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    • We devised a type of intervention that

    2018-10-23

    We devised a type of intervention that, if successful, could be further tested in larger trials and, ultimately, translated into general practice. We focused on pregnant women known to be at increased risk of infection, i.e., women caring for young children. These women were first offered CMV testing and, if seronegative, they were informed about CMV and prevention measures to be adopted. Information was kept as simple as possible. However, as hygiene recommendations implied substantial and sustained behavioral changes, active involvement was encouraged and a positive attitude in the woman was considered crucial for a successful intervention (see Suppl. data). Unlike the two previous studies performed in the USA (Adler et al., 1996, 2004), our intervention did not include an educational video. In addition, use of gloves and recommendation not to sleep in the same bed with the child was not suggested. Finally, liquid soap and disposable gloves were not provided, and home visits were not performed. As a result, an 84% reduction in seroconversion rate was observed: a finding strickingly similar to what previously reported by Adler et al. (2004) Reiteration of recommendations during antenatal S63845 may further improve the intervention effectiveness, as reported for toxoplasmosis (Breugelmans et al., 2004). We do not know which of the suggested recommendations was most effective in reducing the seroconversion rate in the intervention group. No difference was previously reported, for a number of protective or risky behaviors, between infected and uninfected mothers of children excreting CMV (Adler et al., 2004). Adherence to suggested recommendations is still under examination. However, preliminary data indicate that 80% women reported substantial or complete compliance with suggested recommendations. According to one study, mothers were able to make and sustain behavioral changes for more than 6months and were not necessarily concerned about reducing intimate contact with their children (Adler et al., 2004). Importantly, in our study, 93% of the women felt that the recommendations are worth suggesting to all women at risk for infection. This finding shows that an intervention like the one herein reported would be highly acceptable to the target population of women and confirms previous results (Cordier et al., 2012). An additional finding of our study was that 9 primary maternal infections occurred in the first trimester of gestation, the highest risk period in case of virus transmission to the fetus (Enders et al., 2011). Based on results of our study, it is reasonable to hypothesize that some infections would have been avoided had these women been informed at an earlier stage of pregnancy. Ideally, all women should be tested for CMV antibody and informed before pregnancy. A further additional by-product of our study is that hundreds of women enrolled in the comparison group and found to be susceptible to CMV received post-partum CMV information. Should these women become pregnant again, it is less likely they will be inadvertently exposed to CMV. Indeed, in a population of women receiving fertility treatment, preconception screening and counseling seemed to have the potential to reduce CMV exposure in pregnancy (Reichman et al., 2014). Preconception testing would also reduce problems arising from the detection and interpretation of CMV-specific IgM antibody in an already pregnant woman (Revello and Gerna, 2002; Guerra et al., 2007). Finally, in view of the 15–20% rate of spontaneous abortion reported in the general population in Italy (ISTAT, http://www.istat.it,2014), it is difficult to hypothesize whether CMV had an etiological role in the spontaneous abortion observed in the 4 women in the intervention group (representing about 1% of CMV-seronegative women initially enrolled) who could not be further tested. Hopefully, an effective CMV vaccine will eventually limit congenital CMV (Griffiths et al., 2013) but this is not foreseen in the near future. In the meantime, based on the uncertain efficacy of the costly treatment with hyperimmune globulin (Nigro et al., 2005; Revello et al., 2014), reducing rates of primary infection in pregnancy by alternative prevention strategies should be carefully considered.