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Transfusion and Apheresis Science xxx (xxxx) xxx–xxx

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Seroprevalence and molecular detection of Toxoplasma gondii in healthy

blood donors in southwest Iran

J. Sakia, M. Foroutanb, I. Khodkara, , A. Khodadadic, L. Nazarid
Alimentary Tract Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
Abadan School of Medical Sciences, Abadan, Iran
Department of Immunology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
Blood Transfusion Organization, Ahvaz, Iran


Keywords: Background: Toxoplasmosis is a cosmopolitan parasitic disease caused by Toxoplasma gondii (T. gondii). Blood
Toxoplasma gondii transfusion is a probable route of T. gondii transmission. Due to lack of information about seroprevalence of T.
Blood donors gondii in healthy blood donors, this study was aimed to determine the chronic and acute infection using ser-
Seroprevalence ological and molecular methods.
Material and methods: In this cross-sectional investigation, 380 samples were collected from donated bloods.
Anti-Toxoplasma IgG and IgM antibodies were examined using enzyme-linked immunosorbent assay (ELISA).
Also, all IgG positive samples were tested by IgG avidity test. Eventually, to detection of active infection, DNA
was extracted from IgM positive and low IgG avidity samples and then tested using nested-polymerase chain
reaction (PCR).
Results: Among 380 blood donors, 131 (34.47%) were positive for only anti-T. gondii IgG, 2 (0.5%) were positive
for only anti-T. gondii IgM, and 11 (2.9%) were positive for both IgG and IgM antibodies. Then, 142 samples (131
IgG + and 11 IgG +IgM +) were evaluated using IgG avidity test. Of these, 115 (81%) had high avidity IgG
indicates past infection; 16 (11.26%) had low avidity IgG representing recent infection, and 11 (7.74%) were
equivocal. With nested PCR, 20 samples of 50 seropositive samples were diagnosed positive.
Conclusion: Detected active infection using nested-PCR draws attention to the possibility of T. gondii infection via
blood transfusion which emphasizes the importance of parasite DNA screening before donation of blood in high
risk groups such as: multi-transfused persons, immunosuppressed patient, and pregnant women.

1. Introduction among HIV/AIDS, transplant recipients and cancer patients in Iran were
reported 50.05%, 55.1% and 45.06%, respectively [8]. Unfortunately,
Toxoplasmosis is a ubiquitous zoonotic disease, caused by an ob- there is lack of a commercially licensed vaccine to prevent tox-
ligate intracellular protozoan parasite known as Toxoplasma gondii (T. oplasmosis in humans [13–15].
gondii), which can influence various warm-blooded vertebrates such as It has been shown that T. gondii can be transmitted through whole
humans, livestock, birds, marine mammals, etc [1–4]. This protozoa blood or leukocyte transfusion and could be alive in citrated blood at
needs both intermediate and definitive hosts to complete its asexual and 5 °C for more than 50 days; accordingly, the refrigeration of blood packs
sexual replication stages in the life cycle [1,5]. It is estimated at least during storage can't delay and prevent from the transmission of infec-
one-third of the world’s population are seropositive for the parasite and tion [16]. Normal seropositive blood donors, particularly those in-
carry it [6]. Toxoplasmosis in immunocompetent persons is mostly dividuals who are in the acute stage of infection, may have an im-
without symptom; however, among immunocompromised individuals, portant role in the transmission [17]. T. gondii in India country, after
i.e. HIV+/AIDS patients, cancer patients, and organ transplant re- malaria is the commonest protozoan infection, which transmitted by
cipients can cause serious consequences, even death [7–12]. According blood transfusion [18]. In a survey conducted by Siegal et al., the
to recently published systematic review in the Iranian im- transmission of T. gondii in four leukemic patients by leukocyte trans-
munocompromised patients, the pooled seroprevalence of T. gondii was fusion was reported [16]. Also, other transplantation recipients of
estimated 50.01% (95% CI, 43.85–56.17). Also, the rate of infection kidney, lung, heart and bone marrow are at risk to infection [19].

Corresponding author.
E-mail address: (I. Khodkar).
Received 23 June 2018; Received in revised form 15 November 2018; Accepted 5 December 2018
1473-0502/ © 2018 Elsevier Ltd. All rights reserved.

Please cite this article as: Saki, J., Transfusion and Apheresis Science,
J. Saki et al. Transfusion and Apheresis Science xxx (xxxx) xxx–xxx

Frequent blood transfusion from different donors regularly applied for antibodies in the early stage of infection can be differentiated from high
the individuals with sickle cell anemia, thalassemia and aplastic anemia avid antibodies associated with a past infection. The determination of
to survive, whereas pre-transfusion T. gondii screening has not been IgG antibody avidity is an additional analysis to the classic serology in
considered yet [6,7]. regard to the status of a T. gondii infection. All IgG positive samples
In several investigations, seroprevalence of T. gondii was determined were tested by IgG avidity T. gondii commercial kit (NovaLisa T. gondii-
in different population groups in Khuzestan province, southwest Iran IgG avidity; NOVA TEC- GMBH) based on the manufacturer’s protocol
and indicated that this region has high prevalence [7,20–23]. Most [22].
studies on T. gondii in the country and this region, have focused on high
risk categories like pregnant women and immunocompromised pa- 2.5. DNA extraction and molecular technique
tients; hence, due to lack of information about seroprevalence of T.
gondii in healthy blood donors in Ahvaz city, southwest Iran, the current Buffy coat separation was done for all samples and kept in −20 °C
study was aimed to determinate the T. gondii infection using enzyme- until DNA extraction for nested-PCR. DNA from IgM positive and low
linked immunosorbent assay (ELISA) and polymerase chain reaction IgG avidity samples were extracted using SinaPure™ genomic DNA
(PCR). isolation kit (Cat. No: EX6001) based on the manufacturer’s instructions
and kept in −20 °C till tested. Nested-PCR was employed for molecular
2. Materials and methods diagnosis. For this purpose, we used two specific set primers to detect
B1 gene as follows:
2.1. Study area First stage primers
Ahvaz city, capital of Khuzestan province, which located at south- Reverse (R1): 5′−CCGCAGCGACTTCTATCTCT-3′
west Iran country (31°50ʹ N and 49°11ʹ E), is ranked as the 7th largest Second stage primers
city throughout the country and based on the latest census, its popu- Forward (F2): 5′-GGAACTGCATCCGTTCATGAG-3′
lation calculated about 1,395,184 in 352,128 families. Weather tem- Reverse (R2): 5′-TCTTTAAAGCGTTCGTGGTC-3′
perature is highly variable throughout the year so that in summer Ultimately, the PCR products were electrophoresed on 1.5% agarose
temperature exceeds than 50 °C whereas in winter fell down to −5 °C. gel and visualized using Gel Documentation System (Uvidoc, Gel
Also annual average rainfall is approximately 230 mm [7]. Documentation System, Cambridge, UK).

2.2. Study population 2.6. Statistical analysis

In this cross-sectional study that performed between April 2015 to Findings were analyzed by SPSS software (version 19) (SPSS Inc.,
June 2015 in Ahvaz city, blood samples were taken from 380 healthy Chicago, IL, USA).
volunteer blood donors who referred to central Blood Transfusion
Organization (BTO) of Khuzestan province located at Ahvaz city. The 3. Results
collected samples were routinely examined for hepatitis B virus surface
antigen (HBsAg), hepatitis C virus (HCV), human immunodeficiency 3.1. ELISA assay
virus (HIV), human T-lymphotropic virus 1 and 2 (HTLV1, 2) and
Treponema pallidum (T. pallidum) in BTO of Ahvaz city. Inclusion criteria Three hundred and eighty sera samples of donated bloods were
in our study were as follows: 1) individuals ≥ 18 years old; 2) persons examined in this study. The overall prevalence of toxoplasmosis was
who tend to participate in the study (after obtaining a written informed obtained 37.9% (144/380). Of these, 131 (34.47%) were seropositive
consent); 3) blood donors who tested negative for HbsAg, HCV, HIV, only for IgG, 2 (0.5%) were seropositive only for IgM, and 11 (2.9%)
HTLV 1, 2 and T. pallidum. The current study was approved by the were positive for both IgG and IgM.
ethical committee of Ahvaz Jundishapur University of Medical Sciences
(Code no.93596). 3.2. IgG avidity ELISA

2.3. Serology In order to differentiate between acute and chronic phases of T.

gondii infection, IgG avidity ELISA test was done on 131 samples with
From each subject who met the above-mentioned inclusion criteria IgG positive antibody and 11 samples with both IgG and IgM positive
of the study, 5 mL blood was collected. All blood specimens im- antibodies. Among them, 115 (81%) indicated high avidity IgG, which
mediately after sampling transferred to the Department of Medical signifies past infection; 16 (11.26%) had low avidity IgG representing
Parasitology at Ahvaz Jundishapur University of Medical Sciences. At recent infection, and 11 (7.74%) were equivocal.
first, the taken blood were centrifuged at 4000 rpm for 5 min. Then the
sera were separated in order to examination for specific anti- 3.3. Nested PCR
Toxoplasma IgM and IgG antibodies and stored in −20 °C. Furthermore,
buffy coat separation was done and kept in −20 °C until DNA extrac- Nested-PCR was performed on 50 samples including, 21 samples
tion for PCR. All samples were examined for IgM and IgG anti- with high avidity IgG, 5 samples with low avidity IgG, 11 samples with
Toxoplasma antibodies using a commercial available ELISA kit equivocal test, and 13 samples with IgM positive antibody. In total,
(NovaLisa T. gondii-IgG, Cat. No. TOXG0460; NovaLisa T. gondii-IgM, among 50 samples which tested by nested-PCR, 20 samples (40%) were
Cat. No. TOXM0460) based on the manufacturer's instruction, as pre- positive and 30 samples (60%) were negative. The results were as fol-
viously described by Saki et al., 2017 [22]. lows: 1 out of 21 persons with high avidity IgG, 5 persons with low
avidity IgG, 1 persons with equivocal test and all of 13 IgM positive
2.4. T. gondii IgG avidity test samples were positive by the nested-PCR method. Fig. 1 indicates the
results of nested-PCR test of some positive samples.
The avidity determination is a diagnostic method which is used to
differentiate a recent (acute) and a more distant (past) infection with T. 4. Discussion
gondii in patient sera. Avidity is the binding force of the antibody
(serum specimen) with the corresponding antigen. Low avid IgG Although the safety of the blood supply is always under strict

J. Saki et al. Transfusion and Apheresis Science xxx (xxxx) xxx–xxx

Fig. 1. B1 nested-PCR analysis of selected seropositive (IgM, IgG) samples from blood donors. Lane 1, DNA size marker; Lane 2, Positive control; Lanes 3–5, IgM
positive samples; Lanes 6-13. Selected IgG positive samples from IgG avidity test.

control and surveillance, concerns remain regarding transfusion-trans- be lead to occurrence of irreparable consequences. Based on formal
mitted infections [6,24]. Blood transfusion is one of the probable statistics, more than 20,000 thalassemia patients are existing in Iran
transmission routes for T. gondii infection [6]. that many of them live in the southwest Iran [40]. These individuals
The present study is the first survey to evaluate the seroprevalence and other patients with each hematopoietic disorders, needs multiple
of T. gondii infection among apparently healthy blood donors in the transfusion for survival. It is estimated that approximately 25% of the
southwest region of Iran. In this study, 34.47% and 2.9% of blood do- total national blood products are being used for thalassemia patients in
nors were found seropositive for only IgG and for both IgG & IgM an- Iran [41].
tibodies, respectively. Our results are in agreement with other studies In the current study, ELISA method was used. Multiple serological
such as Tappeh et al. in Urmia city (37.8%) [25], Sadooghian et al. in techniques are routinely employed to detect specific IgG and IgM an-
Khorasan Razavi province (37.5%) [26], Bahhaj et al. in Tabriz city tibodies against T. gondii. Among them, ELISA has high sensitivity and
(38.6%) [27], and Zainodini et al. in Rafsanjan city (34.04%) [28], specificity, which can differentiate between chronic and acute phase of
while the lower seroprevalence of the infection was reported from Fars the infection [22,42,43]. Although there is evidence which suggests
province (12.3%) [29], Boyer-Ahmad county (16.3%) [30], and Za- despite the constant presence of anti-T. gondii IgM antibodies in serum,
hedan city (25%) [31]. Also, the rate of T. gondii infection in blood any positive IgM-ELISA could not surely be considered as an acute in-
donors are varies in different zones worldwide. Based on a systematic fection, thus the PCR technique to explore DNA of T. gondii is required
review and meta-analysis paper from a global perspective, the highest [20,43].
and lowest seroprevalence of T. gondii infection among blood donors In conclusion, our results indicate that toxoplasmosis has high
were observed in Africa (46%; 95% CI, 14%–78%) and in Asia (29%; prevalence in terms of chronic and active infection (IgM antibody and
95% CI, 23%–35%), respectively. Moreover, the seroprevalence in circulating DNA using nested-PCR) among apparently healthy blood
America, Europe, and Oceania were 42% (95% CI, 21%–63%), 30% donors in southwest Iran. Thus, it is strongly recommended to design an
(95% CI, 19%–40%), and 42% (95% CI, 36%–48%), respectively [6]. In appropriate screening program for preventing transfusion-transmitted
some regions such as: Egypt [32] and northeast Brazil [33], ser- toxoplasmosis, especially among multi-transfused persons, im-
opositivity in healthy blood donors were reported more than 50%. Also munosuppressed patient, and pregnant women to reduce the trans-
lower rate of infection have been reported from Thailand (9.6%) [34], mission of T. gondii infection. This article provides a foundation for
Taiwan (9.3%) [35], Namibia (0.96%) [36], and Mexico (7.4%) [37]. further studies in the future.
The reason for this discrepancy is due to type of sampling, sample size,
methodology, cultural habit of the region, etc. 5. Limitations
The presence of T. gondii in blood during the period of infection,
especially in the acute stage of the infection may be lead to transmission The limitations of the study are the lack of demographic information
through blood transfusion [38]. In addition, the ability of the protozoa such as age, sex, occupation, etc. These data were not provided by the
to survive in the stored bloods, enhance the risk of transmission through relevant organization.
blood transmission. Also, it has been shown the presence of T. gondii
tachyzoites in stored bloods for several weeks. Therefore, T. gondii can Conflict of interest
be transmitted via blood and leukocyte transfusions, particularly if
parasitized leukocytes are transfused in a high concentration [16]. It None.
has been reported that T. gondii seroprevalence in the Iranian general
population was 39.3%, while the rate of infection in patients with im-
Author contributions
munocompromised disorders was 50% [8,39]. Since these individuals,
particularly transplant recipients require whole blood or other blood
Conceptualization: Jasem Saki, Masoud Foroutan, Ali Khodadadi;
products; accordingly, the presence of T. gondii in blood products may
Data analysis: Jasem Saki, Iman Khodkar; Investigation: Jasem Saki,

J. Saki et al. Transfusion and Apheresis Science xxx (xxxx) xxx–xxx

Masoud Foroutan, Iman Khodkar, Laleh Nazari; Methodology: Jasem recipients: a matched case-control study. Clin Infect Dis 2012;54:355–61.
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patients with end-stage renal disease by enzyme-linked immunosorbent assay and
Saki; Supervision: Jasem Saki; Writing - original draft: Masoud polymerase chain reaction methods. Parasitol Res 2013;112:163–8.
Foroutan; Writing - review & editing: Jasem Saki, Masoud Foroutan. [21] Foroutan-Rad M, Khademvatan S, Majidiani H, Aryamand S, Rahim F, Malehi AS.
Seroprevalence of Toxoplasma gondii in the Iranian pregnant women: a systematic
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