Congenital viral infections in England over five decades: a population-based observational study

Neonatal varicella

Primary infection with varicella zoster virus (VZV) in the final 3 weeks of pregnancy may cause transplacental infection and neonatal varicella. Infants are most at risk of severe disease if born from 5 days before to 2 days after onset of the maternal varicella rash. Administration of post-exposure prophylaxis with varicella zoster immunoglobulin and treatment of varicella with aciclovir for those at highest risk of progression to severe disease is advised. Universal vaccination against VZV significantly reduces the incidence of neonatal varicella.

Long-term follow-up of a series of 24 congenital CMV-infected babies with false negative amniocentesis

BACKGROUND

Congenital CMV infection is the most common congenital infection worldwide and a major cause of neurological impairment and sensorineural hearing loss. Fetal CMV infection is confirmed by a positive PCR test in the amniotic fluid (amniocentesis performed after 18-20 weeks of gestation and at least 8 weeks after maternal infection). However, despite a negative antenatal CMV PCR result, some newborns can be tested positive at birth. Although not widely documented, the prognosis for these babies appears to be good.

OBJECTIVES

The aim of this study is to evaluate the long-term prognosis of fetuses with a false-negative AFS for cCMV, with a minimum follow-up period of 6 years.

STUDY DESIGN

This is a retrospective cohort study of false-negative amniocentesis reported at the CUB-Hôpital Erasme and Hôpital CHIREC in Brussels between 1985 and 2017.

RESULTS

Of the 712 negative CMV PCR amniocenteses, 24 had a CMV PCR positive at birth. The false negative rate was 8.6 %. Of the 24 cases, 9 primary maternal infections occurred in the first trimester, 14 in the second trimester and 1 in the third trimester. Among the 24 children, 2 had symptoms at birth (hyperbilirubinemia and left paraventricular cysts), but all had normal follow-up (minimum 4 years, mean 16,6 years).

DISCUSSION

Only 2 cases could be explained by early amniocentesis. Among the others, the false-negative results could be attributed to a low viral load, a delayed infection or, less likely, to a sample degradation.

CONCLUSION

Despite the false-negative results, all 24 children had a normal long-term follow-up.

Predictors of the Outcome at 2 Years in Neonates With Congenital Cytomegalovirus Infection

BACKGROUND

Approximately 20% of neonates with congenital cytomegalovirus (cCMV) develop long-term sequelae. The ability to accurately predict long-term outcomes as early as the neonatal period would help to provide for appropriate parental counseling and treatment indications. With this study, we aimed to identify neonatal predictive markers of cCMV long-term outcomes.

METHODS

As this study's subjects, we chose neonates diagnosed with cCMV in 13 hospitals throughout France recruited from 2013 to 2017 and evaluated for at least 2 years with thorough clinical, audiology, and imaging evaluations and psychomotor development tests.

RESULTS

A total of 253 neonates were included, and 3 were later excluded because of the identification of a genetic disorder. A total of 227 were followed up for 2 years: 187/227 (82%) and 34/227 (15%) were infected after a maternal primary or nonprimary infection, respectively, 91/227 (40%) were symptomatic at birth, and 44/227 (19%) had cCMV sequelae. Maternal primary infection in the first trimester was the strongest prognosis factor (odds ratio = 38.34 [95% confidence interval, 5.02-293], P < .001). A predictive model of no risk of sequelae at 2 years of age according to normal hearing loss at birth, normal cerebral ultrasound, and normal platelet count had 98% specificity, 69% sensitivity, and 0.89 area under the curve (95% confidence interval, 0.83-0.96).

CONCLUSIONS

In the studied population, children with normal hearing at birth, normal platelet count at birth, and a normal cranial ultrasound had no risk of neurologic sequelae and a low risk of delayed unilateral sensorineural hearing loss. The use of this model based on readily available neonatal markers should help clinicians establish a personalized care pathway for each cCMV neonate.

Herpes simplex virus infection among neonates suspected of invasive bacterial infection: a population-based cohort study

OBJECTIVE

To estimate the incidence of neonatal herpes simplex virus (HSV) infection and the number of neonates with suspected invasive bacterial infection (IBI) needed to treat (NNT) with acyclovir to ensure prompt treatment of invasive HSV infections.

DESIGN

A nationwide population-based cohort study.

SETTING

All neonatal and paediatric emergency departments in Denmark from 1 January 2010 to 31 December 2019.

PATIENTS

Neonates aged 0-28 days with HSV infection.

MAIN OUTCOME MEASURES

The main outcome measures were incidence and NNT. The NNT was calculated based on neonates with invasive HSV infection whose onset symptoms resembled IBI and the estimated number of Danish neonates who received antibiotics for suspected IBI.

RESULTS

Fifty-four neonates with HSV infection were identified, that is, an incidence of 9 per 100 000 live births. Twenty presented with symptoms resembling IBI, all within the first 14 days of life. Of 18 (78%) neonates, 14 had elevated C reactive protein, 14 of 19 (74%) had elevated alanine aminotransferase and 11 of 17 (65%) had thrombocytopaenia. The estimated NNTs with empiric acyclovir at postnatal ages 0-3, 4-7 and 8-14 days were 1139 (95% CI 523 to 3103), 168 (95% CI 101 to 726) and 117 (95% CI 48 to 198), respectively.

CONCLUSIONS

The incidence of neonatal HSV infection was higher than in previous decades; however, the estimated NNT with empiric acyclovir was high. Therefore, we propose not to treat all neonates suspected of IBI with empiric acyclovir, as current European guidelines suggest. However, HSV should be considered in neonates with signs of infection, especially after the third postnatal day and in neonates with high alanine aminotransferases and thrombocytopaenia.

Discrepancies in Management of Congenital Cytomegalovirus in Preterm Infants: An International Survey

We performed an international survey regarding management of infants with congenital cytomegalovirus (cCMV) born at less than 32 weeks gestation or with birth weight under 1500 g. Replies from 51 level 3 neonatal intensive care units across 13 countries demonstrated striking discrepancies in screening practices, testing for cCMV, further investigations of confirmed cases, indications for initiation, and duration of treatment.

A systematic literature review of the economic and healthcare resource burden of cytomegalovirus

OBJECTIVE

Cytomegalovirus (CMV) can infect individuals at any age, including infants, who may contract it from infected mothers (congenital CMV [cCMV]). Whereas CMV infection is typically asymptomatic or causes mild illness in healthy individuals, infection can result in severe outcomes in immunocompromised individuals and in infants with cCMV. This systematic review aims to characterize the economic impact of CMV and cCMV infections.

METHODS

Medline, Embase, and LILACS databases were searched for publications reporting the economic impact of cCMV and CMV infections across all age groups. Manuscripts published between 2010 and 2020 from Australia, Latin America, Canada, Europe, Israel, Japan, the United States, and global (international, worldwide) studies were included; congress materials were excluded. Outcomes of interest included cCMV- and CMV-attributable direct costs/charges, resource utilization, and indirect/societal costs.

RESULTS

Of 751 records identified, 518 were excluded based on duplication, population, outcome, study design, or country. Overall, 55 articles were eligible for full-text review; 25 were further excluded due to population, outcome, study design, or congress abstract. Two publications were additionally identified, resulting in economic impact data compiled from 32 publications. Of these, 24 publications reported cost studies of cCMV or CMV, including evaluation of direct costs/charges, healthcare resource utilization, and indirect/societal costs, and 7 publications reported economic evaluations of interventions. The populations, methods and outcomes used across these studies varied widely.

CONCLUSIONS

CMV and cCMV infections impose a considerable economic impact on different countries, populations, and outcomes. There are substantial evidence gaps where further research is warranted.

Epidemiology of herpes simplex virus type 2 in Europe: systematic review, meta-analyses, and meta-regressions

Background

Herpes simplex virus type 2 (HSV-2) infection is a globally prevalent, life-long, sexually transmitted infection. This study characterized HSV-2 seroprevalence in Europe for various at-risk populations and proportions of HSV-2 detection in genital ulcer disease (GUD) and in genital herpes. Data on neonatal herpes and HSV-2's contribution to HIV transmission were also reviewed.

Methods

Cochrane and PRISMA guidelines were followed to systematically review, synthesize, and report HSV-2 related findings. The search was conducted in PubMed and Embase databases up to February 20, 2022. Any publication reporting data on the outcome measures was included. Meta-analyses and meta-regressions were conducted.

Findings

211 relevant reports were identified, including 12 overall incidence measures, 294 overall (813 stratified by factors such as age and sex) seroprevalence measures, 13 overall (15 stratified by sex) proportions of HSV-2 detection in clinically diagnosed GUD, and 70 overall (183 stratified by factors such as age and sex) proportions of HSV-2 detection in laboratory-confirmed genital herpes. Pooled mean seroprevalence was 12.4% (95% CI: 11.5-13.3%) among general populations, 27.8% (95% CI: 17.5-39.4%) among men who have sex with men, 46.0% (95% CI: 40.1-51.8%) among people living with HIV and people in HIV discordant couples, and 63.2% (95% CI: 55.5-70.6%) among female sex workers. Most measures showed heterogeneity in HSV-2 seroprevalence. The pooled mean seroprevalence among general populations increased with age and was 0.65-fold (95% CI: 0.58-0.74) lower in men than women. Seroprevalence decreased by 1% per calendar year. Pooled mean proportions of HSV-2 detection in GUD and in genital herpes were 22.0% (95% CI: 15.3-29.6%) and 66.0% (95% CI: 62.9-69.1%), respectively. HSV-2 detection in genital herpes cases was 1.21-fold (95% CI: 1.10-1.32) higher in men compared to women and decreased by 1% per calendar year. Incidence of neonatal herpes indicated an increasing trend.

Interpretation

Although seroprevalence is declining, a significant proportion of Europe's population is infected with HSV-2. HSV-2 accounts for approximately one-fifth of GUD cases and two-thirds of genital herpes cases. Findings support the need to invest in HSV-2 vaccine development, and sexual and reproductive health services.

Funding

Qatar National Research Fund [NPRP 9-040-3-008] and pilot funding from the Biomedical Research Program at Weill Cornell Medicine in Qatar supported this study.

The epidemiology and disease burden of congenital TORCH infections among hospitalized children in China: A national cross-sectional study

BACKGROUND

Congenital TORCH (Toxoplasma gondii (T. gondii), rubella virus (RV), cytomegalovirus (CMV), and herpes simplex virus (HSV)) infections are associated with a variety of adverse prenatal and neonatal events, including miscarriage, malformations and developmental abnormalities, and they remain an issue that cannot be neglected in China. However, the current research focuses more on the general screening of TORCH in women of childbearing age, and the medical information of children hospitalized due to congenital and perinatal TORCH infections has not been described in detail. This study summarized and analyzed the epidemiological characteristics, clinical manifestations, length of stay (LOS), and the disease burden of hospitalized children diagnosed with congenital TORCH infections in 27 children's hospitals in China.

METHODOLOGY

Based on the face sheet of discharge medical records (FSMRs) of hospitalized children in 27 tertiary children's hospitals collected in the Futang Research Center of Pediatric Development and aggregated into FUTang Update medical REcords (FUTURE), we summarized and analyzed the epidemiological characteristics, clinical manifestations, LOS, the disease burden (in US dollars, USD) and potential risk factors for hospitalized children diagnosed with congenital toxoplasmosis, congenital rubella syndrome, congenital cytomegalovirus infection, and congenital HSV in 27 children's hospitals in China from 2015 to 2020.

RESULTS

One hundred seventy-three patients aged 0-<1 year were hospitalized for congenital TORCH infections. Among infections with TORCH, hospitalization with congenital toxoplasmosis was the least common, with only five cases were reported (2.89%), while the LOS was the highest. The proportion of patients with congenital rubella syndrome (CRS) was 15.61%, and 86% of children hospitalized with CRS had cardiovascular malformations, and the economic burden was the highest. Congenital CMV infection cases accounted for the largest proportion (76.30%). Overall, 5.20% of patients were infected with HSV, and the expense of hospitalization for congenital HSV infection was relatively low.

CONCLUSION

In the present study, the hospitalization proportion due to congenital TORCH infection was extremely low (17.56 per 100,000 neonates), indicating that China's congenital TORCH infection prevention and control policies remain effective. The lowest proportion of patients was hospitalized with congenital toxoplasmosis, while the LOS was the longest. The economic burden of CRS was heavy, and infants are recommended be vaccinated against RV in a timely manner. Congenital CMV infections accounted for the largest proportion of patients, suggesting that the disease burden of congenital CMV infection cannot be ignored, and the prevention of congenital CMV infection during pregnancy is still an important issue that needs to pay attention. The expense of hospitalization for congenital HSV infection was relatively low, while the disease burden increases significantly when patients develop complications. These data illustrate the importance of improving screening for congenital TORCH infections in the early diagnosis and treatment of neonatal patients.

Incidence of congenital and postnatal cytomegalovirus infection during the first year of life in Mexican preterm infants

Cytomegalovirus infection occurs commonly during infancy. Postnatal infection in term infants is usually asymptomatic; however, infection in preterm infants can be associated with clinical manifestations during the neonatal period. Nevertheless, few studies to assess the frequency of cytomegalovirus infection in preterm infants have been performed outside of high-income countries. We analyzed the incidence of congenital and postnatal cytomegalovirus infection in a cohort of preterm infants. Cytomegalovirus infection was detected during the neonatal period in four of 178 infants; in three of them the virus was detected during the first three weeks of life and, therefore, congenital infection was confirmed (1.7% incidence). Postnatal infection was detected in 44 (36.4%) of 121 infants who were assessed after discharge from the neonatal intensive care unit. Cytomegalovirus infection was significantly associated to duration of breast feeding. In addition, we characterized cytomegalovirus strains detected in infants together with sequences available at GenBank, based on sequences of the UL18 gene. Cytomegalovirus UL18-sequences clustered in five distinct clades (A-E), and sequences obtained from infants in our study were distributed in four of the five clades; 44.4% of these sequences were included in clade E. Breastfeeding duration was shorter in average (5.6 months) in infants with sequences in clade E compared to infants with sequences in the other three clades (8.2 months; P=0.07). In conclusion, we provide information regarding the high incidence of cytomegalovirus infection in preterm infants. Further studies are warranted to assess if cytomegalovirus strain characteristics are associated with the risk of infection acquisition during infancy. This article is protected by copyright. All rights reserved.

Diagnostic analysis of baseline brain MRI features in infants with congenital cytomegalovirus infection: a simplified scoring system

AIM

To characterise the magnetic resonance imaging (MRI) features of infants with congenital cytomegalovirus (CMV) and categorise those into a simplified MRI scoring system.

MATERIALS AND METHODS

Three neuroradiologists reviewed the examinations of 71 infants retrospectively and scored for the presence of a white matter signal abnormality and structural lesion and each MRI was given a score of 0, 1, 2, or 3 for normal, structural abnormality alone, white matter abnormality alone, white matter abnormality plus structural lesion, respectively. Imaging features were outlines according to symptomatology. Chi-square and Spearman's rho were used to test relationships between MRI features and viral loads and MRI score/symptomatic disease respectively. Cohen's Kappa coefficient was used to assess interobserver agreement.

RESULTS

Of the 49 abnormal studies, 40% (n=20) were seen in asymptomatic infants. The commonest finding was white matter signal abnormality, followed by cyst formation and polymicrogyria (86%, n=42; 71%, n=35; and 33%, n=16, respectively). Cysts were significantly positively correlated with white matter abnormalities and polymicrogyria. On the MRI score, 31%, 10%, 15%, and 44% obtained a score of 0, 1, 2, and 3, respectively; the MRI score was positively correlated with log-transformed viral loads. Interobserver agreement for the presence of white matter signal abnormality, cyst formation, malformations of cortical development (MCD), and global MRI score was excellent (k = 0.82, 0.94, 0.96, and 0.86, respectively).

CONCLUSION

Baseline MRI provides information valuable for treatment decisions, especially in "asymptomatic" infants. The simplified scoring system is easier to use, incorporating solely the imaging findings that are anticipated to have an effect on clinical outcome.

Identification of congenital CMV cases in administrative databases and implications for monitoring prevalence, healthcare utilization, and costs

OBJECTIVE

To critically review researchers' use of diagnosis codes to identify congenital cytomegalovirus (cCMV) infection or disease in healthcare administrative databases. Understanding the limitations of cCMV ascertainment in those databases can inform cCMV surveillance and health services research.

METHODS

We identified published studies that used diagnosis codes for cCMV or CMV in hospital discharge or health insurance claims and encounters records for infants to assess prevalence, use of services, or healthcare costs. We reviewed estimates of prevalence and of charges, costs, or expenditures associated with cCMV diagnosis codes.

RESULTS

Five studies assessed hospitalizations with cCMV diagnosis codes recorded in hospital discharge databases, from the United States (n = 3), Australia (n = 1), and the United Kingdom (n = 1). Six other studies analyzed claims or encounters data from the United States (n = 5) or Japan (n = 1) to identify infants with cCMV codes. Prevalence estimates of recognized cCMV ranged from 0.6 to 3.8 per 10,000 infants. Economic analyses reported a wide range of per-hospitalization or per-infant cost estimates, which lacked standardization or comparability.

CONCLUSIONS

The administrative prevalence of cCMV cases reported in published analyses of administrative data from North America, Western Europe, Japan, and Australia (0.6-3.8 per 10,000 infants) is an order of magnitude lower than the estimates of the true birth prevalence of 3-7 per 1,000 newborns based on universal newborn screening pilot studies conducted in the same regions. Nonetheless, in the absence of systematic surveillance for cCMV, administrative data might be useful for assessing trends in testing and clinical diagnosis. To the extent that cCMV cases recorded in administrative databases are not representative of the full spectrum of cCMV infection or disease, per-child cost estimates generated from those data may not be generalizable. On the other hand, claims data may be useful for estimating patterns of healthcare use and expenditures associated with combinations of diagnoses for cCMV and known complications of cCMV.

Herpes Simplex Virus Infection in Infants: 13 Year Evaluation (2005-2017) of Laboratory Confirmed Cases in Queensland, Australia

BACKGROUND

National neonatal surveillance for herpes simplex virus (HSV) disease suggests that the incidence of HSV disease may be higher in Queensland (QLD) than in other Australian States. We sought to investigate the incidence via a retrospective 13-year evaluation of statewide laboratory data, autopsy data and linked clinical records of infants with laboratory confirmed infection.

METHODS

All positive polymerase chain reaction HSV 1 and 2 results were obtained for infants 0-3 months of age from January 1, 2005 to December 31, 2017. Clinical data were obtained from patient records and parent questionnaires were used to evaluate long-term sequelae.

RESULTS

One hundred seventy-two infants with HSV positive polymerase chain reaction results: 121 (70.3%) with HSV 1. Of 104 (60.5%) infants with signs of HSV disease, 76 (73.1%) were neonates (≤28 days of age) [incidence 9.6 (95% confidence interval, 7.0-11.5) per 100,000 live births] and 28 (26.9%) were young infants (29-90 days of age) [3.6 (95% confidence interval, 2.4-5.4) per 100,000 live births]. The annual incidence of neonatal HSV disease increased significantly in Queensland over the study period (P < 0.01). Of the 76 neonates with HSV disease, 58 (76.3%) presented with the skin, eye, mouth (SEM) disease, 17 (22.4%) with HSV encephalitis and 11 (14.5%) had disseminated disease. Young infants presented with HSV skin, eye, mouth disease (21, 75.0%) or HSV encephalitis (6, 21.4%). Death occurred in 12/104 (11.5%) infants (all neonates) with 10 attributable to HSV disease.

CONCLUSION

The incidence of neonatal HSV disease in QLD is almost 3 times the national reported incidence. Further research is being undertaken to explore reasons for this change and implications for practice.

High Rate of Cytomegalovirus Detection in Cholestatic Preterm Infants

Objectives: To evaluate the prevalence of cytomegalovirus (CMV) infection in preterm infants with cholestasis. Study design: Preterm infants (<37 weeks gestational age) with cholestasis were tested for CMV DNA using Taqman PCR in blood cells from sedimented whole blood, plasma, and urine. Infants were regarded as positive for CMV if any sample was tested positive. Their mothers were tested for CMV serostatus simultaneously. A control group of non-cholestatic preterm infants, and their mothers, were tested at a similar age. Results: A total of 69 preterm infants with a median gestational age of 26 weeks and 5 days were included, 45 cholestatic and 24 non-cholestatic. Of the cholestatic infants, 31/45 (69%) were CMV positive vs. 3/24 (13%) of the non-cholestatic infants (p < 0.001). Cholestatic infants were equally preterm as the non-cholestatic ones, but were more severely ill. After adjusting for the risk factors necrotizing enterocolitis, prolonged parenteral nutrition, and gestational age, being CMV positive remained significantly associated with cholestasis in a multivariable logistic regression model. Characteristics of CMV-positive and -negative cholestatic infants showed differences only for necrotizing enterocolitis, occurring in 55% (17/31) of CMV positive vs. 21% (3/14) of CMV negative (p = 0.054), and mortality. Eight cholestatic CMV-positive infants died (26%) vs. none of the CMV-negative infants (p = 0.044). Conclusions: CMV DNA was detected in two out of three cholestatic preterm infants, by far more often than in the non-cholestatic control group. Cholestasis with simultaneous detection of CMV DNA may be associated with increased mortality.

Acute Perinatal Infection and the Evidenced-Based Risk of Intrauterine Diagnostic Testing: A Structured Review

BACKGROUND

The prevalence of perinatal infection from maternal exposure is increasing. The prevalence of acute maternal infections identifies cytomegalovirus, parvovirus B19, toxoplasmosis, and varicella as the most common organisms and in the order of frequency. Maternal informed consent and understanding is required before intrauterine testing for fetal infectious and possible genetic risk assessment.

METHODS

This structured review of the reproductive published literature focuses on the risks of amniocentesis and cordocentesis diagnostic procedure-related fetal loss rates and fetal vertical transmission (VT) rates from published infected pregnant cohorts.

RESULTS

The total postprocedure fetal loss rate for diagnostic amniocentesis procedures, in limited infectious cohorts, is 1.5% and does not appear to be increased compared to "noninfected" amniocentesis cohorts using an estimated background spontaneous fetal loss rate (no procedure) of 0.65%. The "pooled" unintended fetal loss rate is from small infected population cohorts, but can be used for counseling purposes. Postcordocentesis fetal loss risk, in an infected cohort, is not possible to estimate due to limited data. The "biological spontaneous fetal loss rate" risk with a perinatal infection (positive or negative fetal anomalies) and no diagnostic procedure before 20 weeks of gestation is reviewed. The risk of VT in acute infection cohorts as a result of the intra-amniotic diagnostic procedure is not found to be increased.

CONCLUSION

The unintended "fetal loss" rate after amniocentesis for perinatal infected cohorts is similar to that of noninfected cohorts, but the estimate is based on limited infected cohorts. There was no procedure-based risk of fetal VT in the infected cohorts, but identification of postprocedure maternal bleeding into the amniotic cavity increases the potential risk. Maternal knowledge translation and an informed consent process with risk-benefit maternal/fetal risk counseling are required prior to any diagnostic amniocentesis procedure.