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

ACHA 2017

• Virus- Paramyxoviridae family

• Direct contact with infected saliva/ droplets

ACHA 2017

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?

ACHA 2017

What does Mumps Parotitis look like?

ACHA 2017

(Unvaccinated individual)

BEFORE AFTER

ACHA 2017

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

ACHA 2017

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

ACHA 2017

“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”

ACHA 2017

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

ACHA 2017

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

ACHA 2017

Spring Timeline of Cases

ACHA 2017

ACHA 2017

◦ 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

ACHA 2017

CASE REVIEWS

ACHA 2017

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

ACHA 2017

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

ACHA 2017

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”.

ACHA 2017

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.

ACHA 2017

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!

ACHA 2017

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

ACHA 2017

ALL Undergrads must live on campus

All Freshmen eat in this one large dining hall

ACHA 2017

ACHA 2017