When Is It a Good Idea to Immunizie Little Boys Agains Rubella

Measles, Mumps, and Rubella

Disease Bug 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 situation with measles, mumps, and rubella in the United states of america?

In 2019, a conditional total of 1,242 cases of measles from 31 states were reported to CDC. This was the largest number reported in a single yr since 1992; 73% of cases were associated with outbreaks among unvaccinated people in New York. These outbreaks were independent and stopped earlier the end of 2019. Between Jan i and August 19, 2020, just 12 measles cases were reported by 7 jurisdictions. Limited travel equally a upshot of the COVID-19 pandemic drastically reduced opportunities for travelers infected with measles to enter or travel inside the U.s.. CDC measles surveillance updates can exist found at www.cdc.gov/measles/cases-outbreaks.html.

Since the pre-vaccine era, there has been a more than 99% decrease in mumps cases in the United States. Yet, outbreaks however occasionally occur. In 2006, in that location 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 3,000 cases. Since 2015, numerous outbreaks take been reported across the US, in college campuses, prisons, and close-knit communities, including a big outbreak in northwest Arkansas where near three,000 cases were reported in 2016. These outbreaks have shown that when people with mumps have close contact with a lot of other people (such as among residential college students and families in shut-knit communities) mumps tin spread even among vaccinated people. Nevertheless, outbreaks are much larger in areas where vaccine coverage rates are lower. A conditional total of three,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 United States in 2004. Fewer than 10 cases (primarily import-related) have been reported annually in the United States since elimination was alleged. Rubella incidence in the United States has decreased past more than 99% from the pre-vaccine era. A provisional total of 3 cases of rubella, and no cases of congenital rubella syndrome, were reported in 2019.

How serious are measles, mumps, and rubella?

Measles can lead to serious complications and death, even with modern medical intendance. The 1989–1991 measles outbreak in the U.Due south. resulted in more than 55,000 cases and more than 100 deaths. In the United States, from 1987 to 2000, the most commonly reported complications associated with measles infection were pneumonia (6%), otitis media (7%), and diarrhea (eight%). For every 1,000 reported measles cases in the United States, approximately 1 case of encephalitis and ii to 3 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 unremarkably causes fever and parotitis. Up 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, hygienic meningitis, and encephalitis. Mumps illness is typically milder, with fewer complications, in fully vaccinated case patients.

Rubella is more often than not a mild illness with low-grade fever, lymphadenopathy, and angst. Up to fifty% of rubella virus infections are subclinical. Complications can include thrombocytopenic purpura and encephalitis. Rubella virus is teratogenic and infection in a meaning adult female, especially during the first trimester tin 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 look 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 (ruby-red, watery optics). The illness begins with a prodrome of fever and malaise before rash onset. A clinical example of measles is defined as an illness characterized by

• a generalized rash lasting 3 or more than 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 1 to 2 days before the measles rash appears to one to 2 days after. They appear as punctate blue-white spots on the bright red background of the buccal mucosa. Pictures of measles rash and Koplik spots tin can be plant at www.cdc.gov/measles/nigh/photos.html.

Providers should be especially aware of the possibility of measles in people with fever and rash who have recently traveled abroad or who have had contact with international travelers.

Providers should immediately isolate and report suspected measles cases to their local wellness section 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 likely measles.

What should our clinic practice 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 24-hour interval of rash onset. Patients with suspected measles should exist isolated for iv days after they develop a rash. Airborne precautions should be 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 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.South.; healthcare providers should report all cases of suspected measles to public health authorities immediately to assistance reduce the number of secondary cases. Practice not look for the results of laboratory testing to report clinically-suspected measles to the local health department.

More data on measles illness, diagnostic testing, and infection control tin be found at world wide web.cdc.gov/measles/hcp/index.html.

How long does it take to bear witness signs of measles, mumps, and rubella after existence exposed?

For measles, there is an average of 10 to 12 days from exposure to the appearance of the showtime symptom, which is usually fever. The measles rash doesn't normally appear until approximately 14 days after exposure (range: 7 to 21 days), and the rash typically begins 2 to 4 days after the fever begins. The incubation menses of mumps averages 16 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). Notwithstanding, every bit noted above, up to half of rubella virus infections crusade no symptoms.

Vaccine Recommendations Back to meridian

What are the current recommendations for the apply of MMR vaccine?

The almost recent comprehensive ACIP recommendations for the use of MMR vaccine were published in 2013 and are available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf. MMR vaccine is recommended routinely for all children at historic period 12 through 15 months, with a second dose at age 4 through half dozen years. The second dose of MMR tin can be given equally early as 4 weeks (28 days) later on the offset dose and be counted as a valid dose if both doses were given after the kid'southward first birthday. The second dose is not a booster, only rather is intended to produce immunity in the small number of people who fail to respond to the starting time dose.

Adults with no evidence of immunity (bear witness of immunity is defined every bit documented receipt of 1 dose [2 doses 4 weeks apart if high risk] of alive measles virus-containing vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or birth before 1957) should get one dose of MMR vaccine unless the developed is in a loftier-risk group. High-risk people demand 2 doses and include school-historic period children, healthcare personnel, international travelers, and students attending mail-high school educational institutions.

Live attenuated measles vaccine became available in the U.Southward. 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 it was, or are sure information technology was inactivated measles vaccine, that dose should exist considered invalid and the patient revaccinated equally age- and risk-advisable with MMR vaccine. At the discretion of the state public health department, anyone exposed to measles in an outbreak setting tin 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 testify of immunity to measles?

Adequate presumptive testify of immunity against measles includes at least 1 of the following:

• written documentation of adequate vaccination: • laboratory evidence of immunity • laboratory confirmation of measles (verbal history of measles does non count) • nascency before 1957

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

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

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

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

Zero doses:

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

I dose of MMR vaccine:

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

Two doses of MMR vaccine:

� high-risk adults without any prior documented live measles vaccination and no laboratory testify 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 information technology was inactivated measles vaccine, should be revaccinated with either one (if depression-gamble) or ii (if loftier-risk) doses of MMR vaccine.

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

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

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

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

Healthcare facilities should cheque with their country or local health section's immunization program for guidance. Access contact data here: www.immunize.org/coordinators.

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

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

How does being born earlier 1957 confer immunity to measles?

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

Why is a second dose of MMR necessary?

Approximately 7% of people practise not develop measles immunity afterward the first dose of vaccine. This occurs for a multifariousness of reasons. The second dose is to provide another chance to develop measles immunity for people who did non respond to the starting time dose. About 97% of people develop amnesty to measles afterwards two doses of measles-containing vaccine.

Are there any situations where more than 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 take received 2 doses of rubella-containing vaccine and accept rubella serum IgG levels that are not clearly positive should receive one boosted dose of MMR vaccine (maximum of 3 doses). Farther testing for serologic testify of rubella amnesty is not recommended. MMR should not exist administered to a pregnant adult female.

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

When is it appropriate to use MMR vaccine for measles mail-exposure prophylaxis?

MMR vaccine given within 72 hours of initial measles exposure tin reduce the take a chance of getting sick or reduce the severity of symptoms. Some other selection for exposed, measles-susceptible individuals at high gamble of complications who cannot be vaccinated is to give immunoglobulin (IG) within six days of exposure. Do not administer MMR vaccine and IG simultaneously, as the IG invalidates the vaccine.

Information on post-exposure prophylaxis for measles tin can be plant 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 forbid measles?

No. Adults with evidence of amnesty practise non demand whatsoever further vaccines. No "booster" doses of MMR vaccine are recommended for either adults or children. They are considered to have life-long immunity in one case they have received the recommended number of MMR vaccine doses or have other evidence of immunity.

Many people who were immature children in the 1960s practise not have records indicating what type of measles vaccine they received in the mid-1960s. What measles vaccine was most often given in that fourth dimension period? That guidance would assistance many older people who would adopt not to exist revaccinated.

Both killed and live attenuated measles vaccines became available in 1963. Live attenuated vaccine was used more oftentimes than killed vaccine. The killed vaccine was plant to be non effective and people who received it should exist revaccinated with alive vaccine. Without a written record, it is non possible to know what type of vaccine an individual may take received. So persons built-in during or later 1957 who received killed measles vaccine or measles vaccine of unknown type, or who cannot certificate having been vaccinated or having laboratory-confirmed measles disease should receive at least one 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 4 weeks.

Exercise people who received MMR in the 1960s need to have their dose repeated?

Non necessarily. People who have documentation of receiving live measles vaccine in the 1960s practise not need to be revaccinated. People who were vaccinated prior to 1968 with either inactivated (killed) measles vaccine or measles vaccine of unknown type should be revaccinated with at least one dose of live attenuated measles vaccine. This recommendation is intended to protect people who may have received killed measles vaccine which was available in the The 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 loftier take a chance for mumps infection (such as people who work in a healthcare facility) should exist 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. Delight explain.

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

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

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

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

In the 2013 revision of its MMR vaccine recommendations ACIP expanded the apply of post-exposure IG prophylaxis for measles. Intramuscular IG (IGIM) should be administered to all infants younger than 12 months who have been exposed to measles. The dose of IGIM is 0.5 mL/kg of body weight; the maximum dose is 15 mL. Alternatively, MMR vaccine tin be given instead of IGIM to infants age 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 body weight. Severely immunocompromised people, irrespective of evidence of measles amnesty or vaccination, who accept 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 body weight within 3 weeks earlier measles exposure should be sufficient to preclude measles infection. For patients receiving subcutaneous immune globulin (IGSC) therapy, administration of at least 200 mg/kg body weight for two consecutive weeks earlier measles exposure should be sufficient.

Other people who practice not have evidence of measles immunity can receive an IGIM dose of 0.five mL/kg of trunk weight. Give priority to people who were exposed to measles in settings where they have intense, prolonged close contact (such as household, kid care, classroom, etc.). The maximum dose of IGIM is fifteen mL.

IG is not indicated for persons who have received 1 dose of measles-containing vaccine at age 12 months or older unless they are severely immunocompromised. IG should not be used to control measles outbreaks.

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

We ofttimes see higher students who lack vaccination records, but whose titer results show they are not allowed 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.Due south.; the educatee should get the combined MMR vaccine. If a higher educatee or other person at increased run a 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 retrieve receiving MMR vaccine but accept no written tape, or whose parents report the patient has been vaccinated. Should I accept this equally evidence of vaccination?

No. Self-reported doses and history of vaccination provided by a parent or other caregiver are non considered to exist valid. Y'all should but accept a written, dated record equally prove of vaccination.

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

Adults without testify of amnesty and no contraindications to MMR vaccine can be vaccinated without testing. Just adults without prove of immunity might exist considered for testing for measles-specific IgG antibody, simply testing is not needed prior to vaccination.

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

2 documented doses of MMR vaccine given on or after the first birthday and separated by at least 28 days is considered proof of measles immunity, according to ACIP. Documentation of appropriate 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, simply is concerned about the measles exposure risk. Should the patient receive the MMR vaccine?

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

We have adult patients in our practise at loftier run a risk for measles, including patients going back to college or preparing for international travel, who don't remember ever receiving MMR vaccine or having had measles disease. How should nosotros manage these patients?

You take ii options. You tin test for immunity or you lot can but give 2 doses of MMR at least 4 weeks apart. There is no impairment in giving MMR vaccine to a person who may already exist immune to 1 or more than of the vaccine viruses. If you or the patient opt for testing, and the tests betoken the patient is non immune to one or more of the vaccine components, give your patient 2 doses of MMR at least 4 weeks autonomously. If whatever examination results are indeterminate or equivocal, consider your patient nonimmune. ACIP does not recommend serologic testing after vaccination because commercial tests may non be sensitive enough to reliably detect vaccine-induced immunity.

I have a 45-year-former patient who is traveling to Haiti for a mission trip. She doesn't call up ever getting an MMR booster (she didn't go to college and never worked in health care). She was rubella allowed when pregnant xx years agone. Her measles titer is negative. Would you lot recommend an MMR booster?

ACIP recommends 2 doses of MMR given at to the lowest degree 4 weeks apart for any developed born in 1957 or subsequently who plans to travel internationally. There is no harm in giving MMR vaccine to a person who may already be allowed to one or more of the vaccine viruses.

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

No, it is not considered necessary, merely he may exist vaccinated. Before implementation of the national measles vaccination program in 1963, virtually every person caused measles before adulthood. So, this patient tin can be considered immune based on their birth yr. However, MMR vaccine also may exist given to any person born earlier 1957 who does not accept a contraindication to MMR vaccination.

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

Nosotros have measles cases in our community. How can I all-time protect the young children in my practice?

First of all, brand certain all your patients are fully vaccinated according to the U.South. immunization schedule.

In sure circumstances, MMR is recommended for infants age 6 through eleven months. Requite infants this age a dose of MMR earlier international travel. In addition, consider measles vaccination for infants as immature equally age 6 months as a command measure during a U.S. measles outbreak. Consult your land health department to find out if this is recommended in your situation. Do not count any dose of MMR vaccine as part of the ii-dose series if it is administered before a kid'south kickoff birthday. Instead, repeat the dose when the child is historic period 12 months.

In the case of a local outbreak, you also might consider vaccinating children historic period 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 historic period 4 through half-dozen years.

Finally, recollect that infants too young for routine vaccination and people with medical atmospheric condition that contraindicate measles immunization depend on high MMR vaccination coverage among those effectually them. Be sure to encourage all your patients and their family members to get vaccinated if they are not immune.

During a mumps outbreak should we offer a third dose of MMR (MMR II, Merck) to persons who have 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 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, only insufficient for preventing mumps outbreaks in prolonged, shut-contact settings, fifty-fifty where coverage with 2 doses of MMR vaccine is high.

In Jan 2018, the Advisory Committee on Immunization Practices (ACIP) published new guidance for MMR vaccination of persons at increased take a chance 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 role of a group at increased risk for acquiring mumps because of an outbreak should receive a tertiary dose of a mumps virus�containing vaccine to meliorate protection confronting mumps disease and related complications. More data about this recommendation is available at world wide web.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6701a7-H.pdf.

In a measles outbreak, practice children who have not had MMR vaccine pose a threat to vaccinated people? It is my understanding that vaccinated people can nonetheless contract measles. Am I correct?

You are correct that vaccinated people can yet be 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 (sixty% for influenza in years with a good friction match of circulating and vaccine viruses, and lxx% for acellular pertussis vaccines in the 3-5 years after vaccination). More than information is bachelor for each vaccine and illness at www.cdc.gov/vaccines/vpd-vac/default.htm and world wide web.immunize.org/vaccines.

Administering Vaccines Dorsum to top

Our dispensary has been giving MMR by the wrong 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 administration of any of these vaccines is not likely to subtract immunogenicity, and doses given IM practice not demand to exist repeated.

We oft need to requite MMR vaccine to big adults. Is a 25-estimate needle with a length of five/8" 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 exist considered a valid dose?

Yes, still, 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, it may be counted towards completion of the MMR and varicella vaccine series and does not demand to be repeated.

Scheduling Vaccines Back to summit

How before long can nosotros give the second dose of MMR vaccine to a child vaccinated at 12 months onetime?

For routine vaccination, children without contraindications to MMR vaccine should receive two doses of MMR vaccine with the first dose at historic period 12–15 months onetime and the second dose at historic period four–6 years former. The minimum interval is 28 days for dose 2. If you take an outbreak in your community 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 menstruum" apply to the minimum age for administration of the first dose of MMR? What virtually the 28-day minimum interval between doses of MMR?

A dose of MMR vaccine administered upwardly to iv days before the outset birthday may exist counted as valid. Even so, school entry requirements in some states may mandate administration on or after the beginning birthday. The four-day "grace flow" should non be practical to the 28-day minimum interval between ii doses of a live parenteral vaccine.

Can MMR be given on the same day every bit other alive virus vaccines?

Yep. However, if ii parenteral or intranasal alive vaccines (MMR, varicella, LAIV and/or yellow fever) are not administered on the same mean solar day, they should exist separated by an interval of at to the lowest degree 28 days.

If you tin give the second dose of MMR as early as 28 days later on the first dose, why practise nosotros routinely expect until kindergarten entry to requite the 2d dose?

The 2d dose of MMR may exist given as early equally 4 weeks after the first dose, and exist counted as a valid dose if both doses were given after the offset altogether. The second dose is not a booster, but rather it is intended to produce immunity in the small number of people who neglect to reply to the commencement dose. The run a risk of measles is higher in school-age children than those of preschool historic period, so it is of import to receive the 2nd dose by schoolhouse entry. Information technology is besides convenient to give the second dose at this age, since the kid will have an immunization visit for other school entry vaccines.

What is the primeval age at which I can give MMR to an infant who will exist traveling internationally? Also, which countries pose a loftier risk to children for contracting measles?

ACIP recommends that children who travel or live abroad should be vaccinated at an before historic period than that recommended for children who reside in the United States. Before their departure from the United states, children age 6 through 11 months should receive one dose of MMR. The risk for measles exposure tin can be high in high-, eye- and low-income countries. Consequently, CDC encourages all international travelers to be upwardly to date on their immunizations regardless of their travel destination and to keep 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 child a dose of MMR vaccine at 6 months of age considering they are in a community with cases of measles, when should we give the adjacent dose?

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

I have an viii-month-quondam patient who is traveling internationally. The infant needs to exist protected from hepatitis A as well as measles, mumps, and rubella. The family is leaving in 11 days. Can 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 Usa 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 office of the child's routine vaccination series. For details of this recommendation, see the CDC ACIP recommendations for the prevention and control of hepatitis A at www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf, folio 18.

Tin I give the second dose of MMR before than historic period 4 through 6 years (the kindergarten entry dose) to young children traveling to areas of the world where there are measles cases?

Yes. The second dose of MMR can be given a minimum of 28 days subsequently the first dose if necessary.

If I requite MMR to an infant traveler younger than age 1 year, will that dose be considered valid for the U.S. immunization schedule?

No. A measles-containing vaccine administered more than than four days earlier the offset altogether should not be counted as office of the series. MMR should be repeated when the child is age 12 through 15 months (12 months if the child remains in an surface area where affliction risk is high). The second dose should be administered at to the lowest degree 28 days afterward the showtime dose.

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

Aye. A TST can exist applied earlier or on the same day that MMR vaccine is given. However, if MMR vaccine is given on the previous twenty-four hour period or earlier, the TST should be delayed for at least 28 days. Live measles vaccine given prior to the application of a TST can reduce the reactivity of the skin test because of mild suppression of the immune organization.

An 18-twelvemonth-old college student says he had both measles and mumps diseases as a preschooler, but never had MMR vaccine. Is rubella vaccine recommended in such a state of affairs?

This pupil should receive two doses of MMR, separated past at least 28 days. A personal history of measles and mumps is not acceptable as proof of amnesty. Adequate evidence of measles and mumps amnesty includes a positive serologic test for antibody, birth before 1957, or written documentation of vaccination. For rubella, only serologic evidence or documented vaccination should be 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 pregnant.

When not given on the same twenty-four hours, is the interval betwixt yellow fever and MMR vaccines 4 weeks (28 days) or 30 days? I have seen the yellowish fever and live virus vaccine recommendations published both ways.

The General All-time Practise Guidelines for Immunization (run into www.cdc.gov/vaccines/hcp/acip-recs/full general-recs/timing.html) makes the generic recommendation that alive parenterally or nasally administered vaccines not given on the same day should be separated by at least 28 days. The CDC travel wellness website recommends that xanthous fever vaccine and other parenteral or nasal live vaccines should be separated by at to the lowest degree 30 days if possible. Either interval is acceptable.

For Healthcare Personnel Back to top

What is the recommendation for MMR vaccine for healthcare personnel?

ACIP recommends that all HCP born during or subsequently 1957 take adequate presumptive show of amnesty to measles, mumps, and rubella, defined every bit documentation of two doses of measles and mumps vaccine and at least 1 dose of rubella vaccine, laboratory prove of immunity, or laboratory confirmation of disease. 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 birth year who lack laboratory testify of measles or mumps immunity or laboratory confirmation of disease. During outbreaks of rubella, healthcare facilities should recommend 1 dose of MMR for unvaccinated personnel regardless of birth yr who lack laboratory show of rubella immunity or laboratory confirmation of infection or disease.

Would y'all consider healthcare personnel with 2 documented doses of MMR vaccine to be immune even if their serology for 1 or more than of the antigens comes back negative?

Yep. Healthcare personnel (HCP) with 2 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 historic period-appropriate vaccination supersedes the results of subsequent serologic testing. In dissimilarity, HCP who practice not have documentation of MMR vaccination and whose serologic examination is interpreted as "indeterminate" or "equivocal" should be considered not allowed and should receive 2 doses of MMR vaccine (minimum interval 28 days). ACIP does not recommend serologic testing after vaccination. For more than data, come across ACIP's recommendations on the use of MMR vaccine at world wide web.cdc.gov/mmwr/pdf/rr/rr6204.pdf, folio 22.

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

Approximately five to fifteen% of susceptible people who receive MMR vaccine volition develop a low-course fever and/or mild rash seven to 12 days after vaccination. All the same, the person is not infectious, and no special precautions ( such equally exclusion from work) need to exist taken.

A 22-twelvemonth-old female is going to pharmacy school and the school wants her to have a 2d dose of MMR vaccine. She had the kickoff 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 but not immune to rubella. Can I give her a second dose of the MMR with her having measles subsequently the first dose?

Yep, as a healthcare professional, this person should go a second dose of MMR to ensure she is allowed to rubella. In that location is no harm in providing MMR to a person who is already immune to one or more of the components. If she developed measles only ane day later on 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 astringent (anaphylactic) reaction to any vaccine component (e.g., neomycin) or following a previous dose of MMR • pregnancy • severe immunosuppression from either disease or therapy

Precautions:

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

Nosotros accept many patients who are immunocompromised and cannot get the MMR vaccine. How should we advise our patients?

People with medical conditions that contraindicate measles immunization depend on high MMR vaccination coverage among those around them. To aid prevent the spread of measles virus, make sure all your staff and patients who can be vaccinated are fully vaccinated according to the U.Due south. immunization schedule. Besides, encourage patients to remind their family members and other close contacts to get vaccinated if they are non allowed.

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

We have a patient who has selective IgA deficiency. We as well accept patients with selective IgM deficiency. Can MMR or varicella vaccine be administered to these patients?

In that location is no known risk associated with MMR or varicella vaccination in someone with selective IgA or IgM deficiency. Information technology is possible that the allowed response may be 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 look before receiving MMR vaccine?

In that location is no need to wait a specific interval earlier giving MMR. Injectable steroids are not considered immunosuppressive for the purpose of vaccination decisions, and so there is no concern about safety or efficacy of MMR.

Tin I requite 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 have a xl lb six-year-quondam patient who has been taking 15 mg of methotrexate weekly for arthritis for 12 months. Can we give the kid MMR and varicella vaccine based on this methotrexate dosage?

Based on the weight and dosage provided (twoscore lbs and 15 mg/calendar week), the kid is currently receiving more than 0.4 mg/kg/week of methotrexate. This meets the Infectious disease Gild of America (IDSA) definition of loftier-level immunosuppression. Administration 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, come across the 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host: cid.oxfordjournals.org/content/early on/2013/11/26/cid.cit684.total.pdf.

Is it true that egg allergy is non considered a contraindication to MMR vaccine?

Several studies have documented the prophylactic of measles and mumps vaccine (which are grown in chick embryo tissue culture) 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 mother 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 take chances to the babe existence breastfed. Although it is believed that rubella vaccine virus, in rare instances, may be transmitted via breast milk, the infection in the babe is asymptomatic.

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

Yes, only at that place should be sufficient fourth dimension between the claret product and the MMR to reduce the risk of interference. The interval depends on the blood product received. See Table three-5 of ACIP'due south General Best Practice Guidelines for Immunization for more than data, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html.

Is it adequate practice to administer MMR, Tdap, and influenza vaccines to a postpartum mom at the same time as administering RhoGam?

Yep. Receipt of RhoGam is not a reason to delay vaccination. For more data see the ACIP General Best Exercise Guidelines for Immunization, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html.

Delight 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 equally follows:

Administer 2 doses of MMR vaccine to all HIV-infected people age 12 months and older who practise not accept testify of current severe immunosuppression or current bear witness of measles, rubella, and mumps immunity. To be regarded as not having evidence of electric current severe immunosuppression, a kid age 5 years or younger must have CD4 percentages of 15% 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 vi months or longer. If laboratory results state only one type of parameter (percentage or counts) this is sufficient for vaccine decision-making.

Administer the offset dose at 12 through 15 months and the second dose to children historic period 4 through half dozen years, or every bit early on as 28 days subsequently the get-go dose.

Unless they have adequate current evidence of measles, mumps, and rubella amnesty, people with perinatal HIV infection who were vaccinated prior to establishment of effective antiretroviral therapy (ART) should receive 2 accordingly spaced doses of MMR vaccine later effective ART has been established. Established constructive Fine art is divers equally receiving ART for at least 6 months in combination with CD4 percentages of xv% or more for vi months or longer for children historic period five years or younger. People older than 5 years should have CD4 percentages of 15% or more and a CD4 lymphocyte count of 200 or more/mm3 for vi months or longer. If laboratory results state merely one blazon of parameter (percentages or counts) this is sufficient for vaccine controlling.

Pregnancy and Postpartum Considerations Back to pinnacle

What is the recommended length of time a adult female should wait afterward receiving rubella (MMR) vaccine earlier becoming pregnant?

Although the MMR vaccine bundle insert recommends a 3-calendar month deferral of pregnancy afterward MMR vaccination, ACIP recommends deferral of pregnancy for 4 weeks. For details on this upshot, come across 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 child-bearing historic period be screened for pregnancy before MMR vaccination?

ACIP recommends that women of childbearing age exist asked if they are currently pregnant or attempting to become pregnant. Vaccination should be deferred for those who reply "yes." Those who answer "no" should be advised to avert pregnancy for four weeks post-obit vaccination. Pregnancy testing is not necessary.

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

No specific activeness needs to exist 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 cease the pregnancy. You should consult with others in your healthcare setting to identify ways to prevent such vaccination errors in the future. Detailed data about MMR vaccination in pregnancy is included in the most recent MMR ACIP statement, available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf.

We 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 answer "yes." Those who answer "no" should be advised to avoid pregnancy for ane calendar month following vaccination.

Can we requite an MMR to a fifteen-calendar month-old whose mother is 2 months pregnant?

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

If a woman'due south rubella test consequence shows she is "not 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 (encounter www.cdc.gov/mmwr/pdf/rr/rr6204.pdf, pages eighteen–20). It is recommended that women of childbearing age who have received 1 or 2 doses of rubella-containing vaccine and accept rubella serum IgG levels that are non clearly positive should be administered 1 additional dose of MMR vaccine (maximum of 3 doses) and exercise not need to be retested for serologic evidence of rubella immunity. MMR should not exist administered to a pregnant woman.

I have a female person patient who has a non-immune rubella titer two months subsequently her 2nd MMR vaccination. Should she exist revaccinated? If then, should the titer once more be checked to determine seroconversion?

ACIP recommends that vaccinated women of childbearing historic period who take received one or ii doses of rubella-containing vaccine and have a rubella serum IgG levels that is not clearly positive should be administered one additional dose of MMR vaccine (maximum of three doses). Repeat serologic testing for evidence of rubella amnesty is not recommended. See www.cdc.gov/mmwr/pdf/rr/rr6204.pdf, pages eighteen–xx, for more data on this issue.

MMR vaccines should non be administered to women known to exist meaning or attempting to become pregnant. Because of the theoretical risk to the fetus when the mother receives a live virus vaccine, women should be counseled to avoid becoming significant for 28 days after receipt of MMR vaccine.

How shortly after commitment can MMR be given to the female parent?

MMR can be administered whatsoever time after 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 hospital stay, leaves in less than 24 hours, or is breastfeeding.

Vaccine Safety Back to top

Is there any bear witness 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 report in 2004 that concluded there is no evidence supporting an association between MMR vaccine or thimerosal-containing vaccines and the development of autism. For more data on thimerosal and vaccines in full general, visit www.cdc.gov/vaccinesafety/Concerns/thimerosal/index.html.

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

Merck no longer produces single antigen measles, mumps, and/or rubella vaccines for the U.Due south. market. Only combined MMR is available. You should brainwash parents nigh the lack of clan 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) post-obit rubella vaccination occurs but in people who were susceptible to rubella at the fourth dimension of vaccination. Joint symptoms are uncommon in children and in adult males. Nigh 25% of non-allowed post-pubertal women report articulation pain after receiving rubella vaccine, and most x% to 30% study arthritis-like signs and symptoms.

When joint symptoms occur, they generally brainstorm 1 to 3 weeks after vaccination, usually are mild and not incapacitating, last nigh 2 days, and rarely recur.

Is there any harm in giving an extra dose of MMR to a child of age 7 years whose record is lost and the female parent is not sure about the last dose of MMR?

In full general, although it is not ideal, receiving actress doses of vaccine poses no medical problem. However, receiving excessive doses of tetanus toxoid (e.thousand., DTaP, DT, Tdap, or Td) can increase the risk of a local adverse reaction. For details see 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 take adequate documentation of vaccinations. Providers should but have written, dated records as prove of vaccination. With the exception of influenza vaccine and pneumococcal polysaccharide vaccine, self-reported doses of vaccine without written documentation should not be accepted. An endeavour to locate missing records should be fabricated whenever possible by contacting previous healthcare providers, reviewing state or local immunization data systems, and searching for a personally held record.

If records cannot exist located or will definitely not exist available anywhere because of the patient'due south circumstances, children without adequate documentation should be considered susceptible and should receive age-advisable 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 top

How long can reconstituted MMR vaccine exist stored in a fridge before it must be discarded?

The corporeality of time in which a dose of vaccine must be used after reconstitution varies by vaccine and is normally outlined somewhere in the vaccine's parcel insert. MMR must be used inside viii hours of reconstitution. MMRV must be used inside 30 minutes; other vaccines must be used immediately. The Immunization Activeness Coalition has a staff education piece that outlines the time allowed between reconstitution and use, as stated in the parcel inserts for a number of vaccines. Handout tin exist 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 fridge at ii°C to 8°C (36°F to 46°F) or in the freezer at -50°C to -15°C (-58°F to +5°F). The diluent should not be frozen and can be stored in the refrigerator or at room temperature.

If the MMR is combined with varicella vaccine as 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. Can I apply it?

Unfortunately, serious errors in vaccine storage and treatment like this occur besides often. If you doubtable that vaccine has been mishandled, you should store the vaccine as recommended, so contact the manufacturer or state/local health department for guidance on its utilise. This is particularly of import for live virus vaccines similar MMR and varicella.

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

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

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

Only the diluent supplied with the vaccine should exist used to reconstitute whatsoever 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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