In July 1989, Minnesota held a three-week statewide wrestling camp and 175 high school wrestlers aged 14 to 18 came to participate.
Everything went fine until the final week, when many of them started breaking out in rashes around their heads and necks or on their extremities. Several had eye infections. Some had swollen lymph glands, fever and chills, a sore throat, or headaches. The last two days of wrestling were canceled, and within a week after camp ended, 60 kids, 35 percent of the wrestlers, were suffering from one or more of these symptoms.
Health officials held a clinic at the camp to figure out what the problem was, and when they took viral cultures and examined skin lesions, they had their answer: a virus called herpes simplex I. This form of herpes, transmitted by skin contact with viral lesions of wrestlers or rugby players and not by sexual contact, has its own name: herpes gladiatorum, or wrestlers’ herpes.
Herpes viruses are very versatile. They can cause lesions on the mouth, lips, and gums; sores in and around the anus; infections of the finger; eye infections that are a leading cause of blindness; viral encephalitis that affects the central nervous system; and infections of the esophagus, lung, and liver.
Without treatment, newborn babies with herpes infection die 65% of the time, and few of the ones who survive will develop normally. There are about 90 or so species of herpes virus that infect all sorts of animals and plants, but the main ones that infect humans are herpes simplex I and herpes simplex II, or HSV-1 and HSV-2. By the time they are 50 years old, 90 percent of Americans have been infected with HSV-1 and have the antibodies to prove it. Although it can be transmitted by contact during sexual relations, it isn’t normally considered a sexually transmitted disease. HSV-2 is the one that is an STD, usually transmitted only during sex.
Some viruses, like the ones that cause flu, live best in cold weather. Others, like the polio virus, flourish in warm weather. Herpes thrives all year round, all over the world. The usual way HSV-2 is transmitted is by contact with the suppurating lesions on another infected person. The virus is also found in saliva and in secretions from the genital tract of both men and women and unlike many diseases is more easily transmitted when there are active symptoms than when there are none.
Both HSV-1 and HSV-2 can cause genital and facial lesions. Kissing is fun, and often the first place HSV-1 manifests itself is in sores that appear around the mouth. The inside of the cheeks, the lips, the gums, and the skin around the mouth may break out in lesions, which can ulcerate and be very painful. The virus is easily spread from active lesions, but you can be infectious even if you don’t have any sores, because the virus is spread in saliva.
Although HSV-1 is not considered a sexually transmitted disease, it can be spread in genital secretions as well. Sometimes the eruptions are associated with fever and swollen lymph glands in the neck. After the first infection, the symptoms usually disappear, but the virus remains living inside you, no one knows exactly where or in what form, and is often reactivated, for reasons that are not clear. Exposure to sunlight and injuries to the skin seem to have something to do with it, but these are statistical associations, not definitively proven causes.
When HSV-2 is reactivated, the lesions it causes are almost always on the genitals and anus, and HSV-2 is much more likely to reactivate than HSV-1. HSV-1 reactivations, when they occur, are much more likely to affect only the lips and mouth area. These are commonly called cold sores. The symptoms of both viruses almost always remain localized to the site of the initial inoculation of the germ, but in immunocompromised people the virus can spread around the body. In otherwise healthy people, the lesions usually heal within a couple of weeks.
Just because you don’t have sores or any other symptoms of HSV-2 doesn’t mean you can’t transmit the disease. You certainly can. In fact, even though it is more easily transmitted when there are active symptoms, most herpes is transmitted by people who don’t know they have it, either because they have no symptoms or because the symptoms they do have are so mild that they are never recognized for what they are, sometimes the lesions are so minor that they can be mistaken for a rash or mosquito bites.
HSV-2 is one of the most common sexually transmitted diseases in the United States. More than 1 million new cases appear every year. Ninety percent of people who are infected don’t know they are, although they can transmit it to sexual partners. It is not pleasant. It involves recurrent painful ulcers around the genital area, and although the disorder can be treated to reduce the number and severity of recurrences, there is no cure. Once you have it, you have it forever. The virus hides out in a latent form in the sacral sensory nerve ganglia (in the lower part of the spinal cord) and reactivates from time to time, infecting the skin.
Twenty percent of the population between 14 and 49 years old is infected with HSV-2, and it is more common in women than in men, probably because male-to-female transmission is more efficient than the other way around. The disease is everywhere, there are no geographical areas where it is more or less prevalent. It is increasing fastest in young people: herpes prevalence among white teenagers in the 1990s was five times what it was in the 1970s. In white adults in their twenties, prevalence doubled during the same time period. Among Blacks, the statistics are even more depressing: seroprevalence, the number of people in a given population who have the virus in their blood, is about 45 percent among African Americans over 12 years old, and about 17 percent among whites over 12.
How can you tell if you have it, and what can you do about it if you do? The signs and symptoms of the infection vary so greatly that the only sure way is a laboratory test of a sample from one of the sores for the presence of the antibodies.
There is no treatment that can cure herpes, but there are some antiviral medications that can reduce the severity of symptoms, you’ve seen them advertised in those self-consciously decorous commercials on TV. Treatment for the first episode is an antiviral medicine: acyclovir, famciclovir, or valacyclovir. You have to take these medicines several times a day for five to 10 days or more to help heal lesions.
Episodic treatment is helpful when there are recurrences, and the medicines appear to be useful over many years, acyclovir has been used daily to prevent recurrences for as long as six years, and valacyclovir and famciclovir daily for one year without the emergence of resistance in people with normal immune function. These medicines reduce viral shedding, but it isn’t known whether or to what extent they actually prevent transmission of the disease.
The best way to prevent transmission of HSV-2 is to use latex condoms, but they are not 100 percent effective because there may be lesions that a condom doesn’t cover, and the virus is easily passed by contact with an open lesion. You should avoid sex completely when symptoms are present and always use condoms between outbreaks. The outbreak of HSV-1 at the Minnesota wrestling camp would probably have been minimized by excluding wrestlers with suspicious skin lesions.
Most mothers of infants who have herpes at birth have no history of clinically evident herpes infection. The virus is not transmitted while the fetus is in the uterus, but during the birth itself as the baby passes through the birth canal. Herpes-infected births are much more common among women who contract herpes late in pregnancy than those who get it earlier, those women who get it early in pregnancy usually pass along antibodies to their babies, who are then immune. The treatment of HSV-infected infants is complex, and must be managed by a physician expert in this area of medicine.
Infection with HSV-2 has one other extremely unfortunate side effect: it makes you as much as five times more susceptible to HIV infection.