Scenario: Mumps Outbreak

Public Health Practice and Issues

Abrea Johnson

Public Health Practice and Issues

• Required course in MPH program• Lectures online• Concepts applied to real agency• Addresses cross-cutting issues:

-public health biology-ethics-diversity and cultural considerations-informatics-communications

Public Health Practice and Issues

• Scenario: An outbreak of mumps has occurred in northeast Ohio. Akron Community Health Resources has seen several patients with suspected (later confirmed) cases of mumps over the past week. It is revealed that there is a larger outbreak at hand and hundreds of people in the immediate community are ill with mumps.

Biology of Mumps

• Mumps is a contagious viral disease1

• It is spread through direct contact or through respiratory droplet1

• People are contagious 7 days before disease onset to 9 days after the disease onset1

• The incubation period can range from 14-21 days, with an average of 18 days1

• The disease usually resolves within 10 days1

Biology of Mumps

• Early symptoms include: fever, headache, malaise, myalgias, anorexia, and fatigue followed by parotitis in up to 70% of patients1

Biology of Mumps

• The submandibular or sublingual glands may occur alone or in combination with the parotitis1

• Complications may include5:-cerebrospinal fluid (CSF) pleocytosis -orchitis may occur in adolescent and adult males

-oophoritis or mastitis in post pubertal females- and rarely pancreatitis, myocarditis, arthritis,

thyroiditis, or deafness.

Biology of Mumps

• Mumps occurs worldwide1

• Prior to vaccination in the U.S., mumps was most commonly seen in children ages 5-9 years1

• After the vaccine mumps shifted to 10-14 year olds1

• In a 2006 outbreak students aged 18-24 were mostly affected6

Biology of Mumps

• Vaccination for mumps is administered in the MMR combination1

• Recommended vaccination occurs between 12-15 months and again between 4-6 years1

• Two doses is recommended for school children, healthcare workers born in 1957 or after, and international travelers

• Incidence remains very low1

Biology of Mumps

• However, in 2006 and in 2009-2010 there were two large outbreaks7

• In 2006 there were 6,584 cases reported to the CDC mostly centered in Iowa and college student population7

• The outbreak in 2009 and 2010 has reported almost 2,000 cases and is centered in New York and New Jersey in the Hasidic Jew population8

Biology of Mumps

Biology of Mumps

• ACHR has seen several patients with suspected mumps that report they are students at the University of Akron or are a sibling of an U of A student

• Most of these patients are 18-22 years old

• Response should be coordinated with the local departments of health, the ODH and the CDC

Mumps Surveillance

• Informatics will track cases and contacts

• Mumps is a notifiable disease9 • ODH classifies mumps as a B1

disease9

• Healthcare agencies, like ACHR, must report by end of next business day9

• Use the Ohio Confidential Reportable Disease Form, ODRS, or call the local health department the person resides in9

Mumps Surveillance

• The local health department will report to the ODH using ODRS

• The ODH is responsible for maintaining the database, privacy, and confidentiality issues

• The ODH will report mumps cases to the CDC through NNDSS

• Electronic medical records can assist ACHR in reporting

Mumps Surveillance

• ACHR should report the following information:-name of case -diagnosis-date of birth -sex of case-address -telephone number

-health care provider contact information-mumps surveillance worksheet

• Local health departments could use class lists track contacts in schools

Mumps Surveillance

• GIS maps can provide a visual information on location of cases

• Map may show city, county, regional, state, or national cases

• When put all together data will reveal age, gender, race of those affected, incubation period, and place of concentration

• Helps epidemiologists plan disease control

Public Health Communication

• Risk communication has evolved10

• Previously, risk communication was facts to inform public and transform behavior7

• Now risk communication is10:-an exchange of information and

opinion-interactive process-expression of concerns-opinions or reactions to risk messages

or risk management

Public Health Communication

• Both sides should express their perspectives, listen, and respond

• Most importantly: RISK means something different to the public than it is to officials or physicians

• I feel the Health Belief Model is very important in explaining risk perception in people

Public Health Communication

Public Health Diversity

• Diversity of patients must be considered

• What is diversity?• The condition of being diverse : 

variety; especially : the inclusion of diverse people (as people of different races or cultures) in a group or organization.12

• What diversity do you have within ACHR?

• What about the diversity of patients?

Public Health Diversity

• Diversity of people include13:-race-sexual orientation-religion-age-geographic region-education level-economic background-communication styles

Public Health Diversity

Public Health Diversity

• Why is this important?• Organizations need to tailor

services, programs, and planning with diversity in mind

• Vulnerable populations often are at the most risk and the most need for services14

• Organizations should understand what makes populations vulnerable

• Lets think of some things together.

Types of Vulnerable Population

Those dependent on support of services

People who depend on community services or others to function or complete daily tasks may be vulnerable if the support is no longer available.

-Seniors-Disabled-Illiterate-People living in poverty-Children-Illegal residents-Single caregivers-Homeless, marginally housed, or shelter dependent-People with substance dependents-Geographically or culturally isolated-People that do not speak English

Residing in high risk areas

People living in older or lower income areas. Certain areas are high risk for certain types of health related problems.

Limited access People that lack knowledge, trust, resources or the ability to access information.

Social Status People that lack jobs, education, money, or other resources may have a more difficult time with health issues.

No Support systems

People who lack support systems may not have access to information or resources.

Vulnerable Population

Needs

Seniors and those who are Disabled

-arranging personal care-getting food, water, and supplies to isolated-meal delivery -help with filling life sustaining prescriptions or other important medical needs-shelters are physically accessible

Non-English Speaking - information in a variety of languages-coaches or advocates to help with non-English speaking persons-special consideration to make sure needs are being filled

Culturally or Geographically Isolated

-culturally appropriate services-consideration of special dietary needs-making sure health information has reached them

Public Health Diversity

Vulnerable Population

Needs

People with Substance Abuse and Addiction Issues

-drug and detoxification programs-mental health services

Homeless, Marginally Housed, or Shelter Dependent

-mental health and substance abuse support-shelters-transfer of services

People living in Poverty -plan for future sustainability- temporary or subsidized housing-transportation

People with Communication Barriers (not language related)

-sign language trained interpreters-messages that are slow-messages that come in several forms (verbal, readable, large print, etc)

Public Health Diversity

Public Health Diversity

• Who is at the most risk in this case?

• Diversity issues in this case require us to prioritize those at highest risk for contracting mumps

• Bridging the gap between the organization and those at need, requires cultural competence

• Tailor messages and services to the diverse populations at risk

Public Health Communication

• Message mapping is beneficial to risk communication goals15

-identify audience-anticipate questions-develop responses to audience’s

questions-organize into key messages and

supporting information-promote open dialog-ensure messages are consistent

Public Health Communication

• Tips to developing a message map include:15

-limit number of key messages to 3, or 1 key message with 3 parts

-keep ideas brief and easy to understand

-most important messages in the first and last position

-cite key third parties (like CDC or ODH)-balance positive and negative

messages-be honest-use graphics or visual aids-

Public Health CommunicationStakeholder: ACHR’s Patients and Clientele

Question: Am I at risk for contracting mumps?

Key Message 1 Key Message 2 Key Message 3

Mumps is highly contagious

College students are at the highest risk

Vaccinations are available

Supporting Fact 1-1

Supporting Fact 2-1

Supporting Fact 3-1

Mumps is spread person to person

Most mumps patients are U of A students

Everyone needs 2 doses of MMR vacc.

Supporting Fact 2-1

Supporting Fact 2-2

Supporting Fact 3-2

People are contagious before symptoms appear

Most mumps patients are 18-22 years old

U of A clinic, HD’s, and physicians have the MMR vaccine

Public Health Communication

• ACHR will also communicate with the health departments, partnering agencies, and its own employees

• Deciding who will communicate with the partnering agencies and health departments is key

• Training employees to recognize mumps and how to respond will assist in outbreak containment

Public Health Ethics

• Public health focuses on the health of the entire population, rather than individuals16

• Public health measures may infringe on individual rights16

• Ethics of infectious disease are not clear cut

• One person can affect many when comes to infectious disease17

Public Health Ethics

• Basic Public Health ethical principles18:

• Autonomy- respect for individuals decisions, individuals rights

• Beneficence- pursue good, benefits outweigh risks

• Nonmaleficence- do no harm• Justice- be fair, equal, impartial

Public Health Ethics

• Public health asks us to16-19:-reduce harm -maximize benefit-balance power -protect privacy-build/maintain trust -maintain -respect autonomous confidentialitydecisions-make an obligation to communities

Public Health Ethics

• Ethical issues in public health include, but are not limited to16-19:-mandatory testing-notification of authorities-mandatory treatment-surveillance-travel restrictions

-quarantine-informed consent

Public Health EthicsEthical issues in this case

Mandatory QuarantineProtects the community

VS.Person has to miss work,

school, or important events

IsolationKeeps infection from spreading community VS.

Doesn’t take into account diverse families such as

single mothers

Mandatory TestingHelps epidemiologists with

infection control plans VS.May conflict with personal

values, beliefs, or religions.

Protecting PrivacySensitive information

needed for surveillance VS.People may be reluctant to

give information due to concerns

Public Health Ethics

• Conditions to help resolve public health vs. individual rights dilemmas16

-effectiveness: program has been shown to be effective

-proportionality: probable public health benefit outweighs individual risks

-necessity: public health program is necessary

-least infringement: program is the least infringing option

-justification: program can be publically justified

Public Health Ethics

• Ethical considerations for ACHR involves both patients and employees

• Diversity of patients and employees may lead to different autonomous decisions

• ACHR must balance its employee policy with the need for workers and their desire for autonomy

• Ethical dilemmas should be weighed using the basic principles

References1. Averhoff, F., Wharton, M. Mumps. In: Wallace RB, Kohatsu N,

Last JM, eds. Maxcy-Rosenau-Last Public Health and Preventive Medicine. 15th ed. New York, NY; McGraw-Hill; 2008:105-107.

2. Campos-Outcalt, D. Mumps epidemic in 2006: Are you prepared to detect and prevent it? The Journal of Family Practice. 2006;55(6):500-502.

3. Centers for Disease Control. Power Point. Epidemiology of Mumps and Multistate Outbreak United State 2006. Available online at: http://www.bt.cdc.gov/coca/ppt/Mumps_July2006.ppt

4. Picture from: http://www.symptomlog.com/Mumps/What+is+Mumps.htm

5. Online: http://www.cdc.gov/mumps/clinical/qa-physical-complic.html

6. Power Point: Available online: www.cdc.gov/vaccines/Pubs/pinkbook/downloads/Slides/Mumps11.ppt

7. CDC-Mumps. Online: http://www.cdc.gov/mumps/outbreaks.html

8. Update: Mumps Outbreak.-New York and New Jersey. MMWR. 2010;55(5) Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5905a1.htm

References9. Ohio Department of Health. Infectious Disease Control

Manual. Available at: http://www.odh.ohio.gov/healthResources/infectiousDiseaseManual.aspx

10. Ropeik DP. Risk Communication—an Overlooked Tool for Improving Public Health. In: Wallace RB, Kohatsu N, Last JM, eds. Maxcy-Rosenau-Last Public Health and Preventive Medicine. 15th ed. New York, NY; McGraw-Hill; 2008:1029-1034.

11. Hayden, J, Patterson, W. Introduction to Health Behavior Theory. Chapter 4: Health Belief Model. Boston: Jones and Bartlett; 2009.

12. Definition of diversity. Available at: http://www.merriam-webster.com/dictionary/diversity

13. Virginia Department of Behavioral Health and Developmental Services. Cultural on Linguistic Services. What is Cultural Competence. Available at: http://www.dbhds.virginia.gov/2008CLC/documents/clc-pres-What-is-CCC.pdf

References14. California’s Governer’s Office of Emergency Services.

Meeting the Needs of Vulnerable Populations in a Disaster: A Guide for Emergency Managers. May 2000. Available at: http://www.oes.ca.gov/Operational/OESHome.nsf/PDF/Vulnerable%20Populations/$file/Vulnerable%20Populations.pdf

15. Yale Center for Public Health Preparedness. Message mapping. Available at: http://publichealth.yale.edu/ycphp/messagemapping.pdf. Accessed March 1, 2010.

16. Childress, J., Faden, R., Gaare, R., Gostin, L., Kahn, J., Bonnie, R., Kass, N., Mastrioianni, A., Moreno, J. & Nieburg, P. (2002). Public Health Ethics: Mapping the Terrain, Law, Medicine and Ethics, 30, 170-178.

17. Selgelid, M. (2005). Ethics and Infectious Disease, Bioethics 2005; 19(3): 272-289.

18. Author Unknown. Public Health Principles and Methods.Ethics and public Policy. In: Wallace RB, Kohatsu N, Last JM, eds. Maxcy-Rosenau-Last Public Health and Preventive Medicine. 15th ed. New York, NY; McGraw-Hill; 2008:28-31

.

Cite ethics of quarantine.

References19. Coughin, S. Ethical issues in epidemiological research and

public health practice. Emerging Themes in Epidemiology. 2006;3(16). Available at: http://www.ete-online.com/content/3/1/16.

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