Mumps Outbreak Kansas, 2006 Jennifer M. Hill, MPH Good afternoon Jennifer M. Hill, MPH Senior Epidemiologist Kansas Department of Health and Environment Office of Surveillance and Epidemiology

Objectives Describe the mumps outbreak in Kansas Discuss challenges and successes Discuss lessons learned During this presentation I will describe the mumps outbreak in Kansas. Discuss success and challenges of the outbreak. And discuss lessons we learned, all from the Kansas perspective.

Mumps – United States, 1968-2006* Mumps Vaccine licensed 1967 Routine childhood recommendation 1977 Resurgence 2-dose schedule Mumps is the only known cause of epidemic parotitis. Since the introduction of the mumps vaccine in 1967 and routine vaccination in 1977, the incidence of mumps has drastically declined. During the late 1980s there was an resurgence of mumps cases which included an outbreak in Kansas among students in primary and secondary schools. In 1989, a 2 dose MMR schedule was introduced as a result of a second dose recommendation for a measles-containing vaccine. Mumps has remained a rare disease after the routine 2-dose MMR recommendation. That was until late 2005, early 2006. *2005 and 2006 provisional data MMWR; Vol. 55; No. 51 & 52

Mumps in Kansas 2006 968 cases (confirmed & probable) No cases linked to Iowa Gender: 40% Male Age: 40% aged 18 – 24 years Range: 9 months – 96 years 35% of cases in Douglas County In 2006, Iowa lead the mumps outbreak count with approximately 2000 and Kansas was second with 968 cases. This included both confirmed and probable cases. None of the Kansas cases could be linked to cases in Iowa. 40% of the cases were male and 40% were aged 18 to 24 years. 35% of our cases occurred in one county, Douglas. A major university is located in Douglas county.

Mumps Case Count by County Of the 105 counties in Kansas, 73 reported at least one case. Most of the counties had 1 to 5 cases. A majority of the mumps cases were located in several counties. Two counties had more than 100 cases each both located in the northeastern portion on the state. The star indicates Douglas county and the building indicates this conference

Epidemiologic Curve of Mumps Cases In Kansas By on Onset Date, 2006 From late January to mid- March, sporadic cases of mumps were reported in several different counties. On March 24, a case of mumps was reported at the university in Douglas County. Then a few days later on March 27, 2 additional cases of mumps were reported at the same university. All 3 cases lived in the same house. Clusters of cases were reported at several universities throughout the state during April. Cases of mumps in both in the state and Douglas county peaked in late April and early May. The number of cases began to decline in early summer Reported cases of mumps were at low levels by October and have remained there since.

Vaccination History Vaccinated with at least 1 dose of MMR Yes: 73% No: 7% Unknown: 20% Number of doses for those vaccinated 1 dose: 18% 2 or more doses: 64% Unknown: 18% Vaccination history was collected for 80% of the mumps cases. 73% of the cases had received at least 1 dose of MMR. Only 7% of the cases were unvaccinated. Of those who had been vaccinated, 64% had 2 or more doses.

Challenges & Successes Population Case investigation and follow-up Public health measures Communication The successes and challenges of the outbreak can be grouped into four categories. The population affected, case investigation and follow-up, public health measures and communication

Population College Students Approximately 280 cases (30%) 254 identified at single university Where to isolate School vs. home Who is responsible for follow-up? Compliance Approximately, 280 or 30% of the mumps cases were diagnosed in individuals who attended a university or college. 254 of these cases were at a one university. Where to isolate the case was an issue with this population. Students were either isolated at their current residence or permanent residence. This usually meant that cases isolated themselves in counties other that were they were diagnosed. Local health departments asked for clarification on whose responsibility is was to follow-up on the case. The answer is both local health departments were responsible. The health department for the county of diagnosis was responsible for the case investigation and follow-up of contacts that lived in their county, the county were the individual was in isolation was responsible for the household contacts. Another major issue was compliance of isolation. You make think that college students would like to have an excuse to miss class but that was not the case. The outbreak on university campuses peaked during the end of the semester and finals week. Missing 9 days of school was too much at this time of the year. We also heard anecdotally that students that might have had mumps were not going to the student health center because they did not want to be isolated. Cooperation between local health department and student health service center

Population College Students Co-operation between local health department & student health center Able to follow-up cases and contacts

Case Investigation Protocols Several different versions used Difficult to use by inexperienced interviewers Not conducive to outbreak Several different case investigation protocols and resources were being used during the outbreak. Depending on which program was contacted, the local health departments were instructed to follow different protocols. This created much confusion for the local health departments. Eventually one protocol was settled on but it contained erroneous information. The protocol was copyrighted and KDHE was physically unable to alter the document.

Case Investigation Protocols Use of a single protocol Created a new case investigation form The original investigation questionnaire was difficult to use and not helpful for inexperienced interviewers. Both the protocol and questionnaire were not conducive for outbreaks since it focused on the source of infection and NOT the propagation of disease. To solve this problem a new case investigation form was created. The new form focused on the spread of disease.

Case Investigation Surveillance System (HAWK) Multiple counties unable to view same case unless system was ‘tricked’ Data collected on case investigation forms were not able to be entered Unable to easily extract data All mumps cases were entered in to our electronic surveillance system. This web-based system allowed for real-time sharing of data. But it has its limitations. Multiple counties were not able to view the same case and enter in information unless we tricked the system. Data collected during case investigations was not able to be entered in to the system in a consistent manner and so an additional database we created and only a few people had access to it. Also, data the was entered into the surveillance system was not easy to extract. Each time I wanted a updated dataset, I had to place a request with the Surveillance Manager. Eventually, I was given access to the live tables which made analysis and data cleaning more efficient

Case Investigation Surveillance System (HAWK) Web-based Real-time data entry and sharing Developed additional database

Case Investigation Laboratory Surge capacity Laboratory result interpretation Negative results do not rule out disease Asymptomatic positive cases At the start of the outbreak, all mumps specimens were sent to the state lab. For each suspected case multiple specimens were submitted. This increase of specimens overwhelmed the laboratory staff. During the outbreak 2 of the 3 staff will out ill for extended periods of time. To reduce the workload and resources, specimens were refused if the where from a county that had 5 lab confirmed cases. Communication between the lab and state health department was not always effective. Laboratorians are not constantly checking their e-mails unlike the rest of us. So different methods of communication need to be examined.

Case Investigation Laboratory Communication Quick turn around time Not all cases need lab confirmation in outbreaks At the start of the outbreak, all mumps specimens were sent to the state lab. For each suspected case multiple specimens were submitted. This increase of specimens overwhelmed the laboratory staff. During the outbreak 2 of the 3 staff will out ill for extended periods of time. To reduce the workload and resources, specimens were refused if the where from a county that had 5 lab confirmed cases. Communication between the lab and state health department was not always effective. Laboratorians are not constantly checking their e-mails unlike the rest of us. So different methods of communication need to be examined.

Public Health Measures Isolation Changed recommend isolation period twice Until April 6: 9 days April 6 – 24: 4 days April 25: 9 days Kansas regulation: 9 days isolation During the outbreak, KDHE changed the recommended isolation period twice during the outbreak. Originally, we followed what was in our written disease protocols and recommended 9 days. After reviewing several resources we changed the recommendation to 4 days after onset of illness since that was the period of maximum communicability. And we thought that we might have better compliance with a shorter isolation period. Finally, KDHE settled on 9 day isolation based on CDC recommendations and our Kansas regulation. 1-2 days before onset to 5 days after onset of parotid swelling (2003 Red Book) 3 days before to 4th day of active disease (2006 Pink Book)

Public Health Measures Quarantine of Contacts Susceptible persons excluded from child care, school, work, & other social contact Adequate vaccination Lift quarantine if contact receives MMR Exposed persons were considered immune if they had one of the following: born before 1957; had documentation of adequate vaccination; lab evidence of immunity; or documentation of physician diagnosed disease. Those not immune were considered susceptible and were excluded from child care, school, work, and other social contact for the duration of the incubation period which was a minimum of 25 days. During the beginning of the outbreak, adequate vaccination for all persons was considered as one dose of MMR but on May 17th, CDC release new ACIP recommendations that changed adequate vaccination to 2 doses for school aged children (K-12) and adults at high risk (health-care workers, students at universities, and international travelers. For Kansas, receipt of one dose of MMR was enough to lift quarantine.

Public Health Measures Healthcare & Childcare Providers Developed separate guidelines Assessed additional information Daycare providers allowed to self-report vaccination or history of disease Persons who worked in healthcare and childcare followed a separate set of exclusion criteria. Flowcharts and narratives were created for each group. Additional information was assessed. Health care workers needed to have written documentation for vaccination or history of disease but daycare providers were allowed to self report

Communication Public Information Office and Media Information flow Frequent data requests Information flow Physicians Communication both internally and externally was the most important factor of the outbreak. After the press conference announcing the increase in mumps cases on April 11, frequent calls were made to our Public Information Office requesting an updated count of mumps cases which meant running reports on the number of reported cases on an hourly basis or that’s what it felt like. Since the number of cases fluctuated, it was difficult to report out a consistent number of cases. To solve this dilemma, our section and the public information office developed a set schedule for reporting our numbers. This allowed for adequate time data cleaning and case follow-up. The schedule also gave local health departments time to prepare local statements using the same numbers. We held regular conference calls with the local health departments. These calls were frequent starting at twice a week in the beginning. The calls were used to update the local health department on the outbreak and facilitate a question and answer system. In between conference calls, information disseminated using the Kansas Public Health Information Health Exchange or PHIX.

Communication Public Information Office and Media Conference calls Schedule for reporting case numbers Website Conference calls Frequent Update LHDs of outbreak & answer questions Communication both internally and externally was the most important factor of the outbreak. After the press conference announcing the increase in mumps cases on April 11, frequent calls were made to our Public Information Office requesting an updated count of mumps cases which meant running reports on the number of reported cases on an hourly basis or that’s what it felt like. Since the number of cases fluctuated, it was difficult to report out a consistent number of cases. To solve this dilemma, our section and the public information office developed a set schedule for reporting our numbers. This allowed for adequate time data cleaning and case follow-up. The schedule also gave local health departments time to prepare local statements using the same numbers. We held regular conference calls with the local health departments. These calls were frequent starting at twice a week in the beginning. The calls were used to update the local health department on the outbreak and facilitate a question and answer system. In between conference calls, information disseminated using the Kansas Public Health Information Health Exchange or PHIX.

Communication Activation on Incident Command System (ICS) Kansas Public Health Information Exchange (PHIX) Repository for forms, guidelines, factsheets, etc. Update Local Health Departments Communication both internally and externally was the most important factor of the outbreak. After the press conference announcing the increase in mumps cases on April 11, frequent calls were made to our Public Information Office requesting an updated count of mumps cases which meant running reports on the number of reported cases on an hourly basis or that’s what it felt like. Since the number of cases fluctuated, it was difficult to report out a consistent number of cases. To solve this dilemma, our section and the public information office developed a set schedule for reporting our numbers. This allowed for adequate time data cleaning and case follow-up. The schedule also gave local health departments time to prepare local statements using the same numbers. We held regular conference calls with the local health departments. These calls were frequent starting at twice a week in the beginning. The calls were used to update the local health department on the outbreak and facilitate a question and answer system. In between conference calls, information disseminated using the Kansas Public Health Information Health Exchange or PHIX.

Lessons Learned Incident Command System (ICS) Used by KDHE and locals Outbreaks can occur in vaccinated population Recommendations modified during outbreak Based on epi information from outbreak

Changes Made Immunization Medical Investigator Protocols Systematic review Done in-house New surveillance system

Acknowledgements jhill@kdhe.state.ks.us Office of Surveillance & Epidemiology Gail Hansen, DVM, MPH D. Charles Hunt, MPH Mary Aker Amy Biel, MPH Cheryl Bañez Ocfemia, MPH Andrea Hall Amanda Hodle, MPH Angela Huang, MD, MPH Michael Koph, MPH Daniel Neises, MPH Nkolika Obiesie, MPH Lesa Roberts, MPH M. Ella Vajnar Immunization Program Tim Broaderway Todd Durham Betty Grindol Michael Runau Martha Siemsen Trudy Shane Patti Smith Division of Health & Environmental Laboratories Patrick Hays, PhD Kelly McPhail Local Health Departments jhill@kdhe.state.ks.us