Transmission of live, attenuated mumps virus to the human placenta

Molecular biology, pathogenesis and pathology of mumps virus

Mumps is caused by the mumps virus (MuV), a member of the Paramyxoviridae family of enveloped, non-segmented, negative-sense RNA viruses. Mumps is characterized by painful inflammatory symptoms, such as parotitis and orchitis. The virus is highly neurotropic, with laboratory evidence of central nervous system (CNS) infection in approximately half of cases. Symptomatic CNS infection occurs less frequently; nonetheless, prior to the introduction of routine vaccination, MuV was a leading cause of aseptic meningitis and viral encephalitis in many developed countries. Despite being one of the oldest recognized diseases, with a worldwide distribution, surprisingly little attention has been given to its study. Cases of aseptic meningitis associated with some vaccine strains and a global resurgence of cases, including in highly vaccinated populations, has renewed interest in the virus, particularly in its pathogenesis and the need for development of clinically relevant models of disease. In this review we summarize the current state of knowledge on the virus, its pathogenesis and its clinical and pathological outcomes.

Viral infections in pregnancy: advice for healthcare workers

BACKGROUND

Healthcare workers (HCWs) have the potential for increased exposure to infectious disease resulting from the provision of patient care. Pregnancy can confer specific problems in some infections for the mother and her unborn child.

AIMS

To discuss the viral infections encountered in the UK that constitute a particular risk to the pregnant HCW: human immunodeficiency virus, hepatitis B virus, hepatitis C virus, varicella-zoster virus, herpes simplex virus, human parvovirus B19, cytomegalovirus, rubella, measles, enteroviruses, mumps and influenza. Evidence for nosocomial transmission, clinical aspects specific to pregnancy, and recommendations to protect the pregnant HCW at work are included.

METHODS

Medline, EMBASE and Pubmed were searched using a list of keywords specific to each viral infection, including 'nosocomial', 'occupational' and 'healthcare workers'. References from the bibliographies of articles identified were reviewed for relevant material.

FINDINGS

The evidence for increased risk in the healthcare setting for many of these infections, outside of outbreaks, is weak, possibly because of the application of standard protective infection control measures or because risk of community exposure is greater. The pregnant HCW should be advised on protective behaviour in both settings. Potential interventions include vaccination and reducing the likelihood of exposure through universal precautions, infection control and redeployment.

CONCLUSION

Protection of the pregnant HCW is the responsibility of the individual, antenatal care provider and employer, and is made possible through awareness of the risks and potential interventions both before and after exposure. If exposure occurs or if the HCW develops an infective illness, urgent specialist advice is required.

[Safety update on vaccination during pregnancy]

During influenza A pandemia, the vaccination on pregnant women has raised many questions. Pandemia, easiness of travelling, and insufficient vaccinal coverage, expose these patients to infection which may have serious consequences on their pregnancy and on the child to born. On pregnant women, the precautionary principle is a priority and the evaluation of epidemiological risk is essential, in order to prevent adverses events. Prophylactic vaccinal administration against infections should be assessed with caution due to the little amount of available data. Its use will depend on the vaccine's composition and known side effects, the stage of pregnancy, as well as the benefit for the mother and the child to born, and her clinical history. Whatever the vaccine's nature, its administration never justifies a therapeutic abortion; its evolution must be closely followed to cover the occurrence of complication.

Presumed cases of mumps in pregnancy: clinical and infection control implications

Recently, a mumps outbreak in New York and New Jersey was reported by the Centers for Disease Control and Prevention (CDC). Subsequently, the dissemination of the disease was rapid, and, from June 28th 2009 through January 29th 2010, a total of 1,521 cases of mumps were reported in New York and New Jersey. Seven presumed cases occurred in pregnant women cared for at our institution. Mumps diagnosis as per the NYC Department of Health and Mental Hygiene was based on clinical manifestations, particularly parotitis. Prior immunizations with mumps vaccine and negative IgM were not adequate to rule out mumps infections. All of our seven patients had exposure to mumps in either their household or their community, and some of the them had symptoms of mumps. Due to the difficulties in interpreting serologies of these patients, their cases led to a presumed diagnosis of mumps. The diagnosis of mumps lead to the isolation of patients and health care personnel that were in contact with them. In this paper, we detail the presenting findings, diagnostic dilemmas and infection control challenges associated with presumed cases of mumps in pregnancy.

[Measles, mumps and rubella virus infection in pregnancy. Possible adverse effects on pregnant women, pregnancy outcome and the fetus]

Measles, mumps and rubella are common childhood diseases. Therefore, frequent and intense contact with children of preschool age may be associated with a higher infection risk for childcare providers. This overview summarizes current knowledge on possible adverse effects of these infections on pregnant women, pregnancy outcome and the fetus. Acute rubella or mumps virus infections are apparently not more severe in pregnant than non-pregnant women. In contrast, measles virus infection in pregnancy is linked to a higher incidence of pneumonitis and hospitalization. Evidence of congenital defects due to fetal infection is only provided in case of rubella virus infection in early pregnancy. Following rubella virus infection in the first trimester an increased fetal loss rate was reported. In 1966, a prospective study showed also a significant association between maternal mumps in the first trimester and an increased risk of abortion. But other investigators could not confirm this association. Measles and rubella but not mumps virus infections are linked to an increased premature birth rate. Occurring in late pregnancy, all three infections can result in birth of an infected infant. But severe disease occurs rarely and is mostly reported for premature infants with early neonatal measles. Preventive measures, aimed to reduce the risk of infection or severe complications for pregnant childcare providers, should consider the individual history of the employee (e.g. previous immunizations or antibody test results), the current epidemiological situation and possible interventions like passive immunization in case of exposure to measles.

Abort- und Frühgeburtenrate nach akuter Mumpsinfektionin der Schwangerschaft

OBJECTIVE

Since mumps infection is endemic, the occurrence of acute mumps infection during pregnancy is rare. As a result, data on the possible negative consequences of acute mumps infection on pregnancy outcome are limited.

PATIENTS AND METHODS

The clinical diagnosis of acute mumps infection was serologically confirmed in 79 pregnant women between January 1985 and December 2002. Data on pregnancy outcome were obtained from the gynaecologist or obstetrician. Cord blood from 26 of the 57 live-born infants was investigated for mumps-specific IgM and IgG antibodies by enzyme-linked immunoassay.

RESULTS

Sixty-two patients were prospectively followed up with respect to pregnancy outcome. Two of the 62 pregnancies were electively terminated. The overall rate of fetal loss was 6.6% (4/60). Only 2 cases of spontaneous abortion occurred during the first trimester. However, all 4 spontaneous abortions occurred in women who had contracted mumps infection during the first trimester. The time interval between mumps infection and fetal loss varied widely. The median gestational age at delivery was 40 weeks. Only 2 of the 57 live-born infants (3.5%) were delivered before completion of the 37th week of pregnancy. Mumps-specific IgM anti-bodies were not detected in any of the 26 cord blood samples tested.

CONCLUSION

The lack of mumps-specific antibodies in the cord blood samples tested suggests that prenatal mumps infection did not occur. The frequency of premature birth and spontaneous abortion following mumps infection in pregnancy does not appear to be increased over normal levels.

New syndrome of hydrocephalus, endocardial fibroelastosis, and cataracts (HEC syndrome)

We report on two unrelated male infants with similar findings of communicating hydrocephalus, endocardial fibroelastosis (EFE) and congenital cataracts, who died at 4 months of age. Both mothers reported an upper respiratory infection during the first trimester of pregnancy which was further complicated by polyhydramnios in the third trimester. The infants were diagnosed with bilateral congenital nuclear cataracts at birth. Serologic tests for toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus, syphilis, and galactosemia screens were negative. Chromosome analyses were normal. Both children developed communicating hydrocephalus between one and three months after birth. Patient 1 died suddenly at 4 months following an upper respiratory infection. Patient 2 developed congestive heart failure and also died at 4 months. At autopsy, both infants had enlarged hearts with endocardial fibroelastosis. No identifiable organism could be isolated. We discuss the association of birth defects in widely separated organ systems in these patients and suggest that this may represent a genetic syndrome; however, a viral etiology cannot entirely be excluded. We believe this is a distinct disorder and propose the acronym HEC for hydrocephalus, EFE and cataracts.

Human trophoblast interferons

The human placental trophoblasts which constitute the first fetal cells and form the major cell layer of the feto-maternal interface are potent producers of interferons (IFNs). The IFN production is dependent on the gestational age of the trophoblast, type of inducer and the stage of differentiation of the trophoblasts. First trimester trophoblast populations produce higher levels (5-6 times) of IFN than the third trimester trophoblasts when stimulated with viruses. Non-viral inducers, such as poly(rl).poly(rC), induce exclusively IFN-beta whereas viruses such as Sendai and Newcastle Disease Virus (NDV) induce mixtures of IFN-alpha subtypes and IFN-beta. Differentiation of mononuclear cytotrophoblasts into syncytiotrophoblasts in vitro increase the IFN production. High-performance and immunoaffinity chromatography of the virus-induced trophoblast IFN preparations resulted in the isolation of three antigenically distinct IFNs, namely, alpha I, alpha II1 (omega 1), and beta with molecular masses of 16, 22 and 24 kDa, respectively, on SDS-PAGE. The human trophoblast IFNs have physical and antiviral activities characteristic of the Type 1 IFNs. The possible roles of the trophoblast IFNs in human placental and fetal development are also discussed in this review.

Differential interferon production in human first and third trimester trophoblast cultures stimulated with viruses

Stimulation of human placental first and third trimester trophoblast and syncytiotrophoblast cultures with viruses [Newcastle Disease Virus (NDV) and Sendai virus] led to a high interferon (IFN) production. The magnitude of the production was dependent on the gestational age of the trophoblast, type of inducer and the stage of differentiation of the trophoblast. The data obtained indicated that the first trimester trophoblast cultures produced five to sixfold more IFN than the third trimester trophoblast on per cell basis whereas syncytiotrophoblast at term produced twice as much IFN than the mononuclear term trophoblast when stimulated with the viruses. NDV and Sendai virus produced different levels and composition of IFN-alpha and -beta in both first and third trimester trophoblast and syncytiotrophoblast cultures. Purification of the virus-induced trophoblast interferons (tro-IFNs) by tandem high-performance affinity chromatography resulted in specific activities between 0.7 and 2.7 x 10(8) IU/mg of protein when assayed on human amniotic WISH cells. The tro-IFN-alpha protected both human and bovine MDBK cells from virus infection whereas the tro-IFN-beta protected only the human cell lines tested. The possible roles of the tro-IFNs are discussed in light of the observed differences in trophoblast IFN response.

Isolation, purification and biochemical characterization of human placental interferons by tandem high-performance affinity chromatography

Human placental trophoblasts, fibroblasts and the trophoblast-derived malignant cell JAR are potent producers of interferons (IFNs) when stimulated with Sendai virus. The three cell lines produced different levels and compositions of IFN-alpha subtypes and IFN-beta. Anti-IFN globulins, Cibacron Blue F3GA and Concanavalin A were covalently immobilized on pressure-stable, macroporous polymeric matrices derivatized with vinyl sulphone (HEMA-BIO 1000 VS and HEMA 1000 VS). These supports were packed in biocompatible PEEK columns and were coupled with switching valves, to develop a tandem high-performance affinity chromatographic (HPAC) method for the isolation, purification and biochemical characterization of the IFNs produced in Sendai virus-stimulated human placental trophoblasts, fibroblasts and trophoblast-derived malignant cell, JAR, cultures. Silver-stained SDS-PAGE and gel densitometric analysis revealed the purity of the purified proteins to be between 94 and 98%. Specific activities of the purified IFNs ranged between 0.37-2.76 x 10(8) IU/mg of protein with cumulative recoveries between 90 and 92.2%. The purified IFN components exhibited quantitatively different antiviral activities in human and bovine cell lines. The utility of the tandem method for the purification and characterization of human type 1 IFNs produced from other cell lines are also discussed.

Human trophoblast interferon: pattern of response to priming and superinduction of purified term trophoblast and choriocarcinoma cells

We recently described a beta interferon response of primary cultures of term human trophoblast exposed to poly(I:C). The response pattern has now been studied further with priming and superinduction both of normal placental cell types and JAR, JEG-3 and BeWo choriocarcinoma cells. Pre-treating placental trophoblast cells, fibroblasts and macrophages with human interferon generally led to increased yields of interferon after poly(I:C) induction, whereas choriocarcinoma cells did not respond to priming. All the cells showed the superinduction phenomenon although to varying degrees. The combination of priming and superinduction conditions led to the production of very high yields of interferon in placental fibroblast cultures. The combined procedure also produced more interferon in macrophage cultures than priming or superinduction alone. Combined superinduction and priming of normal trophoblast did not produce higher yields than those obtainable by superinduction alone. These data might help to provide additional insight into the cellular control mechanisms of sensitivity of normal and malignantly transformed cells to interferon. Furthermore, the large quantity of trophoblast interferon produced by superinduction could be used for studies of its anti-viral and immunomodulatory effects.

Isolation, purification and characteristics of mononuclear phagocytes from human placentas

Methods for the isolation of mononuclear phagocytes from human placentas by digestion with collagenase or with trypsin are described. Mononuclear phagocytes were approximately 35% of the cells obtained. Preparations were enriched for mononuclear phagocytes by sequential density gradient centrifugation over Ficoll-Hypaque and Percoll, adherence to plastic and removal of contaminating trophoblastic cells with brief trypsin exposure. Monolayers obtained by these methods were greater than 85% mononuclear phagocytes. These cells were predominantly of fetal origin; most were mature macrophages but up to 20% appeared to be recently derived from blood monocytes as determined by ultrastructural peroxidase cytochemistry.

Immunologic mechanisms responsible for adverse reactions to routine immunizations in children

The principal licensed biologicals for human use in the United States have been listed with special emphasis given to antiviral vaccines. Possible adverse reactions of an immunologic nature which may be encountered in the use of these agents in routine immunization programs are described, while at the same time, their relative rarity is emphasized. The special problems one may encounter in immunizing the atopic child, the immunodeficient child, the child with active tuberculosis and the pregnant woman are considered separately, as are the undesirable consequences of hyperimmunization are mentioned.