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CHIEF EDITORS NOTE: This article is the 14th of 36 that will be published in 2001 for which a total of up to 36 Category 1
CME credits can be earned. Instructions for how credits can be earned appear on the last page of the Table of Contents.
Toxoplasmosis is caused by infection with the protozoan parasite Toxoplasma gondii. In the United
States, a serological survey from the Third National
Health and Nutrition Examination Survey found that
an estimated 23% of adolescents and adults have
laboratory evidence of infection with T. gondii (15%
among women of childbearing age) (1; Centers for
Disease Control, unpublished data, 1994). Although
these infections are usually either asymptomatic or associated with self-limited symptoms in adults (e.g.,
fever, malaise, and lymphadenopathy), infections in
pregnant women can cause serious health problems in
the fetus if the parasites are transmitted (i.e., congenital
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Fig. 1.
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cleaning the cat litter box (26), eating raw or undercooked pork, mutton, lamb, beef, or mince meat
products (24, 26, 27), gardening (25), eating raw or
unwashed vegetables or fruits, eating raw vegetables
outside the home (24), contact with soil (27), washing kitchen knifes infrequently (26), having poor
hand hygiene (24), and travel outside of Europe,
U.S., or Canada (27). Protective factors for T. gondii
infection include a meat-free diet (13), living at high
altitudes and in arid climates (28, 29), and living in
climates with frequent freezing and thawing (30).
Owning a cat has not been a consistent risk factor
for T. gondii infection. Owning a cat was not shown
to be a risk factor for T. gondii infection in two
studies of pregnant women (27, 31) and in a study of
HIV-infected persons (32). Risk for T. gondii infection does not occur from merely owning a cat, but
rather from being exposed to cat feces from a cat
shedding oocysts. Cats generally only shed oocysts
for several weeks during their lives if they become
infected with T. gondii. Cats kept indoors that do not
hunt prey or are not fed raw meat are not likely to
acquire T. gondii infection and, therefore, pose little
risk. Unless cats are sick with diarrhea, little or no
feces will stick to their perianal area (11). Usually,
adult cats are not diarrheal during the period in which
they are shedding oocysts (11). Because of their
grooming habits, fecal matter has not been found on
the fur of clinically normal cats (11). In addition, in
a study of cats induced to shed oocysts, no oocysts
could be found on the cats fur after they shed oocysts (33). Therefore, the possibility of transmission
to human beings via touching cats is thought to be
minimal or nonexistent (11). Neighborhood or feral
cats that defecate in gardens or sandboxes may pose
the greatest risk for toxoplasmosis for some persons,
whether or not they own a cat.
It should also be noted that because cats may not
develop antibodies to T. gondii during the oocystshedding period, serologic examination of cats does
not provide useful information regarding the ability
of a particular cat to transmit toxoplasmosis (11). A
cat that has a positive serologic test for T. gondii
probably has shed oocysts previously and, therefore,
may pose less of a risk than a serologically negative
cat, but cats can shed oocysts more that once, thus,
serologic testing of cats is not really helpful in this
instance either.
Outbreaks of toxoplasmosis in humans have been
attributed to ingestion of raw or undercooked ground
beef, lamb, pork, venison (3439), unpasteurized
goats milk (40), contaminated, unfiltered drinking
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TABLE 1
Guide to general interpretation of Toxoplasma
gondii serology results obtained with commercial assays
Results
IgG
IgM
Negative
Negative
Negative
Equivocal
Negative
Positive
Equivocal
Negative
Equivocal
Equivocal
Equivocal
Positive
Positive
Positive
Negative
Equivocal
Positive
Positive
tories in the U.S.1 Confirmatory testing with a serologic profile including the Sabin-Feldman dye test,
IgM enzyme-linked immunosorbent assay (ELISA),
IgA ELISA, IgE ELISA, and differential agglutina1
Editors Note: Toxoplasma Serology Laboratory, Research Institute, Palo Alto Medical Foundation, Ames Building, 795 El
Camino Real, Palo Alto, CA 94301; phone: 650-853-4848, and
MRL Reference Laboratories, 5785 Corporate Ave., Cypress, CA
90630; phone: 800-445-0185.
tion (AC/HS) test has also been useful in distinguishing recently acquired infections (63).
For identification of T. gondii intrauterine infection, polymerase chain reaction (PCR) testing of amniotic fluid has allowed earlier testing than fetal
blood sampling (6468). In addition, PCR of amniotic fluid is more sensitive than fetal blood sampling
(69) and is safer. However, false-positive and falsenegative tests do occur with PCR (70). Because of
advances in PCR testing of amniotic fluid, cordocentesis is indicated rarely today.
SCREENING AND TREATMENT
In France, a screening program was implemented
in 1976 to detect and treat T. gondii infection during
pregnancy. The goal of this program is to institute
preventive measures for seronegative women and to
ensure early diagnosis and treatment of infection
acquired during pregnancy. Since the beginning of
the program, premarital and prenatal medical examinations for T. gondii antibodies have been performed. Premarital examinations are conducted to
distinguish previously infected women from women
who have not been previously infected. When an
uninfected woman becomes pregnant, testing is conducted at her first prenatal examination during her
first trimester and at six additional examinations conducted monthly during her second and third trimesters. In addition, women are educated about prevention methods during pregnancy (71). If these
screening tests detect evidence of acute infection
during pregnancy, treatment for the woman is initiated with spiramycin in an effort to prevent transmission to the fetus. If infection in the fetus is confirmed
through fetal blood sampling and amniocentesis, pyrimethamine and sulfadiazine or sulfadoxine is added
to the regimen (72, 73) because spiramycin does not
generally cross the placenta.
Although the proportion of the population included
in the French program has been incomplete, it has
been associated with a decline in the incidence of
congenital infection, as well as a decline in severe
disease detected at birth. The proportion of the decline specifically attributable to the program or to the
general decline in Europe in rates of seropositivity is
difficult to determine because no unscreened group
of women exists for comparison.
Austria implemented a toxoplasmosis-screening
program in 1975. Nearly all women who become
pregnant are serologically screened early in pregnancy and, if the results are found to be negative
initially, are tested again during the second and third
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still lead to at least 2.9 fetal losses per case of toxoplasmosis avoided. Therefore, they concluded that screening of cat owners would probably not be appropriate. In
a large well-designed study of acute T. gondii infection
in pregnant women from the European Research Network on congenital toxoplasmosis, none of the risk
factors for T. gondii infection increased the risk by as
much as five-fold (27). Nevertheless, in this study, the
highest risks were associated with eating undercooked
lamb or other less conventional meats that included
wild game meats and with travel outside Europe, U.S.,
or Canada.
It would seem prudent to screen pregnant women
for acute toxoplasmosis if there were suspicious ultrasound findings. Such findings include hydrocephalus, intracranial calcifications, microcephaly, fetal
growth restriction, ascites, and hepatosplenomegaly.
In addition, HIV-infected women should be screened
for toxoplasmosis (80).
PREVENTION OF TOXOPLASMOSIS IN
PREGNANT WOMEN
Recommendations for prevention of toxoplasmosis in
pregnant women were discussed at a conference at the
Centers for Disease Control and Prevention and published (71). These recommendations were as follows:
To prevent toxoplasmosis and other food-borne
illnesses, food should be cooked to safe temperatures. A food thermometer should be used to
measure the internal temperature of cooked meat
to ensure that meat is cooked all the way
through. Beef, lamb, and veal roasts and steaks
should be cooked to at least 145F; and pork,
ground meat, and wild game should be cooked
to 160F before eating. Whole poultry should be
cooked to 180F in the thigh to ensure that the
meat is cooked thoroughly.
Fruits and vegetables should be peeled or
washed thoroughly before eating.
Cutting boards, dishes, counters, utensils, and
hands should always be washed with hot soapy
water after they have contacted raw meat, poultry, seafood, or unwashed fruits or vegetables.
Pregnant women should wear gloves when gardening and during any contact with soil or sand
because cat waste might be in soil or sand. After
gardening or contact with soil or sand, hands
should be washed thoroughly.
Pregnant women should avoid changing cat litter if possible. If no one else is available to
change the cat litter, pregnant women should use
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