Mumps Disease and Its Health Impact: An Outbreak-Based Report

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Mumps

Disease

and Its Health

Impact:

An

Outbreak-Based

Report

Kevin

M. Sullivan,

MHA,

MPH,

Thomas

J. Halpin,

MD, MPH,

Robert

Kim-Farley,

MD, MPH,

and James

S. Marks,

MD, MPH

From the Immunization Program and Bureau of PreventWe Medicine, Ohio Department of Health, Columbus; and Divisions of Immunization, Center for Prevention Services, and Nutrition, Center for Health Promotion and Education, Centers for Disease Control, Atlanta

ABSTRACT. An outbreak of mumps in a middle school

(grades 6 to 8) in Ohio during 1981 was investigated to describe the clinical findings, health impact, and costs.

Individuals with clinical mumps in the middle school and

in family members were questioned concerning

symp-toms, complications, hospitalizations, school days absent,

and parental work days missed. There were 62 cases of

clinical mumps in the middle school and 13 cases among

family members. Parotitis lasted an average of 7.4 days

and fever (if present) lasted an average of 2.5 days with a mean temperature of 38.6#{176}C(101.4#{176}F).The duration of parotitis and fever increased with age. Complications included encephalitis, aseptic meningitis, orchitis,

ooph-oritis, mastitis, and pancreatitis. Visits to physicians were

made by 62.7% (47/75) of the individuals with mumps

for atotal of 63 visits, and two patients were hospitalized for a total of six days. Persons who attended middle

school missed an average of 4.9 days of school. The

estimated direct and indirect costs associated with this

outbreak were $2,460 and $1,353, respectively, or $51 per

case. States lacking mumps immunization requirements

experienced a three-times greater incidence of mumps in 1982 than States that required all school pupils to be

immunized. We recommend that all States institute corn-pulsory mumps school immunization laws for all school children. Pediatrics 1985;76:533-536; mumps, vaccine,

cost-benefit.

relatively lower acceptance of the vaccine compared

with measles and rubella vaccines. From 1973

through 1982, 45.0 million doses of mumps vaccine

were distributed in the United States, compared

with 77.5 million doses of measles vaccine and 72.1

million doses of rubella vaccine during the same

time period.2 Results from the United States

Im-munization Survey in 1981 demonstrated that

76.7% of the individuals 5 to 19 years of age had

received mumps vaccine, as verified by an

immu-nization record, compared with 85.6% with measles

vaccine and 85.3% with rubella vaccine.2

Some of the reasons for this lower level of

ac-ceptance may be the result of (1) the perceived

mildness of the disease, (2) concerns about the

duration of protection afforded by the vaccine, and

(3) the perceived effectiveness of the vaccine.

Cost-benefit studies on mumps vaccine have

found savings associated with vaccination.3’4 We

investigated an outbreak of mumps that occurred

in Centerville, Ohio, to determine disease severity

and the health impact of mumps to refine estimates

on the cost-effectiveness of mumps vaccination.

METHODS

The only primary prevention currently available

for mumps is by vaccination with live-virus mumps

vaccine. Although the vaccine has been

demon-strated to be safe and effective,’ there has been a

Received for publication July 11, 1984; accepted Jan 11, 1985. K.M. Sullivan’s current address is Department of Epidemiology, University of Michigan School of Public Health, 109

Observa-tory, Ann Arbor, MI 48109.

Reprint requests to (T.J.H.) Bureau of Preventive Medicine, Ohio Department of Health, P0 Box 118, Columbus, OH 43266-0118.

A case was defined as an instance of parotitis for

one or more days. Suspect cases were investigated

by Ohio Department of Health disease investigators

who used a standardized mumps investigation form.

Information was collected about symptoms,

corn-plications, school days absent (middle school cases

only), visits to physicians, and work days missed by

parents. Certain complications (oophoritis,

pan-creatitis, encephalitis, and meningitis) required a

diagnosis by a physician.

Multiple regression models were used on

contin-uous dependent variables (temperature, fever

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regres-8.0%

7.7%

6.7%

3.8%

2.7%

534

MUMPS DISEASE

sion models for dichotomous dependent variables.

The independent variables were age, mumps

vac-cine status (vaccinated v not vaccinated), and sex.

P values less than .05 were considered significant.

RESULTS

A total of 75 cases were investigated, 62 in middle

school pupils and 13 among family members.

Symptoms

The frequency of symptoms is shown in Table 1.

All of the individuals exhibited parotitis (by case

definition). Parotitis was bilateral in 48 (64.0%) of

the cases and unilateral in the others.

As age increased so did the duration of the fever

(P = .0055) and parotitis (P = .0431) when

con-trolling for the mumps immunization status and

sex. The mean temperature for all who reported a

fever was 38.6#{176}C(101.4#{176}F)and lasted an average of 2.5 days, whereas parotitis had an average duration

of 7.4 days. Whether or not the person was

previ-ously vaccinated for mumps had no significant

ef-fect on disease severity. Two other findings that

were statistically significant but perhaps not

clini-cally important were higher fevers in boys or men

(P = .0158) and a greater frequency of diarrhea in

older patients (P = .016). There were no cases of

“atypical mumps” detected in this outbreak.5

Complications

The frequency of orchitis was 9.1% (2/22) for

boys and men 12 years of age or older. Girls and

women 12 years of age or older had a frequency of

mastitis of 7.7% (2/26). One 11-year-old boy was

diagnosed as having encephalitis and pancreatitis but he was not hospitalized.

Two patients were hospitalized. One 12-year-old

boy was hospitalized for four days with pancreatitis,

dehydration, and vomiting, and a 16-year-old girl

was hospitalized for two days with aseptic

menin-gitis, dehydration, and vomiting.

Health

Impact

Of the 62 cases in the middle school, 37 (59.7%)

of the students made a total of 53 visits to

physi-cians. Age, sex, and vaccine status were not

signifi-cant factors in predicting which children visited a

physician. Of the 13 cases among family members,

nine (69.2%) individuals made a total of ten visits

to physicians.

Middle school pupils ill with mumps missed an

average of 4.9 days of school, resulting in a total of

304 school days absent. When the number of days

absent as reported by parents v school records were

TABLE 1. Symptoms and Complications in Persons with Mumps in Centerville, Ohio (1981)

Symptom/Complication Frequency

Parotitis 100.0%

Fever 81.1%

Malaise 67.1%

Difficulty swallowing 66.2%

Anorexia 63.5%

Headache 61.8%

Earache 44.6%

Sore throat 41.1%

Tartness reaction 33.3%

Irritability 31.9%

Nausea 22.7%

Abdominal pain 22.3%

Generalized tender- 17.1%

16.2% 9.1% ness

Arthralgia

Orchitis (boys and

men 12 yr)

Vomiting

Mastitis (girls and

women 12 yr)

Diarrhea

Oophoritis (girls and

women 12 yr)

Pancreatitis

compared, there was no statistically significant

dif-ference between the sources of information using a

paired t test (P > .50). The number of days absent

was not significantly affected by the age, sex, or

vaccine status among pupils in the middle school

using multiple regression.

Four fathers missed a total of six days of work

when their children had parotitis, for an average of

0.1 days missed per case. Eleven mothers who

worked outside the home missed a total of 22 days

of workfor an average of 0.35 days missed per case.

Using cost figures from a benefit-cost study on

mumps,3 we estimate the direct costs of the

out-break to be $2,460 and the indirect costs to be

$1,353 (Table 2).

DISCUSSION

Mumps disease can be severe and may result in

hospitalizations and occasionally death (1.0 to 3.4

deaths per 10,000 cases).6 Since the licensure of

mumps vaccine iii 1967, there has been a dramatic

decline in the incidence of mumps.’ An increasing

number of states have incorporated mumps vaccine

as a requirement for some or all school children,

from two states in 1976 to 30 states in 1983. The

numbers of reported mumps cases per million

pop-ulation is greater in states without mumps vaccine

requirements than those that have requirements

(Table 3).

No difference was found in the severity of mumps

disease between children who had been previously

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Costs Units 75 63 6 siio* $1,200t

202 $ 808

55 $385

40 $ 160

ACKNOWLEDGMENTS

The authors acknowledge the following individuals for their cooperation, assistance, and/or suggestions: Alex

Browning and Pat Ringold, RN, Centerville City Schools;

Paul C. Nutt, PhD, Steven Strasser, MPH, PhD, and

Melvin Moeschberger, PhD, Ohio State University; John

TABLE 3. Reported Incidence of Mumps by State School Requirements (1982)

Requirement No. of States

No. of Cases 1982* Population (xi,000) Cases/i Million Population Relative Risk K-12 Partial None 15t 16 20 1,080 1,617 2,499 92,996 67,119 72,447 11.6 24.1 34.6 1.0 2.1 3.0

Total 51t 5,196 232,562 22.3

* Provisional data.

t Includes the District of Columbia.

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States in which only certain pupils are required to provide proof of mumps vaccination

or disease, generally the younger pupils.

vaccinated for mumps compared with those who

had not. This suggests that having been immunized

with live-virus mumps vaccine and subsequently

acquiring mumps disease will not result in a milder

illness. Of the 22 symptoms investigated, four were

found to be significant in regression models in

which the independent variables were age, sex, and

vaccine status. Even if a more conservative P value

is utilized, eg, P < .01, the increased duration of

fever found in older individuals would still be

sig-nificant (P = .0055).

In this outbreak, which occurred in an affluent

suburb, approximately 60% of the pupils with

mumps from the middle school made at least one

visit to a physician because of their illnesses. In

another outbreak of mumps that occurred in early

1982 in a rural middle school located in northeast

Ohio,7 27.3% of the students with clinical mumps

were examined by a physician (R. Kim-Farley,

un-published data). The average number ofdays absent

due to mumps in the rural middle school was 6.7

days (R. Kim-Farley, unpublished data), somewhat

more than that found in Centerville.

Benefit-cost studies have found mumps vaccine

TABLE 2. Estimated Cost of a Mumps Outbreak in

Centerville, Ohio (1981)

Indexes

Total no. of illnesses

Visits to physicians Days of

hospitaliza-tion

Work hours missed

(mother) for ill

child

Work hours missed (father) for ill child

Work hours missed (mother) due to

illness

Total $3,813

* Based on $20 per visit.

t Based on $200/d of hospital stay. : Based on an average salary of $4/h. §Based on,an average salary of $7/h.

to be cost beneficial.3’4 In this outbreak, the direct

and indirect costs per case were approximately $51.

The total costs were less than what would be found

by applying the direct and indirect costs

assump-tions by Koplan and Preblud.3 They assume that

every person with mumps would make at least one

visit to a physician. In the outbreak reported here,

this did not occur. Another assumption they made

was about the amount of time a parent would miss

from work to care for the ill child (“Children with

uncomplicated mumps would require 60% of

moth-ers to lose five-sevenths of 40 workday hours or

$114”). Their assumptions may overestimate the

amount of time lost from work. Parents may leave

their ill children alone at home if the child is older and/or the disease is mild. Their benefit-cost study

may have underestimated the proportion of persons

with mumps who will be hospitalized and the length

of hospitalization. (They assume that 1% of the

persons with mumps meningoencephalitis would be hospitalized for three days.3) It is important to note

that the mumps outbreak presented in our report

is based on only 75 cases. Also, because the outbreak

occurred in an affluent community, the proportion

of working mothers may be lower and the wages

higher than the average United States figures.

Nevertheless, we recommend that all states

re-quire mumps vaccine or a prior history of

physician-diagnosed mumps disease for all school pupils

un-less contraindications exist.’ The cost of adding

mumps to measles and rubella vaccine is much less

than the costs associated wtih mumps disease.

Fol-lowing these recommendations would result in a

further decline in the incidence of mumps and also

reduce complications, school absenteeism, visits to

physicians, and hospitalizations associated with

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536

MUMPS DISEASE

Irvin, Fred Wilt, Seth Young, MBA, MS, Sally Sharp,

Geri Rousculp, and Martha Grimm, Ohio Department of

Health; and Walter Orenstein, MD, Centers for Disease Control.

REFERENCES

1. Centers for Disease Control: Recommendations of the Im-munization Practices Advisory Committee (ACIP)-mumps vaccine. MMWR 1982;31:617-625

2. Eddins DL: Indicators of immunization status. 17th Immu-nization Conference Proceedings, US Department of Health

and Human Services, Public Health Service, Atlanta, Con-ters for Disease Control, May 18-19, 1982, pp 47-55 3. Koplan JP, Preblud SR: A benefit-cost analysis of mumps

vaccine. Am eJDis Child 1982;136:362-364

4. Weidermann G, Ambrosch F: Cost-benefit calculations of vaccinations against measles and mumps in Austria. Dev

Biol Stand 1979;43:273-277

5. Gunby P: ‘Atypical’ mumps may occur after immunization. JAMA 1980;243:2374-2375

6. Mumps surveillance, July 1974-December 1976, Atlanta,

Centers for Disease Control, July 1978

7. Kim-Farley R, Doster, S, Stetler S, et al: Clinical mumps vaccine efficacy, Ohio. Am J Epidemiol 1985;121:593-597

JAIL

TERMS

SHORTER

FOR

CRIMES

AGAINST

CHILDREN

People who commit crimes against children go to jail less often and for shorter

terms than other criminals, even though they are convicted more frequently for

those crimes, [according to] a Department of Justice study of four states.

The study, covering 1981 and 1982 data from California, New York, Ohio and

Pennsylvania, found that only 8 percent of people arrested for child-related

felonies are sentenced to prison for more than a year. By comparison, 12 percent

of people charged with similar crimes against victims of all ages received jail

terms of a year or more.

In California, 7 percent of the child-related arrests resulted in jail terms of a

year or more, compared with 14 percent for other arrests.

The Bureau of Justice Statistics branch conducted the study.

Submitted by Birt Harvey

From San Jose Mercury News, Dec 28, 1984, p 16A.

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1985;76;533

Pediatrics

Kevin M. Sullivan, Thomas J. Halpin, Robert Kim-Farley and James S. Marks