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

Improving knowledge of rare disorders since 1993: the Australian Paediatric Surveillance Unit

The Australian Paediatric Surveillance Unit (APSU), established in 1993 to address the paucity of national data on rare childhood disorders, has become an invaluable research resource. It facilitates prospective, active surveillance for a variety of rare disorders, with monthly reporting by ~1500 paediatricians, who are invited to notify incident cases and provide demographic and clinical data. APSU is highly collaborative (used by >400 individuals/organisations), patient-informed and productive (>300 publications). In 30 years, 72 studies have been initiated on rare infections, and genetic, psychological and neurological disorders, and injuries. Return rates of monthly report cards were >90% for 30 years and paediatricians have provided data for >90% of notified cases. Although there are limitations, including case underascertainment in remote regions, APSU often provides the only available national data. APSU has assisted the government in reporting to the WHO, developing national strategies, informing inquiries and investigating disease outbreaks. APSU data have informed paediatrician education, practice, policy, and service development and delivery. APSU was integral in establishing the International Network of Paediatric Surveillance Units (INoPSU) and supporting development of other units. APSU's expanded remit includes one-off surveys, hospital audits, systematic reviews, studies on the impacts of rare disorders on families, surveillance evaluations, and joint studies with INoPSU members. Paediatricians value the APSU, reporting that APSU data inform their practice. They must be congratulated for an outstanding collective commitment to the APSU, in providing unique data that contribute to our understanding of rare disorders and support optimal, evidence-based care and improved child health outcomes.

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 anxiety coming up to every scan-It destroyed me": A qualitative study of the lived experience of cytomegalovirus infection during pregnancy

BACKGROUND

Emerging evidence supporting the use of valaciclovir to reduce fetal infection after maternal primary cytomegalovirus (CMV) infection has stimulated interest in routine CMV serological screening in pregnancy. It is important to understand the healthcare consumer perspective of a CMV infection during pregnancy to minimize unintended harms of screening.

METHODS

We conducted a qualitative study using semi-structured interviews with Australian women who had a lived experience of CMV infection following serological testing during pregnancy. Participants were recruited via social media and healthcare consumer networks, and purposively selected to capture a range of perinatal outcomes. Interview transcripts were analyzed using inductive content analysis.

RESULTS

Twelve participants were interviewed: 6 had a live birth, 4 had terminations of pregnancy, 1 had a neonatal death and 1 was pregnant at the time of interview. Four major categories emerged from the analysis. Women reported a lack of CMV awareness among themselves, their social networks, and among their health care providers. The participants described their experience as "hard" and "stressful". Uncertainty and variability characterized their clinical decision-making process. The pregnancy and postpartum periods were marked by ongoing anxiety about the long-term impacts of CMV. Women supported screening for CMV, decision making and reproductive choice, but acknowledged that routine testing may not be desired by everyone and may increase stress and terminations of pregnancy. Important coping strategies included obtaining support from partners, family, and other families with lived experience of CMV, as well as having access to knowledgeable and sensitive healthcare professionals.

CONCLUSION

Serological diagnosis of maternal CMV infection during pregnancy can have severe and prolonged psychological impacts on parents, regardless of the pregnancy outcome. Improving healthcare professionals' knowledge and public awareness are essential before widespread serological screening can be responsibly introduced. Healthcare administrators that are considering implementing a prenatal screening program for secondary prevention of fetal CMV infection should pay attention to consumer perspectives to minimize unintended harms to women and their families.

Knowledge of cytomegalovirus and available prevention strategies in pregnancy: a cross-sectional study in Portugal

OBJECTIVE

Maternal and fetal congenital infection by cytomegalovirus (CMV) during pregnancy is the leading infectious cause of neurologic impairment and hearing loss. Efforts at limiting CMV exposure are based on hygienic measures. This study assessed the relationship between CMV knowledge and pregnant women's time perspective as per the Zimbardo Time Perspective Inventory (ZTPI) scale.

METHODS

We conducted a prospective descriptive study at a secondary-care Portuguese hospital between October to November 2021. All consecutive pregnant women in antenatal third-trimester appointments were included. The questionnaire included: sociodemographic data, knowledge about CMV, and the ZTPI scale, validated to our population. The number of correct answers in the knowledge section of the questionnaire was tallied to determine the individual knowledge score (KS). We investigated patients subjective perceptions of CMV infection during pregnancy, CMV knowledge, and CMV serologic status of pregnant women.

RESULTS

We enrolled 96 pregnant women. 81.0% had not previously heard about CMV and only 8.8% had heard about it through their obstetrician. No significant association between awareness of CMV and education level was detected. 16.0% of pregnant women declared that they were aware of the hygienic measures for CMV. The CMV serology was performed in 21.3% of those enrolled in the preconception assessment, and 13.8% proved to be immune. From the time perspective, half of the women displayed a future-oriented attitude. Future-oriented women had significantly higher KS. No significant association was found between KS and education level, age, or previous pregnancy. There was a significant association between KS and women that work in health care.

CONCLUSIONS

Most patients had no knowledge of CMV. Being a medical professional and having a future-oriented outlook increases knowledge about CMV. Primary health care and obstetrics doctors may play a crucial role in informing pregnant women of antenatal appointments. The CMV serology coverage is scarce in this sample. This study constitutes a first step toward raising the awareness of the general population about CMV.

Knowledge and attitudes of medical students about clinical aspects of congenital cytomegalovirus infection in newborns: A nationwide cross-sectional study in Greece

Introduction

Cytomegalovirus (CMV) is the most frequent cause of congenital infection worldwide causing severe morbidity in newborns, infants, and children. Despite the clinical importance of congenital CMV (cCMV) infection, studies conducted so far indicate that there is limited awareness in the medical community in the field. The aim of this study was to assess Greek medical students' knowledge on cCMV infection.

Methods

We performed a questionnaire-based nationwide cross-sectional study. A convenience sample of medical students from seven medical schools was enrolled.

Results

Of the 562 respondents, 54,8% considered themselves undereducated on cCMV infection. However, almost half of the participants could correctly recognize some basic principles of cCMV infection including ways of transmission, diagnosis and treatment, while there were aspects of cCMV infection with knowledge deficit. The year of study had a positive impact on the level of knowledge with students of higher years of study being of more sufficient education on the specific topic.

Conclusion

Overall, our study indicates a discrepancy between self-reported awareness and the level of knowledge among medical students in Greece. Further educational opportunities about cCMV should be offered, particularly in areas of the curriculum involving the care of women and children. Establishing medical students' solid background on the disease burden and educating them about preventative strategies for at-risk populations, should be the main pillars of such efforts in order to promote confidence in managing these cases in their future professional careers.

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.

Congenital cytomegalovirus awareness and knowledge among health professionals and pregnant women: an action towards prevention

INTRODUCTION

Cytomegalovirus (CMV), is a major cause of childhood disabilities and consensus recommendations emphasize the importance of hygienic measures to reduce perinatal infection.

OBJECTIVE

To evaluate the level of awareness about CMV among health professionals and pregnant women.

METHODS

We submitted a 20-item online survey regarding CMV perinatal infection to all obstetricians and midwives in Catalonia (Spain) and a 7-item lay-version of the questionnaire to 700 pregnant women. Levels of knowledge were compared among groups.

RESULTS

Of the 1449 health professionals approached, 338 surveys were answered. 72% of professionals considered CMV a relevant problem. 47% of obstetricians and 28% of midwives (p=<0.001) routinely informed pregnant women, and less than half knew the risk of fetal transmission. We observed significant differences in knowledge between obstetricians and midwives concerning the risks of recurrent infections, risk of transmission, and risk of severe infection (60.7% vs 45.6%, p=0.006 and 50.6% vs 22.5% p=<0.001); and regarding maternal and neonatal symptoms, and newborn sequelae (23% vs. 8.8% p=<0.001). Of the 700 women approached, we obtained a response rate of 72%. Only 23% had previously heard about CMV; 22% identified transmission routes, and 15% preventive measures. Compared to women without risk factors for CMV infection women at greater risk had heard more about CMV [mothers of children <3 years: 36% vs. 20% p< 0.001; occupational exposure: 43% vs. 20% p=<0.001] and had received more information (mothers of children <3 years: 18% vs. 9.5% p=<0.001; occupational exposure: 23% vs. 9.3% p=0.001).

CONCLUSIONS

Health care professionals have limited knowledge about CMV and may fail to enforce preventive measures. While pregnant women have limited awareness about CMV infection, they recognize the need for information. Health campaigns should be promoted to enhance awareness about this perinatal infection.

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.

Experiences of pregnant women and healthcare professionals of participating in a digital antenatal CMV education intervention

Objective

The study aimed to explore the perspectives of participating pregnant women and Health Care Professionals (HCPs) towards receiving and providing cytomegalovirus (CMV) education so that barriers and facilitators towards incorporating CMV in routine antenatal care could be better understood.

Design

This process evaluation phase employed a qualitative design using individual, semi-structured, face-to-face interviews.

Setting

Recruitment and interviews took place within a large teaching hospital from an ethnically diverse area of South-west London

Participants

The study sample included 20 participants: 15 pregnant women, and five HCPs. All participants were involved in a single centre randomized controlled trial of a digital CMV educational intervention in pregnancy.

Findings

Pregnant participants expressed a strong desire to receive information about CMV as part of routine antenatal care. Although HCPs were accepting of the need for CMV education, it was evident that they felt unequipped to provide this; reasons included lack of time, uncertainty about clinical pathways and concern about the potential emotive impact of CMV education. Pregnant women suggested that expressing behaviour changes as risk reduction rather than prevention, made the behaviours feel more achievable and realistic. The support of partners was considered a key factor in the successful adoption of behavioural changes by pregnant women.

Key conclusions and implications for practice

There is an onus on HCPs to consider how CMV can be included as part of antenatal education, with messaging framed as risk reducing rather than prevention.

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.

Is it time to adopt routine cytomegalovirus screening in pregnancy? No!

Congenital cytomegalovirus is caused by maternal primary or nonprimary infection during pregnancy and is a major preventable cause of neurodisability. The proposed strategies to reduce congenital cytomegalovirus include primary prevention with maternal hygiene measures and secondary prevention by serologic screening for detecting maternal primary infection. A recent randomized trial found that high-dose valaciclovir treatment resulted in a significant reduction in fetal infection after first-trimester maternal primary infection, leading to calls to start routine serologic screening in pregnancy. Previously, observational studies have found a reduction in fetal infection with after maternal primary cytomegalovirus infection when hyperimmune globulin is administered twice weekly during the first trimester of pregnancy; however, this has not been replicated in randomized trials that have used different regimens. Furthermore, some evidence from a single intervention trial and observational studies do not provide us with the necessary data required for rolling out an appropriate screening program. All screening tests may be associated with harm; in the case of congenital cytomegalovirus, there is the well-recognized potential for increasing terminations of pregnancy without diagnostic confirmation of fetal infection or sequelae. Although valaciclovir and hyperimmune globulin treatments may significantly reduce fetal infection rates, they do not prevent severe cytomegalovirus-related fetal brain damage in all pregnancies. Therefore, it is not clear that the offer of a prenatal intervention will provide sufficient reassurance to screen-positive women. In addition, the effectiveness of a prenatal screening and treatment strategy is predicated on a high rate of maternal primary infection, which is limited to regions with low cytomegalovirus seroprevalence, such as Western Europe. In some countries, such as the United States, Finland, and Brazil, nonprimary maternal infections are responsible for most congenital cytomegalovirus health burdens, limiting the potential impact of pregnancy screening. In this invited clinical perspective, we reviewed the evidence and outlined the steps needed to be taken before determining whether the benefits of routine screening for cytomegalovirus in pregnancy outweigh the harms. Until we have the necessary evidence, we should follow the current advice of multiple national health authorities and focus on promoting primary prevention through maternal hygiene precautions.

An observational study to assess Italian obstetrics providers' knowledge about preventive practices and diagnosis of congenital cytomegalovirus

OBJECTIVES

Congenital cytomegalovirus (cCMV) infection can be easily prevented by hygienic measures. Up to date the majority of the studies in literature highlighted a reduction in cCMV antenatal counseling and its prevention. Our purpose was to evaluate obstetrics providers' knowledge about cCMV infection, management and the behavioral practices to avoid it.

METHODS

This is a cross-sectional survey carried out in Umberto I Hospital, "Sapienza" University of Rome between November 2019 and January 2020. We recruited 148 specialists and residents in Obstetrics and Gynecology through online anonymous multiple-choice 13-questions, 10 min-survey comparing responses between the two groups.

RESULTS

A total of 94.6% of all participants said they always prescribe cytomegalovirus (CMV) serum screening: 73.6% of them regularly counsel about preventive practices, with specialists recording higher percentages (85.4 vs. 65.1%, p<0.005). We identified a good knowledge about the diagnostic pathway, but only 58.1% of our population knows the correct time of late amniocentesis. 12.2% of providers do not consider magnetic resonance (MRI) as a complementary exam.

CONCLUSIONS

Prevention of maternal seroconversion is crucial: even if our data show an acceptable knowledge about antenatal counseling, we encourage clinicians to firmly inform and educate women about behavioral measures.

Hygiene promotion might be better than serological screening to deal with Cytomegalovirus infection during pregnancy: a methodological appraisal and decision analysis

BACKGROUND

Cytomegalovirus infection is the most frequent viral congenital infection, with possible consequences such as deafness, or psychomotor retardation. In 2016, the French High Council of Public Health was mandated to update recommendations regarding prevention of cytomegalovirus infection in pregnant women. We summarize a critical appraisal of knowledge and deterministic decision analysis comparing the current no-screening situation to serological screening during pregnancy, and to hygiene promotion.

METHODS

Screening was defined as systematic serological testing, during the first trimester, with repeated tests as needed, to all pregnant women. Outcomes were: 1) severe sequela: intellectual deficiency with IQ ≤ 50 or hearing impairment < 70 dB or sight impairment (≤ 3/10 at best eye); 2) moderate sequela: any level of intellectual, hearing or sight deficiency; and 3) death or termination of pregnancy. We simulated the one-year course of cytomegalovirus infection in a cohort of 800,000 pregnant women. We developed a deterministic decision model, using best and min-max estimates, extracted from systematic reviews or original studies.

RESULTS

Relevant data were scarce or imprecise. We estimated that 4352 maternal primary infections would result in 1741 foetal infections, and an unknown number of maternal reinfections would result in 1699 foetal infections. There would be 788 cytomegalovirus-related consequences, including 316 foetal deaths or terminations of pregnancy, and 424 moderate and 48 severe sequelae. Screening would result in a 1.66-fold increase of poor outcomes, mostly related to a 2.93-fold increase in deaths and terminations of pregnancy, not compensated by the decrease in severe symptomatic newborns. The promotion of hygiene would result in a 0.75-fold decrease of poor outcomes, related to both a decrease in severe sequelae among symptomatic newborns (RR = 0.75; min-max: 1.00-0.68), and in deaths and terminations of pregnancy (RR = 0.75; min-max: 0.97-0.68).

CONCLUSIONS

Prevention of cytomegalovirus infection during pregnancy should promote hygiene; serological screening should not be recommended.

Fetal therapies for cytomegalovirus: What we tell prospective parents

Congenital CMV is the most common congenital infection in the developed world. Infection results in congenital disease ranging from asymptomatic infection to severe neurodevelopmental impairment, and occasionally fetal or neonatal death. Fetal infection can occur through maternal-fetal transmission during primary maternal infection or maternal reactivation or re-infection. Awareness among maternal health care providers and parents is low. The prevention of maternal CMV infection currently relies on hygiene measures, with no effective CMV vaccine or prophylactic therapies. No licensed treatment options are available to prevent maternal-fetal transmission or fetal disease. Hyperimmunoglobulin and valaciclovir have been investigated for prevention of maternal-fetal transmission or fetal treatment, with some evidence supporting consideration of maternal administration of hyperimmunoglobulin or valaciclovir therapy in certain circumstances. This article outlines the clinical evidence regarding proven preventative behavioral measures and experimental hyperimmunoglobulin and valaciclovir therapies, that is structured around common questions asked by pregnant women about CMV infection. It is aimed to help maternity health care providers counsel prospective parents about congenital CMV disease and the preventative and therapeutic strategies currently available.