-Clinical Commentary-
Infectious Mononucleosis

Mary Marugg, RN
Camp Nurse at Sonlight Christian Camp, Pagosa Springs, CO
CompassPoint, volume 12, no. 2, pg 6.

Nicknamed the “kissing disease” and simply called “mono” for short, infectious mononucleosis is primarily a disease of high school and college aged young adults. Caused by the Epstein-Barr virus (EBV), the disease is spread by contact with oropharyngeal secretions (saliva) of an infected person. Interestingly, Chin (2000) reports that about 50% of people infected with the virus develop clinical infectious mononucleosis; the remaining 50% “are mostly asymptomatic.” This has interesting implications for camp health in that, potentially, asymptomatic infected people could be present and no one – including the infected person – would be aware of it. With an incubation period of four to six weeks, watching for symptoms of infectious mono in both campers and staff is an important component of camp health practices.

Clinical infectious mononucleosis is usually a benign, self-limiting condition characterized by fatigue, high fever, sore throat and painful enlargement of the lymph nodes. It is a relatively mild disorder but the effects on the body are widespread. Lymph nodes enlarge, blood work shows lymphocytosis and the spleen may be two or three times its normal size. Liver function is sometimes impaired and both the peripheral and central nervous systems may be involved in the disease process. The individual feels fatigued and tires easily, even with supposedly “enough sleep.”

Camp nurses should be concerned with more than one aspect of this disease: (a) controlling the spread of the disease and (b) promoting recovery of the infected person. Although mono is typically not spread by casual contact with others, having the disease in camp should trigger increased surveillance of the camp’s infection control practices. Kissing, with its shared salivary exchange, is the most common transmission behavior, but oropharyngeal secretions can also be transferred to hands. Consider the many ways hands are used at camp and it’s easy to identify many contact points. Bare in mind that as many as 50% of EBV infected people are asymptomatic; it, therefore, makes reasonable sense for camp health practices to continually stress hand washing and include comment about mono during talks with staff about disease transmission.

Concern also should be for the camper or staff recently diagnosed with mono. Participation in some camp activities may increase potential for complications of the disease. And the attraction of fun-filled, busy camp days may entice a person who needs more rest to push their limits. If a person is symptomatic and, with their physician’s approval, comes to camp, provide a monitored activity program to ensure continued recovery without complications. Most people who have mono are up and around within two weeks. Mono can, however, produce symptoms lasting much longer. Splenic enlargement is one concern; a blow to the abdomen or excessive physical exertion may cause rupture of the spleen.

It has been noted by experienced camp nurses that campers and staff with a history of mono during the school year prior to their summer camp experience are at greater risk for fatigued-based problems during the summer season. The health screening process would identify this group if the right question were asked via health form or oral interview. However, remember that a quirky characteristic of the Epstein Barr virus is that individuals may harbor it yet be asymptomatic. These folks won’t be identified through screening. It would be prudent for healthcare staff to obtain physician approval and guidelines for campers or staff who have been diagnosed with mono within two months of attending camp. They may require additional rest to keep up with the pace of camp.

The fatigue associated with mono deserves attention. It may persist two or three months beyond the acute state of the disease. In addition, all potentially high impact activities should be reviewed for physician approval: bicycling, contact sports, ropes courses, horseback riding, rock climbing, diving, and activities with belay harnesses cinched around the waist. High exertion activities such as backpacking or canoeing also deserve a physician OK. Rupture of the spleen is a rare complication, only occurring in one or two cases out of 1000, however caution should be exercised.

There is some discussion regarding pain relievers recommended for persons with mono. Some literature suggests that acetaminophen should be avoided because it is processed by the liver. Infectious mononucleosis may compromise an otherwise healthy liver and, in this instance, acetaminophen may be an additional insult. Other literature suggests that aspirin and ibuprofen should be avoided as theoretically either could aggravate a gastrointestinal bleeding problem. Obtain guidelines from the individual’s physician for healthcare routines to be continued at camp.

Identifying campers or staff who have recently been diagnosed with mono is certainly an important part of health screening. Camp may be an appropriate place for someone recovering from mono, with guidelines from their diagnosing physician. Education for activity staff and counselors is important as well as having a system for monitoring the daily health of an affected person. Routines which practice infection control will help prevent the spread of the disease.