increasing awareness and promoting strategies for

Karen B. Fowler1, Susan L. Davies2, Mirjam-Colette Kempf3, Michael Cannon4, Suresh Boppana1, Alan T. Tita5, Rodney K. Edwards5

Departments of 1Pediatrics, 2Health Behavior, 3Nursing, Family, Comm & Health Systems, 5Obstetrics & Gynecology, University of Alabama at

Birmingham, & 4Centers for Disease Control

Increasing Awareness and Promoting Strategies for Prevention of Congenital Cytomegalovirus Infection

(cCMV) Among Young Urban Pregnant Women

CMV Public Health & Policy ConferenceSeptember 27, 2016

Introduction

• Congenital CMV Infection (cCMV) remains the most common congenital infection in the United States (US), and an important cause of hearing loss in children.

However, most women of childbearing age have never heard of cCMV and the risk of cCMV’sdamaging sequelae for their newborns, or how to prevent possible CMV exposures that may result in infection.

Fowler,etal.inpreparation

Objective

To evaluate whether a cognitive-behavioral intervention to increase CMV awareness and CMV prevention counseling can,

1) increase knowledge about cCMV and

2) decrease self-reported risk behaviors among young urban pregnant women.


Study Population:

Between October 2013 and June 2015, 215 pregnant women aged 16 – 29 years were recruited/enrolled following their first prenatal visit into a CMV cognitive-behavioral intervention study.

All women aged 16 - 29 years who enrolled in prenatal care at any of the Jefferson County Health Department Prenatal Clinics and who planned to deliver at UAB Hospital were eligible to participate. Women were contacted either through advertisements in the prenatal ultrasound clinics, and/or telephone calls.

Methods


MethodsBaseline demographics & information on their CMV

exposures and knowledge were collected using questionnaires. Additional prenatal information was collected from their medical record.

CMV serostatus was collected from data available from the Obstetrics/Maternal Fetal Medicine Division for those who had been previously tested, and remnant 3rd

trimester blood specimens were collected for CMV antibody testing for women who were either not previously tested or women who were CMV negative at the beginning of their pregnancy.


MethodsCognitive-Behavioral Intervention:(help individuals to identify helpful and unhelpful behaviors, establish goals, and develop

skills to solve problems and implement new behaviors)

215 women were randomized:

108 “CMV Prevention in Pregnancy” intervention group (PREVENT) – CMV education and prevention intervention

107 “Taking Care of Me” intervention group (CONTROL) educational stress reduction intervention.


MethodsCognitive-Behavioral Intervention, con’t:

For both groups, each woman had • a 15-20 min individual behavioral skills session

with study personnel, • watched a short video, • received a take home packet, • received weekly text messages for 12 weeks to

deliver the PREVENT or CONTROL interventions.


Methods

Cognitive-Behavioral Intervention, con’t:

In addition, each woman attended 6 and 12 week follow-up visits for an intervention boost for the PREVENT group and where post-intervention CMV knowledge and risk behaviors were assessed via questionnaires in both groups.


Methods

196/215 (91.2%) women had both pre- and post-intervention assessments, 97 in the PREVENT group & 99 in the CONTROL group (p=0.48).


Study CharacteristicsAt Enrollment

PREVENTN=97

CONTROLN=99

Age, yrsMean ± SD21.7 ± 3.6

Mean ± SD21.6 ± 3.3 NS

Race & Ethnicity % (95% CI) % (95% CI)

Black 90.7% (83.1 – 95.7%) 90.9% (83.4 – 95.8%) NS

White, Non Hispanic 5.1% (1.7 – 11.6%) 8.1% (3.5 – 15.3%)

White, Hispanic 2.1% (0.2 – 7.2%) 0

Multiracial 2.1% (0.2 – 7.2%) 1.0% (0.3 – 5.5%)

Insurance Status

Public or No Insurance 91.7% (84.4 – 96.4%) 96.0% (90.0 – 98.9%) NS

Educational Level

< 12 years 31.9% (22.9 – 42.2%) 29.3% (20.6 – 39.3%) NS

Marital Status

Single 86.6% (78.2 – 92.7%) 87.8% (79.7 – 93.6%) NS

Study Characteristics at Enrollment



PREVENTN=97

CONTROLN=99

% (95% CI) % (95% CI)

Trimester 1st Prenatal Visit

1st 72.9% (62.1 -80.8%) 81.6% (71.7 – 88.0%) NS

CMV Serostatus

CMV Seropositive 55.7% (45.2 – 65.8%) 69.7% (59.6 – 78.5%) NS

CMV Seronegative 26.8% (18.3 – 36.8%) 15.1% (8.7 – 23.8%)

CMV Status Unknown 17.5% (10.5 – 26.6%) 15.1% (8.7 – 23.8%)

Study Characteristics at Enrollment


PREVENTN=97

CONTROLN=99

% (95% CI) % (95% CI)

Live/ young children (0-6 y) 44.3% (34.2 – 54.8%) 46.5% (36.4 – 56.8%) NS

Children in house attend daycare 16.5% (9.7 – 25.4%) 24.2% (16.1 – 33.9%) NS

Live with their own children 43.3% (33.3 – 53.7%) 46.5% (36.4 – 56.8%) NS

Take care of young children /regular basis 75.3% (65.5 – 83.5%) 80.8% (71.7 – 88.0%) NS

Age of sexual debutMean ± SD

15.6 ± 2.0 yrsMean ± SD

15.7 ± 2.0 yrs NS4+ lifetime sexual partners 64.9% (54.6 – 74.5%) 66.7% (56.5 – 75.8%) NS

Any STIs during pregnancy 71.1% (61.1 – 79.9%) 59.5% (49.3 – 69.3%) NS

History of STIs 47.4% (37.2 – 57.8%) 50.5% (40.3 – 60.7%) NS

Possible CMV Exposures at Enrollment


CMV Awareness & Knowledge

CorrectKnowledgeScore– 0to16


CMV Awareness & Knowledge

PREVENTN=97

CONTROLN=99

P value

PRE Intervention at Enrollment

Ever Heard of CMV? 11.3% (5.8 – 19.4%) 16.2% (9.5 – 24.9%) 0.3

Correct CMV Knowledge Score (0 -16, highest score 16)

7.7 ± 3.2(range, 1 – 15)

7.5 ± 3.3(range, 1 – 15) 0.6

POST InterventionCorrect CMV Knowledge Score (0 -16, highest score 16)

11.3 ± 2.2(range, 3 – 16)

8.5 ± 3.7(range, 1 – 16) <0.0001


CMV Risk Behaviors

1. Afterchangingadirtydiaper,howoftendoyouwashyourhandswithsoap&water(orusehandsanitizer)?

2. Afterchangingawetdiaper,howoftendoyouwashyourhandswithsoap&water(orusehandsanitizer)?

3. Afterfeedingayoungchild,howoftendoyouwashyourhandswithsoap&water(orusehandsanitizer)?

4. Afterwipingachild’snose,mouthordrool,howoftendoyouwashyourhandswithsoap&water(orusehandsanitizer)?

5. Afterhelpingachildusethetoilet,howoftendiddoyouwashyourhandswithsoakandwater(orusehandsanitizer)?

0-Always1-Usually2-Occasionally3–Rarely4–Never1. Howmanydaysinthepastweekdidyoukissachildonthemouth?2. Howmanydaysinthepastweekdidyousharefoodwithachild?3. Howmanydaysinthepastweekdidyoushareeatingutensilswithachild?4. Howmanydaysinthepastweekdidyousharethesamecuporglasswitha

child?5. Howmanydaysinthepastweekdidyouputachild’spacifierinyourmouth?6. Howmanydaysinthepastweekdidyoushareatoothbrushwithachild?

0:0days1:1-2days2:3-4days3:5-6days4:Everyday

RiskBehaviorScore– 0to44


CMV Risk BehaviorsPREVENT

N=97CONTROL

N=99P

valuePRE Intervention at Enrollment

Kiss young children on the mouth 40.2% (30.4 – 50.6%) 40.4% (30.7 – 50.7%) 0.9

Share food, drinks, eating utensils, etc. with young children 47.4% (37.2 – 57.8%) 50.5% (40.3 – 60.7%) 0.7

Not always wash hands after feeding, wiping face & hands, etc. 58.8% (48.3 – 68.7%) 54.5% (44.2 – 64.6%) 0.6

Not always wash hands after changing diapers 29.9% (21.0 – 40.0%) 36.4% (26.9 – 46.6%) 0.3

CMV risk behavior score (0-44, 44 highest risk score)

5.2 ± 5.9(range, 0 - 23)

5.7 ± 6.1(range, 0 - 32) 0.5


CMV Risk Behaviors

PREVENTN=97

CONTROLN=99

P value

PRE Intervention at EnrollmentKiss young children on the mouth 40.2% (30.4 – 50.6%) 40.4% (30.7 – 50.7%) 0.9

POST InterventionKiss young children on the mouth 10.3% (5.1 – 18.1%) 27.3% (18.8 – 37.1%) 0.002

PREVENTN=97

CONTROLN=99

P value

PRE Intervention at EnrollmentShare food, drinks, eating utensils, etc. with young children 47.4% (37.2 – 57.8%) 50.5% (40.3 – 60.7%) 0.7

POST InterventionShare food, drinks, eating utensils, etc. with young children 15.5% (8.9 – 24.2%) 30.3% (21.5 – 40.3%) 0.01


CMV Risk BehaviorsPREVENT

N=97CONTROL

N=99P value

PRE Intervention at EnrollmentNot always wash hands after feeding, wiping face & hands, etc. 58.8% (48.3 – 68.7%) 54.5% (44.2 – 64.6%) 0.6

POST InterventionNot always wash hands after feeding, wiping face & hands, etc. 43.3% (33.3 – 53.7%) 42.4% (32.5 – 52.8%) 0.9

PREVENTN=97

CONTROLN=99

P value

PRE Intervention at EnrollmentNot always wash hands after changing diapers 29.9% (21.0 – 40.0%) 36.4% (26.9 – 46.6%) 0.3

POST InterventionNot always wash hands after changing diapers 20.6% (13.1 – 30.0%) 28.3% (19.7 – 38.2%) 0.2


CMV Risk Behaviors

PREVENTN=97

CONTROLN=99

P value

PRE Intervention at EnrollmentCMV risk behavior score (0-44, 44 highest risk score)

5.2 ± 5.9(range, 0 - 23)

5.7 ± 6.1(range, 0 - 32) 0.5

POST InterventionCMV risk behavior score (0-44, 44 highest risk score)

1.7 ± 2.6(range, 0 - 12)

3.4 ± 4.6(range, 0 - 26) 0.002


Seroconversions


PREVENTN=97

CONTROLN=99

% (95% CI) % (95% CI)

CMV Serostatus

CMV Seropositive 55.7% (45.2 – 65.8%) 69.7% (59.6 – 78.5%) NS

CMV Seronegative 26.8% (18.3 – 36.8%) 15.1% (8.7 – 23.8%)

CMV Status Unknown 17.5% (10.5 – 26.6%) 15.1% (8.7 – 23.8%)

Seroconversions 1/166.2% (1.6 – 30.2%)

2/922.2% (2.8 – 60.0%)


Conclusion

Despite being the group at highest risk for having offspring with cCMV, young women lack awareness or accurate knowledge of cCMV and how to protect themselves and their fetuses/infants from CMV.

This cognitive-behavioral intervention demonstrates that it is possible to raise awareness about cCMV and decrease CMV risk behaviors in young urban pregnant women.


Acknowledgements

Study staff:

Alice Brumbach, RN, MSNEmily Mixon, MPHD’Netria Jackson

Supported by the CDC 1 U01 DD-12-005


increasing awareness and promoting strategies for

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