Prevention and children - genital HSV-1 and herpes Whitlow

[mochicrunch]

My question relates to how we should handle preventative measures for my toddler (2.5 years) and my baby (12 weeks).

Their aunt, my sister-in-law, was diagnosed with HSV-1 oral and genital and also had a very bad outbreak of herpes Whitlow. This was ostensibly her initial outbreak of genital HSV-1 and on the hands.
My sister-in-law has had other STDs in years past (chlamydia) and engages in unprotected anonymous sex, sex tourism, and unprotected sex with at least one needle/drug user. My point is twofold:
1. I don't know what other STDs she may or may not have, as yet undiagnosed, and
2. She is extremely careless about her own health, therefore I am deeply distrustful of her letting us know when she is experiencing an outbreak. She seems unable to deal with the danger of her illness, however temporary, to our children.

We are having difficulty getting medical advice on this due to the mix of genital HSV-1 (not HSV-2, but I never saw any lab results myself) and herpes Whitlow. Obviously all medical advice is "if-then" - if there are no sores, then… if sores, then…. However due to her carelessness about her own health I am distrustful about her being aware of when she is contagious.
This aunt is close with our children and lives nearby, so she often visits us.
My concerns include:  Sharing the toilet in our home, diapering, babysitting, playing with their toys (teething babies mouth everything), feeding and having meals together, visiting her in her apartment, eating food she prepares.

1. What are prudent ways to deal with prevention in lieu of our children? How long can the virus live on objects, especially wet objects? Is there asymptomatic shedding from herpes Whitlow?

2. In your experience, how should we proceed as parents with a person who engages in risky sexual behavior and careless health practices, and who has a history of STDs?

Any advice you have would be much appreciated. Thank you.

[Edward W Hook, MD]

Welcome to the Forum. From your post, it appears that there is a certain amount of tension between you and your sister-in law.  Before I answer your specific questions, a few additional comments.  I would dispute that she has a herpetic whitlow, genital HSV-1 and oral HSV-1.  When persons get HSV (1 or 2), persons typically get it at once site and then are at no further risk for infection with that virus at other sites on their bodies.  The immune response to the initial infection prevents further spread of infection to other parts of the infected person's body.  Secondly, your question suggests that you share the widely held misperception that HSV is highly infectious.  This is not the case.  HSV is transmitted by DIRECT contact and is not transferred by or on inanimate objects such as glasses, toilet seats, etc.  Even with direct contact, most exposures do not lead to transmission.  Thus the practical risk of casual transmission through activities of daily living is negligible. With that as background, let's go on to your questions:

1.  See above, even on wet objects this is not a major concern.  There are no data I am aware of on asymptomatic shedding of HSV from a herpetic whitlow but is reasonable that it occurs.  I suspect however that your S-i-L does not have the extensive HSV that you suggest.
2.  This is a tough question which probably needs to be individualized to your family's interactions with your S-i-L.  If the family is close, to try cut off contact is a non-starter.  My advice would be to discuss it with your husband.  One again however, casual transmission however is uncommon

Finally, there is the issue of HSV-1.  Please remember there is a better that 50/50 chance that you and/or your husband already have HSV-1 which you are unaware of.  HSV-1 while common and not something to be embraced, is also not something to worry too much about.  I don't mean to sound cavalier about this but every time you (or your children) are kissed or kiss someone else there is a 50-50 chance that there is an expsoure to someone with HSV-1.  Life is too short to allow this to disrupt your life.  I hope this comment and perspective is helpful.  EWH

[mochicrunch]

Dear Dr. Hook,

Thank you very much for your quick reply and the advice. I have just two questions to clarify your answer.

First, I am very relieved that HSV cannot be transmitted via objects!

Also, my husband and I do have HSV-1 oral. I had originally put that in my post but cut it so it fit in the 2000 character limit. We are aware of the risk and are very careful about it when we have sores, and are also aware about asymptomatic shedding. Needless to say, we don't kiss our children on the lips and we do a lot of hand washing with diapering, food and eating, etc. Luckily we both rarely have an outbreak, but we are aware that with the intense contact we have with our children, we present the largest risk to them.

Here are my questions:

1. Regarding your first comment that she may not have had an initial outbreak of genital HSV-1 and herpetic whitlow, I am not sure I understand what you mean. (She already had oral HSV-1) Her general practitioner, not an STD expert, tested and diagnosed both things and put her on a course of anti-virals after which both cleared up. Just to clarify, are you saying you think the genital HSV-1 and/or herpetic whitlow was misdiagnosed, or are you saying that she may have actually been having an initial outbreak of HSV-2? Is the usual blood test to distinguish between HSV-1 and -2 reliable? I don't know specifically what test her doctor did.

2. Finally regarding how to proceed with my s-i-l, my husband and I have discussed this a lot. As you say, casual transmission is uncommon, however not impossible. The family is close and no one wants to end contact completely, at the same time, this is about the health of our kids. For my husband and I, it's about a matter of degrees. Not to put you in the middle of it, but as an expert, what would you were in the situation with your children?

Thank you very much, again.

[Edward W Hook, MD]

1.  My comment was directed at the fact that it is most unusual for a person to have both herpetic whitlow and cold sores due to HSV-1.  I would only make such a diagnosis with cultures, not blood tests.  There are numerous dermatological conditions which can mimic both cold sores and HSV-1.  If your  s-i-l has a positive blood test for HSV-1, she has it but without positive cultures I doubt that she has HSV-1 in both locations.  AS to what it might be at either location, without examining her and testing, I cannot say.  She would need to discuss this with a doctor.

2.  With respect to question number 2, my advice would be simply to do your best to teach your children about the importance of avoiding contact with lesions, explain the issue in more detail when you feel they are old enough (i.e. that it is an infection which can be passed from person to person, etc).  Beyond that I would  not do much.  Like it or not, their chances of getting HSV-1 at some point in the future, whether from you, your husband, your s-i-l or someone else is relatively high.  Remember, more that 60% of adults have HSV-1.  I don't mean to be pessimistic, those are just the facts.  Further, while not something to be sought, as you know from your own experience, should you get it HSV is not the end of the world by any means.  EWH