1. Herpes Simplex Virus Type 2 infections in Germany 2008-2011: Results of a nationwide seroprevalence survey Dr. Gerit Solveig Korr, MSc DTMH IUSTI, Marrakech, 10th May 2016

2. 10th May 20162 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 2008-2011: Results of a nationwide seroprevalence survey

3. 10th May 20163 Epidemiology of HSV2 Germany:  No mandatory notification  Disease burden unknown  Survey 1997-1999:  HSV2 seroprevalence 13.3%  higher HSV2 seroprevalence in women who lived in former East Germany  higher HSV2 seroprevalence in age group 18-24 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 2008-2011: Results of a nationwide seroprevalence survey

4. 10th May 20164 Study Objectives  Assess HSV2 seroprevalence of adults in Germany based on a representative nationwide survey in 2008-2011  Identify factors which are associated with positive serostatus …To develop appropriate prevention & control strategies Herpes Simplex Virus Type 2 infections in Germany 2008-2011: Results of a nationwide seroprevalence survey

5. 10th May 20165 German health interview and examination survey for adults  Representative data on adult German population  Combined cross-sectional and longitudinal survey  8,151 participants, Nov 2008 - 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 2008-2011: Results of a nationwide seroprevalence survey German reunification in 1990

6. 10th May 20166 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 2008-2011: Results of a nationwide seroprevalence survey

7. 10th May 20167 HSV2 seroprevalence according to sex and age, Germany 2008-2011 total HSV2 seroprevalence: 9.4 % (95% CI 8.3-10.5) Herpes Simplex Virus Type 2 infections in Germany 2008-2011: Results of a nationwide seroprevalence survey

8. 10th May 20168 HSV2 seroprevalence in women, Germany 2008-2011, 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 2008-2011: Results of a nationwide seroprevalence survey

9. 10th May 20169 HSV2 seroprevalence in men, Germany 2008-2011, 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 2008-2011: Results of a nationwide seroprevalence survey

10. 10th May 201610 Factors associated with positive HSV2 IgG Serostatus, Germany 2008-2011 Variablecrude prevalence ratio (95% CI) adjusted prevalence ratio (95 % CI) female gender1.6 (1.3-2.0) 1.5 (1.2-1.9) age group (years) 18-24reference 25-343.1 (1.3-7.4) 5.7 (1.4-23.2) 35-444.9 (2.3-10.4) 8.4 (2.0-35) 45-547.9 (3.8-16.6) 12.9 (3.0-55.2) 55-648.4 (4.1-17.2) 11.1 (2.6-47.2) lived in former East Germany1.5 (1.1-2.1) 1.3 (1.1-1.7) marital status singlereference married2.0 (1.4-2.7) divorced4.3 (2.8-6.7) 1.7 (1.1-2.8) widowed2.9 (1.8-4.7) HSV1 IgG positivity1.5 (1.1-1.9) Herpes Simplex Virus Type 2 infections in Germany 2008-2011: Results of a nationwide seroprevalence survey

11. 10th May 201611 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 2008-2011: Results of a nationwide seroprevalence survey

12. 10th May 201612 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 2008-2011: Results of a nationwide seroprevalence survey

13. 10th May 201613 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 2008-2011: Results of a nationwide seroprevalence survey

14. 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 2008-2011: Results of a nationwide seroprevalence survey

15. 10th May 201615 Back up slides Herpes Simplex Virus Type 2 infections in Germany 2008-2011: Results of a nationwide seroprevalence survey

16. Representativeness of HSV2 samples 10th May 2016 *ISCED 1997 - International standard classification of education Herpes Simplex Virus Type 2 infections in Germany 2008-2011: Results of a nationwide seroprevalence survey

17. 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 2008-2011: Results of a nationwide seroprevalence survey

18. 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 2008-2011: Results of a nationwide seroprevalence survey

19. Variablep-value Gender>0.0000 Age>0.0000 Marital status>0.0000 Abortion0.0001 Federal state0.0005 HSV1 positive0.0049 North-South0.0054 Stillbirth0.0081 East-West0.0096 Condom use (men only)0.016 General state of health0.0375 Place of residence in 19880.0554 Smoking0.0707 Tiredness in last 4 weeks0.0873 Variablep-value BMI0.1470 Dermatologist in last 12 months0.1562 Number of inhabitants0.2182 Size of community0.2411 Alcohol consumption0.3020 Urologist in last 12 months0.3903 Counselling sexual behaviour0.4363 Chlamydia positive0.4367 Ever depression0.4432 Fixed partner0.5163 Number sex partners last 12 months0.5228 Language of questionnaire0.5586 Counselling alcohol consumption0.5984 Immunsuppressiva0.8468 Socioeconomic status0.9018 Univariable Analysis HSV2 IgG 10th May 2016 Herpes Simplex Virus Type 2 infections in Germany 2008-2011: Results of a nationwide seroprevalence survey