Toxoplasmosis is a disease caused by the protozoal parasite Toxoplasma gondii [1]. Studies show that T. gondii infects up to a third of the world’s population [2]. Humans are usually infected with T. gondii by ingestion of oocysts in food or water that has been contaminated with cat feces or by ingestion of tissue cysts in undercooked meat. Congenital transmission, organ transplantation and blood transfusion are other routes of the infection [3][4].

Congenital toxoplasmosis generally occurs when a woman is newly infected with T. gondii during pregnancy [5], although rare exceptions have been reported in which women were infected just before pregnancy [6]. In addition, in immunosuppressed women, reactivation of a latent infection can lead to congenital toxoplasmosis [7]. Exposure to infection acquired in the first trimester causes more severe congenital illness [8]and it may lead to intra-uterine growth retardation, premature birth [9]or spontaneous abortion [10]. Also, some severely affected infants die in utero or within a few days of birth. Signs of congenital toxoplasmosis at birth can include a maculopapularrash, generalized lymphadenopathy, hepatomegaly, splenomegaly, jaundice, ventricular dilatation, intracranial calcification, and thrombocytopenia. Furthermore, it can result in meningoencephalitis, seizures, chorioretinitis, deafness, hydrocephalus and microcephaly. Some fetuses exposed in the third trimester are more likely to be asymptomatic at birth, although visual impairment, learning disabilities, or mental retardation will become apparent in a large proportion of children several months to years later [11][12].

T. gondii primary infection in immunocompetent children and adults (including pregnant women) is asymptomatic in most patients. When symptoms develop, they are nonspecific and include malaise, fever, headache, lymphocytosis, sore throat, and myalgia. Lymphadenopathy, frequently cervical, is the most common sign. Occasionally, patients may have a mononucleosis-like illness associated with a macular rash and hepatosplenomegaly [11][13]. However, toxoplasmosis among immunocompromised patients manifests primarily as a life threatening condition, toxoplasmic encephalitis. Pneumonia can also be seen but are not as common as toxoplasmic encephalitis [14][15].

Providing an adequate knowledge about toxoplasmosis and its risk factors is considered as powerful preventive method. Many studies have been done to assess the level of awareness about toxoplasmosis around the world. The awareness level among most of childbearing aged female students in King Abdulaziz University in Jeddah city, Saudi Arabia was sufficient [17]. Another study that was done in Netherlands to evaluate the awareness among the pregnant women had revealed that about 76% of the women had read, seen or heard information about this infection [18]. However, among the pregnant women from Malaysia, Philippines, and Thailand, many women had no information concerning toxoplasmosis and how to avoid it during the pregnancy [19]. Likewise, the awareness level of toxoplasmosis was 4.4% among the pregnant women in Sri Lanka [20]. Furthermore, a study that was carried out in primary health care centers in Al-Ahssa, Saudi Arabia, had revealed that a substantial part of the pregnant women did not have a sufficient knowledge about the prevention [21].

High prevalence of infection has been reported among pregnant women and women of childbearing age from different parts of the world including the Middle East [2]. In Saudi Arabia, the prevalence of infection showed wide variations as revealed from previous studies at different parts of the Kingdom. The highest positivity rate was reported in Jeddah 61.4% [22], Al-Ahssa of 51.4% [23]and 35.6% in Makkah [24]. Thus, the pregnant women in Al-Ahssa are substantially vulnerable to toxoplasmosis [21]. The aim of this study is to assess the risk behavior, preventive practices and the awareness of toxoplasmosis among female students in King Faisal University in Al-Ahssa, especially regarding the risk behaviors.

Toxoplasmosis is considered as the most prevalent parasitic zoonotic disease worldwide [25]. Many factors can affect seroprevalence in humans. Climatic factors affect the survival of oocysts in the environment and infection rates in meat-producing animals also play a major role. Higher prevalence is classically observed in tropical countries with a humid and warm climate, and conversely, lower prevalence is found in arid countries or for colder countries. Other factors include dietary habits (method of cooking meat, hand washing, kinds of meat or vegetables consumed, and vegetable cleaning, etc.); economic, social, or cultural habits; quality of water; and sanitation coverage [26]- [28].

The present study demonstrates low awareness about toxoplasmosis, its danger and risk factors. Of 78 female students in King Faisal University, who responded to the survey, 34.6% know about the toxoplasmosis and only 28.2% are aware of its complications or risk factors. These results are in agreement with another study among pregnant women in Makkah, Saudi Arabia which revealed that only around 10% of the participants were aware of the toxoplasmosis [24]. In Brazil, studies presented that only 35% of included pregnant women knew about this disease [29]. 77.3% of the aware participants have studied in scientific colleges which indicate that education represents one of the major sources of the information about toxoplasmosis. Amin et al. (2013) showed that the major source of information about the disease among Saudi pregnant women was the internet [21].

Regardless that most of the participants do not know about the toxoplasmosis, their habits help them to avoid many of its risk behaviors as they do not raise the cats (93.6%), do not consume undercooked meat (92.3%) and unpasteurized or not boiled milk (100%). Also, as they wash their hands with water and soap before eating (51.3%). These findings are close to those of Amin et al. (2013) [21]which showed that 98.2% did not contact with cat and cat's litter, 82.6% did not eat undercooked and raw meat, but about 50% of them did not wash their hands after dealing with raw meats and vegetables.

However, this study reveals that more than 50% of the participants drink unfiltered water. Drinking tank water have been documented to have an influence on T. gondi transmission in different parts of the world as reported by Remington et al. (2001) [10]and Montoya & Liesenfeld (2004) [3]. Oocysts can remain viable for long periods of time in water and can resist freezing and moderately high water temperatures [30]. Furthermore, 78.2% are susceptible to toxoplasmosis as they do not wash the fruits and vegetables with water and soap before eating them since the raw fruits and vegetables may be contaminated with the oocysts [31].

Also, in this study, about 6.4% are at risk of getting toxoplasmosis because they have cats in their houses and they do not clean their boxes daily. Also, some of them do not seek the medical examination for their cats. The cats are the main sources of environmental contamination, because, when infected, they release large quantities of oocysts which are estimated to be more than 100 million oocysts by a single cat, allowing for the continuity of the parasite biological cycle [25][32]. These oocysts require at least 24 hours to sporulate and become infectious [33][34].

The current study proved the low level of knowledge about toxoplasmosis among female students in King Faisal University. However, most of the preventive behaviors that are applied could be explained by the economic, religious and cultural habits in Al-Ahssa. Likewise, this study reflects the necessity to educate people about the hygienic measures which are essential to avoid the infection. These measures include the personal hygiene, applying safe water supply, eating healthy and clean food, checking the cats regularly and changing their litter box daily. Furthermore, the physicians should be at the first line to educate the women who are pregnant or plan to be pregnant in order to reduce the risk of congenital toxoplasmosis.

Not all students have returned the questionnaire back and some questions left unanswered. Those were excluded from the results.

The authors gratefully acknowledge the Deanship of Scientific Research, King Faisal University of Saudi Arabia, for its financial support concerning this research project and Dr. Dalia Ashour for mentoring this research.