Mumps
Mumps - Summary
Mumps is a moderate-to-highly contagious acute viral infection caused by a paramyxovirus, and spread by direct contact with saliva.
Before the introduction of the combined measles, mumps, and rubella (MMR) vaccine in the UK, mumps occurred commonly in school-age children, with around 85% of adults showing evidence of previous mumps infection. Today, mumps is most common in young people who have not been adequately immunised against the infection.
Clinically, mumps presents with:
Parotitis (swollen parotid glands) in around two thirds of people.
Non-specific symptoms of fever, headache, malaise, muscle ache, and loss of appetite.
Epididymo-orchitis (usually unilateral, occurs in about 25% of men).
Oophoritis (occurs in about 5% of women).
Occasionally complications other than diagnostic symptoms can present:
Viral meningitis occurs in about 10% of people with mumps, and is more common in males. Although mumps meningitis is usually benign, about 1 in 1000 people develop encephalitis, which is fatal in 1.5% of cases.
Transient hearing loss affects about 4% of people, but permanent deafness is much less common (about 1 in 20,000 people).
Pancreatitis affects about 4% of people, but is usually mild.
Spontaneous abortion in the first trimester has been described as a complication of mumps in pregnancy, but the evidence for this is conflicting (and spontaneous abortion is generally a recognized complication of acute systemic infections).
Rarer complications of mumps that have been reported include other central nervous system disorders (such as cerebellar ataxia, facial palsy, transverse myelitis, and Guillain–Barre syndrome), thyroiditis, mastitis, prostatitis, hepatitis, and thrombocytopenia.
Mumps is a notifiable disease. If there is any suspicion of infection, the local Health Protection Unit (HPU) should be notified, and they will arrange a testing kit for confirmation and surveillance purposes.
Mumps is usually a self-limiting condition that will usually resolve over the course of about 1 week, with no long-term consequences. Rest and adequate fluid intake is advised; paracetamol or ibuprofen provide symptomatic relief.
Admission to hospital or referral for specialist advice is advised if:
There are signs of mumps encephalitis (for example an altered level or loss of consciousness, focal neurological signs, or seizures).
The person develops mumps meningitis (characterized by severe headache, neck ache, high fever, lethargy, and vomiting)
Following epididymo-orchitis (particularly if it was bilateral), a man has an abnormal semen analysis, or is experiencing infertility.
People who have been in contact with possible mumps should be offered immunization with the combined measles, mumps, and rubella (MMR) vaccine if they are not already fully immunized.
Have I got the right topic?
This CKS topic covers the management of suspected mumps, and the management of people (including pregnant women) who have been in contact with cases of mumps.
This CKS topic does not cover the prevention of mumps (using the combined measles, mumps, and rubella vaccine). This is covered in a separate CKS topic on Immunizations - childhood.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic [NICE, 2013].
October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic [NPC, 2012].
July 2011 — minor update. More exact paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency [MHRA, 2011]. Prescriptions have been updated to reflect the revised dosing. Issued in July 2011.
May 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic [NPC, 2011]. Issued in June 2011.
August 2010 — minor typographical update to the Definition section. Issued in August 2010.
August to December 2009 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.
Update
New evidence
Evidence-based guidelines
Guidelines published since the last revision of this topic:
HPA (2010) Guidance on infection control in schools and other childcare settings. Health Protection Agency. www.hpa.org.uk [Free Full-text]
HTAs (Health Technology Assessments)
No new HTAs since 1 September 2009.
Economic appraisals
No new economic appraisals relevant to England since 1 September 2009.
Systematic reviews and meta-analyses
Systematic reviews published since the last revision of this topic:
He, J., Zheng, M., Zhang, M., and Jiang, H. (2012) Acupuncture for mumps in children (Cochrane Review). The Cochrane Library. Issue 9. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Shu, M., Qiong Zhang, Y., Li, Z., et al. (2012) Chinese medicinal herbs for mumps (Cochrane Review). The Cochrane Library. Issue 9. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Primary evidence
No new randomized controlled trials published in the major journals since 1 September 2009.
Observational studies published since the last revision of this topic:
Nicholson, A., Rait, G., Murray-Thomas, T., et al. (2010) Management of epididymo-orchitis in primary care: results from a large UK primary care database. British Journal of General Practice 60(579), 407-e422. [Abstract] [Free Full-text]
New policies
No new national policies or guidelines since 1 September 2009.
New safety alerts
No new safety alerts since 1 September 2009.
Changes in product availability
No changes in product availability since 1 September 2009.
Goals and outcome measures
Goals
To determine the likelihood of the person having mumps
To notify the Health Protection Unit (HPU) of all cases of suspected mumps, and confirm mumps through laboratory testing when required
To give people with mumps (or their carers) self-care advice
To encourage uptake of the combined measles, mumps, and rubella vaccine, where appropriate
To give men with epididymo-orchitis due to mumps information on fertility and advice on self-care
To appropriately admit people with serious complications for specialist management
QIPP — Options for local implementation
QIPP — Options for local implementation
Non-steroidal anti-inflammatory drugs (NSAIDs)
Review the appropriateness of NSAID prescribing widely and on a routine basis, especially in people who are at higher risk of both gastrointestinal (GI) and cardiovascular (CV) morbidity and mortality (e.g. older patients).
If initiating an NSAID is obligatory, use ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).
Review patients currently prescribed NSAIDs. If continued use is necessary, consider changing to ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).
Review and, where appropriate, revise prescribing of etoricoxib to ensure it is in line with MHRA advice and the NICE clinical guideline on osteoarthritis [CSM, 2005; NICE, 2008].
Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis, rheumatoid arthritis, or low back pain (for people over 45 years) in accordance with NICE guidance [NICE, 2008; NICE, 2009a; NICE, 2009b].
Take account of drug interactions when co-prescribing NSAIDs with other medicines (see Summaries of Product Characteristics). For example, co-prescribing NSAIDs with ACE inhibitors or angiotensin receptor blockers (ARBs) may pose particular risks to renal function; this combination should be especially carefully considered and regularly monitored if continued.
Background information
Definition
What is it?
Mumps is a moderate-to-highly contagious acute viral infection caused by a paramyxovirus.
It is spread by direct contact with saliva.
The incubation period of mumps is around 17 days (range 14–25 days).
Clinically, mumps presents with:
Parotitis (swollen parotid glands) in around two thirds of people.
Non-specific symptoms of fever, headache, malaise, muscle ache, and loss of appetite often occur just before the onset of parotitis, and peak around the time the parotid glands are most swollen.
Other common clinical features of mumps include epididymitis, epididymo-orchitis (unilateral testicular swelling, in about 25% of men, can occur without systemic symptoms), and oophoritis (in about 5% of women).
The illness is most infectious from around 2 days before symptoms present, to about 9 days afterwards, although asymptomatic people (accounting for up to a third of people) may also be infectious.
Nearly all people develop life-long immunity to mumps after one episode of infection, although symptomatic second infection has been documented.
[DH, 2006; Litman and Baum, 2006; HPA, 2008a; Hviid et al, 2008; Senanayake, 2008; Yoshida et al, 2008; BASHH, 2010]
Prevalence
How common is it?
Before the introduction of the combined measles, mumps, and rubella (MMR) vaccine in the UK, mumps occurred commonly in school-age children, with around 85% of adults showing evidence of previous mumps infection [DH, 2006].
Following the introduction of the MMR vaccine in 1988, there was an immediate and significant decrease in the number of people who contracted mumps. Today, mumps is most common in young people who have not been adequately immunized against the infection.
In 1994, a school-based catch-up campaign with measles rubella (MR) vaccine was carried out; it offered no protection against mumps.
This led to a cohort of children (born between 1981 and 1986) who were left unprotected against mumps. In 2005 there was a significant epidemic of mumps, with 56,256 cases in England and Wales. This mainly affected young people 15–24 years of age who had either never received the MMR vaccine (as they were too old when it was introduced) or had received only one dose [HPA, 2011; HPA, 2008a].
Children younger than 1 year of age rarely get mumps, as they have usually acquired passive immunity from placental transfer of maternal antibodies [Litman and Baum, 2006].
Prognosis
What is the prognosis?
Mumps is usually a self-limiting illness, and is generally considered to be more benign than measles or pertussis (whooping cough) [Hviid et al, 2008].
Parotitis typically lasts about 1 week.
Epididymo-orchitis, where present, usually lasts for about 1 week, although in about 20% of affected men it may persist for 2 weeks or longer [Litman and Baum, 2006].
Complications
What are the complications?
Parotitis (inflammation of the parotid glands) usually resolves without complications.
The submandibular and sublingual salivary glands are also affected in about 10% of people with mumps, usually in conjunction with bilateral parotitis. This may cause obstruction of lymphatic drainage in the neck, resulting in presternal oedema in about 6% of affected people and (rarely) supraglottic oedema.
Persistent dilation of the salivary ducts (sialectasia) leading to their chronic inflammation (sialadenitis) has been rarely reported.
Epididymo-orchitis can cause significant anxiety, but rarely results in serious, long-term sequelae.
Although testicular atrophy has been observed in 30–50% of affected men, with reduced sperm count or motility in 7–13%, sterility is rarely seen.
Bilateral epididymo-orchitis, accounting for 15–30% of affected men, tends to have a worse prognosis.
Oophoritis is reported in about 5% of women with mumps, but rarely causes subfertility.
Viral meningitis occurs in about 10% of people with mumps, and is more common in males. Although mumps meningitis is usually benign, about 1 in 1000 people develop encephalitis, which is fatal in 1.5% of cases.
Transient hearing loss affects about 4% of people, but permanent deafness is much less common (about 1 in 20,000 people).
Pancreatitis affects about 4% of people, but is usually mild.
Spontaneous abortion in the first trimester has been described as a complication of mumps in pregnancy, but the evidence for this is conflicting (and spontaneous abortion is generally a recognized complication of acute systemic infections).
Rarer complications of mumps that have been reported include other central nervous system disorders (such as cerebellar ataxia, facial palsy, transverse myelitis, and Guillain–Barre syndrome), thyroiditis, mastitis, prostatitis, hepatitis, and thrombocytopenia.
[Litman and Baum, 2006; Singh et al, 2006; Hviid et al, 2008]
Diagnosis
Diagnosis of mumps
Diagnosis of mumps
How should I clinically diagnose mumps?
Consider a diagnosis of mumps in people presenting with parotitis (swollen parotid glands).
Typically, one parotid gland is affected first, reaching maximal size after 2–3 days, with the other gland closely following it. About a quarter of affected people have unilateral parotitis.
The ear lobe over the affected gland may be deflected upward and outward, and the angle of the mandible may be obscured (this does not occur with cervical adenopathy [swollen neck lymph nodes]).
The affected gland may be tender to touch.
During the period of gland enlargement, the person may complain of earache, and have difficulty with pronunciation of words or chewing.
Other features that are consistent with a diagnosis of mumps include:
Non-specific symptoms, such as low-grade fever, headache, earache, malaise, muscle ache, and loss of appetite. These typically occur 1 day before overt signs of parotitis.
Epididymo-orchitis is usually unilateral, and tends to occur about 1 week after symptoms of parotitis. However, it may occur up to 2 weeks after parotitis, and in a significant minority of men there may be no symptoms of parotitis at all (for more information, see Diagnosis of mumps epididymo-orchitis).
Oophoritis affects about 5% of women and causes nausea, vomiting, and lower abdominal pain. It rarely causes significant complications.
Viral meningitis affects up to 10% of people who contract mumps. This usually occurs about 4 days after parotitis, but may precede it, or occur in its absence. It is usually benign, with symptoms of fever, headache, vomiting, neck stiffness, and lethargy peaking after 2 days, and then resolving over the course of about 1 week.
Deafness affects about 4% of people, but is rarely permanent.
Pancreatitis causes upper abdominal discomfort, and affects about 4% of people, but is nearly always mild and transient in nature.
Assess the likelihood of mumps, by considering:
Immunization history.
Mumps is unlikely in people who have been fully immunized.
Younger people who have not received two doses of the combined measles, mumps, and rubella (MMR) vaccine are most at risk.
History of mumps. Mumps is unlikely in people who have previously had mumps.
Contact with someone with mumps. Significant contact is considered as being in the same room for 15 minutes or more, or face-to-face contact. Mumps may have been contracted up to 4 weeks previously.
Recent outbreaks. Consider contacting the Health Protection Unit (HPU) to find out if there are any localized outbreaks of mumps.
Age. Mumps is unlikely in infants younger than 1 year of age.
Consider a different cause for the symptoms if the person is likely to have immunity to mumps, clinical features are atypical, there is no history of contact with mumps, and there are no local outbreaks.
If a diagnosis of mumps is considered likely, notify the local HPU, which will arrange for an oral fluid sample to be collected for confirmation of the infection.
Basis for recommendation
Basis for recommendation
Immunization status, past history of mumps, and likelihood of correct diagnosis
Historically, almost everybody eventually became infected with mumps at some point in their lives [Senanayake, 2008]. Seroprevalence studies have indicated that around 98% of people born before 1982 have natural immunity to mumps, acquired in the pre-vaccination era [Gupta et al, 2005]. Most people develop life-long immunity to mumps after one episode, and where reinfection does occur, the illness is usually mild in nature [Senanayake, 2008].
Immunization with a single dose of the combined measles, mumps, and rubella (MMR) vaccine confers 61–91% protection against mumps [DH, 2006], but immunity decreases with time. A second dose of vaccine increases the level of protection to about 95%, and although some waning of immunity does still occur, protection remains around 85% 6–7 years after the second dose [Cohen et al, 2007].
The introduction of the booster measles and rubella (MR) vaccine has resulted in a cohort of children, born between 1981 and 1986, who are more susceptible to mumps infection (see Prevalence). Although uptake of the MMR vaccine declined to a low of 79% in 2003 (mainly due to unfounded concern that the measles component of the vaccine was linked to autism and bowel disease [Pearce et al, 2008]) only a small proportion of mumps cases have occurred in children eligible for the routine two-dose MMR programme.
Children younger than 1 year of age rarely get mumps, as they have usually acquired passive immunity from placental transfer of maternal antibodies [Litman and Baum, 2006].
Clinical features of mumps
The clinical features of mumps are described in the textbook Principles and practice of infectious diseases [Litman and Baum, 2006], and in guidelines from the Department of Health [DH, 2006] and the Health Protection Agency [HPA, 2008a].
The World Health Organization defines mumps as 'Acute onset of unilateral or bilateral tender, self-limited swelling of the parotid or other salivary gland, lasting two or more days and without other apparent cause' [WHO, 2003].
Differential diagnosis
What else may cause parotitis?
Special consideration should be given to other causes of parotitis, when:
There is no current outbreak of mumps, or the person is not known to have been in contact with someone who has had confirmed mumps.
The person has previously had laboratory-confirmed mumps, or has been fully immunized against mumps (that is, they have had two doses of the combined measles, mumps, and rubella [MMR] vaccine or an equivalent single vaccine).
Other infectious causes that may present with parotitis include:
Viral infections, such as Epstein–Barr (the virus that causes mononucleosis), parainfluenza, adenovirus, influenza type A, coxsackievirus, parvovirus B19 (the virus that causes erythema infectiosum, also known as slapped cheek syndrome), lymphocytic choriomeningitis virus, and HIV.
Suppurative bacterial infections, including Staphylococcal aureus and atypical mycobacteria (for example tuberculosis).
Non-infectious causes of parotitis include:
Salivary stones or cysts.
Prescription drugs (for example thiazide diuretics, phenothiazines, thiouracil, iodide contrast media).
Metabolic disorders (for example diabetes mellitus, cirrhosis, uraemia).
Autoimmune disease (for example sarcoidosis, Sjogren's syndrome, Wegener's granulomatosis).
Basis for recommendation
Basis for recommendation
Information on the differential diagnosis of parotitis is based on expert opinion from narrative reviews [Gupta et al, 2005; Hviid et al, 2008; Senanayake, 2008].
Observational studies have shown that the most likely causes of parotitis during non-epidemic periods are probably Epstein–Barr virus, parainfluenza virus, and adenovirus [Senanayake, 2008].
Diagnosis of mumps epididymo-orchitis
How should I diagnose mumps epididymo-orchitis?
Mumps epididymo-orchitis can be reasonably diagnosed as the cause of testicular pain and swelling if there are classical symptoms following parotitis.
Symptoms tend to occur 4–8 days after parotitis, and are bilateral in 15–30% of affected men.
Typically, there is an abrupt painful swelling of the testicle, accompanied with systemic symptoms of high fever (39–40°C), chills, headache, and vomiting.
On examination, the affected testicle is usually enlarged (up to four times the normal size), warm, and tender, and the scrotum may be reddened in appearance.
Other causes of testicular symptoms cannot be confidently excluded if there is no associated or preceding parotitis. Consider:
Chlamydia and gonorrhoea, which are the most common sexually transmitted infections that cause epididymo-orchitis (see the CKS topics on Urethritis - male, Chlamydia - uncomplicated genital and Gonorrhoea).
Infection with Escherichia coli, particularly in older men.
Testicular torsion. Typically, there is sudden and severe pain in one testicle, followed by inguinal or scrotal swelling. However, pain and swelling can also develop more slowly. In about a third of men, there may be nausea and vomiting, and less commonly, fever.
Other non-infectious causes of testicular or scrotal swelling that are less likely to be confused with mumps epididymo-orchitis include varicocele, hydrocele, malignancy, and idiopathic scrotal oedema.
Basis for recommendation
Basis for recommendation
Clinical features of mumps epididymo-orchitis
The clinical features of mumps are described in the textbook Principles and practice of infectious diseases [Litman and Baum, 2006] and in narrative reviews [Singh et al, 2006; Hviid et al, 2008].
A UK observational study during the 2005 mumps epidemic indicated that about 13% of men diagnosed with epididymo-orchitis had a preceding history of mumps [Philip et al, 2006]. However, 30–40% of men with mumps epididymo-orchitis do not experience preceding parotitis [Masarani et al, 2006], which makes diagnosis difficult.
Differential diagnosis
The differential diagnosis of mumps epididymo-orchitis is based on expert opinion from narrative reviews [Lane and Hines, 2006; Ludwig, 2008].
It is particularly important to exclude testicular torsion as a cause of testicular pain and swelling, as this requires immediate surgery to prevent necrosis and testicle loss [Minevich and Tackett, 2007].
Management
Management
Scenario: Management: covers the management of mumps, including notification and confirmation, the management of contacts, and the management of mumps epididymo-orchitis.
Scenario: Management
Scenario: Management of mumps
Notification and confirmation
How should I notify and confirm infection with mumps?
Mumps is a notifiable disease. If there is any suspicion of infection, notify the local Health Protection Unit (HPU), and they will arrange a testing kit for confirmation and surveillance purposes.
Mumps is usually confirmed (if required) through an oral fluid swab.
Basis for recommendation
Basis for recommendation
This recommendation is based on advice from the Department of Health and the Health Protection Agency [DH, 2006; HPA, 2008a].
Mumps was made a notifiable disease in the UK at the time of the introduction of the combined measles, mumps, and rubella (MMR) vaccine in 1988 [DH, 2006].
Although mumps usually causes characteristic parotitis, this is is not pathognomic of the disease, and laboratory confirmation is needed. In highly immunized populations and non-epidemic situations, confirmation of true mumps by laboratory investigation remains low.
Between 1989 and 1999, less than 10% of suspected mumps were laboratory-confirmed [Gupta et al, 2005].
However, a clinical diagnosis of mumps can be made with much greater certainty in times of outbreak or epidemic [DH, 2006].
Laboratory testing usually involves assays of mumps-specific immunoglobulin M (IgM) and/or mumps RNA that are found in the saliva of infected people [Smellie et al, 2007]. This is primarily for surveillance purposes, rather than management of the individual (which it does not usually directly impact on) [DH, 2006].
Management of mumps
How should I manage a person with suspected mumps?
Advise the person (or their carer):
That mumps is usually a self-limiting condition. It will usually resolve over the course of about 1 week, with no long-term consequences.
To rest, drink adequate fluids (but avoid citrus fruit juice which may exacerbate parotid pain), and take paracetamol or ibuprofen for symptomatic relief (aspirin should be avoided in children younger than 16 years of age).
To stay off school or work for 5 days after the initial development of parotitis.
Provide written advice about mumps — more information on mumps is available from the Health Protection Agency.
Arrange a follow-up appointment for about 1 week after the onset of parotitis.
Check that symptoms have resolved or are resolving adequately.
Ensure the person is up-to-date with their vaccinations, where applicable (see the CKS topic on Immunizations - childhood).
Advise the person to seek medical advice if they develop symptoms of:
Meningitis — for example severe headache, vomiting, neck stiffness (urgent attention should be sought if altered consciousness or convulsions develop).
Epididymo-orchitis — characterized by swollen and painful testicles. See Management of epididymo-orchitis.
Treatments, such as Human Normal Immunoglobulin (HNIG), antibiotics, or corticosteroids are not recommended for mumps.
Basis for recommendation
Basis for recommendation
These recommendations are based on advice from the Department of Health and the Health Protection Agency (HPA) [DH, 2006; HPA, 2008a].
Prognosis
The natural history of mumps is described in the textbook Principles and practice of infectious diseases [Litman and Baum, 2006]. For most people, measles is a self-limiting but unpleasant illness, and long-term complications are uncommon.
Self-care advice
Adequate fluid intake should be maintained when symptoms of upper respiratory tract infection are present, to replace fluid lost by fever, sweating, and nasal discharge, although there have been no controlled trials that have proven the benefit of this [Guppy et al, 2005].
Anecdotal evidence suggests that acidic drinks (such as fruit juice) can irritate parotitis, and should be avoided [Litman and Baum, 2006].
Paracetamol and ibuprofen are recommended for the symptomatic relief of mumps on the basis that they reduce fever and pain (including headache and myalgia).
The antipyretic and analgesic efficacy of paracetamol and ibuprofen have been confirmed by randomized controlled trials in several conditions, including upper respiratory tract infections (influenza and the common cold) [Eccles, 2006].
Aspirin is not usually recommended, as it has a less favourable adverse effect profile. It is contraindicated in children younger than 16 years of age, because of the risk of Reye's syndrome.
Guidance from the HPA states that children with suspected mumps should be kept away from school or nursery for 5 days after the development of parotitis [HPA, 2006], and this can be reasonably be extrapolated to adults.
Follow up
Follow up is recommended about 1 week after the onset of parotitis, especially in men. By this time, the person will usually have recovered from the illness [Litman and Baum, 2006].
Interventions for acute mumps
There are no specific interventions recommended for the treatment of acute mumps, which is largely considered to be a benign illness [Hviid et al, 2008].
There is no evidence that Human Normal Immunoglobulin (HNIG) is effective in the treatment of mumps, and there are no mumps-specific immunoglobulins available [HPA, 2008b].
Antibiotics are not effective against viral illnesses. On occasion, such as for the treatment of superinfected mumps epididymo-orchitis, antibiotics may be indicated, but specialist advice is needed [Singh et al, 2006].
Corticosteroids have no role in the routine management of mumps [Masarani et al, 2006].
Management of contacts
How should I manage a person who has been in contact with possible mumps?
Offer immunization with the combined measles, mumps, and rubella (MMR) vaccine to people who are not fully immunized (that is, people who have not had two doses of the MMR vaccine) as soon as it is convenient. See the CKS topic on Immunizations - childhood for information on the MMR vaccine, including contraindications.
Advise the person to seek medical advice if they develop symptoms of mumps.
Basis for recommendation
Basis for recommendation
This recommendation is based on guidance from Immunisation against infectious disease (the 'Green Book'), published by the Department of Health [DH, 2006].
Antibody response to the mumps component of the combined measles, mumps, and rubella (MMR) vaccine does not develop soon enough to provide effective prophylaxis following contact with suspected mumps.
However, the consultation provides a good opportunity to offer the MMR vaccine for future prevention of mumps (if it is not contracted) as well as measles and rubella.
The MMR vaccine will not exacerbate the effect of naturally-acquired mumps.
There is no evidence that Human Normal Immunoglobulin (HNIG) is effective in the prophylaxis of mumps, and there are no mumps-specific immunoglobulins available [HPA, 2008b].
Pregnant women
How should I manage a pregnant woman with suspected mumps, or possible exposure to mumps?
Manage pregnant women who are suspected of having mumps in the same way as otherwise healthy people. See Management of mumps for further information.
Advise pregnant women who may have been exposed to mumps to seek medical advice if they develop symptoms of mumps.
The combined measles, mumps, and rubella (MMR) vaccine is contraindicated in pregnancy.
Basis for recommendation
Basis for recommendation
These recommendations are based on advice from the Department of Health and the Health Protection Agency (HPA) [DH, 2006; HPA, 2008a].
There are no specific recommendations for the management of pregnant women. Although it is thought that mumps may increase the risk of spontaneous abortion in the first trimester, the evidence for this is conflicting, and there are no proven interventions to prevent it in any case [Hviid et al, 2008].
Immunocompromised people
How should I manage an immunocompromised person with suspected mumps, or possible exposure to mumps?
Manage immunocompromised people who are suspected of having mumps in the same way as otherwise healthy people. See Management of mumps for further information.
For immunocompromised people who may have been exposed to mumps:
Offer immunization with the combined measles, mumps, and rubella (MMR) vaccine to those people who are not fully immunized (that is, they have not had two doses of the MMR vaccine), provided it is not contraindicated (see the CKS topic on Immunizations - childhood for information on the MMR vaccine, including contraindications).
Advise the person to seek medical advice if they develop symptoms of mumps.
Basis for recommendation
Basis for recommendation
These recommendations are based on advice from the Department of Health and the Health Protection Agency (HPA) [DH, 2006; HPA, 2008a].
There are no specific recommendations for the management of people who are immunosuppressed. There is no evidence that immunocompromised people are more at risk from mumps infection, regardless of their immunization status [Gupta et al, 2005].
Management of epididymo-orchitis
How should I manage suspected mumps epididymo-orchitis?
Offer advice and reassurance if mumps epididymo-orchitis is diagnosed.
Advise the man on symptomatic relief, such as:
Bed rest.
Scrotal support.
Warm or cold topical packs.
Paracetamol or ibuprofen.
Inform the man that, in most cases, the symptoms will completely resolve within 1 week (or 2 weeks at most), and there is unlikely to be long-term problems with fertility.
If the man is concerned about fertility, offer semen analysis 3 months after the mumps has resolved, particularly if there was severe or bilateral epididymo-orchitis.
See the section on Initial investigations in a man in the CKS topic on Infertility for further information.
There is no specific treatment for mumps epididymo-orchitis. Oral corticosteroids and antibiotics are not routinely recommended.
Basis for recommendation
Basis for recommendation
Semen analysis
CKS identified no published literature on when it may be appropriate to conduct semen analysis for men who have had mumps epididymo-orchitis. However, it is reasonable to request this if the man is seeking reassurance, particularly for bilateral epididymo-orchitis, which is a significant cause of infertility [Masarani et al, 2006].
CKS recommends that analysis is performed 3 months after the mumps has resolved, in order to allow time for the developmental cycle of spermatozoa to be completed. This is extrapolated from a 'good practice point' for repeat semen analysis in clinical guidelines published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2004].
Treatment
There are no specific treatments recommended for mumps epididymo-orchitis [Masarani et al, 2006]:
Oral antibiotics have been advocated on the basis that bacterial superinfection may have a role in the inflammatory process, but the effectiveness of antibiotics has not been established, and they are not a routine treatment.
High-dose oral corticosteroids have been the subject of some studies, and may relieve pain and reduce oedema, but do not alter the clinical course of illness or prevent complications. It is widely considered that, because mumps epididymo-orchitis is generally a benign illness, the benefits of oral corticosteroids do not justify the risk of adverse effects.
Recommendations for symptomatic treatment are based on expert opinion [Lane and Hines, 2006; Masarani et al, 2006; Singh et al, 2006; Senanayake, 2008].
Admission and referral
Which people with suspected mumps should be admitted or referred?
Contact the local hospital regarding appropriate isolation before admission.
If the person shows signs of mumps encephalitis (for example an altered level or loss of consciousness, focal neurological signs, or seizures) — admit.
If the person develops mumps meningitis (characterized by severe headache, neck ache, high fever, lethargy, and vomiting) — admit or seek specialist advice, especially if there is any doubt over the diagnosis.
If, following epididymo-orchitis (particularly if it was bilateral), a man has an abnormal semen analysis, or is experiencing infertility — seek specialist advice (or refer to a fertility specialist).
Basis for recommendation
Basis for recommendation
CKS identified no national referral criteria or guidelines for mumps. In the absence of established policy, these recommendations reflect what CKS considers to be good clinical practice.
Encephalitis is a potentially fatal complication of mumps that requires urgent medical attention [Litman and Baum, 2006].
Whilst mumps meningitis is usually benign in nature, it is difficult to exclude other serious causes of meningitis in primary care, or predict which people will go on to develop mumps-induced encephalitis [Hviid et al, 2008].
The main long-term concern associated with epididymo-orchitis is subfertility [Masarani et al, 2006].
Unilateral mumps epididymo-orchitis causes testicular atrophy in 30–50% of affected men, with reduced sperm count or motility in 7–13% of cases. However, sterility is rare.
Bilateral mumps epididymo-orchitis causes infertility in 30–87% of affected men.
For more information, see the CKS topic on Infertility.
Evidence
Evidence
Supporting evidence
There is no supporting evidence section for this CKS topic because interventions for mumps have not been subject to investigation by controlled trials.
For information on the evidence available for the effectiveness of the combined measles, mumps, and rubella vaccine, see the Supporting evidence section on Vaccines for mumps in the CKS topic on Immunizations - childhood.
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on the primary care management of mumps, with additional searches in the following areas:
Post exposure prophylaxis
Management in pregnancy
Mumps orchitis
Self care
Search dates
Medline and Embase: January 1970 – September 2009
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
exp Mumps/, exp Mumps virus, epidemic parotitis.tw, mumps.tw, infectious parotitis.tw, exp Orchitis, mumps orchitis.tw
exp Antiviral Agents/,
exp Anti-Bacterial Agents/
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
National Guidelines Clearinghouse
British Columbia Medical Association
Institute for Clinical Systems Improvement
Guidelines International Network
National Library of Guidelines
National Health and Medical Research Council (Australia)
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
DynaMed
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
References
BASHH (2010) 2010 United Kingdom national guideline for the management of epididymo-orchitis. ..British Association for Sexual Health and HIV.www.bashh.org [Free Full-text]
Cohen, C., White, J.M., Savage, E.J. et al. (2007) Vaccine effectiveness estimates, 2004-2005 mumps outbreak, England. Emerging Infectious Diseases 13(1), 12-17. [Abstract] [Free Full-text]
CSM (2005) Updated advice on the safety of selective COX-2 inhibitors. ..Committee on Safety of Medicines.www.mhra.gov.uk [Free Full-text]
DH (2006) Immunisation against infectious disease - "The Green Book". Chapter 23 - Mumps. ..Department of Health.www.dh.gov.uk [Free Full-text]
Eccles, R. (2006) Efficacy and safety of over-the-counter analgesics in the treatment of common cold and flu. Journal of Clinical Pharmacy and Therapeutics 31(4), 309-319. [Abstract]
Guppy, M.P.B., Mickan, S.M. and Del Mar, C.B. (2005) Advising patients to increase fluid intake for treating acute respiratory infections (Cochrane Review). The Cochrane Library.Issue 4.John Wiley & Sons, Ltd.www.thecochranelibrary.com [Free Full-text]
Gupta, R.K., Best, J. and MacMahon, E. (2005) Mumps and the UK epidemic 2005. British Medical Journal 330(7500), 1132-1135. [Free Full-text]
HPA (2006) Guidance on infection control in schools and other child care settings. ..Health Protection Agency.www.hpa.org.uk [Free Full-text]
HPA (2008a) General information on mumps. ..Health Protection Agency.www.hpa.org.uk [Free Full-text]
HPA (2008b) Mumps. Immunoglobulin Handbook..Health Protection Agency.www.hpa.nhs.uk [Free Full-text]
HPA (2011) Mumps, notifications by age group, 1989-2010. ..Health Protection Agency.www.hpa.org.uk [Free Full-text]
Hviid, A., Rubin, S. and Muhlemann, K. (2008) Mumps. Lancet 371(9616), 932-944. [Abstract]
Lane, T.M. and Hines, J. (2006) The management of mumps orchitis. BJU International 97(1), 1-2. [Free Full-text]
Litman, N. and Baum, S.G. (2006) Chapter 154: mumps virus. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases - Online.6th edn.Elsevier.www.ppidonline.com
Ludwig, M. (2008) Diagnosis and therapy of acute prostatitis, epididymitis and orchitis. Andrologia 40(2), 76-80. [Abstract] [Free Full-text]
Masarani, M., Wazait, H. and Dinneen, M. (2006) Mumps orchitis. Journal of the Royal Society of Medicine 99(11), 573-575. [Abstract] [Free Full-text]
MHRA (2011) Press release: more exact paracetamol dosing for children to be introduced. ..Medicines and Healthcare products Regulatory Agency.www.mhra.gov.uk [Free Full-text]
Minevich, E. and Tackett, L. (2007) Testicular torsion. ..WebMD.www.emedicine.medscape.com [Free Full-text]
NICE (2004) Fertility: assessment and treatment for people with fertility problems (NICE guideline) [Replaced by clinical guideline 156]. .Clinical guideline 11.National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
NICE (2008) Osteoarthritis. The care and management of osteoarthritis in adults (NICE guideline). .Clinical guideline 59.National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
NICE (2009a) Rheumatoid arthritis: the management of rheumatoid arthritis (NICE guideline). .Clinical guideline 79.National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
NICE (2009b) Low back pain: early management of persistent non-specific low back pain (NICE guideline). .Clinical guideline 88.National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
NICE (2013) Key therapeutic topics - medicines management options for local implementation. ..National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
NPC (2011) Key therapeutic topics 2010/11 - Medicines management options for local implementation. ..National Prescribing Centre.www.npc.nhs.uk [Free Full-text]
NPC (2012) Key therapeutic topics - medicines management options for local implementation. ..National Prescribing Centre.www.npc.nhs.uk [Free Full-text]
Pearce, A., Law, C., Elliman, D. et al. (2008) Factors associated with uptake of measles, mumps and rubella vaccine (MMR) and use of single antigen vaccines in a contemporary UK cohort: prospective cohort study. British Medical Journal 336(7647), 754-757. [Abstract] [Free Full-text]
Philip, J., Selvan D and Desmond, A.D. (2006) Mumps orchitis in the non-immune postpubertal male: a resurgent threat to male fertility? BJU International 97(1), 138-141. [Abstract] [Free Full-text]
Senanayake, S.N. (2008) Mumps: a resurgent disease with protean manifestations. Medical Journal of Australia 189(8), 456-459. [Abstract] [Free Full-text]
Singh, R., Mostafid, H. and Hindley, R.G. (2006) Measles, mumps and rubella - the urologist's perspective. International Journal of Clinical Practice 60(3), 335-339. [Abstract]
Smellie, W.S., Forth, J., Coleman, J.J. et al. (2007) Best practice in primary care pathology: review 6. Journal of Clinical Pathology 60(3), 225-234. [Abstract] [Free Full-text]
WHO (2003) WHO-recommended standards for surveillance of selected vaccine-preventable diseases. ..World Health Organization.www.who.int [Free Full-text]
Yoshida, N., Fujino, M., Miyata, A. et al. (2008) Mumps virus reinfection is not a rare event confirmed by reverse transcription loop-mediated isothermal amplification. Journal of Medical Virology 80(3), 517-523. [Abstract]