14. Mumps

Prior to the introduction of immunisation, approximately 85 percent of adults had evidence of past mumps infection. Most infections in those aged under 2 years are subclinical, while those affected in adulthood are more likely to experience severe disease. The peak incidence was in late winter and spring.

More recently, there have been numerous reports of increasing numbers of mumps cases in the US, the UK and elsewhere, thought to be due to a waning of vaccine-induced immunity.[4] Many cases are reported in 18–30-year olds.[5] Outbreaks appear to occur mainly in those in crowded situations, such as university students and other close-knit communities, and have been associated with international travel.[6]

Mumps vaccine (as MMR) was introduced to the Schedule in 1990 for children aged 12 to 15 months, with a second dose introduced in 1992 for children aged 11 years. A two-dose schedule at ages 15 months and 4 years was introduced in 2001 (see Appendix 1 for more information). Prior to 2017, the last mumps epidemic had occurred in 1994. The current two-dose schedule was introduced in 2020 at age 12 months and 15 months.

People aged 12–29 years are at the greatest risk of catching mumps, as they are the group least likely to have been fully immunised as children. Those born in Fiji, Tonga, Kiribati, Nauru, Papua New Guinea, Solomon Islands, Tuvalu and Vanuatu as well as many mainland nations in Asia may not have been offered mumps immunisation as children.

From 1 January 2017 to 31 December 2019, 1,773 cases of mumps were notified (ESR, 8 June 2020). During 2019, the notification rate was 5.4 per 100,000 (264 cases) compared with 9.0 per 100,000 (435 cases) in 2018. In 2019, the highest notification rates were seen in young adults aged 15 to 29 years. Cases were predominantly in the Auckland region, with the highest notification rates in the Middle Eastern/Latin American/African (MELAA) ethnic group (19.9 per 100,000) and Pacific people (15.2 cases per 100,000; ESR, 8 June 2020).

Figure 14.1: Notified cases of mumps, 1997–2019

Mumps vaccine is one of the components of the live attenuated MMR, considered in section 12.4 (and MMRV mentioned in section 22.4). There are no single antigen mumps vaccines available.

Funded vaccine

Other vaccines

M-M-R II (MSD) was the funded vaccine prior to the 1 July 2017 Schedule change (see section 12.4.1).

A 2012 Cochrane review of the safety and effectiveness of MMR estimated that a single dose of MMR was 69–81 percent effective in preventing clinical mumps. Effectiveness of MMR in preventing laboratory-confirmed mumps cases in children and adolescents was estimated to be between 64 and 66 percent for one dose and between 83 and 88 percent for two vaccine doses.[7]

A two-dose vaccination schedule and high immunisation coverage has been very successful in controlling disease. However, outbreaks can still occur in highly immunised populations, because two doses of vaccine are not 100 percent effective. Community coverage needs to be 85–90 percent by 2 years of age to prevent outbreaks from asymptomatic cases.[2] Declining vaccine-induced mumps immunity may also contribute to outbreaks.[4] Data from Finland shows that 20 years after the second MMR dose, immunity to mumps declined with just under 75 percent being seropositive.[8] The antibody avidity also decreased over time, by 24 percent for mumps.[9]

Two doses of MMR are required to ensure a high rate of seroprotection against mumps and induce antibody responses that persist for at least 10 years post-vaccination.[10, 11] However, waning in immunity has been observed in young adults and a third dose of MMR has been used safely and effectively during mumps outbreaks in highly immunised populations.[12, 13] Although the mumps vaccine is not quite as effective as measles and rubella vaccines, cases that have been vaccinated are significantly less likely to experience complications from disease such as orchitis, meningitis and hospitalisation.[14]

Transport according to the National Standards for Vaccine Storage and Transportation for Immunisation Providers 2017 (2nd edition).

Store at +2°C to +8°C. Do not freeze.

MMR must be reconstituted only with the diluents supplied by the manufacturer. Use MMR as soon as possible after reconstitution. If storage is necessary, reconstituted vaccine can be stored at +2°C to +8°C for up to eight hours.

The dose of MMR is all of the reconstituted vaccine (approximately 0.5 mL) administered by intramuscular injection, or subcutaneous injection if indicated (see section 2.2.3).

Co-administration with other vaccines

MMR can be given concurrently with other vaccines, by using separate syringes and giving the injections at different sites. If not given concurrently, live vaccines should be given at least four weeks apart. (See also section 2.2.7 for information about multiple injections at the same visit.)

Interchangeability

The two brands of MMR available in New Zealand (Priorix and M-M-R II) may be used interchangeably for completion of a course.[15]

Two doses of mumps-containing vaccine as MMR are recommended at age 12 months and 15 months (Table 14.1).

The second dose can be given as soon as four weeks after the first dose.

Children who receive MMR when aged under 11 months (MMR0) during an outbreak require two further doses administered after age 12 months. No opportunity should be missed to achieve immunity.

MMR is recommended and funded for children, adolescents and adults (especially those born since 1 January 1969) who are known to be susceptible to one or more of the three diseases (two doses, four weeks apart). See sections 12.5.2 and 19.5.2.

Contacts of immunocompromised individuals

In general, MMR is contraindicated in immunocompromised individuals (see section 4.3). These individuals can be partially protected from exposure to infection by ensuring that all contacts are fully immunised (funded), including hospital staff and family members. There is no risk of transmission of MMR vaccine viruses from a vaccine recipient to the immunocompromised individual (see section 12.7.2).

See also in section 4.3.1.

(Re)vaccination following immunosuppression

MMR is funded for (re)vaccination following immunosuppression. However, it is important to be sure that the individual is immunocompetent enough to safely receive the vaccine.

HIV infection

Discuss vaccination of individuals with HIV infection with their specialist (see ‘HIV infection’ in section 4.3.3).

MMR is recommended for all HIV-positive children, whether they are symptomatic or asymptomatic, if their CD4+ lymphocyte percentage is 15 percent or greater. Asymptomatic children who are not severely immunocompromised are recommended to receive MMR from age 12 months to provide early protection against the three diseases. Susceptible HIV-positive children and adults aged 14 years and older may receive MMR if their CD4+ lymphocyte count is at least 200 cells/mm³. Administration of MMR with CD4+ counts below these recommended levels has been associated with vaccine-related pneumonitis (from the measles component).[16]

MMR is contraindicated during pregnancy. Pregnancy should be avoided for four weeks after MMR vaccination.[16, 17] (see section 14.6.1).

After delivery

If MMR and Rhesus anti-D IG are required after delivery, both the vaccine and anti-D IG may be given at the same time, in separate sites with separate syringes. The vaccine may be given at any time after the delivery. Anti-D IG does not interfere with the antibody response to the vaccine, but whole blood transfusion does inhibit the response in up to 50 percent of vaccines recipients (see section A6.4.1). MMR can safely be given to breastfeeding women.

See section 12.6.1 for specific MMR contraindications.

Anaphylaxis to a previous dose of MMR or any of the vaccine components (including neomycin) is a contraindication to a further dose of MMR.

MMR should not be given to women who are pregnant, and pregnancy should be avoided for four weeks after immunisation.[16, 17] However, inadvertent immunisation with a rubella-containing vaccine in early pregnancy is no longer considered an indication for termination of pregnancy. There have been no cases of teratogenic damage from vaccine virus despite intensive surveillance in the US, the UK and Germany.[18]

Egg allergy, including anaphylaxis, is not a contraindication to MMR. See section 12.6.3 for more information, and section 12.6.2 for further precautions.

For infants aged under 12 months, please discuss immunomodulatory therapies taken during pregnancy with infant’s mother or specialist, or contact IMAC before administration of MMR0 in an outbreak situation. See section 4.3.6.

All suspected mumps cases should have diagnostic testing (eg, by buccal swab detection of wild-type mumps virus by PCR or culture) as there are other causes of parotitis other than the mumps virus. See the latest version of the ‘Mumps’ chapter of the Communicable Disease Control Manual for the specimens required for laboratory confirmation of mumps, or discuss these with the local laboratory. See case definition at Communicable Disease Control Manual.

A susceptible contact is anyone born after 1981 who has not had mumps infection or has not been fully vaccinated for their age.

All susceptible contacts should be offered MMR vaccinations. (All vaccinations given should be recorded on the AIR.) There is no increased risk of adverse events after immunisation during the incubation period of mumps or if the recipient is already immune. Immunoglobulin is ineffective after exposure to mumps.

For detailed information see Management of Cases and Management of Contacts in the Communicable Disease Control Manual. 

Cases

Exclude cases from tertiary education, school, sports, early childhood services or health care or other workplaces and from close contact with other susceptible people for five days from onset of parotitis.[1]

Susceptible contacts

Discuss exclusion of susceptible contacts with the local medical officer of health. Previously immunised (pre-exposure) contacts need not be excluded. Generally, unimmunised contacts who have no previous history of mumps infection should be advised not to attend early childhood services or school because of:

• the risk of catching the disease themselves
• the risk of passing on the disease, when asymptomatic or in the prodromal phase, to other susceptible children.

Health care settings or working or living with immunocompromised people

Advise exclusion of susceptible contacts in health care settings and for those working or living with immunocompromised people from 12 days after the first exposure to 25 days after last exposure to the infectious case.[1] Documented full immunisation with two MMR doses should be required in these situations.[1]

Other settings

Consider advising exclusion of susceptible contacts with no MMR doses from tertiary education, school, early childhood services or workplaces from 12 days after the first exposure to 25 days after last exposure to the infectious case, if there is a high risk of mumps transmission.[1] Exclusion is more important in secondary and tertiary education settings, as these settings are more conducive to outbreaks.[1]

All excluded contacts, in settings other than health care or in contact with immunocompromised people, can be readmitted immediately after they have received the first MMR dose.[1] Those who have a history of one dose of MMR vaccination should be offered their second vaccine dose and be allowed to remain in tertiary education, school, early childhood services or workplaces (except for health care workers or those working or living with immunocompromised people).[1]

Post-exposure prophylaxis

Passive immunisation is not effective. Active immunisation with MMR is not considered effective against incubating infection, but MMR should be offered to susceptible contacts for protection against future exposure.

1. Ministry of Health. 2012. Mumps in Communicable Disease Control Manual. Wellington. URL: https://www.health.govt.nz/publication/communicable-disease-control-manual. (accessed 10 May 2022)
2. Rubin S. 2018. Mumps Vaccines, in Plotkin's Vaccines (7th edition), Plotkin S, Orenstein W, Offit P, et al. (eds). Elsevier: Philadelphia, US.
3. American Academy of Pediatrics. 2018. Mumps. in Red Book: 2018 Report of the Committee on Infectious Diseases, Kimberlin D, Brady M, Jackson M, et al. (eds). Elk Grove Village, IL. URL: https://redbook.solutions.aap.org/book.aspx?bookid=2205. (accessed 3 July 2020)
4. Albertson JP, Clegg WJ, Reid HD, et al. Mumps Outbreak at a University and Recommendation for a Third Dose of Measles-Mumps-Rubella Vaccine - Illinois, 2015-2016. MMWR: Morbidity and Mortality Weekly Report, 2016. 65(29): p. 731-4.
5. Public Health England. 2017. Laboratory-confirmed cases of measles, mumps and rubella, England: October to December 2016. Infection Report. 11(8): p. 1–5. URL: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/594801/hpr0817__mmr.pdf (accessed 11 March 2020)
6. Centers for Disease Control and Prevention. 2019 Measles Cases and Outbreaks. CDC; 2019 [updated 17 September 2019]; URL: https://www.cdc.gov/mumps/outbreaks.html. (accessed 06 November 2019)
7. Demicheli V, Rivetti A, Debalini MG, et al. Vaccines for measles, mumps and rubella in children. Cochrane Database Syst Rev, 2012(2): p. CD004407.
8. Davidkin I, Jokinen S, Broman M, et al. Persistence of measles, mumps, and rubella antibodies in an MMR-vaccinated cohort: a 20-year follow-up. Journal of Infectious Diseases, 2008. 197(7): p. 950-6.
9. Kontio M, Jokinen S, Paunio M, et al. Waning antibody levels and avidity: implications for MMR vaccine-induced protection. Journal of Infectious Diseases, 2012. 206(10): p. 1542-8.
10. Santos EM, Silva e Sa GR, Siqueira MM, et al. Immune response to the mumps component of the MMR vaccine in the routine of immunisation services in the Brazilian National Immunisation Program. Memorias do Instituto Oswaldo Cruz, 2014. 109(3): p. 335-9.
11. Carryn S, Feyssaguet M, Povey M, et al. Long-term immunogenicity of measles, mumps and rubella-containing vaccines in healthy young children: A 10-year follow-up. Vaccine, 2019. 37(36): p. 5323-5331.
12. Cardemil CV, Dahl RM, James L, et al. Effectiveness of a Third Dose of MMR Vaccine for Mumps Outbreak Control. New England Journal of Medicine, 2017. 377(10): p. 947-956.
13. Ogbuanu IU, Kutty PK, Hudson JM, et al. Impact of a third dose of measles-mumps-rubella vaccine on a mumps outbreak. Pediatrics, 2012. 130(6): p. e1567-74.
14. Hahné S, Whelan J, van Binnendijk R, et al. Mumps vaccine effectiveness against orchitis. Emerging Infectious Diseases, 2012. 18(1): p. 191-3.
15. Australian Technical Advisory Group on Immunisation (ATAGI). 2018. Mumps. in Australian Immunisation Handbook. Canberra. URL: https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/mumps. (accessed 20 October 2019)
16. American Academy of Pediatrics. 2018. Measles. in Red Book: 2018 Report of the Committee on Infectious Diseases, Kimberlin D, Brady M, Jackson M, et al. (eds). Elk Grove Village, IL. p. 537-550. URL: https://redbook.solutions.aap.org/redbook.aspx. (accessed 3 July 2020)
17. Strebel P, Papania M, Gastañaduy P, et al. 2018. Measles Vaccine, in Plotkin's Vaccines (7th edition), Plotkin S, Orenstein W, Offit P, et al. (eds). Elsevier: Philadelphia, US.
18. Reef SE ,Plotkin S. 2018. Rubella Vaccines, in Plotkin's Vaccines (7th edition), Plotkin S, Orenstein W, Offit P, et al. (eds). Elsevier: Philadelphia, US.