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DOI: 10.1542/peds.2012-0177; originally published online November 5, 2012;2012;130;e1567PediatricsKathleen Gallagher

Elizabeth Rausch-Phung, Cynthia Schulte, Barbara Valure, Gregory L. Armstrong andAbedi, Stephen Goodell, Jacqueline Lawler, Huong Q. McLean, Lynn Pollock,Ikechukwu U. Ogbuanu, Preeta K. Kutty, Jean M. Hudson, Debra Blog, Glen R.

OutbreakImpact of a Third Dose of Measles-Mumps-Rubella Vaccine on a Mumps

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located on the World Wide Web at:The online version of this article, along with updated information and services, is

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Impact of a Third Dose of Measles-Mumps-Rubella

Vaccine on a Mumps Outbreak

WHATS KNOWN ON THIS SUBJECT: Mumps outbreaks continue to

occur among unvaccinated and highly vaccinated populations. In

highly vaccinated populations, options for outbreak control are

limited. No previous study has documented the impact of a third

measles-mumps-rubella (MMR) vaccine dose on a mumps

outbreak.

WHAT THIS STUDY ADDS: Our study assessed the use of a third

MMR vaccine dose for mumps outbreak control in a setting with

preexisting high 2-dose vaccine coverage. The findings suggest

a potential role of MMR vaccine for outbreak control in such

limited settings.

abstractBACKGROUND AND OBJECTIVE: During 20092010, a northeastern US

religious community experienced a large mumps outbreak despite

high 2-dose measles-mumps-rubella (MMR) vaccine coverage. A

third dose of MMR vaccine was offered to students in an affected

community in an effort to control the outbreak.

METHODS: Eligible sixth- to 12th-grade students in 3 schools were

offered a third dose of MMR vaccine. Baseline and follow-up

surveys and physician case reports were used to monitor mumps

attack rates (ARs). We calculated ARs for defined 3-week periods

before and after the intervention.

RESULTS: Of 2265 eligible students, 2178 (96.2%) provided documen-

tation of having received 2 previous doses of MMR vaccine, and a high

proportion (1755 or 80.6%) chose to receive an additional vaccine dose.

The overall AR for all sixth- to 12th-grade students declined from 4.93%

in the prevaccination period to 0.13% after vaccination (P, .001).

Villagewide, overall AR declined by 75.6% after the intervention. A

decline occurred in all age groups but was significantly greater

(96.0%) among 11- to 17-year-olds, the age group targeted for

vaccination, than among all other age groups. The proportions of

adverse events reported were lower than or within the range of

those in previous reports of first- and second-dose MMR vaccine

studies.

CONCLUSIONS: This is the first study to assess the impact of a third

MMR vaccine dose for mumps outbreak control. The decline in in-

cidence shortly after the intervention suggests that a third dose

of MMR vaccine may help control mumps outbreaks among popu-

lations with preexisting high 2-dose vaccine coverage. Pediatrics

2012;130:e1567e1574

AUTHORS: Ikechukwu U. Ogbuanu, MD, MPH, PhD,

a,b

PreetaK. Kutty, MD, MPH,b Jean M. Hudson, MD, MPH,c Debra Blog,

MD, MPH,d Glen R. Abedi, MPH,b Stephen Goodell, RN, BSN,

MPH,c Jacqueline Lawler, MPH, CPH,c Huong Q. McLean,

MPH, PhD,b Lynn Pollock, RN, MSN,d Elizabeth Rausch-

Phung, MD, MPH,d Cynthia Schulte, RN, BSN,d Barbara

Valure, RN, BSN,c Gregory L. Armstrong, MD,b and Kathleen

Gallagher, MPH, DScb

aEpidemic Intelligence Service, Centers for Disease Control and

Prevention, Atlanta, Georgia; bNational Center for Immunization

and Respiratory Diseases, Atlanta, Georgia; cOrange County

Health Department, Goshen, New York; and dBureau of

Immunization, New York State Department of Health, Albany,

New York

KEY WORDS

measles-mumps-rubella (MMR) vaccine, mumps, outbreak, third

dose

ABBREVIATIONS

ACIPAdvisory Committee on Immunization Practices

ARattack rate

CIconfidence interval

MMRmeasles-mumps-rubella

OCHDOrange County Health Department

RRrelative risk

This work was presented in part at the 2010 International

Conference for Emerging Infectious Diseases; July 1114, 2010;

Atlanta, GA.

The findings and conclusions in this article are those of theauthors and do not necessarily represent the views of the

Centers for Disease Control and Prevention.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-0177

doi:10.1542/peds.2012-0177

Accepted for publication Jul 12, 2012

Address correspondence to Preeta K. Kutty, MD, MPH, 1600 Clifton

Rd, NE, MS A34, Centers for Disease Control and Prevention,

Atlanta, GA 30333. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright 2012 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have

no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

PEDIATRICS Volume 130, Number 6, December 2012 e1567

ARTICLE

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Before the introduction of mumps

vaccine, epidemics of mumps occurred

throughout the United States, fre-

quently in crowded settings such

as prisons, orphanages, schools, and

military facilities.1 In 1967, a live

mumps virus vaccine was licensed inthe United States. In 1977, the Advisory

Committee on Immunization Practices

(ACIP) recommended 1 dose of mumps

vaccine for all children aged 12 months

or older.2 After this, mumps incidence

declined rapidly from 50 to 251 reported

cases/100 000 persons before 1967

to 2/100 000 persons in 1988.3 In

1989, to enhance measles control,

ACIP recommended a second dose of

measles-mumps-rubella (MMR) vaccine;widespread use of 2 doses of MMR

vaccine resulted in further declines in

mumps incidence.4 During 20002005, his-

toric annual lows of,300 mumps cases

were reported (incidence 0.1/100 000

persons). Coverage with at least 1 dose

of MMR vaccine was between 90.5%

and 91.5% nationwide among children

aged 19 to 35 months.5,6 In 2006,

according to the National Immunization

Survey, provider-verified 2-dose cover-age for MMR vaccine among adoles-

cents aged 13 to 17 years was 87.0%.7

Mumps outbreaks in 2006 and 2009

2010 represented outbreaks in high

2-dose populations, with the latter pro-

viding a unique opportunity to study

the use of a third dose for mumps

outbreak control. In 2006, despite con-

tinued high MMR vaccine coverage, the

United States experienced the largest

mumps outbreak in 2 decades, with6584 reported cases (incidence 2.2/

100 000 persons). The highest inci-

dence occurred among persons aged

18 to 24 years (incidence 31.1/100 000

persons versus 8.4/100 000 persons

among all other age groups combined),

many of whom were midwestern col-

lege students who had received 2

doses of mumps-containing vaccine.8

In 2007 and 2008, there were 800

(incidence 0.27/100 000 persons) and 454

(0.15/100 000 persons) reported mumps

cases, respectively.9 In both years, the

1-dose coverage with MMR vaccine

among children aged 19 to 35 months

was 92.1% to 92.3%,5 and the 2-dose

coverage among adolescents aged 13to 17 years was 88.9% to 89.3%.10

In 2009, the United States experienced

the next largest mumps outbreak in 2

decades among highly vaccinated

populations. On June 28, an 11-year-old

US resident with a history of receiving 2

doses of MMR vaccine developed par-

otitis after returning from the United

Kingdom, where a mumps outbreak

was ongoing.11 During his infectious

period, he attended a summer campfor Orthodox Jewish boys in New York

state; subsequently, 25 cases occurred

at the camp. When the camp ended and

attendees returned to their homes,

community transmission occurred,

resulting in mumps outbreaks in mul-

tiple locations in northeastern United

States, including Orange County, New

York. Most cases were among mem-

bers of Orthodox Jewish communities

who had received 2 previous doses ofMMR vaccine.

In Orange County, mumps cases were

first reported in September 2009. By

December 31, 2009, 392 mumps cases

were reported to the Orange County

Health Department (OCHD); 290 (74%)

had received 2 doses of MMR vaccine.

Adolescents aged 11 to 17 years

accounted for 72% of cases; 92% had

received 2 age-appropriate doses of

MMR vaccine. Reported cases wereconcentrated in a singlevillage that had

its own schools. Village members had

limited contact with neighboring vil-

lages. The high average household size

in the affected community (5.7 versus

the US national average of 2.6)12 cre-

ated an environment for possible aug-

mentation of transmission. As a result,

the outbreak continued despite stan-

dard outbreak control measures (eg,

isolation of cases and ensuring ap-

propriate vaccination of contacts). The

characteristics of the village and on-

going mumps transmission in a setting

of high 2-dose MMR vaccine coverage

provided a unique opportunity to eval-

uate the use of a third dose of MMRvaccine for mumps outbreak control.

This report describes the impact of the

third dose of MMR vaccine on the

mumps outbreak.

METHODS

The affected village in Orange County

had a population of 20 363 in 2010 and

a median age of 10.6 years.13 The vil-

lage is served by 4 schools. Health care

is provided mainly by 4 physician

practices.

Because a high proportion of the

mumps cases were among students in

grades 6 to 12, a school-based vacci-

nation interventionwas proposed.To be

eligible, a school needed to provide

evidence of ongoing mumps trans-

mission in the 2 weeks preceding the

vaccination intervention, conducted

from January 19 to February 2, 2010,

and to document high 2-dose mumpsvaccine coverage among the students

by using the Comprehensive Clinical

Assessment Software Application.14

As part of standard mumps outbreak

control, a dose of MMR vaccine was

offered to all students who had 0 or 1

previous MMR doses. However, eligi-

bility for the third dose study was de-

termined by documented evidence of

previous receipt of 2 MMR vaccine

doses. Students were eligible to receivea third dose of MMR vaccine if they

reported no history of mumps during

the current outbreak and provided

a signed consent from their parent or

guardian and their own written assent

before vaccination. Validation of receipt

of 2 previous doses of MMRvaccinewas

conducted by reviewing school vacci-

nation records and, if missing, by

contacting the students physician.

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Because a third dose of MMR vaccine is

not recommended by the ACIP, this

study was reviewed and approved by

the Institutional Review Boards at the

Centers for Disease Control and Pre-

vention and the New York State De-

partment of Health.

Mumps Case Ascertainment and

Estimation of Third Dose

Vaccination Coverage

Mumps reporting is mandatory in New

York.15 We ascertained mumps cases

from 2 sources: notifications to OCHD

and surveys of parents and guardians

in the eligible schools. Reported cases

were investigated to obtain additional

epidemiological, clinical, laboratory,

and vaccination information. Only

mumps cases with onset dates during

the outbreak (September 1, 2009 to

June 30, 2010) were included in our

analyses. Mumps cases were classified

by using the 2008 Council of State

and Territorial Epidemiologists defi-

nitions.16 We checked for duplicate

reports of cases in OCHD registry and

our surveys. There were 3 participants

in OCHD registry who did not report

having mumps in the surveys; thesewere considered mumps cases in the

analysis.

A baseline survey was distributed to all

sixth- to 12th-grade students to collect

information on demographic charac-

teristics, vaccination history, mumps

history, clinical features and compli-

cations of recent episodes of mumps,

and health care provider information.

Two months (ie, .2 incubation peri-

ods) after the vaccination intervention,we distributed a follow-up survey to all

sixth- to 12th-grade students at par-

ticipating schools, whether or not they

had completed the baseline survey or

received vaccine during the interven-

tion. The self-report follow-up survey

collected information on symptoms as-

sociated with mumps that occurred

after the intervention, as well as lo-

cal and systemic adverse events

after the receipt of the third dose

MMR vaccine.

Statistical Analysis

Mumps attack rates (ARs) were calcu-

lated for students who participated in

the study and received a third dose.

Three time periods were defined in

relation to each students date of re-

ceipt of the third dose of MMR vaccine.

We also calculated mumps ARs for the

entire village. For the village analysis,

3 time periods were defined for all

persons, irrespective of vaccination

status. Because the vaccination in-

tervention was limited to schools,

dates of vaccination were not available

for other village residents. Therefore,the 2-week vaccination period, January

19 to February 2, 2010, was excluded

from the periods defined to analyze

villagewide ARs. Data from the surveys

were entered into Microsoft Access

2003 (Microsoft Corp, Redmond, WA)

and deidentified data were analyzed in

SAS 9.2 (SAS Institute Inc, Cary, NC).

P values of,.05 were considered to

indicate statistical significance.

Mumps ARs Among Sixth- to 12th-

Grade Students in the Participating

Schools

Among students in the participating

schools who were eligible for vaccina-

tion and completed the survey, we

calculated ARs during three 21-day time

periods based on each students vac-

cination date; the 21-day time periods

were based on the average mumps

incubation period of 16 to 18 days,

range, 12 to 25 days.17 The 3 timeperiods were: (1) prevaccination, the

21-day period before vaccination; (2)

postvaccination phase 1, 21 days af-

ter the day of vaccination; and (3)

postvaccination phase 2, the 21 days

after postvaccination phase 1. We as-

sumed that some of the cases in post-

vaccination phase 1 were among

students who had been incubating

the virus at the time of vaccination,

whereas cases in postvaccination

phase 2 were a result of exposures

occurring after vaccination. For the

purpose of this analysis, students who

did not receive the vaccine were

assigned a vaccination date, based

on the vaccination dates of students ofthe same class, gender, and age. ARs

were calculated as the number of new

mumps cases occurring in each of the

specified time periods, divided by the

number of susceptible students. Sus-

ceptible students included only those

who did not have mumps at the be-

ginning of the specified time period of

analysis. Relative risks (RRs) and 95%

confidence intervals (CIs) were calcu-

lated. Among students eligible fora third-dose MMR vaccination, we also

calculated the incremental vaccine ef-

fectiveness (ie, the decline in risk of

disease among students who received

the third dose of MMR vaccine in

comparison with students who had

only received 2 doses) by using the

formula (vaccine effectiveness = 1 2

rate ratio).

Mumps ARs Among All Age Groups

VillagewideVillagewide ARs among residents were

calculated by using OCHD mumps reg-

istry for three 21-day time periods de-

fined around the vaccine intervention

period (January 19 to February 2): (1)

preintervention, the 21 days before

the intervention period; (2) post-

intervention phase 1, 21 days after

intervention period; and (3) postin-

tervention phase 2, the 21 days after

the postintervention phase 1.Because most of thesixth- to 12th-grade

students were aged 11 to 17 years, ARs

were calculated for this age group and

other age groups defined as,5 years,

5 to 10 years, 18 to 24 years, and $25

years. ARs for each age group were

calculated by using the village pop-

ulation of 20 363, according to the 2010

US Census.13 Relative declines in ARs

after the intervention were compared

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between age groups with Poisson re-

gression.

RESULTS

From June 1, 2009 through June 30,

2010, 3502 mumps cases related to theNortheast mumps outbreak were re-

ported to the Centers for Disease Control

and Prevention, of which 790 (22.6%)

were from Orange County, New York.

Threeofthe4schoolsinthevillagewere

eligible for this study; the fourth school

reportednomumpstransmissioninthe

2 weeks preceding the intervention.

Ninety-eight percent of schoolchildren

in the village attended these 3 schools.

Among the eligible schools, theweighted2-dose MMR vaccine coverage

based on the Comprehensive Clinical

Assessment Software Application was

94.3%; vaccination records were in-

complete for the remaining 5.7% of

students. The baseline survey was

conducted concurrently with the vac-

cine intervention, whereas the follow-

up survey was conducted April 5 to 18,

2010. Of the 2688 sixth- to 12th-grade

students in the eligible schools, 2537

(94.4%) returned the baseline surveys

and 2356 (87.7%) returned the follow-

up surveys. Of the 2688 students, 2265

(84.2%) were offered an additional

dose of MMR vaccine (either as a part

of standard outbreak control or as part

of the third-dose intervention; Fig 1);

1258 (55.5%) were females. Of the

2265 students, 2178 (96.2%) had a vali-

dated history of receiving 2 previous

doses of MMR vaccine and were eligi-

ble for the third-dose intervention.Of the 2178 eligible students, 1755

(80.6%) received a third dose of MMR

vaccine during the intervention. In the

comparisonof those whoreceived a third

dose of MMR vaccine and those who did

not, the proportion of male students was

similar, but vaccinated students were

more likely to be from school B (the

largest school) and slightly more likely to

be in the upper grades (Table 1).

Mumps ARs Among Sixth- to 12th-

Grade Students in the 3 Eligible

Schools

Among sixth- to 12th-grade students

who had no previous history of mumps,

the overall AR during the 3-week pre-

vaccination period was 4.9%; ARs werehigher among males (6.99%) than

females (3.25%, P, .001 for compari-

son; Table 2). Rates were higher in

schools A (5.1%) and B (5.3%) than in

school C (2.8%). The overall AR declined

significantly (P, .001) from 4.9% in

the prevaccination period to 1.55%

during the postvaccination phase 1.

The decline in the overall AR from

postvaccination phase 1 to the post-

vaccination phase 2 was also statisti-cally significant (P , .001; Table 2).

There were no significant differences

in ARs between males and females

during the postvaccination phase 2

(0.00% for males versus 0.24% for

females; Fisher exact P = .26).

During the postvaccination phase 1, the

overall AR wassimilarin both vaccinated

and unvaccinated students (1.60% and

1.67%, respectively) (Table 2). However,

during the postvaccination phase 2, theAR was eightfold lower among vacci-

nated students (Table 2), although the

difference was not statistically signifi-

cant (0.06% vs 0.48%, respectively; RR:

0.12; 95% CI: 0.011.32; P = .097). The

incremental effectiveness of the third

dose of vaccine (vaccine effectiveness)

was 88.0%, with a large CI that included

0 (95% CI: 231.9% to 98.9%).

Mumps ARs Among All Age GroupsVillagewide

After the third-dose intervention, ARs

fell substantially among all age groups

in the village (Fig 2). Overall, ARs vil-

lagewide declined from 0.86% during

the 3-week preintervention period to

0.21% during the 3-week postinterven-

tion phase 2, a 75.6% relative decline

(Table 3). This decline was statistically

significant only among 11- to 17-year-

olds (96.0% relative decline) and

among 5- to 10-year-olds (72.9% rela-

tive decline). The relative decline in ARs

in the 11- to 17-year age group was

significantly greater (P, .005) than

that in any of the other 4 age groups.

Self-reported Adverse Events After

Immunization

Of the1755individuals whoreceived the

third dose of MMR vaccine, 1597 (91.0%)

returned the follow-up survey.18 Of

those, 115 (7.2%) reported at least 1

local or systemic adverse event in the

2 weeks after vaccination. The most

commonly reported adverse events

were pain, redness, or swelling at the

injection site

(3.6%) andjoint or mus-

cle aches (1.8%). No serious adverse

events were reported in the survey, and

a search of local physician records re-

vealed no serious adverse events among

the affected age groups.

DISCUSSION

This is the first documented study to

assess the impact of a third dose of

MMR vaccine on the course of a mumps

outbreak in a highly vaccinated pop-ulation, in which standard outbreak

response measures had not been ef-

fective in halting theoutbreak. After the

intervention, there was a reduction in

cases in all age groups, but this decline

was particularly prominent and rapid

among the older students (1117 years

of age) targeted for vaccination. The

proportions of adverse events reported

in this study were lower than or within

the range of those in previous reportsoffirst- and second-dose MMR vaccine

studies.

The circumstances of this outbreak

response did not allow for the ideal

evaluation of the effect of a third dose

of vaccine, a randomized, placebo-

controlled clinical trial. In addition,

the intervention occurred immediately

after the peak of the outbreak. For this

reason, it is not possible to exclude the

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possibility that the rapid decline in in-

cidence after the intervention was en-tirely unrelated to our intervention.

Declines in incidence were seen among

19.4% of students eligible for vaccina-

tion (but not vaccinated) after the in-

tervention as well as among age groups

not eligible for vaccination. However,

the decline observed in the vaccinated

age group (96.2% among 11- to 17-year-

olds) was statistically significant,

greater than that seen in any other age

group. Furthermore, because trans-

mission was particularly intenseamong the 11-to 17-year-olds, and such

a large proportion of this group was

vaccinated during the intervention, it is

reasonable to expect the intervention to

provide herd-immunity effects that

would decrease incidence in nonvac-

cinated individuals. One would expect

these effects to be most prominent

among unvaccinated students in the

same classes as the vaccinated students,

as well as among 5- to 10-year-olds, the

only other age group attending the same

schools as the vaccinated children. After

the intervention, incidence of mumps in

this latter group fell by 72.8%, less thanthat observed in the vaccinated age

group but more than that observed in

any other age group.

Mumps-containing vaccines havebeen

used for outbreak control among

populations that were largely un-

vaccinated.1721 In 1976, mumps vac-

cine was administered to a proportion

of the population during an epidemic of

mumps on St. Paul Island, Alaska, and

transmission among vaccinees stop-ped approximately a month earlier than

among those who were unvaccinated.19

Similarly, in 1986, at a time when only 1

dose of MMR vaccine was recom-

mended in the United States, mumps

vaccine was provided to 414 students

and staff of a high school experi-

encing a mumps outbreak primarily

among unvaccinated students.21 The

authors concluded that the vaccination

TABLE 1 Comparison of Demographic Characteristics of the Sixth- to 12th-Grade Students Duringa School-Based Third-Dose MMR Vaccine Intervention: Orange County, New York, 20092010

C haracteris tics S tud ents Who Did Not

Receive a Third Dose

(n= 423), n (%)

Students Who

Received a Third Dose

(n= 1755), n(%)

x2

P

School ,.0001

School A 88 (21) 170 (10)

School B 249 (59) 1329 (76)

School C 86 (20) 256 (15)

Gender .75

Females 234 (55) 986 (56)

Males 189 (45) 769 (44)

Grade category .042

68 201 (48) 738 (42)

912 222 (52) 1017 (58)

FIGURE 1Study enrollment, sixth- to 12th-grade students in the 3 eligible schools, Orange County, New York, 2009 2010.

ARTICLE



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intervention may have had an impact on

controlling the outbreak (postinter-

vention RR = 0 [95% CI: 00.85]). Unlike

these previous studies, this article as-

sessed the use of a third MMR vaccine

dose for outbreak control among apopulation with preexisting high 2-dose

vaccine coverage.

Previous estimates of mumps vaccine

effectiveness have ranged from 66% to

95%for 2 doses, consistently lower than

estimates for measles vaccine effec-

tiveness (95%100%).2229 No data are

available from this study regarding the

immune response after a third MMR

vaccine dose. Because of the high rate

of vaccine uptake (80.6%) and thesmall number of cases (2 among

the 413 unvaccinated students and 1

among the 1723 vaccinated students)

that occurred .1 incubation period

after vaccination, we are unable to

directly evaluate the vaccine effective-

ness. However, during this outbreak

intervention, the rapid decline in

incidence in the target age group

suggests a rapid immune response to

the third dose that resulted in relatively

high mumps vaccine effectiveness. This

finding is consistent with available data

that demonstrated that a third dose of

MMR vaccine administered to seroneg-

ative college students resulted in rapidmumps virus immunoglobulin G re-

sponse, suggesting the capacity to

mount an anamnestic immune response

in previously vaccinated individuals.30

Thus, a gap in protective efficacy as

a result of suboptimal vaccine effec-

tiveness, coupled with the potential for

a rapid anamnestic immune response,

support thepotential role of a third dose

of a mumps-containing vaccine as an

effective strategy for outbreak control ina setting of high 2-dose coverage.

Future mumps outbreaks are likely to

occur among highly vaccinated pop-

ulations, as seen in recent outbreaks in

the United States and elsewhere.8,1720

Factors possibly contributing to these

outbreaks include crowding, primary

vaccine failure, suboptimal vaccine ef-

fectiveness, waning immunity, and the

lack of natural boosting of mumps im-

munity by wild-type virus.8,1720 The

susceptibility of our study population

was likely due to a high force of in-

fection secondary to crowding, al-

though waning immunity might be

a factor as well. It is possible that theunusually large household size and

crowding in the study halls at the re-

ligious schools may have augmented

the transmission of mumps. A similar

trend has been noted in previous

mumps outbreaks in crowded prisons,

orphanages, schools, and military fa-

cilities,1 as well as in the 2006 mumps

outbreak, which affected mostly stu-

dents in college dormitories.8

While the use of a third dose of MMRvaccine may have been effective in

limiting the size and duration of the

outbreak described here, this finding

should not support the routine use of

a third dose of mumps vaccine in na-

tional vaccination programs. Although

there were few mumps cases after the

intervention because of the highuptake

of thevaccine in thetargetedage group,

the results of our study suggest that

TABLE 2 Mumps ARs Among Sixth- to 12th-Grade Students During Selected 3-Week Periods Before and After a School-Based Third-Dose MMR VaccineIntervention During an Outbreak of Mumps, Orange County, New York, 20092010

Prevacc ination (21 d ) Postvaccination

Phase 1a (21 d)

Postvaccination

Phase 2b (21 d)

Comparison of ARs in

Postvaccination Phase 2

and Postvaccination

Phase 1

No. of

MumpsCases

Population

at Risk

AR

(%)

No. of

MumpsCases

Population

at Risk

AR

(%)

No. of

MumpsCases

Population

at Risk

AR

(%)

RR (95% CI) P

All studentsc

All students 113 2291 4.93 35 2258 1.55 3 2223 0.13 0.06 (0.020.19) ,.001

Females 41 1261 3.25 15 1256 1.19 3 1241 0.24 0.21 (0.060.73) .006

Males 72 1030 6.99 20 1002 2.00 0 982 0.00 NCd ,.001

Students with a validated history of 2 previous MMR vaccine doses

Students who did not receive

a third dose of MMR vaccine

7 420 1.67 2 413 0.48 0.3 (0.061.40) .18e

Females 2 234 0.85 2 232 0.86 1.0 (0.147.10) 1.0e

Males 5 186 2.69 0 181 0.00 NCd .06e

Students who received a third

dose of MMR vaccine

28 1751 1.60 1 1723 0.06 0.04 (0.0050.27) ,.001

Females 13 984 1.32 1 971 0.10 0.08 (0.01

0.59) ,.001Males 15 767 1.96 0 752 0.00 NCd ,.001

a Day 1 to day 21 after the vaccination date.b Day 22 to day 42 after the vaccination date.c Refers to students in the eligible 3 schools who did not have a history of mumps and who had not received a third dose of MMR vaccine before the vaccination date.d NC: Could not be calculated because of empty cells.e P value calculated by using the Fisher exact test.

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administration of a third dose of MMR

vaccine may be an effective method of

controlling mumps outbreaks among

highly vaccinated populations in cer-

tain settings. With the changing mumps

epidemiology and limited options for

outbreak control, additional studies to

verify these findings in other settings

are warranted. In addition vaccine im-

munogenicity studies in a highly vac-

cinated population receiving a third

dose is of potential value to aid in un-

derstanding the kinetics of the immune

response. Future studies should also

attempt to better understand the dy-

namics of mumps immunity, as well as

the biological correlates of protection

afforded by the current vaccine.

ACKNOWLEDGMENTS

WethankHardeep S. Sandhu, MD,MBBS,

for supervisory guidance through-

out the study period; Kathleen A.

Wannemuehler, PhD and Aaron Curns,

FIGURE 2Villagewide mumps ARs by age group and by 2-week intervals, Orange County, New York, June 1, 2009 through June 30, 2010 ( n = 790).

TABLE 3 Population-level Age-specific Mumps ARs in the Village, Orange County, New York, 20092010a

Age

Group, y

Preintervention Periodb (21 d) Postintervent ion Phase 1c (21 d ) Postin tervention Ph ase 2d (21 d) Relative % Declin e

No. of Mumps

Cases

Population

at Risk

Age-specific

AR, %

No. of Mumps

Cases

Population

at Risk

Age-specific

AR, %

No. of Mumps

Cases

Population

at Risk

Age-specific

AR, %

All 172 19 993 0.86 87 19 717 0.44 41 19 630 0.21 75.6 (66.0 to 83.0)

,5 7 4592 0.15 11 4575 0.24 5 4564 0.11 26.7 (2126.0 to 77.0)

510 60 4316 1.40 40 4220 0.95 16 4180 0.38 72.9 (52.0 to 84.0)

1117 78 3210 2.40 8 3091 0.26 3 3083 0.10 96.0 (87.0 to 99.0)

1824 17 2355 0.72 7 2333 0.30 8 2326 0.34 52.8 (211.0 to 79.0)

$25 10 5521 0.18 21 5499 0.38 9 5478 0.16 11.1 (2123 to 63.0)

a Mumps cases reported to the OCHD and population for the village based on the 2010 population census by the US Census Bureau.b Preintervention period: 21 days before the third dose MMR vaccine intervention period.

c Postintervention phase 1: 21 days after the intervention, that is, day +1 to day +21.d Postintervention phase 2: 21 days after the intervention period, that is, day +22 to day +42.

ARTICLE



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MPH for statistical support; Jane

Seward, MBBS, MPH, Gregory Wallace,

MD, MPH, and Rafael Harpaz, MD,

MPH, for providing advice on the study

design and data interpretation and

comments on early versions of the

manuscript; and Mary McCauley, MS

for editorial support. We alsoespecially

thank all the students and their par-

ents who participated in the study;

the staff of the affected schools and

the medical clinics that serve the af-

fected community for providing assis-

tance with case finding/documentation

and access to vaccination records; and

the study staff from the New York State

and Orange County health departments

for providing logistical and clinical sup-

port during the school-based mass vac-

cination clinics (see the Supplemental

Information for a complete list).

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DOI: 10.1542/peds.2012-0177; originally published online November 5, 2012;2012;130;e1567PediatricsKathleen Gallagher

Elizabeth Rausch-Phung, Cynthia Schulte, Barbara Valure, Gregory L. Armstrong and

Abedi, Stephen Goodell, Jacqueline Lawler, Huong Q. McLean, Lynn Pollock,Ikechukwu U. Ogbuanu, Preeta K. Kutty, Jean M. Hudson, Debra Blog, Glen R.

OutbreakImpact of a Third Dose of Measles-Mumps-Rubella Vaccine on a Mumps

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