Page 1

Mumps 

Updated 2013 Feb 14 11:46:00 AM: third dose of MMR vaccine associated with reduction in mumps among adolescents residing in a community with a large mumps outbreak (Pediatrics 2012 Dec) view updateShow more updates

General Information Description: 

parotitis

Organs involved: 

upper respiratory tract - lymph nodes - parotid gland, gonads, meninges, pancreas, kidney, heart, thyroid

Who is most affected: 

school age and adolescents

Incidence/Prevalence: 

mumps outbreak in New York and New Jersey and Quebec from June 2009 to June 2010 o 3,502 confirmed or probable cases identified in New York and New Jersey from June 2009 to June 2010 o 97% were Orthodox Jewish persons and 27% were adolescents aged 13-17 years o Reference - N Engl J Med 2012 Nov;367(18):1704 o additional 15 cases associated with this outbreak reported in Quebec, Canada in previous report (MMWR Morb Mortal Wkly Rep 2009 Nov 20;58(45):1270 )

largest mumps outbreak in United States in 17 years reported in 2006 o 5,783 confirmed or probable cases reported in 45 states o 4,858 cases (84%) reported from 6 states (Iowa, Kansas, Wisconsin, Illinois, Nebraska and South Dakota) o Reference - MMWR Morb Mortal Wkly Rep 2006 Oct 27;55(42):1152 o incidence of mumps 2.2 cases per 100,000 in United states in 2006  total cases 6,584, of which 76% occurred from March to May  highest incidence in persons aged 18-24 years  Reference - N Engl J Med 2008 Apr 10;358(15):1580, commentary can be found in N Engl J Med 2008 Aug 7;359(6):654


 

previously rare in United States o 231 cases of mumps in United States reported to CDC in 2003 (MMWR Morb Mortal Wkly Rep 2005 Apr 22;52(54):1 ) o 270 cases of mumps in United States reported to CDC in 2002 (MMWR Morb Mortal Wkly Rep 2004 Apr 30;51(53):1 ) o 31 cases of mumps reported in summer camp in New York in 2005, attributed to camp counselor who had traveled from United Kingdom (MMWR Morb Mortal Wkly Rep 2006 Feb 24;55(7):175 ) Finland is first country documented to be free of indigenous mumps and rubella (and measles) (JAMA 2000 Nov 22-29;284(20):2643) United Kingdom has resurgence of mumps o number of cases of mumps in England and Wales increased from 4,204 in 2003 to 16,436 in 2004 (BMJ 2005 May 14;330(7500):1119 ), commentary can be found in BMJ 2005 Jun 25;330(7506):1509 o almost 5,000 cases reported in month of January 2005, mostly in patients aged 19-23 years (BMJ 2005 May 14;330(7500):1132) o 2004-2005 mumps epidemic in United Kingdom peaked in 2005 with 56,390 cases, most confirmed cases in persons aged 15-24 years who had not been eligible for routine mumps vaccination (MMWR Morb Mortal Wkly Rep 2006 Feb 24;55(7):173 ) Nova Scotia - 2 successive outbreaks among vaccinated adolescents and young adults 2005-2006 o cases included 13 high school students (median age 14 years) and 19 college students and staff (median age 23 years) o 4 high school students and 18 college students/staff had received only 1 dose of MMR vaccine o Reference - CMAJ 2006 Aug 29;175(5):483 , editorial can be found in CMAJ 2006 Aug 29;175(5):491

Causes and Risk Factors Causes: 

mumps virus o 1 serotype o family Paramyxovirus o virus characteristics - RNA polymerase in virion, linear negative singlestrand RNA, helical, envelope other viruses cultured from blood or saliva in cases of acute viral parotitis o influenza and parainfluenza, types 1 and 3 o Coxsackie viruses A and B o ECHO virus o lymphocytic choriomeningitis virus o Reference - Otolaryngol Clin North Am 1999 Oct;32(5):793

Pathogenesis:


   

lives in human (saliva, urine) transmitted via respiratory droplets, direct contact, fomites cell needs protease, budding, M protein, HA (neutralizing Ab) and NA on same spike, F protein and hemolytic risk of transmission based on systematic literature review o moderate risk of transmission (10-30%) in unimmunized populations o incubation period 15-24 days (median 19 days), based on good evidence o duration of shedding from -7 to +14 days, based on limited evidence o period of infectiousness not known (no evidence found) o serial interval (interval between onset of clinical disease in index case and secondary case) 10-31 days (median 19 days), based on good evidence o recommended exclusion period from school  5 days from onset of parotitis, based on moderate evidence (welldesigned study with 5-50 subjects)  exclusion will not be fully effective because cases may be infectious before onset of disease, asymptomatic infections occur and may be involved in transmission  most children are protected by routine immunization o Reference - Pediatr Infect Dis J 2001 Apr;20(4):380, correction can be found in Pediatr Infect Dis J 2001 Jul;20(7):653, commentary can be found in Pediatr Infect Dis J 2001 Dec;20(12):1184

Likely risk factors: 

winter

unvaccinated student with history of recent travel to Western Europe identified as likely source of outbreak with 29 cases on university campus in California, September 2011 (MMWR Morb Mortal Wkly Rep 2012 Dec 7;61:986 )

Complications and Associated Conditions Complications: 

  

complications may include o orchitis (usually unilateral) in 20% of postpubertal young men o oophoritis in 5% of postpubertal young women o aseptic meningitis in 15% o encephalitis in 1 in 6,000 o permanent unilateral deafness in 1 in 15,000 o pancreatitis in up to 5% o arthritis, thyroiditis, myocarditis, and, very rarely, hepatitis o increased risk of miscarriage in first 12 weeks of pregnancy Reference - BMJ 2005 May 14;330(7500):1132 bilateral orchitis may lead to sterility mumps epididymitis reported in case report, ultrasound imaging showed epididymitis without orchitis (Lancet 2006 Feb 25;367(9511):702)


meningitis and cochleitis (unilateral sensorineural hearing loss) usually self-limited

History and Physical History: Chief concern (CC): 

fever, parotid swelling, one-third asymptomatic (like rubella)

History of present illness (HPI): 

prodrome of fever, malaise, anorexia; increased parotid pain with citrus juice

Physical: HEENT:   

tender swelling of parotid(s), parotid swelling obscures jaw line, ears displaced out, can see pus if push on Stensen's duct picture from STFM Group on Immunization Education rare presentation of laryngeal edema in case report of patient with mumps (Lancet 2009 Nov 14;374(9702):1722)

Diagnosis Rule out:  

parainfluenza, bacteria, Stensen duct stones IV radiologic contrast media associated with recurrent iodide mumps in case report o 60-year old male had iodide mumps 6 times after use of 3 different forms of low-osmolar contrast media o recurrence not prevented by prophylactic hyperhydration, corticosteroids and antihistamines o symptoms resolved spontaneously within 1 week o Reference - Ann Intern Med 2006 Jul 18;145(2):155

Testing overview:  

mumps virus antibody screen by enzyme immunoassay (IgG and IgM) mumps virus culture

Blood tests: 

hemagglutination inhibition or complement fixation (soluble [S] Ag is internal nucleocapsid protein)


Biopsy and pathology: 

syncytium formation

Other diagnostic testing: 

sample saliva, urine, CSF - hemadsorption for viral Ag

Treatment Treatment overview:    

no treatment immune serum globulin contraindicated supportive therapy may require anticonvulsants or ventilatory support in most severe neurological cases case isolation may reduce transmission but postexposure prophylaxis appears ineffective

acupuncture plus moxibustion associated with higher recovery rate but longer time to cure compared to moroxydine hydrochloride plus antiparotid injections in children with mumps (level 2 [mid-level] evidence) o based on Cochrane review of randomized trial with blinding not stated o systematic review of randomized trials evaluating acupuncture for mumps in children aged 1-15 years o review identified 1 trial comparing acupuncture plus moxibustion vs. intramuscular injections of moroxydine hydrochloride plus anti-parotid in 239 children aged 3-12 years  recovery defined as no swelling or pain of parotid gland and return to normal body temperature  recovery after 3-5 days of treatment in 88.3% vs. 47.1% (p < 0.0001, NNT 3)  mean time to cure 4.2 days vs. 3.78 days (p < 0.0001)  adverse effects not reported o Reference - Cochrane Database Syst Rev 2012 Sep 12;(9):CD008400

no randomized trials found evaluating Chinese medicinal herbs for mumps o based on Cochrane review o Reference - Cochrane Database Syst Rev 2012 Sep 12;(9):CD008578

Prognosis 

usually resolves within 1 week

Prevention and Screening


Prevention: 

MMR vaccine reported to be effective against measles and mumps in children (level 3 [lacking direct] evidence) o based on noncomparative outcomes from Cochrane review o systematic review of 5 randomized trials, 1 nonrandomized trial, and 58 observational studies (cohort studies, case series, ecological studies) comparing MMR vaccine to no treatment or placebo in about 14,700,000 healthy children up to 18 years old o 6 MMR vaccines  M-M-R by Merck includes Jeryl Lynn strain of mumps  Priorix by Glaxo SmithKline Beecham includes mumps strain derived from Jeryl Lynn strain  Morupar by Chiron includes Urabe AM 9 strain of mumps  Trimovax by Pasteur-Merieux Serums includes Urabe AM 9 strain of mumps  Triviraten Berna vaccine includes Rubini strain of mumps  Pluserix by Smith-Kline Beecham includes Urabe strain of mumps o vaccines had  69%-81% efficacy for preventing clinical mumps  > 95% efficacy for preventing clinical measles o no included studies evaluated efficacy for preventing rubella o Reference - Cochrane Database Syst Rev 2012 Feb 15;(2):CD004407

third dose of MMR vaccine associated with reduction in mumps among adolescents residing in a community with a large mumps outbreak (level 2 [mid-level] evidence) o based on cohort study of 2,265 sixth- to twelfth-grade students residing in a religious community in northeastern United States with a large mumps outbreak during 2009-2010 o 96.2% provided documentation of receiving 2 previous doses of measles, mumps, rubella (MMR) vaccine o 80.6% of students with 2 previous doses of MMR vaccine elected to receive a third MMR vaccine dose o overall mumps attack rates for all sixth- to twelfth-graders evaluated during 3-week periods before and after vaccine intervention o overall mumps attack rate 4.93% in prevaccination period vs. 0.13% after third vaccination offered (p < 0.001) o Reference - Pediatrics 2012 Dec;130(6):e1567

adverse effects appear uncommon after mumps, measles, and rubella (MMR) vaccine (level 2 [mid-level] evidence) o based on Cochrane review of observational studies o systematic review of 5 randomized trials, 1 nonrandomized trial, and 58 observational studies (cohort studies, case series, ecological studies) comparing MMR vaccine to no treatment or placebo in 14,700,000 healthy children up to 18 years old


o

o

o

o

o

o 

6 MMR vaccines  M-M-R by Merck includes Jeryl Lynn strain of mumps  Priorix by Glaxo SmithKline Beecham includes mumps strain derived from Jeryl Lynn strain  Morupar by Chiron includes Urabe AM 9 strain of mumps  Trimovax by Pasteur Merieux Serums includes Urabe AM 9 strain of mumps  Triviraten Berna vaccine includes Rubini strain of mumps  Pluserix by Smith-Kline Beecham includes Urabe strain of mumps for aseptic meningitis  estimated attributable risk was 1 case per 14,000 doses (Urabecontaining MMR vaccine Pluserix) within 11 weeks after start of vaccination campaign in time-series study with > 450,000 children aged 1-11 years  22-71 cases during observation period before vaccination vs. 48-108 within 11 weeks after start of vaccination campaign (vaccine containing Leningrad-Zagreb mumps strains) in 2-center time-series study with > 1,000,000 children  association not significant in cohort and self-controlled case series studies using vaccines containing Jeryl Lynn mumps strains for febrile seizures, estimated absolute risk attributed to MMR vaccine was 1.56 per 1,000 children in 1 cohort study with 537,171 children aged 3 months to 5 years, with highest risk within 2 weeks postvaccination (vaccine contained Moraten measles, Jeryl Lynn mumps, and Wistar RA 27/3 rubella strains) (JAMA 2004 Jul 21;292(3):351) for acute immune thrombocytopenic purpura  estimated attributable risk was 1 case/25,000 doses within 6 weeks after vaccination in 1 case-control study with 139 children; no significant difference between groups from 7-26 weeks postvaccination  estimated attributable risk was 1 case/40,000 doses in 1 selfcontrolled case series study with 63 children aged 12-23 months  3.6% of cases vs. 1.4% of controls received MMR vaccine within 6 weeks before hospitalization in case-control study with 2,311 patients aged 1 month to 18 years MMR vaccine not likely associated with autism, asthma, leukemia, hay fever, type 1 diabetes, gait disturbance, Crohn disease, demyelinating diseases, and infection Reference - Cochrane Database Syst Rev 2012 Feb 15;(2):CD004407

CDC Advisory Committee on Immunization Practices (ACIP) recommendations regarding control and elimination of mumps can be found at MMWR Morb Mortal Wkly Rep 2006 Jun 9;55(22):629 , summary can be found in Am Fam Physician 2006 Nov 15;74(10):1787 CDC, American Academy of Pediatrics (AAP), and Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend 5-day isolation period after onset of parotitis


o

 

isolation applies to persons with mumps in either community or healthcare settings o recommendation also includes use of standard precautions and droplet precautions for 5 days o Reference - MMWR Morb Mortal Wkly Rep 2008 Oct 10;57(40):1103 see MMWR Recomm Rep 1998 May 22;47(RR-8):1 for acceptable presumptive evidence of immunity to measles, mumps and rubella as defined by ACIP vaccination - 95% immunity o live attenuated virus as part of MMR subcutaneously in 2 doses at 12-15 months and 4-6 years o second dose now uniformly recommended at 4-6 years by AAFP, ACIP and AAP with catch-up vaccination for any child > 7 years old who missed it (as opposed to previously AAP recommended second dose at 11-12 years, which was associated with more adverse effects) (Am Fam Physician 1998 Jan 1;57(1):153 ) o contraindications - pregnancy, anaphylaxis to egg products or neomycin, immunoglobulin within 3 months, immunodeficiency o side effects - 5-15% fever 5-12 days after vaccination that lasts 1-5 days; transient rashes, < 1/million CNS disturbances, arthralgias in adolescents o adverse effects of MMR vaccine attributable to vaccine only occurred in 6% patients in crossover trial of 1,162 twins 14-83 months old given vaccine and placebo 3 weeks apart in random order, however 15-20% children developed respiratory symptoms 1 week after both vaccine and placebo injections (Pediatrics 2000 Nov;106(5):e62 ) o fever, diarrhea and rash appear common after first MMR vaccine but not after second dose (level 2 [mid-level] evidence)  based on rates of fever, diarrhea and rash during 2 weeks before vs. 2 weeks after MMR vaccine in 1,800 children  estimated net 18% increase in fever, diarrhea and rash (NNH 6) in 535 toddlers ages 12-24 months, median onset 5-10 days postvaccination, duration 2-5 days  no increases in 633 kindergartners ages 4-6 years or 632 middle schoolers ages 10-12 years  Reference - Pediatrics 2006 Oct;118(4):1422 o vaccine very temperature sensitive o second dose may be given any time at least 1 month after first dose, though still recommended at age 4-6 years or age 11-12 years (MMWR Morb Mortal Wkly Rep 1996 Jan 5;44(51-52):940 in J Watch 1996 Feb 1;16(3):28); Advisory Committee on Immunization Practices recommends second MMR dose at age 4-5 years, while American Academy of Pediatrics recommends second MMR dose at 11-12; study comparing adverse events among 8,514 children given MMR2 at 4-6 and 18,036 given MMR2 at 1012 found older children more likely to have adverse events (Pediatrics 1997 Nov;100(5):767 ) o if allergic to eggs  safe to give standard MMR vaccine with 90 minute observation; live attenuated measles/mumps/rubella (MMR) vaccine is incubated in


o

o

o o

o

cultured chick-embryo fibroblasts, but can be safely administered to children with proven allergy to eggs; study of 54 unvaccinated children age 12-63 months with confirmed clinical history of allergy to eggs who received a 0.5 mL dose of MMR subcutaneously, all children had positive skin-test reactions to eggs, but none had an immediate or delayed adverse reaction to the vaccine, positive skin reactions to MMR are observed in patients with or without egg allergy (N Engl J Med 1995 May 11;332(19):1262 in QuickScan Reviews in Fam Pract 1995 Nov;2), commentary can be found in Am Fam Physician 1998 Sep 15;58(4):863  allergy to eggs should not be a contraindication to MMR vaccination and usually does not require modification of administration protocol, true allergy to MMR vaccine likely unrelated to allergy to eggs (BMJ 2000 Apr 1;320(7239):929 )  allergy to MMR vaccine rare and not generally related to allergy to eggs; in series of 36 cases of allergic reactions to MMR vaccine, 10 were associated with allergy to gelatin (Pediatrics 2001 Feb;107(2):e27 ) mild illness (upper respiratory infection, mild fever, diarrhea, otitis media) is NOT a contraindication to vaccination; study of 386 toddlers (157 with mild illness) showed no difference in seroconversion rates (98% for measles and rubella antigens, 83% for mumps antigen) or side effects (based on telephone interviews of 149 families) in well and ill children; study excluded children with axillary temperatures > 37.8 degrees C (100 degrees F) (but other literature noted to show comparable seroconversion rates in febrile children) (JAMA 1996 Mar 6;275(9):704 in J Watch 1996 Apr 15;16(8):66) previously indicated in asymptomatic HIV infection, but case report of measles pneumonitis from MMR vaccine has changed recommendations; Advisory Committee on Immunization Practices recommends withholding MMR vaccine from patients with HIV infection with CD4 counts < 750 at age < 12 months, < 500 at age 1-5 years, < 200 at age > 5 years, or < 15% total lymphocytes at age < 13 years (MMWR Morb Mortal Wkly Rep 1996 Jul 19;45(28):603 in J Watch 1996 Aug 15;16(16):132, Ann Intern Med 1998 Jul 15;129:104 in J Watch 1998 Aug 15;18(16):129) storage - maintain between 2-8 degrees C (35.6-46.4 degrees F) with daily temperature checks, discard if < 0 degrees C (32 degrees F) vaccination with Jeryl-Lynn or Urabe strain may be more effective than with Rubini strain (BMJ 1999 Aug 7;319(7206):352 ), correction can be found in BMJ 1999 Feb 20;318(7182):477 combination vaccine for measles, mumps, rubella and varicella (ProQuad) FDA approved for children ages 12 months to 12 years (Monthly Prescribing Reference 2005 Oct, MMWR Morb Mortal Wkly Rep 2005 Dec 2;54(47):1213), correction can be found in MMWR Morb Mortal Wkly Rep 2005 Dec 9;54(48):1237  ProQuad immunogenicity demonstrated in randomized trial of 799 children ages 4-6 years (Pediatrics 2006 Feb;117(2):265), correction


can be found in Pediatrics 2006 Jun;117(6):2338, commentary can be found in Pediatrics 2007 Jun;119(6):1251  refrigerator-stable and frozen formulations of ProQuad have similar immunogenicity (level 3 [lacking direct] evidence)  based on randomized trial without clinical outcomes in 1,519 healthy children aged 12-23 months  similar response rates for both formulations  ≥ 97.7% for measles, mumps and rubella  ≥ 88.8% for varicella zoster virus  Reference - Pediatrics 2007 Jun;119(6):e1299, commentary can be found in Pediatrics 2007 Oct;120(4):924 recommended exclusion period from school 5 days from onset of parotitis (UK expert Grade B, Level I/III) o exclusion will not be fully effective because cases may be infectious before onset of disease, asymptomatic infections occur and may be involved in transmission o most children are protected by routine immunization o see Causes and Risk Factors section for information on risk of transmission based on systematic literature review o Reference - Pediatr Infect Dis J 2001 Apr;20(4):380, correction can be found in Pediatr Infect Dis J 2001 Jul;20(7):653, commentary can be found in Pediatr Infect Dis J 2001 Dec;20(12):1184 CDC guidelines for infection control in hospital personnel can be found in Infect Control Hosp Epidemiol 1998 Jun;19(6):407 PDF

Guidelines and Resources Guidelines: United State guidelines: 

New York State Department of Health guideline on infection control can be found at National Guideline Clearinghouse 2010 Sep 27:15722

United Kingdom guidelines: 

expert guideline on exclusion policies for control of communicable disease in schools and preschools can be found in Pediatr Infect Dis J 2001 Apr;20(4):380, correction can be found in Pediatr Infect Dis J 2001 Jul;20(7):653, commentary can be found in Pediatr Infect Dis J 2001 Dec;20(12):1184

Review articles:   

review can be found in Lancet 2008 Mar 15;371(9616):932 review can be found in BMJ 2005 May 14;330(7500):1132 review of mumps outbreak can be found in J Fam Pract 2006 Jun;55(6):500


MEDLINE search: 

to search MEDLINE for (Mumps) with targeted search (Clinical Queries), click therapy, diagnosis, or prognosis

Patient Information   

handout from EBSCO Publishing Health Library PDF or in Spanish PDF handout from KidsHealth handout from Patient UK

ICD-9/ICD-10 CodesReferences Recommendation grading systems used: 

grades of recommendation from guideline commissioned by United Kingdom (UK) Government Department for Education and Employment and Department of Health o grades of recommendation  Grade A - derived from Level I evidence of period of infectiousness and/or effectiveness of exclusion  Grade B - derived from Level II evidence of period of infectiousness and/or effectiveness of exclusion, or Level I-II evidence of duration of shedding and/or serial interval  Grade C - derived from Level III or IV evidence of period of infectiousness, effectiveness of exclusion, duration of shedding, and/or serial interval o levels of evidence  Level I - systematic review, meta-analysis, or well-designed epidemiologic or experimental study with ≥ 50 subjects  Level II - well-designed epidemiologic or experimental study with 550 subjects  Level III - case reports with < 5 subjects, or poorly substantiated larger study  Level IV - opinion or clinical experience of experts (not supported by published data) o Reference - Pediatr Infect Dis J 2001 Apr;20(4):380

Mumps  
Read more
Read more
Similar to
Popular now
Just for you