Increasing Awareness About Mumps and the Importance of Vaccination

RELEASE DATE:

May 1, 2017

EXPIRATION DATE:

May 31, 2019

FACULTY:

Yvette C. Terrie, BS Pharm, RPh
Clinical Pharmacist/Freelance Medical Writer
Haymarket, Virginia

FACULTY DISCLOSURE STATEMENTS:

Dr. Terrie has no actual or potential conflicts of interest in relation to this activity.

Postgraduate Healthcare Education, LLC does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced, objective, and scientifically rigorous. Occasionally, authors may express opinions that represent their own viewpoint. Conclusions drawn by participants should be derived from objective analysis of scientific data.

ACCREDITATION STATEMENT:

Pharmacy
acpePostgraduate Healthcare Education, LLC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
UAN: 0430-0000-17-039-H01-P
Credits: 2.0 hours (0. 20 ceu)
Type of Activity: Knowledge

TARGET AUDIENCE:

This accredited activity is targeted to pharmacists. Estimated time to complete this activity is 120 minutes.

Exam processing and other inquiries to:
CE Customer Service: (800) 825-4696 or cecustomerservice@jobson.com

DISCLAIMER:

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients' conditions and possible contraindications or dangers in use, review of any applicable manufacturer's product information, and comparison with recommendations of other authorities.

GOAL:

To provide pharmacists with a review of mumps (including etiology, transmission, risk factors, and health consequences) and information on the importance of mumps vaccination, especially in light of recent outbreaks.

OBJECTIVES:

After completing this activity, the participant should be able to:

  1. Review the causes and consequences of mumps in the unvaccinated patient population.
  2. Identify the signs and symptoms associated with mumps.
  3. Understand the significance of obtaining the measles-mumps-rubella vaccine.
  4. Explain the pharmacist's role as vaccination advocate and provider.

ABSTRACT: Mumps, an acute, systemic disease caused by Paramyxovirus, is characterized by the swelling of one or both parotid glands. Transmission occurs via contact with respiratory secretions or saliva, and incubation is usually 16 to 18 days. Serious but rare complications include orchitis, meningitis, and pancreatitis. There are no antiviral agents for treatment of the mumps virus; however, supportive therapy may be used for symptoms such as headaches, fever, or pain. Vaccination is still the best measure for preventing mumps, and the vaccine is a combination product containing measles, mumps, and rubella viruses. Pharmacists can play a key role in educating people about mumps and the importance of vaccination, and they can also become certified to administer vaccines in a variety of settings.

According to the World Health Organization (WHO), vaccination has significantly diminished the burden of infectious diseases.1 Vaccines are considered to be one of the most cost-effective protective measures against preventable diseases, and the CDC has declared that vaccinations are one of the top 10 public-health achievements of the 20th century and have saved millions of lives.1-4 According to the WHO, the increase in life expectancy during the 20th century was largely due to improvements in child survival, and vaccinations were chiefly responsible for decreases in mortality from infectious diseases. Unfortunately, infectious diseases remain a chief cause of illness, disability, and death.4

In the United States, recommendations from the Advisory Committee on Immunization Practices (ACIP) currently target 17 vaccine-preventable diseases across the lifespan.4 It is estimated that, annually, 40,000 to 50,000 adults and 300 children in the U.S. die from preventable diseases or their complications.4-6 Vaccines are beneficial to both the patient and the healthcare system because their use prevents approximately 14 million cases of vaccine-preventable disease and 33,000 deaths each year.4 The treatment of patients who do not receive routine and recommended vaccinations accounts for about $10 billion in healthcare costs annually.5,6 It has been estimated that for each U.S. birth cohort receiving the recommended childhood immunizations, 20 million illnesses and more than 40,000 deaths are prevented, resulting in a savings of $70 billion.7,8

The prevention of infectious diseases results in noteworthy health and economic benefits for both individuals and populations, making vaccination an extremely beneficial and cost-effective public-health strategy.9 Although vaccination rates in children remain high, adult vaccination rates for routinely recommended vaccines in the U.S. remain low and are well below projected Healthy People 2020 targets.5,10-12

Mumps Epidemiology, Etiology, and Outbreaks

Mumps is an acute, systemic, and communicable viral infection that is characterized by the swelling of one or both parotid glands; rarely, it can cause more serious complications, such as meningitis, pancreatitis, and orchitis.13-15 Mumps is caused by Paramyxovirus, which has a single-strand, nonsegmented, negative-sense RNA genome; the virus is commonly spread via direct contact with respiratory secretions or saliva.13-16

In recent years, large mumps outbreaks involving mainly adolescents and young adults have occurred in several countries, including the U.S. (TABLE 1).17,18 A report released in December 2016 stated that the number of mumps cases has reached a 10-year high in the U.S. and is particularly common on college campuses.19 To date, mumps outbreaks are regularly reported on college campuses.


table 1

Before a mumps vaccine was developed, the disease was common in the U.S. and caused complications, such as permanent deafness in children and encephalitis (sporadically), which could result in death, although rarely.20 Before the U.S. mumps vaccination program started in 1967, an estimated 186,000 cases were reported annually, and many more unreported cases occurred.20 As a result of the implementation of the mumps vaccine, the number of mumps cases reported in the U.S. has decreased more than 99%.9 From year to year, the number of mumps cases may vary extensively from a couple hundred to a couple thousand; however, outbreaks still occur intermittently.20 Despite the initially high efficacy of the vaccine, which led to herd immunity and an almost complete eradication of mumps in pediatric patients, many huge outbreaks have been reported in young adults, the majority of whom have vaccination records documenting either partial or complete vaccination.21

These outbreaks have demonstrated that when mumps-infected persons have close contact with large groups of people—such as students living in dormitories and students and families in close-knit communities—the virus can spread even to individuals who were previously vaccinated.20 However, outbreaks are much greater in areas where vaccine-coverage rates are lower.20

Acute mumps in an individual and/or community may result from factors including incomplete vaccination, waning immunity over time (≥10 years since vaccination), and/or antigenic variation of mumps viruses.22 Additionally, it is not fully known why symptomatic mumps infections develop in vaccinated persons; there are no definitive correlates of protective immunity for mumps, and it is presumed that neutralizing antibody is critical for protection, but repeated attempts to define a protective threshold titer have yielded questionable results.23 There is some evidence that memory T lymphocytes may be essential to confer protection but are likely inadequate.24 Some studies suggest that the immune response to mumps virus (both wild-type and vaccine) may be innately weak, and the predominant antibody response seems to be directed to the nucleoprotein, which is a nonneutralizing target.25 Other studies show that the frequency of mumpsspecific memory B lymphocytes is extremely low.26,27 This could be due to poor antigenicity and low levels of viral proteins during infection, or possibly to an inadequate T-cell response.16,26,27

Clinical Presentation

After a typical incubation period of 16 to 18 days (although incubation can be anywhere from 12-25 days), mumps generally has a prodromal phase that is marked by nonspecific viral symptoms such as low-grade fever, fatigue, weakness, myalgias, and headache that last for 3 to 5 days.20,28 Following the prodromal phase, the patient often develops unilateral or bilateral parotitis, which typically lasts 2 days but may last longer.20 An estimated 20% of patients are asymptomatic, whereas approximately 50% of patients have nonspecific symptoms or predominantly respiratory symptoms. Patients generally complain of worsening pain when eating or drinking acidic foods, and they may also have symptoms such as fatigue, weakness, headache, neck pain, and fever. The most contagious period is typically considered to be several days before and after the onset of parotitis.20

Mumps is frequently confused with swelling of the lymph nodes in the neck. Lymph node swelling is distinguished from parotid gland swelling by the well-defined borders of the lymph nodes, the location of the lymph nodes behind the jawbone angle, and the absence of ear protrusion and masking of the jaw angle, which are classic features of mumps.20 An estimated 50% of postpubertal males have orchitis and as many as 30% have bilateral involvement, but the development of sterility is infrequent.14 Patients may present with abdominal pain due to pancreatitis or oophoritis; oophoritis occurs in approximately 5% of postpubertal females.14 Rare complications of mumps include pancreatitis, deafness, meningitis, and encephalitis, which have been reported in fewer than 1% of cases in recent U.S. outbreaks.20 No mumps-related deaths have been reported in the recent U.S. outbreaks.20

Diagnosis

A laboratory diagnosis of mumps may be necessary if exposure is suspected, and a sample from a cultured swab of one of the inflamed salivary glands, particularly the parotid duct, may be used to test for the virus.28 The virus may also be detected from a buccal or throat swab via polymerase chain reaction. Measuring immunoglobulin (Ig)M or IgG titers via a serologic test (i.e., enzyme-linked immunosorbent assay) is a simple, sensitive method frequently used to diagnose mumps. IgM titers are beneficial during the initial phase of mumps, but are often not measurable in individuals with one or more doses of mumps-containing vaccine; IgG titers are advantageous from the time between exanthema and the recovery phase to years after the infection. It is important to note that false-negatives are likely; consequently, clinical disease should not be dismissed if exposure has not been confirmed by a laboratory test, but parotitis and other classic mumps symptoms are observed.28

Treatment and Management

In general, mumps without major complications may be managed with supportive therapy for symptoms, and patients should be isolated for 5 days after the onset of symptoms to decrease the risk of transmitting the virus to others.14 There are no antiviral agents for the treatment of the mumps virus; however, analgesics may be used when appropriate for the management of headaches, fever, or pain from parotitis. Bed rest, adequate hydration and the use of warm or cold packs may ease discomfort associated with parotitis, and patients should also be encouraged to avoid acidic foods, which may intensify pain or discomfort.14

Prevention With MMR Vaccine

Vaccination is still the most effective measure for preventing mumps, and two measles-mumps-rubella (MMR) vaccines are available in the U.S.: MMR II (Merck), which contains live, attenuated measles, mumps, and rubella viruses, and ProQuad (Merck), which is a combination product containing live, attenuated measles, mumps, rubella, and varicella (MMRV) viruses.29-31 Healthcare providers should reconstitute and administer the vaccine as recommended by the manufacturer.29-31

The CDC reports that two doses of the MMR vaccine are 88% effective (range, 66%-95%) at preventing mumps and that one dose is 78% effective (range, 49%-91%).29 The first mumps vaccine was licensed in the U.S. in 1967, and by 2005, a high rate of two-dose childhood vaccination coverage reduced disease rates by 99%. MMR protects against currently circulating mumps strains. The MMRV vaccine is licensed only for use in children aged 12 months through 12 years. The dosage for both MMR and MMRV is 0.5 mL administered via subcutaneous injection; the preferred injection site in small children is the anterolateral aspect of the thigh, and the preferred site in older children and adults is the posterior triceps aspect of the upper arm. The ACIP recommends that healthy people without evidence of immunity to measles, mumps, and rubella should receive the MMR vaccine. See TABLE 2 for guidelines from the ACIP and the CDC.29


table 2

Although the ACIP makes no formal recommendations for or against a third MMR dose, the CDC has provided guidelines for use of a third dose as a control measure during mumps outbreaks in settings in which individuals are in close contact with one another, when transmission is continued despite high two-dose MMR vaccine coverage, and when standard control measures fail to halt or slow transmission of the virus.32-34

Only limited data are available regarding the effectiveness of a third dose of mumps vaccine; however, during recent outbreaks, when a third dose was administered as a control measure, the incidence of mumps cases was reduced.15,26,35,36 Still, it is unclear from these reports whether the outcome was a direct result of third-dose vaccination or merely the natural decline in the number of mumps cases resulting from the late timing of the intervention in the development of the mumps outbreak.15 In addition, limited antibody boosting was detected following third-dose vaccination, excluding patients who had extremely low (or no) mumps antibody.15,26

The most commonly reported adverse reactions to the MMR vaccine include injection-site pain, erythema, or swelling; joint or muscle aches; fevers; and, rarely, parotitis.21 Other more serious complications are central nervous system effects, such as deafness, febrile seizures, and encephalitis; these adverse effects occur in fewer than one in one million doses, and their rarity should not deter people from MMR vaccination.22

The CDC recommends that prior to administering the MMR vaccine, healthcare providers should screen for the following conditions37:

  • Presence of a moderate or severe acute illness with or without fever, in which case vaccinations should be postponed until illness resolves (a patient with minor illness, such as diarrhea or mild upper respiratory infection with or without low-grade fever, may be vaccinated)
  • Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product)
  • History of thrombocytopenia or thrombocytopenic purpura
  • Need for tuberculin skin testing
  • Personal or family history of seizures

The CDC notes that contraindications to the MMR vaccine include37:

  • Severe allergic reaction after a previous dose of vaccine or to a vaccine component, including neomycin
  • Known severe primary or acquired immunodeficiency (i.e., from leukemia, lymphomas, solid tumors, tumors involving bone marrow or lymphatic system, AIDS, severe HIV infection, chemotherapy, or long-term use immunosuppressant use)
  • Pregnancy (defer vaccination until completion of pregnancy)

It is important to note that HIV infection is a contraindication only if the immunocompromised state is severe (CDC immunologic category 3 with CD4 <15%).37 Women who have been vaccinated should avoid becoming pregnant for ≥28 days afterward because the vaccine virus may be capable of infecting a fetus during early pregnancy. The vaccine does not cause congenital rubella syndrome, but the risk of fetal damage is estimated to be ≤3%.37

CDC Outbreak-Control Measures

According to the CDC, the foremost tactic for controlling a mumps outbreak is to define the population(s) at risk and transmission setting(s) and to swiftly identify and vaccinate persons without reasonable evidence of immunity; or, if a contraindication exists, to exclude persons without reasonable evidence of immunity from the setting to prevent exposure and transmission.38

The CDC states that, during an outbreak, the MMR vaccine should be administered to persons without evidence of immunity and to those who should be brought up-to-date with age-appropriate vaccination (one or two doses).38 Although MMR has not been shown to be effective in thwarting mumps in persons already infected, it will prevent infection in those who are not yet exposed or infected.38 Persons without evidence of immunity who are vaccinated early in the course of an outbreak may be protected prior to exposure; however, because of the incubation period for mumps, cases are expected to continue to occur for at least 25 days among newly vaccinated persons who may have been infected before vaccination. As is true of all vaccines, some people will not develop protective immunity after receiving the MMR vaccine. The CDC states that, depending on the epidemiology of the outbreak—e.g., the age groups and/or institutions involved—healthcare providers should consider a second dose of mumps-containing vaccine in children aged 1 to 4 years and in adults who have previously received one dose.38

With regard to controlling mumps outbreaks in schools and colleges, the CDC recommends that students who have received no doses of MMR vaccine and have no other indication of mumps immunity not attend schools affected by a mumps outbreak or other schools that are unaffected but are deemed by local public-health authorities to be at risk for transmission of the mumps virus.38 Excluded students may be readmitted immediately after being vaccinated, and students with a history of one dose of MMR should obtain their second vaccine dose and remain in school. Students who have been exempted from mumps vaccination for medical, religious, or other reasons should refrain from attending school until the 26th day after the start of parotitis in the last person with mumps in the affected school.38

During mumps outbreaks, the CDC notes that public-health officials may administer a third dose of MMR vaccine in specifically identified target populations. In order to control a mumps outbreak, the CDC criteria to consider before administration of a third dose in a target population include high two-dose vaccination coverage (i.e., vaccination coverage >90%); intense exposure settings likely to facilitate transmission, such as schools (especially colleges), congregate living quarters, or healthcare settings; high attack rates (i.e., >5 cases per 1,000 population); and evidence of ongoing transmission for at least 2 weeks in the target population.38 To control future outbreaks, the CDC advises that more data on the effectiveness and impact of administering a third dose of MMR vaccine for controlling a mumps outbreak are warranted, and that if a public-health official decides to administer a third dose to control a mumps outbreak, the following data should be collected during an outbreak to evaluate the impact of this intervention38:

  • Mumps occurrence in the target population (before and after intervention, by vaccination status)
  • Frequency of adverse events following vaccination with a third dose
  • Costs related to the intervention (including cost of vaccine and cost for personnel to administer)

According to the CDC, current tactics for controlling a mumps outbreak include efforts to ensure that at-risk populations are up-to-date with the suggested number of MMR vaccine doses and reduction of opportunities for close contact in persons with mumps.38

Dispelling Common Misconceptions About Vaccines

Pharmacists are in a pivotal position to increase patients’ awareness about the safety and efficacy of vaccines, as well as dispel the common myths that deter some people from receiving vaccinations. Over the years, there have been ongoing concerns regarding the safety and efficacy of vaccines, especially the MMR vaccine. One of the most debated issues has been the possible link between autism and thimerosal, a mercury preservative that was used in vaccines, particularly MMR. The Institute of Medicine (IOM) conducted a thorough review of this issue, and the final report from the IOM, Immunization Safety Review: Vaccines and Autism (May 2004), stated that no link was found between the MMR vaccine and autism.39

Currently, with the exception of some influenza vaccines in multidose vials, none of the vaccines used in the U.S. to protect preschool-aged children against 12 infectious diseases contain thimerosal as a preservative.40 Although thimerosal is no longer used in childhood vaccines, some parents are still apprehensive about vaccines and their possible link to autism; therefore, patient education is critical to allaying these concerns.

The facts that pharmacists can provide patients about vaccines are fundamental to eliminating some of the common misconceptions regarding vaccines. In 2011, an IOM report on eight vaccines (MMR; varicella; influenza; hepatitis A; hepatitis B; human papillomavirus; meningococcal; and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) given to children and adults noted that, with rare exceptions, all of them were deemed to be extremely safe.40 A CDC study published in 2013 reported that vaccines do not contribute to autism spectrum disorder (ASD), and an evaluation of the number of antigens from vaccines during the first 2 years of life found that the total amount of antigen from vaccines was the same in children with ASD and those without ASD, thus validating the absence of a link between vaccines and ASD.41

With regard to dispelling the myths associated with common vaccines such as MMR, encouraging news regarding attitudes about routine vaccinations was revealed in a 2017 survey conducted by the Pew Research Center.42 The survey found that 88% of Americans believe that the benefits of the MMR vaccine outweigh the risks, and two-thirds of those surveyed believe the risk of adverse effects is low.42

Pharmacist’s Role as Vaccine Educator and Provider

Pharmacists are uniquely positioned to educate parents on the importance of obtaining the MMR vaccine, as well as other routine vaccines, for their children and to remind adults to make sure that they, too, are up-to-date with CDC vaccination recommendations. Pharmacists are considered one of the most accessible and trusted sources of clinical information, including vaccination, and they can play an integral role in dispelling the common myths associated with vaccines, especially the safety and efficacy of MMR.43 Since the mumps virus is extremely contagious and can be transmitted rapidly to groups of unvaccinated people, it is crucial for parents or patients to understand the importance of timely vaccination, as well as the risks mumps can confer.43

Immunizations are vital to protecting patients from vaccine-preventable diseases, and in order for them to be effective, a team effort is required to improve immunization rates.44 Pharmacists are in a pivotal position to increase awareness about the importance of vaccinations, and the WHO states that healthcare providers who administer vaccines should listen to and attempt to address patients’ concerns about vaccines and provide them with key information regarding safety and efficacy.45

By constantly increasing awareness about the availability and importance of vaccinations, pharmacists can help patients make informed decisions to protect themselves and family members, especially when outbreaks occur. Studies have demonstrated that vaccine accessibility may be enhanced when patients are offered alternative settings—such as retail clinics —for vaccination, and studies report that such settings provide high-quality care, reach new patients, and may reduce healthcare costs.46 A recent study demonstrated that the expanded hours offered by pharmacy-based immunization programs increased adult vaccination rates, and another study showed that patients who had access to vaccinations at a large pharmacy chain had a significantly greater immunization rate than would normally be expected (4.88% vs. 2.90%).47

Currently, all 50 states allow pharmacists to administer certain vaccines once they complete a certification program.48 Nearly all states permit pharmacists to administer all or almost all vaccines, including routine adult vaccines like influenza, herpes zoster, pneumococcal, and travel vaccines, and the majority of states also allow pharmacists to administer the MMR vaccine.48,49 Not all pharmacists will elect to become certified to administer vaccines, but those who do not can play an important role in promoting the importance of immunization in other ways, including (1) patient history and screening, (2) patient counseling, (3) documentation, (4) formulary management, (5) administrative measures, and (6) public education and awareness.48

As some of the most accessible healthcare providers, pharmacists can increase awareness about the importance of obtaining vaccines, and many efforts have been launched to increase awareness. For example, in February 2016, the Department of Health and Human Services announced a plan to improve vaccination rates in U.S. adults because new CDC data are variable and in some cases indicate extremely low rates in adults.50 This program, known as the National Adult Immunization Plan, was established by an assortment of experts, and its four major goals include strengthening the public-health and healthcare systems involved in adult immunization; enhancing access to adult vaccines; increasing awareness of adult vaccine recommendations and use of recommended vaccines; and promoting innovations in adult vaccines, including new vaccines and new ways to administer them.48,50 The continual mumps outbreaks virus serve as a reminder of the significance of vaccination and its pivotal role in protecting populations against preventable diseases. During counseling, pharmacists can make recommendations about the various vaccinations recommended for the adult population, such as the influenza vaccine and the pneumococcal vaccine.

Conclusion

Given that mumps outbreaks continue to occur regularly, especially on college campuses, pharmacists should seize every opportunity to increase awareness about the signs and symptoms of the mumps virus and emphasize the importance of vigilance in obtaining the recommended MMR vaccine and adhering to CDC recommendations for controlling these outbreaks.

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