Chapter 3Infectious Diseases Related To Travel
Preeta K. Kutty, Albert E. Barskey IV, Kathleen M. Gallagher
Mumps virus is an enveloped, negative-strand RNA virus, a member of the genus Rubulavirus. Humans are the only known natural host for mumps virus.
MODE OF TRANSMISSION
Transmission is by respiratory droplets, saliva, or contact with contaminated fomites. Patients are usually contagious from approximately 5 days before until 5 days after symptom onset.
Because of a successful immunization program in the United States, mumps disease rates declined >99% since a vaccine was licensed in 1967. However, large outbreaks occurred in highly vaccinated populations in 2006 (more than 6,500 cases) and 2009–2010 (approximately 3,000 cases). Mumps virus remains endemic in many countries throughout the world, because mumps vaccine is used in only 61% of the World Health Organization member countries. The risk of exposure to mumps among travelers is variable but remains high in many countries of the world, including industrialized countries, such as the United Kingdom, which has had several outbreaks since 2004, and Japan, which does not routinely vaccinate against mumps. Risk is especially high for travelers aged >12 months who do not have evidence of mumps immunity.
The incubation period from exposure to onset of symptoms is generally 16–18 days (range, 12–25 days). Mumps is most often characterized by parotitis (swelling of the parotid salivary glands), either unilateral or bilateral. Onset of illness is usually nonspecific, with symptoms of fever, headache, malaise, myalgia, and anorexia. Approximately 30% of mumps cases are asymptomatic.
Mumps is generally a mild and self-limited disease, but complications do occur. Orchitis (inflammation of the testicles) is the most common complication, occurring in up to one-third of postpubertal males. Other complications include oophoritis or mastitis (inflammation of the ovaries or breasts, respectively), pancreatitis, meningitis, and encephalitis. With the exception of deafness, these complications are more frequent in adults than in children.
Mumps may occur in epidemics; mumps virus is the only known cause of epidemic parotitis. Diagnosis is usually clinical, based on the presence of parotitis and associated signs, symptoms, or complications. The clinical case definition is an illness with acute onset of unilateral or bilateral tender, self-limited swelling of the parotid glands, other salivary glands, or both, lasting ≥2 days, and without other apparent cause. Laboratory criteria include the following:
- Isolation of mumps virus from clinical specimen
- Detection of mumps nucleic acid (standard or real-time RT-PCR assays)
- Detection of mumps IgM
- Demonstration of specific mumps antibody response, in the absence of recent vaccination, either by a 4-fold increase in IgG titer as measured by quantitative assays or by seroconversion from negative to positive by using a standard serologic assay of paired acute- and convalescent-phase serum specimens
Laboratory specimens that can be collected are serum for serology (IgM, IgG) and a buccal swab (or a throat swab) for viral detection or isolation. For more information, see the CDC Laboratory Testing for Mumps Infection website (www.cdc.gov/mumps/lab/index.html). Laboratory confirmation is more challenging in highly vaccinated populations. Serologic tests should be interpreted with caution. A negative laboratory test should not rule out a clinically compatible case, especially in a 2-dose vaccine recipient.
There is no specific antiviral therapy for mumps, and the basic treatment consists of supportive care.
PREVENTIVE MEASURES FOR TRAVELERS
Although vaccination against mumps is not a requirement for entry into any country (including the United States), travelers leaving the United States or living abroad should ensure they are immune to mumps. Acceptable presumptive evidence of immunity to mumps for international travelers includes the following:
- Documented administration of 2 doses of live mumps virus vaccine ≥28 days apart, on or after the first birthday
- Laboratory evidence of immunity
- Birth before 1957
- Documentation of physician-diagnosed mumps
Mumps vaccine contains live attenuated mumps virus. It is available as a combination formulation, such as measles, mumps, and rubella (MMR). Combined MMR vaccine is recommended whenever one or more of the individual components are indicated to provide optimal protection against all 3 viruses. Mumps vaccine is effective in preventing mumps but is not 100% effective. One dose of mumps vaccine is approximately 80% (range, 62%–91%) effective in preventing clinical mumps with parotitis, and 2 doses are approximately 90% (range, 79%–95%) effective.
Mumps vaccine has not been demonstrated to be effective in preventing infection when administered after exposure; however, it can be administered after exposure to protect against subsequent exposures. Immune globulin is not effective in preventing mumps infection after an exposure and is not recommended.
Vaccine Safety, Adverse Reactions, Precautions, and Contraindications to Mumps Vaccine
Refer to the Measles (Rubeola) section earlier in this chapter for information on reactions after MMR vaccine and additional precautions and contraindications. For routine vaccine recommendations, pediatric and catch-up schedules, and recommendations for special populations, refer to Chapters 7 and 8.
- American Academy of Pediatrics. Mumps. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, editors. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009. p. 468–72.
- CDC. Measles prevention: recommendations of the Immunization Practices Advisory Committee on Infectious Diseases (ACIP). MMWR Morb Mortal Wkly Rep. 1989 Dec 29;38 Suppl 9:1–18.
- CDC. Notice to readers: updated recommendations of the Advisory Committee on Immunization Practices (ACIP) for the control and elimination of mumps. MMWR Morb Mortal Wkly Rep. 2006 Jun 9;55(22):629–30.
- CDC. Update: mumps outbreak—New York and New Jersey, June 2009–January 2010. MMWR Morb Mortal Wkly Rep. 2010 Feb 12;59(5):125–9.
- CDC. Updated recommendations for isolation of persons with mumps. MMWR Morb Mortal Wkly Rep. 2008 Oct 10;57(40):1103–5.
- Dayan GH, Quinlisk MP, Parker AA, Barskey AE, Harris ML, Schwartz JM, et al. Recent resurgence of mumps in the United States. N Engl J Med. 2008 Apr 10;358(15):1580–9.
- Harling R, White JM, Ramsay ME, Macsween KF, van den Bosch C. The effectiveness of the mumps component of the MMR vaccine: a case control study. Vaccine. 2005 Jul 1;23(31):4070–4.
- Kutty PK, Kyaw MH, Dayan GH, Brady MT, Bocchini JA, Reef SE, et al. Guidance for isolation precautions for mumps in the United States: a review of the scientific basis for policy change. Clin Infect Dis. 2010 Jun 15;50(12):1619–28.
- Plotkin SA, Rubin S. Mumps vaccine. In: Plotkin SA, Orenstein WA, Offit PA, editors. Vaccines. 5th ed. Philadelphia: Elsevier Saunders; 2008. p. 436–65.
- Quinlisk P. Revision of the surveillance case definition for mumps. Council of State and Territorial Epidemiologists. Infectious Disease Committee; 2007. Available from: http://www.cste.org/PS/2007ps/2007psfinal/ID/07-ID-02.pdf .
- Watson JC, Hadler SC, Dykewicz CA, Reef S, Phillips L. Measles, mumps, and rubella—vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1998 May 22;47(RR-8):1–57.
- World Health Organization. Immunization schedules by antigen, selection centre [database on the Internet]. World Health Organization Vaccine Preventable Diseases Monitoring System. 2010 [cited Apr 29 2010]. Available from: http://apps.who.int/immunization_monitoring/en/globalsummary/ScheduleSelect.cfm .
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