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Measles, Mumps, and Rubella

Ask the Experts: Diseases & Vaccines

Measles, Mumps, and Rubella

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Disease Issues
What is the current situation with measles, mumps, and rubella in the United States?
From 2001 through 2011, a median of 63 measles cases (range: 37 to 220) and four outbreaks (defined as three or more cases linked in time or place, range: 2 to 17), were reported each year in the United States. Of the 911 cases, a total of 372 (41%) were importations, and an additional 432 (47%) were associated with importations. Hospitalization was reported for 225 (25%) cases. Two deaths were reported. Among the 162 cases reported from 2004 through 2008 among unvaccinated U.S. residents eligible for vaccination, a total of 110 (68%) were known to have occurred in persons who declined vaccination because of a philosophical, religious, or personal objection. A provisional total of 69 measles cases was reported in 2016.
From 2000 through 2012 an average of 1,135 mumps cases (range:229 to 6,584) were reported annually in the United States. Large outbreaks occurred in 2006 (6,584 cases) and in 2009 and 2010 (approximately 3,500 cases). Outbreaks occurred primarily among previously vaccinated persons in densely populated settings (colleges and religious communities). A provisional total of 438 mumps cases were reported in 2013.
In 2004, a panel convened by CDC reviewed available data and verified elimination of rubella in the United States. From 2005 through 2011, a median of 11 rubella cases was reported each year in the United States (range: 4 to 18). In addition, two rubella outbreaks involving three cases, as well as four total congenital rubella syndrome (CRS) cases, were reported. Among the 67 rubella cases reported from 2005 through 2011, a total of 28 (42%) cases were known importations. A provisional total of 9 rubella cases and no CRS cases were reported in 2013.
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.
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). 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.
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.
How contagious are measles, mumps, and rubella?
Measles is highly infectious. It is primarily transmitted from person to person via large respiratory droplets. Airborne transmission via aerosolized droplets has been documented in closed areas (such as an office examination room) for up to 2 hours after a person with measles occupied the area. Following exposure, more than 90% of susceptible people develop measles. The virus can be transmitted from 4 days before the rash becomes visible to 4 days after the rash appears. The contagiousness of mumps is similar to that of influenza and rubella but is less than that for measles or varicella.
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, 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 days0. However, as noted above, up to half of rubella virus infections are subclinical.
Vaccine Recommendations Back to top
What are the current recommendations for the use of MMR vaccine?
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 (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 unless the adult is in a high-risk group. High-risk people need 2 doses and include healthcare personnel, international travelers, students at post-high school educational institutions, people exposed to measles in an outbreak setting, and those previously vaccinated with killed measles vaccine or with an unknown type of measles vaccine during 1963 through 1967.
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 (see www.cdc.gov/vaccines/vpd-vac/measles/faqs-dis-vac-risks.htm). 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. Additional information is available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.
Why is a second dose of MMR necessary?
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.
Many people age 60 years and older do not have records indicating what type of measles vaccine they received as children in the early 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. Persons vaccinated before 1979 with either killed mumps vaccine or mumps vaccine of unknown type who are at high risk for mumps infection (such as persons 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. Please explain.
In the 2013 revision of its MMR vaccine recommendations ACIP now 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 and is not recommended.
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 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.
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.
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.
In a mumps outbreak, should we offer a third dose of MMR to persons who have two prior documented doses of MMR?
You should consult with the local health department about the necessity for a third dose of mumps-containing vaccine in this circumstance. Currently, data are insufficient to recommend for or against the routine use of a third dose of MMR vaccine for mumps outbreak control. CDC has issued guidance for considerations for use of a third dose in specifically identified target populations along with criteria for public health departments to consider in decision making. This information can be found at www.cdc.gov/vaccines/pubs/surv-manual/chpt09-mumps.html.
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 infections 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
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 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 additional information on the worldwide measles situation, and on CDC's measles vaccination information for travelers, go to wwwnc.cdc.gov/travel.
I have an 8-month-old patient who is traveling internationally. The infant needs immune globulin (IG) for hepatitis A protection as well as MMR vaccine. The family is leaving in 11 days. Can I give the IG and the MMR vaccine simultaneously?
IG may contain antibodies to measles, mumps, and rubella that could reduce the effectiveness of MMR vaccine. The best course of action is to administer the MMR vaccine and defer the IG. Once the vaccine is given, an antibody-containing blood product like IG can be administered two weeks later. While it may be difficult to get this product administered before leaving, you are better off than if IG were administered first, as a 3-month interval is recommended between IG and MMR.
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 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?
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 Recommendations on Immunization 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 a healthcare provider 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. 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. ACIP does not recommend serologic testing after vaccination. For more information, see ACIP's recommendations on the use of MMR 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.
Contraindications and Precautions Back to top
What are the contraindications and precautions for MMR vaccine?
history of a severe (anaphylactic) reaction to neomycin (or other vaccine component) or following previous dose of MMR
severe immunosuppression from either disease or therapy
receipt of an antibody-containing blood product in the previous 11 months
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 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 IDSA states that administration of varicella vaccine (but not MMR) can be considered for non-varicella-immune patients treated for chronic inflammatory disease who are receiving long-term low-dose immunosuppression. Low-dose immunosuppression for methotrexate is a dosage of less than 0.4 mg/kg/week. See Table 6 (and associated footnotes): 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 5 on page 39 of ACIP's General Recommendations on Immunization, available at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf.
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. See page 9 of ACIP's General Recommendations on Immunization.
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 (or MMR) vaccine before becoming pregnant?
Although the MMR package insert recommends a 3 month deferral of pregnancy after MMR vaccination ACIP recommends deferral of pregnancy for four weeks. For details on this issue see MMWR 2001;50(No. 49):1117.
We received a call from a healthcare provider who inadvertently administered MMR vaccine to a woman who was 2 months pregnant. Please advise as to appropriate action steps. 
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 alone is not a reason to terminate the pregnancy. You should consult with the provider to determine if there is a way to avoid 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.
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 http://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?
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 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. 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.
Editor's note: IAC has developed several handouts for parents: "MMR vaccine does not 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 fraudulent claim that launched the idea that MMR vaccine was somehow linked to the development of autism (see www.immunize.org/bmj-deer-mmr-wakefield/).
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. Receiving excessive doses of tetanus toxoid (e.g., DTP, DTaP, DT, Tdap, or Td) can increase the risk of a local adverse reaction, however. For details, consult the ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 8.
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 should MMR vaccine be stored?
MMR may be stored either in the refrigerator at 2C to 8C (36F to 46F) or in the freezer at -50C to -15C (-58F to +5F). 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 -50C to -15C (-58F to +5F).
A box of MMR vaccine (not reconstituted) was left at room temperature for 3 hours. 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 sterile water 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.
This page was updated on January 9, 2017.
This page was reviewed on December 14, 2016.
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