Risk factors for herpes simplex virus transmission to pregnant women: a couples study

Neonatal herpes simplex virus infection: From the maternal infection to the child outcome

This review examines the recent literature on the management of herpes simplex virus (HSV) infections in neonates. We summarized the three clinical categories of maternal HSV infection during pregnancy (primary first episode, nonprimary first episode, or recurrent episode) and the mechanisms of fetal damage. Considering when the transmission of the infection from the mother to the fetus/newborn occurs, three types of neonatal infection can be distinguished: intrauterine infection (5% of cases), postnatal infection (10% of cases), and perinatal infections (85% of cases). Neonatal presentation could range from a limited disease with skin, eye, and mouth disease to central nervous system disease or disseminated disease: the treatment with acyclovir should be tailored according to symptoms and signs of infection, and virological tests. These children need a multidisciplinary follow-up, to timely intercept any deviation from normal neurodevelopmental milestones. Prevention strategies remain a challenge, in the absence of an available vaccine against HSV.

Herpes simplex virus infection in pregnancy - An update

Herpes Simplex virus (HSV) infection is one of the most common sexually transmitted infections among women of the reproductive age. It is estimated to affect about 2-3% of pregnant women. Vertical transmission during pregnancy is rare occurring in less than 1% of cases but for those with active lesions or shedding the virus asymptomatically the risk of vertical transmission intrapartum is high. Neonates with HSV may develop severe consequences such as disseminated, central nervous system and skin, eye mouth/mucous disease or suffer mortality. A high index of suspicion, timely diagnosis and institution of appropriate treatment during acute and recurrent episodes will reduce the risk of vertical transmission and therefore neonatal consequences. Routine screening for HSV in pregnancy is not recommended. This review provides an overview of HSV in pregnancy, diagnosis and management especially around unique scenarios such as prelabour preterm rupture of fetal membranes and presentation with active disease in labour.

Management of Genital Herpes in Pregnancy: ACOG Practice Bulletinacog Practice Bulletin, Number 220

Genital herpes simplex virus (HSV) infection during pregnancy poses a risk to the developing fetus and newborn. Genital herpes is common in the United States. Among 14- to 49-year-old females, the prevalence of HSV-2 infection is 15.9%. However, the prevalence of genital herpes infection is higher than that because genital herpes is also caused by HSV-1 (). Because many women of childbearing age are infected or will be infected with HSV, the risk of maternal transmission of this virus to the fetus or newborn is a major health concern. This document has been revised to include that for women with a primary or nonprimary first-episode genital HSV infection during the third trimester of pregnancy, cesarean delivery may be offered due to the possibility of prolonged viral shedding.

Acute Herpes Simplex Virus Hepatitis in Pregnancy

BACKGROUND

Herpes simplex virus (HSV) causes only 2-4% of all acute hepatitis but has high morbidity and mortality. Pregnancy is a risk factor for HSV hepatitis. We describe a case of gestational HSV hepatitis.

CASE

A 32-year old woman, gravida 2 para 1, presented at 38 2/7 weeks of gestation with back pain and fetal tachycardia. She became febrile after admission, had spontaneous rupture of membranes, and was delivered by cesarean for malpresentation. Postpartum, she became persistently febrile and developed transaminitis, symptomatic hypotension, and pancytopenia despite antibiotics. Imaging revealed acute liver injury, splenomegaly, pleural effusions, and cardiomyopathy. Serum polymerase chain reaction (PCR) screening identified HSV-1 infection. The patient recovered on acyclovir. There was no evidence of neonatal seroconversion.

CONCLUSION

Herpes simplex virus hepatitis causes significant morbidity, and pregnant women are susceptible to severe infections. Pregnant or peripartum women with acute febrile hepatitis require prompt evaluation for HSV with serum PCR screening.

Seroprevalence of Herpes Simplex Virus Types 1 and 2 Among Pregnant Women and Sexually Active, Nonpregnant Women in the United States

Background

Neonatal herpes is a rare, devastating consequence of herpes simplex virus type 1 (HSV-1) or 2 (HSV-2) infection during pregnancy. The risk of neonatal infection is higher among pregnant women seronegative for HSV-1 or HSV-2 who acquire their first HSV infection near delivery.

Methods

We estimated HSV-1 and HSV-2 seroprevalence among pregnant women aged 20-39 years in 1999-2014, assessed HSV seroprevalence changes between 1999-2006 and 2007-2014, and compared HSV seroprevalence between pregnant women and sexually active, nonpregnant women aged 20-39 years in 2007-2014 using National Health and Nutrition Examination Survey data.

Results

Among pregnant women in 1999-2014, HSV-1 seroprevalence was 59.3%, HSV-2 seroprevalence was 21.1%, and HSV seronegativity was 30.6%. Between 1999-2006 and 2007-2014, HSV-1 and HSV-2 seroprevalence among pregnant women remained stable. However, among pregnant women with ≤3 sex partners (approximately 40% of all pregnant women), seronegativity for both HSV-1 and HSV-2 increased from 35.6% to 51.4% (P < .05). In 2007-2014, nonpregnant women who were (1) unmarried, (2) living below poverty level, or (3) had ≥4 sex partners were more likely than pregnant women to be seronegative for both HSV-1 and HSV-2 (P < .05).

Conclusions

HSV-1 and HSV-2 seroprevalence among US pregnant women remained stable between 1999 and 2014. However, pregnant women with fewer sex partners were increasingly seronegative for both HSV-1 and HSV-2, indicating an increasing proportion of pregnant women who are vulnerable to primary HSV acquisition in pregnancy, which confers an increased risk of transmitting HSV to their neonates.

Incidence of sexually transmitted infections during pregnancy

Prevalence of sexually transmitted infections (STI) is high among pregnant women in certain settings. We estimated STI incidence and compared STI risk in pregnant and non-pregnant women. Data came from the Methods for Improving Reproductive Health in Africa (MIRA) study conducted in South Africa and Zimbabwe 2003-2006. Women aged 18-50 years with at least one follow-up visit within 6 months of enrollment were included. Follow-up visits included laboratory testing for pregnancy, chlamydia, gonorrhea, trichomoniasis, and HIV, as well as self-report of hormonal contraceptive (HC) use, sexual behaviors and intravaginal practices. All visits were classified according to pregnancy status. Incidence of each STI was calculated using follow-up time. Cox proportional hazards models were fitted using pregnancy as a time-varying exposure and sexual behaviors and intravaginal practices as time-varying covariates. Among 4,549 women, 766 (16.8%) had a positive pregnancy test. Median follow-up time was 18 months [IQR: 12-24]. The overall incidence rate of chlamydia was 6.7 per 100 person years (py) and 9.9/100py during pregnancy; gonorrhea incidence was 2.7/100py and 4.9/100py during pregnancy; trichomoniasis incidence was 7.1/100py overall and 9.2/100py during pregnancy. Overall HIV incidence was 3.9/100py and 3.8/100py during pregnancy. In crude models, pregnancy increased risk for chlamydia (hazard ratio (HR) 1.5, 95%CI: 1.1-1.2), however there was no increased risk of any measured STI in adjusted models. STI Incidence was high during pregnancy however pregnancy did not increase STI risk after adjustment for sexual behaviors. Greater efforts are needed to help pregnant women avoid STIs.

[Genital herpes and pregnancy: Epidemiology, clinical manifestations, prevention and screening. Guidelines for clinical practice from the French College of Gynecologists and Obstetrician (CNGOF)]

OBJECTIVES

To analyze the consequences of genital herpes infections in pregnant women.

METHODS

The PubMed database and the recommendations from the French and foreign obstetrical societies or colleges have been consulted.

RESULTS

The symptomatology of herpes genital rash is often atypical (NP2) and not different during pregnancy (Professional consensus). It is most often due to HSV2 (NP2). Seventy percent of pregnant patients have a history of infection with Herpes simplex virus, without reference to genital or labial localization, and this is in most cases type 1 (NP2). The prevalence of clinical herpes lesions at birth in the event of recurrence is about 16% compared with 36% in the case of initial infection (NP4). In HSV+ patients, asymptomatic herpetic excretion is 4 to 10%. The rate of excretion increases in HIV+ patients (20 to 30%) (NP2). The risk of HSV seroconversion during pregnancy is 1 to 5% (NP2), but can reach 20% in case of sero-discordant couple (NP2). Questioning is not always sufficient to determine the history of herpes infection of a patient and her partner (NP2) and the clinical examination is not always reliable (NP2). Herpetic hepatitis and encephalitis are rare and potentially severe (NP4). These diagnoses should be discussed during pregnancy and antiviral therapy should be started as soon as possible (Professional consensus). There is no established link between herpes infection and miscarriages (NP3). There appears to be an association between untreated herpes infection and premature delivery (NP3) but not in the case of treated infections (NP4). Herpetic fetopathies are exceptional (NP4). There is no argument for recommending specific prenatal diagnosis for herpes infection during pregnancy (Professional consensus). Condom use reduces the risk of initial infection in women who are not pregnant (NP3). There is no evidence to justify routine screening during pregnancy (Professional consensus).

CONCLUSION

There is a strong discrepancy between the prevalence of herpetic excretion at the time of delivery and the scarcity of neonatal infections. There is a lack of data on the impact of herpes infections during pregnancy in France. Fetal and maternal consequences are potentially serious but rare.

Diagnosis and treatment of herpes simplex 1 virus infection in pregnancy

A nulliparous woman presented at 21 weeks' gestation with a 72-h history of a rash on her left arm. Initially isolated to the forearm, it had quickly spread, becoming multiple itchy fluid-filled blisters. Blood tests showed mild neutrophilia and raised CRP. Skin swabs demonstrated the presence of herpes simplex virus type 1 (HSV1) DNA. There was no history of previous HSV1 exposure. There is scant literature on uncomplicated cutaneous HSV1 since the majority is oral/genital. The incidence of transmission varies and is dependent on site of infection and immunological status. Type-specific serological testing is recommended to identify a primary first episode infection due to the 30-60% vertical transmission rate. Infection is associated with morbidity and mortality for both mother and fetus including maternal encephalitis, acute retinal necrosis, pneumonia and hepatitis. Neonatal disease can be congenital (cutaneous lesions, microcephaly, hydranencephaly, intracranial calcifications, chorioretinitis, microphthalmia and optic nerve atrophy) or acquired (skin, eyes and mouth disease or central nervous system disease or disseminated disease). Prophylactic aciclovir reduces the number of women with active genital lesions at the time of delivery. If primary infection occurs outside of the first trimester and active genital lesions are present, then vaginal delivery should be avoided. If infection has occurred in the first trimester, vaginal birth can be attempted even in the presence of active lesions. There is no available guidance on prophylactic treatment of non-genital HSV1 in pregnancy.

Asymptomatic Herpes Simplex Virus Infection in Iranian Mothers and Their Newborns

This study aims to determine the prevalence of herpes simplex virus (HSV) infection among pregnant women as well as congenital infection of their newborns in Tehran. One hundred samples of blood sera from pregnant women were analyzed for the presence of HSV specific antibodies. Umbilical cord blood samples from the newborns were analyzed for the presence of HSV DNA using real-time PCR. HSV IgG and IgM antibodies were found in 97% and 2% of pregnant women, respectively. Of all the 100 cord blood samples, 6 were positive for HSV DNA in which 2 cases were from mothers who had detectable IgM. It was notable that all corresponding mothers of six HSV positive infants had detectable IgG antibodies in their sera. It was demonstrated that the presence of HSV DNA in cord blood of newborns could be a risk marker for maternal-fetal transmission of the virus in asymptomatic pregnant women.

First estimates of the global and regional incidence of neonatal herpes infection

Background

Neonatal herpes is a rare but potentially devastating condition (60% fatality without treatment). Transmission usually occurs during delivery from mothers with herpes simplex virus type 1 (HSV-1) or HSV-2 genital infection. The global burden has never been quantified. We developed a novel methodology for burden estimation and present first WHO global and regional estimates of the annual number of neonatal herpes cases during 2010–2015.

Methods

Previous estimates of HSV-1 and HSV-2 prevalence and incidence in women aged 15–49 years were applied to 2010–2015 birth rates to estimate infections during pregnancy. Published risks of neonatal HSV transmission were then applied according to whether maternal infection was incident or prevalent with HSV-1 or HSV-2 to estimate neonatal herpes cases.

Findings

Globally the overall rate of neonatal herpes was estimated to be ~10 cases per 100,000 births, equivalent to a best-estimate of ~14,000 cases annually (HSV-1: ~4,000; HSV-2: ~10,000). We estimated that the most neonatal herpes cases occurred in Africa, due to high maternal HSV-2 infection and high birth rates. HSV-1 contributed more cases than HSV-2 in the Americas, Europe and Western Pacific. High rates of genital HSV-1 infection and moderate HSV-2 prevalence meant the Americas had the highest overall rate. However, our estimates are highly sensitive to the core assumptions, and considerable uncertainty exists for many settings given sparse underlying data.

Interpretation

These neonatal herpes estimates mark the first attempt to quantify the global burden of this rare but serious condition. Better primary data collection on neonatal herpes is critically needed to reduce uncertainty and refine future estimates. This is particularly important in resource-poor settings where we may have underestimated cases. Nevertheless, these first estimates suggest development of new HSV prevention measures such as vaccines could have additional benefits beyond reducing genital ulcer disease and HSV-associated HIV transmission, through prevention of neonatal herpes.

Funding

World Health Organization

High prevalence of herpes simplex virus (HSV)- type 2 co-infection among HIV-positive women in Ukraine, but no increased HIV mother-to-child transmission risk

Background

Over 3500 HIV-positive women give birth annually in Ukraine, a setting with high prevalence of sexually transmitted infections. Herpes simplex virus Type 2 (HSV-2) co-infection may increase HIV mother-to-child transmission (MTCT) risk. We explored factors associated with HSV-2 seropositivity among HIV-positive women in Ukraine, and its impact on HIV MTCT.

Methods

Data on 1513 HIV-positive women enrolled in the Ukraine European Collaborative Study from 2007 to 2012 were analysed. Poisson and logistic regression models respectively were fit to investigate factors associated with HSV-2 seropositivity and HIV MTCT.

Results

Median maternal age was 27 years (IQR 24–31), 53 % (796/1513) had been diagnosed with HIV during their most recent pregnancy and 20 % had a history of injecting drugs. Median antenatal CD4 count was 430 cells/mm³ (IQR 290–580). Ninety-six percent had received antiretroviral therapy antenatally. HSV-2 seroprevalence was 68 % (1026/1513). In adjusted analyses, factors associated with HSV-2 antibodies were history of pregnancy termination (APR 1.30 (95 % CI 1.18–1.43) for ≥2 vs. 0), having an HIV-positive partner (APR 1.15 (95 % CI 1.05–1.26) vs partner’s HIV status unknown) and HCV seropositivity (APR 1.23 (95 % CI 1.13–1.35)). The overall HIV MTCT rate was 2.80 % (95 % CI 1.98–3.84); no increased HIV MTCT risk was detected among HSV-2 seropositive women after adjusting for known risk factors (AOR 1.43 (95 % CI 0.54–3.77).

Conclusion

No increased risk of HIV MTCT was detected among the 68 % of HIV-positive women with antibodies to HSV-2, in this population with an overall HIV MTCT rate of 2.8 %. Markers of ongoing sexual risk among HIV-positive HSV-2 seronegative women indicate the importance of interventions to prevent primary HSV-2 infection during pregnancy in this high-risk group.

Herpes simplex virus 2 infection: molecular association with HIV and novel microbicides to prevent disease

Infection with herpes simplex viruses is one of the most ancient diseases described to affect humans. Infection with these viruses produces vexing effects to the host, which frequently recur. Infection with herpes simplex viruses is lifelong, and currently there is no vaccine or drug to prevent or cure infection. Prevalence of herpes simplex virus 2 (HSV-2) infection varies significantly depending on the geographical region and nears 20% worldwide. Importantly, HSV-2 is the first cause of genital ulcers in the planet. HSV-2 affects approximately 500 million people around the globe and significantly increases the likelihood of acquiring the human immunodeficiency virus (HIV), as well as its shedding. Thus, controlling HSV-2 infection and spread is of public health concern. Here, we review the diseases produced by herpes simplex viruses, the factors that modulate HSV-2 infection, the relationship between HSV-2 and HIV and novel therapeutic and prophylactic microbicides/antivirals under development to prevent infection and pathological outcomes produced by this virus. We also review mutations associated with HSV-2 resistance to common antivirals.

Herpes simplex virus infection during pregnancy

Genital herpes in pregnancy continues to cause significant maternal morbidity, with an increasing number of infections being due to oral-labial transmission of herpes simplex virus (HSV)-1. Near delivery, primary infections with HSV-1 or HSV-2 carry the highest risk of neonatal herpes infection, which is a rare but potentially devastating disease for otherwise healthy newborns. Prevention efforts have been limited by lack of an effective intervention for preventing primary infections and the unclear role of routine serologic testing.

Mucosal herpes immunity and immunopathology to ocular and genital herpes simplex virus infections

Herpes simplex viruses type 1 and type 2 (HSV-1 and HSV-2) are amongst the most common human infectious viral pathogens capable of causing serious clinical diseases at every stage of life, from fatal disseminated disease in newborns to cold sores genital ulcerations and blinding eye disease. Primary mucocutaneous infection with HSV-1 & HSV-2 is followed by a lifelong viral latency in the sensory ganglia. In the majority of cases, herpes infections are clinically asymptomatic. However, in symptomatic individuals, the latent HSV can spontaneously and frequently reactivate, reinfecting the muco-cutaneous surfaces and causing painful recurrent diseases. The innate and adaptive mucosal immunities to herpes infections and disease remain to be fully characterized. The understanding of innate and adaptive immune mechanisms operating at muco-cutaneous surfaces is fundamental to the design of next-generation herpes vaccines. In this paper, the phenotypic and functional properties of innate and adaptive mucosal immune cells, their role in antiherpes immunity, and immunopathology are reviewed. The progress and limitations in developing a safe and efficient mucosal herpes vaccine are discussed.

Preventing neonatal transmission of herpes simplex virus

Herpes simplex virus (HSV) infections are highly prevalent and may have devastating consequences if transmitted to newborns. The highest risk of transmission is when the mother has primary HSV infection (rather than recurrence of chronic infection) late in pregnancy. Clinicians should obtain a careful history, performing serologic testing and counseling as appropriate. Delayed diagnosis of neonatal HSV is associated with high mortality. Even with adequate treatment, permanent sequelae, such as cerebral palsy and developmental delay, may occur. Clinicians should develop prudent strategies to avoid primary HSV acquisition during pregnancy, and provide prophylaxis or treatment when indicated.

A prospective cohort study of partner testing for herpes simplex virus and sexual behavior during pregnancy

BACKGROUND

We investigated whether serotesting sexual partners of pregnant women for herpes simplex virus (HSV) improves adherence to safer-sex practices.

METHODS

A total of 287 HSV-2-seronegative pregnant women were recruited, and their partners were invited for HSV serologic testing. On the basis of test results, women were placed into 4 groups: those at risk for HSV-2 infection, those at risk for HSV-1 infection, those whose partner was not tested, and those not at risk for HSV infection. Women received safer-sex counseling and completed diaries of sexual activity.

RESULTS

Women in HSV-2-serodiscordant couples (ie, those in relationships in which they were at risk for HSV-2 acquisition) reported a smaller percentage of days with unprotected genital sex acts as compared to women who were not at risk (2% vs 8%; relative risk [RR], 0.3 [95% confidence interval {CI}, .1-.8]; P = .002) and to women whose partners' HSV status was unknown (2% vs 11%; RR, 0.2 [95% CI, .1-.8]; P = .02). Women in HSV-1-serodiscordant couples showed no difference in the frequency of genital sex acts, unprotected genital sex acts, or oral sex acts as compared to those not at risk and to those whose partners' status was unknown.

CONCLUSIONS

Pregnant women at known risk of HSV-2 acquisition by partner serotesting were less likely to engage in unprotected genital sex acts than HSV-2-seronegative women with partners who were negative or not tested.

Prevalence and concordance of HPV, HIV, and HSV-2 in heterosexual couples in Kigali, Rwanda

BACKGROUND

In the absence of prospectively collected transmission data, the transmission potential of a sexually transmissible infection (STI) can be estimated by its proxy of concordance in sexual partners. Here we report concordance data of 3 viral STIs: human papillomavirus (HPV), HIV, and herpes simplex virus type 2 (HSV-2) among heterosexual couples in Kigali, Rwanda.

METHODS

Cervical and penile HPV typing was performed among 166 community-sampled fertile couples in Kigali, Rwanda (median sampling interval 10 days (interquartile range: 5-36). HIV and HSV-2 serostatus, curable STIs, and sociobehavioral and clinical characteristics were also assessed.

RESULTS

Concordance rates for all 3 viral STIs were higher than expected by chance alone. Positive concordance among couples was 25% for HSV-2, 15.7% for any HPV, 8.4% for high-risk (HR)-HPV, and 6% for HIV. HR-HPV prevalence among women and men was 19.9% and 26.5%, respectively. Partner's HIV status was more strongly associated with HR-HPV detection in men (OR: 8.5; confidence interval: 2.9-24.6) than in women (OR: 1.9; confidence interval 0.5-6.7).

CONCLUSION

More than half of the couples were discordant for HIV, HPV, and/or HSV-2, indicating that prevention strategies directed to infected cases are important to protect their uninfected sexual partners.

The acceptance of HSV-testing partners of HSV-2 seronegative pregnant women

OBJECTIVES

To estimate the acceptance of HSV testing partners of HSV seronegative pregnant women and identify associated factors.

STUDY DESIGN

Consecutive women identified as HSV-2 seronegative during routine testing in pregnancy were asked to invite their partners for HSV testing to identify serodiscordance. Logistic regression identified factors associated with partner testing.

RESULTS

Between 2001 to 2006, 315 women enrolled (28% of those approached) and 242 (77%) partners were tested. Married couples were most likely to be tested [adjusted odds ratio (aOR) 7.72, 95% CI: 2.47-24.15]. Partners of black women (aOR 0.17, 95% CI: 0.04-0.71), and those with at least a college degree (aOR 0.43, 95% CI: 0.19-0.98) were less likely to be tested.

CONCLUSIONS

In this population, partner testing among HSV-2 seronegative women was feasible which supports further study to determine if identification of partners who pose a potential risk of HSV infection during pregnancy is an effective approach to reduce HSV acquisition in pregnant women.

Managing genital herpes infections in pregnancy

Genital herpes is the leading cause of genital ulcer disease worldwide and it is one of the most common sexually transmitted infections. Genital herpes simplex virus infection during pregnancy poses significant risks, predominantly vertical transmission of infection with resulting neonatal disease. While uncommon, neonatal infection has a high mortality rate and significant long-term morbidity. This article will examine the current recommendations for diagnosis using serologic and viral detection techniques. Treatment options for initial and recurrent genital herpes infection in pregnancy are reviewed. The use of prophylactic antivirals and cesarean delivery are discussed. The article concludes with a look to the future, including potential changes in the management of herpes simplex virus-infected pregnant women.

Pharmaceutical industry marketing: understanding its impact on women's health

The delivery of modern health care entails significant involvement from the pharmaceutical industry, including developing and manufacturing drugs. However, the industry also has tremendous influence on the practice of medicine through its considerable marketing efforts, both to patients through direct to consumer advertising, and to physicians through detailing, providing samples, continuing medical education, and other efforts. This article will review the role that pharmaceutical marketing plays in health care, and the substantial evidence surrounding its influence on patient and physician behaviors, with additional discussion of the medical device industry, all with particular attention to women's health. Understanding the effects of pharmaceutical marketing on women's health, through discussion of relevant examples-including oral contraceptive pills, drugs for premenstrual dysphoric disorder, Pap smear cytology techniques, and neonatal herpes prophylaxis-will help ensure that women receive unbiased, evidenced-based care. We will conclude with a discussion of guidelines that have been proposed by professional organizations, policy makers, and universities, to assist physicians in managing exposure to pharmaceutical marketing.

Serologic detection of herpes simplex virus type 2 antibodies among pregnant women using a point-of-care test from Focus Diagnostics

BACKGROUND

Serologic assays that identify herpes simplex type 2 (HSV-2) type-specific antibodies have been commercially available for more than a decade. Greater acceptance of these tests is hindered by uncertainty regarding their performance in real-world clinical settings.

OBJECTIVES

The primary objective was to compare the test characteristics of the Focus HerpeSelect Express Assay (EA) versus the Focus HerpeSelect enzyme linked immunoassay (ELISA) for detection of HSV-2 type-specific antibodies among pregnant women enrolled from 3 geographic sites with varying prevalences of HSV-2 infection. A second objective was to evaluate the performance of a HSV-2 testing strategy in which EA screens and ELISA confirms HSV-2 serodiagnosis.

STUDY DESIGN

We enrolled 399 pregnant women from Atlanta, GA, Moorestown, NJ, and Pittsburgh, PA into this cross-sectional investigation. Capillary whole blood was obtained from study participants, and evaluated for the presence of type-specific HSV-2 antibodies using the EA. Serum samples were also obtained from all study participants for subsequent identification of HSV-2 type-specific antibodies using both ELISA and the Focus Immunoblot assays.

RESULTS

We observed 96.2% agreement between results obtained with EA and ELISA. Overall, when compared to ELISA results, the sensitivity of EA for detection of HSV-2 type-specific antibodies was 94.2% and the specificity was 97.1%. Using Immunoblot results as our standard for performance calculations, the positive predictive value (PPV) of HSV-2 serodiagnosis increased from 91.7% to 98.2% when ELISA was used to confirm EA testing.

CONCLUSIONS

EA provides similar results to ELISA for the identification of HSV-2 type-specific antibodies among pregnant women. As use of the point-of-care (POC) EA in conjunction with confirmatory ELISA testing improves the PPV of HSV-2 serodiagnosis compared to the use of EA or ELISA testing alone, validation of this diagnostic algorithm in other at-risk populations may be warranted.

Understanding herpes simplex virus: transmission, diagnosis, and considerations in pregnancy management

Genital herpes simplex virus (HSV) infections are frequently asymptomatic or undiagnosed, but more than half the US population is seropositive for HSV, and about one-fifth are positive for HSV-2. These two factors contribute to the risk for sexual transmission and therefore to the risk of late-pregnancy acquisition of HSV. Most neonatal herpes infections are the result of undiagnosed, new-onset HSV infection in the mother. This article reviews the epidemiology of HSV, risks of transmission, and testing and management of HSV during pregnancy. Options for evaluation and management are presented.

No association between antepartum serologic and genital tract evidence of herpes simplex virus-2 coinfection and perinatal HIV-1 transmission

OBJECTIVE

The purpose of this study was to assess the risk of perinatal HIV-1 transmission in women who are coinfected with herpes simplex virus-2 (HSV-2).

STUDY DESIGN

We performed a nested case-control study of 26 women whose HIV-1 was transmitted to their infants and 52 control subjects whose HIV-1 was not transmitted. We assessed antepartum serologic evidence of HSV-2 by HSV-2 serostatus and genital tract evidence of HSV-2 by presence of HSV-2 DNA.

RESULTS

There was no significant association between antepartum serologic evidence of HSV-2 coinfection and the risk of perinatal HIV-1 transmission. There was also no association between antepartum genital tract evidence of HSV-2 coinfection and risk of perinatal HIV-1 transmission.

CONCLUSION

Women who were infected with HIV-1 with antepartum serologic and genital tract evidence of HSV-2 coinfection did not appear to have an increased risk of perinatal HIV-1 transmission. However, further investigations are needed to assess HSV-2 reactivation and the risk of perinatal HIV-1 transmission at the time of delivery.

Prenatal herpes simplex virus serologic screening beliefs and practices among obstetricians

OBJECTIVE

To describe the beliefs and practices of obstetricians related to prenatal serologic testing for HSV infection.

METHODS

A total of 265 (73% of eligible) currently practicing obstetricians in Washington State completed a 36-question mailed survey that assessed beliefs regarding genital herpes in pregnancy, neonatal herpes, serologic testing for herpes in pregnancy, and ease of testing.

RESULTS

Ninety-five percent of respondents believed genital herpes was common in reproductive-aged women, 83% believed neonatal herpes was a serious health issue, and 73% believed it warranted systematic prevention efforts; 74% discussed herpes with pregnant patients as part of prenatal care, 31% provided written materials about herpes, and 15% used serologic tests for herpes in 75% or more of their prenatal patients. Factors independently associated with routine herpes serologic testing were academic practice setting (adjusted odds ratio [aOR] 10.4, 95% confidence interval [CI] 2.8-39.1) and metropolitan practice setting (aOR 3.3, 95% CI 1.4-7.9). Beliefs that testing would cause unnecessary distress in pregnancy (aOR 0.3, 95% CI 0.1-0.7), or that testing was not worth the expense (aOR 0.1, 95% CI 0.0-0.6) were associated with not testing. Availability of serologic tests for HSV was reported to be high and was not associated with prenatal HSV testing.

CONCLUSION

Most obstetricians believe neonatal herpes prevention is important.

LEVEL OF EVIDENCE

II.

Consequences of herpes simplex virus in pregnancy and their prevention

PURPOSE OF REVIEW

New findings reveal that first-time infection of the mother is the most important factor for the transmission of genital herpes from mother to fetus/newborn. Interventions based on these findings will lead to new management of the pregnant patient with genital herpes prior to pregnancy and measures to prevent the acquisition of herpes during pregnancy.

RECENT FINDINGS

Risk factors for the transmission of herpes from mother to newborn have been detailed. It is the pregnant woman who acquires genital herpes as a primary infection in the latter half of pregnancy, rather than prior to pregnancy, who is at greatest risk of transmitting this virus to her newborn. This is true for both herpes simplex virus type-1 and herpes simplex virus type-2. Additional risk factors for neonatal herpes simplex virus infection include the use of a fetal-scalp electrode and maternal age of less than 21 years.

SUMMARY

Risk factors for the transmission of herpes from mother to newborn are detailed. Antiviral suppressive therapy initiated in the late third trimester has been shown to decrease viral shedding and the need for cesarean section.

Antenatal Herpes Serologic Screening

OBJECTIVE

Calls for universal antenatal type-specific herpes simplex virus (HSV) screening to prevent neonatal herpes have recently increased and would affect the four million pregnant women and their partners annually in the United States. We undertook this review to assess the appropriateness of such screening, making relevant comparisons to established antenatal human immunodeficiency virus (HIV) and hepatitis B virus (HBV) screening programs.

DATA SOURCES

We conducted a full PubMed and bibliographic search for relevant literature in English available from 1966 through February 2006, using the terms "genital herpes," "neonatal herpes," "decision analysis" or "cost-effectiveness analysis," and "herpes and pregnancy" or "antenatal herpes screening." Comparison literature was obtained by replacing "herpes" with "HBV" or "HIV".

METHODS OF STUDY SELECTION

We appraised antenatal type-specific HSV screening using well-established criteria for a good screening program, which we articulated as questions. Of 455 articles we selected those that addressed at least one of the questions and were pertinent to the U.S. population.

TABULATION, INTEGRATION, AND RESULTS

We found that neonatal HSV is rare and its incidence is imprecisely defined. There is a lack of evidence supporting the effectiveness of interventions to prevent maternal acquisition of new infection in late pregnancy, which accounts for 60-80% of neonatal herpes. The consequences of universal screening are incompletely understood but include the potential for unnecessary cesarean deliveries and medical treatment, maternal psychosocial stress, and discord among partners. The available evidence indicates universal screening is not cost-effective. In contrast, antenatal HIV and HBV screening programs better satisfy accepted criteria for screening.

CONCLUSION

On the basis of this appraisal, universal antenatal type-specific HSV screening to prevent neonatal herpes does not adequately satisfy criteria of a good screening program, and we recommend against its adoption.