eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Mumps: Follow-up

Author: Cem S Demirci, MD, Fellow in Endocrinology, Children's Hospital of Pittsburgh
Coauthor(s): Walid Abuhammour, MD, FAAP, Associate Professor of Pediatrics, Michigan State University; Director of Pediatric Infectious Disease, Department of Pediatrics, Hurley Medical Center
Contributor Information and Disclosures

Updated: Nov 20, 2009

Follow-up

Deterrence/Prevention

• Droplet precautions are recommended until 9 days after the onset of parotid swelling in patients with mumps. Children should be excluded for 9 days from the onset of parotid gland swelling from going to school and child care centers. If outbreaks occur, all children should be vaccinated.
• Susceptible children, adolescents, and adults should be vaccinated against mumps, unless vaccination is contraindicated. Mumps vaccine is of particular value for children approaching puberty and for adolescents and adults who have not had mumps. MMR vaccine is the vaccine of choice for routine administration and should be used in all situations where recipients are also likely to be susceptible to measles, rubella, or both. The favorable benefit-to-cost ratio for routine mumps immunization is more marked when vaccine is administered as MMR. Persons should be considered susceptible to mumps unless they have documentation of (1) physician-diagnosed mumps, (2) adequate immunization with live mumps virus vaccine on or after their first birthday, or (3) laboratory evidence of immunity.
• Because live mumps vaccine was not used routinely before 1977 and because the peak age-specific incidence was in children aged 5-9 years before the vaccine was introduced, most persons born before 1957 are likely to have been naturally infected from 1957-1977. Therefore, they may generally be considered to be immune, even if they may not have had clinically recognizable mumps disease. However, this cutoff date for susceptibility is arbitrary. Although outbreak control efforts should be focused on persons born after 1956, these recommendations do not preclude vaccination of possibly susceptible persons born before 1957 who may be exposed in outbreak settings.
• Persons who are unsure of their mumps disease history, mumps vaccination history, or both should be vaccinated. No evidence indicates that persons who have previously either received mumps vaccine or had mumps are at any increased risk of local or systemic reactions from receiving live mumps vaccine. Testing for susceptibility before vaccination, especially among adolescents and young adults, is not necessary. In addition to the expense, some tests (eg, mumps skin test, complement-fixation antibody test) may be unreliable, and tests with established reliability (eg, neutralization test, enzyme immunoassay, radial hemolysis antibody test) are not readily available.
• A single dose of vaccine in the volume specified by the manufacturer should be administered subcutaneously. Although not routinely recommended, intramuscular vaccination is effective and safe.
• Administration of the live mumps virus vaccine is recommended at any age on or after the first birthday for all susceptible persons, unless a contraindication is present. Under routine circumstances, mumps vaccine should be administered in combination with measles and rubella vaccines as MMR, following the currently recommended schedule for administration of measles vaccine. It should not be administered to infants younger than 12 months because persisting maternal antibody might interfere with seroconversion. To ensure immunity, all persons vaccinated before the first birthday should be revaccinated on or after the first birthday.
• When administered after exposure to mumps, live mumps virus vaccine may not provide protection. However, if the exposure did not result in infection, vaccine should induce protection against infection from subsequent exposures. No evidence indicates that the risk of vaccine-associated adverse events increases if vaccine is administered to persons incubating disease.
• Immunoglobulin has not been demonstrated to be of established value in postexposure prophylaxis and is not recommended. Mumps immunoglobulin has not been shown to be effective and is no longer available or licensed for use in the United States.

Complications

• Hearing loss
• Meningitis or encephalitis
• Orchitis
• Oophoritis
• Pancreatitis
• Transient myelitis
• Polyneuritis
• Myocarditis
• Nephritis
• Arthritis
• Thyroiditis
• Thrombocytopenia purpura
• Mastitis
• Pneumonia
• Sensorineural deafness

Prognosis

• Overall prognosis in uncomplicated mumps is excellent.
• Prognosis of patients with meningoencephalitis is generally favorable; however, neurologic damage and death can occur. Reported rates of mumps encephalitis range as high as 5 cases per 1000 reported mumps cases. Permanent sequelae are rare, but the reported encephalitis case-fatality rate has averaged 1.4%.
• Sensorineural deafness is one of the most serious of the rare complications involving the CNS. It occurs with an estimated frequency of 0.5-5 cases per 100,000 reported mumps cases. Minor degrees of hearing loss or impairment are likely to occur with higher incidence and are probably reversible. Deafness after mumps is rare, mostly unilateral (20% bilateral), and often permanent.
• Orchitis (usually unilateral) has been reported as a complication in 20-30% of clinical mumps cases in postpubertal males. Some testicular atrophy occurs in about 35% of cases of mumps orchitis, but sterility rarely occurs.
• Symptomatic involvement of other organs has been observed less frequently. Limited experimental, clinical, and epidemiologic data suggest permanent pancreatic damage may result from injury caused by direct viral invasion. Further research is needed to determine whether mumps infection contributes to the pathogenesis of diabetes mellitus.
• Mumps infection in pregnant women seems to increase the risk of embryonic and fetal death and spontaneous abortions, especially during the first trimester of pregnancy (reported to be as high as 27%). No association was found between mumps and congenital anomalies, and the studies relating maternal mumps infection to endocardial fibroelastosis in the fetus are inconclusive. Mumps during pregnancy was rare even before immunization and is even rarer with the widespread use of mumps immunization in childhood.

Patient Education

• The principal strategy to prevent mumps is to achieve and maintain high immunization levels, primarily in infants and young children. Universal immunization as a part of good health care should be routinely carried out in physicians' offices and public health clinics. Programs aimed at vaccinating children with MMR should be established and maintained in all communities. In addition, all other persons thought to be susceptible should be vaccinated unless otherwise contraindicated. This is especially important for adolescents and young adults in light of the recently observed increase in risk of disease in these populations.
• Advise parents and educators to exclude the infected child from large-population facilities until 9 days after the swelling begins or until the swelling subsides.
• Advise all children and adults to follow good handwashing practices.
• For excellent patient education resources, visit eMedicine's Common Childhood Illnesses Center, Children's Health Center, and Bacterial and Viral Infections Center. Also, see eMedicine's patient education articles Mumps and Immunization Schedule, Children.

Miscellaneous

Medicolegal Pitfalls

• Failure to advise isolation for the duration of the contamination period
• Failure to check for complicated cases involving certain organ systems
• Failure to check for pregnancy in postpubertal women, including asking if they are or may be pregnant, excluding those who say they are, and explaining the theoretical risk to those who plan to receive the vaccine

Special Concerns

• Mumps in a childcare facility: If a case of mumps occurs in a childcare facility, notify the local health department. Notify parents. Exclude the infected child from the facility until 9 days after the swelling begins or until the swelling subsides. Make sure all children and adults follow good handwashing practices. In large facilities, follow appropriate group separation practices. Review the immunization records of all children in the facility to assure they have received their first mumps vaccination. Those not adequately vaccinated should be referred to their physicians. Closely observe all children for symptoms and refer anyone developing symptoms to his or her physician.
• Adverse effects of vaccine use: In field trials before licensure, illnesses did not occur more often in vaccinees than in unvaccinated controls. Reports of illnesses following mumps vaccination have mainly involved episodes of parotitis and low-grade fever. Allergic reactions, including rash, pruritus, and purpura, have been temporally associated with mumps vaccination but are uncommon, are usually mild, and are of brief duration. The reported occurrence of encephalitis within 30 days of receipt of a mumps-containing vaccine (0.4 cases per million doses) is not greater than the observed background incidence rate of CNS dysfunction in the healthy population. Other manifestations of CNS involvement, such as febrile seizures and deafness, have also been infrequently reported.⁹ Complete recovery is usual. Reports of nervous system illness following mumps vaccination do not necessarily denote an etiologic relationship between the illness and the vaccine.
• Contraindications to vaccine use in pregnancy: Although mumps vaccine virus has been shown to infect the placenta and fetus, no evidence indicates that it causes congenital malformations in humans. However, because of the theoretical risk of fetal damage, avoiding administration of live virus vaccine to pregnant women is prudent. Vaccinated women should avoid pregnancy for 3 months after vaccination. Routine precautions for vaccinating postpubertal women include asking if they are or may be pregnant, excluding those who say they are, and explaining the theoretical risk to those who plan to receive the vaccine. Vaccination during pregnancy should not be considered an indication for termination of pregnancy. However, the final decision about interruption of pregnancy must rest with the individual patient and her physician.
• Severe febrile illness: Vaccine administration should not be postponed because of minor or intercurrent febrile illnesses, such as mild upper respiratory infections. However, vaccination of persons with severe febrile illnesses should generally be deferred until they have recovered.
• Allergies: Because live mumps vaccine is produced in chick embryo cell culture, persons with a history of anaphylactic reactions (ie, hives, swelling of the mouth and throat, difficulty breathing, hypotension, shock) after egg ingestion should only be vaccinated with caution using published protocols. Children with known allergy should not leave the vaccination site for 20 minutes. Evidence indicates that persons are not at increased risk if they have egg allergies that are not anaphylactic in nature. Such persons may be vaccinated in the usual manner. No evidence indicates that persons with allergies to chickens or feathers are at increased risk of reaction to the vaccine. Because mumps vaccine contains trace amounts of neomycin (25 mcg), persons who have experienced anaphylactic reactions to topically or systemically administered neomycin should not receive mumps vaccine.
• Recent immunoglobulin injection: Passively acquired antibody can interfere with the response to live attenuated-virus vaccines. Therefore, mumps vaccine should be administered at least 2 weeks before the administration of immunoglobulin or deferred until approximately 3 months after the administration of immunoglobulin.
• Exceptions: An exception to these general recommendations is in children infected with human immunodeficiency virus (HIV); all asymptomatic HIV-infected children should receive MMR vaccination at 15 months of age. Patients with leukemia in remission whose chemotherapy has been terminated for at least 3 months may also receive live mumps virus vaccine.

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