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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?
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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
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
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Spring Timeline of Cases
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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!
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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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ACHA 2017