Herpes support - Asymptomatic HSV-2

Author

Asymptomatic HSV-2

Eric

2006-09-19, 9:32 pm

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

Tim Fitzmaurice

2006-09-20, 8:25 am

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 something that more training would spot and what does that mean

In other words its not the simple, throw away issue you somewhat airily
dismiss and the 80-90% fdigure has a place.

Tim
--
When playing rugby, its not the winning that counts, but the taking apart
ICQ: 5178568

Eric

2006-09-20, 4:27 pm

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:
>
>
> 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 something that more training would spot and what does that mean
>
> In other words its not the simple, throw away issue you somewhat airily
> dismiss and the 80-90% fdigure has a place.
>
> Tim
> --
> When playing rugby, its not the winning that counts, but the taking apart
> ICQ: 5178568

Tim Fitzmaurice

2006-09-20, 4:27 pm

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

loss

2006-09-20, 4:27 pm

Tim Fitzmaurice wrote:
> On Wed, 20 Sep 2006, Eric wrote:
>
>
> No, I disagree with at least one and you've missed mine...several of them
> in fact.
>
>
> 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.
>
>
> 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).
>
>
> 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??? 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.
>
>
> 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.
>
>
> 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.

Eric

2006-09-21, 2:28 am

> No, I disagree with at least one and you've missed mine...several of them
> in fact.

That because you need to learn to write concisely and coherently. Gosh
I get a headache everytime I read a reply of yours, and there is no
malice in this statement. Try not to be so darn verbose!

> 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.

Give "Underdiagnosis of genital herpes by current clinical and
viral-isolation procedures" by LA Koutsky, CE Stevens, KK Holmes, RL
Ashley, NB Kiviat, CW Critchlow, and L Corey a read.

The article "Psychosocial Implications When Treating the Patient With
Genital Herpes" surveyed people with HSV-2 and found that less than 69%
of them even told their doctors anything about it! So how can one say
that there is up to a 90% asymptomatic rate when 31% of people are too
fearful to even tell there own doctor!

> 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.

No qualifers here, just literature cited.

> 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.

Look, I'm not getting philosophical about the definition of
asymptomatic. The dictionary says that asymptomatic means "not
exhibiting any symptoms". I'm not arguing that it should be redefined,
I'm saying that only about 20% of people with HSV-2 are truely
asymptomatic, got it? The rest either have symptoms which are not
classic textbook cases and are not recognized (subclinical) or the
person is too afraid to even go to the doctor and just bullshits
themselves, or better yet, the person knows but doesn't say anything to
anybody.

> 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).

No, you are conflating "asymptomatic" and "subclinical". In
asymptomatic people, they TOTALLY lack any symptoms of herpes, by
definition. The subclinical diagnoses are changing due to technology,
improved diagnostic methods and training, etc.

> 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).

> 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.

Read what I wrote above about the difference between aymptomatic and
subclinical.

> 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.

One word, bullshit. When only 69% of people can tell their DOCTOR that
they think they might have HSV-2, clearly psychosocial implications
impart a major problem. Of course there is always going to be
misdiagnoses and underdiagnoses. But even more frequently, there's
always going to be people who stick their heads in the sand and won't
even tell their doctors.

> 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.

I gave you the evidence above from "Psychosocial..." go read it
yourself.

> 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.

Again, read above where I point out how you are conflating asymptomatic
and subclinical. See what I mean about being verbose? This is like the
2nd time I've said "see above where I..."

I'm going to record Bill O'Reilly telling his audience to be pithy and
not bloviate and add to it "be CONCISE" and mail it to you! LOL

~Eric

Tim Fitzmaurice

2006-09-21, 8:24 am

On Thu, 20 Sep 2006, Eric wrote:

>
> That because you need to learn to write concisely and coherently. Gosh
> I get a headache everytime I read a reply of yours, and there is no
> malice in this statement. Try not to be so darn verbose!

Yes I know I can get wordy, Im trying to get everything over in one
go and I tend to fall the side of wordiness as bald statements have
all to often turned round and bit me on the XXX in the lab...OTOH in the
same spirit Ill return with the opinion that you need to stop making
absolute statements and expecting not to get picked up on the precise
details, because you then dont write enough. Conciseness is good, cutting
out context from the short statement is bad as it puts over an apparently
different view to what you might be thinking in what are actually very
complicated concepts with hairsbreadth differences that one owrd can
make large differences.

Yes I know...wordy. Im not gonna argue that I am not wordy.

Actually while Ive written a lot here I think there are two questions I
ask you towards the end that might actually roll us forward a lot in what
you are trying to say...

>
> Give "Underdiagnosis of genital herpes by current clinical and
> viral-isolation procedures" by LA Koutsky, CE Stevens, KK Holmes, RL
> Ashley, NB Kiviat, CW Critchlow, and L Corey a read.

Yes this still has the majority of infected people not exhibiting
symptoms. It lists 22% as being symptomatic - thats 78% asymptomatics.

> The article "Psychosocial Implications When Treating the Patient With
> Genital Herpes" surveyed people with HSV-2 and found that less than 69%
> of them even told their doctors anything about it! So how can one say
> that there is up to a 90% asymptomatic rate when 31% of people are too
> fearful to even tell there own doctor!

Full cite please - no authors means thats not coming up in Pubmed. Umm
also sounds like a percentage of the people who know they have lesions not
telling their doctor - this isnt the same as a population sample in a
research study who are not going to be able to hide it and also have the
benefit of anonymity.

>
> No qualifers here, just literature cited.

Yes Ive cited papers fromt he same authors that contradict it though.
Suggesting there is more to the information than what you are suggesting.

> Look, I'm not getting philosophical about the definition of
> asymptomatic. The dictionary says that asymptomatic means "not
> exhibiting any symptoms".
> I'm not arguing that it should be redefined,
> I'm saying that only about 20% of people with HSV-2 are truely
> asymptomatic, got it?

Yes Im citing later literature byt he same authors that contradicts it,
plus data by other authors eg Sizemore et al, 2006 J Inf Dis vol 193,
p905-911. There is makes a statement that 82.2% had ONLY antibody evidence
of infection - that despite listing a number of symptomatic people also
shedding virus.

Your cited literature had a bunch of people found to be HSV2 positive -
and then having it shoved in their faces a numberof them start reporting
symptoms. One problem with this is that it did NOT control for the
stress of the diagnosis and subsequent self examination. Another is that
it requires hindsight and does not deal with the 'blind' population, who
both the authors of the data you cited and others continue to find
infected but non-symptomatic in the 80+ region.

My point here is that the data you are citing isnt (in my opinion, of
course and this is where we differ) sying what you say is it saying. I
think the authors themselves agree, because they make statements to that
effect in later papers (again I have cited them).

As a side note - you introduce the word 'truely' as a qualifier - you have
done this before - its potentially a massively significant qualifier -
since it steps away from conventional definition but adds a lot of extra
connotation, particularly the way its used in conversation by
people in the field...don't answer here yet there's a bit later on in the
post where its relevant.

> The rest either have symptoms which are not
> classic textbook cases and are not recognized (subclinical)

For subclinial read asymptomatic, for symptoms they mean the same thing.
The difference with subclinical is that it recognises biological activity
much more. Which kind of fits herpes.

> No, you are conflating "asymptomatic" and "subclinical".

Erm why not - at the point of defining symptomology they cover exactly the
same area. Both require no detected clinical signs (ie symptoms). A
symptoms is by definition a clinical event.

> In asymptomatic people, they TOTALLY lack any symptoms of herpes, by
> definition.

Yes and Im citing papers which state that in their dataset, these
conflict with and argue against.

> The subclinical diagnoses are changing due to technology,
> improved diagnostic methods and training, etc.

Diagnostic tests such a PCR and antibody tests do NOT pick up
clinical symptoms, they do not make a person symptomatic.

How you are defining these two terms does raise one significant question,
I have to ask (and here is the point to reintorduce the term truely
asymptomatic).

There is one view out there that viral shedding should itself be
considered a symptom. Its a minority view, not because people think
shedding doesnt mean anything but because there is a long standing
separation of biological activity and clinical activity for the purposes
of pratising medicine that controls the mental boxes used in the attached
research. People in this camp view asymptomatics as a very very tiny
number (Ive had comments of 'Well basically asymptomatic doesnt exist' to
'well there'll be a few true carriers out there but very few, in most its
active').

It strikes me that this is the viewpoint closest to what you are
espousing. So in my typical wordy fashion the questions I ask are...

Would you consider shedding a symptom personally? If you are looking for
true asymptomatics why not include shedding - because if thats remotely
similar to the point you are trying to make then you havent gone far
enough and you ought to be using the phrase 'truely asymptomatic' more.

>
> One word, bullshit. When only 69% of people can tell their DOCTOR that
> they think they might have HSV-2, clearly psychosocial implications
> impart a major problem.

Thats 69% who get symtoms only interacting with the healthcare system.
Thats underreporting of disease incidence NOT cutting chunks out of the
random populations in research studies. You are mixing apples and
oranges. The paper you cite is a social issue, and a problem in getting
people treated and while it raises massively significant issue for the
handling of HSV disease is not revealing some flaw in blind research
study figures.

Tim
--
When playing rugby, its not the winning that counts, but the taking apart
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