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Vertical transmission of bacterial eye infections, Angola, 2011-2012.

Ophthalmia neonatorum (neonatal conjunctivitis) can be easily prevented with prophylactic administration of topical antimicrobial drugs, as recommended by global guidelines for the management of sexually transmitted infections (1). However, in Angola, routine prenatal and prophylactic care to prevent this disease in newborns is lacking. In 2009, a project aimed at developing a national program for ophthalmia neonatorum prophylaxis in all maternity wards of Angola was started through the Spanish Agency for International Cooperation and Development and with the collaboration of the Angolan Ministry of Health. A previous pilot study in Luanda, Angola, showed that clinical cases of acute conjunctivitis among newborns were frequent; [approximately equal to] 12% of infants were born with bilateral acute conjunctivitis (2). However, the absence of microbiology laboratory resources at the study site resulted in the inability to determine the causative pathogens. One of the phases of the program was to analyze the usefulness of molecular biology tests to detect 2 of the most common sexually transmitted pathogens associated with transmission from the mother to the eye of the child-Chlamydia trachomatis and Neisseria gonorrhoeae (3)-and an emerging third pathogen (4), Mycoplasma genitalium. Our aim with this study was to assess the frequency of these 3 infections in a sample of mothers and their newborns in Angola and to determine the rate of vertical transmission.

The Study

In this prospective, observational study, from December 2011 through February 2012, pregnant women and their newborns were recruited from 2 obstetric clinical wards at the Augusto N'Gangula Hospital and the Health Center of Samba in Angola. Study participation was voluntary. Specific informed consent was obtained from all participants before specimens were collected. Approval of the study protocol for scientific and ethical aspects was obtained from the Ethical Commission of the School of Medicine of the Agostinho Neto University (Luanda, Angola). The study was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and later amendments.

Included in the study were mothers who were healthy (with the possible exception of genitourinary disease) and their newborns with a gestational time of 37-40 weeks and a weight of [greater than or equal to] 2.3 kg. Endocervical samples were obtained consecutively from pregnant women who agreed to participate in the study and were collected after removal of postpartum secretions from the endocervical os. Ocular samples were obtained from both eyes of the newborns by vigorous swabbing across the inferior tarsal conjunctiva. Samples from each eye were then pooled for analysis. After sampling, the newborns were prophylactically given 5% povidone iodine eyedrops.

Samples were collected with flocked swabs in Universal Transport Medium (Copan Italia S.p.A., Brescia, Italy), stored at -70[degrees]C, and shipped to the Department of Microbiology at the Hospital Chnico Universitario of Valladolid, Valladolid, Spain. DNA extraction was performed according to routine laboratory standards with the GXT DNA/RNA reagents in a GenoXtract extractor (HainLifescience, Nehren, Germany). A multiplex PCR that co-amplified DNA sequences of C. trachomatis, N. gonorrhoeae, M. genitalium, and an internal control was performed by using the Bio-Rad Dx CT/NG/MG assay (BioRad, Hercules, CA, USA) (5). The primers and probe for C. trachomatis targeted a sequence of the cryptic plasmid located outside the region deleted in the new variant strain of C. trachomatis (6). For N. gonorrhoeae, the target was a sequence in the pilE gene that rarely yields false-positive results. For M. genitalium, the target was a sequence in the MgPa gene. To avoid laboratory or sampling errors, we processed the samples from the mothers and newborns separately and included positive and negative controls in the PCRs. Amplification and detection were performed in a 7500Fast Real-Time PCR system (Life Technologies, Carlsbad, CA, USA), according to the manufacturer's instructions. Statistical analyses were performed by using R Statistical Software (Foundation for Statistical Computing, Vienna, Austria).

A total of 567 samples were analyzed (Table 1). Results of detection by multiplex PCR were considered for prevalence estimates of the 3 infections (Table 2). Transmission rates were 50% for C. trachomatis and N. gonorrhoeae and 10.5% for M. genitalium. For 7 infected mothers (2 C. trachomatis-infected and 5 M. genitalium-infected), no samples could be obtained from their newborns.


The microorganism most frequently found among mothers was M. genitalium, and the microorganism most frequently found among newborns was C. trachomatis. Despite the association of M. genitalium with sexually transmitted infections in men and women (4), we are aware of only 1 other case of conjunctivitis associated with M. genitalium (7).

Only 1 mother was co-infected by 2 microorganisms, C. trachomatis and M. genitalium, consistent with the low rate of this co-infection found in other studies (8). This mother gave birth to 1 of the 4 C. trachomatis-infected newborns. Not answered by this study is the hypothetical role of M. genitalium as a co-factor for transmission of other major sexually transmitted pathogens. M. genitalium has also been studied as a possible contributor to the pathogenesis of trachoma in a trachoma-endemic area of Tanzania, but no evidence was found regarding its contribution (9). Our findings regarding M. genitalium infections in this sample need further study because the relatively small number of infected mothers and children can be a confounding factor and because the real prevalence of M. genitalium needs to be assessed by larger studies.

The frequency of C. trachomatis infection among the study sample (mothers and newborns), 2.1%, was lower than that found in previous studies in different populations in Africa (10). The frequency of N. gonorrhoeae infection among the study sample, 0.5%, was also lower than that found in other African countries, such as the Central African Republic (3.1%) and South Africa (7.8%) (11). The frequency of M. genitalium infection among the study mothers, 6.1%, was slightly higher than that found in other studies of asymptomatic women (8).

Rates of transmission from the mother to the eye of the child differed markedly for each of the 3 microorganisms studied. The rate of M. genitalium transmission was much lower than that for C. trachomatis and N. gonorrhoeae. Vertical transmission of M. genitalium is uncommon; we are aware of only 1 reported case (12). Although M. genitalium is among the most prevalent pathogens in this sample of mothers in Africa, vertical transmission of this microorganism was less frequent than that of other classical sexually transmitted pathogens like C. trachomatis and N. gonorrhoeae. However, high prevalence in any maternal population, even with a relative low rate of transmission, could lead to a large number of neonatal infections.

All infected children were from mothers who were also infected. It can be assumed that, as with HIV infection, detection of any of the assayed microorganisms in conjunctival samples of newborns predicts diagnosis in their mothers (13). This so-called mirror effect is clinically useful in view of cultural behaviors that would complicate detection of sexually transmitted pathogens in adult women, especially in geographic settings of Muslim practices (14).

The major limitation of this study was the difficulty of correctly preserving samples in the hot and humid environment of Angola. To prevent DNA denaturation, samples were frozen immediately after collection and shipped as soon as possible. Unfortunately, those precautions precluded the culturing of samples, so PCR results could not be compared with culture results. Another disadvantage was the lack of more precise clinical information from participants because of the absence of antenatal care for most.

Our study findings indicate that new molecular techniques will help microbiological diagnosis of neonatal conjunctivitis in Africa. They also show the need for a national program for neonatal conjunctivitis prophylaxis in Angola, taking into account the most frequent causative microorganism.

This work was sponsored in part by financial support from the Spanish Agency for International Cooperation and Development, Ministry of Foreign Affairs, Spain; and the Angola Ministry of Health.

Ms. Justel is a pharmacist specialized in microbiology who works in the Microbiology and Immunology Department at the Hospital Clmico Universitario de Valladolid. Her primary research interests are molecular and microbiological diagnosis of sexually transmitted infections and ocular infections.

DOI: 10.3201/eid2103.140312


(1.) World Health Organization. Guidelines for the management of sexually transmitted infections [cited 2014 Apr 14]. http://www.

(2.) Pastor JC, Alexandre I. Development of a national prophylactic program against neonatal conjunctivitis in Angola: pilot study. Poster presented at: Association for Research in Vision and Ophthalmology; 2009 May 3-5; Fort Lauderdale, Florida, USA. Abstract no. 5056.

(3.) Hammerschlag MR. Chlamydial and gonococcal infections in infants and children. Clin Infect Dis. 2011; 53:S99-102.

(4.) McGowin CL, Anderson-Smits C. Mycoplasma genitalium: an emerging cause of sexually transmitted disease in women. PLoS Pathog.2011; 7:e1001324. doi: 10.1371/journal.ppat.1001324

(5.) Le Roy C, Le Hen I, Clerc M, Arfel V, Normandin F, Bebear C, et al. The first performance report for the Bio-Rad Dx CT/NG/MG assay for simultaneous detection of Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium in urogenital samples. J Microbiol Methods. 2012; 89:193-7.

(6.) Ripa T, Nilsson P. A variant of Chlamydia trachomatis with deletion in cryptic plasmid: implications for use of PCR diagnostic tests. Euro Surveill. 2006; 11:E061109.2.

(7.) Bjornelius E, Jensen JS, Lidbrink P Conjunctivitis associated with Mycoplasma genitalium infection. Clin Infect Dis. 2004; 39:e67-9.

(8.) Andersen B, Sokolowski I, 0stergaard L, Kj0lseth M0ller J, Olesen F, Jensen JS. Mycoplasma genitalium: prevalence and behavioural risk factors in the general population. Sex Transm Infect. 2006; 83:237-41.

(9.) Pepin J, Deslandes S, Frost E, Andreassen AA, Solomon AW, Bailey R, et al. Absence of Mycoplasma genitalium in eye samples from a trachoma-endemic area of Tanzania. Br J Ophthalmol. 2008; 92:435.

(10.) Cappuccinelli P, Gomes E, Rubino S, Zanetti S, Lemos C, Calundungo R, et al. Chlamydia trachomatis in gynaecological infections in Luanda, Angola. Genitourin Med. 1995; 71:326-7.

(11.) World Health Organization. Global prevalence and incidence of selected curable sexually transmitted infections overview and estimates [cited 2014 Jan 31]. who_hiv_aids_2001.02.pdf

(12.) Taylor-Robinson D, Lamont RF. Mycoplasmas in pregnancy. BJOG. 2011; 118:164-74.

(13.) De Cock KM, Fowler MG, Mercier E, de Vincenzi I, Saba J, Hoff E, et al. Prevention of mother-to-child HIV transmission in resourcepoor countries: translating research into policy and practice. JAMA. 2000; 283:1175-82.

(14.) Underwood SM, Shaikha L, Bakr D. Veiled yet vulnerable. Breast cancer screening and the Muslim way of life. Cancer Pract. 1999; 7:285-90. j.1523-5394.1999.76004.x

Mar Justel, Isabel Alexandre, Prudencio Martinez, Ivan Sanz, Ana Rodriguez-Fernandez, Itziar Fernandez, Jose Carlos Pastor, Raul Ortiz de Lejarazu

Author affiliations: Hospital Clinico Universitario, Valladolid, Spain (M. Justel, A. Rodriguez-Fernandez, J.C. Pastor, R. Ortiz de Lejarazu); Agostinho Neto University Medical School, Luanda, Angola (I. Alexandre); Instituto Oftalmologico Nacional, Luanda (I. Alexandre); Redigal, Oviedo, Spain (P. Martinez); Centro Nacional de Gripe, Valladolid (I. Sanz, R. Ortiz de Lejarazu); Instituto de Salud Carlos III, Madrid, Spain (I. Fernandez); Instituto Oftalmobiologia Aplicada, Valladolid (I. Fernandez, J.C. Pastor); Universidad de Valladolid, Valladolid (J.C. Pastor, R. Ortiz de Lejarazu)

Address for correspondence: Mar Justel, Hospital Clmico Universitario de Valladolid, Departamento de Microbiologia e Inmunologia, C/Ramon y Cajal Valladolid 47005, Spain; email:
Table 1. Samples collected for analysis of vertical transmission
of eye infections, Angola, 2011-2012

Sample type       Augusto    Health Center of
                 N'Gangula        Samba          Total

Endocervical        169            143            312
Conjunctival *      130            125            255
Total               299            268            567

*For reasons other than exclusion criteria, samples from 57 newborns
were not obtained.

Table 2. Prevalence of microorganisms among mothers and
newborns from Augusto N'Gangula Hospital and Health Center
of Samba in Luanda, Angola, 2011-2012

Microorganism,          No. positive/   Prevalence, %
sample type             no. collected      (95% CI)

Chlamydia trachomatis
  Endocervical              8/312       2.6 (1.3-4.9)
  Conjunctival              4/255       1.6 (0.6-3.9)
  Total                    12/567       2.1 (1.2-3.6)
Neisseria gonorrhoeae
  Endocervical              2/312       0.6 (0.2-2.3)
  Conjunctival              1/255       0.4 (<0.1-2.2)
  Total                     3/567       0.5 (0.2-1.5)
Mycoplasma genitalium
  Endocervical             19/312       6.1 (3.9-9.3)
  Conjunctival              2/255       0.8 (0.2-2.8)
  Total                    21/567       3.7 (2.4-5.6)
All 3 microorganisms
  Endocervical            28/312 *      9.0 (6.3-12.6)
  Conjunctival              7/255       2.7 (1.3-5.5)
  Total                   35/567 *      6.2 (4.5-8.5)

* One mother was co-infected with C. trachomatis and M. genitalium.
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Article Details
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Title Annotation:DISPATCHES
Author:Justel, Mar; Alexandre, Isabel; Martinez, Prudencio; Sanz, Ivan; Rodriguez-Fernandez, Ana; Fernandez
Publication:Emerging Infectious Diseases
Article Type:Report
Geographic Code:4EUSP
Date:Mar 1, 2015
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