Herpes _or babys at risk of herpes_ virus infection
Management of neonates with (or at risk of) Herpes virus infection. (HSV+VZV) HSV
HSV infection in the neonate is associated with high morbidity and mortality. Most commonly the infection is acquired at the time of delivery. The highest risk of infection is associated with maternal 1°inf ection due to heavier or more prolonged virus shedding particularly cervical shedding and possibly the absence of transplacental maternal neutralising antibody, which may have a protective effect. Determining risk of virus shedding at delivery by history taking or antepartum sampling is unreliable. In general women with active genital lesions in labour are delivered by caesarean section. Management of infants born either vaginally or by C/S to mothers with active genital lesions
Infants should be nursed in an incubator. Careful attention to basic infection control precautions is essential. Gloves and aprons should be worn when caring for the baby. Hand decontamination should be undertaken before and after patient contact and after removal of gloves. Samples should be collected for HSV culture - Nasopharyngeal aspirate - Urine - Conjunctival Swabs - Skin lesions If the baby is symptomatic (skin lesions, resp distress, seizures, signs of sepsis) in addition to screening samples (above) send blood (EDTA) and CSF for HSV PCR. Appropriate investigations for the diagnosis of bacterial infection should also be performed. Treatment with aciclovir should commence if specimens are positive or symptoms develop. Treatment should continue for 21 days if systemic infection 10-14 days if localised skin lesion only. Asymptomatic babies with negative cultures should continue to be observed closely for development of symptoms particularly skin rashes. Infections may occur up to 4-6 weeks post delivery. Management of infants born to mother with a history of genital herpes but without active lesions.
Infants in this category should be observed closely for signs of infection. Culture and treat as above if symptoms develop. VZV
Varicella (chickenpox) is a highly infectious disease spread by personal contact or droplet spread. Risk of VZ infection of the foetus and neonate relate to the timing of infection in the mother: <20/40 - Congenital varicella syndrome Incidence <1% in first 12 weeks; 2% between 13 – 20 weeks 2nd and 3rd Trimesters – Herpes zoster (shingles) in an otherwise healthy baby. 1 week prior to 1 week after delivery – Severe (possibly fatal) infection in the neonate. In addition babies on the unit may be exposed to VZV by members of staff or visitors incubating or suffering from the infection. Infection in at risk infants can be avoided or ameliorated by the use of specific varicella zoster immunoglobulin (VZIG) and treatment with acyclovir. Action
All members of staff must be aware of their VZ immunity status. A list of immune and non-immune staff should be kept by the ward manager. A vaccine is available from occupational health for those without immunity to VZV. Maternal Exposure
Babies born to mother who develop chickenpox in the period 7 days before to 7 days after delivery should be given VZIG 250 mg i.u. immediately after birth (in small infants more than one site should be used). As this may prevent infection in only approximately 50% of infants close observation of exposed babies should continue for a least 2 weeks. Intravenous acyclovir (10 µg/kg/8hrly) should be initiated if clinical infection occurs. On discharge parents should be advised to seek immediate medical attention if symptoms develop.
The greatest risk is in the period 4 days prior to 2 days post delivery (in instances of short supply VZIG may be restricted to these patients). Intravenous acyclovir should be considered in this patient group even in the absence of clinical disease. Exposed infants should be nursed in incubators and strict barrier nursing precautions applied. Only Health Care Workers known to be immune to VZ should care for these babies. The number of infants nursed in the same room must be minimised. The following infants do not require VZIG or acyclovir.
Infants born more than seven days after the onset of maternal chickenpox.
Infants whose mothers develop Herpes Zoster (shingles) before or after
Nosocomial (Ward) Exposure
If a member of staff, relative or visitor develops chickenpox or shingles the following people should be informed immediately. Shift leader, ward manager, neonatal consultant and infection control doctor. The shift leader will make a list of all babies exposed, their birth gestation and birth weight and if possible the type and time of exposure e.g. close skin or face to face contact, greater than or less than 5 minutes. The infection control doctor in liaison with the neonatal consultant will conduct a risk assessment based on the exposure. Babies born at <28 weeks gestation and/or <1Kg birth weight will be assumed to be VZ antibody negative, for babies older and heavier than this a test of immunity will be performed (either directly or on maternal serum if practicable). The neonatal consultant and infection control doctor will decide which babies should be given VZIG +/- iv aciclovir. All exposed infants should be nursed using the precautions described above and observed closely for at least 2/52 for signs of chickenpox. The neonatal consultant will inform parents of exposed (and non-exposed) babies of the situation. All specimens for viral investigations are submitted to the laboratory at Aintree University Hospital for processing. VZIG is obtained by telephone the laboratory at Aintree and discussing the case with the consultant virologist/microbiologist. A hospital taxi will be required to collect VZIG from Aintree. Aintree laboratory telephone number 0151 529 4900. References
1. Whitely et al. Herpes Simplex Virus Infections In: Infectious Diseases of
the foetus and newborn infant. 6th Ed. 2006 Sanders.
2. Anzivino et al. Herpes simplex virus infection in pregnancy and in
neonate; status of art of epidemiology, diagnosis therapy and prevention. Virology J. 2009 6: 40
3. Sauerbrei et al. Herpes simplex and varicella-zoster virus infections during
pregnancy: current concepts of prevention, diagnosis and therapy. Med Microbiol Immunol 2007 196: 89-102
4. Townsend the rational management of herpes infection in pregnant
women and their newborn infants. Can Med Assoc. J. 1992 146 1557-60.
5. Nathwani et al. Varicella in Pregnancy and the Newborn. Journal of
6. Immunisation against Infectious Disease. 2006 HMSO. September 9th 2009 (version 2-NICU28)
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