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Update on Mumps Outbreak – 2016-2017 Washington State
Chas DeBolt RN, MPH
Office of Communicable Disease Epidemiology
Vaccine Advisory Committee Quarterly Meeting
October 19, 2017
NOT FOR DISTRIBUTION
Mumps virus basics
Henle et al. (1948), Gupta et. al. (2005)
• Incubation period: 12–25 days
• Infectious period:• Up to 7 days before and 9–14 days after symptom onset
• Contact investigation:• 4 days before through 4 days after symptom onset
• Evidence of immunity:• Vaccination, titer (IgG), born before 1957, documentation of physician-diagnosed mumps
• Potential complications:• Orchitis, mastitis, meningoencephalitis, deafness
• Severity of disease increases with age
Reported mumps cases in the US, 1968–2016
Mumps in Washington, 1920 – August 9, 2017
0
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10000
15000
20000
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Nu
mb
er o
f ca
ses
Year
1967: Mumps vaccine became
available
1989: Second dose of mumps vaccine recommended for
school-aged children and
college students
1977: Mumps vaccine
recommended for routine use
Mumps outbreak cases Washington State by county 10/20/2016 through 8/9/2017County Number of cases
Benton 6
Ferry 3
Grant 45
King 312
Kitsap 2Okanogan 3
Pend Oreille 3
Pierce 62
Skagit 17
Snohomish 87
Spokane 333
Stevens 1
Thurston 6
Whatcom 4
Yakima 5
Total 889
Clallam
Grays
Harbor
Pacific
Cowlitz
Clark
Island
King
Lewis
Mason
Pierce
Skagit
Snohomish
Thurston
Whatcom
Adams
Benton
Chelan
Columbia
Franklin Garfield
GrantKittitas
Klickitat
Lincoln
Okanogan
Spokane
Walla
Walla
Whitman
Yakima
Douglas
Ferry
Stevens
Pend
Oreille
Asotin Skamania
Wahkiakum
JeffersonKitsap
San Juan
1-10 cases
11-50 cases
50-200 cases
200+ cases
0 cases
Mumps outbreak investigations by county as of 8/9/2017
Clallam
Grays
Harbor
Pacific
Cowlitz
Clark
Island
King
Lewis
Mason
Pierce
Skagit
Snohomish
Thurston
Whatcom
Adams
Benton
Chelan
Columbia
Franklin Garfield
GrantKittitas
Klickitat
Lincoln
Okanogan
Spokane
Walla
Walla
Whitman
Yakima
Douglas
Ferry
Stevens
Pend
Oreille
Asotin Skamania
Wahkiakum
JeffersonKitsap
San Juan
1-10 investigations
11-50 investigations
50-200 investigations
200+ investigations
0 investigations
* The Department of Health and local health jurisdictions also assisted with investigations for:AK, CA, FL, IL, OH, OR, and UT residents
Mumps outbreak cases by average number of new cases per day reported to DOH (includes weekends in denominator)December 2016 – August 2017
MonthAverage number of new cases per day reported to DOH
December 3.9
January 6.4
February 7.6
March 5.7
April 3.1
May 1.6
June 0.7
July 0.5
August 0.1
Mumps outbreak cases and other investigations by date of symptom onset (excludes investigations with no onset recorded)October 2017–August 2017
NOT FOR DISTRIBUTION
0
5
10
15
20
25
30
35
40
45
50
10
/29
/16
11
/5/1
6
11
/12
/16
11
/19
/16
11
/26
/16
12
/3/1
6
12
/10
/16
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/17
/16
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/24
/16
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/31
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/17
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/17
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3/1
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/17
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0/1
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7/1
/17
7/8
/17
7/1
5/1
7
7/2
2/1
7
7/2
9/1
7
8/5
/17
Nu
mb
er
of
case
s/in
vest
igat
ion
s
Onset date
Investigated, not outbreak cases
Outbreak cases
Descriptive characteristics of cases (n=889)October 2016 – August 2017
Age range N %
0-4 34 4%
5-9 104 12%
10-14 198 22%
15-19 214 24%
20-39 256 29%
40-64 80 9%
65+ 2 0%
Unknown 1 0%
School aged (5-19 years) 516 58%
Case is Marshallese N %
Yes 465 52%
No 401 45%
Unknown 23 3%
www.medical-explorer.com
Category
Total number of cases
Cases with unknown
vaccination status
Cases with vaccine
information available
Number with 2+ doses
Number with 1 dose
Number with 0 doses
Total number
UTD*
% of cases with
available vaccine
information UTD
School-aged (5-19 years) 516 35 (7%) 481 (93%) 438 27 16 438 91%
School-aged Marshallese (5-19 years)
304 29 (10%) 275 (90%) 255 12 8 255 93%
Marshallese 465 125 (27%) 340 (73%) 268 32 40 288 85%
Entire outbreak 889 229 (26%) 660 (74%) 510 82 68 574 87%
Vaccination status of casesOctober 2016 – August 2017
Orchitis rates among unvaccinated vs. vaccinated males with mumps in Washington StateOctober 2016 – August 2017
Unvaccinated Vaccinated± Unknown vaccination status
Confirmed and probable mumps outbreak cases (n=889)
Total casesNo.
of cases
Cases reporting orchitis
Rate per
1,000 cases
No.of cases
Cases reporting orchitis
Rate per
1,000 cases
No.of cases
Cases reporting orchitis
Rate per
1,000 cases
Male cases 417 31 4 129.0 286** 11 38.5 100 12 120.0
Postpubertal males* 324 24 4 166.7 205*** 10 48.8 95 12 126.3
* Age 11 and over± Documentation of one or more doses of mumps-containing vaccine
** Includes 251 cases with 2 doses, 35 cases with 1 dose***Includes 181 cases with 2 doses, 24 cases with 1 dose
Mumps outbreak cases by outbreak name and date of symptom onsetDecember 2016 – August 2017
0
2
4
6
8
10
12
14
16
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20
10
/29
/16
11
/5/1
6
11
/12
/16
11
/19
/16
11
/26
/16
12
/3/1
6
12
/10
/16
12
/17
/16
12
/24
/16
12
/31
/16
1/7
/17
1/1
4/1
7
1/2
1/1
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7
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/17
2/1
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2/1
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/17
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3/1
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/17
4/1
5/1
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2/1
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4/2
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/17
5/1
3/1
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5/2
0/1
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5/2
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7
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/17
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0/1
7
6/1
7/1
7
6/2
4/1
7
7/1
/17
7/8
/17
7/1
5/1
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7/2
2/1
7
7/2
9/1
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8/5
/17
Nu
mb
er o
f ca
ses
Onset date
Multistate MUM 2016-002
UW MUM 2017-001
We selected specimens for sequencing based on unique epi characteristics
Lack of known epi-link to the outbreak
First case identified in a given local health jurisdiction
History of travel during the likely exposure period
– Spent part of exposure period outside WA (or outside the USA)
Membership in social group or community with no previous cases, or with a high potential for spread
– Fraternity/Sorority
We also put out a request to local jurisdictions to notify us of any case they deemed to be of high interest for sequencing
When one incubation period had passed since the August 12th onset of our last case, we thought it might be our last in the outbreak
Last contagious on August 17
+
2 maximum incubation periods, or 50 days
=
“All clear date” of October 7
Three new positive have subsequently been reported:
King County – 47 year old with a connection to Kosrae
– September 9th onset
Whatcom County 6 year old that attends church regularly in British Columbia – September 14th onset
Thurston County unimmunized 13 year old (17 year old epi-linked sibling)
Two schools involved
– October 2nd onset
Outcome of sequencing:
King County case with Kosrae connection – sequencing showed the virus was identical to that seen in the large multistate outbreak
Last contagious on September 14th
+
2 maximum incubation periods, or 50 days
=
New “All clear date” of November 3rd
Then what……..?
Sequence results pending for Whatcom County case with B.C. connection and Thurston County school – aged case
Thank you.
Questions?
Chas DeBolt RN, MPH
Senior Epidemiologist for Vaccine Preventable Diseases
Office of Communicable Disease Epidemiology
Washington State Department of Health
1610 NE 150th Street
Shoreline. WA 98155
(206) 418-5431