Sidney Crosby, the NHL, and mumps–separating myth from science

crosby-mumps-2Yesterday, I posted an article about the recent mumps outbreak in the National Hockey League, which has hit 13 players (there’s no official number, it varies depending on the source) including one of top stars of the league, Sidney Crosby of the Pittsburgh Penguins. A fourteenth player, also on the Pittsburgh team, may also have the virus, depending on the test results that come back for Pittsburgh Penguins winger Beau Bennett, who has been “put in isolation” by the team.

If this outbreak happened in the general American population, it would get some local news, but since there are just a few hundred cases of mumps in the USA in any given year, not many of us would be writing about it. But since it’s happening in a popular sport (technically the fourth most popular sport in the USA, but number 1 in Canada), it gets more focus.

While writing the story about this outbreak yesterday, I ran across a lot of social media myths that vary from truly odd and scary to plain misinformation. I thought it would be useful to quash some of the most annoying bits of misinformation.

Who is Patient Zero (the first player who spread the measles to everyone else)?

This is almost impossible to answer. Hockey blogger Greg Wyshynski provided this preliminary timeline of the outbreak:

  • Oct. 2014: The St. Louis Blues have several players that tested positive for the mumps, according to the Star Tribune. The team later told the LA Times that they “never confirmed the mumps” despite Joakim Lindstrom and Jori Lehtera both having mumps-like symptoms. As of this writing, no Blues’ illnesses have been formally defined as the mumps.
  • Oct. 17: Keith Ballard misses a game for the Minnesota Wild. The Star Tribune reports it was the mumps.
  • Nov. 5: Francois Beauchemin and Corey Perry of the Anaheim Ducks both come down with the mumps and miss multiple games.
  • Nov. 29: Tanner Glass of the New York Rangers becomes the first player not with the Ducks or Wild to be diagnosed with the mumps.
  • Dec. 12: Sidney Crosby appears before cameras looking like Quagmire, and the Penguins eventually diagnose this as the mumps. And suddenly everyone cared about the mumps.
  • Dec. 14: Beau Bennett of the Pittsburgh Penguins becomes the 15th (or 14th depending on source) player publically diagnosed with the mumps from the Ducks, Wild, New York Rangers and New Jersey Devils: Crosby, Bennett, Perry, Beauchamin, Ballard, Glass, Ryan Suter, Emerson Etem, Marco Scandella, Jonas Brodin, Christian Folin, Clayton Stoner, Adam Larsson, Travis Zajac and Derrick Brassard.

It appears that the St. Louis Blues players were the first, but there’s no confirmation from either the team or league (which does a disservice to everyone involved, something we’ll discuss later). It’s possible that players contracted the mumps from someone other than players (maybe a fan, children, or during travels). Because the infectious period of mumps can be up to 3 weeks, it becomes impossible to find that starting point.

Mumps is easily transmitted from person to person. In a competitive athletic team, players share towels, water bottles, equipment, and are in very close contact. It’s a wonder that more diseases don’t spread through teams.

How did the mumps get to the NHL players in the first place?

It is unknown. Mumps, as I’ve stated above, has not been completely eradicated in the USA. It’s not endemic (naturally occurring) in the USA, but several areas of the world have constant mumps outbreaks, if not epidemics. In our modern world of travel and immigration, people can pick up mumps and bring them to our shores.

Some writers have blamed the outbreak on illegal immigrants (yes, really):

Adults who are heading off to college, military camps, sports teams, or other locations where there are a lot of people in an enclosed space should check their vaccination records and get a MMR booster, if needed. Being vigilant about vaccination status is especially important after the recent rush of unvaccinated immigrants who have surged into this country.

Setting aside the obvious racism, xenophobia and anti-immigration attitudes, there is simply no evidence that illegal immigrants are the source of the outbreak. But at least the writer’s opinion about vaccination is spot on.

Next up–blame Obama.



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What does it matter? Mumps is nothing.

Let’s put this myth to rest right away. Mumps is a virus that causes flu-like symptoms (it is not related to flu) followed by swelling of the salivary glands, causing the iconic swollen look of mumps victims. It’s a rather uncomplicated disease–until such point it causes serious, sometimes dangerous, complications. The most common complication is inflammation of the testicles (orchitis) in males who have reached puberty, which sometimes causes fertility problems including sterility.

Other complications include encephalitis or meningitis which has an extraordinary risk of occurring in 15 out of 100 infected adults (pdf), inflammation of ovaries or breasts in females who have reached puberty, and pancreatitis which has a relatively high risk of occurring in 5 out of 100 infected adults (pdf). Deafness is a rare but statistically significant complication, appearing in 1 out of 20000 infected patients. Death is extremely rare for mumps, but when it does happen, it almost always happens to adults.

There is a general myth out there that vaccine preventable diseases are not very serious. The reason many of us feel this way is that we have lost the cultural memory of massive epidemics of diseases like the mumps, and everyone knew someone in the community whose child ended up in the hospital with a serious complication. Mumps now is so rare that maybe a handful of children (or adults) who get a complication, so we think it’s just a minor disease like a cold. It isn’t.

The mumps vaccine gave the players the mumps!

Yes, I saw that on some Twitter message to me. However, the MMR vaccine simply cannot give mumps to the person who is immunized. The vaccine contains a live attenuated mumps virus–this means the virus has been “attenuated” with various mutations that eliminates or slows its ability to reproduce (and thus be pathogenic). The advantage of this type of vaccine is that it provides maximum antigenicity (that is, the immune system will remember the mumps virus for the future if it encounters the mumps again), without any of the serious risks of a natural mumps infection.

The virus in the vaccine simply cannot cause an infection, because it is so disabled, that it’s really alive long enough to provide a good immune memory of that virus. That’s what we want–all the immunity with none of the disease itself.

Does the mumps vaccine even work any more?

Absolutely. Today, with the success of the mumps vaccination, which is part of the MMR vaccine for mumps, measles and rubella, mumps is extraordinarily rare. In 1967, there were 186,000 cases of mumps in the United States–translating that to the current USA population, there would be approximately 280,000 annual cases. Canada, the other country where the NHL has teams, has had a similar 99% decrease in mumps cases since the release of the MMR vaccine.

According to an article in Forbes by Tara Haelle,

“We know the short-term effectiveness of the mumps vaccine is excellent,” Paul Offit, MD, said. The CDC estimates one dose prevents disease in 78% of those who get it, and a second dose ups that to protecting 88%. Cases in the U.S. dropped from 150,000 to 200,000 a year before the vaccine to a couple hundred a year after its introduction. But two large outbreaks have occurred since then. The largest, involving more than 6,000 cases of mostly college students in the Midwest in 2006, revealed that the vaccine’s effectiveness may wear off gradually over time. Waning immunity, as I’ve described previously, makes someone more susceptible to the disease.

“If you look at the three vaccines, measles and rubella induce larger memory in B and T cells [antibodies that fight off the disease]. They have longer lasting immunity,” Offit said. “Mumps is the weak sister of the three. You start to see vulnerability 10 years after the first dose and 10 years after the second dose.”

And players born before 1990 may not have gotten that second dose. So waning is one of three factors that may be at play here, according to Gregory Poland, professor of medicine and director of the Mayo Clinic’s Vaccine Research Group in Rochester, Minn. The other two factors, he said, are the vaccine’s initial effectiveness and the quality of the specific vaccines the men received.

Though excellent for reducing cases on a macro level, an average effectiveness of 80 to 85% means “Right off the bat, when you give it to 100 people, 15 won’t respond,” Poland said. This is called vaccine primary failure, when a person’s body doesn’t create antibodies in response to the vaccine. (Waning is secondary failure.) The effectiveness of the mumps vaccine has been questioned in a lawsuit against its manufacturer, Merck, but no fact-finding has occurred in that case yet – fully detailed by law scholar Dorit Reiss here – and plenty of high-quality studies have affirmed at least an 70 to 88% effectiveness.

The best data available says that the mumps vaccine component of MMR is extremely effective in preventing mumps.

Let’s look at it another way. Assuming that the vaccine is around 88% effective in preventing mumps, that would mean that in the general population of people, 12 out of 100 might catch the disease. The NHL has around 650 players, so around 70-80 might catch the mumps even if everyone was fully vaccinated. Although it seems like there’s some sort of epidemic coming to the NHL, it isn’t. So far, only 14 or so players have caught the disease, which is substantially lower than expected.

But Sidney was just vaccinated, and still caught the mumps

Yes. And this shows that because of a wide variety of factors, from genetics, to overall health, to any of another dozen factors, one person’s immune response can differ than another. There’s significant variability on how each person’s immune system reacts to each antigen.

Again, from the Forbes article by Ms. Haelle,

And since many players never even got a second dose, a booster shot seems sensible regardless. But that brings us back to Penguins captain Sidney Crosby. He did have a booster, in February before heading to Sochi for the Olympics.

“That’s surprising, but he could have had vaccine failure, or he may not have developed vigorous enough antibodies,” Offit said. “Like all medical products, vaccines are not 100%. A vaccine dramatically lowers your risk, but it doesn’t eliminate it.”

Poland agreed and pointed out another, albeit much rarer, possibility. “There are some people who carry specific forms of immune function genes so that they don’t respond or they respond poorly to a vaccine,” Poland said. Crosby apparently had antibodies to mumps from his booster, but the number of antibodies needed to avoid infection isn’t well-defined, Poland said. Even if it were, an individual’s body could differ from what’s typical at the population level.

Why are you complaining about the NHL in this matter?

I think that the NHL failed to move quickly and dramatically once the outbreak started in St. Louis (although the team still denies it and claims it was caused by some bacteria). The NHL’s medical staff, in a league that is known for protecting the health of its players (as opposed to the NFL, which seems to have a callous disregard for their players) should have recognized the outbreak, and immediately taken steps to prevent its spread.

Their first step should have been to announce what was happening. They really didn’t until early December, and like I said, the St. Louis Blues still deny anything. Were they worried about lost attendance? Lawsuits? I am not an NHL beat writer, so I don’t know. Actually, I don’t care, since the proper action would have been to isolate players, and implement some basic infection control techniques, like not sharing towels or water bottles.

Their second step should have immediate vaccination of all players, coaches and staff before an infected team shows up. Some teams did. The Dallas Stars gave MMR boosters to their players and coaches as soon as the news broke two weeks ago. The Vancouver Canucks have done the same thing, and are closely monitoring their players for early signs and symptoms of mumps.

Their third step should have been to immediately isolate any player with the initial symptoms of mumps, even if those signs could be for other diseases like a cold or flu. The problem is that the mumps is highly infectious prior to all the symptoms being visible, so once the league knew that there was an issue, it should have isolated players that may have the disease from other players. Of course, that may mean keeping star players out of the lineup for a few games, which hurts revenues and the teams’ records. Again, I don’t know what motivated the league from not aggressively handling the disease.

Of course, I’m looking at this issue from hindsight. However, every NHL franchise has a team of physicians who keep players healthy and playing. The NHL itself has physician consultants. They should have done a better job. Because next it could be measles, chickenpox, or a pandemic flu, all of which have more serious consequences.

TL;DR version

  1. We don’t know if or who Patient Zero might be.
  2. Illegal immigrants did not bring the mumps to the NHL. Please.
  3. Mumps can be dangerous, especially to adult males.
  4. The MMR vaccine, which helps prevent mumps infection, still is highly effect. It’s not perfect.
  5. Sidney Crosby is actually a rare case which might have meant he had a reduced immune response to mumps.
  6. The NHL was somewhat negligent in how it handled the initial outbreak. They need to fix this.

 

 

The Original Skeptical Raptor
Chief Executive Officer at SkepticalRaptor
Lifetime lover of science, especially biomedical research. Spent years in academics, business development, research, and traveling the world shilling for Big Pharma. I love sports, mostly college basketball and football, hockey, and baseball. I enjoy great food and intelligent conversation. And a delicious morning coffee!