mumps

Mumps
Clinical ManifestationsEtiologyEpidemiologyDiagnostic TestsTreatmentIsolation of the Hospitalized PatientControl Measures
TopNextCLINICAL MANIFESTATIONS: Mumps is a systemic disease characterized by swelling of one or more of the salivary glands, usually the parotid glands. Approximately one third of infections do not cause clinically apparent salivary gland swelling. More than 50% of people with mumps have cerebrospinal fluid pleocytosis, but fewer than 10% have symptoms of central nervous system infection. Orchitis is a common complication after puberty, but sterility rarely occurs. Other rare complications include arthritis, thyroiditis, mastitis, glomerulonephritis, myocarditis, endocardial fibroelastosis, thrombocytopenia, cerebellar ataxia, transverse myelitis, ascending polyradiculitis, pancreatitis, oophoritis, and hearing impairment.

TopPreviousNextETIOLOGY: Mumps is caused by an RNA virus classified as a Rubulavirus in the Paramyxoviridae family. Other causes of parotitis include infection with cytomegalovirus, parainfluenza virus types 1 and 3, influenza A virus, coxsackieviruses, lymphocytic choriomeningitis virus, enteroviruses, human immunodeficiency virus (HIV), Staphylococcus aureus, and nontuberculous mycobacterium; starch ingestion; drug reactions (eg, phenylbutazone, thiouracil, iodides); and metabolic disorders (diabetes mellitus, cirrhosis, and malnutrition).

TopPreviousNextEPIDEMIOLOGY: Humans are the only known natural hosts. The virus is spread by contact with infected respiratory tract secretions. Infection can occur throughout childhood. During adulthood, infection is likely to produce more severe disease, including orchitis. Death attributable to mumps is rare; the estimated case fatality rate is 1.6 to 3.8 per 10 000. More than half of the fatalities occur in people older than 19 years of age. Mumps infection during the first trimester of pregnancy is associated with an increased rate of spontaneous abortion. Although mumps virus can cross the placenta, no evidence exists that mumps infection during pregnancy causes congenital malformations. Historically, the peak incidence was between January and May; however, seasonality no longer is evident. The incidence in the United States, which has decreased markedly since introduction of the mumps vaccine, is now fewer than 500 reported cases per year. Most of the reported cases of mumps are in children 5 to 14 years of age. In immunized children, most cases of parotitis are not caused by mumps infection. Outbreaks can occur in highly immunized populations. Like measles vaccine, a single dose of mumps-containing vaccine does not always induce protection. The period of maximum communicability is from 1 to 2 days before onset of parotid swelling to 5 days after onset of parotid swelling. Virus has been isolated from saliva from 7 days before through 9 days after onset of swelling.
The incubation period usually is 16 to 18 days, but cases may occur from 12 to 25 days after exposure.

TopPreviousNextDIAGNOSTIC TESTS: Children with parotitis lasting 2 days or more without other apparent cause should undergo diagnostic testing to confirm mumps virus as the cause, because mumps is now an uncommon infection and parotitis has other etiologies, including other infectious agents. Mumps can be confirmed by isolating the virus in cell culture inoculated with throat washing, urine, or spinal fluid specimens or by a significant increase between acute and convalescent titers in serum mumps immunoglobulin (Ig) G antibody titer determined by any standard serologic assay (eg, complement fixation, neutralization, hemagglutination inhibition test, or enzyme immunoassay or mumps IgM antibody test [past infection is best assessed by enzyme immunoassay or a neutralization test; complement fixation and hemagglutination inhibition tests are unreliable for this purpose]). Skin tests also are unreliable and should not be used to test immune status.

TopPreviousNextTREATMENT: Supportive.

TopPreviousNextISOLATION OF THE HOSPITALIZED PATIENT: In addition to standard precautions, droplet precautions are recommended until 9 days after onset of parotid swelling.

TopPreviousCONTROL MEASURES:
School and Child Care. Children should be excluded for 9 days from onset of parotid gland swelling. For control measures during an outbreak, see Outbreak Control, p 442.
Care of Exposed People. Mumps vaccine has not been demonstrated to be effective in preventing infection after exposure. However, mumps vaccine can be given after exposure, because immunization will provide protection against subsequent exposures. Immunization during the incubation period has no increased risk. The routine use of mumps vaccine is not advised for people born before 1957, because most of these people are immune. Mumps Immune Globulin is of no value and no longer is manufactured or licensed in the United States.
Mumps Vaccine. Live-virus mumps vaccine is prepared in chicken embryo cell cultures. Vaccine is administered by subcutaneous injection of 0.5 mL, alone as a monovalent vaccine or, preferably, as the combined measles-mumps-rubella (MMR) vaccine. Antibody develops in more than 95% of all susceptible people after a single dose. Serologic and epidemiologic evidence extending for more than 25 years indicates that vaccine-induced immunity is long lasting.
Vaccine Recommendations.
Mumps vaccine should be given as MMR routinely to children at 12 to 15 months of age, with a second dose of MMR at 4 to 6 years of age. Reimmunization for mumps is important, because mumps can occur in highly immunized populations, including people with a history of mumps immunization. Administration of MMR is not harmful if given to a person already immune to one or more of the viruses (from previous infection or immunization).
Mumps immunization is of particular importance for children approaching puberty, adolescents, and adults who have not had mumps or mumps vaccine. At office visits of prepubertal children and adolescents, the status of immunity to mumps should be assessed. People should be considered susceptible unless they have documentation of at least 1 dose of vaccine on or after their first birthday, documentation of physician-diagnosed mumps, or serologic evidence of immunity or were born before 1957.
Susceptible children, adolescents, and adults born during or after 1957 should be offered mumps immunization (usually as MMR) before beginning travel, because mumps is still endemic throughout most of the world. Because of concern about inadequate seroconversion related to persisting maternal antibodies and because the risk of serious disease from mumps infection is relatively low, people younger than 12 months of age need not be given mumps vaccine before travel.
The routine use of mumps vaccine is not advised for people born before 1957 unless they are considered susceptible, as defined by seronegativity. However, immunization is not contraindicated in these people if their serologic status is unknown.
The MMR vaccine may be given with other vaccines at different injection sites and with separate syringes (see Simultaneous Administration of Multiple Vaccines, p 33).
Adverse Reactions. Adverse reactions attributed to live-virus mumps vaccine are rare. Temporally related reactions, including febrile seizures, nerve deafness, meningitis, encephalitis, rash, pruritus, and purpura, may not be related causally. Orchitis and parotitis have been reported rarely. Allergic reactions also are rare (see Precautions and Contraindications). Other reactions that occur after immunization with MMR are attributable to the measles and rubella components of the vaccine (see Measles, p 419, and Rubella, p 536).
Reimmunization with mumps vaccine (monovalent or MMR) is not associated with an increased incidence of reactions. Reactions might be expected only among people not protected by the first dose.
Precautions and Contraindications.
Febrile Illness. Children with minor illnesses with or without fever, such as upper respiratory tract infections, may be immunized (see Vaccine Safety and Contraindications, p 37). Fever is not a contraindication to immunization. However, if other manifestations suggest a more serious illness, the child should not be immunized until recovered.
Allergies. The widespread use of the mumps vaccine since 1967 has resulted in only rare isolated reports of allergic reactions. Allergic reactions to components of the vaccine (eg, neomycin or gelatin) occasionally may occur. Severe allergic reactions, such as anaphylaxis, rarely are reported. Most children with egg hypersensitivity can be immunized safely with MMR vaccine (see Measles, p 419). People with a history of anaphylactic, anaphylactoid, or other immediate reactions subsequent to egg ingestion may be at an increased risk of immediate-type hypersensitivity reactions after immunization.
Recent Administration of Immune Globulin. Live-virus mumps vaccine should be given at least 2 weeks before or at least 3 months after administration of Immune Globulin (IG) or blood transfusion because of the theoretic possibility that antibody will neutralize vaccine virus and interfere with a successful immunization. Because high doses of IG (such as those given for treatment of Kawasaki syndrome) can inhibit the response to measles vaccine for longer intervals, MMR immunization should be deferred for a longer period after administration of IG (see Measles, p 419).
Altered Immunity. Patients with immunodeficiency diseases and people receiving immunosuppressive therapy (eg, patients with leukemia, lymphoma, or generalized malignant disease), including high doses of systemically administered corticosteroids, alkylating agents, antimetabolites, or radiation or who are otherwise immunocompromised should not receive mumps vaccine (see Immunocompromised Children, p 69). The exceptions are patients with HIV infection who are not severely immunocompromised; these patients should be immunized against mumps with MMR vaccine (see Human Immunodeficiency Virus Infection, p 360). The risk of mumps exposure for patients with altered immunity can be decreased by immunizing their close susceptible contacts. Immunized people do not transmit mumps vaccine virus.
After cessation of immunosuppressive therapy, mumps vaccine usually should be withheld for an interval of at least 3 months (with the exception of corticosteroid recipients, see the next paragraph). This interval is based on the assumptions that immunologic responsiveness will have been restored in 3 months and the underlying disease for which immunosuppressive therapy was given is in remission or under control. However, because the interval can vary with the intensity and type of immunosuppressive therapy, radiation therapy, underlying disease, and other factors, a definitive recommendation for an interval after cessation of immunosuppressive therapy when mumps vaccine can be administered safely and effectively often is not possible.
Corticosteroids. For patients who have received high doses of corticosteroids for 14 days or more and who are not otherwise immunocompromised, the recommended interval is at least 1 month after steroids are discontinued (see Immunocompromised Children, p 69).
Pregnancy. Susceptible postpubertal females should not be immunized if they are known to be pregnant. Live-virus mumps vaccine can infect the placenta, but the virus has not been isolated from fetal tissues of susceptible females who received vaccine and underwent elective abortions. In view of the theoretic risk, however, conception should be avoided for 28 days after mumps immunization.
Outbreak Control. When determining means to control outbreaks, exclusion of susceptible students from affected schools and schools judged by local public health authorities to be at risk of transmission should be considered. Such exclusion should be an effective means of terminating school outbreaks and rapidly increasing rates of immunization. Excluded students can be readmitted immediately after immunization. Pupils who continue to be exempted from mumps immunization because of medical, religious, or other reasons should be excluded until at least 26 days after the onset of parotitis in the last person with mumps in the affected school. Experience with outbreak control for other vaccine-preventable diseases indicates that this strategy is effective.
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Image 084_01. Mumps. Thin-section electron micrograph of mumps virus. Filamentous nucleocapsids can be seen within viral particles and juxtaposed along the viral envelope.
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Image 084_02. Mumps. Electron micrograph of the mumps virus. The mumps virus is a member of the Paramyxoviridae family and is enveloped by a helical ribonucleic-protein capsid, which has a Herring-body–like appearance.
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Image 084_03. Mumps. Mumps parotitis with cervical and presternal edema and erythema that resolved spontaneously.
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Image 084_04. Mumps. A child with mumps parotitis and submandibular lymphadenopathy with striking erythema and edema, all due to the mumps virus, with spontaneous resolution. It is important to differentiate the erythema of the skin from group A streptococcal cellulitis.
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Image 084_05. Mumps. Mumps with parotid and submandibular involvement bilaterally. The differential diagnosis for acute parotitis is broad.
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Image 084_06. Mumps. Mumps orchitis in a 6-year-old boy. This complication is unusual in prepubertal boys. The highest risk for orchitis is in males between 15 and 29 years of age.
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Image 084_07. Mumps. Characteristic appearance of mumps parotitis in an 8-year-old female. Note that the edematous swelling extends below the angle of the mandible. Many children with mumps do not seem to feel very ill.
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Related text in Red Book:
Vaccine Safety and Contraindications
Red Book 2003: 37-49. [Full Version]
Simultaneous Administration of Multiple Vaccines
Red Book 2003: 33. [Full Version]
Immunocompromised Children
Red Book 2003: 69-81. [Full Version]
Rubella
Red Book 2003: 536-541. [Full Version]
Human Immunodeficiency Virus Infection
Red Book 2003: 360-382. [Full Version]
Measles
Red Book 2003: 419-429. [Full Version]

This topic has been referenced by these articles:
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Patja, A., Mäkinen-Kiljunen, S., Davidkin, I., Paunio, M., Peltola, H. (2001). Allergic Reactions to Measles-Mumps-Rubella Vaccination. Pediatrics 107: 27e-27 [Abstract] [Full Version]
Miller, L. C., Comfort, K., Kelly, N. (2001). Immunization Status of Internationally Adopted Children. Pediatrics 108: 1050-1051 [Full Version]
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