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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 19
| Issue : 1 | Page : 51-54 |
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Seroprevalence of cytomegalovirus infection in antenatal women in a Tertiary Care Center in Western India
Mahadevan Kumar1, Mohammad Bashir Nizam2, M Mugunthan3
1 Department of Microbiology, Army Hospital R&R, New Delhi, India
2 Department of Microbiology, AFMC, Pune, Maharashtra, India
3 Department of Microbiology, Yashoda Hospitals, Hyderabad, Telangana, India
| Date of Web Publication | 17-Aug-2017 |
Correspondence Address:
Col Mahadevan Kumar
Department of Lab Sciences (Microbiology), Army Hospital R&R, New Delhi - 110 010,
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmms.jmms_26_17
Context: Human cytomegalovirus (CMV), otherwise called human herpesvirus 5, is a member of the Herpesviridae family. Maternofetal transmission of CMV can occur during pregnancy following primary or recurrent infections in the mother. Infections in utero are associated with fetal abnormalities, intrauterine growth retardation, and intrauterine death. In India, 80%–90% of the adult population show presence of CMV antibodies; however, there are few articles showing the prevalence of CMV infection in pregnant women. Aims: The aim of this study is to assess seroprevalence of CMV infection in antenatal women. Settings and Design: This is a cross-sectional, observational study, study population: women reporting for antenatal care to the OPD at a tertiary care hospital. Subjects and Methods: Three hundred and seventy serum samples drawn from antenatal women attending OPD in a tertiary care center were tested for IgG and IgM antibodies by enzyme-linked immunosorbent assay. Statistical Analysis Used: Statistical significance was estimated by calculating “P value.” Results: Of the 370 samples tested, 83% showed the presence of CMV IgG and 9.46% were positive for CMV IgM. All those cases which were IgM positive were seropositive for CMV IgG as well. Sixteen percent of the antenatal women were both IgG and IgM negative. Conclusion: The prevalence of CMV IgG in antenatal women in this region is high. Around 16% of the women showed lack of IgG. It would be beneficial to screen pregnant women for CMV IgM antibodies is beneficial and will help guide the testing of newborns suspected to be infected with CMV in order that appropriate therapy of the infected infants can be instituted promptly and appropriate advice can be rendered on prevention of transmission.
Keywords: Antenatal care, cytomegalovirus, seroprevalence
How to cite this article:
Kumar M, Nizam MB, Mugunthan M. Seroprevalence of cytomegalovirus infection in antenatal women in a Tertiary Care Center in Western India. J Mar Med Soc 2017;19:51-4 |
| Introduction | |  |
Human cytomegalovirus (CMV), otherwise known as human herpesvirus 5, is a member of the Herpesviridae family.[1] CMV was isolated in three laboratories simultaneously in 1956. Margaret G. Smith recovered the virus from the submaxillary gland after postmortem of an infant while Weller named it as CMV due to its characteristic cytopathic effects.[2] CMV can potentially kill or be present silently in the body lifelong; thus, it is considered as a virus of paradoxes.[3] CMV is highly prevalent in both developed and developing countries and is an important public health problem.[4],[5] CMV infection can be transmitted to the fetus after a primary or a recurrent infection. Infections in utero are associated with intrauterine death or congenital fetal abnormalities and intrauterine growth retardation along with developmental delays, blindness, and deafness as a sequel after the birth.[5],[6] The seroprevalence of CMV has been reported be 80%–90% in the adult population in India.[7],[8] Not much data are available on the prevalence of CMV infection in antenatal women in our area. Hence, the present study was done to estimate the prevalence of IgG and IgM antibodies to CMV in women attending antenatal OPD in our hospital.
| Subjects and Methods | | |
Assuming 95% confidence interval, α of 5%, precision of 5%, and seroprevalence of CMV in pregnant women to be 60%, the required sample size was calculated to be 369.[1],[9] Over 2 years, 370 pregnant women reporting for antenatal care were selected for the study. The subjects included primigravida and women with both normal previous pregnancy or with adverse outcomes, which were selected at random. Following informed consent, blood samples were collected taking all aseptic precautions and sera stored at −20°C before further analysis. The sera were tested for IgG and IgM antibodies at a dilution of 1:100 using an enzyme-linked immunosorbent assay (ELISA) (Omega Diagnostics, Scotland, UK) following the manufacturer's instructions. Absorbance readings were recorded at 450 nm (with the reference filter at 650 nm) using a spectrophotometric ELISA reader (BioRad, USA).
Semi-quantitative estimation of antibody concentration
The optical densities of the standards against their concentration were plotted and a line was drawn through the points. Sample values below 3 IU/ml were labeled as negative, whereas values above 3 IU/ml were regarded as positive. Samples giving values above 30 IU/ml were reassayed at a higher dilution.
| Results | | |
Of the 370 samples tested, 308 (83.24%) were seropositive for CMV IgG and 35 (9.46%) were seropositive for CMV IgM. Four women out of 35 seropositive for IgM had a history of abortion. All IgM positive cases were positive for CMV IgG as well. Samples negative for both IgG and IgM accounted for 16.76%. Seropositivity of CMV IgG and IgM among all the pregnant women in this study is given in [Table 1]. The difference was statistically significant with a P = 0.0107. The age of the patients ranged from 18 to 40 years with a mean age of 24.62 ± 4.04. [Table 2] illustrates serological status of different age groups. The patients in the age group of 18–30 years showed high prevalence of anti-CMV IgG antibodies (83.82%) which is statistically significant with a P = 0.0161, whereas women in the age group of 31–40 years showed 76.67% prevalence which is not significant (P = 0.4193). | Table 1: Difference in seroprevalence of cytomegalovirus IgG and IgM among all pregnant women
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 | Table 2: Difference in seroprevalence of anti-cytomegalovirus IgG and IgM among different age group of pregnant women
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Nearly 9.7% of patients in the age group of 18–30 years showed prevalence of anti-CMV IgM antibodies while the age group of 31–40 years had 6.67% prevalence. There was no statistically significant difference between the two groups.
The maximum seroprevalence of IgG was seen in women in the first trimester (83.66%) followed by 77.78% in the third trimester and 75% in the second trimester. Maximum seroprevalence of IgM was seen in the second trimester (16.67%) followed by 11.1% in the third trimester and 9.17% in the first trimester. The P = 0.0177 for the first trimester showed that the difference between IgG and IgM was statistically significant and P = 0.3711 in the second trimester and P = 0.5708 in the third trimester showed that the differences were not statistically significant.
As far as the number of pregnancy were concerned, the maximum seroprevalence of IgG was seen in the second pregnancy (89.16%) followed by first pregnancy (82.31%) and 60% for third pregnancy, maximum seroprevalence of IgM (10.47%) was seen in the first pregnancy followed (7.23%) by second pregnancy and (0%) for third pregnancy. A P = 0.0173 for first pregnancy showed that the difference was statistically significant while a P = 0.8373 for second pregnancy showed no statistical significance, and for third pregnancy, no statistical correlation existed.
The seroprevalence of IgG was 83.99% for the group without abortions which was not significant (P = 0.7372) whereas the seroprevalence of IgM was 14.29% in cases with a history of abortion which was statistically significant with a P = 0.0171.
| Discussion | | |
CMV is the most common congenital infection worldwide with estimated incidence of 0.2%–2.2% and seroprevalence ranging between 45% and 100%.[10],[11],[12],[13] The seroprevalence in adult population in India is about 80%–90%.[7],[8] The present study showed a seroprevalence of 83.24% for CMV IgG which is similar to the studies which showed a prevalence of 80%–90% and 87.4%.[1],[14] However, positivity of 9.46% for CMV IgM is less as compared to the study which showed seroprevalence of 22.03% for CMV IgM in Punjab [15] while other studies showed a seroprevalence of 15.98% CMV IgM in Kashmir and 12.9% in Delhi.[16],[17]
As per the results of the serology assay, the participants could be divided into four groups as under:
- Group 1: Antenatal women who were negative for both IgG and IgM antibodies. These women were not infected with CMV and were susceptible to a primary infection by CMV. This group had a high risk of transmission of the virus to the fetus in this group [18]
- Group 2: Antenatal women who are IgM seropositive and negative for IgG antibody. These women had an acute infection with CMV
- Group 3: Antenatal women with positive for IgG antibodies and negative for IgM antibodies. These women have immunity and the infection with CMV is before the present pregnancy
- Group 4: Women who were positive for both anti-CMV IgG and IgM. These women were possibly infected with CMV during the current pregnancy or were suffering from a chronic infection. This possibility of a current infection requires to be confirmed by an IgG avidity test which could not be done in this study.[19]
The results of our study indicate that the prevalence of CMV seropositivity in this region is high, but a definite association between CMV infection and abortion could not be established. Most of the antenatal women in this study were immune against CMV infection and maternal immunity has a protective role to play in the fetus.[20] In our study, 16.76% of the antenatal women were potentially susceptible to CMV infection because of lack of IgG. It has been noted that presence of maternal immunity before is highly protective against congenital CMV infection whereas acquired immunity due to CMV infection sees a reduction in congenital CMV infection in future pregnancies by 69%.[20] Primary infection with CMV at any stage of pregnancy poses a risk for intrauterine infection varying from 30% to 50%; however, it has been seen that congenital infection in seropositive mothers ranges only from 0.2% to 1.5%.[21]
CMV infection can occur during intrauterine period, during or after delivery whereas children get infected in early on with the major source being in the child care centers. Such infections are asymptomatic in these children. CMV produces its effects mainly in a fetus where the mother has a primary infection with CMV during pregnancy. Postnatal transmission commonly occurs through transmission of the virus through breast milk in an infected mother. Hence, the prevention of transmission of CMV infection encompasses the following: preventing congenital CMV infection during antenatal period, preventing ingestion of infected maternal genital secretion during delivery, avoiding breastfeed, preventing contact with saliva, and other body fluid containing CMV.[22] Routine hygiene precautions are essential, especially in pregnant females, since it causes irreversible damage to the fetus.[23]
Screening of antenatal women for CMV IgM antibodies is necessary so that the gynecologist or pediatrician can be alerted about the risk of infection to the newborn. Newborns in such cases can be tested for CMV IgM antibodies which will help in timely therapy of the infected neonate and will also prevent the spread of infection to other children. In addition, primary infection in pregnancy poses a higher risk of producing symptomatic congenital infection and fetal loss.[23] However, infected newborns can be asymptomatic at birth with the development of late sequelae such as visual and auditory defects in 10-15% of the cases.[6],[11],[24],[25] Hence, in developing countries, it would be ideal if all women in the childbearing age group are screened for CMV IgM antibodies. This may help in reducing the incidence of debilitating or fatal fetal outcomes. It will also help in appropriate follow-up (keep a watch for late sequelae like visual and auditory defects) of the newborns delivered by the infected mothers.[6] CMV infection during pregnancy is considered a complex infection, due to the propensity of virus reactivation during the child bearing age and possibility of being transmitted to the fetus in spite of maternal immunity.[7]
Various researchers have shown that the prevalence of CMV antibodies among women varies with geographical location, socioeconomic status, and occupation with maximum prevalence being seen in the low socioeconomic status group.[20],[26],[27]
CMV can affect the organs of the fetus through all stages of pregnancy. The damage has been seen to be more severe in infections occurring during the first half of the pregnancy.[28] Transmission of the virus in various ways to the fetus have been suggested; however, hematogenous spread across the placenta followed by infection of placental and amniotic tissue seems to be the most common method of transmission.[29]
| Conclusion | | |
CMV is an important cause of congenital infection and is liable to cause significant perinatal morbidity along with the attendant increase in health-care costs. Therefore, we recommend that pregnant women, especially with bad obstetric history, should be advised to be more attentive to personal hygiene, especially hand hygiene after handling diapers or oral secretions. The three important tips to decrease exposure to the most common sources of CMV, which are to be given as advice, especially to seronegative mothers, is as follows: not to share food, drink, straws, or eating implements with young children; not to kiss young children on or around the mouth or lips; and thorough washing of hands after changing diapers (wet with urine or dirty with stool) and wiping runny nose or mouth drool. We also recommend that high-risk pregnant women or health workers should undergo mandatory screening for CMV in addition to screening for other maternal infection such as Toxoplasmosis, Rubella, and Herpes simplex.
As effective therapy for satisfactory treatment of congenital CMV infection are not available, prevention is paramount.[29] The importance of careful hand hygiene should be impressed on those involved in handling young children, and they should be counseled adequately, an intervention that will result in reduction of the risk of primary CMV infection and subsequent fetal transmission.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]
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