(You “mumpsed out” yet?)(You “mumpsed out” yet?)

MUMPS:A A preprecautionary tale cautionary tale

Gaynor Watson-Creed, MSc, MD, CCFP, FRCP(C)Medical Officer of Health, Capital District Health Authority

(Halifax)

There once was a student with cheek lumpsThere once was a student with cheek lumps

Who knew not what to do with these bumps.Who knew not what to do with these bumps.

So to Halifax s/he fledSo to Halifax s/he fled

To go bar-hopping insteadTo go bar-hopping instead

And so gave his/her hosts the great gift of the And so gave his/her hosts the great gift of the mumps.mumps.

And lo, an outbreak was borne…

About Halifax (CDHA)About Halifax (CDHA)

4 amalgamated municipalities (HRM) + East Hants4 amalgamated municipalities (HRM) + East Hants 5 post secondary institutions + Nova Scotia Community 5 post secondary institutions + Nova Scotia Community

College (4 campuses)College (4 campuses) 420 family docs – private offices, not hospital based420 family docs – private offices, not hospital based 2 large tertiary-care hospitals (11 campuses; 10000 2 large tertiary-care hospitals (11 campuses; 10000

employed at CDHA; 3000 at IWK)employed at CDHA; 3000 at IWK) Department of National Defense – 8700 personnel, 120 Department of National Defense – 8700 personnel, 120

hcwshcws Coast GuardCoast Guard Population: approx 400 000Population: approx 400 000

About Nova ScotiaAbout Nova Scotia

Population – 913 000Population – 913 000 Proportion of persons aged 20-24 – 56 000Proportion of persons aged 20-24 – 56 000 Proportion of persons aged 15-19 – 62 000Proportion of persons aged 15-19 – 62 000 5 additional universities + Nova Scotia 5 additional universities + Nova Scotia

Community College (9 campuses)Community College (9 campuses) DND, Coast GuardDND, Coast Guard

Where we’ve been…Where we’ve been…

PHAC; November 9, 2007

Mumps Cases in Nova Scotia by Week of Onset (n=678)

0

10

20

30

40

50

60

70

Reporting Week

Num

ber

of C

ases

Descriptive Epidemiology – Descriptive Epidemiology – November 30 , 2007 November 30 , 2007

 

Nova Nova ScotiaScotia

CDHACDHA Other DHASOther DHAS

Total CasesTotal Cases

ConfirmedConfirmed

Clinical Clinical

733733

556 (76%)556 (76%)

177 (24%)177 (24%)

585 (80%)585 (80%)

457 (78%)457 (78%)

128 (22%)128 (22%)

148 (20%)148 (20%)

99 (67%)99 (67%)

49 (33%)49 (33%)

Age rangeAge range 4 mo – 69 yrs4 mo – 69 yrs 4 mo – 64 yr4 mo – 64 yr 2 – 69 yr2 – 69 yr

Age GroupsAge Groups

17 - 25: 58%17 - 25: 58%

17 - 37: 84%17 - 37: 84%

38 – 49: 9%38 – 49: 9%

17 - 25: 60%17 - 25: 60%

17 - 37: 88%17 - 37: 88%

38 – 49: 6%38 – 49: 6%

17 - 25: 48%17 - 25: 48%

17 - 37: 72%17 - 37: 72%

38– 49: 18%38– 49: 18%

Median age (years)Median age (years) 2323 2323 2525

Male:Female ratioMale:Female ratio 360:373 (51% 360:373 (51% F)F)

285:300 (51% 285:300 (51% F)F)

75:73 (49% F)75:73 (49% F)

ComplicationsComplications

OrchitisOrchitis

Mumps encephalitisMumps encephalitis

Sensori-neural hearing lossSensori-neural hearing loss

ArthralgiaArthralgia

OöphoritisOöphoritis

Our definition of the precautionary Our definition of the precautionary principle:principle:

In the absence of certainty as to what to do, In the absence of certainty as to what to do, we will use our best knowledge and we will use our best knowledge and understanding of what MIGHT work to control understanding of what MIGHT work to control this outbreak.this outbreak.

PRIMARY ASSUMPTIONPRIMARY ASSUMPTION: that risk of : that risk of mumps and of outbreak required doing mumps and of outbreak required doing somethingsomething

APPLYING PRECAUTION during APPLYING PRECAUTION during mumps: twice unlucky…mumps: twice unlucky…

1.1. Early in the outbreak Early in the outbreak • aggressive case findingaggressive case finding• aggressive contact tracingaggressive contact tracing• aggressive case managementaggressive case management• aggressive contact managementaggressive contact management

• Purpose Purpose • to find as many cases as possible (stop spread)to find as many cases as possible (stop spread)• to find as many contacts as possible (stop spread)to find as many contacts as possible (stop spread)

2. Mid outbreak 2. Mid outbreak • aggressive management of health care workersaggressive management of health care workers

• Purpose Purpose • to prevent hcws from bringing mumps into the to prevent hcws from bringing mumps into the

institutionsinstitutions

Baseline operations

Finding and achieving “New Finding and achieving “New Normal”Normal”

“Denouement”

“NEW NORMAL”

Act

ivit

y L

evel

s (O

per

atio

nal

)

Time

Public Health Services

Other Health Care Responses

Outcomes:Outcomes:

Cases continued to accumulateCases continued to accumulate

Cases became “mumpsed out” – non complianceCases became “mumpsed out” – non compliance

Contacts difficult to find Contacts difficult to find

Massive document management challengesMassive document management challenges

PHS staff overtaken by OH and IC responsePHS staff overtaken by OH and IC response

Exhausted staff – and new programs and other PH Exhausted staff – and new programs and other PH challenges on the horizon!challenges on the horizon!

Our ethical dilemnas became Our ethical dilemnas became these…these…

What is the appropriate response to an outbreak What is the appropriate response to an outbreak in the face of other public health burdens? When in the face of other public health burdens? When is doing nothing ok?is doing nothing ok?

What was the harm to the public from our What was the harm to the public from our precautionary approach to mumps?precautionary approach to mumps?

What was the harm to our organization(s) from What was the harm to our organization(s) from our precautionary approach to mumps?our precautionary approach to mumps?

(con’t)…(con’t)…

Can you know in advance of applying the Can you know in advance of applying the principle that the burden of applying the principle that the burden of applying the precautionary approach might outweigh the precautionary approach might outweigh the benefit (e.g. during an evolving outbreak)? benefit (e.g. during an evolving outbreak)?

…We did, but not without issues…

Can you “take it back”?Can you “take it back”?

Thank you. Questions?Thank you. Questions?

““Thank goodness we have the opportunity to learn Thank goodness we have the opportunity to learn these things through mumps and these things through mumps and

not_____________.”not_____________.”