General information on MMR vaccination Back to top

For whom is MMR vaccination recommended?

The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination for the following groups of persons:

• all children and adolescents, beginning at age 12-15 months •   adults born in 1957 or later without evidence of vaccination or serologic evidence of immunity •   healthcare workers, regardless of age •   non-pregnant women of childbearing age without other evidence of immunity to rubella

For whom should second doses of MMR be given?

All children and adolescents should receive 2 doses, given no less than 4 weeks apart. Most children vaccinated at 12-15 months should receive the second dose at age 4-6 years. All older children and adolescents should receive the second dose at the next available opportunity, as long as there has been a 4 week interval since the previous dose.

ACIP recommends a second dose of MMR for any adult born in 1957 or later who:

• is a student in a post-secondary educational institution •   is a healthcare worker •   plans to travel internationally •   is exposed to measles in an outbreak setting •   was previously vaccinated with killed measles vaccine •   was vaccinated with an unknown type of measles vaccine during 1963-1967

ACIP also recommends that unvaccinated healthcare workers without other evidence of immunity to mumps receive one dose of live virus mumps vaccine (may be given as MMR). During a mumps outbreak, second doses should be considered. (Note: ACIP defines "Other evidence of immunity" as a history of mumps based on healthcare provider diagnosis or laboratory evidence of immunity.)

Why is a second dose of MMR necessary?

Between 2% and 5% of persons 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 persons who did not respond to the first dose.

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

Not necessarily. Persons who have documentation of receiving live measles vaccine in the 1960s do not need to be revaccinated. Persons 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 persons who may have received killed measles vaccine which was available in 1963-1967 and was not effective.

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

Measles vaccine 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. More information on post-exposure prophylaxis for measles is available in the recommendations from the ACIP -- "MMR -- Vaccine Use and Strategies for Elimination of Measles, Rubella, and Congenital Rubella Syndrome and Control of Mumps" (see www.cdc.gov/vaccines/pubs/acip-list.htm).

How should the combined MMR and varicella vaccine (ProQuad) be used?

ProQuad (Merck) was licensed in September 2005 for use in children ages 12 months through 12 years. It combines the MMR and varicella vaccines and therefore can be used in place of the individual MMR and varicella vaccines given at ages 12-15 months and 4-6 years. For more information, consult the package insert at www.fda.gov/cber/label/mmrvmer090605LB.pdf

We often see college students 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?

Although single antigen vaccine is sometimes available, it may be more practical to advise the student to get the combined MMR vaccine. If a person cannot produce written documentation of either immunization or disease, and titers are negative, they should receive two doses of MMR.

I have adult patients going back to college that must show proof of MMR vaccine and are unable to retrieve their immunization records. What are my options?

Depending on the requirements of the college, your options are likely to either vaccinate or to perform serologic testing for all the antigens for which documented immunity is required. There is no evidence that adverse reactions are increased when MMR is given to a person who is already immune to one or more of the components of the vaccine.

MMR scheduling and serology issues Back to top

Can MMR be given on the same day as other live virus vaccines (e.g., varicella)?

Yes. However, if two live vaccines (e.g., MMR and varicella) 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 a month 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 persons 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.

If an employee has 2 documented doses of MMR but has negative titers for one or more of these diseases, should I give an additional MMR dose?

ACIP does not routinely recommend more than two doses of MMR. A negative serology after two documented doses of MMR probably represents a false negative (i.e., antibody titer too low to detect with commercial tests). However, it is theoretically possible to have a 2-dose true vaccine failure. If a person is found to have a negative serology after two documented doses of MMR, it may be prudent to administer one additional dose of MMR. You should also cease doing postvaccination serologic testing if an employee has two documented doses of MMR, which is the ACIP definition of "immune." See www.cdc.gov/mmwr/PDF/rr/rr4708.pdf for more information.

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

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 one month. 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?

Actually, 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, physician diagnosis of disease, birth before 1957, or written documentation of vaccination. For rubella, only serologic evidence or documented vaccination should be accepted as proof of immunity. Additionally, persons born prior to 1957 may be considered immune to rubella unless they are women who have the potential to become pregnant.

Vaccination of healthcare workers Back to top

What is the recommendation for MMR vaccine for healthcare workers (HCWs)?

The ACIP statement titled "Immunization of Health-Care Workers" was published in December 1997 (MMWR 1997;46[RR-18]:1-42). The recommendation for MMR is that all persons who work in a medical facility should have evidence of immunity (defined in the statement), not just those with direct patient contact. For most HCWs born in 1957 or later, this means documentation of two doses of MMR vaccine. For HCWs born before 1957, ACIP recommends that at least one dose of MMR be considered for persons in this age group who do not have documentation of a measles-containing vaccination, history of physician-diagnosed measles, or laboratory evidence of measles and rubella immunity. Following the resurgence of mumps in 2006, ACIP expanded the recommendations for mumps vaccination of HCWs. Healthcare facilities are now encouraged to recommend one dose of a live mumps virus vaccine for unvaccinated HCWs born before 1957 who do not have a history of physician-diagnosed mumps or laboratory evidence of mumps immunity. Further, during an outbreak, strong consideration should be given to administration of a second dose.

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

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

Contraindications and precautions for MMR vaccine Back to top

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.

Is it true that egg allergy is no longer 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 AAP's "Red Book" Committee 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.

MMR vaccine and pregnancy Back to top

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

Four weeks.

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 does not pose a risk to a pregnant household member.

If a pregnant woman with a history of one dose of MMR is tested serologically for rubella and is found to be "not immune," does she need revaccination postpartum?

A negative serologic test for rubella antibody in a person with documented vaccination could represent either failure to respond to the vaccine or an antibody level too low to be detected by the screening test. ACIP does not provide guidance for this situation. Since the person may have failed to respond to the first dose, repeating the MMR vaccine after delivery is a reasonable approach.

How soon after delivery can MMR be given?

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.

MMR vaccine safety concerns Back to top

Is there any evidence that MMR or thimerosal causes autism?

No. This issue has been studied extensively in recent years, 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. To access the IOM committee minutes, as well as the executive summaries and full reports, go to www.iom.edu/CMS/3793/4705.aspx To obtain more information on thimerosal and vaccines in general, visit www.immunize.org/safety/thimerosal.htm

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?

You should educate parents about the lack of association between MMR and autism. If a parent still insists on separating the vaccine components, Merck has limited supplies of separate measles, mumps, and rubella vaccine available. It is preferable to administer separate components of MMR rather than not administer any measles, mumps, or rubella vaccines.

Editor's note: IAC has developed a web page for parents titled "Does MMR vaccine cause autism? Examine the evidence." IAC encourages you to make and distribute copies of this web page. Find it at www.immunize.org/mmrautism

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 persons who were susceptible to rubella at the time of vaccination. Joint symptoms are uncommon in children and in adult males. About 25% of post-pubertal women report joint pain after receiving rubella vaccine, and about 10% report arthritis-like signs and symptoms. When joint symptoms occur, they generally begin 1-3 weeks after vaccination, persist for one day to 3 weeks, and rarely recur. Chronic joint symptoms attributable to rubella vaccine are very rare, if they occur at all.

Administering MMR vaccine Back to top

Our clinic has given 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.

Can single antigen preparations for measles and rubella vaccines be mixed together? We have MMR vaccine and single antigen vaccines for those who only need one.

Absolutely not. Vaccines should never be mixed except when specifically approved by the FDA. Also, ACIP recommends use of combined MMR whenever one or more of the antigens are indicated, so there is little need to stock single antigen vaccines.

Storage and handling of MMR vaccine Back to top

How should MMR vaccine be stored?

MMR may be stored either in the refrigerator at 35-46°F (2-8°C) or in the freezer. The diluent, however, should not be frozen and can be stored in the refrigerator or at room temperature. If the MMR is combined with varicella vaccine as ProQuad by Merck, it must be stored at an average temperature of 5°F (-15°C) or colder (like varicella vaccine).

A box of MMR vaccine (undiluted) was left at room temperature for 3 hours. Can I use it?

Unfortunately, serious errors in vaccine storage and handling occur too often. If you suspect that vaccine has been mishandled, you should contact the manufacturer or state/local health department for guidance on its use. This is particularly important for labile 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 sterile water instead. Is there any problem with doing this?

Only the diluent supplied with the vaccine should be used to reconstitute any vaccine.

Reviewed on 5/08