Maternal cytomegalovirus infection prevention: The role of Dutch primary care midwives

Exploring the implementation of an educational film within antenatal care to reduce the risk of cytomegalovirus infection in pregnancy: A qualitative study

BACKGROUND

Congenital cytomegalovirus (CMV) infection is a leading cause of sensorineural hearing loss and neuro-disability in childhood. In the absence of a licensed vaccine, adoption of hygiene-based measures may reduce the risk of CMV infection in pregnancy, however these measures are not routinely discussed with pregnant women as part of National Health Service (NHS) antenatal care in the United Kingdom (UK).

METHODS

An exploratory qualitative study was conducted, underpinned by Normalization Process Theory (NPT), to investigate how an educational intervention comprising of a short film about CMV may best be implemented, sustained, and enhanced in real-world routine antenatal care settings. Video, semi-structured interviews were conducted with participants who were recruited using a purposive sample that comprised of midwives providing antenatal care from three NHS hospitals (n = 15) and participants from professional colleges and from organisations or charities providing, or with an interest in, antenatal education or health information in the UK (n = 15).

FINDINGS

Midwives were reluctant to include CMV as part of early pregnancy discussions about reducing the risk of other infections due to lack of time, knowledge and absence of guidance or policies relating to CMV in antenatal education. However, the educational intervention was perceived to be a useful tool to encourage conversations and empower women to manage risk by all stakeholders, which would overcome some identified barriers. Macro-level challenges such as screening policies and lack of official guidelines to legitimise dissemination were identified.

DISCUSSION

Successful implementation of education about CMV as part of routine NHS care in the UK will require an increase in awareness and knowledge about CMV amongst midwives. NPT revealed that 'coherence' and 'cognitive participation' between service members are vital to imbed CMV education in routine practice. 'Collective action' and 'reflexive monitoring' is required to sustain service changes.

The DELIVER study; the impact of research capacity building on research, education, and practice in Dutch midwifery

BACKGROUND

Few examples exist of research capacity building (RCB) in midwifery. As in other jurisdictions, at the turn of this century midwives in the Netherlands lagged in research-based practice. Dutch professional and academic organisations recognised the need to proactively undertake RCB. This paper describes how a large national research project, the DELIVER study, contributed to RCB in Dutch midwifery.

METHODS

Applying Cooke's framework for RCB, we analysed the impact of the DELIVER study on RCB in midwifery with a document analysis comprising the following documents: annual reports on research output, websites of national organizations that might have implemented research findings, National Institute for Public Health and the Environment (RIVM)), midwifery guidelines concerning DELIVER research topics, publicly available career information of the PhD students and a google search using the main research topic and name of the researcher to look for articles in public papers.

RESULTS

The study provided an extensive database with nationally representative data on the quality and provision of midwifery-led care in the Netherlands. The DELIVER study resulted in 10 completed PhD projects and over 60 publications. Through close collaboration the study had direct impact on education of the next generation of primary, midwifery care practices and governmental and professional bodies.

DISCUSSION

The DELIVER study was intended to boost the research profile of primary care midwifery. This reflection on the research capacity building components of the study shows that the study also impacted on education, policy, and the midwifery profession. As such the study shows that this investment in RCB has had a profound positive impact on primary care midwifery in the Netherlands.

Cytomegalovirus Infection in Pregnancy Prevention and Treatment Options: A Systematic Review and Meta-Analysis

OBJECTIVES

Cytomegalovirus (CMV) infection is a significant health concern affecting numerous expectant mothers across the globe. CMV is the leading cause of health problems and developmental delays among infected infants. Notably, this study examines CMV infection in pregnancy, its management, prevention mechanisms, and treatment options.

METHODS

Specifically, information from the Cochrane Library, PUBMED, Wiley Online, Science Direct, and Taylor Francis databases were reviewed along with additional records identified through the register, the Google Scholar search engine. Based on the search, 21 articles were identified for systematic review.

RESULTS

A total of six randomized controlled trials (RCTs) were utilized for a meta-analytic review. As heterogeneity was substantial, the random effects model was used for meta-analysis. Utilizing the random-effects model, the restricted maximum likelihood (REML) approach, the estimate of effect size (d = -0.479, 95% CI = -0.977 to 0.019, p = 0.060) suggests the results are not statistically significant, so it cannot be inferred that the prevention methods used were effective, despite an inverse relationship between treatment and number of infected cases. The findings indicated that several techniques are used to prevent, diagnose, and manage CMV infection during pregnancy, including proper hygiene, ultrasound examination (US), magnetic resonance imaging (MRI), amniocentesis, viremia, hyperimmunoglobulin (HIG), and valacyclovir (VACV).

CONCLUSIONS

The current review has significant implications for addressing CMV infection in pregnancy. Specifically, it provides valuable findings on contemporary management interventions to prevent and treat CMV infection among expectant mothers. Therefore, it allows relevant stakeholders to address these critical health concerns and understand the effectiveness of the proposed prevention and treatment options.

Primary, Secondary, and Tertiary Prevention of Congenital Cytomegalovirus Infection

Cytomegalovirus infection is the most common congenital infection, affecting about 1% of births worldwide. Several primary, secondary, and tertiary prevention strategies are already available during the prenatal period to help mitigate the immediate and long-term consequences of this infection. In this review, we aim to present and assess the efficacy of these strategies, including educating pregnant women and women of childbearing age on their knowledge of hygiene measures, development of vaccines, screening for cytomegalovirus infection during pregnancy (systematic versus targeted), prenatal diagnosis and prognostic assessments, and preventive and curative treatments in utero.

Cross-sectional study to assess awareness of cytomegalovirus infection among pregnant women in Germany

BACKGROUND

Study aimed to assess awareness of congenital cytomegalovirus (CMV) infection and its determinants in pregnancy.

METHODS

Cross-sectional survey was conducted in five hospital-based maternity units in Germany. Pregnant women attending the maternity departments completed interviewer/self-administered survey questionnaire. High-risk group was defined according to contact with children under five years of age (at home or at work). Quantitative analyses using multivariable logistic regression were performed.

RESULTS

One thousand two hundred thirty-three pregnant women were included. 48.5% (n = 598) of women reported any knowledge about risk of CMV infection during pregnancy. CMV infection was less known than other infections or diseases (education about toxoplasmosis 95.5% (n = 1,177), listeriosis 60.5% (n = 746). 38% (n = 468) of participants received education about CMV. CMV awareness was associated with the level of education and employment in childcare or medical care. Only 32% (n = 394) of the women made use of serological screening for CMV during pregnancy (individual health service). 40.8% (n = 503) of pregnant women were classified as high-risk group. They had significantly higher knowledge and education about CMV, and msignificantlycant more often use of the serological screening.

CONCLUSIONS

Less than half of pregnant women surveyed were aware of potential risk associated with CMV infection during pregnancy. In our study,one-third third of pregnant women made use of the serological screening for CMV. Regarding the lack of current consensus on the role of serological CMV screening for pregnant women, hygiene preventive measures are the only evidence-based recommendation for pregnant women and knowledge increase could potentially have major public health impact.

eLearning significantly improves maternity professionals' knowledge of the congenital cytomegalovirus prevention guidelines

Aims

Cytomegalovirus (CMV) is a preventable cause of neurodevelopmental disability. Australian guidelines recommend that pregnant women are informed about CMV to reduce their risk of infection; however, less than 10% of maternity health professionals routinely provide prevention advice. The aim was to develop and evaluate the effectiveness of an eLearning course for midwives to improve knowledge and confidence about CMV.

Materials and Methods

Participants undertaking the course between March and November 2020 were invited to complete an evaluation questionnaire: before the course (T1), immediately after (T2) and three months post completion (T3). A linear mixed model was used to evaluate change in participant scores; P < 0.05 was considered statistically significant.

Results

Midwives (316/363, 87%), midwifery students (29/363, 8%) and nurses (18/363, 5%) participated. At T1 80% indicated they had not received education about CMV. Total adjusted mean scores for questionnaires completed between T1 (n = 363) and T2 (n = 238) increased significantly (from 17.2 to 22.8, P < 0.001). Limited available T3 scores (n = 27) (−1.7, P < 0.001), while lower than T2, remained higher than at T1 (+3.6, P < 0.001). Participants’ awareness of CMV information resources improved from 10 to 97% from T1 to T2. Confidence in providing CMV advice increased from 6 to 95% between T1 and T2 (P < 0.001) and was maintained at T3. Almost all (99%) participants indicated they would recommend the course to colleagues.

Conclusion

Participants who completed the eLearning course had significantly improved knowledge and confidence in providing advice about CMV. Programs targeting other maternity health professionals should be considered, to further support the implementation of the congenital CMV prevention guidelines.

Survey of physician knowledge of congenital cytomegalovirus infection and clinical practices in Japan: A web-based survey

Congenital cytomegalovirus infection (cCMVi) can cause serious and long-term effects in newborns. Without available vaccines or antiviral prophylaxis, prevention strategies for cCMVi and cytomegalovirus disease during pregnancy are limited to hygiene and behavioral interventions to prevent transmission. The objective of this study was to assess cCMVi-related awareness, knowledge, and physicians' actual and preferred clinical practices in Japan. This web-based cross-sectional survey was conducted using online panels. Survey invitations were sent by email to physicians (pediatricians, obstetricians, otolaryngologists, and internists). Participants were asked about their awareness of congenital conditions, including cCMVi. Participants who were aware of cCMVi were then asked additional questions related to the study objectives. Participants included 292 pediatricians, 245 obstetricians, 245 otolaryngologists, and 279 internists. Awareness of cCMVi was generally high (69.2%-97.6%). Pediatricians and obstetricians were most knowledgeable about cCMVi; however, responses to specific questions such as those pertaining to risk factors, patient counseling, and clinical management of cCMVi varied. For example, correct identification of potential cytomegalovirus transmission routes among pediatricians ranged from 36.8% to 65.6%. Survey results showed a discrepancy between responses when physicians were asked about their actual and preferred clinical practices to manage cCMVi. For example, although around 90% of obstetricians and pediatricians considered it preferred practice to educate pregnant women about cCMVi, only 60.1% of obstetricians reported being able to actually do so in current practice.This survey revealed that knowledge about cCMVi among Japanese physicians could be improved and identified variability in clinical practice.

Guideline No. 420: Cytomegalovirus Infection in Pregnancy

OBJECTIVE

To provide an update on current recommendations for cytomegalovirus (CMV) infection during pregnancy. The objectives of this guideline are: TARGET POPULATION: Patients of child-bearing age, pregnant patients, and patients planning a pregnancy.

BENEFITS, HARMS, AND COSTS

The patient partners urged us to make awareness of preventive strategies a high priority, despite concern that discussing CMV with patients could cause unnecessary anxiety. CMV educational interventions have shown benefits from increased awareness of cCMV prevalence and preventive strategies among providers, patients, and families.

EVIDENCE

We searched MEDLINE, EMBASE, and CENTRAL databases for CMV in pregnancy. The search terms were developed using MeSH terms and keywords (Appendix). The results were filtered for articles published between January 2010 and October 2020 and systematic reviews, meta-analyses, clinical trials, and observational studies. The main inclusion criteria were pregnant patients and infants, as the target population, and CMV infection, as the diagnosis of interest. Recommendations are graded according to the U.S. Preventive Services Task Force grade of recommendations and level of certainty.

VALIDATION METHODS

We collaborated with patient partners, including members of CMV Canada (cmvcanada.com). In formulating our recommendations, we included patients' voices to add a unique and valuable perspective, thus ensuring that our recommendations are relevant to the patient-provider partnership.

INTENDED AUDIENCE

All perinatal health care providers. RECOMMENDATIONS (GRADE AND LEVEL OF CERTAINTY IN PARENTHESES).

Congenital cytomegalovirus infection: do pregnant women and healthcare providers know enough? A systematic review

BACKGROUND

Cytomegalovirus (CMV) is the most frequent cause of congenital infection worldwide causing serious morbidity in newborns, infants, and children. Despite the clinical importance of congenital CMV (cCMV), studies conducted so far conclude that there is limited awareness in both the medical community and public of cCMV infection. The aim of this systematic review was to assess the knowledge and awareness of cCMV among pregnant women and healthcare providers during the last decade.

METHODS

A literature search was performed in PubMed and Scopus, including studies published between 2011 and 2020. Eligibility criteria included articles focusing on either pregnant women or healthcare providers and reporting data about cCMV awareness. We included cross-sectional and interventional studies. Study quality was assessed using the Study Quality Assessment Tools by National Institute of Health.

RESULTS

Overall, 23 studies fulfilled the inclusion criteria, 13 studies referred to pregnant women and 10 to healthcare providers. A total of 6521 pregnant women and 3609 healthcare providers were included. The level of awareness of pregnant women about cCMV was low to moderate. However, pregnant women showed willingness to adopt hygiene strategies following interventional-educational practices. Concurrently, awareness among healthcare providers varied depending on the specialty. Nonetheless, a great proportion admitted feeling inadequate in advising pregnant women for cCMV screening and prevention.

CONCLUSION

The role of healthcare providers in growing awareness among pregnant women is of paramount importance. Due to the lack of an effective vaccine as yet, education of women regarding hygiene measures is currently the best strategy to prevent cCMV disease.

Cytomegalovirus (CMV) Shedding in French Day-Care Centers: A Nationwide Study of Epidemiology, Risk Factors, Centers' Practices, and Parents' Awareness of CMV

BACKGROUND

Congenital cytomegalovirus (CMV) remains an important healthcare burden, resulting from primary or secondary infection in pregnant women. Exposure to young children's saliva is a major risk factor, as prevalence of CMV shedding can reach 34%.

METHODS

This cross-sectional, multicenter, nationwide study was conducted in randomly selected day care centers (DCCs), and complemented with a survey among parents and DCCs. All children aged >3 months were eligible. The study measured the CMV shedding prevalence in children's saliva and described CMV genotypes epidemiology. The risk factors for CMV shedding and high viral load were evaluated using multivariable models.

RESULTS

A total of 93 DCCs participated. Among the 1770 enrolled children with evaluable samples, the CMV shedding prevalence was 40% (713/1770, 95% confidence interval, 34.6-46.1), independently associated with children aged between 12 and 18 months, history of CMV infection in ≥1 parents, a mid-level income. Prevalence increased with DCC staff workload and attending children number. Viral load was ≥5 log-copies CMV/mL in 48% (342/713). Risk factors for higher viral load included children aged between 12 and 18 months, and still being breastfed. The most frequent genotype combinations were gB1-gN4c-gH2 (6.9%), gB1-gN2-gH2 (6.3%), gB4a-gN3a-gH1 (6.3%), and gB1-gN3b-gH2 (5,7%). CMV awareness was low in parents: their serological status was unknown by 72% of mothers and 82% of fathers. Only 41% knew something about CMV.

CONCLUSIONS

CMV shedding was independently associated with risk factors related to the children, family and DCC. Some of these risk factors may influence prevention strategies, including through an improved information provided to parents.

CLINICAL TRIALS REGISTRATION

NCT01704222.

Development and Assessment of a Prenatal Cytomegalovirus (CMV) Educational Survey: Implementation and Impact in a Metropolitan University-Based Clinic

Purpose

Congenital CMV infection can result in serious sequelae in the newborn. The goal of this study was to assess pregnant women's knowledge and understanding of CMV infection during pregnancy and develop an educational tool about CMV infection to be utilized during prenatal care.

Materials and Methods

This is a prospective intervention study that assessed pregnant women's knowledge before and after receiving an educational handout about CMV infection in pregnancy and the perceived value of this education. Pre- and post-education questionnaires were utilized to assess knowledge. The pre-education questionnaire and CMV educational handout were given at the same clinic visit. The educational handout was given after the pre-education questionnaire had been completed. The post-education questionnaire was given at the next scheduled prenatal clinic appointment and included questions regarding the level of satisfaction with the education and the perceived value of the information. Pregnant women less than 34 weeks of gestation were eligible.

Results

A total of 263 women were enrolled, 263 completed the pre-CMV educational questionnaire and 215 women completed both questionnaires. Some women only partially completed the questionnaires and those partial responses have been included. Prior to education, 33% (85/261) of participants had heard of CMV. This increased to 75% (160/214) after education. Participants scored each of the recommended hygiene practices between 1 and 5 (5 is the most acceptable) and each recommended hygiene practice received an average score between 3.8 and 5. 74% (134/180) of participants reported increasing their hygienic practices after education. 96% (180/188) of participants indicated they were satisifed to have received the education. 98% (187/190) thought more women should receive this education during prenatal care.

Conclusion

Pregnant women viewed education about CMV favorably and increased the frequency of recommended hygiene practices. Introducing an educational handout to routine prenatal care may be beneficial in increasing awareness of CMV infection in pregnancy.

Knowledge of congenital cytomegalovirus (CMV) in pregnant women in Australia is low, and improved with education

BACKGROUND

Cytomegalovirus (CMV) is the most common congenital infection and can cause hearing loss and neurodevelopmental disability in infected infants. International research shows women have limited knowledge about CMV.

AIMS

To assess pregnant women's knowledge and attitudes about CMV before and after provision of information.

MATERIALS AND METHODS

Cross-sectional survey of pregnant women between November 2017 and February 2018 at two Australian hospitals. Participating women completed an initial survey on maternal characteristics, knowledge of infections, and CMV risk behaviours. Participants were then given an information leaflet and completed a follow-up survey.

RESULTS

Four hundred and fifty-seven women completed the initial survey, of whom 73/457 (16%) had heard of CMV. Behaviours increasing risk of CMV transmission were common: 58% reported regularly kissing their child on the lips; 57% did not always wash their hands after changing a wet nappy. Knowledge about CMV significantly improved after reading the leaflet in the 145 women completing the follow-up survey. More women correctly identified that CMV could cause deafness in a baby (35% before, 85% after), was spread by saliva (38% vs 94%) or urine (27% vs 86%) and prevented by hand-washing (55% vs 99%; all P < 0.001).

CONCLUSION

Knowledge about CMV was low in pregnant women. An educational leaflet was effective in improving knowledge.

Congenital cytomegalovirus infection

Each year, thousands of children are born with or develop permanent disabilities such as hearing loss, vision loss, motor and cognitive deficits from congenital CMV infection (cCMV). However, awareness of cCMV and its associated sequelae is very low in pregnant women and healthcare providers. Both targeted and universal approaches to screen newborns for CMV infection are now achievable due to recent scientific advances including the development of a rapid, high-throughput method for detecting CMV in saliva, the efficacy of antiviral treatment in symptomatic infants, and the demonstration of cost effectiveness of CMV screening. Future studies are needed to address gaps in our understanding on the role of non-primary maternal CMV infections, the evaluation of antiviral treatment in asymptomatic infants, and the implementation of prevention strategies for cCMV.

International opinions and national surveillance suggest insufficient consensus regarding the recognition and management practices of infants with congenital cytomegalovirus infections

AIM

This study evaluated the recognition and management practices with regard to congenital cytomegalovirus (cCMV) infections by a select group of experts and through a national surveillance study.

METHOD

A questionnaire was sent to international experts involved in mother and infant care in 2014-2015. Monthly surveillance was conducted among Dutch paediatricians for cases of cCMV infections from 2013 until 2015.

RESULTS

The questionnaire was completed by 63/103 (62%) respondents, who indicated that recognition and management practices varied. Maternal screening was performed by 17/63 (27%) and infant screening by 3/61 (5%) of the respondents. Infant CMV diagnostics were most frequently initiated due to hepatosplenomegaly and/or an increase in liver transaminases. Management practices included cranial ultrasound (57/63, 91%) and audiological follow-up in symptomatic (61/63, 97%) and asymptomatic (52/63, 83%) infants. In terms of antiviral treatment, 46/63 (73%) treated symptomatic infants only and 6/63 (9%) treated all infected infants. In total, 48 cases were registered through the Dutch surveillance study and 43/48 (90%) infants were symptomatic.

CONCLUSION

This study indicates that infants with cCMV infection were insufficiently recognised and highlights the need for consensus on management practices. Screening of infants and the development of an international management guideline are recommended.

Cytomegalovirus (CMV) infection and pregnancy-potential for improvements in Australasian maternity health providers' knowledge

PURPOSE

To assess the knowledge, practice and attitudes of maternity clinicians regarding congenital cytomegalovirus (CMV). It is the most common congenital infection, and well-recognized cause of neurodevelopmental disability and hearing loss. New consensus recommendations state all pregnant women and health-care providers should be educated about congenital CMV infection and preventive measures.

MATERIALS AND METHODS

An email questionnaire was distributed in October 2015 to specialists, diplomates (general practitioners), and trainees of the Royal Australian New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and Victorian and New South Wales midwives.

RESULTS

774 responded: (37.3% specialists, 17.3% diplomates, 16.8% trainees, 28.6% midwives). Clinicians had variable knowledge of fetal sequelae, transmission routes and prevention. Overall, 30.2% felt confident about discussing CMV in pregnancy: less than 10% of midwives (7.4%) and less than half of specialists (47.1%, p < .0001). Only 8.8% of respondents routinely discussed CMV prevention with pregnant women. The majority (69.3%) responded that professional societies should make practice recommendations, and 88% thought more patient information was needed, preferably leaflets.

CONCLUSIONS

Australasian maternity clinicians lack confidence and knowledge about congenital CMV. Few (<10%) routinely provide advice on prevention. There is urgent need for clinical guidance and patient information to reduce the burden of disease.

Disease burden of congenital cytomegalovirus infection at school entry age: study design, participation rate and birth prevalence

Congenital cytomegalovirus infection (cCMV) may lead to symptoms at birth and long-term consequences. We present a nationwide, retrospective cohort study on the outcome of cCMV up to age 6 years. For this study we identified cCMV, using polymerase chain reaction, by analysing dried blood spots, which are taken shortly after birth for neonatal screening. The group of children with cCMV were compared to a group of children who were cCMV negative at birth. Data were collected about their health and development up to age 6 years. Parents of 73 693 children were invited to participate, and 32 486 (44·1%) gave informed consent for testing of their child's dried blood spot for CMV. Of the 31 484 dried blood spots tested, 156 (0·5%) were positive for cCMV. Of these, four (2·6%) children had been diagnosed with cCMV prior to this study. This unique retrospective nationwide study permits the estimation of long-term sequelae of cCMV up to the age of 6 years. The birth prevalence of cCMV in this study was 0·5%, which is in line with prior estimates. Most (97·4%) children with cCMV had not been diagnosed earlier, indicating under-diagnosis of cCMV.