Hygiene promotion might be better than serological screening to deal with Cytomegalovirus infection during pregnancy: a methodological appraisal and decision analysis

Abstract

Background: Cytomegalovirus infection is the most frequent viral congenital infection, with possible consequences such as deafness, or psychomotor retardation. In 2016, the French High Council of Public Health was mandated to update recommendations regarding prevention of cytomegalovirus infection in pregnant women. We summarize a critical appraisal of knowledge and deterministic decision analysis comparing the current no-screening situation to serological screening during pregnancy, and to hygiene promotion. Methods: Screening was defined as systematic serological testing, during the first trimester, with repeated tests as needed, to all pregnant women. Outcomes were: 1) severe sequela: intellectual deficiency with IQ ≤ 50 or hearing impairment < 70 dB or sight impairment (≤ 3/10 at best eye); 2) moderate sequela: any level of intellectual, hearing or sight deficiency; and 3) death or termination of pregnancy. We simulated the one-year course of cytomegalovirus infection in a cohort of 800,000 pregnant women. We developed a deterministic decision model, using best and min-max estimates, extracted from systematic reviews or original studies.

Is it time to adopt routine cytomegalovirus screening in pregnancy? No!

“…Unless our settings have addressed the essential components for a screening program 31 (Table 1), the answer should be "no"! For now, we should focus on practicing primary prevention to reduce the prevalence of cCMV 6,14,16 (Figure 3), and conduct the necessary groundwork to determine if the benefits of routine serological screening and treatment outweigh the human and economic costs. Table 1.…”

“…Primary prevention of maternal infection with hygiene precautions is already recommended by the French High Council of Public Health, the US Centre for Disease Control, the Australian government and the UK National Health Service. [11][12][13][14] The maternal seroconversion rate has been estimated at < 2% with maternal education on hygiene precautions compared with 8% without education. 15 This approach has the important advantages of being cheap, universally applicable, and addressing both primary and nonprimary maternal infections.…”

“…32 In addition, IgG avidity assays vary from one laboratory to another, and CMV IgG false positives have also been reported. 14 Hence time and expertise may be required to make or exclude a diagnosis of primary CMV, and what was thought to be primary CMV may later be reclassified on the basis of further serology results. This was the case in 2 patients in the study by Shahar-Nissan et al, where primary infection was ruled out after randomisation.…”

“…52 The French High Council of Public Health recently reviewed its national recommendations for prevention of cytomegalovirus infection in pregnant women and concluded that hygiene promotion alone should be the preferred strategy, and recommended against routine serological screening. 14 In the 2020 publication summarizing their analysis, the working party concluded that routine serological screening would actually result in a 1.66-fold increase in poor outcomes, mostly related to an increase in terminations of pregnancy that were not compensated by the decrease in severe symptomatic newborns. 14 While this analysis did not examine the impact of a valaciclovir for secondary prevention, it clearly concluded that there were significant harms associated with screening for a condition where data on treatment is scarce, and the natural history is uncertain.…”

“…14 In the 2020 publication summarizing their analysis, the working party concluded that routine serological screening would actually result in a 1.66-fold increase in poor outcomes, mostly related to an increase in terminations of pregnancy that were not compensated by the decrease in severe symptomatic newborns. 14 While this analysis did not examine the impact of a valaciclovir for secondary prevention, it clearly concluded that there were significant harms associated with screening for a condition where data on treatment is scarce, and the natural history is uncertain.…”