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For whom is MMR
vaccination recommended? |
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| The Advisory Committee on Immunization
Practices (ACIP) recommends routine vaccination for the following
groups of people: |
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all children,
beginning at age 12-15 months |
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adults born in 1957
or later without documentation of vaccination |
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healthcare workers, who lack
evidence of immunity, regardless of age |
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non-pregnant women of
childbearing age without evidence of immunity to rubella |
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| For whom should second doses of MMR
be given? |
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| 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. |
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| ACIP recommends a second dose of MMR
for any adult born during 1957 or later who: |
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is a student in a
post-secondary educational institution |
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is a healthcare
worker |
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plans to travel internationally |
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is exposed to measles in an
outbreak setting |
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was previously vaccinated with
killed measles vaccine |
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was vaccinated with an unknown
type of measles vaccine during 1963-1967 |
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| ACIP also recommends a second dose of
MMR vaccine to healthcare workers exposed to measles or mumps in an
outbreak setting, regardless of age. |
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| Why is a second dose of MMR
necessary? |
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| Between 2% and 5% 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. |
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| Do people who received MMR in the
1960s need to have their dose repeated? |
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| 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 1963–1967 and was not effective. |
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| Is there anything that can be done
for unvaccinated people who have already been exposed to measles? |
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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. 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). |
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| 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? |
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| Single antigen vaccine is no longer
available in the U.S., therefore, the student should 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. |
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| 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? |
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| 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. |
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| Can MMR be given on the same day as
other live virus vaccines (e.g., varicella)? |
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| Yes. However, if two live vaccines
(e.g., MMR, varicella, and LAIV) are not administered on the same day,
they should be separated by an interval of at least 28 days. |
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| 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? |
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| 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 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. |
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| 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? |
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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 monovalent measles vaccine (if
available) or MMR. The risk for measles exposure can be high in both
developed and developing 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 continually updated
information on the worldwide measles situation, and on CDC's measles
vaccination information for travelers, go to
wwwn.cdc.gov/travel/content/in-the-news/measles.aspx. |
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| Can I give the second dose of MMR
earlier than age 4 through 6 years (i.e., the kindergarten entry dose)
to young children traveling to areas of the world where there are
measles cases? |
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| Yes. The second dose of MMR can be
given a minimum of 28 days after the first dose if necessary. |
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| 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? |
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| No. A measles-containing vaccine
administered before the first birthday should not be counted as part
of the series. MMR should be repeated when the child is age 12 to 15
months of age (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. |
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| How would I follow up with a new
healthcare worker (HCW) who has 2 documented doses of
measles-mumps-rubella (MMR) vaccine but whose serologic testing
doesn't show immunity to one of these diseases? (Taken from August
2010 Needle Tips) |
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Two documented doses of MMR vaccine is
considered proof of immunity according to ACIP. However, what ACIP
recommends is not
always what schools and institutions accept. Here are some basics
about MMR vaccination and healthcare personnel. |
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| 1. |
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ACIP considers
receipt of 2 documented doses of MMR vaccine, given on or after
the first birthday and separated by at least 28 days, to be
proof of immunity to measles, mumps, and rubella. No serologic
testing is required or recommended to confirm immunity in this
instance. |
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If a HCW does not
have any documented doses of MMR, he or she can (1) be tested
for immunity or (2) just be given 2 doses of MMR at least 4
weeks apart. If the testing option is used, and the test
indicates that the HCW is not immune to one or more of the
vaccine components, the HCW should receive 2 doses of MMR at
least 4 weeks apart. Note that a test finding of an
"indeterminate" or "equivocal" level of immunity indicates that
a HCW who lacks 2 documented doses of MMR vaccine be considered
nonimmune. Also note, that ACIP does not recommend serologic
testing after vaccination. |
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ACIP does not routinely
recommend more than 2 doses of MMR vaccine. A negative serology
after 2 documented doses probably represents a false negative
(i.e., antibody titer is too low to detect with commercial
tests). If a healthcare setting relies on post-vaccination
testing to determine immunity, a negative serology can
erroneously indicate that a HCW needs additional doses.
Remember, ACIP does not recommend routine serologic testing
after MMR vaccination. |
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| For more information, see ACIP's
recommendations on the use of MMR at
www.cdc.gov/mmwr/PDF/rr/rr4708.pdf. |
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| Would you consider a person with 2
documented doses of MMR vaccine to be immune even if their serology
for 1 or more of the antigens comes back negative? |
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| There is no ACIP recommendation for
this situation. A negative serology would more likely be the result of
an insensitive test than of a true vaccine failure. No more doses are
necessary. |
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| Can I give a tuberculin skin test (TST)
on the same day as a dose of MMR vaccine? |
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| 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. |
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| 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? |
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| 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, people born prior to 1957 may be considered
immune to rubella unless they are women who have the potential to
become pregnant. |
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| What is the recommendation for MMR
vaccine for healthcare personnel? |
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| In June of 2009, ACIP strengthened its
recommendations for MMR requirements for healthcare personnel (HCP).
The Healthcare Infection Control Practices Advisory Committee (HICPAC)
endorsed the changes. In summary, 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, during an outbreak of measles,
mumps, or rubella, healthcare facilities should recommend vaccination
of all healthcare personnel who were born before 1957 and who lack
laboratory evidence of measles, mumps, and/or rubella immunity or
laboratory confirmation of disease with two doses of MMR vaccine (for
measles and mumps) and one dose of MMR vaccine (for rubella), and
should consider recommending the same during routine circumstances. |
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| If a healthcare worker develops a
rash and low-grade fever after MMR vaccine, is s/he infectious? |
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| Approximately 5–15% of susceptible
people 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. |
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| Contraindications and precautions for MMR vaccine |
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| Can I give MMR to a child whose
sibling is receiving chemotherapy for leukemia? |
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| Yes. MMR and varicella vaccines should
be given to the healthy household contacts of immunosuppressed
children. |
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| Is it true that egg allergy is no
longer considered a contraindication to MMR vaccine? |
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| 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. |
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| Can I give MMR to a breastfeeding
mother or to a breastfed infant? |
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| 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. |
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| What is the recommended length of time a woman should wait after receiving rubella (or MMR) vaccine before becoming pregnant? |
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| Four weeks. |
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| We require a pregnancy test for all our 7th graders before giving an MMR. Is this necessary? |
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| 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. |
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| Can we give an MMR to a 15-month-old whose mother is 2 months pregnant? |
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| 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. |
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| 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? |
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| CDC does not routinely recommend more
than 2 doses of MMR vaccine. A negative serology after 2 documented
doses probably represents a false negative (i.e., antibody titer too low
to detect with commercial tests). If a person is found to have a
negative serology after 2 documented doses of MMR, it is best to stop
testing for rubella. CDC's recommendations for the use of MMR vaccine
can be accessed at www.cdc.gov/mmwr/PDF/rr/rr4708.pdf |
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| How soon after delivery can MMR be given? |
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| 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. |
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| Is there any evidence that MMR or
thimerosal causes autism? |
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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. For more information on thimerosal
and vaccines in general, visit
www.immunize.org/safety/thimerosal.htm |
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| 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? |
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| Merck no longer produces single
antigen measles, mumps, and/or rubella vaccines for the U.S. market.
You should educate parents about the lack of association between MMR
and autism. |
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Editor's note: IAC has
developed several handouts for parents: "Does MMR vaccine cause
autism? Examine the evidence." and "Evidence shows vaccines unrelated
to autism." IAC encourages you to make and distribute copies of these
handouts. You can find these and other related handouts at
www.immunize.org/concerns/mmr.asp. You can also find information
about the false claims that launched the idea that MMR vaccine was
somehow linked to the development of autism (see
www.immunize.org/bmj-deer-mmr-wakefield/). |
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| How likely is it for a person to
develop arthritis from rubella vaccine? |
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| 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 post-pubertal women report joint pain after
receiving rubella vaccine, and about 10% report arthritis-like signs
and symptoms. |
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| 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. |
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| Our clinic has given MMR by the
wrong route (IM rather than SC) for years. Should these doses be
repeated? |
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| 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. |
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| 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? |
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| Yes. A 5/8" needle is recommended for
subcutaneous injections for people of all sizes. |
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| How should MMR vaccine be stored? |
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| 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). The lower limit of the
temperature is -58° F (-50° C). |
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| A box of MMR vaccine (not
reconstituted) was left at room temperature for 3 hours. Can I use it? |
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| 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. |
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| Once MMR vaccine has been
reconstituted with diluent, how soon must it be used? |
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| 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. |
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| I misplaced the diluent for the MMR
dose so I used sterile water instead. Is there any problem with doing
this? |
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| Only the diluent supplied with the
vaccine should be used to reconstitute any vaccine. |
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| Reviewed on 3/11 |
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