1. 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

2. 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.

3. 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

4. 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.

5. 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

6. 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.

7. 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.

8. 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

9. 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 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

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

11. 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.

12. 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.

13. 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

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

15. 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 s unlike the rest of us. So different methods of communication need to be examined.

16. 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 s unlike the rest of us. So different methods of communication need to be examined.

17. 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)

18. 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.

19. 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

20. 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.

21. 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.

22. 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.

23. 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

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

25. 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