Comments regarding “Current evidence gaps to support systematic cytomegalovirus screening in pregnancy”

We read with interest the viewpoint from Billette de Villemeur,¹ recently published in your journal. This viewpoint suggested that the current literature pertaining to screening and management of cCMV remains poorly understood and that some important evidences are still lacking.

Regarding the cost of CMV screening during pregnancy, our study² has been wrongly referred to and we wish to correct several important issues. We developed a cost-effectiveness model to evaluate both costs and cost-effectiveness of 4 screening strategies for CMV primary infection (PI) during pregnancy in France (Table 1).

Table 1.

Description of the strategies and associated costs.

Strategy	Description of the strategy	Screening/diagnosis discounted costs (€)	Total discounted costs (€)
Strategy 1	No systematic screening as currently recommended by French public health authorities until 2025	5,576,000	98,263,000
Strategy 2	Current screening in real life in France, that is 25–50% of screening for T1 PI	16,696,000	106,012,000
Strategy 3	Universal T1 CMV PI screening	35,229,000	118,927,000
Strategy 4	Universal T1 CMV PI screening followed by treatment with valaciclovir once T1 CMV PI is diagnosed, as recommended by European recommendations	2 37,171,000	98,598,000

We showed that strategy 2 (screening in real life) is a more expensive strategy than strategy 4 (T1 CMV PI + valaciclovir) (Table 1). The authors used the term “inefficient” to describe this result although our model demonstrated that the current situation was the most expensive strategy, focusing only on costs and disregarding effectiveness. In addition, screening + valaciclovir would be cost-saving compared to real life because valaciclovir would avoid a proportion of congenital infections following T1 CMV PI, which are the infections most likely to cause sequelae and not because our interpretation was “an intent-to-treat effectiveness on sequelae” as reported by Billette de Villemeur.

Regarding cost-effectiveness of universal screening, we stratified our analysis and distinguished:

• -Effectiveness in term of supplemental diagnosis: universal T1 PI screening (strategy 3) led to an additional cost €38,552 per additional in-utero diagnosis, compared with no screening (strategy 1).
• -Effectiveness in term of congenital avoided infections: universal screening associated with valaciclovir (strategy 4) led to an additional €893 per avoided congenital infection compared with no screening (strategy 1).

Our model demonstrated the three pieces of evidence exposed above and we believe it needed to be explicitly clarified to make sure that our results are considered honestly, completely and are not misinterpreted against prenatal CMV screening.

Moreover, several articles from different teams and countries demonstrated the efficiency of valaciclovir to prevent mother-to-child CMV transmission3, 4, 5; this is not accepted by the authors. The tools used for the diagnosis and timing of maternal primary infection are reliable, but again this is not accepted. Overall, it seems very confusing that two publications citing the same references can reach diametrically opposed conclusions.⁶ Women deserve to be informed and to benefit of the best actual strategies to prevent and to treat CMV during pregnancy. Screening and valaciclovir are the pillars to fight CMV; this is why, since 2025, the French High Authority for Health has recommended systematic screening for CMV for all pregnant women during the first trimester of pregnancy.

Contributors

CPD wrote the manuscript and provided the results detailed in this Viewpoint; OP and CVF supervised the work; AV and YV carefully proofread and edited the manuscript.

Declaration of interests

All the authors declare no conflict of interest for this work.