The study was conducted to analyze the role of Cytomegalovirus (CMV), Rubella and Herpes Simplex Virus (HSV-2) as an etiological agent in congenital infections in infants. The study was carried out at National Reference Centre i.e. NCDC, Delhi where samples are referred from various government hospitals of Delhi from the period of January 2013–December 2013. The samples were tested for CMV, Rubella and HSV specific IgM antibodies by μ capture ELISA (Enzyme linked Immunoassay).

1. The study of congenital cytomegalovirus, Rubella and Herpes
Simplex Virus-2 infections in infants

2. Original Article
The study of congenital cytomegalovirus, Rubella
and Herpes Simplex Virus-2 infections in infants
Bhagat Shweta a,*
, Gupta Nupur a
, Arvindan Archana b
,
Gandhok Inderjeet c
, Gupta Suman d
, Baweja Manisha e
, Dutt Thakur f
,
Reza Shakir g
, Khare Shashi h
a
Specialist Grade II (Microbiology), NCDC, India
b
Specialist Grade II (Public Health), NCDC, India
c
Junior Microbiologist, GDDIC, India
d
Research Assistant (Microbiology), NCDC, India
e
Laboratory Assistant (Microbiology), NCDC, India
f
Laboratory Technician (Microbiology), NCDC, India
g
Technical Assistant, GDDIC, India
h
Addl. Director & HOD (Microbiology), NCDC, India
a r t i c l e i n f o
Article history:
Received 12 January 2015
Accepted 3 February 2015
Available online xxx
Keywords:
Rubella
Cytomegaloovirus (CMV)
Herpes simplex virus (HSV)
a b s t r a c t
Aims: The study was conducted to analyze the role of Cytomegalovirus (CMV), Rubella and
Herpes Simplex Virus (HSV-2) as an etiological agent in congenital infections in infants.
Material and methods: The study was carried out at National Reference Centre i.e. NCDC,
Delhi where samples are referred from various government hospitals of Delhi from the
period of January 2013eDecember 2013. The samples were tested for CMV, Rubella and HSV
specific IgM antibodies by m capture ELISA (Enzyme linked Immunoassay).
Results: In children the overall positivity of CMV, Rubella and HSV-specific IgM antibodies
was 20.7%, 5.4%, and 2.3% respectively.
Conclusion: The study indicated that maternal infection with CMV, Rubella and HSV-2 is a
major contributory factor for congenital infections in neonates and infants and therefore
screening for these viruses in early pregnancy should be made mandatory.
Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
The maternal infections are transmissible in utero at several
stages of the pregnancy. These infections are caused by many
organisms of which the members of the TORCH complex,
namely Toxoplasma gondii, Rubella virus, Cytomegalovirus
(CMV), the Herpes Simplex Virus (HSV) occupy prominent
positions.1
These infections are associated with inadvertent
outcomes like multiple abortions, intrauterine fetal deaths,
* Corresponding author. Department of Microbiology, National Centre for Disease Control (NCDC), 22 Shamnath Marg, Civil Lines, Delhi
54, India.
E-mail address: dr.shwetabhagat@yahoo.co.in (B. Shweta).
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1 e4
Please cite this article in press as: Shweta B, et al., The study of congenital cytomegalovirus, Rubella and Herpes Simplex Virus-2
infections in infants, Apollo Medicine (2015), http://dx.doi.org/10.1016/j.apme.2015.02.001
http://dx.doi.org/10.1016/j.apme.2015.02.001
0976-0016/Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.

3. still births, congenital malformations and other reproductive
failures, especially when they are acquired during the first
trimester of the pregnancy. These maternal infections during
the early gestation can result in fetal loss or malformations
because of the ability of the fetus to resist infectious organ-
isms is limited and the fetal immune system is unable to
prevent the dissemination of infectious organisms to various
tissues.2
Human cytomegalovirus (CMV), Rubella Virus and Herpes
Virus are increasingly being recognized as important causes of
congenital infection. Cytomegalovirus is a leading cause of
congenital infections and long-term neurodevelopmental
disabilities among children. Intrauterine transmission of CMV
to the baby can occur irrespective of prior maternal exposure;
whereas rubella if contracted during the first trimester of
pregnancy infects the fetus, leading to congenital rubella
syndrome (CRS). The previous exposure to rubella actually
prevents the virus from crossing the placenta by generating
protective antibodies.3
On the other hand neonatal HSV dis-
ease is most commonly acquired intrapartum or post natally
and can result from primary or recurrent infection.4
The incidence of congenital CMV ranges from 0.5 to 3.0% in
all live births.5
CMV is also linked to late abortions and still
births. The endemicity of the rubella virus has also been
established in India.6
However following the rubella vaccina-
tion, the incidence of Rubella has reduced drastically in
developed countries but in developing countries congenital
Rubella Syndrome (CRS) is still an important cause of
congenital infection in babies. The incidence of neonatal HSV
infection ranges from 1 in 2500 to 1 in 20,000 live births and
two-thirds of cases are caused by HVS-2.7
The present study was carried out to find the incidence of
CMV, Rubella and HSV infection in suspected cases of
congenital infections by detection of virus specific IgM anti-
bodies by enzyme immunoassay (EIA).
2. Material and methods
Samples of babies exhibiting clinical symptoms suggestive of
congenital infection are referred regularly to NCDC (National
Centre For Disease Control), New Delhi, from various gov-
ernment hospitals of Delhi for the diagnosis of RCH (Rubella,
Cytomegalovirus, Herpes Simplex-2) infections.
In this study serum samples of 130 such children up to the
age of 1 year with symptoms suggestive of congenital in-
fections were selected. These samples were received for
routine diagnosis of viral etiology of congenital infections,
from the period January 2013 to December 2013. These chil-
dren presented with one or more of the following clinical
manifestations e fever, pneumonia, jaundice, hep-
atosplenomegaly, facial palsy, encephalitis, microcephaly,
cardiac anomalies, hearing defects, congenital cataract, fever
with rash syndrome, growth retardation, or ascites. The
serum samples were screened for CMV, Rubella and HSV-2
IgM antibodies by commercially available IgM m capture
ELISA kits (Enzy-well DIESSIE Diagnostica Senese SpA).
Interpretation of the results was based on controls pro-
vided with the kit. A test sample was said to be positive for IgM
antibodies when its absorbance value was higher than the
absorbance value of the cut-off control.
Positivity of IgM antibodies against CMV or Rubella or HSV-
2 in a sample indicates active infection of this group of viruses.
The samples belonged to a mixed population of urban and
rural areas.
3. Results
Of the children suspected with congenital infections, CMV,
Rubella, HSV-2 specific IgM antibodies were positive in 27
(20.7%), 7 (5.4%) and 3 (2.3%) cases respectively. The babies
were divided into 3 age groups: 0e29 days, 1 month-6 months
and >6 months to 1 year. Amongst them, the 54 babies
belonged to the age group of new born to one month, 46 were
in the age group of one month to 6 months and 30 were from
>6 months to one year (Table 1 and Fig. 1). Various clinical
features in these positive cases have been compiled in Table 2,
Fig. 2. Among clinical manifestations reported in babies,
hepatosplenomegaly was the most common feature in CMV
positive cases; microcephaly and congenital cataract were
most common symptoms in Rubella positive cases whereas
meningoencephalitis was the most common presenting
feature in HSV-2 cases.
None of the cases was positive for mixed infection.
4. Discussion
This study was conducted to find out the incidence of CMV,
Rubella and HSV-2 in children with suspected intrauterine
infections. The evidence of congenital CMV was seen in 20.7%
of children with suspected congenital infections, which is in
accordance with the earlier studies.8,9
In this study laboratory evidence of Rubella infection in the
form of IgM antibodies was found in 5.4% children of sus-
pected congenital infections. The earlier studies have shown
the declining trend in the incidence of congenital rubella
syndrome from 34.5% in 1988 to 0% in 200210
and is much less
than the earlier reports of 10e20%.11,12
The reason for this
declining trend shown by the most of the recent studies is
Table 1 e Age specific prevalence of Rubella, CMV and
HSV-2 specific IgM antibodies in children.
Age group Serology
performed
No.
tested
IgM
positive
Percent
positivity
0e29 days CMV 54 15 27.7
Rubella 54 2 3.7
HSV-2 54 2 3.7
1 monthe6 months CMV 46 7 15.2
Rubella 46 5 10.9
HSV-2 46 1 2.2
>6 monthse1 year CMV 30 5 16.7
Rubella 30 0 0
HSV-2 30 0 0
Total CMV 130 27 20.7
Rubella 130 7 5.4
HSV-2 130 3 2.3
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1 e42
Please cite this article in press as: Shweta B, et al., The study of congenital cytomegalovirus, Rubella and Herpes Simplex Virus-2
infections in infants, Apollo Medicine (2015), http://dx.doi.org/10.1016/j.apme.2015.02.001

4. increase in immunity to rubella infection in women because
of effective rubella vaccination.
The IgM positivity to HSV in the current study was found to
be 2.3%. There have been limited studies on the incidence of
HSV in children with suspected congenital infections in India.
Various studies have shown the variation in the rate of sero-
prevelance of HSV by geographic location. Also great deal of
variation is seen within regions. Although not enough data is
available regarding incidence and prevalence of HSV-2 in
children from India, studies have shown HSV-2 seropreva-
lences among sexually transmitted diseases clinic at-
tendees13,14
ranging from 43% to 83%, and lower prevalence's
in population-based cross-sectional studies,15e17
from 7.9% to
14.6%. There is a strong association between HSV-2 and HIV
infection. Decrease in HSV-2 prevalence could be because of
adopting HIV risk-reduction strategies, such as limiting the
number of sex partners and using condoms consistently and
correctly. Increasing awareness of the high HSV-2 prevalence
and the link between HSV-2 and HIV infections are important
factors contributing to decrease in HSV-2 seroprevelance.
Multiple prevention strategies used alone or in combination
are potentially useful in limiting acquisition and transmission
of HSV-2.
In our study, significantly higher CMV positivity was seen
in children with hepatosplenomegaly, neonatal cholestasis
and sepsis; whereas in rubella positive cases the most
important clinical manifestation was congenital cataract and
microcephaly. Herpes positive case although very less in
number, had meningoencephalitis as the most common
clinical manifestation. It is well known that congenital CMV
infection usually presents as hepatosplenomegaly, neonatal
cholestasis leading to jaundice, low birth weight, choriortei-
nitis.5
The congenital rubella syndrome usually manifests in
the form of development defects like cataract, microcephaly,
and cardiac defects.18
On the other hand, congenital herpes
infections usually manifests as a localized infection affecting
the skin, eyes, or mouth and as Central nervous system (CNS)
disease in the form of encephalitis.7
Thus the finding of our
present study is in agreement with earlier observation.
Various trials regarding anti-viral treatment of symptom-
atic CMV infections with ganciclovir has shown positive
response in babies. Also stringent actions taken for rubella
vaccination have decreased the incidence of congenital in-
fections with Rubella. Proper management of Sexually
Transmitted Disease which has been taken care of by National
AIDS Control Organization (NACO) guidelines can reduce the
incidence of herpes infections in these babies. Therefore rapid
and correct diagnosis may help the pediatrician to carry
out the appropriate therapeutic treatment and case
management.
The limitation of the study was that only the symptomatic
children were included in the study, and this may not repre-
sent the true incidence of congenital CMV, Rubella or Herpes
infection since it is known that all children infected with these
Fig. 1 e Age specific prevalence of Rubella, CMV and HSV-2 specific IgM antibodies in children.
Table 2 e The clinical profile of congenital infections attributable to CMV, Rubella and HSV-2 infections.
Prominent clinical feature Total no. of positive cases Positive viral etiology
Rubella CMV Herpes
Hepatosplenomegaly 11 1 10 0
Neonatal cholestasis 07 0 7 0
Microcephaly 03 3 0 0
Congenital cataract 02 2 0 0
Bronchopneumonia 04 0 4 0
Meningoencephalitis 03 0 0 3
Sepsis 04 0 4 0
Cardiac abnormality (like PDA) 02 0 2 0
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Please cite this article in press as: Shweta B, et al., The study of congenital cytomegalovirus, Rubella and Herpes Simplex Virus-2
infections in infants, Apollo Medicine (2015), http://dx.doi.org/10.1016/j.apme.2015.02.001

5. viruses may not develop clinical manifestations of the disease
during the early period of life.
5. Conclusion
1. It has been seen from the present study that the Rubella,
CMV and HSV-2 maternal infections are the major
contributory factors for congenital infections in neonates
and infants.
2. Screening of these viruses in early pregnancy should be
made mandatory to decrease the incidence of congenital
malformed babies.
3. Rubella infection is vaccine preventable disease but still
carries a significant disease burden in developing coun-
tries. Therefore rubella vaccination of the childbearing age
females should be included in the national immunization
programme.
Conflicts of interest
All authors have none to declare.
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Fig. 2 e The clinical profile of congenital infections attributable to CMV, Rubella and HSV-2 infections.
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1 e44
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