Seroepidemiology of Toxoplasma infection in blood donors in Jahrom District，Southern Iran

Mohammad Hassan Davami，Morteza Pourahmad，Rasoul Baharlou，Abdolreza Sotoodeh Jahromi，Abbass Ahmadi Vasmejani，Kavous Solhjoo，Hamid Reza Fallah，Mohsen KalantariZoonoses Research Center，Faculty of Medicine，Jahrom University of Medical Sciences，Jahrom，Iran

2Department of Internal Medicine，Faculty of Medicine，Jahrom University of Medical Sciences，Jahrom，Iran

3Department of Medical Microbiology，Faculty of Medicine，Jahrom University of Medical Sciences，Jahrom，Iran

4Jahrom University of Medical Sciences，Jahrom，Iran

5Research Centre for Health Sciences，Shiraz University of Medical Sciences，Shiraz，Iran

6Department of Health，Mamasani Higher Education Complex for Health，Shiraz University of Medical Sciences，Shiraz，Iran

Seroepidemiology of Toxoplasma infection in blood donors in Jahrom District，Southern Iran

Mohammad Hassan Davami1，Morteza Pourahmad2，Rasoul Baharlou3，Abdolreza Sotoodeh Jahromi3，Abbass Ahmadi Vasmejani3，Kavous Solhjoo3，Hamid Reza Fallah4，Mohsen Kalantari5，6*
1Zoonoses Research Center，Faculty of Medicine，Jahrom University of Medical Sciences，Jahrom，Iran

2Department of Internal Medicine，Faculty of Medicine，Jahrom University of Medical Sciences，Jahrom，Iran

3Department of Medical Microbiology，Faculty of Medicine，Jahrom University of Medical Sciences，Jahrom，Iran

4Jahrom University of Medical Sciences，Jahrom，Iran

5Research Centre for Health Sciences，Shiraz University of Medical Sciences，Shiraz，Iran

6Department of Health，Mamasani Higher Education Complex for Health，Shiraz University of Medical Sciences，Shiraz，Iran

ARTICLE INFO

Article history:

in revised form 24 Sep，2nd revised form 26 Nov 2014

Accepted 30 May 2015

Available online 19 Oct 2015

Toxoplasma

Blood donors

ELISA

Iran

Objective:To identify the anti-Toxoplasma antibodies from blood donors who referred to blood transfusion bases of Jahrom County，using ELISA method.

Methods:Based on the prevalence and characteristics method，400 serum samples were collected from blood donors referred to Jahrom blood transfusion bases，Southern Iran，during 2010-2011，designed at testing by ELISA.IgM and IgG antibodies against Toxoplasma gondii were tested using ELISA kits（Dia-Pro）on serums.The data were analysed by SPSS 19 software.

Results:Review of 400 cases，54 of them were IgG positive for parasites（13.5%）and 346 ofthosewithnegativeIgG（86.5%）.InIgMexamination，1.75%ofthemhavebeenpositive IgM（7 cases）and 98.25%of them were IgM negative（393 cases）.By comparing the different group ages，40-50 year age group had the highest prevalence of IgG positive（17.9%）andtheagegroupof30-40yearshadthehighestincidenceofIgMnegative（2.5%）. Conclusions:Due to the serological infection rate of toxoplasmosis obtained from this study，toxoplasmosis should be considered as a significant transfusion risk factor in Jahrom and also in any region with similar situations.

Epidemiological investigationhttp://dx.doi.org/10.1016/j.apjtb.2015.09.016

1.Introduction

Toxoplasmosis is one of the most common parasitic infections between human and animals［1，2］.This infection has a worldwide distribution and cats，birds and domestic animals are the most important reservoirs of the parasite［3］.Eating of infected undercooked meat，vegetables and fruits，transmissionthrough the placenta，blood transfusion and transplantation are the main route of transmission to humans［4-6］.

Most people infected with toxoplasmosis are asymptomatic and the infection can persist for years in the body［5］.The main symptoms of this disease include severe brain and ocular complications of abortion［2］.The highest prevalence has been reported among Paris residents（in France）（up to 93%）［2］. The lowest prevalence has been reported from Northern Mexico（7.4%）［7，8］.In Iran，the rate of infection is also remarkable（Tehran 82%，Shiraz 77%，and Isfahan 57%）［9-12］.However，in a recent study done by Sarkari et al.，it seems that the infection is reduced in Shiraz（19.3%）［13］.

Latent Toxoplasma gondii（T.gondii）infection in blood donors could be one of the modes of transmission of infection to recipients of blood［7，14］.Due to the high risks of transfusion transmitted infection in healthy and asymptomatic donors，theuse of these bloods in surgical transplants such as kidney，bone marrow，and blood bags，which require several different donors，is important to clean the screen for Toxoplasma infection in the donors.Moreover，all transplant recipients and children with different types of blood diseases such as leukemia，aplastic anaemia，and thalassemia will have a reduced immune system to prevent infection，and these blood transfusions will create a lot of problems to their safety［15］.

Seroprevalence of Toxoplasma infection was studied in blood donors in Jahrom District，Southern Iran.This cross-sectional study was conducted to identify the anti-Toxoplasma antibodies from blood donors who referred to blood transfusion bases of Jahrom County，using ELISA method.

2.Materials and methods

2.1.Study area

Fars Province placed in south of Iran covers an area of about 122400 km2.Jahrom County is located in the southeast of province and situated at 30°4′45′′North，51°43′29′′East，and 1050 m above the sea level（Figure 1）［16］.

2.2.Sampling

2.3.Serological assay

Prevalence of anti-Toxoplasma antibodies in blood donors was done according to the immunoglobulin class，sex，age and different locations of Jahrom County.After centrifugation，serum samples were separated.They were maintained at-70°C in the freezer temperature before assessment.After collecting all samples，IgM and IgG antibodies against T.gondii were tested using ELISA.Kits and materials used in this study were prepared from Italy（Dia-Pro，Milan，Italy）.During the test，the whole kit was used according to the instructions given in the brochure ahead.In this assay，there was a 96-well（holes）plate，which made it possible to perform 96 tests simultaneously［17］.

Samples were addedto the plate andincubated for30 min，and then plates were washed three times to remove excess molecules. After further washing and incubation，chromatogen was added to the cavity containing the substrate material.After 5-10 min，a colorless substrate is converted to a colored end product in the presence of peroxidase.The color changes were measured and recorded by spectrophotometer at a wavelength of 450 nm［17］.

2.4.Data analysis

Statistical analyses of tables and graphs were performed using SPSS 19 statistical software（SPSS Inc.，Chicago，USA）. Descriptive statistics were shown in either mean standard deviation note or as frequency tables.Relationships between the categorical variables were evaluated by Chi-square assay.P-values less than 0.05 were considered as statistical significant.

3.Results

Review of 400 cases，13.5%of them were IgG positive for parasites that are equal to 54 and 86.5%of those with negative IgG were equivalent to 346 cases.In IgM examination，1.75%of them have been positive IgM against 7 people and 98.25%of subjects were negative for IgM against 393 individuals.By grouping together people of different ages and comparing them，40-50 year age group had the highest prevalence of positive IgG（equivalent to 17.9%）.The highest incidence of IgM was in the age group 30-40 years（2.5%）（Table 1）.

In terms of gender，the prevalence of IgM in men and women were 1.7%and 0%，respectively.Moreover，IgG prevalence in maleandfemalewere13.6%and9.1%，butthesedifferenceswere not statistically significant（P＞0.05）.Also，no significant correlation was found between positive serology and a chance encounter with a cat against parasites.In people who had washed theirhandswithsoap，IgGandIgMpositiverateswere13.9%and 1.8%separately.But these rates were zero percent in those who washed their hands without soap；consequently，the relationship was not significant according to the statistical test（P＞0.05）.IgG and IgM-positive rates were 11.7%and 0.6%respectively in people who had washed their hands before meals.These rates were 12.3%and 0%among people who washed their hands after meals.These amounts were 15.3%and 2.2%in the people who washed their hands before and after meals.Statistically，results indicated that there was not statistically significant relationship between toxoplasmosis rates and washing hands before and/or after meals.In the people who washed the vegetables with disinfectant，IgG and IgM-positive rates were 12%and 1.7% respectively，but these amounts were 12.4%and 1.6%in thosewho only washed them with water.Moreover，these rates were 40%and 0%among people who washed them with water and disinfectantrespectively.However，nosignificantassociationwas found between vegetable consumption methods of washing and serological antibodies（P＞0.05）（Table 2）.

Table 2 Statistical results of Toxoplasma risk factors among blood donors in Jahrom County，Southern Iran.

Among those who used meat broth boil，these amounts were 19.4%and 1.3%in people who have eaten grilled meat.In people who used both types of meat，these rates were 9.1%and 3.2% respectively.Although the percentage difference could be seen between the different types of meat，this difference was not statistically significant.IgG and IgM-positive rates were 11%and 3.6%respectively in people who had high direct contact with the soil，these percentages were 17.2%and 0.7%in people who have had little contact with the soil.Moreover，11.9%and 1.6%of IgG and IgM rates were positive in people who have had no direct contact with the ground at all.These differences were not statistically significant（P＞0.05）.There was a little difference between the rates of IgG and IgM positivity among urban and rural residents（P≤0.05）.Among people living in urban areas，these rates were 12.7%and 1.7%respectively.However，these rates were 13.2%and 1.5%among rural residents（Table 2）.

4.Discussion

Toxoplasmosis is a common parasitic disease in the world that infects humans and a wide range of mammalians and birds［12，18］. Several factors are known to be effective in increasing the prevalence of the disease.Some of them consist of age，climatic conditions，habits and behaviours related to nutrition，soil or cat exposure，occupation，gender and education level［19，20］.The factors that enter into the living human parasitic disease directly orfacilitateitindirectlyincreasetheincidenceoftoxoplasmosis［19］.

实验组在同样采用常规西药治疗的基础上,给予中药治疗方法,实现中西医结合。中药治疗中涉及的药方为:黄芪20g,红藤30g,贯众15g,蒲公英20g,续断15g,丹参15g,枸杞子10g,牡丹皮10g,菟丝子10g,赤芍15g,红花10g,山药15g。在中医中,需要践行辩证施治方法,需要在其基础上,针对湿热型患者在原药方中加入黄柏10g,薏苡仁15g,白术15g,茵陈20g。如果是肝肾阴虚型,则还需要在其中加入地黄15g,茯苓20g,巴戟天15g,麦冬12g。需要将这些药品放在400ml的水中进行煎熬,使其形成汤汁,每日口服,一日三次,保证汤药温度,连续服用一个月,三个月为一疗程。

Consuming unwashed agricultural crops，cats and contact with cat feces（oocyst），not frozen meat and poultry before eating animals，undercooked animal meat，and not using gloves when in contact with meat and viscera of animals are the most important factors that increase the incidence of toxoplasmosis［21，22］.Occupation，gender，and level of education may indirectly have effect on the prevalence of the disease［19］.

ELISA assay，with a sensitivity of 100%and specificity of 97%，is considered as one of the best laboratory tool to detect the serum antibodies and immune levels against specific diseases［17］.In the present study，the serological infection rate of toxoplasmosis（13.5%）was closed to results obtained from Fasa County（10%）［23］.The rate was less than results obtained from Isfahan，Bushehr，Tehran and Shahre Rey［10，11，24］，but more than results obtained from different parts of Iran，which probably due to different conditions in the same geographical regions of Jahrom and other studied regions［23］.

The rate of infection in men and women was not significantly different.This result is similar to the report from Meshkinshar by Keshavarz et al.［25］.Keshavarz and colleagues in a study conducted in Islamshahr reported the infection in men（27.8%）and women（42.6%），where the difference was significant［26］. Moreover，another study was conducted in Tehran by Salahi Moghaddam and Hafizi that infection rates were 49.7%and 75.4%in men and women separately，which was significant［10］.

Therewerenosignificantdifferencesbetweenagegroups.IgG immunoglobulin is usually chronic and past infection is separated from the patient.Especially in toxoplasmosis which is contaminated for the first time and tissue cyst formation in the different tissues，most of the older adult population is positive for IgG.In a study conducted in Meshkinshar，the highest infection rate reported in those aged over 40 was 25.4%，and the infection rate increased with age［25］.In Isfahan，center of Iran，the highest rate of infection has been reported at the age of 40（50%）［11］.In Islamshahr，the highest rate of infection was seen at the age of 30 years（52.8%）［26］.Mansouri and colleagues conducted a study in Kermanshah which obtained the highest infection rate in the age group of 30-40 years（48.3%）［27］.Moteallehi Ardakani and colleagues conducted a study in Yazd reported the highest infection rate in the age group of 30-40 years［28］.

Inthisstudy，nosignificantrelationshipwasfoundbetweenthe frequency of toxoplasmosis and cat contact，which may be due to lack of awareness of participants about ways of infection with parasites excreted by cats or other pets when filling out the questionnaire.In other studies like Keshavarz et al.in Meshkinshahr，no relationship was seen in this group as well［25］，but inFasa，the relationship between contact with the cats and the increasingpercentageofToxoplasmainfectedwassignificant［23］.

Use of raw and cooked meats listed as the risk factors for these parasites.The method of cook meat consumption introduced as the most common cause of toxoplasmosis infection in Sanliurfa Province（Turkey）by Tekay and Ozbek［29］.In the present study，the prevalence of T.gondii in individuals who consumed grilled meat was higher than those who ate beef broth or poached meat（12.6%）.However，thedifferenceswerenotstatistically significant.In the study conducted in Fasa，no correlation was seen between type of cooking and Toxoplasma infection［23］.

In Iran，the prevalence of toxoplasmosis were reported higher in the rural areas than in urban areas from Kermanshah，Islamshahr，andChaharmahalandBakhtyari［26，27，30］.These differences were not significant in any of these studies. Contact with soil，arable land，rural people can be different cited as the causes of contamination in urban and rural areas. InthestudiedareaofIsfahan，Saveh，andBushehr，contamination in urban areas has been reported more than in rural areas and only the difference in Saveh was significant［10，31，32］.In the present study，the infection rates in rural areas（13.2%）were more than in urban areas（12.7%），which was not statistically significant.In other study done by Sarkari et al.in Shiraz，12.3%and 5.47%of the blood donors were seropositive for only IgG and IgM，respectively.Moreover，1.6%were positive for both IgG and IgM［13］.

Conflict of interest statement

We declare that we have no conflict of interest.

Acknowledgments

The authors are grateful for the logistical and financial support given by the Vice-Chancellor for Research and Technology，Shiraz University of Medical Sciences，Shiraz，Iran.

［1］Jones JL，Kruszon-Moran D，Wilson M，McQuillan G，Navin T，McAuley JB.Toxoplasma gondii infection in the United States: seroprevalence and risk factors.Am J Epidemiol 2001；154:357-65.

［2］Hill DE，Chirukandoth S，Dubey JP.Biology and epidemiology of Toxoplasma gondii in man and animals.Anim Health Res Rev 2005；6:41-61.

［3］Akta M，Dumanli N，Bab¨ur C，Karaer Z，¨Ong¨or H.Determination of seropositivity for Toxoplasma gondii infection in pregnant and aborted sheep in Elazig and vicinity by Sabin-Feldman（SF）test. Turk J Vet Anim Sci 2000；24:239-42.

［4］Karabulut A，Polat Y，T¨urk M，Is¸ikbalci Y.Evaluation of rubella，Toxoplasma gondii，and cytomegalovirus seroprevalences among pregnantwomeninDenizliprovince.TurkJMedSci2011；41:159-64.

［5］Asgari Q，Motazedian MH，Esmaeelzadeh B，Kalantari M，Hatam GHR.The prevalence of Toxoplasma infection among freeranging chickens in Southern Iran using IFA and nested-PCR.Iran J Parasitol 2009；4:29-36.

［6］Tany¨uksel M，Uzun¨O Araz E，Koru¨O，Bab¨ur C.Possible role of toxoplasmosis in patients with first-episode schizophrenia.Turk J Med Sci 2010；40:399-404.

［7］Alvarado-Esquivel C，Mercado-Suarez MF，Rodríguez-Briones A，Fallad-Torres L，Ayala-Ayala JO，Nevarez-Piedra LJ，et al. Seroepidemiology of Toxoplasma gondii in healthy blood donors of Durango，Mexico.BMC Infect Dis 2007；7:75.

［8］Alvarado-Esquivel C，Sifuentes-Alvarez A，Narro-Duarte SG，Estrada-MartínezS，Díaz-GarcíaJH，LiesenfeldO，etal. Seroepidemiology of Toxoplasma gondii infection in pregnant women in a public hospital in northern Mexico.BMC Infect Dis 2006；6:113.

［9］Assmar M，Amirkhani A，Piazak N，Hovanesian A，Kooloobandi A，Etessami R.［Toxoplasmosis in Iran.Results of a seroepidemiological study］.Bull Soc Pathol Exot 1997；90:19-21.French.

［10］Salahi-Moghaddam A，Hafizi A.A serological study on Toxoplasma gondii infection among people in south of Tehran，.Iran Korean J Parasitol 2009；47:61-3.

［11］Mostafavi SN，Ataei B，Nokhodian Z，Yaran M，Babak A. Seroepidemiology of Toxoplasma gondii infection in Isfahan province，central Iran:a population based study.J Res Med Sci 2011；16:496-501.

［12］Asgari Q，Fekri M，Monabati A，Kalantary M，Mohammadpour I，Motazedian MH，et al.Molecular genotyping of Toxoplasma gondii in human spontaneous aborted fetuses in Shiraz，southern Iran.Iran J Public Health 2013；42:620-5.

［13］Sarkari B，Shafiei R，Zare M，Sohrabpour S，Kasraian L.Seroprevalenceand molecular diagnosisofToxoplasma gondiiinfectionamong blood donors in southern Iran.J Infect Dev Ctries 2014；8:543-7.

［14］SundarP，MahadevanA，JayshreeRS，SubbakrishnaDK，Shankar SK.Toxoplasma seroprevalence on healthy blood donors from urban Karnataka.Indian J Med Res 2007；126:50-5.

［15］ElsheikhaHM，AzabMS，AbousamraNK，RahbarMH，Elghannam DM，Raafat D.Seroprevalence of and risk factors for Toxoplasma gondii antibodies among asyptomatic blood donors in Egypt.Parasitol Res 2009；104:1471-6.

［16］DavamiMH，MotazedianMH，KalantariM，AsgariQ，Badzohre A，Mohammadpour I.First microscopical and molecularbased characterization of Leishmania major within naturally infected Phlebotomus salehi（Diptera；Psychodidae）in Fars province，southern Iran.Ann Trop Med Parasitol 2011；105:485-91.

［17］Mostafavi N，Ataei B，Nokhodian Z，Monfared LJ，Yaran M，Ataie M，et al.Toxoplasma gondii infection in women of childbearing age of Isfahan，Iran:a population-based study.Adv Biomed Res 2012；1:60.

［18］Asgari Q，Mehrabani D，Moazeni M，Akrami Mohajeri F，Kalantari M，Motazedian MH，et al.The soroprevalence of bovine toxoplasmosis in Fars province，Southern Iran.Asian J Anim Vet Adv 2010；5:210-6.

［19］Mandell GL，Bennett JE，Churchill Dolin R.Mandell，Douglas，and Bennett's principles and practice of infectious diseases.7th ed. Philadelphia:Churchhill Livingston Elsevier；2010，p.4028.

［20］Asgari Q，Mehrabani D，Motazedian MH，Kalantari M，Nouroozi J，Adnani Sadati SJ.The viability and infectivity of Toxoplasma gondii tachyzoites in dairy products undergoing food processing. Asian J Anim Sci 2011；5:202-7.

［21］Asgari Q，Moazzeni M，Akrami Mohajeri F，Kalantari M，Zarifi M，Ghalebi SR，et al.Seroprevalence of Toxoplasma gondii among caprines inFars province，Southern Iran.J VetParasitol 2007；21:153-5.

［22］AsgariQ，SarneveshtJ，KalantariM，AdnaniSadatSJ，Motazedian MH，Sarkari B.Molecular survey of Toxoplasma infection in sheep and goat from Fars province，Southern Iran.Trop Anim Health Prod 2011；43:389-92.

［23］Hatam G，Shamseddin A，Nikouee F.Seroprevalence of toxoplasmosis in high school girls in Fasa district，Iran.Iran J Immunol 2005；2:177-81.

［24］Fouladvand M，Barazesh A，Naeimi B，Zandi K，Tajbakhsh S. Seroprevalence of toxoplasmosis in high school girls in Bushehr city，south-west of Iran.Afr J Microbiol Res 2010；4:1117-21.

［25］Keshavarz H，Mohebali M，Arshi SH.Seroepidemiologic study of human Toxoplasma infection in residents of Meshkin-Shahr.J Sch Pub Health Inst Pub Health Res 2003；1:57-72.

［26］Keshavarz H，Eskandari SE.A seroepidemiologic survey of toxoplasmosis in Islamshahr district of Tehran.Iran Modares J Med Sci 2003；2:111-9.

［27］Mansouri F，Mahdavian B，Hashemian AH.Epidemiology of toxoplasmosis in Kermanshah province.Behbood 2003；17:12-9.

［28］MoteallehiArdakaniA，MohammadZadehM，EbadiM. A seroepidemiological survey of toxoplasmosis in Yazd city. J Shahid Sadoughi Univ Med Sci 2003；4:59-65.

［29］Tekay F，Ozbek E.［The seroprevalence of Toxoplasma gondii in women from Saliurfa，a province with high raw meatball consumption］.Turk Parazitol Derg 2007；31:176-9.Turkish.

［30］Manouchehri-Naeini K，Keshavarz H，Dehkordi RA，Zebardast N，Kheiri S，Khalafian P，et al.［Seroprevalence of anti-Toxoplasma antibodies among pregnant women from Chaharmahal and Bakhtyari province using indirect immunoflurescent in 2006-2007］. J Shahrekord Univ Med Sci 2008；30:74-80.Persian.

［31］Chegini S，Asmar M，Abadi AR，Bagheri Yazdi SA.Toxoplasma infection in human and domestic animals.J Babol Univ Med Sci 1999；12:47-52.

［32］Fouladvand M，Barazesh A，Zandi K，Naeimi B，Tajbakhsh S. Sero-epidemiological study of toxoplasmosis in childbearing age women in Bushehr City，south west of Iran in 2009.Afr J Biotechnol 2010；9:5809-12.

9 Sep 2014

Mohsen Kalantari，Department of Public Health，Mamasani Higher Education Complex for Health，Shiraz University of Medical Sciences，Shiraz，Iran/Department of Medical Entomology and Vector Control，School of Health，Shiraz University of Medical Sciences，Shiraz，Iran.

Tel:+98（0）9177041090

E-mail:kalantari22@yahoo.com

Peer review under responsibility of Hainan Medical University.

Foundation Project:This research has been supported by Vice Chancellery of Shiraz University of Medical Sciences and Jahrom University of Medical Sciences（Grant No.2.90）.