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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES Programme 2. - Herpes
RADIO 4
TUESDAY 8TH APRIL 2008
PRESENTER: MARK PORTER
REPORTER: ANNA LACEY
CONTRIBUTORS: RAJ PATEL
STACEY EFSTATHIOU
VANESSA LUCAS
MARION NICHOLSON
JOHN GREEN
CHRISTOPH LEES
PRODUCER: ERIKA WRIGHT
NOT CHECKED AS BROADCAST
CLIP
Without any knowledge that I may have any infection I had a small sore, it went after a couple of days, I didn't really think anymore of it than oh I've got a spot, certainly nothing I can ever put - pin down and say yeah I had a sore throat or I felt really ill or anything at all. It was only when I got a second infection in exactly the same place that I realised that it was probably herpes, just guess work. I've never been to the doctors about it. I had one more episode some while after that and that's been the only outbreaks that I've had at all.
PORTER
It may come as a surprise to learn that you've probably got herpes. I know I have.
Few people make it past the age of 30 without becoming infected with at least one strain of the herpes family. Eight out of ten carry one of the two viruses that cause cold sores and genital herpes by the time they reach their mid-20s.
Tradition has it that herpes simplex 1 causes cold sores, and herpes simplex 2 the genital form. But we now know the two are interchangeable - put simply both cause blisters and sores on the part of the skin they infect. If that happens to be your face then it's called a cold sore, and if it's on your nether regions, we call it genital herpes.
But if genital herpes is basically nothing more than cold sores around the genitals, why does the mere mention of the term instil so much fear? I visited the Genito-Urinary Medicine Clinic at Royal South Hants Hospital in Southampton to find out.
PATIENT
I'd been with my partner for two years and I'd separated from him about a week, I think, before I actually came to the clinic. I'd found out just a few days before that that he had given genital herpes to his previous girlfriend. I just couldn't believe it when I found out. I didn't feel that I'd had any symptoms for genital herpes but afterwards I did have very large cold sores on my lips and just under my nose and I obviously thought that may have been due to the oral sex. From speaking to the nurse I understood that you could do tests for genital herpes and that ...
PATEL
.... it's complicated because there is a blood test ...
PORTER
Dr Raj Patel is a consultant in genitor-urinary medicine with a special interest in herpes.
PATEL
The clinic in Southampton sees 12,000 inpatients a year. Within that we probably see a few hundred patients, new patients a year, with herpes infections. Genital herpes is due to herpes simplex virus and it's one of the members of the herpes family - there are eight different viruses in that - two of them - herpes simplex 1 and 2 - cause genital herpes.
PORTER
Does it matter which of those two viruses that you get?
PATEL
Two herpes viruses - herpes simplex 1 and 2 - are very closely related, about 50% of their DNA is identical, but 50% is different. And in those differences lies the key to the range of illnesses they cause depending on which bits of the body they infect. So over tens of thousands, probably millions of years, these viruses have evolved apart and depending on which bit of the body you get these viruses you get different types of illnesses. So if you get HSV1, the commonest herpes simplex type 1, the common cause of cold sores, if you get that outside of the face, the mouth, if you get it in the genital area although it can cause an identical illness when you acquire it, it tends not to cause frequent or severe recurrences. So if it's HSV2, type 2, they tend to recur four to six times that first year, if it's type 1 they will tend to only recur once in the first year, probably once every other year thereafter.
PORTER
So let's take a typical, an average, case. Say somebody comes into contact with herpes simplex 2 and they catch it on their genitals, what are they likely to experience, how do they know something's gone wrong?
PATEL
Two-thirds of people will actually have - will not even know that they've got anything. For the other one-third though that develops symptoms they will probably notice a bit redness, bit of itching, in the first few days, then probably at day four or five they might notice little bumps appearing in the skin that was exposed. So if it's a genital acquisition - that means the virus was acquired through the genital skin - they'll notice some spots appearing, some bumps appearing, in the genital skin. These bumps will fill with liquid, turning into blisters and these blisters tend to be very fragile and they can be quite extensive - they can be on both sides of the midline and they can affect areas at this stage which were outside of the area of immediate sexual contact. Those blisters usually pop very easily and when they pop they're painful. At the same time as this is going on our patient may notice some symptoms generally - they may have a headache, they may have muscular aches, they may start feeling unwell.
PORTER
And that goes on for how long?
PATEL
We know that from start to finish the illness lasts about three weeks and gets to its peak severity at about day 11.
PORTER
And herpes simplex 1 and 2 aren't the only members of the herpes family that cause blistering rashes. Herpes Varicellae, or Zoster as it's often known, is the virus responsible for chickenpox and shingles - as Anna Lacey discovered when she met Dr Stacey Efstathiou, Head of the Division of Virology at Cambridge University.
EFSTATHIOU
Chickenpox is a disease that's caused by a herpes virus and we get infected by breathing in infected skin or free virus particles released from another infected individual and this causes an infection of the respiratory tract and the virus then gains access to the blood and spreads throughout the body to ultimately result in lesions over the skin surface which are really loaded with infectious viral particles.
LACEY
Now how does it differ from the other kind of herpes that people might have heard of, like cold sores or genital herpes?
EFSTATHIOU
Yeah well this is an electron microscopic picture of a herpes virus and actually all herpes viruses look very similar when you look at them down the electron microscope. So they're 200 nanometres in diameter, spherical in shape and contain what we call a capsid, which is a spherical protein shell which contains the nucleic acid of these viruses.
LACEY
That's the DNA?
EFSTATHIOU
That's right, that's the DNA. And this is where the viruses start differing in some ways, so varicella zoster virus, which causes chickenpox, is the smallest virus, so it's got a genome which is 120,000 base pairs in length, whereas herpes simplex virus which causes a genital herpes or cold sores has got a larger genome size. So all the viruses look very similar but they've got different biological characteristics.
LACEY
And those differences are contained within that extra genetic information?
EFSTATHIOU
Exactly. At the end of the day it's all dictated by the genes of the viruses.
PORTER
So herpes infection is endemic, most children get chickenpox and few will make it into adulthood without picking up the herpes simplex viruses. But there's been a significant change in how and when they first meet them, changes that could explain why the genital form of HSV infection has become more common. For an increasing number of them the first infection with the cold sore virus will be later in life through some form of sexual contact.
PATEL
We know that comparing cohorts of children and young adults from the '50s to now the levels of HSV1 infection in those groups has declined dramatically, less than a quarter of young adults who'll be setting off on their sexual lives will actually have HSV1 infection already, so they are susceptible. A generation ago most of them would have had HSV1, so they're not going to be susceptible. We also know that if you have HSV1 because this virus is so closely related to HSV2 many of the antibodies you already have will give you partial immunity to HSV2. Now there is some controversy in the area as to whether it will actually protect you from catching it but what we do know is that if you've already got antibodies to the cold sore type - HSV1 - it will give you a much milder illness with HSV2. So you won't have such a noticeable first acquisition illness and your recurrences are likely to be less frequent and milder. Conversely though it may make you more infectious because you will probably not notice your recurrences and if you're relying on that to limit transmission then you won't - that strategy won't be as effective.
PORTER
And do we know why this exposure to HSV1 has changed?
PATEL
We suspect it's to do with changes in family structure, that families are smaller, it's less socially acceptable to kiss other people's children and it may well be that children don't get exposed.
PORTER
Raj, for people of my generation, I mean I'm in my 40s, the first time I heard the term herpes was this sort of epidemic that was supposed to be sweeping the developed world - I think it was the late '70s and early '80s - it was on all the headlines and we were all going to - it was going to be the end of the sexual revolution. Can you put that into context now looking back 30 years later?
PATEL
Herpes infections have been around since times of antiquity, they're very well described in the literature. I think what happened in the '70s and '80s was that tests became available to allow doctors to relatively simply diagnose these illnesses and so it became possible to say with some confidence what patients had. I think at the same time clinics specialising in sexually transmitted diseases started looking for these conditions and started reporting what was out there.
NICHOLSON
I developed feverish symptoms, the flu-like symptoms that are so often talked about in the classic cases.
PORTER
Marion Nicholson, now Director of the Herpes Association, developed genital symptoms after a holiday romance in the 80's.
NICHOLSON
It was only a few days after that that spots developed and then I realised that something was going on down there. I phoned him up, he said ah yes, well um, I do have herpes, I didn't think I had anything going on at the time. And I subsequently got diagnosed at a GU clinic when I was back in England.
PORTER
And at the time what was your understanding of herpes?
NICHOLSON
Nothing at all, I'd never heard it, until my sister, who lived in the States, sent me an American magazine
GREEN
It really became prominent I think in America in the late '70s or the early '80s and it started to get a lot of press coverage.
PORTER
Dr John Green is a clinical psychologist with a special interest in genital herpes.
GREEN
There was a famous cover on Time magazine in I think about '82, sometimes round about then, "Herpes - Today's Scarlet Letter", with very large red herpes on the cover. And it portrayed herpes as being this dreadful disease that was sweeping America.
PORTER
Everybody used to think of it as a new disease, but it had been around for some time, though there wasn't even actually an epidemic at the time was there?
GREEN
No, I mean they did think of it as a new disease but I think the most serious about it was it took what is essentially a skin condition, it's essentially a spot, it's a cold sore and turned it into this monster and it really was only when HIV came along that HIV pushed herpes off the list. But in terms of the actual physical damage that it does to people herpes is probably one of the least damaging of sexually transmitted diseases.
NICHOLSON
Looking back on it you can see that it really was not an epidemic at all, it was just that because newspapers talked about it a few more people went along to GU clinics and got diagnosed.
PORTER
Your companion on your holiday romance hadn't warned you that you might be at risk of contracting an infection but presumably once you knew you had the diagnosis it was something that worried you, what happened the next time that you found yourself in a situation where you might have passed it on?
NICHOLSON
Sure, it did worry me hugely at the time and indeed I joined the Herpes Viruses Association because I thought that no normal person would ever have me. In fact through the Herpes Viruses Association I realised that it was just a cold sore and it wasn't anymore serious than a cold sore and therefore when I had a new relationship I did tell my partner that I had in my past caught cold sores on the genitals that are called herpes simplex and that there would be occasions when I would have to say no sex tonight and that if I felt a little unsure, in other words I was getting the itchy tingling pressure that tells me that an outbreak might be on its way, I'd ask him to use a condom. And we had sex like that for 10 years and as far as we know he never caught it.
PORTER
So that was how you explained it in your own relationship but as regards the association what should they say to their new partners who may have no understanding of the condition?
NICHOLSON
If they choose to tell their partner then we suggest that they do indeed mention to their partner that they get cold sores on their genitals. Using the word cold sores on the genitals allows people to think about it without immediately freaking out because it is the word herpes that makes people freak out and not the actual condition.
GREEN
I certainly advise my patients that they should talk to their partners about the fact that they've got genital herpes.
PORTER
That's not the easiest thing to raise.
GREEN
No it's not the easiest thing to raise and people find it very difficult. But the experience and results of the research that we've done is that if you tell your partner up front partners react much better than most people would fear.
PORTER
Which was exactly what happened to this couple attending Dr Patel's clinic. The man knew that he had genital herpes - an infection that he had caught during a previous relationship - and that he had to disclose the fact to his new partner.
COUPLE WITH HERPES
He just quite simply stated - there's something I really do need to tell you - and it was one of those moments when you think well what on earth could you tell me because things were going so well at the start of our relationship. And he just said I've got herpes.
With a deep breath.
I recall not saying an awful lot because my knowledge of the infection really wasn't that good and I knew I wanted to find out a little bit more about it and think about it. And then I think it was me that made the decision and drove it that I wanted to go and seek more professional advice and help and run tests and just have more information so that we could then make the decision of how we're going to live our lives with it.
It was difficult, it had to be said before we started and once it was out in the open it was easy to deal with wasn't it?
Yeah, yeah.
PATEL
Telling your partner you have herpes appears to reduce the risk of you transmitting herpes to them by about 50%. Now we're not completely clear how this can work. We suspect this works because your partner can work with you to limit transmission, so they won't pester you for sex, for instance, on the days that you tell them that it's inappropriate to have sex, if you think that there's a lesion coming through for instance. If you choose to use condoms they may help to make sure that you use them consistently and they may also help you look for recurrences.
PORTER
Vanessa Lucas is a health advisor working at the clinic in Southampton.
LUCAS
They're generally concerned about the stigma attached with the word, is it going to go, are they going to experience it again, how soon are they going to have another episode. I think there's a lot of misconceptions about what herpes is, the word for most people brings up horrible thoughts in their mind, it's something that they've heard of but don't know very much about and a lot of people don't associate it being the same virus that causes cold sores.
PORTER
Where do you think that stigma comes from?
LUCAS
I think it's a stigma that's attached to any sexually transmitted infection, I think we generally - anything associated with sex we don't like to talk about, so people don't openly talk about having herpes, which is a very common virus that a lot of people have been exposed to. If you talk about cold sores, people will talk about cold sores but they won't disclose that they've got genital herpes which could be the same virus that causes cold sores.
PORTER
I mean presumably they're quite relieved when you explain it that way, you can say well you know your long term outlook is similar to someone who's got a cold sore and indeed almost identical and even treated in the same way in many cases.
LUCAS
That's right yeah. They can be quite relieved to find out that they've got type 1 herpes which is caught generally from a cold sore although the treatments and the prognosis, their expectations of whether they'll have any recurrences, whether it'll happen again in the future and how we treat those episodes again in the future is exactly the same, doesn't matter which type of the virus it is.
PORTER
Do you get partners of people with the infection coming in to talk to you?
LUCAS
Yeah I have had quite a number of partners who've come in where sometimes that they've been confronted by somebody blaming them for giving them herpes and just trying to give them accurate information about how the infection's passed on, what it is.
PORTER
The herpes simplex virus is spread by skin to skin contact. Those infected are most likely to pass the virus on when they have active sores - either on their face or genitals - but spread can also sometimes occur when they are apparently symptom free.
Abstaining from sexual contact when sores are present, and/or using condoms will reduce the risk of passing the infection on, but neither will provide 100% protection. That said the risk is comparatively small. Most people with herpes probably won't pass the infection on if they are careful - and anyway there's a good chance their partner already has at least one of the strains.
But passing the virus on is only part of the problem for those unlucky enough to be prone to recurrent flare ups. So why does the herpes simplex virus keep resurfacing in some people?
PATEL
Left to its own devices the body is able to clear this virus from the skin but the virus, whilst it's multiplying in the skin, will also infect the ends of nerves and will enter into the nerves and travel down to the cell body of the nerve, which sits close to the spinal column. It'll remain there and during this time, whilst the virus is being cleared from the skin, the body will develop a strong immune response to it, so you'll develop antibodies, some cell [indistinct word] immunity, which will help control the virus should it ever come back out of the nerves. For the majority of people we know that the virus does come out of the nerves at some stage and when it comes out the immune system is usually on top of it fairly quickly but you will get a mild illness in many people.
PORTER
In patients who have problems with regular cold sores around their lips you often hear them say well I get them when I get run down or if I expose myself to too much sunlight or whatever, are there similar triggers in genital herpes?
PATEL
We do get patients who seem to find patterns in the recurrences. What we'd say is you've got to be very careful about attributing anything to this virus. I think being run down probably does trigger recurrences, certainly in our patients whose immune systems are very fragile there seems to be a link. Exposing the skin to bright sunshine seems to stimulate recurrences and in the lab we know that vigorous or aggressive trauma to that area will also bring on recurrences.
PORTER
The ability to re-emerge isn't confined to the herpes simplex viruses - the same can happen with strain responsible for chickenpox. Herpes varicellae also hides in the nervous tissue once the initial infection has settled. As immunity wanes with time - or as a result of some other illness - the virus can re-emerge along a nerve root producing the classic one sided blistering rash of shingles. Something that can happen decades after the original infection that caused chickenpox, as Dr Efstathiou explains to Anna Lacey.
EFSTATHIOU
It would have been no use to the virus if it just stayed dormant in the body forever because of course ultimately what the virus wants to do is to escape from the infected individual to infect new people who've never seen the virus before. And these are very sneaky viruses, so they stay dormant or quiescent within these nerve cells but then at later times during life the virus can, if you like, reawaken to produce new virus particles and these can travel back down nerve fibres, back to the skin, to cause a distinct form of lesions which are known as shingles and a case of shingles.
LACEY
Now there's some confusion about the relationship between chickenpox and shingles. So, for instance, I've had chickenpox as a child and imagining now say you had shingles could I catch that from you?
EFSTATHIOU
No, you can't transmit shingles okay? If you've had chickenpox you're protected from ever catching chickenpox again from another individual, all that can happen to you is development of shingles by reactivation of your own chickenpox virus in your body. However, if you've never been exposed to chickenpox as a child you're clearly susceptible to catching chickenpox. You can catch this from another individual showing the symptoms of chickenpox and you can also catch the virus from somebody who's having a reactivation and has a case of shingles. In both cases what's released from the individual is the chickenpox virus and so you will only develop chickenpox.
LACEY
Because you have to have chickenpox first, I suppose is what we're saying?
EFASTHATIOU
Absolutely, so shingles can't be transmitted to cause shingles.
LACEY
If you catch chickenpox as a child then the symptoms are usually quite mild but if you catch it as an adult or during pregnancy then the effects can be more serious. To find out about the risks I went to the Rosie Maternity Hospital in Cambridge and spoke to Christoph Lees, a consultant in obstetrics and foetal medicine.
LEES
Chickenpox luckily is not common in pregnancy and the complications are most serious early on in pregnancy and very late on in pregnancy for the baby. So early on in pregnancy, before about 16 or 18 weeks, chickenpox can affect a baby, causing limb abnormalities, eye abnormalities - such as cataracts - or even brain developmental problems. I've got to say this is extremely rare and happens to considerably fewer than 1% of babies where the mother gets chickenpox. Later on in pregnancy if a baby is born to a mother who has only just had chickenpox then the poor baby is born and has a virus in its bloodstream but it can't produce the antibodies to fight that virus and of course can get quite severe disease which can be quite dangerous for them.
LACEY
Of course we've talked about the baby but what about the mother if she gets chickenpox while she's pregnant?
LEES
About 10% of women who get chickenpox in pregnancy can get quite significant respiratory problems and pneumonia particularly and if the pneumonia becomes severe it can actually kill women. This is luckily extremely rare and fewer than less than one woman a year dies of the condition in the UK but just occasionally women will end up on intensive care units needing ventilation and quite intensive support with chickenpox pneumonia.
LACEY
Whether it's genital herpes, chickenpox or cold sores it's very rare for herpes viruses to be fatal. But they can still have long lasting health effects.
EFSTATHIOU
In the case of chickenpox virus you could say well it's generally a benign infection but of course in the elderly, who have cases of shingles, one can get a very painful condition, even once shingles has cleared, which is called post-herpetic neuralgia. And what that really means is that there's severe pain that's caused by damage of the nervous system and this can go on for many months and it can be very severe indeed. And similarly in the case of genital herpes, for example, it might not be a life threatening infection but of course it can be a major problem for individuals suffering from these recurrent infections.
PORTER
The treatment of herpes virus infections centres around anti-viral drugs which can be used to treat acute flare ups - such as shingles, a cold sore, or genital herpes - or as regular suppressive therapy to stop recurrences. The most widely used drug is aciclovir - normally used in cream form for cold sores, and in tablet form for shingles and genital herpes. But if it is to work aciclovir needs to be taken at the first sign of trouble.
PATEL
We think that if you don't take them within the first 24 hours of an episode starting then they're not particularly effective which means patients have to carry these with them and they have to get their doctor to agree to give them a prescription that they can cash in either as quickly as they get an episode or to cash in and use for their next episode.
PORTER
Because the advice we give with cold sores around the lips is that you start treatment when you feel tingling phase, with genital herpes do you get similar sensations?
PATEL
Absolutely, that tingling phase, which is technically called the prodrome, is the best time to start treatment.
PORTER
What about if I was starting off in a new relationship and we were getting to the stage where sexual contact was likely and I wanted to make sure that I reduced the odds as much as possible, so I didn't have any active sores, I was using a condom but I wanted to take medication as well, how soon would I have to start that before that extra level of protection would come in?
PATEL
The studies that have been done looking at the shedding of virus from the skin and how quickly it responds to taking anti-virals suggest that at least five full days of treatment should have been started to get the maximal effect, so we'd say start the week before.
PORTER
We've talked about the similarities between cold sores and genital herpes, essentially one and the same thing, may be caused by the same virus indeed, is there a case then for people with cold sores to take preventative therapy?
PATEL
Preventative therapy will work for cold sores and I think most people in the field are aware that it's slowly moving into this area, certainly there's quite a few people already taking it who have troublesome frequent disease, people who rely on their good looks for their living, so some models will be on it and some sportsmen who will have a lot of close contact in their sport - rugby players, wrestlers - we know take this. I think there is a drift towards providing therapy for patients that are troubled with cold sores but it tends to be the minority of people that get treatment and I would say that's because although the viruses are similar our perceptions and our patients perceptions of them are quite different.
PORTER
They treat the genital version as much more serious?
PATEL
Absolutely.
GREEN
These are just a very, very common set of infections, doesn't mean to say that you shouldn't try and avoid them, obviously you should, but they have a reputation which is tied up in all sorts of ideas about sex and morality.
PORTER
So what you're saying is you're sitting in the clinic there, people coming in with genital herpes, there's absolutely no difference from the sort of person who gets genital herpes as the sort of person who gets cold sores, indeed they're one and the same condition.
GREEN
Ordinary people get sexually transmitted diseases, that's the truth. It's something that most couples eventually settle down with.
COUPLE WITH HERPES
I'm on aciclovir twice a day, I haven't had any outbreaks and if I did well then obviously we'd have to stop any sexual intercourse until such a time as the infection went away because clearly that is a serious risk of passing it on then but it's something we've now got to come to grips with and live with for the rest of our lives, it's not going to go away. We've accepted there is the risk of you getting the infection, if you do we're not willing to let it ruin our lives or stop us from enjoying anything we want to do together. It's slid into the background really now hasn't it - I take me tablets morning and evening and that's the only part of our lives that it impacts at all.
We just want a sort of happy active physical relationship.
ENDS
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