Guidelines for the Prevention and Control of Mumps Outbreaks in Canada Michael Garner Shalini Desai The Canadian Mumps Guidelines Working Group* Centre for Immunization and Respiratory Infectious Diseases Public Health Agency of Canada
*Canadian Mumps Guidelines Working Group Members Newfoundland/Labrador Butler, Gillian O'Keefe, Cathy Yetman, Marion Prince Edward Island Neatby, Anne Sweet, Lamont Nova Scotia Clay, Susan Coombs, Ann Sarwal, Shelly New Brunswick Akwar, Holy T. Cochrane, Lynn Dhaliwal, Jastej Giffin, Scott Schellenberg, Gwyn Quebec Landry, Monique Ontario Dolman, Sharon Manitoba Dyck, Myrna Hilderman, Tim Long, Michelle Richards, Lisa Whitlock, Mandy Saskatchewan Bangura, Helen Findlater, Ross Levett, Paul Sly, Lisa Tuchscherer, Rosalie Alberta Lachance, Lisa Smith, Susan E. St.Jean, Theresa British Columbia Anderson, Maureen Harry, Regina Naus, Monika Nunavut Palacios, Carolina Northwest Territories Case, Cheryl White, Wanda Yukon Larke, Bryce QE II Health Science Centre Johnston, Lynn Hatchette, Todd Alberta Provincial Laboratory Public Health Agency of Canada O Neil, Laurie Tipples, Graham Tsang, Raymond Hickey, Raymonde Welsh, Frank Badger, Gillian McGihon, Julie Harris, Tara Law, Barbara Macey, Jeannette Moffatt, Carolyn Tam, Theresa Thom, Alan Johnson, Lynn Varughese, Paul 2 Fonseca, Kevin
Outline Introduction to Guidelines Methods Mumps Epidemiology in Canada Outbreaks Immunizations Recommendations Definitions, management Special situations: Health Care Workers, Gatherings, Travellers 3
Introduction Over the past 10 years, mumps outbreaks have occurred in numerous regions in Canada In 2007-08, there was a large outbreak in Nova Scotia, New Brunswick and Alberta In response to these outbreaks, CCMOH requested that guidelines be developed The guidelines are based on: National and international expertise Outbreak experiences Best practices 4
Outbreak Guidelines The guidelines are intended to: Assist Canadian public health authorities with the investigation and management of mumps outbreaks Provide consistent case and contact definitions To improve reporting and surveillance information to guide outbreak management 5
Guidelines Development Guidelines were written by a task group of: Federal Provincial and Territorial Partners National teleconferences were held to discuss the development of this document The guidelines were approved: by all members of the FPT task group reviewed by the Canadian Immunization Committee (CIC) approved by Communicable Disease Control Expert Group (CDCEG) Approved by Council of Chief Medical Officers of Health (CCMOH) 6
Mumps Epidemiology in Canada Mumps is an acute viral disease characterized by fever, swelling and tenderness of one or more of the salivary glands Since the approval of the vaccine against mumps in 1969, the number of reported mumps cases in Canada has declined by 99% 7
Recent Outbreaks in Post-vaccine Era From 1998 to 2007, Canada had five outbreaks, with the number of cases ranging from 13 to over 1600 These outbreaks primarily involved pre-school or school-aged children, adolescents and young adults 8
Number of Cases 1400 1200 1000 800 600 400 200 4 3.5 3 2.5 2 1.5 1 0.5 Rate per 100,000 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007* Year 0 Number of Cases Rate/100000 9
2007/08 Mumps outbreak in Canada Confirmed* Mumps Cases in Canada with onset December 31, 2006 to July 13th, 2008 n=1,590** 80 70 60 50 40 30 20 10 NL PE QC ON MB SK AB BC NB NS 0 Dec-31-2006 Jan-21-2007 Feb-11-2007 Mar-04-2007 Mar-25-2007 Apr-15-2007 May-06-2007 May-27-2007 Jun-17-2007 Jul-08-2007 Jul-29-2007 Aug-19-2007 Sep-09-2007 Sep-30-2007 Oct-21-2007 Nov-11-2007 Dec-02-2007 Dec-23-2007 Jan-13-2008 Feb-03-2008 Feb-24-2008 Mar-16-2008 Apr-06-2008 Apr-27-2008 May-18-2008 Jun-08-2008 Jun-29-2008 Number of Confirmed Cases Date of Onset * A confirmed case is either a laboratory-confirmed case OR (clinically compatible and linked to a laboratoryconfirmed case) as of 2008-03-05 ** Remainder of the 1,661 confirmed cases that were reported are missing onset dates. 10
Mumps Immunization By 1983, all provinces and territories were routinely immunizing infants with MMR vaccine. On the basis of the community epidemiology of mumps, most people born in Canada before 1970 are immune to mumps likely exposed to the wild mumps virus that was circulating during their childhood 11
Mumps Immunization In August 2007, NACI issued a revised statement for mumps-containing vaccine two-dose mumps immunization is now recommended for infants and children, as well as certain adult high-risk groups consideration of a single dose of MMR vaccine for high-risk adults (e.g. health care workers) born before 1970 All provinces and territories now offer two dose schedule 12
Canadian cohorts offered one dose of mumpscontaining vaccine by jurisdiction and birth year jurisdiction Nunavut Yukon Northwest Territories Newfoundland PEI Nova Scotia New Brunswick Quebec Ontario Manitoba Saskatchewan Alberta BC (12-37 years old) (17-35 years old) (12-38 years old) (24-35 years old) (17-35 years old) (17-33 years old) (12-31 years old) (17-32 years old) (15-33 years old) (17-25 years old) (08-28 years old) (17-26 years old) (12-27 years old) 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 birth year 13
Recommendations The guidelines make recommendations regarding: Definitions Case and contact management Health care workers Laboratories Gatherings Travel 14
Confirmed Case Definition Any one of the following in the absence of recent immunization (i.e. in the previous 28 days): i. mumps virus detection or isolation from an appropriate specimen (buccal swab is preferred); ii. positive serologic test for mumps IgM antibody in a person who has mumps-compatible clinical illness iii. significant rise (four-fold or greater) or seroconversion in mumps IgG titre; iv. mumps-compatible clinical illness, in a person with an epidemiologic link to a laboratory-confirmed case. 15
Clinicial/Probable Case Definition Acute onset of unilateral or bilateral parotitis lasting longer than 2 days without other apparent cause 16
Contact Definition Any of the following during the infectious period (i.e. approximately 7 days before to 5 days after symptom onset): i. household contacts of a case; ii. persons who share sleeping arrangements with the case, including shared rooms (e.g. dormitories); iii. direct contact with the oral/nasal secretions of a case (e.g. face-to-face contact, sharing cigarettes/drinking glasses/food/cosmetics like lip gloss, kissing on the mouth); iv. children and staff in child care and school facilities. 17
Laboratories RT-PCR is reliable for the definitive diagnosis of an acute mumps infection, but its sensitivity can be influenced by the following: timing of the specimen collection in relation to onset of illness; specimen integrity (rapid specimen processing). Buccal swab or saliva from the buccal cavity collected within the first 3 to 5 days of parotitis or symptom onset is the preferred specimen Testing for mumps-specific IgM class antibody has been shown to be poorly predictive for the diagnosis of acute mumps in a partially immunized population (may only be detectable in 30% of acute cases). 18
Case Management Clinical cases should be managed as confirmed cases until laboratory evidence suggests otherwise 1. Mumps is a reportable disease in all Canadian jurisdictions, and public health authorities should be notified through the usual channels. 2. In the absence of an epidemiologic link to a confirmed case, an oral swab (buccal specimen is preferred) should be obtained for laboratory confirmation. 3. Assess risk factors: obtain immunization and/or disease history, assess epidemiologic links to cases or settings, including travel. 19
Case Management 4. There is no specific treatment for mumps, only supportive care. Health care providers can offer second dose of mumps vaccine if patient has only received one previously. 5. Advise the case to: a. stay home (self-isolate) for 5 days from symptom onset b. wash or sanitize their hands often c. avoid sharing drinking glasses, eating utensils or any object used on the nose or mouth d. cover coughs and sneezes with a tissue or forearm 20
Contact Management Dissemination of information to contacts should include: Information on mumps, its symptoms and prevention Advice to visit one s health-care provider should any symptoms develop, but call before going (if possible) Offer immunization to susceptible groups as defined by the epidemiology of the outbreak Immunization may not prevent disease if the individual is already infected Previous outbreaks have indicated that immunization uptake is low 21
Health Care Workers Pre-placement of HCWs: Occupational Health should document HCW immune status at the pre-placement examination Existing HCWs: Occupational Health should provide MMR to all HCWs unless the individual has documented immunity HCWs who are cases: Clinical cases are managed as confirmed cases until laboratory evidence suggests otherwise Advise case to stay home for 5 days from symptom onset and until symptoms have resolved 22
Health Care Workers HCWs who are contacts: Contact in the facility if unprotected face-to-face interaction within 1 metre of an infectious mumps case: assess immunity to mumps if unknown draw blood for MMR IgG serology provide a dose of MMR vaccine while waiting for serology results, exclude HCW from work for the period of communicability if IgG positive, then consider immune if IgG negative, then consider susceptible 23
Gatherings During an outbreak, events need not be cancelled Public exposure settings should be communicated to the public, and event organizers should advise participants as follows: of the potential for exposure and how to prevent spread of the disease of mumps disease, its symptoms and prevention of the need to visit their health care provider should any symptoms develop 24
Travellers Travellers should ensure that their routine immunizations are up to date In Canada, individuals can be refused permission to board an aircraft or cruise ship if they appear to have an infectious disease Travellers with symptoms of mumps should postpone travelling until they are better 25
Travellers Airplanes: Individual follow-up is not recommended, although notification of implicated public health authorities is suggested as other jurisdictions may have different protocols Cruise Ships: The cruise ship s health services would have the responsibility for the traveller's health during the cruise and would follow up with contacts according to the conveyance operator's policy 26
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Guidelines Development August 2007 to February 2008 Guidelines written by F/P/T working group February 2008 F/P/T working group consensus on guidelines June 2008 Full version of guidelines presented to CIC July 2008 Comments on guidelines received from CIC October 2008 Working group meets to discuss changes November 2008 Working group consensus on guidelines February 2009 Presentation of revised guidelines version to CIC March 2009 Presentation of guidelines to CDCEG approval received April 2009 Presentation of guidelines to CCMOH - approved 28