Asymptomatic HSV-2
in [Herpes]
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From: Eric on 19 Sep 2006 21:11 I'm tired of hearing people say that the asymptomatic rate of genital HSV-2 is 90%. This is just plain not true. "It is estimated that about 20% of patients with HSV-2 antibodies are truly asymptomatic or have lesions only in locations, such as the cervix, that are impossible to observe". The remaining 60-70% of "underdiagnosed" people have symptoms that they either don't recognize as herpes, don't want to recognize as herpes, or simply ignore. More importantly, "the majority of patients with atypical, unrecognized symptoms can learn to recognize their own unique manifestations of recurrent episodes". So the amount of asymptomatic people are 20%, NOT 90%. The article that this information came from can be read at: http://cmr.asm.org/cgi/reprint/12/1/1 ~Eric
From: Tim Fitzmaurice on 20 Sep 2006 06:16 On Wed, 19 Sep 2006, Eric wrote: > I'm tired of hearing people say that the asymptomatic rate of genital > HSV-2 is 90%. This is just plain not true. You're tired of it....hmmm, OK better trip to the International Herpesvirus Workshop and tell 'em. You've read one paper and the experts obviously no nothing. OK a harsh response on my part but hopefully I've got your attention...so back to reality and a slightly more sensible discussion of your comment. Your statements are over-reaching. You are ignoring a lot of context and a lot of the information in that paper - or rather not in that paper as is relies entirely on citing previous work for the statment you produce. Also as one paper your defining of another figure falls flat on its face. Also most comments on the newsgroup actually are of the ilk of 80-90% of people don't know and then they reference to asymptomatic shedding. The work you cite comes back to Larry Corey's work in the 80s and subsequently (the review you cite doesnt actually include the data, you need to go back further). The issue of defining asymptomatic is complex and not the simple plain one way or another you are pulling out of the bag of 'hey if they can be trained its not asymptomatic so its only 20%'. What you have pulled up is the 'unrecognised fraction' - the paper you cite actually doesnt present data but cites back to a paper from Corey's group - Langenberg et al, 1989, Ann Intern Med, vol 110, 882-887. Most people will lump them into the asymptomatic group - for the simple reason that if they havent had symptoms sufficient to identify a problem then its not exactly a symptom from a clinical perspective....Its well recognised but the meaning and quantity is whats still under discussion. If you look at Langenberg and Coreys own work later than the cite above where they describe a 63% asymptomatic rate at first transmission despite looking for it (therefore not including those who miss mild first symptoms and become asymptomatic thereafter and so would fall into the seropositive but reporting no symptoms). Langenberg AG, Corey L, Ashley RL, Leong WP, Straus SE. A prospective study of new infections with herpes simplex virus type 1 and type 2. Chiron HSV Vaccine Study Group. N Engl J Med. 1999 Nov 4;341(19):1432-8. Same main authors, well aware of the unrecognised issues, in fact the proponents f it - and suddenly in a high examined population are getting 63% asymptomatics. Opening sentence in another paper of Corey's "Most persons who have serologic evidence of infection with herpes simplex virus (HSV) type 2 (HSV-2) are asymptomatic" (Wald A, Zeh J, Selke S, Warren T, Ryncarz AJ, Ashley R, Krieger JN, Corey L. Reactivation of genital herpes simplex virus type 2 infection in asymptomatic seropositive persons. N Engl J Med. 2000 Mar 23;342(12):844-50) and from the same paper 'There has been controversy regarding the biologic and clinical meaning of asymptomatic HSV-2 infection' - indicating that what the term means varies from person to person. Its also probably the most important line in the paper to be honest....what does it mean is the question it raises. By the way, thats also going to include differences in stringency between say a clinician of the view that 'No dis-ease therefore no disease', a biologist of the opinion that 'shedding is a symptom hence no asymptomatics' and those wondering what no earth to do with the 'trainables'. All the above exist.... So your 'Its wrong plain and simple' followed by an absolute statment that its 20% is Im afraid by its own standards wrong. You need to take a wider look at the field. People still routinely use the idea of 80-90% for a reason, and its not simply ignoring Corey's work - you simply can't do that with Larry Corey, he's far too big and far too important a name and body of work in the field. So its time to examine why people say this, and also why Corey himself is NOT routinely citing 20% as the figure... Fundamentally its because these unrecognised cases are grouped in with asymptomatics - at least until the point that they can reliably detect clinically. Why, because that defines whats going on out there inthe population. If someone cant differentiate a random itch in the genital region from one caused by a reactivation then it essentially isnt a symptom becuase it tells you nothing, beyond the need to scratch. There is no disease there is it doesnt cause problems. "But" I hear you say "if there is something there that might be detectable it cant be asymptomatic". OK is my reply - but that includes any biological activity including the shedding and you should place yourself into the category that suggests that shedding is a symptom itself whether its detected by an individual or not. Medicine however as a rule tends to work on a separatino of infection status and actual clinically evident disease (ie symptoms) - yes that will include perception issues. This separates biologial activity and symptomology (yes I sit in that camp myself - hopefully that should be obvious). A number of conditions fit this sort of description and issue and more often you will find the terms clinical and subclinical being used, Larry Corey uses the term in relation to shedding in a 2003 review he co-authored (Koelle DM, Corey L. Recent progress in herpes simplex virus immunobiology and vaccine research. Clin Microbiol Rev. 2003 Jan;16(1):96-113. [Actually well worth reading as its freely available in PubmedCentral on the web and has a lot of discussion on HSV1 vs HSV2). I could certainly see an argument that these are better terms and possibly its reasonable to suggest that thats really what people are describing when saying symptomatic/asymptomatic. Historical attachment to the terms mean its more likely that such issues get included in the old terminology definition rather than change terminology. So yes, you raise a relevant issue with the unrecognised. You are just exceptionally over-reaching by deciding what it means, without (it appears) being aware of the long standing discussion on he matter and th simple issue of perspectice when it comes to a clinical description - perspective that is rather important. Even were the 20% a solid reproducible figure it still begs the question of the other 20% - are they missing somet
From: Eric on 20 Sep 2006 09:26 Tim, I know you're going to argue who said what in which paper and that the 20% of truely asymptomatic people is just an estimate. But you miss the larger point. People have a tendency to run and hide behind the term asymptomatic. Any major researcher or physician will tell you that it is nowhere near 90% of people who have truly asymptomatic outbreaks, i.e. no symptoms at all or no clinically discernible symptoms. Instead, most people have symptoms associated with HSV-2, oftentimes they present with things other than the classic textbooks cases. The others in the "asymptomatic" category either ignore their symptoms out of fear, don't want to know what could be causing their atypical symptoms, or don't care. Clearly, probably the biggest contender of all is fear. People are highly resistant to a disease with a stigma attached to it, as with HSV-2, so unless they have pretty clear cut outbreaks or are pretty severe, they bullshit themselves. So my point is, people bulshitting themselves out of thinking that they have HSV-2 is NOT being asymptomatic. Being truly asymptomatic means actually not having any symptoms. So again, I reiterate, people who are asymptomatic are in the clear minority, people who don't want to know, don't care, know something is up but won't tell their doctors, or are too busy bulshitting themselves definitely have the majority. Tim Fitzmaurice wrote: > On Wed, 19 Sep 2006, Eric wrote: > > > I'm tired of hearing people say that the asymptomatic rate of genital > > HSV-2 is 90%. This is just plain not true. > > You're tired of it....hmmm, OK better trip to the International > Herpesvirus Workshop and tell 'em. You've read one paper and the > experts obviously no nothing. > > OK a harsh response on my part but hopefully I've got your attention...so > back to reality and a slightly more sensible discussion of your comment. > Your statements are over-reaching. You are ignoring a lot of context and a lot > of the information in that paper - or rather not in that paper as is > relies entirely on citing previous work for the statment you produce. Also > as one paper your defining of another figure falls flat on its face. Also > most comments on the newsgroup actually are of the ilk of 80-90% of people > don't know and then they reference to asymptomatic shedding. > > The work you cite comes back to Larry Corey's work in the 80s and > subsequently (the review you cite doesnt actually include the data, you > need to go back further). The issue of defining asymptomatic is complex > and not the simple plain one way or another you are pulling out of the bag > of 'hey if they can be trained its not asymptomatic so its only 20%'. > > What you have pulled up is the 'unrecognised fraction' - the paper you > cite actually doesnt present data but cites back to a paper from Corey's > group - Langenberg et al, 1989, Ann Intern Med, vol 110, 882-887. Most > people will lump them into the asymptomatic group - for the simple reason > that if they havent had symptoms sufficient to identify a problem then its > not exactly a symptom from a clinical perspective....Its well recognised > but the meaning and quantity is whats still under discussion. > > If you look at Langenberg and Coreys own work later than the cite above > where they describe a 63% asymptomatic rate at first transmission despite > looking for it (therefore not including those who miss mild first symptoms > and become asymptomatic thereafter and so would fall into the seropositive > but reporting no symptoms). Langenberg AG, Corey L, Ashley RL, Leong WP, > Straus SE. A prospective study of new infections with herpes simplex virus > type 1 and type 2. Chiron HSV Vaccine Study Group. N Engl J Med. 1999 Nov > 4;341(19):1432-8. > Same main authors, well aware of the unrecognised issues, in fact the > proponents f it - and suddenly in a high examined population are getting > 63% asymptomatics. > > Opening sentence in another paper of Corey's "Most persons who have > serologic evidence of infection with herpes simplex virus (HSV) type 2 > (HSV-2) are asymptomatic" (Wald A, Zeh J, Selke S, Warren T, Ryncarz AJ, > Ashley R, Krieger JN, Corey L. Reactivation of genital herpes simplex > virus type 2 infection in asymptomatic seropositive persons. N Engl J Med. > 2000 Mar 23;342(12):844-50) and from the same paper 'There has been > controversy regarding the biologic and clinical meaning of asymptomatic > HSV-2 infection' - indicating that what the term means varies from person > to person. Its also probably the most important line in the paper to be > honest....what does it mean is the question it raises. By the way, thats > also going to include differences in stringency between say a clinician of > the view that 'No dis-ease therefore no disease', a biologist of the > opinion that 'shedding is a symptom hence no asymptomatics' and those > wondering what no earth to do with the 'trainables'. All the above exist.... > > So your 'Its wrong plain and simple' followed by an absolute statment that > its 20% is Im afraid by its own standards wrong. You need to take a wider > look at the field. > > People still routinely use the idea of 80-90% for a reason, and its not > simply ignoring Corey's work - you simply can't do that with Larry Corey, > he's far too big and far too important a name and body of work in the > field. So its time to examine why people say this, and also why Corey > himself is NOT routinely citing 20% as the figure... > > Fundamentally its because these unrecognised cases are grouped in with > asymptomatics - at least until the point that they can reliably detect > clinically. Why, because that defines whats going on out there inthe > population. If someone cant differentiate a random itch in the genital > region from one caused by a reactivation then it essentially isnt a > symptom becuase it tells you nothing, beyond the need to scratch. There > is no disease there is it doesnt cause problems. "But" I hear you say "if > there is something there that might be detectable it cant be > asymptomatic". OK is my reply - but that includes any biological > activity including the shedding and you should place yourself into the > category that suggests that shedding is a symptom itself whether its > detected by an individual or not. > > Medicine however as a rule tends to work on a separatino of infectio
From: Tim Fitzmaurice on 20 Sep 2006 11:08 On Wed, 20 Sep 2006, Eric wrote: > Tim, > > I know you're going to argue who said what in which paper and that > the 20% of truely asymptomatic people is just an estimate. But you miss > the larger point. No, I disagree with at least one and you've missed mine...several of them in fact. > term asymptomatic. Any major researcher or physician will tell you that Sorry that simply isnt true - several have said just that to me...others argue the point, some more so than that idea that only a fraction are completely asymptomatic. This is what Im trying to bring out. THe issue is there is more to the phrase than simply this is an itch, or they havent reported genital herpes etc. There is a working definition for a reason. I have no doubt you will as usual introduce a bunch of qualifier about 'what you meant' - stop making simple absolute statements if you dont want people to take them as such - introduce the qualifiers at the start - it makes discussion more productive. If you had raised the data you did and said 'What does this mean about asymptomatics, and should it be redfined, this is what I think...' then this discussion would probably have been a lot easier to get into some serious gritty details - but you didnt - you said clearly this, and obviosuly that and X or Y is absolutely so and so on. I included a bunch of facets on this in my reply but you seem to have either ignored them or failed to read far enough into my post to reach 'em. > it is nowhere near 90% of people who have truly asymptomatic outbreaks, Some will say what you say, some won't. My point is what 'asymptomatic' means is a) variable depending on who you talk to, b) still discussed on an ongoing fashion as the biology of the virus and the precise nature of the biological effects are described better and c) going to change over time (remembr it used to not be considered an option at all - OK a long time ago but its a point). Larry Corey, who defined the whole 'train and they can see it' made that point inthe discussion of one paper I cited...you also just added the word 'truely'. That might seem minor to you - it is in fact a major point of discussion in this area - I did raise that issue by questioning how should the remaining 20% from the Corey paper be viewed - ie really no symptoms, not trained enough etc (focus on the how do you define and not the 20% - because the question is relevant whatever the percentage). > i.e. no symptoms at all or no clinically discernible symptoms. Instead, > most people have symptoms associated with HSV-2, oftentimes they Part of symptomology is not just spotting an effect, but differentially using it. Part of the problem with the whole training issue, and one of the major counters to separating these people before the training is that there is no detailing of a differential that can be used prior to the diagnosis - at that point you dont have adetectable symptomology. I have no doubt it may change. > Clearly, probably the biggest contender of all is fear. People are Clearly??? No sorry I have to disagree - Id put knowledge or rather lack of it in there. The training of identification experiments didnt really seem to be heavily confounded by false reporting, but did change counting with knowledge. > So my point is, people bulshitting themselves out of thinking that they > have HSV-2 is NOT being asymptomatic. Oh that I can agree with and there are undoubtedly people who do this - both with and without a diagnosis. I just dont think there is evidence that it is the major feature. Lack of knowledge rings truer to me- particularly from Corey's work. > actually not having any symptoms. So again, I reiterate, people who are > asymptomatic are in the clear minority, people who don't want to know, > don't care, know something is up but won't tell their doctors, or are > too busy bulshitting themselves definitely have the majority. To fit your model you have to a) redefine asymptomatic to what it not defined as at the moment and also add a bunch of qualifier and b) put a lot of human intent into the model which you have zero evidence for in contrast to, for instance, not noticing or not knowing. Asymptomatic as a word has a definition. Its possible it might not be the best word or the best definition, but its there for a reason. It may well change. You qualified at one point using the word 'truely' which represents an extreme of the current definition. I discussed the idea of clinical and subclinical as better descriptors. Corey points to the development of the idea fromt he 80s when it has its genesis and to the knowledge we have now. There is a lot to discuss in there - I made that point in my last post, but you seem to have missed that entirely - but if you want to discuss it you have to be aware of what the current definitions are, why and what it contains and your initial post came over to me as not knowing this, but just falling into a common trap of grabing paper X and saying 'but this is obvious that this is all wrong' without the context, variables and the discussions that go around with it. Tim -- When playing rugby, its not the winning that counts, but the taking apart ICQ: 5178568
From: loss on 20 Sep 2006 11:55
Tim Fitzmaurice wrote: > On Wed, 20 Sep 2006, Eric wrote: > > > Tim, > > > > I know you're going to argue who said what in which paper and that > > the 20% of truely asymptomatic people is just an estimate. But you miss > > the larger point. > > No, I disagree with at least one and you've missed mine...several of them > in fact. > > > term asymptomatic. Any major researcher or physician will tell you that > > Sorry that simply isnt true - several have said just that to me...others > argue the point, some more so than that idea that only a fraction are > completely asymptomatic. This is what Im trying to bring out. THe issue is > there is more to the phrase than simply this is an itch, or they havent > reported genital herpes etc. There is a working definition for a reason. > > I have no doubt you will as usual introduce a bunch of qualifier about > 'what you meant' - stop making simple absolute statements if you dont want > people to take them as such - introduce the qualifiers at the start - it > makes discussion more productive. > > If you had raised the data you did and said 'What does this mean about > asymptomatics, and should it be redfined, this is what I think...' then > this discussion would probably have been a lot easier to get into some > serious gritty details - but you didnt - you said clearly this, and > obviosuly that and X or Y is absolutely so and so on. I included a bunch > of facets on this in my reply but you seem to have either ignored them or > failed to read far enough into my post to reach 'em. > > > it is nowhere near 90% of people who have truly asymptomatic outbreaks, > > Some will say what you say, some won't. My point is what 'asymptomatic' > means is a) variable depending on who you talk to, b) still discussed on > an ongoing fashion as the biology of the virus and the precise nature of > the biological effects are described better and c) going to change over > time (remembr it used to not be considered an option at all - OK a long > time ago but its a point). > > Larry Corey, who defined the whole 'train and they can see it' made that > point inthe discussion of one paper I cited...you also just added the word > 'truely'. That might seem minor to you - it is in fact a major point of > discussion in this area - I did raise that issue by questioning how should > the remaining 20% from the Corey paper be viewed - ie really no symptoms, > not trained enough etc (focus on the how do you define and not the 20% - > because the question is relevant whatever the percentage). > > > i.e. no symptoms at all or no clinically discernible symptoms. Instead, > > most people have symptoms associated with HSV-2, oftentimes they > > Part of symptomology is not just spotting an effect, but differentially > using it. Part of the problem with the whole training issue, and one of > the major counters to separating these people before the training is that > there is no detailing of a differential that can be used prior to the > diagnosis - at that point you dont have adetectable symptomology. I have > no doubt it may change. > > > Clearly, probably the biggest contender of all is fear. People are > > Clearly??? No sorry I have to disagree - Id put knowledge or rather lack > of it in there. The training of identification experiments didnt really > seem to be heavily confounded by false reporting, but did change counting > with knowledge. > > > So my point is, people bulshitting themselves out of thinking that they > > have HSV-2 is NOT being asymptomatic. > > Oh that I can agree with and there are undoubtedly people who do this - > both with and without a diagnosis. I just dont think there is evidence > that it is the major feature. Lack of knowledge rings truer to me- > particularly from Corey's work. > > > actually not having any symptoms. So again, I reiterate, people who are > > asymptomatic are in the clear minority, people who don't want to know, > > don't care, know something is up but won't tell their doctors, or are > > too busy bulshitting themselves definitely have the majority. > > To fit your model you have to a) redefine asymptomatic to what it not > defined as at the moment and also add a bunch of qualifier and b) put a > lot of human intent into the model which you have zero evidence for in > contrast to, for instance, not noticing or not knowing. > > Asymptomatic as a word has a definition. Its possible it might not be the > best word or the best definition, but its there for a reason. It may well > change. You qualified at one point using the word 'truely' which > represents an extreme of the current definition. I discussed the idea of > clinical and subclinical as better descriptors. Corey points to the > development of the idea fromt he 80s when it has its genesis and to the > knowledge we have now. There is a lot to discuss in > there - I made that point in my last post, but you seem to have missed > that entirely - but if you want to discuss it you have to be aware of what > the current definitions are, why and what it contains and your > initial post came over to me as not knowing this, but just falling into a > common trap of grabing paper X and saying 'but this is obvious that this > is all wrong' without the context, variables and the discussions that go > around with it. > > > Tim > -- > When playing rugby, its not the winning that counts, but the taking apart > ICQ: 5178568 Gentlemen, Please be gentle, as you know, this is coming from a complete, newbie. I have to agree with Tim or is it Eric on his point that most of the public's denial or ingnorance of their symptoms of HSV2 is due more to total lack of knowledge and not outright denial. I always thought that the symptoms of HSV2 were blatant, hidious sores, pain, foaming at the mouth ect... .when in actuality they can be very subtle. |