eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Cytomegalovirus Infection: Follow-up

Author: Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School
Contributor Information and Disclosures

Updated: Nov 18, 2009

Follow-up

Deterrence/Prevention

  • Ultimately, control of cytomegalovirus (CMV) infection, particularly the devastating sequelae of congenital cytomegalic inclusion disease (CID), depends on immunization. The major target population for a cytomegalovirus vaccine is women of childbearing age. Although immunization is unlikely to prevent all congenital infection, immunization will hopefully have a significant and major impact on the prevalence of CID.
  • A vaccine can also be useful in controlling cytomegalovirus disease in organ transplant recipients. A live attenuated vaccine, the Towne vaccine, showed promise for prevention of cytomegalovirus disease in studies involving renal transplant recipients reported in the 1980s. However, the Towne strain of cytomegalovirus is poorly immunogenic, probably because it has been overly attenuated during the process of tissue culture passage.
  • Newer technologies using recombinant chimeric viruses that represent genetic hybrids between Towne virus and a low-passage clinical isolate, the Toledo strain, are currently under investigation as the next generation of live-virus cytomegalovirus vaccines.
  • Subunit vaccine approaches are also being explored. These use molecularly cloned eucaryotically expressed forms of the major immunogenic cytomegalovirus envelope protein, gB, and are being actively investigated in clinical trials.
  • A phase II, placebo-controlled, randomized, double blind trial by Pass et al evaluated a recombinant cytomegalovirus vaccine (envelope glycoprotein B with MF59 adjuvant). Three doses of the cytomegalovirus vaccine or placebo were administered at 0, 1, and 6 months to 464 cytomegalovirus–seronegative women within 1 year after they had given birth. After a minimum of 1 year of follow-up, 49 confirmed infections were noted, 18 in the vaccine group and 31 in the placebo group. One congenital infection among infants of the study subjects occurred in the vaccine group, and 3 infections occurred in the placebo group. Ongoing research continues to evaluate the potential for a cytomegalovirus vaccine to decrease maternal and congenital cytomegalovirus infection.16
  • A vectored vaccine approach in a genetically engineered poxvirus vector, canarypox, is also under evaluation. In addition to gB, this approach targets the major cytotoxic T-cell (CTL) target, the UL83 gene product.
  • Until the goal of a cytomegalovirus vaccine is realized, educating women of childbearing age about the risks of cytomegalovirus and about how to avoid disease transmission are the only control strategies available.
  • Seronegative women who regularly come in close contact with large numbers of young children, particularly in daycare environments, may be at particularly high risk.
  • Behaviors known to be associated with transmission of infection, particularly kissing and sharing eating utensils, can be avoided, and careful handwashing after diaper changes can be stressed.

Patient Education

  • Increased awareness of the complications of congenital cytomegalovirus infection is needed. With a greater educational effort, women of childbearing age can be better prepared to anticipate risk factors for cytomegalovirus transmission during pregnancy.17
  • A national cytomegalovirus registry provides education and support for families affected by congenital cytomegalovirus infection. Contact the National Congenital CMV Disease Registry at Feigin Center, Suite 1150, 1102 Bates Street, MC 3-2371, Houston, TX, 77030-2399, (832) 824-4387, or visit the Web site at http://www.bcm.tmc.edu/pedi/infect/cmv/.
  • Better education of the risks of cytomegalovirus infection for young women is a must. The CDC is also an excellent educational resource.
  • Other foundations provide education and resources for parents interested in learning more about congenital cytomegalovirus, including the CMV Foundation.

Miscellaneous

Medicolegal Pitfalls

  • Neonatal infections
    • Undertaking a complete evaluation for treatable entities in the evaluation of the newborn with stigmata suggestive of congenital infection is important. Thorough serologic evaluation for congenital HIV infection, syphilis, herpes simplex virus (HSV) infection, lymphocytic choriomeningitis virus (LCMV) infection, toxoplasmosis, and congenital cytomegalovirus infection is warranted in any infant with features of TORCH illness (eg, small for gestational age [SGA], microcephaly, unusual exanthemata, organomegaly, thrombocytopenia).
    • The potential for development of sensorineural hearing loss or developmental disability is particularly important. Failure to identify infants who may benefit from early intervention programs or hearing aids could delay institution of useful interventions. If antiviral therapy (ganciclovir) for the neonate proves to be effective for prevention of hearing loss in infants with congenital infection, an indication for treatment of such infants could be forthcoming.
  • Adult infections
    • Relatively few pitfalls tend to be considered in adults with cytomegalovirus infection because such illnesses virtually are always asymptomatic. However, a woman who is cytomegalovirus seronegative and works in a health care or daycare environment presents a special problem. If such women are contemplating pregnancy, questions often arise about risks in the workplace and the responsibility of employers. Such decisions should be made on an institution-by-institution basis.
    • Women who work in daycare centers have never been shown to be at a higher risk for acquisition of cytomegalovirus infection than woman in the general population. Programs that attempt to identify patients with active cytomegalovirus excretion in order to label such babies with precautions, such as "no pregnant caregiver," are not warranted.
    • In every patient-care encounter, consider the possibility of transmission of cytomegalovirus or other pathogens if universal blood and body fluids precautions are ignored.
    • Simply following appropriate precautions is sufficient to protect caregivers. As a matter of policy, no work restrictions are recommended by most experts irrespective of pregnancy status.

Special Concerns

  • Acquisition of primary cytomegalovirus infection during pregnancy is a major concern. Women at high risk include those with extensive daycare contact, particularly individuals who work in large daycare facilities in which repeated exposures are common.18  
  • The added risk, if any, for nurses, physicians, or other health care providers is unclear because studies do not uniformly suggest an increased rate of acquisition of primary infection compared with that reported in the general population.
 


More on Cytomegalovirus Infection

Overview: Cytomegalovirus Infection
Differential Diagnoses & Workup: Cytomegalovirus Infection
Treatment & Medication: Cytomegalovirus Infection
Follow-up: Cytomegalovirus Infection
Multimedia: Cytomegalovirus Infection
References
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References

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Further Reading

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Keywords

cytomegalovirus, CMV, CMV disease, human CMV, HCMV, cytomegalic inclusion disease, CID, cytomegalovirus disease, herpes, congenital cytomegalovirus infection, congenital CMV infection, CMV mononucleosis, treatment, diagnosis, symptoms

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Contributor Information and Disclosures

Author

Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School
Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

David Jaimovich, MD, Chief Medical Officer, Joint Commission International and Joint Commission Resources
David Jaimovich, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Leslie L Barton, MD, Professor, Program Director, Department of Pediatrics, University of Arizona School of Medicine
Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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