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Herpes simplex virus disease in infants younger than 90 days: a British Paediatric Surveillance Unit study
Julia R R Dudley1, Annalie Shears2,3,4, Georgina Yan1,5
1Academic Department of Paediatrics, Royal Alexandra Children's Hospital, Brighton, West Sussex, UK.
Insights
Neonatal herpes simplex virus (HSV) infections in infants under 90 days are common, with delayed treatment leading to poor outcomes. Early empirical testing and treatment are crucial for unwell neonates.
Area of Science:
- Neonatal infections
- Virology
- Epidemiology
Background:
- Herpes simplex virus (HSV) infections in neonates pose a significant health risk.
- Understanding the incidence and clinical spectrum of neonatal HSV is crucial for effective management.
Purpose of the Study:
- To estimate the incidence of HSV infections in infants under 90 days in the UK and Ireland.
- To describe the clinical presentation and outcomes of neonatal HSV infections.
Main Methods:
- Prospective population-based national surveillance study.
- Utilized British Paediatric Surveillance Unit (BPSU) methodology.
- Covered infants under 90 days with confirmed HSV infection from August 2019 to February 2022.
Main Results:
- Identified 6.0 cases per 100,000 live births.
- Disseminated disease (32.5%), CNS disease (35%), and SEM disease (32.5%) were observed.
- High mortality (23.9%) and neurodevelopmental impairment (29.3% at 24 months) were reported, with delayed treatment common.
Conclusions:
- Neonatal HSV can present atypically, without fever or skin lesions, leading to treatment delays.
- Outcomes remain poor, with high case fatality and long-term morbidity.
- Clinicians should maintain a low threshold for empirical testing and treatment of HSV in neonates.
Objective:
Estimate the incidence of herpes simplex virus (HSV) infections in infants under 90 days in the UK and Ireland and describe clinical presentation and outcomes.
Design:
Prospective population-based national surveillance study of infants <90 days with HSV infection, using British Paediatric Surveillance Unit (BPSU) methodology (August 2019-February 2022).
Results:
117 infants with confirmed HSV infection were identified (6.0 cases/100 000 live births (95% CI 4.9, 7.2)). One-third (34.5%) of infants were premature (<37 weeks) and the majority (81.4%) were born to women without a known/disclosed history of genital herpes. Neonatal HSV was classified as disseminated (32.5%), central nervous system (CNS) (35%) or skin, eye, mouth (SEM) (32.5%) disease. Median age at symptom onset was 8 days (IQR 5-13) in all infants (D8 SEM, D14 CNS, D6 disseminated). 56.7% of infants commenced aciclovir >24 hours after symptom onset. Infants with disseminated infections presented with non-specific signs of sepsis: 65.8% were afebrile and 73.7% had no SEM lesions. Median C reactive protein at presentation was 4 mg/L (IQR 1-14). Overall mortality was 23.9%, rising to 65.8% among infants with disseminated disease. Of the 41 infants with follow-up data at 24 months, 29.3% had neurodevelopmental impairment (11.8% SEM, 45% CNS, 25% disseminated).
Conclusions:
Infants with neonatal HSV can present without fever, SEM lesions or elevated infection markers; treatment delay is subsequently common. Outcomes remain poor with high case-fatality rates and long-term morbidity. Clinicians should have a low threshold for empirically testing for and treating herpes in unwell neonates.
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