Mumps in Detention Facilities: A closer look at an outbreak in South Texas
EMILIE PROT, DO, MPH REGIONAL MEDICAL DIRECTOR, REGION 11 Department of State Health Services October 18th, 2019 Presenter Disclosure
I have no financial disclosure or conflicts of interest with presented materials in this presentation.
10/28/2019 2 Objectives
• Define high risk populations for mumps by country of origin, age, vaccination history
• Describe the role of public health in mumps surveillance, prevention and education
• Discuss mumps prevention strategies in correctional facilities and ICE guidelines
• Analyze mumps outbreak in a detention center in South Texas
10/28/2019 3 10/28/2019 4 Public Health Preparedness
1. Be aware and be informed • Identify migratory flows • Identify at-risk populations 2. Strengthen epidemiologic surveillance • Ensure timely detection • Laboratory confirmation 3. Provide a rapid response • Continued coordination and communication at all levels 4. During outbreaks, establish protocols to avoid transmission • Isolation rooms
5 Public Health Preparedness (cont)
5. Vaccinate to maintain homogenous coverage of 95% of VPDs 6. Vaccinate at-risk populations • Healthcare workers • Persons working in tourism and transportation (border crossings, airports etc…) • International travelers 7. Maintain inventory and stock of vaccine and supply
10/28/2019 6 Mumps vaccine
• Before routine mumps vaccination, 95% of adults had serological markers, with peak acquisition during childhood • Following the use of MMR in the USA in the late 1960s, disease incidence declined dramatically • By 2001 the disease was on the verge of elimination, with <0.1 cases/100,000 population reported, representing a 99.9% decrease in disease incidence compared to the prevaccination era.
Rubin S, Eckhaus M, Rennick LJ, Bamford CG, Duprex WP. Molecular 10/28/2019 biology, pathogenesis and pathology of mumps virus. J Pathol. 7 2015;235(2):242–252. doi:10.1002/path.4445. Accessed 10/16/19. Mumps today…
However, within a few years of these historic lows, large, sporadic mumps outbreaks began to appear globally, involving a high percentage of persons with a history of vaccination
Rubin S, Eckhaus M, Rennick LJ, Bamford CG, Duprex WP. Molecular 10/28/2019 biology, pathogenesis and pathology of mumps virus. J Pathol. 8 2015;235(2):242–252. doi:10.1002/path.4445. Accessed 10/16/19. MMWR: Notes from the field, August 30th 2019
• On October 12, 2018, five confirmed cases of mumps • By December 11, eight Texas detention facilities and six facilities in five other states had reported 67 mumps cases
Leung J, Elson D, Sanders K, et al. Notes from the Field: Mumps in Detention Facilities that House Detained Migrants — United States, September 2018– August 2019. MMWR Morb Mortal Wkly Rep 2019;68:749–750. DOI: http://dx.doi.org/10.15585/mmwr.mm6834a4external icon 9 10/28/2019 10 Texas Mumps Cases in Facilities that House Detained Migrants, October 2018-2019*
Public Health Region Case Counts*,**
Region 1 0
Region 2/3 4
Region 4/5N 22
Region 6/5S 78
Region 7 17
Region 8 110
Region 9/10 25
Region 11 295
Total 551
*Data is provisional as of 10/1/2019 and is subject to change. **This includes U.S. Marshals (USMS), U.S. Customs and Border Protection (CBP), U.S. Immigration and Customs Enforcement (ICE), Federal Bureau of Prisons (BOP) and unaccompanied minors in ORR custody and detainees/unaccompanied minors not in ORR custody. 11 Mumps cases as of October 2019
10/28/2019 12 Texas mumps cases: Age groups
Age Group Number of Cases (years) < 18 34
≥ 18 517
Total 551
10/28/2019 13 Outbreak investigation Timeline
Determine Confirm Describe Control cause
10/28/2019 14 Confirm What is the baseline level of disease in this population?
Mumps virus
10/28/2019 15 Mumps transmission
Replication in respiratory tract
16 Who is a case?
1. Confirmed: a. A positive mumps laboratory confirmation for mumps virus with reverse transcription polymerase chain reaction (RT-PCR) or culture in a patient with an acute illness characterized by any of the following: i. Acute parotitis or other salivary gland swelling, lasting at least 2 days ii. Aseptic meningitis iii. Encephalitis iv. Hearing loss v. Orchitis vi. Oophoritis vii. Mastitis viii. Pancreatitis 2. Probable: a. Acute parotitis or other salivary gland swelling lasting at least 2 days, or orchitis or oophoritis unexplained by another more likely diagnosis, in: i. A person with a positive test for serum anti-mumps immunoglobulin M (IgM) antibody, OR ii. A person with epidemiologic linkage to another probable or confirmed case or linkage to a group/community defined by public health during an outbreak of mumps. 3. Suspect: a. Parotitis, acute salivary gland swelling, orchitis, or oophoritis unexplained by another more likely diagnosis, OR b. A positive lab result with no mumps clinical symptoms (with or without epidemiological-linkage to a confirmed or probable case). Laboratory Testing
Reverse transcription polymerase chain reaction (RT-PCR) or culture serum anti-mumps immunoglobulin M (IgM) antibody
10/28/2019 18 Time
10/28/2019 19
Confirmed Mumps Cases Fall 2018
10/28/2019*The first reported case of mumps at the Detention Center in 2018 20 had an onset date of 03/08/2018. Place
A detention center in South Texas: • Houses 1000 detainees • A total of 100 adults per unit with 96 isolation beds • Men (more recently women)
10/28/2019 21 Restroom facilities
Photo courtesy of Butler-Cohen Design and Build. 10/28/2019 22 Accessed on 10/15/19 Sleeping quarters
Photo courtesy of Butler-Cohen Design and Build. 10/28/2019 Accessed on 10/15/19 23 Dining Hall
Photo courtesy of Butler-Cohen Design and Build. 10/28/2019 Accessed on 10/15/19 24 From intake to unit
Bus
Intake: property removed and itemized
Shower and uniforms
Medical intake within 12 hours
10/28/2019 25 Units
1st case (C): 10/12/18 suspect mumps placed in isolation PCR (+) on 10/15/18 2nd case (D): onset 10/12/18 10/15/18 isolation 3rd case (D): onset 10/17/18 10/18/18 isolation PCR (+) 4th case (C): onset 10/22/18 10/22/18 isolation Court
Court is held in Detention Center # 2
Distance > 48 mi
Time: minimum 48 minute drive
10/28/2019 27 Symptom Frequency
Cough Fever Headache Loss of Appetite Facial pain/Swelling Runny Nose Testicular Pain/Swelling
10/28/2019 From 2018 data 28 Determine the cause What caused the outbreak? Migrant Health Accidental injuries Respiratory infections Cardiovascular events
Migrant populations Poor living conditions Poor hygiene
10/28/2019 29 Southwest border migration 2019
10/28/2019 30 Single adult apprehensions* By country
Country FY16 FY17 FY18 FY19TD AUG
El Salvador 27,222 16,495 12,751 19,804 Guatemala 32,621 26,387 42,994 46,566 Honduras 22,528 17,110 26,161 42,783 Mexico 175,353 116,790 139,860 136,658
*Numbers reflect Fiscal Year 2016-2018 and 2019
Source: https://www.cbp.gov/newsroom/stats/sw-border- 10/28/2019 migration/usbp-sw-border-apprehensions 31 Honduras
32 El Salvador
10/28/2019 33 What location in the process?
• Border Patrol Station
• Processing Center #1
• Detention Facility #1
• Detention Center #2
• Processing Center #2
10/28/2019 34 Control
Managing the spread of infection Droplet precautions Isolation units Education and training MMR Cleaning & disinfecting Detention Center Timely reporting Limit shift turnover
10/28/2019 35 Key actions taken
1. Vaccine provided to Detention Center #1 and additional exposed individuals identified, quarantined and/or vaccinated as appropriate. 2. Detention Center #2 monitored for any new cases. Additional exposed individuals identified and quarantined. Consider vaccination of detainees and staff. 3. 42 guards at Detention Center#1 vaccinated on 11/02/18 by PHR 11 DSHS Harlingen Team.
10/28/2019 36 Recommendations
1. Any staff who had close contact with mumps suspect/case 5 days prior to onset should have their movements restricted. They should not be allowed to work in areas with residents or staff who are unexposed 2. Suspect mumps detainee/staff should be isolated or excluded from work for at least 5 days after the onset of parotitis or until mumps disease has been ruled out. 3. All exposed detainees should be placed in quarantine and should not be moved outside of their quarantined area until 25 days have passed after the last date of exposure.
10/28/2019 37 Improvements
1. Communication between TDSHS & ICE / Communication between PHR11 and Detention Center 2. Facility’s medical department spoke to corporate to have access to monitor movement 3. Temperature checks in quarantine units . Every 12 hours vitals . Button in cell 4. PPE for employees 5. No pregnant women staff in isolation/quarantine units
10/28/2019 38 Challenges
1. Sanitation: small soap bar, small toothbrush 2. Difficulty to get quarantined unit cleaned (secretions) 3. Low uptake of available MMR 4. Laboratory specimen pick up
10/28/2019 39 Probable and confirmed cases 2019: ongoing Summary
• Maintain enhanced surveillance • Communication • Re-inforce the need for improved hygiene • Identification of cases upon arrival (medical intake) to include training of staff
10/28/2019 41 Thank you
EMILIE PROT, DO, MPH
REGIONAL MEDICAL DIRECTOR, REGION 11 Department of State Health Services
Email: [email protected] 42 Outbreak: The Hepatitis-A Edition
Montique Shepherd II, MPA Public Health Advisor Centers for Disease Control and Prevention (CDC) Overview
• Hepatitis-A Virus • National Statistics • West Virginia Statistics • CDC Coordinated West Virginia Hepatitis-A Emergency Response Detail
2 Definition: Outbreak
• The occurrence of disease cases in excess of normal expectancy. • The number of cases varies according to the disease- causing agent, and the size and type of previous and existing exposure to the agent.
3 Hepatitis-A Virus
• Highly contagious liver infection • Range from a mild illness lasting a few weeks to a severe illness lasting several months • Can cause death in some people • Vaccine-preventable disease
4 Hepatitis-A in the United States
Source: CDC, National Notifiable Diseases Surveillance System (NNDSS) 5 Transmission
• Hepatitis A usually spreads when a person unknowingly ingests the virus from objects, food, or drinks contaminated by small, undetected amounts of stool from an infected person. • Hepatitis A can also spread from close personal contact with an infected person such as through sex or caring for someone who is ill.
6 Symptoms
Older children and adults typically have symptoms. If symptoms develop, they can appear abruptly and can include: • Fever • Fatigue • Loss of appetite • Nausea • Vomiting • Abdominal pain • Dark urine • Diarrhea • Clay-colored stools • Joint pain • Jaundice (yellowing of the skin and eyes) 7 Diagnosis A doctor can determine if you have hepatitis A by discussing your symptoms and taking a blood sample.
8 Treatment • To treat the symptoms of hepatitis A, doctors usually recommend rest, adequate nutrition, and fluids. • Some people will need medical care in a hospital. It can take a few months before people with hepatitis A begin to feel better.
9 Prevention
Vaccine Manufacturer Vatqa Merck Havrix GlaxoSmithKline (GSK) Twinrix GlaxoSmithKline (GSK)
• Hepatitis A vaccine is an inactivated (killed) vaccine. 2 doses needed for long-lasting protection. • Doses should be given at least 6 months apart.
10 Hepatitis-A Outbreak CDC Coordinated Emergency Response Detail
11 National Statistic’s
• Total number of states reporting = 30 • Total # of Cases = 26,276 • Total # of Hospitalizations = 15,819 (60%) • Total # of Deaths = 268 • First case reported = January 1, 2019
Source: www.cdc.gov/hepatitis/outbreaks/2017March- HepatitisA.htm 12 National Statistic’s
State-Reported Hepatitis A Outbreak Cases as of September 27, 2019
Source: www.cdc.gov/hepatitis/outbreaks/2017March- 13 HepatitisA.htm West Virginia Statistic’s
• 1.8 million residents • 93.5% Caucasian • 3.6% African American • 1.7% Hispanic • Median Income $44K • Poverty % = 17.8%
Source: www.census.gov/quickfacts/WV 14 West Virginia Hepatitis-A Virus Statistic’s
• Total # of Cases = 2,555 • Total # of Hospitalizations = 1,262 (49%) • Total # of Deaths = 23 • First case reported = March 19, 2018
Source: www.cdc.gov/hepatitis/outbreaks/2017March- HepatitisA.htm 15 High Risk Groups
• People who use drugs (injection or non- injection) • People experiencing unstable housing or homelessness • Men who have sex with men (MSM) • People who are currently or were recently incarcerated • People with chronic liver disease, including cirrhosis, hepatitis B, or hepatitis C
16 Outreach Mass clinic coordination: • Homeless Shelters • Jails/Prisons • Drug Treatment Centers • Private Providers • Local Health Departments • Federal Qualified Health Centers (FQHCs) • Private Providers • Hospital • Nursing homes
17 WV Statewide Immunization Information System (WV SIIS) Population-based immunization registry that helps public health agencies and vaccine providers make informed decisions that improve the health of children and the entire community.
18 My Emergency Response Activities
• Planning and coordination committee • Operations at a mass vaccination clinic located at a methadone treatment center • Record look-up and data entry of vaccine administrations into WVSIIS • Develop WV user guide to assist with entering vaccine administrations into WVSIIS • Created a dashboard to track vaccines distributed vs. vaccines administered and accounted for in WVSIIS
19 Clinic Planning & Coordination
• Discuss the nature of the outbreak • Inform stakeholders of federal/state processes • Coordinate dates/times for mass clinics in coordination with LHDs
20 Mass Clinic Operations
• Set-up mass clinic procedures • Provide Hepatitis-A vaccine • Complete temperature monitoring • Document vaccine administrations in WVSIIS
21 Ensure Vaccine Accountability
• Ensure immunization record look-up during mass vaccination clinics • Had a code identifier in the registry • Enter all vaccine administrations given in WVSIIS accordance to Hepatitis- A vaccine response
22 Develop Guidance Documents
• Guidelines for Recording Vaccine Doses in the Registry • Guidance for Local Health Departments • Improve vaccine accountability for outbreak response initiative
23 Hepatitis-A Outbreak Dashboard
• Total number of facilities involved in response efforts • Tool used to display doses shipped vs. doses administered • Doses administered determined based on doses reported into the immunization registry • Doses remaining from emergency vaccine doses
24 Hepatitis-A Outbreak Dashboard
25 Summary
• Outbreak response activities still ongoing • Infrastructure built • Relationships established • Standard Operating Procedures developed • Processes defined • Continued surveillance
26 Thank you
Montique Shepherd II, MPA CDC Public Health Advisor Email: [email protected]
27