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Chapter 15: Mumps; Epidemiology and Prevention of Vaccine

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Chapter 15: Mumps; Epidemiology and Prevention of Vaccine Mumps Mariel Marlow, PhD, MPH; Penina Haber, MPH; Carole Hickman, PhD; and Manisha Patel, MD, MS Mumps is an acute viral illness. Parotitis and orchitis were Mumps described by Hippocrates in the 5th century BCE. In 1934, ● Acute viral illness Claud Johnson and Ernest Goodpasture showed that mumps could be transmitted from infected patients to rhesus monkeys ● Parotitis and orchitis described by Hippocrates and demonstrated that mumps was caused by a filterable in 5th century BCE agent present in saliva. This agent was shown to be a virus in 1935. Mumps was one of the most common causes of aseptic ● Viral etiology described meningitis and sensorineural hearing loss in childhood in the by Johnson and Goodpasture United States until the introduction of a vaccine in 1967. In in 1934 1971, mumps vaccine was licensed in the United States as a ● Before vaccine, one of the combined measles, mumps, and rubella (MMR) vaccine. In 2005, most common causes of a combination measles, mumps, rubella, and varicella (MMRV) aseptic meningitis and hearing vaccine was licensed. loss among children and hospitalization among military During World War I, only influenza and gonorrhea were more ● Vaccination led to common than mumps as causes of hospitalization among over 99% reduction in soldiers. A successful 2-dose vaccination program in the United mumps cases States led to a greater than 99% reduction in the number of mumps cases reported annually. However, starting in 2006, there has been an increase in mumps cases and outbreaks, particularly in close-contact settings, with many occurring among fully vaccinated persons. Mumps Virus 15 Mumps Virus Mumps virus is a paramyxovirus in the same group as ● Paramyxovirus (RNA) parainfluenza and Newcastle disease viruses, which produce antibodies that cross-react with mumps virus. The virus has a ● Rapidly inactivated by single-stranded RNA genome. chemical agents, heat, and ultraviolet light The virus can be isolated or propagated in cultures of various human and monkey tissues and in embryonated eggs. It has been recovered from the saliva, cerebrospinal fluid, urine, blood, semen, breastmilk, and infected tissues of patients with mumps. Mumps virus is rapidly inactivated by formalin, ether, chloroform, heat, and ultraviolet light. Pathogenesis Mumps Pathogenesis The virus is acquired by respiratory droplet transmission. It ● Respiratory transmission replicates in the nasopharynx and regional lymph nodes. of virus During viremia, the virus spreads to multiple tissues, including ● Replication in nasopharynx the meninges, salivary glands, pancreas, testes, and ovaries. and regional lymph nodes Inflammation in infected tissues leads to characteristic symptoms of parotitis and other complications such as orchitis ● Multiple tissues infected and aseptic meningitis. during viremia 225 https://www.cdc.gov/vaccines/pubs/pinkbook/mumps.html Aug 2021 Mumps Clinical Features Mumps Clinical Features The incubation period of mumps is usually 16 to 18 days but ● Incubation period usually 16 to can range from 12 to 25 days. The prodromal symptoms are 18 days (range, 12 to 25 days) nonspecific and include myalgia, anorexia, malaise, headache, ● Nonspecific prodrome of and low-grade fever. myalgia, malaise, headache, low-grade fever Mumps typically presents as parotitis (i.e., swelling of the ● Typically presents parotid gland) or other salivary gland swelling lasting about as parotitis 5 days. Parotitis may be unilateral or bilateral, and swelling of any combination of single or multiple salivary glands may be ● May presents with respiratory present. Parotitis may first be noted as earache and tenderness symptoms on palpation of the angle of the jaw. Emergence of contralateral or be subclinical or same side parotitis within weeks to months after apparent recovery has been described. Mumps infection may present only with nonspecific or primarily respiratory symptoms or may be a subclinical infection. Before the introduction of the mumps vaccine, approximately 15% to 24% of infections were asymptomatic. The frequency of asymptomatic infection in vaccinated persons is unknown, but mumps is generally milder among vaccinated persons. Mumps virus is the only infectious agent known to cause epidemic parotitis. Cases of mumps reinfection have been reported. 15 Mumps Complications Complications Complications of mumps occur with or without parotitis or ● Orchitis, oophoritis, mastitis, pancreatitis, hearing loss, other salivary gland swelling and generally include orchitis, meningitis, and encephalitis oophoritis, mastitis, pancreatitis, hearing loss, meningitis, and encephalitis. Nephritis, myocarditis and other sequelae, ● More common among adults including paralysis, seizures, cranial nerve palsies, and than children hydrocephalus, in mumps patients have also been reported but ● Less likely in vaccinated persons are rare. Complications associated with mumps infection are compared to unvaccinated usually more common among adults than children. Vaccinated persons persons are less likely to have mumps complications than ● Meningitis, encephalitis, unvaccinated persons. pancreatitis, and hearing loss 1% or less among infected Orchitis is the most common complication in post-pubertal persons in the postvaccine era males, occurring in approximately 30% of unvaccinated and 6% of vaccinated post-pubertal males. With mumps-associated orchitis, there is usually abrupt onset of testicular swelling, tenderness, nausea, vomiting, and fever. Pain and swelling may subside in 1 week, but tenderness may last for multiple weeks. About half of patients with mumps orchitis develop testicular atrophy of the affected testis. While there is a theoretical risk for sterility based on the pathogenesis of the disease, no study has demonstrated a risk for sterility in men with mumps orchitis compared to those without mumps orchitis. In the prevaccine era, oophoritis and mastitis had been reported in 7% and 30%, respectively, of post-pubertal women with mumps. Among vaccinated post-pubertal women, oophoritis 226 Mumps and mastitis are reported in 1% or fewer of mumps patients. Oophoritis may mimic appendicitis. Among unvaccinated patients, clinical aseptic meningitis occurred in up to 10%, pancreatitis in up to 4%, and sensorineural hearing loss in up to 4%. Meningitis is usually mild. Hearing loss is usually transient but may be permanent. In the postvaccine era, among all persons infected with mumps, reported rates of meningitis, encephalitis, pancreatitis, and hearing loss (either transient or permanent) have all been 1% or less. Permanent sequelae and death are very rare in both vaccinated and unvaccinated patients. Laboratory Testing The diagnosis of mumps is usually suspected based on clinical presentation, in particular the presence of parotitis. However, if mumps is suspected, laboratory testing should be performed. Other infectious causes of parotitis that may also be tested as part of the differential diagnosis include Epstein-Barr virus, cytomegalovirus, parainfluenza virus types 1 and 3, influenza A virus (most commonly H3N2), enteroviruses, lymphocytic choriomeningitis virus, human immunodeficiency virus (HIV), and non-tuberculous mycobacterium. 15 Mumps is confirmed by reverse transcriptase-polymerase chain reaction (RT-PCR) or viral culture from buccal/oral or urine specimens. A negative RT-PCR or viral culture in a person with clinically compatible mumps symptoms does not rule out mumps as a diagnosis. Acute mumps infection can be detected by the presence of serum mumps IgM. However, this test cannot be used to confirm a diagnosis of mumps. IgM response may be transient, delayed, or not detected. This may be because of previous contact with mumps virus either through vaccination or natural infection. A negative IgM in a person with clinically compatible mumps symptoms does not rule out mumps as a diagnosis. False negatives are common so results should be interpreted with caution. Collection of serum 3 to 10 days after parotitis onset improves the ability to detect IgM. Acute mumps infection can also be detected by a significant rise in IgG antibody titer between acute and convalescent- phase serum specimens, also known as IgG seroconversion. However, this test cannot be used to confirm a diagnosis of mumps. False positive results can occur in both unvaccinated and vaccinated persons because assays may be affected by other diagnostic entities that cause parotitis. In addition, false negative results can occur in vaccinated and unvaccinated persons. By the onset of symptoms, in 227 Mumps someone who is vaccinated or had previous infection, the acute-phase IgG may already be elevated, and therefore a 4-fold rise cannot be detected when compared to the convalescent-phase serum sample. Laboratory testing can confirm the presence of mumps vaccine virus in a recently vaccinated and potentially exposed individual. Epidemiology Mumps Epidemiology ● Reservoir Occurrence Mumps occurs worldwide, with 500,000 cases reported on ■ Human average annually. ● Transmission ■ Infectious respiratory droplet Reservoir secretions Mumps is a human disease. Although persons with ■ Saliva asymptomatic or nonclassical infection can transmit the ● Temporal pattern virus, no carrier state is known to exist. No animal or insect reservoir exists. ■ No temporal pattern ● Communicability Transmission ■ 2 days before through 5 days Mumps is spread through infectious respiratory droplet after onset of parotitis secretions and saliva. 15 Temporal Pattern Mumps is reported
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