Herpes simplex virus disease in infants younger than 90 days: a British Paediatric Surveillance Unit study

Objective Estimate the incidence of herpes simplex virus (HSV) infections in infants under 90 days in the UK and Ireland and describe clinical presentation and outcomes. Design Prospective population-based national surveillance study of infants <90 days with HSV infection, using British Paediatric Surveillance Unit (BPSU) methodology (August 2019–February 2022). Results 117 infants with confirmed HSV infection were identified (6.0 cases/100 000 live births (95% CI 4.9, 7.2)). One-third (34.5%) of infants were premature (<37 weeks) and the majority (81.4%) were born to women without a known/disclosed history of genital herpes. Neonatal HSV was classified as disseminated (32.5%), central nervous system (CNS) (35%) or skin, eye, mouth (SEM) (32.5%) disease. Median age at symptom onset was 8 days (IQR 5–13) in all infants (D8 SEM, D14 CNS, D6 disseminated). 56.7% of infants commenced aciclovir >24 hours after symptom onset. Infants with disseminated infections presented with non-specific signs of sepsis: 65.8% were afebrile and 73.7% had no SEM lesions. Median C reactive protein at presentation was 4 mg/L (IQR 1–14). Overall mortality was 23.9%, rising to 65.8% among infants with disseminated disease. Of the 41 infants with follow-up data at 24 months, 29.3% had neurodevelopmental impairment (11.8% SEM, 45% CNS, 25% disseminated). Conclusions Infants with neonatal HSV can present without fever, SEM lesions or elevated infection markers; treatment delay is subsequently common. Outcomes remain poor with high case-fatality rates and long-term morbidity. Clinicians should have a low threshold for empirically testing for and treating herpes in unwell neonates.