Perspectives on the relative resurgence of mumps in the United States

Although the United States has enjoyed great success in the control of mumps since the licensure of live virus mumps vaccine in 1967, a relative resurgence of mumps during the 1986-1987 period has raised concerns about the long-term effectiveness of mumps vaccine. We received mumps surveillance data, historical information on mumps vaccine distribution and recommendations for its use, survey data on levels of mumps immunization in US children during the 1973-1985 period, the effect of mumps immunization school laws on the reported incidence of mumps among states with and without such laws, and studies of mumps vaccine effectiveness. Following licensure, a decade elapsed before mumps vaccine was endorsed as a routine immunization of childhood, while immunization survey and vaccine distribution data reflected only gradual acceptance of the vaccine. However, mumps incidence declined during this period, resulting in a relatively underimmunized cohort of children born between 1967 and 1977 who grew up during a period when the risk of exposure to mumps was rapidly declining. The resurgence of mumps since 1986 has been characterized by a selective increase in incidence and a shift in the age group at highest risk to middle and high school students in those states lacking comprehensive mumps immunization school laws. Postlicensure field evaluations of mumps vaccine effectiveness have not demonstrated waning vaccine-induced immunity. The data indicate that the relative resurgence of mumps in the United States is chiefly due to a failure to vaccinate all susceptible persons, especially those who are now between 10 and 19 years old. Mumps immunization school laws offer an approach to deal with the problem of continuing susceptibility in school-age populations.     

Effectiveness of mumps vaccine in a school outbreak

An outbreak of mumps in a middle school (grades 6 through 8) in Ohio during 1981 was investigated to determine the effectiveness of mumps vaccine. Of the 481 middle school students on whom questionnaires were completed, 62 (12.4%) exhibited clinical mumps. The overall vaccine efficacy was 81.2% when children with a history of mumps disease are excluded from the analysis. Using a logistic regression model with the presence or absence of clinical mumps as the dependent variable, three factors were found to be significant: mumps vaccine, a history of mumps disease, and sex. Factors that did not significantly affect the rate of disease among vaccinated pupils included whether the mumps vaccine was administered singly or in combination with rubella and/or measles vaccine, age at vaccination, year of vaccination, and month of vaccination.     

Mumps outbreak in a highly vaccinated population

From October 1988 to April 1989, a large mumps outbreak occurred in Douglas County, Kansas. Of the 269 cases, 208 (77.3%) occurred among primary and secondary school students, of whom 203 (97.6%) had documentation of mumps vaccination. Attack rates were highest for students attending junior high school (8.0%), followed by high school (2.0%) and elementary school (0.7%). A retrospective cohort study conducted at one junior high school with an attack rate of 12.9% did not find age at vaccination or type of vaccine received (single or combined antigen) to be risk factors for vaccine failure. Students vaccinated more than 4 years before the outbreak appeared to have a higher attack rate than those vaccinated more recently (relative risk (RR) = 4.3; 95% confidence interval (CI) = 0.6, 30.0); however, this association did not exist when risk was evaluated based on number of vaccine doses received. Students who had documentation of receiving only one dose of vaccine were at greater risk than those who had received two doses (RR = 5.2; 95% CI = 1.0, 206.2). Overall, vaccine effectiveness among Douglas County junior high school students was estimated to be 83% (95% CI = 57%, 94%). These data suggest that mumps vaccine failure and the failure to vaccinate have contributed to the relative resurgence of mumps observed in the United States since 1986. The recent change in immunization policy to recommend a two-dose schedule of measles-mumps-rubella vaccine should help reduce the occurrence of mumps outbreaks in highly vaccinated populations.     

Nonmedical costs associated with rotavirus disease requiring hospitalization

BACKGROUND: As the most common cause of severe diarrhea among children, rotavirus has a significant economic impact. Previous studies focused on the direct medical costs of rotavirus infections; however, nonmedical costs account for the majority of the financial burden from this disease. Herein, we report the results from the largest prospective study in the United States determining the nonmedical costs of severe rotavirus infections. METHODS: Prospective, active, gastroenteritis case surveillance was conducted between November 1997 and December 1999 at 3 pediatric medical centers. Rotavirus infection was identified for 548 children admitted between 2 weeks and 5 years of age. Detailed information about nonmedical costs during the prehospitalization, hospitalization and posthospitalization periods was obtained through interviews. RESULTS: The average nonmedical cost per case of rotavirus disease was USD $448.77, including $359.04 for missed work, $56.66 for transportation, $11.90 for oral rehydration solutions, $9.59 for diapers, $6.83 for child care changes, $3.82 for special foods and $0.93 for formula changes. More than one-half of these expenses (53%) occurred outside the hospitalization period, and 80% of the cost was attributable to missed work. CONCLUSIONS: With an estimated 50,000 hospitalizations attributable to rotavirus each year in the United States, the nonmedical costs of severe rotavirus infections may exceed USD $22 million annually. Previous cost effectiveness analyses of rotavirus vaccines substantially underestimated this burden, suggesting that the nonmedical costs associated with mild to moderate rotavirus disease have been similarly underestimated. These findings are needed to assess accurately the cost effectiveness of future rotavirus immunization strategies.     

Clinical and economic impact of enterovirus illness in private pediatric practice

OBJECTIVE: To characterize the acute clinical course and economic burden of nonpolio enteroviral (NPEV) illness in the summer/fall season as seen in private pediatric practice. METHODS: We prospectively studied 380 children aged 4 to 18 years with systemic NPEV syndromes presenting to private suburban pediatric practices. Seventy-three asymptomatic controls were concurrently enrolled. Clinical diagnosis of NPEV illness was based on the presence of fever plus at least one of the following: headache and stiff neck (n = 2); myalgia and malaise (n = 105); nonpuritic maculopapular rash (n = 10); papulovesicular stomatitis (n = 214); papular rash of the hands, feet, and mouth (H/F/M) (n = 30); or pleurodynia (n = 11). Study participants were enrolled during a 4-month time span (July-October, 1994) and followed daily for 14 days. A parent symptom diary card and twice weekly phone contacts by study nurses characterized the illness to include the frequency of health care contacts, the necessity for laboratory tests, medication use, and school/work absenteeism. RESULTS: Three hundred seventy-two (98%) children completed the study; 122 (33%) of the patients were confirmed to be infected with NPEV. Confirmed NPEV infection was more frequently observed in Rochester, NY (85/147 = 58%) than in Scottsdale, AZ (32/224 = 14%). The age group 4 to 12 years comprised 79% to 90% of the enrollees, depending on the syndrome. Median duration of illness and median number of missed days of school/summer camp/work for the enrolled patients was: meningitis (7 days ill, 2 days missed), myalgia/malaise (9 days ill, 3 days missed), rash (6 days ill, 4 days missed), stomatitis (7 days ill, 2 days missed), H/F/M (7 days ill, 1 day missed), and pleurodynia (8 days ill, 3 days missed). Direct medical costs varied from $69 per case to $771 per case and indirect costs, attributable primarily to parent missed work and/or sick-child care, varied from $63 per case to $422 per case for H/F/M and meningitis, respectively. In households, H/F/M spread to 50% of siblings and 25% of parents. CONCLUSIONS: In our study population, NPEV infection: 1) caused sufficient illness to prompt physician visits in summer and fall; 2) occurred more frequently in 4 to 12 year olds than in adolescents; 3) produced various clinical syndromes concurrently during the same months in the same season of a given year; 4) varied in occurrence geographically; 5) was characterized by numerous symptoms of longer duration than previously recognized; and 6) produced a significant economic impact by generating both direct and indirect costs.     

Mumps as a cause of admission to hospital: An estimate for Western Australia 1981

Close to 40% of children admitted to Princess Margaret Hospital with mumps over the period 1979 to 1982 were diagnosed retrospectively as a result of virological tests and their illness was not coded as being due to mumps. This clinical underestimate of the incidence of mumps is due to the frequent absence of salivary gland enlargement, especially in preschool children. In such cases there is usually evidence of inflammation of the upper respiratory tract. The main clinical features leading to admission were neck stiffness, fits and high fever. An appropriate adjustment was made to the figures obtained from the computerised data on discharges with the diagnosis of mumps from Western Australian hospitals in 1981. This led to the estimate that 104 patients suffering from mumps were discharged from hospital during that year. It was also estimated that mumps was responsible for 379 in-patient days. Our findings show that the benefit cost ratios for mumps immunization of others are underestimates.     

Mumps as a cause of admission to hospital: an estimate for Western Australia 1981

Close to 40% of children admitted to Princess Margaret Hospital with mumps over the period 1979 to 1982 were diagnosed retrospectively as a result of virological tests and their illness was not coded as being due to mumps. This clinical underestimate of the incidence of mumps is due to the frequent absence of salivary gland enlargement, especially in preschool children. In such cases there is usually evidence of inflammation of the upper respiratory tract. The main clinical features leading to admission were neck stiffness, fits and high fever. An appropriate adjustment was made to the figures obtained from the computerised data on discharges with the diagnosis of mumps from Western Australian hospitals in 1981. This led to the estimate that 104 patients suffering from mumps were discharged from hospital during that year. It was also estimated that mumps was responsible for 379 in-patient days. Our findings show that the benefit cost ratios for mumps immunization of others are underestimates.     

Evaluation of a quadrivalent measles, mumps, rubella and varicella vaccine in healthy children

BACKGROUND: A quadrivalent measles, mumps, rubella and varicella vaccine would facilitate universal immunization against all 4 diseases, improve compliance and immunization rates and decrease the number of injections given to children and visits to physicians' offices. OBJECTIVES: To evaluate 1- and 2-dose regimens of a combined measles, mumps, rubella and varicella vaccine (ProQuad, referred to as MMRV) manufactured with a varicella component of increased potency. METHODS: In this partially blind, multicenter study, 480 healthy 12- to 23-month-old children were randomized to receive either MMRV and placebo or M-M-RII and VARIVAX. Injections were given concomitantly at separate sites. Subjects randomized to receive MMRV and placebo received a second dose of MMRV 90 days later. Subjects were followed for 42 days after each vaccination for adverse experiences. Immunogenicity was evaluated 6 weeks after each vaccination. RESULTS: Measles-like rash and fever during days 5-12 were more common after the first dose of MMRV (rash, 5.9%; fever, 27.7%) than after M-M-RII and VARIVAX (rash, 1.9%; fever, 18.7%). The incidence of other adverse events were similar between groups. Response rates were >90% to all vaccine components in both groups. Geometric mean titers to measles and mumps were significantly higher after 1 dose of MMRV than after administration of M-M-RII and VARIVAX. The second dose of MMRV elicited slight to moderate increases in measles, mumps and rubella antibody titers and a substantial increase in varicella antibody titer (from 13.0 to 588.1 glycoprotein antigen-based enzyme-linked immunosorbent assay units/mL). CONCLUSION: A 1- or 2-dose regimen of MMRV is generally well-tolerated when administered to 12- to 23-month-old children and has a safety and immunogenicity profile similar to that of M-M-RII and VARIVAX administered concomitantly.     

Dengue in New Caledonia. Study of 68 pediatric cases]

New Caledonia is a French territory of Pacific Ocean, where frequent dengue outbreaks occur. In 1995 and 1996, 3042 cases (including 18.3% children) were diagnosed in Pasteur Institute of Noumea. PATIENTS AND METHODS: This work was a clinical and biological study of 68 in-patients of different ethnical groups in children. Among these young patients, 14 cases of dengue hemorrhagic fever occurred. RESULTS: The children were admitted to hospital after an average of 2.7 days of complaint, and during 6.7 days. The most important symptoms were fever at 39 degrees C (100%) during 2.2 days, sweatings (100%), malaise (57%) and headache (50%). Forty children had, at least, one hemorrhagic symptom. Leucopenia was noticed in 42 children, on an average of 4.2 days. A thrombocytopenia (mean 114,746 platelets/mm3) occurred in 5.3 days in 34 children (six cases with less than 10,000 platelets/mm3). A bacterial infection arised in 23.5% of children. CONCLUSION: Dengue is an important problem of public health, which occurs in all population, including the young children. The fight against dengue fever by a rapid destruction of larvae and adult mosquitoes led to the decrease of the outbreak.     

An outbreak of scarlet fever in a primary school

Scarlet fever, due to infection with an erythrogenic toxin-producing Group A streptococcus, is an uncommon and generally mild illness, although serious sequelae do occur. In March 2009, 57 of the 126 (45%) pupils in a primary school in Lancashire, UK developed scarlet fever over a 4-week period. Infection was transmitted via direct contact between pupils, particularly among the youngest pupils. A significant degree of transmission also occurred between siblings. The median number of days absent from school was 3 (range 1-10 days). No children were hospitalised. Control measures, including hygiene advice to the school and exclusion of pupils for 24h while initiating penicillin treatment, were ineffective. The outbreak occurred against a background of an unusually high incidence of invasive Group A streptococcal infection. While there are national guidelines for the control of invasive disease, none exist for the control of scarlet fever outbreaks. This prolonged outbreak of scarlet fever highlights the need for an evidence based approach to outbreak management.     

The safety and immunogenicity of a quadrivalent measles, mumps, rubella and varicella vaccine in healthy children: a study of manufacturing consistency and persistence of antibody

BACKGROUND: This clinical trial was conducted to demonstrate that each of 3 consistency lots of a combined measles, mumps, rubella and varicella vaccine (MMRV) would be well tolerated, induce clinically acceptable and similar immune responses to each antigen and induce immune responses similar to measles, mumps and rubella vaccine (MMR) administered concomitantly with varicella vaccine (V). An additional objective was to evaluate the persistence of antibodies 1 year postvaccination. METHODS: Study participants 12 to 23 months of age received a single injection of either one of 3 consistency lots of MMRV or MMR + V administered at separate injection sites. RESULTS: A total of 3,928 healthy children were enrolled at study sites in the United States and Canada. Immune responses to measles, mumps, rubella and varicella in children immunized with each of 3 lots of MMRV were similar and the combined response to all 3 lots was comparable to that of the control group. The 1-year antibody persistence rates for measles, mumps, rubella and varicella viruses were each greater than 95% and comparable among the recipients of the 3 consistency lots of MMRV and the control group. All vaccines were generally well tolerated during the 42 days after vaccination and the overall incidence of adverse experiences was comparable between recipients of MMRV and MMR + V. Rates of fever (temperature >or=38.9 degrees C oral equivalent or tactile) were greater in recipients of MMRV than in recipients of MMR + V (39.1% versus 33.1%, P = 0.001). Fevers were transient and there was no difference in the incidence of febrile seizures. CONCLUSIONS: MMRV was generally well tolerated and had comparable immunogenicity and overall safety profiles to MMR + V administered concomitantly. Long-term persistence of antibodies after receipt of MMRV is expected based on similar antibody titers against all 4 antigens 1 year postvaccination compared with recipients of MMR and V.     

Illness among schoolchildren during influenza season: effect on school absenteeism,parental absenteeism from work,and secondary illness in families

BACKGROUND: High attack rates of Influenzavirus among school-aged children tend to be expected to cause significant disruption of usual activities at school and at home. OBJECTIVE: To quantify the effect of influenza season on illness episodes, school absenteeism, medication use, parental absenteeism from work, and the occurrence of secondary illness in families among a cohort of children enrolled in an elementary school during the 2000-2001 influenza season. DESIGN: Prospective survey study. SETTING: Kindergarten through eighth grade elementary school in Seattle, Wash. PATIENTS OR OTHER PARTICIPANTS: All children enrolled in the school were eligible for the study. Study participants were 313 children in 216 families. MAIN OUTCOME MEASURES: The primary outcome measure was missed school days. Secondary outcomes measures included total illness episodes, febrile illness episodes, medication usage, physician visits, parental workdays missed, and secondary illnesses among family members of children in the study cohort. Differences between the rates of study events among participants when influenza was circulating and the event rates during the winter season when influenza was not circulating were used to calculate influenza-attributable excess events. RESULTS: Total illness episodes, febrile illness episodes, analgesic use, school absenteeism, parental industrial absenteeism, and secondary illness among family members were significantly higher during influenza season compared with the noninfluenza winter season. For every 100 children followed up for this influenza season, which included 37 school days, an excess 28 illness episodes and 63 missed school days occurred. Similarly, for every 100 children followed up, influenza accounted for an estimated 20 days of work missed by the parents and 22 secondary illness episodes among family members. CONCLUSION: Influenza season has significant adverse effects on the quality of life of school-aged children and their families.     

Cost-effectiveness of early intervention with once-daily budesonide in children with mild persistent asthma: results from the START study

The inhaled Steroid Treatment As Regular Therapy in early asthma (START) study has shown that early intervention with inhaled budesonide in mild persistent asthma improves clinical outcomes in both adults and children. The aim of this study was to estimate the incremental cost-effectiveness of early treatment with budesonide Turbuhaler in children aged 5–10 yr who participated in START. Direct and indirect costs associated with asthma were determined for 1974 children participating in the double-blind, 3-year part of the study. Randomization was to placebo or to budesonide 200  μ g once daily in each case in addition to usual asthma care. Cost-effectiveness ratios were calculated from the healthcare payer's and societal perspectives (using US prices). The addition of once-daily budesonide therapy to usual asthma care was associated with 16 additional symptom-free days (SFDs) per child over the 3-yr period (p < 0.001), with a substantial reduction (50%) in the mean number of days spent in hospital, and with reduced frequency of emergency room visits and missed school and caregiver work days. From the healthcare payer's perspective (direct costs), the increase in mean direct cost over 3 yr with budesonide was $169, which translated into an incremental cost of early intervention with budesonide in children of $10.50 (95% CI $1.20–33.30) per SFD gained. From the societal perspective, there was a cost reduction over 3 yr of $192 with budesonide relative to placebo. From a societal perspective, budesonide was therefore dominant. In conclusion, early intervention with once-daily budesonide added to usual asthma care in children with mild persistent asthma is cost-saving from a societal perspective and is acceptably cost-effective when viewed from a healthcare payer perspective.     

Complications of mumps requiring hospitalization in children

During the years 1987-1988, an outbreak of mumps was reported among the paediatric population in Israel. Mumps immunization in Israel was not universal at that time and most of the population had not been immunized. During that period, 66 children with evidence of recent mumps parotitis with several complications, i.e. meningo-encephalitis, cerebellar ataxia, arthritis, orchitis, transverse myelitis, deafness and presternal oedema were treated in our department. All patients had recovered completely except one who had permanent hearing loss.     

Changing epidemiology of mumps and its impact on university campuses

The reported incidence of mumps has declined dramatically since licensure of the live attenuated mumps vaccine in the United States in 1967, particularly in young children. Because administration of the vaccine was not widely practiced during the first decade it was available, there is now a cohort of teenagers and young adults who are relatively underimmunized. Reported mumps cases in this cohort increased substantially during 1986 to 1987. Mumps outbreaks at three Illinois universities, from which 123 clinical cases were reported between September 1986 and May 1987, were investigated. Meningeal involvement was reported in 17% of case-patients, orchitis occurred in 19% of 64 men, 6% of patients were hospitalized, and direct health care costs were estimated at $264 per case and more than $32,000 for the three outbreaks combined. The risk of mumps illness was greater for students less than 20 years of age (relative risk [RR] = 2.1, 95% confidence interval [CI] = 1.4, 3.1); students residing in dormitories (RR = 2.7, 95% CI = 1.6, 4.6); and out-of-state students (RR = 1.8, 95% CI = 1.0, 3.0). Because the available data suggest that mumps in college-aged persons is due chiefly to a failure to vaccinate susceptible persons, colleges and universities should become one major focus of mumps prevention activities to reduce susceptibility in this high-risk population.     

A benefit-cost analysis of mumps vaccine

Applying benefit-cost analysis, we determined the savings in morbidity, mortality, and costs of mumps vaccination in the United States. Using reported mumps incidence rates in a model cohort of 1 million persons followed up for 30 years, mumps vaccination would prevent more than 74,000 cases of mumps and three deaths. Approximating the actual incidence rate of mumps, by assuming that 90% of people are infected by age 30 and 60% of these have had clinical illness, mumps vaccination would prevent more than 540,000 cases of mumps and 23 deaths. A mumps vaccination program, in which mumps was given as part of a measles-mumps-rubella combination, would reduce costs associated with mumps by more than 86%, with a benefit-cost ratio of 7.4:1, using reported incidence rates. The program has a benefit-cost ratio of 39:1 when approximations of actual mumps incidence are used in the analysis. Mumps vaccination is highly cost beneficial.     

Regional services for children and youth with diabetes.

A regional diabetes program for children and youth comprising outreach clinics, frequent routine and emergency telephone contact, and a camping program was developed within the State Children's Medical Services (Crippled Children's) Program. The pediatric nurse specialist in diabetes served as the pivotal professional in the education and supervision of patients. Cost benefit was calculated from estimated hospital days prevented based on average length of admissions at diagnosis (14 days) and hospital days in the year prior to referral of those with established diabetes. During the first year 369 hospital days were prevented, for an estimated savings of $65,000; the second year 547 hospital days were avoided, a value of $96,000. Total annual program costs to the state and private patients (including camp fees) were $36,000. Although hospital costs are an apparent and useful reference to justify funding, the main value of the program must be in the prevention of secondary physical and emotional disability. This requires continuous commitment and availability of persons who know the patient and family, who can interpret information related to metabolic control of diabetes, and who are able to influence the family and community to respond appropriately to the youngster's needs.     

Economic evaluation of the 7-vaccine routine childhood immunization schedule in the United States, 2001

OBJECTIVE: To evaluate the economic impact of the routine US childhood immunization schedule: diphtheria and tetanus toxoids and acellular pertussis; tetanus and diphtheria toxoids; Haemophilus influenzae type b conjugate; inactivated poliovirus; measles, mumps, and rubella; hepatitis B; and varicella vaccines. DESIGN: Decision tree-based analysis was conducted using population-based vaccination coverage, published vaccine efficacies, historical data on disease incidence before vaccination, and disease incidence reported for 1995-2001. Costs were estimated using the direct cost and societal (direct and indirect costs) perspectives. Program costs included vaccine, administration, vaccine-associated adverse events, and parent travel and time lost. All costs were inflated to 2001 US dollars, and all costs and benefits in the future were discounted at a 3% annual rate. PARTICIPANTS: A hypothetical 2001 US birth cohort of 3,803,295 infants was followed up from birth through death. MAIN OUTCOME MEASURES: Net present value (net savings) and benefit-cost ratios of routine immunization. RESULTS: Routine childhood immunization with the 7 vaccines was cost saving from the direct cost and societal perspectives, with net savings of 9.9 billion dollars and 43.3 billion dollars, respectively. Without routine vaccination, direct and societal costs of diphtheria, tetanus, pertussis, H influenzae type b, poliomyelitis, measles, mumps, rubella, congenital rubella syndrome, hepatitis B, and varicella would be 12.3 billion dollars and 46.6 billion dollars, respectively. Direct and societal costs for the vaccination program were an estimated 2.3 billion dollars and 2.8 billion dollars, respectively. Direct and societal benefit-cost ratios for routine childhood vaccination were 5.3 and 16.5, respectively. CONCLUSION: Regardless of the perspective, the current routine childhood immunization schedule results in substantial cost savings.     

Foster care for child maltreatment. II. Impact on school performance

At least 150,000 children currently reside in foster care in the United States because of child maltreatment. Nearly 15% of all confirmed maltreatment reports record foster care as one of the acute interventions. Yet, the impact of foster care has been largely unexamined. We conducted a historical cohort study of the impact of foster care on subsequent school performances for 114 children placed in foster care because of maltreatment. A comparison cohort was constituted of 106 maltreated children who were similar in age, race, sex, and year of diagnosis but who were left in their homes after report. School records were reviewed for 96 of the foster care children and 69 of the home care children. School attendance had improved for both groups at the time of follow-up nearly 8 years later. Children in school at the time of report who were then placed in foster care missed an average of 15.6% of the school year prior to the report compared with missing only 3.48% of the most recent school year. The children from the comparison group missed an average of 8.5% of the school year prior to their index maltreatment report and 7.2% of their most recent year in school. Forty-four percent of the foster care group achieved average or above average grades on follow-up compared with the passing rate for the home care group of 32% (P = .17). The foster care children were more likely to receive special education services. Overall, both groups were doing poor work in school an average of 8 years after maltreatment report. There appears to be no evidence for a significant rehabilitative effect of foster care as measured by subsequent school performance.