Using the integrated Public Health Information System (iPHIS) to

Conduct Enhanced Mumps Surveillance in Ontario

Ahalya MahendraEpidemiologist

Infectious Disease Surveillance SectionMOHLTC

2Mumps

• Mumps is an acute viral infection characterized by fever, swelling and tenderness of one or more salivary glands, usually the parotid glands (in front of the ears).

• Complications of mumps infection can include hearing loss, pancreatitis, orchitis (inflammation of the testicles), meningitis/encephalitis and spontaneous abortion.

• 20-30% of all cases are asymptomatic; these cases can be communicable.

CDC: Public Health Image Library

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Transmission

• Mumps is spread by direct contact with respiratory droplets, or saliva from an infected person.

• The incubation period is usually 16 to 18 days but can range from 14 to 25 days.

• An infected person is communicable for up to 7 days prior to the onset of parotitis and up to 9 days after.

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Surveillance

• Mumps is a reportable disease in Ontario. Under the Health Protection and Promotion Act, physicians and other specified health care practitioners are required to report all suspect and confirmed cases of mumps to their local medical officer of health.

• Health unit staff enter mumps case information in the integrated Public Health Information System (iPHIS) and contact the Public Health Division of the MOHLTC if they require assistance with case and outbreak management.

5The Mumps Outbreak in the Maritimes

• There has been an ongoing outbreak in three Maritime provinces - Nova Scotia, New Brunswick and Prince Edward Island since the middle of January 2007

• Cases have been exported to nine out of 13 Canadian Provinces and Territories

• As of October 5th , 2007, 836 confirmed cases related to the outbreak have been reported from all the affected Provinces

25 confirmed cases in Ontario

• Most reported cases have occurred in university students (median age 22).

6The Mumps Outbreak in the Maritimes

Case definitions:• For the purposes of follow-up of cases in Ontario linked to the

Maritimes outbreak, • a confirmed outbreak case is defined as a case with a history

of recent travel or residence in the Maritimes since January 2007 and laboratory confirmation of mumps or clinical illness in a person who is epidemiologically linked to a laboratory confirmed case

• Please note that this definition differs from a confirmed surveillance case definition used for the purposes of routine provincial mumps surveillance

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iPHIS Enhanced Surveillance Directive (ESD) and Mumps Surveillance in Ontario• Several cases of mumps associated with the larger outbreak in the

Maritimes were reported in Ontario starting in the spring of 2007. • To facilitate the increased surveillance requirements for this

situation, the Ministry of Health and Long Term Care (MoHLTC) issued one of its first Enhanced Surveillance Directives (ESD) to Public Health Units (PHUs) in the weekly iPHIS Notice.

• The purpose of an ESD is to provide direction to PHUs on data entry priorities in response to urgent infectious disease situations, along with specific instructions on how to enter required information into iPHIS.

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iPHIS ESDAs per the data entry instructions in this directive, please enter all the fields listed in

the client demographic and case details screens (Table 1) for any new mumps cases (confirmed, PUI), into iPHIS within one business day of receiving this information.In addition to all mandatory fields in the client demographics, please enterthe following:

• Origin• Country of Birth

Please enter the following information as soon as it is available. Thesecases must be linked to provincial outbreak number 0000-2007-004.

• Lab Results (Tables 2-4)• Symptoms (Table 5)

Exposures (Tables 6-8)- Exposure information is especially important in order toidentify cases linked to Nova Scotia and mumps cases due to importation spread (i.e.secondary cases)

• Hospitalization information (Table 9)• Immunizations (Table 10)-including dose number• Complications (Table 11)• Outcome (Table 12)

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Using the Data for Surveillance

• The MoHLTC generated daily reports on the data requested in the ESD to monitor mumps cases associated with the Maritimes outbreak across Ontario.

• However, several challenges were encountered when conducting enhanced mumps surveillance at the provincial level using iPHIS, the most serious of which was obtaining timely and complete data.

10 Epidemiology of Mumps cases in Ontario Associated with the Maritimes Outbreak

Ontario Mumps cases associated with the Maritimes outbreak, 2007

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Onset Date

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Confirmed Confirmed secondary transmission Probable

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Ontario Mumps cases associated with the Maritimes Outbreak by Age Group

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(15)

(1)

(4)(2) (3)

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Confirmed Case CharacteristicsMale: Female ratio = 4:1 Median age = 23 years (range:19-66 years)Symptoms: • 92% (N=23) of cases had either unilateral or bilateral parotitis

• 64% (N=16) had fever • 35% (N=7) of males had orchitisImmunization:• For 15 of the 25 cases immunization information was recorded

• 93% (N=14) of these cases had only one dose of MMR• 6% (N=1) of these case had two doses of MMR

Complications: 1 over night hospital stay, 1 case of hearing loss

13Improving Surveillance Response• Data Quality

• Completeness of records• Validity of data recorded

• Timeliness of reporting• Timeliness reflects the speed between steps in a public health

surveillance system • Critical measure is the time between onset and reporting to the PHU’s and then to the MOHLTC

• Has to be recognized that some issues are out of the PHUs control

• Once the information is received from the physician or lab it has be entered into iPHIS as soon as possible.

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Data Quality

• Exposure information on Mumps cases• Was not always complete • Was entered days after the case details were entered into

iPHIS• Some cases of Mumps associated with the Maritimes

outbreak were entered as sporadic cases

• Incomplete records in iPHIS• Immunization information unavailable on 40% of all cases• Not known if cases were students, this was important

given the cohort involved in this outbreak

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Timeliness of Reporting• Delayed entry of cases into iPHIS despite the ESD which

called for entry of certain data elements with in 24 hours• Approximately 44% of cases were reported 3 days or more

after the health unit had been notified• Delayed entry of all data elements into iPHIS once a case had

been entered• Much of the case information was obtained in an ad hoc

manner by verbal contact with the PHU or the program area instead of through iPHIS data entry

16Conclusion• Due to the limitations identified, this outbreak could not be

managed using only iPHIS

• If this outbreak had been larger we would not have been able to conduct effective surveillance and share the appropriate information with PHAC/partners in a timely manner.

• If we can rely on iPHIS data, surveillance can be conducted in a more efficient manner

• Typically conducted follow up to ask about the details of the case

• In the future all required data elements should be entered as requested in the ESD with in the requested time frame

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Acknowledgements

• MOHLTC:

• Sharon Dolman

• Michael Whelan

• Tina Badiani

• PHU and PHL partners that enable us to get the data we need to conduct surveillance

Contact information:

Email: Ahalya.Mahendra@ontario.ca

Phone: (416) 327-7387