Should Elderly Be Vaccinated Again for Measles

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 Issues

What is the current state of affairs with measles, mumps, and rubella in the U.s.?

In 2019, a provisional total of ane,242 cases of measles from 31 states were reported to CDC. This was the largest number reported in a single twelvemonth since 1992; 73% of cases were associated with outbreaks among unvaccinated people in New York. These outbreaks were contained and stopped before the finish of 2019. Between January 1 and August 19, 2020, just 12 measles cases were reported past seven jurisdictions. Limited travel as a consequence of the COVID-19 pandemic drastically reduced opportunities for travelers infected with measles to enter or travel within the U.s.a.. CDC measles surveillance updates can be institute 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. Notwithstanding, outbreaks even so occasionally occur. In 2006, there was an outbreak affecting more than 6,584 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 three,000 cases. Since 2015, numerous outbreaks take been reported across the Us, in college campuses, prisons, and close-knit communities, including a large outbreak in northwest Arkansas where near iii,000 cases were reported in 2016. These outbreaks accept shown that when people with mumps have shut contact with a lot of other people (such equally among residential college students and families in shut-knit communities) mumps can spread even among vaccinated people. Nevertheless, outbreaks are much larger in areas where vaccine coverage rates are lower. A conditional total of iii,484 cases of mumps were reported to CDC in 2019.

Rubella was declared eliminated (the absence of endemic transmission for 12 months or more) from the Us in 2004. Fewer than ten cases (primarily import-related) take been reported annually in the United states of america since elimination was alleged. Rubella incidence in the United States has decreased by more 99% from the pre-vaccine era. A provisional full 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 modern medical care. The 1989–1991 measles outbreak in the U.South. resulted in more than than 55,000 cases and more 100 deaths. In the The 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 one,000 reported measles cases in the United states, approximately ane example of encephalitis and 2 to three deaths resulted. The risk for death from measles or its complications is greater for infants, immature 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 affliction is typically milder, with fewer complications, in fully vaccinated instance 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 adult female, especially during the start 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 await for in diagnosing measles?

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

• a generalized rash lasting 3 or more days, and • a temperature of 101°F or higher (38.three°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 one to 2 days before the measles rash appears to i to 2 days afterward. They announced as punctate blue-white spots on the bright red background of the buccal mucosa. Pictures of measles rash and Koplik spots can exist establish at world wide web.cdc.gov/measles/virtually/photos.html.

Providers should exist 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.

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

Measles is highly contagious. A person with measles is infectious up to 4 days earlier through four 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 study suspected measles cases to their local health section and obtain specimens for measles testing, including serum sample for measles serologic testing and a pharynx 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 non await for the results of laboratory testing to study clinically-suspected measles to the local wellness department.

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

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

For measles, there is an average of x 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 two to 4 days later on 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). Notwithstanding, equally noted higher up, up to half of rubella virus infections crusade no symptoms.

Vaccine Recommendations Back to pinnacle

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

The nigh contempo 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 age 12 through 15 months, with a 2nd dose at age 4 through 6 years. The second dose of MMR can be given as early equally 4 weeks (28 days) after the offset dose and be counted as a valid dose if both doses were given subsequently 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 neglect to respond to the first dose.

Adults with no evidence of amnesty (evidence of amnesty is defined as documented receipt of 1 dose [2 doses 4 weeks apart if high risk] of live measles virus-containing vaccine, laboratory testify of immunity or laboratory confirmation of disease, or birth earlier 1957) should get one dose of MMR vaccine unless the adult is in a high-take chances group. Loftier-risk people need 2 doses and include school-age children, healthcare personnel, international travelers, and students attending post-high school educational institutions.

Alive attenuated measles vaccine became bachelor in the U.S. in 1963. An ineffective, inactivated measles vaccine was too bachelor in the U.Southward. 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 blazon of vaccine information technology was, or are sure it was inactivated measles vaccine, that dose should be considered invalid and the patient revaccinated as age- and gamble-appropriate with MMR vaccine. At the discretion of the state public health department, anyone exposed to measles in an outbreak setting tin receive an additional dose of MMR vaccine even if they are considered completely vaccinated for their age or risk condition.

What is considered acceptable show of immunity to measles?

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

• written documentation of adequate vaccination: • laboratory prove of immunity • laboratory confirmation of measles (exact history of measles does non count) • birth earlier 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 testify of immunity with two 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 twelvemonth if they lack laboratory evidence of measles immunity.

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

Zero, 1, or ii doses of MMR vaccine are needed for the adults described below.

Null doses:

• adults built-in before 1957 except healthcare personnel* • adults built-in 1957 or later who are at low risk (i.due east., not an international traveler or healthcare worker, or person attention higher or other mail service-loftier schoolhouse educational institution) and who have already received one or more documented doses of live measles vaccine • adults with laboratory bear witness of immunity or laboratory confirmation of measles

I dose of MMR vaccine:

• adults born 1957 or later who are at low adventure (i.e., not an international traveler, healthcare worker, or person attending college or other mail-high school educational establishment) and have no documented vaccination with alive measles vaccine and no laboratory evidence of amnesty or prior measles infection

Ii doses of MMR vaccine:

� loftier-take a chance 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 depression-risk) or 2 (if high-risk) doses of MMR vaccine.

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

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

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 bear witness of measles amnesty, laboratory confirmation of disease, or vaccination with two appropriately spaced doses of MMR vaccine.

Nevertheless, during a local outbreak of measles, all healthcare personnel, including those born earlier 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 wellness department'south immunization program for guidance. Access contact information here: www.immunize.org/coordinators.

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

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

How does being born before 1957 confer immunity to measles?

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

Why is a second dose of MMR necessary?

Approximately 7% of people practice not develop measles immunity after the first dose of vaccine. This occurs for a multifariousness of reasons. The second dose is to provide another take a chance to develop measles immunity for people who did non respond to the get-go dose. Most 97% of people develop immunity to measles later on 2 doses of measles-containing vaccine.

Are there any situations where more than 2 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 accept rubella serum IgG levels that are not conspicuously positive should receive 1 additional dose of MMR vaccine (maximum of iii doses). Farther testing for serologic evidence of rubella amnesty is not recommended. MMR should non 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 every bit being part of a group or population at increased risk for acquiring mumps because of an outbreak should receive a 3rd dose of a mumps virus�containing vaccine (MMR or MMRV) to improve protection against mumps affliction and related complications. More data about this recommendation is available at www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6701a7-H.pdf.

When is information technology appropriate to utilize MMR vaccine for measles mail service-exposure prophylaxis?

MMR vaccine given within 72 hours of initial measles exposure tin reduce the risk of getting sick or reduce the severity of symptoms. Another option for exposed, measles-susceptible individuals at loftier take chances of complications who cannot be vaccinated is to requite immunoglobulin (IG) within half dozen days of exposure. Practise non administer MMR vaccine and IG simultaneously, every bit 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.

Practise any adults need "booster" doses of MMR vaccine to preclude measles?

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

Many people who were young children in the 1960s do non take records indicating what blazon of measles vaccine they received in the mid-1960s. What measles vaccine was nigh oft given in that time period? That guidance would assistance many older people who would prefer not to be revaccinated.

Both killed and alive attenuated measles vaccines became available in 1963. Live attenuated vaccine was used more oftentimes than killed vaccine. The killed vaccine was establish to be not constructive and people who received information technology 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 built-in during or after 1957 who received killed measles vaccine or measles vaccine of unknown type, or who cannot certificate having been vaccinated or having laboratory-confirmed measles affliction should receive at least 1 dose of MMR. Some people at increased take chances of exposure to measles (such every bit healthcare professionals and international travelers) should receive ii doses of MMR separated by at least iv weeks.

Practise 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 exist revaccinated with at least one dose of alive attenuated measles vaccine. This recommendation is intended to protect people who may have received killed measles vaccine which was available in the U.s. in 1963 through 1967 and was non effective. People vaccinated before 1979 with either killed mumps vaccine or mumps vaccine of unknown blazon who are at high risk for mumps infection (such equally people 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 in 2013. Please explain.

In the 2013 revision of its MMR vaccine recommendations ACIP includes laboratory confirmation of affliction as evidence of immunity for measles, mumps, and rubella. ACIP removed medico diagnosis of disease every bit evidence of amnesty for measles and mumps. Doctor diagnosis of illness had not previously been accepted equally prove of immunity for rubella. With the decrease in measles and mumps cases over the last xxx years, the validity of physician-diagnosed disease has become questionable. In add-on, documenting history from physician records is not a practical option for most adults. The 2013 MMR ACIP recommendations are bachelor at world wide web.cdc.gov/mmwr/pdf/rr/rr6204.pdf.

Is there anything that can be washed for unvaccinated people who have already been exposed to measles, mumps, or rubella?

Measles vaccine, given equally MMR, may be effective if given within the get-go 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 modify the clinical severity of mumps or rubella. Notwithstanding, if the exposed person does not accept evidence of mumps or rubella amnesty they should be vaccinated since not all exposures result in infection.

What are the current ACIP recommendations for use of immune globulin (IG) for measles, mumps, and rubella postal service-exposure prophylaxis?

In the 2013 revision of its MMR vaccine recommendations ACIP expanded the utilise 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 trunk weight; the maximum dose is 15 mL. Alternatively, MMR vaccine tin can be given instead of IGIM to infants historic period 6 through 11 months, if it can be given inside 72 hours of exposure.

Pregnant women without testify of measles immunity who are exposed to measles should receive an intravenous IG (IGIV) dose of 400 mg/kg of torso weight. Severely immunocompromised people, irrespective of evidence of measles amnesty 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 torso weight within 3 weeks before measles exposure should be sufficient to prevent measles infection. For patients receiving subcutaneous allowed 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 practice not have evidence of measles amnesty 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 take intense, prolonged shut contact (such every bit household, kid care, classroom, etc.). The maximum dose of IGIM is fifteen mL.

IG is not indicated for persons who take received 1 dose of measles-containing vaccine at historic period 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.

Nosotros often run across higher students who lack vaccination records, but whose titer results show they are not immune to some combination of measles, rubella, and/or mumps. What blazon of vaccine should these students receive?

Single antigen vaccine is no longer bachelor in the U.South.; the educatee should become the combined MMR vaccine. If a higher 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 take no written record, or whose parents report the patient has been vaccinated. Should I have 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. Yous should only take a written, dated record as prove of vaccination.

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

Adults without show of immunity and no contraindications to MMR vaccine tin be vaccinated without testing. Only adults without bear witness of immunity might be considered for testing for measles-specific IgG antibiotic, only testing is not needed prior to vaccination.

CDC does non recommend measles antibody testing after MMR vaccination to verify the patient's immune response to vaccination.

Two documented doses of MMR vaccine given on or later on the offset altogether and separated by at least 28 days is considered proof of measles amnesty, according to ACIP. Documentation of appropriate vaccination supersedes the results of serologic testing for measles, mumps, rubella, and varicella.

A patient built-in 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 well-nigh the measles exposure risk. Should the patient receive the MMR vaccine?

A history of having had measles is not sufficient testify of measles immunity. A positive serologic test for measles-specific IgG will confirm 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 then MMR vaccine is contraindicated in this person.

We take developed patients in our practice at loftier risk for measles, including patients going back to college or preparing for international travel, who don't remember e'er receiving MMR vaccine or having had measles disease. How should we manage these patients?

Y'all have two options. You can exam for immunity or you tin just requite 2 doses of MMR at least 4 weeks autonomously. 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 y'all or the patient opt for testing, and the tests bespeak the patient is not allowed to one or more of the vaccine components, give your patient two doses of MMR at least 4 weeks apart. If any test results are indeterminate or equivocal, consider your patient nonimmune. ACIP does non recommend serologic testing afterward vaccination because commercial tests may not exist sensitive plenty 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 wellness care). She was rubella immune when meaning twenty years ago. Her measles titer is negative. Would you recommend an MMR booster?

ACIP recommends two doses of MMR given at to the lowest degree iv weeks autonomously for any adult born in 1957 or subsequently who plans to travel internationally. At that place is no impairment in giving MMR vaccine to a person who may already be immune to 1 or more of the vaccine viruses.

A patient who was born 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, it is non considered necessary, but he may exist vaccinated. Earlier implementation of the national measles vaccination programme in 1963, virtually every person caused measles before adulthood. So, this patient can be considered immune based on their birth twelvemonth. Nonetheless, MMR vaccine too may exist given to any person born before 1957 who does not take a contraindication to MMR vaccination.

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

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

Beginning of all, make certain all your patients are fully vaccinated co-ordinate to the U.S. immunization schedule.

In certain circumstances, MMR is recommended for infants age six through 11 months. Give infants this age a dose of MMR earlier international travel. In improver, consider measles vaccination for infants as young as age half dozen months every bit a control measure during a U.S. measles outbreak. Consult your land health section to find out if this is recommended in your situation. Do not count whatsoever dose of MMR vaccine as role of the ii-dose series if information technology is administered earlier 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 loftier MMR vaccination coverage amongst those effectually them. Be sure to encourage all your patients and their family unit members to get vaccinated if they are not immune.

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

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

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

In a measles outbreak, do children who take not had MMR vaccine pose a threat to vaccinated people? It is my agreement that vaccinated people can still contract measles. Am I correct?

You are right that vaccinated people can still exist infected with viruses or bacteria 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 adept match of circulating and vaccine viruses, and 70% for acellular pertussis vaccines in the 3-v years afterwards vaccination). More than information is available for each vaccine and affliction at world wide web.cdc.gov/vaccines/vpd-vac/default.htm and www.immunize.org/vaccines.

Administering Vaccines Back to top

Our dispensary has been giving MMR by the incorrect 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 assistants of whatsoever of these vaccines is non likely to subtract immunogenicity, and doses given IM do not demand to exist repeated.

We often demand to requite MMR vaccine to large adults. Is a 25-gauge needle with a length of 5/viii" 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, withal, this issue is not addressed in the 2010 MMRV ACIP recommendations. Although this is off-label employ, CDC recommends that when a dose of MMRV is inadvertently given to a patient age thirteen years and older, information technology may be counted towards completion of the MMR and varicella vaccine series and does not need to exist repeated.

Scheduling Vaccines Dorsum to top

How before long 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 first dose at age 12–15 months old and the second dose at age 4–half-dozen years former. The minimum interval is 28 days for dose 2. If you have an outbreak in your community or a kid is traveling internationally, then consider using the minimum interval instead of waiting until age 4–6 years old for dose 2.

Does the four-day "grace period" employ to the minimum age for administration of the commencement dose of MMR? What most the 28-twenty-four hours minimum interval betwixt doses of MMR?

A dose of MMR vaccine administered up to 4 days before the offset birthday may be counted as valid. Even so, school entry requirements in some states may mandate administration on or later the first birthday. The iv-day "grace period" should non exist practical to the 28-day minimum interval betwixt two doses of a live parenteral vaccine.

Tin MMR be given on the same day as other live virus vaccines?

Yes. However, if ii parenteral or intranasal live vaccines (MMR, varicella, LAIV and/or yellow fever) are non administered on the same mean solar day, they should exist separated by an interval of at least 28 days.

If y'all can give the 2d dose of MMR as early on equally 28 days afterwards the first dose, why practice we routinely await until kindergarten entry to give the 2d dose?

The 2d dose of MMR may be given as early on as 4 weeks after the outset dose, and exist counted as a valid dose if both doses were given after the starting time altogether. The second dose is non a booster, just rather it is intended to produce immunity in the pocket-size number of people who neglect to respond to the first dose. The risk of measles is higher in school-age children than those of preschool age, and then it is important to receive the 2d dose by school entry. Information technology is also convenient to give the second dose at this historic period, since the kid will have an immunization visit for other school entry vaccines.

What is the earliest age at which I can give MMR to an baby who will exist traveling internationally? As well, which countries pose a high chance 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 of america. Before their divergence from the United States, children age half dozen through 11 months should receive i dose of MMR. The take chances for measles exposure can be high in loftier-, middle- and low-income countries. Consequently, CDC encourages all international travelers to exist up to date on their immunizations regardless of their travel destination and to continue a copy of their immunization records with them equally they travel. For additional information on the worldwide measles situation, and on CDC'south measles vaccination information for travelers, go to wwwnc.cdc.gov/travel.

If we give a child a dose of MMR vaccine at 6 months of age because they are in a community with cases of measles, when should we give the next dose?

The side by side dose should exist given at 12 months of age. The kid volition besides demand another dose at least 28 days later. For the child to be fully vaccinated, they need to have 2 doses of MMR vaccine given when the kid is 12 months of age and older. A dose given at less than 12 months of age does not count as part of the MMR vaccine two-dose serial.

I have an 8-month-old patient who is traveling internationally. The babe needs to be protected from hepatitis A equally well as measles, mumps, and rubella. The family unit is leaving in xi 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 6 through 11 months traveling outside the United States when protection against hepatitis A is recommended. MMR and hepatitis A vaccine may be safely co-administered to children in this age grouping. Neither vaccine is counted equally part of the child's routine vaccination series. For details of this recommendation, encounter the CDC ACIP recommendations for the prevention and command of hepatitis A at www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf, page eighteen.

Can I give the 2d dose of MMR earlier than historic period iv through half dozen years (the kindergarten entry dose) to immature children traveling to areas of the world where there are measles cases?

Yes. The 2nd dose of MMR can be given a minimum of 28 days after the get-go dose if necessary.

If I give MMR to an infant traveler younger than age 1 year, will that dose exist considered valid for the U.Due south. immunization schedule?

No. A measles-containing vaccine administered more than 4 days before the first birthday should not be counted as part of the series. MMR should exist repeated when the child is historic period 12 through fifteen 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 later on the first dose.

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

Yeah. 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 mean solar day or earlier, the TST should be delayed for at least 28 days. Alive measles vaccine given prior to the application of a TST can reduce the reactivity of the skin exam considering of balmy suppression of the allowed system.

An 18-year-old college pupil says he had both measles and mumps diseases equally a preschooler, but never had MMR vaccine. Is rubella vaccine recommended in such a situation?

This educatee should receive ii doses of MMR, separated past at to the lowest degree 28 days. A personal history of measles and mumps is non acceptable as proof of immunity. Acceptable show of measles and mumps amnesty includes a positive serologic exam for antibody, nascency before 1957, or written documentation of vaccination. For rubella, only serologic evidence or documented vaccination should exist accepted as proof of immunity. Additionally, people born prior to 1957 may exist considered immune to rubella unless they are women who have the potential to become significant.

When not given on the aforementioned 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 Best Practice Guidelines for Immunization (encounter world wide web.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 aforementioned 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 xxx days if possible. Either interval is adequate.

For Healthcare Personnel Back to top

What is the recommendation for MMR vaccine for healthcare personnel?

ACIP recommends that all HCP built-in during or later 1957 take adequate presumptive evidence of immunity to measles, mumps, and rubella, defined every bit documentation of two doses of measles and mumps vaccine and at least one dose of rubella vaccine, laboratory bear witness of immunity, 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 past at least iv 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 i dose of MMR for unvaccinated personnel regardless of nascency yr who lack laboratory bear witness of rubella immunity or laboratory confirmation of infection or affliction.

Would you consider healthcare personnel with 2 documented doses of MMR vaccine to be allowed fifty-fifty if their serology for 1 or more of the antigens comes back negative?

Yes. Healthcare personnel (HCP) with ii 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-advisable vaccination supersedes the results of subsequent serologic testing. In dissimilarity, HCP who practise not accept documentation of MMR vaccination and whose serologic exam is interpreted every bit "indeterminate" or "equivocal" should be considered not immune and should receive two doses of MMR vaccine (minimum interval 28 days). ACIP does not recommend serologic testing after vaccination. For more information, encounter ACIP's recommendations on the utilize of MMR vaccine 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 v to 15% of susceptible people who receive MMR vaccine will develop a low-grade fever and/or mild rash seven to 12 days subsequently vaccination. However, the person is non infectious, and no special precautions ( such as exclusion from work) need to be taken.

A 22-year-old female is going to pharmacy schoolhouse and the schoolhouse wants her to have a 2nd 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 immune to mumps and measles just non immune to rubella. Tin can I requite her a second dose of the MMR with her having measles after the kickoff dose?

Yes, equally a healthcare professional, this person should get a 2d dose of MMR to ensure she is immune to rubella. There is no harm in providing MMR to a person who is already immune to 1 or more of the components. If she developed measles only one mean solar day after getting her first MMR, she must have been exposed to the affliction prior to vaccination.

Contraindications and Precautions Dorsum to top

What are the contraindications and precautions for MMR vaccine?

Contraindications:

• history of a astringent (anaphylactic) reaction to any vaccine component (east.1000., neomycin) or following a previous dose of MMR • pregnancy • astringent immunosuppression from either disease or therapy

Precautions:

• receipt of an antibiotic-containing blood product in the previous three–xi months, depending on the type of blood product received. Run across www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html, Tabular array 3-5 for more information on this issue • moderate or severe acute illness with or without fever • history of thrombocytopenia or thrombocytopenic purpura • Of import details about the contraindications and precautions for MMR vaccine are in the electric current MMR ACIP statement, bachelor at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.

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

People with medical conditions that contraindicate measles immunization depend on loftier MMR vaccination coverage amidst those around them. To assist forbid the spread of measles virus, make certain all your staff and patients who can exist vaccinated are fully vaccinated according to the U.S. immunization schedule. Also, encourage patients to remind their family members and other close contacts to become vaccinated if they are not immune.

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

We have a patient who has selective IgA deficiency. We also take patients with selective IgM deficiency. Tin MMR or varicella vaccine be administered to these patients?

At that place is no known take a chance associated with MMR or varicella vaccination in someone with selective IgA or IgM deficiency. It is possible that the immune response may exist weaker, but the vaccines are likely effective.

I accept a patient who is traveling internationally and needs MMR vaccine. He recently received an injectable steroid. How long should he await before receiving MMR vaccine?

In that location is no need to wait a specific interval before giving MMR. Injectable steroids are non considered immunosuppressive for the purpose of vaccination decisions, and and then in that location is no business concern well-nigh condom or efficacy of MMR.

Tin I requite MMR to a kid whose sibling is receiving chemotherapy for leukemia?

Yes. MMR and varicella vaccines should exist given to the healthy household contacts of immunosuppressed children.

We accept a 40 lb six-twelvemonth-sometime patient who has been taking fifteen mg of methotrexate weekly for arthritis for 12 months. Can we requite the kid MMR and varicella vaccine based on this methotrexate dosage?

Based on the weight and dosage provided (twoscore lbs and 15 mg/week), the child is currently receiving more than 0.4 mg/kg/week of methotrexate. This meets the Communicable diseases Gild of America (IDSA) definition of high-level immunosuppression. Assistants of both varicella and MMR vaccines are contraindicated until such fourth dimension as the methotrexate dosage can be reduced. The 2013 IDSA definition of low-level immunosuppression for methotrexate is a dosage of less than 0.4 mg/kg/week. For additional details, see the 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host: cid.oxfordjournals.org/content/early/2013/xi/26/cid.cit684.total.pdf.

Is it true that egg allergy is not considered a contraindication to MMR vaccine?

Several studies accept 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 University of Pediatrics nor ACIP consider egg allergy equally a contraindication to MMR vaccine. ACIP recommends routine vaccination of egg-allergic children without the use of special protocols or desensitization procedures.

Can I requite MMR to a breastfeeding mother or to a breastfed infant?

Yeah. Breastfeeding does non 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 claret product, can he or she receive MMR vaccine?

Yes, simply at that place 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. Come across Tabular array 3-5 of ACIP'due south General Best Practise Guidelines for Immunization for more than information, bachelor at www.cdc.gov/vaccines/hcp/acip-recs/full general-recs/timing.html.

Is it acceptable practice to administer MMR, Tdap, and influenza vaccines to a postpartum mom at the aforementioned time equally administering RhoGam?

Yes. Receipt of RhoGam is not a reason to delay vaccination. For more information see the ACIP General All-time Practise Guidelines for Immunization, bachelor at world wide web.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html.

Please depict the current ACIP recommendations for the employ 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 every bit follows:

Administer ii doses of MMR vaccine to all HIV-infected people age 12 months and older who do not accept evidence of current severe immunosuppression or current evidence of measles, rubella, and mumps immunity. To exist regarded as not having evidence of current astringent immunosuppression, a child age 5 years or younger must have CD4 percentages of 15% or more than for 6 months or longer; a person older than five years must take CD4 percentages of 15% or more than and a CD4 lymphocyte count of 200 or more/mm3 for half-dozen months or longer. If laboratory results land only i type of parameter (percentage or counts) this is sufficient for vaccine conclusion-making.

Administer the commencement dose at 12 through 15 months and the 2nd dose to children age 4 through vi years, or equally early as 28 days after the first dose.

Unless they accept adequate current bear witness of measles, mumps, and rubella immunity, people with perinatal HIV infection who were vaccinated prior to establishment of effective antiretroviral therapy (ART) should receive two appropriately spaced doses of MMR vaccine after effective ART has been established. Established effective ART is divers as receiving Art for at least 6 months in combination with CD4 percentages of 15% or more for half-dozen months or longer for children historic period 5 years or younger. People older than 5 years should have CD4 percentages of xv% or more and a CD4 lymphocyte count of 200 or more/mm3 for six months or longer. If laboratory results state but 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 expect later receiving rubella (MMR) vaccine earlier becoming pregnant?

Although the MMR vaccine packet insert recommends a iii-calendar month deferral of pregnancy after MMR vaccination, ACIP recommends deferral of pregnancy for 4 weeks. For details on this effect, meet ACIP's Control and Prevention of Rubella: Evaluation and Management of Suspected Outbreaks, Rubella in Pregnant Women, and Surveillance for Congenital Rubella Syndrome.

How should teenage girls and women of changeable age be screened for pregnancy earlier MMR vaccination?

ACIP recommends that women of childbearing age be asked if they are currently pregnant or attempting to go pregnant. Vaccination should exist deferred for those who answer "yep." Those who answer "no" should exist advised to avert pregnancy for 4 weeks following vaccination. Pregnancy testing is not necessary.

If a pregnant woman inadvertently receives MMR vaccine, how should she be advised?

No specific action needs to be taken other than to reassure the adult female that no adverse outcomes are expected as a result of this vaccination. MMR vaccination during pregnancy is not a reason to terminate the pregnancy. You lot should consult with others in your healthcare setting to identify means to foreclose such vaccination errors in the future. Detailed information about MMR vaccination in pregnancy is included in the near contempo 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 historic period be asked if they are currently pregnant or attempting to become pregnant. Vaccination should be deferred for those who reply "yep." Those who reply "no" should be advised to avoid pregnancy for i calendar month following vaccination.

Can we give an MMR to a 15-month-old whose mother is 2 months pregnant?

Yeah. Measles, mumps, and rubella vaccine viruses are not transmitted from the vaccinated person, then MMR vaccination of a household contact does not pose a risk to a pregnant household member.

If a woman'due south rubella test result shows she is "not allowed" during a prenatal visit, but she has 2 documented doses of MMR vaccine, does she demand a third dose of MMR vaccine postpartum?

In 2013, ACIP changed its recommendation for this situation (meet www.cdc.gov/mmwr/pdf/rr/rr6204.pdf, pages 18–xx). Information technology is recommended that women of childbearing historic period who take received 1 or ii doses of rubella-containing vaccine and accept rubella serum IgG levels that are not clearly positive should be administered one boosted dose of MMR vaccine (maximum of 3 doses) and do not need to be retested for serologic evidence of rubella amnesty. MMR should non be administered to a pregnant woman.

I accept a female person patient who has a non-immune rubella titer two months after her second MMR vaccination. Should she be revaccinated? If then, should the titer again exist checked to determine seroconversion?

ACIP recommends that vaccinated women of childbearing age who accept received 1 or two doses of rubella-containing vaccine and have a rubella serum IgG levels that is not clearly positive should be administered ane additional dose of MMR vaccine (maximum of three doses). Echo serologic testing for testify of rubella immunity is non recommended. See www.cdc.gov/mmwr/pdf/rr/rr6204.pdf, pages 18–20, for more than information on this effect.

MMR vaccines should not be administered to women known to be pregnant or attempting to become significant. Because of the theoretical risk to the fetus when the mother receives a live virus vaccine, women should be counseled to avoid condign pregnant for 28 days after receipt of MMR vaccine.

How soon after delivery can MMR exist given to the mother?

MMR can be administered whatever time after delivery. The vaccine should be administered to a woman who is susceptible to either measles, mumps, or rubella before hospital discharge, fifty-fifty if she has received RhoGam during the hospital stay, leaves in less than 24 hours, or is breastfeeding.

Vaccine Safety Back to superlative

Is there whatever evidence that MMR or thimerosal causes autism?

No. This issue has been studied extensively, including a thorough review by the independent Institute of Medicine (IOM). The IOM issued a study in 2004 that ended there is no show supporting an association 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 separate components of the MMR vaccine considering they fearfulness MMR may exist 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 nearly the lack of association between MMR and autism.

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

Arthralgia (joint pain) and transient arthritis (joint redness or swelling) following rubella vaccination occurs but in people who were susceptible to rubella at the time of vaccination. Joint symptoms are uncommon in children and in developed males. About 25% of not-immune post-pubertal women report articulation pain after receiving rubella vaccine, and about 10% to 30% study arthritis-similar signs and symptoms.

When joint symptoms occur, they generally begin 1 to 3 weeks after vaccination, commonly are mild and non incapacitating, concluding most ii days, and rarely recur.

Is there any harm in giving an extra dose of MMR to a kid of historic period seven years whose record is lost and the mother is not sure well-nigh the last dose of MMR?

In general, although information technology is not platonic, 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 into the Extra Doses of Vaccine Antigens section of the ACIP General Best Practice Guidelines for Immunization at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html.

Vaccination providers frequently meet people who do not have acceptable documentation of vaccinations. Providers should only accept written, dated records as evidence of vaccination. With the exception of flu vaccine and pneumococcal polysaccharide vaccine, self-reported doses of vaccine without written documentation should non be accustomed. An attempt to locate missing records should be made whenever possible by contacting previous healthcare providers, reviewing state or local immunization data systems, and searching for a personally held tape.

If records cannot be located or will definitely non be available anywhere because of the patient'southward circumstances, children without acceptable documentation should exist considered susceptible and should receive age-appropriate vaccination. Serologic testing for immunity is an alternative to vaccination for certain antigens (eastward.g., measles, rubella, hepatitis A, diphtheria, and tetanus).

Storage and Handling Back to top

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

The corporeality of time in which a dose of vaccine must be used later reconstitution varies by vaccine and is usually outlined somewhere in the vaccine'due south package insert. MMR must be used within 8 hours of reconstitution. MMRV must be used within 30 minutes; other vaccines must be used immediately. The Immunization Action Coalition has a staff teaching piece that outlines the time allowed between reconstitution and use, equally stated in the parcel inserts for a number of vaccines. Handout tin be found at the following link: world wide web.immunize.org/catg.d/p3040.pdf.

How should MMR vaccine be stored?

MMR may be stored either in the refrigerator at 2°C to 8°C (36°F to 46°F) or in the freezer at -fifty°C to -15°C (-58°F to +v°F). The diluent should not be frozen and tin can exist stored in the refrigerator or at room temperature.

If the MMR is combined with varicella vaccine equally MMRV (ProQuad, Merck), it must exist stored in the freezer at -50°C to -15°C (-58°F to +5°F).

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

Unfortunately, serious errors in vaccine storage and handling like this occur besides often. If you doubtable 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 utilize. This is particularly important for live virus vaccines like MMR and varicella.

One time MMR vaccine has been reconstituted with diluent, how soon must it be used?

Information technology is preferable to administer MMR immediately afterwards reconstitution. If reconstituted MMR is non used within 8 hours, it must be discarded. MMR should always exist refrigerated and should never be left at room temperature.

I misplaced the diluent for the MMR dose then I used normal saline instead. Is there any trouble with doing this?

Only the diluent supplied with the vaccine should exist used to reconstitute any vaccine. Whatever vaccine reconstituted with the wrong diluent should be repeated.

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

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