“Can I notify a case of meningitis?” asked the sleepy sounding Junior Doctor.
“You notify Public Health England, not Microbiology” explained the Microbiologist.
“Damn, I thought I asked for PHE, sorry” said the Doctor. “Oh well, I‘ll call them in a moment. Can I ask you about the patient as well?”
“Sure”
“The patient is an eighteen year old student back from University for the holidays. They have a severe headache, neck stiffness and photophobia. We are about to do a lumbar puncture. Is there anything additional we should look for?”
“Don’t forget the protein and glucose, but have you thought of mumps? Has the patient been vaccinated?”
“Errrr….sorry I don’t know”
“You notify Public Health England, not Microbiology” explained the Microbiologist.
“Damn, I thought I asked for PHE, sorry” said the Doctor. “Oh well, I‘ll call them in a moment. Can I ask you about the patient as well?”
“Sure”
“The patient is an eighteen year old student back from University for the holidays. They have a severe headache, neck stiffness and photophobia. We are about to do a lumbar puncture. Is there anything additional we should look for?”
“Don’t forget the protein and glucose, but have you thought of mumps? Has the patient been vaccinated?”
“Errrr….sorry I don’t know”
“Okay, get some more history and find out if they have had the MMR and are therefore vaccinated against mumps. See if they have any tender salivary glands, especially the parotid, and do still get that LP done. To begin with cover for bacterial meningitis anyway with Ceftriaxone and watch out for any signs of encephalitis such as confusion, reduced consciousness or seizures, oh and if you’ve been up most of the night…schedule in a coffee break, you won’t work any better on your last legs!”
“OK, thanks, I’ll get a cup while I’m on hold for the PHE!” said the junior and rang off.
Why do we vaccinate against mumps?
In the UK, prior to the introduction of MMR in 1988, 90% of adults had evidence of past infection with mumps. Mumps presents in various ways:
Okay, so none of these presentations are particularly pleasant but they don’t really explain why a mumps vaccine is so important. The reason we vaccinate against mumps is because it used to be the most common cause of meningitis in the UK, not to mention it was a leading cause of hearing loss in children. Meningitis occurs in 10% of mumps cases but is usually self-limiting. So what, it’s self-limiting…. But added to this, encephalitis occurs in 1 in 6,000 patients with mumps. I know this doesn’t sound like much either but with a population of 65 million in the UK that meant the UK got about 10,000 cases per year…before we had the MMR vaccine. Some of these patients with mumps encephalitis develop long term complications too such as paralysis, seizures and hydrocephalus, oh… and 1% died.
In fact, prior to MMR, mumps was responsible for 1200 admissions to hospital and 100 deaths per year in the UK. And not only did mumps cause serious infections it was also responsible for many lost days of work as parents took time off to look after their children who were off from school. This is why we vaccinate against mumps! Remember we vaccinate for economic reasons too, not just the medical ones.
What is the current state of mumps in the UK?
Mumps, like all infections prevented by routine childhood vaccinations, is a notifiable disease in the UK. All suspected cases should be notified urgently to Public Health England (PHE).
It has been widely reported that measles, one of the other infections covered by MMR, is on the rise in the UK but what is going on with mumps?
Up until 2003 there had only been about 100-800 cases per year of mumps in the UK but since then as a result of falling vaccine coverage, the number of cases of mumps has climbed; with a large epidemic of over 40,000 cases in 2005. Rates have hovered around the 2000-4000 mark most years since, dropping to 1031 in 2018. In the first 3 months of 2019 there have already been 800 cases. In particular there have been a number of outbreaks in UK universities this year as the current students are part of the generation who grew up during the MMR scandal and therefore have not been vaccinated.
“OK, thanks, I’ll get a cup while I’m on hold for the PHE!” said the junior and rang off.
Why do we vaccinate against mumps?
In the UK, prior to the introduction of MMR in 1988, 90% of adults had evidence of past infection with mumps. Mumps presents in various ways:
- The most common presentation with mumps is a 2 day flu-like illness followed by painful swelling of the salivary glands, usually the parotid gland in the cheek but occasionally the sublingual or submaxillary glands, as well as a fever. The swelling usually lasts 7-10 days.
- Most doctors are aware that 20-30% of post-pubertal males with mumps develop orchitis (inflammation of the testicles) which is usually unilateral, and 5% of post-pubertal women develop oophoritis (inflammation of the ovaries). Even though sterility is a very rare sequel the alarm and reflex wince caused by the thought of painful testicles or ovaries is probably why most doctors know about this form of mumps!
- Respiratory symptoms are common in mumps (40-50%) of cases, especially in children under 5 years old.
- A mild pancreatitis is present in 4% of patients with mumps.
- 20-25% of patients with mumps are asymptomatic.
Okay, so none of these presentations are particularly pleasant but they don’t really explain why a mumps vaccine is so important. The reason we vaccinate against mumps is because it used to be the most common cause of meningitis in the UK, not to mention it was a leading cause of hearing loss in children. Meningitis occurs in 10% of mumps cases but is usually self-limiting. So what, it’s self-limiting…. But added to this, encephalitis occurs in 1 in 6,000 patients with mumps. I know this doesn’t sound like much either but with a population of 65 million in the UK that meant the UK got about 10,000 cases per year…before we had the MMR vaccine. Some of these patients with mumps encephalitis develop long term complications too such as paralysis, seizures and hydrocephalus, oh… and 1% died.
In fact, prior to MMR, mumps was responsible for 1200 admissions to hospital and 100 deaths per year in the UK. And not only did mumps cause serious infections it was also responsible for many lost days of work as parents took time off to look after their children who were off from school. This is why we vaccinate against mumps! Remember we vaccinate for economic reasons too, not just the medical ones.
What is the current state of mumps in the UK?
Mumps, like all infections prevented by routine childhood vaccinations, is a notifiable disease in the UK. All suspected cases should be notified urgently to Public Health England (PHE).
It has been widely reported that measles, one of the other infections covered by MMR, is on the rise in the UK but what is going on with mumps?
Up until 2003 there had only been about 100-800 cases per year of mumps in the UK but since then as a result of falling vaccine coverage, the number of cases of mumps has climbed; with a large epidemic of over 40,000 cases in 2005. Rates have hovered around the 2000-4000 mark most years since, dropping to 1031 in 2018. In the first 3 months of 2019 there have already been 800 cases. In particular there have been a number of outbreaks in UK universities this year as the current students are part of the generation who grew up during the MMR scandal and therefore have not been vaccinated.
Click for larger image
How is mumps diagnosed?
Mumps is usually diagnosed by looking for virus by PCR on a buccal swab (a swashbuckle!?!)… No editor chief in charge!!!! The buccal swab is taken from inside the cheek around the outflow from the parotid duct after gently massaging the parotid gland (be gentle, this is uncomfortable!). In the UK the kit for taking a swashbuckle, I mean, a buccal swab is obtained from PHE who will post the kit directly to the patient or their relatives with clear instructions on what to do.
Mumps is usually diagnosed by looking for virus by PCR on a buccal swab (a swashbuckle!?!)… No editor chief in charge!!!! The buccal swab is taken from inside the cheek around the outflow from the parotid duct after gently massaging the parotid gland (be gentle, this is uncomfortable!). In the UK the kit for taking a swashbuckle, I mean, a buccal swab is obtained from PHE who will post the kit directly to the patient or their relatives with clear instructions on what to do.
As well as taking the swab it is a good idea to take acute serum to look for IgM. IgM is usually produced within 5 days of onset of symptoms so if the acute sample is negative it should be repeated after 5-10 days to confirm antibody production and hence infection.
PCR can also be performed on CSF when meningitis or encephalitis is suspected.
How is mumps treated?
There is no specific treatment for mumps, but supportive care with antipyretics and fluids may be required. Complications such as seizures may require specialist management e.g. by a Neurologist.
Infection control precautions
Mumps is highly infectious, spread by droplets from the respiratory tract. Patients are infectious from 2 days before the salivary gland inflammation occurs until 5 days after. The incubation period is usually 16-18 days (range 12-25 days).
Patients should have precautions in place during the infectious period and if at home self-isolation should be undertaken, however in hospital precautions are:
PCR can also be performed on CSF when meningitis or encephalitis is suspected.
How is mumps treated?
There is no specific treatment for mumps, but supportive care with antipyretics and fluids may be required. Complications such as seizures may require specialist management e.g. by a Neurologist.
Infection control precautions
Mumps is highly infectious, spread by droplets from the respiratory tract. Patients are infectious from 2 days before the salivary gland inflammation occurs until 5 days after. The incubation period is usually 16-18 days (range 12-25 days).
Patients should have precautions in place during the infectious period and if at home self-isolation should be undertaken, however in hospital precautions are:
Hand Hygiene |
With soap and water or alcohol gel |
PPE |
Gloves (for contact), plastic apron, googles or visor (for splashes) and face masks (as the virus is airborne) Remove ALL PPE before leaving room |
Isolation |
Side room with own toilet facility Door to be kept closed |
Staffing |
Patients with Mumps Virus should only be cared for by staff who are known to be immune to this infection |
Environmental decontamination |
Deep cleaning of the clinical area daily and after patient is discharged |
Patient care |
If patients require investigations in other departments, inform those departments of patient’s condition in advance Patient should be last on a list and deep cleaning commence after patient’s departure |
Contacts of cases |
Contacts of cases with mumps are managed by PHE |
So after speaking to the patients parents it turned out our patient hadn’t been vaccinated against mumps, they asked the obvious question parents ask, “is this our fault!?” The standard response for this type of enquiry is “as medical staff, we are non-judgemental”.
Our patient did indeed have tender parotid glands and his lumbar puncture showed a viral meningitis. The Junior Doctor notified PHE that this was probable mumps meningitis, which was later confirmed by PCR on the CSF. Fortunately our patient didn’t develop any symptoms or signs of encephalitis and soon made a full recovery. After his discharge from hospital he did go on to have his MMR vaccine as he and his parents were now worried as he was obviously also at risk of getting measles… Maybe our non-verbal communication skills weren’t so “non-judgemental!” Please vaccinate your kids; vaccines are exceptionally safe, but many viruses, bacteria and infections are not!
Our patient did indeed have tender parotid glands and his lumbar puncture showed a viral meningitis. The Junior Doctor notified PHE that this was probable mumps meningitis, which was later confirmed by PCR on the CSF. Fortunately our patient didn’t develop any symptoms or signs of encephalitis and soon made a full recovery. After his discharge from hospital he did go on to have his MMR vaccine as he and his parents were now worried as he was obviously also at risk of getting measles… Maybe our non-verbal communication skills weren’t so “non-judgemental!” Please vaccinate your kids; vaccines are exceptionally safe, but many viruses, bacteria and infections are not!
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