Measles vaccines
VACCINE TYPE
Live attenuated measles virus vaccine
INDICATIONS
ACIP RECOMMENDATIONS
- All adults and children should have routine vaccination at 12-15 months (first MMR dose) and 4-6 years (second dose of MMR).
- All persons who work in health-care facilities must have acceptable evidence of immunity.
- All adults born during or after 1957 should receive >1 dose of MMR unless they have a medical contraindication, documentation of >1 dose, history of measles based on health-care provider diagnosis, or laboratory evidence of immunity.
- The second dose of MMR is recommended for adults who: 1) have been recently exposed to measles or are in an outbreak setting; 2) received killed measles vaccine or have been vaccinated with an unknown type of measles vaccine during 1963–1967; 3) are students in postsecondary educational institutions; 4) work in a health-care facility; or 5) plan to travel internationally.
- A third dose of MMR (e.g., a mumps-containing vaccine) is recommended for individuals who have previously received two vaccinations who are part of a population at risk for mumps during an outbreak.
OTHER INFORMATION
- Vaccination is recommended for susceptible international travelers leaving the U.S.
- Vaccination following exposure to natural measles may provide protection if the vaccine is given within 3 days of the exposure.
- High-risk, susceptible individuals should receive measles immune globulin within 6 days of exposure. HIV-infected children and adolescents receive IG regardless of immunization status.
FORMS
brand name | preparation | manufacturer | route | form | dosage^ | cost* |
ProQuad | Measles, Mumps, Rubella and Varicella (MMRV, live) | Chiron | SC | vial | 3-4.3-3 | $180.05 |
M-M-R II | Measles, Mumps, Rubella (MMR, live) | Merck | SC | vial | 12500/0.5 | $62.79 |
Attenuvax | Measles (live, further attenuated); no longer manufactured in the U.S. | Merck | SC | vial | one vial |
*Prices represent cost per unit specified, are representative of "Average Wholesale Price" (AWP).
^Dosage is indicated in mg unless otherwise noted.
PATHOGEN DIRECTED PROTECTION
DOSE/ADMINISTRATION
Adult PRIMARY SERIES
- All adults born during or after 1957 should receive >1 dose of MMR unless they have a medical contraindication, documentation of >1 dose, history of measles based on health-care provider diagnosis, or laboratory evidence of immunity.
- The second dose of MMR is recommended for adults who: 1) have been recently exposed to measles or are in an outbreak setting; 2) received killed measles vaccine or have been vaccinated with an unknown type of measles vaccine during 1963–1967; 3) are students in postsecondary educational institutions; 4) work in a health-care facility; or 5) plan to travel internationally.
- Administration for those living with HIV Infection
- Vaccination is contraindicated with CD4< 200 cells/mm3 because it is a live vaccine.
- Use routine vaccination indications when CD4>200 cells/mm3.
- Use the routine schedule for asymptomatic infants with HIV.
- Vaccination is contraindicated with CD4< 200 cells/mm3 because it is a live vaccine.
Pediatric PRIMARY SERIES
Primary Immunization
- Children ≥ 12 months of age: 0.5 mL per dose subcutaneously for a total of two doses. Dose 1 is indicated at age 12-15 months of age, and dose 2 is indicated at 4-6 years of age (recommended prior to entering kindergarten or first grade)
- The minimum interval between doses: 4 weeks
International Travel
- Infants aged 6 - 11 months of age: administer dose 1 prior to departure; revaccinate with 2-dose series (dose 1 at 12-15 months of age, and dose 2 as early as 4 weeks later)
- Unvaccinated children aged ≥ 12 months of age: administer the 2-dose series, with at least 4 weeks between doses, prior to departure.
Catch-Up Immunization
- Unvaccinated children and adolescents: administer the 2-dose series with at least 4 weeks between doses.
Measles Outbreak Without Acceptable Evidence of Immunity / At Risk of Exposure
- The dose should be administered within 72 hours post-exposure
- Infants 6 - 11 months of age: 0.5 mL per dose subcutaneously for a single dose. Revaccinate with 2-dose series (dose 1 at 12-15 months of age, and dose 2 as early as 4 weeks later).
- Children 1 - 4 years of age who have received 1 dose of MMR previously should be considered for their second dose if the outbreak involves preschool-aged children.
ADVERSE DRUG REACTIONS
COMMON
- Fever (associated with the measles component of the vaccine, occurs in ~5%)
- Transient rash (5%)
- Urticaria or a wheal and flare at the injection site
- Pain at the injection site
OCCASIONAL
- Transient lymphadenopathy
- Arthralgia and transient arthritis (associated with rubella components)
RARE
- Parotitis
- Anaphylaxis reaction
- Thrombocytopenia (use with caution with a history of thrombocytopenia)
- Febrile seizure (9 per 10,000 vaccinations among MMRV vaccine recipients vs. 4 per 10,000 vaccinations among MMR + varicella vaccine recipients; adjusted OR of 2.3)
- Aseptic meningitis (associated with the Urabe strain mumps vaccine)
- Encephalitis
- Guillain-Barre syndrome (but no increase incidence over background rates)
VACCINE/DRUG INTERACTIONS
- M-M-R II may be co-administered with varicella virus vaccine (Varivax) and Haemophilus b conjugate vaccine using separate injection sites and syringes.
- Although data are limited concerning the simultaneous administration of the entire recommended vaccine series (i.e., DTaP, IPV [or OPV], Hib with or without hepatitis B vaccine, and varicella vaccine), data from numerous studies have indicated no interference between routinely recommended childhood vaccines (either live, attenuated, or killed).
- Avoid immune globulin administration within 3 months of vaccination.
- Measles vaccine administration should be delayed for 3-12 months after receiving immune globulin (source: AAP Red Book, 2020).
CONTRAINDICATIONS
- Immunosuppressed patients (e.g., blood dyscrasias, leukemia, lymphomas, malignant neoplasms of bone or lymphatics, cellular immune deficiencies, hypogammaglobulinemia, dysgammaglobulinemia).
- Severe allergy to components of the vaccine (including neomycin and gelatin).
- Severe febrile illness.
- Pregnancy (should be avoided for 30 days post-vaccination).
- Use with caution in patients with a history seizure and severe thrombocytopenia.
- Egg allergy is not a contraindication (risk of a serious reaction to M-M-R is extremely low).
- May be administered in HIV pts if not severely immunosuppressed (CD4 % < 15%), although there is the possibility of an inadequate immune response.
IMMUNE RESPONSE
- The immune response is measured by the presence of detectable antibodies in the serum using the ELISA assay for measles.
- The protective antibody response to measles was seen with greater than 255 mIU/ml. In several randomized trials, children 12 to 23 months of age received a single dose of ProQuad and achieved response rates of the following: 97.4% for measles, 95.8% to 98.8% for mumps, 98.5% for rubella.
- The duration of immune response is at least 11 to 15 years in patients receiving 2-dose series.
CLINICAL EFFICACY
OTHER INFORMATION
- Almost all recent cases of measles in the U.S. have been initiated as a consequence of an imported strain of virus carried by a susceptible traveler or immigrant.
Basis for recommendation
- McLean HQ, Fiebelkorn AP, Temte JL, et al. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62(RR-04):1-34. [PMID:23760231]
Comment: Current ACIP recommendations for the use of the MMR vaccines and prevention of associated syndromes.
References
- Marin M, Marlow M, Moore KL, et al. Recommendation of the Advisory Committee on Immunization Practices for Use of a Third Dose of Mumps Virus-Containing Vaccine in Persons at Increased Risk for Mumps During an Outbreak. MMWR Morb Mortal Wkly Rep. 2018;67(1):33-38. [PMID:29324728]
Comment: Updated ACIP recommendations for the third dose of a mumps-containing vaccine to be provided to those at risk during an outbreak situation.
- Perry RT, Murray JS, Gacic-Dobo M, et al. Progress toward regional measles elimination - worldwide, 2000-2014. MMWR Morb Mortal Wkly Rep. 2015;64(44):1246-51. [PMID:26562349]
Comment: Rates are decreasing despite difficulties with using a vaccine that requires maintenance with a cold chain.
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