1. The Iowa Mumps Epidemic Patricia Quinlisk, MD, MPH Medical Director/State Epidemiologist Iowa Department of Public Health

2. Number of Cases of Mumps, Iowa, 1930 -2006* *As of August 22, 2006 One dose Measles required ↓ Two doses MMR required ↓

3. Pre-Outbreak Status Today in Iowa: –93% of Iowa’s 19-35 months old children have at least l dose of MMR –98% children at school entry have two doses of MMR (plus all other required) –About 1-5 cases of Mumps/ year

4. Mumps cases by county and onset date- MMWR weeks 1-4, Iowa

5. Mumps cases by county and onset date- MMWR weeks 5-8, Iowa

6. Mumps cases by county and onset date- MMWR weeks 9-13, Iowa

7. Mumps cases by county and onset date- MMWR weeks 14-17, Iowa

8. Mumps cases by county and onset date- MMWR weeks 18-22, Iowa

9. Mumps cases by county and onset date- MMWR weeks 23-33, Iowa

10. Born in 1957 ↓

11. Began mass vaccination ↓

12. Week of Onset for Mumps Cases in the Eight the Outbreak States, 1 January – 20 June, 2006 (n=3860 )

13. Mumps Outbreak, United States 2006* 1,921 4 134 650 85* 501 193 349 3 782 2 1 1 Total reported cases 4,602 *In PA, 14 of the 85 cases are considered outbreak-associated. *Provisional Number of Cases by State as of June 20, 2006

14. Summary Profile Female67% College students 25% Mean age at onset 22 Health care workers 8.5% (144/1705) Doses of MMR 0 doses7% (122/1775) 1 dose13% (242/1775) 2 or more doses 49% (878/1775) Unknown30% (533/1775) With any history of MMR = 63%

15. Symptoms and Complications Orchitis- 7%(39/573) –historically 20% - 50% of post- pubertal males Encephalitis- 0.2% (4/1775) –historically 15% of clinical cases

16. Public Health Issues Addressed, Challenges and Lessons Learned During the Mumps Epidemic

18. Information and Education Seven press conferences/news releases Phone banks to answer health care worker questions (used CDC’s phone bank for public’s questions) Bi-weekly web updates with graphs and tables on web to address media questions ER/Clinic screening tools Fact sheets for public in English and Spanish Isolation and quarantine guidelines for HCW’s Laboratory specimen and submission information Recommendations for schools, clinics, travelers, health care workers, college students, etc

19. Mumps Information Following are current resources provided by the Iowa Department of Public Health on Mumps. This information covers mump disease, prevention and control measures, testing protocols and the scope of the outbreak. This site will continually post information as it becomes available. FAQ General Public Health Care Providers Local Public Health Mumps Information County Contact Information Examples Explaining Mumps Vaccine Effectiveness Information for Mumps Patients Letter to Health Care Facilities LPHA Disease Containment Activities Mass Gathering Policy - April 18, 2006 Mumps Background Mumps Epi Manual chapter (rev.5/06) Mumps Fact Sheet Mumps Fact Sheet - Emergency Departments & Health Care Providers Mumps Fact Sheet - en español (Spanish) Mumps Fact Sheet - ZAVISE INFORMACIJA NA BOSANSKOM JEZIKU, KLIKNITE OVDJE (Bosnian) Mumps Information Mumps Screening Tool for Clinic/Emergency Room Receptionists MMWR Dispatch - April 11, 2006 MMWR Dispatch - March 30, 2006 MMWR vol. 55 - Iowa Mumps Epidemic Public Health Partner Letter Recommendations for Groups Traveling Out of Iowa School Letter STOP if Symptoms of Mumps Mumps Updates Laboratory Information Laboratory diagnosis of mumps timeline Summary and Laboratory Guidance on Mumps Non-Respiratory Request Test Form (Mumps) Non-Respiratory Collection Instructions

20. Control and containment measures –Mumps vaccine administered after exposure to mumps does not provide clinical protection or alter the severity of disease. –However evidence suggests that mass vaccination during a mumps outbreak may help terminate the outbreak.

21. Statewide Vaccination Interventions Three-phase targeted mass vaccination strategy –Targeted college-age population –Stockpile MMR vaccine –Affecting age group most affected and likely to spread to other age groups Phase I: 18-22 year olds (April 20) Phase II: 18-25 year olds (April 28) Phase III: 18-46 year olds (May 10)

22. Health Care Surge Capacity Only about 10 people hospitalized Some clinics saw large numbers of symptomatic patients Student health centers at foci of epidemic were overwhelmed for months Requests from counties for epi assistance had to be denied because of lack of state staff State health requested/received about 3 epidemiologists senior staff members from CDC per week during peak of epidemic

23. Isolation and Quarantine Isolation of cases for 5 days or until symptoms resolve, which ever is longer: college students did not follow Health care worker guidelines were more stringent: –Immune status checked of Iowa health care workers, public health lab couldn’t do –Work quarantine if exposed and not immune/status not known, i.e.no patient contact –If ill, isolation until medically cleared

24. Quarantine No use of quarantine for public (unlike measles outbreak two years before): –20-30% of cases asymptomatic –Can spread 3 days prior to symptoms –Some very mildly ill so not reported –Generally mild illness

25. Travel Related Issues Have had many Iowans travel on flights while infectious with mumps Worked with CDC’s Quarantine/Airport division to identify potentially exposed passengers Notified other passengers of exposure with information on mumps and recommendations Follow-up study done on transmission risk- determined to be very low (only 2 possible incidents of spread identified)

26. Mass Gathering Policy Put together policy, sent on to those coordinating events such as Drake Relays, First National Special Olympics, etc. –Do not cancel events –Come to Iowa, but check vaccination status, recommend two doses of MMR before you come, especially if coming to college campuses

27. Mumps Vaccine Recommendations (ACIP) Prior to Epidemic 1989 recommended second dose of MMR for school-aged children and college students (response to measles) Prior to 2006: Documentation of mumps immunity through vaccination consisted of only one dose for all groups, including health care workers

28. Born in 1957 ↓

29. Health Care Worker Vaccination Recommendations 2006 (ACIP) All HCW should be immune to mumps Born 1957 or after, need 2 doses Born prior to 1957, consider giving 1 dose who did not have physician diagnosed mumps During outbreaks, even those born prior to 1957 should strongly consider 2 doses or laboratory evidence of immunity

30. Overall Lessons Learned Large outbreaks can occur even in highly vaccinated populations Rapid detection and implementation of mass vaccination needed to prevent a large outbreak Vaccination campaigns are a challenge –Advertising how to motivate young adults –Apathy towards vaccination (timing)

31. More Lessons Learned Health care workers not adequately vaccinated and do not use barrier methods systematically Conference calls with partners (LPH, other states, community partners) invaluable Takes time to get vaccines (monies, shipping, clinic set-up)

32. More Overall Lessons Learned Bio-emergency preparedness planning was invaluable –Used Incident Management Structure –Vaccine distribution and clinics –Education of state partners and media –Use of HAN/weekly epi-update e-mail Epidemiologic capacity was a limiting factor Use of centralized lab for all testing worked well, but some limits (no testing of HCW immune status done could be done)

33. Outcome of Mumps Epidemic Almost 2,000 cases in Iowa alone Overall resources taxed –State and local public health –College student health services –Iowa clinics –Spread easily and quickly to other states

34. AND IOWANS!