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. 2017 Sep 1;6(3):e55-e61.
doi: 10.1093/jpids/piw088.

Geographic Disparities in Cytomegalovirus Infection During Pregnancy

Affiliations

Geographic Disparities in Cytomegalovirus Infection During Pregnancy

Paul M Lantos et al. J Pediatric Infect Dis Soc. .

Abstract

Background: Cytomegalovirus (CMV) is the most common infectious cause of fetal malformations and childhood hearing loss. CMV is more common among socially disadvantaged groups, and it clusters geographically in poor communities. We conducted a geospatial analysis of chronic and primary CMV infection among pregnant women around Durham, NC.

Methods: We performed a geospatial analysis of subjects from an ongoing study of CMV infection among pregnant women using geographic information systems and spatial statistics. Subjects were categorized on the basis of results of their CMV immunoglobulin G avidity testing as seronegative, seropositive, or primary infection. We used generalized additive models to analyze the spatial distributions of individuals who fell into each category and to control for confounders such as race and age. We used a generalized estimating equation to correlate community-level variables with CMV status.

Results: Of 3527 pregnant women aged 15 to 59 years, 93.4% were either white or black. CMV seropositivity was significantly more common among non-Hispanic white subjects than among minority subjects (odds ratio, 3.76 [95% confidence interval, 3.25-4.34]). We identified a cluster in which women had elevated odds of CMV seropositivity in the urban neighborhoods of Durham. Cases of primary CMV infection were more common in areas with higher-than-average CMV seroprevalence. Neighborhood median family income was associated inversely with the prevalence of chronic CMV.

Conclusions: We found a high prevalence of CMV seropositivity in urban low-income neighborhoods among pregnant women, particularly among racial and ethnic minorities. Seronegative pregnant women from these communities might be at heightened risk for primary CMV infection.

Keywords: African American; black; cluster; cytomegalovirus; disparity; epidemiology; generalized additive model; geographic information system (GIS); poverty; segregation; serology; spatial epidemiology.

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Figures

Figure 1.
Figure 1.
Study area. We selected study subjects who lived within Durham County, North Carolina, or 1 of its 5 adjacent counties. To maximize the sampling density of our subjects, we further limited the cohort to an ellipse containing 2 standard deviations (95%) of the subjects.
Figure 2.
Figure 2.
Age distribution of cytomegalovirus (CMV) prevalence according to race. We categorized our subjects into age intervals of 5 years, beginning with 15- to 19-year-olds and ending with women aged 40 years or older. Prevalences varied between 30% and 45% among non-Hispanic white women, and no increase in prevalence with age was found. In contrast, more than 50% of teenaged minority women were seropositive, and this rate increased to more than 80% in the oldest age group.
Figure 3.
Figure 3.
Generalized additive model (GAM) showing geographic variation and clustering of cytomegalovirus (CMV) seropositivity. This analysis was similar to logistic regression, but in the GAM, the response variable was correlated with a 2-dimensional spatial smoothing function, which results in a continuous odds ratio (OR) surface. The response variable in this model was the binary result of CMV testing (CMV seropositive vs uninfected). Areas with significantly high or low odds of CMV are circled with a contour, which represents a 2-tailed P value of .05. (A) Unadjusted GAM. Our unadjusted model identified a cluster with significantly high odds of CMV seropositivity overlying the city of Durham; several large clusters with significantly low odds of CMV seropositivity were found also. (B) Adjusted GAM. Adjusting for subject race and age diminished the OR range, but clustering was still observed in a similar distribution, which suggests that the heterogeneous distribution of CMV cannot be explained solely by racial segregation. (C) Odds clusters generated by our unadjusted GAM superimposed on a census tract map. Census tracts are shaded according to the proportion of the population that is nonwhite. The high-odds cluster circumscribed the high minority urban tracts in Durham, whereas the low-odds clusters encircled areas with lower minority populations. (D) Geographic distribution of cases of primary CMV infection. The approximate location of the subjects with primary CMV infection, as defined by low anti-CMV IgG avidity, are displayed. Most of the 23 women with primary CMV infection lived in the densely sampled areas of Durham County. To preserve anonymity, only approximate subject locations are shown.

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