Transmission Of Herpes Simplex Virus Research Articles

Herpes simplex virus: the importance of asymptomatic shedding

Herpes simplex virus (HSV) is frequently shed after infection of the genital or perianal area. HSV shedding, as determined by culture, occurs on about 3% of days for immunocompetent women and men, and more for persons with HIV infection or if measured by polymerase chain reaction (PCR). Most horizontal and vertical transmission of HSV occurs during unrecognized or asymptomatic shedding, and the majority of HSV-2-infected persons are unaware of their infection. Many persons with 'asymptomatic' HSV-2 infection can learn to recognize genital signs and symptoms as recurrences of HSV-2 infection. However, some shedding episodes remain truly asymptomatic even after patient education. Antiviral therapy dramatically reduces asymptomatic shedding, and trials to evaluate its effect on HSV transmission are underway.

Public Health Strategies to Prevent Genital Herpes: Where Do We Stand?

At least 25% of the United States population has overt or subclinical genital herpes simplex virus (HSV) infection, and herpes probably is the sexually transmitted disease of greatest concern to sexually active persons, aside from AIDS. In addition to its direct clinical and psychosexual complications, genital herpes is an important determinant of sexual transmission of HIV. Genital herpes is usually transmitted by persons with subclinical infection, whether entirely asymptomatic or with unrecognized symptoms. Although the composition and efficacy of a national genital herpes prevention program are in debate, clinicians should adopt a public health perspective in managing patients to help prevent transmission. Specific approaches include accurate diagnosis of genital ulcer disease by routine use of virologic tests for HSV; use of type-specific serologic tests to diagnose subclinical HSV infection in patients' sex partners and others at high risk; counseling patients to recognize symptoms and defer sex with uninfected partners when symptomatic; and serologic testing and counseling of pregnant women and their partners to prevent neonatal herpes. Antiviral chemotherapy may be effective in preventing herpes-related cesarean sections, and its efficacy in preventing sexual transmission of HSV is under study.

Neutralizing antibodies inhibit axonal spread of herpes simplex virus type 1 to epidermal cells in vitro.

The ability of antibodies to interfere with anterograde transmission of herpes simplex virus (HSV) from neuronal axons to the epidermis was investigated in an in vitro model consisting of human fetal dorsal root ganglia innervating autologous skin explants in a dual-chamber tissue culture system. The number and size of viral cytopathic plaques in epidermal cells after axonal transmission from HSV type 1 (HSV-1)-infected dorsal root ganglionic neurons were significantly reduced by addition to the outer chamber of neutralizing polyclonal human sera to HSV-1, of a human recombinant monoclonal group Ib antibody to glycoprotein D (gD), and of rabbit sera to HSV-1 gB and gD but not by rabbit anti-gE or anti-gG. A similar pattern of inhibition of direct infection of epidermal cells by these antibodies was observed. High concentrations of the monoclonal anti-gD reduced transmission by 90%. Rabbit anti-gB was not taken up into neurons, and human anti-gD did not influence spread of HSV in the dorsal root ganglia or axonal transport of HSV antigens when applied to individual dissociated neurons. These results suggest that anti-gD and -gB antibodies interfere with axonal spread of HSV-1, possibly by neutralizing HSV during transmission across an intercellular gap between axonal termini and epidermal cells, and thus contribute to control of HSV spread and shedding. Therefore, selected human monoclonal antibodies to protective epitopes might even be effective in preventing epidermis-to-neuron transmission during primary HSV infection, especially neonatal infection.

New therapies and prevention strategies for genital herpes.

Genital herpes is among the most prevalent sexually transmitted diseases. Optimal management of genital herpes includes accurate diagnosis, antiviral therapy, and counseling of patients about complications and transmission of herpes simplex virus (HSV). Antiviral therapy offers significant palliation, and the option of episodic or suppressive treatment should be offered to all patients with genital herpes. Valacyclovir and famciclovir are two newer antiviral agents that are effective and safe for the treatment of genital herpes. Prevention strategies for sexual and perinatal transmission of HSV have not been well defined. Availability of type-specific serological tests for HSV antibodies may assist in identifying persons at risk for acquiring or transmitting HSV infection. Further research is needed to define strategies to prevent the spread of this epidemic infection.

The axonal transmission of herpes simplex virus to epidermal cells: a novel use of the freeze substitution technique applied to explant cultures retained on cover slips.

Retaining the ultrastructural arrangement of a mixed-cell culture on a solid support while processing for immunocytochemical study is a technical challenge. We developed a technique to study the axonal transport of the Herpes simplex virus from dorsal root ganglia sensory neurones to epidermal cells. Autologous explants of human foetal dorsal root ganglia and skin were cultured on plastic cover slips. Axon fascicles grew from the ganglia to the epidermal cells and the ganglia were inoculated selectively with virus. The whole preparation, retained on the cover slip, was fixed with formaldehyde 4% (freshly prepared from paraformaldehyde)/glutaraldehyde 0.1%, processed by freeze substitution, and embedded in Lowicryl HM20 resin. The edges of the cover slip in the block were trimmed, allowing clean and complete separation from the resin block, which retained the tissue. The resin block was placed in fresh HM20 and repolymerized. The polymerizing resin bonded strongly to the existing block. After trimming, serial sections were easily obtained and successfully immunolabelled for viral proteins. This is a convenient technique for immunolabelling tissue grown on cover slips in which the preservation of the ultrastructural interactions between different cells is important. It should be adaptable to a number of cell-culture applications and has a number of advantages over other techniques.

Genital herpes infection: a review.

Genital herpes infection is life-long and may result in painful and recurrent genital lesions, systemic complications, serious psychosocial morbidity, and rare but serious outcomes in neonates born to infected women, including permanent neurological handicap and death. Herpes simplex virus (HSV)-2 is the principal cause, with an increasing proportion of first-episode disease caused by HSV-1. Genital HSV transmission is usually due to asymptomatic viral shedding by people who are unaware that they are infected and clinical screening fails to detect most infections. Type-specific serological assays can distinguish the two viral subtypes, but these are expensive and currently restricted to a few research settings. Most infections are asymptomatic, or cause a mild illness which does not lead to health service attendance; but the limited evidence suggests a rise in disease incidence, perhaps related to a fall in HSV-1 age-specific prevalences. The prevalences of HSV genital infections increase with age and numbers of sexual partners, with higher rates in specific ethnic and low socioeconomic groups. However, infection is not restricted to high-risk populations. Antiviral agents, such as acyclovir, can reduce disease severity, prevent recurrences and shorten periods of viral shedding, but currently there are no effective population control measures. This may change with the advent of HSV vaccines, if their safety and long-term efficacy are confirmed. Possible applications for vaccines may include the suppression of disease and recurrences in patients with genital infections (immunotherapy), the prevention of viral transmission to their seronegative partners, and immunoprevention through vaccinating the latter. Economic evaluations of existing and potential control strategies, age-specific population HSV-1 and 2 seroprevalence studies for targeting future interventions, and cohort studies to elucidate the natural history of HSV-2 infections are needed.

High interferon alpha levels in placenta, maternal, and cord blood suggest a protective effect against intrauterine herpes simplex virus infection.

Interferons (IFN) are produced by the placenta during pregnancy, and they can be detected in the maternal and fetal blood. Although the antiviral potential of IFNs is well established, it remains unclear whether the IFNs associated with pregnancy can prevent transplacental spread of viral infection. The present study was undertaken in order to determine the possible protective effect of placentally produced IFN-alpha on fetal acquisition of herpes simplex virus (HSV). Nine mothers with a known history of genital HSV infection were studied. In five cases IFN-alpha was detected in the placenta, maternal, and fetal blood, whereas in three cases IFN-alpha could not be detected. in the remaining case, IFN-alpha was found only in the maternal blood. As corroborated by the serological evidence of early HSV infection in the cord blood, the single case of vertical HSV transmission was observed in the group of IFN nonproducers. Furthermore, virus transmission did not occur in cases where IFN-alpha was present in the placenta and simultaneously in the maternal and fetal circulations. Thus, the present data indicate that high levels of IFN during pregnancy may protect the fetus from acquiring a possibly fatal intrauterine HSV infection.

Vertical transmission of herpes simplex virus acquired after primary outbreak in second trimester of a dichorionic twin gestation

Background The incidence of genital herpes simplex virus (HSV) has increased in recent years, particularly among women of reproductive age. This places more neonates at risk for severe morbidity and mortality. Treatment recommendations for primary disease in pregnancy are lacking, particularly for those who acquire HSV remote from term. Purpose A patient at 17 weeks of gestation carrying dichorionic twins developed primary herpes with subsequent vertical transmission of the virus and significant neonatal morbidity. Conclusion Data regarding risks and benefits of treatments such as acyclovir and immunoprophylaxis are lacking at a time when the incidence of HSV infection is on the rise. Infect. Dis. Obstet. Gynecol. 5:380–385, 1997. © 1998 Wiley-Liss, Inc.

Role of mannose-6-phosphate receptors in herpes simplex virus entry into cells and cell-to-cell transmission.

Herpes simplex virus (HSV) glycoprotein D (gD) is essential for virus entry into cells, is modified with mannose-6-phosphate (M-6-P), and binds to both the 275-kDa M-6-P receptor (MPR) and the 46-kDa MPR (C. R. Brunetti, R. L. Burke, S. Kornfeld, W. Gregory, K. S. Dingwell, F. Masiarz, and D. C. Johnson, J. Biol. Chem. 269:17067-17074, 1994). Since MPRs are found on the surfaces of mammalian cells, we tested the hypothesis that MPRs could serve as receptors for HSV during virus entry into cells. A soluble form of the 275-kDa MPR, derived from fetal bovine serum, inhibited HSV plaques on monkey Vero cells, as did polyclonal rabbit anti-MPR antibodies. In addition, the number and size of HSV plaques were reduced when cells were treated with bovine serum albumin conjugated with pentamannose-phosphate (PM-PO4-BSA), a bulky ligand which can serve as a high-affinity ligand for MPRs. These data imply that HSV can use MPRs to enter cells; however, other molecules must also serve as receptors for HSV because a reasonable fraction of virus could enter cells treated with even the highest concentrations of these inhibitors. Consistent with the possibility that there are other receptors, HSV produced the same number of plaques on MPR-deficient mouse fibroblasts as were produced on normal mouse fibroblasts, but there was no inhibition with PM-PO4-BSA with either of these embryonic mouse cells. Together, these results demonstrate that HSV does not rely solely on MPRs to enter cells, although MPRs apparently play some role in virus entry into some cell types and, perhaps, act as one of a number of cell surface molecules that can facilitate entry. We also found that HSV produced small plaques on human fibroblasts derived from patients with pseudo-Hurler's polydystrophy, cells in which glycoproteins are not modified with M-6-P residues and yet production of infectious HSV particles was not altered in the pseudo-Hurler cells. In addition, HSV plaque size was reduced by PM-PO4-BSA; therefore, it appears that M-6-P residues and MPRs are required for efficient transmission of HSV between cells, a process which differs in some respects from entry of exogenous virus particles.

Seroprevalence of herpes simplex virus infections in a family medicine clinic.

To determine the prevalence of herpes simplex virus (HSV) antibody in a general medical practice setting and to assess the frequency of subclinical infection. Prevalence study. A family practice clinic at the University of Washington Medical Center, Seattle. Five hundred randomly selected patients between the ages of 18 and 45 years. Serum samples were tested by Western blot assay to detect the presence of antibody to HSV type 1 (HSV-1) and HSV-2. Demographic information and clinical history of oral and genital herpes were obtained. One hundred fourteen patients (23%) were seropositive for HSV-2 antibody, 277 patients (56%) were seropositive for HSV-1 antibody, 59 patients (12%) were seropositive for both HSV-2 and HSV-1 antibodies, and 163 patients (33%) were seronegative for both. Women were almost twice as likely as men to be seropositive for HSV-2 antibody (28% vs 15%, P < .001). Blacks had the highest rates of HSV-2 antibody seropositivity (60%) compared with whites (20%) and Asians (6%) (P < .001). Other demographic correlates of seropositivity included being older, having fewer years of education, and having public insurance. The specificity of a clinical history of genital herpes or sores for HSV-2 infection was high (99%), but the sensitivity was low (27%). Herpes simplex virus infection is common among patients seeking primary care. Women, blacks, and patients of lower socioeconomic status are most likely to be seropositive for HSV-2 antibody. The high frequency of unrecognized HSV infection has implications for primary care physicians in counseling patients regarding HSV infection and transmission.

Frequent Detection of Genital Herpes Simplex Virus DNA by Polymerase Chain Reaction Among Pregnant Women

Objective. —To investigate the prevalence and level of genital herpes simplex virus (HSV) among women at delivery. Design, Patients, and Setting. —A prospective analysis of HSV by culture and by polymerase chain reaction (PCR) of genital specimens and by HSV serologic studies in 100 asymptomatic women in labor; prospective analysis of HSV by PCR among 50 seronegative nonpregnant women at a student health center; and retrospective analysis of genital specimens for HSV by PCR from 17 HSV culture-positive women with uninfected neonates and from two HSV culture-negative women with HSV-infected neonates. All pregnant women were at a university hospital. Main Outcome Measures. —Presence of HSV by culture and levels of HSV by quantitative, type-specific PCR in cervical and vulvar specimens; HSV serologic testing by Western blot. Results. —All of the 100 asymptomatic women in labor who were studied prospectively were HSV culture negative. In nine HSV was recovered by PCR. Herpes simplex virus was recovered by PCR in one of the 50 seronegative nonpregnant women; she soon became seropositive. All 17 culture-positive women had HSV recovered by PCR. High levels of HSV DNA were obtained by PCR from the two culture-negative women with infected neonates. Among those from whom HSV was recovered by PCR, HSV DNA levels were 250 times higher from culture-positive samples than from culture-negative samples (11 571 genome equivalents vs 46 genome equivalents;P Conclusions. —The frequency of infant exposure to HSV DNA—containing secretions from HSV-seropositive mothers is about eight times higher than previously reported using HSV culture methods. High maternal levels of HSV DNA may be associated with an increased frequency of transmission of HSV to the infant. (JAMA. 1994;272:792-796)

Maternal transmission of HSV underestimated?

The frequency of infant exposure to secretions containing herpes simplex virus (HSV) from seropositive women might be eight times higher than previously estimated and might be associated with an increased frequency of transmission.

Frequent Detection of Genital Herpes Simplex Virus DNA by Polymerase Chain Reaction Among Pregnant Women

To investigate the prevalence and level of genital herpes simplex virus (HSV) among women at delivery. A prospective analysis of HSV by culture and by polymerase chain reaction (PCR) of genital specimens and by HSV serologic studies in 100 asymptomatic women in labor; prospective analysis of HSV by PCR among 50 seronegative nonpregnant women at a student health center; and retrospective analysis of genital specimens for HSV by PCR from 17 HSV culture-positive women with uninfected neonates and from two HSV culture-negative women with HSV-infected neonates. All pregnant women were at a university hospital. Presence of HSV by culture and levels of HSV by quantitative, type-specific PCR in cervical and vulvar specimens; HSV serologic testing by Western blot. All of the 100 asymptomatic women in labor who were studied prospectively were HSV culture negative. In nine HSV was recovered by PCR. Herpes simplex virus was recovered by PCR in one of the 50 seronegative nonpregnant women; she soon became seropositive. All 17 culture-positive women had HSV recovered by PCR. High levels of HSV DNA were obtained by PCR from the two culture-negative women with infected neonates. Among those from whom HSV was recovered by PCR, HSV DNA levels were 250 times higher from culture-positive samples than from culture-negative samples (11,571 genome equivalents vs 46 genome equivalents; P < .001). The frequency of infant exposure to HSV DNA-containing secretions from HSV-seropositive mothers is about eight times higher than previously reported using HSV culture methods. High maternal levels of HSV DNA may be associated with an increased frequency of transmission of HSV to the infant.

Axonal transport of herpes simplex virions to epidermal cells: evidence for a specialized mode of virus transport and assembly.

To examine the transmission of herpes simplex virus (HSV) from axon to epidermal cell, an in vitro model was constructed consisting of human fetal dorsal root ganglia cultured in the central chamber of a dual-chamber tissue culture system separated from autologous skin explants in an exterior chamber by concentric steel cylinders adhering to the substratum through silicon grease and agarose. Axons grew through the agarose viral diffusion barrier and terminated on epidermal cells in the exterior chamber. After inoculation of HSV onto dorsal root ganglia, anterograde axonal transport of glycoprotein and nucleocapsid antigen was observed by confocal microscopy to appear in exterior chamber axons within 12 h and in epidermal cells within 16 h, moving at 2-3 mm/h. Although both enveloped and unenveloped nucleocapsids were observed in the neuronal soma by transmission electron microscopy, only nucleocapsids were observed in the axons, closely associated with microtubules. Nodule formation at the surface of HSV-infected axons, becoming more dense at the axon terminus on epidermal cells, and patches of axolemmal HSV glycoprotein D expression were observed by scanning (immuno)electron microscopy, probably representing virus emerging from the axolemma. These findings strongly suggest a specialized mode of viral transport, assembly, and egress in sensory neurons: microtubule-associated intermediate-fast anterograde axonal transport of unenveloped nucleocapsids with separate transport of glycoproteins to the distal regions of the axon and assembly prior to virus emergence at the axon terminus.

Herpes simplex virus infections of women and their offspring: implications for a developed society.

Herpes simplex virus infections of humans have been known since ancient times. Contemporary society has witnessed a series of devastating manifestations of herpes simplex virus infections--namely, genital herpes simplex virus infection and neonatal herpes simplex virus infection. With the evolution of society, particularly advances in birth control and increasing promiscuity, the seroprevalence of herpes simplex virus type 2 infections has increased worldwide, however, more so in developed societies. As a consequence, individuals of child-bearing age are at risk for either reactivation of herpes simplex virus at termination of gestation or acquisition of a new primary infection at that time. The consequences of vertical transmission of herpes simplex virus from mother to child, resulting in neonatal herpes simplex virus infection, can be devastating. Current efforts, which are directed toward the treatment of neonatal herpes, have established the value of drugs such as vidarabine and acyclovir. However, the real emphasis for future programs is the prevention of herpes simplex virus infections to avoid person-to-person transmission either horizontally or vertically. The development of vaccines directed against herpes simplex virus may be of value toward this end.

Nosocomial herpes simplex virus infection associated with oral endotracheal intubation

Background: To determine by culture the frequency of herpes simplex virus reactivation complicating oral endotracheal intubation. Additionally, clinical appearance and recognition of patient infection by attendant health care workers were studied. Last, evidence of any occupational acquisition of herpes simplex virus infection was sought. Methods: In a prospective, non-randomized study, three serial viral cultures were taken of oro-facial or mucosal sites on the day of oral endotracheal intubation and in the subsequent 3rd and 5th or 7th days from 51 consecutive adults undergoing oral endotracheal intubation in a suburban community hospital. Clinical variables including appearances of lesions and therapeutic interventions were noted during serial assessments by study authors. Employee health records were reviewed for evidence of health care worker occupational herpes simplex virus infection associated with these cases. Results: Of 51 patients, 4 were culture positive on the day of oral endotracheal intubation. Of the remaining 47 patients, serial cultures during the first week post intubation revealed herpes simplex virus in 25 (53.2%) patients. Of cohort variables studied, a history of prior oral herpes simplex virus was significantly associated with a subsequent positive viral culture for herpes simplex virus (relative risk, 2.29; 95% confidence interval, 1.48 to 3.56). Typical or atypical lesions were visible in only 52% of the herpes simplex virus culture-positive cases. No occupational transmission of herpes simplex virus was detected. Tape-securing practices appeared to contribute to the morbidity of herpes simplex virus eruptions. Conclusions: Nosocomial reactivation of herpes simplex virus infection complicated oral endotracheal intubation in our patient population in approximately one half of the patients who were intubated for more than 48 hours during the first week after the procedure. Clinically, the infection was recognizable in only one half of the virus culture-positive cases. Increased awareness of this infection is needed by health care workers, patients, and families. More information is needed on optimal therapy and prevention.

Risk of Acquisition of Genital Herpes Simplex Virus Type 2 in Sex Partners of Persons with Genital Herpes: A Prospective Couple Study

In a prospective study of factors associated with genital herpes simplex virus (HSV) type 2 transmission in couples in whom 1 partner had clinical genital HSV and the other did not, 11 (19%) of the 57 history-negative partners had HSV-2 antibody by Western blot at entry. In follow-up (mean, 16 months) of 29 HSV-2-seronegative partners, overall 4 (14%) seroconverted compared with 3 (23%) of 13 HSV-1- and -2-seronegative partners and 1 (6%) of 16 HSV-1-seropositive partners. Since all seroconverters were women, the risk of transmission may be higher in HSV-seronegative women. No significant differences were found between HSV-2-seronegative partners and seroconverters regarding duration of relationships, number of partner recurrences, intercourse frequency, or contraceptive method. However, 2 seroconverters were exposed to lesions without barrier contraception. This study suggests that infection is commonly asymptomatic and that although the overall risk of genital HSV transmission in couples is low (10%/year), the risk may be significantly increased in women and in seronegative individuals.

Risk factors for the sexual transmission of genital herpes.

To determine the risk of sexual transmission of genital herpes simplex virus (HSV) in heterosexual couples. Prospective study of couples who were participants in a clinical trial. Each source partner had symptomatic, recurrent genital HSV, and each susceptible partner was without serologic or clinical evidence of genital herpes. Couples were followed for a median of 334 days. Two university-based research clinics. One hundred forty-four heterosexual couples were studied out of an initial enrollment of 214 couples. Development of culture-proven HSV infection or type-specific antibodies in the susceptible partner. Transmission occurred in 14 (9.7%) couples, including 11 (16.9%) of 65 couples with male and 3 (3.8%) of 79 with female source partners (P = 0.05). The annual rate of acquisition was higher (31.8%) in susceptible female partners who lacked antibodies to either HSV type 1 or 2 at entry compared with females with HSV type 1 antibodies at entry (9.1%). Couples avoiding transmission of HSV reported fewer days with genital lesions in source partners. Detailed histories were available at the time of transmission in 13 couples. In nine couples, transmission occurred when the source partner was reported to be asymptomatic and in four, it resulted from sexual contact at the time of prodrome (1 case) or within hours before lesions were first noticed by the source partner (3 cases). Despite clear recognition of genital herpes in source partners, there was substantial risk for transmission; in 70% of patients, transmission appeared to result from sexual contact during periods of asymptomatic viral shedding. The risk for acquisition of HSV was higher in women than men, and previous HSV type 1 infection appeared to reduce the risk for acquisition of HSV type 2 infection among women.

Relationships between maternal immunity to herpes simplex virus and the risk of neonatal herpesvirus infection.

Current seroepidemiologic studies performed with assays that measure type-specific antibodies to herpes simplex virus (HSV) type 2 have demonstrated that infection due to the virus is common among women of child-bearing age. With regard to perinatal transmission of HSV, the virus infects nearly 50% of infants whose mothers have primary genital herpes, whereas less than 5% of infants exposed to recurrent maternal infection at the time of delivery become infected. Maternal immunity may also influence the clinical manifestations of neonatal herpes, with primary maternal infection more likely to be associated with disseminated disease in the infant. An effective HSV vaccine could alter the prevalence of neonatal herpes by (1) reducing women's risk of acquiring primary genital herpes during pregnancy and (2) boosting immunity in mothers for whom serologic evidence of previous infection due to HSV type 2 has been noted, which will enhance the transplacental transfer of virus-specific antibodies.

General Discussion and Future Directions

The National Institute of Allergy and Infectious Diseases (NIAID) considers herpes simplex virus (HSV) vaccines an important priority. Our primary purpose in organizing this meeting was to generate discussion about the kinds of research the herpes vaccine research community considers important to pursue and to obtain a sense of the state of the science. We have done this through the presentations and now have the opportunity to share some thoughts you have about what needs to be accomplished in the future. We face an enormous challenge in the next few yearsnamely the identification of the resources to support this research. To a certain degree, we can redistribute some resources internally but it will still be a major challenge. The budgetary situation of the federal government is rather severe, and we have to be as forceful, energetic, and articulate as possible in developing arguments for obtaining the resources required to achieve our goals. Returning to Dr. Bernard Roizman's introductory comments, we first ought to discuss what the goals for an HSV vaccine might be. There is obvious interest in preventing infection and disease, and an interest in using such a vaccine to decrease rates of HSV transmission. Attenuated vaccines