Mumps

What

Mumps is an acute viral illness. Symptomatic disease can range from mild upper respiratory symptoms to widespread systemic involvement.

Who

Mumps-containing vaccine is recommended for:

• children ≥12 months of age
• adolescents and adults born during or since 1966 who have not received 2 doses of mumps-containing vaccine

How

Mumps-containing vaccine is recommended for children at 12  months of age as MMR (measles-mumps-rubella) vaccine, and at 18 months of age as MMRV (measles-mumps-rubella-varicella) vaccine.

All adolescents and adults born during or since 1966 should have either:

• documented evidence of 2 doses of mumps-containing vaccine given at least 4 weeks apart and with both doses given ≥12 months of age, or
• serological evidence of immunity to measles, mumps and rubella

Why

Mumps occurs worldwide. Complications from mumps can include meningeal symptoms and deafness.

Mumps vaccines available in Australia

The Therapeutic Goods Administration website provides product information for each vaccine.

See also Vaccine information and Variations from product information for more details.

Dose and route 

The dose of Priorix and M-M-R II (MMR) vaccine for both children and adults is 0.5 mL given by either subcutaneous or intramuscular injection.

The dose of ProQuad and Priorix-tetra (MMRV) vaccine for children <14 years of age is 0.5 mL given by subcutaneous or intramuscular injection.²

MMRV vaccine is not recommended as the 1st dose of measles-containing vaccine in children <4 years of age. This is due to a small but increased risk of fever and febrile seizures when MMRV vaccine is given as the 1st dose of measles-containing vaccine in this age group. (See Adverse events).

If MMRV vaccine is inadvertently given as dose 1 of measles-containing vaccine, the dose does not need to be repeated (providing it was given at ≥12 months of age). The scheduled 18-month dose of MMRV should still be given at the usual time. See Table. Minimum acceptable age for the 1st dose of scheduled vaccines in infants in special circumstances in Catch-up vaccination. Advise parents and carers about the small but increased risk of fever and febrile seizures (compared with that expected after MMR vaccine).

MMRV vaccine is not recommended for use in people ≥14 years of age. No data are available on safety, immunogenicity or efficacy in this age group.

If a person ≥14 years of age is inadvertently given a dose of MMRV vaccine, this dose does not need to be repeated.

Co-administration with other vaccines

People can receive MMR or MMRV vaccine at the same time as other live attenuated parenteral vaccines or other inactivated vaccines,³ or other immunisation productions (such as RSV-specific monoclonal antibody), using separate syringes and injection sites. If a person does not receive MMR or MMRV vaccine at the same time as other live attenuated parenteral vaccines, wait at least 4 weeks between vaccinations.^4,5

Measles, mumps and rubella vaccines are not available separately as an alternative to MMR vaccine. However, a monovalent varicella vaccine is available (see Varicella).

If a person receives MMR vaccine at the same time as monovalent varicella vaccine, use separate syringes and injection sites. Do not mix MMR vaccine and monovalent varicella vaccine together before injection.

Interchangeability of MMR-containing vaccines

The 2 brands of MMR vaccine are interchangeable, so the 2nd MMR vaccine dose does not have to be the same brand as the 1st. 

The same principle applies to the 2 MMRV vaccines,³ although they are not routinely recommended in a 2-dose schedule.

Contraindications

Anaphylaxis to vaccine components

MMR and MMRV vaccines are contraindicated in people who have had:

• anaphylaxis after a previous dose of any MMR-containing vaccine
• anaphylaxis after any component of an MMR-containing vaccine

See Anaphylaxis in Adverse events for more details about MMR vaccination for people with a known egg allergy.

Pregnant women

MMR-containing vaccines are contraindicated in pregnant women.

Vaccinated women should avoid pregnancy for 28 days after vaccination.⁶

There is no risk to pregnant women from contact with people who have recently been vaccinated. The vaccine viruses is not transmitted from vaccinated people to susceptible contacts.⁷

See also Rubella, Varicella, Vaccination for women who are planning pregnancy, pregnant or breastfeeding and Table. Vaccines that are contraindicated in pregnancy: live attenuated vaccines for more details.

Breastfeeding women can receive MMR vaccines. See also Rubella.

People who are severely immunocompromised 

MMR-containing vaccines contain live attenuated viruses and are contraindicated in people who are severely immunocompromised as a result of a primary/secondary medical condition(s), or receiving certain immunosuppressive therapies (e.g. B-cell depleting biological therapy). See Table. Types of medical conditions and immunosuppressive therapy and associated levels of immunocompromise in Vaccination for people who are immunocompromised.

However, MMR vaccine may be considered for certain types of immunodeficiencies, well-controlled immunocompromising conditions or after a specific period following the completion of immunosuppressive therapies (see Precautions).

Precautions

Vaccination after receiving immunoglobulin or a blood product

A recent blood transfusion with washed red blood cells is not a contraindication to MMR or MMRV vaccines.

People who have received an immunoglobulin-containing blood product should wait 3–11 months before receiving a mumps-containing vaccine. This is because the immunoglobulin may impair the expected immune response to the vaccine.^5,8

The interval between receiving the blood product and the vaccine depends on the amount of immunoglobulin in each product.⁵ See Table. Recommended intervals between immunoglobulins or blood products, and measles-mumps-rubella, measles-mumps-rubella-varicella or varicella vaccination and Vaccination for people who have recently received normal human immunoglobulin and other blood products.

People may receive MMR vaccine at the same time as anti-D immunoglobulin, but at different injection sites. They can also receive MMR vaccine at any time after anti-D immunoglobulin. Anti-D immunoglobulin does not interfere with the antibody response to the vaccine.

Immunoglobulin or blood product administration after vaccination

People who have received a mumps-containing vaccine should not receive immunoglobulin-containing products for 3 weeks after vaccination, unless the benefits of receiving the blood product outweigh the benefits of vaccination. If the person receives an immunoglobulin-containing product within 3 weeks after a mumps-containing vaccine, the vaccinated person should be either:

• revaccinated later at the appropriate time, as indicated in Table. Recommended intervals between immunoglobulins or blood products, and measles-mumps-rubella, measles-mumps-rubella-varicella or varicella vaccination, or
• tested for immunity 6 months later and then revaccinated if seronegative

People may receive anti-D immunoglobulin at any time after receiving MMR vaccine.

People who are mildly or moderately immunocompromised

Vaccination with MMR vaccines can be considered for people who are not severely immunocompromised based on a risk-benefit assessment, taking into account the level of immunocompromise or consult a specialist if needed. 

See Table. Types of medical conditions and immunosuppressive therapy and associated levels of immunocompromise in Vaccination for people who are immunocompromised.

For more detailed guidance on each type of immunodeficiency, see the following tables:

• Table. Vaccination for people with inborn errors of immunity: live vaccines
• Table. Recommendations for vaccination before and after solid organ transplant
• Table. Recommendations for vaccination after haematopoietic stem cell transplant in children and adults
• Table. Recommendations for vaccination in children and adults with HIV
• Table. Recommendations for vaccination before and after completion of chemotherapy
• Table. Recommended timing of live vaccine administration for people receiving immunosuppressive therapies
• Table. Recommended timing of live vaccine administration for people receiving corticosteroids

People with inborn errors of immunity, including primary immunodeficiency

People with less severe inborn errors of immunity, including primary immunodeficiency (eg. defects of innate immunity and complement deficiencies) can receive the MMR vaccine. Advice on vaccination of children or adults who have been diagnosed with specific immunodeficiencies, such as interferon-alpha/beta receptor subunit 1 (IFNAR1) deficiency, should be sought from their immunologist.

See Inborn errors of immunity, including primary immunodeficiency.

People receiving immunosuppressive therapies

For people receiving immunosuppressive therapy (eg, high doses of corticosteroids, conventional immunosuppressive therapies, small molecule targeted therapies, and biological therapies), live vaccines including MMR-containing vaccines should ideally be administered at least 4 weeks before starting treatment. If this is not feasible, live vaccines should be administered after the designated waiting period once therapies are completed, with the timing varying based on the specific agent.

See Secondary (acquired) immunodeficiency due to medical therapies.

People with malignancies

In general, live vaccines are contraindicated in people with immunodeficiency due to malignancies or cancer treatments, especially in people undergoing B- or T-cell-targeting biological therapies, immunosuppressive chemotherapy or radiotherapy. However, live vaccines, including MMR vaccine may be administered in cancer patients when:

• a malignancy is in remission, and
• immune competence is demonstrated (such as lymphocyte count >1 × 109/L), and
• immunosuppressive chemotherapy, immunotherapy or radiotherapy have not been administered for at least 3 months, and
• no anti-B-cell therapies (such as rituximab) have not been administered in the past 6 months

See People with malignancies: recommendations for vaccination.

People receiving a solid organ transplant

MMR vaccine may be considered at least 1 year after solid organ transplant following a risk–benefit assessment including the level of immunocompromise.^9,10

MMRV vaccine is not recommended for people who have received a solid organ transplant because there are no data relating to the safety or efficacy of MMRV vaccine in this group.

See Solid organ transplant: recommendations for vaccination.

People receiving a haematopoietic stem cell transplant (HSCT)

People undergoing HSCT can receive the MMR vaccine at least 2 years after HSCT, but only when:  

• there is no evidence of chronic graft-versus-host disease, and
• immunosuppressive therapy has been discontinued for at least 3 months, and
• the person is deemed immunocompetent by their treating specialist

See Haematopoietic stem cell transplant: recommendations for vaccination.

People with HIV

MMR vaccine can be given to people with well-controlled HIV who are not severely immunocompromised, ie. asymptomatic children >12 months of age with an age-specific CD4+ count of ≥15%; adults with a CD4+ cell count ≥200 cells/μL.^6,11-15

There have been no studies on the safety, immunogenicity or efficacy of combination MMRV vaccines in asymptomatic people with HIV or people with an age-specific CD4⁺ count of ≥15%.^6,8 Therefore, it is recommended that these groups receive only MMR vaccine (and monovalent varicella vaccine — see Varicella).^13,15,16

See People with HIV: recommendations for vaccination.

People receiving corticosteroid therapy

People on low-dose systemic corticosteroids can receive MMR-containing vaccines. Low-dose systemic corticosteroid therapy includes:

• children on doses of ≤2 mg per kg per day for less than 1 week
• people on doses of 1 mg per kg per day or alternate-day regimens for longer periods

People receiving high-dose corticosteroids can receive MMR-containing vaccines after they have stopped corticosteroid therapy for at least 1 month (see Contraindications).¹⁵

Some experts suggest temporarily stopping lower doses of steroids 2–3 weeks before vaccination with live viral vaccines, if possible.^8,15

See also Vaccination for people who are immunocompromised.

Household contacts of people who are immunocompromised

Household contacts of people who are immunocompromised should ensure that they are age-appropriately vaccinated against, or are immune to, measles, mumps, rubella and varicella.

Household contacts of people who are immunocompromised can safely receive mumps-containing vaccines, because the vaccine viruses are not transmissible from vaccinated people to others.⁶ See also Close contacts of people who are immunocompromised.

If using MMRV vaccine, see Varicella for details about varicella vaccine virus transmission.

People receiving long-term aspirin or salicylate therapy

There is no need to avoid salicylates before or after receiving MMR or MMRV vaccine.

People taking long-term salicylate therapy (aspirin) can receive MMRV vaccine if needed. The benefit is likely to outweigh any possible risk of Reye syndrome after vaccination with a varicella-containing vaccine (see Varicella).

People with a history of thrombocytopenia

Thrombocytopenia is a rare adverse event associated with MMR vaccination (see Adverse events).^16-18

In children who have had an episode(s) of idiopathic thrombocytopenia purpura (ITP), the risk of vaccine-associated thrombocytopenia after a dose of MMR vaccine is uncertain.^6,18 However, a systematic review concluded that MMR vaccination, either a 1st or 2nd dose, did not lead to a recurrence of ITP.¹⁹ In children due for their 2nd dose, serological testing can be used to determine whether the child needs the extra dose of MMR or MMRV vaccine.

Personal or close family history of seizures or convulsions

Children with a personal or close family history of seizures or convulsions can receive MMR or MMRV vaccine.

Ensure that the parents or carers understand that the child may develop a fever 6–14 days after vaccination.⁶ Advise parents or carers about how to manage the fever with paracetamol or ibuprofen and other measures (see Adverse events following immunisation in After vaccination).

MMRV vaccines are only recommended for use as the 2nd dose of mumps-containing vaccine. This is because the risk of fever and febrile convulsions is higher if children receive MMRV vaccine as their 1st dose. See Recommendations and Adverse events.

Tuberculin skin testing after MMR vaccination

The measles virus inhibits the response to tuberculin. Tuberculin-positive people may become tuberculin-negative for 4–6 weeks after measles infection, and measles-containing vaccines have a similar effect.^6,21 Because of this, a tuberculin skin test (TST; Mantoux) may be unreliable for at least 4–6 weeks in people who have received MMR vaccine.

There are no studies on if and how MMR or MMRV vaccination affects the results of interferon-gamma release assays used for testing for M. tuberculosis infection.²²

Adverse events after receiving a mumps-containing vaccines are generally mild and well tolerated.¹ Adverse events are much less common after the 2nd dose of MMR or MMRV vaccine than after the 1st dose.

Fever and febrile convulsions

MMR vaccines

People who receive MMR vaccine may develop a fever 7–10 days (range 5–12 days) after vaccination. This can last 2–3 days. The fever may be associated with malaise and/or a non-infectious rash. Up to 15% of young children receiving MMR vaccine develop a high fever (>39.4°C).^6,23

An increased risk of febrile seizures of about 1 case per 3000–4000 doses occurs during the same time period.⁶

This time frame coincides with the period of peak measles vaccine virus replication.

Inform vaccine recipients, or their parents or carers, about:

• possible symptoms occurring 5–12 days after vaccination
• how to manage the symptoms, including using paracetamol or ibuprofen for fever 

See Adverse events following immunisation in After vaccination. 

MMRV vaccines

In clinical trials, people who received MMRV vaccine had higher rates of fever than people who received MMR vaccine and monovalent varicella vaccine at the same time but at separate sites.^24-27 Rates of fever were highest in young children who received MMRV vaccine as their 1st dose.

Post-marketing studies in the United States identified an approximately 2-fold increased risk of fever and febrile convulsions 7–10 days²⁸ (or 5–12 days)²⁹ after vaccination in children who received MMRV vaccine as a 1st dose. MMRV recipients were compared with recipients of separate MMR and varicella vaccines. MMRV vaccination resulted in 1 additional febrile seizure for every 2300 doses compared with separate MMR and varicella vaccination.²⁸ Children in these studies were mostly 12–23 months of age.

In the United States, post-marketing studies did not find an increase in fever or febrile convulsions after children received the 2nd dose of ProQuad (MMRV) vaccine. However, most 2nd-dose recipients were aged 4–6 years, an age at which the incidence of febrile convulsions is low.³⁰ This side effect profile is expected to be similar in children who receive Priorix-tetra.

Rare adverse events

Anaphylaxis

Anaphylaxis after receiving an MMR vaccine is very rare (1.8–14.4 per million doses).⁶

Although no cases of anaphylaxis were reported in MMRV vaccine clinical trials, the incidence is likely to be similar to that of MMR vaccine.

Anaphylaxis after vaccination is probably due to anaphylactic sensitivity to gelatin or neomycin, not an egg allergy. Measles and mumps (not rubella or varicella) vaccine viruses are grown in chick embryo tissue cultures, but measles- and mumps-containing vaccines have negligible amounts of egg ovalbumin. See Variations from product information and Vaccination for people who have had an adverse event following immunisation.

People with an egg allergy can safely receive an MMR or MMRV vaccine.^17,31,32 Skin testing is not needed before vaccination.¹⁷

Thrombocytopenia 

Thrombocytopenia has been very rarely associated with the rubella or measles component of MMR vaccine. It is usually self-limiting and occurs in 3–5 per 100,000 doses of MMR vaccine.^17-19 This is considerably less frequent than after natural measles, mumps and rubella infections.¹⁹

Any association with MMRV vaccine is expected to be similar.

Encephalopathy 

It is uncertain whether people can develop encephalopathy after MMR vaccination. If they do, it is at least 1000 times less frequent than encephalopathy as a complication from natural infection.²³

Lymphadenopathy, arthralgia and parotitis

Other rare adverse events attributed to MMR vaccine include:⁶

• transient lymphadenopathy
• arthralgia (see Rubella)
• parotitis

Parotitis can occur after mumps vaccination,¹ usually 10–14 days after vaccination. The incidence depends on the vaccine strain. 0.5–1.6% of people who received the Jeryl Lynn mumps strain had parotid or submandibular swelling.^1,33,34

An increased risk of aseptic meningitis after vaccination with the Urabe strain of mumps vaccine has been seen in some countries.¹ However, Australia does not use the Urabe strain. The MMR and MMRV vaccines available in Australia contain a Jeryl Lynn–derived strain of mumps, which is not associated with an increased risk of aseptic meningitis.^35,36

Conditions not linked to MMR vaccination

MMR vaccine is not associated with:

• autism
• autistic spectrum disorder
• inflammatory bowel disease

No credible scientific evidence supports a link between MMR and these conditions. Most proponents of the link have retracted this claim.^37,38 There is a substantial body of evidence to refute these claims.^39-42

Mumps is caused by a paramyxovirus from the genus Rubulavirus. The mumps virus has a single-stranded RNA genome.

It is rapidly inactivated by:⁷

• heat
• formalin
• ether
• chloroform
• light

Pathogenesis

Mumps is an acute viral illness with an incubation period of 12–25 days.⁴³

Transmission

Mumps is transmitted by:⁴³

• respiratory secretions, including aerosol transmission
• direct contact with saliva or possibly urine

People may be infectious from 7 days before parotid swelling (see Symptoms of mumps in Clinical features) until 9 days after. Maximum infectiousness is between 2 days before onset of illness and 5 days afterwards.⁴³

Symptoms of mumps

Asymptomatic infection occurs in one-third of cases.⁴⁴

Symptomatic disease ranges from mild upper respiratory symptoms to widespread systemic involvement.⁴⁴

Many mumps infections involve non-specific symptoms, including:¹

• fever
• headache
• malaise
• myalgia
• anorexia

60–70% of clinical cases develop the characteristic bilateral or, occasionally, unilateral parotid swelling.^1,45

Orchitis (usually unilateral) occurs in about 15–30% of post-pubertal males who acquire mumps.^46,47

Other glands and organs are not commonly affected. Rarely, people develop:^1,7

• pancreatitis
• oophoritis
• hepatitis
• myocarditis
• thyroiditis
• mastitis

Complications of mumps

About 10% of people with mumps develop meningeal symptoms and signs, but permanent neurologic sequelae are rare.⁴³ About 0.01–0.02% of people with mumps develop mumps encephalitis, with a case-fatality rate of around 1.0%.⁴⁷

Deafness is relatively common in mumps meningoencephalitis, although permanent nerve deafness is rare (0.005%, or 1 in 20,000 infections).

Orchitis can lead to subfertility and, rarely, infertility.⁴⁷

Mumps infection during the 1st trimester of pregnancy may result in spontaneous abortion.^1,44 Maternal infection is not associated with an increased risk of congenital malformation.^1,44

Mumps in Australia

In Australia between 2009 and 2014, the national notification rate for mumps was <1 per 100,000 population. Peak incidence rates were reported in young and middle-aged adults.^48-51 These people may have missed mumps vaccinations as a child and were born at a time when circulating disease was low.

Since then, the rate has increased, from 2.7 per 100,000 population in 2015 to 3.4 per 100,000 population in 2017.⁵² This has been associated with a rise in the number of cases reported in adolescents.⁵³

Similar to Australia, the United States and Europe have had mumps outbreaks, where the peak rates of disease have been in the 18–24 years age group.^54-57

Mumps in Aboriginal and Torres Strait Islander communities

Despite high immunisation rates, multiple mumps outbreaks have occurred in Australia, mainly in Aboriginal and Torres Strait Islander communities.^58-60 For example, in 2016, the Northern Territory recorded 129 outbreak cases of mumps, with 91% of cases occurring in Aboriginal and Torres Strait Islander people in the Alice Springs, Barkly and Katherine regions. Of the outbreak cases with vaccination status recorded:⁶⁰

• 48.6% were fully vaccinated
• 38.1% were partially vaccinated 
• 13.3% were unvaccinated

Monovalent mumps vaccine is not available in Australia. People receive mumps vaccine as either MMR or MMRV vaccine.

Immunogenicity

Clinical trials of MMR vaccine indicate:¹

• 95% mumps seroconversion after a single dose
• up to 100% seroconversion after a 2nd dose

Clinical trials of MMR vaccine compared with MMRV vaccine were mainly done in children 12 months to 6 years of age. MMRV vaccines produce similar rates of seroconversion to all 4 vaccine components as MMR and monovalent varicella vaccines given at the same time at separate injection sites.^24-27

Vaccine effectiveness

Outbreak investigations and post-marketing studies have reported 1-dose MMR vaccine effectiveness of 60–90%.^55,61 A Cochrane review reported 1-dose vaccine effectiveness to be:⁶²

• 69–81% for the vaccine containing the Jeryl Lynn mumps strain
• 70–75% for the vaccine containing the Urabe strain

Although people who receive 2 doses of mumps-containing vaccine are better protected, recent outbreaks have reported mumps in people who have received 2 doses. This is particularly so for young adults who received the vaccination more than 10 years ago.^56,57,63,64

Transport according to National vaccine storage guidelines: Strive for 5.⁶⁵ Store at +2°C to +8°C. Do not freeze. Protect from light.

Both MMR and MMRV vaccines must be reconstituted. Add the entire contents of the diluent container to the vial containing the pellet. Shake until the pellet completely dissolves.

Use reconstituted Priorix (MMR), M-M-R II (MMR) and Priorix-tetra (MMRV) vaccines as soon as practicable. If reconstituted vaccine must be stored, hold at +2°C to +8°C for no more than 8 hours.

Use reconstituted ProQuad (MMRV) vaccine immediately. If it must be stored, hold at:

• +2°C to +8°C for no more than 2.5 hours, or
• +20°C to +25°C for no more than 1 hour

Mumps is a notifiable disease in all states and territories in Australia.

State and territory public health authorities can provide advice about the public health management of mumps, including management of cases and their contacts.

Mumps-containing vaccine does not protect people if they receive it after they have been exposed to mumps.^6,7

However, if the exposure did not result in infection, the vaccine will protect the person against future infection.

Normal human immunoglobulin is not useful for post-exposure prophylaxis for mumps.^6,7

People with egg allergy

The product information for Priorix, M-M-R II and Priorix-tetra states that people with a history of anaphylactic or anaphylactoid reactions to egg should not receive these vaccines.

The Australian Technical Advisory Group on Immunisation (ATAGI) recommends that these people can receive Priorix, M-M-R II, Priorix-tetra or ProQuad.⁶ 

Women planning pregnancy

The product information for M-M-R II and ProQuad recommends that women of child-bearing age should avoid pregnancy for 1 month after vaccination.

ATAGI recommends that these women should avoid pregnancy for 28 days after vaccination,⁶ as for Priorix and Priorix-tetra.

People taking salicylates

The product information for ProQuad and Priorix-tetra states that people should avoid taking salicylates for 6 weeks after vaccination. This is because Reye syndrome has been reported after using salicylates during natural varicella infection.

ATAGI recommends that non-immune people on long-term salicylate therapy can receive varicella-containing vaccines, because the benefit is likely to outweigh any possible risk of Reye syndrome after vaccination.

Recommended ages for MMR vaccines

The product information for M-M-R II and Priorix states vaccine is for use in children ≥12 months of age.

ATAGI recommends that children ≥9 months can receive both MMR vaccines in certain circumstances, including travel and during outbreaks.

Recommended ages for MMRV vaccines

The product information for ProQuad states that this vaccine is for use in children 12 months to 12 years of age. The product information for Priorix-tetra states that children ≥9 months of age can receive this vaccine.

ATAGI recommends that children up to 14 years of age can receive both MMRV vaccines. ATAGI also recommends that MMRV vaccine should not be used routinely as the 1st dose of MMR-containing vaccine in children aged <4 years.

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3. Blatter MM, Klein NP, Shepard JS, et al. Immunogenicity and safety of two tetravalent (measles, mumps, rubella, varicella) vaccines coadministered with hepatitis A and pneumococcal conjugate vaccines to children twelve to fourteen months of age. Pediatric Infectious Disease Journal 2012;31:e133-40.
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