1. Mumps Outbreak — New Jersey, September 2009–April 2010
Andria Apostolou, PhD, MPH
New Jersey Department of Health and Senior Services
EIS Field Assignments Branch,
DAS (proposed), SEPDPO (proposed)
Good afternoon
Today I will be presenting to you the NJ experience on the mumps outbreak from September to April 2010.

2. Background
NJ Department of Health and Senior Services notified on 9/22/2009
Cluster of mumps cases in Jewish Orthodox community
Part of multistate outbreak
NY (including NYC) NJ CT
On September 22nd 2009 the New Jersey Department of Health and Senior Services was notified of a potential cluster of mumps cases in the Jewish Orthodox community in Ocean County. Upon contacting the patients and physicians involved we identified that this was part of a multistate outbreak extending to NY, NYC, NJ, and very recently to CT.

3. Probable Outbreak Source
Summer camp for Orthodox Jewish boys
June 2009, upstate NY
Index patient
11-year-old child who traveled to UK prior to attending camp
Transmission occurred when camp-attendees returned home
Transmission started in an upstate NY summer camp for Orthodox Jewish boys that was held in June The index patient is believed to be an 11 year old child that traveled to the UK prior to attending the camp. UK was at the time experiencing an outbreak of mumps. Transmission to other states occurred when camp attendees returned home.

4. Objectives Characterize outbreak in NJ Control outbreak
Identify mumps cases
Identify susceptible individuals
Control outbreak
The objectives of this investigation was to characterize the outbreak in NJ by identifying mumps cases and susceptible individuals and to control the outbreak.

5. Case Ascertainment Contacted health care providers in affected area
Reviewed patient records from clinics and ICD–9 codes
Interviewed patients and guardians
Identified additional cases during case interviews
Sent notifications to health care providers and public health officials
In order to ascertain cases health care providers in affected areas were contacted. Patient records were reviewed and ICD9 codes for mumps, parotitis and orchitis were used to identify further cases. Patients and guardians were interviewed which sometimes led to the identification of additional cases. Furthermore local and state-wide notifications were sent to health care providers and public health officials across the country were notified via Epi-X.

6. Laboratory Confirmation
Isolation of mumps virus
Detection of mumps by PCR
Detection of mumps IgM antibody
Demonstration of specific mumps antibody response in absence of recent vaccination
Four-fold increase in IgG level
Seroconversion
A diagnosis of mumps was confirmed by any of the following: Isolation of mumps virus from clinical specimen, detection of mumps by PCR, detection of mumps IgM antibody, or demonstration of specific mumps antibody response in absence of recent vaccination, either a four-fold increase in IgG titer, or a seroconversion using serologic assays of paired acute and convalescent serum specimens.

7. Mumps Cases — NJ, 2005–2010* Number of cases Year
Here you can see the number of classified mumps cases in NJ between 2005 and present. On the Y axis you see the number of cases and on the x axis the year of reporting. Confirmed cases as represented in orange and probable cases are represented in yellow data represent cases classified between Jan and April As you can see the number of cases in 2009 and 2010 have dramatically increased compared to previous years. The vast majority of these cases are part of the ongoing outbreak and are concentrated in one affected county, Ocean county, where most cases reside.
Year
* Through April 10th

8. Mumps Cases, by MMWR week — NJ, 09/2009–04/2010
In this graph you can see the number of mumps cases in NJ associated with the outbreak by MMWR week. The first case had illness onset reported on 9/12 and the latest onset date is 4/10. The number of cases has been almost constant throughout the fall and winter with peaks observed during MMWR weeks 2 and 4 in The total number of cases to date in Ocean County is 315 cases whereas 17 cases have occurred elsewhere in NJ. The reporting lag has been about 1-2 weeks.

9. Characteristics of Impacted Community
Most affected area — Lakewood Township, Ocean County
Jewish Orthodox community
Patients live in close proximity
Patients reported attending same schools, places of worship
Household size 2–14 members (average 7.9)
The most affected area in NJ is Lakewood Township in Ocean County that contains a Jewish Orthodox community. Many cases have been identified to live in close proximity to each other. Patients reported attending same schools, religious sites and interacting very little with members from outside their community. In addition household size ranges from 2-14 members with an average household size of 7.9 people. These characteristics potentially represent constant exposure of individuals to the circulating mumps virus.

10. Patient Characteristics* (n = 315)
Age, median (range)
18 years (3 mos– 62yrs)
Male, No. (%)
224 (71.1)
Complications, No. (%)
24 (7.6)
Orchitis
21 (16.5)
Oophoritis
2 (2.2)
Facial Bell’s Palsy
1 (<0.01)
Non-Orthodox
10 (3.2)
The patient characteristics for the Ocean County confirmed and probable cases are displayed. The median age of affected individuals is 18 years with a range between 3months and 62 years. 71 % are male. No hospitalizations occurred but complications were observed in 24 individuals. Among these 21 had orchitis, 2 had oophoritis and 1 had Facial Bell’s Palsy.
Only 10 individuals were not Orthodox Jewish but these 10 persons had known exposure to the Orthodox population.
* Ocean County confirmed and probable cases only

11. Laboratory Results Test Positive / Total (%) IgG (+) 147 / 152 (97)
IgM (+)
70 / 157
(45)
RNA (+)
16 / 28
(57)
Genotype G
8 / 8
(100)
Laboratory results are presented here. Of interest 97% of IgG test results were positive but only about 50% of IgM and RNA tests were positive. When subtyped all were genotype G the same strain that circulated in the UK.

12. Vaccination status of patients under 18 years with confirmed or probable mumps — NJ, September 2009–April 2010
No. of doses
Age group
Total
0–1 years
1–6 yrs
7–18 yrs
No.
(%) 4
(100.0) 5
(19.2)
(3.8) 14
(8.5) 1
(0.0) 13
(50.0) 3
(2.2) 16
(9.8) 2 8
(30.8)
123
(91.8)
131
(79.9)
Unknown
(1.8) 26
134
164
In this table you can see the vaccination status of children and adolescents with confirmed or probable mumps by age group and by number of mumps containing vaccine doses received. Age groups are found in columns and number of mumps vaccine doses in rows. All children between 0-1 year had age appropriate vaccination status.

13. Vaccination status of patients under 18 years with confirmed or probable mumps — NJ, September 2009–April 2010
No. of doses
Age group
Total
0–1 years
1–6 yrs
7–18 yrs
No.
(%) 4
(100.0) 5
(19.2)
(3.8) 14
(8.5) 1
(0.0) 13
(50.0) 3
(2.2) 16
(9.8) 2 8
(30.8)
123
(91.8)
131
(79.9)
Unknown
(1.8) 26
134
164
80 % of children 1-6 yrs old received age appropriate vaccination.

14. Vaccination status of patients under 18 years with confirmed or probable mumps — NJ, September 2009–April 2010
No. of doses
Age group
Total
0–1 years
1–6 yrs
7–18 yrs
No.
(%) 4
(100.0) 5
(19.2)
(3.8) 14
(8.5) 1
(0.0) 13
(50.0) 3
(2.2) 16
(9.8) 2 8
(30.8)
123
(91.8)
131
(79.9)
Unknown
(1.8) 26
134
164
For the 7-18 years group the rate of age appropriate vaccination is 92%.

15. Vaccination status of patients under 18 years with confirmed or probable mumps — NJ, September 2009–April 2010
No. of doses
Age group
Total
0–1 years
1–6 yrs
7–18 yrs
No.
(%) 4
(100.0) 5
(19.2)
(3.8) 14
(8.5) 1
(0.0) 13
(50.0) 3
(2.2) 16
(10.7) 2 8
(30.8)
123
(91.8)
131
(79.9)
Unknown
(1.8) 26
134
164
Only 1.8% of case patients under 18 had unknown vaccination status.

16. Vaccination status of adult patients with confirmed or probable mumps — NJ, September 2009–April 2010
No. of doses
Age group
Total
19–32 years
33–52 yrs
53+ yrs
No.
(%) 2
(1.9) 1
(2.2)
(25.0) 4
(2.6) 8
(7.9) 20
(44.5)
(0.0) 28
(18.6) 73
(71.6) 10
(22.2) 83
(55.0)
Unknown 19 14
(31.1) 3
(75.0) 36
(23.8)
102
(100.0) 45
151
The age appropriate vaccination status for adults between years is 80%.

17. Vaccination status of adult patients with confirmed or probable mumps — NJ, September 2009–April 2010
No. of doses
Age group
Total
19–32 years
33–52 yrs
53+ yrs
No.
(%) 2
(1.9) 1
(2.2)
(25.0) 4
(2.6) 8
(7.9) 20
(44.5)
(0.0) 28
(18.6) 73
(71.6) 10
(22.2) 83
(55.0)
Unknown 19 14
(31.1) 3
(75.0) 36
(23.8)
102
(100.0) 45
151
For year olds it is 67%

18. Vaccination status of adult patients with confirmed or probable mumps — NJ, September 2009–April 2010
No. of doses
Age group
Total
19–32 years
33–52 yrs
53+ yrs
No.
(%) 2
(1.9) 1
(2.2)
(25.0) 4
(2.6) 8
(7.9) 20
(44.5)
(0.0) 28
(18.6) 73
(71.6) 10
(22.2) 83
(55.0)
Unknown 19 14
(31.1) 3
(75.0) 36
(23.8)
102
(100.0) 45
151
And for over 53 years is 100%. Of note is that individuals born before 1957 are believed to have immunity due to natural infection and are not required to receive vaccinations.

19. Vaccination status of adult patients with confirmed or probable mumps — NJ, September 2009–April 2010
No. of doses
Age group
Total
19–32 years
33–52 yrs
53+ yrs
No.
(%) 2
(1.9) 1
(2.2)
(25.0) 4
(2.6) 8
(7.9) 20
(44.5)
(0.0) 28
(18.6) 73
(71.6) 10
(22.2) 83
(55.0)
Unknown 19 14
(31.1) 3
(75.0) 36
(23.8)
102
(100.0) 45
151
Of significance is that vaccination status is unknown in adults for 24%.

20. Vaccination Status Summary
For individuals with known status
Population vaccination coverage — 94%
Similar in children and adults (91% vs. 97%)
For individuals with known / unknown status
Population vaccination coverage — 83%
Different in children and adults (91% vs. 76%)
24% of adults have unknown vaccination status vs. <2% in children
Among individuals with known vaccination status the overall age appropriate vaccination coverage is 94% and it is similar between children and adults. If we look at all individuals with known and unknown vaccination status the population vaccination coverage drops to 83% and it is different for children and adults. This is because 24% of adults have unknown vaccination status compared to less than 2% in children.

21. Control Measures Enhanced active surveillance
Physicians in affected area
Health care clinics
School rabbis
Audited school records to identify mumps immunization status
Over 99% vaccinated coverage level
Provided vaccine to unimmunized or under-immunized individuals
Little uptake (38 / 100 vaccines provided)
Verified available vaccine lot numbers
All confirmed
Several measures were established to control the outbreak. Active surveillance was enhanced reaching out to health care providers and school rabbis to request case reporting and to share control and prevention measures. In order to identify susceptible individuals we have audited schools in the affected areas. Records revealed over 99% compliance with state vaccination regulations and the majority of schools had 100% compliance. In addition vaccine was provided to unimmunized or under – immunized individuals but this was not highly utilized. We also verified available vaccine lot numbers and all were found to be legitimate.

22. Control Measures — Communications
Continuous communication — NY, NYC, CT & CDC
Notifications to providers / public health partners
Epi-X
LINCS (Health alert for NJ health care providers and public health officials)
MMWR (Nov 2009) & MMWR update (Feb 2010)
Media
Radio / TV
NJDHSS website
Jewish newspapers
Flyers to community
Continuous communication between the affected jurisdictions and CDC has been in place since September. These communications not only keep all jurisdictions involved up to date regarding the nature and extend of the outbreak but have also provided a brainstorming session and a resource sharing network.
Furthermore notifications were sent to providers and public health partners. These notifications were sent out both nationally through Epi-X and within the state through LINCS. 2 MMWR publications were released in November and February. Finally the media was utilized to inform the community and to provide recommendations for control measures. Most recently flyers have been distributed to high schools and colleges in the affected area in preparation for the travel for the Passover holidays. These flyers were also utilized for the general population due to Easter and spring break travel concerns especially since there was a recent reporting of an outbreak among non-Orthodox individuals at an upstate NY university.

23. Limitations Underreporting Laboratory Reporting fatigue
Cultural barriers and stigma
Laboratory
Antibody testing not suitable for 2 dose vaccinees
Testing not always performed
Several limitations exist. Under reporting and hesitation of reporting cases has been the biggest challenge. Since the outbreak has been ongoing for almost 8 months now, there seems to be reporting fatigue and more effort needs to be placed to identify cases. Cultural barriers and stigma might also have contributed to underreporting. Additionally antibody testing is not always suitable especially in this population with the majority of affected individuals already having 2 doses of MMR. Further more testing is not always performed by the physicians which makes it more difficult to classify cases appropriately.

24. Conclusions Largest U.S. mumps outbreak reported since 2006
> 300 cases identified in NJ between Sept 2009 and April 2010
> 3000 cases in all jurisdictions
Confined to Orthodox Jewish community
Affected mostly 7–18 year old males
Affected highly vaccinated community
Ongoing
MMR vaccination remains most effective control measure
In conclusion this is the largest mumps outbreak reported in the US since To date over 300 cases have been identified in NJ alone and over 3000 cases in all jurisdictions. So far the outbreak has been confined to the Orthodox Jewish Community and has affected mostly 7-18 year old males. Most importantly it has affected a highly vaccinated community. This outbreak is still ongoing and efforts are still in place to contain it. The most effective control measure remains still vaccination with 2 doses of MMR vaccine and isolation of cases to prevent transmission.

25. Recommendations
Perform additional research to determine if 3rd dose vaccine is beneficial in congregate settings (i.e., camps, colleges)
Maintain active surveillance
Enhance prevention measures through education of the public
Establish better communication between
Physicians and the public health community
Public health officials at different jurisdictions
Further research is still needed to determine whether a 3rd dose booster vaccine is beneficial in congregate settings like camps and colleges.
Active surveillance needs to be maintained and more resources need to be devoted for that purpose. Prevention measures through education of the public about risk factors for mumps transmission need to be enhanced. Furthermore better communication needs to be in place between physicians and the public health community as well as between public health officials at different jurisdictions.

26. Future studies Enzyme-Linked Immunosorbent SPOT (ELISPOT) assay study
To understand immunologic response after vaccination
To establish better laboratory detection methods for MMR vaccinees
At the moment in NJ we are currently working with the CDC mumps laboratory to launch a study to examine the immunologic response in 2-dose vaccines and to establish better laboratory detection methods for 2-dose recipients. We hope this study in addition to the other studies undergoing in NY State and NYC will provide both insights to why this extensive outbreak has occurred but also provide directions to control and prevent future outbreaks.

27. Acknowledgments New Jersey Department of Health and Senior Services
Tina Tan, MD, MPH
Corey Robertson, MD, MPH
Barbara Montana, MD, MPH
Elizabeth Handschur, MPH
Obiora Eze, MD
Ocean County Department of Health
Patricia High, MHS
Jennifer Crawford, MPH
CDC
Kris Bisgard, DVM, MPH
Division of Viral Diseases, Al Barskey, MPH
Carole Hickman, PhD and Don Latner, PhD (Mumps Laboratory)
NYCDOH, NY DOH & CT DOH
Thank You.
The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

28. Questions?

29. Extra Slides

30. Mumps Acute viral infection Transmission (highly infectious)
Myalgia, anorexia, malaise & fever
Unilateral or bilateral parotitis
Transmission (highly infectious)
Direct contact with droplets, saliva or contact with contaminated surfaces
Incubation period
12–25 days (usually 16–18 days)
Communicable period
2–7 days prior to symptom onset up to 9 days post symptom onset
No treatment exists
Mumps is an acute viral infection characterized by a prodrome of myalgia, anorexia, malaise and fever and followed by unilateral or bilateral parotitis.
It is a highly infectious disease that can spread by direct contact with droplets, saliva or contact with contaminated surfaces.
The incubation period is usually days and the communicable period can extend from 2-7 days prior to symptom onset up to 9 days post symptom onset.
No specific treatment exists and palliative care is usually provided.

31. Complications Orchitis (inflammation of testicles)
Oophorits (inflammation of ovaries)
Mastitis (inflammation of breasts)
Pancreatitis
Meningitis/encephalitis
Deafness
Mumps complications include inflammation of testicles, ovaries and breasts, pancreatitis, meningitis , encephalitis and deafness.

32. Mumps Vaccine and Epidemiology
MMR vaccination
1st dose: 12–18 months
2nd dose: 4–6 years
Average annual 260 cases reported
2006 Outbreak
6,584 reported cases
18–24 year olds (range: 1 – 90 yrs)
Mostly 2-dose MMR recipients
The MMR vaccine covers mumps and according to ACIP guidelines is administered at months and at 4-6 years.
Since 1989 when the MMR vaccine was introduced in the US the number of cases have decreased dramatically. On average about 260 cases of mumps have been observed in the US per year in the last decade.
The exception was the large outbreak that occurred in 2006 that resulted in 6584 reported cases. The majority of the cases during that outbreak occurred in year olds and mostly 2- dose MMR recipients.

33. Number of reported mumps cases, by year --- United States, 1980-2006

34. Mumps Incidence, by year —United States, 1997 – 2007
2 doses of MMR
recommended

35. Case Definitions
Clinical definition — Acute onset of unilateral or bilateral tender, self-limited swelling of the parotid or other salivary gland(s) lasting 2+ days without other apparent cause
Confirmed
Meets clinical definition or has clinically compatible disease, AND
Either laboratory-confirmed or epidemiologically linked to a clinically compatible case
Probable
Meets clinical case definition
Epidemiologically linked to clinically compatible case without laboratory confirmation
The 2008 CSTE/CDC clinical case definition of mumps is an illness with acute onset of unilateral or bilateral tender, self-limited swelling of the parotid or other salivary gland, lasting 2 or more days, and without other apparent cause. A confirmed case of mumps is one that meets the clinical case definition or has clinically compatible disease and is either laboratory confirmed or is epidemiologically linked to a clinically compatible case. A case is classified as probable if it meets the clinical case definition and is epidemiologically linked but is not laboratory-confirmed.

36. School Attack Rates School Attack Rate (%) #1 58 / 6400 0.9 #2
20 / 152
16.3 #3
11 / 1561
0.8
School is considered to be one of the leading exposure sites for children. The attack rates in different schools varied significantly from 0.8% to 16% but this probably reflects the school size since smaller schools were mostly affected.

37. Vaccine Effectiveness (VE) if PPV=99%
VE = (PPV - PCV) / ((1 - PCV) * PPV)
= ( )/ ((1-0.94)*0.99 )
=0.84
PCV= Proportion of Confirmed Cases* Vaccinated
=260/278=0.94
PPV= Proportion of Population Vaccinated
*with known vaccination status

38. Total Numbers in All Jurisdictions, June 2009–April 10th 2010
Camp: 25
NYC: 1591
Rockland: 425
NJ: 332
Orange: 781
CT: 13
Total: 3167

39. Vaccination status of patients with confirmed or probable mumps, by age group and number of mumps-containing vaccine doses received --- New York and New Jersey, June January 2010
No. of doses
Age group
Total
<16 mos
16 mos--6 yrs
7--18 yrs
≥19 yrs
Unknown
No.
(%) 21
(80.8) 32
(29.9) 56
(6.0) 30
(6.6)
---
139
(9.1) 1 3
(11.5) 33
(30.8) 72
(7.8) 29
(6.4)
137
(9.0) 2 36
(33.6)
713
(76.7) 90
(19.7)
839
(55.2)
(7.7) 6
(5.6) 88
(9.5)
307
(67.3)
(100.0)
406
(26.7) 26
107
929
456
1,521

40. Number (n = 1,494) of reported confirmed or probable mumps cases, by week of illness onset and age group --- New York and New Jersey, June January 2010