ACIP Updates Mumps Vaccination Schedule

The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention has updated its recommendations for mumps vaccination and immunity. The recommendations appear in the June 9, 2006, issue of Morbidity and Mortality Weekly Report.

Failure to control infection has occurred in hospitals and long-term care facilities that house adolescent or young adult patients, resulting in nosocomial transmission. When exposed to an outbreak of mumps, those same health care settings can experience unexpected costs, which may include reassignment of staff members or the closure of wards.

From January 1 through May 2, 2006, there were 2,597 reported cases of mumps in 11 states. This outbreak emphasized the limitations of the 1998 recommendations on the prevention of mumps transmission in health care and other high-risk settings.

Documentation of adequate vaccination, laboratory evidence of immunity, birth before 1957, or documentation of physician-diagnosed mumps presume acceptable evidence of immunity to mumps. However, documented evidence of immunity is now defined as one dose of a live mumps virus vaccine for preschool-age children and adults who are not at high risk for mumps, or two doses for school-age children and high-risk adults such as health care professionals, college students, and international travelers.

It is recommended that family physicians and other health care professionals be immune to mumps. Health care professionals who were born during or after 1957 should receive two doses of a live mumps virus vaccine to achieve adequate vaccination. Those with no history of a mumps vaccination and no other evidence of immunity should receive two doses, and health care professionals who have received only one dose previously should be given a second dose.

Health care facilities should consider recommending one dose of a live mumps virus vaccine to their unvaccinated health care employees who were born before 1957 who do not have a history of physician-diagnosed mumps or laboratory evidence of immunity. A second dose of the mumps vaccine also is recommended for children one to four years of age or for adults who have received only one dose.

These new recommendations for health care professionals may offer increased protection against mumps during an outbreak; however, reviewing the vaccination status of health care professionals may be inefficient, and facilities may want to consider only a routine review of immunity status while still providing other annual disease-prevention measures.

Noncontraceptive Uses of the Levonorgestrel Intrauterine System

Although the levonorgestrel-releasing intrauterine system (Mirena) is approved for contraception, it also may have noncontraceptive uses, such as treating idiopathic menorrhagia. The American College of Obstetricians and Gynecologists published a committee opinion in the June 2006 issue of Obstetrics & Gynecology to address the noncontraceptive uses of this system.

The levonorgestrel intrauterine system reduces up to 86 percent of menstrual blood loss after three months in women with idiopathic menorrhagia and up to 97 percent after 12 months. At 12 months after insertion of the system, reported rates of amenorrhea vary from 20 to 80 percent. It is suggested that the levonorgestrel intrauterine system is significantly more effective than oral cyclical norethindrone as a treatment for heavy menstrual bleeding.

However, discontinuing use of the levonorgestrel intrauterine system may result in irregular bleeding, mood swings, acne, breast tenderness, and other hormonal side effects.

Hormone therapy regimens that combine estradiol-delivering methods (i.e., oral, gel, transdermal, or vaginal ring) with the levonorgestrel intrauterine system can effectively reduce climacteric symptoms and induce amenorrhea in 59 to 83 percent of women after one year. However, the long-term effects are unknown.

It is suggested that physicians evaluate women with persistent bleeding in a typical manner regardless of their use of the levonorgestrel intrauterine system.

Oral progestin therapy also is recommended as a treatment option for patients with atypical endometrial hyperplasia, with results consistent with other progestational agents.

Use of the levonorgestrel intrauterine system may be cautiously considered for patients with previous breast cancer who have used tamoxifen (Nolvadex) for more than one year; the system may prevent tamoxifen-induced endometrial changes. However, long-term randomized trials are needed before the levonorgestrel intrauterine system can be recommended as an adjuvant therapy with tamoxifen in women with a history of breast cancer.

It is reasonable to consider use of the levonorgestrel intrauterine system by women with endometriosis who desire effective, long-term contraception.

Physicians are advised to consider the levonorgestrel intrauterine system as an option for the treatment of idiopathic menorrhagia, but additional studies are required to recommend it as a reliable treatment option for endometriosis-associated pelvic pain, endometrial adenocarcinoma, hyperplasia, or as an adjuvant therapy with tamoxifen.