Fifteen-minute consultation: diagnosis and management of congenital CMV

The cost-effectiveness of maternal and neonatal screening for congenital cytomegalovirus infection in Japan

Congenital cytomegalovirus infection is the most common congenital infection. Using a decision tree model, cost-effectiveness of maternal screening with subsequent prenatal valacyclovir treatment and newborn screening with neonatal valganciclovir treatment was evaluated. The incremental cost-effectiveness ratio (ICER) was calculated for (1) universal maternal antibody screening with prenatal valacyclovir treatment compared to targeted newborn screening, and (2) universal newborn screening with postnatal valganciclovir treatment compared to targeted newborn screening. We performed a one-way sensitivity analysis. Compared to targeted newborn screening, the ICERs for universal newborn screening and maternal screening were 2 966 296 Japanese Yen (JPY) (21 188 USD) and 1 026 984 JPY (7336 USD), respectively. In all scenarios in the one-way sensitivity analysis, the ICERs of the maternal screening and the universal newborn screening strategies were less than three gross domestic product per capita compared with the targeted newborn screening strategy. Both maternal and universal newborn screening strategies may be cost-effective than a targeted newborn screening program. The potential utility of the maternal screening with valacyclovir treatment strategy, while potentially cost effective in regions with lower baseline seroprevalence rates, requires further study as the modeling was based on limited evidence.

Disease burden of congenital cytomegalovirus infection in Japan

INTRODUCTION

Cytomegalovirus is the most frequently acquired congenital infectious agent that causes malformation in newborns in developed countries. Although there are many discussions worldwide about neonatal screening and treatment, there is scarce information relating to the lifetime economic burden of this disease, which is essential for calculating the cost-effectiveness of any screening and treatment programs.

MATERIALS AND METHODS

Economic and lifetime health burdens of congenital cytomegalovirus infection in the Japanese annual birth cohort in 2019 were calculated, using demographic, epidemiologic, health value, and economic indicators. The economic burden was divided into medical and social costs. Sensitivity analysis was performed, using high and low values for some indicators.

RESULTS

Our model estimated that the overall cost due to congenital cytomegalovirus infection in 2019 was 27.6 billion JPY. Acute care costs comprised a small portion of the medical costs. Social costs were much higher than medical costs.

CONCLUSION

Our study revealed the economic burden of congenital cytomegalovirus infection in Japan, which highlighted the significance of this disease. Our study will be helpful for guiding national strategies in Japan, including neonatal screening and early treatment.

Parenting a child with congenital cytomegalovirus infection: a qualitative study

BACKGROUND

Congenital cytomegalovirus (CMV) is the most common infectious cause of congenital disability, which can cause lifelong impairments including sensorineural hearing loss and developmental delay. This study aimed to explore the experiences of parenting a child with congenital CMV and the impact this has on families.

METHODS

Ten parents living with a child with congenital CMV in the UK participated in semistructured interviews and data were analysed using thematic analysis.

RESULTS

The findings illustrate that delays in making the diagnosis of congenital CMV are associated with parental distress and lack of knowledge about CMV among medical professionals can exacerbate this distress. Parents expressed frustration about not knowing about CMV infection during their pregnancies and therefore not having the opportunity to take measures to reduce their risk of acquiring CMV while pregnant. The uncertainty about the long-term outcomes of children with congenital CMV adds additional emotional burden for parents. Family and wider societal networks have the potential to facilitate coping and alleviate stress, but the lack of awareness of CMV acts as a barrier to receiving support from family and friends.

CONCLUSIONS

There is a need to increase awareness of CMV among medical professionals, pregnant women and wider society to improve the diagnostic process and to provide better support for families caring for children with congenital CMV infection.

Advances in the treatment of cytomegalovirus

BACKGROUND

Human cytomegalovirus (HCMV) is a threat to immunologically weak patients. HCMV cannot yet be eliminated with a vaccine, despite recent advances.

SOURCES OF DATA

Sources of data are recently published research papers and reviews about HCMV treatments.

AREAS OF AGREEMENT

Current antivirals target the UL54 DNA polymerase and are limited by nephrotoxicity and viral resistance. Promisingly, letermovir targets the HCMV terminase complex and has been recently approved by the FDA and EMA.

AREAS OF CONTROVERSY

Should we screen newborns for HCMV, and use antivirals to treat sensorineural hearing loss after congenital HCMV infection?

GROWING POINTS

Growing points are developing drugs against latently infected cells. In addition to small molecule inhibitors, a chemokine-based fusion toxin protein, F49A-FTP, has shown promise in killing both lytically and latently infected cells.

AREAS TIMELY FOR DEVELOPING RESEARCH

We need to understand what immune responses are required to control HCMV, and how best to raise these immune responses with a vaccine.

Real-time PCR versus shell vial culture on urine of patients with suspected congenital cytomegalovirus infection

Aims: Cytomegalovirus (CMV) is the most common cause of congenital infection. Aim of this study is to support quantitative real-time polymerase chain reaction (PCR) versus shell vials culture for CMV screening in urine samples. Patients & methods: A retrospective study was conducted on 255 urine samples belonging to patients admitted to Bambino Gesù Pediatric Hospital, Rome, Italy, with suspected congenital CMV infection. Results & conclusion: Quantitative real-time PCR resulted more standardized, faster, less operator-dependent, less laborious and most of all cost saving and more sensitive than shell vial culture. Since a negative result for CMV in urine means no congenital infection, a more sensitive tool for detection of CMV DNA is essential to improve patient management and to reduce healthcare costs associated to a late diagnosis.

A new MRI severity score to predict long-term adverse neurologic outcomes in children with congenital Cytomegalovirus infection

BACKGROUND

Congenital cytomegalovirus (CMV) infection is one of the main causes of deafness in childhood. It frequently causes serious long-term neurological sequelae. In children who are asymptomatic at birth, tests to accurately predict these sequelae are still unavailable.

AIMS

We describe different brain MRI patterns of congenital CMV infection correlated with clinical data and propose a new MRI severity score to early predict long-term neurological sequelae.

MATERIALS AND METHODS

We explored clinical records and neuroimaging data of 224 neonates and children with congenital Cytomegalovirus infection, 180 of them did not meet inclusion criteria. Forty-four babies met inclusion criteria and were enrolled in the study. We retrospectively collected clinical data concerning hospitalization, 2 years outpatient follow-up and brain MRI findings of those 44 children, symptomatic and asymptomatic at birth. Clinical data were then correlated with children's brain MRI examinations. We defined neurological and sensorial impairment (hearing or visual) as "adverse neurological outcomes". Brain MRI score was constructed assigning different values to white matter and ventricular dilation.

RESULTS

In 44 children enrolled in the study we found that 28/35 (80%) with abnormal and 2/9 (22,2%) with normal MRI examination developed adverse neurological outcomes (OR = 3.6) (95% IC 1.0-12.0). Infants who were symptomatic at birth showed a probability of MRI brain lesions 3.2 times higher than those who were asymptomatic. Ten out of 17 (59%) children who were asymptomatic at birth showed MRI-WM alterations or ventriculomegaly.

CONCLUSIONS

Brain MRI abnormalities, such as WM alterations and ventriculomegaly, expressed as MRI score higher than 2 are associated with an increased probability of long-term adverse neurological outcome in congenitally CMV infected infants, symptomatic and asymptomatic at birth.

Economic cost of congenital CMV in the UK

OBJECTIVE

Congenital cytomegalovirus (cCMV) is the most common infectious cause of congenital disability. It can disrupt neurodevelopment, causing lifelong impairments including sensorineural hearing loss and developmental delay. This study aimed, for the first time, to estimate the annual economic burden of managing cCMV and its sequelae in the UK.

DESIGN

The study collated available secondary data to develop a static cost model.

SETTING

The model aimed to estimate costs of cCMV in the UK for the year 2016.

PATIENTS

Individuals of all ages with cCMV.

MAIN OUTCOME MEASURES

Direct (incurred by the public sector) and indirect (incurred personally or by society) costs associated with management of cCMV and its sequelae.

RESULTS

The model estimated that the total cost of cCMV to the UK in 2016 was £732 million (lower and upper estimates were between £495 and £942 million). Approximately 40% of the costs were directly incurred by the public sector, with the remaining 60% being indirect costs, including lost productivity. Long-term impairments caused by the virus had a higher financial burden than the acute management of cCMV.

CONCLUSIONS

The cost of cCMV is substantial, predominantly stemming from long-term impairments. Costs should be compared against investment in educational strategies and vaccine development programmes that aim to prevent virus transmission, as well as the value of introducing universal screening for cCMV to both increase detection of children who would benefit from treatment, and to build a more robust evidence base for future research.

Congenital cytomegalovirus - who, when, what-with and why to treat?

Congenital cytomegalovirus (CMV) is the commonest cause of congenital infection worldwide and the leading non-genetic cause of sensorineural hearing loss in children. Appropriate investigations and timely decision on treatment is required as studies have shown that treatment with antiviral therapy leads to improved hearing and neurodevelopmental outcomes in the long term when started in the first month of life. This paper outlines the epidemiology, investigations in the diagnosis of congenital CMV infection and current evidence surrounding treatment.

Disparities in access to pediatric hearing health care

PURPOSE OF REVIEW

There are significant disparities in care facing children with hearing loss. The objective of this review is to assess the current disparities in pediatric hearing healthcare delivery, describe the barriers of efficient and effective pediatric hearing health care, and explore the innovations to improve pediatric hearing healthcare delivery.

RECENT FINDINGS

Children with hearing loss from certain geographic regions or ethnic background are significantly delayed in diagnosis and treatment. Multiple patient characteristics (presentation of hearing loss), parental factors (insurance status, socioeconomic status, educational status, and travel distance to providers), and provider barriers (specialist shortage and primary care provider challenges) prevent the delivery of timely hearing health care. Advances, such as improved screening programs and the expansion of care through remote services, may help to ameliorate these disparities.

SUMMARY

Timely identification and treatment of pediatric hearing loss is critical to prevent lifelong language complications. Children from vulnerable populations, such as rural residents, face significant disparities in care. Careful assessment of these barriers and implementation of culturally acceptable interventions are paramount to maximize communication outcomes of children with hearing loss.

Contribution of targeted saliva screening for congenital CMV-related hearing loss in newborns who fail hearing screening

BACKGROUND

We previously reported a 2.2% rate of infants born with sensorineural hearing loss (SNHL) due to congenital cytomegalovirus (cCMV) infection identified by universal neonatal screen for cCMV using saliva.

OBJECTIVE

To evaluate the contribution of targeted saliva screening for cCMV to the detection of infants born with cCMV-related SNHL who failed universal newborn hearing screening (UNHS).

METHODS

We retrospectively reviewed the audiological and medical records of infants who failed UNHS and were tested for cCMV using saliva sample prior to discharge at Sheba Medical Center between 2014 and 2015. Positive cases were confirmed by urine sample.

RESULTS

Two hundred (1%) of the 19 830 infants tested during the study period failed in-hospital hearing screening. A saliva specimen was obtained prior to discharge in 187 infants (93.5% of those who failed UNHS). In 178 infants saliva testing was performed at ≤21 days of chronological age and yielded results. cCMV infection was identified in 4/178 tested infants (2.25%, 95% CI 0.8% to 5.3%), of whom three were diagnosed with SNHL (1.7%, 95% CI 0.5% to 4.4%) and offered antiviral treatment. Two of the tested infants (1.12%, 95% CI 0.2% to 3.6%) were diagnosed with cCMV solely due to failure in UNHS. Occult central nervous system (CNS) symptoms of cCMV infection were detected in 2/4 infants following targeted investigation.

CONCLUSIONS

Targeted cCMV screening in newborns who failed UNHS contributed to the early detection of infants born with cCMV-related isolated SNHL or with occult CNS symptoms who could potentially benefit from antiviral treatment.

Infectious causes of microcephaly: epidemiology, pathogenesis, diagnosis, and management

Microcephaly is an important sign of neurological malformation and a predictor of future disability. The 2015-16 outbreak of Zika virus and congenital Zika infection brought the world's attention to links between Zika infection and microcephaly. However, Zika virus is only one of the infectious causes of microcephaly and, although the contexts in which they occur vary greatly, all are of concern. In this Review, we summarise important aspects of major congenital infections that can cause microcephaly, and describe the epidemiology, transmission, clinical features, pathogenesis, management, and long-term consequences of these infections. We include infections that cause substantial impairment: cytomegalovirus, herpes simplex virus, rubella virus, Toxoplasma gondii, and Zika virus. We highlight potential issues with classification of microcephaly and show how some infants affected by congenital infection might be missed or incorrectly diagnosed. Although Zika virus has brought the attention of the world to the problem of microcephaly, prevention of all infectious causes of microcephaly and appropriately managing its consequences remain important global public health priorities.