Seroprevalence of herpes simplex virus type-2 among pregnant women in Wad Madani-Sudan: a cross sectional study

Hind Ahmed; Nuha Abbu; Samar Saeed; Wafaa Abdalla; Kawthar MohammedSalih; Ahmed Abd Alla; Ahmed Hashim

doi:10.12688/f1000research.111054.1

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Research Article

Seroprevalence of herpes simplex virus type-2 among pregnant women in Wad Madani-Sudan: a cross sectional study

[version 1; peer review: 3 approved with reservations]

Hind Ahmed ¹, Nuha Abbu¹, Samar Saeed¹, [...] Wafaa Abdalla¹, Kawthar MohammedSalih², Ahmed Abd Alla³, Ahmed Hashim¹

Hind Ahmed ¹, Nuha Abbu¹, [...] Samar Saeed¹, Wafaa Abdalla¹, Kawthar MohammedSalih², Ahmed Abd Alla³, Ahmed Hashim¹

PUBLISHED 06 Jul 2022

Author details Author details

¹ Department of Microbiology, College of Medical Laboratory Science, Sudan University of Science and Technology, Sudan, Khartoum, Sudan
² Department of Hematology, Sudan University of Science and Technology, Khartoum, Khartoum, Sudan
³ Department of Parasitology and Medical Entomology, Sudan University of Science and Technology, Khartoum, Khartoum, Sudan

Hind Ahmed
Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation

Nuha Abbu
Roles: Data Curation, Investigation, Methodology, Resources

Samar Saeed
Roles: Data Curation, Validation, Writing – Review & Editing

Wafaa Abdalla
Roles: Data Curation, Visualization, Writing – Review & Editing

Kawthar MohammedSalih
Roles: Validation, Visualization, Writing – Review & Editing

Ahmed Abd Alla
Roles: Formal Analysis, Visualization, Writing – Review & Editing

Ahmed Hashim
Roles: Conceptualization, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background: Sexually transmitted diseases are known to pose a significant public health threat. Herpes simplex virus type 2 (HSV-2) is a viral infection with high prevalence in Sudan, particularly among pregnant women. The aim of this study was to determine the seroprevalence of HSV-2 among pregnant women as well as their associated potential risk factors in Wad Madani-Sudan.
Methods: In total, 92 pregnant women who attended the Maternity Hospital and Dr. Altigani Sedeeg Fertility Center at Wad Madani, AL-Gezira State, between April and August 2018 were included in this study. HSV-2 Immunoglobulins (IgG and IgM) were assayed by the enzyme-linked immunosorbent assay technique.
Results: The seroprevalence of HSV-2 IgM and IgG were 35(38%) and 90(97.8%), respectively. A Higher prevalence of HSV-2 IgG 45(48.9%) and 13(14.1%) for IgM was detected in pregnant women aged 15-24 years old with a significant association between HSV-2 IgM and age distribution group (p-value=0.001). HSV-2 IgM and IgG seropositivity were highest in the first trimester; 26(34.2%), and 75(81.5%), respectively. The highest rate of HSV-2 IgM was detected in 19 (20.7%) women with a history of abortion, while the highest rate of HSV-2 IgG was seen in 50 (54.3%) women without a history of abortion. The statistical analysis results did not reveal significant differences between gestational stages and history of abortion with the presence of HSV-2 antibodies.
Conclusion: The prevalence of HSV-2 was significant among pregnant women in Wad Madani- Sudan. There was a strong association between HSV-2 IgM seropositivity and the age of pregnant women.

Keywords

HSV-2, IgM, IgG, ELISA, pregnant women, Wad Madani, Sudan

Corresponding author: Hind Ahmed

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2022 Ahmed H et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Ahmed H, Abbu N, Saeed S et al. Seroprevalence of herpes simplex virus type-2 among pregnant women in Wad Madani-Sudan: a cross sectional study [version 1; peer review: 3 approved with reservations]. F1000Research 2022, 11:752 (https://doi.org/10.12688/f1000research.111054.1) First published: 06 Jul 2022, 11:752 (https://doi.org/10.12688/f1000research.111054.1) Latest published: 06 Jul 2022, 11:752 (https://doi.org/10.12688/f1000research.111054.1)

Introduction

Herpes viruses are double-strand DNA viruses that belong to the family herpesviridae, subfamily Alpha herpesvirinae.¹ Infection with herpes simplex virus (HSV) is one of the world’s most common viral sexually transmitted diseases² that is categorised into HSV-type 1 (HSV-1) transmitted through oral contact, and HSV-type 2 (HSV-2) which is transmitted through sexual contact.³ Although there are a lot of undiagnosed cases as most infected persons are either asymptomatic or have genital symptoms that remain unrecognized,⁴ HSV-2 is the most leading cause of genital herpes, particularly in third world countries.⁵

The seropositivity of HSV-2 is increasing in individuals between the ages of 27-28 years worldwide.⁶ The seroprevalence of HSV-2 is higher in developing countries than in developed ones.⁷ Substantially greater HSV-2 levels have been observed in sub-Saharan Africa, where the prevalence in adults ages ranging from 10 to 50% in men and 30 to 80% in women.⁸ Females are more susceptible to HSV-2 (30%-80%) than males (10%-50%),⁹ because male-to-female transmission is easier than female-to-male transmission.¹⁰ The prevalence of Asian countries’ overall population indicates elevated values, from 10% to 30%.¹¹ In developing nations, it is unusual to have regular health checks unless there is a sign and symptom of the disease, which contributes to the increasing rate of this disease. The frequency of HSV-2 infection among commercial female sex workers is above 80% in some African countries.⁹

As a prevalent pathogen, HSV also contributes to lifelong latent infection, and it is possibly associated with mother-to-fetus transmission involving the feto-placental unit.¹¹^,¹² As such, this infection can cause considerable miscarriage among pregnant women and a higher risk to their infants leading to serious complications including intrauterine growth retardation, intrauterine fetal death, preterm labour, miscarriage, congenital and neonatal herpes infections¹³

The mortality rate for neonatal herpes (both HSV1 and 2) is 60% when left untreated.¹⁴ The risk of neonatal infection is 30% to 50% when HSV infection is acquired in the last trimester, although the risk in early pregnancy is only 1%.¹⁵ Approximately, 90% of all neonates’ HSV infections are transmitted during delivery and at least 5% are transmitted in utero.¹⁶ Despite the burden caused by these viruses, there are limited epidemiological data regarding these infections in Sudan. Therefore, the aim of this study was to assess the seroprevalence of HSV-2 and associated risk factors among pregnant women in Wad-Madani at Al Gezira State-Sudan.

Methods

This descriptive cross-sectional study was conducted in Wad-Madani Maternity Hospital and Dr. Altigani Sedeeg Fertility Center in Al Gezira State in Sudan between April and August 2018. Data was collected through a questionnaire from pregnant women. Additionally, blood specimens were taken from selected pregnant women who had given consent after the aims and significance of the study had been explained.

Ethical statement

The study was approved by the Ethical Committee of the College of Medical Laboratory Science, Sudan University of Science and Technology ethical approval No: (ECC-MLS-01-18).

Consent

Written informed consent was obtained from each participant before data collection and publication.

Enzyme-Linked Immune Sorbent Assay (ELISA) detection of HSV-2 IgM and IgG

Blood samples for antibody detection were collected from 92 randomly selected pregnant women and centrifuged at 3000 rpm for 5 minutes to obtain serum then stored at -20°C until tested.

The ELISA technique (Chemux BioScience, USA) (HSV2 IgM Kits Lot No: 18-D4-061 HSV2 IgG Kits Lot No: 18-D4-018) was done according to the instruction sheet. The samples were left to reach room temperature for at least 30 minutes after which they were mixed thoroughly by the vortex, prior to use. Dilutions (1:40) were prepared by adding 5 μL of the sample (added once), negative control, positive control, and calibrator, to 200 μL of sample diluent. 100 μL of diluted sera, calibrator, and controls were added to a flat-bottom 96-well plate. The plate was incubated at room temperature for 30 minutes. A 100 μL of enzyme conjugate was added to each well and incubated for further 30 minutes at room temperature, then the enzyme conjugate from all wells were removed, and the plate was washed three times with washing buffer. A 100 μL of 3,3′5,5′-Tetramethylbenzidine (TMB) chromogenic substrate was added to each well and incubated for 15 minutes at room temperature, followed by 100 μL of stop solution. The plate was read on a microplate reader at 450 nm (the sample added once). HSV-2 IgM/IgG Index less than 0.90 was considered negative for IgM/IgG antibody, while HSV-2 IgM/IgG Index between 0.91-0.99 were considered as equivocal. HSV-2 IgM/IgG Index of 1.00 or greater is positive for IgM/IgG antibody.

Statistical analysis

The data were analyzed by Statistical Package for Social Sciences (SPSS) software version 11.5. Frequencies, means and standard deviations (SD) were calculated. Pearson Chi-square test was performed between qualitative variables. A p.value of ≤ 0.05 was considered as significant for all statistical tests in this study.

Results

In this study, 92 pregnant women aged between 15 till 44 years (26+ 6.103 SD) were included. In total, 46 of pregnant women were 15-24 years old, 35 were 25-34 years old, and 11 were 35-45 years old.

It was observed that the seroprevalence of HSV-2 IgM antibodies was 35(38%), while for HSV-2 IgG it was 90(97.8%) (Figure 1. When considering the age group, ut of the 92 pregnant women; HSV-2 IgM was detected in 13 (14.1%) and IgG in 45 (58.9%) among age group¹⁵^–²⁴ years; 12(13%) for IgM, and 34(36.9%) for IgG among (25-34) years; and 10(10.9%) for IgM and 11(12%) for IgG among (35-44) years. Furthermore, the seropositivity of HSV-2 IgM/IgG during gestational stages were: 26/35 (34.2%), 75/90 (81.5%) in the first trimester, and 9/35 (9.8%), 15/90 (16.3%) in the second trimester for IgM and IgG, respectively. The seroprevalence of HVS-2 IgM among pregnant women with a history of abortion was 19 (20.7%), while HSV-2 IgG was 40 (43.5%). In addition, 16 (17.4%) cases of IgM and 50 (54.3%) cases of IgG were detected among pregnant women without a history of abortion. In this study, the seroprevalence of HSV-2 IgM showed a high association with the age of pregnant women (p.value=0.001), while gestational stage and history of abortion showed no association with seroprevalence of both HSV-2 IgM and IgG (p.value >0.05) as shown in Table 1.

Figure 1. Sero-prevalence of HSV-2 IgM and IgG among pregnant women.

Table 1. The association of HSV-2 IgM, IgG with age, gestational stage and history of abortion among pregnant women.

Character		Seropositvity
Character		IgG	P value	IgM	P value
Age/years	15-24	45(48.9%)	0.852	13(14.1%)	0.001
	25-34	34(36.9%)		12(13.0 %)
	35-44	11(12.0%)		10(10.9%)
	Total	90(97.8%)		35(38%)
Gestational trimester	First	75(81.5%)	0.229	26(34.2%)	0.087
	Second	15(16.3%)		9(9.8%)
	Total	90(97.8%)		35(38%)
History of abortion	Yes	40(43.5%)	0.210	19(20.7%)	0.078
	No	50(54.3%)		16(17.4%)
	Total	90(97.8%)		35(38%)

Discussion

HSV is a common sexually transmitted infection, and the prevalence of this infection has increased significantly over the last two decades in many developed and developing countries.¹⁷ In the reproductive age group, it is an important cause of intra-uterine fetal and neonatal infection when transmitted from mother to fetus.¹⁷

The results of this study indicated that the seroprevalence of HSV-2 IgM among pregnant women was 38% and 97.8% for IgG. Slightly similar results were observed by Alshareef et al. (2017) in Sudan, who reported 87.8% of pregnant women were HSV-2 IgG positive.¹⁸ Another study conducted by Zaki and Goda (2007), in Egypt showed that 40% of pregnant women were positive for IgM,¹⁹ while a study conducted in Cote D’Ivoire by Cisse et al. (2015) indicated that 96.5% tested positive for HSV-2 IgG.²⁰

The obtained results were relatively high when compared with similar studies carried out in other Sudan states and other countries.²¹^,²² The reason for this difference could be related to the rate of virus exposure, the virus’s presence in a certain region, the virus’s susceptibility rate, and people’s immunological condition. Unlike the mentioned studies, lower results were obtained by Hussan (2014) in Baghdad, who reported that the prevalence of HSV-2 IgM was 4.76% among pregnant women.²³

The present study found an increase in HSV-2 seroprevalence in the age groups 15–24 years 12(34. 2%), this was consistent with many studies done in Sudan such as Edress and Elhag (2015) and El-Amin et al. (2013).²¹^,²² Also, the similar result was found in a study by Tiwari et al. (2016) in New Delhi, India.²⁴ There are many reasons that may explain the high incidence of HSV-2 in women in this age group, especially individuals aged 20 to 29 years, as these women are highly reproductive in this age range and are more susceptible to chronic infections such as HSV-2, and the prevalence of primary or recurrent HSV-2 infection peaks during this time period.

According to the gestational stage, HSV-2 IgM and IgG were the highest in the second trimester (52.9%) followed by the first trimester (34.6%). These findings agreed with Edress and Elhag (2015), who reported the percentage of IgM to be 1.7% in the first trimester and 3.7% in the second trimester²¹ and Mezher et al. (2018) in Iran found that HSV-2 seropositivity was (16.7%), (29.2%) in the first trimester, and (45.8%), (8.3%) in the second trimester for aborted and pregnant women, respectively.²⁵ While, Mohammad and Salman showed a maximum rate of HSV-2 infection at second trimester,²⁶ and Amar et al. (2015) in India showed that the seropositivity of IgM were 3.3% in the first, and 1.1% in the second trimester.²⁷

The prevalence of HSV-2 IgG, IgM antibody among women who have had a history of abortion was not significant (p value>0.05) compared to women without a history of abortion. These finding was not in line with Assayaghi et al. (2017) in Yemen (p-value 0.6, 0.4) and Oluwapelumi et al. (2020).²⁸^,²⁹ Another study by Mezher et al. (2018) indicated that the detection of HSV-2 in women who had a history of abortion was higher than in pregnant, and that may improve the probability of this virus as one of the main viral agents that cause abortion. Many studies have suggested that HSV-2 infection may be a risk factor for miscarriage abortion; nevertheless, HSV-2 infection was detected in a small percentage of women with a history of abortion, suggesting that HSV infection is unlikely to be a major factor in abortion.²⁵

The variation in the obtained results may be due to geographical regions where the studies were conducted, the sample size technique used for analysis, and the limited period which those studies were carried out.

Conclusion

To the authors’ knowledge, there is no published data about the prevalence of HSV-2 among pregnant women in Wad-Madani, Al Gezira State, Sudan. As a result of this study there was a significant frequency of HSV-2 infection among pregnant women in Wad-Madani, particularly among those aged 15 to 24 years.

There was a significant relationship between HSV-2 IgM seropositivity and the age of the pregnant woman. However, the differences between HSV-2 IgG and IgM seropositivity rates in other socio- epidemiological data (gestational trimester and history of abortion) didn’t display statistical significance.

Further studies were recommended.

Limitations

It is necessary to analyze these findings with more advanced techniques and study the role of HSV-2 in abortion with a larger sample size in order to fully support these conclusions. Also, the analytical study designs can give more accurate results. As this was a cross-sectional study, no assessments were done for pregnant women for subsequent miscarriage or neonatal death. Case control or cohort’s studies will obtain more accurate results and the relation between risk factors and outcomes will be highlighted clearly.

Data availability

Underlying data

Figshare: Herpes simplex virus, https://doi.org/10.6084/m9.figshare.19375088.v4

This project contains the following underlying data:

Data file 1. Study questionnaire

Data file 2. ELISA data

Nuha.xls (HSV-2 raw Data)

Nuha dictionary.docx. (HSV-2 data dictionary)

Data are available under the terms of the Attribution 4.0 International (CC BY 4.0)

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