title: The role of schools in the spread of mumps among unvaccinated children: a retrospective cohort study.
abstract: BACKGROUND
  In the Netherlands, epidemics of vaccine preventable diseases are largely confined to an orthodox protestant minority with religious objections to vaccination. The clustering of unvaccinated children in orthodox protestant schools can foster the spread of epidemics. School closure has nevertheless not been practiced up until now. A mumps epidemic in 2007-2008 gave us an opportunity to study the role of schools in the spread of a vaccine preventable disease in a village with low vaccination coverage.
  
  
  METHODS
  A retrospective cohort study was conducted among the students in four elementary schools and their siblings. The following information was collected for each child: having had the mumps or not and when, school, age, MMR vaccination status, household size, presence of high school students in the household, religious denomination, and home village. The spread of mumps among unvaccinated children was compared for the four schools in a Kaplan-Meier analysis using a log-rank test. Cox proportional hazard analyses were performed to test for the influence of other factors. To correct for confounding, a univariate Cox regression model with only school included as a determinant was compared to a multivariate regression model containing all possible confounders.
  
  
  RESULTS
  Out of 650 households with children at the schools, 54% completed a questionnaire, which provided information on 1191 children. For the unvaccinated children (N = 769), the Kaplan-Meier curves showed significant differences among the schools in their cumulative attack rates. After correction for confounding, the Cox regression analysis showed the hazard of mumps to be higher in one orthodox protestant school compared to the other (hazard ratio 1.43, p < 0.001). Household size independently influenced the hazard of mumps (hazard ratio 1.44, p < 0.005) with children in larger households running a greater risk.
  
  
  CONCLUSIONS
  If and when unvaccinated children got mumps was determined by the particular school the children and their siblings attended, and by the household size. This finding suggests that school closure can influence the spread of an epidemic among orthodox protestant populations, provided that social distancing is adhered to as well. Further research on the effects of school closure on the final attack rate is nevertheless recommended.
authors.affiliation: Department of Primary and Community Care, Academic Collaborative Centre AMPHI, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ Nijmegen, The Netherlands. h.ruijs@elg.umcn.nl
authors.forename: Wilhelmina L M
authors.initials: WL
authors.lastname: Ruijs
authors.forename: Jeannine L A
authors.initials: JL
authors.lastname: Hautvast
authors.forename: Reinier P
authors.initials: RP
authors.lastname: Akkermans
authors.forename: Marlies E J L
authors.initials: ME
authors.lastname: Hulscher
authors.forename: Koos
authors.initials: K
authors.lastname: van der Velden
mesh_terms: D000293:Adolescent; D002648:Child; D015331:Cohort Studies; D005260:Female; D006801:Humans; D017053:Infection Control / Q000379:methods; D008297:Male; D009107:Mumps / Q000453:epidemiology* / Q000517:prevention & control / Q000635:transmission*; D009426:Netherlands / Q000453:epidemiology; D012929:Psychological Distance; D012189:Retrospective Studies; D012574:Schools; D055815:Young Adult