Working to improve the health of the population and the quality of life of the people we serve.
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August 28, 2008
Although our many control efforts have slowed the mumps outbreak, it has now spread to most of Fraser Health. Worse, with fall coming and students returning to school, we may see even more mumps activity. You can track our mumps outbreak by going to www.fraserhealth.ca and clicking on the “Mumps” link under “News” on the right-hand side of the page. Posted there are maps that will be updated weekly, along with other mumps information. The maps show only the cases reported to us – there are, alas, many more. Please help us contain this rotten virus – tell the Health Unit when you see a patient with possible mumps. There’s no need to wait for lab confirmation, so don’t be shy. The Health Act CD Regulation S2(1) and 2(2) require us all (including physicians) to tell Public Health when we suspect someone might have mumps. Mumps spreads by stealth. About two-thirds of people infected with - and infectious for - mumps virus either have no symptoms or have only common cold-like symptoms. We are seeing people with lab-proven mumps who have no idea where they caught it. In other words, all sorts of patients can bring mumps virus to your office, with or without symptoms of mumps or any symptoms at all. People with mumps shed the virus in a 1-metre cloud that goes around with them, even if all they’re doing is breathing. Coughing and sneezing into a sleeve helps by catching respiratory droplets in fabric, where they are less likely to be spread to office doorknobs and other surfaces. The sleeve above the elbow is best so people don’t accidentally contaminate their hands later when they cross their arms. Best of all, give a surgical mask to all who are coughing or sneezing or think they might have mumps as soon as they cross your threshold. Easily-reachable hand You’ll find an “Ask For A Mask” poster you can use in your office at fraserhealth.ca Our immune system has trouble remembering mumps: immunity wanes, faster after vaccination than after disease. While anamnestic memory can provide partial immunity even in the absence of detectable IgG, partially-immune people can and do get infected, infect others, and sometimes develop characteristic mumps illness. Our oldest reported case so far is 59 years old, and the oldest in the Ontario, Nova Scotia, and New Brunswick outbreaks were 66, 73, and 79 years old respectively. I urge you and your staff to take advantage of the free MMR vaccine available to all Fraser Health physicians and health care workers: two documented doses if you were born 1957 or later, one if you were born 1956 and before. If you’re not sure of your vaccination history, it’s good to know that side effects with MMR vaccine are less likely with each succeeding dose. In comparison, having mumps is no fun at all, even without complications, not to mention you don’t want to spread mumps to susceptible family, friends, colleagues, or patients. Getting MMR now will also protect you against measles, now increasingly active in the USA. For those who are not health care workers, highest priority is to give everyone born in 1970 or later at least one documented dose of vaccine against mumps (e.g., MMR). Secondary and post-secondary students need at least one documented dose; National Advisory Committee on Immunization recommends two doses. Chilliwack secondary students were offered a second dose this spring and Fraser Health is looking at doing the same for other students in areas of high mumps risk. In the meantime, Public Health MMR vaccine clinics will be starting in health units the week of September 8 and possibly earlier; clinic schedules will be posted on www.fraserhealth.ca. If you provide MMR in your office, please use it to vaccinate your staff and to give a second dose of MMR to any secondary or post-secondary student who asks for it. Please also give contacts of mumps cases MMR as needed to get them up to a lifetime total two doses; this will protect them against future exposure and help stop the transmission of virus within their social circles, although it won’t protect them against prior exposures. If you don’t provide MMR in your office, please ask those needing MMR to call their Health Unit. Despite timely and appropriate testing, you can’t always diagnose mumps via lab testing – and sometimes you can’t even rule out mumps. Lab testing works well in completely non-immune people when blood for mumps IgM is drawn 5 days after symptom onset or later. However, people with some prior immunity who get mumps may have a really short IgM rise that is over by the time they see you, and already have IgG present, and no longer be shedding virus. In these people, we try to confirm mumps by getting a second IgG to see if the level goes up, but sometimes even this fails, because the IgG has already gone as high as it’s going to by the time the first sample is taken. In these situations, we have to fall back on the old rule of “treat the patient, not the lab report.” Therefore, when you suspect mumps, please do order lab work as described in previous faxes - then let the Health Unit know without waiting for the lab results. “He who knows mumps knows medicine” (with apologies to Dr. Osler): exocrine and endocrine glands are often affected: parotitis and other sialadenitis are most likely, with orchitis, oophoritis, pancreatitis, mastitis, and thyroiditis less so. Mumps meningitis is common. Meningoencephalitis is unusual, which is fortunate, because it can lead to sudden and sometimes permanent deafness, paralysis, seizures, cranial nerve palsies or hydrocephalus, and rarely death. Other possible effects of mumps include viral arthritis and first-trimester miscarriage (but not congenital malformation.) Like other viruses causing mesenteric lymphadenopathy, mumps can trigger acute appendicitis. In a mumps outbreak, in cases like these, ask yourself, “Could this be a mumps infection?” But . . . Mumps has admiring imitators. In a mumps outbreak, you’d *think* you’d be entitled to assume that anyone with painful swollen salivary glands or testicles or ovaries has mumps, and mumps certainly is the diagnosis to put on top of your differential. Unfortunately, we are seeing mumps-like illness from other viruses, including enterovirus and mononucleosis. Mono is particularly problematic because it can stimulate B cell polyclonal activation, thus causing a rise not only of IgM against Ebstein-Barr virus but also of IgM against other viruses, including mumps. We have just seen a case of parotitis with positive tests for IgM against mumps AND EBV. As mumps doesn’t trigger polyclonal activation, we believe that illness in this case was due to mononucleosis. If you have a patient who poses a mumps testing conundrum, please feel free to consult with your local Medical Health Officer. An algorithm for mumps lab testing will be faxed to you shortly www.fraserhealth.ca . If you or your staff are exposed to mumps: exposed health care workers with two documented doses of mumps-containing vaccine or recent lab-proven mumps infection can keep working. Otherwise, draw serology for mumps IgG and (unless there is a contraindication such as pregnancy) give a dose of MMR right away. After this, those with a total of two documented doses of mumps-containing vaccine can keep working. The rest should be off work from the 10th day after the first exposure until the 26th day after the last exposure UNLESS their serology comes back IgG positive. References:
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