Characterization of a Large Mumps Outbreak Among Adolescents in Jerusalem, Israel in Communities Associated with Jewish Communities in New York Mumps outbreak in Jerusalem affecting mainly male adolescents. Stein-Zamir C, Shoob H, Abramson N, Tallen-Gozani E, Sokolov I, Zentner G. Euro Surveill Dec 17;14(50). 1 Chen Stein-Zamir MD MPH Jerusalem District Health Office Ministry of Health Israel

Mumps in Israel Year Number of cases Rate / 100,000 Data Source: Dep. Epidem. And ICDC, Ministry of Health, Israel

Incidence Rate /100,000 by age-group, Israel: Data Source: Dep. Epidem. And ICDC, Ministry of Health, Israel

Mumps in Israel Year Number of cases Data Source: Dep. Epidem. And ICDC, Ministry of Health, Israel

Mumps Vaccine schedule in Israel  MMR schedule: 12 months, 6 years of age.  Since 2008 MMRV (Priorix-Tetra, GSK)  Composition: Jeryl Lynn strain 5

Mumps outbreak in Jerusalem, Israel 16 Sept Mars 2010: 1862 reported cases in Jerusalem > 2600 reported cases of mumps in Israel 6 Data Source: Jerusalem District Health Office, Ministry of Health, Israel

Mumps Outbreak Case Definition case definition: an illness with acute onset of unilateral / bilateral tender, self- limited swelling of the parotid / other salivary glands, lasting at least 2 days, and without other apparent cause. Probable case: a case that meets the clinical case definition without laboratory confirmation + epidemiologically linked to a clinically compatible case Confirmed case: a case that 1) meets the clinical case definition or occurs in a patient with a clinically compatible illness and 2) is either laboratory confirmed or is epidemiologically linked to a confirmed case. 7

Cases’ Characteristics  Males: 1218/1862 (65.4%).  > 90% members of ultra-orthodox Jewish communities.  1232 (66.2%) religious colleges and schools.  Geographic distribution: - Jerusalem 61.1% - Other cities 39.9% 8 Data Source: Jerusalem District Health Office, Ministry of Health, Israel

Case ascertainment  Positive mumps IgM antibody: 104 patients.  Positive mumps IgG antibody: 121 patients.  Positive real-time RT-PCR in urine: 5 patients.  Genotype G 5 identified.  The others- diagnosed on the basis of clinical features and epidemiologic association. 9 Data Source: Jerusalem District Health Office, Ministry of Health, Israel

Number of cases Mumps outbreak - Jerusalem epidemic curve - September March 2010 September OctoberNovemberDecemberJanuaryFebruaryMarch Data Source: Jerusalem District Health Office, Ministry of Health, Israel

Number of cases Age group Mumps outbreak in Jerusalem cases age-group and gender distribution Mean age=14.4± 8.9 Median= Data Source: Jerusalem District Health Office, Ministry of Health, Israel

Schools Total number of casesNumber of schoolsNumber of Mumps cases per school Total 12 Data Source: Jerusalem District Health Office, Ministry of Health, Israel

Vaccination status Parental report. Review of vaccination cards. Verification from health-care providers. 13

Number of cases Age group Mumps outbreak - Jerusalem cases age & vaccination status cases: vaccine status unknown Data Source: Jerusalem District Health Office, Ministry of Health, Israel

Vaccine coverage: Israel  MMR1 in 2006 among children at 2Y :.96%  MMR 1in 1992 – 82.3 %. 15

Epidemiologic Links 1.Contact with yeshiva students from New York. 2.Visited Israel during the High Holidays, Sept Some reported to have recently had mumps. 16

Mumps Outbreak: NY & Jerusalem 58%61%Age 7–18 years 82%91%Age > 6 years 12.9 y15 yMedian age 4 months- 66 years3 months- 90 yearsAge range 65.4%76%Male (%) 74%75%2 doses MMR vaccine 1.8%1.3%Hospitalization Update: mumps outbreak - New York and New Jersey, June 2009-January Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep Feb 12;59(5): Data Source: Jerusalem District Health Office, Ministry of Health, Israel

Prevalence of mumps antibodies / Population group 82.3%92.5%18-19y olds 83.3%94.1%18-19y olds 68.5%18-19y olds Foreign-born 86.1%18-19y olds Israeli born 77%Age-stratified population sample 59%10-13y olds 18 1.Amital H, Weiss Y. Medax 2001 – Summary of the medical corps session. IMAJ 2002:4: Huerta et al Vaccine Sep 11;24(37-39): Muhsen et al Epidemiol Infect May;136(5):

Control measures  Investigation: Relevant schools  Student vaccination status.  Referral for completion of MMR.  Isolation.  Routine Vaccination – Coverage.  Information: Circulated to all HMOs in the District, and to the public via the mass media. 19

Why?  Vaccine failure?  Failure to vaccinate?  Waning immunity?  Accumulation of susceptibles?  Setting, high risk for transmission?  Characteristics of mumps infection of immunity?  Misdiagnosis of mumps? 20