Jill Stauffer Field Epidemiologist – District 8 April 6, 2017 Mumps Jill Stauffer Field Epidemiologist – District 8 April 6, 2017 Today I will be presenting on Mumps. I will first go through some information on mumps and give an update on the current outbreak situation. Second, I will talk about the types of pro-active actions facilities or universities can take in order to be prepared at their location, should cases arise. Third, I will talk about laboratory testing, and finally, I will cover the resources ISDH has available on Mumps.

Mumps Epidemiology Reservoir Transmission Temporal Pattern Symptoms Humans only Transmission Respiratory droplets Temporal Pattern Peak in late winter-early spring Symptoms Parotid swelling (uni- or bilateral) and jaw pain (9-94%) Low grade fever, cough, upper respiratory s/s, malaise, body aches, fatigue, ear pain, headaches Up to 30% are asymptomatic Infectious Period Two days before until five days after the date of parotitis onset Incubation Period Average: 16-18 days after exposure Range: 12-25 days after exposure Symptoms may be atypical in vaccinated persons Complications: orchitis (most common); oophoritis, meningitis, encephalitits, pancreatitis,

Mumps Outbreak Update Indiana 2017 Outbreak Case Counts as of March 28, 2017 (confirmed cases): Indiana University, Bloomington: 7 Private Business, Columbus: 4 An additional 15 cases unrelated to any university outbreaks have been identified across Indiana since February. Indiana Case Counts in Previous Years (confirmed cases): 2011: 3 2012: 0 2013: 0 2014: 8 2015: 3 2016: 242 Mumps is a viral disease that used to be a very common childhood illness until vaccination with measles, mumps, and rubella vaccine (or MMR) became routine and required for school entry. 2 doses of MMR are considered about 88% effective, but vaccinated persons can still get mumps. Symptoms of mumps include unilateral or bilateral parotitis or parotid tenderness, occasionally preceded by or coinciding with headache, malaise, low grade fever, earache, etc. Symptoms in vaccinated people can be altered or milder than those in unvaccinated people. Three cases is defined as an outbreak of mumps by the CDC. In previous years, Indiana has had relatively low case counts of mumps, but since late January of 2016, four universities, IU Bloomington, Purdue, IUPUI, and Butler University, have been experiencing outbreaks primarily among their student populations. These have come amidst what appears to be a recent rash of cases and outbreaks in university populations across the country, including outbreaks in Connecticut, Illinois, Iowa, Kentucky, California, Massachusetts, North Carolina, and New Hampshire. Three of the four universities held large vaccination clinics for students and staff of the campuses. The counts above can be found on the ISDH mumps website and are updated every Friday. Please keep in mind that these counts are part of an ongoing investigation and counts may change pending new information.

2016 Mumps Epidemic Curve Figure 1. Mumps cases by week of parotid swelling onset. MMWR Week 3 corresponds with the week ending January 23, 2016. MMWR Week 38 corresponds with the week ending September 24, 2016.

2016 Mumps Outbreak Epidemiology Setting Confirmed Case Count Outbreak Start Date Outbreak End Date Butler University 24 2/12/16 5/9/16 Indiana University Bloomington 74 2/17/16 9/10/16 IUPUI 8 3/11/16 8/13/16 Purdue University 59 4/2/16 8/20/16 Community 77 n/a Total 242 SYMPTOMS n (%) Fever 100 (41.3%) Headache 64 (26.4%) Parotitis 235 (97.1%) Earache 51 (21.1%) Malaise/Body Aches/Fatigue 6 (2.5%) Jaw pain 15 (6.2%) Sore throat 10 (4.1%) Orchitis 4 (1.6%) Meningitis 1 (0.4%) Vaccination Status Doses University Cases Community Cases 1 MMR 4.8% 15.6% 2 MMR 70.3% 50.6% (self report) 7.9% 14.2% 3+ MMR 6.7% 0.0% unvaccinated 2.4% 3.9% unknown Ages of university cases ranged from 18 to 38 years (mean: 21.6 years; median: 21 years) Ages of community cases ranged from 4 to 55 years old (mean: 29.1 years; median 26 years). Seven vaccination clinics were held at three; ~5100 MMR doses administered Just an overview of the outbreak(s), takeaways, challenges, future actions.

Proactive Actions University: Know the vaccination status of the student and staff population, including exemptions Healthcare facilities: Check vaccination status or titers of staff and provide MMR vaccination where needed Persons who have 2 appropriately given doses of MMR but a low titer DO NOT need additional doses of MMR vaccine. Recommend individuals who are unsure of status to see their provider and consider a dose of vaccine Ensure providers understand signs and symptoms and testing recommendations for suspect mumps patients As you can imagine, this recent bump in cases has caused many healthcare facilities and universities to ask themselves what they could be doing to ensure they are ready if they experience mumps cases in the coming weeks. One of the main things would be to know the vaccination status of employees and students, wherever possible. Most universities do not collect records for faculty and staff the same way they do for students, so now could be a time to send communication to encourage faculty and staff to find their records or consider seeing their doctor about getting a dose of MMR if they are unable to find their records. During an outbreak of mumps the CDC and the Indiana Communicable Disease Rule recommend exclusion of susceptible close contacts (defined as those who have spent greater than 5 minutes of face-to-face contact with or come into contact with droplets from an infected person) from day 12 to day 25 after the last exposure. Anyone who cannot provide an appropriate proof of immunity (which I’m going to discuss on the next slide) is considered susceptible to mumps. Finally, providers should ensure they are up to date on sign/symptoms and the current testing protocols and guidance (which I’ll also go through later in this presentation).

Proof of Immunity At least one of the following: Written documentation of receipt of one or more doses of a mumps-containing vaccine administered on or after the first birthday for preschool-aged children, and two doses of mumps- containing vaccine for school-aged children and adults; Laboratory evidence of immunity; Birth before 1957** Laboratory documentation of previous mumps infection **Not sufficient for healthcare personnel during an outbreak. As I mentioned before, proof of immunity is required for close contacts of confirmed cases in order to not be excluded from work, school, public gatherings, or other social activities. Acceptable proofs are written documentation of all age-appropriate MMR doses, laboratory evidence of immunity (so an IgG titer), birth before 1957 (which is not considered acceptable proof for healthcare workers in Indiana), or laboratory documentation of previous mumps infection.

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Resources The ISDH Mumps Website includes up-to-date information on: Mumps signs and symptoms Vaccination General Public FAQs Testing at ISDH Lab: Mumps Testing Decision Tree Flowchart Specimen Collection and Submission Guidelines Virology Submission Form Links to CDC and WHO measles information and resources Links to immunization schedules, resources, and requirements URL: http://in.gov/isdh/25450.htm Finally, I want to highlight some resources that are available for education, lab testing, and vaccination on the ISDH mumps website. Outbreak counts for IU and Butler are updated every Friday and general FAQs, including some outbreak specific questions have been developed.