Measles, Mumps, and Rubella Vaccine and Immunodeficiency

• Generic Name: measles virus vaccine / mumps virus vaccine / rubella virus vaccine / varicella virus vaccine
• Dosage Forms: n.a.
• Other Brand Names: ProQuad

Prevention of measles, mumps, and rubella in adults, adolescents, and children ≥12 months of age.

USPHS Advisory Committee on Immunization Practices (ACIP), AAP, and American Academy of Family Physicians (AAFP) recommend that all children be vaccinated against measles, mumps, and rubella using a 2-dose regimen of MMR beginning at 12 through 15 months of age, unless contraindicated. (See Contraindications under Cautions.) In addition, catch-up vaccination with MMR is recommended for all children and adolescents up to 18 years of age who are unvaccinated or have previously received only a single dose.

ACIP, AAP, AAFP, American College of Obstetricians and Gynecologists (ACOG), and American College of Physicians (ACP) recommend that all adults receive 1 or 2 doses of MMR, unless they have evidence of immunity to measles, mumps, and rubella.

The fixed-combination vaccine containing MMR and varicella vaccine (MMRV; ProQuad) may be used in children 12 months through 12 years of age when a dose of MMR and a dose of varicella vaccine is indicated. Although use of MMRV (ProQuad) reduces the number of required injections when both vaccines are indicated during a single health-care visit, there is some evidence that the relative risk for fever and febrile seizures in infants 12 through 23 months of age may be higher with MMRV (ProQuad) than when a dose of MMR and a dose of Varivax are given concomitantly at separate sites. (See Use of Fixed Combinations under Cautions.)

Although monovalent vaccines containing measles, mumps, or rubella antigens have been used to stimulate active immunity to measles, mumps, or rubella, these single-antigen vaccines are no longer commercially available in the US. MMR vaccine should be used to complete immunization against measles, mumps, and rubella in adults, adolescents, or children who previously received single doses of the monovalent vaccines.

CDC states that individuals already immune to measles, mumps, or rubella because of previous vaccination or natural disease can receive MMR without an increased risk of adverse reactions.

Evidence of measles immunity. Individuals born before 1957 generally are considered immune to measles. Individuals born during or after 1957 can be considered immune to measles if there is documentation of adequate immunization against measles (2 doses of MMR or measles-containing vaccine with first dose given on or after 12 months of age and second dose given at least 28 days after first dose), natural measles infection diagnosed by a health-care provider, laboratory evidence of measles immunity, or laboratory confirmation of measles infection. All individuals without evidence of immunity should be considered susceptible to measles and should receive 2 doses of MMR, unless contraindicated. In addition, individuals vaccinated against measles prior to 1968 received measles vaccine that is less immunogenic than the currently available vaccine and should be revaccinated with MMR.

Evidence of mumps immunity. Individuals born before 1957 generally are considered immune to mumps. Individuals born during or after 1957 can be considered immune to mumps if there is documentation of adequate vaccination against mumps (2 doses of MMR or mumps-containing vaccine for school aged-children in grades K-12, college students, health-care personnel, international travelers; at least 1 dose in adults not at high risk), natural mumps infection diagnosed by a health-care provider, laboratory evidence of mumps immunity, or laboratory confirmation of mumps infection. All individuals without evidence of immunity should be considered susceptible to mumps and should be vaccinated, unless contraindicated.

Evidence of rubella immunity. Individuals who have documentation of adequate vaccination (at least 1 dose of MMR or rubella-containing vaccine given at ≥12 months of age) or serologic evidence of rubella immunity are considered immune to rubella. Birth before 1957 only provides presumptive evidence of rubella immunity and does not guarantee immunity. Clinical diagnosis of rubella is unreliable and should not be considered when assessing immune status. All women of childbearing age, regardless of birth year, should be tested for rubella immunity and counseled regarding congenital rubella syndrome (CRS). Nonpregnant women without evidence of immunity should be vaccinated; those who are pregnant should be vaccinated during the immediate postpartum period. (See Pregnancy under Cautions.)

Health-care personnel should be immune to measles, mumps, and rubella. Those without evidence of immunity to measles and mumps (2 doses of measles virus-containing and mumps virus-containing vaccine with first dose given on or after 12 months of age and second dose given at least 28 days after first dose, laboratory evidence of immunity, laboratory confirmation of disease) and those without evidence of immunity to rubella (at least 1 dose of a rubella virus-containing vaccine on or after 12 months of age, laboratory evidence of immunity, laboratory confirmation of disease) should receive 2 doses of MMR. Health-care personnel who have received only a single dose should receive a second dose. Because birth before 1957 is only presumptive evidence of immunity, health-care facilities should consider recommending 2 doses of MMR during an outbreak of measles or mumps for unvaccinated personnel born before 1957 who do not have laboratory evidence of immunity to measles and mumps or laboratory confirmation of these diseases and should consider recommending 1 dose of MMR for individuals in this age group during an outbreak of rubella.

Travelers may be at high risk of exposure to measles, mumps, and rubella outside the US and should be immune to these diseases before leaving the US. Measles occurs worldwide and remains endemic in many countries; many measles cases reported in the US occur from exposure to the disease in foreign countries. Mumps remains endemic in many countries and rubella occurs worldwide and is endemic and may be epidemic in many countries.

HIV-infected individuals are at increased risk for severe complications if infected with measles. ACIP, AAP, CDC, National Institutes of Health (NIH), IDSA, Pediatric Infectious Diseases Society, and others state that all asymptomatic HIV-infected children, adolescents, and adults should receive MMR according to the usually recommended immunization schedules. In addition, MMR should be considered for all symptomatic HIV-infected individuals who do not have evidence of severe immunosuppression and who otherwise would be eligible for vaccination. MMR is contraindicated in HIV-infected individuals who are severely immunosuppressed (i.e., children <12 months of age with CD4+ T-cell count <750/mm3; children 1 through 5 years of age with CD4+ T-cell count <500/mm3; children ≥6 years of age, adolescents, and adults with CD4+ T-cell count <200/mm3; children <13 years of age with CD4+ T-cell percentage <15%); such individuals should receive immune globulin IM (IGIM) if protection against measles is needed (e.g., in travelers, following exposure to measles). AAP and ACIP recommend that HIV-infected individuals receive IGIM following exposure to measles, regardless of their vaccination status.

Internationally adopted children whose immune status is uncertain should either be revaccinated or have serologic tests performed to confirm immunity to measles, mumps, and rubella. The child may have received monovalent measles vaccine in their country of origin, but MMR is not used in most countries. Therefore, although serologic testing is available to verify immunization status in children ≥12 months of age, CDC states that administration of MMR is preferable to serologic testing unless there is documentation that the child has had mumps and rubella. ACIP states that the simplest approach is to revaccinate with 1 or 2 doses of MMR according to the US recommended childhood and adolescent immunization schedule. (See Dosage and Administration.)

Postexposure vaccination (given within 72 hours of exposure) with MMR may provide some protection against measles and provides future protection in individuals who do not contract the disease.

For most situations (including measles outbreaks in schools or childcare centers), postexposure vaccination within 72 hours of measles exposure is preferable to use of IGIM. If vaccine is contraindicated (e.g., infants <6 months of age, pregnant women, immunocompromised individuals) or it has been >72 hours but <6 days since exposure, susceptible individuals may receive an immediate dose of IGIM.

If a measles outbreak occurs in a child-care facility, school (elementary, middle, junior high, senior high), college, university, or other secondary educational institution, ACIP and AAP recommend that all students (and their siblings) and all school personnel born during or after 1957 be vaccinated against measles, unless they have documentation indicating receipt of 2 doses of measles vaccine at ≥12 months of age or other evidence of measles immunity.

During measles outbreaks, children as young as 6 months of age should be vaccinated if exposure to natural measles is considered likely. However, these children should be considered inadequately immunized and should receive the usual 2-dose MMR vaccination regimen beginning at 12 through 15 months of age. (See Infants 6 through 11 Months of Age (MMR) under Dosage and Administration.)

There is no evidence that postexposure vaccination provides protection against mumps; however, if exposure does not result in infection, postexposure vaccination may be given to provide protection against subsequent infection.

Because about 90% of adults who have no knowledge of past infection are immune by serologic testing, postexposure vaccination with mumps virus vaccine live is not routinely indicated for individuals born prior to 1957 unless they are known to be seronegative; however, vaccination of such individuals also is not precluded and can be undertaken in outbreak settings.

In an outbreak setting, ACIP recommends that consideration be given to administering a second dose of MMR or mumps vaccine to children 1–4 years of age and to adults at low risk (provided it has been at least 28 days since they received the first dose). In addition, in an outbreak setting, ACIP states that health-care facilities should strongly consider recommending 2 doses of MMR to unvaccinated personnel born before 1957 who do not have evidence of immunity.

Postexposure vaccination with rubella vaccine has not been shown to prevent illness. Because postexposure vaccination provides future protection to individuals who do not contract the disease and because there is no evidence that administering the vaccine to an individual who is incubating rubella would be harmful, such vaccination is recommended by the ACIP and AAP, unless contraindicated.

Rubella outbreak control is essential for eliminating indigenous rubella and preventing congenital rubella infection and CRS. Because the incidence of rubella is low in the US, CDC states that even a single case of rubella should be considered a potential outbreak. Report suspected cases of rubella, CRS, or congenital rubella infection to local health departments within 24 hours; do not delay reporting while waiting for laboratory confirmation. Implement control measures as soon as a case of rubella is identified; maintaining control measures is essential when pregnant women are possible contacts of patients with rubella.

During a rubella outbreak, patients should be isolated for 5–7 days after rash onset and susceptible contacts identified and vaccinated (unless contraindicated). Pregnant women exposed to rubella who do not have adequate proof of immunity should be tested for serologic evidence of the disease. Susceptible pregnant women should be counseled regarding the risks for intrauterine rubella infection and should be advised to avoid activities where they might be exposed to rubella and to avoid contact with individuals with confirmed, probable, or suspected rubella for at least 6 weeks after rash onset in the last identified patient.

If a rubella outbreak occurs in a congregate environment (e.g., household, jail, day-care center, military setting, school, place of worship, athletic event, other social gathering), exposed individuals without adequate proof of rubella immunity should be vaccinated. If an outbreak occurs in a health-care setting (e.g., hospital, doctor’s office, clinic, nursing home, other facility where patients receive subacute or extended care), health-care workers without adequate evidence of immunity should be excluded from work and vaccinated (especially in settings where pregnant women could be exposed). Despite subsequent vaccination, exposed health-care workers should be excluded from direct patient care for 23 days after the last exposure to rubella. Health-care facilities should strongly recommend a dose of a rubella-containing vaccine to workers born before 1957 who do not have serologic evidence of immunity. If a community-wide outbreak occurs, any person exposed to a patient with rubella or CRS who cannot demonstrate proof of immunity should be vaccinated or restricted from contact with patients with rubella or CRS.

Consult CDC’s recommendations for evaluation and management of suspected rubella outbreaks for additional information, including information on criteria for rubella case classification (suspected, probable, confirmed, asymptomatic confirmed), criteria for case classification of CRS (suspected, probable, confirmed, infection only), laboratory diagnosis of rubella and CRS, surveillance and control measures, and outreach activities to prevent future rubella outbreaks.