Incidence of herpes simplex virus type 2 infection in the United States

Analytic Characterization of the Herpes Simplex Virus Type 2 Epidemic in the United States, 1950-2050

Background

We analytically characterized the past, present, and future levels and trends of the national herpes simplex virus type 2 (HSV-2) epidemic in the United States.

Methods

A population-level mathematical model was constructed to describe HSV-2 transmission dynamics and was fitted to the data series of the National Health and Nutrition Examination Survey.

Results

Over 1950–2050, antibody prevalence (seroprevalence) increased rapidly from 1960, peaking at 19.9% in 1983 in those aged 15–49 years, before reversing course to decline to 13.2% by 2020 and 8.5% by 2050. Incidence rate peaked in 1971 at 11.9 per 1000 person-years, before declining by 59% by 2020 and 70% by 2050. Annual number of new infections peaked at 1 033 000 in 1978, before declining to 667 000 by 2020 and 600 000 by 2050. Women were disproportionately affected, averaging 75% higher seroprevalence, 95% higher incidence rate, and 71% higher annual number of infections. In 2020, 78% of infections were acquired by those 15–34 years of age.

Conclusions

The epidemic has undergone a major transition over a century, with the greatest impact in those 15–34 years of age. In addition to 47 million prevalent infections in 2020, high incidence will persist over the next 3 decades, adding >600 000 new infections every year.

Placental Immune Responses to Viruses: Molecular and Histo-Pathologic Perspectives

As most recently demonstrated by the SARS-CoV-2 pandemic, congenital and perinatal infections are of significant concern to the pregnant population as compared to the general population. These outcomes can range from no apparent impact all the way to spontaneous abortion or fetal infection with long term developmental consequences. While some pathogens have developed mechanisms to cross the placenta and directly infect the fetus, other pathogens lead to an upregulation in maternal or placental inflammation that can indirectly cause harm. The placenta is a temporary, yet critical organ that serves multiple important functions during gestation including facilitation of fetal nutrition, oxygenation, and prevention of fetal infection in utero. Here, we review trophoblast cell immunology and the molecular mechanisms utilized to protect the fetus from infection. Lastly, we discuss consequences in the placenta when these protections fail and the histopathologic result following infection.

Management of Genital Herpes in Pregnancy: ACOG Practice Bulletinacog Practice Bulletin, Number 220

Genital herpes simplex virus (HSV) infection during pregnancy poses a risk to the developing fetus and newborn. Genital herpes is common in the United States. Among 14- to 49-year-old females, the prevalence of HSV-2 infection is 15.9%. However, the prevalence of genital herpes infection is higher than that because genital herpes is also caused by HSV-1 (). Because many women of childbearing age are infected or will be infected with HSV, the risk of maternal transmission of this virus to the fetus or newborn is a major health concern. This document has been revised to include that for women with a primary or nonprimary first-episode genital HSV infection during the third trimester of pregnancy, cesarean delivery may be offered due to the possibility of prolonged viral shedding.

Molecular docking analysis of a secondary metabolite with the glycoprotein receptors of HSV 1 and HSV 2

Herpes simplex viruses (HSV) are alpha herpes viruses, which causes life-threatening illness. Therefore, it is of interest to design and develop potential drugs to treat HSV infections. We show the optimal molecular docking properties of a secondary metabolite (3, 7, 11, 15 tetra methyl-2-2-hexadecen-'1-ol) with the glycoprotein receptors of HSV1 and HSV 2 for further consideration.

Differential expression of mRNA and miRNA in guinea pigs following infection with HSV2v

MicroRNAs (miRNAs) are 22-nucleotide single-stranded RNAs which regulate gene expression by targeting 3′ untranslated regions. Previous studies have suggested that miRNAs may be used as markers for investigating the molecular regulation of gene expression. In the present study, miRNA and mRNA expression profiles were investigated using a massively parallel next generation sequencing technique to compare herpes simplex virus (HSV)2-infected (n=3) and healthy (n=3) epithelial tissues from guinea pigs. Total RNA was isolated and RNA sequencing was performed using a HiSeq 2000 sequencing system. Differential expression of miRNA and mRNA was analyzed using two-tailed t-tests. A negative correlation was detected between the miRNAs and their predicted target genes. Following infection with HSV2, 205 and 159 miRNAs were demonstrated to be upregulated and downregulated, respectively. These differentially expressed miRNAs were associated with cellular and metabolic processes, biological regulation, response to stimuli and cellular components of the immune system, as determined by functional gene ontology analysis. Following HSV2 infection, 6 upregulated miRNAs including miR-592, miR-1245b-5p, miR-150, miR-342-5p, miR-1245b-3p and miR-124 were demonstrated to participate in the toll-like receptor (TLR) pathway by targeting related genes. These results suggested that the downregulated genes were associated with the TLR pathway after infection with HSV2. The results of reverse transcription-quantitative polymerase chain reaction analysis were consistent with RNA sequencing, indicating that the increased expression of these miRNAs downregulated the TLR pathway-associated genes, which may mediate the progression of HSV2-induced genital herpes.

Antiviral and Cytotoxic Activities of Polysaccharides Extracted from Four Tropical Seaweed Species

Polysaccharides extracted from Rhodymenia pseudopalmata, Solieria filiformis, Hydropuntia cornea (Rhodophyta) and Sargassum fluitans (Phaeophyceae) were evaluated for its cytotoxic and antiviral activities against Herpes simplex virus (HSV-Type 1). Chemical structures were characterized by FT-IR spectroscopy and 13C-NMR analyses. Polysaccharides from Sargassum fluitans (EC50 = 42.8 μg/ml) and Solieria filiformis (EC50 = 136.0 μg/ml) showed antiviral activity against herpes simplex virus type-I in vitro at a multiplicity of infection (MOI) of 0.01 ID50/cells without cytotoxicity (1–200 μg/mL). The activity observed suggests that sulphation, molecular weight and carbohydrate nature of these polysaccharides may be involved in this activity. To better understand the antiviral activity of the polysaccharides evaluated, it seems important to study the mechanism of action involved. These polysaccharides could be studied further to evaluate their potential use as antiviral drugs.

Effects of a traditional Chinese medicine, Longdanxiegan formula granule, on Toll-like receptor pathway in female guinea pigs with recurrent genital herpes

OBJECTIVE

The aim of the present study was to investigate the effects of Longdanxiegan formula granule (LDXGFG), a Chinese traditional medicine on Toll-like receptor (TLR) pathway in recurrent genital herpes.

MATERIALS AND METHODS

An experimental recurrent genital herpes model was constructed using herpes guinea pig model. The effect of LDXGFG on expression levels of TLR pathway genes were detected using real-time polymerase chain reaction. Furthermore, the dendritic cells and Langerhans cells were isolated and the TLR pathway genes of these cells were assayed after LDXGFG treatment.

RESULTS

The result suggested two different expression patterns of TLR pathway genes in genital herpes and recurrent genital herpes, including upregulated genes and downregulated genes. TLR1, TLR4, TLR6, TLR7, TLR8, TLR9, and TLR10 showed a significant decrease while, TLR2, TLR3, and TLR5 increased in genital herpes and recurrent genital herpes guinea pigs. Meanwhile, the downregulated genes in genital herpes and recurrent genital herpes were stimulated by LDXGFG. By contrast, the upregulated genes decreased significantly after LDXGFG treatment. In both dendritic cells and Langerhans cells, the TLR pathway genes exhibited same pattern: the LDXGFG corrected the abnormal expression of TLR pathway genes.

CONCLUSION

The present results suggest that LDXGFG is an alternative, inexpensive, and lasting-effect medicine for herpes simplex virus 2 infection.

Vaginal gene therapy

In the last years, vaginal gene therapy has gained increasing attention mainly for the treatment and control of sexually transmitted infections. DNA delivery has been also suggested to improve reproductive outcomes for women with deficiencies in the female reproductive tract. Although no product has reached clinical phase, preclinical investigations reveal the potential of the vaginal tract as an effective administration route for gene delivery. This review focuses on the main advantages and challenges of vaginal gene therapy, and on the most used nucleic acid delivery systems, including viral and non-viral vectors. Additionally, the advances in the application of vaginal gene therapy for the treatment and/or prevention of infectious diseases such as the human immunodeficiency virus (HIV), the human papillomavirus (HPV) or the herpes simplex virus (HSV) are presented.

Frequent genital HSV-2 shedding among women during labor in Soweto, South Africa

Background. Despite high herpes simplex virus type 2 (HSV-2) incidence and prevalence among women in Africa, we are unaware of published neonatal herpes reports. To assess neonatal HSV transmission potential in South Africa, we investigated the frequency of the strongest risk factors: HSV acquisition in late pregnancy and HSV shedding during labor. Methods. Women admitted in early labor to a hospital in Soweto underwent HSV serologic testing and genital swab collection for HSV PCR. HSV-2 seronegative women were assessed for seroconversion 4–6 weeks after delivery. Results. Of 390 women enrolled, 229 (58.7%) were HSV-2 seropositive. Genital HSV-2 was detected in 17.2% of HSV-2 seropositive women, including 26 of 115 HIV-positive and 13 of 110 HIV-negative women (22.6% versus 11.8%; RR, 1.91; 95% CI, 1.04–3.53; P = 0.038), but in none of 161 HSV-2 seronegative women. Among the 91 HSV-2 seronegative women followed after delivery, none seroconverted. Conclusions. HSV-2 reactivation is common among South African women during labor, especially those with HIV coinfection. To determine the epidemiology of neonatal herpes in South Africa and to investigate whether the lack of reported cases is due to alterations in immune control or HSV-2 virulence, studies evaluating acutely ill neonates for HSV and studies of maternal HSV-2 shedding patterns are needed.

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.

Statistical genetic analysis of serological measures of common, chronic infections in Alaska Native participants in the GOCADAN study

This paper describes genetic investigations of seroreactivity to five common infectious pathogens in the Genetics of Coronary Artery Disease in Alaska Natives (GOCADAN) study. Antibody titers and seroprevalence were available for 495 to 782 (depending on the phenotype) family members at two time points, approximately 15 years apart, for Chlamydophila pneumoniae, Helicobacter pylori, cytomegalovirus (CMV), herpes simplex virus 1 (HSV-1), and herpes simplex virus 2 (HSV-2). Seroprevalence rates indicate that infections with most of these pathogens are common (≥20% for all of them, >80% for H. pylori, CMV, and HSV-1). Seropositive individuals typically remain seropositive over time, with seroreversion rates of <1% to 10% over ∼15 years. Antibody titers were significantly heritable for most pathogens, with the highest estimate being 0.61 for C. pneumoniae. Significant genome-wide linkage evidence was obtained for C. pneumoniae on chromosome 15 (logarithm of odds, LOD score of 3.13). These results demonstrate that individual host genetic differences influence antibody measures of common infections in this population, and further investigation may elucidate the underlying immunological processes and genes involved.

Costs and effectiveness of neonatal male circumcision

OBJECTIVE

To evaluate the expected change in the prevalence of male circumcision (MC)-reduced infections and resulting health care costs associated with continued decreases in MC rates. During the past 20 years, MC rates have declined from 79% to 55%, alongside reduced insurance coverage.

DESIGN

We used Markov-based Monte Carlo simulations to track men and women throughout their lifetimes as they experienced MC procedure-related events and MC-reduced infections and accumulated associated costs. One-way and probabilistic sensitivity analyses were used to evaluate the impact of uncertainty.

SETTING

United States.

PARTICIPANTS

Birth cohort of men and women.

INTERVENTION

Decreased MC rates (10% reflects the MC rate in Europe, where insurance coverage is limited).

OUTCOMES MEASURED

Lifetime direct medical cost (2011 US$) and prevalence of MC-reduced infections.

RESULTS

Reducing the MC rate to 10% will increase lifetime health care costs by $407 per male and $43 per female. Net expenditure per annual birth cohort (including procedure and complication costs) is expected to increase by $505 million, reflecting an increase of $313 per forgone MC. Over 10 annual cohorts, net present value of additional costs would exceed $4.4 billion. Lifetime prevalence of human immunodeficiency virus infection among males is expected to increase by 12.2% (4843 cases), high- and low-risk human papillomavirus by 29.1% (57 124 cases), herpes simplex virus type 2 by 19.8% (124 767 cases), and infant urinary tract infections by 211.8% (26 876 cases). Among females, lifetime prevalence of bacterial vaginosis is expected to increase by 51.2% (538 865 cases), trichomoniasis by 51.2% (64 585 cases), high-risk human papillomavirus by 18.3% (33 148 cases), and low-risk human papillomavirus by 12.9% (25 837 cases). Increased prevalence of human immunodeficiency virus infection among males represents 78.9% of increased expenses.

CONCLUSION

Continued decreases in MC rates are associated with increased infection prevalence, thereby increasing medical expenditures for men and women.

Epidemiological impact of a genital herpes type 2 vaccine for young females

Genital Herpes, which is caused by Herpes Simplex Virus-1 or -2 (HSV-1, -2, predominantly HSV-2) is a sexually transmitted infection (STI) that causes a chronic latent infection with outbreak episodes linked to transmission. Antiviral therapies are effective in reducing viral shedding during these episodes, but are ineffective as a whole since many outbreaks are asymptomatic or have mild symptoms. Thus, the development of a vaccine for genital herpes is needed to control this disease. The question of how to implement such a vaccine program is an important one, and may be similar to the vaccination program for Human Papilloma Virus (HPV) for young females. We have developed a mathematical model to describe the epidemiology of vaccination targeting young females against HSV-2. The model population is delineated with respect to age group, sexual activity and infection status including oral infection of HSV-1, which may affect vaccine efficacy. A threshold parameter R(C), which determines the level of vaccine uptake needed to eradicate HSV-2, is found. Computer simulation shows that an adolescent-only vaccination program may be effective in eliminating HSV-2 disease, however, the success of extinction greatly depends on the level of vaccine uptake, the vaccine efficacy, the age of sexual maturity and safe sex practices. However, the time course of eradication would take many years. We also investigate the prevalence of infection in the total population and in women between 16-30 years of age before and after vaccination has been introduced, and show that the adolescent-only vaccination program can be effective in reducing disease prevalence in these populations depending on the level of vaccine uptake and vaccine efficacy. This will also result in a decrease of maternal-fetal transmission of HSV-2 infection. Another important, if commonsense, conclusion is that vaccination of some females reduces infection in men, which then reduces infection in women.

National estimates of seroincidence and seroprevalence for herpes simplex virus type 1 and type 2 among US military adults aged 18 to 29 years

BACKGROUND

While population-based seroprevalence studies of herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) are widespread, seroincidence studies are largely limited to select or high-risk populations. The US military offers a potential population to derive national seroincidence rate estimates for young adults (ages 18-29).

METHODS

We used banked, longitudinal serum specimens collected in a cohort of 1094 military personnel aged 18 to 30 years who served between 1989 and 2005 to estimate national HSV-1 and HSV-2 seroincidence and seroprevalence for the young, adult military population, weighted according to the US Census. Serum was tested with indirect ELISA (enzyme-linked immunosorbent assay).

RESULTS

Estimated national seroincidence rates for the US young, adult military population were 9.1 per 100 person-years (95% confidence interval: 4.6-13.5) for HSV-1 and 6.2 (95% confidence interval: 3.1-9.3) for HSV-2. Female sex and black race were associated with significantly higher HSV-2 seroconversion rates. Our estimated HSV1/2 seroprevalences were comparable to US national data provided by National Health and Nutrition Examination Surveys' serosurveys except for non-Hispanic blacks and Hispanics.

CONCLUSION

Although these US 2000 Census-weighted estimates of HSV-1 and HSV-2 seroincidence apply only to young, military adults, they nonetheless supply, to our knowledge, the only national figures that might be used to predict US national HSV1/2 seroincidence in young adults. Thus, we believe that our findings in this military population can be used to inform the planning of HSV-1 and 2 prevention measures in the general, young-adult US population.

Seroprevalence of 13 common pathogens in a rapidly growing U.S. minority population: Mexican Americans from San Antonio, TX

Background

Infection risks vary among individuals and between populations. Here we present information on the seroprevalence of 13 common infectious agents in a San Antonio-based sample of Mexican Americans. Mexican Americans represent the largest and most rapidly growing minority population in the U.S., and they are also considered a health disparities population.

Methods

We analyzed 1227 individuals for antibody titer to Chlamydophila pneumoniae, Helicobacter pylori, Toxoplasma gondii, cytomegalovirus, Epstein-Barr virus, herpes simplex virus-1, herpes simplex virus-2 (HSV-2), human herpesvirus-6 (HHV-6), varicella zoster virus (VZV), adenovirus-36, hepatitis A virus, and influenza A and B. Seroprevalence was examined as a function of sex, age, household income, and education.

Results

Seroprevalence estimates ranged from 9% for T. gondii to 92% for VZV, and were similar in both sexes except for HSV-2, which was more prevalent in women. Many pathogens exhibited a significant seroprevalence change over the examined age range (15-94 years), with 7 pathogens increasing and HHV-6 decreasing with age. Socioeconomic status significantly correlated with serostatus for some pathogens.

Conclusions

Our findings demonstrate substantial seroprevalence rates of these common infections in this sample of Mexican Americans from San Antonio, Texas that suffers from high rates of chronic diseases including obesity and type-2 diabetes.

Genetic factors influence serological measures of common infections

BACKGROUND/AIMS

Antibodies against infectious pathogens provide information on past or present exposure to infectious agents. While host genetic factors are known to affect the immune response, the influence of genetic factors on antibody levels to common infectious agents is largely unknown. Here we test whether antibody levels for 13 common infections are significantly heritable.

METHODS

IgG antibodies to Chlamydophila pneumoniae, Helicobacter pylori, Toxoplasma gondii, adenovirus 36 (Ad36), hepatitis A virus, influenza A and B, cytomegalovirus, Epstein-Barr virus, herpes simplex virus (HSV)-1 and -2, human herpesvirus-6, and varicella zoster virus were determined for 1,227 Mexican Americans. Both quantitative and dichotomous (seropositive/seronegative) traits were analyzed. Influences of genetic and shared environmental factors were estimated using variance components pedigree analysis, and sharing of underlying genetic factors among traits was investigated using bivariate analyses.

RESULTS

Serological phenotypes were significantly heritable for most pathogens (h(2) = 0.17-0.39), except for Ad36 and HSV-2. Shared environment was significant for several pathogens (c(2) = 0.10-0.32). The underlying genetic etiology appears to be largely different for most pathogens.

CONCLUSIONS

Our results demonstrate, for the first time for many of these pathogens, that individual genetic differences of the human host contribute substantially to antibody levels to many common infectious agents, providing impetus for the identification of underlying genetic variants, which may be of clinical importance.

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.

A history of chagas disease transmission, control, and re-emergence in peri-rural La Joya, Peru

Background

The history of Chagas disease control in Peru and many other nations is marked by scattered and poorly documented vector control campaigns. The complexities of human migration and sporadic control campaigns complicate evaluation of the burden of Chagas disease and dynamics of Trypanosoma cruzi transmission.

Methodology/Principal Findings

We conducted a cross-sectional serological and entomological study to evaluate temporal and spatial patterns of T. cruzi transmission in a peri-rural region of La Joya, Peru. We use a multivariate catalytic model and Bayesian methods to estimate incidence of infection over time and thereby elucidate the complex history of transmission in the area. Of 1,333 study participants, 101 (7.6%; 95% CI: 6.2–9.0%) were confirmed T. cruzi seropositive. Spatial clustering of parasitic infection was found in vector insects, but not in human cases. Expanded catalytic models suggest that transmission was interrupted in the study area in 1996 (95% credible interval: 1991–2000), with a resultant decline in the average annual incidence of infection from 0.9% (95% credible interval: 0.6–1.3%) to 0.1% (95% credible interval: 0.005–0.3%). Through a search of archival newspaper reports, we uncovered documentation of a 1995 vector control campaign, and thereby independently validated the model estimates.

Conclusions/Significance

High levels of T. cruzi transmission had been ongoing in peri-rural La Joya prior to interruption of parasite transmission through a little-documented vector control campaign in 1995. Despite the efficacy of the 1995 control campaign, T. cruzi was rapidly reemerging in vector populations in La Joya, emphasizing the need for continuing surveillance and control at the rural-urban interface.

The historically rural problem of Chagas disease is increasing in urban areas in Latin America. Peri-rural development may play a critical role in the urbanization of Chagas disease and other parasitic infections. We conducted a cross-sectional study in an urbanizing rural area in southern Peru, and we encountered a complex history of Chagas disease in this peri-rural environment. Specifically, we discovered: (1) long-standing parasite transmission leading to substantial burden of infection; (2) interruption in parasite transmission resulting from an undocumented insecticide application campaign; (3) relatively rapid re-emergence of parasite-infected vector insects resulting from an unsustained control campaign; (4) extensive migration among peri-rural inhabitants. Long-standing parasite infection in peri-rural areas with highly mobile populations provides a plausible mechanism for the expansion of parasite transmission to nearby urban centers. Lack of commitment to control campaigns in peri-rural areas may have unforeseen and undesired consequences for nearby urban centers. Novel methods and perspectives are needed to address the complexities of human migration and erratic interventions.

Nature killer cells in the central nervous system

Natural killer (NK) cells, a prominent component of the innate immune system, are large granular lymphocytes that respond rapidly to a variety of insults via cytokine secretion and cytolytic activity. Recently, there has been growing insight into the biological functions of NK cells, in particular into their roles in infection, tumorurveillance and autoimmunity. Under these pathophysiological circumstances, NK cells readily home to the central nervous system (CNS) tissues to combat infection and presumably to curb progression of tumor. Bystander neuronal and/or glial cell damage can occur in this setting. Paradoxically, NK cells appear to have an inhibitory role for autoimmune responses within the CNS. As in the periphery, NK cells act in concert with T cells and other lymphocytes responsible for CNS pathology and immune regulation. Insights into the molecular signals and pathways governing the diverse biological effects of NK cells are keys for designing NK cell-based therapy for CNS infections, tumor and autoimmune diseases.NK cells readily accumulate in homing to CNS tissues under the pathophysiological situations. This process is tightly controlled by a number of chemokines and chemokine receptors. There is ample of evidence that NK cells within the CNS contribute to the control of infections and might limit progression of certain tumor. Bystander neuronal and/or glial cell damage can occur. In certain autoimmune conditions of the CNS, NK cells appear to have an inhibitory role. Disassociation of disease-inhibiting versus disease-promoting effects of NK cells is a key to harnessing NK cells for therapeutic purposes. To achieve this goal, a generation of genetic models with selective NK cell deficiency, and development of reagents (antibodies) for visualizing subsets of NK cells in situ will be necessary.

Common gynecologic infections

Many women seek care for vulvar, vaginal, or pelvic complaints. Primary care providers should possess a solid understanding of the differential diagnosis and treatment of gynecologic infections. Many infections in the reproductive tract are sexually transmitted, whereas other common infections are attributable to an overgrowth of the normally present bacteria or yeast in the vagina. Presenting symptoms and signs are helpful in determining the source of infection, but often a battery of tests must be performed to make a definitive diagnosis.

Herpes simplex virus type 2 and HIV infection among US military personnel: implications for health prevention programmes

US military personnel are routinely screened for HIV infection. Herpes simplex virus type 2 (HSV-2) is a risk factor for HIV acquisition. To determine the association between HSV-2 and HIV, a matched case-control study was conducted among US Army and Air Force servicemembers with incident HIV infections (cases) randomly matched with two HIV-uninfected servicemembers (controls) between 2000 and 2004. HSV-2 prevalence was significantly higher among cases (30.3%, 138/456) than among controls (9.7%, 88/912, P < 0.001). HSV-2 was strongly associated with HIV in univariate (odds ratio [OR] = 4.2, 95% confidence interval [CI] = 3.1–5.8) and multiple analyses (adjusted [OR] = 3.9, 95% CI = 2.8–5.6). The population attributable risk percentage of HIV infection due to HSV-2 was 23%. Identifying HSV-2 infections may afford the opportunity to provide targeted behavioural interventions that could decrease the incidence of HIV infections in the US military population; further studies are needed.

Epidemiology of infections in women

This article describes the epidemiologic profiles of sexually transmitted infections seen in US women. We present a brief description of the infectious agent, describe the epidemiology of the infection among women in terms of race/ethnicity and age (if those data are available), and present what is known about the behavioral risk factors associated with acquisition.

Left out but not forgotten: Should closer attention be paid to coinfection with herpes simplex virus type 1 and HIV?

Herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) are among the most common coinfections seen in individuals infected with HIV-1. Most research on HSV-HIV coinfection has focused on HSV-2, and in particular, on its impact on HIV transmission. HSV-2 is associated with micro- and macroulcerations in genital mucosal surfaces, increased numbers of HIV target cells in genital mucosal tissue and increases in plasma HIV viral load of up to 0.5 log(10) copies/mL, such that HSV-2 infection increases the risk of both HIV acquisition and transmission. Because plasma HIV RNA levels are a major determinant of rates of CD4 cell decline, HSV-2 coinfection may also adversely affect the progression of HIV disease. Anti-HSV medications have in fact been associated with reciprocal decreases in HIV viral load in short-term studies. These findings have led to the development of several clinical trials of HSV-2 suppression as strategies for preventing HIV transmission and slowing the rate of HIV disease progression. HSV-1 coinfection has largely been ignored from this growing body of research, yet there are several reasons that this coinfection remains an important issue for study. First, the seroprevalence of HSV-1 is consistently higher than that of HSV-2 among both HIV-infected and HIV-uninfected populations, underscoring the relevance of HSV-1 coinfection to the majority of HIV-infected persons. Second, pre-existing HSV-1 antibodies in individuals may modulate the course of subsequently acquired HSV-2 infection; the implications of such changes on HSV-HIV coinfection remain unexplored. Third, HSV-1 and HSV-2 are closely related viruses that share 83% genetic homology. Their virological and pathobiological similarities suggest that their implications on HIV pathogenesis may be similar as well. Finally, HSV-1 is becoming increasingly relevant because the incidence of genital HSV-1 has risen. Although genital herpes is traditionally associated with HSV-2, recent studies have shown that the majority of serologically confirmed primary genital herpes in some settings is attributable to HSV-1. Because the genital tract is an important site of biological interaction between HSV and HIV, this epidemiological change may be clinically important.

Risk factors for incident herpes simplex type 2 virus infection among women attending a sexually transmitted disease clinic

OBJECTIVES

To estimate the incidence of herpes simplex type 2 virus (HSV-2) infection, to identify risk factors for its acquisition, and to assess the protective effect of condoms.

STUDY DESIGN

Prospective study of 293 HSV-2 seronegative women, aged 18 to 35 years, attending a sexually transmitted disease clinic in Alabama from 1992 to 1995.

RESULTS

Incidence of HSV-2 infection was 20.5 per 100 woman-years [95% confidence interval (CI), 13.1-30.5]. Young women (18-20 years) had a significantly higher risk of incident HSV-2 infection [adjusted hazard ratio (HR), 2.8; 95% CI, 1.3-6.4] than older women. Women diagnosed with prevalent or incident bacterial vaginosis had a higher incidence of HSV-2 infection than those who were not so diagnosed (adjusted HR, 2.4; 95% CI, 1.1-5.6). No significant protective effect was observed for consistent (100%) condom use without breakage and slippage against HSV-2 acquisition (adjusted HR, 0.8; 95% CI, 0.2-2.3).

CONCLUSION

Acquisition of HSV-2 infection among study participants was higher than previous estimates for adult female sexually transmitted disease clinic attendees, and no protective effect for condoms was demonstrated. The high incidence of HSV-2 infection with its potential for adverse health consequences emphasizes the need for better prevention strategies.

Facile biocatalytic access to 9-fluorenylmethyl polyglycosides: evaluation of antiviral activity on immunocompetent cells

The biological activities of a series of mono- and oligosaccharides (beta-xylosides and alpha-glucosides) of 9-fluorenylmethanol were investigated together with mono-beta-galactoside and beta-glucoside of this aglycone, produced by biocatalytic routes. By using marine glycoside hydrolases and inexpensive donors such as maltose or xylan, access to mono-alpha-glucoside or mono-beta-xyloside of 9-fluorenylmethanol was obtained. Additionally, interesting polyglycoside derivatives were isolated. Biological testing indicated that in vitro treatment with these carbohydrate derivatives may influence the balance of cytokines in the environment of human peripheral blood mononuclear cells (PBMC), restricting the harmful effect of herpes simplex type 2 replication. In fact, these carbohydrate derivatives tested in WISH cells did not show any significant antiviral activity.

Regression of herpes viral infection symptoms using melatonin and SB-73: comparison with Acyclovir

Infection with Herpes simplex virus type 1 (HSV-1) typically causes lesions of the mouth, face, skin, esophagus, or brain. Herpes simplex virus type 2 (HSV-2) usually causes infections of the genitals, rectum, skin, hands, or meninges. The herpes viruses are a major cause of blindness from keratitis. The usual drugs used for herpes are Vidarabine, Acyclovir, Penciclovir and Ganciclovir; they are associated with several complications. The aim of this study was to investigate if a formulation containing 2.5 mg melatonin and 100 mg SB-73 would help patients with herpes, and to compare the preparation with 200 mg Acyclovir. SB-73 is a mixture of magnesium, phosphate, fatty acids extracted from Aspergillus sp. which has anti-herpes virus properties. A single blind randomized study was performed in which 70 patients underwent treatment using the supplement cited above (group A) and 75 received treatment of 200 mg Acyclovir (group B). Sixty-seven patients of the group A (95.7%) reported a complete regression of symptoms after 7 days of treatment. By comparison, 64 subjects (85.3%) of the Acyclovir reported regression of symptoms in the same period. There was statiscally significant difference between the groups (P < 0.05).

Prenatal herpes simplex virus serologic screening beliefs and practices among obstetricians

OBJECTIVE

To describe the beliefs and practices of obstetricians related to prenatal serologic testing for HSV infection.

METHODS

A total of 265 (73% of eligible) currently practicing obstetricians in Washington State completed a 36-question mailed survey that assessed beliefs regarding genital herpes in pregnancy, neonatal herpes, serologic testing for herpes in pregnancy, and ease of testing.

RESULTS

Ninety-five percent of respondents believed genital herpes was common in reproductive-aged women, 83% believed neonatal herpes was a serious health issue, and 73% believed it warranted systematic prevention efforts; 74% discussed herpes with pregnant patients as part of prenatal care, 31% provided written materials about herpes, and 15% used serologic tests for herpes in 75% or more of their prenatal patients. Factors independently associated with routine herpes serologic testing were academic practice setting (adjusted odds ratio [aOR] 10.4, 95% confidence interval [CI] 2.8-39.1) and metropolitan practice setting (aOR 3.3, 95% CI 1.4-7.9). Beliefs that testing would cause unnecessary distress in pregnancy (aOR 0.3, 95% CI 0.1-0.7), or that testing was not worth the expense (aOR 0.1, 95% CI 0.0-0.6) were associated with not testing. Availability of serologic tests for HSV was reported to be high and was not associated with prenatal HSV testing.

CONCLUSION

Most obstetricians believe neonatal herpes prevention is important.

LEVEL OF EVIDENCE

II.

Incidence of cytomegalovirus infection among the general population and pregnant women in the United States

Background

Cytomegalovirus (CMV) is a common opportunistic infection among HIV-infected individuals, a major source of serious complications among organ-transplant recipients, and a leading cause of hearing loss, vision loss, and mental retardation among congenitally infected children. Women infected for the first time during pregnancy are especially likely to transmit CMV to their fetuses. More children suffer serious disabilities caused by congenital CMV than by several better-known childhood maladies such as Down syndrome or fetal alcohol syndrome

Methods

Using CMV seroprevalence data from the nationally representative Third National Health and Nutrition Examination Survey, we estimated CMV incidence among the general United States population and among pregnant women. We employed catalytic models that used age-specific CMV seroprevalences as cumulative markers of past infections in order to derive estimates of three basic parameters: the force of infection, the basic reproductive rate, and the average age of infection. Our main focus was the force of infection, an instantaneous per capita rate of acquisition of infection that approximates the incidence of infection in the seronegative population.

Results

Among the United States population ages 12–49 the force of infection was 1.6 infections per 100 susceptible persons per year (95% confidence interval: 1.2, 2.4). The associated basic reproductive rate of 1.7 indicates that, on average, an infected person transmits CMV to nearly two susceptible people. The average age of CMV infection was 28.6 years. Force of infection was significantly higher among non-Hispanic Blacks (5.7) and Mexican Americans (5.1) than among non-Hispanic Whites (1.4). Force of infection was significantly higher in the low household income group (3.5) than in the middle (2.1) and upper (1.5) household income groups. Based on these CMV incidence estimates, approximately 27,000 new CMV infections occur among seronegative pregnant women in the United States each year.

Conclusion

These thousands of CMV infections in pregnant women, along with the sharp racial/ethnic disparities in CMV incidence, are compelling reasons for accelerating research on vaccines and other interventions for preventing congenital CMV disease. Nevertheless, the relatively low force of infection provides encouraging evidence that modestly effective vaccines and rates of vaccination could significantly reduce CMV transmission.

Susceptibility of CCR5-deficient mice to genital herpes simplex virus type 2 is linked to NK cell mobilization

Following genital herpes simplex virus type 2 (HSV-2) exposure, NK cells and T cells are mobilized to sites of infection to control viral replication and spread. The present investigation sought to determine the role of the chemokine receptor CCR5 in this process. Mice deficient in CCR5 (CCR5-/-) displayed a significant reduction in cumulative survival following infection in comparison to wild-type, HSV-2-infected controls. Associated with decreased resistance to viral infection, CCR5-/- mice yielded significantly more virus and expressed higher levels of tumor necrosis factor alpha, CXCL1, CCL2, CCL3, and CCL5 in the vagina, spinal cord, and/or brain stem than did wild-type mice. Whereas there was no difference in absolute number of leukocytes (CD45high), CD4 T cells, or CD8 T cells residing in the draining lymph nodes, spleen, spinal cord, or brain stem comparing HSV-2-infected wild-type to CCR5-/- mice prior to or after infection, there were significantly more NK cells (NK1.1+ CD3-) residing in the brain stem and spleen of infected wild-type mice. Functionally, NK activity from cells isolated from the brain stem of HSV-2-infected wild-type mice was greater than that from HSV-2-infected CCR5-/- mice. In addition, antibody-mediated depletion of NK cells resulted in an increase in HSV-2 levels in the vaginal, spinal cord, and brain stem tissue of wild-type but not CCR5-/- mice. Collectively, the absence of CCR5 expression significantly impacts the ability of the host to control genital HSV-2 infection, inflammation, and spread associated with a specific reduction in NK cell expansion, infiltration, and activity in the nervous system.

Suppressive Valacyclovir Therapy: Impact on the Population Spread of HSV-2 Infection

OBJECTIVES

Recent trial results demonstrate that the transmission probability of HSV-2 in monogamous couples is nearly halved by the use of valacyclovir as suppressive therapy.

GOAL

The goal of this study is to understand the potential impact of suppressive valacyclovir therapy on the transmission of HSV-2 within a population.

STUDY DESIGN

A mathematical model of HSV-2 epidemiology was developed which included suppressive therapy with the efficacy observed in the clinical trial. The model represented HSV-2 spread in an age and sexual activity stratified population where rates of viral shedding declined based on time since infection. The model tested the impact of a range of suppression coverage levels.

RESULTS

Suppressive therapy reduces the population incidence of HSV-2. With coverage rates of 3.2%, the incidence of HSV-2 would be reduced by between 1.8% and 2.8%. Higher coverage rates were estimated to reduce the incidence of new cases up to 13%. Starting suppression closer to the time of infection also reduces the incidence of new cases.

CONCLUSION

The impact of suppressive therapy on the HSV-2 epidemic is modest at current coverage levels but could be substantially increased with higher rates of diagnosis and a focus on coverage soon after infection.

A recombinant multivalent combination vaccine protects against Chlamydia and genital herpes

Chlamydia trachomatis and Herpes simplex virus type 2 (HSV-2) genital infections pose a considerable public health challenge worldwide. Considering the high incidence of coinfections by the two pathogens, a combination vaccine that can be administered as a single regimen would be highly desirable. Recombinant Vibrio cholerae ghosts (rVCG) offer an attractive approach for the induction of humoral and cellular immune responses against human and animal pathogens. In this study, we evaluated a bivalent combination vaccine formulation comprising rVCG expressing chlamydial MOMP and HSV-2 glycoprotein D in mice for immunogenicity and protective efficacy against genital challenge with either pathogen. Mice immunized with the combination vaccine elicited secretory IgA and IgG2a antibodies to both chlamydial and HSV-2 antigens in serum and vaginal secretions. Robust antigen-specific mucosal and systemic T helper type 1 responses were induced in mice as measured by increased interferon-gamma levels produced by immune T cells in response to restimulation with target antigen in vitro. In addition, mice immunized with the combination vaccine were prophylactically protected from genital challenge with high doses of live Chlamydia and HSV-2. Thus, the combination vaccine regimen delivered by rVCG elicited adequate immune effectors that simultaneously protected against the individual pathogens.

The lack of RNA-dependent protein kinase enhances susceptibility of mice to genital herpes simplex virus type 2 infection

Mice deficient in RNA-dependent protein kinase (PKR-/-) or deficient in PKR and a functional 2',5'-oligoadenylate synthetase (OAS) pathway (PKR/RL-/-) are more susceptible to genital herpes simplex virus type 2 (HSV-2) infection than wild-type mice or mice that are deficient only in a functional OAS pathway (RL-/-) as measured by survival over 30 days. The increase in susceptibility correlated with an increase in virus titre recovered from vaginal tissue or brainstem of infected mice during acute infection. There was also an increase in CD45+ cells and CD8+ T cells residing in the central nervous system of HSV-2-infected PKR/RL-/- mice in comparison with RL-/- or wild-type control animals. In contrast, there was a reduction in the HSV-specific CD8+ T cells within the draining lymph node of the PKR/RL-/- mice. Collectively, activation of PKR, but not of OAS, contributes significantly to the local control and spread of HSV-2 following genital infection.

Risk of herpes simplex virus type 2 acquisition increases over early adulthood: evidence from a cohort study

DESIGN/ SETTING: A cohort study of 1037 people born in Dunedin, New Zealand, in 1972 or 1973.

PARTICIPANTS

At assessment at age 32 years, 884 participants (432 women and 452 men; 87.1% of the surviving cohort) provided both sera and information on sexual behaviour.

MAIN OUTCOME MEASURES

The proportion of participants with antibodies to HSV-2 infection at ages 26 and 32 years was measured, and the incidence rates from first coitus to age 26 years and from age 26 to 32 years calculated, adjusting for the number of sexual partners and same-sex contact in these age periods.

RESULTS

At age 32 years, 14.6% of men and 22.5% of women had antibodies to HSV-2. The incidence rates for men and women from first coitus to age 26 years were, respectively, 6.5 and 14.3 per 1000 person-years. The incidence rates for men and women from age 26-32 years, respectively, were 14.3 and 15.8 per 1000 person-years. When adjusted for sexual behaviour, the incidence rate ratio, comparing the older with the younger age periods, was 2.9 (95% confidence interval (CI) 1.7 to 4.9) for men and 2.0 (1.2 to 3.4) for women. The adjusted incidence rate ratio when comparing women to men from first coitus to age 26 years was 2.5 (1.6 to 4.0), and from age 26-32 years was 1.3 (0.78 to 2.2). A test for interaction indicated that men and women had different patterns of incidence over time (p = 0.039).

CONCLUSION

In the general population, the risk of acquiring HSV-2 infection seems to increase with age at least to the early 30s, and differences in risk of acquisition for women compared with men become less with age. Health promotion and treatment to control HSV-2 infection should be aimed at all ages, not just at the young.

Valacyclovir prophylaxis to prevent recurrent herpes at delivery: a randomized clinical trial

OBJECTIVE

To measure the efficacy of valacyclovir suppression in late pregnancy to reduce the incidence of recurrent genital herpes in labor and subsequent cesarean delivery.

METHODS

A total of 350 pregnant women with a history of genital herpes were assigned randomly to oral valacyclovir 500 mg twice a day or an identical placebo from 36 weeks of gestation until delivery. In labor, vulvovaginal herpes simplex virus (HSV) culture and polymerase chain reaction (PCR) specimens were collected. Vaginal delivery was permitted if no clinical recurrence or prodromal symptoms were present. Neonatal HSV cultures and laboratory tests were obtained, and infants were followed up for 1 month after delivery. Data were analyzed using chi2 and Student t tests.

RESULTS

One hundred seventy women treated with valacyclovir and 168 women treated with placebo were evaluated. Eighty-two percent of the women had recurrent genital herpes; 12% had first episode, nonprimary genital herpes; and 6% had first episode, primary genital herpes. At delivery, 28 women (8%) had recurrent genital herpes requiring cesarean delivery: 4% in the valacyclovir group and 13% in the placebo group (P = .009). Herpes simplex virus was detected by culture in 2% of the valacyclovir group and 9% [corrected] of the placebo group (P =.02). No infants were diagnosed with neonatal HSV, and there were no significant differences in neonatal complications. There were no significant differences in maternal or obstetric complications in either group.

CONCLUSION

Valacyclovir suppression after 36 weeks of gestation significantly reduces HSV shedding and recurrent genital herpes requiring cesarean delivery.

LEVEL OF EVIDENCE

I.

Ocular herpes simplex: changing epidemiology, emerging disease patterns, and the potential of vaccine prevention and therapy

PURPOSE

To review the changing epidemiology of herpes simplex virus infection, emerging patterns of herpetic ocular disease, and the challenges and promise of herpes simplex virus vaccine therapy.

DESIGN

Perspective.

METHODS

Literature review.

RESULTS

An epidemic increase in genital herpes simplex type 2 infection is reflected in a 30% increase in HSV-2 antibodies in the United States since 1976. Approximately one in four people in the United States over age 30 is infected with HSV-2. Primary acquisition of herpes simplex type 1 is becoming progressively delayed in many industrialized countries, in contrast to developing nations where the virus is acquired early in life and is ubiquitous. Changes in sexual behavior among young adults have been associated with a recent increase in genital HSV-1 infection, resulting from oral-genital rather than genital-genital contact. Clinical trials of HSV vaccines using selected herpes simplex virus type 2 proteins mixed in adjuvant have shown limited efficacy in seronegative women, but not in men.

CONCLUSIONS

The recent epidemic of genital herpes simplex type 2 infection is likely to result in an increase in neonatal ocular herpes and in delayed cases of acute retinal necrosis syndrome. The increase in genital HSV-1 may lead to industry production of vaccines that contain components of both HSV-1 and HSV-2 targeted toward limiting genital disease and transmission. As newer herpes simplex vaccines become available, ophthalmologists must be vigilant that a boost in immunity against HSV does not have a paradoxical effect in exacerbating break-through cases that develop immune-mediated herpes simplex stromal keratitis.

Infektionen mit Herpes-simplex- und Varicella-zoster-Viren in der Schwangerschaft

Primary infections with herpes simplex virus (HSV) and varicella-zoster virus (VZV) may lead to severe illness in pregnancy. Both diseases may be associated with transplacental virus transmission and fetal infection. Such infections can lead to intrauterine death, severe malformations and premature birth; the fetal/congenital varicella syndrome is well-defined. Herpes genitalis and varicella at the time of labor may lead to life threatening neonatal-herpes or varicella of the newborn. Currently neither active immunization nor neutralizing immunoglobulin is available for HSV infections. VZV-seronegative women in child-bearing age can be vaccinated and pregnant women exposed to VZV can be given specific immunoglobulins. While an infection is rarely blocked, the severity is generally reduced. For severe disease antiviral treatment is necessary, with valacyclovir and acyclovir represents the drugs of choice. Primary or recurrent overt disease of the genital tract at the time of delivery an indication for caesarean section. Suppression of recurrent genital herpes during the last weeks of pregnancy with valacyclovir and acyclovir reduces the need for surgical intervention. Neonates exposed to VZV should receive specific immunoglobulin. If neonates show signs of either infection, immediate treatment with acyclovir must be initiated.

Ano-genital herpes in children

Many American children and families are affected by child sexual abuse. The diagnosis of sexual abuse is typically made on the basis of the child's history. Objective evidence of sexual abuse, including abnormal physical findings noted on physical examination or the presence of a sexually transmitted disease, are rare. Ano-genital herpes is one of the most common sexually transmitted diseases found in adults. However, is the presence of ano-genital herpes in children evidence of sexual abuse? The link between ano-genital herpes and sexual abuse requires an understanding of viral transmission and typing to properly interpret its significance. Ano-genital herpes in children creates serious medical, social, and legal implications. It is important that primary care providers have an understanding of the appearance, mode of transmission, and diagnostic technique of ano-genital herpes. Implications for practice will provide guidelines for diagnosing, evaluating, and properly managing ano-genital herpes in children.

"Are they still having sex?" STI's and unintended pregnancy among mid-life women

Research has shown that women remain sexually active throughout mid-life and into the post-menopausal years. Recent data reveal that significant numbers of STIs (sexually transmitted infections) and unintended pregnancies occur among mid-life women. Data on STI prevalence indicate several STIs have relatively high rates among women over age 30, including HIV and HSV-2. Racial/ethnic disparities in STI prevalence between mid-life African American, Hispanic, and Caucasian women have also been noted. Data from the 1995 National Survey of Family Growth reveal 51% of pregnancies among women 40 and older are unintended. Both STIs and unintended pregnancy can result in serious health consequences for mid-life women. STIs can result in pelvic inflammatory disease and ectopic pregnancy. Unintended pregnancy can result in increased morbidity and mortality to the woman and the fetus. Mid-life women are also highly likely to go through relationship transitions (e.g., separation, divorce) and the subsequent initiation of new sexual relationships. As a result, these women are at elevated risk of STIs and unintended pregnancy. Despite these realities, there is a lack of programs addressing these two health issues among mid-life women and the unique life circumstances of women at this stage of life. The authors assert there is a compelling need for interventions to reduce STIs and unintended pregnancy in this population of women, review the literature regarding STIs and unintended pregnancy in mid-life women, identify gaps in current resources, and make recommendations for health care practice and future research.

Single-Day, Patient-Initiated Famciclovir Therapy for Recurrent Genital Herpes: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Orally administered antiviral therapy for genital herpes improves the time to lesion healing and resolves symptoms during an outbreak. Although traditional therapy for a recurrent episode for healthy adults has consisted of twice-daily dosing for 5 days, recent studies have indicated that shorter courses of antiviral therapy are effective. This study was conducted to assess the efficacy and safety of a patient-initiated, single-day regimen of famciclovir therapy, compared with placebo, in immunocompetent adult patients with recurrent genital herpes.

METHODS

This multicenter, multinational, randomized, double-blind, parallel-group, placebo-controlled study compared single-day, patient-initiated oral famciclovir (1000 mg given twice daily) with placebo for the treatment of recurrent genital herpes. Patients were instructed to initiate therapy within 6 h after onset of prodromal symptoms or genital herpes lesions.

RESULTS

Famciclovir reduced (P < .001) the time to healing of nonaborted lesions (i.e., those that progressed [corrected] beyond the papule stage) (median time, 4.3 vs. 6.1 days) and all nonaborted and aborted lesions (median time, 3.5 vs. 5.0 days), compared with placebo. The proportion of patients with aborted lesions was larger in the famciclovir group than in the placebo group (23.3% vs. 12.7%; P = .003). Adverse events in the famciclovir group were infrequent overall; most were of mild-to-moderate severity and were similar to adverse events in the placebo group.

CONCLUSIONS

A single-day regimen of patient-initiated famciclovir treatment was well tolerated and safe, and the healing of recurrent genital herpes lesions occurred approximately 2 days faster than with placebo. Moreover, single-day famciclovir treatment stopped the development or progression of lesions beyond the papule stage. This convenient single-day regimen has the potential for improving patient compliance and satisfaction with therapy.

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.

Neonatal herpes should be a reportable disease

Neonatal herpes is a devastating disease, the most serious complication of genital herpes, one of the most common serious congenital or perinatal infections, and the most frequent complication of sexually transmitted infections among children. Nevertheless, neonatal herpes is not reportable to health authorities in most states. The potential for prevention has been enhanced by recent diagnostic and therapeutic advances, and the disease meets widely accepted criteria for reporting, including incidence rates that exceed those of comparable conditions, epidemiologic instability, disease severity, direct and indirect socioeconomic costs, concern by persons at risk, the potential for prevention by public health interventions, and the prospect that the resulting data would influence public health policy. The absence of national surveillance contributes to beliefs by healthcare providers and the public health community that genital and neonatal herpes are uncommon conditions that affect small segments of society, beliefs that directly interfere with prevention. Neonatal herpes should be a reportable condition.

Genital Herpes Complicating Pregnancy

Approximately 22% of pregnant women are infected with herpes simplex virus (HSV)-2, and 2% of women will acquire HSV during pregnancy. Remarkably, up to 90% of these women are undiagnosed because they are asymptomatic or have subtle symptoms attributed to other vulvovaginal disorders. Diagnosis of genital herpes relies on laboratory confirmation with culture or polymerase chain reaction assay of genital lesions and type-specific glycoprotein G-based serologic testing. Neonatal herpes is the most severe complication of genital HSV infection and is caused by contact with infected genital secretions at the time of labor. Maternal acquisition of HSV in the third trimester of pregnancy carries the highest risk of neonatal transmission. Despite advances in the diagnosis and treatment of neonatal herpes, little change in the incidence or serious sequelae from this infection has occurred. As such, prevention of the initial neonatal infection is critically important. Obstetricians are in a unique position to prevent vertical HSV transmission by identifying women with genital lesions at the time of labor for cesarean delivery, prescribing antiviral suppressive therapy as appropriate, and avoiding unnecessary invasive intrapartum procedures in women with genital herpes. Enhanced prevention strategies include identification of women at risk for HSV acquisition during pregnancy by testing women and possibly their partners for HSV antibodies and providing counseling to prevent transmission to women in late pregnancy.

The effects of herpes simplex virus-2 on HIV-1 acquisition and transmission: a review of two overlapping epidemics

Increasing evidence demonstrates a substantial link between the epidemics of sexually transmitted HIV-1 and herpes simplex virus (HSV)-2 infection. More than 30 epidemiologic studies have demonstrated that prevalent HSV-2 is associated with a 2- to 4-fold increased risk of HIV-1 acquisition. Per-sexual contact transmission rates among couples from Rakai, Uganda indicate that at all levels of plasma HIV-1 RNA in the source partner, HSV-2-seropositive HIV-1-susceptible persons have a 5-fold greater risk of acquiring HIV-1 compared with HSV-2-negative persons. In vitro and in vivo studies suggest that mucosal HIV-1 shedding is more frequent and in greater amounts during mucocutaneous HSV-2 replication, including subclinical mucosal reactivations. Most HIV-1-infected persons are coinfected with HSV-2, and most experience frequent subclinical and clinical reactivations of HSV-2. Subclinical HSV reactivation elevates serum HIV-1 RNA levels, and daily therapy with acyclovir appears to reduce plasma HIV-1 RNA. These data show that greater attention to the diagnosis and treatment of HSV-2 among HIV-1-infected persons is warranted, especially those who continue to be sexually active, those not on antiretroviral therapy, or those whose disease is not well suppressed by antiretrovirals.