Welcome to the Canadian Breakpoint, a Canadian infectious diseases podcast by Canadian infectious
diseases physicians.
I'm Summer Stewart, here with Dr. Rupeena Purewa, pediatric infectious diseases specialist
from Saskatoon.
In this episode, Dr. Purewal welcomes Dr. Ari Bittnan, professor of pediatrics at the University
of Toronto to discuss cytomegla virus or CMV.
Dr. Pirwal.
Hi, welcome to another episode of the Canadian Breakpoint.
Today we have Dr. Ari Bittnan, who is a professor in the Department of Pediatrics, University
of Toronto and a staff physician in the Division of Infectious Diseases at the Hospital of
Sick Children.
His main areas of interest are pediatric HIV, congenital infections and infections of the
central nervous system.
He is the director of the congenital and perinatal clinic at SickKids and has been managing children
with congenital CMV for many years.
Welcome Dr. Bittnan.
Glad to be here.
Thanks for inviting me.
Of course.
So today we're going to talk about an important topic on CMV.
And so I want to kind of walk through, you know, in general, because this is a podcast
that's for many clinicians, so not just infectious disease physicians, but also family doctors,
pediatricians, and definitely even nurses and pharmacists.
So I think being aware of what CMV is and how does it really affect newborns and infants.
When we briefly touch on that topic, we can just introduce the topic of CMV today.
Okay, so I mean, I guess in general, everyone's, if they're medical, they're familiar with
CMV or the virus.
I think some key things to remember is it's extremely common.
So it depends a little bit where you are in the world in terms of seroprevalence.
But in general, by the time people reach adulthood, most people are infected.
We can talk a little bit about the prevalence in Canada compared to other places.
But in general, in resource limited settings, the seroprevalence can be almost 100% by the
time you reach adulthood.
In resource rich settings like ours, it can be more somewhere between 40 and 70, depending
on what country you're in.
So extremely common, and most people aren't aware of it because it doesn't cause any symptoms
in most cases.
Or if it does, it causes a mild non-specific illness and doesn't really cause any long
term issues.
And I guess the focus here today, there are several situations where CMV can cause trouble.
One is an immune compromised host, which we're not talking about today.
And the other is in the context of an infection in pregnancy and the potential implications
of that for the fetus and the child.
So I think that's kind of a good place to start.
I guess one other thing to say in terms of transmission as an intro.
So it's very readily transmitted.
It's secreted in body secretions.
So saliva, urine, breast milk, semen, et cetera.
So all of those fluids can contain CMV and transmit the virus.
And so like you mentioned, obviously CMV can affect newborns and infants in a certain way.
Definitely our newborns, that's kind of why we're talking about this today.
So in terms of obviously me being a pediatric infectious disease specialist, I see it a
lot as well.
And we see most of them that are asymptomatic and don't really present with anything.
But they can have some long term complications.
And that's probably really pertinent for pediatricians to be aware of.
So can we maybe touch on some of the long term complications that we should be aware
of?
Sure.
So first, maybe just before I say that, I think one thing that I think is important to
remember is as you mentioned, most babies are asymptomatic.
And if you do in studies that have been prospective, if you look at the overall group, 80% of them
never have any problem at all long term.
So it's about a fifth that end up with some kind of long term sequela.
And the most common there is sensorineural hearing loss.
People tend to be familiar with the severe end of the spectrum.
You know, a baby that's born with microcephaly, cerebral calcifications, they might have choreoretonitis,
they might have hearing loss, and then they might have the systemic symptoms as well,
like the big liver, big explain, they might have thrombocytopenia with rash.
But really, it's a spectrum ranging from asymptomatic to the very severe end.
And the very severe end is really a small minority.
They're tragic cases, but they're a small minority.
In terms of the ones that are symptomatic, the more common ones tend to be, you know,
mildly to moderately symptomatic.
So it might be something as simple as just a baby with a particular rash and you have
low platelets and that's the only manifestation.
So quite variable.
The other thing to remember is it's non-specific symptoms and so a lot of times it's missed
because people don't think about CMV because it's a non-specific manifestation, like it
could be colostatic jaundice or something like that and people don't think CMV.
So even the symptomatic ones can be missed.
Right.
Okay, and that leads me on to the next question because now we have some provinces, including
Saskatchewan, that were doing universal screening.
So screening for CMV, I think, has probably been a huge discussion across probably many
nations and internationally there's probably a lot of differences as well.
But here in Canada, so we always talk about this universal versus targeted screening.
Do you want to maybe touch on some of the differences, maybe some of the pros and cons?
Because I know Ontario has been doing universal screening for quite a while now compared to
other provinces.
And I'm not sure actually in Saskatchewan, this is a very, very fresh topic.
We just started getting some of those reports in and so it's causing some anxiety among
their clinicians.
And so maybe we could, you could walk us kind of through, you know, what is the differences
between what we're seeing now and what's targeted screening?
Sure.
So first off, I don't know if you might want to come back to this.
Some people bring up the idea of screening in pregnancy, which I personally think is
a mistake.
So if you, we can avoid that altogether if you want, but with respect to newborn screening,
I think this is what's going to happen eventually everywhere because it's such a common condition
and it's hard to diagnose and it has the long-term complications.
So I think over time it's going to start to be implemented in more and more places.
Targeted screening in general basically refers to you, if you have a baby that screens positive
for hearing loss, then you test them for CMV because CMV is one of the more common causes
of hearing loss in children.
So there's genetic causes and then there's CMV is the most common cause of acquired hearing
loss in childhood.
So that would be targeted screening.
The baby fails their newborn screen.
You have the confirmatory ABR and if they are confirmed to have hearing loss, you test
them automatically for CMV.
So that's targeted.
So it's kind of what it says, you screen all babies and then it becomes a question of what
modality you use.
There's advantages and disadvantages to each.
You want me to go through that?
Yeah.
So I think maybe just touch on a type of specimen and just, you know, what people, I think more
so for clinicians, it's going to be important kind of walking through when we see the results,
knowing what the dried blood spot is actually indicative of and how to follow up that.
So we'll touch a little bit on that, but yeah, you can definitely talk about the testing
and the specimens that are used.
Okay.
So yeah, so the options for screening for targeted screening would be you just use the
birth, dry blood spot.
The advantage of the birth, dry blood spot is it's collected anyway for metabolic diseases.
And so in terms of the infrastructure, it's relatively straightforward because you're
just adding another test to a sample that's already being collected.
And the filter paper strategy has been, it's been studied and CMV can be detected in it.
So that's the easiest in terms of, you know, if you want it to implement something now,
right?
The infrastructure is there.
The downside is that the sensitivity of the dry blood spot is not great.
If you look at some of the studies, it talks about up to about 85% sensitivity.
I think in reality, it's probably lower than that.
It really ranges vastly between study to study, but I would say it's probably more around
50% or so, but don't quote me on a specific number.
I think the point, the main point is not, is to realize that the sensitivity is, is
lowish.
So you're missing cases.
The specificity is high, but you can still have false positives and people talk about
why that might be.
I mean, obviously there's lab false positives that can happen, but also I think the filter
papers can get stacked.
And so you could theoretically have contamination between filter papers.
So sometimes you can have false positives.
They're not common, but they do come up and they do come up in a screening program.
And then you have to kind of go back and try and figure out, was this a false positive
or not?
So it does happen.
The ideal specimen really is saliva.
The reason it's ideal is it's very highly sensitive, much more sensitive than the dry
blood spot.
It's easy to collect once you've trained people on how to do it.
And so for, if you were to implement that, it would be relatively straightforward to
train people to do it.
It's been studied already, not a huge amount, but it's been studied on filter paper where
people collected on filter paper.
So I think it's probably the, ultimately the best way to go.
That would be my preferred strategy for screening would be the saliva because it's much more
sensitive.
The one thing with the saliva that people have to be careful of is you don't want to
take that sample too close to when the baby breastfed because you can get false positives
if mom is shedding.
So that's one caveat that needs to be kept in mind.
And then the other obvious aspect is if you were to go that route, you have to have that,
the whole setup for that.
So everyone has to be trained on collection.
You have to have the mechanism for transporting all these samples to the lab that's going
to be doing the assays and have the assay set up.
So it's more of a upfront undertaking to establish that compared to the dry blood spot.
The third option is urine.
I think urine is not a good strategy for screening because it's way too messy.
You'll get too many cases where it's contaminated with stool and it's hard to do that on a universal
basis.
It's a great test and it is the test you should probably use to confirm congenital CMV, but
not as a screening.
So ultimately I think saliva is the way to go, but as a starting point, I think dry blood
spot is good.
Yeah.
I think that's how I would put it.
And so now, so lately, I guess in my last few weeks of call here, we introduced the
universal screening.
So it's created a huge, almost like a lot of questions have come out because they'll
see this new results on this dried blood spot.
And I'll kind of walk through what we're doing here in Saskatchewan, but I think in general,
you guys have been in Ontario, been doing it much longer.
And so I guess what are the kind of next steps?
Like we talked about urine being the confirmatory and we know, and most people know with congenital
CMV, that that urine sample in the first 21 days is a confirmatory sample.
So is that kind of what you guys are doing when you're seeing these results and kind
of what's the steps that clinicians should be aware of?
Yeah.
So if we get a positive report, so I mean, I don't know if we can talk about the infrastructure
and the personnel if you want, or you would just want to touch on a test right now.
Yeah, I think in general, probably the test because that would be kind of what my other
physicians would be ordering or seeing.
Yeah.
So I think automatically you need to confirm it.
I think as a first step, you do the urine to confirm the infection.
And you know, surprisingly, you will find sometimes that the screen, the dry blood spot
being positive and the urine is negative and that causes a little bit of consternation
and confusion, but it does happen.
If it's positive, it's easy.
You've confirmed the diagnosis and then you go on to do the workup that you kind of have
decided upon that should be protocolized.
And that's straightforward.
If the urine is negative, we've kind of gone back to the dry blood spot and repeated the
testing and also repeated the urine and sometimes we've sent serology.
You know, sometimes it's helpful to do that because then you can, so for example, if you
had a dry blood spot that ding positive and then your urine is negative, you repeat the
urine again and it's again and negative again and CMV serology is negative.
Then you sort of say, oh, this is a false positive for sure.
Right.
You might have some other scenarios where it ends up being equivocal, right?
Where your serology is reactive.
I mean, that could be maternal antibody that can get complicated, but if the urine is negative,
it sort of argues against it being a real infection.
Yeah, no, that's fair.
Yeah.
We had one of those actually and so had to, so something I didn't, I think, realize was
if there's premature infants that you're dealing with, they would actually have two newborn
screens.
Yes.
So that caused a lot of anxiety last week because we had a case where, you know, we
had to repeat or we didn't have the newborn screen implemented, the universal CMV screen
on the first, when the baby was first born.
And then three weeks later when it was redone or closer to, yeah, probably six weeks later
when it was done.
Now we have the universal screen on the CMV screen on the newborn screen.
So now we have this positive, but we've never done it before.
So obviously we just went back to the previous dried blood spot and reran it.
But I think that creates a little bit of a, I actually probably didn't even think about
outlining that when we were coming up with our protocol because it was something that
just didn't come across that, oh, it can actually be positive later on.
So it's on the road that we're facing now.
And with anything you implement.
Yeah.
I think they usually do that second sample at three weeks.
If it's done at three weeks and it's positive, it's still, I mean, it's right on the border,
obviously, but it's probably congenital, right?
Yeah, exactly.
It's weeks that becomes much more messy.
Yeah.
No, that's fair.
So yeah.
So here in Saskatchewan currently what we're doing is we obviously have a newborn screen
come back.
Some of the times if they're in the NICU, they'll still be in hospital, obviously.
And then if some of them get discharged, that's usually the harder part because now you have
to locate the family and let them know about the newborn screen because it comes back a
few days later after they've already been discharged from the hospital.
And then we have a genetics team, like a genetics resource center, who once that comes are positive,
they will actually reach out to the family and get that urine sent for the confirmatory
and ideally within that first 21 days.
That's easier for us as infectious disease physicians to say, yes, this is confirmatory
or not, and this is congenital versus not acquired.
And then after that, the steps start with risk stratification.
And so if the CMV urine comes back positive, then audiology is a huge component of that,
like we just talked about, because I think as clinicians that makes a huge difference
for us, especially in these isolated central neuroherring loss and cases where you're a
little bit conflicted in terms of I think the data is a bit conflicted as to what to
do in those cases.
Obviously, the severe cases are simpler to manage because they're more black and white.
And then we get involved from infectious diseases and we kind of go through the process of risk
stratifying as mild, moderate, severe or asymptomatic central neuroherring loss or not, and then
come up with our management plan and then a long-term follow-up.
So I would assume kind of a similar process maybe in Ontario or is it...
The way it works, I mean, Ontario obviously is a much larger population and much...
Definitely.
The way it's structured is there's five nurse practitioners, basically based on region,
where the pediatric hospitals are.
And so each of those nurse practitioners will be the one notified about the result in their
region and then they would be the ones to reach out to the family and do what you said
the genetics people do, where they disclose that initial diagnosis field, initial questions,
and then arrange for their follow-up wherever that needs to be.
So the way we've structured it is babies that are asymptomatic go to certain pediatricians.
So we identified certain pediatricians in the regions that agreed to take on this role
because there's also some paperwork in terms of follow-up that they need to do, but they
agreed to take on this role, do the initial workup with ID as kind of a backup if they
have any concerns.
The ones that are symptomatic come automatically to ID.
So ID, the ones that are initially symptomatic, as well as the ones where the pediatrician
had some questions, like let's say for example, the head ultrasound showed some subtle finding
and they weren't sure what to do with it, then they would consult with us.
So there's a group of pediatricians, a group of ID docs that would see the kids, do a standardized
workup.
Our standardized workup is kind of what you'd expect.
It's a CBC, liver function tests, head ultrasound, audiology.
Ophthalmology was routine.
We can talk a little bit about that because we've kind of gone through a two-year data
and we've kind of modified what we're doing so we could talk about that.
That's our basic workup.
And then we go from there.
MRIs vary selectively, mostly it's head ultrasound.
And then once they're in, then the decisions on treatment would be ID.
So ID would make decisions on the treatment.
And if they're being treated, we would follow them closely.
Whereas the ones that are not being treated would be followed by the pediatricians.
And then they're followed.
So you would have a standardized follow-up with some forms that you fill out at particular
times and submit those to the NSO, the newborn screening program.
Okay.
Yeah.
Definitely well structured.
So hopefully we'll get to that too in Saskatchewan because currently it's...
You need to have an evaluation of it, right?
So you need to read, like how many people are you testing?
Are you missing any?
And then how many of those that you test positive are actually seen?
Like there's all these factors in terms of evaluating the program that you really need
to put in place.
Yeah.
And I think that's kind of where the next steps are for us because we're so brand new
at introducing it.
So we're going to have to look at definitely our data in terms of how many positives came
out of how many got tested, et cetera.
And so definitely area for room for research always with DMV.
Perfect.
So yeah, why don't we talk a little bit about the follow-up?
Because there's a lot of pediatricians that do tune into this podcast.
And so, I mean, there is a Canadian Pediatric Society statement that we've obviously been
involved in and written for us.
And so I think there's a couple of things.
Like, I mean, I think some of the main developmental follow-ups are quite similar to other congenital
infections.
But some of the specific ones, like in terms of the ophthalmology follow-up, and also I
do remember that there's some enamel issues.
And so there's a question about dental follow-ups.
I'm not sure if those are some things that actually are being implemented or there's
more studies around that.
So maybe you can touch on that.
Okay.
Yeah.
So I think in terms of the development, it really depends on the case.
And I think this is a pediatrician kind of make that call if they're asymptomatic and
completely well or they're completely well.
I mean, I think actually it's kind of one of the disadvantages of a saliva screening
base, I'm kind of going back a little bit, but one of the disadvantages is you're picking
up all the cases.
Yeah.
Right.
So you're picking up a lot of babies who, most of them will never have anything.
And so to some extent, you're medicalizing those kids, right?
And some parents are going to get more anxious than others, but you are medicalizing them.
So that's kind of, it just ties into the follow-up.
But if you have one of these asymptomatic kids, it seems completely normal, then you
keep it in the back of your mind and you do your routine pediatric follow-up and assess
them as you would normally.
I think if they've got symptoms or if they're showing some kind of signs, you can follow
them a little more closely.
The eyes, what we found is that very few babies had eye manifestations.
Only if they're asymptomatic, we have none.
And the exam is actually uncomfortable.
Like if you do a full ophthalmologic exam where they open the eye and it's not comfortable.
So we've kind of modified that where we're not automatically doing eye exams at all,
and everyone.
So that's something that the ophthalmologists in Ontario could maybe connect with your group
and talk about that because it's a rare manifestation.
And in general, most of when we do find something, it's usually quiet, like it's a scar.
So they don't necessarily even need follow-up.
And so it would be selective based on ophthalmology.
The big thing is the hearing, obviously they need to have very close follow-up for the
hearing.
So that's kind of what I would suggest.
Okay.
Yeah.
And yeah, definitely.
I think we're also finding to me a little bit of that process because even for decision
making, I mean, the hearing is so important when you think about whether you're going
to start.
And then one comment to bring up is that this is actually progressive hearing loss.
And so that's why we need to make sure that we're having routine kind of follow-up for
the babies.
And so just to like I mentioned, which is a little bit different than some of our other
congenital infections, because usually you can, I mean, I'm sure there are like we're
seeing a lot of syphilis out here and so they can also have hearing loss, but usually as
a result of like already in utero transmission.
And so they present with that.
So I think that's something that's quite important because it's almost, you don't want to give
parents false reassurance either, but the hearing is now normal.
But I think counseling is a huge component of this.
And there is a little bit more anxiety as I'm doing these follow-ups with parents because
they're anxious because CMV was never, and moms will usually remember that they had a
bit of a cold during pregnancy and that's really it.
So they're a little bit shocked to hear that that could have led to this type of transmission.
So it's definitely, yeah, congenital CMV, I think is very fascinating, probably why
you're interested in it, right?
Yeah, it's complicated.
It's much more complicated and nuanced than some other conditions.
Yeah, so why don't we, I guess to kind of, I think we talked a lot about, you know, what
CMV is, what the screening is.
And I think as different provinces are going to start doing some more universal screening,
I think some of that remembering when to test for CMV is going to go away because it's going
to be obviously a natural process.
I think you did mention some indications for us for, so for provinces that are not currently
doing universal screening, we talked about like the hearing loss component.
Are there some other indications that kind of, or clear cut indications that we should
share?
I mean, I think the key thing is just to remember that congenital CMV is common.
Like it's one, in Canada it's probably around one in 200 babies.
And so just any baby that has some kind of nonspecific manifestation, I can go through
those in a second, CMV should be on your differential diagnosis.
That doesn't mean that you're going to test every single one of them, but just have it
in the back of your mind because there's been studies showing that a lot of symptomatic
babies are missed because people just don't think of it.
Because once you think of it, it's easy to diagnose.
You just send a urine and you're done.
So I mean, the tough one for me is IUGR because IUGR is so nonspecific and I don't think that
people should automatically send a urine CMV on every baby with IUGR.
But I think you do need to ask yourself, do I have an explanation for the IUGR?
And if you don't, you should at least think about doing the test because it's an easy
test to do.
It's not that expensive and you're making an important diagnosis.
I think if you have a patechial rash, if you have liver dysfunction, again, it's in the
differential diagnosis.
If it's more severe, then I think it becomes more obvious.
You have a baby with microcephaly, it's clearly in the differential diagnosis.
But it's the more subtle things like the rash, the liver, and the IUGR.
Those would be the three where people might not think of CMV that they should.
The hearing is kind of obvious.
Yeah.
And I think I've sometimes encountered, like we talked about a little bit, the direct or
the conjugated hyperbilarubinemia because that's odd to have outside of like bilirotresia
and those kinds of conditions.
And so something I've seen in my clinical practice where that sometimes gets overlooked
because we're just not familiar with having direct hyperbilarubinemia in pediatrics.
We always think about jaundice and we think about indirect rate.
And so most conditions talk about that, but I think it's something to remember as pediatricians
as well, for sure.
So I think too, it's such good information for us because I think it's important.
CMV is always changing.
I remember as a fellow, even as a resident, things were really different.
There wasn't every clear cut guidelines, even with the CPSA even coming out, I think that
was a huge help because now we have an outline of something that people can look to.
Those are always helpful in that way.
And so why don't we touch on some newer trials?
Because I don't know how familiar or how much you want to talk about those, but what's new
like in the CMV world?
Like what are we looking at in the next few years here?
Is there a lot of changes?
Well, if you want to be optimistic, I think, you know, there's been two published vaccine
studies that were not very efficacious.
Like they provided some degree of protection, but really nothing that would lead to a vaccine
being licensed.
There are lots of vaccine, I guess, possibilities moving forward, including mRNA ones.
And so I think that's probably the biggest thing that might come about.
It's going to take time.
It's not going to be like COVID where they develop a vaccine urgently in a year.
It's going to take time to do.
But I mean, if you could develop a vaccine, a preventive vaccine, that would obviously
be amazing.
Biggest challenge there, we know, and this is another fact that people don't understand
is that most congenital CMV is a consequence of non-primary CMV infection in pregnancy.
So most people think, oh, if I'm seropositive, I don't need to worry.
My baby won't have congenital CMV and it's not correct because there's good data that
does infection with second strains or can cause congenital CMV and maybe in some cases
reactivation of latent virus, but probably more often it's infection with different strains.
And so if you have, if natural infection doesn't protect you from subsequent infection with
new strains, it just tells you that a vaccine isn't going to be easy.
But that would be kind of ultimately the best new thing.
I think there's not a lot of stuff there.
There's relatively recent stuff on management in pregnancy.
If you diagnose primary infection, I don't know if you want to talk about that too much.
I think that things, there's questions that we throw about between us as colleagues, Jason
and me and others.
What do you do if you make the diagnosis when the baby is three months old, right?
As opposed to neonate.
And what do you do?
Is six months really the right duration?
Like six months was made up, right?
They just decided six months for no...
And I've done this for a long time.
So I've had kids that have had normal hearing, they've gotten their six months, they've been
normal and then at three they've got hearing loss.
So even the six months doesn't prevent you from losing the hearing later.
Granted, it gets you through that critical phase where you're developing speech and all
that.
So it's not that it's not a benefit, but it doesn't prevent subsequent hearing loss
necessarily.
So is six months the right duration?
Should we go 12 months?
So I think those are the two, for me, the big ID related questions that need to be answered
and I'm not sure how quickly they will be answered.
There is also the question of isolated hearing loss.
I've never understood this dilemma.
Basically people have decided that there's not evidence for treating isolated hearing
loss and there's different opinions on this, granted.
But I've never understood that.
And the reason I've never understood that is the main benefit that we've shown with
medical therapy is that you prevent further hearing loss.
So if you have a child who's got, let's say, moderate hearing loss on one side and normal
hearing on the other side and they have no other manifestations, why would you not treat
them?
I generally treat those kids, but not everyone does.
Not everyone does.
At the very least, I think it's one of those things that you need to discuss with the family.
You know, the process.
Yeah, exactly.
Yeah.
There's a ton that I'm aware of beyond that.
Those are my big questions.
Okay.
Yeah.
And I, yeah, and I think there were a few kind of recently, like waiting publications.
So obviously there's like some trials on clinical trials that I've seen come through in terms
of how long, like when to start.
Like when is it, you know, that three month is if you miss that month window, do we now
go ahead and treat?
And I guess it's still again, risk versus benefit because all of this, you know, these
numbers and it's like 21 days even, it's a very quick turnaround time, right?
So to diagnose this.
So and I always kind of question that clinically too.
Like what's the difference between 21 and 28?
You know, like why would I not treat them?
28 and 50, right?
Like why, like, you know, they still have a key part of their development that we have
to get through.
And so if they do progressively develop hearing loss and we didn't act on it now, that's a
little bit unsettling, I think, as an infectious disease physician, because it's one of those
things that it's not as clear and you have to think with your level of experience, you
probably feel like you can make the decision a bit better at times because you've seen
the long-term outcomes of it.
So I mean, the way I approach the ones that are over, I mean, once they get to six months,
I, it's too late, but if they're kind of in that in between one and let's say four, four
pushing at five, but let's say one to four months, if they come to your attention at
that point and they've got some manifestation, so they probably have some hearing loss with
or without something else.
I have a discussion with the parents about the pros and cons, and I explained that there's
no, we don't have great data for this.
There's only some case series in terms of starting treatment, but I've treated some
of those kids.
And actually when you started later, my experience has been as you run into less problems with
toxicity than if you started them as a UNAID.
So in terms of tolerability, it's usually better.
So yeah.
Yeah.
No, I agree.
I think there's times when definitely, I think the toxicity is the part that's always the
limiting factor.
And so you always, you get to this one month mark being on GANS, like LeVera Valgan, and
that's it.
You're like bone marrow suppression, and now you're just like chasing numbers almost it
feels because you're just running, and they also go through, like you said, so like a
lot of them are going to hit the physiological nadir for anemia, let's say, and then it's
confounding, whether it was, you know, did I add to this, they accentuate it.
So yeah, so definitely.
But yeah, so I think that was pretty much what I wanted to discuss today in terms of
CMV and whether it's, I feel like you're going to be, I may reach out to you again to have
kind of follow up questions that will come around, especially as we're implementing this
universal screening.
I think, you know, having guidance from other provinces is important because people have
done it a little bit longer than us.
We're going to run into some hurdles here.
And so just having an overview, I think for us was important.
And I think a lot of other provinces and other clinicians will definitely benefit from listening
to this talk.
So I really appreciate it, Dr. Rittman, for taking the time to come on the podcast.
And the Canadian Breakpoint is definitely a new initiative, you know, to bring out ID
topics, bring out general pediatric topics as well that are related to ID for microbiologists.
We discussed a lot of different things.
And now we're on Spotify as well.
So it's a little bit easier to listen to.
So yeah, so thank you again.
Okay, can I say one more thing?
Yeah, of course.
So the other part of this that has really been as generalized, the health care profession
in general, we've done a terrible job on prevention.
Like the number of times you see, you know, a mom coming in with a baby with congenital
CMV and nobody told them anything about simple things to reduce risk.
You know, simple hygiene things like hand washing, you know, don't pick up the toddler's
pacifier that fell on the sidewalk and stick it in your mouth before giving it back to
the toddler.
You know, washing your hands after you change the diaper.
When you have a toddler and now you have a baby, those kind of very simple things.
And there's actually randomized trials showing that doing those basic things reduces the
risk.
So I mean, I think that's something that we could improve on as in general.
That would be one other thing.
Yeah.
No, and that's actually a very, very important topic.
I mean, whenever we're talking about congenital infections, I think the first step to all
of this is prevention, right?
Because these can be prevented.
And so a lot of them, like we can implement these types of clinical, you know, practices
or day to day practices, right?
In their, in parents' lives to like make sure that they're even awareness, I think, is crucial,
right?
And so CMV, it's, you know, it's just a virus.
And that's what it sounds like to everybody.
But actually, I don't think that until you start seeing more and more of it and the long
term kind of outcomes in newborns, I think parents also aren't just aware of it, right?
And so I think, you know, these are maybe with discussions we should have with our maternity,
like odds and gyne and family colleagues and family doctors.
Yeah.
And we can counsel early on, like this is really important, just like how we counsel
for toxoplasmosis, like, you know, don't have, you know, not going close to cat litter and
changing that out and, you know, really implementing just day to day practices because this is
preventable for sure.
Yeah.
And, and that also leads on to actually, even afterwards, you know, parents are asking even
if they're, you know, like if there is viral shedding, how long are we shedding for in
the baby, some of the, some of these infants that we're managing that don't get started
on treatment, they go into group homes and group care.
And so there's always probably another discussion for another time.
But you get the questions from, you know, the mom will say, well, I have a friend who's
pregnant and can we go over and visit and all this, these kinds of things.
And I try and reassure them, but yeah, it's a, cause the really transmission, if you adhere
to simple hand hygiene, it's really.
Yeah.
That's great.
Awesome.
Any other kind of last words on CMV that you want us to know?
Oh, there's, there's tons, but that, that's a good start.
Happy to do this again.
And yeah, I mean, I think like you reach out, if you want to reach out to the program, you
know, I'm sure they'd be happy to share the various forms and protocols and all that,
if that's helpful, maybe you have your own, but if not.
No, very helpful.
Yeah.
And I think for other provinces too, right?
Like when they are going to this process, knowing that Ontario has been this for a long
time, or much longer time than any of us have, and also universal screening and, and now
Saskatchewan be on board.
So I think other provinces as they, as they implement these protocols, I think it's really
important.
And you know, one day being having more of a standardized approach, you know, in certain
settings, and obviously it's a little bit different when you have different populations
and provinces are, you know, managed differently to healthcare, provincial healthcare has a
lot of networks within it.
So obviously maybe everything will, it couldn't be standard, but I think overall, like universal
screening, it's either we, you know, it's good to have those discussions with other
provinces, are we going to be doing this or not?
Yeah.
In terms of follow-ups, because also I was thinking the other day, you know, you could
have a child that's born here to get to the universal screen, but then parents move, you
know, in the interim, and then, and then it becomes a little bit of a challenge to interpret
that and what are the next steps, right?
And so I think it's something to be, to understand that it's coming out there now and then maybe
other provinces will be tagging along with universal screening.
Awesome.
Okay.
Awesome.
Thanks, Dr. Bitnan.
Thank you, Dr. Purwall and Dr. Bitnan.
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