Debra Blog

Mumps Outbreak in Orthodox Jewish Communities in the United States

BACKGROUND By 2005, vaccination had reduced the annual incidence of mumps in the United States by more than 99%, with few outbreaks reported. However, in 2006, a large outbreak occurred among highly vaccinated populations in the United States, and similar outbreaks have been reported worldwide. The outbreak described in this report occurred among U.S. Orthodox Jewish communities during 2009 and 2010. METHODS Cases of salivary-gland swelling and other symptoms clinically compatible with mumps were investigated, and demographic, clinical, laboratory, and vaccination data were evaluated. RESULTS From June 28, 2009, through June 27, 2010, a total of 3502 outbreak-related cases of mumps were reported in New York City, two upstate New York counties, and one New Jersey county. Of the 1648 cases for which clinical specimens were available, 50% were laboratory-confirmed. Orthodox Jewish persons accounted for 97% of case patients. Adolescents 13 to 17 years of age (27% of all patients) and males (78% of patients in that age group) were disproportionately affected. Among case patients 13 to 17 years of age with documented vaccination status, 89% had previously received two doses of a mumps-containing vaccine, and 8% had received one dose. Transmission was focused within Jewish schools for boys, where students spend many hours daily in intense, face-to-face interaction. Orchitis was the most common complication (120 cases, 7% of male patients ≥12 years of age), with rates significantly higher among unvaccinated persons than among persons who had received two doses of vaccine. CONCLUSIONS The epidemiologic features of this outbreak suggest that intense exposures, particularly among boys in schools, facilitated transmission and overcame vaccine-induced protection in these patients. High rates of two-dose coverage reduced the severity of the disease and the transmission to persons in settings of less intense exposure.

Impact of a Third Dose of Measles-Mumps-Rubella Vaccine on a Mumps Outbreak

BACKGROUND AND OBJECTIVE: During 2009–2010, a northeastern US religious community experienced a large mumps outbreak despite high 2-dose measles-mumps-rubella (MMR) vaccine coverage. A third dose of MMR vaccine was offered to students in an affected community in an effort to control the outbreak. METHODS: Eligible sixth- to 12th-grade students in 3 schools were offered a third dose of MMR vaccine. Baseline and follow-up surveys and physician case reports were used to monitor mumps attack rates (ARs). We calculated ARs for defined 3-week periods before and after the intervention. RESULTS: Of 2265 eligible students, 2178 (96.2%) provided documentation of having received 2 previous doses of MMR vaccine, and a high proportion (1755 or 80.6%) chose to receive an additional vaccine dose. The overall AR for all sixth- to 12th-grade students declined from 4.93% in the prevaccination period to 0.13% after vaccination (P < .001). Villagewide, overall AR declined by 75.6% after the intervention. A decline occurred in all age groups but was significantly greater (96.0%) among 11- to 17-year-olds, the age group targeted for vaccination, than among all other age groups. The proportions of adverse events reported were lower than or within the range of those in previous reports of first- and second-dose MMR vaccine studies. CONCLUSIONS: This is the first study to assess the impact of a third MMR vaccine dose for mumps outbreak control. The decline in incidence shortly after the intervention suggests that a third dose of MMR vaccine may help control mumps outbreaks among populations with preexisting high 2-dose vaccine coverage.

Effectiveness of Previous Mumps Vaccination During a Summer Camp Outbreak

OBJECTIVES. Mumps is a vaccine-preventable disease that may cause outbreaks. In July 2005, an outbreak of mumps occurred during a childrens summer camp in upstate New York. An investigation was initiated to describe the cases and evaluate vaccine effectiveness. METHODS. A retrospective cohort study was conducted among 541 children from the United States and abroad who attended a 1- or 2-month overnight summer camp. Patients with mumps were interviewed; serologic analysis was conducted for 6 case patients. Vaccine effectiveness was calculated by retrospective review of immunization records for 507 attendees who were eligible for vaccination and had verified immunization history. RESULTS. Thirty-one camp attendees were identified as having mumps (attack rate: 5.7%); 5 (83%) of 6 patients tested had positivity for mumps immunoglobulin M. Of the 507 participants (including 29 patients) with available immunization history, 440 (including 16 [87%] patients) were 2-dose recipients of mumps vaccine (attack rate: 3.6%); 46 participants (including 4 [9%] patients) were 1-dose recipients (attack rate: 8.7%); and 21 (including 9 [4%] patients) were unvaccinated (attack rate: 42.9%). Vaccine effectiveness was 92% for 2 doses and 80% for 1 dose. CONCLUSIONS. Outbreaks of mumps in settings such as summer camps can occur despite high vaccination rates. Vaccine effectiveness for 2 mumps vaccinations was greater than vaccine effectiveness for 1 mumps vaccination. Therefore, recommendation of 2 mumps vaccinations for summer camp participants continues to be appropriate. Control of mumps disease relies on broad vaccination coupled with correct clinical diagnosis and strict control measures.

Fatal varicella due to the vaccine-strain varicella-zoster virus

We describe a death in a 15-mo-old girl who developed a varicella-like rash 20 d after varicella vaccination that lasted for 2 mo despite acyclovir treatment. The rash was confirmed to be due to vaccine-strain varicella-zoster virus (VZV). This is the first case of fatal varicella due to vaccine-strain VZV reported from the United States. The patient developed severe respiratory complications that worsened with each new crop of varicella lesions; vaccine-strain VZV was detected in the bronchial lavage specimen. Sepsis and multi-organ failure led to death. The patient did not have a previously diagnosed primary immune deficiency, but her failure to thrive and repeated hospitalizations early in life (starting at 5 mo) for presumed infections and respiratory compromise treated with corticosteroids were suggestive of a primary or acquired immune deficiency. Providers should monitor for adverse reactions after varicella vaccination. If severe adverse events develop, acyclovir should be administered as soon as possible. The possibility of acyclovir resistance and use of foscarnet should be considered if lesions do not improve after 10 d of treatment (or if they become atypical [e.g., verrucous]). Experience with use of varicella vaccine indicates that the vaccine has an excellent safety profile and that serious adverse events are very rare and mostly described in immunocompromised patients. The benefit of vaccination in preventing severe disease and mortality outweigh the low risk of severe events occurring after vaccination.

Vaccinating My Way—Use of Alternative Vaccination Schedules in New York State

OBJECTIVE To identify children vaccinated following an alternative vaccine schedule using immunization information system data and determine the impact of alternative schedule use on vaccine coverage. STUDY DESIGN Children born in New York State, outside New York City, between January 1, 2009 and August 14, 2011 were assessed for vaccination patterns consistent with use of an alternative schedule. Children who by 9 months of age had at least 3 vaccination visits recorded in the statewide mandatory immunization information system after 41 days of age were classified as either attempting to conform to the Centers for Disease Control and Prevention published recommended vaccination schedule or an alternative schedule. The number of vaccination visits and up-to-date status at age 9 months were compared between groups. RESULTS Of the 222 628 children studied, the proportion of children following an alternative schedule was 25%. These children were significantly less likely to be up-to-date at age 9 months (15%) compared with those conforming to the routine schedule (90%, P < .05). Children following an alternative schedule on average had about 2 extra vaccine visits compared with children following a routine schedule (P < .05). CONCLUSIONS Almost 1 in 4 children in this study appear to be intentionally deviating from the routine schedule. Intentional deviation leads to poor vaccination coverage leaving children vulnerable to infection and increasing the potential for vaccine-preventable disease outbreaks.

Zika Virus Testing Considerations: Lessons Learned from the First 80 Real-Time Reverse Transcription-PCR-Positive Cases Diagnosed in New York State.

ABSTRACT The performance and interpretation of laboratory tests for Zika virus (ZKV) continue to be evaluated. Serology is cross-reactive, laborious, and frequently difficult to interpret, and serum was initially solely recommended for molecular diagnosis. ZKV testing was initiated in January 2016 in New York State for symptomatic patients, pregnant women, their infants, and patients with Guillain-Barré syndrome who had traveled to areas with ZKV transmission. Subsequently, eligibility was expanded to pregnant women with sexual partners with similar travel histories. Serum and urine collected within 4 weeks of symptom onset or within 6 weeks of travel were tested with real-time reverse transcription-PCR (RT-PCR) assays targeting the ZKV envelope and NS2B genes. In this review of lessons learned from the first 80 positive cases in NYS, ZKV RNA was detected in urine only in 50 patients, in serum only in 19 patients, and in both samples concurrently in 11 patients, with average viral loads in urine a log higher than those in serum. Among 93 positive samples from the 80 patients, 41 were positive on both gene assays, 52 were positive on the envelope only, and none were positive on the NS2B only. Of the 80 infected patients, test results for 74 (93%) would have defined their infection status as not detected or equivocal if the requirement for positive results from two assay targets (two-target-positive requirement) in the initial federal guidance to public health laboratories was enforced, if urine was not tested, or if the extended eligibility time for molecular testing was not implemented. These changes facilitated more extensive molecular diagnosis of ZKV, reducing reliance on time-consuming and potentially inconclusive serology.

Risk factors for transmission of mumps in a highly vaccinated population in Orange County, NY, 2009-2010.

Background: In 2009–2010, we investigated a mumps outbreak among a highly vaccinated Orthodox Jewish population in a village in Orange County, NY, to identify risk factors associated with mumps transmission among persons with 2 doses of mumps-containing vaccine. Methods: Demographic and epidemiologic characteristics were collected on students in grades 6–12 in 3 schools. A mumps case was defined as a student, who self-reported parotitis, orchitis, jaw swelling and/or a mumps-related complication or whose mumps illness was reported to the Orange County Health Department during September 1, 2009, to January 18, 2010. Log-binomial regression analyses were conducted separately for boys and girls as they attended different schools and had different hours of study. Results: Of the 2503 students with 2 documented doses of mumps-containing vaccine, 320 (13%) developed mumps. Risk of mumps increased with increasing number of mumps cases in the class [≥8 vs. ⩽3 cases: boys aRR = 3.1; 95% confidence interval (CI): 2.0–5.0; girls aRR = 2.6; 95% CI: 1.6–4.1] and household (>1 vs. 0 cases: boys aRR = 4.3 95% CI: 3.7–5.6; girls aRR = 10.1 95% CI: 7.1–14.3). Age at first dose, time since last dose, time between first and second dose, school, class size, number of hours at school per week and household size were not significantly associated with having mumps. Conclusions: Two doses of mumps-containing vaccine may not be as effective in outbreak settings with multiple, prolonged and intense exposure. Additional studies are required to understand why such mumps outbreaks occur and how they can be prevented in the future.

Epidemiology and the economic assessment of a mumps outbreak in a highly vaccinated population, Orange County, New York, 2009–2010

Studies assessing the economic burden of a mumps outbreak in a highly vaccinated population are limited. The Orange County Health Department (OCHD), New York State Department of Health (NYS DOH), and the Centers for Disease Control and Prevention conducted a mumps investigation in an affected village with a highly vaccinated population. To understand the epidemiology, standardized mumps case definition and active surveillance were used to identify mumps cases. In addition, an economic assessment of a combined outbreak investigation and third dose measles-mumps-rubella (MMR) vaccine intervention conducted by OCHD and NYS DOH was performed; estimated by retrospectively evaluating public health response-related activities including use of a third dose of MMR vaccine. From September 24, 2009, through June 15, 2010, 790 mumps cases were reported—64% were male and highest attack rate was among 11–17 year age group (99.1 cases per 1000 individuals). Of the 658 cases with known vaccination history, 83.6% had documentation of 2 doses of mumps containing vaccine. No deaths were reported. The 2 major exposure settings were schools (71.8%) and households (22.5%). Approximately 7736 h of public health personnel time were expended with the total approximate cost of US

Secondary and Tertiary Transmission of Vaccinia Virus from US Military Service Member

463 000, including US

Expansion of adult hepatitis A and B vaccination in STD clinics and other settings in New York State.

34 392 for MMR vaccine—the estimated cost per household was US