratory study aimed to assess the risk behavior and knowledge related to toxoplasmoisis among Saudi pregnant women attending primary health care centers (PHCs) in Al Hassa, Saudi Arabia and to determine socio-demographic characteristics related to risk behavior and knowledge.

METHODS

All Saudi pregnant women attending antenatal care at randomly selected six urban and four rural PHCs were approached. Those agreed to participate were interviewed using a pre-tested structured questionnaire collecting data regarding socio-demographic, obstetric history, toxoplasmosis risk behaviors and related knowledge.

RESULTS

Of the included pregnant women, 234 (26.8%) have fulfilled the criteria for toxoplasmosis preventive behavior recommended by Centers for Disease Prevention and Control to prevent congenital toxoplasmosis, while 48.9% reported at least one risk behavior and 24.3% reported ? two risk behaviors. Logistic regression model revealed that pregnant women aged 20 to < 30 years and those with previous history of unfavorable pregnancy outcome were more likely to follow toxoplasmosis preventive behavior. Toxoplasmosis-related knowledge showed that many women had identified the role of cats in disease transmission while failed to identify other risk factors including consumption of undercooked meats, unwashed fruits and vegetables, and contacting with soil. Predictors for pregnant women to be knowledgeable towards toxoplasmosis included those aged 30 to <40 years (OR=1.53), with ? secondary education (OR=1.96), had previous unfavorable pregnancy outcomes (OR=1.88) and investigated for toxoplasmosis (OR=2.08) as reveled by multivariate regression model.

CONCLUSION

Pregnant women in Al Hasas, Saudi Arabia, are substantially vulnerable to toxoplasmosis infection as they are lacking the necessary preventive behavior. A sizable portion have no sufficient knowledge for primary prevention of congenital toxoplasmosis, health education at primary care is necessary to avert the potential toxoplasmosis related complications especially in the neonates.

Knowledge of toxoplasmosis among doctors and nurses who provide prenatal care in an endemic region

Congenital toxoplasmosis is a potentially severe infection and its prevention is most often based on serological screening in pregnant women. Many cases could be prevented by simple precautions during pregnancy. Aiming to assess the knowledge about toxoplasmosis among professionals working in antenatal care in a high prevalent region, a questionnaire was administered to 118 obstetric nurses and physicians attending at primary care units and hospitals. The questionnaire was self-completed and included questions on diagnosis, clinical issues, and prevention. Only 44% of total answers were corrected. Lower scores were observed among those with over 10 years of graduation, working in primary care units, and nurses. Errors were mainly observed in questions of prevention and diagnosis. As congenital toxoplasmosis is a mother-to-child (MTC) transmitted disease, early diagnosis and treatment can prevent serious and irreversible fetal damage. Thus, doctors and nurses who provide prenatal care must be appropriately trained on prophylactic, diagnostic, and clinical aspects of toxoplasmosis. The authors suggest that measures should be taken for continuing education regarding toxoplasmosis in pregnancy.

Obstetrician/gynecologists' knowledge, attitudes, and practices regarding prevention of infections in pregnancy

BACKGROUND

Maternal infection during pregnancy is a well-recognized cause of birth defects and developmental disabilities, as well as an important contributor to other adverse pregnancy outcomes. The objective of the present survey was to gain information about the knowledge, attitudes, and practices of obstetrician/gynecologists regarding prevention of infections during pregnancy.

METHODS

A survey was mailed to 606 Collaborative Ambulatory Research Network (CARN) members of the American College of Obstetricians and Gynecologists (ACOG) (approximately 2% of membership). CARN members were sampled to demographically represent ACOG.

RESULTS

Of the 606 eligible respondents, surveys were received from 305 (response rate: 50%). Most obstetrician/gynecologists knew that specific actions by pregnant women could reduce the risk of infection. Seventy-nine to eighty-eight percent reported counseling pregnant women about preventing infection from Toxoplasma gondii, hepatitis B virus, and influenza, 50%-68% about varicella-zoster virus, Listeria monocytogenes, and Parvovirus B19, and <50% about cytomegalovirus, Bordetella pertussis, and lymphocytic choriomeningitis virus. The majority reported time constraints were a barrier to counseling, although most reported educational materials would be helpful.

CONCLUSIONS

Knowledge was accurate and preventive counseling was appropriate for some infections, but for others it could be improved. Further studies are needed to identify strategies to increase preventive counseling.

Toxoplasmosis prevention and testing in pregnancy, survey of obstetrician-gynaecologists

Toxoplasmosis in pregnant women can lead to congenital disease with severe neurological and ocular complications in the foetus. In 2006, we surveyed US obstetrician-gynaecologists to determine their knowledge and practices about toxoplasmosis prevention and testing. Questionnaires were mailed (four mailings) to a random sample of 1200 of the 33,354 members of the American College of Obstetricians and Gynecologists (ACOG). Of the 1200 surveyed, 502 (42%) responded. The respondents were similar to all ACOG members by gender, region of the country and practice type (P > 0.5), and age (respondents were slightly younger, mean 46 years versus 47 years). To prevent toxoplasmosis, most respondents indicated that they counsel pregnant women about cat litter (99.6%), but fewer counselled about eating undercooked meat (77.6%), handling raw meat (67.4%), gardening (65.4%) or washing fruits and vegetables (34.2%). Many (73.2%) respondents were not aware that some Toxoplasma IgM tests have had a high false positive rate, and most (91.2%) had not heard of the avidity test, which can help determine the timing of Toxoplasma gondii infection in relation to pregnancy. There is a need for more education about T. gondii serological testing, particularly the Toxoplasma avidity test. US obstetrician-gynaecologists are providing beneficial counselling to their patients, but could provide more information about undercooked meat and soil risks.

Avaliação da aplicação do protocolo de triagem pré-natal para toxoplasmose em Belo Horizonte, Minas Gerais, Brasil: estudo transversal em puérperas de duas maternidades

Foi realizado estudo transversal, em duas maternidades públicas de Belo Horizonte, Minas Gerais, Brasil, com entrevista de 420 puérperas, de agosto de 2004 a maio de 2005, para avaliar a aplicação do protocolo de triagem pré-natal para toxoplasmose implantado, e as orientações oferecidas às gestantes suscetíveis. A cobertura do pré-natal foi de 98%, e da primeira triagem sorológica de 97%. O início do pré-natal e a realização da primeira sorologia ocorreram em média com 16 semanas. Foram identificadas 163 gestantes suscetíveis à toxoplasmose: 44% não repetiram a sorologia, e 42% alegaram não ter recebido orientações para prevenção da toxoplasmose. O início precoce do pré-natal e um maior número de consultas foram associados à repetição da sorologia e ao recebimento de orientações. As informações oferecidas foram: evitar contato com gatos (95%), não ingerir ou manipular carne crua (70%) e lavar cuidadosamente as hortaliças (53%). Concluiu-se que a adesão inadequada ao protocolo de triagem pré-natal de toxoplasmose encontrada no estudo pode gerar gastos financeiros sem melhoria na qualidade do cuidado perinatal.

Symptomatic toxoplasma infection due to congenital and postnatally acquired infection

AIMS

To determine the incidence and severity of symptomatic toxoplasma infection presenting during childhood due to congenital or postnatally acquired infection.

METHODS

Between 2002 and 2004, newly diagnosed children (<16 years) with signs or symptoms of congenital or ocular toxoplasmosis were reported by clinicians to the British Paediatric and Ophthalmic Surveillance Units or by toxoplasma referral laboratories. Confirmed cases were estimated to have a greater than 50% probability of congenital and/or ocular toxoplasmosis, based on clinical and serological findings.

RESULTS

Thirty eight children had confirmed toxoplasma infection. Twenty two (58%) were classified with congenital infection (cumulative incidence for England and Wales 1.62[corrected]/100,000 live births; 95% CI 0.85[corrected] to 2.83[corrected]), of whom 2 (9%) were stillborn, 7 (32%) live births had intracranial abnormalities and/or developmental delay (5 of whom had retinochoroiditis), and 10 (45%) had retinochoroiditis with no other abnormalities reported. A further 16 (42%) children were classified as infected after birth; all had retinochoroiditis.

CONCLUSIONS

The low burden of symptomatic congenital toxoplasmosis combined with the lack of evidence of an effective treatment support current policy not to offer prenatal or neonatal screening for toxoplasma infection. Primary prevention strategies need to address acquisition of infection in childhood which accounts for half the ocular disease due to toxoplasma infection in children in the UK and Ireland.

Commercial laboratory IgM testing for Toxoplasma gondii in pregnancy: a 20-year experience

OBJECTIVE

This study was performed to review the clinical utility of commercial laboratory Toxoplasmosis-specific IgM testing during pregnancy and outcomes of the gestation at our institution.

METHODS

A retrospective review of all women referred for suspected acute Toxoplasma gondii infection during pregnancy from 1984 through 2004 was performed. Women were diagnosed with suspected acute toxoplasmosis based on commercial laboratory serologic antibody testing. All women had blood sent to a recognized reference laboratory for antibody testing within 2 weeks of the commercial laboratory results. The study protocol was approved by the Institutional Review Board. Chi-square analysis were used with a significance of P < .05.

RESULTS

A total of 130 women were evaluated during the study period with 116 IgM positive results from the commercial laboratories. The commercial laboratory antibodies were as follows: IgM positive with IgG negative (n = 20), IgM positive with IgG positive (n = 96), and IgM negative with IgG positive (n = 14). There was a significant reduction in the IgM positive results when comparing commercial laboratory (n = 116) with the reference laboratory results (n = 28; p < .001). Acute toxoplasmosis infection was diagnosed in 7 (5%) of the women. All cases of acute toxoplasmosis infection had a positive commercial laboratory IgM result. The false positive rate for the commercial laboratory IgM was 88.6% and the diagnostic indices were sensitivity 100%, specificity 11.4%, positive predictive value 6% and negative predictive value 100%.

CONCLUSION

Commercial laboratory Toxoplasmosis-specific IgM is associated with a high false positive rate. The commercial and reference laboratory IgM results identified all cases of acute toxoplasmosis infection. Commercial laboratories reflexively obtaining reference laboratory confirmation of positive results could reduce costs associated with testing, referrals, retesting, and invasive procedures.

Prevention of toxoplasmosis in pregnancy: knowledge of risk factors

BACKGROUND: Infection with Toxoplasma gondii is common and usually asymptomatic, although it can have catastrophic consequences in a pregnant woman if passed to her developing fetus. Counseling of pregnant women about risk factor reduction may reduce the risk of congenital toxoplasmosis. This study was undertaken to assess and compare the knowledge of obstetricians and internists or family practitioners regarding well-established risk factors for toxoplasmosis infection. METHODS: The study surveyed 102 obstetricians, internists and family practitioners to assess their knowledge of risk factors for toxoplasmosis infection as well as their practices for primary prevention counseling of pregnant women. Responses were analyzed for differences. RESULTS: Obstetricians were more likely than internists or family practitioners to provide appropriate counseling on reducing the two most common risk factors for toxoplasmosis infection (undercooked meat consumption and gardening without gloves). However, over one quarter of all participants inappropriately advised pregnant women to avoid all cat contact. Obstetricians, internists and family practitioners were all likely to fail to identify undercooked meat consumption as the primary risk factor for toxoplasmosis transmission. CONCLUSIONS: Obstetricians appear to provide more appropriate counseling for primary prevention of toxoplasmosis than internists and family practitioners, but both groups of physicians inappropriately advised avoidance of all cat contact. Education of obstetricians, internists and family practitioners on risk factors for toxoplasmosis transmission is needed and may lower the rate of congenital toxoplasmosis as well as decrease the frequency of cat abandonment during pregnancy.

Toxoplasmosis in pregnancy

Pregnant women who acquire infection from Toxoplasma gondii usually remain asymptomatic, although they can still transmit the infection to their fetuses with severe consequences. Given the asymptomatic nature of most Toxoplasma infections, primary prevention in pregnant women may lower the risk of congenital toxoplasmosis. Both consumption of undercooked meat and unprotected contact with soil are independent risk factors for T. gondii seroconversion during pregnancy, while contact with cat litter may pose a risk in certain situations. However, many pregnant women lack knowledge of these risk factors. This article reviews toxoplasmosis infection in pregnancy, with an emphasis on risk factors and appropriate counseling of pregnant women.

Toxoplasmosis-related knowledge and practices among pregnant women in the United States

Background: Infection with Toxoplasma gondii during pregnancy can lead to severe illness in the fetus. Many T. gondii infections are preventable by simple hygienic measures.

Methods: We surveyed pregnant women in the US to determine their knowledge about toxoplasmosis and their practices to prevent infection. Volunteer obstetricians selected to be demographically representative of the American College of Obstetricians and Gynecologists recruited the participants.

Results: Of 403 women responding to the survey, 48% indicated that they had heard or seen information about toxoplasmosis; however, only 7% were aware of being tested for the disease. Forty percent of responding women knew that toxoplasmosis is caused by an infection, but 21% thought that a poison causes it. The highest level of knowledge was about cats and T. gondii ; 61% responded that the organism is shed in the feces of infected cats and 60% responded that people could acquire toxoplasmosis by changing cat litter. There was a low level of knowledge about other risk factors; only 30% of the women were aware that T. gondii may be found in raw or undercooked meat. Nevertheless, a high percentage of women indicated that they do not eat undercooked meat during pregnancy and that they practice good hygienic measures such as washing their hands after handling raw meat, gardening or changing cat litter.

Conclusion: Except for the risk of transmission from cats, knowledge among pregnant women about toxoplasmosis is low. However, toxoplasmosis-preventive practices are generally good, suggesting that providers should continue to offer education about practices that help prevent foodborne diseases in general as well as information about preventing toxoplasmosis specifically.