Mumps Virus: Modification of the Identify-Isolate-Inform Tool for Frontline Healthcare Providers

Kristi L. Koenig, MD; Siri Shastry, MD; Bandr Mzahim, MD; Abdulmajeed Almadhyan, MD; Michael J. Burns, MD

Disclosures

Western J Emerg Med. 2016;17(5):490-496. 

In This Article

Abstract and Introduction

Abstract

Mumps is a highly contagious viral infection that became rare in most industrialized countries following the introduction of measles-mumps-rubella (MMR) vaccine in 1967. The disease, however, has been re-emerging with several outbreaks over the past decade. Many clinicians have never seen a case of mumps. To assist frontline healthcare providers with detecting potential cases and initiating critical actions, investigators modified the "Identify-Isolate-Inform" tool for mumps infection. The tool is applicable to regions with rare incidences or local outbreaks, especially seen in college students, as well as globally in areas where vaccination is less common. Mumps begins with a prodrome of low-grade fever, myalgias and malaise/anorexia, followed by development of nonsuppurative parotitis, which is the pathognomonic finding associated with acute mumps infection. Orchitis and meningitis are the two most common serious complications, with hearing loss and infertility occurring rarely. Providers should consider mumps in patients with exposure to a known case or international travel to endemic regions who present with consistent signs and symptoms. If mumps is suspected, healthcare providers must immediately implement standard and droplet precautions and notify the local health department and hospital infection control personnel.

Introduction

Several international public health crises have emerged in recent years, including Ebola, Middle East respiratory syndrome (MERS), and Zika virus. In addition to these novel threats, there has been a resurgence of previously nearly eradicated infectious diseases, including mumps. In recent years, the numbers of mumps cases in the United States has fluctuated from hundreds to thousands of cases per year. In 2006, a multi-state mumps outbreak in the Midwest consisted of over 6,500 cases. In 2009–2010, two large outbreaks occurred in New York City and Guam, affecting about 3,000 and 500 persons respectively. In 2011–2013, there were smaller outbreaks in several states.[1] Many of the outbreaks occurred among college students. There was also a large outbreak in late 2014 among professional hockey players involving at least five teams in the National Hockey League (NHL), which began with players on the Anaheim Ducks. In March 2016, California public health officials issued an advisory noting that five college students at the University of San Diego had been diagnosed with mumps; this was followed by a subsequent advisory identifying three additional mumps cases in college students diagnosed in Orange County, California.[2,3] In April 2016, a high profile outbreak reported at Harvard University and surrounding areas resulted in more than 40 cases of mumps in less than two months. As of May 5, 2016, nearly 80 cases were reported in the state of Massachusetts with 50 cases at Harvard.[4] Over a 5-year period from 2011 to 2016, mumps cases reported to the Centers for Disease Control and Prevention (CDC) have been steadily increasing, from 370 in 2011 to 1,148 as of May 21, 2016.[5] These cases and outbreaks as well as the potential decrease in measles-mumps-rubella (MMR) vaccination uptake due to parental refusal underscore the importance of the emergency department (ED) as a primary location for identification and containment of public health threats. Patients frequently present to the ED with undifferentiated chief complaints, making rapid and accurate diagnosis challenging. Most contagious diseases that manifest with nonspecific influenza-like illness symptoms and signs will not ultimately be determined to be rare and deadly diseases like Ebola or MERS; however, they may be contagious and require immediate isolation. This underscores the need for emergency physicians to have the necessary information and tools to rapidly identify potential public health threats. While the mumps virus is typically mild and self-limited, it is highly contagious for susceptible patients when proper isolation and containment measures are not rapidly initiated; a single case can result in up to 12 secondary cases in a susceptible population.[6] Infection can occur despite vaccination, and most cases seen in college outbreaks have occurred in fully vaccinated patients. Further, the mumps virus can sometimes have serious long-term sequelae including infertility/subfertility, central nervous system (CNS) infection, deafness, and severe pancreatitis. In rare cases, these complications can be fatal.[7]

Given the highly contagious nature of the virus, it is paramount that frontline providers be aware of how to identify the clinical manifestations of mumps virus and understand how to properly isolate potentially infected patients and rapidly inform necessary authorities of a potential case. This paper provides a comprehensive review of mumps infection followed by a brief discussion of the novel 3I tool, initially developed for Ebola virus and subsequently for measles, MERS and Zika virus,[8–11] as adapted for use by healthcare providers in the initial detection and management of mumps.

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