TORCH screening: time for abolition?

W. L. Lim and D. A. Wong

Abstract
The acronym TORCH (toxoplasma, rubella, cytomegalovirus, herpes simplex virus) was intro-
duced to highlight a group of agents which cause congenital and perinatal infections. TORCH
screening is now widely requested by clinicians investigating suspected cases of congenital and
perinatal infection. There is concern that such requests are inappropriate and requests for inves-
tigation should be targeted more specifically. The prevalence of TORCH infections in Hong
Kong are examined in this study. Toxoplasmosis is a rare infection in Hong Kong with a
seropositivity rate of only 2.4% among women of child-bearing age; 87.5% of women of child-
bearing age are already seropositive for cytomegalovirus (CMV) and therefore most cases of
congenital CMV infection are likely to result from maternal reinfection which carries a much
lower risk of severe congenital abnormalities. Congenital rubella infections still occur each year
in small numbers. Neonatal herpes simplex virus (HSV) infection is very rare in Hong Kong. It is
apparent that requests for TORCH screening has been over-ordered and clinicians should be
encouraged to send appropriate specimens for specific tests depending on the clinical features of
the individual case.

Keywords: TORCH; Seroprevalence; Congenital infections

Introduction Patients and specimens

The acronym TORCH was introduced in 1971 by
Nahmias et al. to highlight a group of agents which
affect the foetus and newborn, namely Toxoplasma
gondii, rubella virus, cytomegalovirus (CMV), and
herpes simplex virus (HSV).1 These agents often pro-
vide a similar clinical picture which include one or
more of the following clinical signs: low birth weight,
prematurity, purpura, jaundice, anaemia, micro-
cephaly/hydrocephaly, cerebral calcification,
chorioretinitis, cataracts, microphthalmia, and
pneumonitis. TORCH screening is now widely re-
quested by clinicians investigating infants and
pregnant women for congenital, perinatal and
neonatal infections. There is concern among micro-
biologists that such requests are often inappropriate
and that resources would be better utilized if requests
for investigation were targeted more specifically2. We
decided to conduct a study in order to assess the
frequency of congenital TORCH infections in Hong
Kong.
Virus Unit, Queen Mary Hospital, Pokfulam, Hong Kong
W. L. Lim, MRCPath, FRCPA
D. A. Wong, MB, ChB, MSc
Correspondence to: Dr D. A. Wong
All requests for toxoplasma serology, whether as part
of the TORCH screen or otherwise, were documented,
as were all requests for CMV antibody status for the
period from 1 July 1992 to the 30 June 1993. All re-
quests for toxoplasma serology were initially tested
for specific IgG by indirect immunofluorescence and
paired sera were requested to detect rising antibody
titre. Those with a titre of 80 or greater were tested for
the presence of specific IgM by immunofluorescence.
The seroprevalence rate for women of child-bearing
age were compiled from TORCH requests taken from
women who presented with maternal illness, intrau-
terine growth retardation, abortion, premature rupture
of membrane (PROM) and foetal distress. Sera for
CMV antibody status were first screened for the pres-
ence of CMV antibodies by complement fixation tests.
Those which were negative by complement fixation
test were retested by enzyme-linked immunosorbent
assay (ELISA) (Behring) for the presence of specific
IgG. All requests for CMV culture for urine, saliva
and throat swabs collected from neonates less than 14
days old were documented over the same period.
Diagnosis of rubella infection was made when there
is a rising antibody titre detected by haemag-
glutination inhibition tests and that specific IgM
antibody is detectable by ELISA (Abott and Pasteur).

306
 Lim & Wong: TORCH screening 307

Table 1. Toxoplasma serology requests (1 July 1992 to 30 June 1993).

Clinical presentation No. Pos

IUGR/SGA/LBW 310 6 1.93

lUD/Abortion 245 8 3.26
Neonatal symptoms 493 10 2.02
Prematurity 143 3 2.09
PROM/leakage/foetal distress/preterm labour 79 2 2.53
Maternal fever and illness 33 0 0
Postnatal symptoms 206 11 5.33
Bone marrow transplant 137 2 1.45
AML/NHL/other haematological conditions 41 2 4.87
HIV+ve 162 15 9.25
Others/no details available 237 13 5.48

Total 2086 72 3.45

Women of child-bearing age 667 16 2.40

IUGR Intrauterine growth retardation

SGA Small for gestational age
LBW Low birth weight
IUD Intrauterine death
PROM Premature rupture of membrane
AML Acute myeloid leukaemia
NHL Non Hodgkin's lymphoma

Herpes simplex virus infection is diagnosed by virus
isolation. A search was carried out on our positive
record files for the years 1986 to 1992 for cases of
confirmed congenital rubella and neonatal herpes
simplex virus infection.
were symptomatic adults. 1,303 (62.5%) were requests
for TORCH screening of which only 29 (2.22%) sam-
ples had IgG antibody against toxoplasma, none of
which had current infection. The seropositivity rate
among women of child-bearing age was 2.4%.

Results Cytomegalovirus infection

For the period from 1 July 1992 to 30 June 1993, there
were 953 requests for CMV serology of which 887
Toxoplasmosis (93.1%) had demonstrable CMV antibodies, which
For the period from 1 July 1992 to 30 June 1993, the shows that Hong Kong has a high prevalence of CMV
Virus Unit received requests for toxoplasma antibody infection. 161 out of 184 (87.5%) specimens taken from
testing from 2,086 patients (Table 1). Only 72 (3.45%) women of child-bearing age (16-40 years) were posi-
were positive for IgG antibody against toxoplasma tive for CMV antibodies. Over the same period, urine,
which is indicative of past infection. IgM antibodies saliva or throat swabs specimens were received from
were demonstrated in only two patients both of whom 712 neonates less than 14 days old for CMV isolation
(Table 2). Only 10 (1.4%) were positive for CMV by
the CMV DEAFF test. How many, if any, of these
infants had cytomegalic inclusion disease was not
Table 2. Requests for CMV isolation from neonates less known. Serological testing for CMV antibodies using
than 14 days of age (1 July 1992 to 30 June
1993). complement-fixation tests were carried out on seven
of these infants (Table 3), only in one case (patient 4)
Clinical presentation Total no. Pos
was a significant rise in CMV antibody titre demon-
strated.
IUGR/SGA/LBW 166 2
Neonatal symptoms 231 4
Prematurity 134 1 Rubella
PROM/leakage/foetal distress/ 16 1
preterm labour
A small number of infants with congenital rubella
Others/no details available 165 2 syndrome are born each year (Table 4). For the period
from 1 July 1992 to 30 June 1993, of the 4,145 requests
Total 712 10 for rubella antibody testing by haemagglutination-
308 J Hong Kong Med Assoc Vol. 46, No. 4, December 1994

Table 3. Serological results (by complement-fixation pean countries such as France, which has a screening
tests for CMV antibodies) and clinical condition programme in operation so that pregnant women
of the 10 neonates who were excreting CMV in
their urine within 14 days of birth.
diagnosed as having an acute toxoplasma infection
are offered the options of either abortion or antimi-
crobial chemotherapy.4 This low seroprevalence rate
CMV antibody titres
suggests that too many unnecessary requests for
Patient 1st titre 2nd titre Clinical condition toxoplasma serology had been made. Certain condi-
tions such as prematurity, premature rupture of
1 10 <10 small for gestational age membranes and foetal distress should not have been
2 <10 <10 prematurity investigated by TORCH screening (Table 1).
3 <10 <10 neonatal jaundice
4 80 80 petechiae, rash The foetus can be infected from primary or recur-
5 40 40 meconium stained liquor rent maternal CMV infection. There is a 40% risk of
6 anti-complementary petechiae transmission to the foetus following primary infection
7 not available sepsis of which up to 25% are likely to have congenital
8 not available feeding difficulty defects.5, 6 The risk of transmission to the foetus in
9 not available sepsis
10 <10 10 small for gestational age cases of maternal reinfection or reactivation of latent
infection is much lower and had been estimated to be
0.5 to 1%, of which O to 1% of the affected infants will
have clinically apparent disease or sequelae.6 The se-
inhibition tests, there were 1,135 requests from verity of the congenital defects seen is much lower
neonates less than 14 days old, and 499 requests from than that following primary maternal infection.5, 6 In
women who had signs of intra-uterine growth retar- populations with high seroprevalence rates such as
dation, premature rupture of membrane, intra-uterine Hong Kong, most foetal infections result from recur-
death, abortion and still birth, making a total of 1,634 rent maternal infections and thus the incidence of
requests as part of TORCH screening. severe congenital defects is considerably lower. Thus
congenital CMV infection is not as an important
problem in Hong Kong as in other developed coun-
Herpes simplex vims infection
tries. Congenital CMV infection is reliably diagnosed
Neonatal herpes is also very rare in Hong Kong, with by the isolation of the virus from the urine of infants
less than one reported case per year (Table 4). within two weeks of birth. After two weeks of birth,
the presence of CMV in the urine may indicate
perinatal infection rather than congenital infection.
Discussion Serology has a limited role to play in the diagnosis of
CMV infection. Rising titres of antibody are not usu-
The low seroprevalence rate of Toxoplasma gondii seen ally detected by the complement fixation and specific
in Hong Kong compared with other parts of the world CMV-IgM antibody may not be detectable.2 This is
is consistent with earlier studies.3 For the years 1989 borne out by our own results (Table 3), where a sig-
to 1991, the seropositivity rate for those patients whose nificant rise in CMV antibody titre was detected in
sera were tested for IgG antibodies against toxoplasma only one of the seven neonates who were excreting
was between 2.3 to 3.32% (unpublished observations, CMV.
Virus Unit). There were only three cases of confirmed Although there are now only a small number of
acute toxoplasmosis during this period. There were cases of confirmed congenital rubella infection re-
no confirmed cases of congenital toxoplasmosis re- ported per year, the actual number of terminations of
ported for the past seven years. This low prevalence pregnancies carried out in case of suspected rubella
rate would certainly make any screening programme infection in early pregnancy is thought to be much
in pregnancy impractical in contrast to some Euro- higher. A survey carried put in Hong Kong showed

Table 4. Number of cases of confirmed neonatal HSV2 and congenital rubella infection, 1986-1992.

Year

86 87 88 89 90 91 92

Neonatal HSV2 infection 1 1 0 0 1 1 0

Congenital rubella 11 0 2 6 5 7 1
 Lim & Wong: TORCH screening
that 90% of nulliparous women and 93% of multipa-
rous women of child-bearing age were positive of
rubella antibody.7 This showed that despite the im-
plementation of selective rubella vaccination in
primary six school girls in 1978 and the extension of
immunization to postpartum women who are found
to be seronegative while attending antenatal clinics, a
sizable percentage of women of child-bearing age were
still susceptible to rubella infection. Therefore it is of
utmost importance that all women are immunized
against rubella. All suspected contacts with rubella,
or any clinical symptoms of rubella infection in preg-
nancy should be investigated by rubella serology.
From our data, neonatal herpes is not an important
problem in Hong Kong. Neonatal herpes is best diag-
nosed by the virus culture of specimens taken from
affected sites such as vesicle fluid, saliva, mouth swabs
and CSF rather than by serology.2
To conclude, with the exception of rubella, TORCH
agents are not as common a cause of congenital infec-
tion in Hong Kong as in other developed countries.
We feel that the test had been over-ordered. The con-
cept of a common presentation of congenital infection
(TORCH syndrome) and a common investigative
pathway (TORCH screening) should be actively dis-
couraged. Instead, clinicians should be encouraged to
send specimens for specific tests depending on the
clinical features of individual cases. For example,
cataracts and cardiac lesions are common in congeni-
tal rubella but not with any other TORCH agent:
cerebral calcification is extremely rare in rubella and
309
is only widely distributed in toxoplasmosis: deafness
is associated only with rubella and CMV infection.
Thus appropriate samples such as urine, saliva and
vesicle fluid should be cultured for CMV and HSV in
the case of suspected congenital CMV or HSV infec-
tion. Neonatal sera are useful for the diagnosis of
congenital rubella and toxoplasma infection, but of
little value in the diagnosis of neonatal CMV and
HSV infections.
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