1 00:00:00,000 --> 00:00:14,540 Welcome to the Canadian Breakpoint, a Canadian infectious diseases podcast by Canadian infectious 2 00:00:14,540 --> 00:00:16,460 diseases physicians. 3 00:00:16,460 --> 00:00:21,480 I'm Summer Stewart, here with Dr. Rupeena Purewa, pediatric infectious diseases specialist 4 00:00:21,480 --> 00:00:23,280 from Saskatoon. 5 00:00:23,280 --> 00:00:29,340 In this episode, Dr. Purewal welcomes Dr. Ari Bittnan, professor of pediatrics at the University 6 00:00:29,340 --> 00:00:34,000 of Toronto to discuss cytomegla virus or CMV. 7 00:00:34,000 --> 00:00:35,000 Dr. Pirwal. 8 00:00:35,000 --> 00:00:39,760 Hi, welcome to another episode of the Canadian Breakpoint. 9 00:00:39,760 --> 00:00:44,120 Today we have Dr. Ari Bittnan, who is a professor in the Department of Pediatrics, University 10 00:00:44,120 --> 00:00:49,320 of Toronto and a staff physician in the Division of Infectious Diseases at the Hospital of 11 00:00:49,320 --> 00:00:50,320 Sick Children. 12 00:00:50,320 --> 00:00:56,120 His main areas of interest are pediatric HIV, congenital infections and infections of the 13 00:00:56,120 --> 00:00:57,120 central nervous system. 14 00:00:57,120 --> 00:01:02,760 He is the director of the congenital and perinatal clinic at SickKids and has been managing children 15 00:01:02,760 --> 00:01:06,080 with congenital CMV for many years. 16 00:01:06,080 --> 00:01:07,080 Welcome Dr. Bittnan. 17 00:01:07,080 --> 00:01:08,080 Glad to be here. 18 00:01:08,080 --> 00:01:09,080 Thanks for inviting me. 19 00:01:09,080 --> 00:01:10,080 Of course. 20 00:01:10,080 --> 00:01:15,960 So today we're going to talk about an important topic on CMV. 21 00:01:15,960 --> 00:01:21,160 And so I want to kind of walk through, you know, in general, because this is a podcast 22 00:01:21,160 --> 00:01:27,080 that's for many clinicians, so not just infectious disease physicians, but also family doctors, 23 00:01:27,080 --> 00:01:31,400 pediatricians, and definitely even nurses and pharmacists. 24 00:01:31,400 --> 00:01:37,680 So I think being aware of what CMV is and how does it really affect newborns and infants. 25 00:01:37,680 --> 00:01:42,720 When we briefly touch on that topic, we can just introduce the topic of CMV today. 26 00:01:42,720 --> 00:01:48,320 Okay, so I mean, I guess in general, everyone's, if they're medical, they're familiar with 27 00:01:48,320 --> 00:01:50,800 CMV or the virus. 28 00:01:50,800 --> 00:01:55,120 I think some key things to remember is it's extremely common. 29 00:01:55,120 --> 00:01:59,800 So it depends a little bit where you are in the world in terms of seroprevalence. 30 00:01:59,800 --> 00:02:04,360 But in general, by the time people reach adulthood, most people are infected. 31 00:02:04,360 --> 00:02:08,800 We can talk a little bit about the prevalence in Canada compared to other places. 32 00:02:08,800 --> 00:02:13,920 But in general, in resource limited settings, the seroprevalence can be almost 100% by the 33 00:02:13,920 --> 00:02:15,840 time you reach adulthood. 34 00:02:15,840 --> 00:02:20,240 In resource rich settings like ours, it can be more somewhere between 40 and 70, depending 35 00:02:20,240 --> 00:02:21,240 on what country you're in. 36 00:02:21,240 --> 00:02:26,520 So extremely common, and most people aren't aware of it because it doesn't cause any symptoms 37 00:02:26,520 --> 00:02:27,520 in most cases. 38 00:02:27,520 --> 00:02:31,800 Or if it does, it causes a mild non-specific illness and doesn't really cause any long 39 00:02:31,800 --> 00:02:33,640 term issues. 40 00:02:33,640 --> 00:02:37,880 And I guess the focus here today, there are several situations where CMV can cause trouble. 41 00:02:37,880 --> 00:02:41,120 One is an immune compromised host, which we're not talking about today. 42 00:02:41,120 --> 00:02:46,560 And the other is in the context of an infection in pregnancy and the potential implications 43 00:02:46,560 --> 00:02:48,560 of that for the fetus and the child. 44 00:02:48,560 --> 00:02:52,560 So I think that's kind of a good place to start. 45 00:02:52,560 --> 00:02:56,720 I guess one other thing to say in terms of transmission as an intro. 46 00:02:56,720 --> 00:02:58,520 So it's very readily transmitted. 47 00:02:58,520 --> 00:03:01,400 It's secreted in body secretions. 48 00:03:01,400 --> 00:03:05,400 So saliva, urine, breast milk, semen, et cetera. 49 00:03:05,400 --> 00:03:13,040 So all of those fluids can contain CMV and transmit the virus. 50 00:03:13,040 --> 00:03:19,840 And so like you mentioned, obviously CMV can affect newborns and infants in a certain way. 51 00:03:19,840 --> 00:03:24,160 Definitely our newborns, that's kind of why we're talking about this today. 52 00:03:24,160 --> 00:03:29,160 So in terms of obviously me being a pediatric infectious disease specialist, I see it a 53 00:03:29,160 --> 00:03:30,360 lot as well. 54 00:03:30,360 --> 00:03:36,760 And we see most of them that are asymptomatic and don't really present with anything. 55 00:03:36,760 --> 00:03:40,240 But they can have some long term complications. 56 00:03:40,240 --> 00:03:43,160 And that's probably really pertinent for pediatricians to be aware of. 57 00:03:43,160 --> 00:03:47,360 So can we maybe touch on some of the long term complications that we should be aware 58 00:03:47,360 --> 00:03:48,360 of? 59 00:03:48,360 --> 00:03:49,360 Sure. 60 00:03:49,360 --> 00:03:54,880 So first, maybe just before I say that, I think one thing that I think is important to 61 00:03:54,880 --> 00:03:58,520 remember is as you mentioned, most babies are asymptomatic. 62 00:03:58,520 --> 00:04:05,040 And if you do in studies that have been prospective, if you look at the overall group, 80% of them 63 00:04:05,040 --> 00:04:07,200 never have any problem at all long term. 64 00:04:07,200 --> 00:04:11,800 So it's about a fifth that end up with some kind of long term sequela. 65 00:04:11,800 --> 00:04:16,760 And the most common there is sensorineural hearing loss. 66 00:04:16,760 --> 00:04:19,440 People tend to be familiar with the severe end of the spectrum. 67 00:04:19,440 --> 00:04:26,500 You know, a baby that's born with microcephaly, cerebral calcifications, they might have choreoretonitis, 68 00:04:26,500 --> 00:04:30,160 they might have hearing loss, and then they might have the systemic symptoms as well, 69 00:04:30,160 --> 00:04:34,680 like the big liver, big explain, they might have thrombocytopenia with rash. 70 00:04:34,680 --> 00:04:39,080 But really, it's a spectrum ranging from asymptomatic to the very severe end. 71 00:04:39,080 --> 00:04:41,880 And the very severe end is really a small minority. 72 00:04:41,880 --> 00:04:44,840 They're tragic cases, but they're a small minority. 73 00:04:44,840 --> 00:04:49,480 In terms of the ones that are symptomatic, the more common ones tend to be, you know, 74 00:04:49,480 --> 00:04:51,640 mildly to moderately symptomatic. 75 00:04:51,640 --> 00:04:55,760 So it might be something as simple as just a baby with a particular rash and you have 76 00:04:55,760 --> 00:04:58,880 low platelets and that's the only manifestation. 77 00:04:58,880 --> 00:05:00,800 So quite variable. 78 00:05:00,800 --> 00:05:06,160 The other thing to remember is it's non-specific symptoms and so a lot of times it's missed 79 00:05:06,160 --> 00:05:10,240 because people don't think about CMV because it's a non-specific manifestation, like it 80 00:05:10,240 --> 00:05:14,660 could be colostatic jaundice or something like that and people don't think CMV. 81 00:05:14,660 --> 00:05:17,080 So even the symptomatic ones can be missed. 82 00:05:17,080 --> 00:05:18,080 Right. 83 00:05:18,080 --> 00:05:24,320 Okay, and that leads me on to the next question because now we have some provinces, including 84 00:05:24,320 --> 00:05:27,800 Saskatchewan, that were doing universal screening. 85 00:05:27,800 --> 00:05:34,640 So screening for CMV, I think, has probably been a huge discussion across probably many 86 00:05:34,640 --> 00:05:39,400 nations and internationally there's probably a lot of differences as well. 87 00:05:39,400 --> 00:05:43,920 But here in Canada, so we always talk about this universal versus targeted screening. 88 00:05:43,920 --> 00:05:48,160 Do you want to maybe touch on some of the differences, maybe some of the pros and cons? 89 00:05:48,160 --> 00:05:53,040 Because I know Ontario has been doing universal screening for quite a while now compared to 90 00:05:53,040 --> 00:05:54,040 other provinces. 91 00:05:54,040 --> 00:05:58,800 And I'm not sure actually in Saskatchewan, this is a very, very fresh topic. 92 00:05:58,800 --> 00:06:03,480 We just started getting some of those reports in and so it's causing some anxiety among 93 00:06:03,480 --> 00:06:04,480 their clinicians. 94 00:06:04,480 --> 00:06:09,960 And so maybe we could, you could walk us kind of through, you know, what is the differences 95 00:06:09,960 --> 00:06:12,840 between what we're seeing now and what's targeted screening? 96 00:06:12,840 --> 00:06:13,840 Sure. 97 00:06:13,840 --> 00:06:16,680 So first off, I don't know if you might want to come back to this. 98 00:06:16,680 --> 00:06:19,840 Some people bring up the idea of screening in pregnancy, which I personally think is 99 00:06:19,840 --> 00:06:20,840 a mistake. 100 00:06:20,840 --> 00:06:25,960 So if you, we can avoid that altogether if you want, but with respect to newborn screening, 101 00:06:25,960 --> 00:06:32,360 I think this is what's going to happen eventually everywhere because it's such a common condition 102 00:06:32,360 --> 00:06:35,920 and it's hard to diagnose and it has the long-term complications. 103 00:06:35,920 --> 00:06:41,480 So I think over time it's going to start to be implemented in more and more places. 104 00:06:41,480 --> 00:06:48,280 Targeted screening in general basically refers to you, if you have a baby that screens positive 105 00:06:48,280 --> 00:06:54,880 for hearing loss, then you test them for CMV because CMV is one of the more common causes 106 00:06:54,880 --> 00:06:56,680 of hearing loss in children. 107 00:06:56,680 --> 00:07:02,920 So there's genetic causes and then there's CMV is the most common cause of acquired hearing 108 00:07:02,920 --> 00:07:03,920 loss in childhood. 109 00:07:03,920 --> 00:07:06,560 So that would be targeted screening. 110 00:07:06,560 --> 00:07:09,440 The baby fails their newborn screen. 111 00:07:09,440 --> 00:07:13,400 You have the confirmatory ABR and if they are confirmed to have hearing loss, you test 112 00:07:13,400 --> 00:07:14,840 them automatically for CMV. 113 00:07:14,840 --> 00:07:17,720 So that's targeted. 114 00:07:17,720 --> 00:07:22,480 So it's kind of what it says, you screen all babies and then it becomes a question of what 115 00:07:22,480 --> 00:07:25,480 modality you use. 116 00:07:25,480 --> 00:07:28,320 There's advantages and disadvantages to each. 117 00:07:28,320 --> 00:07:29,320 You want me to go through that? 118 00:07:29,320 --> 00:07:30,320 Yeah. 119 00:07:30,320 --> 00:07:34,800 So I think maybe just touch on a type of specimen and just, you know, what people, I think more 120 00:07:34,800 --> 00:07:39,280 so for clinicians, it's going to be important kind of walking through when we see the results, 121 00:07:39,280 --> 00:07:43,840 knowing what the dried blood spot is actually indicative of and how to follow up that. 122 00:07:43,840 --> 00:07:47,680 So we'll touch a little bit on that, but yeah, you can definitely talk about the testing 123 00:07:47,680 --> 00:07:50,400 and the specimens that are used. 124 00:07:50,400 --> 00:07:51,400 Okay. 125 00:07:51,400 --> 00:07:57,960 So yeah, so the options for screening for targeted screening would be you just use the 126 00:07:57,960 --> 00:07:59,600 birth, dry blood spot. 127 00:07:59,600 --> 00:08:04,160 The advantage of the birth, dry blood spot is it's collected anyway for metabolic diseases. 128 00:08:04,160 --> 00:08:08,440 And so in terms of the infrastructure, it's relatively straightforward because you're 129 00:08:08,440 --> 00:08:13,920 just adding another test to a sample that's already being collected. 130 00:08:13,920 --> 00:08:19,040 And the filter paper strategy has been, it's been studied and CMV can be detected in it. 131 00:08:19,040 --> 00:08:24,560 So that's the easiest in terms of, you know, if you want it to implement something now, 132 00:08:24,560 --> 00:08:25,560 right? 133 00:08:25,560 --> 00:08:27,960 The infrastructure is there. 134 00:08:27,960 --> 00:08:32,640 The downside is that the sensitivity of the dry blood spot is not great. 135 00:08:32,640 --> 00:08:36,720 If you look at some of the studies, it talks about up to about 85% sensitivity. 136 00:08:36,720 --> 00:08:40,720 I think in reality, it's probably lower than that. 137 00:08:40,720 --> 00:08:46,720 It really ranges vastly between study to study, but I would say it's probably more around 138 00:08:46,720 --> 00:08:50,160 50% or so, but don't quote me on a specific number. 139 00:08:50,160 --> 00:08:55,400 I think the point, the main point is not, is to realize that the sensitivity is, is 140 00:08:55,400 --> 00:08:56,400 lowish. 141 00:08:56,400 --> 00:08:59,200 So you're missing cases. 142 00:08:59,200 --> 00:09:05,360 The specificity is high, but you can still have false positives and people talk about 143 00:09:05,360 --> 00:09:06,360 why that might be. 144 00:09:06,360 --> 00:09:12,040 I mean, obviously there's lab false positives that can happen, but also I think the filter 145 00:09:12,040 --> 00:09:13,880 papers can get stacked. 146 00:09:13,880 --> 00:09:17,860 And so you could theoretically have contamination between filter papers. 147 00:09:17,860 --> 00:09:20,300 So sometimes you can have false positives. 148 00:09:20,300 --> 00:09:24,120 They're not common, but they do come up and they do come up in a screening program. 149 00:09:24,120 --> 00:09:27,080 And then you have to kind of go back and try and figure out, was this a false positive 150 00:09:27,080 --> 00:09:28,080 or not? 151 00:09:28,080 --> 00:09:30,200 So it does happen. 152 00:09:30,200 --> 00:09:35,840 The ideal specimen really is saliva. 153 00:09:35,840 --> 00:09:40,920 The reason it's ideal is it's very highly sensitive, much more sensitive than the dry 154 00:09:40,920 --> 00:09:43,400 blood spot. 155 00:09:43,400 --> 00:09:47,360 It's easy to collect once you've trained people on how to do it. 156 00:09:47,360 --> 00:09:51,560 And so for, if you were to implement that, it would be relatively straightforward to 157 00:09:51,560 --> 00:09:55,000 train people to do it. 158 00:09:55,000 --> 00:10:00,040 It's been studied already, not a huge amount, but it's been studied on filter paper where 159 00:10:00,040 --> 00:10:01,440 people collected on filter paper. 160 00:10:01,440 --> 00:10:05,840 So I think it's probably the, ultimately the best way to go. 161 00:10:05,840 --> 00:10:11,120 That would be my preferred strategy for screening would be the saliva because it's much more 162 00:10:11,120 --> 00:10:12,160 sensitive. 163 00:10:12,160 --> 00:10:15,520 The one thing with the saliva that people have to be careful of is you don't want to 164 00:10:15,520 --> 00:10:20,480 take that sample too close to when the baby breastfed because you can get false positives 165 00:10:20,480 --> 00:10:22,360 if mom is shedding. 166 00:10:22,360 --> 00:10:27,440 So that's one caveat that needs to be kept in mind. 167 00:10:27,440 --> 00:10:32,120 And then the other obvious aspect is if you were to go that route, you have to have that, 168 00:10:32,120 --> 00:10:33,280 the whole setup for that. 169 00:10:33,280 --> 00:10:35,200 So everyone has to be trained on collection. 170 00:10:35,200 --> 00:10:38,520 You have to have the mechanism for transporting all these samples to the lab that's going 171 00:10:38,520 --> 00:10:42,080 to be doing the assays and have the assay set up. 172 00:10:42,080 --> 00:10:52,680 So it's more of a upfront undertaking to establish that compared to the dry blood spot. 173 00:10:52,680 --> 00:10:54,280 The third option is urine. 174 00:10:54,280 --> 00:10:58,520 I think urine is not a good strategy for screening because it's way too messy. 175 00:10:58,520 --> 00:11:04,280 You'll get too many cases where it's contaminated with stool and it's hard to do that on a universal 176 00:11:04,280 --> 00:11:05,280 basis. 177 00:11:05,280 --> 00:11:10,760 It's a great test and it is the test you should probably use to confirm congenital CMV, but 178 00:11:10,760 --> 00:11:12,040 not as a screening. 179 00:11:12,040 --> 00:11:17,480 So ultimately I think saliva is the way to go, but as a starting point, I think dry blood 180 00:11:17,480 --> 00:11:19,280 spot is good. 181 00:11:19,280 --> 00:11:21,080 Yeah. 182 00:11:21,080 --> 00:11:23,760 I think that's how I would put it. 183 00:11:23,760 --> 00:11:29,080 And so now, so lately, I guess in my last few weeks of call here, we introduced the 184 00:11:29,080 --> 00:11:30,080 universal screening. 185 00:11:30,080 --> 00:11:38,240 So it's created a huge, almost like a lot of questions have come out because they'll 186 00:11:38,240 --> 00:11:41,360 see this new results on this dried blood spot. 187 00:11:41,360 --> 00:11:45,560 And I'll kind of walk through what we're doing here in Saskatchewan, but I think in general, 188 00:11:45,560 --> 00:11:48,120 you guys have been in Ontario, been doing it much longer. 189 00:11:48,120 --> 00:11:50,680 And so I guess what are the kind of next steps? 190 00:11:50,680 --> 00:11:56,160 Like we talked about urine being the confirmatory and we know, and most people know with congenital 191 00:11:56,160 --> 00:12:01,600 CMV, that that urine sample in the first 21 days is a confirmatory sample. 192 00:12:01,600 --> 00:12:05,400 So is that kind of what you guys are doing when you're seeing these results and kind 193 00:12:05,400 --> 00:12:08,400 of what's the steps that clinicians should be aware of? 194 00:12:08,400 --> 00:12:09,400 Yeah. 195 00:12:09,400 --> 00:12:15,360 So if we get a positive report, so I mean, I don't know if we can talk about the infrastructure 196 00:12:15,360 --> 00:12:21,080 and the personnel if you want, or you would just want to touch on a test right now. 197 00:12:21,080 --> 00:12:26,160 Yeah, I think in general, probably the test because that would be kind of what my other 198 00:12:26,160 --> 00:12:28,760 physicians would be ordering or seeing. 199 00:12:28,760 --> 00:12:29,760 Yeah. 200 00:12:29,760 --> 00:12:31,640 So I think automatically you need to confirm it. 201 00:12:31,640 --> 00:12:35,880 I think as a first step, you do the urine to confirm the infection. 202 00:12:35,880 --> 00:12:42,320 And you know, surprisingly, you will find sometimes that the screen, the dry blood spot 203 00:12:42,320 --> 00:12:47,200 being positive and the urine is negative and that causes a little bit of consternation 204 00:12:47,200 --> 00:12:50,940 and confusion, but it does happen. 205 00:12:50,940 --> 00:12:52,400 If it's positive, it's easy. 206 00:12:52,400 --> 00:12:56,560 You've confirmed the diagnosis and then you go on to do the workup that you kind of have 207 00:12:56,560 --> 00:13:00,800 decided upon that should be protocolized. 208 00:13:00,800 --> 00:13:01,800 And that's straightforward. 209 00:13:01,800 --> 00:13:08,760 If the urine is negative, we've kind of gone back to the dry blood spot and repeated the 210 00:13:08,760 --> 00:13:13,960 testing and also repeated the urine and sometimes we've sent serology. 211 00:13:13,960 --> 00:13:19,840 You know, sometimes it's helpful to do that because then you can, so for example, if you 212 00:13:19,840 --> 00:13:23,680 had a dry blood spot that ding positive and then your urine is negative, you repeat the 213 00:13:23,680 --> 00:13:28,800 urine again and it's again and negative again and CMV serology is negative. 214 00:13:28,800 --> 00:13:31,520 Then you sort of say, oh, this is a false positive for sure. 215 00:13:31,520 --> 00:13:32,520 Right. 216 00:13:32,520 --> 00:13:36,120 You might have some other scenarios where it ends up being equivocal, right? 217 00:13:36,120 --> 00:13:37,680 Where your serology is reactive. 218 00:13:37,680 --> 00:13:43,360 I mean, that could be maternal antibody that can get complicated, but if the urine is negative, 219 00:13:43,360 --> 00:13:46,040 it sort of argues against it being a real infection. 220 00:13:46,040 --> 00:13:48,520 Yeah, no, that's fair. 221 00:13:48,520 --> 00:13:49,520 Yeah. 222 00:13:49,520 --> 00:13:50,520 Yeah. 223 00:13:50,520 --> 00:13:57,440 We had one of those actually and so had to, so something I didn't, I think, realize was 224 00:13:57,440 --> 00:14:02,320 if there's premature infants that you're dealing with, they would actually have two newborn 225 00:14:02,320 --> 00:14:03,320 screens. 226 00:14:03,320 --> 00:14:04,320 Yes. 227 00:14:04,320 --> 00:14:09,640 So that caused a lot of anxiety last week because we had a case where, you know, we 228 00:14:09,640 --> 00:14:15,520 had to repeat or we didn't have the newborn screen implemented, the universal CMV screen 229 00:14:15,520 --> 00:14:18,280 on the first, when the baby was first born. 230 00:14:18,280 --> 00:14:22,640 And then three weeks later when it was redone or closer to, yeah, probably six weeks later 231 00:14:22,640 --> 00:14:23,640 when it was done. 232 00:14:23,640 --> 00:14:29,840 Now we have the universal screen on the CMV screen on the newborn screen. 233 00:14:29,840 --> 00:14:32,800 So now we have this positive, but we've never done it before. 234 00:14:32,800 --> 00:14:37,360 So obviously we just went back to the previous dried blood spot and reran it. 235 00:14:37,360 --> 00:14:43,240 But I think that creates a little bit of a, I actually probably didn't even think about 236 00:14:43,240 --> 00:14:48,320 outlining that when we were coming up with our protocol because it was something that 237 00:14:48,320 --> 00:14:52,440 just didn't come across that, oh, it can actually be positive later on. 238 00:14:52,440 --> 00:14:55,280 So it's on the road that we're facing now. 239 00:14:55,280 --> 00:14:56,840 And with anything you implement. 240 00:14:56,840 --> 00:14:57,840 Yeah. 241 00:14:57,840 --> 00:15:00,200 I think they usually do that second sample at three weeks. 242 00:15:00,200 --> 00:15:04,480 If it's done at three weeks and it's positive, it's still, I mean, it's right on the border, 243 00:15:04,480 --> 00:15:07,720 obviously, but it's probably congenital, right? 244 00:15:07,720 --> 00:15:08,720 Yeah, exactly. 245 00:15:08,720 --> 00:15:10,960 It's weeks that becomes much more messy. 246 00:15:10,960 --> 00:15:11,960 Yeah. 247 00:15:11,960 --> 00:15:12,960 No, that's fair. 248 00:15:12,960 --> 00:15:13,960 So yeah. 249 00:15:13,960 --> 00:15:18,960 So here in Saskatchewan currently what we're doing is we obviously have a newborn screen 250 00:15:18,960 --> 00:15:19,960 come back. 251 00:15:19,960 --> 00:15:24,880 Some of the times if they're in the NICU, they'll still be in hospital, obviously. 252 00:15:24,880 --> 00:15:29,320 And then if some of them get discharged, that's usually the harder part because now you have 253 00:15:29,320 --> 00:15:34,280 to locate the family and let them know about the newborn screen because it comes back a 254 00:15:34,280 --> 00:15:38,240 few days later after they've already been discharged from the hospital. 255 00:15:38,240 --> 00:15:44,040 And then we have a genetics team, like a genetics resource center, who once that comes are positive, 256 00:15:44,040 --> 00:15:50,800 they will actually reach out to the family and get that urine sent for the confirmatory 257 00:15:50,800 --> 00:15:53,400 and ideally within that first 21 days. 258 00:15:53,400 --> 00:15:58,200 That's easier for us as infectious disease physicians to say, yes, this is confirmatory 259 00:15:58,200 --> 00:16:02,480 or not, and this is congenital versus not acquired. 260 00:16:02,480 --> 00:16:05,280 And then after that, the steps start with risk stratification. 261 00:16:05,280 --> 00:16:12,760 And so if the CMV urine comes back positive, then audiology is a huge component of that, 262 00:16:12,760 --> 00:16:17,120 like we just talked about, because I think as clinicians that makes a huge difference 263 00:16:17,120 --> 00:16:23,840 for us, especially in these isolated central neuroherring loss and cases where you're a 264 00:16:23,840 --> 00:16:28,800 little bit conflicted in terms of I think the data is a bit conflicted as to what to 265 00:16:28,800 --> 00:16:29,800 do in those cases. 266 00:16:29,800 --> 00:16:36,560 Obviously, the severe cases are simpler to manage because they're more black and white. 267 00:16:36,560 --> 00:16:43,320 And then we get involved from infectious diseases and we kind of go through the process of risk 268 00:16:43,320 --> 00:16:48,960 stratifying as mild, moderate, severe or asymptomatic central neuroherring loss or not, and then 269 00:16:48,960 --> 00:16:52,920 come up with our management plan and then a long-term follow-up. 270 00:16:52,920 --> 00:16:58,040 So I would assume kind of a similar process maybe in Ontario or is it... 271 00:16:58,040 --> 00:17:03,720 The way it works, I mean, Ontario obviously is a much larger population and much... 272 00:17:03,720 --> 00:17:04,720 Definitely. 273 00:17:04,720 --> 00:17:11,560 The way it's structured is there's five nurse practitioners, basically based on region, 274 00:17:11,560 --> 00:17:13,840 where the pediatric hospitals are. 275 00:17:13,840 --> 00:17:19,200 And so each of those nurse practitioners will be the one notified about the result in their 276 00:17:19,200 --> 00:17:24,360 region and then they would be the ones to reach out to the family and do what you said 277 00:17:24,360 --> 00:17:31,200 the genetics people do, where they disclose that initial diagnosis field, initial questions, 278 00:17:31,200 --> 00:17:35,800 and then arrange for their follow-up wherever that needs to be. 279 00:17:35,800 --> 00:17:42,320 So the way we've structured it is babies that are asymptomatic go to certain pediatricians. 280 00:17:42,320 --> 00:17:50,760 So we identified certain pediatricians in the regions that agreed to take on this role 281 00:17:50,760 --> 00:17:54,160 because there's also some paperwork in terms of follow-up that they need to do, but they 282 00:17:54,160 --> 00:17:59,720 agreed to take on this role, do the initial workup with ID as kind of a backup if they 283 00:17:59,720 --> 00:18:01,280 have any concerns. 284 00:18:01,280 --> 00:18:05,880 The ones that are symptomatic come automatically to ID. 285 00:18:05,880 --> 00:18:11,060 So ID, the ones that are initially symptomatic, as well as the ones where the pediatrician 286 00:18:11,060 --> 00:18:16,400 had some questions, like let's say for example, the head ultrasound showed some subtle finding 287 00:18:16,400 --> 00:18:19,240 and they weren't sure what to do with it, then they would consult with us. 288 00:18:19,240 --> 00:18:24,960 So there's a group of pediatricians, a group of ID docs that would see the kids, do a standardized 289 00:18:24,960 --> 00:18:25,960 workup. 290 00:18:25,960 --> 00:18:28,360 Our standardized workup is kind of what you'd expect. 291 00:18:28,360 --> 00:18:33,360 It's a CBC, liver function tests, head ultrasound, audiology. 292 00:18:33,360 --> 00:18:34,720 Ophthalmology was routine. 293 00:18:34,720 --> 00:18:38,520 We can talk a little bit about that because we've kind of gone through a two-year data 294 00:18:38,520 --> 00:18:42,160 and we've kind of modified what we're doing so we could talk about that. 295 00:18:42,160 --> 00:18:43,480 That's our basic workup. 296 00:18:43,480 --> 00:18:45,480 And then we go from there. 297 00:18:45,480 --> 00:18:52,000 MRIs vary selectively, mostly it's head ultrasound. 298 00:18:52,000 --> 00:18:55,640 And then once they're in, then the decisions on treatment would be ID. 299 00:18:55,640 --> 00:18:58,160 So ID would make decisions on the treatment. 300 00:18:58,160 --> 00:19:01,800 And if they're being treated, we would follow them closely. 301 00:19:01,800 --> 00:19:04,840 Whereas the ones that are not being treated would be followed by the pediatricians. 302 00:19:04,840 --> 00:19:05,840 And then they're followed. 303 00:19:05,840 --> 00:19:08,880 So you would have a standardized follow-up with some forms that you fill out at particular 304 00:19:08,880 --> 00:19:14,320 times and submit those to the NSO, the newborn screening program. 305 00:19:14,320 --> 00:19:15,320 Okay. 306 00:19:15,320 --> 00:19:16,320 Yeah. 307 00:19:16,320 --> 00:19:17,320 Definitely well structured. 308 00:19:17,320 --> 00:19:25,360 So hopefully we'll get to that too in Saskatchewan because currently it's... 309 00:19:25,360 --> 00:19:27,560 You need to have an evaluation of it, right? 310 00:19:27,560 --> 00:19:31,080 So you need to read, like how many people are you testing? 311 00:19:31,080 --> 00:19:32,080 Are you missing any? 312 00:19:32,080 --> 00:19:35,040 And then how many of those that you test positive are actually seen? 313 00:19:35,040 --> 00:19:38,720 Like there's all these factors in terms of evaluating the program that you really need 314 00:19:38,720 --> 00:19:39,720 to put in place. 315 00:19:39,720 --> 00:19:40,720 Yeah. 316 00:19:40,720 --> 00:19:41,720 Yeah. 317 00:19:41,720 --> 00:19:42,720 Yeah. 318 00:19:42,720 --> 00:19:45,080 And I think that's kind of where the next steps are for us because we're so brand new 319 00:19:45,080 --> 00:19:46,440 at introducing it. 320 00:19:46,440 --> 00:19:51,540 So we're going to have to look at definitely our data in terms of how many positives came 321 00:19:51,540 --> 00:19:53,520 out of how many got tested, et cetera. 322 00:19:53,520 --> 00:19:58,680 And so definitely area for room for research always with DMV. 323 00:19:58,680 --> 00:19:59,680 Perfect. 324 00:19:59,680 --> 00:20:03,640 So yeah, why don't we talk a little bit about the follow-up? 325 00:20:03,640 --> 00:20:08,840 Because there's a lot of pediatricians that do tune into this podcast. 326 00:20:08,840 --> 00:20:15,240 And so, I mean, there is a Canadian Pediatric Society statement that we've obviously been 327 00:20:15,240 --> 00:20:17,480 involved in and written for us. 328 00:20:17,480 --> 00:20:20,400 And so I think there's a couple of things. 329 00:20:20,400 --> 00:20:26,760 Like, I mean, I think some of the main developmental follow-ups are quite similar to other congenital 330 00:20:26,760 --> 00:20:27,760 infections. 331 00:20:27,760 --> 00:20:34,480 But some of the specific ones, like in terms of the ophthalmology follow-up, and also I 332 00:20:34,480 --> 00:20:37,520 do remember that there's some enamel issues. 333 00:20:37,520 --> 00:20:40,000 And so there's a question about dental follow-ups. 334 00:20:40,000 --> 00:20:43,240 I'm not sure if those are some things that actually are being implemented or there's 335 00:20:43,240 --> 00:20:44,520 more studies around that. 336 00:20:44,520 --> 00:20:46,320 So maybe you can touch on that. 337 00:20:46,320 --> 00:20:47,320 Okay. 338 00:20:47,320 --> 00:20:48,320 Yeah. 339 00:20:48,320 --> 00:20:51,120 So I think in terms of the development, it really depends on the case. 340 00:20:51,120 --> 00:20:54,560 And I think this is a pediatrician kind of make that call if they're asymptomatic and 341 00:20:54,560 --> 00:20:56,360 completely well or they're completely well. 342 00:20:56,360 --> 00:21:03,480 I mean, I think actually it's kind of one of the disadvantages of a saliva screening 343 00:21:03,480 --> 00:21:08,560 base, I'm kind of going back a little bit, but one of the disadvantages is you're picking 344 00:21:08,560 --> 00:21:09,560 up all the cases. 345 00:21:09,560 --> 00:21:10,560 Yeah. 346 00:21:10,560 --> 00:21:11,560 Right. 347 00:21:11,560 --> 00:21:16,480 So you're picking up a lot of babies who, most of them will never have anything. 348 00:21:16,480 --> 00:21:19,960 And so to some extent, you're medicalizing those kids, right? 349 00:21:19,960 --> 00:21:24,300 And some parents are going to get more anxious than others, but you are medicalizing them. 350 00:21:24,300 --> 00:21:27,080 So that's kind of, it just ties into the follow-up. 351 00:21:27,080 --> 00:21:31,480 But if you have one of these asymptomatic kids, it seems completely normal, then you 352 00:21:31,480 --> 00:21:34,800 keep it in the back of your mind and you do your routine pediatric follow-up and assess 353 00:21:34,800 --> 00:21:36,160 them as you would normally. 354 00:21:36,160 --> 00:21:41,220 I think if they've got symptoms or if they're showing some kind of signs, you can follow 355 00:21:41,220 --> 00:21:43,120 them a little more closely. 356 00:21:43,120 --> 00:21:52,640 The eyes, what we found is that very few babies had eye manifestations. 357 00:21:52,640 --> 00:21:56,480 Only if they're asymptomatic, we have none. 358 00:21:56,480 --> 00:22:00,240 And the exam is actually uncomfortable. 359 00:22:00,240 --> 00:22:06,680 Like if you do a full ophthalmologic exam where they open the eye and it's not comfortable. 360 00:22:06,680 --> 00:22:11,160 So we've kind of modified that where we're not automatically doing eye exams at all, 361 00:22:11,160 --> 00:22:12,160 and everyone. 362 00:22:12,160 --> 00:22:19,640 So that's something that the ophthalmologists in Ontario could maybe connect with your group 363 00:22:19,640 --> 00:22:24,520 and talk about that because it's a rare manifestation. 364 00:22:24,520 --> 00:22:29,600 And in general, most of when we do find something, it's usually quiet, like it's a scar. 365 00:22:29,600 --> 00:22:31,600 So they don't necessarily even need follow-up. 366 00:22:31,600 --> 00:22:34,480 And so it would be selective based on ophthalmology. 367 00:22:34,480 --> 00:22:37,640 The big thing is the hearing, obviously they need to have very close follow-up for the 368 00:22:37,640 --> 00:22:40,720 hearing. 369 00:22:40,720 --> 00:22:42,600 So that's kind of what I would suggest. 370 00:22:42,600 --> 00:22:43,600 Okay. 371 00:22:43,600 --> 00:22:44,600 Yeah. 372 00:22:44,600 --> 00:22:45,600 And yeah, definitely. 373 00:22:45,600 --> 00:22:49,000 I think we're also finding to me a little bit of that process because even for decision 374 00:22:49,000 --> 00:22:52,800 making, I mean, the hearing is so important when you think about whether you're going 375 00:22:52,800 --> 00:22:53,800 to start. 376 00:22:53,800 --> 00:22:59,000 And then one comment to bring up is that this is actually progressive hearing loss. 377 00:22:59,000 --> 00:23:05,360 And so that's why we need to make sure that we're having routine kind of follow-up for 378 00:23:05,360 --> 00:23:06,360 the babies. 379 00:23:06,360 --> 00:23:10,000 And so just to like I mentioned, which is a little bit different than some of our other 380 00:23:10,000 --> 00:23:14,920 congenital infections, because usually you can, I mean, I'm sure there are like we're 381 00:23:14,920 --> 00:23:21,480 seeing a lot of syphilis out here and so they can also have hearing loss, but usually as 382 00:23:21,480 --> 00:23:24,280 a result of like already in utero transmission. 383 00:23:24,280 --> 00:23:25,400 And so they present with that. 384 00:23:25,400 --> 00:23:30,160 So I think that's something that's quite important because it's almost, you don't want to give 385 00:23:30,160 --> 00:23:35,200 parents false reassurance either, but the hearing is now normal. 386 00:23:35,200 --> 00:23:39,360 But I think counseling is a huge component of this. 387 00:23:39,360 --> 00:23:43,960 And there is a little bit more anxiety as I'm doing these follow-ups with parents because 388 00:23:43,960 --> 00:23:47,880 they're anxious because CMV was never, and moms will usually remember that they had a 389 00:23:47,880 --> 00:23:51,200 bit of a cold during pregnancy and that's really it. 390 00:23:51,200 --> 00:23:57,560 So they're a little bit shocked to hear that that could have led to this type of transmission. 391 00:23:57,560 --> 00:24:02,960 So it's definitely, yeah, congenital CMV, I think is very fascinating, probably why 392 00:24:02,960 --> 00:24:05,160 you're interested in it, right? 393 00:24:05,160 --> 00:24:06,440 Yeah, it's complicated. 394 00:24:06,440 --> 00:24:11,400 It's much more complicated and nuanced than some other conditions. 395 00:24:11,400 --> 00:24:18,200 Yeah, so why don't we, I guess to kind of, I think we talked a lot about, you know, what 396 00:24:18,200 --> 00:24:20,560 CMV is, what the screening is. 397 00:24:20,560 --> 00:24:25,080 And I think as different provinces are going to start doing some more universal screening, 398 00:24:25,080 --> 00:24:30,720 I think some of that remembering when to test for CMV is going to go away because it's going 399 00:24:30,720 --> 00:24:33,880 to be obviously a natural process. 400 00:24:33,880 --> 00:24:39,560 I think you did mention some indications for us for, so for provinces that are not currently 401 00:24:39,560 --> 00:24:45,240 doing universal screening, we talked about like the hearing loss component. 402 00:24:45,240 --> 00:24:50,200 Are there some other indications that kind of, or clear cut indications that we should 403 00:24:50,200 --> 00:24:51,200 share? 404 00:24:51,200 --> 00:24:59,200 I mean, I think the key thing is just to remember that congenital CMV is common. 405 00:24:59,200 --> 00:25:03,180 Like it's one, in Canada it's probably around one in 200 babies. 406 00:25:03,180 --> 00:25:09,280 And so just any baby that has some kind of nonspecific manifestation, I can go through 407 00:25:09,280 --> 00:25:13,280 those in a second, CMV should be on your differential diagnosis. 408 00:25:13,280 --> 00:25:16,320 That doesn't mean that you're going to test every single one of them, but just have it 409 00:25:16,320 --> 00:25:20,460 in the back of your mind because there's been studies showing that a lot of symptomatic 410 00:25:20,460 --> 00:25:23,000 babies are missed because people just don't think of it. 411 00:25:23,000 --> 00:25:25,080 Because once you think of it, it's easy to diagnose. 412 00:25:25,080 --> 00:25:28,440 You just send a urine and you're done. 413 00:25:28,440 --> 00:25:35,080 So I mean, the tough one for me is IUGR because IUGR is so nonspecific and I don't think that 414 00:25:35,080 --> 00:25:40,660 people should automatically send a urine CMV on every baby with IUGR. 415 00:25:40,660 --> 00:25:45,680 But I think you do need to ask yourself, do I have an explanation for the IUGR? 416 00:25:45,680 --> 00:25:49,520 And if you don't, you should at least think about doing the test because it's an easy 417 00:25:49,520 --> 00:25:50,520 test to do. 418 00:25:50,520 --> 00:25:54,240 It's not that expensive and you're making an important diagnosis. 419 00:25:54,240 --> 00:25:58,600 I think if you have a patechial rash, if you have liver dysfunction, again, it's in the 420 00:25:58,600 --> 00:26:00,840 differential diagnosis. 421 00:26:00,840 --> 00:26:03,120 If it's more severe, then I think it becomes more obvious. 422 00:26:03,120 --> 00:26:06,720 You have a baby with microcephaly, it's clearly in the differential diagnosis. 423 00:26:06,720 --> 00:26:14,120 But it's the more subtle things like the rash, the liver, and the IUGR. 424 00:26:14,120 --> 00:26:18,880 Those would be the three where people might not think of CMV that they should. 425 00:26:18,880 --> 00:26:21,160 The hearing is kind of obvious. 426 00:26:21,160 --> 00:26:22,160 Yeah. 427 00:26:22,160 --> 00:26:23,160 Yeah. 428 00:26:23,160 --> 00:26:24,160 Yeah. 429 00:26:24,160 --> 00:26:29,120 And I think I've sometimes encountered, like we talked about a little bit, the direct or 430 00:26:29,120 --> 00:26:34,960 the conjugated hyperbilarubinemia because that's odd to have outside of like bilirotresia 431 00:26:34,960 --> 00:26:36,600 and those kinds of conditions. 432 00:26:36,600 --> 00:26:43,840 And so something I've seen in my clinical practice where that sometimes gets overlooked 433 00:26:43,840 --> 00:26:47,320 because we're just not familiar with having direct hyperbilarubinemia in pediatrics. 434 00:26:47,320 --> 00:26:51,000 We always think about jaundice and we think about indirect rate. 435 00:26:51,000 --> 00:26:55,280 And so most conditions talk about that, but I think it's something to remember as pediatricians 436 00:26:55,280 --> 00:26:57,360 as well, for sure. 437 00:26:57,360 --> 00:27:03,640 So I think too, it's such good information for us because I think it's important. 438 00:27:03,640 --> 00:27:06,480 CMV is always changing. 439 00:27:06,480 --> 00:27:13,600 I remember as a fellow, even as a resident, things were really different. 440 00:27:13,600 --> 00:27:17,720 There wasn't every clear cut guidelines, even with the CPSA even coming out, I think that 441 00:27:17,720 --> 00:27:24,920 was a huge help because now we have an outline of something that people can look to. 442 00:27:24,920 --> 00:27:27,800 Those are always helpful in that way. 443 00:27:27,800 --> 00:27:32,000 And so why don't we touch on some newer trials? 444 00:27:32,000 --> 00:27:37,680 Because I don't know how familiar or how much you want to talk about those, but what's new 445 00:27:37,680 --> 00:27:39,280 like in the CMV world? 446 00:27:39,280 --> 00:27:42,160 Like what are we looking at in the next few years here? 447 00:27:42,160 --> 00:27:44,720 Is there a lot of changes? 448 00:27:44,720 --> 00:27:54,160 Well, if you want to be optimistic, I think, you know, there's been two published vaccine 449 00:27:54,160 --> 00:27:59,080 studies that were not very efficacious. 450 00:27:59,080 --> 00:28:05,440 Like they provided some degree of protection, but really nothing that would lead to a vaccine 451 00:28:05,440 --> 00:28:07,960 being licensed. 452 00:28:07,960 --> 00:28:19,160 There are lots of vaccine, I guess, possibilities moving forward, including mRNA ones. 453 00:28:19,160 --> 00:28:24,760 And so I think that's probably the biggest thing that might come about. 454 00:28:24,760 --> 00:28:25,840 It's going to take time. 455 00:28:25,840 --> 00:28:29,040 It's not going to be like COVID where they develop a vaccine urgently in a year. 456 00:28:29,040 --> 00:28:31,200 It's going to take time to do. 457 00:28:31,200 --> 00:28:36,800 But I mean, if you could develop a vaccine, a preventive vaccine, that would obviously 458 00:28:36,800 --> 00:28:39,960 be amazing. 459 00:28:39,960 --> 00:28:44,960 Biggest challenge there, we know, and this is another fact that people don't understand 460 00:28:44,960 --> 00:28:52,520 is that most congenital CMV is a consequence of non-primary CMV infection in pregnancy. 461 00:28:52,520 --> 00:28:56,760 So most people think, oh, if I'm seropositive, I don't need to worry. 462 00:28:56,760 --> 00:29:03,760 My baby won't have congenital CMV and it's not correct because there's good data that 463 00:29:03,760 --> 00:29:10,440 does infection with second strains or can cause congenital CMV and maybe in some cases 464 00:29:10,440 --> 00:29:15,320 reactivation of latent virus, but probably more often it's infection with different strains. 465 00:29:15,320 --> 00:29:20,480 And so if you have, if natural infection doesn't protect you from subsequent infection with 466 00:29:20,480 --> 00:29:26,080 new strains, it just tells you that a vaccine isn't going to be easy. 467 00:29:26,080 --> 00:29:31,480 But that would be kind of ultimately the best new thing. 468 00:29:31,480 --> 00:29:34,080 I think there's not a lot of stuff there. 469 00:29:34,080 --> 00:29:37,680 There's relatively recent stuff on management in pregnancy. 470 00:29:37,680 --> 00:29:45,040 If you diagnose primary infection, I don't know if you want to talk about that too much. 471 00:29:45,040 --> 00:29:52,900 I think that things, there's questions that we throw about between us as colleagues, Jason 472 00:29:52,900 --> 00:29:55,880 and me and others. 473 00:29:55,880 --> 00:29:59,720 What do you do if you make the diagnosis when the baby is three months old, right? 474 00:29:59,720 --> 00:30:03,200 As opposed to neonate. 475 00:30:03,200 --> 00:30:04,600 And what do you do? 476 00:30:04,600 --> 00:30:06,840 Is six months really the right duration? 477 00:30:06,840 --> 00:30:09,440 Like six months was made up, right? 478 00:30:09,440 --> 00:30:13,360 They just decided six months for no... 479 00:30:13,360 --> 00:30:15,440 And I've done this for a long time. 480 00:30:15,440 --> 00:30:19,240 So I've had kids that have had normal hearing, they've gotten their six months, they've been 481 00:30:19,240 --> 00:30:21,980 normal and then at three they've got hearing loss. 482 00:30:21,980 --> 00:30:25,600 So even the six months doesn't prevent you from losing the hearing later. 483 00:30:25,600 --> 00:30:30,560 Granted, it gets you through that critical phase where you're developing speech and all 484 00:30:30,560 --> 00:30:31,560 that. 485 00:30:31,560 --> 00:30:36,000 So it's not that it's not a benefit, but it doesn't prevent subsequent hearing loss 486 00:30:36,000 --> 00:30:37,000 necessarily. 487 00:30:37,000 --> 00:30:39,400 So is six months the right duration? 488 00:30:39,400 --> 00:30:41,760 Should we go 12 months? 489 00:30:41,760 --> 00:30:49,200 So I think those are the two, for me, the big ID related questions that need to be answered 490 00:30:49,200 --> 00:30:51,580 and I'm not sure how quickly they will be answered. 491 00:30:51,580 --> 00:30:54,320 There is also the question of isolated hearing loss. 492 00:30:54,320 --> 00:30:58,200 I've never understood this dilemma. 493 00:30:58,200 --> 00:31:03,120 Basically people have decided that there's not evidence for treating isolated hearing 494 00:31:03,120 --> 00:31:08,480 loss and there's different opinions on this, granted. 495 00:31:08,480 --> 00:31:11,000 But I've never understood that. 496 00:31:11,000 --> 00:31:15,200 And the reason I've never understood that is the main benefit that we've shown with 497 00:31:15,200 --> 00:31:19,600 medical therapy is that you prevent further hearing loss. 498 00:31:19,600 --> 00:31:23,080 So if you have a child who's got, let's say, moderate hearing loss on one side and normal 499 00:31:23,080 --> 00:31:28,600 hearing on the other side and they have no other manifestations, why would you not treat 500 00:31:28,600 --> 00:31:29,600 them? 501 00:31:29,600 --> 00:31:34,920 I generally treat those kids, but not everyone does. 502 00:31:34,920 --> 00:31:37,640 Not everyone does. 503 00:31:37,640 --> 00:31:41,360 At the very least, I think it's one of those things that you need to discuss with the family. 504 00:31:41,360 --> 00:31:42,360 You know, the process. 505 00:31:42,360 --> 00:31:43,360 Yeah, exactly. 506 00:31:43,360 --> 00:31:44,360 Yeah. 507 00:31:44,360 --> 00:31:45,360 Yeah. 508 00:31:45,360 --> 00:31:47,960 There's a ton that I'm aware of beyond that. 509 00:31:47,960 --> 00:31:49,680 Those are my big questions. 510 00:31:49,680 --> 00:31:50,680 Okay. 511 00:31:50,680 --> 00:31:51,680 Yeah. 512 00:31:51,680 --> 00:31:58,120 And I, yeah, and I think there were a few kind of recently, like waiting publications. 513 00:31:58,120 --> 00:32:02,920 So obviously there's like some trials on clinical trials that I've seen come through in terms 514 00:32:02,920 --> 00:32:05,320 of how long, like when to start. 515 00:32:05,320 --> 00:32:11,160 Like when is it, you know, that three month is if you miss that month window, do we now 516 00:32:11,160 --> 00:32:12,160 go ahead and treat? 517 00:32:12,160 --> 00:32:16,160 And I guess it's still again, risk versus benefit because all of this, you know, these 518 00:32:16,160 --> 00:32:21,640 numbers and it's like 21 days even, it's a very quick turnaround time, right? 519 00:32:21,640 --> 00:32:23,320 So to diagnose this. 520 00:32:23,320 --> 00:32:26,720 So and I always kind of question that clinically too. 521 00:32:26,720 --> 00:32:29,400 Like what's the difference between 21 and 28? 522 00:32:29,400 --> 00:32:31,440 You know, like why would I not treat them? 523 00:32:31,440 --> 00:32:32,800 28 and 50, right? 524 00:32:32,800 --> 00:32:37,000 Like why, like, you know, they still have a key part of their development that we have 525 00:32:37,000 --> 00:32:38,440 to get through. 526 00:32:38,440 --> 00:32:42,920 And so if they do progressively develop hearing loss and we didn't act on it now, that's a 527 00:32:42,920 --> 00:32:47,760 little bit unsettling, I think, as an infectious disease physician, because it's one of those 528 00:32:47,760 --> 00:32:52,040 things that it's not as clear and you have to think with your level of experience, you 529 00:32:52,040 --> 00:32:56,600 probably feel like you can make the decision a bit better at times because you've seen 530 00:32:56,600 --> 00:32:58,360 the long-term outcomes of it. 531 00:32:58,360 --> 00:33:03,160 So I mean, the way I approach the ones that are over, I mean, once they get to six months, 532 00:33:03,160 --> 00:33:09,000 I, it's too late, but if they're kind of in that in between one and let's say four, four 533 00:33:09,000 --> 00:33:13,160 pushing at five, but let's say one to four months, if they come to your attention at 534 00:33:13,160 --> 00:33:20,080 that point and they've got some manifestation, so they probably have some hearing loss with 535 00:33:20,080 --> 00:33:21,960 or without something else. 536 00:33:21,960 --> 00:33:25,960 I have a discussion with the parents about the pros and cons, and I explained that there's 537 00:33:25,960 --> 00:33:28,240 no, we don't have great data for this. 538 00:33:28,240 --> 00:33:34,080 There's only some case series in terms of starting treatment, but I've treated some 539 00:33:34,080 --> 00:33:37,560 of those kids. 540 00:33:37,560 --> 00:33:42,800 And actually when you started later, my experience has been as you run into less problems with 541 00:33:42,800 --> 00:33:46,720 toxicity than if you started them as a UNAID. 542 00:33:46,720 --> 00:33:51,160 So in terms of tolerability, it's usually better. 543 00:33:51,160 --> 00:33:52,160 So yeah. 544 00:33:52,160 --> 00:33:53,160 Yeah. 545 00:33:53,160 --> 00:33:54,400 No, I agree. 546 00:33:54,400 --> 00:34:00,640 I think there's times when definitely, I think the toxicity is the part that's always the 547 00:34:00,640 --> 00:34:02,160 limiting factor. 548 00:34:02,160 --> 00:34:08,080 And so you always, you get to this one month mark being on GANS, like LeVera Valgan, and 549 00:34:08,080 --> 00:34:09,080 that's it. 550 00:34:09,080 --> 00:34:14,560 You're like bone marrow suppression, and now you're just like chasing numbers almost it 551 00:34:14,560 --> 00:34:19,880 feels because you're just running, and they also go through, like you said, so like a 552 00:34:19,880 --> 00:34:25,120 lot of them are going to hit the physiological nadir for anemia, let's say, and then it's 553 00:34:25,120 --> 00:34:30,720 confounding, whether it was, you know, did I add to this, they accentuate it. 554 00:34:30,720 --> 00:34:32,200 So yeah, so definitely. 555 00:34:32,200 --> 00:34:38,440 But yeah, so I think that was pretty much what I wanted to discuss today in terms of 556 00:34:38,440 --> 00:34:45,320 CMV and whether it's, I feel like you're going to be, I may reach out to you again to have 557 00:34:45,320 --> 00:34:50,600 kind of follow up questions that will come around, especially as we're implementing this 558 00:34:50,600 --> 00:34:51,600 universal screening. 559 00:34:51,600 --> 00:34:57,360 I think, you know, having guidance from other provinces is important because people have 560 00:34:57,360 --> 00:34:59,400 done it a little bit longer than us. 561 00:34:59,400 --> 00:35:01,640 We're going to run into some hurdles here. 562 00:35:01,640 --> 00:35:06,240 And so just having an overview, I think for us was important. 563 00:35:06,240 --> 00:35:11,040 And I think a lot of other provinces and other clinicians will definitely benefit from listening 564 00:35:11,040 --> 00:35:12,040 to this talk. 565 00:35:12,040 --> 00:35:17,040 So I really appreciate it, Dr. Rittman, for taking the time to come on the podcast. 566 00:35:17,040 --> 00:35:23,320 And the Canadian Breakpoint is definitely a new initiative, you know, to bring out ID 567 00:35:23,320 --> 00:35:29,560 topics, bring out general pediatric topics as well that are related to ID for microbiologists. 568 00:35:29,560 --> 00:35:31,640 We discussed a lot of different things. 569 00:35:31,640 --> 00:35:33,240 And now we're on Spotify as well. 570 00:35:33,240 --> 00:35:35,520 So it's a little bit easier to listen to. 571 00:35:35,520 --> 00:35:38,320 So yeah, so thank you again. 572 00:35:38,320 --> 00:35:40,520 Okay, can I say one more thing? 573 00:35:40,520 --> 00:35:41,520 Yeah, of course. 574 00:35:41,520 --> 00:35:48,520 So the other part of this that has really been as generalized, the health care profession 575 00:35:48,520 --> 00:35:53,440 in general, we've done a terrible job on prevention. 576 00:35:53,440 --> 00:35:58,320 Like the number of times you see, you know, a mom coming in with a baby with congenital 577 00:35:58,320 --> 00:36:03,600 CMV and nobody told them anything about simple things to reduce risk. 578 00:36:03,600 --> 00:36:08,480 You know, simple hygiene things like hand washing, you know, don't pick up the toddler's 579 00:36:08,480 --> 00:36:12,200 pacifier that fell on the sidewalk and stick it in your mouth before giving it back to 580 00:36:12,200 --> 00:36:13,960 the toddler. 581 00:36:13,960 --> 00:36:16,880 You know, washing your hands after you change the diaper. 582 00:36:16,880 --> 00:36:21,040 When you have a toddler and now you have a baby, those kind of very simple things. 583 00:36:21,040 --> 00:36:26,920 And there's actually randomized trials showing that doing those basic things reduces the 584 00:36:26,920 --> 00:36:28,200 risk. 585 00:36:28,200 --> 00:36:35,840 So I mean, I think that's something that we could improve on as in general. 586 00:36:35,840 --> 00:36:36,840 That would be one other thing. 587 00:36:36,840 --> 00:36:37,840 Yeah. 588 00:36:37,840 --> 00:36:40,040 No, and that's actually a very, very important topic. 589 00:36:40,040 --> 00:36:44,560 I mean, whenever we're talking about congenital infections, I think the first step to all 590 00:36:44,560 --> 00:36:46,400 of this is prevention, right? 591 00:36:46,400 --> 00:36:49,120 Because these can be prevented. 592 00:36:49,120 --> 00:36:55,520 And so a lot of them, like we can implement these types of clinical, you know, practices 593 00:36:55,520 --> 00:36:58,160 or day to day practices, right? 594 00:36:58,160 --> 00:37:03,840 In their, in parents' lives to like make sure that they're even awareness, I think, is crucial, 595 00:37:03,840 --> 00:37:04,840 right? 596 00:37:04,840 --> 00:37:08,200 And so CMV, it's, you know, it's just a virus. 597 00:37:08,200 --> 00:37:10,440 And that's what it sounds like to everybody. 598 00:37:10,440 --> 00:37:15,960 But actually, I don't think that until you start seeing more and more of it and the long 599 00:37:15,960 --> 00:37:21,160 term kind of outcomes in newborns, I think parents also aren't just aware of it, right? 600 00:37:21,160 --> 00:37:27,680 And so I think, you know, these are maybe with discussions we should have with our maternity, 601 00:37:27,680 --> 00:37:32,040 like odds and gyne and family colleagues and family doctors. 602 00:37:32,040 --> 00:37:33,040 Yeah. 603 00:37:33,040 --> 00:37:36,280 And we can counsel early on, like this is really important, just like how we counsel 604 00:37:36,280 --> 00:37:41,400 for toxoplasmosis, like, you know, don't have, you know, not going close to cat litter and 605 00:37:41,400 --> 00:37:46,400 changing that out and, you know, really implementing just day to day practices because this is 606 00:37:46,400 --> 00:37:48,400 preventable for sure. 607 00:37:48,400 --> 00:37:49,400 Yeah. 608 00:37:49,400 --> 00:37:54,240 And, and that also leads on to actually, even afterwards, you know, parents are asking even 609 00:37:54,240 --> 00:37:58,800 if they're, you know, like if there is viral shedding, how long are we shedding for in 610 00:37:58,800 --> 00:38:04,640 the baby, some of the, some of these infants that we're managing that don't get started 611 00:38:04,640 --> 00:38:07,960 on treatment, they go into group homes and group care. 612 00:38:07,960 --> 00:38:13,040 And so there's always probably another discussion for another time. 613 00:38:13,040 --> 00:38:17,280 But you get the questions from, you know, the mom will say, well, I have a friend who's 614 00:38:17,280 --> 00:38:20,560 pregnant and can we go over and visit and all this, these kinds of things. 615 00:38:20,560 --> 00:38:25,040 And I try and reassure them, but yeah, it's a, cause the really transmission, if you adhere 616 00:38:25,040 --> 00:38:28,160 to simple hand hygiene, it's really. 617 00:38:28,160 --> 00:38:29,160 Yeah. 618 00:38:29,160 --> 00:38:30,160 Yeah. 619 00:38:30,160 --> 00:38:31,160 That's great. 620 00:38:31,160 --> 00:38:32,160 Awesome. 621 00:38:32,160 --> 00:38:37,960 Any other kind of last words on CMV that you want us to know? 622 00:38:37,960 --> 00:38:41,800 Oh, there's, there's tons, but that, that's a good start. 623 00:38:41,800 --> 00:38:42,800 Happy to do this again. 624 00:38:42,800 --> 00:38:49,640 And yeah, I mean, I think like you reach out, if you want to reach out to the program, you 625 00:38:49,640 --> 00:38:54,480 know, I'm sure they'd be happy to share the various forms and protocols and all that, 626 00:38:54,480 --> 00:38:57,960 if that's helpful, maybe you have your own, but if not. 627 00:38:57,960 --> 00:38:58,960 No, very helpful. 628 00:38:58,960 --> 00:38:59,960 Yeah. 629 00:38:59,960 --> 00:39:01,600 And I think for other provinces too, right? 630 00:39:01,600 --> 00:39:05,560 Like when they are going to this process, knowing that Ontario has been this for a long 631 00:39:05,560 --> 00:39:11,560 time, or much longer time than any of us have, and also universal screening and, and now 632 00:39:11,560 --> 00:39:12,760 Saskatchewan be on board. 633 00:39:12,760 --> 00:39:17,240 So I think other provinces as they, as they implement these protocols, I think it's really 634 00:39:17,240 --> 00:39:18,240 important. 635 00:39:18,240 --> 00:39:22,880 And you know, one day being having more of a standardized approach, you know, in certain 636 00:39:22,880 --> 00:39:26,240 settings, and obviously it's a little bit different when you have different populations 637 00:39:26,240 --> 00:39:32,200 and provinces are, you know, managed differently to healthcare, provincial healthcare has a 638 00:39:32,200 --> 00:39:34,120 lot of networks within it. 639 00:39:34,120 --> 00:39:39,680 So obviously maybe everything will, it couldn't be standard, but I think overall, like universal 640 00:39:39,680 --> 00:39:44,040 screening, it's either we, you know, it's good to have those discussions with other 641 00:39:44,040 --> 00:39:46,680 provinces, are we going to be doing this or not? 642 00:39:46,680 --> 00:39:47,680 Yeah. 643 00:39:47,680 --> 00:39:51,720 In terms of follow-ups, because also I was thinking the other day, you know, you could 644 00:39:51,720 --> 00:39:58,480 have a child that's born here to get to the universal screen, but then parents move, you 645 00:39:58,480 --> 00:40:03,360 know, in the interim, and then, and then it becomes a little bit of a challenge to interpret 646 00:40:03,360 --> 00:40:05,600 that and what are the next steps, right? 647 00:40:05,600 --> 00:40:10,900 And so I think it's something to be, to understand that it's coming out there now and then maybe 648 00:40:10,900 --> 00:40:15,360 other provinces will be tagging along with universal screening. 649 00:40:15,360 --> 00:40:16,360 Awesome. 650 00:40:16,360 --> 00:40:17,360 Okay. 651 00:40:17,360 --> 00:40:18,360 Awesome. 652 00:40:18,360 --> 00:40:19,360 Thanks, Dr. Bitnan. 653 00:40:19,360 --> 00:40:22,480 Thank you, Dr. Purwall and Dr. Bitnan. 654 00:40:22,480 --> 00:40:23,920 Have a topic suggestion? 655 00:40:23,920 --> 00:40:30,320 Email us at thecanadianbreakpoint at gmail.com and be sure to follow us on Twitter at CA 656 00:40:30,320 --> 00:40:31,440 Breakpoint. 657 00:40:31,440 --> 00:40:34,040 You can also find us now on LinkedIn. 658 00:40:34,040 --> 00:40:49,680 See you again soon at the Canadian Breakpoint.