If You Have Had the Measels Can You Get It Again

Measles, Mumps, and Rubella

Disease Issues Contraindications and Precautions Vaccine Recommendations Pregnancy and Postpartum Considerations Administering Vaccines Vaccine Safety Scheduling Vaccines Storage and Handling For Healthcare Personnel

Disease Issues

What is the current situation with measles, mumps, and rubella in the United States?

In 2019, a provisional total of 1,242 cases of measles from 31 states were reported to CDC. This was the largest number reported in a single year since 1992; 73% of cases were associated with outbreaks among unvaccinated people in New York. These outbreaks were contained and stopped before the end of 2019. Between January 1 and August 19, 2020, just 12 measles cases were reported by 7 jurisdictions. Limited travel as a result of the COVID-19 pandemic drastically reduced opportunities for travelers infected with measles to enter or travel within the United States. CDC measles surveillance updates can be found at www.cdc.gov/measles/cases-outbreaks.html.

Since the pre-vaccine era, there has been a more than 99% decrease in mumps cases in the United States. However, outbreaks still occasionally occur. In 2006, there was an outbreak affecting more than 6,584 people in the United States, with many cases occurring on college campuses. In 2009, an outbreak started in close-knit religious communities and schools in the Northeast, resulting in more than 3,000 cases. Since 2015, numerous outbreaks have been reported across the US, in college campuses, prisons, and close-knit communities, including a large outbreak in northwest Arkansas where almost 3,000 cases were reported in 2016. These outbreaks have shown that when people with mumps have close contact with a lot of other people (such as among residential college students and families in close-knit communities) mumps can spread even among vaccinated people. However, outbreaks are much larger in areas where vaccine coverage rates are lower. A provisional total of 3,484 cases of mumps were reported to CDC in 2019.

Rubella was declared eliminated (the absence of endemic transmission for 12 months or more) from the United States in 2004. Fewer than 10 cases (primarily import-related) have been reported annually in the United States since elimination was declared. Rubella incidence in the United States has decreased by more than 99% from the pre-vaccine era. A provisional total of 3 cases of rubella, and no cases of congenital rubella syndrome, were reported in 2019.

How serious are measles, mumps, and rubella?

Measles can lead to serious complications and death, even with modern medical care. The 1989–1991 measles outbreak in the U.S. resulted in more than 55,000 cases and more than 100 deaths. In the United States, from 1987 to 2000, the most commonly reported complications associated with measles infection were pneumonia (6%), otitis media (7%), and diarrhea (8%). For every 1,000 reported measles cases in the United States, approximately one case of encephalitis and two to three deaths resulted. The risk for death from measles or its complications is greater for infants, young children, and adults than for older children and adolescents.

Mumps most commonly causes fever and parotitis. Up to 25% of persons with mumps have few or no symptoms. Complications of mumps include orchitis (inflammation of the testicle) and oophoritis (inflammation of the ovary). Other complications of mumps include pancreatitis, deafness, aseptic meningitis, and encephalitis. Mumps illness is typically milder, with fewer complications, in fully vaccinated case patients.

Rubella is generally a mild illness with low-grade fever, lymphadenopathy, and malaise. Up to 50% of rubella virus infections are subclinical. Complications can include thrombocytopenic purpura and encephalitis. Rubella virus is teratogenic and infection in a pregnant woman, especially during the first trimester can result in miscarriage, stillbirth, and birth defects including cataracts, hearing loss, mental retardation, and congenital heart defects.

What are the signs and symptoms healthcare providers should look for in diagnosing measles?

Healthcare providers should suspect measles in patients with a febrile rash illness and the clinically compatible symptoms of cough, coryza (runny nose), and/or conjunctivitis (red, watery eyes). The illness begins with a prodrome of fever and malaise before rash onset. A clinical case of measles is defined as an illness characterized by

• a generalized rash lasting 3 or more days, and • a temperature of 101°F or higher (38.3°C or higher), and • cough, coryza, and/or conjunctivitis.

Koplik spots, a rash present on mucous membranes, are considered pathognomonic for measles. Koplik spots occur from 1 to 2 days before the measles rash appears to 1 to 2 days afterward. They appear as punctate blue-white spots on the bright red background of the buccal mucosa. Pictures of measles rash and Koplik spots can be found at www.cdc.gov/measles/about/photos.html.

Providers should be especially aware of the possibility of measles in people with fever and rash who have recently traveled abroad or who have had contact with international travelers.

Providers should immediately isolate and report suspected measles cases to their local health department and obtain specimens for measles testing, including viral specimens for confirmation and genotyping. Providers should also collect blood for serologic testing during the first clinical encounter with a person who has suspected or probable measles.

What should our clinic do if we suspect a patient has measles?

Measles is highly contagious. A person with measles is infectious up to 4 days before through 4 days after the day of rash onset. Patients with suspected measles should be isolated for 4 days after they develop a rash. Airborne precautions should be followed in healthcare settings by all healthcare personnel. The preferred placement for patients who require airborne precautions is in a single-patient airborne infection isolation room. Providers should immediately isolate and report suspected measles cases to their local health department and obtain specimens for measles testing, including serum sample for measles serologic testing and a throat swab (or nasopharyngeal swab) for viral confirmation.

Measles is a nationally notifiable disease in the U.S.; healthcare providers should report all cases of suspected measles to public health authorities immediately to help reduce the number of secondary cases. Do not wait for the results of laboratory testing to report clinically-suspected measles to the local health department.

More information on measles disease, diagnostic testing, and infection control can be found at www.cdc.gov/measles/hcp/index.html.

How long does it take to show signs of measles, mumps, and rubella after being exposed?

For measles, there is an average of 10 to 12 days from exposure to the appearance of the first symptom, which is usually fever. The measles rash doesn't usually appear until approximately 14 days after exposure (range: 7 to 21 days), and the rash typically begins 2 to 4 days after the fever begins. The incubation period of mumps averages 16 to 18 days (range: 12 to 25 days) from exposure to onset of parotitis. The incubation period of rubella is 14 days (range: 12 to 23 days). However, as noted above, up to half of rubella virus infections cause no symptoms.

Vaccine Recommendations Back to top

What are the current recommendations for the use of MMR vaccine?

The most recent comprehensive ACIP recommendations for the use of MMR vaccine were published in 2013 and are available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf. MMR vaccine is recommended routinely for all children at age 12 through 15 months, with a second dose at age 4 through 6 years. The second dose of MMR can be given as early as 4 weeks (28 days) after the first dose and be counted as a valid dose if both doses were given after the child's first birthday. The second dose is not a booster, but rather is intended to produce immunity in the small number of people who fail to respond to the first dose.

Adults with no evidence of immunity (evidence of immunity is defined as documented receipt of 1 dose [2 doses 4 weeks apart if high risk] of live measles virus-containing vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or birth before 1957) should get 1 dose of MMR vaccine unless the adult is in a high-risk group. High-risk people need 2 doses and include school-age children, healthcare personnel, international travelers, and students attending post-high school educational institutions.

Live attenuated measles vaccine became available in the U.S. in 1963. An ineffective, inactivated measles vaccine was also available in the U.S. in 1963–1967. Combined MMR vaccine (MMRII, Merck) was licensed in 1971. For people who previously received a dose of measles vaccine in 1963–1967 and are unsure which type of vaccine it was, or are sure it was inactivated measles vaccine, that dose should be considered invalid and the patient revaccinated as age- and risk-appropriate with MMR vaccine. At the discretion of the state public health department, anyone exposed to measles in an outbreak setting can receive an additional dose of MMR vaccine even if they are considered completely vaccinated for their age or risk status.

What is considered acceptable evidence of immunity to measles?

Acceptable presumptive evidence of immunity against measles includes at least one of the following:

• written documentation of adequate vaccination: • laboratory evidence of immunity • laboratory confirmation of measles (verbal history of measles does not count) • birth before 1957

Although birth before 1957 is considered acceptable evidence of measles immunity, healthcare facilities should consider vaccinating unvaccinated personnel born before 1957 who do not have other evidence of immunity with 2 doses of MMR vaccine (minimum interval 28 days).

During an outbreak of measles, healthcare facilities should recommend 2 doses of MMR vaccine at the appropriate interval for unvaccinated healthcare personnel regardless of birth year if they lack laboratory evidence of measles immunity.

For which adults are 0, 1, or 2 doses of MMR vaccine recommended to prevent measles?

Zero, one, or two doses of MMR vaccine are needed for the adults described below.

Zero doses:

• adults born before 1957 except healthcare personnel* • adults born 1957 or later who are at low risk (i.e., not an international traveler or healthcare worker, or person attending college or other post-high school educational institution) and who have already received one or more documented doses of live measles vaccine • adults with laboratory evidence of immunity or laboratory confirmation of measles

One dose of MMR vaccine:

• adults born 1957 or later who are at low risk (i.e., not an international traveler, healthcare worker, or person attending college or other post-high school educational institution) and have no documented vaccination with live measles vaccine and no laboratory evidence of immunity or prior measles infection

Two doses of MMR vaccine:

� high-risk adults without any prior documented live measles vaccination and no laboratory evidence of immunity or prior measles infection, including:

Persons who previously received a dose of measles vaccine in 1963–1967 and are unsure which type of vaccine it was, or are sure it was inactivated measles vaccine, should be revaccinated with either one (if low-risk) or two (if high-risk) doses of MMR vaccine.

* Healthcare personnel born before 1957 should be considered for MMR vaccination in the absence of an outbreak, but are recommended for MMR vaccination during outbreaks.

Given the risk of outbreaks of measles in the U.S., should all healthcare personnel, including those born before 1957, have 2 doses of MMR vaccine?

Although birth before 1957 is considered acceptable evidence of measles immunity for routine vaccination, healthcare facilities should consider vaccinating unvaccinated healthcare personnel (HCP) born before 1957 who do not have laboratory evidence of measles immunity, laboratory confirmation of disease, or vaccination with 2 appropriately spaced doses of MMR vaccine.

However, during a local outbreak of measles, all healthcare personnel, including those born before 1957, are recommended to have 2 doses of MMR vaccine at the appropriate interval if they lack laboratory evidence of measles.

Healthcare facilities should check with their state or local health department's immunization program for guidance. Access contact information here: www.immunize.org/coordinators.

If there is an outbreak in my area, can we vaccinate children younger than 12 months?

MMR can be given to children as young as 6 months of age who are at high risk of exposure such as during international travel or a community outbreak. However, doses given BEFORE 12 months of age cannot be counted toward the 2-dose series for MMR.

How does being born before 1957 confer immunity to measles?

People born before 1957 lived through several years of epidemic measles before the first measles vaccine was licensed in 1963. As a result, these people are very likely to have had measles disease. Surveys suggest that 95% to 98% of those born before 1957 are immune to measles. Persons born before 1957 can be presumed to be immune. However, if serologic testing indicates that the person is not immune, at least 1 dose of MMR should be administered.

Why is a second dose of MMR necessary?

Approximately 7% of people do not develop measles immunity after the first dose of vaccine. This occurs for a variety of reasons. The second dose is to provide another chance to develop measles immunity for people who did not respond to the first dose. About 97% of people develop immunity to measles after two doses of measles-containing vaccine.

Are there any situations where more than 2 doses of MMR are recommended?

There are two circumstances when a third dose of MMR is recommended. ACIP recommends that women of childbearing age who have received 2 doses of rubella-containing vaccine and have rubella serum IgG levels that are not clearly positive should receive 1 additional dose of MMR vaccine (maximum of 3 doses). Further testing for serologic evidence of rubella immunity is not recommended. MMR should not be administered to a pregnant woman.

In 2018, ACIP published guidance for MMR vaccination of people at increased risk for acquiring mumps during an outbreak. People previously vaccinated with 2 doses of a mumps virus�containing vaccine who are identified by public health authorities as being part of a group or population at increased risk for acquiring mumps because of an outbreak should receive a third dose of a mumps virus�containing vaccine (MMR or MMRV) to improve protection against mumps disease and related complications. More information about this recommendation is available at www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6701a7-H.pdf.

When is it appropriate to use MMR vaccine for measles post-exposure prophylaxis?

MMR vaccine given within 72 hours of initial measles exposure can reduce the risk of getting sick or reduce the severity of symptoms. Another option for exposed, measles-susceptible individuals at high risk of complications who cannot be vaccinated is to give immunoglobulin (IG) within six days of exposure. Do not administer MMR vaccine and IG simultaneously, as the IG invalidates the vaccine.

Information on post-exposure prophylaxis for measles can be found in the 2013 ACIP guidance at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf, page 24.

Do any adults need "booster" doses of MMR vaccine to prevent measles?

No. Adults with evidence of immunity do not need any further vaccines. No "booster" doses of MMR vaccine are recommended for either adults or children. They are considered to have life-long immunity once they have received the recommended number of MMR vaccine doses or have other evidence of immunity.

Many people who were young children in the 1960s do not have records indicating what type of measles vaccine they received in the mid-1960s. What measles vaccine was most frequently given in that time period? That guidance would assist many older people who would prefer not to be revaccinated.

Both killed and live attenuated measles vaccines became available in 1963. Live attenuated vaccine was used more often than killed vaccine. The killed vaccine was found to be not effective and people who received it should be revaccinated with live vaccine. Without a written record, it is not possible to know what type of vaccine an individual may have received. So persons born during or after 1957 who received killed measles vaccine or measles vaccine of unknown type, or who cannot document having been vaccinated or having laboratory-confirmed measles disease should receive at least 1 dose of MMR. Some people at increased risk of exposure to measles (such as healthcare professionals and international travelers) should receive 2 doses of MMR separated by at least 4 weeks.

Do people who received MMR in the 1960s need to have their dose repeated?

Not necessarily. People who have documentation of receiving live measles vaccine in the 1960s do not need to be revaccinated. People who were vaccinated prior to 1968 with either inactivated (killed) measles vaccine or measles vaccine of unknown type should be revaccinated with at least one dose of live attenuated measles vaccine. This recommendation is intended to protect people who may have received killed measles vaccine which was available in the United States in 1963 through 1967 and was not effective. People vaccinated before 1979 with either killed mumps vaccine or mumps vaccine of unknown type who are at high risk for mumps infection (such as people who work in a healthcare facility) should be considered for revaccination with 2 doses of MMR vaccine.

I understand that ACIP changed its definition of evidence of immunity to measles, rubella, and mumps in 2013. Please explain.

In the 2013 revision of its MMR vaccine recommendations ACIP includes laboratory confirmation of disease as evidence of immunity for measles, mumps, and rubella. ACIP removed physician diagnosis of disease as evidence of immunity for measles and mumps. Physician diagnosis of disease had not previously been accepted as evidence of immunity for rubella. With the decrease in measles and mumps cases over the last 30 years, the validity of physician-diagnosed disease has become questionable. In addition, documenting history from physician records is not a practical option for most adults. The 2013 MMR ACIP recommendations are available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.

Is there anything that can be done for unvaccinated people who have already been exposed to measles, mumps, or rubella?

Measles vaccine, given as MMR, may be effective if given within the first 3 days (72 hours) after exposure to measles. Immune globulin may be effective for as long as 6 days after exposure. Postexposure prophylaxis with MMR vaccine does not prevent or alter the clinical severity of mumps or rubella. However, if the exposed person does not have evidence of mumps or rubella immunity they should be vaccinated since not all exposures result in infection.

What are the current ACIP recommendations for use of immune globulin (IG) for measles, mumps, and rubella post-exposure prophylaxis?

In the 2013 revision of its MMR vaccine recommendations ACIP expanded the use of post-exposure IG prophylaxis for measles. Intramuscular IG (IGIM) should be administered to all infants younger than 12 months who have been exposed to measles. The dose of IGIM is 0.5 mL/kg of body weight; the maximum dose is 15 mL. Alternatively, MMR vaccine can be given instead of IGIM to infants age 6 through 11 months, if it can be given within 72 hours of exposure.

Pregnant women without evidence of measles immunity who are exposed to measles should receive an intravenous IG (IGIV) dose of 400 mg/kg of body weight. Severely immunocompromised people, irrespective of evidence of measles immunity or vaccination, who have been exposed to measles should receive an IGIV dose of 400 mg/kg of body weight.

For persons already receiving IGIV therapy, administration of at least 400 mg/kg body weight within 3 weeks before measles exposure should be sufficient to prevent measles infection. For patients receiving subcutaneous immune globulin (IGSC) therapy, administration of at least 200 mg/kg body weight for 2 consecutive weeks before measles exposure should be sufficient.

Other people who do not have evidence of measles immunity can receive an IGIM dose of 0.5 mL/kg of body weight. Give priority to people who were exposed to measles in settings where they have intense, prolonged close contact (such as household, child care, classroom, etc.). The maximum dose of IGIM is 15 mL.

IG is not indicated for persons who have received 1 dose of measles-containing vaccine at age 12 months or older unless they are severely immunocompromised. IG should not be used to control measles outbreaks.

IG has not been shown to prevent mumps or rubella infection after exposure and is not recommended for that purpose.

We often see college students who lack vaccination records, but whose titer results show they are not immune to some combination of measles, rubella, and/or mumps. What type of vaccine should these students receive?

Single antigen vaccine is no longer available in the U.S.; the student should get the combined MMR vaccine. If a college student or other person at increased risk of exposure cannot produce written documentation of either immunization or disease, and titers are negative, they should receive two doses of MMR.

I have patients who claim to remember receiving MMR vaccine but have no written record, or whose parents report the patient has been vaccinated. Should I accept this as evidence of vaccination?

No. Self-reported doses and history of vaccination provided by a parent or other caregiver are not considered to be valid. You should only accept a written, dated record as evidence of vaccination.

Under what circumstances should adults be considered for testing for measles-specific antibody prior to getting vaccinated?

Adults without evidence of immunity and no contraindications to MMR vaccine can be vaccinated without testing. Only adults without evidence of immunity might be considered for testing for measles-specific IgG antibody, but testing is not needed prior to vaccination.

CDC does not recommend measles antibody testing after MMR vaccination to verify the patient's immune response to vaccination.

Two documented doses of MMR vaccine given on or after the first birthday and separated by at least 28 days is considered proof of measles immunity, according to ACIP. Documentation of appropriate vaccination supersedes the results of serologic testing for measles, mumps, rubella, and varicella.

A patient born in 1970 has a history of measles disease and is also immunosuppressed due to multiple myeloma. The patient wants to travel to Africa, but is concerned about the measles exposure risk. Should the patient receive the MMR vaccine?

A history of having had measles is not sufficient evidence of measles immunity. A positive serologic test for measles-specific IgG will confirm that the person is immune and is not at risk of infection regardless of the multiple myeloma. Multiple myeloma is a hematologic cancer and is considered immunosuppressive so MMR vaccine is contraindicated in this person.

We have adult patients in our practice at high risk for measles, including patients going back to college or preparing for international travel, who don't remember ever receiving MMR vaccine or having had measles disease. How should we manage these patients?

You have two options. You can test for immunity or you can just give 2 doses of MMR at least 4 weeks apart. There is no harm in giving MMR vaccine to a person who may already be immune to one or more of the vaccine viruses. If you or the patient opt for testing, and the tests indicate the patient is not immune to one or more of the vaccine components, give your patient 2 doses of MMR at least 4 weeks apart. If any test results are indeterminate or equivocal, consider your patient nonimmune. ACIP does not recommend serologic testing after vaccination because commercial tests may not be sensitive enough to reliably detect vaccine-induced immunity.

I have a 45-year-old patient who is traveling to Haiti for a mission trip. She doesn't recall ever getting an MMR booster (she didn't go to college and never worked in health care). She was rubella immune when pregnant 20 years ago. Her measles titer is negative. Would you recommend an MMR booster?

ACIP recommends 2 doses of MMR given at least 4 weeks apart for any adult born in 1957 or later who plans to travel internationally. There is no harm in giving MMR vaccine to a person who may already be immune to one or more of the vaccine viruses.

A patient who was born before 1957 and is not a healthcare worker wants to get the MMR vaccine before international travel. Does he need a dose of MMR?

No, it is not considered necessary, but he may be vaccinated. Before implementation of the national measles vaccination program in 1963, virtually every person acquired measles before adulthood. So, this patient can be considered immune based on their birth year. However, MMR vaccine also may be given to any person born before 1957 who does not have a contraindication to MMR vaccination.

Routine testing of patients born before 1957 for measles-specific antibody is not recommended by CDC.

We have measles cases in our community. How can I best protect the young children in my practice?

First of all, make sure all your patients are fully vaccinated according to the U.S. immunization schedule.

In certain circumstances, MMR is recommended for infants age 6 through 11 months. Give infants this age a dose of MMR before international travel. In addition, consider measles vaccination for infants as young as age 6 months as a control measure during a U.S. measles outbreak. Consult your state health department to find out if this is recommended in your situation. Do not count any dose of MMR vaccine as part of the 2-dose series if it is administered before a child's first birthday. Instead, repeat the dose when the child is age 12 months.

In the case of a local outbreak, you also might consider vaccinating children age 12 months and older at the minimum age (12 months, instead of 12 through 15 months) and giving the second dose 4 weeks later (at the minimum interval) instead of waiting until age 4 through 6 years.

Finally, remember that infants too young for routine vaccination and people with medical conditions that contraindicate measles immunization depend on high MMR vaccination coverage among those around them. Be sure to encourage all your patients and their family members to get vaccinated if they are not immune.

During a mumps outbreak should we offer a third dose of MMR (MMR II, Merck) to persons who have two prior documented doses of MMR?

In recent years, mumps outbreaks have occurred primarily in populations in institutional settings with close contact (such as residential colleges) or in close-knit social groups. The current routine recommendation for 2 doses of MMR vaccine appears to be sufficient for mumps control in the general population, but insufficient for preventing mumps outbreaks in prolonged, close-contact settings, even where coverage with 2 doses of MMR vaccine is high.

In January 2018, the Advisory Committee on Immunization Practices (ACIP) published new guidance for MMR vaccination of persons at increased risk for acquiring mumps during an outbreak. Persons previously vaccinated with 2 doses of a mumps virus�containing vaccine who are identified by public health authorities as being part of a group at increased risk for acquiring mumps because of an outbreak should receive a third dose of a mumps virus�containing vaccine to improve protection against mumps disease and related complications. More information about this recommendation is available at www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6701a7-H.pdf.

In a measles outbreak, do children who have not had MMR vaccine pose a threat to vaccinated people? It is my understanding that vaccinated people can still contract measles. Am I correct?

You are correct that vaccinated people can still be infected with viruses or bacteria against which they are vaccinated. No vaccine is 100% effective. Vaccine effectiveness varies from greater than 95% (for diseases such as measles, rubella, and hepatitis B) to much lower (60% for influenza in years with a good match of circulating and vaccine viruses, and 70% for acellular pertussis vaccines in the 3-5 years after vaccination). More information is available for each vaccine and disease at www.cdc.gov/vaccines/vpd-vac/default.htm and www.immunize.org/vaccines.

Administering Vaccines Back to top

Our clinic has been giving MMR by the wrong route (IM rather than SC) for years. Should these doses be repeated?

All live injected vaccines (MMR, varicella, and yellow fever) are recommended to be given subcutaneously. However, intramuscular administration of any of these vaccines is not likely to decrease immunogenicity, and doses given IM do not need to be repeated.

We often need to give MMR vaccine to large adults. Is a 25-gauge needle with a length of 5/8" sufficient for a subcutaneous injection?

Yes. A 5/8" needle is recommended for subcutaneous injections for people of all sizes.

MMRV was mistakenly given to a 31-year-old instead of MMR. Can this be considered a valid dose?

Yes, however, this issue is not addressed in the 2010 MMRV ACIP recommendations. Although this is off-label use, CDC recommends that when a dose of MMRV is inadvertently given to a patient age 13 years and older, it may be counted towards completion of the MMR and varicella vaccine series and does not need to be repeated.

Scheduling Vaccines Back to top

How soon can we give the second dose of MMR vaccine to a child vaccinated at 12 months old?

For routine vaccination, children without contraindications to MMR vaccine should receive 2 doses of MMR vaccine with the first dose at age 12–15 months old and the second dose at age 4–6 years old. The minimum interval is 28 days for dose 2. If you have an outbreak in your community or a child is traveling internationally, then consider using the minimum interval instead of waiting until age 4–6 years old for dose 2.

Does the 4-day "grace period" apply to the minimum age for administration of the first dose of MMR? What about the 28-day minimum interval between doses of MMR?

A dose of MMR vaccine administered up to 4 days before the first birthday may be counted as valid. However, school entry requirements in some states may mandate administration on or after the first birthday. The 4-day "grace period" should not be applied to the 28-day minimum interval between two doses of a live parenteral vaccine.

Can MMR be given on the same day as other live virus vaccines?

Yes. However, if two parenteral or intranasal live vaccines (MMR, varicella, LAIV and/or yellow fever) are not administered on the same day, they should be separated by an interval of at least 28 days.

If you can give the second dose of MMR as early as 28 days after the first dose, why do we routinely wait until kindergarten entry to give the second dose?

The second dose of MMR may be given as early as 4 weeks after the first dose, and be counted as a valid dose if both doses were given after the first birthday. The second dose is not a booster, but rather it is intended to produce immunity in the small number of people who fail to respond to the first dose. The risk of measles is higher in school-age children than those of preschool age, so it is important to receive the second dose by school entry. It is also convenient to give the second dose at this age, since the child will have an immunization visit for other school entry vaccines.

What is the earliest age at which I can give MMR to an infant who will be traveling internationally? Also, which countries pose a high risk to children for contracting measles?

ACIP recommends that children who travel or live abroad should be vaccinated at an earlier age than that recommended for children who reside in the United States. Before their departure from the United States, children age 6 through 11 months should receive 1 dose of MMR. The risk for measles exposure can be high in high-, middle- and low-income countries. Consequently, CDC encourages all international travelers to be up to date on their immunizations regardless of their travel destination and to keep a copy of their immunization records with them as they travel. For additional information on the worldwide measles situation, and on CDC's measles vaccination information for travelers, go to wwwnc.cdc.gov/travel.

If we give a child a dose of MMR vaccine at 6 months of age because they are in a community with cases of measles, when should we give the next dose?

The next dose should be given at 12 months of age. The child will also need another dose at least 28 days later. For the child to be fully vaccinated, they need to have 2 doses of MMR vaccine given when the child is 12 months of age and older. A dose given at less than 12 months of age does not count as part of the MMR vaccine two-dose series.

I have an 8-month-old patient who is traveling internationally. The infant needs to be protected from hepatitis A as well as measles, mumps, and rubella. The family is leaving in 11 days. Can I give hepatitis A IG and MMR vaccine simultaneously?

No. IG may contain antibodies to measles, mumps, and rubella that could reduce the effectiveness of MMR vaccine. For this reason, in February 2018 ACIP voted to recommend that hepatitis A vaccine should be administered to infants age 6 through 11 months traveling outside the United States when protection against hepatitis A is recommended. MMR and hepatitis A vaccine may be safely co-administered to children in this age group. Neither vaccine is counted as part of the child's routine vaccination series. For details of this recommendation, see the CDC ACIP recommendations for the prevention and control of hepatitis A at www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf, page 18.

Can I give the second dose of MMR earlier than age 4 through 6 years (the kindergarten entry dose) to young children traveling to areas of the world where there are measles cases?

Yes. The second dose of MMR can be given a minimum of 28 days after the first dose if necessary.

If I give MMR to an infant traveler younger than age 1 year, will that dose be considered valid for the U.S. immunization schedule?

No. A measles-containing vaccine administered more than 4 days before the first birthday should not be counted as part of the series. MMR should be repeated when the child is age 12 through 15 months (12 months if the child remains in an area where disease risk is high). The second dose should be administered at least 28 days after the first dose.

Can I give a tuberculin skin test (TST) on the same day as a dose of MMR vaccine?

Yes. A TST can be applied before or on the same day that MMR vaccine is given. However, if MMR vaccine is given on the previous day or earlier, the TST should be delayed for at least 28 days. Live measles vaccine given prior to the application of a TST can reduce the reactivity of the skin test because of mild suppression of the immune system.

An 18-year-old college student says he had both measles and mumps diseases as a preschooler, but never had MMR vaccine. Is rubella vaccine recommended in such a situation?

This student should receive two doses of MMR, separated by at least 28 days. A personal history of measles and mumps is not acceptable as proof of immunity. Acceptable evidence of measles and mumps immunity includes a positive serologic test for antibody, birth before 1957, or written documentation of vaccination. For rubella, only serologic evidence or documented vaccination should be accepted as proof of immunity. Additionally, people born prior to 1957 may be considered immune to rubella unless they are women who have the potential to become pregnant.

When not given on the same day, is the interval between yellow fever and MMR vaccines 4 weeks (28 days) or 30 days? I have seen the yellow fever and live virus vaccine recommendations published both ways.

The General Best Practice Guidelines for Immunization (see www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html) makes the generic recommendation that live parenterally or nasally administered vaccines not given on the same day should be separated by at least 28 days. The CDC travel health website recommends that yellow fever vaccine and other parenteral or nasal live vaccines should be separated by at least 30 days if possible. Either interval is acceptable.

For Healthcare Personnel Back to top

What is the recommendation for MMR vaccine for healthcare personnel?

ACIP recommends that all HCP born during or after 1957 have adequate presumptive evidence of immunity to measles, mumps, and rubella, defined as documentation of two doses of measles and mumps vaccine and at least one dose of rubella vaccine, laboratory evidence of immunity, or laboratory confirmation of disease. Further, ACIP recommends that healthcare facilities should consider vaccination of all unvaccinated healthcare personnel who were born before 1957 and who lack laboratory evidence of measles, mumps, and/or rubella immunity or laboratory confirmation of disease. During an outbreak of measles or mumps, healthcare facilities should recommend 2 doses of MMR separated by at least 4 weeks for unvaccinated healthcare personnel regardless of birth year who lack laboratory evidence of measles or mumps immunity or laboratory confirmation of disease. During outbreaks of rubella, healthcare facilities should recommend 1 dose of MMR for unvaccinated personnel regardless of birth year who lack laboratory evidence of rubella immunity or laboratory confirmation of infection or disease.

Would you consider healthcare personnel with 2 documented doses of MMR vaccine to be immune even if their serology for 1 or more of the antigens comes back negative?

Yes. Healthcare personnel (HCP) with 2 documented doses of MMR vaccine are considered to be immune regardless of the results of a subsequent serologic test for measles, mumps, or rubella. Documented age-appropriate vaccination supersedes the results of subsequent serologic testing. In contrast, HCP who do not have documentation of MMR vaccination and whose serologic test is interpreted as "indeterminate" or "equivocal" should be considered not immune and should receive 2 doses of MMR vaccine (minimum interval 28 days). ACIP does not recommend serologic testing after vaccination. For more information, see ACIP's recommendations on the use of MMR vaccine at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf, page 22.

If a healthcare worker develops a rash and low-grade fever after MMR vaccine, is s/he infectious?

Approximately 5 to 15% of susceptible people who receive MMR vaccine will develop a low-grade fever and/or mild rash 7 to 12 days after vaccination. However, the person is not infectious, and no special precautions ( such as exclusion from work) need to be taken.

A 22-year-old female is going to pharmacy school and the school wants her to have a second dose of MMR vaccine. She had the first dose as a child and developed measles within 24 hours of receiving the vaccine. Recent serologic testing showed she is immune to mumps and measles but not immune to rubella. Can I give her a second dose of the MMR with her having measles after the first dose?

Yes, as a healthcare professional, this person should get a second dose of MMR to ensure she is immune to rubella. There is no harm in providing MMR to a person who is already immune to one or more of the components. If she developed measles only one day after getting her first MMR, she must have been exposed to the disease prior to vaccination.

Contraindications and Precautions Back to top

What are the contraindications and precautions for MMR vaccine?

Contraindications:

• history of a severe (anaphylactic) reaction to any vaccine component (e.g., neomycin) or following a previous dose of MMR • pregnancy • severe immunosuppression from either disease or therapy

Precautions:

• receipt of an antibody-containing blood product in the previous 3–11 months, depending on the type of blood product received. See www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html, Table 3-5 for more information on this issue • moderate or severe acute illness with or without fever • history of thrombocytopenia or thrombocytopenic purpura • Important details about the contraindications and precautions for MMR vaccine are in the current MMR ACIP statement, available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.

We have many patients who are immunocompromised and cannot get the MMR vaccine. How should we advise our patients?

People with medical conditions that contraindicate measles immunization depend on high MMR vaccination coverage among those around them. To help prevent the spread of measles virus, make sure all your staff and patients who can be vaccinated are fully vaccinated according to the U.S. immunization schedule. Also, encourage patients to remind their family members and other close contacts to get vaccinated if they are not immune.

If patients who cannot get MMR vaccine are exposed to measles, CDC has guidelines for immune globulin for post-exposure prophylaxis which can be found at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.

We have a patient who has selective IgA deficiency. We also have patients with selective IgM deficiency. Can MMR or varicella vaccine be administered to these patients?

There is no known risk associated with MMR or varicella vaccination in someone with selective IgA or IgM deficiency. It is possible that the immune response may be weaker, but the vaccines are likely effective.

I have a patient who is traveling internationally and needs MMR vaccine. He recently received an injectable steroid. How long should he wait before receiving MMR vaccine?

There is no need to wait a specific interval before giving MMR. Injectable steroids are not considered immunosuppressive for the purpose of vaccination decisions, and so there is no concern about safety or efficacy of MMR.

Can I give MMR to a child whose sibling is receiving chemotherapy for leukemia?

Yes. MMR and varicella vaccines should be given to the healthy household contacts of immunosuppressed children.

We have a 40 lb six-year-old patient who has been taking 15 mg of methotrexate weekly for arthritis for 12 months. Can we give the child MMR and varicella vaccine based on this methotrexate dosage?

Based on the weight and dosage provided (40 lbs and 15 mg/week), the child is currently receiving more than 0.4 mg/kg/week of methotrexate. This meets the Infectious Disease Society of America (IDSA) definition of high-level immunosuppression. Administration of both varicella and MMR vaccines are contraindicated until such time as the methotrexate dosage can be reduced. The 2013 IDSA definition of low-level immunosuppression for methotrexate is a dosage of less than 0.4 mg/kg/week. For additional details, see the 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host: cid.oxfordjournals.org/content/early/2013/11/26/cid.cit684.full.pdf.

Is it true that egg allergy is not considered a contraindication to MMR vaccine?

Several studies have documented the safety of measles and mumps vaccine (which are grown in chick embryo tissue culture) in children with severe egg allergy. Neither the American Academy of Pediatrics nor ACIP consider egg allergy as a contraindication to MMR vaccine. ACIP recommends routine vaccination of egg-allergic children without the use of special protocols or desensitization procedures.

Can I give MMR to a breastfeeding mother or to a breastfed infant?

Yes. Breastfeeding does not interfere with the response to MMR vaccine. Vaccination of a woman who is breastfeeding poses no risk to the infant being breastfed. Although it is believed that rubella vaccine virus, in rare instances, may be transmitted via breast milk, the infection in the infant is asymptomatic.

If a patient recently received a blood product, can he or she receive MMR vaccine?

Yes, but there should be sufficient time between the blood product and the MMR to reduce the chance of interference. The interval depends on the blood product received. See Table 3-5 of ACIP's General Best Practice Guidelines for Immunization for more information, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html.

Is it acceptable practice to administer MMR, Tdap, and influenza vaccines to a postpartum mom at the same time as administering RhoGam?

Yes. Receipt of RhoGam is not a reason to delay vaccination. For more information see the ACIP General Best Practice Guidelines for Immunization, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html.

Please describe the current ACIP recommendations for the use of MMR vaccine in people who are infected with HIV.

ACIP recommendations for vaccinating people with HIV infection were revised in 2013. The current recommendations are as follows:

Administer 2 doses of MMR vaccine to all HIV-infected people age 12 months and older who do not have evidence of current severe immunosuppression or current evidence of measles, rubella, and mumps immunity. To be regarded as not having evidence of current severe immunosuppression, a child age 5 years or younger must have CD4 percentages of 15% or more for 6 months or longer; a person older than 5 years must have CD4 percentages of 15% or more and a CD4 lymphocyte count of 200 or more/mm3 for 6 months or longer. If laboratory results state only one type of parameter (percentage or counts) this is sufficient for vaccine decision-making.

Administer the first dose at 12 through 15 months and the second dose to children age 4 through 6 years, or as early as 28 days after the first dose.

Unless they have acceptable current evidence of measles, mumps, and rubella immunity, people with perinatal HIV infection who were vaccinated prior to establishment of effective antiretroviral therapy (ART) should receive 2 appropriately spaced doses of MMR vaccine after effective ART has been established. Established effective ART is defined as receiving ART for at least 6 months in combination with CD4 percentages of 15% or more for 6 months or longer for children age 5 years or younger. People older than 5 years should have CD4 percentages of 15% or more and a CD4 lymphocyte count of 200 or more/mm3 for 6 months or longer. If laboratory results state only one type of parameter (percentages or counts) this is sufficient for vaccine decision-making.

Pregnancy and Postpartum Considerations Back to top

What is the recommended length of time a woman should wait after receiving rubella (MMR) vaccine before becoming pregnant?

Although the MMR vaccine package insert recommends a 3-month deferral of pregnancy after MMR vaccination, ACIP recommends deferral of pregnancy for 4 weeks. For details on this issue, see ACIP's Control and Prevention of Rubella: Evaluation and Management of Suspected Outbreaks, Rubella in Pregnant Women, and Surveillance for Congenital Rubella Syndrome.

How should teenage girls and women of child-bearing age be screened for pregnancy before MMR vaccination?

ACIP recommends that women of childbearing age be asked if they are currently pregnant or attempting to become pregnant. Vaccination should be deferred for those who answer "yes." Those who answer "no" should be advised to avoid pregnancy for 4 weeks following vaccination. Pregnancy testing is not necessary.

If a pregnant woman inadvertently receives MMR vaccine, how should she be advised?

No specific action needs to be taken other than to reassure the woman that no adverse outcomes are expected as a result of this vaccination. MMR vaccination during pregnancy is not a reason to terminate the pregnancy. You should consult with others in your healthcare setting to identify ways to prevent such vaccination errors in the future. Detailed information about MMR vaccination in pregnancy is included in the most recent MMR ACIP statement, available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.

We require a pregnancy test for all our 7th graders before giving an MMR. Is this necessary?

No. ACIP recommends that women of childbearing age be asked if they are currently pregnant or attempting to become pregnant. Vaccination should be deferred for those who answer "yes." Those who answer "no" should be advised to avoid pregnancy for one month following vaccination.

Can we give an MMR to a 15-month-old whose mother is 2 months pregnant?

Yes. Measles, mumps, and rubella vaccine viruses are not transmitted from the vaccinated person, so MMR vaccination of a household contact does not pose a risk to a pregnant household member.

If a woman's rubella test result shows she is "not immune" during a prenatal visit, but she has 2 documented doses of MMR vaccine, does she need a third dose of MMR vaccine postpartum?

In 2013, ACIP changed its recommendation for this situation (see www.cdc.gov/mmwr/pdf/rr/rr6204.pdf, pages 18–20). It is recommended that women of childbearing age who have received 1 or 2 doses of rubella-containing vaccine and have rubella serum IgG levels that are not clearly positive should be administered 1 additional dose of MMR vaccine (maximum of 3 doses) and do not need to be retested for serologic evidence of rubella immunity. MMR should not be administered to a pregnant woman.

I have a female patient who has a non-immune rubella titer two months after her second MMR vaccination. Should she be revaccinated? If so, should the titer again be checked to determine seroconversion?

ACIP recommends that vaccinated women of childbearing age who have received one or two doses of rubella-containing vaccine and have a rubella serum IgG levels that is not clearly positive should be administered one additional dose of MMR vaccine (maximum of three doses). Repeat serologic testing for evidence of rubella immunity is not recommended. See www.cdc.gov/mmwr/pdf/rr/rr6204.pdf, pages 18–20, for more information on this issue.

MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant. Because of the theoretical risk to the fetus when the mother receives a live virus vaccine, women should be counseled to avoid becoming pregnant for 28 days after receipt of MMR vaccine.

How soon after delivery can MMR be given to the mother?

MMR can be administered any time after delivery. The vaccine should be administered to a woman who is susceptible to either measles, mumps, or rubella before hospital discharge, even if she has received RhoGam during the hospital stay, leaves in less than 24 hours, or is breastfeeding.

Vaccine Safety Back to top

Is there any evidence that MMR or thimerosal causes autism?

No. This issue has been studied extensively, including a thorough review by the independent Institute of Medicine (IOM). The IOM issued a report in 2004 that concluded there is no evidence supporting an association between MMR vaccine or thimerosal-containing vaccines and the development of autism. For more information on thimerosal and vaccines in general, visit www.cdc.gov/vaccinesafety/Concerns/thimerosal/index.html.

A few parents are asking that their children receive separate components of the MMR vaccine because they fear MMR may be linked to autism. What should I do?

Merck no longer produces single antigen measles, mumps, and/or rubella vaccines for the U.S. market. Only combined MMR is available. You should educate parents about the lack of association between MMR and autism.

How likely is it for a person to develop arthritis from rubella vaccine?

Arthralgia (joint pain) and transient arthritis (joint redness or swelling) following rubella vaccination occurs only in people who were susceptible to rubella at the time of vaccination. Joint symptoms are uncommon in children and in adult males. About 25% of non-immune post-pubertal women report joint pain after receiving rubella vaccine, and about 10% to 30% report arthritis-like signs and symptoms.

When joint symptoms occur, they generally begin 1 to 3 weeks after vaccination, usually are mild and not incapacitating, last about 2 days, and rarely recur.

Is there any harm in giving an extra dose of MMR to a child of age seven years whose record is lost and the mother is not sure about the last dose of MMR?

In general, although it is not ideal, receiving extra doses of vaccine poses no medical problem. However, receiving excessive doses of tetanus toxoid (e.g., DTaP, DT, Tdap, or Td) can increase the risk of a local adverse reaction. For details see the Extra Doses of Vaccine Antigens section of the ACIP General Best Practice Guidelines for Immunization at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html.

Vaccination providers frequently encounter people who do not have adequate documentation of vaccinations. Providers should only accept written, dated records as evidence of vaccination. With the exception of influenza vaccine and pneumococcal polysaccharide vaccine, self-reported doses of vaccine without written documentation should not be accepted. An attempt to locate missing records should be made whenever possible by contacting previous healthcare providers, reviewing state or local immunization information systems, and searching for a personally held record.

If records cannot be located or will definitely not be available anywhere because of the patient's circumstances, children without adequate documentation should be considered susceptible and should receive age-appropriate vaccination. Serologic testing for immunity is an alternative to vaccination for certain antigens (e.g., measles, rubella, hepatitis A, diphtheria, and tetanus).

Storage and Handling Back to top

How long can reconstituted MMR vaccine be stored in a refrigerator before it must be discarded?

The amount of time in which a dose of vaccine must be used after reconstitution varies by vaccine and is usually outlined somewhere in the vaccine's package insert. MMR must be used within 8 hours of reconstitution. MMRV must be used within 30 minutes; other vaccines must be used immediately. The Immunization Action Coalition has a staff education piece that outlines the time allowed between reconstitution and use, as stated in the package inserts for a number of vaccines. Handout can be found at the following link: www.immunize.org/catg.d/p3040.pdf.

How should MMR vaccine be stored?

MMR may be stored either in the refrigerator at 2°C to 8°C (36°F to 46°F) or in the freezer at -50°C to -15°C (-58°F to +5°F). The diluent should not be frozen and can be stored in the refrigerator or at room temperature.

If the MMR is combined with varicella vaccine as MMRV (ProQuad, Merck), it must be stored in the freezer at -50°C to -15°C (-58°F to +5°F).

A box of MMR vaccine (not reconstituted) was left at room temperature overnight. Can I use it?

Unfortunately, serious errors in vaccine storage and handling like this occur too often. If you suspect that vaccine has been mishandled, you should store the vaccine as recommended, then contact the manufacturer or state/local health department for guidance on its use. This is particularly important for live virus vaccines like MMR and varicella.

Once MMR vaccine has been reconstituted with diluent, how soon must it be used?

It is preferable to administer MMR immediately after reconstitution. If reconstituted MMR is not used within 8 hours, it must be discarded. MMR should always be refrigerated and should never be left at room temperature.

I misplaced the diluent for the MMR dose so I used normal saline instead. Is there any problem with doing this?

Only the diluent supplied with the vaccine should be used to reconstitute any vaccine. Any vaccine reconstituted with the incorrect diluent should be repeated.

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Source: https://www.immunize.org/askexperts/experts_mmr.asp

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