EPIDEMIOLOGY OF GENITAL HERPES INFECTIONS

Remoteness influences access to sexual partners and drives patterns of viral sexually transmitted infection prevalence among nomadic pastoralists

Sexually transmitted infections (STIs) comprise a significant portion of the infectious-disease burden among rural people in the Global South. Particular characteristics of ruralness-low-density settlements and poor infrastructure-make healthcare provision difficult, and remoteness, typically a characteristic of ruralness, often compounds the difficultly. Remoteness may also accelerate STI transmission, particularly that of viral STIs, through formation of small, highly connected sexual networks through which pathogens can spread rapidly, especially when partner concurrency is broadly accepted. Herein, we explored the effect of remoteness on herpes simplex virus type-2 (HSV-2) epidemiology among semi-nomadic pastoralists in northwestern (Kaokoveld) Namibia, where, in 2009 we collected HSV-2-specific antibody status, demographic, sexual network, and travel data from 446 subjects (women = 213, men = 233) in a cross-sectional study design. HSV-2 prevalence was high overall in Kaokoveld (>35%), but was heterogeneously distributed across locally defined residential regions: some regions had significantly higher HSV-2 prevalence (39-48%) than others (21-33%). Using log-linear models, we asked the following questions: 1) Are sexual contacts among people in high HSV-2-prevalence regions more likely to be homophilous (i.e., from the same region) than those among people from low-prevalence regions? 2) Are high-prevalence regions more "functionally" remote, in that people from those regions are more likely to travel within their own region than outside, compared to people from other regions? We found that high-prevalence regions were more sexually homophilous than low-prevalence regions and that those regions also had higher rates of within-region travel than the other regions. These findings indicate that remoteness can create contact structures for accelerated STI transmission among people who are already disproportionately vulnerable to consequences of untreated STIs.

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.

Clinical and Laboratory Findings That Differentiate Herpes Simplex Virus Central Nervous System Disease from Enteroviral Meningitis

Background. It can be difficult for clinicians to distinguish between the relatively benign enteroviral (EnV) meningitis and potentially lethal herpes simplex virus (HSV) central nervous system (CNS) disease. Very limited evidence currently exists to guide them. Objective. This study sought to identify clinical features and cerebrospinal fluid (CSF) findings associated with HSV CNS disease. Methods. Given that PCR testing often is not immediately available, this chart review study sought to identify clinical and cerebrospinal fluid (CSF) findings associated with HSV meningitis over a 6-year period. In cases where PCR was not performed, HSV and EnV were assigned based on clinical criteria. Results. We enrolled 166 consecutive patients: 40 HSV and 126 EnV patients. HSV patients had a mean 40.4 versus 31.3 years for EnV, p = 0.005, seizures 21.1% versus 1.6% for EnV, p < 0.001, altered mental status 46.2% versus 3.2% for EnV, p < 0.001, or neurological deficits 44.7% versus 3.9% for EnV, p < 0.001. CSF neutrophils were lower in HSV (median 3.0% versus 9.5%, p = 0.0002); median lymphocytes (87.0% versus 67.0%, p = 0.0004) and protein (0.9 g/L versus 0.6 g/L, p = 0.0005) were elevated. Conclusion. Our study found that HSV patients were older and more likely to have seizure, altered mental status, or neurological deficits than patients with benign EnV meningitis. HSV cases had lower CSF neutrophils, higher lymphocytes, and higher protein levels.

Genital Herpes: Management Issues for the Next Century

Genital herpes (GH) is caused by herpes simplex virus (HSV) types 1 and 2. HSV-2 is more commonly the causal agent, and is responsible for 98% of recurrences. A first episode may become clinically apparent within 2–21 days post-infection. Symptomatic recurrences present as vesiculo-ulcerative lesions, which typically resolve within 5 days. The overall recurrence rate for GH is 60–90%. Asymptomatic shedding occurs in both sexes on 1–5% of days. Aciclovir, famciclovir and valaciclovir are the approved drugs for GH, and one of these should be used in all first episodes. Episodic treatment is often used where recurrences are infrequent and easily recognized. Oral treatment with famciclovir, aciclovir or valaciclovir reduces the duration of lesions, viral shedding and uncomfortable symptoms. Patients with frequent or problematic recurrences are candidates for prophylaxis with antivirals which suppress both symptomatic and asymptomatic reactivation. A herpes diagnosis often leaves patients emotionally vulnerable, concerned about asymptomatic shedding and fearful of transmission to sexual partners. GH can be devastating, occasionally leading to clinical depression and/or suicidal ideation. Patients commonly fear discussing GH with their physician or partners, but doing so is vitally important for their psychological health. Counselling to assist in this process is helpful. In summary, good management of GH requires careful attention to proper diagnosis and therapy, with psychosocial intervention: all three provided in the context of accurate information.

Herpes simplex virus type 2 among mobile pastoralists in northwestern Namibia

BACKGROUND

Although herpes simplex virus type 2 (HSV-2) epidemiology has been described for many western and/or urban populations, disease burden has not been characterized for remote, non-western, under treated populations, where patterns of risk and vulnerability may be very different.

AIMS

To understand demographic, behavioural and geographic influences on risk for HSV-2 in a population of mobile, rural pastoralists in northwestern Namibia.

SUBJECTS AND METHODS

The authors conducted a cross-sectional survey of reproductively aged adults (n = 445) across 28 villages in Kaokoveld, Namibia. All participants completed a questionnaire of demographic data, ecological interactions and sexual behaviour, and a rapid test specific for HSV-2.

RESULTS

HSV-2 status was significantly associated with being female (OR = 3.1, 95% CI = 2.00, 4.71), increasing age (men: OR = 7.5, 95% CI = 2.67, 20.85; women: OR = 6.2, 95% CI = 2.48, 15.50) and with higher wealth among men (OR = 5.1, 95% CI = 1.98, 13.09).

CONCLUSIONS

Higher risk among women can be explained, in part, by local hygiene practices and a preference for "dry" sex. There was considerable variation in prevalence by region, which appears to be linked to geographic remoteness. Culturally contextualized epidemiologic studies of remote, vulnerable populations can provide essential information for limiting the introduction and spread of new infections.

Antiviral therapy for genital herpes infections in pregnancy

One of the most deleterious consequences of maternal infection with herpes simplex virus is neonatal herpes, which results in death or significant neurodevelopmental impairment in the majority of infected babies. Herpes simplex virus infection during pregnancy can also impact the psychologic health of the mother. The ability to minimize the risk of herpes simplex virus transmission has improved in tandem with advances in understanding of the mechanisms and epidemiology of acquisition of neonatal herpes simplex virus. In particular, antiviral pharmacotherapy is now recognized as an important option both for reducing the risk of transmission of herpes simplex virus from a seropositive to a seronegative partner and, potentially, for modifying several risk factors for transmission of the virus from a herpes simplex virus-infected mother to the neonate. This review discusses the consequences and management of herpes simplex virus infection during pregnancy, with a focus on the evolving role of antiviral therapy.

Lavomax - new potential of the complex therapy of genital herpes

The goal of this study was to assess clinical efficacy and safety of Lavomax and to provide pathogenetic grounds for its use in the complex therapy of patients suffering from genital herpes. The study subjects were 64 patients suffering from genital herpes. Their diagnosis was verified on the basis of ELISA and PCR results. Immunoassays revealed various disorders of immune homeostasis and natural resistance. These results confirm that there are pathogenetic grounds to use Lavomax in the complex therapy of genital herpes. Complex treatment with the use of Lavomax normalizes immune homeostasis and quickly reduces clinical manifestations of herpes significantly reducing the frequency and duration of recurrences of the disease.

One-day famciclovir vs. placebo in patient-initiated episodic treatment of recurrent genital herpes in immunocompetent Black patients

BACKGROUND

There are no known racial differences in genital herpes disease pathogenesis or response to therapy. Despite high herpes simplex virus (HSV) seroprevalence in Black persons, clinical trials investigating the treatment of recurrent genital herpes (RGH) have typically enrolled a small proportion of Black patients.

METHODS

This multicenter, double-blind, placebo-controlled study evaluated the efficacy and safety of patient-initiated, 1-day famciclovir 1000 mg twice-daily in immunocompetent Black adults (USA and South Africa) with RGH. Eligible patients were randomized (2:1) to famciclovir or placebo. The primary endpoint was time to healing of non-aborted genital herpes lesions (i.e., lesions that progressed beyond papule stage). Secondary endpoints included proportion of patients with aborted genital herpes lesions, time to resolution of associated symptoms, and safety.

CLINICAL TRIAL REGISTRATION

www.ClinicalTrials.gov ; trial identifier NCT00477334.

RESULTS

A total of 299 patients with RGH (66% female, median age = 37 years) received either 1-day famciclovir 1000 mg twice-daily (n = 201) or placebo (n = 98). In the modified intent-to-treat population, the estimated median time to healing of non-aborted genital herpes lesions was 5.38 days for famciclovir and 4.79 days for placebo (median of treatment differences = 0.26 days; 95% CI [-0.40, 0.98]; p = 0.416). Consistent findings were reported in the completer and per-protocol populations. No significant differences were reported for all secondary analyses. Adverse events (AEs) were consistent with the established safety profile of famciclovir: 18 (6%) patients had drug-related AEs (16 [8%] famciclovir; 2 [2%] placebo), none of which were serious or led to discontinuation or dose adjustment/interruption. There are some limitations of this research: many study sites either lacked prior experience in conducting clinical studies in patients with HSV infection or enrolled small numbers of patients, which may have compromised efficacy outcomes. Also, HIV antibody testing was not mandated at enrollment.

CONCLUSION

This study showed similar efficacy and tolerability of 1-day treatment with famciclovir 1000 mg twice-daily compared to placebo in immunocompetent Black adults with RGH. Famciclovir has proven efficacy and safety in the overall RGH population. Further understanding of the efficacy of antiherpes therapy in Black patients with recurrent genital herpes may be warranted.

Genital herpes simplex virus type 1 in women: detection in cervicovaginal specimens from gynecological practices in the United States

Herpes simplex virus types 1 and 2 (HSV-1 and -2) are significant human pathogens causing clinically indistinguishable facial and genital lesions. Recently, the number of reported genital herpes cases caused by type 1 virus has increased. Identifying the HSV type is of clinical importance to determine proper treatment, as there is no licensed vaccine or cure. We assessed, by PCR, the frequency of HSV-1 and HSV-2 present in more than 60,000 clinical cervicovaginal specimens derived from samples originating from 43 continental U.S. states. Fourteen percent were positive for HSV-1 and/or HSV-2. This likely represents subclinal shedding. It was not a measurement of the prevalence of HSV infection. While the majority were HSV-2, 32% were HSV-1. The distribution of HSV types varied between the states with the largest number of specimens, New Jersey, Florida, and Texas. Specimens from women under the age of 24 had an HSV-1 positivity rate of 47 percent. Importantly, in New Jersey, an observed age effect was the disproportionately high prevalence of genital HSV-1 in young women. This represents the largest analysis of HSV types reported and has important public health implications, particularly for younger women.

Epidemiology of Herpes Simplex Virus Infection in Pregnancy: A Pilot Study

Herpes simplex virus (HSV) infection is one of the most common sexually transmitted viral diseases worldwide. HSV type 2 causes most genital herpes and HSV type 1 is usually transmitted via non-sexual contacts. We studied 109 pregnant women between January 2007 and December 2008, in relation to their age, condom use, number of sexual partners, age at first intercourse, parity and smoking habits. The aim of this study is to evaluate the prevalence of HSV cervical infection and HSV co-infection with other genital microorganisms associated with poor neonatal outcome. Our results show that of the 109 outpatients enrolled, 30% were HSV1 and/or HSV2 positive, of whom 30% were infected with both HSV1 and HSV2, 18% were infected with HSV1 alone and 52% with HSV2 alone. A significant association between HSV1 and HSV2 infection was found, and the prevalence of HSV2 infection in women infected with HSV1 was 63%. The prevalence of HSV1/2 varied in the presence of other vaginal microorganisms but a statistical significant association was not found. This pilot study is probably too small to obtain statistically significant results. Nevertheless, using these observed results, we calculated that about 530 patients with comparable features should be enrolled to detect an increase of 50% in HSV infection due to the presence of other genital infections and potential risk factors.

[Update on the treatment of genital herpes]

Genital herpes is a chronic infection characterized by periodic reactivation. It can produce symptomatic disease in the host although asymptomatic viral excretion can also occur. It is currently the main cause of genital ulceration and an important public health problem that has substantial clinical, psychological, and economic repercussions. This review analyzes the currently available therapeutic options and regimens, which are based mainly on systemic use of antiviral agents such as aciclovir, valacyclovir, and famciclovir. In addition, special emphasis is placed on the prevention and management of this infection in specific situations, such as pregnant, pediatric, and immunocompromised patients.

A case of maternal herpes simplex virus encephalitis during late pregnancy

BACKGROUND

A pregnant 25-year-old woman at 32 weeks' gestation was admitted to an emergency unit after her husband had found her drowsy and with her tongue bitten. The day before admission, the patient had developed a fever of 39 degrees C, was suffering from headaches, was nauseated and had vomited. On admission, she had anterograde and retrograde amnesia, but no somatic neurological deficits were detected.

INVESTIGATIONS

Routine laboratory testing, lumbar puncture, cerebrospinal fluid analysis, routine bacteriology, brain MRI, and polymerase chain reaction testing for neurotropic viruses including herpes simplex virus types 1 and 2.

DIAGNOSIS

Maternal herpes simplex virus type 1 encephalitis.

MANAGEMENT

Antiviral and anticonvulsive therapy, supportive treatment, and cesarean section.

Reconsideration of viral protein immunoblotting for differentiation of human herpes simplex viruses

Herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) are ubiquitous human pathogens that infect their hosts for life and reactivate to cause disease at or near the initial site of infection. As the incidence of genital HSV-1 infections increase, there is an increased demand for valid viral typing diagnostics. In this report, we reconsidered and developed a triple-phase immune-typing procedure that compares differences in electrophoretic mobilities of viral ICP4, ICP27, and VP22 proteins between HSV-1 and HSV-2 strains. We isolated and immunotyped 5 primary HSV-1 strains derived from orofacial, ocular, and genital areas along with 2 primary HSV-2 strains from the genital area. Advantages of this methodology include its general technical simplicity, sensitivity, and ability to definitively type HSV. It is anticipated that this methodology will be useful in distinguishing viruses obtained in clinical cultures.

Asymptomatic shedding of herpes simplex virus (HSV) in the oral cavity

OBJECTIVE

The aim of this study was to investigate the rate of herpes simplex virus (HSV) shedding from the oral cavity, because recent studies suggest that shedding is more frequent than originally reported. Factors that could influence the rate and duration of shedding from the oral cavity were examined.

METHODS

Existing epidemiologic data from 22 reports of HSV shedding from more than 3,500 individuals were analyzed with regard to demographics, frequency of sampling, and methodologic assays.

RESULTS

HSV-1 was more likely to be detected than HSV-2 in the oral cavity of asymptomatic persons (7.5 odds ratio, 95% confidence interval 4.4-12.8; P < .0001). The rate of shedding was highly variable among individuals, ranging from none to 92% of days tested, and occurred in seropositive and seronegative individuals. In cell culture studies, the rate of detection on a single day was 6.3%. Polymerase chain reaction studies provided a different picture. HSV-1 DNA was present in 97 of 180 patients (53.9%) at multiple visits, with a rate of daily detection of 33.3%. The mean duration of shedding was between 1 and 3 days, but more than 3 days in about 10% of patients.

CONCLUSIONS

At least 70% of the population shed HSV-1 asymptomatically at least once a month, and many individuals appear to shed HSV-1 more than 6 times per month. Shedding of HSV-1 is present at many intraoral sites, for brief periods, at copy numbers sufficient to be transmitted, and even in seronegative individuals. The dental implications of these findings are discussed.

Seroepidemiological study of herpes simplex virus type 2 in patients with the acquired immunodeficiency syndrome in the city of Niterói, Rio de Janeiro, Brazil

This study was designed to determine the seroprevalence of herpes simplex virus type 2 (HSV-2) and to evaluate its association with age, sex as well as other demographic and behavioural factors in 150 human immunodeficiency virus (HIV) positive adults patients attending the general medical outpatient ward for routine care of Niterói, state of Rio de Janeiro, Brazil. Serum samples were screened for HSV-2 antibodies using an indirect ELISA. Eighty-three patients were men (mean age: 38.8) and 67 were women (mean age: 35.4). The estimated prevalence of HSV-2 was 52% (95% CI: 44-60%) and it was higher among men (53%) than among women (50.7%). Overall, the age of first sexual intercourse and past history of genital herpes were associated with HSV-2 seropositivity. Analysis by gender disclosed significant association of number of lifetime sex partners only among men. Although HSV-2 antibodies were frequent in the study group, genital herpes was reported by 21.8% of the HSV-2 positive subjects, indicating low awareness of the HSV-2 infection. These results may have public health importance for Brazil as the high rate of HSV-2 infection may act as a cofactor of HIV transmission.

New management of the pregnant patient to reduce the risk of transmitting herpes to the newborn

Growing understanding of the mechanisms and epidemiology of neonatal herpes simplex virus acquisition allows for the development of a new management of the pregnant patient, one that will reduce the risk of transmitting herpes to the newborn. Maternal herpes simplex virus infection, especially acquired during pregnancy, can result in transmission to the newborn. Infection of the CNS of the newborn results in death or significant neurodevelopmental impairment in most of these infected babies. Herpes simplex virus infection acquired prior to or during pregnancy has a physical and psychologic impact on the health of the mother. Newer, more sensitive and specific serology testing for herpes simplex virus in combination with antiviral pharmacotherapy is now recognized as an important option for reducing the risk of herpes simplex virus transmission from mother to newborn. This review discusses new information concerning the prevention, diagnosis and treatment options for the management of herpes simplex virus infection during pregnancy with a focus on the evolving role of prevention.

Herpes simplex virus in pregnancy: new concepts in prevention and management

Genital herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted diseases in the United States. It is estimated that 45 million adolescents and adults are infected with genital HSV. Most genital herpes infections in the United States are caused by HSV type 2 (HSV-2), and 25% to 30% of women of reproductive age have HSV-2 antibodies. What is more striking is that genital herpes is frequently under-recognized, and that only 5% to 10% of these women have a history of genital herpes. Because such a small percentage of women are aware of being infected with HSV, the risk of maternal transmission of this virus to the fetus or newborn is a significant health issue.

Prevalence and determinants of genital shedding of herpes simplex virus among women attending Italian colposcopy clinics

OBJECTIVES

To determine the prevalence of herpes simplex virus (HSV) shedding among women attending Italian colposcopy clinics and describe their lifestyle, demographic characteristics, genital symptoms and signs.

STUDY DESIGN

A cross-sectional study was performed to assess shedding of HSV among 4565 women requiring a gynecological consultation. An amplified enzyme immunoassay that detects an HSV type-common glycoprotein D was used to reveal HSV shedding in cervical specimens. Statistical analysis was performed using Chi-square test and Student's t test.

RESULTS

A prevalence of 7.8% was found among colposcopy clinic patients. No significant differences regarding patients' average age, age at first sexual intercourse, contraceptive method used, and number of sexual partners in the previous year were found between subjects with and without viral shedding (P > 0.05). The detection of a concomitant genital infection with Trichomonas vaginalis as well as the report of previous episodes of genital herpes (GH) were significantly higher in the positive group (P < 0.01). Only 2.8% of the patients shedding HSV presented with vesicles and ulcers, with the majority of them being asymptomatic.

CONCLUSION

This is the first Italian survey on genital herpes conducted among colposcopy clinic patients. Our data show that the prevalence of HSV shedding in this study population is high and confirms that the disease is often asymptomatic. The demographics and behavioural variables of women shedding HSV seem to differ from the ones assessed in high risk patients.

Risk factors and reproductive disorders associated with canine herpesvirus-1 (CHV-1)

Canine herpesvirus-1 (CHV-1) is presumed to be enzootic in the dog population and is associated with fertility disorders and neonatal mortality. In this study we screened for risk factors affecting CHV-1 antibody titers and investigated the association between antibody titers and reproductive disorders. Therefore, serum from 545 dogs used for reproduction was analysed with an ELISA. Using a forward stepwise procedure and retaining significant risk factors (P<0.05), best fitting multifactorial generalized linear model (glm) procedures were built for males and females. The effect of antibody titers on reproductive disorders was analysed with logistic regression analysis. The association between reproductive disorders and seroprevalence was analysed in chi-square analyses using contingency tables. In both sexes, kennel cough and breeding management were found to have an impact on the CHV-1 antibody titer. Also, the influence of kennel cough on the antibody titer was correlated to the hygienic status of the kennel. In females, age, kennel size and cycle stage had an effect on CHV-1 antibody titers. Furthermore, kennel size and hygiene were found to be correlated. In males, mating experience had an impact on CHV-1 antibody titers. An association was observed between serological status and a history of abortion in bitches. In conclusion, this study suggests CHV-1 antibody titers may be affected by many factors, both on an environmental and host level. Therefore, interpretation of the serological status requires precaution. Furthermore, oronasal and venereal transmission seem to play a role in the spreading of infection.

Prevalence and risk factors for herpes simplex virus type 2 infection among pregnant women in Israel

BACKGROUND

Although usually a nuisance to the adult patient, herpes simplex virus type 2 (HSV-2) infection can have devastating consequences on the infected newborn. It is thus important to document the prevalence and risk factors of this infection among pregnant women in a defined population. The availability of the new type-specific assays that provide accurate serologic results prompted us to study the seroprevalence of HSV-2 infection among pregnant women in Israel.

STUDY DESIGN

In a cross-sectional descriptive study, 512 pregnant women were tested. The study population included Israeli-born Jewish and Arab women, and new immigrants from the former Soviet Union. A competition-based enzyme-linked immunosorbent assay (ELISA) was used to detect type-specific HSV-1 and HSV-2 antibodies. Univariate and multivariate analyses were performed to identify risk factors for HSV-2 seropositivity.

RESULTS

The prevalence of HSV-2 infection was 13.3% (95% confidence interval, 10.5-16.5%) and that of HSV-1 was 94.9%. History of genital or labial herpes was reported by 1.3% and 26.8% of the participants, respectively. The HSV-2 infection rate was 3-fold higher among immigrants from the former Soviet Union (27.5%) than among Israeli-born Jewish and Arab women (9%). The only risk factor independently associated with HSV-2 seropositivity was multiple lifetime sexual partners.

CONCLUSION

We have documented a relatively low seroprevalence of HSV-2 infection in a demographically mixed group of pregnant women in Israel. The role of high-risk sexual behavior in the spread of the infection has been reconfirmed.

Herpes simplex virus type 2 and heterosexual spread of human immunodeficiency virus infection in developing countries: hypotheses and research priorities

Herpes simplex virus type 2 (HSV-2) infection is almost always sexually transmitted, and causes genital ulceration. Significant progress in our understanding of HSV infection has occurred over the last decade, in part related to the development of accurate and sensitive laboratory tests to study HSV-2. The application of PCR and type-specific serology to individual cases and in population-based studies has enabled the identification of a potentially important role for HSV-2 infection as a cofactor in the sexual transmission of HIV. This is a particular issue in developing countries. This review describes the epidemiology of HSV-2 infection in the HIV era, the hypotheses regarding HSV-HIV interactions, and research priorities for the developing world.

Congenital infections

Despite major medical advances, such as the introduction of the rubella vaccine and prolonged postnatal therapy of infants with congenital toxoplasmosis, intrauterine infections remain important causes of deafness, vision loss, and behavioral or neurologic disorders among children worldwide. This article describes the common pathogens causing intrauterine infections and summarizes the current status of diagnosis, treatment, and prevention.

Viral diseases of the skin: diagnosis and antiviral treatment

Viral diseases in children can present with characteristic mucocutaneous manifestations. This article focuses, from a practical clinical point of view, on the laboratory and clinical diagnoses, and treatment of pediatric dermatological diseases that have specific antiviral therapies: herpes virus infections (including varicella), papillomavirus infections and molluscum contagiosum. Special issues, such as viral infections in pregnancy, therapy of viral infections in immunosuppressed children, as well as special problems associated with the epidemiology of genital herpes and papillomavirus infections in adolescents are discussed. The antivirals discussed in detail include: aciclovir, valaciclovir, famciclovir, penciclovir, cidofovir, foscarnet and the immune response modulator, imiquimod. Since these antiviral drugs generally have not been evaluated in children, caution should be exercised with their usage.

Can behavior change explain increases in the proportion of genital ulcers attributable to herpes in sub-Saharan Africa? A simulation modeling study

BACKGROUND

The proportion of cases of genital ulcer disease attributable to herpes simplex virus type 2 (HSV-2) appears to be increasing in sub-Saharan Africa.

GOAL

To assess the contributions of HIV disease and behavioral response to the HIV epidemic to the increasing proportion of genital ulcer disease (GUD) attributable to HSV-2 in sub-Saharan Africa.

STUDY DESIGN

Simulations of the transmission dynamics of ulcerative sexually transmitted diseases (STDs) and HIV with use of the model STDSIM.

RESULTS

In simulations, 28% of GUD was caused by HSV-2 before a severe HIV epidemic. If HIV disease was assumed to double the duration and frequency of HSV-2 recurrences, this proportion rose to 35% by year 2000. If stronger effects of HIV were assumed, this proportion rose further, but because of increased HSV-2 transmission this would shift the peak in HSV-2 seroprevalence to an unrealistically young age. A simulated 25% reduction in partner-change rates increased the proportion of GUD caused by HSV-2 to 56%, following relatively large decreases in chancroid and syphilis.

CONCLUSION

Behavioral change may make an important contribution to relative increases in genital herpes.

Identification of herpes simplex virus genital infection: comparison of a multiplex PCR assay and traditional viral isolation techniques

Genital herpes simplex virus (HSV) is of major public health importance, as indicated by the marked increase in the prevalence of genital herpes over the past two decades. Viral culture has traditionally been regarded as the gold standard for diagnosis. In this study, we compared viral culture and the amplification of HSV DNA by the polymerase chain reaction (PCR) with respect to sensitivity, cost, clinical utility, and turnaround time. Patient sample swabs from 100 individuals were inoculated onto MRC-5 cells for isolation. Positive results were confirmed via a direct fluorescent antibody technique, and serotyping, when requested, was performed using HSV-1 and -2-type-specific sera. PCR techniques employed an extraction step of the same initial swab specimen, followed by PCR amplification, using a multiplex assay for HSV-1, 2 DNA. HSV-positive results were found in 32/100 samples via culture and in 36/100 samples via PCR. PCR-positive results yielded 16 (44%) patients infected with HSV-1 and 20 (56%) patients infected with HSV-2. Turnaround time for viral culture averaged 108 hours for positive results and 154 hours for negative results; PCR turnaround time averaged 24--48 hours. Laboratory cost using viral culture was $3.22 for a negative result and $6.49 for a positive result (including direct fluorescent antibody). Serotyping added $10.88 to each culture-positive test. Although laboratory costs for PCR were higher at $8.20/sample, reimbursement levels were also higher. We propose a multiplex PCR assay for diagnosis of HSV-1 and HSV-2 from patient swabs for use in a routine clinical laboratory setting. This assay offers increased sensitivity, typing, and improved turnaround time when compared with traditional viral culture techniques. Although it appears that PCR testing in a routine clinical laboratory setting is cost prohibitive compared with the case of nonserotyped viral culture, it may be very useful when clinical utility warrants distinguishing between HSV 1 and 2 and may be cost effective when reimbursement issues are examined.

Herpes simplex virus type 2 seroepidemiology in Spain: prevalence and seroconversion rate among sexually transmitted disease clinic attendees

BACKGROUND

Only limited data on the seroprevalence of herpes simplex virus type 2 (HSV-2) are available from European countries. Until recently, serologic tests for HSV-2 serotyping have been hampered by cross-reactivity to type-common antigens. The present study aims at providing data on the prevalence of HSV-2 infection in a group of STD clinic attendees using a reliable type-specific immunoassay.

GOAL

To evaluate the seroprevalence of HSV-2 and the accumulated incidence of clinical genital herpes infection in a sample of Spanish sexually transmitted disease (STD) clinic attendees.

STUDY DESIGN

The study consisted of two parts. First, a cross-sectional study of HSV-2 seroprevalence was conducted in patients with STDs. Second, a prospective cohort study was undertaken to evaluate the accumulated incidence of infection by HSV-2 and of clinical episodes of genital herpes in HSV-2-negative patients included in the first study during a follow-up period of 6 to 18 months.

RESULTS

Of the 374 patients (129 men, 245 women) studied, 25% were seropositive for HSV-2 (12% of men, 30% of women). Antibodies to HSV-2 were related to female gender (odds ratio, 2.7; P < 0.001) and to the number of sexual partners (odds ratio, 4.1; P < 0.001). Fifty-two percent of patients (145 of 281 patients) who were initially seronegative returned to the clinic for a second serologic testing, of whom 1% (2 of 145 patients) had seroconverted. None of the patients developed genital herpes during the follow-up period.

CONCLUSION

The relatively high seroprevalence (25%) and the low rate (4%) of HSV-2 previously reported in the general population in Spain suggest that the virus circulation may be restricted to certain risk groups. Therefore, future healthcare measures may target specific groups, such as patients with STDs.

Herpes simplex virus DNA in amniotic fluid without neonatal infection

Twenty-one pregnant women were studied to determine the distribution of herpes simplex virus (HSV): 10 had symptomatic genital herpes, including 1 with primary cervical HSV infection, and 11 had asymptomatic genital herpes. Samples from vesicles, the cervix, and amniotic fluid (AF) were analyzed with 2 separate polymerase chain reaction (PCR) tests and with viral culture. For newborns, clinical examinations and pharyngeal HSV cultures were performed, and cord blood IgM antibodies to HSV were measured. HSV DNA was present in the AF of 3 women with symptomatic HSV infection, but all cultures were negative. HSV was detected more often with PCR than with culture, in both vesicle and cervical samples. For the asymptomatic group, all AF samples were negative, whereas 4 cervical samples were positive by PCR (none were positive by culture). All isolates were HSV type 2. All infants were healthy, and none had cord blood IgM antibodies to HSV, including those with PCR-positive AF.

Cellulose acetate phthalate (CAP): an 'inactive' pharmaceutical excipient with antiviral activity in the mouse model of genital herpesvirus infection

The spread of sexually transmitted infections caused by herpes simplex virus type 2 (HSV-2) has continued unabated. At least 20% of the United States population has been infected with HSV-2 and there is a high probability of further virus transmission by asymptomatic carriers. Given the absence of effective vaccines, this indicates the need to develop prophylactic measures such as topical microbicides that have antiviral activity. Recent studies indicate that cellulose acetate phthalate (CAP), an inactive pharmaceutical excipient commonly used in the production of enteric tablets and capsules, is a broad specificity microbicide against diverse sexually transmitted pathogens. When appropriately formulated in micronized form, it inactivates various viruses, including HSV-2, in vitro. Here we show that CAP inhibits HSV-2 infection in the mouse model of genital HSV-2 infection. Pretreatment with micronized CAP formulated in a glycerol-based cream with colloidal silicone dioxide significantly reduced the proportion of HSV-2-infected mice (10% virus shedding, 0-5% lesion development and 0% fatality for CAP as compared to 84% shedding, 63% lesion development and 63% fatality in saline-treated mice). These differences were significant (P < or = 0.0002 by the test of equality of two proportions). Virus titres in the minority of mice that developed infection were similar to those in untreated mice. HSV-2 infection was not inhibited by treatment with CAP formulated with other inactive ingredients (for example povidone plus crosprovidone) instead of silicone dioxide, presumably reflecting CAP complexation/inactivation. These data suggest that properly formulated, CAP may be an efficacious agent for preventing vaginal transmission of genital herpesvirus infections.

Adolescents and sexually transmitted diseases

Pediatricians with busy practices have limited time to spend with each patient. But because much of adolescent morbidity and mortality is related to behavioral issues, time and energy are crucial to providing effective counseling and care to adolescents. Many barriers to provision of services to adolescents exist, including time, space, décor, office hours, office fees, and support personnel. Despite these barriers to care of adolescents and, in particular, sexually active adolescents, the need for pediatricians to provide these services is clear. Services include anticipatory guidance and counseling about developing sexuality and sexual behaviors, as well as management of health consequences of sexual behavior. Primary care providers have an opportunity to assist adolescents to develop mature and healthy sexual relationships. This necessitates a full understanding of each patient's unique situation, listening to adolescents' concerns, and honest and straightforward discussion of sensitive information. Beginning the process of discussion of sexuality and relationships early in the pediatric years may help adolescents and their parents to develop healthy sexual attitudes and behaviors.

Genital herpes, "the new paradigm"

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Herpes simplex virus

Herpes simplex virus (HSV) infection is prevalent worldwide. Herpes labialis, caused predominantly by HSV-1, and herpes vulvovaginitis, caused predominantly by HSV-2, may result in significant morbidity and mortality for infected neonates exposed during delivery. The diagnosis of HSV infection is made by serological testing, viral culture, or polymerase chain reaction. Women with primary herpes vulvovaginitis exhibit a painful vesicular rash which is self-limited but may be followed by multiple recurrences. Women at greatest risk to transmit HSV to their neonates are those who experience their first episode of HSV during the latter stage of pregnancy. If infected, their neonates may have localized skin, eye and mucosal lesions, invasive central nervous system infection, or disseminated disease. Because of the potentially devastating outcome for a baby infected with HSV, pregnant women with active HSV lesions at delivery should be offered a cesarean section. Still, many neonates who are infected with HSV are born to women with asymptomatic HSV shedding. Therefore, prevention of HSV during pregnancy is exceedingly important.

Sexually transmitted diseases update

STDs have worldwide distribution and result in immense social and economic cost. Knowledge of the clinical signs, symptoms, current clinical tests, and treatment recommendations is important for all health care professionals.

Comparison of virus culture and the polymerase chain reaction for diagnosis of mucocutaneous herpes simplex virus infection

BACKGROUND AND OBJECTIVES

The diagnosis of mucocutaneous herpes simplex virus (HSV) is hampered by suboptimal sensitivity of virus culture and atypical clinical morphology.

GOALS

To compare the diagnostic usefulness of the polymerase chain reaction (PCR) and virus culture.

STUDY DESIGN

Consecutive samples from 246 patients at an urban sexually transmitted diseases clinic were tested for HSV by both PCR and virus culture.

RESULTS

Only 59% of HSV-positive samples were correctly diagnosed by the clinician; 11% had an atypical appearance. HSV-positive lesions were more often vesiculoulcerative or crusted than HSV-negative lesions, and of shorter median duration. Thirty-one samples were PCR positive and virus culture negative; these were often from crusted or older lesions. However, PCR was negative in 27 instances in which HSV was diagnosed clinically, of which 2 were vesicular and 15 ulcerative.

CONCLUSIONS

HSV PCR is more rapid and sensitive than virus culture for diagnosis of mucocutaneous lesions. The data suggesting that PCR may be suboptimally sensitive need to be further investigated.

Perinatal herpesvirus infections. Herpes simplex, varicella, and cytomegalovirus

The herpesvirus infections (herpes simplex, varicella, and cytomegalovirus) create many dilemmas when encountered during pregnancy. This article reviews the epidemiologic diagnosis and management of perinatal herpesvirus infections. A review of possible future trends is also included.

Psychoeducational groups for young adults with genital herpes: training group facilitators

Genital herpes is one of the sexually transmitted diseases that can have serious long-term psychological and physical consequences for young adults who contract the disease. Because of the chronic, reoccurring nature of genital herpes, these young adults need education about the transmission of the herpes virus and about safer sexual practices in addition to emotional support. Psychoeducational groups have shown to be a nursing intervention that can effectively provide this education and support. Yet community health nurses may not be knowledgeable about or comfortable with using this type of intervention. In this article we explain the process of training community health nurses to be nurse facilitators who conduct psychoeducational groups for young adults with genital herpes. The training consisted of a 1-day workshop and three follow-up sessions. The content and format of this training workshop and the follow-up sessions is presented in addition to recommendations to enhance this nursing intervention.