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MUMPS - USA (NEW YORK, NEW JERSEY), CANADA (QUEBEC)
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A ProMED-mail post
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ProMED-mail is a program of the
International Society for Infectious Diseases
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Date: Thu 12 Nov 2009
Source: CDC. MMWR Morb Mortal Wkly Rep 2009; 58 (dispatch): 1-4 [edited]
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d1112a1.htm?s_cid=mm58d1112a1_e>
Mumps outbreak: New York, New Jersey, Quebec, 2009
--------------------------------------------------
Mumps is a vaccine-preventable viral infection characterized by fever
and inflammation of the salivary glands and whose complications
include orchitis, deafness, and meningo-encephalitis (1). In August
2009, CDC was notified of the onset of an outbreak of mumps in a
summer camp in Sullivan County, New York. The outbreak has spread and
gradually increased in size and is now the largest US mumps outbreak
since 2006, when the United States experienced a resurgence of mumps
with 6584 reported cases (2). On [18 Aug 2009], public health
departments in Sullivan County, New York state, and CDC began an
investigation into the mumps outbreak, later joined by departments in
New York City and other locales. As of [30 Oct 2009], a total of 179
confirmed or probable cases had been identified from multiple
locations in New York and New Jersey, and an additional 15 cases had
been reported from Canada.
The outbreak has primarily affected members of a tradition-observant
religious community; median age of the patients is 14 years, and 83
percent are male. 3 persons have been hospitalized. Although little
transmission has occurred outside the [religious] community, mumps can
spread rapidly in congregate settings such as colleges and schools;
therefore, public health officials and clinicians should heighten
surveillance for mumps and ensure that children and adults are
appropriately vaccinated.
Mumps cases in the United States have been classified according to the
2008 case definition of the Council of State and Territorial
Epidemiologists, and cases in Canada have been classified in
accordance with Case Definitions for Diseases Under National
Surveillance. Patients in the United States are considered to have
age-appropriate vaccinations for mumps if they are aged 1-6 years and
have received 1 dose of a mumps-containing vaccine, aged 7-18 years
and have received 2 doses of vaccine, or aged 19-52 years and have
received 1 dose of vaccine (3,4). Patients aged 7-18 years who have
received 1 dose are considered to have received a partially
age-appropriate vaccination.
Outbreak reports
----------------
Sullivan County, New York. On [18 Aug 2009], the New York State
Department of Health was notified of mumps cases in a summer camp
serving approximately 400 boys from the tradition-observant religious
community. The index patient was a boy aged 11 years who had returned
on [17 Jun 2009] from the United Kingdom, where a mumps outbreak is
ongoing with approximately 4000 cases, primarily in unvaccinated young
adults in the general population. The boy became symptomatic at camp
on [28 Jun 2009]. A total of 25 cases were reported among camp
attendees and staff members. The median age of patients was 12 years
(range: 9-30 years), and all were male. Of the 24 patients for whom
vaccination status was reported, 20 (83 percent) had received
age-appropriate vaccination with 2 doses, one (4 percent) had received
partial age-appropriate vaccination with 1 dose, and 3 (13 percent)
were unvaccinated. The attack rate in this camp was approximately 6
percent (25 of 400).
Brooklyn, New York. The majority of campers were residents of the
Borough Park neighborhood of Brooklyn, where mumps transmission began
after their return home from camp. Although returning campers were
implicated in most of the initial exposures, no predominant focus of
spread was identified. By [30 Oct 2009], 79 additional persons from
Brooklyn or other boroughs who were linked to the outbreak had been
reported, exclusive of returning campers. The median age of these
patients was 14 years (range: 8 months-84 years), and 81 percent were
male. Of the 61 patients (77 percent) for whom vaccine is recommended
and vaccination status and age were reported, 47 (77 percent) had
received age-appropriate vaccination, 6 (10 percent) had received
partial age-appropriate vaccination, and 8 (13 percent) were
unvaccinated.
Ocean County, New Jersey. On [26 Sp 2009], the New Jersey Department
of Health and Senior Services was informed of 8 suspected mumps cases
in 2 Ocean County private schools for boys with both boarder and
commuter students from the same religious community. The index
patient, who became symptomatic at one of the boarding schools on [6
Sep 2009], was aged 20 years and a resident of the Borough Park
neighborhood of Brooklyn, New York. Transmission was initially limited
to the schools but subsequently was observed in households and the
community. By [30 Oct 2009], a total of 40 cases had been reported.
The median age of patients was 19.5 years (range: 1-65 years), and 83
percent were male. Mumps vaccination status was reported for 29 (73
percent) patients, of whom 28 (97 percent) had received
age-appropriate vaccination.
Rockland County, New York. 4 of the patients who had attended the
Sullivan County summer camp resided in Rockland County, New York. By
[30 Oct 2009], an additional 27 cases (exclusive of returning campers)
had been reported among members of the same religious community, with
transmission occurring in a variety of settings, including a school
for boys. The median age of patients was 12 years (range: 1-62 years),
and 23 (85 percent) were male. Mumps vaccination status was reported
for 19 (70 percent), of whom 11 had received age-appropriate
vaccination, and 2 had received partial age-appropriate vaccination.
Orange County, New York. In September [2009], members of the same
religious community in Orange County visited a synagogue in Brooklyn.
During [8-14 Oct 2009], 8 cases occurred among the travelers. The
median age of patients was 18 years (range: 11-23 years), and 5 were
male. 7 patients had received age-appropriate vaccination with 2
doses, and one was unvaccinated.
Quebec, Canada. Members of affected New York and New Jersey
communities traveled to the province of Quebec to attend religious
gatherings during [19 Sep-11 Oct 2009]. By [30 Oct 2009], 15 cases
(patient age range: 8-47 years) from Montreal and the Laurentian
region of the province had been reported to the Public Health Agency
of Canada. All patients were male, and 11 had documented vaccination
with at least 1 dose of mumps-containing vaccine.
Transmission outside the religious community
------------------------------------------------
During [28 Jun-30 Oct 2009], 5 cases outside the affected religious
community were reported. 2 cases occurred in New York City, and 3
occurred in Ocean County, New Jersey. The 2 New York City patients
were a man aged 40 years who had probable worksite exposures to
members of the affected community and a boy aged 4 years who had no
identified exposure. The 3 New Jersey cases were patients aged 17, 29,
and 66 years who had no identified exposures. 2 of the 5 patients had
received 2 documented doses of mumps-containing vaccine, 1 had
received 2 undocumented doses, and 2 had unknown vaccination status.
Laboratory testing
------------------
Of the 179 cases reported as of [30 Oct 2009] in the United States, 85
(47 percent) have been laboratory-confirmed, and the remaining 94
cases (53 percent) have met the clinical case definition. Laboratory
tests used to confirm cases of mumps included detection of mumps
immunoglobulin M antibodies by various methods, detection of mumps RNA
by real-time reverse transcription-polymerase chain reaction (5), and
isolation of mumps virus in cell culture. These tests were conducted
by CDC and state and commercial laboratories. Mumps virus classified
as genotype G was identified from multiple specimens sent to CDC,
consistent with the probable importation of mumps into Sullivan County
from the ongoing mumps outbreak in the United Kingdom (6).
Epidemiologic summary
---------------------
Of the 178 (99 percent) patients whose sex is known, 149 (84 percent)
are male. The median age of the 178 patients for whom age is known is
14 years (range: 8 months-84 years). Of the 141 patients (79 percent)
for whom vaccine is recommended and vaccination status and age were
reported, 113 (80 percent) had received age-appropriate vaccination, 9
(6 percent) had received partial age-appropriate vaccination, and 19
(13 percent) were unvaccinated. Of the 141 patients, 102 (72 percent)
had received 2 doses, 20 (14 percent) 1 dose, and 19 (13 percent) zero
doses.
Complications have occurred in 16 (9 percent) cases, including
orchitis (15 cases) and temporary deafness (1 case). 3
hospitalizations for orchitis have been reported. No deaths have
occurred.
Response measures
-----------------
Health officials issued alerts in New Jersey, New York City, and
elsewhere in New York state to health-care providers, urging them to
increase active surveillance for mumps, to consider mumps diagnoses
even if patients had documented vaccinations and, when indicated, to
perform appropriate diagnostic testing. Isolation and quarantine
procedures were reviewed, and health-care providers were urged to
ensure that all children and adults were appropriately vaccinated.
[Reported by a long list of names, available at the source URL]
MMWR editorial note
-------------------
Before routine mumps vaccination was initiated, most persons acquired
infection during childhood. In 1967, a live, attenuated mumps virus
vaccine was licensed in the United States, and by 2005 high coverage
with 2 doses among children had reduced the incidence of mumps by 99
percent (2). In 2006, a resurgence occurred in the United States, with
the highest attack rate among persons aged 18-24 years; 57 percent of
patients had previously received 2 doses of vaccine (2). In 2007 and
2008, incidence declined to 800 and 454 cases, and outbreaks involved
fewer than 20 cases.
The ongoing mumps outbreak is the largest since 2006 and primarily has
affected a tradition-observant religious community. Mumps outbreaks
perpetuated by community transmission outside of congregate settings
(such as, camps, schools, and colleges) are unusual in highly
vaccinated populations (2). In this outbreak, the limited transmission
of mumps into the general population might be attributable to
generally high vaccination levels and little interaction between
members of the affected religious community and persons in surrounding
communities. Vaccination rates in the religious community in this
outbreak have not been measured, but according to the 2008 National
Immunization Survey, overall age-appropriate mumps vaccination rates
for children in New York City, New York state, and New Jersey were
high: 90 percent or higher for receipt of 1 dose among children aged
19-35 months and 90 percent or higher for receipt of 2 doses among
adolescents aged 13-17 years. However, mumps incidence commonly peaks
in the winter (2), and vaccine-preventable diseases have spread from
religious communities to the general population during the peak
transmission season (7).
Of those patients in this outbreak whose vaccination status was known,
72 percent had received 2 doses of mumps-containing vaccine, compared
with 57 percent in the 2006 outbreak. Mumps vaccine effectiveness has
been estimated at 73-91 percent for 1 dose and 76-95 percent for 2
doses (8,9). Studies during the 2006 US mumps resurgence suggested
that outbreaks could occur among highly-vaccinated populations such as
college students, where frequent close contact occurs and where more
than 10 years have passed since most of the population received a 2nd
dose (9). However, even in such settings, attack rates were less than
8 percent in 2006 for those with 2 doses, suggesting that the vaccine
was highly effective in preventing disease for the vast majority of
those exposed (9). In the current outbreak, the attack rate at the
summer camp was approximately 6 percent.
Because 43 percent of the world's nations have no mumps vaccination
program (10), and certain nations with mumps vaccination programs,
such as the United Kingdom, have experienced large-scale outbreaks,
the risk for mumps exposure is increased with foreign travel. When
importations occur, congregate settings in the United States, such as
colleges and schools, have been foci of indigenous mumps transmission
(2).
When possible, persons with suspected mumps should be isolated for 5
days after onset of parotitis and, if they visit a health-care
setting, droplet precautions should be initiated immediately. Clinical
specimens (both serum and buccal swabs) should be collected from
persons with suspected mumps as soon as possible after symptom onset.
Adults and children should receive age-appropriate vaccination.
University students, health-care personnel, and persons with potential
mumps outbreak exposure should have documentation of 2 doses of mumps
vaccine or other proof of immunity to mumps. Although vaccination is
not considered effective postexposure prophylaxis for mumps,
non-immune contacts should be vaccinated with measles, mumps, rubella
(MMR) vaccine to prevent risk from subsequent exposures. Any suspected
mumps case should be reported to the health department in the area
where the patient resides. Additional information regarding mumps
vaccination is available at
<http://www.cdc.gov/vaccines/vpd-vac/mumps/default.htm#recs>.
References
----------
1. Plotkin SA, Rubin SA: Mumps vaccine. In: Plotkin SA, Orenstein WA,
Offit PA, eds. Vaccines. 5th ed. Philadelphia, PA: Elsevier; 2008:
435-65.
2. Barskey AE, Glasser JW, LeBaron CW: Mumps resurgences in the United
States: a historical perspective on unexpected elements. Vaccine 2009;
27(44): 6186-95 [abstract available at
<http://www.ncbi.nlm.nih.gov/pubmed/19815120>].
3. CDC. Measles, mumps, and rubella -- vaccine use and strategies for
elimination of measles, rubella, and congenital rubella syndrome and
control of mumps: recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR 1998; 47(No. RR-8) [available at
].
4. CDC. Updated recommendations of the Advisory Committee on
Immunization Practices (ACIP) for the control and elimination of
mumps. MMWR 2006; 55: 629-30 [available at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5522a4.htm>].
5. Boddicker JD, Rota PA, Kreman T, et al: Real-time reverse
transcription-PCR assay for detection of mumps virus RNA in clinical
specimens. J Clin Microbiol 2007; 45: 2902-8 [available at
<http://jcm.asm.org/cgi/content/full/45/9/2902>].
6. Rota JS, Turner JC, Yost-Daljev MK, et al: Investigation of a mumps
outbreak among university students with two measles-mumps-rubella
(MMR) vaccinations, Virginia, September-December 2006. J Med Virol
2009; 81(10): 1819-25 [abstract available at
<http://www.ncbi.nlm.nih.gov/pubmed/19697404>].
7. Parent du Chatelet I, Floret D, Antona D, et al: Measles resurgence
in France in 2008, a preliminary report. Eurosurveill 2009; 14(6): 5-7
[available at
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19118>].
8. Dayan GH, Rubin S: Mumps outbreaks in vaccinated populations: are
available mumps vaccines effective enough to prevent outbreaks? Clin
Infect Dis 2008; 47(11): 1458-67 [available at
<http://www.journals.uchicago.edu/doi/full/10.1086/591196>].
9. Marin M, Quinlisk P, Shimabukuro T, et al: Mumps vaccination
coverage and vaccine effectiveness in a large outbreak among college
students - Iowa, 2006. Vaccine 2008; 26(29-30): 3601-7 [abstract
available at
,http://www.ncbi.nlm.nih.gov/pubmed/18539365>].
10. World Health Organization. Global status of mumps immunization and
surveillance. Wkly Epidemiol Rec 2005; 80:418-24 [available at
<http://www.who.int/wer/2005/wer8048.pdf>].
--
Communicated by:
ProMED-mail
<promed@promedmail.org>
[This ongoing mumps outbreak is the largest since 2006 and primarily
has affected a religious community. Mumps vaccine effectiveness has
been estimated at 73-91 percent for 1 dose and 76-95 percent for 2
doses. Thus, outbreaks may occur among highly vaccinated populations
such as college students, where frequent close contact occurs and
where more than 10 years have passed since most of the population
received a 2nd dose.
The MMWR recommendation is that public health officials should be
aware that a mumps outbreak is ongoing, consider the diagnosis of
mumps in patients with symptoms consistent with the disease, and
ensure that children and adults (particularly in congregate settings
such as universities and hospitals) have received an appropriate
number of MMR vaccine doses. - Mod.CP]
[see also:
Mumps - USA (04): (NY) 20091106.3835
Mumps - USA (03): (NY) 20091023.3655
Mumps - USA (02): (MA), students 20090917.3265
Mumps: USA (MA); UK (Scotland) 20090419.1482
Mumps - USA: (MA) ex Ireland 20090417.1455]
........................................cp/mj/jw
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