Using the integrated Public Health Information System (iPHIS) to Conduct Enhanced Mumps Surveillance in Ontario

1. Using the integrated Public Health Information System (iPHIS) to Conduct Enhanced Mumps Surveillance in Ontario Ahalya Mahendra Epidemiologist Infectious Disease Surveillance Section MOHLTC

2. Mumps • 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

3. 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.

4. 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.

5. The 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).

6. The 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

7. 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.

8. iPHIS ESD As 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 enter the following: • Origin • Country of Birth Please enter the following information as soon as it is available. These cases 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 to identify 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)

9. 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

12. Confirmed Case Characteristics Male: 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 orchitis Immunization: • 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

13. Improving 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.

14. 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

15. 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

16. Conclusion • 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

17. 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