1. Update on Mumps and Current Status of Outbreak in NW Arkansas
Cat Waters, BSN
Outbreak Response Section Chief
Arkansas Department of Health

2. Vaccine infographic created by Leon Farrant
Vaccines have been proven to prevent millions of illnesses and thousands of deaths each year in the United States
Smallpox eliminated from the US in 1949, polio in 1979, measles in 2000, and rubella in 2004
Vaccine infographic created by Leon Farrant
>5,000, ,036

3. Mumps Major cause of outbreaks in pre-vaccine era
Vaccination has reduced mumps by 99% in the US
Recently, a few outbreaks have centered around colleges and schools
Particularly in dormitory settings and dense housing
Also in the National Hockey League
Only influenza and gonorrhea were more frequent among military personnel.

4. Mumps Virus Paramyxovirus Enveloped RNA virus One antigenic type
Rapidly inactivated by UV light, heat, and various chemical agents
13 genotypes of mumps (a-k), immunologically monotypic meaning that in a lab setting you would see protection against all 13 genotypes no matter which one it was.

5. Mumps Laboratory Diagnosis
Isolation of mumps virus
Detection of RNA via PCR
Serologic testing
positive IgM antibody
significant increase in IgG antibody between acute and convalescent specimens

6. Mumps virus

7. Mumps Pathogenesis Respiratory transmission of virus
(droplet nuclei)
Subclinical infections may transmit
Replication in nasopharynx and regional lymph nodes
Viremia days after exposure with spread to tissues
Infective dose – medium. Typical 2o attack rate of 31%

8. Mumps Clinical Features
Incubation period days
Nonspecific prodrome of low-grade fever, headache, malaise, myalgias
Parotitis in 30%-40%
Up to 20% of infections asymptomatic
May present as lower respiratory illness, particularly in preschool-aged children

9. Mumps Epidemiology Reservoir Human
Temporal pattern Peak in late winter and spring
Communicability Three days before to four days after onset of active disease

10. Mumps – United States, 1968- 2005*
1967 mmr vaccine was introduced with the jeri lynn strain. Around yr 2000 less than 300 cases per year, thought was we could eliminate mumps but show next slide
*2005 provisional data

11. Mumps – United States,
Resurgencee in More recent national data not published, but we are seeing more outbreaks recently. Genotype G

12. Age Distribution of Reported Cases
Mumps - United States,
Age Distribution of Reported Cases

13. Mumps Immunity Born before 1957
Documentation of physician- diagnosed mumps
Serologic evidence of mumps immunity
Documentation of adequate vaccination

14. Common Symptoms
Parotitis: Inflammation of the salivary glands under the ear
Fever
Headache
Muscle Aches
Fatigue
Loss of Appetite
CDC

15. Classic Swelling of Cheek and Neck (Parotitis) Seen with Mumps
CDC Public Health Image Library

16. Rare but Serious Complications
Inflammation of the:
Testicles
Pancreas
Ovaries
Breast
Encephalitis or Meningitis
Deafness
Male infertility
CDC

17. Mumps Complications CNS involvement 15% of clinical cases Orchitis
Pancreatitis
Deafness
Death
15% of clinical cases
20%-50% in post- pubertal males
2%-5%
1/20,000
1-3/10,000
This is in absence of vaccination
Prior to vaccination, mumps was the number one cause of encephalitis

18. Epidemiological Characteristics
Persistence in Environment:
Readily inactivated by UV light, formalin, heat, acid
High risk groups:
Post pubertal males – orchitis, atrophy, cancer?
Persons with diabetes
Epidemic Potential:
High – epidemic parotitis
Challenges
Imported cases
immunity may not be lifelong
No need to ‘terminally clean’ for mumps. It is inactive within an hour

19. Mumps Vaccine Effectiveness 88% after two doses
Duration of Immunity Generally lifelong
Schedule 1st dose at months, 2nd after age 4 and for adults at higher risk
Administered with measles and rubella (MMR)
Developed from the Jeryl Lynn strain (genotype B)
B is most distant genetically from G (which is currently circulating)
Raises question of virus evolving away from vaccine
Also we have questions about the marshallese immune systems

20. Vaccine Side Effects Brief achy joints (up to 25% of women)
Uncommon in children
Uncommon symptoms (less than 1%)
Fever
Rash
Itching
Extremely rare events (less than 1/100,000)
Brief orchitis
Mild parotitis
Encephalitis (~1 in 800,000 doses)

22. Current Status of Outbreak
Will need to update. Haytham can do it
N=769 as of 10/26
N=1,270 as of 11/15
* Numbers for most recent week are provisional

23. Vaccination Status Among Those Who Have Been Investigated
Age Groups
Vaccination Status of Cases
<1
1 - 4
5 - 17
18+
Total
0 MMR 3 18 25
191
237
1 MMR 16 36 70
2+ MMR 8
775 98
881 44
816
325
1188
Total Up-to-date 26
134
935
% Up-to-date
N/A
59.1%
95.0%
41.2%
78.7%
Haytham can update
There are 81 more cases under investigation whose vaccine status is not known

24. Benefits of 2nd (or 3rd) MMR shot
9 fold lower risk of illness
Milder disease if you do get mumps
Much less likely to transmit to others
If vaccinated and you get mumps, you only shed for 2-3 days and at lower levels

25. What is ADH Doing? Using the best evidence to control the outbreak
Interviewing all suspect cases and contacts
Excluding under-vaccinated kids from school
Performing vaccination clinics (65 complete, 4 others scheduled)
4,622 vaccines provided to date
Providing advice to doctors and schools
Communicating to many audiences
Numbers need updating

27. Questions / Comments
Appreciation to those that have been involved in the outbreak response!

28. Cost-Benefit Analysis of Commonly Used Vaccines
(Saving per $ invested)
Medical Societal* Dollars Dollars
Vaccine Saved Saved
DTaP
MMR
Hib
Polio vaccine
Varicella
Hepatitis B
*Includes work loss, disability and death
Source: CDC, ASTHO
The perception of parental declining confidence, a complex immunization schedule and the high price of vaccines today make prevention even more important.
According to CDC and ASTHO (Association of State & Territorial Health Officials) as you can see from this slide, our direct medical savings plus the indirect medical savings can be tremendous for the amount of effort that we make with a single “shot”.
Even with this knowledge childhood immunization rates are still suboptimal. I challenge each of you to look for strategies to increase coverage levels in your individual practice, so Arkansas can reach the Healthy People 2010 of 90% for infant immunization.
Despite the decline of vaccine preventable diseases, these disease do exist, and many are only an airplane ride away!
Overall per Zhou et al 2014, in terms of the entire vaccination series every dollar spent saves at least 10

29. Adult Immunization Recommendations from ACIP
Generally recommended for all adults
Influenza (every year)
Tdap (once as adult then Td booster every ten years
Chickenpox (AKA varicella)
Need physician diagnosed illness, immunity, or 2 doses
HPV (up to 26 years old, 3 doses)
Shingles (AKA zoster) (once ≥ 60 years old)
MMR (up to 59 years old)
Immunity or 2 doses after 1967, unless born prior to 1957
Pneumococcal vaccine (two different vaccines ≥ 65 years old)
Recommended for certain subgroups (see CDC website for detail)
Hepatitis A (2 doses)
Hepatitis B (3 doses)
Pneumococcal vaccine (below age 65)
Meningococcal vaccine (2 doses)