IAC Express 2011
Issue number 937: June 22, 2011
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- Read "Ask
the Experts" Q&As about measles and MMR vaccination
AAFP, American Academy of Family Physicians; AAP,
American Academy of Pediatrics; ACIP, Advisory Committee on Immunization
Practices; AMA, American Medical Association; CDC, Centers for Disease
Control and Prevention; FDA, Food and Drug Administration; IAC, Immunization
Action Coalition; MMWR, Morbidity and Mortality Weekly Report; NCIRD,
National Center for Immunization and Respiratory Diseases; NIVS, National
Influenza Vaccine Summit; VIS, Vaccine Information Statement; VPD,
vaccine-preventable disease; WHO, World Health Organization.
Issue 937: June 22, 2011
Read "Ask the Experts" Q&As about measles and MMR vaccination
Many readers of Needle Tips and Vaccinate Adults
consistently rank "Ask the Experts" as their favorite
feature in these publications. As a thank-you to our loyal
IAC Express readers, we periodically publish Extra Editions
with new "Ask the Experts" Q&As answered by CDC experts.
IAC thanks medical epidemiologists William L. Atkinson, MD,
MPH, and Andrew T. Kroger, MD, MPH, and nurse educator Donna
L. Weaver, RN, MN, at the National Center for Immunization
and Respiratory Diseases, CDC, for agreeing to answer the
All the Q&As in this edition of IAC Express deal with
measles and MMR vaccination, in response to the increased
number of measles cases around the nation in 2011.
We encourage you to reprint any of these Q&As in your own
newsletters. Please credit the Immunization Action Coalition
and the Centers for Disease Control and Prevention.
Information about IAC's preferred citation style can be
found at http://www.immunize.org/citeiac
You can access more "Ask the Experts" Q&As in our online
archive at http://www.immunize.org/askexperts
Editor's note: Information about submitting a question to
"Ask the Experts" is provided at the end of this Extra
Q: Please provide some details about the measles cases we're
experiencing across the United States.
A: We are currently seeing an increased number of measles
importations into the U.S. due to recent increases in
measles cases in countries commonly visited by U.S.
travelers (e.g., France, India). During 2001-08, a median of
56 measles cases were reported to CDC each year. By
contrast, during the first 19 weeks of 2011, 23 states
reported 118 cases. Of the 118 cases, 89% were associated
with importation from other countries.
Of the 118 cases, 47 (40%) resulted in hospitalization. All
but one hospitalized patient were unvaccinated. The
vaccinated patient reported having received 1 dose of
measles-containing vaccine and was hospitalized for
Measles-mumps-rubella (MMR) vaccine is safe and highly
effective in preventing measles and its complications.
Maintaining high immunization rates with MMR vaccine is the
cornerstone of outbreak prevention.
Q: How serious is measles?
A: Measles can lead to serious complications and death, even
with modern medical care. The 1989-91 measles outbreak in
the U.S. resulted in over 55,000 cases and more than 100
deaths. The current outbreak in France has resulted in
10,000 cases during the first four months of 2011, including
12 cases of encephalitis, 360 cases of severe measles
pneumonia, and 6 measles-related deaths. Of the 118 cases
reported in the U.S. in the first 19 weeks of 2011, 40% had
to be hospitalized and nine had pneumonia.
Q: What are the signs and symptoms healthcare providers
should look for in diagnosing measles?
A: Healthcare providers should suspect measles in patients
with a febrile rash illness and the clinically compatible
symptoms of cough, coryza (symptoms of a head cold), 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 38.3 degrees C or higher (101 degrees F
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 1-2 days before the measles rash appears to 1-2 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
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
Q: How contagious is measles?
A: 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 (e.g., office examination room)
for up to 2 hours after a person with measles occupied the
Following exposure, up to 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.
Q: How long does it take to show signs of measles after
A: It takes an average of 10-12 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, 2-3 days after the fever begins.
Q: If a susceptible person is exposed to measles, can
anything prevent them from developing the disease?
A: If the person has not been vaccinated, measles vaccine
may prevent disease if given within 72 hours of exposure.
Immune globulin (a blood product containing antibodies to
the measles virus) may prevent or lessen the severity of
measles if given within 6 days of exposure.
Q: What are the recommendations for the use of MMR vaccine
to prevent measles?
A: (1) MMR vaccine is recommended routinely for all children
at age 12-15 months, with a second dose at age 4-6 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.
(2) 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, documentation of physician-diagnosed
measles, 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; they 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 1963-1967.
(3) Infants age 6-11 months should receive 1 dose of MMR
vaccine before international travel. Any dose of MMR
administered before the first birthday should not be counted
as part of the 2-dose series, and should be repeated when
the child is age 12-15 months.
Q: We have measles cases in our community. How can I best
protect the young children in my practice?
A: 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
6-11 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 12-15 months) and giving the
second dose 4 weeks later (at the minimum interval) instead
of waiting until age 4-6 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.
Q: My adult patient doesn't remember if he ever received MMR
vaccine or had measles disease and is planning an
international trip. How should I handle this situation?
A: You have the choice of testing for immunity or just
giving 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 test indicates
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 the test result is indeterminate or
equivocal, consider your patient nonimmune. ACIP does not
recommend serologic testing after vaccination because
commercial tests are not sensitive enough to detect vaccine-induced immunity reliably.
Q: I'm a healthcare worker. How can I ensure I am protected
A: If you do not have acceptable evidence of immunity for
healthcare workers--documented receipt of 2 doses of live
measles virus-containing vaccine at least 4 weeks apart or
laboratory evidence of immunity--either get tested for
immunity or get 2 doses of MMR at least 4 weeks apart. If
you choose the testing route, and your result is negative,
indeterminate, or equivocal, get 2 doses of MMR at least 4
weeks apart. ACIP does not recommend serologic testing after
Q: Can I give my patients measles vaccine instead of MMR?
A: No. Merck has not produced single-antigen measles, mumps,
and rubella vaccines for the U.S. market since 2008. Even
before that time, ACIP recommended the combined MMR vaccine
whenever one or more of the individual antigens were
Q: Does the increase in measles cases indicate that
vaccination with MMR isn't effective?
A: No. Unvaccinated people accounted for 105 (89%) of the
118 cases. Among the 45 U.S. residents ages 12 months
through 19 years who acquired measles, 39 (87%) were
unvaccinated, including 24 whose parents claimed a religious
or personal exemption and eight who missed opportunities for
vaccination. Among the 42 U.S. residents age 20 years and
older who acquired measles, 35 (83%) were unvaccinated,
including six who declined vaccination because of personal
objections to vaccination. Of the 33 U.S. residents who were
vaccine-eligible and had traveled abroad, 30 were
unvaccinated and one had received only 1 of the 2
HOW TO SUBMIT A QUESTION TO "ASK THE EXPERTS"
IAC works with CDC to compile new "Ask the Experts" Q&As for
our publications based on commonly asked questions. We also
consider the need to provide information about new vaccines
and recommendations. Most of the questions are thus a
composite of several inquiries.
You can email your question about vaccines or immunization
to IAC at email@example.com As we receive hundreds of
emails each month, we cannot guarantee that we will print
your specific question in the "Ask the Experts" feature.
However, you will get an answer. To see if your question has
already been answered, you can first check the "Ask the
Experts" online archive at http://www.immunize.org/askexperts
You can also email CDC's immunization experts directly at
firstname.lastname@example.org There is no charge for this service.
If you have a question about IAC materials or services,
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