vaccine preventable diseases team update...vaccine preventable diseases team update vaccine...
TRANSCRIPT
12/4/2017
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Vaccine Preventable Diseases Team Update
Vaccine Preventable Diseases (VPD) Team
Charles “Chip” Cohlmia – Team Lead
Allison Sierocki – Epidemiologist II
Kelsey Sanders – Epidemiologist I
Raymond Dinnan – PHPS III
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VPD Team Conditions • Acute Flaccid Myelitis
• Congenital Rubella Syndrome
• Diphtheria
• Haemophilus influenzae, invasive
• Hepatitis A
• Hepatitis B (acute and perinatal)
• Measles
• Meningococcal disease, invasive
• Mumps
• Pertussis
• Streptococcus pneumoniae, invasive
• Polio (paralytic)
• Rubella
• Tetanus
• Varicella
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VPD Team Roles• Provide support for the local and regional health
departments:
➢Resources
➢Recommendations for control of the spread of infectious disease
• Specimen coordination
• Approve investigations
• Health advisories
• Data analysis
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State Resources• Emerging and Acute Infectious Disease
Investigation Guidelines
➢Appendix C: Laboratory Resource
• Epi Case Criteria Guide
• Texas National Electronic Disease Surveillance System (NEDSS) Data Entry Guidelines
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VPD Team Partners
• Internal Partners:➢ Immunization Unit within Department of State Health
Services (DSHS)➢ DSHS Austin Laboratory➢ Legislative bodies
• External Partners:➢ Texas local and regional health departments
➢ Schools
➢Hospitals/clinics
➢ Texas Medical Association
➢Centers for Disease Control and Prevention (CDC)
➢Other state health departments
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External Public Health Partnerships
• Work with the CDC and other states as needed for outbreaks or additional lab testing (such as mumps)
➢ Epidemiology and Laboratory Capacity (ELC) Grant
• Stay up-to-date with new criteria for disease classifications decided by Council of State and Territorial Epidemiologists (CSTE) or the CDC
• CDC's Epidemic Information Exchange (Epi-X)
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Vaccine Preventable Disease Case Counts, Texas, 2012-2016
12/4/2017 * Before 2016, only type b was reportable 9
ConditionNumber of Cases
2012 2013 2014 2015 2016
Acute Flaccid Myelitis (AFM) 0 0 3 0 19
Haemophilus influenzae, invasive 3 5 12 11 317*
Hepatitis A, acute 134 109 123 147 139
Hepatitis B Viral Infection, Perinatal 4 2 3 1 2
Hepatitis B, acute 170 142 122 159 156
Measles (Rubeola) 0 27 10 1 1
Mumps 15 13 15 20 191
Neisseria meningitidis, invasive
(Mening. disease)37 30 22 30 23
Pertussis 2,218 3,985 2,576 1,504 1,286
Poliomyelitis, Paralytic 0 1 0 0 0
Rubella 0 0 0 2 0
Rubella, Congenital Syndrome (CRS) 0 0 0 0 0
Streptococcus pneumoniae, invasive
disease (IPD)1,535 1,715 1,562 1,693 1,737
Tetanus 3 2 4 2 2
Varicella (Chickenpox) 2,410 1,874 1,647 1,491 1,341
Total Deaths due to VPDs Case Counts, Texas, 2012-2016
ConditionNumber of Cases
2012 2013 2014 2015 2016
Haemophilus influenzae, invasive 0 0 1 0 42*
Neisseria meningitidis, invasive
(Mening. disease)4 6 2 4 3
Pertussis 7 5 2 0 0
Poliomyelitis, Paralytic 0 1 0 0 0
Streptococcus pneumoniae, invasive
disease (IPD)73 103 114 102 117
Tetanus 1 0 1 0 0
Varicella (Chickenpox) 1 0 1 0 0
12/4/2017 10* Before 2016, only type b was reportable
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Varicella
Varicella Epidemiology
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• Infectious Agent: Human herpesvirus 3 (varicella-zoster virus)
• Transmission: Droplet or airborne spread of vesicle fluid, respiratory tract secretions, or contact with lesions
• Incubation period: Average of 14-16 days (range 10-21 days)
• Communicability period lasts 1-2 days before and 4-5 days after lesion onset (until crusting)
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Varicella Epidemiology cont’d
• Clinical Illness: maculopapulovesicular rash often accompanied by fever
➢ Lesions mainly on trunk
• Temporal pattern: Most cases happen in winter and early spring
• Breakthrough varicella:
➢ Varicella infection in vaccinated persons >42 days after varicella vaccination
➢ Mild illness
➢ Few lesions
➢ Usually no fever
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Varicella Rash
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Unvaccinated child
Vaccinated child
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Varicella Vaccine
• Single-antigen varicella vaccine➢70% to 90% effective against any varicella
disease
➢90% to 100% effective against severe varicella disease
• MMRV➢Similar levels of detectable antibody as varicella
vaccine
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Number of Varicella Cases by Month, Texas, 2016
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106 106
114
138
183
95
80
70
118109
105
117
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40
60
80
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120
140
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180
200
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Varicella Surveillance
• CDC ELC Requirements:
• CDC Hospitalization Report
• CDC Outbreak Report
• Varicella completeness
• Working on a new varicella reporting form
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2016 Varicella Breakdown
• 1,341 cases reported in 2016
➢1,029 cases (77%) ≤18 years old
➢312 cases (23%) >18 years old
• 41 cases (3%) were hospitalized
• 15 outbreaks in 2016
➢The 2 largest outbreaks had 20 cases each• School bus outbreak
• Correctional facility outbreak
➢ The 3rd largest outbreak had 10 cases on a college/university campus
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2016 Varicella Vaccination Breakdown
• 1,341 cases reported in 2016
➢ 1,135 cases (85%) had a known vaccination status
• 620 cases (55%) were vaccinated
• 515 cases (45%) were not vaccinated
➢ 206 cases (15%) had an unknown vaccination status
• The reasons for not being vaccinated varied:
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Born outside the U.S.21%
Parent/Patient refusal or
philosophical objection
10%
Underage for vaccination
27%
Unknown34%
Other 8%
Varicella Cases, Texas, 2000-2016
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0
2000
4000
6000
8000
10000
12000
14000
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
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ACIP recommends 2nd
dose
MMRV licensed
1995 Varicella licensed
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Varicella Cases and Incidence, Texas, 2012-2016
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0
1
2
3
4
5
6
7
8
9
10
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500
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61+ years
41-60 years
21-40 years
11-20 years
6-10 years
1-5 years
<1
Total
Incidence
Pertussis
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Pertussis Epidemiology
• Infectious Agent: Bordetella pertussis
• Transmission: Respiratory droplets
• Incubation period: Average 7-10 days (range is 4-21 days)
• Communicability: Lasts up to 21 days after cough onset or after antibiotic treatment has been completed (usually 5 days)
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Pertussis Epidemiology cont’d
• Clinical illness: Three phases of disease-
1. Catarrhal stage: onset of runny nose, sneezing, low-grade fever, slight cough that gradually becomes more severe (1-2 weeks)
2. Paroxysmal cough stage: coughing fits, may be followed by inspiratory whoop, apnea, or vomiting (1-6 weeks)
3. Convalescence: gradual resolution of paroxysmal cough (weeks to months)
➢ Vaccinated individuals who become sick will likely have a milder illness
• No temporal pattern
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2016 Pertussis Breakdown
• 1,286 cases
➢291 cases (23%) had a known vaccination status
• 242 cases (83%) were vaccinated
• 49 cases (17%) were not vaccinated
➢995 cases (77%) had an unknown vaccination status
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2016 Pertussis Breakdown
• For the 49 cases (17%) who were not vaccinated, reasons for not being vaccinated included:
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Medical Contraindication
10%Never offered
vaccine6%
Other2%
Parent/Patient forgot to vaccinate
4%
Parent/Patient refusal or religious
exemption
27%
Under age for vaccination
22%
Unknown29%
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Number of Pertussis Cases, Texas, 2000-2016
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4500
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Pertussis Cases and Incidence, Texas, 2012-2016
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0
2
4
6
8
10
12
14
16
0
500
1000
1500
2000
2500
3000
3500
4000
4500
2012 2013 2014 2015 2016
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6-10 years
61+ years
41-60 years
21-40 years
1-5 years
11-20 years
<1 year
Total Incidence
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15
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Pertussis Vaccines• 5 doses of DTaP and 1 dose of Tdap
• Pregnant women should have a single dose of Tdapduring every pregnancy (27-36 weeks)
➢ In 2013, Texas started collecting information about Tdap in pregnant woman when investigating a case of pertussis in child <5 years of age.
• Estimates have the vaccine as an 80%-85% efficacy
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Tdap Timeline
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2005• FDA licensed two different Tdap vaccines
2011• FDA approval for Tdap in older persons
2012• ACIP recommendation for pregnant woman to receive
Tdap irrespective of receiving Tdap previously
2013• ACIP recommendation for pregnant woman to
received Tdap during each pregnancy
Maternal Vaccination Status of Pertussis Case-Patients 0-4 years old, Texas, 2013-2016
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26
163
138 127
18
210
147
107
0
50
100
150
200
250
2013 2014 2015 2016
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Not Vaccinated Vaccinated
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Just to show you, a work in progress:
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0
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2013 2014 2015 2016
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MMWR Year
Unknown Not Vaccinated Vaccinated
Invasive Disease
• Invasive: When the bacteria invade parts of the body that are normally free from germs, like spinal fluid or blood, this is known as "invasive disease.“➢Invasive disease is usually severe and can
sometimes result in death
12/4/2017 https://www.cdc.gov/hi-disease/about/types-infection.html 34
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Haemophilus influenzae, Invasive (H. flu)
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H. flu Epidemiology
• Infectious Agent: Haemophilus influenzae (H.flu) a bacterium capable of causing a range of diseases including:
➢ Ear infections
➢ Cellulitis (soft tissue infection)
➢ Upper respiratory infections
➢ Pneumonia, and
➢ Serious invasive infections:
• Meningitis with potential brain damage and epiglottitis with airway obstruction
• Transmission: Respiratory droplets and discharge from the nose and/or throat of an infected/colonized person
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H. flu Epidemiology cont’d
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• Incubation period: Hard to define➢ Many are asymptomatic ➢ If become ill usually within 10 days of
exposure• Communicability: Organism is present in
discharge from the nose or throat ➢ Communicability ends within 24 hours of
initiation of appropriate chemoprophylaxis ➢ Serotype b cases are probably most
infectious during the 3 days prior to onset of symptoms
• Despite its name, this bacterium has nothing to do with the influenza viruses
H. flu Invasive Clinical Illness
• All serotypes of Haemophilus influenzae can cause illness
• Invasive forms: ➢ Meningitis – brain swelling➢ Bacteremia – blood infection➢ Periorbital or other cellulitis – skin lesions➢ Septic arthritis – joint infection➢ Osteomyelitis – bone infection➢ Pericarditis – infection of the sac around the
heart➢ Pneumonia – lung infection➢ Epiglottitis – Swelling of the windpipe
• Non-invasive forms: ➢ Conjunctivitis, otitis media, or bronchitis
➢ Not reportable
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H. flu Serotypes• At least 6 serotypes of H. flu
➢Designated a, b, c, d, e, f
➢Unencapsulated strains (nontypeable)
➢ In 2016 all serotypes became reportable
• Type b (Hib)
➢Cause of most severe illness
➢Only type preventable by vaccine
➢ Post-exposure prophylaxis (PEP) is available for Hib on case-by-case basis
• Serotyping
➢ Performed at the DSHS laboratory
➢Recommended for all H. flu isolates from sterile sites
➢Required on isolates from children under 5 years old by Texas Administrative Code (TAC) §97.3(a) (4)
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Number of Invasive H.flu Cases, Texas, 1980-2016*
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0
100
200
300
400
500
600
700
800
900
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
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1st Hib vaccine licensed
All serotypes reportable in Texas
Hib became nationally reportable
Hib vaccine licensed for use for children
Hib vaccine licensed for use for babies
*1980-2015 only Hib cases reported; 2016 all serotypes reported
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Hib Vaccine
• CDC recommends Hib vaccination for children under 5 years of age
➢Usually given to babies starting at 2 months of age
• Primary series 2 or 3 doses and a booster
➢Older children and adults usually do not need a Hib vaccine
• Of the 15 Hib case-patients reported in 2016, 6 (40%) had a reported vaccination status
➢Of the 6 case-patients with a known vaccination status, 5 (83%) were previously vaccinated
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Number of Invasive H. flu Cases and Incidence, Texas, 2012-2016*
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3 5 12 11
317
0
0.2
0.4
0.6
0.8
1
1.2
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50
100
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*2012-2015 only Hib cases; 2016 all serotypes reported
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Number of Invasive H. flu Cases by Age Group, Texas, 2016
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43
18
40
60
156
0
20
40
60
80
100
120
140
160
180
0-4 years 5-17 years 18-49 years 50-64 years 65+ years
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Age Group
Number of Invasive H. flu Cases by Serotype, Texas, 2016
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15 15
0 2
10
2015
114
47
79
0
20
40
60
80
100
120
a b c d e f Non-b NonTypeable
Nottested
Unknown
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Serotype
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Number of Invasive H. flu Case-patients Under the Age of 5 by Serotype, Texas, 2016
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8
3
0 0
2
10
19
4
6
0
2
4
6
8
10
12
14
16
18
20
a b c d e f Non-b NonTypeable
Nottested
Unknown
Nu
mb
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ases
Serotype
Streptococcus pneumoniae, Invasive (Strep Pneumo)
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Invasive Streptococcus pneumoniae Epidemiology
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• Infectious Agent: Streptococcus pneumoniae
• Transmission: Direct person to person contact through respiratory droplets and by autoinoculation in persons carrying the bacteria in their upper respiratory track
• Incubation period: Varies but can be as short as 1 to 3 days
• Communicability: Time frame unknown
➢ May be as long as the organism is present in the respiratory tract secretions
➢ Probably less than 24 hours after effective antimicrobial therapy is started
• Texas Administrative Code (TAC) requires isolates be sent to DSHS lab for serotyping for cases of children under 5 years old➢ Complications with isolate submission
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2017 Updates
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Number of Invasive S. pneumoniaeCases, Texas, 2003- 2016
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0
500
1,000
1,500
2,000
2,500
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
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Single dose of PCV13 approved; expanded use to adults; 92 known serotypes of S. pneumoniae
1977 1st polysaccharide vaccine licensed for use in US;1983 reformulated to cover 23 serotypes
PCV13 licensed for use in US replaced PCV7 for routine use for children
In 2000, 1st conjugate vaccine (PCV7) licensed for use in US recommended for children 2-23 months of age
Pneumococcal Vaccination
• Conjugate vaccine recommended:➢2 months, 4 months, 6 months, and 12-15
months of age
➢Adults 65 years of age and older
• Polysaccharide vaccine recommended:➢Adults 65 years of age and older
➢Adults 19 through 64 years of age who smoke
cigarettes or have asthma
➢Anyone 2 through 64 years of age with certain
long-term health problems or with a weakened
immune system
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Number of Invasive S. pneumoniae Cases and Incidence, Texas, 2012-2016
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1,535
1,715
1,562
1,6931,737
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7
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Number of Invasive S. pneumoniae Cases by Age, Texas, 2016
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151
62
355
562
607
0
100
200
300
400
500
600
700
0-4 years 5-17 years 18-49 years 50-64 years 65+ years
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Age Group
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Meningococcal Disease, Invasive (Neisseria meningitidis)
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Meningococcal Epidemiology
• Infectious Agent: Bacterium Neisseria meningitidis
• Transmission: Person to person ➢ Direct contact with respiratory secretions
(e.g. kissing)➢ Indirect contact (e.g. sharing utensils)➢ Aerosol droplets (e.g. coughing and
sneezing)
• Incubation Period: Usually 3-4 days (range is 1-10 days)
• Communicability: As long as the bacteria are present in discharges from the nose and mouth
➢ Person is no longer infectious after 24 hours of appropriate antimicrobial treatment
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Number of N. meningitidis Cases, Texas, 1980-2016
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0
50
100
150
200
250
300
350
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
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1993
1994
1995
1996
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2nd conjugate vaccine licensed for use in US for 11-55 year olds & ACIP recommends booster dose for college
Quadrivalent polysaccharide vaccine licensed in US for 2+ year olds
1st conjugate vaccine licensed for use in US for under 2 year olds & added to recommended immunization schedule
Serogroup B vaccines
licensed
Serogroups Worldwide
12/4/2017Millar BC, Moore PJA, Moore JE Meningococcal disease: has the battle been won? Journal of the Royal Army Medical Corps 2017;163:235-241 56
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Meningococcal Vaccinations
• Vaccines available in the US➢Conjugate/polysaccharide:
• Covers serotypes A, C, Y, and W• Recommended for 11-12 year olds • Booster recommended 5 years after (16-18 years
old)• Colleges require proof of conjugate vaccination
within 5 years before starting school
➢Serogroup B:• Covers serotype B only• Recommended for 10-23 year olds (preferably
16-18 years old)
• Recommended for certain groups of at increased risk for meningococcal disease
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Number of N. meningitidis Cases by Serogroup, Texas, 2012-2016
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0
5
10
15
20
25
30
35
40
2012 2013 2014 2015 2016
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MMWR Year
Non-Typable
Unknown
Y
W135
C
B
A
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Number of N. meningitidis Cases and Incidence, Texas, 2012-2016
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37
30
22
30
23
0.14
0.11
0.08
0.11
0.08
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
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5
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25
30
35
40
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Number of N. meningitidis Case-Patients by Age Group, Texas, 2016
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2 2 2
0 0
4 4
1
2
6
0
1
2
3
4
5
6
7
<1 year 1-4 yrs 5-9 yrs 10-14yrs
14-19yrs
20-29yrs
30-39yrs
40-49yrs
50-59yrs
60 andUp
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Age Group
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Case Study
• Original notification of a potential meningococcal case in Regional Health Department 6/5S on 4/20/2017
➢Culture returned a few days later resulting in culture-confirmed Neisseria meningitidis
➢Individual was not vaccinated
➢Individual started symptoms on 4/16/2017
▪ Attended a social gathering on 4/16/2017
Now… about this social event.
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Bunnies on the Bayou
• Volunteer organization “dedicated to the raising and distributing of funds for various charitable and cultural programs that seek to improve the quality of life and promote education and awareness of human rights for the individuals in the Houston LGBT community.”
• Social calendar culminates in an event held in Houston, Texas on Easter Sunday every year
➢Heralded as “the largest outdoor cocktail party in Texas”
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Bunnies on the Bayou
• Regional Health Department 6/5S worked alongside local health departments to identify high-risk contacts
➢Nine individuals were found to be high-risk and were given PEP
➢An Epi-X was sent out to other states, informing them of the potential exposure and to keep an eye out for meningococcal cases reporting attendance at this event
• No additional cases were reported
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Mumps
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Mumps Epidemiology
• Infectious Agent: Mumps virus, a single-stranded RNA paramyxovirus
• Transmission: Respiratory droplets or direct contact with nasopharyngeal secretions
• Incubation period: Average is 16-18 days (range is 12-25 days)
• Communicability as early as 3 days before and up to 5 days after symptom onset
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Mumps Epidemiology cont’d
• Clinical Illness:
➢ Prodromal symptoms are non-specific and include myalgia, anorexia, malaise, headache, and low-grade fever that lasts 3-4 days
➢ Parotitis (inflammation or swelling of the parotid glands)
➢ 20% of cases are asymptomatic
➢ Most common complication is orchitis (50% of males)
• Temporal pattern
➢ Peak in cases in late winter and early spring
12/4/2017
From the Merck Manual Consumer Version, edited by Robert Porter. Copyright 2015 by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co, Inc, Kenilworth, NJ. Available
at merckmanuals.com
66
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Mumps Vaccination• 2 doses of MMR or MMRV began recommendation in
1989 and implemented in 2006
• Still researching effectiveness of a 3rd dose
• 88% effectiveness with two doses
(78% with one dose)
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Timeline
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(1) Epidemiology and Prevention of Vaccine-Preventable Diseases – CDC Pink Book
(2) http://www.immunize.org/timeline/ 68
1945•Mumps virus isolated1,2
1948•Inactivated mumps vaccine developed (later discontinued) 1
1967•Single antigen vaccine licensed1,2
1971•MMR licensed by Merck2
1977•One-dose MMR recommended for routine use1
1989•Two-dose measles vaccination policy1
2005•MMRV licensed by Merck2
2006•Two-dose mumps vaccine policy1
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Mumps Cases, Texas, 1990-2017*
12/4/2017 *2017 data provisional as of 11-1-2017 69
470
363
388
231 234
43 44
75
42 35 2714 15 18 23 25
58
21 2040
121
68
15 13 15
20
191
411
0
50
100
150
200
250
300
350
400
450
500
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
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2015
2016
2017*
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Two-dose mumps policy implemented
Mumps Cases and Incidence, Texas, 2012-2016
12/4/2017*2017 data provisional as of 11-1-2017
70
15 13 15 20
191
411
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
0
50
100
150
200
250
300
350
400
450
2012 2013 2014 2015 2016 2017*
In
cid
en
ce p
er 1
00
,00
0 P
op
ula
tio
n
Nu
mb
er o
f C
ases
12/4/2017
36
Mumps Cases and Incidence by Age Group, Texas, 2012-2017*
12/4/2017 *2017 data provisional as of 11-1-2017 71
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
0
50
100
150
200
250
300
350
400
450
500
2012 2013 2014 2015 2016 2017*
In
cid
en
ce p
er 1
00
,00
0 P
op
ula
tio
n
Nu
mb
er o
f C
ases 61+ years
41-60 years
21-40 years
11-20 years
6-10 years
1-5 years
<1 year
Total Incidence
Mumps Breakdown*• 565 cases of mumps since 10/1/2016
➢369 (65%) are outbreak related—divided among 16 outbreaks
▪ Largest outbreak: Johnson County – 191 cases
▪ Smallest outbreaks: Amarillo, Wichita, and Beeville, TX – 2 cases each
▪ 196 cases denoted as not being associated with an outbreak
• 41 counties affected
12/4/2017 *Data provisional as of 11-2-2017 72
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37
12/4/2017 73
Mumps Vaccination, Texas, October 2016-2017*
• 565 cases of mumps since 10/1/2016
• 486 cases (86%) of mumps cases have a known vaccination history
• Of these 486 cases (86%) who we know their vaccination history:
➢407 cases (84%) have been vaccinated
➢79 cases (16%) have not been vaccinated
• Breakdown by age group:
12/4/2017 *Data provisional as of 11-9-2017 74
Age GroupVaccinated
N / (Column %)
Not Vaccinated
N / (Column %)
≤18 years of age 223 / (55) 14 / (18)
>18 years of age 184 / (45) 65 / (82)
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Texas Mumps Outbreaks
Mumps Outbreaks in Texas*• An outbreak is classified as at least 2 confirmed or
probable cases
• 2016—4 outbreaks
➢ Johnson County outbreak went into 2017 as well
• 2017—14 outbreaks*
• Johnson County was our largest outbreak—191 cases
12/4/2017 *2017 data provisional as of 11-1-2017 76
2016
(N / Column %)
2017*
(N / Column %)
Not part of an outbreak 51 / 27 167 / 41
Outbreak 140 / 73 244 / 59
Total 191 411
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Number of Mumps Cases by Month and Outbreak, Texas, 2016-2017*
12/4/2017 *2017 Data is provisional as of 11-1-2017 77
0
20
40
60
80
100
120
Jan
Feb
Mar
Apr
May
Jun
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
2016 2017
Nu
mb
er o
f C
ases
2016 UT
2016 Dallas
Johnson
Cheerleader
2017 Dallas 1
Beeville
2017 Dallas 2
SPI
Tarrant
Bexar
Willacy 1
Amarillo
2017 UT
Wichita
2017 Dallas 3
2017 Travis
Willacy 2
Not Outbreak Related
Number of Outbreak-related Mumps Cases by Month and Outbreak, Texas, 2016-2017*
12/4/2017 *2017 Data is provisional as of 11-1-2017 78
0
10
20
30
40
50
60
70
80
90
100
Jan
Feb
Mar
Apr
May
Jun
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
2016 2017
Nu
mb
er o
f C
ases
2016 UT
2016 Dallas
Johnson
Cheerleader
2017 Dallas 1
Beeville
2017 Dallas 2
SPI
Tarrant
Bexar
Willacy 1
Amarillo
2017 UT
Wichita
2017 Dallas 3
2017 Travis
Willacy 2
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40
Number of Mumps Cases by Outbreak and MMWR Year, Texas, 2016-2017*
12/4/2017*2017 data provisional as of 11-1-2017
**ongoing outbreak79
2016 2017* Total
2016 UT 15 0 15
2016 Dallas 6 0 6
Collin 12 0 12
Johnson 107 84 191
2017 Dallas 1 0 71 71
Beeville 0 2 2
2017 Dallas 2 0 4 4
SPI 0 4 4
Tarrant 0 12 12
Bexar 0 7 7
Willacy 1 0 22 22
Amarillo 0 2 2
2017 UT 0 20 20
Wichita 0 2 2
2017 Dallas 3 0 7 7
2017 Travis 0 4 4
Willacy 2** 0 3 3
Number of Mumps Cases Associated with the Johnson County Outbreak by Demographic Indicators and MMWR Year, Texas, 2016-2017*
12/4/2017 *2017 data provisional as of 11-1-2017 80
Age Group 2016 2017* Outbreak Total Percent of Total
0-5 years 4 4 8 4%
6-10 years 17 15 32 17%
11-15 years 26 17 43 23%
16-20 years 25 16 41 21%
21-25 years 10 4 14 7%
26-30 years 7 10 17 9%
31-40 years 12 11 23 12%
41-50 years 5 3 8 4%
51-60 years 0 3 3 2%
61+ years 1 1 2 1%
Total 107 84 191 100%
Race 2016 2017* Outbreak TotalPercent of
Total
Asian 8 0 8 4%
Black or African American 3 6 9 5%
Native Hawaiian or Other Pacific Islander 42 48 90 47%
Unknown 4 0 4 2%
White 50 30 80 42%
Total 107 84 191 100%
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41
Issues with Mumps• Reporting — Increase in cases over the past year
are due to both increased awareness about mumps and higher prevalence of the virus
• Infection—Mumps virus is shed up to 3 days prior to symptom onset
➢ This makes it hard to assess 3rd dose effectiveness
• Vaccine is 88% effective at 2 doses
• No effective post-exposure prophylaxis
• Lab testing—PCR vs IgM
12/4/2017 81
3rd dose MMR in Outbreaks
• CDC guidelines for a 3rd dose in 2012:
1.>90% 2-dose vaccination coverage
2.Depends on the setting—schools and correctional facilities
3.High attack rates (> 5 cases per 1,000)
4.Ongoing transmission (> 2 weeks) (1)
• ACIP recommendation for 3rd dose campaigns in outbreak situations from October 2017
http://www.aappublications.org/news/2017/10/26/Mumps102617
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Why the increase in mumps outbreaks?
• Outbreaks in high population density areas and high contact areas (i.e. universities, schools)
• Vaccine efficacy (88% 2-dose with a range of 66%-95%)
• Is there a waning of vaccine-induced immunity?1
➢Only suggestions as of right now
➢Does not explain geographic nature of mumps outbreaks
➢Oldest vaccinated cohorts not always the most affected
• Is immunity due to vaccination less effective on different mumps strains?
➢No evidence yet but length of time since vaccination may be a possibility1
12/4/2017(1) https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2017-
02/mumps-02-marin.pdf 83
Resources
12/4/2017 84
• The Centers for Disease Control and Prevention. (2015). Epidemiology and Prevention of Vaccine-Preventable Disease (13th ed.). Atlanta, GA: US Department of Health and Human Services.
• Centers for Disease Control and Prevention website www.cdc.gov
• EAIDB Case Criteria Guide http://www.dshs.texas.gov/idcu/default.shtm
• EAIDB Investigation Guidance http://www.dshs.texas.gov/IDCU/investigation/Investigation-Guidance.doc
• “Vaccine Timeline.” Historic Dates and Events Related to Vaccines and Immunization, Immunization Action Coalition, 30 Dec. 2016, www.immunize.org/timeline/.
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12/4/2017 85
Thank youVaccine Preventable Diseases Epidemiologists
Emerging and Acute Infectious Disease Branch
Texas Department of State Health Services
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