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PEDIATRICS Vol. 63 No. 2 February 1979

247

Maternal

Oral

Herpes:

Isolation

Policy

Richard L. Schreiner, M.D., Martin B. Kleiman, M.D., and Edwin L. Gresham, M.D.

1ro,i the Department of Pediatrics, Indi(ln(( ( nirersity Se/moo! of ‘sledicine (10(1 ti’ J(lflles %iIut(o,nb Riley iIospit(ll for Children, In(!iauapolis

A BSTRA( ;T. Cmmrrent official recommendations are that

parents amid personnel with oral herpes lesions he isolated

from IieWl)Orfl infants. A survey of 1 10 neonatal centers, 50%

of themii replying, showed that most centers do not isolate

mothers with oral herpes from their newborn infants. A

review of the literature suggests that exposure of infants to

personnel or faniily with oral herpes lesions might

occasion-ally result ill disseminated neonatal herpes simplex virus

disease. Since the separation of a mother from her newl)orn

infant U to 1 week of age is a decision that should not be

taken lightly, more information is urgently needed to decide

whether or IlOt to isolate mothers and hospital personnel

vitli oral herpes lesions froimi newl)orn infants. Recoin

nien-dations to obtain more information concerning these infants

are provided. Pediatrics 63:247-249, 1979. cold sores, herpes simplex, ,meui)orn nursery, nosoconijal injection.

Herpes

simplex

virus

(HSV)

infections

in

the

neWI)orn

are

frequently

devastating,

resulting

in

death

or permanent

CNS

damage.

The

majority

of

infections

are due

to

HSV

type

2 and

apparent-ly are

acquired

during

delivery

through

a

contaIn-mated

birth

canal.

Transmission

of

HSV

from

adults

with

nongenital lesions is less clearly

understood,’ yet is important in instituting

infec-tion control procedures regarding hospital

per-sonnel,

parents,

and

other

people

with

whom

the

infant comes in contact.

The

sixth

edition

of the

American

Academy

of

Pediatrics’ St(1 11(1(1

rds

a nd

Recominenda

tions

for

Hospital

Care

of \Tetvbor;i

Infants

states

that

although there is no direct evidence of transmission of herpes

virus froni adults (mothers or personmiel) to infants in the

neonatal period, compelling indirect evidence suggests that

this tVl)e of transmission can occur. Therefore, the hospital must develop procedures for the protection of newly born

infants from adults (including parents) with herpetic

infec-tion.

The

difference

between

this

infection

control

recommendation and our own policy stimulated

us to search

the

literature

for

possible

cases

of

neonatal

HSV

disease

secondary

to

exposure

to

people

with

active

oral

lesions,

and

to

survey

neonatal

centers

in

this

country

regarding

their

isolation policies.

MATERIALS, METHODS, AND RESULTS

Q

uestionnaires concerning isolation policies for

patients

were

sent

to

1 10 hospitals

with

neonatal

fellowship

training

programs.

Fifty-five

centers

(

50%)

returned

the

completed

questionnaire.

Thirty-five

(64%)

(Table

I)

do

not

separate

a

mother

with

an oral

herpes

lesion

from

her

baby.

Of

the

20

centers

that

do

separate

mother

from

baby,

nine

do so until

the

lesion

forms

a crust

and

11

until

the

lesion

clears

completely.

Eighteen

centers isolate the asymptomatic infant of a

mother

with

oral

herpes

from

other

babies

in the

nursery, whereas 34

do not.

Three

centers

transfer

the

mother

with

an

oral

lesion

off

the

obstetrics

floor

completely.

Of

the

37

centers

discharging

mother

and

baby

together,

35 instruct

the

mother

not

to kiss

her

baby,

and

15 recommend

she

wear

a face mask until oral lesions clear.

DISCUSSION

It is recommended

by

many

authors,

as well

as

by

the

American

Academy

of

Pediatrics,’

that

infants be “protected” from adults with herpetic

lesions.

That

exposure

to oral

herpes

lesions

may

result in neonatal infection is based on isolated

case reports and the higher percentage of type 1

HSV

infection

in neonates

than

can

be

accounted

for

by

the

incidence

of HSV

genital

infections

in

females.

Table

II sunimanizes

1 1 cases

of disseminated

neonatal

HSV

disease

in

which

there

was

expo-sure

to a person

with

nongenital

HSV

infection.

Received May 5; revision accepted for publication July 7, 1978.

ADDRESS FOR REPRINTS: (R.L.S.) Department of Pediat-rics, Indiana University School of Medicine, 1 100 \Vest Michigan Street, Indianapolis, IN 46202.

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(2)

248

MATERNAL

ORAL HERPES

TABLE I

RESULTS OF SURVEY

No. of

Hospitals

(N = 55)

Yes No

Isolate mother from baby 20 35

Until lesion clears 1 1 ...

Until lesion scabs 9 ...

Isolate babies from other

babies in nursery 18 34

Transfer mother off obstetrics floor 3 50 Allow mother and baby to go home together 37 14

Instruct mother not to kiss baby 35 ...

Instruct mother to use face mask 15 ...

In nine

of these,

the

contact

had

oral

lesions.

The

HSV

type

was

recorded

in

only

four

of

these

incidences;

all

were

type

1.

In

an

extensive

review

of

neonatal

herpes

infections,

27%

of

neonates

had

infection

with

type 1 disease, while the incidence of recognized

type 1 genital lesions in females

was

only

8%.

However,

more

recent

data

from

Wolontis

and

J

eansson suggest that approximately one third of

patients

15 to 24 years

of age

have

infection

in the

genital

area

with

type

1. In this

study,

the

overall

percent

of

type

1 HSV

responsible

for

genital

infection

in

females

of

all

ages

was

16%.

The

higher

incidence

of type

1 infection

in

younger

women

who

give

birth

to

most

of

the

infants

might

explain

the

higher

percentage

of

type

1

infections

in neonates.

Chang

et al’ also

reported

that

genital

disease

produced

by

type

1 serotype

has

increased

from

7% to 13.5% in recent years.

Thus,

the

data

are

suggestive,

but

certainly

equivocal,

that

mothers

with

oral

herpes

lesions

may

infect

their

newborn

infants.

Separation

of a

mother

from

her

newborn

may

adversely

affect

the

establishment

of

a satisfactory

mother-child

relationship.

Of

greater

economic

impact

is the

questionable

necessity

of

removing

personnel

with

cold

sores

from

nurseries.

The

difference

between

the

guidelines

of the

American

Academy

of Pediatrics’

and

the

isolation

protocols

used

by

academic

institutions

suggests

that

more

data

are

required

before

recommendations

based

on

objec-tive

evidence

may

be

formulated.

RECOMMENDATIONS

To

obtain

more

information

concerning

the

epidemiology

and

potential

nosocomial

source

of

infection

of neonatal

HSV

infection,

it is

recoin-mended

that

physicians

perform

the

following

in

every case of neonatal HSV infection:

1.

Determine

through

the

State

Board

of

Health,

medical

school,

or

other

laboratory

the

location

of facilities

for

culturing

and

typing

HSV

for

that

particular

geographical

area.

2. Obtain typing of

all

newborn

HSV

isolates.

TABLE II

CASES OF NONGENITALLY ACQUIRED HERPES SIMPLEX VIRUS (HSV) INFECTION

Source HSV Type Age at Exposure Outcome

Onset

Wolontis & 1 10 days Mother: oral lesion Skin lesions

I

eansson only; normal

at 6 mo

J

ack & Perry ?

?

?

?

Nurse: oral lesion

Mother: oral lesion 3 days before delivery

? ?

Francis et al 2 6 wk ? Indirect contact with

another neonate with HSV type 2 disease

Died

Bellanti et al’’ 1 18 wk 4-year-old sibling: oral lesion 7 days prior to illness

Died

Bird et al’ ?

?

?

7 days

10 days

5 days

15-year-old sibling: oral lesion 1 wk earlier Maternal grandmother: oral

lesion 6 days earlier Mother: oral lesion 1 day

after delivery

Died

Died

Died

Kurtz & Sykes’2 1 6 days Hospital staff: oral lesion Died Linnemann et a17 1

1

5 days 7 days

Father: oral lesion Above patient

Normal at 1 yr

Died

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(3)

ARTICLES

249

3.

Obtain

genital

cultures

and

typing

of HSV

on mothers of

all

infants

with

neonatal

HSV

infection,

even

if no

obvious

genital

lesion

is

present

on

the mother.

4.

If there

is a contact

(personnel,

family,

or

other) with

a herpetic

infection

or cold

sore,

viral

cultures

and

typing

should

be obtained.

5.

To

identify

the

strain

as

type

1 or

type

2

HSV,

enzyme

restriction

assays

of

HSV

DNA

should

be performed to determine if the infant’s

HSV

isolate

is similar

to

or

different

from

that

recovered from maternal, family, or personnel

contact.T

6.

Physicians should maintain continued

vigi-lance

of pregnant

women

in the

third

trimester

for

genital

HSV

infection

and

provide

appro-priate obstetrical management

of

these

patients

to prevent the vast majority of neonatal HSV

infections.

REFERENCES

I. Nahmias AJ, Visimitine AM, Reimer GB, et al: Herpes SimIll)ICX virus infection of the fetus and newl)orn, in

Krugmiian 5, Cershon AA (eds): Infections of the

1’etu.s (iii(I the Vewborn Infant. New York, Alan R

Liss, mc, 1975, vol 3, p 63.

2. \ld({;allllmfl FO, Partridge JW: Fetal-maternal

relation-ships in herpes simplex. Arch Dis Child 43:265, 1968.

3. Standards and Recommendations for Hospital Care of Newborn infants, ed 6. Evanston, Ill, American

Academy of Pediatrics, 1977.

4. Nahmias AJ, Roizman B: Infection with herpes-simplex

vinises 1 and 2. N Engi

I

Med 289:781, 1973.

5. Wolontis 5, Jeansson 5: Correlation of herpes simplex

virus types 1 and 2 with clinical features of

infec-tion.

I

Infect Dis 135:28, 1977.

6. Chang T, Fiumara NJ, Weinstein L: Genital

herpes-some clinical and laboratory observations.

JA.IA 229:544, 1974.

7. Linnemann CC Jr, Buchman TG, Light IJ, et al:

Transniission of herpes-simplex virus type I in a

nursery for the newborn, identification of viral isolates by DNA “fingerprinting.” Lancet 1:964,

1978.

8. Jack I, Perry JW: Herpes simplex infection in the

new-born. Med

I

AUSI 1 :640, 1959.

9. Francis DP, Herrmann KL, MacMahon JR. et al:

Noso-comial and maternally acquired herpesvirus

homin-is infections. Am

I

Dis Child 129:889, 1975. 10. Bella,iti JA, Catalano LW, Chambers RW: Herpes

siniplex encephalitis: Virologic and serologic study

of a patielit treated with an interferon inducer. I Pediatr 78: 136, 1971.

I 1. Bird T, Ennis JE, Wort AJ, et al: Disseminated herpes

simplex in newborn infants.

I

C/in Pathol 16:423,

1963.

12. Kurtz JB, Sykes DW: Herpes-simplex virus (type 1)

transmitted to a neonate. Lancet 1:1580, 1974.

THE VOICE OF FASHION

The

voice

of fashion

has not

fallen

silent;

rather

it screams in

a thousand

languages

and

dialects.

. .

. . . its symbolic language has now become overlaid with printed verbal

messages.

T-shirts

advertise

favorite

products,

cultured

tastes

(VILLAGE

VOICE,

JEFFERSON

STAR-SHIP),

political

opinions,

membership

in real

or

imaginary

organizations

(HARVARD

UNIVERSITY,

OLYMPIC

SCREWING

TEAM),

real

or

imaginary

personality

(FOXY

LADY,

MALE

CFIAUVINIST

PIG),

sexual

preference

(GAY

POWER,

EAT

ME),

and

current

mood

(SMILE,

BLUE

MONDAY).

...

. . . according to my teenage son, the very brand of blue jeans worn in junior

high

school

is a sign:

“Freaks

always

wear

Lees,

greasers

wear

Wranglers,

and

everyone else wears Levis.”

A.

L0RIE

Submitted

by Student

From Lone A: The dress code. New York Review of Books November 25, 1976, p 17.

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(4)

1979;63;247

Pediatrics

Richard L. Schreiner, Martin B. Kleiman and Edwin L. Gresham

Maternal Oral Herpes: Isolation Policy

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(5)

1979;63;247

Pediatrics

Richard L. Schreiner, Martin B. Kleiman and Edwin L. Gresham

Maternal Oral Herpes: Isolation Policy

http://pediatrics.aappublications.org/content/63/2/247

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1979 by the

been published continuously since 1948. Pediatrics is owned, published, and trademarked by the

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has

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