- [1] Mumps - Virginia
- Date: Thu 18 May 2006
- From: Raymond Weinstein
-
- I thought you might be interested to
learn that today [Thu 18 May 2006] I diagnosed what I believe is the 1st
case of mumps in Virginia associated with the current multistate outbreak.
The patient is a 17 year old female from Manassas with no known recent
contact with anyone having mumps and no recent travel or visitors from
outside Virginia. She became ill with fever and headache about 5 days ago
and developed symptoms of bilateral parotitis within the last 2 days.
-
- Laboratory confirmation of the diagnosis
is pending. What ties this case to the other outbreaks is the fact that
this patient is originally from Kansas and received her 2 MMR vaccinations
there in 1990 and 1994.
-
- This occurrence makes me wonder: 1. Since
this patient was vaccinated in Kansas, but no longer lives there, could
this be an indication of vaccine failure? 2. Does her development of mumps,
with no known contact with the illness, in a community with a high vaccination
rate and where an outbreak is not occurring, indicate that there may be
an intermittent subclinical occurrence of the illness? I can imagine a
scenario where this might occur in patients who have partial immunity from
previous vaccination and who might shed virus without having any symptoms,
or at least symptoms to suggest mumps.
-
- --
- Raymond Weinstein, MD
- Manassas,Virginia
- USA
-
- Some of Dr Weinstein's observations are
dealt with in detail in the
- following MMWR dispatch. - Mod.CP
-
- __________
-
- Mumps Now Multi-State Outbreak
- Source: MMWR Dispatch 18 May 2006 / 55(Dispatch);1-5
- http://www.cdc.gov/mmwr/preview/mmwrhtml/mm55d518a1.htm?s_cid=mm55d518a1_e
-
- Update: multi-state outbreak of mumps
- United States; 1 Jan to 2 May 2006
-
- -----------------------------------------------------
-
- CDC and state and local health departments
continue to investigate an outbreak of mumps that began in Iowa in December
2005 (1) and involved at least 10 additional states as of 2 May 2006. This
report summarizes preliminary data reported to CDC from these 11 states
and provides recommendations to prevent and control mumps during an outbreak.
-
- Cases of mumps are reportable through
the National Notifiable Diseases Surveillance System (NNDSS) (2). NNDSS
reports are transmitted electronically to CDC each week and include information
on individual cases such as age, sex, date of symptom onset, vaccination
status, and complications of illness. Mumps cases included in this report
are those with onset from [1 Jan 2006] (MMWR week 1) through [29 Apr 2006]
(MMWR week 17) that were reported to CDC as of [2 May 2006] through NNDSS
(or the Iowa mumps outbreak-specific reporting system) from Iowa and 10
additional states that reported one or more cases of mumps epidemiologically
linked to the multistate outbreak. In addition to cases reported through
NNDSS, to provide information rapidly during this outbreak, states have
been reporting aggregate numbers of mumps cases and mumps-related hospitalizations
and complications biweekly to CDC. Cases reported in this manner through
[2 May 2006], also are included in this report.
-
- The clinical case definition of mumps*
is 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 case is classified
as probable if it meets the clinical case definition but is neither laboratory-confirmed
nor linked to another confirmed or probable mumps case. In accordance with
these definitions, asymptomatic, laboratory confirmed infections were counted
as confirmed cases in all states except Iowa. In Iowa, laboratory-confirmed
cases that were asymptomatic or had clinical information pending, and cases
for which high suspicion for mumps existed but case classification was
not yet determined were classified as suspect.
-
- During the period 1 Jan to 2 May 2006,
11 states reported 2597 cases of mumps. Eight states (Illinois, Iowa, Kansas,
Missouri, Nebraska, Pennsylvania, South Dakota, and Wisconsin) reported
mumps outbreaks with ongoing local transmission or clusters of cases; 3
states (Colorado, Minnesota, and Mississippi) reported cases associated
with travel from an outbreak state. The majority of mumps cases (1487 [57
per cent]) were reported from Iowa; states with the next highest case totals
were Kansas (371), Illinois (224), Nebraska (201), and Wisconsin (176)
(Figure 1 [see URL link above]). Of the 2597 cases reported overall, 1275
(49 per cent) were classified as confirmed, 915 (35 per cent) as probable,
and 287 (11 per cent) as suspect; for 120 (5 per cent) cases, classification
was unknown. Twelve mumps viral isolates from 6 states were characterized;
all were mumps genotype G.
-
- For 2067 (80 per cent) of the 2597 mumps
cases with patient age available, the median age was 21 years (range: less
than 1 year to 96 years). In the 8 states with outbreaks, the incidence
rate was highest among persons aged 18 to 24 years (17.1 per 100 000 population),
followed by persons aged 5 to 17 years (5.2) and 25 to 39 years (4.8) (Figure
2 [see URL link above]). Among the 2073 patients for whom sex was known,
1244 (60 per cent) were female. Among the 2073 cases for which week of
onset was known, 1426 (69 per cent) were reported in April (Figure 3 in
original text). The peak week of onset has been April 2 to 8 (week 14)
in Iowa and April 16 to 22 (week 16) in other states.
-
- However, additional cases with onset
dates in April continue to be reported. Parotitis was reported in 870 (66
per cent) of the 1327 patients for whom such data were available. Data
regarding mumps complications and hospitalizations are incomplete. However,
complications have included 27 reports of orchitis, 11 meningitis, 4 encephalitis,
4 deafness, and one each of oophoritis, mastitis, pancreatitis, and unspecified
complications. A total of 25 hospitalizations were reported, but insufficient
data were provided to determine whether mumps caused all the hospitalizations.
No deaths have been reported.
-
- Vaccination status of reported mumps
patients is being ascertained. In Iowa, preliminary vaccination data were
reported through [3 May 2006].*** Among 1192 patients, 69 (6 per cent)
were unvaccinated, 141 (12 per cent) had received 1 dose of measles, mumps,
and rubella (MMR) vaccine, and 607 (51 per cent) had received 2 doses of
MMR vaccine; the vaccination status of 375 (31 per cent) patients, the
majority of whom were adults who did not have vaccination records, was
unknown. Preliminary data, as of [10 Apr 2006], from 2 mumps outbreaks
on college campuses in an Iowa county affected early in the outbreak, identified
attack rates of reported mumps cases*** of 2.0 per cent (31 of 1542 students)
and 3.8 per cent (44 of 1168 students). Preliminary data from vaccine coverage
surveys suggest that the college with the higher attack rate had a smaller
proportion (77 per cent versus 97 per cent) of students documented as having
received 2 doses of MMR vaccine.
-
- As of [10 May 2006], a total of 11 persons
potentially infected with mumps who traveled by aircraft during [26 Mar-25
Apr 2006] had been identified on 33 commercial flights operated by 8 different
airlines. Notifications had either been initiated or completed for persons
potentially exposed on all identified flights. As of [12 May 2006], of
about 575 persons potentially exposed on the flights, 132 had received
follow-up greater than 25 days after their potential exposure. Two cases
of mumps were identified, possibly associated with transmission during
air travel. Both cases occurred among Iowa residents, one of whom was a
traveling companion of a person known to have mumps.
-
- (Reported by: K Gershman, MD, S Rios,
D Woods-Stout, Colorado Dept of Public Health and Environment. M Dworkin,
MD, K Hunt, Illinois Dept of Public Health. DC Hunt, MPH, J Hill, MPH,
Kansas Dept of Health and Environment. P Quinlisk, MD, M Harris, MPH, Iowa
Dept of Public Health. C Kenyon, MPH, Minnesota Dept of Health. C Evans,
K Mills McNeill, MD, PhD, RG Travnicek, MD, Mississippi Dept of Health.
B Zhu, MD, E Hedrick, HL Marx Jr, R Renicker, MSA, Missouri Dept of Health
and Senior Svcs. AL O'Keefe, MD, T Safranek, MD, Nebraska Health and Human
Svcs System. S Slagy, S Silvestri, Allegheny County Health Dept; J Sullivan,
York City Health Bur; J Mankowski, Erie County Health Dept; R Grill, K
Luckenbill, P Lurie, MD, R Rickert, MPH, H Stafford, Pennsylvania Dept
of Health. S Gannon, L Kightlinger, PhD, South Dakota Dept of Health. J
Berg, J Davis, MD, J Gabor, Wisconsin Dept of Health and Family Svcs. F
Averhoff, MD, K Marienau, MD, Div of Global Migration and Quarantine; M
Bell, MD, E Bolyard, MPH, C McDonald, MD, A Srinivasan, MD, Div of Healthcare
Quality Promotion, National Center for Preparedness, Detection, and Control
of Infectious Diseases (proposed); TA Santibanez, PhD, and J Santoli, MD,
Immunization Svcs Div, SW Roush, MPH, PU Srivastava, MS, Div of Bacterial
Diseases, L Anderson, MD, B Bellini, PhD, CB Bridges, MD, G Dayan, MD,
ST Goldstein, MD, M Marin, MD, U Parashar, MD, S Redd, S Reef, MD, J Rota,
MPH, PA Rota, PhD, J Seward, MBBS, C Shawney, Div of Viral Diseases, National
Center for Immunization and Respiratory Diseases (proposed); A Huang, MD,
A Parker, MSN, MPH, T Shimabukuro, MD, EIS officers, CDC.)
-
- MMWR editorial note
- -------------------
-
- In the United States, the reported incidence
of mumps declined after introduction of mumps vaccine in 1967 and the recommendation
for its routine use in 1977 (3). After expanded recommendations for a 2-dose
MMR vaccine schedule for measles control in 1989 (3), mumps cases declined
further (Figure 4 [see URL link above]). During the period 2001 to 2003,
fewer than 300 mumps cases were reported each year, a 99 per cent decline
from the 185 691 cases reported in 1968 (2).
-
- The current multistate mumps outbreak,
with 2597 cases reported through [2 May 2006], is the largest number of
mumps cases reported to CDC in a single year since 1991, when 4264 cases
were reported (2). The first cases in the current outbreak were detected
on a college campus in eastern Iowa in December 2005; the source of these
initial cases is unknown (1). Although the age group most affected (38
per cent of cases) has been young adults aged 18 to 24 years, many of whom
are college students, the outbreak has spread to all age groups (1).
-
- Multiple factors might have contributed
to the spread of mumps in this outbreak and on college campuses. First,
the college campus environment (such as living in dormitories with frequent
and extended close contact with other students) facilitates transmission
of mumps and other illnesses that are spread through respiratory and oral
secretions. Second, only 25 states***** and the District of Columbia report
a college admission requirement of 2 doses of MMR vaccine, including 3
of the 11 states with outbreak-associated cases of mumps; no data on implementation
and evaluation of the 2-dose college admission requirement are available
(CDC, unpublished data, 2006).
-
- Thus, 2-dose coverage with mumps-containing
vaccine among college students likely is lower than the median 97 per cent
(range: 57 per cent --99 per cent) coverage for measles-containing vaccine
(almost exclusively administered as MMR vaccine) for students entering
elementary school and the median 98 per cent (range: 62 per cent -- 99
per cent) coverage for students entering middle school reported in 2000
from 38 and 25 states, respectively (4).
-
- Third, delayed recognition and diagnosis
of mumps cases might have contributed to the spread in this outbreak; younger
physicians in the United States likely have not seen mumps, and physicians
might not consider the diagnosis in vaccinated persons. Fourth, 2 doses
of MMR vaccine are not 100 per cent effective in preventing disease, and
accumulation of susceptible persons who were not successfully immunized
might be sufficient to sustain transmission in certain settings. In addition,
the vaccine might be less effective in preventing asymptomatic infection
or atypical mumps than in preventing parotitis, and persons with asymptomatic
infection or mild disease might contribute to transmission.
-
- Finally, waning immunity has been postulated
as a contributing factor in this outbreak. Young adults aged 18-24 years
would most commonly have received their most recent dose of mumps-containing
vaccine (i.e., MMR vaccine) 6-17 years ago. High vaccination coverage with
2 doses of MMR vaccine, especially in school-aged populations in the United
States, likely prevented thousands of additional cases of mumps in this
outbreak. Post-licensure studies conducted in the United States during
the period 1973 to 1989 determined that one dose of mumps or MMR vaccine
was 75 to 91 per cent effective in preventing mumps with parotitis that
lasts greater than 2 days (5).
-
- Although fewer data are available on
the effectiveness of 2 doses of MMR vaccine against mumps, one study from
the United Kingdom documented vaccine effectiveness of 88 per cent with
2 doses (6).
-
- In a mumps outbreak in a high school
in Kansas, students vaccinated with 1 dose of MMR vaccine had an attack
rate 5 times that of students vaccinated with 2 doses (7).
-
- In a mumps outbreak in a middle school
in 1982, before mumps vaccination became widespread, attack rates of 25
to 49 per cent occurred among unvaccinated students, depending on how cases
were ascertained (8).
-
- During the 1986 to 1990, after widespread
implementation of a 1-dose mumps vaccination policy, attack rates of 2
to 18 per cent (most greater than 6 per cent) were documented in mumps
outbreaks among junior high and high school students with vaccination coverage
of greater than 95 per cent (7,9).
-
- In contrast, preliminary data from 2
colleges in Iowa during the current outbreak identified attack rates of
2.0 per cent and 3.8 per cent, respectively, with the lower attack rate
in the college with higher 2-dose vaccination coverage.
-
- To prevent mumps, the Advisory Committee
on Immunization Practices (ACIP) recommends a 2-dose MMR vaccination series
for all children, with the first dose administered at ages 12-15 months
and the second dose at ages 4-6 years (3).
-
- Two doses of MMR vaccine are recommended
for school and college entry unless the student has other evidence of immunity
(3). In a specially convened meeting on [17 May 2006], ACIP redefined evidence
of immunity to mumps through vaccination as follows: 1 dose of a live mumps
virus vaccine** for preschool children and adults not at high risk; 2 doses
for children in grades K--12 and adults at high risk (i.e., persons who
work in health-care facilities, international travelers, and students at
post-high school educational institutions). Other criteria for evidence
of immunity (i.e., birth before 1957, documentation of physician-diagnosed
mumps, or laboratory evidence of immunity) are unchanged. Furthermore,
health-care facilities should consider recommending 1 dose of MMR vaccine
to unvaccinated health-care workers born before 1957 who do not have other
evidence of mumps immunity.
-
- During an outbreak and depending on the
epidemiology of the outbreak (e.g., the age groups and/or institutions
involved), a 2nd dose of vaccine should be considered for adults and for
children aged 1-4 years who have received 1 dose. The 2nd dose should be
administered as early as 28 days after the first dose, the minimum recommended
interval between 2 MMR vaccine doses. In addition, during an outbreak,
health-care facilities should strongly consider recommending 2 doses of
MMR vaccine to unvaccinated workers born before 1957 who do not have other
evidence of mumps immunity. An MMWR Notice to Readers will be published,
summarizing these interim recommendations in more detail.
-
- Additional means to decrease transmission
in outbreak settings include exclusion of persons without evidence of immunity
to mumps from institutions such as schools and colleges that are affected
by the outbreak. Once vaccinated, students and staff can be readmitted
to school immediately, even if they have been exposed to a case of mumps.
The period of exclusion for those who remain unvaccinated is 26 days after
the onset of parotitis in the last person in the affected institution.
Students who acquire mumps illness should be excluded from school until
9 days after the onset of parotitis. After an exposure to mumps, unvaccinated
health-care workers without evidence of immunity should be vaccinated and
excluded from duty from the 12th day after the first exposure through the
26th day after the last exposure. Health-care workers with mumps illness
should be excluded from work until 9 days after the onset of parotitis.
-
- In response to the current outbreak,
the Iowa Department of Public Health (IDPH) issued vaccination recommendations
in March targeting college campus and health-care worker populations at
high risk. On 14 Apr, CDC issued a Health Advisory Notice summarizing vaccine
policy recommendations for mumps prevention and control. In conjunction
with local health departments, IDPH launched a statewide vaccination campaign
during 24-26 Apr, targeting persons aged 18-22 years in the 35 Iowa counties
with the state's largest colleges and universities. In the second phase
of the campaign, conducted 2-4 May, vaccination was expanded to the remaining
64 counties, targeting persons aged 18-25 years. A third phase of the vaccination
campaign was begun 10 May and targets persons aged 18-46 years. Vaccination
activities also are being conducted or planned in Kansas, South Dakota,
and Wisconsin.
-
- The data presented in this report are
preliminary; the case count is likely to change as additional data become
available. Certain reported cases might not have been caused by mumps;
cases in persons without parotitis might have been masculinized on the
basis of serologic tests. Because of the low number of reported mumps cases
during the last decade, laboratorians have limited experience with mumps
tests, particularly IgM antibody tests (10). Several different mumps IgM
antibody tests are in use; however, neither the sensitivities nor specificities
of these tests when used with serum specimens from either unvaccinated
or vaccinated persons have been clearly defined. Consequently, interpretation
of these antibody test results is difficult, especially in previously vaccinated
persons.
-
- Studies to define the sensitivity and
specificity of mumps IgM antibody tests and reverse transcription-polymerase
chain reaction (RT-PCR) tests for mumps virus RNA are in progress. CDC
continues to work with state and local health departments to conduct mumps
surveillance, assist with prevention and control activities, and evaluate
vaccine effectiveness, duration of immunity, and risk factors for mumps
illness.
-
- References
- ----------
- 1. CDC. Mumps epidemic -- Iowa, 2006.
MMWR 2006; 55: 366-8. <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5513a3.htm>
2. CDC. Summary of notifiable diseases---United States, 2003. MMWR 2005;
52(54). <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5254a1.htm> 3.
CDC. Measles, mumps, and rubella---vaccine use and strategies for elimination
of measles, rubella, and congenital rubella syndrome and control of mumps:
recommendations of the Advisory Committee on Immunization Practices (ACIP).
MMWR 1998; 47(No. RR-8). <http://www.cdc.gov/mmwr/preview/mmwrhtml/00053391.htm>
4. Kolasa MS, Klemperee-Johnson S, Papania MJ. Progress toward implementation
of a second-dose measles immunization requirement for all schoolchildren
in the United States. J Infect Dis 2004; 189(Suppl 1): S98-103. 5. Plotkin
SA, Orenstein WA, eds. Vaccines. 4th ed. Philadelphia, PA: Elsevier; 2003:
441-5. 6. Harling R, White JM, Ramsay ME, Macsween KF, van den Bosch C.
The effectiveness of the mumps component of the MMR vaccine: a case control
study. Vaccine 2005; 23: 4070-4. 7. Hersh BS, Fine PE, Kent WK, et al.
Mumps outbreak in a highly vaccinated population. J Pediatr 1991; 119:
187-93. 8. Kim-Farley R, Bart S, Stetler H, et al. Clinical mumps vaccine
efficacy. Am J Epidemiol 1985; 121: 593-7. 9. Cheek JE, Baron R, Atlas
H, Wilson DL, Crider RD. Mumps outbreak in a highly vaccinated school population:
evidence for large-scale vaccination failure. Arch Pediatr Adolesc Med
1995; 149: 774-8. 10. Warrener L, Samuel D. Evaluation of a commercial
assay for the detection of mumps specific IgM antibodies in oral fluid
and serum specimens. J Clin Virol 2006; 35: 130-4.
-
- Notes
- -----
- * Available at <http://www.cste.org/ps/1999/1999-id-09.htm>.
** Combined MMR vaccine generally should be used whenever any of its component
vaccines are indicated. For children aged 1-12 years, MMRV vaccine can
be considered if varicella vaccine is indicated. *** Available at <http://www.idph.state.ia.us/adper/common/pdf/mumps/mumps_update_050406.pdf>.
**** Defined as isolation of mumps virus from a clinical specimen; parotitis
or orchitis; or submaxillary or submental swelling. ***** Arizona, Arkansas,
Colorado, Connecticut, Delaware, Georgia, Hawaii, Illinois, Indiana, Kansas,
Louisiana, Massachusetts, Mississippi, Montana, Nevada, New York, North
Carolina, North Dakota, Oklahoma, Oregon, Rhode Island, Tennessee, Texas,
Vermont, and Virginia.
-
- --
- ProMED-mail
- <promed@promedmail.org>
-
- [Despite the monotypic nature of mumps
virus, different genetic lineages exist and co-circulate globally. Genotypes
A to J have been defined on the basis of the nucleotide sequence of the
most variable gene, the SH gene. The different lineages are useful properties
for tracking the spread of mumps virus, but there is no clear association
of the different lineages with different clinical symptoms. This outbreak
appears to be homogeneous in that 12 isolates from 6 of the 11 affected
states have been characterised as genotype G viruses. It has been stated
previously that G genotype mumps virus has been rarely observed in the
United States and most recently has been associated with outbreaks in the
United Kingdom. However, the possibility of introduction of the virus and
its spread to neighboring states within the United States by exposure during
airline travel could not be confirmed conclusively. Only 2 of 575 airline
passengers at risk might potentially have been exposed to virus. - Mod.CP]
-
-
- Patricia A. Doyle DVM, PhD
- Bus Admin, Tropical Agricultural Economics
- Univ of West Indies
-
-
- Please visit my "Emerging Diseases"
message board at:
- http://www.emergingdisease.org/phpbb/index.php
- Also my new website:
- http://drpdoyle.tripod.com/
- Zhan le Devlesa tai sastimasa
- Go with God and in Good Health
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