E D I T O R I A L C O M M E N TA R Y
Prenatal Toxoplasma gondii
Edward S. Linn
Department of Obstetrics and Gynecology, Cook County Health and Hospital System, Northwestern University Feinberg School of Medicine, Chicago, Illinois
(See the article by Boyer et al, on pages 1081–9.)
One of the first lessons regarding con-
genital infections taught to third-year
medical students on obstetrics and re-
inforced during their pediatric rotations
are the variety and pathogenesis of
perinatal viral and parasitic infections
that can affect pregnant women and
their fetuses. From the time of their
residency training, obstetricians have
been instructed to counsel their patients
about strategies to reduce the risk of
acquiring these infections. Ideally, these
discussions should occur during visits
focused on prepregnancy counseling.
However, it is the standard of care to
provide this information to pregnant
women during early prenatal care visits.
Obstetricians focus on the protozoan
parasite Toxoplasma gondii because of the
concern that maternal exposure, which is
often asymptomatic, could lead to fetal
infection resulting in congenital toxo-
plasmosis and the devastating neuro-
logic and ocular sequelae that may
occur in the affected child. Patients are
Received 11 August 2011; accepted 26 August 2011;
electronically published 21 October 2011.
Corresponding author: Edward S. Linn, MD, Department of
Obstetrics and Gynecology, Cook County Health and Hospital
System and John H. Stroger Jr Hospital, 1900 West Polk St,
Rm 544, Chicago, IL 60612 (edlinn@gmail.com).
Clinical Infectious Diseases 2011;53(11):1090–1091
Ó The Author 2011. Published by Oxford University Press on
behalf of the Infectious Diseases Society of America. All rights
reserved. For Permissions, please email:journals.permissions@
oup.com. This is an Open Access article distributed under the
terms of the Creative Commons Attribution Non-Commercial
License (http://creativecommons.org/licenses/by-nc/3.0/), which
permits unrestricted non-commercial use, distribution, and
reproduction in any medium, provided the original work is
properly cited.
1058-4838/2011/5311-0007$14.00
DOI: 10.1093/cid/cir688
1090 d CID 2011:53 (1 December) d EDITORIAL COMMENTARY
counseled that avoidance of fecal con-
tamination from cats and consumption
of undercooked meat and meat prod-
ucts can significantly reduce the risk
of exposure to this parasite. Strict
avoidance strategies have been dem-
onstrated by European investigators
to be effective in reducing the rate of
maternal toxoplasmosis infection.
To further reduce the disease burden
of toxoplasmosis infection, the concept
of prenatal serologic screening and
treatment has been investigated by
a number of researchers but is currently
the source of significant controversy.
Epidemiologic studies in Europe have
supported the use of widespread sero-
logic screening and treatment to avoid
congenital toxoplasmosis. However,
well-designed randomized controlled
trials to evaluate the effectiveness and
safety of both perinatal screening and
treatment are currently lacking.
Routine prenatal screening and treat-
ment has been the standard practice in
France for many years. Currently, screen-
ing recommendations from respected au-
thorities and professional societies in the
United States, such as the American
College of Obstetrics and Gynecology,
do not recommend routine serologic
screening during pregnancy except in
immunocompromised patients, such as
human immunodeficiency virus–infected
women. These US recommendations have
been supported by the lack of strong
scientific evidence establishing the value
of more aggressive screening strategies
in pregnancy and the fact that the rate
of toxoplasmosis is much higher in
France and Latin America than in North
America.
The article by Boyer et al [1] raises
significant questions about contempo-
rary US screening recommendations. In
their study, Boyer and colleagues used
new and novel methodologies to de-
termine whether mothers of infants with
congenital toxoplasmosis could be
identified by risk factor identification,
thereby providing strong support for
educating pregnant women about risk
avoidance in an effort to eliminate this
congenital disease. The investigators
used stored serum samples obtained
from a cohort of North American
women who delivered infants who re-
ceived a diagnosis of congenital toxo-
plasmosis and who were previously
interviewed about recognized risk
factors as part of the National Collab-
orative Chicago-Based Congenital Toxo-
plasmosis Study (NCCCTS). In this
current investigation, the previously ac-
quired serum samples were tested using
a new method to identify an antibody
specific to the T. gondii sporozoite,
indicating infection of oocysts formed
in cats.
The results of this study indicate that
high rates of exposure to oocysts occurred
in the NCCCTS mothers. However, the
authors found that demographic charac-
teristics did not reliably predict exposure
to oocysts and that there was a lack of
correlation between oocyst exposure and
the severity of maternal or infant illness. In
addition, the recognition of risk factors
had limited sensitivity and specificity in
identifying those individuals infected by
oocysts.
The conclusions of this study are quite
interesting from a scientific and epidemi-
ologic perspective, but quite sobering
from a clinician’s point of view. Toxo-
plasmosis acquired during pregnancy can
lead to devastating problems for the chil-
dren of infected mothers. Patients need to
be encouraged to avoid exposure to well-
established environmental risk factors.
However, the results of this study and
other observations strongly suggest that,
despite avoidance strategies, women are
being exposed unknowingly to T. gondii
oocysts. Even those who do not own or
handle cats may be exposed to environ-
mental feline fecal contaminants. Indi-
viduals may wear gloves while gardening,
carefully wash fruits and vegetables, and
thoroughly cook the meats that they
consume but, theoretically, can acquire
the T. gondii oocysts from their beloved
canine companion whose fur was con-
taminated while rolling in the park where
infected cats had been.
As the authors have concluded in this
fascinating and thought-provoking study,
‘‘only systematic screening of pregnant
women and/or a vaccine have the po-
tential to prevent the fetal disease caused
by acquisition of T. gondii during ges-
tation by pregnant women in North
America’’ [1]. Years ago, the French
medical and public health authorities
accepted the concept of perinatal
screening and treatment to reduce the
incidence of congenital toxoplasmosis.
The current state of screening technol-
ogy has evolved, and the economic ar-
gument against widespread screening
appears to be dated. In the United States,
can future mothers and their offspring
afford to wait years for additional data
to be accumulated from long-term, well-
designed randomized controlled trials to
evaluate the effectiveness and safety of
EDITORIAL COMMENTARY
both perinatal screening and treatment?
Can this society afford the cost of
funding these studies along with the
additional financial and social burden of
life-long support for those individuals
who experience the major sequelae of
congenital toxoplasmosis? It is time for
these concepts to be seriously and care-
fully revisited in the United States.
Note
Potential conflict of interest. E. S. L. has
been a consultant and served on the speakers’
bureau for family planning and menopause-re-
lated therapeutics for TEVA Pharmaceuticals.
The author has submitted the ICMJE Form
for Disclosure of Potential Conflicts of Interest.
Conflicts that the editors consider relevant
to the content of the manuscript have been
disclosed.
References
1. Boyer K, et al. Unrecognized ingestion of
Toxoplasma gondii oocysts leads to congenital
toxoplasmosis and causes epidemics in North
America. Clin Infect Dis 2011; 53:1081–9.
d CID 2011:53 (1 December) d 1091
Copyright of Clinical Infectious Diseases is the property of Infectious Diseases Society of America and its
content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for individual use.