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Πέμπτη 6 Ιουλίου 2017

CANCON to set consensus guidelines for Advanced Head and Neck Cancer management - BSI bureau (press release)


CANCON to set consensus guidelines for Advanced Head and Neck Cancer management
BSI bureau (press release)
The Head and Neck Oncologists at Cytecare Cancer Hospital in association with The Foundation for Head and Neck Oncology, Association of Otolaryngologists of India & Bangalore Chapter and Association of Oral and Maxillofacial Surgeons of India ...


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Sleep in neurological disorders, sleep apnea, sleep duration and body weight



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Issue Information



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Free-flap surgical correction of facial deformity after anteromedial maxillectomy

Free-flap surgical correction of facial deformity after anteromedial maxillectomy: Summary

Anteromedial maxillectomy is typically performed in conjunction with low-dose radiotherapy and intraarterial chemotherapy. In doing so, the extent of surgical defects is reduced. However, nasal deviation and oral incompetence may ensue, due to cicatricial contracture of wounds, and may be distressing to these patients. Herein, we report a series of eight free perforator flap procedures (anterolateral thigh [ALT] flap, 6; thoracodorsal artery perforator [TAP] flap, 2) used to correct such deformities. The TAP flap was combined with scapular tip [ST] osseous flap in patients with added zygomatic prominence defects. Three adipocutaneous parts developed from each perforator flap were applied as follows: two to reconstruct nasal lining and oral vestibule, and one to augment cheek volume. All aesthetic results proved satisfactory, although orbital dystopia and contracture of mimic muscles were not resolved completely. These secondary interventions are suitable for sequelae of simple anteromedial maxillectomy. Immediate reconstruction should be considered if orbital floor and mimic muscles are involved.


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Use of fused deposit modeling for additive manufacturing in hospital facilities: European certification directives

Use of fused deposit modeling for additive manufacturing in hospital facilities: European certification directives: The goal of this study was to identify current European Union regulations governing hospital-based use of fused deposit modeling (FDM), as implemented via desktop three-dimensional (3D) printers.




Materials and Methods

Literature and Internet sources were screened, searching for official documents, regulations/legislation, and views of specialized attorneys or consultants regarding European regulations for 3D printing or additive manufacturing (AM) in a healthcare facility. A detailed review of the latest amendment (2016) of the European Parliament and Council legislation for medical devices and its classification was performed. It has regularly updated published guidelines for medical devices, which are classified by type and duration of patient contact. As expected, regulations increase in accordance with the level (I-III) of classification.

Results

Custom-made medical devices are subject to different regulations than those controlling serially mass-produced items, as originally specified in 98/79/EC European Parliament and Council legislation (1993) and again recently amended (2016). Healthcare facilities undertaking in-house custom production are not obliged to fully follow the directives as stipulated, given an exception for this scenario (Article 4.4a, 98/79/EC).

Conclusion

Patient treatment and diagnosis with the aid of customized 3D printing in a healthcare facility can be performed without fully meeting the European Parliament and Council legislation if the materials used are ISO 10993 certified and article 4.4a applies.


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Grammatical Morphology in Monolingual and Bilingual Children With and Without Language Impairment: The Case of Dutch Plurals and Past Participles

Grammatical Morphology in Monolingual and Bilingual Children With and Without Language Impairment: The Case of Dutch Plurals and Past Participles:

Purpose
Grammatical morphology is often a locus of difficulty for both children with language impairment (LI) and bilingual children. In contrast to previous research that mainly focused on verbal tense and agreement markings, the present study investigated whether plural and past participle formation can disentangle the effects of LI and bilingualism and, in addition, can point to weaknesses of LI that hold across monolingual and bilingual contexts.

Method
Monolingual and bilingual children with and without LI (n = 33 per group) were tested at 2 waves with a word formation task that elicited Dutch noun plurals and past participles. The quantity and quality of errors as well as children's development over time were examined.

Results
The plural formation task discriminated between monolingual children with and without LI, but a less differentiated picture emerged in the bilingual group. Moreover, plural accuracy showed fully overlapping language profiles of monolinguals with LI and bilinguals without LI, in contrast to accuracy scores on the past participle formation task. Error analyses suggested that frequent omission of participial affixes may be indicative of LI, irrespective of lingual status.

Conclusion
The elicited production of past participles may support a reliable diagnosis of LI in monolingual and bilingual learning contexts.

Supplemental Material
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Measuring Explicit Word Learning of Preschool Children: A Development Study

Measuring Explicit Word Learning of Preschool Children: A Development Study:

Purpose
The purpose of this article is to present preliminary results related to the development of a new measure of explicit word learning. The measure incorporated elements of explicit vocabulary instruction and dynamic assessment and was designed to be sensitive to differences in word learning skill and to be feasible for use in clinical settings.

Method
The explicit word learning measure included brief teaching trials and repeated fine-grained measurement of semantic knowledge and production of 3 novel words (2 verbs and 1 adjective). Preschool children (N = 23) completed the measure of explicit word learning; standardized, norm-referenced measures of expressive and receptive vocabulary; and an incidental word learning task.

Results
The measure of explicit word learning provided meaningful information about word learning. Performance on the explicit measure was related to existing vocabulary knowledge and incidental word learning.

Conclusions
Findings from this development study indicate that further examination of the measure of explicit word learning is warranted. The measure may have the potential to identify children who are poor word learners.

Supplemental Material
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Fish as bioindicators for trace element pollution from two contrasting lakes

 in the Eastern Rift Valley, Kenya: spatial and temporal aspects:

Abstract

Lake Turkana and Lake Naivasha are two freshwater lakes in the Kenyan Rift Valley that differ significantly in water chemistry and anthropogenic influence: Lake Turkana is believed to be rather pristine and unpolluted, but a previous study has shown rather high levels of Li, Zn, and Cd in the migratory fish species Hydrocynus forskahlii, questioning this pristine status. Lake Naivasha is heavily influenced by agricultural activity in its catchment area and by direct water use, and high levels of metal pollutants have been reported in fish. This study presents the distribution of nine important trace elements in liver and muscle of the nonmigratory red belly tilapia Tilapia zillii from Lake Turkana and from Lake Naivasha (before and after a significant rise in water level due to as yet not fully understood reasons). In addition, trace element levels in the common carp Cyprinus carpio from Lake Naivasha are presented. Metal concentrations measured in the liver and muscle of T. zillii collected in Lake Turkana confirm the pristine status of the study site, but contrast with the results obtained for the migratory H. forskahlii. Comparing T. zillii from the two lakes reveals a clear difference in accumulation patterns between essential and nonessential trace elements: physiologically regulated essential elements are present in a very similar range in fish from both lakes, while levels of nonessential metals reflect short- or long-term exposure to those elements. The comparison of trace element concentrations in the fish samples from Lake Naivasha showed lower levels of most trace elements after the significant increase of the water level. This study demonstrates that fish are valuable bioindicators for evaluating trace element pollution even in contrasting lakes as long as the way-of-life habits of the species are taken into account.



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Reorganization of gene network for degradation of polycyclic aromatic hydrocarbons (PAHs) in Pseudomonas aeruginosa PAO1 under several conditions

Reorganization of gene network for degradation of polycyclic aromatic hydrocarbons (PAHs) in Pseudomonas aeruginosa PAO1 under several conditions:

Abstract

Although polycyclic aromatic hydrocarbons (PAHs) are harmful to human health, their elimination from the environment is not easy. Biodegradation of PAHs is promising since many bacteria have the ability to use hydrocarbons as their sole carbon and energy sources for growth. Of various microorganisms that can degrade PAHs, Pseudomonas aeruginosa is particularly important, not only because it causes a series of diseases including infection in cystic fibrosis patients, but also because it is a model bacterium in various studies. The genes that are responsible for degrading PAHs have been identified in P. aeruginosa, however, no gene acts alone as various stresses often initiate different metabolic pathways, quorum sensing, biofilm formation, antibiotic tolerance, etc. Therefore, it is important to study how PAH degradation genes behave under different conditions. In this study, we apply network analysis to investigating how 46 PAH degradation genes reorganized among 5549 genes in P. aeruginosa PAO1 under nine different conditions using publicly available gene coexpression data from GEO. The results provide six aspects of novelties: (i) comparing the number of gene clusters before and after stresses, (ii) comparing the membership in each gene cluster before and after stresses, (iii) defining which gene changed its membership together with PAH degradation genes before and after stresses, (iv) classifying membership-changed-genes in terms of category in Pseudomonas Genome Database, (v) postulating unknown gene's function, and (vi) proposing new mechanisms for genes of interests. This study can shed light on understanding of cooperative mechanisms of PAH degradation from the level of entire genes in an organism, and paves the way to conduct the similar studies on other genes.



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Functionality of temporary isolation rooms


S01966553.gif
Publication date: Available online 6 July 2017
Source:American Journal of Infection Control
Author(s): Brett G. Mitchell, Anthony Williams, Zorana Wong
BackgroundChallenges with limited single rooms and isolation facilities in hospitals have created an opportunity for temporary, portable isolation technology. This article describes the process used to evaluate the prototype of a new isolation room (RediRoom; CareStrategic Ltd, Brisbane, Queensland, Australia) that can be installed in existing hospital ward areas. Our aim is to assess the functionality of this new room, and in so doing, to evaluate the methods used.MethodsWe employed a mixed-methods approach involving video recording, interviews, and objective temperature and humidity measurements within a crossover interventional study. Participants completed a range of clinical activities in the RediRoom and a control. The setting for the study was a clinical ward environment at an Australian higher education institution.ResultsThere were similarities between the RediRoom and the control using a range of measures. The time taken to complete a range of clinical activities in both rooms was broadly consistent. Network analysis also suggested broad similarities in the movement of nurses undertaking activities in both rooms.ConclusionOur study attempted to simulate a clinical environment and clinical activities and provide the best possible comparison by completing activities sequentially, with immediate feedback to researchers. Video recording added significant value to the process because it provided some objectivity. A form of reflexive ethnography with participants could be of value in similar studies in the future.


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Risk factors for development of surgical site infections


S01966553.gif
Publication date: Available online 6 July 2017
Source:American Journal of Infection Control
Author(s): Ramon Antônio Oliveira, Ruth Natália Teresa Turrini, Vanessa de Brito Poveda
BackgroundSurgical site infection (SSI) is an important complication in the postoperative period of recipients of liver transplantation. The purpose of this integrative literature review is to summarize the knowledge available about the risk factors contributing to the development SSI among adults undergoing liver transplantation.MethodsWe reviewed the Medical Literature Analysis and Retrieval System Online/PubMed, the Cumulative Index to Nursing and Allied Health Literature, the Latin American and Caribbean Health Sciences Literature, Scopus, and Web of Science databases.ResultsTwo hundred sixteen articles were identified and the final sample of 9 articles was analyzed in full length. The SSI rate found in the investigations ranged between 9.6% and 35.5%. Risk factors for SSI were grouped into categories related to the preoperative period, such as Model for End-Stage Renal Disease score > 35 and ventilated support on day of transplant; to the intraoperative period activity, such as transfusion of packed red blood cells, extended surgical time, hyperglycemia >200 mg/dL, use of vasopressor drugs, and ascites flow 1 L; and to the donor/recipient relationship, such as age differences >10 years, ratio of donor liver mass to recipient body mass < 0.01. Additionally, centers that annually perform 50>


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Stress-responsively modulated ymdAB-clsC operon plays a role in biofilm formation and apramycin susceptibility in Escherichia coli

Stress-responsively modulated ymdAB-clsC operon plays a role in biofilm formation and apramycin susceptibility in Escherichia coli:

Abstract
The YmdB protein, an inhibitor of biofilm formation and an inducer of apramycin susceptibility in Escherichia coli (E. coli), is part of a putative operon. However, transcription of this operon and its subsequent effects on biological pathways has not been fully studied. Here, we characterized the operon in terms of promoter activity, transcription and function. Promoter activity assays identified two new growth- and cold-shock-responsive upstream (PymdA) and inner (PclsC) promoters, respectively. Moreover, investigation of the operon-derived transcripts identified different polycistronic transcripts harboring multiple heterogeneous 3΄ ends. Overexpression of YmdA or ClsC proteins inhibited biofilm formation and affected apramycin susceptibility, a process dependent on the sucA gene, suggesting that the operon genes or their encoded proteins are functionally linked. Additional investigation of the effects of polycistronic transcripts on the response of E. coli cells to apramycin revealed that transcripts containing ymdA (–213 to +27) are required for apramycin susceptibility. Thus, ymdAB-clsC is a new stress-responsive operon that plays a role in inhibiting undesired biofilm forming and antibiotic-resistant bacterial populations.




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Herpes simplex infections (HSV1/2) are characterized by recurrent symptoms, a risk of neonatal herpes, and the facilitation of HIV transmission. In Germany, HSV1/2 infections are not notifiable and data are scarce. A previous study found higher HSV1/2 seroprevalences in women in East Germany than in women in West Germany. We assessed changes in the HSV1/2 seroprevalences over time and investigated determinants associated with HSV1/2 seropositivity to guide prevention and control.



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Decreasing seroprevalence of herpes simplex virus type 1 and type 2 in Germany leaves many people susceptible to genital infection: time to raise awareness and enhance control

BMC Infectious DiseasesBMC series – open, inclusive and trusted201717:471
DOI: 10.1186/s12879-017-2527-1
©  The Author(s). 2017
Received: 17 November 2016
Accepted: 6 June 2017
Published: 6 July 2017

Abstract

Background

Herpes simplex infections (HSV1/2) are characterized by recurrent symptoms, a risk of neonatal herpes, and the facilitation of HIV transmission. In Germany, HSV1/2 infections are not notifiable and data are scarce. A previous study found higher HSV1/2 seroprevalences in women in East Germany than in women in West Germany. We assessed changes in the HSV1/2 seroprevalences over time and investigated determinants associated with HSV1/2 seropositivity to guide prevention and control.

Methods

The study was based on the German Health Interview and Examination Survey for Adults (DEGS; 2008–2011) and the German National Health Interview and Examination Survey (GNHIES; 1997–1999). We tested serum samples from DEGS participants for HSV1 and HSV2 immunoglobulin G. We used Pearson's χ2 test to compare the HSV1/HSV2 seroprevalences in terms of sex, age, and region of residence (East/West Germany) and investigated potential determinants by calculating prevalence ratios (PR) with log-binomial regression. All statistical analyses included survey weights.

Results

In total, 6627 DEGS participants were tested for HSV1, and 5013 were also tested for HSV2. Overall, HSV1 seroprevalence decreased significantly from 1997–1999 (82.1%; 95%CI 80.6–83.6) to 2008–2011 (78.4%; 95%CI 77.8–79.7). In the same period, overall HSV2 seroprevalence decreased significantly from 13.3% (95%CI 11.9–14.9) to 9.6% (95%CI 8.6–10.8), notably in 18–24-year-old men (10.4 to 0%) in East Germany. Women were more likely than men to be seropositive for HSV1 (PR 1.1) or HSV2 (PR 1.6). A lower level of education, smoking, and not speaking German were associated with HSV1 in both sexes. Women of older age, who smoked, or had a history of abortion and men of older age or who had not attended a nursery school during childhood were more often seropositive for HSV2.

Conclusion

The reduced seroprevalences of HSV1 and HSV2 leave more people susceptible to genital HSV1/2 infections. Practitioners should be aware of HSV infection as a differential diagnosis for genital ulcers. We recommend educational interventions to raise awareness of the sexual transmission route of HSV1/2, possible consequences, and prevention. Interventions should especially target pregnant women, their partners, and people at risk of HIV.

Keywords

Herpes simplex Herpes genitalis Health survey Seroepidemiology Germany

Background

Herpes simplex virus is the main cause of genital ulcers worldwide [1]. Both Herpes simplex virus 1 (HSV1) and Herpes simplex virus 2(HSV2) infect the epithelial cells of the skin and mucosa through minor breaks, and then travel by retrograde transport to the sensory root ganglia, where they persist throughout life [2]. Most new infections remain undiagnosed because they are asymptomatic or cause only short-lived symptoms [3]. Clinical lesions typically occur after a primary infection in about 10–25% of infections [4]. Reactivation from the latent state results in the release of the virus from the surface of the skin or mucosa, which is called 'shedding' [5]. Viral shedding can occur with or without symptoms and leads to further transmission [4]. The specific tropism of the virus means that HSV1 predominantly infects the orolabial tissue and is transmitted by contact with infected saliva, which often occurs early in life [6]. HSV2 typically infects the genitalia and is transmitted through sexual contact. However, in recent decades, an increasing proportion of genital HSV infections have been caused by HSV1 [7, 8, 9]. Two main developments have been suggested to be responsible for this trend: an increased proportion of adolescents and young adults who are HSV1 negative and therefore more susceptible to the acquisition of HSV1 through the sexual route, and an increased frequency of oral sex [10].
The classic clinical presentation of genital herpes infection is characterized by erythematous papules and vesicles on the external genitalia with pain, itching, burning, and, especially in women, dysuria [1]. About 40% of symptomatic men and 70% of symptomatic women present with fever, headache, malaise and myalgias. Complications include aseptic meningitis, extragenital lesions and autonomic dysfunction including urinary detention. Genital herpes can be associated with psychosocial consequences including anger, low self-esteem, fear of rejection by sexual partners, and depression.
Approximately 57 and 89% of individuals with a history of primary HSV1 or HSV2 infection, respectively, experience symptomatic HSV reactivation (recurrence) with symptoms lasting between 5 and 10 days [1, 11]. Individuals with genital HSV2 infection experience about four recurrences per year whereas those with genital HSV1 infection experience about one recurrence per year [11]. Prospective follow-up has shown a reduction of recurrences over time in most but not all patients [1].
Genital herpes infection can be transmitted from mother to child, with primary infection in a mother close to delivery or within the last trimester being the greatest risk [4]. Symptoms in the neonate include skin and eye disease, encephalitis, or disseminated infection [12]. Cognitive impairment, severe neurological disease, organ dysfunction, and death are among the common sequelae [1]. It has also been shown that genital herpes increases the risk of acquiring Human immunodeficiency virus (HIV), HIV transmission, and HIV progression [13,14].
In 2012, an estimated 3709 million people aged 0–49 years were infected with HSV1 worldwide and an estimated 417 million people aged 15–49 years were living with HSV2, which constitutes a global HSV1 seroprevalence of 67% and a global HSV2 seroprevalence of 11.3% [15, 16].
In the World Health Organization European region, approximately 207 million women and 187 million men aged 0–49 years were living with HSV1 in 2012, corresponding to seroprevalences of 69 and 61%, respectively [15]. In the same region, 21.7 million women and 9.7 million men aged 15–49 years were estimated to be HSV2 seropositive [16]. In national cross-sectional serological surveys performed in European countries between 1989 and 2000, the age-standardized HSV1 seroprevalence ranged from 52% in Finland to 84% in Bulgaria and the age-standardized HSV2 seroprevalence ranged from 4% in England and Wales to 24% in Bulgaria [17].
A German survey based on representative data collected in 1997–1999 found an overall age-standardized HSV1 seroprevalence of 82.6% and an overall HSV2 seroprevalence of 13.3% [18]. Interestingly, women residing in the area of the former German Democratic Republic (GDR), now the east of unified Germany, had significantly higher age-adjusted seroprevalences of HSV1 and HSV2 than women residing in the former Federal Republic of Germany (FRG), now the west of unified Germany. The authors of that study discussed a potentially different sexual behavior of these women as a possible explanation for these disparities [18].
The different political and economic system of the GDR which ceased to exist in 1990 impacted the East German society profoundly. The contrast between the GDR and the FRG included differences in family planning, partner relationships and sexual behavior [19]. For example, in the GDR, sexual health education at schools was not very common, hormonal contraception was available free of charge, and use of condoms was less common when compared to the FRG. After reunification, risk perception and sexual behavior of East Germans started to change gradually. From 1990 to 2000 differences between the incidence of syphilis (median incidence GDR vs. FRG: 2.1 vs. 1.3 per 100.000 population) and gonorrhea (median incidence GDR vs. FRG: 7.2 vs. 4.1 per 100.000 population) decreased from 3.5- to 1.7-fold for syphilis and from 2.1- to 1.1-fold for gonorrhea [18]. Whereas in 1994 the number of 14–17-year-olds which affirmed to have sexual health education at schools differed between former GDR (around 45%) and former FRG (around 83%), in 2014 about 95% of 14–17-year-olds affirmed to have sexual health education at their schools, regardless whether they lived in the former GDR or former FRG [20].
Given the described high seroprevalence of HSV1 and HSV2 in Germany [18] and the recurrent nature of the infections, the clinical and psychosocial burden of the genital ulcer disease caused by HSV is probably very high. However, there has been little research into genital herpes in Germany, possibly because it is not reportable in Germany and there are no specialized sexual health clinics with an established routine surveillance strategy for sexually transmitted infections (STIs).
In this paper, we provide recent representative data and describe the latest developments in HSV1 and HSV2 seroepidemiology in Germany to guide prevention and control of HSV1/2 infections and to promote research into this important public-health issue. Based on a large nationwide representative survey undertaken in 2008–2011, we assessed the seroprevalence of HSV1 and HSV2 in adults in Germany, compared these seroprevalences to the findings of a previous survey in 1997–1999, and investigated factors such as sociodemographic variables and sexual behavior associated with HSV1 and HSV2 seropositivity.

Methods

Study design and population

The study was based on the German National Health Interview and Examination Survey (GNHIES) and the German Health Interview and Examination Survey for Adults (DEGS), which were conducted in 1997–1999 and 2008–2011, respectively [21, 22]. Both studies are part of the national health monitoring conducted by the Robert Koch Institute (RKI).
The GNHIES was based on a stratified, multistage, cross-sectional, national representative sample of individuals aged 18–79 years from the noninstitutionalized population of Germany. It had a total of 7124 participants corresponding to a 61.5% response proportion (18).
Nationwide representative data on the health status of the adult (18–79 years) German resident population were collected in the DEGS. In total, 8151 individuals participated. The response proportion was 48.4%. The analysis of nonresponder questionnaires revealed high population representativeness. The survey design was both cross-sectional and longitudinal. Almost half of all the participants were already enrolled in the GNHIES.
Both surveys included questionnaires, physical tests, and the collection of biomaterial. The sampling design and data collection of both surveys are described in detail elsewhere [21, 22]. The DEGS questionnaire included variables involving self-reported morbidity, medication use, symptoms and complaints, mental health, subjective health, sex-specific health issues, injuries, falls, functional capacities, disability, health-related behavior, living and social conditions, sociodemographic context variables, and health-care services utilization. In our study, we used the following DEGS variables: sex, age, educational classification, income, employment status, current smoking, number of other children in the household during childhood, attendance at a nursery school during childhood, degree of urbanization, region of residence, German mother tongue, number of sexual partners in the preceding 12 months, HSV1/2 serostatus, current use of birth control methods (only women were asked), miscarriage, abortion, and condom use (women were only asked about condom use in the context of birth control methods, so this variable could only be used for men in terms of general safer sex behavior).

Laboratory methods

Serum samples from the DEGS participants were tested for HSV1 (gG1) and HSV2 (gG2) with a chemiluminescence immunoassay (CLIA) (LIAISON® HSV1/2, DiaSorin, von Hevesy-Strasse 3, 63,128 Dietzenbach). The light signal, and hence the amount of isoluminol-antibody conjugate, was measured by a photomultiplier as relative light units (RLU). An index value of <0.9 was defined as immunoglobulin G (IgG) negative and an index value >1.1 as IgG positive. Because retesting samples with an equivocal result for HSV using immunoblotting usually produces a negative result and equivocal results have been classified as negative in other seroprevalence studies [17], we classified all of our equivocal samples (0.3% of all the samples for HSV1 and 0.8% of all the samples for HSV2) as negative.
In a previous seroepidemiological survey of HSV1/2, researchers tested serum samples from 3792 GNHIES participants with another indirect ELISA (MRL Diagnostics, Los Angeles, CA, USA, now HerpesSelect®, Focus Technologies, Cypress, CA, USA) [18].
It has been demonstrated that both assays compare well in terms of their sensitivity and specificity, with almost 100% concordance in comparative analyses [23, 24].

Statistical analyses

All statistical analyses included survey weights based on sex, age, federal state of residence, municipality size, nationality (German yes/no), and education level to account for any deviations of the survey sample from German population statistics [21].
Using the more recent survey (DEGS), we:
  • calculated the overall and age- and sex-specific HSV1 and HSV2 seroprevalences and their 95% confidence intervals (CIs);
  • used Pearson's χ2 test to investigate the potential associations between seroprevalence and sex, age, and region of residence (East or West Germany); and
  • investigated potential determinants associated with HSV1/2 seropositivity by calculating the PRs using log-binomial regression. Because the questions concerning sexual behavior differed for men and women, we performed the univariable and multivariable analyses separately for each sex. If a p-value was <0.2 in the univariable analysis, we included that variable in a stepwise forward variable selection to find a suitable multivariable model. As only a small number of behavioral variables were available within the survey, we set the cutoff for the p-value at 0.2 to take these variables sufficiently into account. Two-way interaction terms were generated for biologically relevant covariate pairs, and retained in the model if significant (p ≤ 0.05).
To examine changes in the HSV1 and HSV2 seroprevalences between 1997–1999 and 2008–2011 in 18–64-year-olds in Germany, we also used the HSV1 and HSV2 test results from GNHIES and applied Pearson's χ2 test. These analyses were adjusted for the reparticipation rate of the GNHIES participants in the DEGS, in addition to the above mentioned weighting procedure [21].
All data analyses were performed with Stata 14 (Stata Statistical Software: Release 14. StataCorp LP, College Station, TX).

Results

Characteristics of the study participants

A total of 6627 adults, representing 91.6% of the DEGS survey population with available blood samples, were tested for HSV1 IgG. Of these, 5013 were also tested for HSV2 IgG. HSV1/2 were not tested in the other participants because the amount of blood available for all the tests performed in the survey was limited. Neither the study population tested for HSV1 nor the study population tested for HSV2 differed from the total DEGS study population with regard to sex, age, or region of residence.

Weighted seroprevalence of HSV1

The overall seroprevalence of HSV1 in the DEGS was 78.7% (95%CI 77.2–80.1). The HSV1 seroprevalence was significantly higher in women (82.0%, 95%CI 80.0–83.7) than in men (75.4%, 95%CI 73.4–77.3). HSV1 seropositivity increased with age from 46.8% (95%CI 42.4–51.2) in the 18–24-year age group to 91.9% (95%CI 89.8–93.6) in the 65+ −year age group. HSV1 seroprevalence was significantly higher in residents of East Germany (81.7%, 95%CI 79.0–84.1) than in residents of West Germany (77.9%, 95%CI 76.2–79.5). However, when stratified by sex, this effect was only significant for women in the age groups 35–44 years (East: 90.2%, 95%CI 84.3–94.1; West: 80.7, 95%CI 75.3–85.1), 45–54 years (East: 91.7%, 95%CI 88.3–94.1; West: 85.1%, 95%CI 80.9–88.5), and 65+ years (East: 96.2%, 95%CI 93.3–97.9; West: 92.1, 95%CI 88.6–94.5) (Fig. 1). In women aged 25–34 and 55–64 years, the effect was reversed: the women in West Germany had a higher HSV1 seroprevalence than their counterparts in East Germany, although the difference was not statistically significant.
12879_2017_2527_Fig1_HTML.gif
Fig. 1
Weighted HSV1 seroprevalence according to sex, age and region of residence, Germany 2008–2011. *HSV1 seroprevalence differed significantly between women and men. °HSV1 seroprevalence differed significantly between women in East Germany vs. women in West Germany in the age groups 35–44, 45–54 and 65+

Weighted seroprevalence of HSV2

The overall seroprevalence of HSV2 in the DEGS was 9.4% (95%CI 8.3–10.5). HSV2 seroprevalence was significantly higher in women (11.7%, 95%CI 10.2–13.3) than in men (7.2%, 95%CI 5.9–8.6). HSV2 seropositivity increased from 1.6% (95%CI 0.8–3.2) in the 18–24-year age group to 13.4% (95%CI 10.9–16.4) in the 55–64-year age group, decreasing thereafter to 11.7% (95%CI 9.6–14.2) in study participants aged 65+. The seroprevalence of HSV2 was significantly higher in the residents of East Germany (11.9%, 95%CI 9.9–14.3) than in the residents of West Germany (8.7%, 95%CI 7.5–10.0). However, when stratified by sex, only women in East Germany had a higher seroprevalence than their counterparts in West Germany (East: 14.6%, 95%CI 11.5–18.4; West: 10.8%, 95%CI 9.2–12.7). When stratified by age and sex, the higher HSV2 seroprevalence in East Germany was only significant for women aged 65+ years (East: 18.1%, 95%CI 12.2–26.0; West: 10.3%, 95%CI 7.3–14.3) and men aged 25–34 years (East: 6.2%, 95%CI 3.0–12.6; West: 1.8%; 95%CI 0.6–5.2) (Fig. 2). The opposite trend was observed in both women and men aged 18–24 and 55–64 years, although the differences were not statistically significant.
12879_2017_2527_Fig2_HTML.gif
Fig. 2
Weighted HSV2 seroprevalence according to sex, age and region of residence, Germany 2008–2011. *HSV2 seroprevalence differed significantly between women and men. °HSV2 seroprevalence differed significantly between 25-34 year old men in East vs. West Germany and in women aged 65+ in East vs. West Germany. #There were no HSV2 positive results among 18-24 year old male study participants living in East Germany

Factors associated with HSV1 seropositivity

In the DEGS, women were more likely to be HSV1 IgG positive than men (crude prevalence ratio [CPR] 1.1; 95%CI 1.1–1.1). The results of the univariable analyses, stratified by sex, are shown in Tables 1 and 2.
Table 1
Associations between variables and HSV1 seropositivity in women, Germany 2008–2011
Variables
N
Weighteda prevalence %
(95% CI)
Univariable Analysis
Multivariable Analysis
PRb(95% CI)
p-value
PRc(95% CI)
p-value
Age group (years)
 18–24
283
51.4
(45.3–57.5)
Ref
Ref
Ref
Ref
 25–34
400
70.4
(64.6–75.5)
1.4 (1.2–1.6)
0.000
1.2 (1.0–1.4)
0.057
 35–44
519
82.4
(77.9–86.1)
1.6 (1.4–1.8)
0.000
1.4 (1.2–1.6)
0.000
 45–54
714
86.5
(83.1–89.2)
1.7 (1.5–1.9)
0.000
1.4 (1.2–1.7)
0.000
 55–64
630
91.8
(88.7–94.1)
1.8 (1.6–2.0)
0.000
1.5 (1.3–1.8)
0.000
 65+
895
93.1
(90.4–95.1)
1.8 (1.6–2.0)
0.000
1.6 (1.3–1.8)
0.000
CASMIN educational classification
 Low
1117
90.0
(87.6–91.9)
1.3 (1.2–1.4)
0.000
1.2 (1.1–1.3)
0.000
 Medium
1772
79.3
(76.4–82.0)
1.2 (1.1–1.2)
0.000
1.2 (1.1–1.3)
0.000
 High
531
68.8
(63.7–73.5)
Ref
Ref
Ref
Ref
Income
 Low
991
83.4
(80.1–86.2)
Ref
Ref
−
−
 Medium
2031
82.0
(79.7–84.2)
1.0 (0.9–1.0)
0.481
−
−
 High
419
76.9
(70.6–82.2)
0.9 (0.8-1.0)
0.066
−
−
Employment situation
 Worker
827
91.2
(88.5–93.4)
1.1 (1.1–1.2)
0.000
1.1 (1.0–1.1)
0.004
 Employee
1611
81.4
(78.5–83.9)
Ref
Ref
Ref
Ref
 Civil servant
169
70.3
(60.5–78.5)
0.9 (0.8–1.0)
0.036
0.9 (0.8–1.1)
0.482
 Free-lance/self-reliant
233
84.9
(77.9–90.0)
1.0 (1.0–1.1)
0.232
1.0 (1.0–1.1)
0.379
 Family worker
64
87.5
(75.2–94.1)
1.1 (1.0–1.2)
0.201
1.0 (0.9–1.2)
0.551
 other
124
51.8
(40.9–62.5)
0.6 (0.5–0.8)
0.000
0.8 (0.6–1.0)
0.086
Smoking, currently
 Daily
643
84.2
(80.0–87.7)
1.0 (1.0–1.1)
0.266
1.1 (1.0–1.1)
0.035
 Occasionally
179
75.1
(67.2–81.6)
0.9 (0.8-1.0)
0.090
1.1 (1.0–1.2)
0.023
 No, not anymore
825
82.1
(77.7–85.7)
1.0 (1.0–1.1)
0.841
1.0 (0.9–1.1)
0.898
 Never smoked
1776
81.6
(79.1–83.9)
Ref
Ref
Ref
Ref
Number of other children in household during childhood
 0
369
76.6
(70.6–81.7)
Ref
Ref
−
−
 1–2
1478
74.9
(71.9–77.7)
1.0 (0.9–1.1)
0.579
−
−
  > 2
1594
90.6
(88.5–92.3)
1.2 (1.1–1.3)
0.000
−
−
Visit of nursery during childhood
 No
801
87.9
(84.4–90.7)
1.2 (1.1–1.2)
0.000
−
−
 Yes
1705
74.8
(71.9–77.5)
Ref
Ref
−
−
Degree of urbanization
 Rural
607
83.8
(78.3–88.2)
Ref
Ref
−
−
 Provincial
844
84.0
(80.1–87.3)
1.0 (0.9–1.1)
0.956
−
−
 Urban
963
80.2
(76.3–83.6)
1.0 (0.8–1.0)
0.238
−
−
 Metropolitan
1027
81.1
(77.7–84.0)
1.0 (0.9–1.0)
0.347
−
−
Region of residence
 West Germany
2350
81.2
(78.9–83.2)
Ref
Ref
−
−
 East Germany (including Berlin)
1091
85.0
(81.4–88.0)
1.0 (1.0-1.1)
0.052
−
−
German mother tongue
 Yes
3170
81.0
(78.9–83.0)
Ref
Ref
Ref
Ref
 No
242
88.4
(82.2–92.6)
1.1 (1.0–1.2)
0.000
1.1 (1.1–1.2)
0.000
Number of sexual partners in last 12 months
 None
1051
85.4
(82.3–88.0)
1.0 (1.0–1.1)
0.043
−
−
 1
2110
81.5
(78.9–83.9)
Ref
Ref
−
−
 2–3
153
62.3
(53.1–70.7)
0.8 (0.7–0.9)
0.001
−
−
  > 3
24
76.6
(49.1–91.8)
0.9 (0.7–1.2)
0.668
−
−
HSV2 serostatus
 HSV2 seronegative
2262
81.6
(79.1–83.8)
Ref
Ref
−
−
 HSV2 seropositive
323
88.9
(83.7–92.6)
1.1 (1.0–1.2)
0.004
−
−
Current use of birth control methods
 Yes
978
72.0
(68.5–75.3)
Ref
Ref
−
−
 No
1523
84.1
(81.6–86.3)
1.2 (1.1–1.2)
0.000
−
−
Which birth control method
 -Contraceptive pill
  Yes
470
67.2
(62.1–72.0)
Ref
Ref
−
−
  No
478
77.1
(72.1–81.5)
1.1 (1.0–1.3)
0.005
−
−
 -Condoms
  Yes
287
71.8
(65.3–77.6)
Ref
Ref
−
−
  No
661
72.3
(67.9–76.4)
1.0 (0.9–1.1)
0.891
−
−
Miscarriage
 None
2008
77.1
(74.5–79.5)
Ref
Ref
−
−
 1 or more
549
88.3
(83.8–91.6)
1.1 (1.1–1.2)
0.000
−
−
Abortion
 None
2047
77.3
(74.8–79.7)
Ref
Ref
−
−
 1 or more
471
88.5
(84.0–91.9)
1.1 (1.1–1.2)
0.000
−
−
In italics: PR is statistically significant (p < 0.05)
aWe used survey weights to account for deviations of the survey sample from the sampling parameters (i.e. age, sex, region, urban/rural region, community size, citizenship and education)
bIf a p-value was <0.2 in the univariable analysis, we included that variable in a stepwise forward variable selection to find a suitable multivariable model
cAdjusted prevalence rates (PR) of variables which stayed in the final model (p-value ≤0.05) are reported
Table 2
Associations between variables and HSV1 seropositivity in men, Germany 2008–2011
Variables
N
Weighteda prevalence %
(95% CI)
Univariable Analysis
Multivariable Analysis
PRb (95% CI)
p-value
PRc (95% CI)
p-value
Age group (years)
 18–24
289
42.2
(35.8–48.9)
Ref
Ref
Ref
Ref
 25–34
364
64.5
(58.4–70.2)
1.5 (1.3–1.8)
0.000
1.5 (1.2–1.8)
0.000
 35–44
448
72.8
(67.1–77.9)
1.7 (1.5–2.0)
0.000
1.7 (1.4–2.0)
0.000
 45–54
627
81.2
(77.1–84.6)
1.9 (1.6–2.3)
0.000
1.9 (1.6–2.2)
0.000
 55–64
559
85.9
(81.8–89.2)
2.0 (1.7–2.4)
0.000
2.0 (1.7–2.3)
0.000
 65+
899
90.6
(87.5–92.9)
2.1 (1.8–2.5)
0.000
1.9 (1.6–2.3)
0.000
CASMIN educational classification
 Low
1045
85.2
(82.2–87.7)
1.2 (1.1–1.3)
0.000
1.2 (1.1–1.2)
0.000
 Medium
1407
69.7
(66.4–72.8)
1.0 (0.9–1.1)
0.967
1.1 (1.0–1.2)
0.062
 High
714
69.8
(65.0–74.2)
Ref
Ref
Ref
Ref
Income
 Low
855
79.1
(75.6–82.2)
Ref
Ref
−
−
 Medium
1837
74.2
(71.6–76.6)
0.9 (0.9–1.0)
0.015
−
−
 High
494
72.3
(67.1–76.9)
0.9 (0.8–1.0)
0.022
−
−
Employment situation
 Worker
1109
80.2
(77.0–83.0)
1.1 (1.0–1.2)
0.004
−
−
 Employee
1033
73.2
(69.4–76.8)
Ref
Ref
−
−
 Civil servant
224
76.2
(68.3–82.6)
1.0 (0.9–1.2)
0.462
−
−
 Free-lance/self-reliant
394
78.6
(72.0–84.0)
1.1 (1.0-1.2)
0.133
−
−
 Family worker
6
100.0
  
1.4 (1.3–1.4)
0.002
−
−
 Other
93
48.0
(35.7–60.5)
0.7 (0.5–0.9)
0.000
−
−
Smoking, currently
 Daily
706
76.1
(72.0–79.8)
1.1 (1.0–1.2)
0.040
1.1 (1.0–1.1)
0.060
 Occasionally
201
74.0
(65.4–81.1)
1.0 (0.9–1.2)
0.440
1.1 (1.0–1.3)
0.013
 No, not anymore
1181
79.5
(76.2–82.4)
1.1 (1.1–1.2)
0.000
1.0 (0.9–1.1)
0.985
 Never smoked
1081
70.6
(66.7–74.2)
Ref
Ref
Ref
Ref
Number of other children in household during childhood
 0
341
70.0
(63.5–75.7)
Ref
Ref
Ref
Ref
 1–2
1323
64.8
(61.7–67.7)
0.9 (0.8-1.0)
0.127
0.9 (0.9–1.0)
0.184
  > 2
1522
88.1
(86.0–90.0)
1.3 (1.1–1.4)
0.000
1.1 (1.0–1.2)
0.039
Visit of nursery during childhood
 No
726
80.5
(76.8–83.7)
Ref
Ref
−
−
 Yes
152
67.1
(64.1–70.0)
1.2 (1.1–1.3)
0.000
−
−
Degree of urbanization
 Rural
636
77.2
(73.2–80.7)
Ref
Ref
−
−
 Provincial
799
77.3
(73.3–80.8)
1.0 (0.9–1.1)
0.974
−
−
 Urban
866
72.8
(68.8–76.4)
0.9 (0.9-1.0)
0.105
−
−
 Metropolitan
885
75.3
(71.6–78.8)
1.0 (0.9–1.0)
0.490
−
−
Region of residence
 West Germany
2151
74.6
(72.3–76.7)
Ref
Ref
Ref
Ref
 East Germany (including Berlin)
1035
78.4
(74.5–81.9)
1.1 (1.0-1.1)
0.075
1.1 (1.0–1.1)
0.003
German mother tongue
 Yes
2952
73.8
(71.7–75.8)
Ref
Ref
Ref
Ref
 No
208
86.7
(79.6–91.6)
1.2 (1.1–1.3)
0.000
1.2 (1.1–1.3)
0.000
Number of sexual partners in last 12 months
 None
632
74.1
(68.6–78.9)
1.0 (0.9–1.0)
0.414
−
−
 1
2113
76.4
(74.0–78.6)
Ref
Ref
−
−
 2–3
205
65.2
(57.1–72.5)
0.9 (0.7–1.0)
0.012
−
−
  > 3
98
68.8
(57.0–78.6)
0.9 (0.8-1.1)
0.193
−
−
HSV2 serostatus
 HSV2 seronegative
2221
74.8
(72.5–76.9)
Ref
Ref
−
−
 HSV2 seropositive
207
77.4
(69.6–83.6)
1.0 (0.9–1.1)
0.472
−
−
Use of condoms
 Generally
398
59.3
(53.7–64.7)
Ref
Ref
−
−
 Occasionally
400
67.5
(61.6–73.0)
1.1 (1.0-1.3)
0.034
−
−
 No
1881
78.0
(77.3–82.4)
1.3 (1.2–1.5)
0.000
−
−
 N/a
372
79.1
(72.6–84.3)
1.3 (1.2–1.5)
0.000
−
−
In italics: PR is statistically significant (p < 0.05)
aWe used survey weights to account for deviations of the survey sample from the sampling parameters (i.e. age, sex, region, urban/rural region, community size, citizenship and education)
bIf a p-value was <0.2 in the univariable analysis, we included that variable in a stepwise forward variable selection to find a suitable multivariable model
cAdjusted prevalence rates (PR) of variables which stayed in the final model (p-value ≤0.05) are reported
Among women, older age, a lower level of education, being employed as a 'worker' rather than an 'employee', smoking, and not speaking German as a first language were associated with HSV1 seropositivity in the multivariable model (Table 1).
Among men, older age, a lower level of education, smoking, more than two other children in the household during childhood, residence in East Germany, and not speaking German as a first language were associated with HSV1 seropositivity in the multivariable model (Table 2). We found no significant interactions among the relevant covariate pairs for either men or women.

Factors associated with HSV2 seropositivity

Women were also more likely to be seropositive for HSV2 than men (CPR 1.6; 95%CI 1.3–2.0). The results of the univariable analysis, stratified by sex, are shown in Tables 3 and 4. We found that older age, smoking, and a history of abortion were associated with HSV2 seropositivity in women (Table 3) and that older age, not attending a nursery school during childhood, and the occasional use of condoms (as opposed to their consistent use) were associated with HSV2 seropositivity in men (Table 4). We found no relevant covariate pairs.
Table 3
Associations between variables and HSV2 seropositivity in women, Germany 2008–2011
Variables
N
Weighteda prevalence %
(95% CI)
Univariable Analysis
Multivariable Analysis
PRb (95% CI)
p-value
PRc (95% CI)
p-value
Age group (years)
 18–24
227
2.0
(0.8–4.8)
Ref
Ref
Ref
Ref
 25–34
277
7.6
(4.5–12.5)
3.9 (1.4–11.1)
0.012
3.5 (1.2–10.4)
0.021
 35–44
405
11.5
(7.9–16.4)
5.9 (2.3–15.2)
0.000
5.6 (2.1–14.7)
0.001
 45–54
535
16.1
(12.8–20.0)
8.2 (3.2–21.2)
0.000
7.3 (2.7–19.5)
0.000
 55–64
461
15.5
(12.0–19.8)
7.9 (3.3–18.9)
0.000
8.0 (3.1–20.5)
0.000
 65+
680
12.3
(9.4–15.6)
6.3 (2.4–16.3)
0.000
6.5 (2.5–17.0)
0.000
CASMIN educational classification
 Low
841
10.5
(8.2–13.3)
1.2 (0.7–1.8)
0.522
−
−
 Medium
1335
12.6
(10.6–15.0)
1.4 (0.9-2.1)
0.131
−
−
 High
392
9.1
(6.3–13.0)
Ref
Ref
−
−
Income
 Low
750
10.8
(8.2–14.1)
Ref
Ref
−
−
 Medium
1529
11.7
(9.8–13.8)
1.1 (0.8–1.5)
0.652
−
−
 High
306
14.5
(10.2–20.2)
1.3 (0.9–2.1)
0.204
−
−
Employment situation
 Worker
623
12.4
(9.6–16.0)
1.0 (0.7–1.3)
0.884
−
−
 Employee
1174
12.7
(10.5–15.4)
Ref
Ref
−
−
 Civil servant
128
14.5
(8.6–23.4)
1.1 (0.7–1.9)
0.623
−
−
 Free-lance/self-reliant
174
13.2
(8.3–20.5)
1.0 (0.6–1.7)
0.874
−
−
 Family worker
47
5.3
(1.4–18.8)
0.4 (0.1–1.6)
0.202
−
−
 Other
96
4.0
(1.4–10.8)
0.3 (0.1–0.9)
0.033
−
−
Smoking, currently
 Daily
486
15.2
(11.8–19.2)
1.5 (1.1–2.1)
0.006
1.6 (1.0–2.4)
0.033
 Occasionally
133
8.7
(4.9–15.1)
0.9 (0.5–1.6)
0.673
1.1 (0.5–2.3)
0.847
 No, not anymore
607
13.4
(10.6–16.5)
1.3 (1.0–1.8)
0.031
1.2 (0.9–1.7)
0.226
 Never smoked
1345
9.9
(8.1–12.0)
Ref
Ref
Ref
Ref
Number of other children in household during childhood
 0
272
12.5
(8.2–18.6)
Ref
Ref
−
−
 1–2
1125
9.6
(8.0–11.6)
0.8 (0.5–1.2)
0.221
−
−
  > 2
1188
13.6
(11.1–16.5)
1.1 (0.7–1.7)
0.728
−
−
Visit of nursery during childhood
 No
614
14.5
(11.7–17.8)
1.5 (1.1–2.0)
0.008
−
−
 Yes
1264
9.7
(7.8–12.0)
Ref
Ref
−
−
HSV1 serostatus
 HSV1 seronegative
431
7.3
(4.8–11.1)
Ref
Ref
−
−
 HSV1 seropositive
2154
12.6
(10.9–14.5)
1.7 (1.1–2.7)
0.017
−
−
Degree of urbanization
 Rural
424
9.6
(6.2–14.6)
Ref
Ref
−
−
 Provincial
651
11.3
(8.5–14.7)
1.2 (0.7–2.0)
0.539
−
−
 Urban
792
10.1
(8.0–12.7)
1.1 (0.6–1.7)
0.835
−
−
 Metropolitan
718
14.4
(11.7–17.7)
1.5 (0.9-2.4)
0.095
−
−
Region of residence
 West Germany
1778
10.8
(9.2–12.7)
Ref
Ref
−
−
 East Germany (including Berlin)
807
14.6
(11.5–18.4)
1.3 (1.0–1.8)
0.037
−
−
German mother tongue
 Yes
2390
11.5
(9.9–13.3)
Ref
Ref
−
−
 No
172
10.9
(6.9–16.8)
0.9 (0.8–1.5)
0.825
−
−
Number of sexual partners in last 12 months
 None
788
12.7
(10.2–15.7)
1.1 (0.8–1.5)
0.500
−
−
 1
1588
11.5
(9.6–13.7)
Ref
Ref
−
−
 2–3
116
12.0
(5.3–24.8)
1.0 (0.5–2.3)
0.917
−
−
  > 3
17
10.3
(1.4–49.0)
0.9 (0.1–6.2)
0.912
−
−
Current use of birth control methodsd
 Yes
740
8.5
(6.3–11.3)
Ref
Ref
−
−
 No
1140
14.1
(12.0–16.6)
1.7 (1.2–2.3)
0.003
−
−
Which birth control method
 -Contraceptive Pill
  Yes
363
7.0
(4.4–10.8)
Ref
Ref
−
−
  No
353
9.6
(6.5–14.0)
1.4 (0.8–2.4)
0.264
−
−
 -Condoms
  Yes
217
8.0
(4.7–13.4)
Ref
Ref
−
−
  No
499
8.4
(5.7–12.3)
1.0 (0.5–2.1)
0.892
−
−
Miscarriage
 None
1504
10.4
(8.5–12.6)
Ref
Ref
−
−
 1 or more
424
15.9
(12.1–20.6)
1.5 (1.1–2.1)
0.009
−
−
Abortion
 None
1538
10.1
(8.4–12.2)
Ref
Ref
Ref
Ref
 1 or more
351
20.1
(15.3–25.9)
2.0 (1.4–2.7)
0.000
1.5 (1.1–2.2)
0.023
In italics: PR is statistically significant (p < 0.05)
aWe used survey weights to account for deviations of the survey sample from the sampling parameters (i.e. age, sex, region, urban/rural region, community size, citizenship and education)
bIf a p-value was <0.2 in the univariable analysis, we included that variable in a stepwise forward variable selection to find a suitable multivariable model
cAdjusted prevalence rates (PR) of variables which stayed in the final model (p-value ≤0.05) are reported
dWomen older than 65 years of age were not asked about their current use of birth control methods
Table 4
Associations between variables and HSV2 seropositivity in men, Germany 2008–2011
Variables
N
Weighteda prevalence %
(95% CI)
Univariable Analysis
Multivariable Analysis
PRb (95% CI)
p-value
PRc (95% CI)
p-value
Age group (years)
 18–24
222
1.2
(0.4–3.9)
Ref
Ref
Ref
Ref
 25–34
283
2.8
(1.4–5.3)
2.3 (0.6–9.0)
0.247
2.0 (0.5–7.8)
0.314
 35–44
343
4.3
(2.2–8.2)
3.5 (0.9-13.9)
0.075
3.1 (0.8–12.0)
0.100
 45–54
477
9.4
(6.3–13.8)
7.7 (2.5–24.0)
0.000
5.4 (1.7–17.1)
0.004
 55–64
418
11.4
(8.2–15.7)
9.3 (2.8–31.2)
0.000
6.9 (2.1–23.1)
0.002
 65+
685
11.0
(8.1–14.8)
9.0 (2.6–31.1)
0.001
d
d
CASMIN educational classification
 Low
806
8.7
(6.4–11.8)
1.1 (0.7–1.7)
0.768
−
−
 Medium
1069
5.7
(4.3–7.5)
0.7 (0.4-1.1)
0.109
−
−
 High
538
8.2
(5.8–11.4)
Ref
Ref
−
−
Income
 Low
656
6.1
(4.3–8.6)
Ref
Ref
−
−
 Medium
1414
7.2
(5.7–9.2)
1.2 (0.8–1.8)
0.374
−
−
 High
358
9.5
(6.1–14.4)
1.6 (0.9-2.8)
0.127
−
−
Employment situation
 Worker
844
7.9
(5.8–10.7)
1.0 (0.6–1.5)
0.890
−
−
 Employee
773
8.1
(6.0–10.9)
Ref
Ref
−
−
 Civil servant
183
7.0
(3.7–12.8)
0.9 (0.4–1.7)
0.659
−
−
 Free-lance/self-reliant
293
8.5
(5.6–12.5)
1.0 (0.6–1.8)
0.880
−
−
 Family worker
4
−
−
−
−
−
−
 Other
64
0.9
(0.1–6.5)
0.1 (0.1–0.1)
0.031
−
−
Smoking, currently
 Daily
524
6.3
(4.3–9.2)
0.9 (0.6–1.5)
0.761
−
−
 Occasionally
151
3.8
(1.7–8.2)
0.6 (0.2-1.3)
0.182
−
−
 No, not anymore
899
9.0
(6.8–11.7)
1.3 (1.0-1.8)
0.089
−
−
 Never smoked
843
6.8
(5.1–9.0)
Ref
Ref
−
−
Number of other children in household during childhood
 0
257
5.5
(3.2–9.3)
Ref
Ref
−
−
 1–2
999
5.8
(4.3–7.9)
1.1 (0.6–1.9)
0.839
−
−
  > 2
1172
8.9
(7.2–11.1)
1.6 (0.9-2.8)
0.087
−
−
Visit of nursery during childhoodd
 No
561
10.8
(7.9–14.5)
2.4 (1.7–3.5)
0.000
1.5 (1.0–2.2)
0.036
 Yes
1153
4.4
(3.4–5.8)
Ref
Ref
Ref
Ref
HSV1 serostatus
 HSV1 seronegative
548
6.5
(4.6–9.0)
Ref
Ref
−
−
 HSV1 seropositive
1880
7.4
(6.0–9.1)
1.1 (0.8–1.7)
0.494
−
−
Degree of urbanization
 Rural
435
6.5
(3.2–12.6)
Ref
Ref
−
−
 Provincial
620
6.1
(3.9–9.4)
0.9 (0.4–2.1)
0.875
−
−
 Urban
712
7.7
(5.7–10.3)
1.2 (0.6–2.5)
0.660
−
−
 Metropolitan
661
7.9
(6.2–10.2)
1.2 (0.6–2.5)
0.582
−
−
Region of residence
 West Germany
1675
6.6
(5.2–8.4)
Ref
Ref
−
−
 East Germany (including Berlin)
753
9.2
(7.0–11.9)
1.4 (1.0-2.0)
0.070
−
−
German mother tongue
 Yes
151
7.4
(6.1–8.9)
Ref
Ref
−
−
 No
2256
5.7
(3.2–9.9)
0.8 (0.4–1.4)
0.394
−
−
Number of sexual partners in last 12 months
 None
486
8.3
(5.5–12.3)
1.1 (0.7–1.8)
0.594
−
−
 1
1613
7.3
(5.8–9.1)
Ref
Ref
−
−
 2–3
155
5.3
(2.6–10.7)
0.7 (0.3–1.5)
0.395
−
−
  > 3
73
6.9
(2.8–16.2)
0.9 (0.4–2.4)
0.905
−
−
Use of condoms
 Generally
289
2.7
(1.5–4.9)
Ref
Ref
Ref
Ref
 Occasionally
314
6.8
(4.2–10.8)
2.5 (1.1–5.7)
0.024
2.3 (1.0–5.1)
0.050
 No
1454
8.0
(6.4–9.9)
3.0 (1.6–5.5)
0.001
1.7 (0.9–3.2)
0.105
 N/a
275
9.9
(5.7–16.5)
3.7 (1.6–8.6)
0.003
1.6 (0.6–4.7)
0.345
In italics: PR is statistically significant (p < 0.05)
aWe used survey weights to account for deviations of the survey sample from the sampling parameters (i.e. age, sex, region, urban/rural region, community size, citizenship and education)
bIf a p-value was <0.2 in the univariable analysis, we included that variable in a stepwise forward variable selection to find a suitable multivariable model
cAdjusted prevalence rates (PR) of variables which stayed in the final model (p-value ≤0.05) are reported
dMen older than 65 years of age were not asked whether they visited a nursery

Changes in HSV1 seroprevalence from 1997–1999 to 2008–2011

Since the GNHIES survey in 1997–1999, the overall seropositivity for HSV1 in Germany has declined statistically significantly (Fig. 3a–d). Whereas the total adult HSV1 seroprevalence was 82.1% (95%CI 80.6–83.6) in the GNHIES, it was 78.4% (95%CI 77.8–79.7) in the DEGS. The decline was significant in men (1997–1999: 80.7%, 95%CI 78.7–82.5; 2008–2011: 75.3%, 95%CI 73.3–77.1) but not in women (1997–1999: 83.7%, 95%CI 81.4–85.8; 2008–2011: 81.6%, 95%CI 79.8–83.3). When stratified by region of residence, the decline was significant in both men (1997–1999: 83.6, 95%CI 81.0–86.0; 2008–2011: 77.7%, 95%CI 73.8–81.1) and women (1997–1999: 88.7%, 95%CI 86.0–91.0; 2008–2011: 83.3%, 95%CI 79.8–86.3) in East Germany, but only for men in West Germany (1997–1999: 79.5%, 95%CI 77.0–81.8; 2008–2011: 74.6%, 95%CI 72.3–76.7) (Fig. 3a).
12879_2017_2527_Fig3_HTML.gif
Fig. 3
Change of HSV1 seroprevalence in Germany between 1997–1999 and 2008–2011, according to sex and region. a in adults aged 18–65 years, b in adults aged 18–24 years, c in adults aged 25–44 years, d in adults aged 45–64 years
In the group aged 18–24 years, HSV1 seropositivity declined from 64.0% (95%CI 59.1–68.5) in 1997–1999 to 46.7% (95%CI 42.4–51.1) in 2008–2011 (Fig. 3b). This effect was significant for both sexes, but more pronounced in men (1997–1999; 63.1%, 95%CI 57.4–68.5; 2008–2011: 41.9%, 95%CI 35.5–48.6) than in women (1997–1999: 64.8%, 95%CI 58.1–71.0; 2008–2011: 51.6%, 95%CI 45.6–57.6) in this age group. When stratified by region of residence, HSV1 seroprevalence declined significantly from 71.9% (95%CI 60.4–81.0) to 41.8% (95%CI 27.2–58.0) among 18–24-year-old men in East Germany, from 61.1% (95%CI 54.6–67.2) to 41.9% (95%CI 35.0–49.2) among 18–24-year-old men in West Germany, and from 64.3% (95%CI 56.5–71.5) to 49.7% (95%CI 42.8–56.6) among 18–24-year-old women in West Germany. Among 18–24-year-old women in East Germany, the decline in HSV1 seropositivity from 66.8% (95%CI 54.3–77.3) to 59.6% (95%CI 48.0–70.2) was not significant.
In 1997–1999, women aged 25–44 years in East Germany were more likely to be HSV1 seropositive (86.7%, 95%CI 81.9–90.3) than their counterparts in West Germany (83.1%, 95%CI 78.2–87.1), but the situation was reversed in 2008–2011 (East Germany: 72.5%, 95%CI 63.2–80.2; West Germany: 76.7%, 95%CI 72.6–80.4) (Fig. 3c). HSV1 Seropositivity in men aged 25–44 years decreased in East Germany (81.3%, 95%CI 76.8–85.1 to 71.8%, 95%CI 64.8–77.8) and West Germany (79.1%, 95%CI 74.2–83.2 to 68.8%, 95%CI 64.1–73.1).

Changes in HSV2 seroprevalence from 1997–1999 to 2008–2011

The overall HSV2 seropositivity in Germany decreased significantly from 13.3% (95%CI 11.9–14.9) to 9.6% (95%CI 8.6–10.8) in these years (Fig. 4a–d). The decline was significant for both women (1997–1999: 16.0%, 95%CI 13.9–18.4; 2008–2011: 12.1%, 95%CI 10.6–13.7) and men (1997–1999: 10.9%, 95%CI 9.2–12.8; 2008–2011: 7.3%, 95%CI 6.0–8.8). When stratified by region of residence, the decline was significant in both East Germany (1997–1999: 17.1%, 95%CI 14.9–19.6; 2008–2011: 12.8%, 95%CI 10.7–15.3) and West Germany (1997–1999: 11.8%, 95%CI 10.1–13.7; 2008–2011: 8.8%, 95%CI 7.6–10.1).
12879_2017_2527_Fig4_HTML.gif
Fig. 4
Change of HSV2 seroprevalence in Germany between 1997–1999 and 2008–2011, according to sex and region. a in adults aged 18–65 years, b in adults aged 18–24 years, c in adults aged 25–44 years, d in adults aged 45–64 years
In the study participants aged 18–24 years at the time of the surveys, there was a decline in HSV2 seroprevalence from 4.2% (95%CI 2.6–6.5) to 1.6% (95%CI 0.8–3.3). No change in HSV2 seroprevalence was observed in this age group when the study participants lived in West Germany (men: from 1.6% [95%CI 0.6–4.1] to 1.5% [95%CI 0.5–4.8]; women: 2.2% [95%CI 0.7–6.9] to 2.2% [95%CI 0.8–6.0]), but in East Germany, HSV2 seropositivity for men declined from 10.4% (95%CI 5.5–18.9) to 0% and for women from 17.6% (95%CI 10.0–29.0) to 1.6% (95%CI 0.2–10.0) (Fig. 4b).
In the age group 25–44 years, HSV2 seropositivity dropped from 14.4% (95%CI 12.4–16.7) to 6.5% (95%CI 5.1–8.4), and when stratified by sex and region of residence, this reduction was significant for women in East Germany (from 23.2% [95%CI 17.9–29.5] to 11.4% [95%CI 7.2–17.4]), women in West Germany (from 16.9% [95%CI 13.2–21.8] to 9.1% [95%CI 6.4–12.7]), and men in West Germany (from 9.4% [95%CI 6.5–13.4] to 3.0% [95%CI 1.4–6.0]), but not for men in East Germany (from 12.6% [95%CI 9.8–16.0] to 7.6% [95%CI 4.2–13.4]) (Fig.4c).

Discussion

Based on two population-based surveys, we estimated that the HSV1 seroprevalence in adult Germans decreased from 82.1% in 1997–1999 to 78.4% in 2008–2011. Declines in HSV1 seroprevalence have been seen in many countries worldwide, including the USA [25], England and Wales [26], Israel [27], and the Netherlands [28]. Fewer siblings in industrialized countries, less-crowded institutions, improvements in living conditions, and better hygiene have been suggested to explain for these declines [25]. We assume that many factors contributed to the decrease of HSV1 seroprevalence in Germany. The increasing number of single households (35% in 1998, 40% in 2010) and the decreasing number of households with three or more generations in Germany (by 41% between 1995 and 2015) [29] could have generally led to a reduced chance to transmit the virus. Hypotheses concerning the sexual transmission routes include the increased use of condoms in young adults (women from 68% to 75%, men from 55% to 76% between 1998 and 2009) and a higher coverage of sexual health education at schools [20].
A reduced seroprevalence of HSV1 has also been linked to more symptomatic HSV2 infections and more cases of genital HSV1, both of which pose a threat to neonates whose mothers acquire the infection in the third trimester of pregnancy [1, 30]. Therefore, the decline in HSV1 seroprevalence, especially its decline in young adults, is of concern.
We estimated a decline in the seroprevalence of HSV2 in adult Germans from 13.3% in 1997–1999 to 9.6% in 2008–2011. A reduction in HSV2 seroprevalence between 1984 and 2002 has also been reported in young adults in Israel [28, 27]. Although reductions in HSV2 seroprevalence were observed in 20–24-year-old men and 15–19-year-old women in the Netherlands between 1995– 1996 and 2006–2007 (14), the overall seroprevalence of HSV2 in the Netherlands remained stable during that period (14). In the USA, HSV2 seroprevalence did not change significantly between 1999 and 2010 [25]. The reduced seroprevalence of HSV2 in Germany leave more people susceptible to genital HSV infections which, again, especially combined with the reduced HSV1 seroprevalence, is a threat to neonates whose mothers acquire the infection in the third trimester of pregnancy [1, 30].
The seroprevalence of both HSV1 and HSV2 was higher in women than in men in Germany. The greater biological susceptibility of women to infection by genital transmission is well known [4]. Because the genital disease is more likely to be asymptomatic in men [31], men are likely to be underdiagnosed and to continue to engage in sexual activities, increasing male-to-female transmission. We found increasing seroprevalence of both HSV1 and HSV2 with increasing age, which is consistent with other studies and correlates with cumulative exposure [17, 32].
Less-educated women and men were more likely to be HSV1 seropositive in our study. It is well known that education plays an important role in the prevention of infections. A lower level of education is probably associated with a lower parental income and cheaper housing during childhood, although we did not examine these relationships in our survey. HSV1 acquisition is also known to be linked to socioeconomic status and a crowded living environment [33]. Interestingly, compared with never-smokers, women and men in our survey who currently smoked were more likely to be HSV1 seropositive, which may be attributable to the usually lower socioeconomic status of smokers [34] or reflect the lowered (local) immune response caused by cigarette smoking. Not speaking German as the first language was also associated with HSV1 seropositivity in both sexes. However, the DEGS did not adequately represent non-Germans and the number of study participants was low in the subset of non-German speakers (Tables 1 and 2).
Smoking was associated with HSV2 seropositivity in women but not in men when the data were adjusted for age. Interestingly, women who had had one or more abortion were 1.5 times more likely to be HSV2 seropositive. Genital herpes is not an indication for medically induced abortion [35]. We strongly encourage further studies to analyze this finding [36, 37]. In men, the multivariable analysis revealed a positive association between HSV2 IgG and not having attended a nursery school during childhood, which is consistent with the theory that low exposure to HSV1 during childhood increases the risk of genital HSV2 (or HSV1) acquisition later in life [38]. However, we found no correlation between HSV1 serostatus and HSV2 serostatus in the multivariable analysis. Men who only occasionally used condoms were more likely to be HSV2 seropositive than men who consistently used condoms. However, men who did not use condoms at all were not more likely to be HSV2 seropositive than men who consistently used condoms.
In a previous survey based on the GNHIES data from 1997 to 1999, HSV2 seroprevalence was higher in women living in East Germany than in women living in West Germany [18]. Although we still observed this trend in the older age groups in the survey performed in 2008–2011, there was a remarkable decline in HSV2 seroprevalence between 1997–1999 and 2008–2011 in both women and men aged 18–24 years residing in East Germany. In this age group, HSV2 seroprevalence no longer differed between East and West Germany, regardless of sex. Because young people aged 18–24 years in 2008–2011 were born and raised around the time of the reunification of Germany in 1990, this finding may be partly attributable to the change in attitude to the prevention of sexually transmitted diseases and the change in sexual behavior in East Germany since 1990. In the former GDR, hormonal contraception was predominant and available free of charge from the age of 14 years [19]. After reunification, the pill only remained free for women under the age of 20 years and condoms became more easily available and more popular in East Germany. Moreover, in East Germany before 1990, adolescents tended to establish a family to gain the right to rent an apartment, whereas remaining single became popular after reunification because a flexible and independent individual has a greater chance of employment in the free market economy. Reunification also brought changes in the abortion law, the perception of homosexuality, divorce, prostitution, and pornography. Altogether, these changes probably resulted in a higher awareness of HIV, greater condom use, and consequently fewer HSV2 infections in the 18–24-year-olds residing in East Germany.
There were a number of limitations to our study. Both surveys collected data with research questions that focused on non-communicable diseases. Only very few questions about sexual behavior were included. Furthermore, the participants' HIV status or affiliations to a group with an increased risk of STI were not known. The study participants were not asked about the site of their infection. Because seropositivity does not distinguish between different routes of transmission, we were unable to draw any conclusions about the ratio of genitally to non-genitally acquired HSV1 and HSV2 infections. Moreover, although we measured seroprevalence, we did not investigate the burden of the disease, such as the number of clinical episodes, or the number of infected neonates and the grade of severity. A number of items in the questionnaire only covered the past year of the study participant's life and it is possible that their behavior had been different before that period. Making assumptions about the determinants of a lifelong infection is difficult in a cross-sectional study. Lastly, non-German citizens were underrepresented in both surveys and we were unable to investigate the differences in HSV1/2 seropositivity between persons with German or non-German nationality.

Conclusions

The estimated seroprevalence of both HSV1 and HSV2 imposes large clinical and psychosocial burdens on Germany. Therefore, the declines in HSV1 and HSV2 seroprevalence between the late 1990s and 2008–2011 benefit the nation. However, they also have a negative consequence, because they increase the susceptibility of sexually active people to genital HSV infections, including pregnant women. Therefore, practitioners should be aware of HSV infection as a differential diagnosis for genital ulcers, and should improve the counseling of affected patients and optimize the diagnosis, treatment, and prevention. This includes asking women at their first antenatal visit if they or their partner have had herpes, offering an explanation of possible preventive strategies, and counseling parents to avoid direct contact between herpetic lesions and the neonate [35, 39]. We recommend educational interventions to raise awareness of the sexual transmission route of the infection, of its possible consequences, and of its prevention. Interventions should especially target pregnant women and their partners, as well as people at risk of HIV and their partners.
It is important to continue to measure the seroprevalence of HSV1 and HSV2 in Germany over time to monitor trends, and it is essential to expand the data collected in future surveys to include a comprehensive set of questions regarding sexual behavior and HIV status. This will allow the influence of HSV infections on the HIV epidemic (and vice versa) in Germany to be assessed. We also encourage studies that explore the proportions of HSV1 and HSV2 infections among genital infections in Germany and to measure and monitor the number of neonatal HSV infections.

Abbreviations


CASMIN: 
Comparative Analysis of Social Mobility in Industrial Nations
CI: 
Confidence Interval
CPR: 
Crude prevalence ratio
DEGS: 
German Health Interview and Examination Survey for Adults
ELISA: 
Enzyme-linked immunosorbent assay
FRG: 
Federal Republic of Germany
GDR: 
German Democratic Republic
GNHIES: 
German National Health Interview and Examination Survey
HIV: 
Human immunodeficiency virus
HSV: 
Herpes simplex virus
OD: 
Optical density
PR: 
Prevalence ratio
STI: 
Sexually transmitted infection

Declarations

Acknowledgments

GK would like to thank the team of the German Postgraduate Training for Applied Epidemiology (PAE) for their continuous support. All authors thank Dr. Thea Riedel (Robert Koch Institute) for providing information regarding the laboratory procedures, Prof. Dr. Sauerbrei (German Reference Laboratory for Herpes Simplex Virus and Varicella Zoster Virus) for information regarding the analysis of the test results, and Dr. Ronny Kuhnert (Robert Koch Institute) for answering questions regarding the design and analysis options for the surveys. Finally, special thanks go to all the study participants.

Funding

The surveys were funded by the German Federal Ministry of Health. The funders had no role in study design, analysis, interpretation, write up and decision to publish results.

Availability of data and materials

The dataset supporting the conclusions of this article is available at the 'Health Monitoring' Research Data Centre at the Robert Koch Institute (RKI) and can be accessed on-site by all interested researchers. The 'Health Monitoring' Research Data Centre is accredited by the German Data Forum, based on uniform and transparent standards (http://ift.tt/2swicEp). On-site access to the dataset is possible at the Secure Data Center of the RKI's 'Health Monitoring' Research Data Centre, which is located at General-Pape Strasse 64, Berlin, Germany. Requests should be made to Dr. Ronny Kuhnert at the Robert Koch Institute, 'Health Monitoring' Research Data Centre, General-Pape Strasse 64, 12,101 Berlin, Germany (e-mail: fdz@rki.de).

Authors' contributions

KJ and VB formulated the initial research question. GK and KJ developed the study design, which was based on existing data and the methods used in the two surveys described, which were collected and provided by Department 2 of the RKI. GK and IC performed the statistical analyses. GK, KJ, CPM, and MT interpreted the findings. GK drafted the manuscript. All the authors contributed to the drafting and revision of the paper. All the authors have read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests. Klaus Jansen is a member of the editorial board (Associate Editor) of this journal.

Consent for publication

Not applicable.

Ethics approval and consent to participate

The GNHIES was approved by the local ethics committee; participation was voluntary and written informed consent was obtained from all the participants before the interview and examination. The DEGS study protocol was approved by the ethics committee of Charité-University Medicine Berlin in September 2008 (no. EA2/047/08); participation was voluntary and written informed consent was obtained from all the participants.

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Authors' Affiliations

(1)
Postgraduate Training for Applied Epidemiology (PAE, German Field Epidemiology Training Programme), Robert Koch Institute
(2)
European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC)
(3)
Robert Koch Institute (RKI)

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