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Measles, Mumps, and Rubella

Disease Issues Contraindications and Precautions Vaccine Recommendations Pregnancy and Postpartum Considerations Administering Vaccines Vaccine Safety Scheduling Vaccines Storage and Handling For Healthcare Personnel

Disease Bug

What is the electric current situation with measles, mumps, and rubella in the United states?

In 2019, a provisional total of one,242 cases of measles from 31 states were reported to CDC. This was the largest number reported in a single year since 1992; 73% of cases were associated with outbreaks amidst unvaccinated people in New York. These outbreaks were contained and stopped before the cease of 2019. Betwixt January ane and August 19, 2020, just 12 measles cases were reported past 7 jurisdictions. Limited travel every bit a consequence of the COVID-xix pandemic drastically reduced opportunities for travelers infected with measles to enter or travel within the United States. CDC measles surveillance updates tin be found at www.cdc.gov/measles/cases-outbreaks.html.

Since the pre-vaccine era, there has been a more than 99% subtract in mumps cases in the United States. However, outbreaks still occasionally occur. In 2006, there was an outbreak affecting more than half dozen,584 people in the United States, with many cases occurring on higher campuses. In 2009, an outbreak started in close-knit religious communities and schools in the Northeast, resulting in more than than three,000 cases. Since 2015, numerous outbreaks have been reported across the The states, in college campuses, prisons, and shut-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 shut contact with a lot of other people (such as amid residential higher students and families in close-knit communities) mumps tin can spread even among vaccinated people. Nonetheless, outbreaks are much larger in areas where vaccine coverage rates are lower. A conditional total of 3,484 cases of mumps were reported to CDC in 2019.

Rubella was alleged eliminated (the absenteeism of endemic transmission for 12 months or more) from the United states in 2004. Fewer than ten cases (primarily import-related) have been reported annually in the United States since emptying 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 built rubella syndrome, were reported in 2019.

How serious are measles, mumps, and rubella?

Measles can lead to serious complications and death, even with modernistic medical care. The 1989–1991 measles outbreak in the U.S. resulted in more than 55,000 cases and more 100 deaths. In the Usa, from 1987 to 2000, the almost unremarkably reported complications associated with measles infection were pneumonia (half dozen%), otitis media (7%), and diarrhea (8%). For every i,000 reported measles cases in the U.s., approximately i case of encephalitis and ii to 3 deaths resulted. The gamble for expiry from measles or its complications is greater for infants, young children, and adults than for older children and adolescents.

Mumps nearly usually causes fever and parotitis. Upwards to 25% of persons with mumps accept 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 mostly a mild illness with depression-class fever, lymphadenopathy, and angst. Upwards 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 outset trimester tin can result in miscarriage, stillbirth, and nascency defects including cataracts, hearing loss, mental retardation, and congenital heart defects.

What are the signs and symptoms healthcare providers should wait for in diagnosing measles?

Healthcare providers should suspect measles in patients with a febrile rash affliction and the clinically compatible symptoms of cough, coryza (runny nose), and/or conjunctivitis (red, watery optics). 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 college (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 ii days before the measles rash appears to one to two days later on. They announced equally punctate blue-white spots on the bright red groundwork of the buccal mucosa. Pictures of measles rash and Koplik spots tin can be institute at www.cdc.gov/measles/about/photos.html.

Providers should exist especially aware of the possibility of measles in people with fever and rash who accept recently traveled abroad or who accept 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.

What should our clinic do if we suspect a patient has measles?

Measles is highly contagious. A person with measles is infectious up to iv days before through 4 days afterward the solar day of rash onset. Patients with suspected measles should be isolated for iv days after they develop a rash. Airborne precautions should exist followed in healthcare settings past 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 written 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 illness 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 expect for the results of laboratory testing to report clinically-suspected measles to the local wellness department.

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

How long does it have to show signs of measles, mumps, and rubella after being exposed?

For measles, there is an boilerplate of 10 to 12 days from exposure to the appearance of the first symptom, which is ordinarily fever. The measles rash doesn't usually announced until approximately 14 days later exposure (range: seven to 21 days), and the rash typically begins 2 to 4 days later on the fever begins. The incubation period of mumps averages xvi to eighteen 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, every bit noted above, upwards to half of rubella virus infections cause no symptoms.

Vaccine Recommendations Back to top

What are the electric current recommendations for the use of MMR vaccine?

The most recent comprehensive ACIP recommendations for the utilise of MMR vaccine were published in 2013 and are available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf. MMR vaccine is recommended routinely for all children at historic period 12 through fifteen months, with a second dose at age iv through 6 years. The second dose of MMR tin can be given as early as 4 weeks (28 days) after the first dose and exist counted as a valid dose if both doses were given after the kid'south first altogether. The second dose is not a booster, only rather is intended to produce amnesty in the small number of people who fail to respond to the first dose.

Adults with no bear witness of immunity (evidence of immunity is defined as documented receipt of one dose [ii doses four weeks apart if loftier adventure] of live measles virus-containing vaccine, laboratory evidence of immunity or laboratory confirmation of illness, or birth before 1957) should get 1 dose of MMR vaccine unless the adult is in a high-risk group. High-hazard people need 2 doses and include school-age children, healthcare personnel, international travelers, and students attending postal service-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. For people who previously received a dose of measles vaccine in 1963–1967 and are unsure which type of vaccine information technology was, or are sure information technology was inactivated measles vaccine, that dose should be considered invalid and the patient revaccinated as age- and take a chance-appropriate with MMR vaccine. At the discretion of the country public wellness 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.

What is considered acceptable evidence of immunity to measles?

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

• written documentation of adequate vaccination: • laboratory testify of immunity • laboratory confirmation of measles (verbal history of measles does not count) • birth before 1957

Although birth before 1957 is considered acceptable testify of measles immunity, healthcare facilities should consider vaccinating unvaccinated personnel born before 1957 who do not have other evidence of amnesty 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 nascency yr if they lack laboratory evidence of measles immunity.

For which adults are 0, 1, or 2 doses of MMR vaccine recommended to prevent measles?

Nothing, i, or two doses of MMR vaccine are needed for the adults described beneath.

Naught doses:

• adults born before 1957 except healthcare personnel* • adults born 1957 or later who are at low take chances (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 i or more documented doses of alive measles vaccine • adults with laboratory show of amnesty or laboratory confirmation of measles

One dose of MMR vaccine:

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

Two doses of MMR vaccine:

� high-adventure adults without any prior documented live measles vaccination and no laboratory evidence of immunity or prior measles infection, including:

Persons 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 loftier-risk) doses of MMR vaccine.

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

Given the take a chance of outbreaks of measles in the U.Southward., should all healthcare personnel, including those born before 1957, have 2 doses of MMR vaccine?

Although nativity 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 practice not take laboratory prove of measles immunity, laboratory confirmation of disease, or vaccination with ii appropriately spaced doses of MMR vaccine.

However, during a local outbreak of measles, all healthcare personnel, including those built-in 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 land or local health section'southward immunization plan for guidance. Admission contact information here: www.immunize.org/coordinators.

If there is an outbreak in my area, tin can we vaccinate children younger than 12 months?

MMR can be given to children equally young as half dozen months of age who are at loftier take chances of exposure such as during international travel or a community outbreak. All the same, doses given BEFORE 12 months of age cannot be counted toward the 2-dose series for MMR.

How does beingness born before 1957 confer immunity to measles?

People built-in earlier 1957 lived through several years of epidemic measles before the start measles vaccine was licensed in 1963. Equally a result, these people are very likely to accept had measles affliction. Surveys advise that 95% to 98% of those born before 1957 are immune to measles. Persons born earlier 1957 can be presumed to be immune. Nonetheless, if serologic testing indicates that the person is not immune, at least i dose of MMR should exist administered.

Why is a 2d dose of MMR necessary?

Approximately 7% of people exercise non develop measles amnesty afterwards the outset 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 non respond to the showtime dose. About 97% of people develop immunity to measles after two doses of measles-containing vaccine.

Are there whatsoever situations where more than two doses of MMR are recommended?

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). Farther testing for serologic evidence of rubella amnesty is non recommended. MMR should not exist administered to a meaning 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 past public health authorities as being role of a group or population at increased risk for acquiring mumps considering 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 near this recommendation is available at www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6701a7-H.pdf.

When is information technology appropriate to use MMR vaccine for measles post-exposure prophylaxis?

MMR vaccine given within 72 hours of initial measles exposure tin reduce the chance of getting sick or reduce the severity of symptoms. Another option for exposed, measles-susceptible individuals at high risk of complications who cannot exist vaccinated is to requite immunoglobulin (IG) within half dozen days of exposure. Practice non administer MMR vaccine and IG simultaneously, as the IG invalidates the vaccine.

Data on mail-exposure prophylaxis for measles can be constitute in the 2013 ACIP guidance at world wide web.cdc.gov/mmwr/pdf/rr/rr6204.pdf, page 24.

Do any adults need "booster" doses of MMR vaccine to prevent measles?

No. Adults with prove 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 take life-long amnesty once they accept received the recommended number of MMR vaccine doses or have other evidence of immunity.

Many people who were young children in the 1960s do not have records indicating what type of measles vaccine they received in the mid-1960s. What measles vaccine was virtually frequently given in that time period? That guidance would help many older people who would prefer not to exist revaccinated.

Both killed and alive adulterate measles vaccines became available in 1963. Live adulterate vaccine was used more than often than killed vaccine. The killed vaccine was found to exist not effective and people who received it should exist revaccinated with live vaccine. Without a written record, it is not possible to know what blazon of vaccine an individual may have received. So persons built-in 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 equally healthcare professionals and international travelers) should receive 2 doses of MMR separated by at least four 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 practice not demand to exist revaccinated. People who were vaccinated prior to 1968 with either inactivated (killed) measles vaccine or measles vaccine of unknown type should exist revaccinated with at least one dose of alive attenuated measles vaccine. This recommendation is intended to protect people who may accept received killed measles vaccine which was bachelor 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 blazon who are at high hazard for mumps infection (such equally people who work in a healthcare facility) should be considered for revaccination with 2 doses of MMR vaccine.

I sympathise that ACIP changed its definition of evidence of immunity to measles, rubella, and mumps in 2013. Please explain.

In the 2013 revision of its MMR vaccine recommendations ACIP includes laboratory confirmation of disease as evidence of amnesty for measles, mumps, and rubella. ACIP removed physician diagnosis of illness as evidence of immunity for measles and mumps. Physician diagnosis of illness had not previously been accepted as bear witness of immunity for rubella. With the subtract in measles and mumps cases over the last xxx years, the validity of physician-diagnosed disease has go questionable. In addition, documenting history from medico records is non a practical option for virtually adults. The 2013 MMR ACIP recommendations are bachelor at world wide web.cdc.gov/mmwr/pdf/rr/rr6204.pdf.

Is at that place anything that can exist done for unvaccinated people who have already been exposed to measles, mumps, or rubella?

Measles vaccine, given as MMR, may exist constructive if given within the first 3 days (72 hours) after exposure to measles. Allowed globulin may exist effective for as long every bit vi days after exposure. Postexposure prophylaxis with MMR vaccine does not prevent or modify 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 effect in infection.

What are the current ACIP recommendations for employ 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 fifteen mL. Alternatively, MMR vaccine can be given instead of IGIM to infants age 6 through 11 months, if it tin be given within 72 hours of exposure.

Pregnant women without prove 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 take been exposed to measles should receive an IGIV dose of 400 mg/kg of body weight.

For persons already receiving IGIV therapy, assistants of at least 400 mg/kg body weight within iii weeks before measles exposure should be sufficient to forestall measles infection. For patients receiving subcutaneous immune globulin (IGSC) therapy, assistants of at least 200 mg/kg body weight for 2 consecutive weeks before measles exposure should be sufficient.

Other people who do not accept evidence of measles immunity can receive an IGIM dose of 0.5 mL/kg of torso weight. Give priority to people who were exposed to measles in settings where they take intense, prolonged close contact (such as household, child care, classroom, etc.). The maximum dose of IGIM is 15 mL.

IG is non indicated for persons who accept received i dose of measles-containing vaccine at age 12 months or older unless they are severely immunocompromised. IG should not exist used to control measles outbreaks.

IG has not been shown to foreclose mumps or rubella infection after exposure and is non recommended for that purpose.

We oftentimes see college students who lack vaccination records, but 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?

Unmarried antigen vaccine is no longer available in the U.South.; the pupil should get the combined MMR vaccine. If a college educatee or other person at increased risk of exposure cannot produce written documentation of either immunization or disease, and titers are negative, they should receive ii doses of MMR.

I have patients who claim to think receiving MMR vaccine but accept no written tape, or whose parents written report the patient has been vaccinated. Should I accept this as evidence of vaccination?

No. Cocky-reported doses and history of vaccination provided by a parent or other caregiver are not considered to be valid. You lot should simply accept a written, dated record as evidence of vaccination.

Under what circumstances should adults be considered for testing for measles-specific antibody prior to getting vaccinated?

Adults without evidence of amnesty and no contraindications to MMR vaccine can be vaccinated without testing. But adults without evidence of amnesty might be considered for testing for measles-specific IgG antibody, but testing is non needed prior to vaccination.

CDC does not recommend measles antibody testing after MMR vaccination to verify the patient'southward immune response to vaccination.

Two documented doses of MMR vaccine given on or after the get-go birthday and separated by at least 28 days is considered proof of measles immunity, co-ordinate to ACIP. Documentation of advisable vaccination supersedes the results of serologic testing for measles, mumps, rubella, and varicella.

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 adventure. Should the patient receive the MMR vaccine?

A history of having had measles is non sufficient evidence of measles amnesty. A positive serologic test for measles-specific IgG will ostend that the person is allowed and is not at risk of infection regardless of the multiple myeloma. Multiple myeloma is a hematologic cancer and is considered immunosuppressive and so MMR vaccine is contraindicated in this person.

We have developed patients in our practise at loftier risk for measles, including patients going back to higher 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 lot have two options. You can exam for immunity or yous can but give 2 doses of MMR at least 4 weeks apart. At that place is no harm in giving MMR vaccine to a person who may already be immune to one or more than of the vaccine viruses. If you or the patient opt for testing, and the tests betoken the patient is not immune to one or more of the vaccine components, give your patient ii doses of MMR at least 4 weeks apart. If whatsoever test results are indeterminate or equivocal, consider your patient nonimmune. ACIP does non recommend serologic testing after vaccination because commercial tests may not exist sensitive plenty to reliably find vaccine-induced immunity.

I accept a 45-year-old patient who is traveling to Haiti for a mission trip. She doesn't retrieve always getting an MMR booster (she didn't get to college and never worked in wellness care). She was rubella allowed when pregnant twenty years ago. Her measles titer is negative. Would yous recommend an MMR booster?

ACIP recommends two doses of MMR given at least 4 weeks autonomously for any adult born in 1957 or later who plans to travel internationally. At that place is no harm in giving MMR vaccine to a person who may already be immune to ane or more than of the vaccine viruses.

A patient who was built-in before 1957 and is not a healthcare worker wants to get the MMR vaccine before international travel. Does he need a dose of MMR?

No, information technology is not considered necessary, just he may be vaccinated. Before implementation of the national measles vaccination programme in 1963, virtually every person acquired measles before machismo. So, this patient can be considered immune based on their birth year. However, MMR vaccine as well may exist given to any person born earlier 1957 who does not have a contraindication to MMR vaccination.

Routine testing of patients born before 1957 for measles-specific antibody is not recommended by CDC.

We have measles cases in our community. How can I best protect the young children in my do?

First of all, brand sure all your patients are fully vaccinated according to the U.Due south. immunization schedule.

In sure circumstances, MMR is recommended for infants age 6 through 11 months. Give infants this age a dose of MMR earlier international travel. In addition, consider measles vaccination for infants as immature equally historic period 6 months as a control mensurate during a U.S. measles outbreak. Consult your country health section to find out if this is recommended in your state of affairs. Do non count any dose of MMR vaccine as part of the 2-dose series if it is administered earlier a child's first birthday. Instead, echo 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 vi years.

Finally, remember that infants too immature for routine vaccination and people with medical conditions that contraindicate measles immunization depend on high MMR vaccination coverage among those around them. Be certain to encourage all your patients and their family unit members to become vaccinated if they are not immune.

During a mumps outbreak should we offer a 3rd dose of MMR (MMR II, Merck) to persons who have two prior documented doses of MMR?

In recent years, mumps outbreaks accept occurred primarily in populations in institutional settings with close contact (such as residential colleges) or in close-knit social groups. The current routine recommendation for 2 doses of MMR vaccine appears to be sufficient for mumps control in the general population, but insufficient for preventing mumps outbreaks in prolonged, close-contact settings, even where coverage with 2 doses of MMR vaccine is loftier.

In January 2018, the Advisory Committee on Immunization Practices (ACIP) published new guidance for MMR vaccination of persons at increased run a risk for acquiring mumps during an outbreak. Persons previously vaccinated with 2 doses of a mumps virus�containing vaccine who are identified by public health authorities as being part of a group at increased adventure for acquiring mumps because of an outbreak should receive a third dose of a mumps virus�containing vaccine to improve protection confronting mumps affliction and related complications. More than data about this recommendation is available at www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6701a7-H.pdf.

In a measles outbreak, do children who have non had MMR vaccine pose a threat to vaccinated people? Information technology is my agreement that vaccinated people tin still contract measles. Am I correct?

You are right that vaccinated people can still be infected with viruses or leaner 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 flu in years with a good match of circulating and vaccine viruses, and seventy% for acellular pertussis vaccines in the 3-five years after vaccination). More than information is available for each vaccine and affliction at www.cdc.gov/vaccines/vpd-vac/default.htm and www.immunize.org/vaccines.

Administering Vaccines Back to pinnacle

Our dispensary has been giving MMR by the wrong route (IM rather than SC) for years. Should these doses exist repeated?

All live injected vaccines (MMR, varicella, and yellow fever) are recommended to exist given subcutaneously. However, intramuscular administration of whatsoever of these vaccines is non probable to decrease immunogenicity, and doses given IM do not need to exist repeated.

We often demand to give MMR vaccine to large adults. Is a 25-approximate needle with a length of 5/8" sufficient for a subcutaneous injection?

Yeah. A v/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, nonetheless, 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 historic period 13 years and older, information technology may be counted towards completion of the MMR and varicella vaccine series and does non demand to be repeated.

Scheduling Vaccines Back to acme

How before long tin can we give the second dose of MMR vaccine to a child vaccinated at 12 months old?

For routine vaccination, children without contraindications to MMR vaccine should receive 2 doses of MMR vaccine with the get-go dose at age 12–xv months former and the second dose at age 4–6 years erstwhile. The minimum interval is 28 days for dose 2. If you have an outbreak in your customs or a child is traveling internationally, then consider using the minimum interval instead of waiting until historic period four–6 years old for dose 2.

Does the 4-day "grace period" use to the minimum age for administration of the start dose of MMR? What about the 28-mean solar day minimum interval betwixt doses of MMR?

A dose of MMR vaccine administered upwards to four days before the get-go birthday may be counted as valid. Nonetheless, school entry requirements in some states may mandate administration on or after the start altogether. The iv-day "grace period" should not be practical to the 28-day minimum interval between ii doses of a live parenteral vaccine.

Can MMR be given on the same twenty-four hours as other live virus vaccines?

Yes. Yet, if ii parenteral or intranasal live vaccines (MMR, varicella, LAIV and/or yellow fever) are not administered on the aforementioned day, they should be separated by an interval of at least 28 days.

If you can give the second dose of MMR every bit early every bit 28 days after the start dose, why practise we routinely wait until kindergarten entry to give the 2nd dose?

The second dose of MMR may be given as early on as 4 weeks later on the first dose, and be counted as a valid dose if both doses were given afterward the starting time birthday. The second dose is not a booster, just rather it is intended to produce amnesty in the small number of people who fail to respond to the beginning dose. The risk of measles is higher in schoolhouse-age children than those of preschool historic period, so it is important to receive the second dose by school entry. It is likewise user-friendly to give the 2d dose at this age, since the child will have an immunization visit for other schoolhouse entry vaccines.

What is the earliest age at which I can requite MMR to an infant who volition be traveling internationally? Also, which countries pose a high gamble to children for contracting measles?

ACIP recommends that children who travel or live abroad should be vaccinated at an before age than that recommended for children who reside in the U.s.a.. Before their divergence from the United States, children age 6 through 11 months should receive 1 dose of MMR. The take a chance for measles exposure can be high in high-, heart- and depression-income countries. Consequently, CDC encourages all international travelers to be up to engagement on their immunizations regardless of their travel destination and to go on a copy of their immunization records with them as they travel. For additional information on the worldwide measles state of affairs, and on CDC's measles vaccination information for travelers, go to wwwnc.cdc.gov/travel.

If we give a kid a dose of MMR vaccine at 6 months of historic period because they are in a customs with cases of measles, when should nosotros give the next dose?

The next dose should be given at 12 months of age. The child will as well need another dose at to the lowest degree 28 days later. For the child to exist fully vaccinated, they demand to have 2 doses of MMR vaccine given when the child is 12 months of age and older. A dose given at less than 12 months of age does not count as function of the MMR vaccine ii-dose series.

I accept an 8-month-sometime patient who is traveling internationally. The babe needs to be protected from hepatitis A as well as measles, mumps, and rubella. The family is leaving in 11 days. Tin I give hepatitis A IG and MMR vaccine simultaneously?

No. IG may contain antibodies to measles, mumps, and rubella that could reduce the effectiveness of MMR vaccine. For this reason, in February 2018 ACIP voted to recommend that hepatitis A vaccine should be administered to infants age six through 11 months traveling outside the United states of america when protection against hepatitis A is recommended. MMR and hepatitis A vaccine may exist safely co-administered to children in this age group. Neither vaccine is counted as part of the child'due south routine vaccination series. For details of this recommendation, see the CDC ACIP recommendations for the prevention and control of hepatitis A at world wide web.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf, page xviii.

Can I give the second dose of MMR earlier than historic period 4 through half dozen years (the kindergarten entry dose) to young children traveling to areas of the world where there are measles cases?

Yes. The 2nd dose of MMR tin be given a minimum of 28 days after the first dose if necessary.

If I give MMR to an infant traveler younger than age ane year, will that dose be considered valid for the U.S. immunization schedule?

No. A measles-containing vaccine administered more than four days before the commencement 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 kid remains in an area where affliction gamble is high). The 2d dose should exist administered at least 28 days after the first dose.

Can I give a tuberculin pare examination (TST) on the same mean solar day as a dose of MMR vaccine?

Yes. A TST can be applied earlier or on the same day that MMR vaccine is given. However, if MMR vaccine is given on the previous day or before, the TST should be delayed for at to the lowest degree 28 days. Live measles vaccine given prior to the application of a TST can reduce the reactivity of the skin test considering of mild suppression of the immune organization.

An 18-twelvemonth-old higher 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 pupil should receive two doses of MMR, separated by at to the lowest degree 28 days. A personal history of measles and mumps is not acceptable every bit proof of immunity. Adequate evidence of measles and mumps immunity includes a positive serologic test for antibiotic, nativity before 1957, or written documentation of vaccination. For rubella, only serologic show or documented vaccination should exist accepted every bit proof of immunity. Additionally, people built-in prior to 1957 may be considered immune to rubella unless they are women who have the potential to go pregnant.

When not given on the same twenty-four hour period, is the interval between yellowish fever and MMR vaccines iv weeks (28 days) or 30 days? I have seen the yellow fever and live virus vaccine recommendations published both means.

The General Best Practice Guidelines for Immunization (encounter www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html) makes the generic recommendation that live parenterally or nasally administered vaccines not given on the same solar 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 exist separated by at least xxx days if possible. Either interval is acceptable.

For Healthcare Personnel Back to tiptop

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, divers as documentation of two doses of measles and mumps vaccine and at least one dose of rubella vaccine, laboratory evidence of amnesty, or laboratory confirmation of illness. 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 nascency yr who lack laboratory testify of measles or mumps immunity or laboratory confirmation of illness. During outbreaks of rubella, healthcare facilities should recommend 1 dose of MMR for unvaccinated personnel regardless of nascence twelvemonth who lack laboratory evidence of rubella amnesty or laboratory confirmation of infection or disease.

Would you consider healthcare personnel with two documented doses of MMR vaccine to exist allowed 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 examination for measles, mumps, or rubella. Documented age-appropriate vaccination supersedes the results of subsequent serologic testing. In contrast, HCP who do not have documentation of MMR vaccination and whose serologic test is interpreted as "indeterminate" or "equivocal" should be considered non immune and should receive 2 doses of MMR vaccine (minimum interval 28 days). ACIP does not recommend serologic testing later on vaccination. For more than data, see ACIP's recommendations on the utilize of MMR vaccine at world wide web.cdc.gov/mmwr/pdf/rr/rr6204.pdf, page 22.

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

Approximately v to fifteen% of susceptible people who receive MMR vaccine will develop a depression-grade fever and/or mild rash seven to 12 days later vaccination. Nonetheless, the person is not infectious, and no special precautions ( such as exclusion from work) demand to exist taken.

A 22-year-old female is going to pharmacy schoolhouse and the school wants her to take a second dose of MMR vaccine. She had the first dose as a child and developed measles within 24 hours of receiving the vaccine. Recent serologic testing showed she is allowed to mumps and measles just not allowed to rubella. Tin I requite her a second dose of the MMR with her having measles afterwards the first dose?

Yeah, equally a healthcare professional, this person should become a second dose of MMR to ensure she is immune to rubella. There is no damage in providing MMR to a person who is already immune to i or more of the components. If she developed measles but one day subsequently getting her first MMR, she must have been exposed to the disease prior to vaccination.

Contraindications and Precautions Back to top

What are the contraindications and precautions for MMR vaccine?

Contraindications:

• history of a severe (anaphylactic) reaction to whatsoever vaccine component (east.one thousand., neomycin) or post-obit a previous dose of MMR • pregnancy • severe immunosuppression from either disease or therapy

Precautions:

• receipt of an antibody-containing blood production in the previous 3–xi months, depending on the type of blood production received. See world wide web.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html, Table 3-5 for more information on this effect • moderate or severe acute illness with or without fever • history of thrombocytopenia or thrombocytopenic purpura • Important details almost the contraindications and precautions for MMR vaccine are in the electric current MMR ACIP statement, available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.

We have many patients who are immunocompromised and cannot go the MMR vaccine. How should we advise our patients?

People with medical weather that contraindicate measles immunization depend on loftier MMR vaccination coverage amongst those around them. To help preclude the spread of measles virus, brand sure all your staff and patients who tin exist vaccinated are fully vaccinated co-ordinate to the U.Southward. immunization schedule. Besides, encourage patients to remind their family members and other close contacts to get vaccinated if they are not immune.

If patients who cannot go MMR vaccine are exposed to measles, CDC has guidelines for immune globulin for post-exposure prophylaxis which tin be found at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.

Nosotros have a patient who has selective IgA deficiency. We also have patients with selective IgM deficiency. Can MMR or varicella vaccine exist 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 constructive.

I accept 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 await a specific interval before giving MMR. Injectable steroids are not considered immunosuppressive for the purpose of vaccination decisions, and 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 accept a xl lb half-dozen-year-former 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 2013 IDSA definition of depression-level immunosuppression for methotrexate is a dosage of less than 0.4 mg/kg/calendar week. For additional details, see the 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host: cid.oxfordjournals.org/content/early/2013/11/26/cid.cit684.full.pdf.

Is it truthful 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 civilization) 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.

Tin can I give MMR to a breastfeeding female parent 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 exist transmitted via chest milk, the infection in the infant is asymptomatic.

If a patient recently received a blood production, can he or she receive MMR vaccine?

Yeah, merely there should be sufficient time betwixt the blood product and the MMR to reduce the chance of interference. The interval depends on the blood product received. See Tabular array 3-5 of ACIP's General Best Practice Guidelines for Immunization for more than information, bachelor at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html.

Is information technology acceptable exercise to administrate MMR, Tdap, and flu vaccines to a postpartum mom at the same time as administering RhoGam?

Yes. Receipt of RhoGam is non a reason to delay vaccination. For more information see the ACIP General All-time Practice Guidelines for Immunization, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html.

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:

Administrate 2 doses of MMR vaccine to all HIV-infected people age 12 months and older who do non have testify of current astringent immunosuppression or current evidence of measles, rubella, and mumps immunity. To be regarded as non having prove of current severe immunosuppression, a child age v years or younger must have CD4 percentages of fifteen% 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 blazon of parameter (percentage or counts) this is sufficient for vaccine decision-making.

Administer the first dose at 12 through 15 months and the 2d dose to children age 4 through 6 years, or every bit early as 28 days after the commencement dose.

Unless they have acceptable current bear witness of measles, mumps, and rubella immunity, people with perinatal HIV infection who were vaccinated prior to establishment of constructive antiretroviral therapy (Art) should receive ii accordingly spaced doses of MMR vaccine afterwards 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 historic period 5 years or younger. People older than 5 years should have CD4 percentages of xv% or more than and a CD4 lymphocyte count of 200 or more than/mm3 for 6 months or longer. If laboratory results state merely one type of parameter (percentages or counts) this is sufficient for vaccine controlling.

Pregnancy and Postpartum Considerations Back to top

What is the recommended length of time a adult female should look after receiving rubella (MMR) vaccine before becoming pregnant?

Although the MMR vaccine packet insert recommends a 3-calendar month deferral of pregnancy subsequently MMR vaccination, ACIP recommends deferral of pregnancy for iv weeks. For details on this result, see ACIP's Control and Prevention of Rubella: Evaluation and Management of Suspected Outbreaks, Rubella in Significant Women, and Surveillance for Built Rubella Syndrome.

How should teenage girls and women of child-bearing age be screened for pregnancy before MMR vaccination?

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 "yeah." Those who answer "no" should be advised to avoid pregnancy for 4 weeks following vaccination. Pregnancy testing is non necessary.

If a meaning woman inadvertently receives MMR vaccine, how should she be brash?

No specific activity 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 is not a reason to finish the pregnancy. You should consult with others in your healthcare setting to identify ways to forestall such vaccination errors in the future. Detailed data about MMR vaccination in pregnancy is included in the most recent MMR ACIP argument, available at world wide web.cdc.gov/mmwr/pdf/rr/rr6204.pdf.

Nosotros require a pregnancy test for all our seventh 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 respond "aye." Those who respond "no" should be advised to avoid pregnancy for i month following vaccination.

Tin we give an MMR to a 15-month-old whose female parent is 2 months meaning?

Yes. Measles, mumps, and rubella vaccine viruses are non transmitted from the vaccinated person, so MMR vaccination of a household contact does not pose a hazard to a meaning household member.

If a woman'southward rubella examination result shows she is "non immune" during a prenatal visit, but she has 2 documented doses of MMR vaccine, does she need a third dose of MMR vaccine postpartum?

In 2013, ACIP changed its recommendation for this situation (see www.cdc.gov/mmwr/pdf/rr/rr6204.pdf, pages 18–20). It is recommended that women of childbearing historic period who have received 1 or two doses of rubella-containing vaccine and have rubella serum IgG levels that are non conspicuously positive should be administered i additional dose of MMR vaccine (maximum of 3 doses) and practice not need to be retested for serologic prove of rubella amnesty. MMR should non be administered to a pregnant woman.

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 historic period who accept received i or 2 doses of rubella-containing vaccine and take a rubella serum IgG levels that is not conspicuously positive should be administered one additional dose of MMR vaccine (maximum of iii doses). Repeat serologic testing for evidence of rubella immunity is non recommended. See www.cdc.gov/mmwr/pdf/rr/rr6204.pdf, pages 18–20, for more information on this issue.

MMR vaccines should non be administered to women known to exist pregnant or attempting to go significant. Because of the theoretical chance 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 commitment can MMR be given to the mother?

MMR tin can be administered any time later on delivery. The vaccine should be administered to a adult female who is susceptible to either measles, mumps, or rubella before hospital discharge, even if she has received RhoGam during the infirmary stay, leaves in less than 24 hours, or is breastfeeding.

Vaccine Rubber Back to tiptop

Is at that place any evidence that MMR or thimerosal causes autism?

No. This result has been studied extensively, 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 clan between MMR vaccine or thimerosal-containing vaccines and the development of autism. For more data on thimerosal and vaccines in general, visit www.cdc.gov/vaccinesafety/Concerns/thimerosal/index.html.

A few parents are asking that their children receive split components of the MMR vaccine because they fear MMR may be linked to autism. What should I do?

Merck no longer produces unmarried antigen measles, mumps, and/or rubella vaccines for the U.S. market. But combined MMR is available. You should educate parents about the lack of clan betwixt MMR and autism.

How likely is information technology for a person to develop arthritis from rubella vaccine?

Arthralgia (joint hurting) and transient arthritis (articulation redness or swelling) following rubella vaccination occurs only in people who were susceptible to rubella at the fourth dimension of vaccination. Joint symptoms are uncommon in children and in adult males. Nearly 25% of non-immune mail-pubertal women report joint hurting later on receiving rubella vaccine, and nearly x% to 30% written report arthritis-like signs and symptoms.

When joint symptoms occur, they generally begin 1 to three weeks later on vaccination, usually are mild and not incapacitating, last nigh 2 days, and rarely recur.

Is there whatsoever harm in giving an extra dose of MMR to a child of age seven years whose tape is lost and the female parent is not certain nearly the last dose of MMR?

In full general, although it is not ideal, receiving extra doses of vaccine poses no medical problem. However, receiving excessive doses of tetanus toxoid (e.g., DTaP, DT, Tdap, or Td) can increase the risk of a local adverse reaction. For details run across the Extra Doses of Vaccine Antigens section of the ACIP General Best Practice Guidelines for Immunization at world wide web.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html.

Vaccination providers frequently encounter people who do non have adequate documentation of vaccinations. Providers should merely accept written, dated records as evidence of vaccination. With the exception of influenza vaccine and pneumococcal polysaccharide vaccine, cocky-reported doses of vaccine without written documentation should non be accepted. An attempt to locate missing records should be made whenever possible past contacting previous healthcare providers, reviewing state or local immunization information systems, and searching for a personally held record.

If records cannot exist located or will definitely non be available anywhere because of the patient's circumstances, children without acceptable 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 Dorsum to pinnacle

How long tin reconstituted MMR vaccine exist stored in a refrigerator before it must be discarded?

The amount of time in which a dose of vaccine must exist used afterward reconstitution varies by vaccine and is usually outlined somewhere in the vaccine'south package insert. MMR must be used within 8 hours of reconstitution. MMRV must be used within thirty minutes; other vaccines must be used immediately. The Immunization Activity Coalition has a staff education piece that outlines the time immune between reconstitution and use, as stated in the parcel inserts for a number of vaccines. Handout tin can be plant at the post-obit link: www.immunize.org/catg.d/p3040.pdf.

How should MMR vaccine be stored?

MMR may exist stored either in the fridge at two°C to 8°C (36°F to 46°F) or in the freezer at -50°C to -15°C (-58°F to +five°F). The diluent should not be frozen and tin exist stored in the refrigerator or at room temperature.

If the MMR is combined with varicella vaccine every bit MMRV (ProQuad, Merck), it must be stored in the freezer at -50°C to -15°C (-58°F to +v°F).

A box of MMR vaccine (not reconstituted) was left at room temperature overnight. Tin can I use information technology?

Unfortunately, serious errors in vaccine storage and handling like this occur too ofttimes. If you doubtable that vaccine has been mishandled, yous should store the vaccine as recommended, then contact the manufacturer or land/local health section for guidance on its utilize. This is peculiarly of import for live virus vaccines like MMR and varicella.

In one case MMR vaccine has been reconstituted with diluent, how soon must information technology exist used?

It is preferable to administrate MMR immediately later on reconstitution. If reconstituted MMR is not used inside 8 hours, it must be discarded. MMR should e'er be refrigerated and should never exist left at room temperature.

I misplaced the diluent for the MMR dose and so I used normal saline instead. Is at that place whatever problem with doing this?

But the diluent supplied with the vaccine should be used to reconstitute whatever vaccine. Any vaccine reconstituted with the incorrect diluent should exist repeated.

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Source: https://www.immunize.org/askexperts/experts_mmr.asp

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