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Revista do Instituto de Medicina Tropical de São Paulo

versão On-line ISSN 1678-9946

Rev. Inst. Med. trop. S. Paulo vol.56 no.5 São Paulo set./out. 2014

http://dx.doi.org/10.1590/S0036-46652014000500011 

Toxoplasmosis

TOXOPLASMOSIS-RELATED KNOWLEDGE AMONG PREGNANT AND POSTPARTUM WOMEN ATTENDED IN PUBLIC HEALTH UNITS IN NITERÓI, RIO DE JANEIRO, BRAZIL

Conhecimento sobre toxoplasmose entre gestantes e puérperas atendidas na rede pública de saúde do município de Niterói, Rio de Janeiro, Brasil

Patricia Riddell Millar (1)   (2)  

Fernanda Loureiro de Moura (1)   (2)  

Otílio Machado Pereira Bastos (1)  

Danuza Pinheiro Bastos Garcia de Mattos (1)  

Ana Beatriz Monteiro Fonseca (3)  

Adriana Pittella Sudré (1)  

Daniela Leles (1)  

Maria Regina Reis Amendoeira (2)  

(1)Departamento de Microbiologia e Parasitologia da Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil

(2)Laboratório de Toxoplasmose, LabTOXO, Instituto Oswaldo Cruz -Fiocruz, Rio de Janeiro/RJ, Brazil

(3)Departamento de Estatística da Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil

ABSTRACT

The present study conducted a toxoplasmosis-related knowledge level survey with 400 pregnant and puerperal women attended in public health units in the municipality of Niterói, Rio de Janeiro. Only 111 (27.8%) women claimed to know about the disease. Most of them (n = 289; 72.2%) had never heard about toxoplasmosis nor knew how to prevent the infection by Toxoplasma gondii. A significant difference (p = 0.013) regarding the presence of anti-T. gondii IgG was observed between women who claimed to know about the disease and those who had never heard about it. These results highlight the importance of a systematic serological screening process for toxoplasmosis, as well as the importance of primary prevention by accurate information during prenatal care, an important Public Health action to be implemented.

Key words: Toxoplasmosis; Pregnant women; Knowledge; Primary prevention

RESUMO

Este estudo teve por objetivo realizar um levantamento do conhecimento de 400 gestantes e puérperas atendidas na rede pública de saúde do município de Niterói, Estado do Rio de Janeiro sobre a toxoplasmose. Apenas 111 (27,8%) participantes relataram conhecer a doença. A maioria 289 (72,2%) nunca ouviu falar sobre a toxoplasmose, principalmente sobre as formas de prevenção da infecção pelo Toxoplasma gondii. Foi encontrada diferença significativa entre as pacientes que disseram conhecer a toxoplasmose e aquelas que relataram desconhecer a doença com relação à presença de anticorpos IgG anti- T.gondii (p = 0,013). Estes resultados permitem ressaltar a importância do rastreamento sorológico sistemático na infecção toxoplásmica, bem como a prevenção primária por meio de informações corretas durante o pré-natal, sendo esta uma importante medida de saúde pública a ser implementada.

INTRODUCTION

Toxoplasmosis is a parasitic infection caused by protozoan Toxoplasma gondii (T. gondii). T. gondii is a facultative heteroxenous parasite, intracellular obligatory, found in different species of vertebrates, including humans11,27. In felids, its definitive hosts, the parasite reproduces asexually and sexually, while in its intermediate hosts (birds and mammals), the parasite only reproduces asexually.

Transmission varies according to several factors, such as the environment, nutrition, and cultural habits12. Susceptible humans can be infected by T. gondii through ingestion of bradyzoites in raw or undercooked meat and other animal products6,25; contact with feces of domestic felids or soil contaminated with sporulated oocysts10,15; ingestion of sporulated oocysts contaminating water7,3, fruits and vegetables2,34; and also by tachyzoites transmitted through placenta, blood transfusion, and organ transplant22,27.

T. gondii can cause a congenital infection when women are infected during pregnancy35, or less commonly when chronic infections become disseminated due to immune-compromising32 or reinfections16,20,. Studies reported that most infected women are asymptomatic28. If congenital toxoplasmosis is not treated, severe or fatal sequelae can occur21. Fetal transmission rates depend on three concomitant factors: maternal parasitemia, gestational age at infection, and maternal immune response to T. gondii37.

The most frequently observed clinical signs of congenital toxoplasmosis are premature birth, low birth weight, retinocoroiditis, squint, jaundice, cerebral calcifications, hydrocephalus, and hepatosplenomegaly5.

There are very few reports of prenatal screening in Brazil14. Moreover, most of the studies were based on selected sampling, because there is no national screening of women or children for toxoplasmosis in the country. Studies on pregnant women reported anti-T.gondii IgG occurrence ranging from 31%, in Rio Grande do Sul17, to 91.6%, in Mato Grosso do Sul13 (two different states in Brazil). The risks of fetal infection are directly associated with disease prevalence in the population, and with the number of women in fertile age not infected and susceptible to infection during pregnancy23. Thus, the importance of preventive actions should be emphasized, as well as the early diagnosis and treatment, to prevent or attenuate fetal infection4,9,18,24,31,36.

A previous survey of pregnant and postpartum women in the same population in Niterói29 showed that a significant number (41.5%) of susceptible women can acquire Toxoplasma gondii during pregnancy. These susceptible patients are at risk of transmitting the parasite to their offspring through vertical transmission.

Congenital toxoplasmosis prevention can be performed at primary, secondary, and tertiary levels1. Primary prevention is characterized by educational programs and Public Health19. Secondary prevention consists of serological screening procedures during prenatal care to detect and treat acute infections by T. gondii, thus reducing the sequelae caused by congenital toxoplasmosis19. Tertiary prevention is focused on the newborn, in which newborns with subclinical congenital toxoplasmosis are treated in order to prevent further complications, especially ocular and risks of reactivation26.

The present study surveyed pregnant and puerperal women who attended public health units in the municipality of Niterói, Rio de Janeiro, in order to assess their toxoplasmosis-related knowledge level. Questions in the survey focused on infection pathways and disease prevention.

MATERIAL AND METHODS

A cross-sectional survey was given to pregnant (n = 276) and puerperal (n = 124) women from September 2010 to September 2011. All women signed the Free and Informed Consent term, according to resolution No. 196/96 of the National Health Council. The women were interviewed using a survey made up of multiple choice questions regarding transmission, symptoms, prevention, vertical transmission, diagnosis, and treatment of Toxoplasma gondii. Personal information (age and educational level) of the pregnant women were also collected. After the interview, a brochure with information about toxoplasmosis and prevention of this zoonosis was given to each woman. All women had already been subjected to serological tests for toxoplasmosis in a previous study29, where IgG and IgM anti-T. gondii antibodies were analyzed using an indirect fluorescent antibody test (IFAT) with a cutoff point of 1:16; and ELISA (BioKit®, Barcelona, Spain), in which readings at or above the cutoff value were considered positive.

Participants were selected by convenience sampling. Postpartum women between the first and tenth day postpartum and pregnant women at any gestational age were eligible. On the other hand, women who did not agree to sign the consent statement were excluded from the analysis.

The questionnaires guided the face-to-face interviews conducted by the researchers, who provided guidance about the proposed research and read the consent form out loud, which the interviewees then signed. The questions were answered orally by the interviewees and recorded by the researchers, in order to facilitate the understanding of the subject matter. As the participant's name was written on the questionnaire, the risk of interviewing the same person twice was eliminated.

This study was conducted in the municipality of Niterói, located in Rio de Janeiro State. This municipality is considered of medium size (133 km2 of territorial extension) with approximately 489,562 inhabitants, and an urbanization index of 100%. The urban growth setting is unequal, and neighborhoods of high and medium classes coexist alongside slums, where households exhibit poor health and sanitation conditions, with a low-income population.

Data were collected at a maternity and prenatal ambulatory of the Antônio Pedro University Hospital of the Fluminense Federal University; at the Viradouro, Souza Soares, Palácio and Preventório I and II units of the “Programa Médico de Família” (Family Doctor Program); and at the “Policlínica Comunitária Sérgio Arouca” (Sérgio Arouca Community Polyclinic) of the Municipal Health Foundation of Niterói.

The Antônio Pedro University Hospital is a referral hospital for high-risk pregnancy, and receives patients living in Niterói, as well as in other neighboring cities, such as São Gonçalo, Maricá and Itaboraí. Units of the “Programa Médico de Família” as well as the “Policlínica Comunitária Sérgio Arouca” provide prenatal care for low-risk patients who live in specified regions of Niterói. Hence, each unit has its own area of activity and number of registered families. The people who use these services are characterized mostly by low educational level, financial difficulties, and lack of adequate sanitary conditions.

Statistical analyses were performed using the Chi-square test and the exact Fisher test. A p value below 0.05 was considered significant. Data were analyzed using the software SPSS 10.0 (Statistical Package for the Social Sciences).

The present study was approved by the Ethics Committee for Research on Human Beings of the Fluminense Federal University and Antônio Pedro University Hospital (CAAE number 0059.0.258.000-10), in accordance with Resolution 196/96 of the National Health Council.

RESULTS

Out of the 400 completed questionnaires, 276 (69%) were answered by pregnant and 124 (31%) by postpartum women. Regarding the knowledge about toxoplasmosis, only 111 (27.8%) women claimed to know about the disease. Most of them (n = 289; 72.2%) had never heard about toxoplasmosis nor knew how to prevent the infection by Toxoplasma gondii. The presence of IgG anti-T.gondii was significantly different between patients who knew about toxoplasmosis and those who did not (Table 1). There was no significant difference between the knowledge about toxoplasmosis and the location where data were collected (Table 2).

Table 1 Distribution of pregnant and postpartum women referred to public health units of Niterói-RJ, Brazil, according to toxoplasmosis knowledge and presence of anti-Toxoplasma gondii IgG antibodies, 2010-2011 

Variables Reagents n (%) Not reagents n (%) Total n (%) p
Know about toxoplasmosis
Yes 54 (48.6) 57 (51.4) 111 (100.0) 0.013
No 180 (62.3) 109 (37.7) 289 (100.0)
Total 234 (58.5) 166 (41.5) 400 (100.0)

IgG: Immunoglobilin G.

Table 2 Distribution of pregnant and postpartum women referred to public health units of Niterói-RJ, Brazil, according to toxoplasmosis knowledge and sampling places 

Variables Know n (%) Do not know n (%) Total n (%) p
HUAP* 89 (29.7) 211 (70.3) 300 (100.0)
PCSA 17 (25.4) 50 (74.6) 67 (100.0) 0.187
PMF 5 (15.2) 28 (84.8) 33 (100.0)
Total 111 (27.8) 289 (72.2) 400 (100.0)

*Reference category; HUAP: Hospital Universitário Antônio Pedro; PCSA: Policlínica Comunitária Sérgio Arouca; PMF: Programa Médico de Família.

From all women who claimed to know about toxoplasmosis, 36.9% (41/111) correctly associated T. gondii transmission with the consumption of raw and/or undercooked meat, 25.2% (28/111) with the consumption of vegetables, and 95.5% (106/111) with contact to feline feces. On the other hand, 26.1% (29/111) erroneously answered that transmission also occurs by pigeon's feces, and 36.9% (41/111) that it also occurs by other animals' feces, such as dogs, rabbits, rats and birds. It is noteworthy that 14.4% (16/111) of the women that knew about toxoplasmosis did not know that this disease could be vertically transmitted.

Regarding outcome, 83.8% of the women did not know the symptoms of toxoplasmosis. Among the women who claimed to know some of the symptoms, fetal malformations and visual impairment were the most cited ones (11.5% [n = 46] and 11% [n = 44], respectively). Fever, headache and muscular pain were also mentioned.

The lack of knowledge about how to prevent the disease was observed in 85% (n = 340) of the interviews, even in those women who claimed to know about toxoplasmosis (Table 3). Relationship between educational level and the knowledge about toxoplasmosis is demonstrated in Table 4.

Table 3 Description of knowledge about toxoplasmosis prevention from pregnant and postpartum women referred to public health units of Niterói-RJ, Brazil 

Variables n (400) %
Forms of prevention
Wash raw foods with clean water. 48 12.0
Wash hands before and after handling food, soil and cat litter box. 53 13.3
Not ingest raw or undercooked meat. 50 12.5
Use gloves when handling soil or cat litter box. 40 10.0
Feed cats with cat food or well cooked meat. 24 6.0
When pregnant women get infected, she should look for medical assistance to avoid transmission to the baby. 44 11.0
Do not know. 340 85.0

Table 4 Distribution of pregnant and postpartum women referred to public health units of Niterói-RJ, Brazil, according to toxoplasmosis knowledge and schooling, 2010-2011 

Schooling Know n (%) Do not know n (%) Total n (%) p
Incomplete fundamental education* 14 (11.9) 104 (88.1) 118 (100.0) -
Complete fundamental education 07 (20.0) 28 (80.0) 35 (100.0) 0.170
Incomplete medium education 15 (19.5) 62 (80.5) 77 (100.0) 0.105
Complete medium education 50 (36.2) 88 (63.7) 138 (100.0) 0.000
Incomplete higher education 12 (70.6) 05 (29.4) 17 (100.0) 0.000
Complete higher education 13 (86.7) 02 (13.3) 15 (100.0) 0.000
Total 111 (27.8) 289 (72.2) 400 (100.0)

*Reference category.

DISCUSSION

The present study demonstrated that 72.2% (n = 289) of the interviewed women had never heard about toxoplasmosis, especially how to prevent it. This condition puts these women in a high risk group, since the lack of information could allow the exposition of pregnant women to T. gondii, leading to an acute infection and consequently raising the risks of congenital transmission and even fetal death. Amongst women who did not know about toxoplasmosis, 180 (62.3%) were reactive.

Previous studies have already reported the unawareness of pregnant and postpartum women about this zoonosis in other regions of Brazil. In Mato Grosso23, 78% of the participant women did not know about toxoplasmosis. In Rio Grande do Sul8 and Minas Gerais18, 64.9% and 93% of the pregnant women had never heard about this disease, respectively. In Paraná4, only 16.2% of the pregnant women received information regarding toxoplasmosis prevention during prenatal care. In a study conducted in the United States22, 61% of the pregnant women knew that T. gondii is eliminated in the feces of infected cats, however, only 30% knew that the protozoa can be transmitted by raw or undercooked meat, and 29% knew that it can be transmitted by practicing gardening without gloves. In the present study, 95.5% (106/111) of the women who claimed to know about toxoplasmosis were aware that transmission can occur by infected cat's feces, 36.9% (41/111) knew that transmission can occur by raw or undercooked meat and 25.2% (28/111) by poorly washed vegetables.

The amount of people who knew the risk factors associated with T. gondii infection was very low in the studied population. Consequently, hygienic and dietary habits that could avoid the infection during pregnancy are not adopted, putting the fetus's health at risk. Moreover, there are many misconceptions regarding T. gondii transmission produced by the local press or schools that could be clarified by well-informed health agents. For example, it is possible for pregnant women to have cats in their homes, provided that hygienic habits are kept and there is no direct contact with cat's feces. An additional misunderstanding was that toxoplasmosis could be transmitted by dog's or pigeon's feces.

Another important finding of this study is that 83.8% of the participating women did not know the symptoms of toxoplasmosis. Although toxoplasmosis in pregnancy is asymptomatic in most cases, this is a very critical point, because recognizing the symptoms (when they are present) can be helpful for an early diagnosis during pregnancy. Moreover, these symptoms are severe in children and can cause permanent sequelae, such as ocular lesion or even death.

According to Table 4, educational level and the percentage of women who claimed to know the disease are directly related. In this regard, educational level is a protection factor against T. gondii infection.

The present results reflect the situation observed in the prenatal care of public health institutes of Niterói, which is similar to what is found in other Brazilian cities. Primary prevention actions to avoid exposure to T. gondii and other infectious agents are not performed during prenatal care, such as meeting groups to exchange information and experiences, as well as orientation by a health agent. Information during prenatal care contributed to a 63% reduction in T. gondii first infection during pregnancy19. A study in Canada30 highlighted the importance of education to prevent toxoplasmosis during prenatal care.

In Londrina, Paraná, after the implementation of a congenital toxoplasmosis control program, it was observed a 63% reduction in the number of infected pregnant women and a 42% reduction in the number of children forwarded to reference services. The definition of the protocols resulted in standardized assistance procedures and greater safety for decision-making by the doctors24.

Another study in 2006 with pregnant teenagers in Ceará also highlighted the importance of preventive actions for toxoplasmosis during pregnancy9. In order to evaluate the toxoplasmosis-related knowledge of doctors and nurses, a study was conducted in Juiz de Fora, Minas Gerais. Only 44% of the answers were correct, and most of the incorrect answers were related to prevention and diagnosis. These results demonstrated the lack of interest and information update by health agents33.

Health agents need to be well-informed and capable to give correct information to the patients; otherwise, all care will be compromised. The high rate of unawareness about toxoplasmosis (72.2%), observed in the present study, indirectly reflects the assistance quality provided by the health agents to the patients during prenatal care. These findings become more important with the results obtained by MOURA et al. (2013)29 in the same region, which observed that 41.5% (166/400) of pregnant and postpartum women were susceptible to T. gondii infection. In Niterói, there is no program to control congenital toxoplasmosis. This situation can make the health agents insecure to correctly inform their patients, since they will have to get information by themselves, i.e., without the help of specialized professionals.

Primary prevention actions against congenital toxoplasmosis during prenatal care is a national need, since the results observed in the city where the study was conducted are similar to those observed in other Brazilian cities.

The lack of knowledge about the disease observed in most of the interviewed population indicates that a large number of women are susceptible to T.gondii infection during pregnancy. These susceptible women can transmit the protozoa to their offspring, leading to severe sequelae and even death. These results highlight the importance of serological screening programs, as well as primary prevention by providing correct information during prenatal care. Guidelines for women who intend to get pregnant are also important in reducing the occurrence of congenital toxoplasmosis.

ACKNOWLEDGEMENTS

CAPES, Laboratório de Toxoplasmose (LABToxo) of Instituto Oswaldo Cruz (IOC/Fiocruz), Instituto de Pesquisas Clínicas Evandro Chagas, Fiocruz and Universidade Federal Fluminense.

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Received: September 11, 2013; Accepted: February 20, 2014

Correspondence to: Dra. Patricia Riddell Millar, Departamento de Microbiologia e Parasitologia, Instituto Biomédico, Universidade Federal Fluminense. R. Professor Hernani Melo 101, São Domingos, 24.210-130 Niterói, RJ, Brasil. Phone: +55 21 2629-2424 or +55 21 2629-2425. Email: patriciariddell@vm.uff.br

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