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Ask the Experts: MMR (Measles, Mumps, and Rubella)

Results (77)

In 2022, a provisional total of 121 cases of measles from 6 states were reported to CDC. The sharply limited global travel and social interactions precipitated by the COVID-19 pandemic, which began in early 2020, also reduced the opportunities for introduction and transmission of measles, mumps, and rubella viruses in the United States. Current CDC measles surveillance updates can be found at www.cdc.gov/measles/cases-outbreaks.html.

Since the pre-vaccine era, there has been a more than 99% decrease in mumps cases in the United States. However, outbreaks still occasionally occur. In 2006, there was an outbreak affecting more than 6,584 people in the United States, with many cases occurring on college campuses. In 2009, an outbreak started in close-knit religious communities and schools in the Northeast, resulting in more than 3,000 cases. Since 2015, numerous outbreaks have been reported across the US, in college campuses, prisons, and close-knit communities, including a large outbreak in northwest Arkansas where almost 3,000 cases were reported in 2016. These outbreaks have shown that when people with mumps have close contact with a lot of other people (such as among residential college students and families in close-knit communities) mumps can spread, even among vaccinated people. However, outbreaks are much larger in areas where vaccine coverage rates are lower. A provisional total of 322 cases of mumps were reported to CDC in 2022.

Rubella was declared eliminated (the absence of endemic transmission for 12 months or more) from the United States in 2004. Fewer than 10 cases (primarily import-related) have been reported annually in the United States since elimination was declared. Rubella incidence in the United States has decreased by more than 99% from the pre-vaccine era. A provisional total of 3 cases of rubella, and no cases of congenital rubella syndrome, were reported in 2022.

Last reviewed: June 19, 2023

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

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

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

Last reviewed: June 19, 2023

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

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

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

Providers should be especially aware of the possibility of measles in people with fever and rash who have recently traveled abroad or who have had contact with international travelers.  Providers should immediately isolate and report suspected measles cases to their local health department and obtain specimens for measles testing, including viral specimens for confirmation and genotyping. Providers should also collect blood for serologic testing during the first clinical encounter with a person who has suspected or probable measles.

Last reviewed: June 19, 2023

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

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

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

Last reviewed: June 19, 2023

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

Last reviewed: June 19, 2023

The most recent comprehensive ACIP recommendations for the use of MMR vaccine were published in 2013 and are available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf. CDC published the ACIP recommendations for the use of Priorix (GSK) brand of MMR vaccine on November 18, 2022, and they are available here: www.cdc.gov/mmwr/volumes/71/wr/pdfs/mm7146a1-H.pdf.

There is no difference in recommendations between Priorix and MMRII (Merck) brands of MMR vaccine. Priorix may be used in any situation where MMR vaccination is recommended. Despite minor differences in manufacturing (MMRII contains gelatin, Priorix does not) and approved route of administration (MMRII is approved for subcutaneous or intramuscular injection, Priorix is approved for subcutaneous injection only), the two vaccines may be considered functionally identical and interchangeable.

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 should get 1 dose of MMR vaccine (evidence of immunity is defined as documented receipt of 1 dose of live measles virus-containing vaccine [or 2 doses, if high risk], laboratory evidence of immunity or laboratory confirmation of disease, or birth before 1957), unless the adult is in a high-risk group. Susceptible high-risk people need 2 doses of vaccine, given 4 weeks apart. High risk people include school-age children, healthcare personnel, international travelers, and students attending post-high school educational institutions.

Live-attenuated measles vaccine became available in the U.S. in 1963. An ineffective, inactivated measles vaccine was also available in the U.S. in 1963–1967. Combined MMR vaccine (MMRII, Merck) was licensed in 1971; Priorix (GSK) MMR vaccine was licensed and recommended in 2022. For people who previously received a dose of measles vaccine in 1963–1967 and are unsure which type of vaccine it was, or are sure it was inactivated measles vaccine, that dose should be considered invalid and the patient revaccinated as age- and risk-appropriate with MMR vaccine. At the discretion of the state public health department, anyone exposed to measles in an outbreak setting can receive an additional dose of MMR vaccine even if they are considered completely vaccinated for their age or risk status.

Last reviewed: June 19, 2023

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

  • written documentation of adequate vaccination:
    • one or more doses of a measles-containing vaccine administered on or after the first birthday for preschool-age children and adults not at high risk
    • two doses of measles-containing vaccine for school-age children, adolescents, and adults at high risk, including college students, healthcare personnel, and international travelers
  • laboratory evidence of immunity
  • laboratory confirmation of measles (verbal history of measles does not count)
  • birth before 1957

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

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

Last reviewed: June 19, 2023

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

Zero doses:

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

One dose of MMR vaccine:

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

Two doses of MMR vaccine:

  • high-risk adults without any prior documented live measles vaccination and no laboratory evidence of immunity or prior measles infection, including:
    • healthcare personnel*
    • international travelers born in 1957 or later
    • people attending colleges and other post-high school educational institutions

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

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

Last reviewed: June 19, 2023

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

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

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

Last reviewed: June 19, 2023

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

Last reviewed: June 19, 2023

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

Last reviewed: June 19, 2023

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

Last reviewed: June 19, 2023

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

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

Last reviewed: June 19, 2023

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

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

Last reviewed: June 19, 2023

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

Last reviewed: June 19, 2023

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, people 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.

Last reviewed: June 19, 2023

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

Last reviewed: June 19, 2023

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

Last reviewed: June 19, 2023

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

Last reviewed: June 19, 2023

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.

In addition to infants under the age of 12 months, immune globulin may be used as measles post-exposure prophylaxis for susceptible pregnant people or susceptible people who are severely immunocompromised. For details on the dosage and use of immune globulin, please refer to the measles control section in Chapter 7 of the CDC Manual for the Surveillance of Vaccine-Preventable Diseases:  www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.html#control.

IG is not indicated for people 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.

Last reviewed: June 19, 2023

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