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					                Milestones in Public Health: U.S. Public Health Infrastructure Chapter #11

                                                 Case Study
                                     The Case of Michael Smith: Mumps

Learning Objectives

Through this case study, research, and class discussion, students are expected to:

      Describe the role of the public health workforce in the U.S. public health infrastructure
      Describe the role of disease surveillance and information systems in the U.S. public health system
      Describe the organizational capacity within the U.S. public health system
      Describe the “Essential Public Health Services” and how they relate to a mumps outbreak
      Describe the importance of a team approach in solving public health problems
      List the accomplishments and primary functions of the Centers for Disease Control and Prevention

Background and Case Materials

It is December 2008 and Michael Smith, a 20-year-old undergraduate student at a university in the District of
Columbia, presents to the student out-patient clinic with high fever and right-sided testicular swelling. Michael
lives in a dormitory with 200 other students and reports that some students have had similar symptoms. Michael
is diagnosed with mumps, as are several other students in his dormitory. You are a primary care physician
working at the student out-patient clinic.
Mumps Basics

A clinical case definition of mumps follows: “an illness with acute onset of unilateral or bilateral tender, self-
limited swelling of the parotid or other salivary gland, lasting 2 or more days, and without other apparent cause.
A confirmed case of mumps is one that is laboratory confirmed or meets the clinical case definition and is
linked epidemiologically to a confirmed or probable case. A probable case meets the clinical case definition but
is neither laboratory confirmed nor linked to another confirmed or probable mumps case.” (Council of State and
Territorial Epidemiologists (CSTE). 1999 position statements. Position Statement ID-9. CSTE National
Meeting, Madison, WI, 1999. Available at http://www.cste.org/ps/1999/1999-id-09.htm.)

In layperson’s terms, mumps is an acute, self-limited viral infection characterized by fever, muscle aches, and
swelling of the parotid salivary glands (which are located within the cheek, near the jaw line, below one’s ears)

Other key facts follow:

      An estimated of 20-30% of mumps cases are asymptomatic
      Complications are rare, but can include inflammation of: the testicles (orchitis), ovaries (oophoritis),
       breasts (mastitis), tissue covering the brain (meningitis), brain (encephalitis), spontaneous abortion, and
       deafness
      Mumps vaccine, usually Measles Mumps Rubella (MMR), is the best way to prevent mumps. Children
       should be given their first dose of MMR vaccine after their first birthday (12-15 months) and their
       second dose before the start of kindergarten
      The virus is transmitted through direct contact with respiratory secretions or saliva or through fomites
       (an inanimate object or substance that is capable of transmitting infectious organisms from one
       individual to another)
      Diagnosis of mumps is based on clinical presentation and or lab tests
      Currently there is no treatment for mumps
      Cases of mumps are reportable through the National Notifiable Diseases Surveillance System (NNDSS).
        Reports are transmitted electronically via NNDSS to the Centers for Disease Control and Prevention
       (CDC) on a weekly basis and include individual case information such as age, sex, date of symptom
       onset, vaccination status, and complications of illness

Details on the 2005-2006 Iowa Mumps Outbreak

The first reports of a mumps-like illness to the Iowa Department of Public Health occurred in December 2005 at
a university in eastern Iowa, where several students with glandular swelling were tested, and two tested positive
for mumps. In mid-January 2006, an isolate from an unrelated patient was cultured and identified as mumps
virus at Iowa’s state public health laboratory. By mid-February, active surveillance had been initiated in seven
geographic areas, including the campuses of the three largest universities in Iowa. As of March 2006, of the 219
cases reported in Iowa, the median patient age was 21 years with 48% of the patients aged 17-25 years old; 30%
were known to be college students. Of 133 with investigated vaccine history, 87 (65%) had documentation of
receiving two doses, 19 (14%) received one dose, and eight 6% received no doses. Vaccine status could not be
documented in 19 (14%) of patients.




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As of March 28, 2006, investigators had determined that only 36 (16%) of the 219 were linked
epidemiologically. Many health care providers who had not seen cases of mumps required education on
diagnosing the disease. To educate health care professionals in Iowa regarding the epidemic and mumps,
information was distributed via Iowa Health Alert Network (HAN), in weekly electronic newsletters, and via
frequent conference calls. The Iowa Department of Public Health provided biweekly updates, county case
counts, fact sheets, and guidance to local health departments on case-investigations. As a result of the mumps
outbreak, national recommendations for mumps prevention were updated

Prior to the case session, the students should review the Milestones Chapter 11 U.S. Public Health Infrastructure
lecture. At the beginning of the case session, the students can watch News Hour with Jim Lehrer, “CDC Chief
Responds to Mumps Reappearance in Eight States,” http://www.pbs.org/newshour/bb/health/jan-
june06/mumps_4-20.html.

Discussion Aids

Questions to ask the class follow:

   1. What are the clinical manifestations of mumps? How do you diagnose, treat, and prevent mumps?

   2. Once you make the clinical diagnosis of mumps what are your next steps in terms of notifying public
      health authorities?

   3. What roles do the clinic, local health department, DC Department of Public Health, and CDC play
      respectively in addressing a mumps outbreak?

   4. How do the Ten Essential Public Health Services relate to this case?

   5. What are the accomplishments and roles of the CDC?

   6. How are the different components of the public health infrastructure represented in this case? What
      challenges within the public health infrastructure relate to this case?

   7. Why is Julie Gerberding on TV talking about mumps?

   8. Concerned parents and the news-media are calling your clinic about the epidemic, and you are asked by
      the president of the University to design a communication plan for the student body at large. What do
      you communicate and how?

Readings and Other Resources

   1. Hviid A, Rubin S, Mühlemann K. Mumps. The Lancet. 2008;371(9616):932-944.

   2. Centers for Disease Control and Prevention. Mumps epidemic—Iowa. MMWR. 2006;55(13):366-368.
      Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5513a3.htm.




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