Public health labs at center of 2017 mumps outbreaks: ‘This really could be a new normal for mumps’

Public health labs at center of 2017 mumps outbreaks: ‘This really could be a new normal for mumps’ | www.APHLblog.org

by Kim Krisberg

As of December 2, more than 4,900 cases of mumps had been reported to the Centers for Disease Control and Prevention in 2017. That’s less than the previous year’s case count of more than 6,000, but it’s still thousands more than any year in over a decade. Peter Shult, who works in one of the nation’s four Vaccine Preventable Disease Reference Centers, believes the last two years may be the new normal.

“This is happening in well-immunized populations,” said Shult, PhD, director of the Communicable Disease Division at the Wisconsin State Laboratory of Hygiene. “So (unlike measles outbreaks), it’s not an issue that people are unvaccinated — it’s probably more that we have a less-than-perfect vaccine. And with no new mumps vaccine coming down the pipeline anytime soon, this really could be a new normal for mumps.”

In early January, the Wisconsin Department of Health Services reported 62 confirmed mumps cases since November 2016, mostly clustered on college campuses. Many fellow Midwestern states — Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri and Kansas — reported mumps cases as well this year, some outbreaks numbering in the hundreds. In Wisconsin, 65% of those diagnosed with mumps had received two doses of vaccine, 6% had received one dose and 29% had an unknown immunization history. Wisconsin’s state public health lab conducts all the mumps testing for the state, but as a Vaccine Preventable Disease Reference Center, it also provides mumps testing for state public health labs that drew down such testing capacity as vaccine-preventable outbreaks became less common in the U.S.

Since summer 2016, according to Shult, the Wisconsin lab has received about 1,300 specimens for mumps testing — that’s a significantly higher number than in recent years, he added. Hundreds of those samples came in from other states, most notably from Alabama and Missouri, both of which experienced recent mumps outbreaks on university campuses. Of those 1,300 samples, about 220 tested positive for mumps, said Tim Davis, senior microbiologist in the Wisconsin lab.

Responding to a surge in mumps testing demands, especially during the typically busy flu season, means a “pretty substantial uptick” in the lab’s overall workload, said Shult, who also serves as the lab’s associate director. Fortunately, as one of the country’s four reference labs, the Wisconsin lab has built up the capacity to handle such surges. Lab technicians processed up to 20 mumps specimens a day, with a goal of delivering results the same day they’re received for both in-state and out-of-state samples. That speed is essential for the epidemiologists working to get ahead of a spreading outbreak and stop transmission. If a specimen comes back positive for mumps, it undergoes genotyping to determine if it’s linked to a larger outbreak.

Commercial labs in Wisconsin can do diagnostic testing for mumps, Shult said, but not as quickly and not as accurately as the state public health lab.

“It’s really the public health lab,” he said, “that’s on the front line.”

To the west in Washington state, the mumps case count from October 2016 to September 2017 was at 891 — that’s at least 700 more cases than any year since 2005. As of the end of August, the Washington State Department of Health Public Health Laboratories had received just more than 2,600 specimens for mumps testing, according to Ailyn Perez-Osorio, PhD, supervisor for molecular PFGE and virology. She said lab staff worked with epidemiologists to triage the daily flow of mumps specimens, using criteria such as date of illness onset and the risk of disease transmission to prioritize samples for testing. The lab also gathered results from commercial labs and shipped specimens for testing to the Minnesota Public Health Laboratory Division, which serves as a Vaccine Preventable Disease Reference Center.

One goal of the triage system, Perez-Osorio said, was making sure the lab’s rapid mumps testing capacity directly supported outbreak containment efforts, instead of only providing diagnostic results.

“We took a lot of consideration with our testing decisions to make sure we weren’t using up all of our resources,” Perez-Osorio said. “We had to preserve our capacity to prioritize testing for the public health response over diagnostic testing.”

The lab’s mumps screening is “highly complex,” she said, requiring RNA extraction and real-time polymerase chain reaction (RT-PCR) testing. Testing specimens in batches of about 30, it takes about five hours to get a result. Perez-Osorio said while additional staff were trained in mumps testing, the outbreak was simply too big to handle all the specimens without triaging the need and depending on outside help.

“People often stayed late, the majority were having to work extra hours — it was very taxing because of how long the outbreak went on for,” she said.

As of September, Perez-Osorio said mumps testing in the Washington lab had slowed to every other day, instead of every day, and the outbreak was tapering down. Thankfully, she said, the bulk of the outbreak didn’t happen during the summer when the same staff responsible for mumps testing is busy responding to peak rabies testing season.

On the issue of mumps spreading among vaccinated populations, Perez-Osorio said “it leaves a lot of questions.” On the flip side, she said her main concern is with pockets of anti-vaccine sentiment.

“It’s definitely hard to see people going in that direction because vaccines have brought so much safety to our communities,” she said. “It seems people have forgotten how horrible mumps and measles were back in the day.”

Emerging research is pointing to waning mumps immunity as a contributor to recent outbreaks. For example, a study published earlier this year in Frontiers in Physiology that studied mumps outbreaks in Scotland found that “waning immunity is the main factor in a repeated pattern of outbreaks.” In another study published in September in the New England Journal of Medicine, researchers studied the impact of a third dose of the measles-mumps-rubella vaccine in stemming an outbreak on an Iowa college campus. They found the third dose did improve mumps control and that waning immunity likely contributed to the outbreak’s spread. In late October, CDC’s Advisory Committee on Immunization Practices recommended a third dose of mumps vaccine as part of public health’s outbreak response.

Shult, at the Wisconsin State Laboratory of Hygiene, said just a handful of years ago, he wouldn’t have argued that all public health labs needed the complex testing capacity to deal with mumps outbreaks. As vaccine-preventable disease outbreaks became less common in the U.S., it just wasn’t practical for every state public health lab to sustain state-of-the-art testing technologies for the diseases. And, in fact, current funding levels wouldn’t even support all 50 states in building and maintaining that kind of lab capacity, which makes the country’s four Vaccine Preventable Disease Reference Centers all the more important.

Today, however, Shult said it’s “reasonable” to expect annual mumps outbreaks into the foreseeable future. And if that’s the case, he said it might be time to consider strengthening mumps testing across state public health labs.

“Moving forward, we should be asking ourselves if this is a capability that more states need or maybe we need to expand this part of the reference lab,” he said. “One could argue that states will be inundating reference labs (with mumps testing) in the future, and so we have to at least ask those questions.”

For more on recent mumps outbreaks, visit www.cdc.gov/mumps/outbreaks.html.

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Preparedness and Response in Action: Stories from the States

Celebrating 15 Years of PHEP

CDC’s Public Health Emergency Preparedness (PHEP) cooperative agreement is a critical source of funding, guidance, and technical assistance for state, local, tribal, and territorial public health departments to strengthen their public health preparedness capabilities.  Since 9/11, the PHEP program has saved lives by building and maintaining a nationwide public health emergency management system that enables communities to rapidly respond to public health threats.

The following stories are examples of how PHEP has equipped states for each of the four stages of preparedness: Ready. Steady. Show. Go!

READY: Planning for the inevitable6 domains of preparedness

Often the emergency managers and public health professionals who respond to an emergency are personally impacted by the same event. The ability of emergency response staff to take action during a disaster is limited when they are stranded in their homes due to an ice storm, without power, or unable to make it into the office.

The Connecticut State Department of Health, led by Jonathan Best, took on the challenge to ensure that operations can run smoothly even when their own staff are directly impacted by an emergency. They developed the Red Sheet Program, which trains three people for every key position in the emergency management structure – a primary contact with two back-ups. This means the health department can be fully staffed and ready to respond to a crisis within 20 minutes.

STEADY: Solving two problems at once

As the saying goes, even the best laid plans often go awry. Planning is an essential part of any preparedness program, but it is often difficult to imagine every scenario and obstacle that may arise during an emergency. But we also know that practice is the best way to identify and address those gaps– and practice is exactly what the Oklahoma State Department of Health does to improve its preparedness programs.

In September 2016, the Oklahoma Strategic National Stockpile team prepared to conduct a full-scale exercise of its ability to distribute medical countermeasures – medications and other products used to prevent and treat health conditions that may arise during a public health emergency.  Before the exercise began, the state realized they had shipments of flu vaccines that they needed to distribute around the state and the team distributed the vaccines as part of their regularly scheduled exercise. The team transported 11,960 doses of vaccine to eight local health departments while simultaneously completing this practice exercise.

SHOW: Creating a culture of preparedness

Emergencies impact all sectors of health, and experts from across departments are often asked to weigh in, from epidemiologists, to laboratorians, to mental health experts. However, public health staff in these positions may not often consider their roles in an emergency situation.

To build a culture of preparedness across the entire Oregon Health Authority, the Emergency Operations Division provided all staff with a 72-hour emergency kit, worked to enroll staff in the Health Alert Network, and trained staff on the Incident Management System. Since this initiative, staff personally feel more prepared for an emergency, and more staff are now prepared to respond should the need arise. “The culture has shifted. People are now talking in the elevator about what they would do in the event of a large-scale disaster,” acting PHEP director Akiko Saito said. “If we can build this culture of preparedness here, then we’re better equipped to build community resiliency on a larger scale.”

GO! Putting plans into action

While we all hope that emergencies never occur, they are inevitable and the true test of any preparedness system. Washington experienced an outbreak of mumps that affected more than 800 people of all ages in late 2016 and early 2017.

During this outbreak, the state and local health departments in Washington investigated new cases, advised local school districts on prevention measures, and developed culturally appropriate risk communication materials. Due to a robust preparedness system and the efforts of the health department staff and partners, more than 5,000 more people were vaccinated for measles, mumps, and rubella compared to previous years.

For 15 years, PHEP has been there, from Katrina to SARS; Joplin to H1N1 influenza. To find out more about how the PHEP program has equipped jurisdictions to prepare for, respond to, and recover from public health emergencies, check out our Stories from Field.

Read our other National Preparedness Month blogs:

PulseNet helps Washington public health solve largest Salmonella outbreak in recent history

PulseNet helps Washington public health solve largest Salmonella outbreak in recent history | www.APHLblog.org

By Kim Krisberg

In Washington state, it’s not entirely unusual for tiny clusters of foodborne illness to pop up throughout a given year. But in mid-2015, when reports of Salmonella clusters began popping up one right after another across multiple counties, public health workers knew they had a bigger problem on their hands.

Eventually, with the help of the nationwide lab network known as PulseNet, state and local public health investigators were able to connect the nearly two-dozen Salmonella clusters and trace the source to contaminated pork from Washington-based Kapowsin Meats, which ended up recalling more than 116,000 pounds of whole pigs and more than 523,000 pounds of pork products. But solving this outbreak came with a number of twists and turns, with public health workers first suspecting an entirely different culprit — beef.

“At the beginning, we weren’t sure what was making people sick,” said Ailyn Pérez-Osorio, PhD, molecular epidemiologist in the Washington State Department of Health’s Public Health Laboratories. “One of the first clusters was from an Ethiopian graduation party and they don’t typically eat pork, so it was pretty confusing.”

The Salmonella clusters began surfacing in June 2015, with the largest one a group of eight people who had attended an Ethiopian graduation party. A similar incident had occurred the year before also at parties and restaurants in the Ethiopian community, and those Salmonella clusters had been traced back to raw beef included in a traditional Ethiopian dish known as kitfo, said Beth Melius, MN, MPH, RN, foodborne and enteric disease epidemiologist at the Washington State Department of Health. So when the eight-person cluster popped up in summer 2015 and had the same serotype as the previous year’s Salmonella strain, Salmonella I 4,[5],12:i:-, public health investigators naturally looked to raw beef as the potential source.

But then events took a turn. Within days and weeks of the Ethiopian party cluster, state and local public health began receiving reports of Salmonella illnesses connected to pig roasts and live pig exposures as well. After receiving isolates from ill patients, public health lab staff went to work, using pulsed-field gel electrophoresis, or PFGE, to determine the samples’ DNA fingerprints. PFGE results found the same pattern over and over again. But public health investigators were still puzzled — the PFGE pattern was particularly uncommon in Washington, so it would make sense that all of the illnesses were connected to the same contaminated source. But how were the raw beef from the Ethiopian celebrations and the pork from the pig roasts related?

Public health and environmental health investigators hit the ground, interviewing residents who had purchased the whole pigs connected to the Salmonella clusters, gathering as many leftover foods as possible for testing, and reaching out to the markets and restaurants where sick residents had shopped or eaten. Eventually, public health workers with the Washington State Department of Health and Public Health — Seattle & King County traced the likely source of the contaminated pork back to Kapowsin Meats. The entire investigation took less than two months, Melius said. As for sickened residents who hadn’t reported eating pork, public health inspectors determined that cross-contamination was the culprit. For instance, said Pérez-Osorio, at an Ethiopian restaurant where sickened residents had eaten, inspectors found remnants of the contaminated pork in a meat grinder also used for beef.

In all, according to the Centers for Disease Control and Prevention, 192 people were infected with outbreak strains of Salmonella I 4,[5],12:i:- (188) and Salmonella Infantis (4) in five states: 184 people in Washington, one in Alaska, two in California, two in Idaho and three in Oregon. In addition, CDC’s National Antimicrobial Resistance Monitoring System lab conducted antibiotic-resistance testing on isolates from 10 patients sickened during the outbreak, finding that all 10 samples were multidrug resistant.

Among the 180 patients for whom information is available, 17 percent had to be hospitalized. No deaths were reported during the outbreak, which Melius described as the state’s largest Salmonella outbreak in recent history.

Both Pérez-Osorio and Melius said PulseNet, which celebrated its 20th anniversary in 2016, was invaluable to solving the outbreak.

“PulseNet allows you to view data not just by pattern, but by where the cases are coming from — it helps you map it all out,” said Pérez-Osorio. “It’s not just the connectivity between states; it’s the whole PulseNet system that allows our lab access to the methods that can lead us to quickly solving these outbreak investigations.”

Melius said PulseNet allowed public health workers to “crack” the multicounty outbreak much quicker than they would have otherwise. With so many little outbreaks happening across a dozen Washington counties, she said PulseNet was key in helping investigators determine which clusters and individual illnesses were connected to the larger outbreak.

“I don’t think we’d solve even half the outbreaks that happen without PulseNet,” said Melius, who also noted that the state’s public health lab conducted PFGE testing on more than 100 samples over the course of just a couple months, with each isolate requiring 16 hours of hands-on work. “It’s a combination of epidemiology, lab work and PulseNet — that’s how we solve our outbreaks and we couldn’t do it without all those pieces.”

On a side note, Pérez-Osorio mentioned that solving such investigations could face additional challenges in the future with the emergence of culture-independent diagnostic testing in clinical labs. She explained that such testing allows clinical labs to identify the general type of bacteria making a person sick, without having to grow or culture the bacteria in the lab. That means clinical labs can determine the cause of a person’s illness much quicker and at lower costs. On the flip side, the method doesn’t generate the particular isolates that public health labs need to connect seemingly separate illnesses and detect a larger outbreak.

“The issue is that generating an isolate is very expensive and as a public health lab, we’re not set up to do that — we’re set up to analyze the isolate,” said Pérez-Osorio. “Right now, all public health labs are facing this issue to one degree or another.”

According to CDC, PulseNet identifies about 1,500 clusters of foodborne illness every year, about 250 clusters that cross state lines, and about 30 multistate outbreaks traced back to a food source. A recent economic evaluation of PulseNet found that every year, the laboratory network prevents more than 266,500 illnesses from Salmonella, nearly 9,500 illnesses from E. coli and 56 from Listeria. That translates into $507 million in reduced medical and productivity costs.

 

(Photo credit: USDA)

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Happy hikers pass in front of Table Mountain in Washington,…



Happy hikers pass in front of Table Mountain in Washington, April 1960.Photograph by B. Anthony Stewart, National Geographic

Happy hikers pass in front of Table Mountain in Washington,…



Happy hikers pass in front of Table Mountain in Washington, April 1960.Photograph by B. Anthony Stewart, National Geographic