Transcription:
CMV (Cytomegalovirus)

Tiffany Kaczorowski (Host): Welcome to Inside Pediatrics, a podcast brought to you by Children’s Hospital of Alabama in Birmingham. I'm Tiffany Kaczorowski and today we’re discussing a virus that effects 1 in 200 newborns each year. It’s passed from a pregnant woman to her baby, and 91% of women don’t even know about it. It’s called cytomegalovirus, or CMV for short. We have two guests in the studio today. Dr. Karen Fowler is a professor of pediatrics and epidemiology in the division of pediatric infectious diseases at UAB—the University of Alabama at Birmingham. Her research has focused on CMV infections and CMV related hearing loss in children. Also with us is Dr. Shannon Ross. She is an associate professor of pediatrics and microbiologist also in the division of pediatric infectious diseases at UAB. Dr. Ross sees patients in our infectious diseases clinic at Children’s and she’s also a researcher focusing on CMV and hearing loss. Welcome ladies.

Karen Fowler, Ph.D. (Guest): Thanks.

Shannon Ross, M.D., M.S.P.H (Guest): Thank you.

Host: So June is CMV awareness month and that’s one of the reasons why we’re talking today. As I said in the intro, this is something that most pregnant women do not know about. So what exactly is CMV?

Dr. Ross: So CMV is a virus, cytomegalovirus. It’s actually quite common. Most people at some time in their life will acquire CMV. Most of the time they don’t even know they have acquired it. In most individuals, it doesn’t even cause an illness. What we’re interested in studying, and what is one of the main problems it can cause, is when it is acquired when a woman’s pregnant, she can pass it on to her child and cause the child to have illness.

Host: If a pregnant woman does contract CMV, does have this virus, will she have any outward symptoms? Sniffling, sneezing, any cold like symptoms at all?

Dr. Fowler: She might, but she might not know that she even acquired CMV during pregnancy. So she may not know until the baby is born and the doctor says, “Um, the baby looks a little different or we need to do a test.” And they come back and say the baby has CMV. That’s what a lot of mothers tell us is they didn’t know when. Some women know, but the vast majority it’s asymptomatic or they just didn’t know when they acquired the virus during pregnancy.

Host:   Okay. What are some of the common symptoms at birth or some of the signs that a child does have CMV when they're born?

Dr. Ross: So most children who are born with it actually look completely healthy. So if you take 10 babies with congenital CMV, nine of those babies will look completely normal in the nursery. A small percentage of babies will have symptoms. They can vary. The most common things we see is babies can sometimes have a rash that’s called petechiae, little red spots on the skin. It can sometimes cause their liver or their spleen to be enlarged. This is typically, again, all in the newborn period. It can effect their eyes. You have to detect this by an eye exam, but it can cause problems in the eyes. Their head can be small for their age or their gestational age when they're born. Sometimes they can have even neurologic signs. They may have seizures at birth, rarely, but often times they can.

Host: Okay.

Dr. Fowler: I think probably what most people, if the baby has no symptoms at birth, they have the baby get the newborn hearing screening test that all babies get in the United States. It may come back and say the baby didn’t pass that hearing test. So at that time, it would be important to have a CMV test. Now it doesn’t happen in all hospitals, but it’s beginning to in the United States.

Host:   Okay.

Dr. Fowler: Then the baby comes back, and they’ll say well the baby didn’t pass, and then the baby needs a further diagnostic audiology test or hearing test to confirm because CMV is the leading cause of hearing loss, the non-genetic cause of hearing loss in newborns and young children. So it’s important to be aware of that. So the first time many parents hear about it is when their baby doesn’t pass the hearing test.

Host: That’s right. So let’s talk about newborn screenings and what we do now in the United States, or even around the world, to detect CMV versus what you guys are advocating for or what researchers, scientists, parents, advocates about CMV are pushing for.

Dr. Ross: Right now, for the most part, we don’t actively screen all newborns for CMV. As we mentioned earlier, sometimes in same areas of the U.S., if a baby does refer or they don’t pass their newborn hearing screen, that will sort of alert physicians that they need to look for a congenital CMV. So that’s not everywhere though. That’s just in selected areas around the U.S.

Host:   Okay.

Dr. Ross: But because we know that this is a common virus, really the only way to detect this virus is to test babies in the first few weeks of life. There's more and more interest to screen all newborns for congenital CMV. So this is something that we don’t do, but there is a lot of interest. This is from different parent groups across the country. There’s various parent groups who advocate for CMV who are really for universal screening of all babies, but it’s not routinely done on children now.

Host:   So how do we screen for CMV with newborns?

Dr. Fowler: Right. So one way you can do it is with saliva. It’s easy to collect saliva from a newborn and test them. Because, as Shannon said, it’s very important to test them in the first two to three weeks of life. We also can use urine. Babies shed—that are positive for CMV—shed a lot of virus in their saliva and urine. So those are both good ways. Blood is not so good because not all babies will have virus in the blood.

Host: Okay.

Dr. Fowler: So there has been some interest in the dried blood spots, but so far those tests haven’t shown a high enough sensitivity to be used for screening. Although, if they are positive—if a blood spot is positive—it’s very indicative that the baby has CMV, but it’s not conclusive if it’s negative. Saliva you can have the baby, it will test positive. You can always, if you're concerned about any contamination due to breastmilk for a positive mom, you can follow it up—and you should follow it up—with a diagnostic test by three weeks of age. Usually that’s done with urine. So there are PCR methodology that’s used in most hospital laboratories or there’re also private labs that do this testing. So it’s available all over the country, and most states and hospitals are using it to test babies, if they test the babies.

Host:   Okay. Either or if they fail that newborn screening or fail that hearing test.

Dr. Ross: Right, right. Saliva typically is preferred because it’s so easy to collect. So we usually advocate to get a saliva first, but then you always want to do a confirmation with a saliva or a urine—preferably a urine if it’s positive. The saliva’s so easy to collect on the baby we usually advocate for using that to screen.

Dr. Fowler: You really need two positive tests. You don’t want to start any kind of treatment if you're not 100% certain that this baby has CMV. So that’s very important.

Host: Yeah. That brings up a point. You really need to find out as soon as possible so that you can start some type of intervention and treatment.

Dr. Ross: To diagnose a congenital infection, you’ve got to do it within the first three weeks of life.

Host: Okay. And congenital means they're born with it?

Dr. Ross: They are born with it. Right. It was acquired in the womb.

Host: Okay, alright. So let’s go ahead and talk about some of the treatments that are available for children who acquire CMV.

Dr. Ross: Obviously you know people always ask is there a medication. There is one medication. We call it an antiviral because it works against the virus that is available, but it only treats a subset of patients. So it’s only been tested in the babies who are sicker, the babies we call symptomatic who are born with outward symptom of the infection. Those are the only children we will give the antiviral. It’s called valganciclovir or ganciclovir. We usually need to start it within the first month of life. The reason we give it is that there’s been some studies that have shown it may help—not in all babies, but in some babies—it may help prevent them from having hearing loss or worsening of their hearing loss.

Host: Okay.  

Dr. Ross: And it’s a six month course. But, again, it’s a very small subset of babies that we’re able to give the drug too. There's other treatment modalities, which I think Karen can talk about.

Dr. Fowler: Yeah. So I think, we do know that for most states—and I know in the state of Alabama—that if a baby’s born with CMV, regardless of whether there’s hearing loss or they have symptoms, they qualify for early intervention services in the state. Now those services may vary because obviously some children need many services where others don’t need, but it will help them get what they need, such as routine hearing tests.

So with CMV, you can have hearing loss at birth, but you can also have hearing loss later, which is very unusual for most people. So maybe you have a child who is normal, who looked normal at birth, who tested positive for CMV, and then their hearing is normal. But then at three years of age or four years of age, they develop a unilateral hearing loss. So it’s important for them to have follow up hearing tests routinely, maybe every six months, for the first three or four years of life and then yearly. Or if the parents notice something before then, they should have them tested. That means a good relationship with an audiologist. There's some great audiologists here at Children’s Hospital that test these children. So that’s very important.

So that gets them into early intervention so that you can put a hearing aid on a three month old baby. So if they need it, that’s incredible because they need to begin to develop. They can also then move on to any type of speech, any type of physical therapy that might be needed, and then also later or maybe sooner than later cochlear implants if that’s what they need to improve their hearing and their hearing outcomes.

Host:   Okay. We talked about how 91% of women are not even aware of CMV and its causes and effects. Let’s talk about awareness and prevention. Are OBs talking about this with their patients?

Dr. Fowler: I don’t think that many OBs are talking about it with their patients. We hope there’ll be more of them. I think an OB, to be fair, is very, very busy. So many of them aren’t really aware of the latest information about CMV and that there is some studies that have shown that it looks like there’s ways that they can prevent not all infections, but some. So I think that we need to—I think that we found it that women want to hear from their healthcare providers. They want to hear from them what's important. So I think it’s important for us to continue to educate OBs about CMV as well as women. So I think it’s important to include pediatricians in that too because they have opportunities to talk to moms even before they're pregnant. I think we’ve got to look at other ways to reach out to where women are in social media for them to be aware. Because there’s some things you can do to lessen your risk.

Host:   Let’s go ahead and talk about that. Are there some easy things—just hygiene wise—some easy things that women can do to try to prevent this virus?

Dr. Fowler: Yeah. I think one of the most important things we need to do is encourage women to avoid contact with saliva from young children and babies. Whether it’s their own child, whether it’s their niece or nephew, or whether it’s their friend’s children. So we found that young children in daycares or even in church nurseries that are between zero and three years of age shed a lot of virus. We may not even know that. So they're sharing it with one another, as children like to do, and they like to also share with us. So women acquire it. So it’s important to avoid things like the saliva. Avoid sharing utensils when you're eating, drinks, straws, those types of things. Of course, it’s important not to collect saliva when you're kissing a child. So if you can avoid the straight kisses on the lips, try to stay away from the saliva if you can. Then also, of course, hand-washing’s very important. Also, remember, we talked about you can acquire CMV from saliva and urine, but I think most of us wash out hands after we’re exposed to urine. It’s more the saliva.

Host:   Right, right. When changing a diaper. Right.

Dr. Fowler: Exactly. So those are all important things to do. Of course not sharing toothbrushes, not taking--

Dr. Ross: Popsicles.  

Dr. Fowler: Popsicles.

Host: Or pacifier.

Dr. Ross: Pacifier.

Dr. Fowler: Pacifier.

Host:   That’s one thing. I was thinking about, I mean gosh when my babies were little--

Dr. Ross: Pick it up and clean it off.

Host: Yeah, yeah. You just kind of, if it falls on the floor, you stick it in your mouth and hold it until you can get to a sink to wash it off. So that can be dangerous. I mean…

Dr. Fowler: I think also kind of cleaning up areas. That’s a little bit less direct but wiping up or cleaning up toys that have been slobbered on all day or for all weekend or whatever.

Host:   Right.

Dr. Ross: Right.

Dr. Fowler: That’s especially important when we start to talk about daycares and nurseries and things like that for them to have that type—If they do those types of things, they're going to lower their risk of exposure and children acquiring CMV in those places.

Host:   Okay.

Dr. Ross: It’s important to remember, they only need to do this during pregnancy.

Host: Right, okay.

Dr. Ross: I mean it’s not something they necessarily need to practice when they're not pregnant.

Host: So really, pregnant women are the most at risk because obviously they would pass it on--

Dr. Ross: Pass it on to their baby if they acquire it during pregnancy.

Dr. Fowler: I think it’s important for us also just mention quickly because we haven’t really said this is that just because you're exposed to the virus during pregnancy doesn’t mean that it’s 100% that your baby is going to have the virus. It’s just one in three. But still, you want it to be zero and three is your goal with that.

Host:   Right, absolutely. Now, one of the things that we need to mention is Birmingham is really a mecca for CMV research and has a rich history—UAB has such a rich history dating back to the 1970s with CMV research. That’s one of the reasons why you guys recently hosted a huge international conference here in Birmingham. Do you want to tell us about the conference?

Dr. Ross: Sure. In the CMV field, every two years we have an international conference from scientists to clinicians, all different aspects of people who study the virus come together. Several years ago, we offered and were chosen to host the conference here. One of the reasons was is because there’s been such a long history of CMV study at UAB. Charlie Alford is one of the individuals who started this. He was a division director and he sort of started that legacy. It’s continued now for 50 something years. We had about over 300 international participants from 24 countries get together and talk about the latest advances in research, what needs to be done in research. It was a great event.

Host: You also had some parents there, right, talking about advocacy and ways that they could help move the needle as far as awareness and prevention.

Dr. Fowler: Right. We had parents from all over the country that came through the National CMV Foundation, which is a very active advocacy group. We have a very great relationship with them, and I think it’s been good to work and hear their concerns and try to respond. Because, you know, it’s very frustrating as a parent because researchers are always talking about research. You just want it fixed for your child. So I think they’ve been very positive. We also had parents from Canada and also from the UK. So they were there and they’re very excited also. So there's movements all over the world. They're working on some ad campaigns to educate women. So that’s what they're up to these days

Host:   Wonderful. Some of the researchers who were here for the conference had worked in Dr. Alford’s lab here in Birmingham. Is that right?

Dr. Fowler: Right. So we had people from England, Italy, other parts of the United States who were here who had, in the past, come and worked in the labs at UAB.

Host:   Then, of course, that baton has carried on in the years from his lab in the 1970s now researchers who were here today.

Dr. Fowler: Right. So he brought, not only did people come from far away, but he brought people in too, such as Dr. Sergio Stagno, Dr. Rich Whitley, Dr. Bill Britt, Dr. Bob Pass were some of the first ones that arrived and worked with Charlie Alford and then continued with Dr. Boppana, myself, and of course Shannon and Dr. Kimberlin—David Kimberlin—who’s here now. It continues because we continue to have younger faculty members join us and work with us with CMV. So he’s left us a real legacy in Alabama, an opportunity to really talk about congenital CMV. We wouldn’t be here if he hadn’t had the forethought to pursue this area and to focus on it. He really did care about the children in Alabama.

Host:   Absolutely. Well, if anybody has any interest in learning more about CMV, what are some of the resources, what are some of the places they can go if they want to learn more about?

Dr. Fowler: Well some of the great information the National CMV Foundation has. They have a website and they also are present on social media and on Twitter and Instagram.

Host:   Okay. That website is www.cmvfoundation.org. Well thank you ladies for joining us today.

Dr. Ross: Thank you.

Dr. Fowler: It was great. Thank you.

Host:   We enjoyed it. Thanks for listening to Inside Pediatrics. More podcasts like this one can be found at childrensal.org/insidepediatrics.