24 INFECTIOUS DISEASE, DISASTER PLANNING & WOUND CARE | 2019 | www.elitecme.com inappropriately stored vaccine, or inadequate records. Most patients who fail to develop a response to the first dose will develop a response to a second dose of MMR vaccine; approximately 99% of people who received two doses of MMR vaccine (with the first dose after their first birthday) will develop immunity (CDC, 2016). Vaccine-induced immunity develops a lower level of antibodies than natural disease, but the level of immunity to measles associated with vaccination appears to be long-term and probably life-long. Patients with low antibody titers after two immunizations who are revac- cinated often develop a large number of anti- bodies in recognition of the pathogens present in the vaccine, indicating a high likelihood of immunity from the original vaccinations. Revaccination is associated with an increase in measles antibody levels, but the increased level of antibodies may not be sustained (CDC, 2016). Blood testing for measles immunity does not need to be completed before vaccinat- ing against measles unless the medical facil- ity determines it to be cost-effective. Testing should only be done if there are systems in place to ensure that patients who are deter- mined to be susceptible to measles receive appropriate vaccination in a timely manner (CDC, 2016). Evidence-Based Practice: Demicheli, et al. conducted a systematic review assessing out- comes associated with 3,104 participants that received immunization with the MMR vac- cination product. According to their findings, in cases where subjects received one dose of vaccine, a protective rate of 95% was obtained in preschool aged children. In schoolchil- dren and adolescents, a 98% effective rate was obtained (Demicheli, et al. 2012). MUMPS: DEFINITION Mumps is a contagious viral illness that is spread through respiratory droplets or contact with infected saliva. It is initially characterized by fever, headache, fatigue, loss of appetite, and muscle aches. These symptoms are followed by swelling of the salivary glands (parotitis), which are located under the ears or jaw on the sides of the face. Swelling in other parts of the body, such as the testicles and ovaries, can also be associated with mumps. Mumps can be prevented through the use of immunizations administered that follow recommended vaccination schedules (McLean, 2013). HISTORY OF MUMPS Hippocrates first described the symptoms of mumps thousands of years ago in the 5th century BC. Before a vaccination was devel- oped, outbreaks occurred every two to five years, especially among people aggregating in confined areas, such as school-aged children. Mumps outbreaks were incredibly common among military personnel in World War I. It was not until 1934 that Johnson and Goodpasture discovered that mumps was caused by an agent present in the saliva. This agent was determined to be a virus; it was first isolated in 1945. Isolation of the mumps virus allowed for the first vaccine to be developed in 1949. This single-entity, inactivated vaccine provided only short-term immunity and was replaced with a live attenuated vaccine created by Maurice Hilleman. Hilleman used viral strains isolated from his own daughter’s case of mumps and called it the Jeryl Lynn strain. This live attenuated vaccine was released in 1967 (CDC, 2016-1). EPIDEMIOLOGY OF MUMPS After the release of the live attenuated vac- cine, mumps was classified as a nationally reportable disease in the U.S. in 1968. The introduction of the live vaccine significantly decreased reported mumps cases—from an estimated 212,000 cases in 1964 to an average of 3,000 cases per year between 1983 and 1985 (CDC, 2016-1). A resurgence of mumps occurred in 1987: 12,848 cases of mumps were reported that year. The most commonly affected individu- als during this time were children and young adults from 10 to 19 years of age. Many of the affected individuals during these outbreaks were born before the routine recommenda- tion of mumps vaccination and before com- prehensive state immunization requirements for mumps were developed. Several outbreaks among populations who were largely vaccinated with one dose of mumps vaccine were also reported during this resurgence, which demonstrated that one dose of the mumps vaccine may not be enough to prevent the transmission of mumps. This led to the 1989 addition of a second dose to the vaccination recommendations (CDC, 2016-1). The number of reported cases of mumps declined steadily—from 5,712 cases in 1989 to 258 instances in 2004. However, a multi-state outbreak of 6,584 cases occurred in 2006— mostly among Midwestern college students living in dormitories. The following two years saw low numbers of mumps cases. Another outbreak began in the summer of 2009 (CDC, 2016-1). The 2009 outbreak began when an 11-year- old male picked up the virus in an outbreak that occurred in the United Kingdom. He brought the virus back to New York: this resulted in 3,502 reported cases of mumps. This outbreak was largely confined to Orthodox Jewish communities, which com- prised 97% of the reported cases. Over 50% of the cases in this outbreak occurred in children ages five to 17 years. Analysis of the afflicted patients suggested that although vaccination is effective at preventing mumps, patients who receive both doses of vaccine enjoy greater lev- els of immunity. Of the patients whose vac- cination status was reported, 90% of patients received one dose of mumps-containing vac- cine; 76% of patients received two doses of the vaccine (CDC, 2016-1). Outbreaks of mumps are ongoing. In 2014, a mumps outbreak among professional hockey players and close contacts affected approxi- mately 20 players, despite widespread vacci- nation efforts. Although cases of mumps can occur in vaccinated individuals, maintaining high vaccination rates is crucial to controlling outbreaks and preventing the spread of disease (McLean, 2013). SYMPTOMS OF MUMPS The mumps virus is acquired through respi- ratory droplets or contact with infected saliva. After transmission, the virus multiplies within the nasopharynx and in some lymph nodes. After an incubation period of 12-25 days, a systemic viremia develops. This can persist for three to five days and allows the virus to spread throughout many parts of the body. Inflammation results in infected tissues, leading to the classic symptoms of parotitis and aseptic meningitis (CDC, 2016-1). Within a time-frame of 16-18 days after exposure to the virus, parotitis (the most com- mon clinical manifestation) generally devel- CONTINUING EDUCATION  |