e76 • CID 2010:51 (15 November) • Stadler et al
M A J O R A R T I C L E
Seroprevalence of Cytomegalovirus (CMV)
and Risk Factors for Infection in Adolescent Males
Laura Patricia Stadler,1David I. Bernstein,2S. Todd Callahan,3Jennifer Ferreira,5Gina A. Gorgone Simone,5
Kathryn M. Edwards,4Lawrence R. Stanberry,6and Susan L. Rosenthal6
1Department of Pediatrics, Division of Infectious Diseases, University of Kentucky, Lexington;
Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;
Corporation, Rockville, Maryland; and
2Department of Pediatrics, Division of Infectious
3Department of Adolescent Medicine, Vanderbilt University,
4Department of Pediatrics, Division of Pediatric Infectious Disease, Vanderbilt Vaccine Research Program, Nashville, Tennessee;
6Department of Pediatrics, Columbia University Medical Center, New York, New York
loss, developmental delay, and mental retardation. Although the seroprevalence of CMV and associated exposure
and behavioral risk factors have been reported in adolescent females, few data exist about males.
Serum samples were obtained from males aged 12–17 years from June 2006 through July 2007 in
Cincinnati, Ohio; Galveston, Texas; and Nashville, Tennessee. The samples were tested for CMV immunoglobulin
G antibody with a commercial assay. Participants completed a computer-assisted screening interview to assess 7
A total of 397 adolescent males were screened, and 165 (47%) were seropositive. African American
race, older age, and exposure to children ?3 years of age in the home were significant predictors of CMV infection
in the univariate analysis. Hispanic ethnicity, group living situations, saliva-sharing behaviors, and intimate sexual
contact were not associated with CMV infection. However, among those with a history of sexual contact, the
number of life-time partners was associated with CMV. In the final multivariate model, CMV seroprevalence was
significantly higher in African American subjects (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.27–2.95)
and subjects ?14 years of age (OR, 1.1; 95% CI, 1.0–1.28). With each additional risk factor, males had a 1.6 times
increased risk of CMV.
CMV infections are common in adolescent males and are associated with African American race
and increasing age. Further study is needed to understand these risk factors in preparation for a CMV vaccine
targeted at both adolescent males and females.
Cytomegalovirus (CMV) is an extremely common in-
fection with estimates of seroprevalence among ado-
lescents ranging from 47% to 89% [1–8]. Studies of
CMV indicate that it may be transmitted from a variety
of sources, including saliva, urine (or handling of di-
apers), blood, cervical secretions, and semen [4, 8–14].
Understanding the prevalence of CMV is important,
because it is one of the leading causes of birth defects
and childhood disability in the United States . Each
year in the United States, an estimated 8,000 infants
Received 7 May 2010; accepted 5 August 2010; electronicallypublished11October
Reprints or correspondence: Dr Laura Patricia Stadler, University of Kentucky,
Kentucky Clinic J414, 740 S Limestone St, Lexington, KY 40536-0284 (laura.stadler@
Clinical Infectious Diseases2010;51(10):e76–e81
? 2010 by the Infectious Diseases Society of America. All rights reserved.
develop disabilities, including mental retardation and
sensorineural deafness [16–19], with an estimated an-
nual cost of caring for these children of $1 billion–$2
billion . Although risk factors have been previously
evaluated, primarily in women of childbearing age, few
data exist regarding risk factors associated with CMV
acquisition in adolescent males. Adolescent males en-
gage in personal behaviors (such as saliva-sharing be-
haviors, including sharing drinks and kissing) and have
exposures (such as caring for infants and toddlers and
living in groups) and the onset of sexual activity, all of
which may place adolescents at risk. Given the likeli-
hood of an effective vaccine in the near future , it
is critical to understand the prevalence and risk factors
for CMV infection among adolescent males aged 12–
18 years, which may represent a period of increased
CMV acquisition. These are likely to be the target ages
for vaccination and catch-up vaccination. Thus, we
sought to determine the seroprevalence of CMV in ad-
CMV Infections in Adolescent Males • CID 2010:51 (15 November) • e77
Table 1. Cytomegalovirus (CMV) Serostatus of Adolescent Males by Site Location
American White MultiracialOther
nificant factor (odds ratio, 1.07; confidence interval, 0.65–1.77). CCHMC, Cincinnati Children’s Hospital Medical
Center; UTMB, University of Texas Medical Branch in Galveston; VUMC, Vanderbilt University Medical Center.
Data are no. (%) of participants, unless otherwise indicated. Study site was not a statistically sig-
olescent males and to examine some of the exposures and be-
haviors associated with infection.
MATERIALS AND METHODS
Study population and design.
of CMV and factors associated with CMV infection in prep-
aration for CMV vaccine trials, males aged 12 through 17 years
were recruited from established patient populations of adoles-
cent health clinics affiliated with Cincinnati Children’sHospital
Medical Center (CCHMC; Cincinnati, OH), The University of
Texas Medical Branch at Galveston (UTMB), and Vanderbilt
University Medical Center (VUMC; Nashville, TN) from June
2006 through July 2007. A blood specimen was obtained for
each subject for the evaluation of CMV serumimmunoglobulin
G antibody using a commercial enzyme-linkedimmunosorbent
assay (Wampole; Inverness Medical Professional Diagnostics)
in accordance with the manufacturer’s instructions. All CMV
antibody tests wereperformedatCCHMClaboratoriesforstan-
dardization. Participants completed a computer-assisted screen-
ing interview (CASI) to assess 7 categories of risk: race, ethnicity,
age, exposure tochildren?3yearsofageinthehousehold,group
sexual activity. Race was established by having the participants
list all applicableterms fromthefollowinglist:AfricanAmerican/
black, American Indian/Alaskan Native, Asian, Hawaiian/Pacific
Islander, and Caucasian/white. In addition, a participant was
asked to describe himself as “Hispanic” or “non-Hispanic,” re-
gardless of race. For participants aged ?14 years (legal age of
consent), the CASI includeditemsregardingintimatesexualcon-
tact (oral, vaginal, and anal intercourse). The CASI was derived
from questions in a previous study  and the experience of the
investigators. The institutional review boards of each site ap-
proved this study before its initiation, and a certificate of con-
fidentiality was obtained.
Data analysis was performed withSAS,
version 9.2 (SAS Institute). The overall seroprevalence of CMV
was determined bypointprevalencecalculations.Weperformed
x2analyses to determine factors associated withCMVinfection.
When performing initial analyses, questions qualifying various
To determine seroprevalence
exposures as “sometimes,” “often,” or “never or rarely” were
collapsed into “sometimes or often” versus “never or rarely”
categories. For purposes of the analyses, those of African Amer-
ican race were compared with those of “non–African American
race.” Of 45 participants who defined themselves as “multi-
racial” or who listed ?1 race, subjects were considered “African
American” if this was listed and “non–African American” if it
After we performed the univariate analyses of 7 variables
(discussed above), risk factors were entered into a multivariate
logistic regression model with a cut-off value of
a forward strategy for adding significant variables and a back-
ward strategy for removing nonsignificant variables. We also
evaluated whether the number of significant factors in the uni-
variate analysis may be additive in determining an adolescent’s
risk for CMV antibody.
, usingP ! .10
subjects did not have CMV serology results, and another 9
subjects (with serology results) did not fully answer the ques-
tionnaire. The remaining 397 participants had available serol-
ogy results and a completed questionnaire and subsequently
were included in the statistical analysis. Table 1 displays the
characteristics of adolescent males at participating clinics with
regard to race, ethnicity, mean age, and CMV serostatus. There
were no significant differences in CMV serostatus on the basis
of site (odds ratio [OR], 1.07; 95% confidence interval [CI],
0.65–1.77). Therefore, data from all sites were combined for
further analyses. The mean age (?SD) of the participants was
14.4 ? 1.67 years. The sample was 58% African American,
31% white, and 11% multiracial. Regardless of race, 13% of
the participants reported Hispanic ethnicity.Overall,186(47%)
of the 397 participants were seropositive for CMV.
Table 2 displays the CMV serostatus of adolescent males by
risk factor. Being African American was associated with a 2-
fold increased risk of being CMV seropositive (CI, 1.31–3.03).
Hispanic ethnicity was not associated with CMV antibody
status (OR, 0.97; CI, 0.54–1.74). When age was studied as an
Of 411 adolescent males initially enrolled, 5
e78 • CID 2010:51 (15 November) • Stadler et al
Table 2. Cytomegalovirus (CMV) Serostatus of Adolescent Males by Risk Factor
Risk factorn CMV+OR (95% CI)P
African American race
Age ?14 years
Presence of children ?3 years old in home
1.99 (1.31–3.03) .001
1.56 (1.04–2.34) .03
Data are no. (%) of participants, unless otherwisespecified.CI,confidenceinterval;OR,odds
ordinal variable, it was associated with a statistically significant
increase in CMV infection (OR, 1.17; CI , 1.04–1.32). The rate
of CMV infection increased from 36% in 12-year-olds to 57%
in 17-year-olds. When age was categorized as !14 years and
?14 years, males ?14 years of age were ∼2 times more likely
to be CMV positive (OR, 1.96; CI, 1.28–3.0).
Exposure to young children in the home.
jects (42%) reported exposure to children ?3 years of age in
the home (mean number of children, 2.7; range, 0–30). Ex-
posure to a young child in the home was significantlyassociated
with CMV infection (OR, 1.56; CI, 1.04–2.34); however, in-
dividual activities related to caring for young children in the
home (i.e., changing diapers, feeding children, and watching
young children) were not significantly associated with CMV
Group living situations.
One hundred eighty (45%) of 397
adolescent males had experienced a form of group living,which
was defined as serving as an overnight camp counselor (n p
), attending overnight camp (10
juvenile detention and/or jail (n p 40
a treatment program for drug, alcohol, or mental problems
( ). Participants who had experienced one of these groupn p 11
living situations didnot haveanysignificantdifferencesinCMV
serostatus, compared with those who had not (OR, 1.31; CI,
that may transmit saliva (such as sharing drinks, lip balm, or
toothbrushes), 226 (57%) of the adolescents shared ?1 item.
Of the 226 participants whoshareditems,106(47%)wereCMV
seropositive; there was no difference in serostatus based on
sharing these items (OR, 1.0; 95% CI, 0.68–1.5). Of the 397
adolescent males studied, 294 (74%) reported kissing another
adolescent (male or female). Of these 294 participants, 143
Overall, 165 sub-
), staying overnight in
), or staying overnight in
n p 140
When evaluated for behaviors
(49%) were CMV seropositive. Kissing was not a statistically
significant risk factor for CMV antibody (OR, 1.27; 95% CI,
0.80–2.0). When sharing items and kissing were grouped to-
gether in a saliva-sharingpersonalbehaviorcategory,336(85%)
of the adolescents engaged in this behavior. This also was not
statistically predictive of CMV infection (OR, 1.44; 95% CI,
Of the 261 participants ?14 years of age
and thus eligible to answer the questions regarding sexual ac-
tivity, 132 (51%) reported some form of intimatesexualcontact
(defined as anal, oral, or vaginal intercourse). Of those who
had a history of sexual contact, 52% were CMV seropositive,
which was not significantly different from the rate of those who
did not (OR, 1.08; 95% CI, 0.66–1.76). When the 3 individual
sexual intercourse behaviors were examined individually, there
were also no significant associations with CMV infection. The
mean time from first intimate sexual contact to participation
in the study (?SD) was 2.46 ? 1.79 years, with no statistically
significant differences in CMV serostatus (
among those with a history of sexual contact, there was a sig-
nificant difference between the mean number of vaginal inter-
course partners for those who were CMV seropositive (5.36 ?
4.53) and the mean number of vaginal intercourse partners for
those who were CMV seronegative (3.79 ? 5.18) (
Table 3 displays a summary of the
relationship of the 7 factors evaluated with regard to CMV
antibody. Multivariate logistic regression analysis was per-
formed with the 3 significant predictors in the univariate anal-
yses (African American race, age, and exposure to children ?3
years of age in the home). In the final model, only African
American race () and age (P p .044
dictors of CMV antibody. African American race was associated
with a 2-fold risk of CMV seropositivity (OR, 1.93; CI, 1.27–
). However,P p .11
).P p .036
) remained as pre-P p .002
CMV Infections in Adolescent Males • CID 2010:51 (15 November) • e79
Table 3.Summary of Risk Factors and Odds Ratios (ORs)
Risk factorn CMV+ OR (95% CI)P
Age (continuous variable)
Children ?3 years in home
Group living situations
fidence interval; CMV, cytomegalovirus.
Data are no. (%) of participants, unless otherwise specified. CI, con-
Factors and Presence of Cytomegalovirus (CMV)
Relationship Between Significant Risk
specified. With each additional risk factor, adolescent males
had a 1.66 times increased risk of CMV (confidence interval,
1.32–2.08; ). Significant risk factors included AfricanP !.001
American race, age, and presence of children ?3 years old
in the home.
Data are no. (%) of participants, unless otherwise
2.95). Each additional year of age was associated with a 1.1
times increased risk of CMV (95% CI, 1.00–1.28).
To examine whether there were an increased risk of CMV
infection in subjects with multiple risk factors, the 3 significant
factors were evaluated in an additive fashion with respect to
CMV antibody. Number of lifetime sexual partners was not
included, because the data was limited to those ?14 years of
age who had a history of sexual contact. Table 4 displays the
relationship of the number of risk factors to CMV infection.
It is interesting that of 40 subjects with no risk factors, only 8
(20%) were CMV seropositive. However, of 88 adolescents with
all 3 risk factors, 51 (58%) were seropositive. As the number
of risk factors increased, so did the percentage of adolescents
who were CMV positive (OR, 1.6; 95% CI, 1.32–2.08).
CMV infections are common in adolescent males. Forty-seven
percent of males in this study were CMV seropositive, which
is comparable with prior US estimates (41%–89%) [1, 2, 7, 8,
11, 22]. Given that approximately half of allmalesarebecoming
infected with CMV by adolescence, it is important to under-
stand what factors, exposures, and personal behaviors may be
associated with infection.
Previous reports (about both females and males) indicated
that both African Americans and Hispanics may have higher
rates of positive CMV antibody [1, 4, 22–24] than do white
subjects. Our study supported higher rates in African Ameri-
cans but did not detect higher rates in Hispanic participants.
The literature suggests that the 2 main periods of CMV ac-
quisition are in early childhood (as documented in day care
studies [9, 25–27]) and in young adulthood (presumed to be
linked to sexual exposure because CMV has been isolated from
saliva, cervical specimens , and semen ). Studies of
young women have supported the significance of sexual trans-
mission, because increased CMV infection rates have been
found in those with heterosexual contact , early sexual
debut [4, 25], an increased number of partners , and a
history of sexually transmitted infections .
Our study indicates that seroprevalence increases with age
in males; 36% of 12-year-olds had evidence of CMV, whereas
by age 17 years, 57% showed antibody. However, we did not
find a direct link to sexual exposure (either kissing or intimate
sexual contact). Yet, among those with a history of sexual in-
tercourse, an increasing number of sexual partners did increase
risk. Whether this association represents increased sexual ex-
posure, identifies those who engage in more numerous risky
behaviors or perhaps in riskier behaviors, or selects individuals
who are exposed to a different partner pool is unknown. In a
recent comprehensivestudy, severalsexualactivitymarkers
were evaluated in both young women and young men. Al-
though associations between CMV infection and sexual activity
were detected in non-Hispanic females, little or no association
was detected within each racial and/or ethnic group of males.
The associations between CMV infection and sexual activity in
women may be related more to efficient transmission from the
receptive nature of vaginal intercourse, biologic differences,
and/or high viral titer in semen, which may account for the
finding that females have higher rates of CMV infection [1,
29–32] than do males.
It is also possible that the gender difference in CMV se-
roprevalence reflects females’ exposure to young children. In
our study, 42% of adolescent males had children ?3 years of
age in the household, and these adolescents were more likely
to be CMV seropositive. Although the relationship of child
care to CMV infection has been presumed to be attributable
to the presence of CMV at high titers in urine and/or saliva,
we were not able to find specific behaviors that increase ex-
posure that were associated with a greater likelihood of CMV
infection in males. Nevertheless, the study presented here sug-
gests that, similar to females, adolescent males are at an in-
creased risk of CMV infection when exposed to young chil-
dren in the household.
Previous studies have also noted that both group living and
living in crowded situations havebeenpositivelyassociatedwith
e80 • CID 2010:51 (15 November) • Stadler et al
CMV infection [1, 33–36]. In our study, we examined group
living exposure without a precise assessment of how much close
contact that involved. After evaluating various types of group
living situations and varied durations of exposure to those set-
tings individually, this variable was not significant. Therefore,
the specific types anddurationswerecombinedasagroupliving
variable; however, it still was not statistically significant.
One of the possible sources of transmission is saliva, and
saliva-sharing behaviors increase during adolescence. These be-
haviors are common, with 57% of adolescents having shared
items and 74% having a history of kissing. When evaluated
collectively, the relationship was not significant; however, this
could have been a sample size issue, because the relationship
approached significance. It may be thatkissingisakeybehavior,
but the cross-sectional design, older age of our subjects (mean
age, 14.4 years), and limited assessment of the amount and
type of kissing did not allow us to capture the impact of this
behavior. Lastly, when placed in a multivariate analysis, African
American race and age remained in the model, and exposure
to young children did not. Furthermore, there appeared to be
an additive effect of various risk factors, such that seropositivity
increased with the number of risk factors that were present.
There are a number of limitations to this study, including a
sample size that may have been unable to detect small differ-
ences between groups and to evaluate differences in frequency
and amount of specific behaviors. Given that only 262 of 397
participants were ?14 years of age and thus eligible to answer
questions regarding sexual activity, our ability to fully assess
sexual activity was limited. Factors related to the postinfancy
years and early childhood (such as country of origin, breast-
feeding, and day care) were not evaluated, because we wanted
to focus on issues pertinent to adolescents. Lastly, the cross-
sectional design of this study limits the analysis to associations
and does not allow us to pair the timing of increases in risk
behavior in adolescence with new infections. Future studies
should examine these relationships in a longitudinal design of
sufficient sample size to evaluate these exposuresandindividual
behaviors in adolescent males in preparationforaCMVvaccine
targeted at adolescents.
We thank Dick Ward andJesse LePage,forperformingtheCMVantibody
assays; study coordinators Tara Foltz, Danielle Shoreman (CCHMC), and
Heather Meza (UTMB), as well as Lisa Sherden, Matt Urmy, and Mary
Vozar (VUMC), for their efforts in recruitment and sound advice; Jennifer
Kissner and Emily Foster (VUMC), for their involvement in the study; and
Heather Hill (Emmes), for help in developing the CASI.
National Institute ofAllergyandInfectiousDiseases
(grants N01-AI-25459, AI-80006 to Cincinnati Children’s Hospital, and
N01-AI-8007 to Vanderbilt University); Molecular EpidemiologyChildEn-
vironmental Health–National Institute of Environmental Health Sciences
(training grant 5-T32-ES010957-08 to L.P.S.); National Institutes of Health
(loan repayment extramural grant funding 2L30AI066732-02 for clinical
research from October 2005 through July 2008 to L.P.S.).
Potential conflicts of interest.
Novartis for meningococcal vaccines and with Sanofi Pasteur for serologic
studies for pertussis, serves as a consultant to NexBio, and receives contract
support from National Institutes of Health and Centers for Disease Control
and Prevention. All other authors: no conflicts.
K.M.E. participates in research with
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