Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey Dr. Gerit Solveig Korr, MSc DTMH IUSTI, Marrakech, 10th May 2016

10th May Herpes simplex type 2 (HSV2) infections  High disease burden:  50-80% of genital lesions worldwide  orolabial Herpes  neonatal infections  facilitation of HIV acquisition as well as HIV transmission  Lifelong infection  Often asymptomatic Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

10th May Epidemiology of HSV2 Germany:  No mandatory notification  Disease burden unknown  Survey :  HSV2 seroprevalence 13.3%  higher HSV2 seroprevalence in women who lived in former East Germany  higher HSV2 seroprevalence in age group who lived in former East Germany Europe:  Large intercountry and intracountry differences in HSV2 prevalence (range 4 – 24 %) Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

10th May Study Objectives  Assess HSV2 seroprevalence of adults in Germany based on a representative nationwide survey in  Identify factors which are associated with positive serostatus …To develop appropriate prevention & control strategies Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

10th May German health interview and examination survey for adults  Representative data on adult German population  Combined cross-sectional and longitudinal survey  8,151 participants, Nov Dec 2011  Two-step sampling: 180 study communities  participants  Questionnaire and examination part  Focus on non-communicable diseases old sample sites new sample sites Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey German reunification in 1990

10th May Methods  Laboratory Methods:  Type-specific HSV2 (gG2) indirect ELISA assay (DiaSorin) on serum samples of 5013 study participants  Epidemiological Methods:  Pearson’s chi-squared test  Prevalence ratios (PR) using log-binomial regression, uni- and (if p<0.2) multivariable analysis  Survey weights used throughout the analysis Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

10th May HSV2 seroprevalence according to sex and age, Germany total HSV2 seroprevalence: 9.4 % (95% CI ) Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

10th May HSV2 seroprevalence in women, Germany , according to age and region of residence in 1988 Women who lived in the former East of GermanyWomen who lived in the former West of Germany Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

10th May HSV2 seroprevalence in men, Germany , according to age and region of residence in 1988 Men who lived in the former East of Germany Men who lived in the former West of Germany * * No HSV2 positives Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

10th May Factors associated with positive HSV2 IgG Serostatus, Germany Variablecrude prevalence ratio (95% CI) adjusted prevalence ratio (95 % CI) female gender1.6 ( ) 1.5 ( ) age group (years) 18-24reference ( ) 5.7 ( ) ( ) 8.4 (2.0-35) ( ) 12.9 ( ) ( ) 11.1 ( ) lived in former East Germany1.5 ( ) 1.3 ( ) marital status singlereference married2.0 ( ) divorced4.3 ( ) 1.7 ( ) widowed2.9 ( ) HSV1 IgG positivity1.5 ( ) Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

10th May Limitations  No knowledge about time, site and state of infection (sero-positivity doesn't reflect clinical symptoms)  Survey did not include sufficient questions on sexual behaviour  HIV status or affiliation to risk groups not known Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

10th May Conclusions  HSV2 infections in Germany are common  Women more likely to be HSV2 seropositive  Increasing HSV2 seroprevalence with age  Higher seroprevalences in women who lived in former East Germany  Compared to previous survey, lower HSV2 seroprevalence Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

10th May Recommendations  Raise awareness for infection, mode of transmission and prevention, not only among the young  Clinicians should be aware of HSV2 as differential diagnosis for genital ulcers not only in young age groups  Improve survey with respect to examination of sexual behaviour to identify groups at risk  Studies to explore different situation in East Germany Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

Robert Koch Institute, Berlin Postgraduate Training for Applied Epidemiology Irina Czogiel Christian Winter Katharina Alpers Unit 34 - HIV, STI & bloodborne infections Klaus Jansen Viviane Bremer Unit 22 – Epidemiology Laboratory Michael Thamm Unit 25 – Physical Health Christiane Poethko-Müller 10th May 2016 Acknowledgements all study participants funding: German Ministry of Health Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

10th May Back up slides Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

Representativeness of HSV2 samples 10th May 2016 *ISCED International standard classification of education Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

10th May 2016 Questions on marital status and sexual behaviour  Which marital status do you have? (married & living together/married & not living together/single/divorced/widowed)  Do you have a fixed partner? (yes/no)  How many sexual partners did you have in the last 12 months? (both sexes; absolute number) men only:  Do you use condoms for sexual intercourse? (yes, generally/yes, occasionally/no/n/a) women only:  Did you ever use the pill? (yes->how many years; no)  Are you currently using contraceptives? (yes-> pill/condoms/diaphragm/contraceptive coil/natural methods/other; no)  ever been pregnant (yes->live births/still births/abortions; no) Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

10 th May 2016 Number of samples tested Examination survey: 7237 No serum samples taken or insufficient amount of blood: 2224 HSV2 tests: 5013 Total participants: 8151 Questionnaire only: 914 Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey

Variablep-value Gender> Age> Marital status> Abortion Federal state HSV1 positive North-South Stillbirth East-West Condom use (men only)0.016 General state of health Place of residence in Smoking Tiredness in last 4 weeks Variablep-value BMI Dermatologist in last 12 months Number of inhabitants Size of community Alcohol consumption Urologist in last 12 months Counselling sexual behaviour Chlamydia positive Ever depression Fixed partner Number sex partners last 12 months Language of questionnaire Counselling alcohol consumption Immunsuppressiva Socioeconomic status Univariable Analysis HSV2 IgG 10th May 2016 Herpes Simplex Virus Type 2 infections in Germany : Results of a nationwide seroprevalence survey