Sue Fitzgerald, RN, MHA, CIC Harvard University Health ...

Sue Fitzgerald, RN, MHA, CIC

Harvard University Health Services

Internal Medicine / Infection Prevention

ACHA 2017

Clinical presentation of mumps infection

Role of Immunizations

Outbreaks in a vaccinated vs. unvaccinated population

Management of cases in different campus settings

Atypical Presentations

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• Virus- Paramyxoviridae family

• Direct contact with infected saliva/ droplets

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Fever, headache, fatigue, facial pain -2 days

Jaw pain /swelling caused by Parotitis - 3-7 days

Less Common: Testicular pain/swelling, abdominal pain (oophoritis)

RARE: pancreatitis, endocarditis, meningitis, encephalitis, miscarriage

Infectious 2 days BEFORE symptoms of swelling & Incubation is 12-25 days

Who here remembers what they were doing 3 weeks ago?

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What does Mumps Parotitis look like?

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(Unvaccinated individual)

BEFORE AFTER

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20% of all cases are Asymptomatic!

23655833

** Jan 1 2017-April 27 over 2,570 cases

http://www.cdc.gov/mumps/outbreaks.html

2017 cases are already surpassing total cases in 2015

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Measles-Mumps-Rubella◦ Mumps component is:

78% effective after 1st immunization

88% effective after 2nd immunization

Vaccination : 90-99% reduction in Mumps cases◦ Had been less than 2,000 cases / year

Despite Vaccination--Sporadic outbreaks ◦ 2006- 6,500 cases

◦ 2009- 3,000 cases

◦ Currently- Mid-West, Northeast, Canada, NHL

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“Highly Vaccinated”◦ Requires documentation, No Self-reporting

99% Undergrads & 98% Grad students had 2 or 3 MMR’s

◦ Health Care Workers Immunized & titers required for MMR, Varicella and

Hepatitis B

◦ Medical, Dental School, Public Health Immunized & titers required

Unvaccinated: ◦ Religious or Medical Exempt ◦ Too young to be vaccinated◦ Children of Baby-Boomer “Anti-vacc’ers”

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At Harvard University 2016-Present

◦ February 5th, 2016

20 cases of Parotitis (none ‘seemingly’ connected)

“Showed Immunity” to Mumps (High IGG and low IGM)

Differentials: Wisdom tooth, TMJ, viral illness, salivary stones

◦ By Feb 21st, 2016 per DPH, switched to Buccal swab for PCR-testing

◦ 6 positive Mumps, 1 Negative PCR in 2 week period

It then became an Outbreak

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Month Cases POSFeb 24 6Mar 53 16April 54 27May 54 16

June 3 1July 4 2

August 1September 1 1October 2 2November 7 2December 3 1February '17 5 1March '17

April ’17May ‘ 17

3

32

2

1TOTAL 219 78

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Spring Timeline of Cases

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◦ Dorm/ residential students

Need single room / bathroom

Avoid face to face contacts; no class/ sports

Avoid common dining settings

◦ Local Students/ Commuters

Send home with mask, no public transportation

No classes, sports

Ensure no at-risk family members

◦ Faculty/ Employees

No work

Self-isolate

Ensure no at-risk family members

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CASE REVIEWS

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19 year old Member of Student Club◦ 2 days sore throat & neck pain; no obvious swelling

◦ Denies contact with any Mumps cases

◦ Negative rapid strep

◦ Had 3 MMR documented (1 was before 1st birthday)

◦ Positive IGG in Mumps serology

◦ Is it really Mumps?

◦ YES

◦ On second day had parotitis and Positive Mumps PCR swab

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67 year old Faculty Member No immunization records but “sure he had

Mumps as a child” (Born in 1950) Was told last year he might have TMJ Presents with bilateral jaw pain Left > right

◦ Is it Really Mumps?

◦ YES◦ Later in day had parotitis; next day went to ER with

painful and swollen testicles. ◦ Positive Mumps PCR swab

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45 year old staff member, in “student facing role”◦ Facial swelling◦ Has had fever◦ Worried about mumps in her office-mates◦ Has no records, but believes she had MMR

◦ Is it Really Mumps?

◦ NO◦ By second day of self-isolation had to see oral surgeon.

Had dental abscess with adenopathy. ◦ Negative Mumps PCR swab; alternate diagnosis comes

off “list”.

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22 year old Senior, Hockey Player◦ Presented with “pulled groin muscle”◦ “cold symptoms” requires clearance to

practice ◦ Evasive about any ill contacts

◦ Is it Really Mumps?

◦ YES◦ Bilateral swollen testicles. No parotitis. Admits his girlfriend is currently in isolation for Mumps. Doesn’t

want to miss a game. Positive Mumps PCR swab

ACHA 2017

20 year old student◦ Presented with Left sided parotitis (PCR positive) last

week. ◦ Spent 5 days in self-isolation. Has been home for 5

days◦ New Right sided parotitis.◦ No alternate diagnosis

◦ Is it Really Mumps?

◦ YES, AGAIN

◦ New Positive Mumps PCR swab, and even though has been 10 days since onset, still potentially infectious. Back into

isolation.

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Vaccines are good but not perfect

Don’t assume it can’t be mumps — providers may not be familiar with presentation

“Childhood diseases”

“They are immune”

Jury still out on a 3rd MMR as a Booster

Other colleagues can be great allies!

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Massachusetts Department of Public Health

Cambridge Public Health Department

Harvard University Health Services

Harvard University Emergency Management Teams

CDC http://www.cdc.gov/mumps/outbreaks.html

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ALL Undergrads must live on campus

All Freshmen eat in this one large dining hall

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