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Mumps

Queensland Health Guidelines for Public Health Units

Revision History

VersionDateChanges
1.0 February 2012 Full revision of guidelines
2.0 January 2019 Full revision of guideline

Infectious Agent

The agent is the mumps virus, a member of the Rubulavirus genus (family Paramyxoviridae).

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Notification Criteria

Clinical evidence:
A clinically compatible illness characterised by swelling of the parotid or other salivary glands without other apparent cause.

Laboratory suggestive evidence:
Detection of mumps-specific IgM antibody in the absence of recent mumps vaccination.

Laboratory definitive evidence:
Detection of mumps virus by nucleic acid testing

OR

Isolation of mumps virus

OR

IgG seroconversion or a significant increase in antibody level or a fourfold or greater rise in the titre in paired sera to mumps virus EXCEPT when there has been recent mumps-containing immunisation.

Epidemiological evidence:
An epidemiological link is established when there is:

1. Contact between two people, with clinical symptoms suggestive of mumps, involving a plausible mode of transmission at a time when one of them is likely to be infectious (6–7 days before onset of parotitis to 9 days after onset of parotitis) and the other has an illness that starts within approximately 12 to 25 days after this contact;

AND

2. At least one case in the chain of epidemiologically linked cases (which may involve many cases) is laboratory confirmed.

Community outbreak criteria:
An outbreak is defined as more than the expected incidence of cases in a defined community.

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Notification Procedure

Pathology Laboratories:
To notify on microbiological confirmation, by usual means.

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Reporting to NOCS

Report confirmed and probable cases.

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Confirmed case

A  confirmed case requires either:

1. Laboratory definitive evidence

OR

2. Laboratory suggestive evidence AND clinical evidence

OR

3. Clinical evidence AND epidemiological evidence.

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Probable case

Clinical evidence in a case who is a member of a community, where community outbreak criteria have already been met.

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Objectives of surveillance

1. To monitor the epidemiology of mumps in Queensland (including the impact of mumps vaccination).

2. To detect outbreaks of mumps so that public health measures can be promptly implemented.

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Public Health Significance and Occurrence

The epidemiology of mumps is changing. Decades after widespread mumps vaccination (MMR) was introduced in developed countries, it is clear that vaccine-derived immunity can wane in the general absence of circulating wild virus. Individuals with waning immunity plus unvaccinated individuals and primary vaccine failures, can lead to an accumulation of susceptible persons. Eventually this leads to infrequent, slowly evolving community outbreaks, typically in older children and adults. This is in contrast to the pre-vaccination, endemic era where most mumps cases occurred in young children. At particular risk are those living in settings where overcrowding is common, such as in remote Indigenous communities, college and boarding school dormitories, hostels and residential care facilities.

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Clinical Features

An acute viral disease characterised by fever, swelling and tenderness of the parotid and/or other salivary glands. Recent outbreaks appear to indicate milder course of disease with about one third of infections being subclinical. While pre-vaccination era mumps infections are described as more severe in adults, residual vaccine-derived immunity appears to confer some protection resulting in milder symptoms and fewer complications based on observations from recent outbreaks. Where mumps is suspected, a buccal swab PCR is the preferred method for confirming the diagnosis.

There may be respiratory symptoms (40–50% of infections especially in children under 5). Symptomatic aseptic meningitis may present in up to 10% of infections, however permanent neurological sequelae are rare. While orchitis occurs in 20–30% of post pubertal males, sterility resulting from orchitis is extremely rare. Other rare sequelae include sensorineural hearing loss, encephalitis, and pancreatitis. Mumps infection during the first trimester of pregnancy has been associated with spontaneous abortion, but there is no firm evidence that mumps during pregnancy causes congenital malformations. Death from mumps is extremely rare.

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Reservoir

Humans

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Mode of Transmission

Mumps is readily spread by droplets and saliva of an infected person.

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Incubation Period

About 16–18 days (range 12–25 days).

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Period of Communicability

Virus has been isolated from saliva from 7 days before to 9 days after the onset of parotitis. For the purposes of case exclusion maximum infectiousness occurs between 2 days before and 5 days after onset of parotid swelling. Inapparent infections can be communicable.

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Susceptibility and Resistance

Immunity after either inapparent or clinical infections is generally lifelong. Most adults, particularly those born before 1966 are likely to have been infected and may be considered immune even if they did not have recognised disease. Vaccine derived immunity may wane within a decade of even two MMR vaccinations. This is supported by data from recent outbreaks where most cases occur in people between the ages of 10 to 40 years and who have been vaccinated. The demonstration of mumps IgG is acceptable evidence of mumps immunity.

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Management

Cases

Investigation: Nil routine
Restriction: Exclusion from school or workplace for 5 days after onset of parotitis if susceptible contacts are present.
Isolation: If hospitalised: respiratory isolation and private room for 5 days from onset of swelling. NB Restriction and isolation recommendations are based on review of available evidence as of March 2018. The Queensland Health Timeout poster (2018) recommends 5 days from the onset of parotid swelling.
Counselling: The case should be advised of the nature of the infection and its mode of transmission.

Contacts

Contact Tracing: The long incubation period and subclinical cases make contact tracing difficult, and it is often not possible to establish the chain of infection. Attempts at tracing and immunising household contacts during an outbreak may be misplaced. Unlike measles, MMR does not provide post-exposure protection for mumps and people already exposed are the least likely to benefit. Rather, efforts to improve immunity through catch-up or third dose MMR should target a wider circle of contacts and the at-risk population within the community.
Definition: A person who is not immune to mumps and has had exposure to droplets of saliva of an infectious case.
Exclusion: Not excluded
Management:
Although immunisation after exposure to natural mumps does not prevent disease in contacts, those who do not develop the disease would be protected against infection from subsequent exposures and prevent further spread of the disease.
Normal human immunoglobulin is not effective and not recommended.
Counselling: The contacts should be advised of the nature of the infection, its mode of transmission, and to undertake personal surveillance for symptoms.

Community outbreaks/epidemics:

An outbreak is defined as more than the expected incidence of cases in a defined community. Outbreak detection requires adequate surveillance and clinical judgement by the Public Health Physician.

Queensland is now seeing infrequent, slowly evolving outbreaks, including cases in a minority of older persons who may not/no longer be immune. Poor and overcrowded settings allow for greater intensity of transmission, which may explain the much higher attack rate in Indigenous communities.

Among populations with high coverage with 2 doses of MMR, a third dose of MMR vaccine is indicated for individuals older than 8 years AND born after 1965 who reside in, work in, or regularly visit a defined community or institutional setting with a current mumps outbreak1. MMR vaccination campaigns should be considered for Indigenous Communities and institutional settings such as boarding schools and prisons2 with current mumps outbreaks.

Aboriginal and Torres Strait Islander people residing in urban areas may have cultural and family ties with rural and remote Indigenous communities. For urban settings, Public Health Units may inform Aboriginal and Torres Strait Islander Health Services about mumps outbreaks in rural and remote Indigenous communities. MMR vaccination should be offered opportunistically to Indigenous patients who have not completed two doses of MMR vaccine. A third dose of MMR vaccine may be recommended for Indigenous patients older than 8 years AND born after 1965 depending on the local context.

Once a mumps outbreak has been established by testing, any further suspected cases should be notified to Public Health Units and tested where appropriate. This is to monitor the epidemiology of the outbreak. In an established outbreak, a line listing form should be provided to the health service to ensure that clinically diagnosed cases are reported3.

Recommendations for women of childbearing age:

MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant. Because of the theoretical risk to the foetus when the mother receives a live virus vaccine, women should be counselled to avoid becoming pregnant for 28 days after receipt of MMR vaccine. If the vaccine is inadvertently administered to a pregnant woman or a pregnancy occurs within 28 days of vaccination, she should be counselled about the theoretical risk to the foetus.

Routine pregnancy testing of women of childbearing age before administering a live-virus vaccine is not recommended. MMR or varicella vaccination during pregnancy should not be considered a reason to terminate pregnancy.

Provision of Normal Human Immunoglobulin following exposure to an infectious case is not recommended, as this has not been shown to be effective in preventing mumps infection.

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Preventive measures

Vaccination:

  • see current edition of The Australian Immunisation Handbook
  • usually confers immunity which may wane within a decade.

Public education by health care providers to:

  • immunise susceptible individuals
  • reinforce the importance of hand hygiene
  • ensure correct case exclusion times are adhered to (see Queensland Health Time Out poster).

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Summary

Not applicable.

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References

Marin M, Marlow M, Moore K, Patel M. Recommendation of the Advisory Committee on Immunisation Practices for Use of a Third dose of Mumps Virus-Containing Vaccine in Persons at Increased Risk for Mumps During an Outbreak. MMWR 2018; 67(1): 33-38

Ikechukwu U, Ogbuanu, Preeta K, et al. Impact of a Third Dose of Measles-Mumps-Rubella Vaccine on a Mumps Outbreak. Pediatrics 2012; 130; e1567

Cardemil C, Dahl R, James L, et al. Effectiveness of a Third Dose of MMR Vaccine for Mumps Outbreak Control. N Engl J Med 2017; 377:947-56.

Aratchige PE, McIntyre PB, Quinn HE, Gilbert GL. Recent increases in mumps incidence in Australia: the "forgotten" age group in the 1998 Australian Measles Control Campaign. Med J Aust 2008; 189: 434-437.

Heymann, D. (Ed).  Control of Communicable Diseases Manual, 20th edition. American Public Health Association: Washington, 2015.

MMWR. Updated recommendations for isolation of persons with mumps. 2008, 57(40): 1103-1105.

National Health and Medical Research Council. The Australian Immunisation Handbook, 10th edition. National Capital Printing: Canberra, 2013.

National Health and Medical Research Council. Staying Healthy: Preventing Infectious Diseases in early Childhood Education and Care Services, 5th edition. 2013.

Queensland Mumps Update 2018. Epidemiology and Research Unit Communicable Disease Branch Department of Health. Queensland Government.

Queensland Health Time Out Poster: Keeping Your Child and other Kids Healthy 2018. Queensland Government Brisbane 2018.

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Notes

  1. It is not necessary to check MMR vaccination status prior to offering MMR vaccine to prisoners.
  2. Prisoners are vulnerable to mumps due to crowding and close living conditions. Mumps may be introduced into the prison setting as a result of transfer of prisoners. In 2017 / 2018, mumps outbreaks were reported in Queensland prisons. MMR vaccination campaigns should be encouraged in Queensland prisons as a proactive measure to prevent mumps outbreaks. A third dose of MMR may be offered to prisoners and prison staff born after 19651.
  3. As per the case definition, cases with clinical evidence AND epidemiological evidence should be reported to NOCS.

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Last updated: 15 January 2019