sue fitzgerald, rn, mha, cic harvard university health
TRANSCRIPT
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Sue Fitzgerald, RN, MHA, CIC
Harvard University Health Services
Internal Medicine / Infection Prevention
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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)
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BEFORE AFTER
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20% of all cases are Asymptomatic!
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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
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◦ 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
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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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