Herpes Virus: Transmission and Transmittability

What is Genital herpes?

Genital herpes is a sexually transmitted disease (STD) caused by the herpes simplex virus (HSV). There are two types of HSV: HSV-1 and HSV-2. HSV-1 infects about 80% of the U.S. population and usually appears on the lips in cold sores. HSV-2 is usually appears on the genital area. However, both HSV-1 and HSV-2 viruses can cause herpes outbreaks in either area.

While HSV can be a frustrating and painful condition for some people, in general the virus is less a medical problem than a social problem. For most of us, genital herpes is no more dangerous than a cold sore.

Most people with genital herpes don't know they have it, and are unaware they may be spreading it to others. Many have no symptoms or mistake their symptoms for something else, such as jock itch, insect bites, hemorrhoids, yeast infections, razor burn, or allergies to laundry detergent.

Difference between HSV-1 and HSV-2

The primary difference between the two types of herpes virus is in where they typically establish latency in the body - their "site of preference."

  • HSV-1 usually establishes latency in the trigeminal ganglion, a collection of nerve cells near the ear. From there, it tends to recur on the lower lip or face.
  • HSV-2 usually establishes latency in the sacral ganglion at the base of the spine. From there, it recurs in the genital area.

Transmission & Transmittability

Herpes virus is spread only through direct skin-to-skin contact or mucous membrane contact. Herpes simplex virus enters the body through broken area of skin or intact mucous membranes. It can be transmitted through penile-vaginal intercourse, anal intercourse, oral-genital sex, and other sexual body-to-body contact.

Genital herpes is not hereditary. The virus has no effect on fertility and is not transmitted via men's sperm or women's ova.

It is more common for oral HSV-1 to be transmitted to the genitals through oral sex, than it is for HSV-2 to be transmitted to the mouth. If a person has oral herpes (cold sores), and performs oral sex on the partner, it is possible for that person to transmit the virus to the genitals from this action, and vice versa.

Acquisition of one type of HSV is more difficult (though certainly possible) if you already have the other HSV type. This is because either type, contracted orally or genitally, causes the body to produce antibodies, some of which are active against both HSV-1 and HSV-2. This acquired immune response gives some limited protection if the body encounters a second type. When a person with a prior HSV infection does contract the second type, the first episode tends to be less severe than when no prior antibodies are present.

Almost all HSV-2 is encountered after childhood, when people become sexually active. Those who have a prior infection with HSV-1 have an acquired immune response that lowers (though doesn't eliminate) the risk of acquiring HSV-2. According to one study (Mertz, Annals of Internal Medicine, 1992), previous oral HSV-1 infection reduces the acquisition of subsequent HSV-2 infection by 40%.

A prior infection with oral HSV-1 lowers the risk of acquiring genital HSV-1 even further. Studies show that genital HSV-1 infections almost always occur in people who have no prior infection with HSV of either type (Corey, Annals of Internal Medicine, 1983). In the absence of prior oral infection, however, HSV-1 spreads easily to the genital area, usually through oral sex. In some countries, such as Japan and parts of Great Britain, genital HSV-1 is as common as genital HSV-2, or more common.

If you have genital HSV-1 and your partner has genital HSV-2 and you have unprotected sex, there is a small but real risk that you will get HSV-2, resulting in more outbreaks and more shedding. There are documented cases where a person acquires HSV-2 after a prior genital HSV-1 infection. It doesn't happen often, but it does happen. However, it's very unlikely that your partner will get genital HSV-1 from you. It's possible, but very unusual.

If your partner has genital HSV-2 and you perform oral sex on him or her, there is a very low risk that you will get oral HSV-2. According to one study, almost 100% of recognizable HSV-2 infection is genital (Nahmias, Scandinavian Journal of Infectious Diseases Supplement, 1990). One reason is that most adults are already infected with HSV-1 orally, which provides some immunity against infection with HSV-2. Another reason is that oral HSV-2 rarely reactivates, so even if an infection does exist, no one knows (1).

If you acquire genital HSV-1 through oral sex, you can spread the virus to a partner through genital sex. But probably it is not as easily as it was spread through oral sex. The main reason is that the virus reactivates and sheds less often outside its site of preference. Only about 25% of people with genital HSV- 1 shed virus at all in the absence of symptoms, while 55% of people with HSV-2 do (Wald, New England Journal of Medicine, 1995). However, transmission of genital HSV-1 during asymptomatic shedding has been documented. In other words, genital HSV-1 can be spread through genital sex, even when there are no symptoms.

The herpes virus is quite fragile. HSV does not survive outside the body for more than about 10 seconds, and although it can survive for slightly longer in warm, damp conditions, it dies very quickly once exposed to the air. Transmission through inanimate objects such as toilet seats is unlikely. Precautions include not sharing towels, underwear, or other objects that come into contact with genital lesions.

Viral shedding
The medical terminology for the virus being released from the surface of the skin is called viral shedding. Viral shedding can occur with symptoms (symptomatic herpes) and without symptoms (asymptomatic herpes). You may (if you have classic herpes lesions) or may not be aware that viral shedding is occurring. The virus cannot be spread when it is inactive (in the nerve cell). There is no simple way to know if the herpes virus is active when there are no symptoms. In fact, studies have shown that most people get HSV from sexual contact during times of asymptomatic viral shedding.

When Herpes virus is most likely to be transmitted
Herpes virus is most likely to be transmitted from the time the prodromal symptoms are noticed until the area is completely healed and the skin looks normal again. Sexual contact (oral, vaginal, or anal) is very risky during this time.

Likelihood of HSV transmission
Let's say you have an infected male and an uninfected female. If they avoid sex during outbreaks, don't use condoms regularly, and don't take antiviral therapy every day, the risk of transmission is about 10% per year. But if you add condoms, it reduces transmission by about 50%, if he takes Valtrex 500 mg once a day, he can reduce transmission also by about 50%. So you can see that the numbers get very low! If it is a woman infected with HSV 2 having sex with an uninfected male, given the circumstances listed above again, then the transmission rate is about 4% prior to the interventions of condoms and Valtrex.

Asymptomatic shedding and transmission

Individuals who reactivate the virus without visible symptoms still release the virus in the oral or genital tract. Asymptomatic viral shedders are at risk of unknowingly spreading the virus to partners.

Virus type
Researchers have found that people with HSV-2 genital herpes tend to have more shedding than those with HSV-1 genital herpes. The rate of asymptomatic shedding from the genital area for HSV-1 is approximately 5% of the time when the person has no symptoms. Typically in the first year of infection with genital HSV-2, one will shed about 6-10% of those days when there are no symptoms. This of course will decrease over time as well.

Duration of infection
The rate of shedding decreases over time. People with new infections are more likely to shed the virus than those with an infection more than a year old.

Frequency of recurrences
Rate of asymptomatic shedding of HSV also related to frequency of recurrences of genital herpes. People with frequent recurrences may shed the virus more often, but this is still an area being studied. About 50% of asymptomatic shedding events occur more than 7 days before or after a herpes outbreak.

Why Herpes virus is not curable?

Neural tissue transport of herpes simplex virus results in life-long latent infection. HSV remain in the body for life, hidden in a dormant state inside nerve cells.

The virus escapes the usual immune response by penetrating nerve fibres. As the immune system moves in to control the infection, the virus conceals itself within nerve cells. The virus is carried to the nerve "cell body" in a swelling called a ganglion located close to the spinal cord. When it reaches the cell body, the viral DNA is added alongside the nerve cell's own DNA in the nucleus. It remains there, hidden within the nerve cell and in an inactive state, for the lifetime of the infected individual.

Retrograde transport through adjacent neural tissue to sensory ganglia leads to lifelong latent infection. Once reactivated, the virus is transported by the neuron back to the epithelium, where more replication occurs, and another outbreak ensues.

Genital Herpes symptoms

Symptoms of genital herpes can vary in appearance and intensity. Some people have no symptoms or such mild symptoms that they don't suspect they have an infection. For others, the first episode of herpes (primary infection) can cause one or more very painful lesions to erupt on the skin.

Genital herpes lesions usually appear within 2 to 10 days after being exposed to the virus, and can last from two to four weeks. First to appear are small red bumps, which develop into blisters. Then the blisters become open sores, which later dry up, crust over, and heal without leaving a scar. Symptoms experienced during lesion formation include: swollen lymph glands, headaches, fever or general malaise, pain, muscle aches.

After the initial outbreak, the virus moves away from the skin surface and travels along the nerve pathways to nerve roots at the base of the spine and goes into an inactive phase. The virus may reactivate, lesions reappear at the same site as the original infection, but usually are much less severe. If the infection is caused by HSV-1, the (first year) recurrence rate is 50%. The HSV-2 (first year) recurrence rate is 80-90%.

Frequency of outbreaks

Researchers don't know why recurrences happen, or why their frequency and severity vary.

How much of a physical problem HSV poses for a person depends largely on three factors:

  • How well the person's immune system is able to control the infection. It's also the reason that both HSV-1 and HSV-2 can pose serious challenges for infants, who have a limited immune response.
  • How long a person has had the infection. Over time, recurrences of both HSV- 1 and HSV-2 tend to decrease. It is not clear why a decrease of herpes outbreaks occurs over time, but is believed to be due to the buildup of antibodies in the infected persons system.
  • Whether the virus is established in its site of preference. While HSV can infect both genital and oral areas, both types cause milder infections when they are away from "home" territory. Outside their site of preference, both type 1 and 2 lose most of their power. Oral HSV-1 infection recurs more frequently than oral HSV-2, and genital HSV-2 recurs more often than genital HSV-1 (2). Research conducted by Lawrence Corey, MD, and colleagues at the University of Washington in Seattle shows that genital HSV-2 recurs 10 times more often than genital HSV-1. It is estimated that HSV-1 now accounts for as many as 30% of all genital herpes cases in the U.S and 2-5% of the recurring outbreaks are associated with the herpes type 1 virus.

Most people diagnosed with HSV-2 affecting the genital area typically have four or five symptomatic recurrences the first year. After the first year, most people have fewer and milder recurrences, lasting a week or less.

HSV-2 infection in the oral area very rarely causes problems. Oral HSV-2 infections are very rare. But even when an infection occurs, recurrent outbreaks are extremely rare. In one study (Lafferty et al., New England Journal of Medicine, 1987), oral HSV-2 recurred an average of 0.01 times a year in newly infected people.

Outbreaks triggers

Some triggers of outbreaks:

  • stress
  • illness
  • poor nutrition
  • menstruation
  • vigorous sex
  • sunlight
  • local physical injury
  • suppression of the immune system

Sources & References:

  • 1. Wald A, Ericsson M, Krantz E, Selke S, Corey L. Oral shedding of herpes simplex virus type 2. Sex Transm Infect. 2004 Aug;80(4):272-6. PubMed
  • 2. Lafferty WE, Coombs RW, Benedetti J, Critchlow C, Corey L. Recurrences after oral and genital herpes simplex virus infection. Influence of site of infection and viral type. N Engl J Med. 1987 Jun 4;316(23):1444-9. PubMed
  • 3. Dr. Edward K. Wagner's Herpes simplex virus Research
  • 4. Genital Herpes: A Hidden Epidemic - Article from the FDA reveals many facts about herpes
  • 5. National Herpes Resource Center A service of the American Social Health Association
  • 6. Genital Herpes - Information from U.S. Centers for Disease Control and Prevention

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