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					       MUMPS:
            A precautionary tale

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




                                              (You “mumpsed out” yet?)
And lo, an outbreak was borne…




         There once was a student with cheek lumps
        Who knew not what to do with these bumps.
                    So to Halifax s/he fled
                  To go bar-hopping instead
     And so gave his/her hosts the great gift of the mumps.
          About Halifax (CDHA)
 4 amalgamated municipalities (HRM) + East Hants
 5 post secondary institutions + Nova Scotia Community
  College (4 campuses)
 420 family docs – private offices, not hospital based
 2 large tertiary-care hospitals (11 campuses; 10000
  employed at CDHA; 3000 at IWK)
 Department of National Defense – 8700 personnel, 120
  hcws
 Coast Guard
 Population: approx 400 000
         About Nova Scotia

   Population – 913 000
   Proportion of persons aged 20-24 – 56 000
   Proportion of persons aged 15-19 – 62 000
   5 additional universities + Nova Scotia
    Community College (9 campuses)
   DND, Coast Guard
Where we’ve been…




               PHAC; November 9, 2007
                        Mumps Cases in Nova Scotia by Week of Onset (n=678)
                  70
                  60
Number of Cases




                  50
                  40
                  30
                  20
                  10
                  0
                    8
                   10
                        12
                        14
                             16
                             18
                                   20
                                   22
                                          24
                                          26
                                                28
                                                30
                                                       32
                                                       34
                                                              36
                                                              38
                                                                     40
                                                                     42
                                                                              44
                                                                              46
                                            Reporting Week
              Descriptive Epidemiology –
                November 30 , 2007
                     Nova            CDHA           Other DHAS
                     Scotia
Total Cases              733          585 (80%)       148 (20%)
 Confirmed             556 (76%)      457 (78%)        99 (67%)
 Clinical              177 (24%)      128 (22%)        49 (33%)
Age range            4 mo – 69 yrs   4 mo – 64 yr      2 – 69 yr
                      17 - 25: 58%   17 - 25: 60%    17 - 25: 48%
Age Groups            17 - 37: 84%   17 - 37: 88%    17 - 37: 72%
                      38 – 49: 9%    38 – 49: 6%     38– 49: 18%
Median age (years)        23             23               25

Male:Female ratio    360:373 (51%    285:300 (51%    75:73 (49% F)
                          F)              F)
   Complications

Orchitis
Mumps encephalitis
Sensori-neural hearing loss

Arthralgia
Oöphoritis
Our definition of the precautionary
             principle:

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


PRIMARY ASSUMPTION: that risk of mumps
and of outbreak required doing something
APPLYING PRECAUTION during
   mumps: twice unlucky…
1. Early in the outbreak
   • aggressive case finding
   • aggressive contact tracing
   • aggressive case management
   • aggressive contact management

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

2. Mid outbreak
    • aggressive management of health care workers

•   Purpose
       • to prevent hcws from bringing mumps into the
           institutions
                            Finding and achieving “New
                                     Normal”
                                Public Health Services
                                Other Health Care Responses
Activity Levels (Operational)




                                                           “NEW NORMAL”



                                                                          “Denouement”


                                     Baseline operations

                                                                              Time
Outcomes:
     Cases continued to accumulate
     Cases became “mumpsed out” – non compliance
     Contacts difficult to find
     Massive document management challenges
     PHS staff overtaken by OH and IC response
     Exhausted staff – and new programs and other PH
       challenges on the horizon!
      Our ethical dilemnas became
                 these…
   What is the appropriate response to an outbreak
    in the face of other public health burdens? When
    is doing nothing ok?

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

   What was the harm to our organization(s) from
    our precautionary approach to mumps?
                        (con’t)…



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

Can    you “take it back”?




                              …We did, but not without issues…
      Thank you. Questions?

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

				
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