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
majorityof
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 clearlyunderstood,’ 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 forpatients
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 34do 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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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 ofpatients
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 isrecoin-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; normalat 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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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
ispresent
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’sHSV
isolate
is similar
to
or
different
from
that
recovered from maternal, family, or personnel
contact.T
6.
Physicians should maintain continuedvigi-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: Herpessiniplex 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 ina 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.
L0RIESubmitted
by Student
From Lone A: The dress code. New York Review of Books November 25, 1976, p 17.