Changes

December 2023 — reviewed. A literature search was conducted in November 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to recommendations have been made.

Update

Goals

To support primary healthcare professionals to:

• Make a diagnosis of mumps.
• Notify the local Health Protection Team of all cases of suspected mumps, and confirm mumps using laboratory testing when required.
• Give people with mumps (or their carers) self-care advice.
• Encourage uptake of the combined measles, mumps, and rubella vaccine, where appropriate.
• Give men with epididymo-orchitis due to mumps information on fertility and advice on self-care.
• Admit people with serious complications for specialist management when appropriate. 

Outcome measures

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

What is it?

• Mumps is an acute infectious disease caused by a paramyxovirus, characterised by bilateral parotid swelling. 
• It is spread by respiratory droplets, fomites or saliva and replicates mainly in the upper respiratory mucosa.
• The incubation period of mumps is 14-18 days (range 12–25 days) 
• It is most infectious from around 1–2 days before the onset of symptoms to about 9 days afterwards, although it may be asymptomatic in 15–20% of people. 
  • Asymptomatic mumps infection is common in children.
• Nearly all people develop life-long immunity to mumps after one episode of infection. 
  • However, 1–2% of cases are thought to be re-infections.

[UKHSA, 2013; Barbel, 2017; BMJ Best Practice, 2023]

How common is it?

• Before the introduction of the combined measles, mumps, and rubella (MMR) vaccine in the UK in 1988, mumps occurred commonly in school-age children, with around 85% of adults showing evidence of previous mumps infection.
  • Following the introduction of the MMR vaccine, there was an immediate and significant decrease in the number of people who contracted mumps. 
• In 2019, in England and Wales, there were 4,411 laboratory-confirmed cases of mumps. In the two subsequent years, case numbers were much lower, likely due to COVID-19 restrictions.
  • Most confirmed cases were in adults aged 18 years or over. 
• Children under 1 year of age rarely get mumps, as they have usually acquired passive immunity from placental transfer of maternal antibodies.

  [UKHSA, 2013; Litman, 2016; UKHSA, 2022; BMJ Best Practice, 2023]

What is the prognosis?

• Mumps is usually a self-limiting disease that resolves within 1–2 weeks, and most people recover without any long-term complications. 
• Although generally rare, complications occur more frequently among adults than children.

[Barbel, 2017; BMJ Best Practice, 2023]

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 pre-sternal 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 — the most common complication affecting approximately 25% of post-pubertal men. 
  • Mumps rarely leads to infertility but can contribute to sub-fertility. 
  • Unilateral mumps epididymo-orchitis can significantly, but only transiently, diminish sperm count, mobility, and morphology. 
    • Impairment of fertility is estimated to occur in about 13% of men.
  • Epididymo-orchitis is bilateral in 15–30% of affected men and tends to have a worse prognosis.
    • Bilateral mumps epididymo-orchitis causes infertility in 30–87% of affected men.
  • Of affected testicles,  up to 50% show a degree of atrophy. 
  • Most men recover after 2 weeks, although in about 20% of affected men, it may persist for longer.
• Encephalitis — occurs in about 0.1% of people. The presence of seizures, decreased level of consciousness, and focal neurological symptoms indicate mumps encephalitis. Abnormalities in EEG can also be seen and usually resolve in a few weeks. Mortality is 1–5%, and long-term morbidity is rare.
• Oophoritis — reported in about 5% of post-pubertal women with mumps, but rarely causes infertility or premature menopause. 
• Aseptic meningitis — occurs in up to 25% of people with mumps and is three times more common in men. Mumps meningitis is usually benign, and almost all patients have a complete recovery with no residual neurological deficits and no risk of mortality. 
• Transient hearing loss — affects about 4% of people, but permanent deafness is much less common (about 1 in 20,000 people). Bilateral hearing loss is very rare. 
• Myocardial complications — ECG changes, including ST segment depression, T wave inversion, and prolonged PR intervals, are seen in 15% of mumps infections. Fatal myocarditis with dilated cardiomyopathy has been reported but is extremely rare. 
• Pancreatitis — affects about 4% of people but is usually mild. 
• 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), migratory polyarthritis, thyroiditis, mastitis, prostatitis, hepatitis, and thrombocytopenia.

[Hviid, 2008; Litman, 2016; BMJ Best Practice, 2023]

When should I suspect a diagnosis of mumps?

• The diagnosis of mumps is usually clinical and is confirmed by laboratory analysis of a saliva sample to detect the presence of immunoglobulin (Ig)M mumps antibody. 
• Consider a diagnosis of mumps in people presenting with parotitis (swollen parotid glands) — this is present in 95% of symptomatic cases.  
  • Typically, one parotid gland is affected first, reaching a 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).
  • 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 (which may precede parotitis), such as low-grade fever, headache, earache, malaise, muscle ache, and loss of appetite — typically occur 1 day before overt signs of parotitis and peak around the time the parotid glands are most swollen.
  • Complications — these may occur in the absence of parotitis.
    • Epididymo-orchitis — 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. It 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 the section on Epididymo-orchitis in the CKS topic Scrotal pain and swelling. 
    • Oophoritis — this causes nausea, vomiting, and lower abdominal pain. 
    • Viral meningitis — 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 — this is usually unilateral and is rarely permanent.
    • Pancreatitis — causes upper abdominal discomfort 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.
    • Young adults who have not received two doses of the combined measles, mumps, and rubella (MMR) vaccine are most commonly affected. 
  • History of mumps infection — 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 local Health Protection Team (HPT) to find out if there are any localized outbreaks of mumps.
  • Age — mumps is unlikely in infants aged under 1 year.
• 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 HPT — notification should be based on clinical suspicion and should not await laboratory confirmation. 

What else may cause parotitis?

• 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.
  • Acute suppurative parotitis — acute bacterial infection, most commonly caused by Staphylococcal aureus. It may also be caused by atypical mycobacteria (for example, tuberculosis).
• Non-infectious causes of parotitis include:
  • Parotid duct obstruction – for example, salivary stones, cysts or tumours. 
  • 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, granulomatosis with polyangIitis [previously known as Wegener's granulomatosis]).

Scenario: Management

From birth onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of mumps, with additional searches on the management of mumps in pregnant women and immunocompromised patients. 

Search dates

December 2018 - November 2023

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 3rd December 2018). Search filters were not applied, and all results were screened. The strategy was adapted for The Cochrane Library databases. 

S5    S1 OR S2 OR S3 OR S4
S4    AB ( (epididymo-orchitis or epididymoorchitis or orchitis) ) OR TI ( (epididymo-orchitis or epididymoorchitis or orchitis) )
S3    (MH "Orchitis")
S2    AB mumps OR TI mumps
S1    (MH "Mumps")

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • 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
• The Cochrane Library:
  • 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

• The Cochrane Library:
  • 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

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.