Mumps and the UK epidemic 2005
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7500.1132 (Published 12 May 2005) Cite this as: BMJ 2005;330:1132
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We would like to highlight an issue not raised by the excellent reviews by Gupta et al 1 and Savage et al 2, namely the management of hospital contacts of mumps. Mumps is usually a mild illness, but complications are significant and can be serious 3,4. Transmission may occur prior to (-5days), and after (+9days), development of symptoms or during an asymptomatic infection. In order to minimise ongoing transmission, we have introduced a protocol for managing potentially susceptible exposed healthcare workers (HCW) which includes determining their immune status by mumps IgG testing (Vidas, bioMerieux SA, France). Following exposure, seronegative HCW are excluded from clinical duties during the most likely infectious period (12-25d after), and offered MMR vaccine to protect against secondary and tertiary cases. Recent guidance5 does not recommend such testing and exclusion, partly based upon an assumption of immunity in those people born before 1980.
Analysis of the age related mumps serostatus of over 1,500 patients, tested as part of this strategy at the Specialist Virology Centre (SVC), Bristol, and the Gloucestershire Hospitals NHS Foundation Trust microbiology laboratory, confirms the relatively high rate of susceptibility (around 17%) expected between age 18 to 23, but also a seronegative rate of approximately 8% amongst those aged 35 years and over. These figures assume that all antibody equivocal patients are immune. These findings are consistent with the age distribution of mumps as laboratory reported cases (SVC), and notifications to the HPA SW Regional Epidemiology Unit (table 1).
Although we are unable to assess the impact of this strategy on nosocomial transmission of mumps, we believe that age alone is not a reliable indicator of mumps immunity, and consideration should be given to establishing the immune status of all new hospital staff, along with offering MMR where appropriate. This may also have benefit with respect to measles and rubella immunity.
REFERENCES
1. Gupta RK, Best J, MacMahon E. Mumps and the UK epidemic. BMJ, May 2005; 330: 1132 - 1135.
2. Savage E, Ramsay R, White J, Beard S, Lawson H, Hunjan R and Brown D. Mumps outbreak across England and Wales in 2004:observational study. BMJ, May 2005; 330: 1119 - 1120.
3. Sonmez FM, Odemis E, Ahmetoglu A, Ayvaz A. Brainstem encephalitits and acute disseminated encephalomyelitis following mumps. Pediatr Neurol 2004;30:132-4
4. Caksen H, Ustunbas HB. A fatal case of acute transverse myelitis associated with mumps . J Emerg Med 2004;24:341-2
5.Mumps National Outbreak Team, Mumps FAQ
www.hpa.org.uk/infections/topic_az/mumps/mumps_faq.htm#10
(accessed 10 August 2005)
|
All Notified Mumps Cases in Avon |
||||
|
|
2004 |
2005 |
||
|
AGE GROUP |
Avon |
SW |
Avon |
SW |
|
0-4 |
31 |
106 |
23 |
150 |
|
5-9 |
21 |
99 |
34 |
197 |
|
10-14 |
57 |
202 |
65 |
524 |
|
15-19 |
405 |
1408 |
361 |
2088 |
|
20-24 |
249 |
988 |
275 |
1375 |
|
25-29 |
30 |
129 |
54 |
254 |
|
30-39 |
26 |
151 |
47 |
287 |
|
40-44 |
9 |
45 |
16 |
111 |
|
45-49 |
8 |
38 |
14 |
84 |
|
50-54 |
4 |
27 |
3 |
48 |
|
55-59 |
5 |
26 |
3 |
31 |
|
60+ |
3 |
25 |
5 |
38 |
|
Unknown |
1 |
16 |
8 |
59 |
|
Grand Total |
849 |
3260 |
908 |
5246 |
Table 1
Notifications of mumps cases for Avon and the South West region by age.
Source: Health Protection Agency South West, Regional Epidemiology Unit.
Data extracted from NOIDS reports on 12 August 2005.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
ROSEOLA IS CONFUSED WITH RUBELLA
One of your correspondents, a consultant paediatrician, admonished
another correspondent in the following terms:-
Heptonstall seems to allege that rubella is now often misdiagnosed as
roseola. This would be odd, as the symptoms associated with these
childhood exanthems are so very different." [1]
However, according to what appears a classic paper on the topic, it
would seem that roseola was commonly confused with rubella when rubella
was prevalent:-
these, the disorders most commonly confused with rubella, are measles,
scarlet fever, and roseola ...."
[2]
Accordingly, it would seem plausible that the reverse could occur now
should physicians hold the belief that rubella vaccinated individuals
are asymptomatic at all times. Further, it would also seem such
misdiagnosis would not be 'odd'.
Whilst I have had this information for some good time, I apologise to
Mr Heptonstall for not bringing this to the readers' attention earlier
but it appears to have become an Herculean task for those who message
is iconoclastic to be published of late in the BMJ Rapid Responses.
[1] Re:
The Cost of a Rubella Outbreak Would be More than Just Financial
30 June 2005 Theo H Fenton, Consultant
Paediatrician Mayday Hospital, Croydon CR7 7YE
[2] BACTERIOLOGICAL REVIEWS - Kibrick - Vol. 28, No. 4, p. 452-457
December, 1964
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
False Government Rubella Scare
Stories - Demonstrating the Figures are False
The USA has to date vaccinated
approximately 120 million children with rubella vaccine, either
monovalent or in MMR. [1]The contributions of
Peter Flegg, Consultant physician, Blackpool and Tony
Floyd, Medical Student, Newcastle University
[2], [3]help to
provide more proof this has been done on the basis of flawed and inflated
figures
bearing no relation to actual cases and promulgated by
government and those who speak for it.
We can
calculate an initial ceiling beyond which we know the numbers of US
congenital rubella syndrome (CRS)
cases could not go. Demonstrating this
initial ceiling is an order of magnitude or more higher than the real
figure is also not
difficult. The more accurate
calculation remains one based on real
figures for an entire US
state in 1964, and
particularly a state served by Johns Hopkins. [4]
We are
told [2]
a paper cites 17 CRS cases from 6000
pregnancies in 11 US hospitals in 1964. If we assume the number
of US
hospitals were roughly similar in 1964 to 1980, the 1980 figure is 7156
US hospitals
[5]. This provides the starting point of an 11,000 ceiling for US
CRS cases.
Approximately
1000 of these 7156 hospitals were psychiatric units. Further, of
the remainder, not all US hospitals have now or had in 1964 maternity
units. One might reasonably expect less than half to have
had. Additionally, not all hospitals are the same size. The
1980 figures show then they ranged in size from
6 beds to over 500
beds. [5] This also
shows overall substantial variations in local populations
served by hospitals of substantially varying sizes. And
then there would be regional variations in incidence of CRS.
There were also substantially fewer hospitals with the higher numbers
of beds. It would also be a reasonable assumption that the 11
hospitals cited as having 17 CRS cases were of the larger size with
maternity units as it is more likely researchers would concentrate on
the larger bed size hospitals with substantial maternity units.
Accordingly, it can be easily seen that the numbers of CRS cases in the
US would be bound to be vastly lower than 11,000 and likely by an order
of magnitude or more. This is also without taking into account whether it is
realistic to assume
all 1963/4 US pregnancies received ante-natal care in hospital rather
than with local general practice or mid-wifery practices and how many
could, in 1964 afford much ante-natal care? It may have been that
the 6000 cases from 11 hospitals were only
those cases where hospital care was necessary.
What is
indisputably bizarre about the alleged 1964 rubella 'pandemic'
is that for something so allegedly serious, with such allegedly serious
outcomes and for so
many, is that the authorities feel the need to overstate the
true figures. Rubella
vaccination is motivated by government desire to save money, not to
protect children.
There is
also something seriously wrong in the world of 'professional' medicine when a student in a
medical school will not agree 300,000 US
CRS cases in 1964 is a figure bearing no relation to
reality. [3]
________________________________
email: to
email Clifford
Miller substitute '@' where it says "insert an 'at'
sign" in this email address:
an 'at' sign"cliffordmiller.com
________________________________
[1] This figure
assumes 4 million per annum birth rate since the 1969
introduction of rubella vaccine and 80% vaccination coverage over that
period.
[2] Re:
False Government Rubella Scare Stories - Now 300,000 Congenital Rubella
Cases! -
30th June 2005 - Peter Flegg
[3] Re:
The Cost of a Rubella Outbreak Would be More than Just Financial 30
June 2005 Tony Floyd
[4]
False
Government Rubella Scare Stories - Only 20,000 Percent Overstated 1
June 2005 - Clifford Miller
[5] ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/Health_US/hus04tables/Table109.xls
Competing interests:
None declared
Competing interests: No competing interests
Mr Heptonstall seems to allege that rubella is now often misdiagnosed
as roseola. This would be odd, as the symptoms associated with these
childhood exanthems are so very different.
In an attempt to support his allegation, Mr Heptonstall cites two
papers from Archives of Disease in Childhood (ADC). Unsurprisingly, these
papers contradict his argument.
I was particularly puzzled by Mr Heptonstall's use of quotation
marks:
...the latter [rubella] probably far less frequently diagnosed since
physicians began to vaccinate against rubella "believing it can no longer
exist in quantity"(2)
The reference (2) was from ADC:
http://adc.bmjjournals.com/cgi/content/full/87/3/202. Strangely, nowhere
in the ADC article do any of the words "believing", "longer", "exist", or
"quantity" appear.
A piece of propaganda often quoted by anti-vaccinationists is that
whoooping cough still occurs almost as often as it used to, but it's just
called croup these days. Another is that diphtheria is still common, but
it's called epiglottitis.
Ridiculous, of course, and it might even be funny -- except that some
people might believe it.
Competing interests:
None declared
Competing interests: No competing interests
The devastating legacy of congenital rubella syndrome (CRS) in the
United States during the epidemic that occurred prior to the introduction
of rubella vaccine has obviously discomfited those who would like to claim
congenital rubella is of little consequence.
Clifford Miller, who still seems to think there were less than 200
cases of CRS in the entire United States in 1964, is dismissive of
Professor Cooper's series of 400 cases from a single centre in New York
(1) which obviously comprised only part of the city's total. Professor
Cooper states these 400 cases were published, but that he actually had
contact with over twice that number. I would refer Miller to some of
Professor Cooper's work on the subject(1).
It is quite unedifying to see
Miller try and reject this experience as "anecdotal" (if only all
"anecdotes" were as solid) and to make issue with the non-disclosure of
Professor Cooper's subsequent on the CRS and rubella vaccination after
1964 as though this implies partiality.
If one wishes to leave aside estimates of cases of clinical rubella,
which are obviously open to misdiagnosis and errors of under-reporting,
one can look at data that no-one can misinterpret, namely clinical cases
of CRS and the number of overall births. In one study of 6000 pregnant
women from 11 urban hospitals in the USA, 750 women either developed
clinical rubella in the first trimester or recorded exposure to an active
case in 1964 (2). In total 9% of these exposed women went on to develop
either clinical or serologically-confirmed rubella. There were 16
spontaneous abortions, 10 therapeutic abortions, 19 stillbirths and 17 CRS
infants, 2 of whom died neonatally. These cases of early-diagnosed CRS
are likely to greatly under-represent the true total of infants affected
by CRS. The authors state that many infants with minor neuro-
developmental/cardiac abnormalities or with deafness may not be diagnosed
as suffering from CRS for many months or even years. Widespread use of
gamma-globulin helped prevent many more cases of CRS in exposed women.
Perhaps I can give Miller a new extrapolation to calculate: - If 17
cases of CRS (and the true number is probably more than twice that) occur
for every 6000 births, how many cases of CRS might he expect from the 4
million or so births that occurred that year in the whole of the USA?
(1) Cooper LZ.
The history and medical consequences of rubella.
Rev Infect Dis. 1985 Mar-Apr;7 Suppl 1:S2-10
(2) Sever JL, Nelson KB, Gilkeson MR.
Rubella epidemic, 1964: effect on 6,000 pregnancies.
Am. J. Dis. Child. 1965 Oct;110(4):395-407.
Competing interests:
None declared
Competing interests: No competing interests
Mr Miller has written:
> “Tony Floyd's new figure of 300,000 congenital rubella syndrome ('CRS') cases in 1964"
I'm sure Mr Miller has also read that CRS was widely under reported, but whether 300,000 is realistic or not I am not going to debate. He would also be quite capable of noticing that I gave the reference (1) which was published in 2000 and the quote I gave referring to 'the past 5 years.' This would, one might think, refer to the late 1990's, not 1964.
So I did not give a 'new figure' for 1964.
(1) Reef SE, Plotkin S, Cordero JF, Katz M, Cooper L, Schwartz B, Zimmerman-Swain L, Danovaro-Holliday MC, Wharton M. Preparing for elimination of congenital Rubella syndrome (CRS): summary of a workshop on CRS elimination in the United States. Clin Infect Dis. 2000 Jul;31(1):85-95. Epub 2000 Jul 25.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
FALSE
GOVERNMENT RUBELLA SCARE STORIES - NOW 300,000 CONGENITAL RUBELLA CASES!
I am grateful
to Tony Floyd, Medical Student, Newcastle University for his recent
comments [1]. He notes Professor Louis Z. Cooper is the
appropriate commentator, as the author of a book on the subject.
Tony Floyd's
new figure of 300,000 congenital rubella syndrome ('CRS') cases in
1964 [2] again demonstrates how easy these government scare stories are
to generate on the basis of just one journal reference. Whilst
Professor Cooper's
doubling of 'estimates' of 20,000 CRS cases to 40,000
[4] is perhaps
not quite in accord with a scientific approach and, more importantly,
not in accord with a factual one either, it is nothing compared to Tony
Floyd's. Tony Floyd's stratospheric new figure is an order of
magnitude higher
than Professor Cooper's 40,000 figure, taking us another 1500
percent higher than the original 20,000 Orenstein 'estimate' [5].
It is not clear
what point Tony Floyd wants to make, and he overlooks
answering the other points previously made [6]. Further, as
Professor
Cooper's comments were anecdotal, it is not derision for me to point
that out,
particularly when responding with fact. Tony Floyd's
further intervention is tinged with desperation to succeed in the
argument but is fundamentally flawed. The debate concerns rubella
and congenital rubella incidence prior to rubella vaccination.
Yet Mr Floyd cites figures from a 2000 paper [7]. That is at a
time of compulsory US mass child vaccination which he compares to 1964
when US rubella vaccination did not exist. As Tony Floyd's
300,000 CRS figure shows, this approach is akin to comparing apples
with concrete.
Mr Floyd also
makes a further fundamental mistake. Whilst it could become so,
the current debate is not about whether artificially infecting children
with rubella virus to generate a form of immunity is appropriate.
The debate is about whether we should apply this kind of prophylaxis to
children en masse as an unnecessary medical intervention, with our eyes
shut to the numbers of dead and injured. This is especially so
when the consequences of not vaccinating are nothing like the
exaggerated figures government is so desperate to give the
public.
The reason why
government shuts its eyes to the dead and injured is because
vaccination is not to save children's lives but to save government
money, and when it comes to government money, government tends not to
let small things like childrens' lives affect its calculations.
Mr Floyd makes
the point for me, that by administering vaccines, government thinks it
saves the cost of treating 1.8 million annual measles, mumps and
rubella cases. In 1960s England (and Wales), around 600,000 live
births annually equated to this number of cases for the UK National
Health Service to treat, even if these were just general practitioner
visits and irrespective of mildness.
Regrettably,
none of the points Mr Floyd makes in this latest posting contributes
anything of substance to this debate save than accidentally and
unintentionally.
To email
Clifford Miller: insert an '@' sign before cliffordmiller.com in the
following address: bmj050620cliffordmiller.com
_______________________________________________
[1] Re: The Cost of a
Rubella Outbreak Would be More than Just Financial
19 June 2005 Tony Floyd
[2] This
figures arises from Tony Floyd's new figure of 24:1000 rubella cases
having
congenital rubella syndrome outcomes [1], and his figure of
12.5 million 1964 US rubella cases [3].
[3] The Cost of a
Rubella Outbreak Would be More than Just Financial
25 May 2005 Tony Floyd
[4] Re: False Government
Rubella Scare Stories - Only 20,000 Percent Overstated
3 June 2005 Prof Louis Z Cooper
[5] Orenstein
WA, Bart KJ, Hinman AR, Preblud SR, Greaves WL, Doster
SW, Stetler HC, Sirotkin B. The opportunity and obligation to eliminate
rubella from the United States. JAMA. 1984 Apr 20;251(15):1988-94.
[6] False Government
Rubella Scare Stories - Reply to Professor Louis Z Cooper
6 June 2005 Clifford Miller
[7] Reef SE,
Plotkin S, Cordero JF, Katz M, Cooper L, Schwartz B, Zimmerman-Swain L,
Danovaro-Holliday MC, Wharton M. Preparing for elimination of
congenital Rubella syndrome (CRS): summary of a workshop on CRS
elimination in the United States. Clin Infect Dis. 2000
Jul;31(1):85-95. Epub 2000 Jul 25.
Competing interests:
None declared
Competing interests: No competing interests
With reference to Tony Floyd's questions for Clifford Miller:-
"Whether these outbreaks of disease causing deaths and birth
deformities are called epidemics or pandemics, why did the last major one
occur in 1964-1965?...Why none since rubella vaccination was commenced in
1969?"
Perhaps they can be answered through an investigation of the
relationship between diagnoses of roseola and rubella (1), the former
having multiplied since HHV6 was identified as the cause, and the latter
probably far less frequently diagnosed since physicians began to vaccinate
against rubella "believing it can no longer exist in quantity"(2)...
Regards
John H.
1.
http://adc.bmjjournals.com/cgi/content/abstract/archdischild;65/12/1297
2. http://adc.bmjjournals.com/cgi/content/full/87/3/202
Competing interests:
None declared
Competing interests: No competing interests
In reference to my discussion of the 20 000 cases of congenital rubella syndrome in 1964 (1), Mr Miller has responded with:
> “The incidence in 1964 would have resulted in less than 200 [sic] congenital rubella syndrome ('CRS') cases for the whole of the USA and not 20,000."
Now Professor Louis Cooper, who authored the very book that I referenced (1), was kind enough to respond himself and advise that he himself took care of more than 400 children during that particular outbreak of CRS. Rather than retract the overly enthusiastic rounding-down from 20 000 to 200, Mr Miller derides Professor Cooper's experience as being 'anecdotal'. What else could a personal experience be? In this case Mr Miller might like to revise his estimates or explain how Professor Cooper is mistaken.
Mr Miller also stated that:
> “The sub-group of CRS cases was typically 1:1000 of total rubella cases"
However Susan Reef MD (2) reported that:
5 of congenital rubella syndrome (CRS) annually for the past
5 years in the United States..."
5 in 212 would make 24:1000, not 1:1000.
Also in reference to the outbreak of rubella in 1964 Miller writes:
> “It is strange therefore that other more recent texts appear not to refer to these figures, making passing reference and no more, such as 'epidemics of rubella occurred every 6-9 years, with the last major U.S. epidemic occurring in 1964-1965.' and without mentioning 'pandemic'."
Whether these outbreaks of disease causing deaths and birth deformities are called epidemics or pandemics, why did the last major one occur in 1964-1965?
Why none since rubella vaccination was commenced in 1969?
Coincidence?
References:
(1) Cooper, LZ, Preblud, SR, Alford, CA. Rubella, In: Remington JS, Klein JO eds. Infectious diseases of the fetus and newborn, 4th edition. Philadelphia: WB Saunders;1995. p. 268.
(2) Reef SE, Plotkin S, Cordero JF, Katz M, Cooper L, Schwartz B,
Zimmerman-Swain L, Danovaro-Holliday MC, Wharton M.
Preparing for elimination of congenital Rubella syndrome (CRS): summary of a
workshop on CRS elimination in the United States.
Clin Infect Dis. 2000 Jul;31(1):85-95. Epub 2000 Jul 25.
Competing interests:
None declared
Competing interests: No competing interests
Re: Mumps and Hospital Contacts
Sir/Madam
As the NHS has for some years been recruiting overseas, and has a
great many staff who are now employed in various NHS occupations drawn
from many areas of the world, it would be of some value to analysts of the
data provided by Monique I Andersson et al for them to identify the
following:-
1. How many cases in Avon, and the SW, were of NHS workers who
immigrated specifically for NHS jobs and what is their immunisation status
for mumps vaccine.
2. How many cases at each age group had been immunised against mumps
and how many not.
The nature of immigration might confound the assumption that all
cases shown, born before 1980, had wild mumps.
Regards
John H.
Competing interests:
None declared
Competing interests: No competing interests