This Podcast Will Kill You - Ep 105 Down in the Mumps

Episode Date: September 13, 2022

We’ve covered measles, we’ve taken on rubella, and now we’re finishing up the classic MMR vaccine by exploring the other M: mumps. To some listeners, mumps may be a painful childhood memory while to others it’s just a letter in a vaccine they were too young to remember getting. But by the end of this episode, we promise that you’ll all be much more familiar with this strange little virus. How does the mumps virus make you sick and give you that classic swollen face look? What is so bad about the mumps that Maurice Hilleman decided to snag a sample from his sick daughter to make a vaccine? Where do we stand with mumps today and what do declining vaccination rates have to do with those not-so-great numbers? Tune in to hear our take on all these questions and many more in this classic TPWKY episode. See omnystudio.com/listener for privacy information.

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On March 23, 1963, at 1 a.m., Gerald Lynn Hilliman woke up with a sore throat. Five years old, with penetrating blue eyes and an adorable pixie haircut, Gerald quietly tiptoed into her father's bedroom and stood at the foot of his bed. Daddy, she whispered, Hilleiman shook himself awake, rose to his full height of six feet one inch, bent down and gently touched the side of his daughter's face. There, at the angle of her jaw, he felt a lump. Gerald winced in pain. At the time of his daughter's illness, Hillamon was a single father. Four months earlier, his wife, Thelma, had died of breast cancer. Although he wasn't sure what was happening to Gerald, Hillamon had a pretty good idea. Near his bed was a book titled The Merck Manual, a simply written compendium of medical information. Thumbing through it, he soon found what he was looking for. Oh my God, he said, you've got the mumps. Then Hillamond did something that few fathers would have done.

He walked down the hallway, knocked on the housekeeper's door, and told her that he'd be gone for a while. Then he went back to his bedroom, picked up his daughter, and put her back to bed. I'll be back in about an hour, he said. "'Where are you going, Daddy?' asked Gerald, to work, but I won't be long. Hillamon got into his car and drove 15 miles to Merck. He rummaged around his laboratory, opening and closing drawers, until he found cotton swabs and a vial of straw-colored nutrient broth. By the time he got home, Gerald had fallen back to sleep,

so he gently touched her shoulder, woke her up, stroked the back of her throat with a cotton swab, and inserted it into the vial of broth. then he comforted her, drove back to work, put the nutrient broth in a laboratory freezer, and drove home. Most parents thought that mumps was a mild, short-lived illness, but Hillamon knew better. He was scared about what might happen to his daughter. Although he knew that it was too late for Jarrell, Hillamon wanted to find a way to prevent mumps. He decided to use his daughter's virus to do it.

I love it. It's so good. so exciting. It is. It's amazing. I also just love what a nerd he was that he slept next to the Merc Manual, like had it on his bedside table. Maurice. It's amazing. As if you don't do the same thing, Aaron. I have a stack of medical books on my bedside table right now. See? Yeah, I know. It's embarrassing. Nerds unite. That amazingly written story is true story, is from the book vaccinated, One Man's Quest to Defeat

the World's Deadliest Diseases by Paul Offutt, and it is about Maurice Hilliman. Yeah. Who played a big part, a huge part, a crucial part, as well as his daughter, in the creation of the mumps vaccine, which is the subject of today's episode. It sure is.

Hi, I'm Aaron Welsh. And I'm Aaron Alman Updike. And this is, this podcast will kill you. We're really excited to be bringing back yet another of the vaccine preventable diseases. We sure are. I mean, this is the last of the MMR that we needed to cover. Yeah, the other M, we've got it. The other M. Yeah. Speaking of the other M, what are we drinking this week?

That's what we're drinking. The other M. I feel like most people, when the other M, when the other M, I feel like most people, when the other. they think of MMR. It's sort of all blurred together, right? It's measles, mumps, rebella. You barely take a breath between them or even a pause. It's just all one word. But I also kind of think that maybe measles springs to mind first for most people. I think it depends on the generation. I think that there's a good chunk of people who remember mumps more than anything because of some of its distinctive signs. But yeah, measles, I think, steals the show in that vaccine. Yeah, maybe. Maybe it's because there have been more recent outbreaks of measles, although there have been recent outbreaks of mumps.

So, yeah. We are drinking the other M in any case. And in the other M, it's a tasty little concoction with bourbon, sage simple syrup, because my garden has way too much sage. And some orange tossed in there. Yeah. It's delicious. I can't wait. It's very early fall.

Fantastic. And we will post the full recipe. for the quarantini, as well as the non-alcoholic placebo burita on our website, This Podcast Will Kill You.com, as well as on all of our social media channels. We sure will. On our website, this podcast will kill you.com, you all know how many amazing things you can find there.

Do we even do this anymore? We've skipped it a few times. Check out our website. I like it. Yeah. And I don't think there's any more business. So can we dive into the last of the MMR? I am really excited.

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now available in Canada, too. That's Q-U-I-N-C-E.com slash this podcast to get free shipping and 365-day returns. Quince.com slash this podcast. So, mumps. Mumps is the disease, that's the name of the disease, that's caused by a vise. that is named the same thing, the mumps virus, which I think we've covered a number of viruses whose disease are named the same thing, but I don't know why I expected mumps virus to be named something different, like something more virus sounding. That's a good point. Yeah, it's like,

it's the mumps virus virus. It causes mumps. I mean, surely it has like a virus family and that's stuff like that That sounds a little more professional. We can do that, of course. It's in the family paramexavira day. There we go. Which is, as it turns out, the same family as the measles virus, as well as para-influenza, canine distemper, RSV, a whole bunch of other viruses that are pathogenic to humans as well as our dogs. Mumps virus has a single-stranded RNA genome. It's an enveloped virus.

So outside its little protein capsid, it has this lipid and glycrow. protein envelope that helps it evade our immune response. And from what I could tell, there are at least 12 different genotypes of this virus that do vary geographically. But it's unclear whether these genotypes vary that much in virulence, probably not substantially, at least as far as we know so far. Serotype-wise, if you remember in our leptosporosis episode, I talked a little bit about the differences between like what is the serotype, etc. Right. So serotypes are things that vary based on their outside surface proteins.

And so we can categorize them like based on different epidemic outbreaks and things like that based on different serotypes or serovars. And in the case of mumps, it doesn't seem like there are a lot of different stereotypes, but there are differences in their genes. So there are different genotypes, but it's unclear how much. these genetic differences really translate to differences in the virus and how it interacts with our immune system and causes disease, if that makes sense. Yeah. Okay. So, for instance, when it comes to different serotypes, you might not have cross protection or as much cross protection from one compared to the other because the surface protein is different and your immune system might not recognize a different serotype that you haven't previously been infected with, whereas different

genotypes, you could be infected with one and then your immune system would recognize another because those surface proteins aren't substantially different. Right. Exactly. Yeah. Okay. Okay. That was a more succinct summary than my blathering. Yeah. I felt like I went on and on. But I think that that makes a lot of sense. And I think that's really interesting from both a public health perspective as well as an evolutionary perspective. Yeah, yeah, exactly. And vaccines. And vaccines. So mumps is. a human-specific virus. It does not infect other animals naturally, just humans.

And it's a very contagious disease. The R-Not, which we haven't talked about for a long time, so excited to bring it back. The R-Not is a number that is used in epidemiology to estimate the average number of infections that result from a single infection in an entirely susceptible. population. I feel like we all know are not from COVID now. I know, but now it's been two and a half years, so people might have forgotten. You know what I mean? But yes, a little refresher. But this is an estimate so it can vary, right, depending on the population and the study that you're doing. So for months, the average is estimated at around 4.4. So every one case results in four and a half-ish additional

cases. But depending on the population, that can vary from three to 10. Wow. Yeah, in different studies. So potentially up to one person can infect up to 10 people in some studies. Huh. Okay. That's very contagious. Very contagious. And transmission is by primarily respiratory droplets, as well as close contact in general because respiratory droplets are generally close contact transmission, as well as potentially foam mites or surfaces like doorknobs or pillows or whatever that become contaminated. And that would be contaminated through your saliva? Exactly. It's very much like influenza. And how durable is this virus in the environment?

Great question. I actually didn't see any data on that, so I do not know. Okay. Yeah. Yeah. Good question, though. But yeah, it can be transmitted that way. So it's very much like influenza and a lot of other crowd diseases that we've covered. And also like a lot of those diseases, people become contagious or infectious at least a day or two before their symptoms start. And virus has been isolated from saliva and nasal mucosa up to a week before symptoms. start. Which is terrifying. Yeah. Okay. Question. How long is the incubation period then? Great question. It's very long. It's between 15 to 24 days. So like two to three weeks. That is so interesting. Why is it so long? I don't know, Erin. I have a lot of I don't knows about mumps. So once we get exposed to the virus, let's say a couple of toddlers at preschool. breathing on each other like they do. Yep.

The virus then predominantly infects the cells that line our respiratory tract, or at least initially, begins to infect those cells, especially the upper respiratory tract, usually doesn't make its way into our lungs, not causing like a lower respiratory infection. And then one of the primary cell types that it infects and begins to replicate within is our parodid glands. Our parodid glands are a pair of salivary glands. in your cheeks, kind of like back near the angle of your jaw. And this infection of this glandular epithelium, that's the cells that are lining the glands, like in your parodic glands, leads to what's called a parotitis. That just means inflammation of these glands. And that is what leads to one of the

hallmark symptoms of mumps infection, which are super, super swollen cheeks. But this is not a virus that only infects our parodic glands. It can infect a variety of glandular epithelial cells. It can infect our respiratory epithelium, of course. It can infect our central nervous system. And wherever it goes, what it does is essentially replicate a lot. And this replication causes a lot of local inflammation, infiltrates of our white blood cells, trying to fight off this virus by killing those infected cells, which can then lead to hemorrhage or necrosis of various tissues within these organs, and significant swelling and potentially increased pressure in these various glands. So what we see with infection with a mumps virus is both direct damage from

the virus replicating in our cells, but also a lot of indirect damage from our immune response to such a highly proliferative virus. Okay. Questions. Why does it go where it goes? Especially like the central nervous system and outside of the salivary glands and respiratory tract. Great questions. So what's very interesting is that one of the papers I read suggested that Mumps virus actually has a very high, we've talked on this podcast about tissue tropisms. So particular tissue types that viruses are very good at infecting. And in animal models, mumps virus actually has a very strong tissue tropism for nervous tissue. So it invades and replicates really well in nervous tissue in animal models. But in humans, we actually don't see very common. It's not the hallmark symptom to have neurologic

involvement. As we'll talk about, you definitely can. But primarily, it seems to infect these other epithelial cell layers. Why does it have a particular tropism for these glandular epithelial cells? I don't have an answer for you. And what's very interesting is that it really is these parodid glands specifically that are the hallmark and other salivary glands, because our parodids are not our only salivary glands. We have others under our mandible and under our tongue. Those tend to not be infected, at least not without also having pirated gland involvement. Like, it's much less common. Does that make sense? Yeah. How fascinating. Yeah. And I will talk about this isn't restricted to that glandular epithelium. It can infect epithelial cells in a lot of other

organs as well. And I think it just is a matter of does it manage to make it all the way to those organs evading our immune response on its way there? And then if it does, then it can set up shop and just replicate like it does in our parotids. One more quick question. Okay. How does infectivity change throughout the duration of infection? Yeah. Your most infectious, those couple of days before symptoms start, and then for the first week-ish after that. Okay. Yeah. But we know that virus can be detected for up to a week before symptoms, and I think for

even longer than a week after symptoms begin, but the most highly infectious time seems to be that kind of more narrow time window of just before symptoms start and for a few days, maybe up to a week after. Okay. Yeah. So let's talk about what those symptoms actually look like, shall we? Yeah. Just talked about this virus itself. Let's talk about what's happening to us. So first of all, and this kind of like messes up what I just said, Erin, about the parotot glands. But 30% of the time, this is an asymptomatic infection. Right. Yeah. Yeah. Which I did not know. And I feel like it makes it that much more terrifying, considering how long the incubation period is, how much you can shed before symptoms even start. How much are asymptomatic carriers contributing to spread?

Ooh, scary. Yeah. Okay. But that's 30%. So let's talk about the other 70, shall we? Uh-huh. In that 70-ish percent of people who become symptomatic, the infection usually starts with a little bit of a fever,

but not like, I'm laid out, I'm feverish, I'm so ill. It's just like feeling run down, maybe not having much of an appetite, often having a headache, feeling sick. And then over two to three days is when that hallmark sign of paratitis begins. The parodid glands can get so big that they actually lift up your earlobe kind of up and out and you completely lose that angle of the jaw. If you look at pictures of people with mumps, it's hard for me to describe well, but you just really have two ginormous chipmunk cheeks.

Also, if you've watched Brooklyn Nine-Nine, there's an episode where Jake and Captain Holt get mumps. Yeah, I forgot about that. And they named them. Oh, my gosh. They name their big swollen lumps. That's hilarious. How accurate is it? Well, let me go through and you'll tell me.

I mean, it's been a long time, but it's, yeah, it's been a long time since I've watched it. But, yeah. And this swelling can persist for up to a. entire week, and it is incredibly painful. It's a very, very inflamed organ. It's super tender. 90% of the time, it's bilateral, so you're miserable on both sides. And usually it starts on one side, and then the second side takes a couple extra days to come in. That part is accurate from Brooklyn 9-9, I'm pretty sure. I love that. And 95% of people who show symptoms do have this parotitis. So it is very very, very classic. The testes are another very common site of mumps's infection, especially in

post-puberdle people with testes. 15 to 30 percent of post-peuberdle people with testes can get an infection that is often an epididymmo orchitis. Oh gosh. It's both epididymitis and orchitis. So let me tell you what those two things are, shall we? Yeah, yeah. So the These symptoms often start several days to a week after the parotitis. It is possible to get it without that parodotid gland swelling, but it's much less common. And it's two different things that can happen. First, it's an orchitis, which is inflammation of the testes themselves, the sperm-producing little oval structures in the scrotum.

With that inflammation, think of it just like your parodotid glands. its swelling, its warmth, its tenderness, extreme tenderness, because of all this inflammation. Then on top of that, you can also get an epididymitis, which is inflammation of the epididymis, which is the tube that carries sperm away from the testes themselves and kind of stores the sperm as well. And with that, you usually also see more general constitutional symptoms, like a worsened fever, headache, vomiting, just overall looking a lot sicker. So that's very miserable. In terms of the long-term effects of this epididymal or chitis, it seems still controversial from what I could tell whether there is a long-term association with like infertility or subfertility or reduced sperm

production. There are some studies that do suggest a small deal. decrease in testicular size and or abnormalities in spermatograms, whether that be sperm count, sperm morphology, or sperm motility. But this is only in a percentage of people, and it doesn't seem like we have great data on like how common this is or what the real effects of this are. Like, why is this causing more long-term effects? Overees can also be affected, but it tends to be much less common. About 5% of post-puberital or reproductive age people with ovaries get oopiritis. So again, just inflammation, same situation happening, but in the ovaries. You have a question. Like, your face is saying like, why? And I don't know why. Yeah, why is it less common?

Is really what I was going to ask? I wonder if it has anything to do with like differences in body temperature or something. Like the testes and the salivary glands are in a very different place in your body, in your abdomen. But I don't know because they can also replicate in your kidneys just fine. So maybe it's just that it's a more indirect route to try and get there for the virus. I don't have an answer for you. Do we just diagnose it less? I don't know. I don't know.

I don't have any answer. Interesting. Now, all of those symptoms are horrible. they're painful. They may or may not cause residual symptoms in the case of an orchitis or an epitomitis, but they do tend to be self-limiting in all those cases. The problem with mumps virus is that it can also infect the central nervous system and it can result in a meningitis or an encephalitis. It is rare. Most estimates I saw suggested that about five to ten percent of cases, Cases of mumps will cause a meningitis, although one World Health Organization article suggested

up to 15%. And less than half a percent, 0.5 percent, cause encephalitis, which is the worst one. Five to 10 percent still seems pretty dang high. It is. Absolutely. And apparently up to half of the time with a meningitis, it can happen even without that parodid gland swelling and infection. So you might not have had that as a preceding symptom to know that this meningitis is likely related to the mumps, if that makes sense.

And if that's not enough that it can happen without even the parotic gland swelling, it can also happen in any order. So you can see meningitis that starts before salivary gland involvement or after salivary gland involvement. Okay. Now, mumps meningitis is a more severe infection. You can see things like high, high fevers, headaches, vomiting, all the scary kind of meningial signs when you have inflammation of these meninges lining your nervous system, like stiff neck, like lethargy. But in general, very low mortality from mumps meningitis and very little long-term issues and problems that arise as a result of this meningitis, which is really in contrast to other causes

of meningitis. Okay. However. There's always a however. There's always a however. There can be a progression to encephalitis, which is inflammation happening in the brain itself, in the parankuma of the brain. And that does lead to the potential for severe and lasting damage, including seizures,

behavioral changes, hearing loss. Asterisk, hearing loss is actually a well-known complication of mumps that happens in about 4% of cases overall. So not only in these encephalitis cases, but unlike hearing loss as a consequence of other forms of meningitis, it's often unilateral rather than bilateral, one ear, not both. And it's often transient, which is good, but it can be permanent, which is not good. And despite how rare this encephalitis is in a mumps infection, mumps was the leading cause of viral encephalitis in the United States and many other countries until the vaccine was widely available. So this is not a benign disease, even though the vast majority of people who get it will have a very sort of self-limited disease course. So yeah, that's kind of the worst of the things that can happen. Like I kind of alluded to, mumps can infect a lot of other organs. It can cause a pancreatitis, which is inflammation in your pancreas. It can cause kidney infections. It can infect your heart. Really, it can go anywhere. But the ones I talked about are kind of the most common places that we see mumps infection happening. Overall, the fatality rate is very low, about one to three per 10,000 infections and almost exclusively in cases of inseffable.

I have a question. Okay. So clearly it can cross the blood-brain barrier and cause problems in your central nervous system. Correct. Can it cross the placenta? Great question. I believe so. Mumps, it's not very strong associations, but there is some suggestion that mumps can be associated with spontaneous abortion, early pregnancy loss, even in a few case reports that I saw. neonatal infection leading to neonatal death when someone was infected like very much at the end of their pregnancy like a few days before delivery. So yeah. But part of the problem about kind of all of these questions is that most of what we know about the pathogenesis of mumps comes from animal models and this is a human specific virus. So all these animal models are imperfect. And I think it's probably

a part of why we don't know maybe as much about the specific pathogenesis as we do about other viruses. Right. Okay. That makes sense. But we do have a vaccine. We do. It's the second M in the MMR vaccine, measles mumps and rubella.

The vaccine for mumps is a live attenuated vaccine, which means it's a live virus that has been grown in laboratory culture to not be very. so it doesn't cause symptomatic disease. And it's available in MMR, but also as like on its own, like just mumps. And there's actually a lot of different vaccine strains that exist out there. And some of them do seem to be more effective than others, which is very interesting, especially in the context of the fact that we don't know that genotypes are all that different. You know, what I mean? And what's very interesting, and I'll kind of talk more about what has happened as a result of this, some cases of aseptic meningitis.

So meningitis that you can't grow anything from, like in culture, have happened as a result of vaccination with specific strains of the vaccine, of the Mumps vaccine. But this vaccine isn't really in use very commonly anymore because of that. and importantly, all of the cases of asymptic menendritis that happened from this vaccine strain of the virus did not result in any kind of long-term consequences or any deaths as far as everything that I read. Okay. But important to note. Okay. I have a question about the disease itself, months.

So you mentioned that in infants, the disease can be very severe. do we see any other patterns when it comes to age, for instance, in terms of whether someone has certain symptoms or more likely to have a more severe course of infection, stuff like that? Yeah, great question. It actually tends to be more severe like a lot of childhood illnesses if you get it later in life. So as an adolescent or an adult, especially with testes because we really don't see that testicular infection. prior to puberty, very commonly at all. Right. Okay.

So then that leads me to a question about the vaccines, which is waning immunities. How does the vaccine durability change across these different vaccine strains? That's a great question, Aaron. The whole waning immunity thing is a really important part of vaccination. So in general, childhood infection with mumps induces a very persistent, long-lasting. immunity that as far as we know is pretty much lifelong. But again, infection can also cause meningitis, encephalitis, and death. So we vaccinate to avoid those consequences. Vaccination with mumps specifically does seem to have a waning immunity, although it's not for everyone. On average,

some studies have found that vaccination can lead to 27 years or more of immunity to mumps, which is a really long time. Yeah. But up to 25% of people might lose that protection within just seven or eight years. Okay. So the 27 years is an average, but that average has a really widespread. And the question of why that is is something that we still don't really know. Mm-hmm. Okay.

And I'll talk a lot more in the current event section about what the consequences of that have been in terms of outbreaks that we've seen in adolescents and young adults, especially, that likely this waning immunity plays a big role. Yeah, of course. So that's the biology of mumps. What a weird little virus. Isn't it? It's interesting, though. It's really interesting. Yeah.

So tell me, Aaron, where did this weird little guy come from? I won't answer that question, but I'll get into more about months and the history of this disease right after this break. Anyone who works long hours knows the routine. Wash, sanitize, repeat. By the end of the day, your hands feel like they've been through something. That's why O'Keefe's working hands hand cream is such a relief. It's a concentrated hand cream that is specifically designed to relieve extremely dry, cracked hands caused by concentrated. constant hand washing and harsh conditions. Working hands creates a protective layer on the skin that

locks in moisture. It's non-greasy, unscented, and absorbs quickly. A little goes a long way. Moisturization that lasts up to 48 hours. It's made for people whose hands take a beating at work, from health care and food service to salon, lab, and caregiving environments. It's been relied on for decades by people who wash their hands constantly or work in harsh conditions because it actually works. O'Keefs is my hand cream of choice in these dry Colorado winters when it feels like my skin is always on the verge of cracking. It keeps them soft and smooth, no matter how harsh it is outside. We're offering our listeners 15% off their first order of O'Keef's. Just visit o'keefscom.com slash this podcast and code this podcast at checkout. This is Bethany

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That's the best part. There's such a huge demand for personal trainers that ISS guarantees you'll get a job. I'm in. How do I get started? Just send them a text. Get your free personal training evaluation kit today. Just text train to 32 323232. To 32 32 32 32. Trane to 32 32 32. Trane to 32 32 32. Trem to 32 32 32. Mumps is a classic. It's a classic TPWKY topic. Historically, it's been a classic TPWKY topic. Historically, it's been a classic childhood illness, and now, thankfully, it's a classic vaccine-preventable disease. Such a classic. It's a classic.

And most of what I'm going to talk about today is the story of the mumps vaccine as well as the man behind this and many other vaccines, Maurice Hilliman. If you're a listener, you know his name. You certainly do. But before I get there, I want to briefly take you through the early history and prehistory of mumps, or at least as far as we know. Where the mumps virus came from seems like somewhat of a difficult question to answer. It's possible that it's spilled over from pigs to humans during the agricultural revolution when humans first began to domesticate pigs. And that's based on the

fact that there's a very similar virus found in pigs. They seem to be related. Or another option is that it spilled over from humans to pigs. Ah, maybe. And more recently, a virus very similar to the human mumps virus has been found in certain bat species, leading some researchers to hypothesize that perhaps the mumps virus spilled over from bats into humans and maybe also pigs. This is kind of my long way of saying that we don't know. We don't know. We don't know where mumps virus came from and when it first started infecting humans. And maybe that information is out there. And I just. didn't search for it well, but I couldn't find anything more specific than that.

But we do have a better sense for when mumps was first written about, and that is, of course, from the Hippocratic texts around the 5th century BCE. Retrospective diagnosis of any disease can be difficult and a little bit hand-wavy, but as you described, a typical infection with mumps is pretty distinctive. to those chipmunk swellings around your jaw. And so this quote from the Hippocratic text describing an outbreak of an illness on the island of Thassas seems pretty clearly mumps. Tell me if you agree.

Okay. Quote, swelling appeared about the ears in many on either side and in the greatest number on both sides. In some instances earlier and in others later, inflammation with pain seized sometimes one of the testicles and sometimes both. Yep. Sounds like mumps. Sounds like mumps.

Yeah. And in later centuries, historians and physicians recorded outbreaks of a disease that sounds pretty similar to mumps. And as early as 1755, people suspected that it was contagious. I just love those stories when people knew that it was contagious before they knew like what the heck a virus or a bacteria or anything was. What was the actual contagious agent? Unit, yeah.

Yeah. Yeah. And by the way, I just have to throw in here the etymology of mumps. Oh, please. So the English word for the disease, mumps, it's different in other languages. The origin of that is a bit of a mystery. It could refer to like lumps around your face. Okay.

Could refer to the English verb mump, meaning to be sulky, or it's even been suggested that it comes from the difficulty in speaking experienced by people who have those salivary gland swellings. Like mumm-wam-m-mong-mong. Yeah. I don't know. But one of the things I thought was really hilarious, especially when you were talking about how, like, why doesn't the mumps virus have a more scientific sounding name? Yeah.

So one of the earliest articles about mumps, like scientific articles from 17. is titled, quote, An account of a distemper by the common people in England vulgarly called the mumps. So, and the author, like, in the text immediately said, like, I beg leave to call it not mumps, but angina maxillaris. Mm-hmm. He was like, we can't call it mumps. It's too improper. So it's the mumps is the vulgar name for it, I guess.

Who knows? Hilarious. But anyway, by the late 1700s, interest in mumps had increased, with the result that people began to take a closer look at the more severe manifestations of infection, like the nervous system involvement that you talked about. They also began to recognize its cyclic pattern. So every few years, like, I don't know, three to seven years or so, an epidemic would occur as the number of susceptible individuals in a given area increased, which is something that we commonly see for crowd diseases, especially

prototypically childhood diseases. People also started to note its global distribution, which was truly seemed to be global, and they also observed how it spread rapidly under certain conditions, things like prisons, boarding schools, ships, and of course, soldiers at war. The estimate for some military populations was as high as 6,000 cases per 100,000 individuals. Wow. Wow. It's pretty high. It is. And it's interesting that like they're going to be grownups. It's like there's that many people who are still susceptible in that population for that outbreak to happen. Yeah. That's interesting. Yeah, it is. Yeah. How did they escape it? I mean, they just missed the window. They just missed the window. Ooh. And unfortunately hit it later on. Yeah. I mean, so during the U.S. Civil War, about 11,200 cases of mumps were reported during the first year. And, and over 13,400 in the second. Wow. So again, these are not, these are people who escaped it as children.

As children, yeah. Mumps also ran rampant during World War II with the Surgeon General of the U.S. Public Health Service stating in 1940 that it was, quote, one of the most disabling of the acute infections among armed forces recruits, exceeded only by the venereal diseases. Wow. End quote. Yeah. I had no idea how prevalent this was. And I feel like a lot of people, a lot of us who were born after the mumps vaccine already existed, maybe just didn't realize how widespread it was. It was just sort of an inevitability almost of childhood.

I feel like mumps has been one of the most brushed under the rug. Like a vaccine came out and then our collective consciousness like forgot how bad it was because I didn't know how bad it. was. I feel like the same thing. Maybe measles was like that too until measles started increasing and people were reminded of just how horrible this disease could be. Maybe. Yeah. So yeah, but I agree. It does sort of seem like an afterthought. And it certainly didn't used to be just an afterthought. It used to be a hugely important disease and that made it a public health priority to find out how it was transmitted and what caused it. What was the pathogenic agent? In 1934, C.D. Johnson and E.W. Goodpasture demonstrated that mumps was caused by a filterable

transmissible agent, aka a virus. I love it. In saliva, and they did this by transmitting the disease from humans infected with mumps to rhesus monkeys. And a little more than 10 years after that, The virus was first cultivated by K. Havill. And a few years after that, in 1948, G. Henley and his colleagues investigated the relatively high rate of asymptomatic infections. Interesting.

Apparently, there was an experimental killed virus vaccine that came out in the early 1950s. But I don't know if it was just, if it stayed experimental, you know, or if it was ever distributed widely. And I'm kind of guessing that it wasn't because there was still such a need for mumps was still infecting millions of people every year. Yeah. And in order for mumps to become this afterthought like we talked about simply like one of the Ms in MMR in many places around the world, which kind of is today, although things are changing, that transition would take a more effective vaccine. And for that, we needed, of course, Maurice Hilliman. Let's hear it for Maurice. Let's hear it for Maurice.

From the start of the 20th century to the end of it, Americans lived 30 years longer on average. And that's thanks to an improvement in many different technologies and infrastructure. From seatbelts to access to clean drinking water and improved sanitation, antibiotics, workplace safety regulations, improved nutrition, and many other things. But the most impactful of all medical advances was certainly vaccines. And the person responsible for developing a great number of these life-saving vaccines was one Maurice Hilliman. Like you said, Aaron, if you've listened to the podcast before, Maurice Hilliman's name probably

sounds familiar to you, especially if you've listened to our vaccines episodes. where we mention some of the incredible work that he did in vaccine research. But we didn't talk about him in too much detail. And since this Mumps episode marks the last of the diseases covered by the MMR vaccine that we've done on the podcast, I thought I'd take just a little bit more time to talk about Maurice. I can't wait. Maurice Hilliman was born at his family's home on the banks of the tongue and Yellowstone rivers near Miles City, Montana, on August 30th, 1919.

It's like Eastern Plains, Montana, just out there. Okay. His birth was marked not only by global tragedy. He was born at the end of the influenza pandemic that had killed tens of millions of people around the world, but also by personal tragedy. His twin sister died at birth, and his mother followed shortly after from Eclampsia.

Ugh. Yeah. Maurice later said, quote, I always felt that I cheated death. Wow. He spent his childhood living with his aunt and uncle, but working during the day at the family farm, the Riverview Garden and Nursery, and getting into trouble and adventures when he wasn't working. Nearly drowning in the Yellowstone River while floating on a makeshift boat, getting diphtheria,

nearly getting hit by a freight train while riding his bike across a train bridge. Uh, yeah, rough and tumble childhood. Uh-huh. His childhood heroes were Charles Darwin. He got caught reading on the origin of species in church. Oh, my God. And also Howard Taylor Ricketts, who I talked a lot about during our Rocky Mountain Spotted Fever episode. Yeah, Ricketts of Rickettsia. He worked in Montana trying to understand how Rocky Mountain Spotted Fever was transmitted and the role of the tick plate, et cetera, et cetera, and find the causative agent. As Maurice got to the end of high school, he struggled with what to do next.

The thought of going to seminary school to become a preacher, which was a very common path at that time for people in his town, that didn't really appeal to him. And so he applied and got a full scholarship from Montana State University. He graduated in 1941, first in his class, with a degree in chemistry and microbiology. His plans were to go to medical school, but he couldn't afford it. he turned his sights to grad school. He applied to microbiology programs all over the country, and his top pick was University of Chicago. He got into all of them, but he chose Chicago, where he quickly made impressive progress on his dissertation, discovering that chlamydia was not caused by a virus, as was the prevailing thought at the time, but rather a small intracellular

bacterium. After finishing that up, the expectation from every at the university was that he would stay in academia, teaching and doing research. But that didn't really sound great to him. Didn't sound as good as a job at a pharmaceutical company because he wanted to take what he had learned in graduate school and apply it to industry, be able to scale up like vaccine production, be able to quality control stuff instead of just one project after the next, after the next. Yeah. But the University of Chicago didn't want him to go into industry.

And so they set up various obstacles to make it more difficult, including a French exam. And Maurice hadn't studied French. So he spent six months learning the language, passed the test, and finally was permitted to work at the pharmaceutical company, ER Squibb in New Jersey. Wait, I'm sorry. Like, they wouldn't give him his degree or something until he jumped through these. I don't know if it was like not giving him his degree or just I can't remember what what the book said.

But yeah. Oh my gosh. I know. It's academia. Yeah. And at Squibb, he worked on the mass production of influenza vaccines. After about four years there, he headed to the Walter Reed Army Medical Research Institute to try to develop new influenza vaccines. And that's something that would serve him very well when he led the charge to produce a vaccine for the 1957 pandemic strain of influenza.

Wow. The 1957 flu pandemic doesn't get a whole lot of attention, I feel, because maybe it wasn't as severe as the 1918 one. But what it did was demonstrate the potential for another influenza strain to sweep through populations, especially those that had no previous immunity to a similar strain. And Maurice was not only one of the first in the U.S. to recognize the potential for pandemic spread, but also he was able to get people to take it seriously, pushing for vaccine development when others were like, you know what, it's not here. We're going to be fine. We don't need to worry about it. And he was like, no, we absolutely need to worry about it. And part of the reason why the 1957 flu pandemic didn't turn out to be as deadly as the 1918 one, was likely due to the vaccine that Maurice produced and pushed. Wow. After the 1957 pandemic, Maurice broadened his scope beyond influenza. He left Walter Reed to become the director of virus and cell biology at Merck Research Laboratories.

And in his new position, he had one simple, easy goal to prevent every viral and bacterial disease that commonly hurt or killed children. Oh, my goodness. I know. Super easy, right? Like simple. Super simple. No problem. Doesn't have like big goals or anything.

No. But honestly, he got pretty close. Wow. He created and tested more than 30 vaccines over the next 30 years of his career. And one of those vaccines was, of course, for the subject of this episode, mumps. Mump. As you heard in the first-hand account, the mumps vaccine got at start when Gerald Lynn Hilliman, whose father was Maurice Hilliman, came down with the infection in March 1963. Maurice took that throat sample that he had gotten from Gerald and brought it into the lab, where he set to work on trying to make a mumps vaccine.

Not for Gerald, of course, like was mentioned, since it wouldn't do her any good at that point, but for the rest of the world. during the 1960s, about a million people in the U.S. got infected with mumps every year. And so when you were talking about these numbers, Aaron, of, oh, well, 5 to 10 percent of people get meningitis, and then a smaller percentage of point get encephalitis, those seem like small numbers. But when you have millions of cases every single year, those are thousands of lives. Exactly. That's the thing about mumps. 95 to 100 percent of people will get mumps in their lifetime if they are unvaccinated if the entire population is susceptible. Yeah. So like this is not a disease that only affects some people. It literally affects everyone in unvaccinated populations. And that's what it did until we had a vaccine. Yeah. Yeah. Those those percent of the people.

points can make the risk of diseases like this seem low. But when you have the number of susceptible people, first of all, the actual number of people impacted can be high. Second of all, no matter how low the risk is, if you can avoid it, why risk it? Just, yeah. I know. I mean, I think, you know, like we've talked about, many of us today don't maybe think about mumps all that often, especially those born after the vaccine was available. And I think our distance from that time period when mumps was a persistent childhood threat, basically in inevitability, means that we don't recognize how fortunate we are to not have to think about mumps. We're like, oh, we never think about mumps.

It's brushed under the rug. How amazing is that? That's a wonderful thing. Yeah. And so Marese was not just thinking, oh, hey, no one's. made a mumps vaccine yet, guess I'll give it a go. This seems like a solvable problem, something fun. He knew that if he could successfully create a vaccine, he could save millions of people around the world from this potentially harmful infection. Yeah. And so he took Gerald Sample to the lab,

and he inoculated it into an incubating hen's egg, and then passed the virus into more eggs, and then grew the virus in chick cells that he had cultured. Again, he transferred the virus from one flask of chick cells to the next, seeing the virus get better and better at infecting the chick cells with every passage. And Maurice took this to mean that the virus was losing its ability to infect humans as it was getting better at infecting these chicken cells. Right. But perhaps, even though it couldn't cause disease in humans, maybe it could induce an immune response, enough for protection. This serial passage process that Maurice used had been used and has been used by many researchers for decades to make vaccines. It's how Louis Pasteur made the rabies vaccine, for instance.

But how can you know for certain that the virus you've created using this process, or any process really, is actually A, effective at preventing infection, while B, not giving you the disease itself, and C, being safe? Yeah. You have to test it out. And this is where we come to the part of the story that is not surprising, but still disappointing, frustrating, appalling. Choose your adjective. But it's important to talk about. And that is the testing of vaccines and other medical studies in children with developmental disabilities. This was not an uncommon practice in the 1930s, 1940s, 1950s, and into the 1960s, including with Maurice Hilliman's Mumps vaccine. Paul Offutt in his book Vaccinated writes that from our perspective today, we may think of the scientists heading those studies as amoral, viewing those children as expendable opportunities to conduct their studies. But he argues that these doctors really saw the children as more vulnerable, more in need of protection, especially those living in crowded and underfunded state-run facilities where infectious diseases often ran unchecked. And part of his reasoning to back that up

is that many of these researchers, including Maurice Hilliman, including Jonas Salk, also tested the early versions of their vaccines on their own children. So why would they inject their kids with something they thought could be unsafe? I'm not sure that I agree with that take entirely. I think it's likely that some researchers did feel that way, that they had good intentions with their studies and who they chose to test out those untested products on. But others may not have felt that way, may have truly looked at these children as less than or as dispensable. And maybe others didn't really think that much at all about the ethics of this beyond seeing these children as an opportunity. Administration of the vaccine and

follow-up was easy because they were all in one place. Infection rates were high. Infection rates were high, so you could get a good sense of how well these vaccines protected, and many of the children were wards of the state, so you didn't have to deal with the parents. And my point here is not try to decipher what these researchers thought about what they did, whether their intentions were good or bad, or how they reconciled it with their ethics. And I'm also not going to go into the history of how we got from there to where we are today with much stricter guidelines on how these studies are conducted, who gets chosen or who gets asked to participate in the study, informed consent, and so on. I'm also not saying, oh, it was a different time. Everyone did it and no one thought

much of it. And I'm also not saying progress could only have happened at the expense of these non-consenting individuals, which is certainly not the case. So enough about what I am not trying to do. What I do want to do, what I want to get across is just that this has. happened. This is a crucial part of the history of the mumps vaccines, of polio vaccines, of hepatitis B virus, and so many other things. When talking about the history of a disease or a medication or medical technology, we need to address the cost of progress and acknowledge who actually paid for it, which in many cases has been non-consenting individuals. Where did the earliest data come from that showed that the mumps vaccine was safe and effective.

It came from children whose consent was not or could not be given, and that should be a part of the story we tell when talking about the history of mumps. Okay, so what happened? The first mumps vaccine test was actually a pretty small study, 16 children at the Trenbler School in Pennsylvania, which was a home for developmentally delayed children, and these 16 children were injected with, Maurea's experimental mumps vaccine in June of 1965. The results were clear. Fortunately, the vaccine

was both safe and produced antibodies against mumps. And so a second trial was carried out. This time on 60 children with developmental delays living at other schools, again demonstrating that the vaccine induced the production of antibodies against the mumps virus. But one thing still had to be answered. did this vaccine actually prevent disease? We saw antibodies, but were those antibodies enough to prevent disease from actually, infection from actually happening? And to answer that, they had to scale up. And for this, Maurice and his colleagues, thankfully, turned away from using these state-run schools. And instead, for several months, Maurice and his colleagues went around to preschools and elementary schools in the Philadelphia area and handed out flyers to parents telling them,

about this new vaccine, and that there would be info sessions held at local churches. At these sessions, researchers on the project would describe the vaccine, how it was made, a bit about how it worked, and then they would open it up to questions. If a parent was interested in allowing their kid to get the vaccine, they filled out a three-by-five-inch card that said, I allow my child to get a mumps vaccine. And had a signature at the bottom. This was this three-by-five little index card was a far cry from the informed consent forms that you see today with info about the safety of the vaccine, the timeline of the project, a list of the ingredients, what the study would entail in terms of tests or follow-ups, all the things that were known. But I found it really

funny to read that it did include the home and work phone numbers of Robert Weibel, who is one of the lead investigators on the project. He was like, call anytime you have any questions, any concerns. Yeah, that's good. In total, about 400 children were enlisted in the study, with 200 getting the mumps vaccine and 200 getting a placebo. Love it. Several months after the study began, a mumps epidemic swept through Philadelphia.

And when the dust settled, 63 children in the study had gotten mumps. Two had been given the vaccine, and the remaining 61 had not. Wow. Pretty good, pretty clear. Yeah. Yeah. And on March 30th, 1967, a couple years after this study and four years after Jeryl Lynn came down with Mumps, the Jeryl Linn Mumps vaccine was licensed for use in the U.S. and cases of the disease dropped rapidly. And since that time, this vaccine has prevented millions, like countless millions of cases of people.

mumps around the world. I want to read this quote from a reporter that has been widely circulated about the mumps vaccine because I think it's hilarious. Quote, Gerald recovered from mumps virus, but mumps virus never recovered from infecting gerald. Isn't that cute? I love it. I love that. Within a few years, the mumps vaccine was combined with the measles vaccine, also made by Hillamon, and the Rubella vaccine made by Stanley Plotkin to be the one-shot MMR vaccine we know today. And this was simply to reduce the number of injections that a child had to get. There are more and more combo vaccines coming out because there are more and more vaccines. More and more vaccines. It's awesome.

This combo shot, of course, was the same that would later be falsely attacked by Andrew Wakefield, who did his best, along with many other people, to undermine the effort. of Maurice Hilliman and others to keep children safe. If you want to hear more about the history of the anti-vaccine movement and just how completely wrong and unethical, Andrew Wakefield was, check out our Vaccines Part 2 episode. And I'll also recommend the books, Vaccines Did Not Cause Rachel's Autism by Peter Hottes, our fave, and also deadly choices by Paul Offit. And there are many other great books and other resources out there.

But please be careful where you find your information. Books aren't peer reviewed. And anyone can write a book and claim anything they want to in it. And even though they aren't peer reviewed, there are reviews of nonfiction scientific books that can often be found in academic journals. So it's a bit more homework, but I will recommend plugging a book title into Google Scholar, seeing if a review. pops up, read the review to see whether it's good or not. I love that. Yeah, recommend. Anyway, back to mumps and Maurice. Over the course of his career, Maurice Hilliman and his team created tens of vaccines, including eight of the 14 routinely used in U.S. vaccination schedules.

Measles, mumps, hepatitis A, hepatitis B, chickenpox, nisceria managinidus, streptococcus pneumonia, and homophilus influenza. His vaccines have saved the lives of, I don't even know if we have a number, like countless people around the world, and continue to prevent death and illness in millions annually. His name and work really should be more widely known, at least as well known as someone like Louis Pasteur

or Jonas Salk or Alexander Fleming. And that's a part of the reason why I wanted to spend a little time talking about his life and what led up to the creation of the mumps vaccine. Unfortunately, several of the diseases for which Maurice developed these vaccines have been making a comeback over the last few decades due to a lack of access to vaccines, vaccine hesitancy or anti-vaccine sentiment, and waning immunity. And mumps is no exception. I so, so wish it were the case that the last chance that the last chance of the last chance of chapter in the book of mumps was, here's this life-saving vaccine. Everyone used it and mumps went away

forever. But sadly, that's not the case. So, Aaron, tell me where we actually stand, what the most up-to-date chapter is on mumps today and what college campuses have to do with it. I can't wait. We'll take a quick break and then I'll let you know. Turns out, Aaron, college campuses have a lot to do. with it. I thought so. Yeah. While we've had a vaccine for mumps since, like you said, the 1960s, mumps is not quite as common of a vaccine included in national immunization programs worldwide

as things like measles, rebella, even polio. About 50 to 60 percent of countries, depending on which. which paper I read include mumps in their national vaccine schedules. But in places where it has been very highly uptaken, I guess, the effect was dramatic. Finland actually eliminated mumps entirely in the country for a while and only had imported cases here and there. It's so awesome, but also your verb tenses are worrying. I know.

Yeah, they're valid. The U.S. had a decline of like 99%. We were down in 2001 to less than 0.1 case per 100,000 people. Wow. From a million cases per year to less than 0.1 per 100,000 people. That is... It's so great. And I hate where this is going. Okay. Yeah. Since those numbers, which really I would say probably like peaked in the early 2000. in terms of overall effectiveness and decline of Mumps cases, probably peak early 2000s, 2001, et cetera.

Since then, we have seen increasing numbers and an increase in sporadic outbreaks in the U.S., in Europe, which is highly vaccinated and across the globe. The reasons for this are very multifactorial. and what's interesting about these outbreaks, especially in the U.S., is that they tend to actually be among vaccinated individuals and not unvaccinated individuals, as we saw with measles outbreaks several years ago. So it's likely that this idea of waning immunity that we talked about in the biology section likely plays a really big role when it comes to mumps that. it plays less of a role as we see with other infections. So think more like pertussis, which is another one we've already covered, waning immunity leading to segments of populations that are now newly immune and therefore you can have an outbreak. This has happened on college campuses because

nothing's wrong with college campuses, but it's just a place where all of this huge group of people all got vaccinated at around the same time. Some proportion of them had waning immunity at around the same time. And they're in close quarters, sharing saliva, and et cetera. Now you have an outbreak, right for an outbreak. So in the U.S., we had outbreaks in 2006, 2016, 2017, and 2019 that were all pretty big. Most of those had case numbers of over 6,000 in these outbreaks. That's a lot. It's a lot. And in 2019, the outbreak was over 3,000. Wow. Not all of this was college campuses, but a number of these outbreaks were associated with college campuses. Do you remember, Erin, 2016, Illinois? I was living in Panama that

whole year. Oh, well, it was University of Illinois. And they were recommending MMR boosters for everyone. I think I do remember that vaguely. Remember the emails at least? Mm-hmm. Yeah. Mm-hmm. Worldwide, it's hard to get great numbers. There have been outbreaks like this, that number in the thousands in the UK, in other countries in Europe, in Australia. It's hard to get a number globally, but one paper that I read estimated an global annual average of more than 500,000 cases between 2005 and 2010. Huh. Okay.

So it's not like this is a virus that we have, you know, even come close to eliminating by any means. And it's human specific, so in theory. In theory. In theory, Aaron. Part of the issue, I think, has been in addition to perhaps issues of vaccine access, which always come up, a number of countries had initially implemented national vaccine campaigns and then made them more like voluntary and not as part of the national vaccine program. And part of this had to do with these

cases of aseptic menendritis. And so I want to kind of get into this a little bit more, especially because there has been polio in the news recently. And this kind of relates to what we have seen with polio as well. So let me get into this idea that viruses can cause infection. If you have listened to our polio episode. We talked a lot about the fact that there are two different polio vaccines. In the U.S., we used to use an oral polio vaccine. Across the globe, we used to use this exclusively, an oral polio vaccine. And this is a live attenuated vaccine. Highly effective. It was an oral vaccine, so easy to administer, and it replicated in our guts, which is how polio is transmitted, it's fecal oral. So this oral vaccine can, for example.

really good protection, and it was also possible for people to shed this live virus through their feces, which meant you could have passive immunization of, say, household contacts through this fecal-oral root of a non-virulent strain of this virus. It's awesome. It's awesome. However, this non-virulent strain can mutate, potentially, to become more virulent and actually cause disease. And so over time, as we massively decreased the number of polio cases, the risk-benefit analysis of using this live attenuated vaccine shifted into the other direction.

And so we no longer use the oral polio vaccine in the U.S. and in a lot of other countries that have eliminated or greatly reduced polio, we now use an inactivated, injected polio virus vaccine. that's what we use in most of the world. Now, when it comes to mumps, this exact series of events has not been shown to happen. We don't have things like passive immunization and that sort of thing. We haven't seen outbreaks from the viral strain the way that we have in cases of polio. However, there have been case reports of aseptic meningitis. So inflammation occurring in the meninges, importantly, not encephalitis, not inflammation in the brain itself, but aseptic meningitis from some strains

of the vaccine. And so understandably, this caused a lot of concern and led to the withdrawal of these vaccines strains and in some cases stopping vaccination for months entirely or making it voluntary rather than part of a national immunization campaign, which has implications not only for like vaccine uptake and acceptance, but also a lot of times for funding. Like, countries don't fund it if it's not part of the like national campaign. Yeah. One country where this happened, where these cases happened because of the particular vaccine strain that was used and then the national vaccine program stopped was in Japan.

And Japan now has one of the highest rates of mumps among high income countries with over a million cases reported annually as of 2015. So that's a huge issue. Yeah. Wow. I know. So I feel like what this comes down to, it's several different things. One, there are other strains of this vaccine, like the one that we use here in the U.S.

that are not associated with aseptic menendritus. I want to emphasize that the vast majority of strains that are used for this have not been associated with this and are very, very, very, safe and well-studied vaccines. The strains that have caused this generally are not used, and the cases all were, while scary, self-limiting. But I do feel like this kind of touches on something that I think is important when it comes to a disease like mumps and a vaccine, like the mumps vaccine that was developed many years ago. I think that this is a good example of why we can't be, complacent. Both in terms of like we can't assume that a disease is gone just because we have a vaccine

for it, right? Like we don't know how long immunity is going to last when we come up with a vaccine. So it's quite possible that this could reemerge at a later date. So we shouldn't be complacent in that way. But we also shouldn't be complacent in terms of the vaccine itself. We have a vaccine. It's very effective, though. the immunity might not last as long as we'd like, and it can prevent morbidity and mortality.

But can we make it better? Can we make it more safe? Can we make it more effective? Especially as we are doing such a good job of reducing the population disease incidence overall, can we make a more effective vaccine with less potential for side effects? So I think that that is kind of the place I'm most excited to see Mumps research go in the future is towards maybe new vaccine research. Yeah. But I don't have an update on where we're at with that. No, but I agree. That was really well put about complacency.

Like there's we can still look forward. We don't have to be like, okay. Like pop our hands, we're done. When we can't forget where we came from. why it was so important to begin with and why it's still so important to get this vaccine. Yeah. It's the full picture. The full picture.

So that, Erin, is the mumps. The mumps. Should we do sources? We should. We should do some sources. Okay. I have several, but I'm only going to shout out two. One is the Cambridge World History of Human Disease, the Mumps chapter.

and the other is, of course, vaccinated by Paul Offutt, which was also the source for our first-hand account. Recommend Great Read. I had one particular favorite paper for the biology section, and that was titled Mumps. Got to love it. Yeah, from The Lancet in 2008. I had a couple of others for more details on the pathogenesis, and then a number of papers on the epidemiology of mumps, especially.

in the era post-vaccines. So you can find the list of our sources from this episode and all of our episodes on our website. Did we tell you about it? This podcast, We Kill You.com. Thank you to Bloodmobile for providing the music for this episode and all of our episodes. Thank you to the Exactly Right Network. And thank you to you, listeners. We hope you liked this one. We hope you thought it was interesting, yeah. Did you like it? learn more about mumps than you ever thought you would. More than you wanted to, but you're so happy you did. I hope so.

And a special thank you, as always, to our patrons. Thank you so, so, so much for your support. Yeah, absolutely. Okay, well, until next time, wash your hands. You filthy animals. This is Bethany Frankel from Just Be with Bethany Frankel. Listen, I have a bone to pick with these dog food brands calling themselves fresh. Natural, healthy. Sounds great, but a lot of these, quote-unquote, fresh dog foods in your fridge are not even 100% human grade, which is why feed your babies, just food for dogs. It's good enough for big and smalls, my precious babies, so it's good enough for your babies. 100% human grade, real ingredients, beef, sweet potatoes, green beans, delicious. These are foods that you would want to eat. Not that the babies would ever share. Just food for dogs is the number one bet recommended fresh dog food back by over a decade of.

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