Immunization Action Coalition and the Hepatitis B Coalition

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Issue Number 593            April 17, 2006

CONTENTS OF THIS ISSUE

  1. Important: Corrected CDC Health Advisory presents information and guidance for the current mumps outbreak
  2. MMWR publishes report alerting healthcare providers about recent U.S. air travel by persons infectious with mumps
  3. New: NIP website posts up-to-date resources regarding the current mumps outbreak
  4. IAC posts another thimerosal resource to its website homepage
  5. Updated: IAC revises "It's federal law!" and other education pieces for health professionals and patients
  6. CDC updates its Influenza web section with current information about avian influenza
  7. WHO issues guidelines for preparing for and mitigating pandemic influenza in refugee and displaced populations
  8. CDC publishes recommendations for animal rabies prevention and control

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ABBREVIATIONS: AAFP, American Academy of Family Physicians; AAP, American Academy of Pediatrics; ACIP, Advisory Committee on Immunization Practices; CDC, Centers for Disease Control and Prevention; FDA, Food and Drug Administration; IAC, Immunization Action Coalition; MMWR, Morbidity and Mortality Weekly Report; NIP, National Immunization Program; VIS, Vaccine Information Statement; VPD, vaccine-preventable disease; WHO, World Health Organization.
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April 17, 2006
IMPORTANT: CORRECTED CDC HEALTH ADVISORY PRESENTS INFORMATION AND GUIDANCE FOR THE CURRENT MUMPS OUTBREAK

On April 14, CDC issued a Health Advisory with information about the current mumps outbreak. On April 15, CDC issued a Health Update to correct an error in the Health Advisory. The corrected document is reprinted below in its entirety, with the exception of references.

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This is an official CDC Health Update
Distributed via Health Alert Network
April 15, 2006, 12:39 EDT

CORRECTED: MULTI-STATE MUMPS OUTBREAK

This message is being sent to correct the flight arrival city in Arkansas indicated for this outbreak. The arrival city was BENTONVILLE, AR not Lafayette.

Original information from the CDC Advisory #00243, transmitted April 14, 2006:

The state of Iowa has been experiencing a large outbreak of mumps that began in December 2005. As of April 12, 2006, 605 suspect, probable, and confirmed cases have been reported to the Iowa Department of Public Health (IDPH) (IDPH, unpublished data). The majority of cases are occurring among persons 18–25 years of age, many of whom are vaccinated. Additional cases of mumps, possibly linked to the Iowa outbreak, are also under investigation in eight neighboring states, including Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin (CDC unpublished data, April 14, 2006).

In addition, the Iowa Department of Public Health has identified two persons diagnosed with mumps who were potentially infectious during travel on nine different commercial flights involving two airlines between March 26, 2006 and April 2, 2006. The origin and arrival cities for these flights include Cedar Rapids and Waterloo, IA; Dallas, TX; Detroit, MI; Lafayette, AR [corrected to BENTONVILLE, AR, in the Health Update]; Minneapolis, MN; St. Louis, MO; Tucson, AZ; and Washington, DC.

The source of the current US outbreak is unknown. However the mumps strain has been identified as genotype G, the same genotype circulating in the United Kingdom (UK). The outbreak in the UK has been ongoing from 2004 to 2006 and has involved [more than] 70,000 cases. Most UK cases have occurred among unvaccinated young adults. The G genotype is not an unusual or rare genotype and, like the rest of known genotypes of mumps, it has been circulating globally for decades or longer.

MUMPS CLINICAL MANIFESTATIONS AND TRANSMISSION
Mumps is an acute viral infection characterized by a non-specific prodrome including myalgia, anorexia, malaise, headache, and fever, followed by acute onset of unilateral or bilateral tender swelling of parotid or other salivary glands. In unvaccinated populations, an estimated 30–70% of mumps infections are associated with typical acute parotitis. However, as many as 20% of infections are asymptomatic and nearly 50% are associated with non-specific or primarily respiratory symptoms, with or without parotitis.

Complications of mumps infection can include deafness, orchitis, oophoritis, or mastitis (inflammation of the testicles, ovaries, or breasts respectively), pancreatitis, meningitis/encephalitis, and spontaneous abortion. With the exception of deafness, these complications are more common among adults than children.

Transmission of mumps virus occurs by direct contact with respiratory droplets [or] saliva or contact with contaminated fomites. The incubation period is generally 16–18 days (range 12–25 days) from exposure to onset of symptoms. Mumps virus has been isolated from saliva from between two and seven days before symptom onset until nine days after onset of symptoms.

MUMPS PREVENTION
The principal strategy to prevent mumps is to achieve and maintain high immunization levels. The Advisory Committee on Immunization Practices (ACIP) recommends that all preschool-aged children 12 months of age and older receive one dose of measles-mumps-rubella vaccine (MMR) and all school-aged children receive two doses of MMR, and to ensure that all adults have evidence of immunity against mumps. As noted below, two doses of mumps vaccine are more effective than a single dose. Consequently, during outbreaks and for at-risk populations, ensuring high vaccination coverage with two doses is encouraged. For example, healthcare workers may be at increased risk of acquiring mumps and transmitting to patients and thus should receive two doses of MMR vaccine or provide proof of immunity. Since vaccination is the cornerstone of mumps prevention, public and private health entities concerned about spread of mumps in a population can review the vaccination status of populations of interest and work to address gaps in vaccination.

MUMPS VACCINE EFFECTIVENESS
Data from outbreak investigations have shown that the effectiveness of MMR against mumps is approximately 80% after one dose, and limited data suggest effectiveness of approximately 90% after two doses. Available evidence suggests that mumps vaccination should provide immunity against the genotype G virus responsible for the current US outbreak. A study of a 2005 New York outbreak that began with imported disease from the UK, demonstrated vaccine effectiveness in the expected range for both one and two doses (New York, unpublished data). However, since the vaccine is not 100% effective, some cases can occur in vaccinated persons. When a highly vaccinated population is exposed to disease, most cases of disease would be expected to be among vaccinated persons. Mumps vaccine has not been shown to be effective in postexposure prophylaxis, and an interval of 2–4 weeks after vaccination may be required for the vaccine's full immunogenicity to be achieved. For these reasons, and because of the mumps' incubation period of 12–25 days, during an outbreak, newly vaccinated persons may develop mumps disease as long as a month after vaccination.

CONTROL OF MUMPS OUTBREAKS
The main strategies for controlling a mumps outbreak are to define the at-risk population and transmission setting, identify and isolate suspected cases, and rapidly identify and vaccinate susceptible persons or, if a contraindication to MMR vaccine exists, to exclude susceptible persons from the setting to prevent exposure and transmission. Specific strategies are listed below.

1. Offer MMR vaccine to persons without evidence of immunity. Evidence of immunity includes physician diagnosis or laboratory evidence of mumps infection, birth before 1957, or one dose of MMR vaccine. For pre-school aged children, the first MMR dose should be administered as close to age 12 months as possible. Although birth before 1957 is usually considered proof of immunity, during an outbreak, vaccination can be considered for this age group if the epidemiology of the outbreak suggests that they are at increased risk of disease. Since two doses of MMR vaccine [are] more effective than one dose for preventing mumps, a second dose of MMR vaccine is recommended for the following groups: healthcare workers, school-aged children, students at post-high school educational institutions, and other age groups considered at high risk of exposure.

2. Surveillance for mumps should be enhanced in all affected areas for persons with parotitis or other salivary gland inflammation. Enhanced surveillance should continue for 50 days (two times the maximum incubation period) after the date of illness onset in the last identified case. CSTE [Council of State and Territorial Epidemiologists] approved case definitions and case classifications for mumps are available.

3. Persons with suspected mumps should be tested and reported immediately to local public health officials. Information on collection and testing of clinical specimens for mumps will be available by Monday April 17, 2006, at http://www.cdc.gov/nip/diseases/mumps/mumps-lab.htm Testing is essential as not all cases of parotitis are mumps, although mumps is the only known cause of epidemic parotitis.

4. Persons suspected of having mumps should be isolated for nine days after symptom onset. In healthcare settings, the use of respiratory precautions is recommended.

5. Exclusion of persons without evidence of immunity to mumps from institutions such as schools and colleges affected by a mumps outbreak (and other, unaffected institutions judged by local public health authorities to be at risk for transmission of disease) should be considered. Once vaccinated, students can be readmitted to school. The period of exclusion for those that remain unvaccinated should be for at least 25 days after the onset of parotitis in the last person with mumps in the affected institution.

Additional information on mumps and the prevention and control of mumps outbreaks, including vaccination, can be found at the following website:
http://www.cdc.gov/nip/diseases/mumps/mumps-outbreak.htm

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To access the corrected Health Update from the Health Alert Network, go to:
http://www.phppo.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?AlertNum=00244
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April 17, 2006
MMWR PUBLISHES REPORT ALERTING HEALTHCARE PROVIDERS ABOUT RECENT U.S. AIR TRAVEL BY PERSONS INFECTIOUS WITH MUMPS

CDC published "Exposure to Mumps During Air Travel—United States, April 2006" in the April 14 issue of MMWR. Previously, the article was available only in electronic format as an MMWR Dispatch.

To access a web-text (HTML) version of the MMWR article, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5514a6.htm

To access a ready-to-print (PDF) version of this issue of MMWR, go to: http://www.cdc.gov/mmwr/PDF/wk/mm5514.pdf

To receive a FREE electronic subscription to MMWR (which includes new ACIP statements), go to:
http://www.cdc.gov/mmwr/mmwrsubscribe.html
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April 17, 2006
NEW: NIP WEBSITE POSTS UP-TO-DATE RESOURCES REGARDING THE CURRENT MUMPS OUTBREAK

On April 16, NIP updated its website with links to resources regarding the current mumps outbreak. Resources include information for the public and healthcare professionals.

To access these resources, go to:
http://www.cdc.gov/nip/diseases/mumps
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April 17, 2006
IAC POSTS ANOTHER THIMEROSAL RESOURCE TO ITS WEBSITE HOMEPAGE

IAC recently added "CDC's key messages: Thimerosal, vaccines, and autism," to the homepage of its website at http://www.immunize.org This resource will be useful to providers in discussing thimerosal with their patients. You'll find the link in the upper right corner of the homepage, along with other links.

To access this resource directly, go to:
http://www.immunize.org/cdc_thimerosal.pdf
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April 17, 2006
UPDATED: IAC REVISES "IT'S FEDERAL LAW!" AND OTHER EDUCATION PIECES FOR HEALTH PROFESSIONALS AND PATIENTS

IAC recently added updated information to several of its print pieces, including the professional-education piece "It's federal law! You must give your patients current Vaccine Information Statements (VISs)." The updated pieces include the following:

FOR HEALTH PROFESSIONALS
1. "It's federal law! You must give your patients current Vaccine Information Statements (VISs)": The information about VIS dates was made current.

To access a ready-to-print (PDF) version, go to:
http://www.immunize.org/catg.d/2027law.pdf

To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/2027law.htm

2. "Quiz #1: Immunization": Information about Tdap vaccine was added.

To access a ready-to-print (PDF) version, go to:
http://www.immunize.org/catg.d/p7001qz.pdf

To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p7001qz.htm

3. "Emergency response worksheet: What to do in case of a power failure or another event that results in vaccine storage outside of the recommended temperature range": Vaccine manufacturers' telephone numbers were updated.

To access a ready-to-print (PDF) version, go to:
http://www.immunize.org/catg.d/p3051.pdf

4. "Vaccine handling tips: Outdated or improperly stored vaccines won't protect patients!" Information about rotavirus vaccine was added.

To access a ready-to-print (PDF) version, go to:
http://www.immunize.org/catg.d/p3048.pdf

5. "Maintaining the cold chain during transport": Information about rotavirus vaccine was added.

To access a ready-to-print (PDF) version, go to:
http://www.immunize.org/catg.d/p3049.pdf

6. "Notification of vaccination letter": Information about rotavirus vaccine was added.

To access a ready-to-print (PDF) version, go to:
http://www.immunize.org/catg.d/p3060not.pdf

FOR PATIENTS
7. "What if you don't immunize your child?" The statistic on annual worldwide measles mortality was updated.

To access a ready-to-print (PDF) version, go to:
http://www.immunize.org/catg.d/p4017.pdf

To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p4017.htm

8. "If you, your parents, or your children were born in any of these places . . . give this brochure to your healthcare provider and ask to find out your hepatitis B status": The most recent version (dated 9/05) has been translated into Russian. IAC gratefully acknowledges the California Department of Health Services for the translation.

To access a ready-to-print (PDF) version in Russian, go to:
http://www.immunize.org/catg.d/p4170ru.pdf

To access a ready-to-print (PDF) version in English, go to:
http://www.immunize.org/catg.d/p4170ref.pdf

To access a web-text (HTML) version in English, go to:
http://www.immunize.org/catg.d/p4170.htm
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April 17, 2006
CDC UPDATES ITS INFLUENZA WEB SECTION WITH CURRENT INFORMATION ABOUT AVIAN INFLUENZA

CDC recently updated two pages of its Influenza web section:

  1. Questions & answers about avian influenza (bird flu) & avian influenza virus (posted 4/12/06)
  2. Embargo of birds from specified countries [Burkina Faso and Pakistan] (posted 4/10/06)

To access these materials, go to: http://www.cdc.gov/flu/whatsnew.htm#updated and click on the pertinent links.

To access a broad range of continually updated information on seasonal influenza, avian influenza, and pandemic influenza, go to: http://www.cdc.gov/flu
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April 17, 2006
WHO ISSUES GUIDELINES FOR PREPARING FOR AND MITIGATING PANDEMIC INFLUENZA IN REFUGEE AND DISPLACED POPULATIONS

WHO recently issued "Pandemic influenza preparedness and mitigation in refugee and displaced populations: WHO guidelines for humanitarian agencies." It focuses on a potential pandemic situation and human health, describing the expected response in settings with populations of refugees and internally displaced persons.

To access the guidelines, go to:
http://www.who.int/csr/disease/avian_influenza/guidelines/avian2006-04-9.pdf
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April 17, 2006
CDC PUBLISHES RECOMMENDATIONS FOR ANIMAL RABIES PREVENTION AND CONTROL

CDC published "Compendium of Animal Rabies Prevention and Control, 2006: National Association of State Public Health Veterinarians, Inc. (NASPHV)" in the April 14 issue of MMWR Recommendations and Reports. The introductory paragraph is reprinted below in its entirety, excluding references.

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Rabies is a fatal viral zoonosis and a serious public health problem. The recommendations in this compendium serve as the basis for animal rabies prevention and control programs throughout the United States and facilitate standardization of procedures among jurisdictions, thereby contributing to an effective national rabies-control program. This document is reviewed annually and revised as necessary. These recommendations do not supersede state and local laws or requirements. Principles of rabies prevention and control are detailed in Part I; Part II contains recommendations for parenteral vaccination procedures; all animal rabies vaccines licensed by the United States Department of Agriculture (USDA) and marketed in the United States are listed in Part III.

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To obtain a web-text (HTML) version of the recommendations online, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5505a1.htm

To obtain a ready-to-copy (PDF) version, go to:
http://www.cdc.gov/mmwr/PDF/rr/rr5505.pdf

 

Immunization Action Coalition1573 Selby AvenueSt. Paul MN 55104
E-mail: admin@immunize.org Web: http://www.immunize.org/
Tel: (651) 647-9009Fax: (651) 647-9131

This page was updated on April 17, 2006