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West Nile virus (WNV) is a single-stranded RNA flavivirus with antigenic
similarities to Japanese encephalitis and St. Louis encephalitis viruses.
It is transmitted to humans primarily through the bites of infected mosquitoes.
Flavivirus infection during pregnancy has been associated rarely with both
spontaneous abortion and neonatal illness but has not been known to cause
birth defects in humans.1-4 During
2002, a total of 4,156 cases of WNV illness in humans, including 2,946 cases
of neuroinvasive disease, were reported to CDC by state health departments.
In 2002, a woman who had WNV encephalitis during the 27th week of her pregnancy
delivered a full-term infant with chorioretinitis, cystic destruction of cerebral
tissue, and laboratory evidence of congenitally acquired WNV infection.5,6 Although this case demonstrated
intrauterine WNV infection in an infant with congenital abnormalities, it
did not prove a causal relation between WNV infection and these abnormalities.
During 2002, CDC investigated three other instances of maternal WNV infection.
In all three cases, the infants were born at full term with normal appearance
and negative laboratory tests for WNV infection; cranial imaging studies and
ophthalmologic examinations were not performed. During 2003, CDC received
reports of approximately 9,100 cases of WNV illness, including approximately
2,600 cases of neuroinvasive disease.* CDC is gathering data on pregnancy
outcomes for approximately 70 women with WNV illness during pregnancy (CDC,
unpublished data, 2003).
To develop guidelines for evaluating infants born to mothers who acquire
WNV infection during pregnancy, on December 2, 2003, CDC convened a meeting
of specialists in the evaluation of congenital infections. This report summarizes
the interim guidelines established during that meeting.
No specific treatment for WNV infection exists, and the consequences
of WNV infection during pregnancy have not been well defined. For these reasons,
screening of asymptomatic pregnant women for WNV infection is not recommended.
Pregnant women who have meningitis, encephalitis, acute flaccid paralysis,
or unexplained fever in an area of ongoing WNV transmission should have serum
(and cerebrospinal fluid [CSF], if clinically indicated) tested for antibody
to WNV. If serologic or other laboratory tests indicate recent infection with
WNV, these infections should be reported to the local or state health department,
and the women should be followed to determine the outcomes of their pregnancies.
If WNV illness is diagnosed during pregnancy, a detailed ultrasound
examination of the fetus to evaluate for structural abnormalities should be
considered no sooner than 2-4 weeks after onset of WNV illness in the mother,
unless earlier examination is otherwise indicated. Amniotic fluid, chorionic
villi, or fetal serum can be tested for evidence of WNV infection. However,
the sensitivity, specificity, and predictive value of tests that might be
used to evaluate fetal WNV infection are not known, and the clinical consequences
of fetal infection have not been determined. In case of miscarriage or induced
abortion, testing of all products of conception (e.g., the placenta and umbilical
cord) for evidence of WNV infection is advised to document the effects of
WNV infection on pregnancy outcome.
When an infant is born to a mother who was known or suspected to have
WNV infection during pregnancy, clinical evaluation is recommended (see sidebar 1 ). Further evaluation should be considered
if any clinical abnormality is identified or if laboratory testing indicates
that an infant might have congenital WNV infection (see sidebar 2 ).
Pregnant women who live in areas with WNV-infected mosquitoes should
apply insect repellent to skin and clothes when exposed to mosquitoes and
wear clothing that will help protect against mosquito bites. In addition,
whenever possible, pregnant women should avoid being outdoors during peak
mosquito-feeding times (i.e., usually dawn and dusk).
E Hayes, MD, D O'Leary, DVM, Div of Vector-Borne Infectious Diseases,
National Center for Infectious Diseases; SA Rasmussen, MD, Div of Birth Defects
and Developmental Disabilities, National Center on Birth Defects and Developmental
Neither the proportion of WNV infections during pregnancy that result
in congenital infection nor the spectrum of clinical abnormalities associated
with congenital WNV infection is known. However, one case reported in 2002
suggests that intrauterine transmission of WNV in certain instances might
affect the newborn adversely. To evaluate the possible effects of WNV infection
during pregnancy, CDC is gathering clinical and laboratory data on outcomes
of pregnancies of women who were known or suspected to be infected with WNV
during pregnancy. Guidance on diagnosis of WNV can be obtained from local
or state health departments and from CDC, telephone 970-221-6400. Guidance
also is available at http://www.cdc.gov/ncidod/dvbid/westnile/resources/fact_sheet_clinician.htm. Clinicians are encouraged to report cases of WNV infections in pregnant
women to their state or local health departments or CDC.
This report is based on contributions by JM Friedman, PhD, Univ of British
Columbia, Vancouver, Canada. K Jones, MD, Univ of California, San Diego. M
Abzug, MD, The Children's Hospital and Univ of Colorado School of Medicine,
Denver; J Paisley, MD, Poudre Valley Hospital, Fort Collins; W Tyson, MD,
Presbyterian/St. Luke's Hospital, Denver; M Wheeler, MD, Univ of Colorado
Health Sciences Center, Denver; J Pape, Colorado Dept of Public Health and
Environment. M Mets, MD, Children's Memorial Hospital, Chicago, Illinois.
W Allan, MD, Foundation for Blood Research, Scarborough, Maine. C Meissner,
MD, Tufts New England Medical Center, Boston, Massachusetts. J Bale, MD, Univ
of Utah and Primary Children's Medical Center, Salt Lake City, Utah. J Rutledge,
MD, Children's Hospital and Regional Medical Center, Seattle, Washington.
J Brown, DVM, G Campbell, MD, S Kuhn, R Lanciotti, PhD, A Marfin, MD, S Montgomery,
DVM, L Petersen, MD, Div of Vector-Borne Infectious Diseases, National Center
for Infectious Diseases; J Cordero, MD, J Mulinare, MD, National Center on
Birth Defects and Developmental Disabilities, CDC.
*Data as of February 18, 2004.
Interim Guidelines for the Evaluation of Infants Born to Mothers Infected With West Nile Virus During Pregnancy. JAMA. 2004;291(12):1436–1438. doi:10.1001/jama.291.12.1436
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