Emerging/Re-Emerging Infectious Disease: Mumps

Samantha McKee

SBL 222 01

Dr. Butela

Nov. 11, 2016

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There are numerous instances in today’s world of emerging and re-emerging

infectious diseases. What exactly are emerging and re-emerging infectious diseases?

An emerging disease is a disease which is either newly occurring in humans,

previously only occurring in very small populations, or has recently been credited to

an identifiable pathogen. A re-emerging disease is a disease that was once very

serious, affecting a large population, began to decline, and have returned again. There

are many reasons that can be attributed to the cause of disease re-emergence including

drug resistance and under immunization (NIH 2007). Studying these emerging and re-

emerging diseases can be very beneficial in learning the best ways to treat and prevent

these diseases and breaking the cycle of their infections. For various reasons, many

diseases that were once thought to be eradicated by vaccines or other medical

developments have begun to re-emerge in today’s society. One particularly notable

re-emerging disease that was once eradicated and has now begun to recur is the

Mumps.

The Mumps is an infectious viral disease caused by the Rubulavirus. The

disease was first noted in the fifth century BC by the ancient Greek physician

Hippocrates (Immunisation Advisory Center 2016). However, as medical techniques

and methods were very underdeveloped in these times, the disease along with its signs

and symptoms were noted, they were not credited to an infectious disease until the

19th century AD. Identified as a disease-causing pathogen in the 19th century, the
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Rubulavirus was later classified as an enveloped, single-stranded RNA virus (Hviid et

al. 2008) in the 20th century. The single-stranded RNA genome is linear and the

capsid of the virus is enclosed in a lipid bilayer membrane, likely from a prior host.

Through genotyping, it has been learned that there are 12 different genotypes (A

through L) of mumps virus that vary in geographic distribution. The genotypes C, D,

E, G, and H can commonly be found in the western hemisphere whole the genotypes

B, F, and I are most commonly found in Asia (Hviid et al. 2008). The mumps virus is

very widespread, increasing its reach through the population.

The Rubulavirus is a very easily transmissible pathogen, making it a fairly

infectious disease. Once someone has been infected, the Rubulavirus is a moderate to

highly transmissible pathogen that can be passed from person to person via

respiratory droplets, contaminated fomites, or direct person-to-person contact (Hviid

et al. 2008). As a respiratory infection that is spread mostly from respiratory droplets,

Rubulavirus is likely most common in populations with poor hygiene like small

children, or adults who are in very close contact with other people and thrive in the

winter and early-spring time of year when people are confined to close quarters

indoors by the weather. The disease is commonly passed from one person to another

through sneezing or coughing and touching an inanimate object, which is then

touched by another person who then proceeds to touch their nose or mouth.

Rubulavirus primarily causes upper respiratory symptoms. The viral infection

typically infects the respiratory tract but on some occasions can spread to affect the
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central nervous system, urinary tract, and urogenital organs (Hviid et al. 2008). The

pathogen may travel to other body systems through the lymphatic circuit or the

vascular system. The point of entry of the virus is the respiratory tract, allowing the

virus to infect the cells of the upper respiratory or nasal mucosa. Rubulavirus

expresses an affinity for glandular tissue, making the parotid gland a favorable target

for infection (Hviid et al. 2008). The parotid gland is the salivary gland located in the

oropharynx, allowing for easy access of the parotid gland to the organism, which is

usually transmitted via the oral/nasal route.

Once the organism has invaded the host, the average incubation period of the

mumps can vary from 15 to 24 days and infected patients are most contagious in the

first few days prior to the onset of symptoms (Hviid et al. 2008). This is concerning as

people are most likely to spread the disease before they have even developed

symptoms, unknowingly passing it along to others before they realize something is

wrong.

The Mumps infection can vary greatly in clinical presentation but has a few

more indicative hallmark signs and symptoms. Nearly one third of mumps infections

go unnoticed, as the infected people are asymptomatic (Hviid et al. 2008).

Asymptomatic carriers are still able to pass the virus to others. This is extremely

concerning as the spread of disease can go unnoticed before symptoms develop,

allowing the pathogen to spread to a great deal of people before they begin to seek

treatment by a medical care provider. Children under two years of age are mostly
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asymptomatic and symptoms tend to be more severe in adults (Immunisation

Advisory Center 2016). This tells us that small children, being asymptomatic, are a

great reservoir for the disease, as it can spread from child to child without any notice.

The trademark symptom of a mumps infection, Parotitis, is the inflammation

of the parotid salivary glands. Parotitis can cause very swollen and tender parotid

glands on one or both sides of the face, and can be accompanied by countless other

symptoms. Some additional generalized signs and symptoms include things such as

myalgias, fatigue, fevers, headaches, and loss of appetite (CDC 2016). Many of these

vague and generalized signs and symptoms are consistent with the viral nature of the

mumps infection. These signs and symptoms can also make it difficult to notice that

something is wrong early on during the onset of symptoms. These symptoms can be

seen in common, uncomplicated mumps infections. Mumps can often have more

severe reactions in some cases, one being in pregnancy. A mumps infection in early

pregnancy can sometimes result in spontaneous abortion (Hviid et al. 2008). As stated

previously, the infection can migrate to other areas and systems of the body, resulting

in other more serious symptoms.

The mumps infection can travel from the respiratory system to other systems

such as the central nervous system and the urogenital system. Infection of the central

nervous system can lead to many serious complications such as acute encephalitis,

chronic encephalitis, ataxia, hydrocephalus, deafness, and transverse myelitis (Saijo

and Fujito 1997). Infection that spreads to the urogenital tract can cause severe
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swelling of the testicles, which can lead to sterility (Hviid et al. 2008). While a typical

mumps infection can be self-limiting, spread of the infection can lead to much more

serious complications. Pancreatitis is seen as a complication in about 4% of mumps

infections and on occasion electrocardiographic abnormalities - such as ST depression

or inverted T waves - are noted (Hviid et al. 2008). This is extremely concerning as

changes in the electrical circuitry of the heart can lead to further complications

involving stress on the heart or serious heart damage. A mumps outbreak in Europe in

2004/2005 resulted in many complications leaving those infected hospitalized with

meningitis, orchitis, oophoritis, and pancreatitis. These numbers show that mumps

can lead to morbidity and a large increase in hospitalized patients (Yung 2016). With

such potentially serious repercussions, it is important to identify a mumps infection

early on so treatment may be started so as to head off any potential for worsening

infection that could possibly lead to fatal complications.

The clinical indication of mumps can often be pretty self-explanatory, but the

only way to confirm with complete certainty that someone has been infected by the

Rubulavirus is by performing diagnostic testing. Serological tests are often used to

detect a viral nucleic acid of IgM antibody concentrations to confirm a mumps

infection through the collection and testing of saliva, urine, seminal fluid, or

cerebrospinal fluid (Hviid et al. 2008). However, the replication of the mumps virus is

short-lived, so the fluid samples from a patient must be collected within the first week

of the onset of symptoms for a reliable, definitive serological indication of a mumps

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infection. After that first week, the likeliness of successful Rubulavirus isolation from

a patient sample decreases, and has only been isolated from blood cultures within the

first 48 hours of symptoms (Hviid et al. 2008). Clinically obtained samples often

undergo immunofluorescence staining or RT-PCR to confirm the presence of

Rubulavirus. When these two diagnostic test fail, serological markers are usually used

in order to make a successful mumps diagnosis. The ELISA method is used to test for

specific IgM antibodies that are associated with the mumps Rubulavirus antigen,

allowing for definitive diagnosis of the presence of the viral illness.

A Rubulavirus infection cannot be treated once it has begun its course and

typically only supportive care is recommended for the treatment of associated

symptoms. This pathogen is viral and thus cannot be treated with antibiotics, but the

disease can be managed through symptom control. For example, analgesic

medications are recommended to treat discomfort or a lumbar puncture to help treat

headaches associated with meningitis as a result of the mumps infection, while

steroids are not recommended (Hviid et al. 2008). However, a vaccine can prevent

Rubulavirus. The vaccine for mumps is a live, attenuated vaccine given as a group of

vaccines along with the vaccines for measles and rubella. The measles-mumps-rubella

(MMR) vaccine was licensed in 1967 (CDC 2016). The vaccine is often given in two

doses, an initial dose followed by a booster. Booster vaccines are important to ensure

a strong immune response in those who have been vaccinated. Although the vaccines

are very effective, they are not 100% foolproof.

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While the MMR vaccine had reduced the incidence of mumps 99% by 2005

(CDC 2016), mumps has been re-emerging in recent times. An outbreak spanning

New York and New Jersey from summer 2009 to spring 2010 was documented and

demonstrates how the mumps infection is easily spread amongst young, unvaccinated

children. The outbreak began with a young child who had recently returned from a

trip to the United Kingdom and then attended a summer camp in New York. There

were 1,521 reported cases of the mumps in this outbreak (Update: Mumps… 2010),

which demonstrates how efficiently the virus can spread.

In 2011, an unvaccinated college student had returned from a trip abroad,

bringing with him a mumps infection. The infection was then spread to the student's

roommate, who had previously been vaccinated against the mumps virus (Mumps

Outbreak… 2011). The incidence of mumps infection in an individual who had

already received two vaccinations is very concerning. An outbreak of mumps on an

Illinois college campus in 2015/2016 brings to light the suggestion of possibly adding

an additional booster, bringing about a total of three mumps vaccinations (Albertson

et al. 2016). While adding a third booster vaccine may seem like a good idea, this is

somewhat alarming, as the characteristics of an effective vaccine include as few

boosters as possible.

Another outbreak that demonstrated illness in a large population of previously

vaccinated individuals occurred in Portugal in the winter season of 2012-2013. With a

total of 148 mumps-related cases, 92% of those infected had been vaccinated, with
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86.8% of them having received two doses of the vaccine and 17.7% of them having

received one dose of the vaccine (Cordeiro et al. 2015). This is an extremely

concerning finding and could make one question whether a new vaccine against the

Rubulavirus should be developed, as the current one, even with two doses does not

seem to be particularly effective at preventing the disease in recent times.

In fact, an outbreak in New York from September 2009 - August 2011 showed

that statistically, the amount of previous vaccine doses was inversely related to the

clinical severity of the mumps illness in most patients (Zamir et al. 2015). This shows

that the addition of more boosters of the mumps vaccine can help to reduce the effects

of the illness. The reports goes on to detail the importance of further research to

examine the possibility of increasing the number of boosters for the MMR vaccine or

possibly creating a new vaccine altogether that would be more effective with less

booster doses. This is an important area of development for various reasons.

Medically, as laboratory techniques and equipment have improved over the years,

developing a new, more effective, vaccine may be much more practically than

previously. This can also open up a large window for economic purposes. The

development of a new vaccine opens up the job market for new scientists to work on

this research and even for health care providers to give the new vaccine.

For as much support as there is for vaccines, there is just as much resistance to

vaccines for various reasons. In recent years, the anti-vaccination craze has spread

like wildfire across the United States. Many parents refuse to vaccinate their children
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against common infectious diseases, especially refusing the MMR vaccine. Parents

often try to defend this choice by expressing concern of putting harmful or unnatural

toxins into their children's bodies. In 1998, a report was released that claimed there

was a relation between vaccines and autism, which fueled the anti-vaccination

movement even more. Parents were very concerned that vaccinating their children

against possibly life-threatening diseases could cause autism. The study, released by

Andrew Wakefield, had many flaws and has been disproved by innumerable studies

since but the stigma of the correlation between vaccinations and autism remained

(Rao 2011).

Scientists have spent the past couple of decades trying to show how important

vaccinating children is for many reasons. With such an advanced medical field today,

vaccines are created to be as safe as possible, allowing medical providers to help

prevent countless infectious diseases that could take a serious toll on the population.

Medical professionals have spent so much time trying to ensure disease prevention is

a possibility and to ease parents fears about the potential risks of vaccines by

explaining that the benefits - preventing possibly fatal diseases - far outweigh any of

the risks that could be associated with vaccinations.

With today’s face of medicine urging the public to vaccinate children not only

for themselves, but for the general public, a societal standard has been set showing the

importance of vaccinations. Parents have a responsibility to ensure that their children

are protected from harmful pathogens and diseases. Catholic Social Teaching (CST)
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focuses on the individual's right and responsibility to their community. The question

of whether or not to be vaccinated or to vaccinate children has been very controversial

as of late. Many people believe that vaccinations can be harmful and refuse to get

them. This mindset is very harmful to herd immunity. Herd immunity is crucial to

maintain a high level of vaccinated individuals to prevent the spread of disease to

those who are too young to get vaccinations or who cannot be immunized due to

immunosuppression.

Studies have shown that the incidence of mumps outbreaks in areas of under

immunization and immunization refusal increases greatly (Lieu 2015). It is a civic

duty to get vaccinated and help protect those who must rely on herd immunity. With

the retraction of Andrew Wakefield's study connecting childhood vaccinations to

autism in children (Rao 2011), one can hope that the general population will assume

the responsibility of vaccinating their children and protecting both their children and

the general population from a preventable disease with potentially harmful

complications, like the mumps.

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Mumps Outbreak among Highly Vaccinated Teenagers and Children in the

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