Mumps

Mumps is in the same vaccine as measles and rubella and gets the least attention of the three. In gynaecology it is a subject all the same – because of a worry that is raised regularly and for women is almost always unfounded: the question of fertility.

What mumps is

Mumps is caused by a virus that mainly affects the salivary glands. It is transmitted by droplets and by saliva – when speaking, coughing, kissing or through shared crockery.

Between infection and illness lie 16 to 18 days. You are infectious from two days before to five days after the glands swell. About a third of all infections run without any recognisable symptoms – you are infectious all the same.

The typical picture is swelling of the parotid gland: on one side at first, usually on both after a few days. The face looks puffed out like a hamster’s, chewing hurts, and sour foods make the pain worse. Fever, headache and aching limbs come with it. After about a week it settles.

Treatment is purely for relief, because there is no medicine against the virus itself: soft, non-acidic food, drinking enough, cooling or warming the swelling – whichever feels better – painkillers and something for the fever. The illness heals by itself as a rule, and treatment serves to make the week more bearable.

The question of fertility

This worry is the commonest one about mumps and comes from a connection that applies to men and to women only in a limited way.

In men after puberty, inflammation of a testicle occurs in about twenty to thirty per cent of cases, usually on one side. It is painful and can lead to shrinkage of the affected testicle. Lasting infertility is nevertheless rare – it occurs practically only after inflammation on both sides, and that is itself rare.

In women the counterpart is inflammation of an ovary, an oophoritis. It occurs in about five per cent of women who fall ill after puberty and shows itself as lower abdominal pain with fever. And here is the decisive information: lasting impairment of fertility is not established in women. The inflammation heals without damaging the egg reserve.

So if you ask in fertility counselling whether having had mumps could be the reason for difficulty conceiving: for women the answer is practically always no. The assessment then belongs in other directions – cycle, ovulation, thyroid, fallopian tubes, and of course the partner as well.

Mumps in pregnancy

The mumps virus causes no malformations. It is therefore considerably more harmless than rubella and than measles.

For the first trimester a slightly raised risk of miscarriage was described in older studies. Newer data support that only weakly, and the number of cases studied is small – mumps in pregnancy has become very rare since the vaccination was introduced.

What remains is the general strain of a febrile illness with difficulty swallowing. Treatment is symptomatic: drink enough, soft food, cooling, and paracetamol for pain and fever, which is the first choice in pregnancy. There is no treatment directed at the cause.

Why the vaccination belongs before the pregnancy

Mumps is a component of the measles-mumps-rubella vaccine, and that is a live vaccine with weakened but reproducing viruses. Such vaccines are not given in pregnancy.

In practice that means: two doses at least four weeks apart, and then a month’s wait before a pregnancy. If vaccination was inadvertently given in an existing pregnancy, no further measures follow – in the registers of inadvertently vaccinated pregnant women no harm occurred.

Because mumps is in the same vaccine as rubella and measles, the decision about it is not a separate one anyway. Anyone settling their rubella protection before a pregnancy settles mumps automatically. That is the practical reason why this subject rarely gets a consultation of its own.

After the birth the vaccination is unproblematic and expressly possible while breastfeeding. If you find during the postnatal period that protection is missing, make it good then.

Difficulty conceiving: what is actually assessed

Because the question about mumps almost always comes from this direction, here is the context it belongs in. Difficulty conceiving is spoken of when no pregnancy has occurred after twelve months of regular intercourse without contraception – in women from 35 after six months, because time weighs differently there.

The assessment starts with both partners at the same time, and for a factual reason: in about a third of cases the cause lies with the woman, in a third with the man and in a third with both or it remains unexplained. A semen analysis is simple, quick and painless – putting it at the beginning often saves months of investigation in the wrong direction.

In the woman the questions come in order:

• Is ovulation happening? That is shown by the pattern of the cycle, a progesterone value about seven days after the presumed ovulation, and following the follicle on ultrasound.
• Are the hormones right? FSH, LH, oestradiol and AMH on day three to five of the cycle, plus thyroid and prolactin. Polycystic ovary syndrome is the commonest hormonal cause in the childbearing years.
• Are the tubes open? That is checked by contrast ultrasound or by laparoscopy.
• Are there changes in the uterus? Fibroids, polyps and adhesions are shown by ultrasound.
• Is there endometriosis? Painful periods, pain during intercourse and discomfort on opening the bowels during bleeding are the clues that are followed up.

What does not appear in this list is having had mumps. It appears in no guideline on assessing female fertility either – simply because no established connection exists.

What does need checking before any planned pregnancy: rubella protection, thyroid, iron and vitamin D, plus folic acid from four weeks before conception. The screening planner lists it.

The MMR vaccine in detail

The vaccine contains weakened viruses of all three illnesses. In Austria it is given in the first and second year of life; the first dose from the completed ninth month, the second at the earliest four weeks later. For adults without sufficient protection the same two-dose schedule applies.

The typical side effects follow from its live nature: in about five in a hundred vaccinated people, a slight fever and a fleeting rash appear one to two weeks afterwards, so-called vaccine measles. They are not infectious. Swelling of the parotid gland as a reaction to the mumps component occurs and is harmless; in women temporary joint pain can occur, going back to the rubella component.

Between two live vaccines – such as MMR and chickenpox – either the same day or at least four weeks should apply. An allergy to hen’s egg is, contrary to the widespread assumption, no obstacle. Vaccination is not given with marked immune deficiency, during immunosuppressive treatment, or in pregnancy.

The protection and its limit

The mumps component is the weakest of the three in the MMR vaccine. After two doses effectiveness is around eighty to eighty-eight per cent – for measles it is over ninety-five, and for rubella likewise.

In addition, protection wanes over the years. That explains a phenomenon that recurs in Europe and North America: mumps outbreaks among young adults who have had two doses – typically in student halls, sports teams or the military, wherever many young people live closely together.

These outbreaks are occasionally cited as an argument against vaccination. That does not hold: vaccinated people fall ill less often and considerably more mildly, and complications are considerably rarer in them. Protection of eighty per cent is not absent protection. The error of reasoning behind it is statistical: in an almost fully vaccinated population most of those who fall ill are necessarily vaccinated, because there are hardly any unvaccinated people – that says nothing about effectiveness, only something about the composition of the population.

During outbreaks a third dose is temporarily recommended for the groups affected. A general third dose for everyone is not provided for.

Why mumps is vaccinated against although it seems harmless

Of the three illnesses in the MMR vaccine, mumps has the most harmless reputation – and not entirely undeservedly: in small children it usually runs unspectacularly, and a third notice nothing at all.

The reason for including it in the programme lies elsewhere. Before vaccination, practically everyone had mumps at some point, usually in childhood. As soon as a population is partly vaccinated, the age of illness shifts upwards – and that is exactly where complications become more frequent. Inflammation of testicle and ovary occurs almost exclusively after puberty, as does inflammation of the pancreas.

From that follows a principle that applies to several vaccinations: half-hearted coverage can be worse than none, because it shifts the illness into a less favourable age without preventing it. That is why, with mumps as with rubella, consistent completion of the two-dose schedule is emphasised.

The second reason is inner ear deafness. It is rare but permanent, and before vaccination mumps was one of the commonest causes of one-sided deafness in childhood. Lasting damage of that kind weighs differently from a week with swollen cheeks.

Complications that occur

• Meningitis. In up to ten per cent of cases signs of involvement of the meninges appear. It usually runs mildly and heals without consequence – but is the commonest reason for a hospital stay with mumps.
• Inner ear deafness. Rare, usually one-sided, but permanent. Before vaccination mumps was one of the commonest causes of acquired one-sided deafness in childhood.
• Inflammation of the pancreas. In about four per cent, with nausea and upper abdominal pain.
• Inflammation of testicle and ovary after puberty, see above.

This list explains why mumps is in the vaccination programme despite its harmless reputation. The course in children is usually unspectacular – the later in life the illness occurs, the more frequent the complications.

Mumps while breastfeeding

If a breastfeeding mother falls ill, breastfeeding is as a rule continued. The virus does pass into breast milk, but the baby has already had contact through close proximity anyway – and with the milk it also receives antibodies. Stopping breastfeeding in this situation brings nothing but extra effort in an already exhausting time.

What does make breastfeeding harder in practice is something else: the swollen, tender salivary glands make every movement of the head uncomfortable. A comfortable feeding position, cooling from outside and a painkiller help more than any consideration about the milk. Paracetamol and ibuprofen are both possible while breastfeeding.

The MMR vaccination itself is expressly safe while breastfeeding. The weakened vaccine virus passes into the milk only in small amounts and causes no illness in the baby. So if you find during the postnatal period that protection is missing, make it good then – the next opportunity before a pregnancy often comes later than planned.

How mumps is diagnosed

The swollen parotid gland is typical but not conclusive. Mumps is confused with a bacterial infection of the salivary gland, with a salivary stone, with swollen lymph nodes and with illnesses caused by other viruses that can produce the same picture.

The diagnosis is confirmed by PCR from a throat swab, from saliva or from urine, supplemented by IgM antibodies in the blood. In vaccinated people serology is hard to interpret, because vaccination produces the same antibodies and the IgM response can be absent in reinfection – here PCR is the more reliable route.

Mumps is notifiable in Austria. An investigation of contacts follows from the notification; unprotected contacts can be temporarily excluded from community facilities.

After contact, vaccination within three days is possible. Unlike with measles, however, that does not reliably prevent the illness breaking out – the incubation period of over two weeks is too long and protection builds too slowly. It is still worthwhile, because it establishes lasting protection and covers further contacts. For pregnant women without protection the same applies as with the other live vaccines: do not vaccinate, but avoid contacts and have symptoms investigated.

The vaccination card: what should actually be in it

Because this text refers to the vaccination card several times, here is what to look for specifically. What you are looking for is an entry with a trade name such as Priorix, M-M-RVaxPro or – for four-component vaccines including chickenpox – ProQuad or Priorix-Tetra, each with a date and batch number. Two such entries at least four weeks apart mean full protection against measles, mumps and rubella.

Common pitfalls: a single entry is not full immunisation. Older single vaccines against only one of the three count only for that one. And entries from abroad use different trade names – here the list of components, which is usually written alongside, helps.

If the card is missing entirely, there are three routes. Ask at the paediatric or GP practice of your childhood; a blood test for the titre; or simply vaccinate. The third is often the most pragmatic: an additional MMR dose where protection already exists does no harm, it is neutralised by the immune system before it can do anything. In terms of cost it makes no difference in Austria anyway, because the vaccination is available free of charge.

A note for planning: anyone who has to catch up two doses needs at least four weeks between them and then a month before a pregnancy – around two months in all. That is little if you plan for it, and annoying if it occurs to you when the test is positive.

What this means for you

The practical part is short. Look in your vaccination card before a pregnancy occurs. If two MMR doses are recorded, measles, mumps and rubella are all settled at once. If there is one or none, it can be resolved with two appointments and a month’s wait; the vaccination is available free of charge in Austria for all age groups.

And if the question of fertility is behind it: for women, having had mumps is practically never the explanation for difficulty conceiving. What needs assessing instead is in the screening planner – and the question of whether and when ovulation happens can at least be narrowed down with the ovulation calculator before you talk about it.

To settle your vaccination status, for pre-conception counselling or for antenatal care: make an appointment.