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Pediatric Re-emerging Infections and Vaccines

Measles and Mumps: A Primer for Providers

Rachel F. Esposito, D.O.Elizabeth A. Negrón, MPH, RN, CIC

POMA District VIII Winter SeminarJanuary 2020

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Disclosure

• We have no actual or potential conflict of interest in relation to this program/presentation.

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Objectives

• Review epidemiology of measles & mumps

• Review clinical features of measles & mumps

• Discuss specimens recommended for measles & mumps diagnosis

• Review measures to prevent transmission of measles & mumps

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Measles

Source: CDC Public Health Image Library

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Measles Epidemiology

• Agent: measles virus• Reservoir: humans• Transmission: airborne – virus can

remain airborne up to 2 hours • Incubation: average is 14 days (range

7–21 days)• Temporal Pattern: peak disease

occurrence late winter and early spring• Communicability: 4 days before through

4 days after onset of rash

Source: CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases.

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Measles Global Distribution

Source: CDC. Global Health. Retrieved from: https://www.cdc.gov/globalhealth/measles/globalmeaslesoutbreaks.htm

Number of Measles Cases Reported to WHO (January-June 2019)

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U.S. Measles Epidemiology

Reported US measles incidence, 1950–2001

Source: The Journal of Infectious Diseases, Volume 189, Issue Supplement_1, May 2004, Pages S1–S3, https://doi.org/10.1086/377693

*First initiative was termed "eradication"

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U.S. Measles Epidemiology (cont.)

Number of Measles Cases Reported by Year, U.S., 2010-2019**

**Cases as of December 5, 2019. Case count is preliminary and subject to change. Data are updated monthly.

Source: CDC. Measles Cases and Outbreaks. retrieved from: https://www.cdc.gov/measles/cases-outbreaks.html

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PA Measles Epidemiology

1

8

2

9

2

3

1

14

2

13

2

3

1

5

2

17

0

2

4

6

8

10

12

14

16

18

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Case

Cou

nt

Year Counted

Measles Cases (confirmed & probable), Pennsylvania, 2000-2019*

*2019 Data are provisional

Source: PANEDSS mmwrall.sas7dat Dataset

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Measles Clinical Features

• ProdromeBegins 8-12 days after exposureFever with stepwise increase (peaking at 1030F – 1050F), malaise Cough, coryza, and conjunctivitisKoplik’s spots may occur 1-2 days before rash

Source: CDC Public Health Image Library.

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Measles Clinical Features (cont.)

• Rash2-4 days after prodrome, average 14 days after exposurePersists 5-6 daysBegins on face and head followed by movement downward and outwardMaculopapular, becomes confluentFades in order of appearance

Source: CDC Public Health Image Library

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Measles Diagnosis

• Consider clinical features – are they consistent with measles?

• Consider whether the patient was potentially exposed – travel to an area where they are cases? contact with another case?

• *Consider whether the patient is immune by age, vaccination status or titer

*Patients with 2 documented doses can still become infected

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Laboratory Testing for Measles

• Measles virus detection with real-time polymerase chain reaction (RT-PCR), collect:

Throat or nasopharyngeal swab andUrine

Ideal collection timing is within 3 days of rash onset

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Lab Testing for Measles (cont.)

• Serological testing – collect as soon as possible and 2-3 weeks later (convalescent serum)

• Interpret results with caution, taking into account:

Symptoms and their onset(s)Vaccination status of patientTiming of collectionThe PA Department of Health (PA DOH) can assist with interpretation

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Important Note About Serology

• To determine immunity in asymptomatic patients, obtain measles IgG

• Do not order IgM if patient is asymptomatic or was recently vaccinated with measles-containing vaccine

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Measles Prevention

Combination vaccine: MMR* (measles, mumps, rubella)• Recommended routinely for children:

1st dose: 12 – 15 months2nd dose: 4 – 6 years

• Recommended for adults at high risk (healthcare workers (HCW), international traveler, those at post-high school educational institutions)

• May prevent infection in an exposed contact if given within 72 hours of exposure

*MMRV (+ varicella) is available for children 12 months - 12 years

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Presumptive Evidence of Measles Immunity

• Written documentation of adequate vaccination:

Receipt of >1 dose of measles-containing vaccine administered on or after the 1st

birthday for pre-school aged children & adults not at high-risk for exposure transmission2 doses of measles-containing vaccine for school-aged children & adults at high risk for exposure transmission; or

• Lab evidence of immunity; or• Lab confirmation of disease; or• Birth before 1957

ACIP: Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices, June 14, 2013

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Healthcare Workers & Measles Immunity

Evidence of measles immunity for HCW include:• Written document of vaccination with 2

doses of measles-containing vaccine administered at least 28 days apart; or

• Lab evidence of immunity; or• Lab confirmation of disease

ACIP: Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices, November 25, 2011

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Protocols - Measles

Right now:• Obtain and store a copy of vaccine records or titer reports

for all current staff and each newly-hired staff• Vaccinate staff without evidence of immunity

If you examine a suspected case:• Ensure staff follow infection prevention & control measures

to limit transmission• Report suspected case the Department of Health

immediately for:Consultation and authorization for testing at the PA DOH labInfection control recommendationsContact tracing

• Ensure mechanism to identify all potentially exposed persons in the office - staff, patients, family members, visitors, etc.

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Infection Control Measures - Measles

If examining a patient with febrile rash illness:• Immediately mask any suspected case who

presents for care• Implement airborne & standard precautions

Place in negative pressure isolation room, if available, orPlace in single room with door(s) closed and do not use room for at least 2 hours after patient leaves

• Minimize exposure to others (e.g. collect specimens in exam room)

• Instruct patient to self-isolate at home immediately after leaving your facility/office until informed of release from you or the Department of Health

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Mumps

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Mumps Epidemiology

• Agent: mumps virus• Reservoir: humans; asymptomatic cases

may transmit disease• Transmission: Respiratory droplet nuclei• Incubation: about 16-18 days (range 12–25

days)• Temporal Pattern: Peak in late winter and

spring• Communicability: 3 days before to 5 days

after onset of parotitis

Source: CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases.

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Mumps Epidemiology - Outbreaks

• >3 cases linked by place and time• Can occur in highly vaccinated

communities, especially where close contact facilitates transmission

Schools, universities, camps, church groups, families, etc.

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U.S. Mumps Epidemiology

* Case count is preliminary and subject to change.**Cases as of December 6. Case count is preliminary and subject to change.Source: CDC. Mumps Cases and Outbreaks. retrieved from: https://www.cdc.gov/mumps/outbreaks.html

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U.S. Mumps Epidemiology (cont.)

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PA Mumps Epidemiology

69

3 421 19 14 15

116

144

448

0

50

100

150

200

250

300

350

400

450

500

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Case

Cou

nt

Year Counted

Mumps Cases (confirmed & probable), Pennsylvania, 2010-2019*

*2019 Data are provisional

Source: PANEDSS mmwrall.sas7dat Dataset

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Mumps Clinical Features

• Prodrome is non-specificBegins 14-18 days after exposureMyalgia, malaise, headache, low-grade fever

• Parotitis occurs in 30%-40% of infected persons

1 or more salivary glands may be affectedUsually occurs in first 2 days, lasts up to 7-10 daysUnilateral or bilateral

• Up to 20% of infections are asymptomatic

Source: Merck Manual Consumer Version, edited by Robert Porter.

Source: CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases.

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Mumps Clinical Features (cont.)

• Complications:Orchitis, oophoritis, mastitis, meningitis, encephalitis, pancreatitis, and hearing lossCan occur in the absence of parotitisLess frequent in vaccinated personsDeath is very rare

Source: CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases.

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Mumps Diagnosis

• Mumps infection is generally suspected based on clinical manifestations, especially parotitis

• Patients who received 1 or 2 doses of MMR can become infected with mumps virus

Source: Merck Manual

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Mumps Diagnosis (cont.)

• Influenza virus• Parainfluenza virus

types 1 and 3• Epstein Barr virus• Coxsackie A virus,

echovirus• Lymphocytic

choriomeningitis virus

• Human immunodeficiency virus

• Noninfectious causesDrugsTumorsImmunologic diseasesObstruction of the salivary duct

Be aware of other etiologies of parotitis:

Mumps virus is the only etiology that causes parotitis on an epidemic scale

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Laboratory Testing for Mumps

• Mumps virus detection with RT-PCR or culture (longer turnaround time)

Patients with parotitis: obtain buccal swabPatients with other manifestation(s): obtain buccal swab & urine specimen

• Yield is lower if collected >3 days after onset

• Negative results do not rule out infection

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Lab Testing for Mumps (cont.)

• Serological testing enhances ability to diagnose mumps

• Results affected by:Timing of collection – antibodies generally detectable 5 days after onsetVaccination status of patient

• Detection of mumps-specific IgG is evidence of exposure to virus or vaccine but does not necessarily predict protection from infection

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Lab Testing for Mumps (cont.)

• Consider tests to identify other etiologies that may cause parotitis, especially respiratory panel

• The PA DOH can assist with interpretation of lab results

• Testing may not be needed, if the symptomatic patient is part of a group associated with an outbreak

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Mumps Prevention

Combination vaccine: MMR* (measles, mumps, rubella) • Recommended routinely for children:

1st dose: 12 – 15 months2nd dose: 4 – 6 years

• Recommended for adults at high risk (HCW, international traveler, those at post-high school educational institutions)

• A 3rd dose is recommended for those at increased risk, as defined by public health authorities

• Vaccination after exposure is not harmful and may possibly avert later disease

*MMRV (+ varicella) is available for children 12 months -12 years

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Presumptive Evidence of Mumps Immunity

• Written documentation of adequate vaccination:

Receipt of >1 dose of mumps-containing vaccine administered on or after the 1st

birthday for pre-school aged children & adults not at high-risk for exposure transmission2 doses of mumps-containing vaccine for school-aged children & adults at high risk for exposure transmission; or

• Lab evidence of immunity; or• Lab confirmation of disease; or• Birth before 1957

ACIP: Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices, June 14, 2013.

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Healthcare Workers & Mumps Immunity

Evidence of mumps immunity for HCW include:• Written document of vaccination with 2

doses of mumps-containing vaccine administered at least 28 days apart; or

• Lab evidence of immunity; or• Lab confirmation of disease

ACIP: Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices, November 25, 2011

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Protocols - Mumps

Right now:• Obtain and store a copy of vaccine records or

titer reports for all current staff and each newly-hired staff

• Vaccinate those without evidence of immunity

If you examine a suspected case of mumps:• Ensure staff follow infection prevention &

control measures to limit transmission• Report all suspected cases the Department of

Health

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Infection Control Measures - Mumps

For patients suspected of being infected with mumps virus:• Isolate patient using droplet precautions,

which includes use of surgical mask by staff in close contact with patient

• Minimize exposure to others (e.g. collect specimens in exam room)

• Instruct patient to self-isolate at home immediately after leaving your facility/office until 5 days after onset of parotitis

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https://youtu.be/7L1q4C0MkV8

Additional Slide

WellSpan doctor, fully vaccinated against measles, is the second case in York CountyPublished 2:36 p.m. ET Sept. 16, 2019

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Questions