Measles, Mumps and Rubella

Advisory Committee on Immunization Practices (ACIP) Recommendations

Infants and Children

• All children without contraindications should receive two doses of measles-mumps-rubella combination vaccine (abbreviation: MMR; trade names: M-M-R II^®, Priorix^TM) after 1 year of age and at least 4 weeks apart. The first dose is usually administered at a minimum of 12 months of age, and is generally given between 12 and 15 months of age. The second dose is usually given between 4 and 6 years of age, prior to entering school, although it can be given anytime at least 4 weeks after the first dose for children at increased risk of exposure.
• The CDC recommends that MMR and varicella vaccine (trade name: Varivax^®) be administered separately for the first dose in order to reduce the small increased risk of febrile seizures in toddlers associated with the measles-mumps-rubella-varicella combination vaccine (abbreviation: MMRV; trade name: ProQuad^®) compared to the separate but simultaneous administration of MMR and varicella vaccines. MMRV is generally preferred for the second dose.

Adults

• One dose of MMR should be administered to all adults at least 18 years of age without evidence of immunity to these diseases (acceptable evidence of immunity includes documentation of previous receipt of MMR or MMRV vaccine, laboratory confirmation of immunity or disease, or having been born before 1957). Two doses separated by at least 4 weeks are recommended for adults at high risk for exposure and transmission (such as international travelers; college students; and health care personnel).^1,2

All Age Groups

• Persons previously vaccinated with two doses of a mumps-containing vaccine who are identified by public health as at increased risk for mumps because of an outbreak should receive a third dose of a mumps-containing vaccine to improve protection against mumps disease and related complications. ³

For More Information

• ACIP recommendations
  • MMR: https://www.cdc.gov/acip-recs/hcp/vaccine-specific/mmr.html
  • MMRV: https://www.cdc.gov/acip-recs/hcp/vaccine-specific/mmrv.html
• Vaccine Information Statements
  • MMR: https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mmr.html
  • MMRV: https://www.cdc.gov/vaccines/hcp/vis/vis-statements/mmrv.html
• Immunization Schedules: http://www.cdc.gov/vaccines/imz-schedules/index.html

Important Information for Obstetric Providers

• Measles, Mumps and Rubella are all live attenuated vaccines and are contraindicated during pregnancy.

• However, rubella vaccination is emphasized for all non-pregnant individuals of childbearing age, especially those born outside of the United States. Rubella immunity should be verified either by documentation of at least one dose of rubella-containing vaccine given after the first year of life or by serology. Those without such evidence of immunity should be given MMR vaccine, excluding women who are pregnant or likely to become pregnant within the next 4 weeks.
• If a pregnant individual is inadvertently vaccinated or becomes pregnant within 4 weeks after MMR vaccination, she should be counseled again as to the theoretical risks, but this should not be considered an indication for termination of the pregnancy.

Disease

Measles is a highly contagious acute disease caused by an RNA paramyxovirus, genus Morbillivirus, with one antigenic type. Measles is transmitted via the respiratory route and secondary attack rates in families among susceptible persons are often greater than 90%. Measles virus can survive up to 2 hours in air or on surfaces. The average incubation period of 10-12 days is followed by cough, runny nose, and stepwise increase in fever up to 103-105°F. A maculopapular rash begins on the face and head a few days after onset of respiratory symptoms and persists for 5-6 days. Common complications include diarrhea, otitis media, and pneumonia, and rare complications include encephalitis, seizures, and death. Measles illness during pregnancy increases the risk of premature labor, low-birthweight children, spontaneous abortion, as well as pneumonia and encephalitis.

Mumps is caused by an RNA paramyxovirus with one antigenic type and is acquired through respiratory transmission. The incubation period is 12-25 days. Symptoms are generally nonspecific at first, including myalgia, malaise, headache, and fever. Approximately one-third of mumps infections are asymptomatic; however, asymptomatic persons can transmit the virus. Possible complications of mumps infection include parotitis, orchitis, oophoritis, deafness, meningitis, encephalitis, and pancreatitis.

Rubella, also known as “German measles”, is caused by an RNA togavirus, genus Rubivirus, with one antigenic type. Rubella is acquired through respiratory transmission and the incubation period is about 14 days. Symptoms include mild fever and malaise; up to 50% of cases are subclinical. A maculopapular rash lasting about 3 days generally occurs 14 to 17 days after infection, beginning on the face and spreading downwards. This rash is usually fainter than the measles rash, and does not coalesce. Arthralgia and arthritis are common after puberty, especially in females.¹ Among pregnant individuals who are infected with wild-type rubella virus, transplacental infection of the fetus can occur, causing congenital defects or stillbirth.^1,2

Vaccine

Measles, mumps and rubella vaccines are all live attenuated viral vaccines that are only available in combination as MMR in the United States. The MMRV vaccine also includes varicella vaccine.¹

Vaccine Effectiveness

One dose of MMR vaccine is estimated to be 93% effective in preventing measles and 97% effective in preventing rubella. A second dose has been shown to increase the effectiveness of measles vaccine to an estimated 97%, mainly by producing immunity in those who failed to respond to the initial dose ^1,2,5.

Effectiveness of two doses of MMR vaccine against mumps is estimated to be between 66 and 95%, and vaccine-induced protection has been shown to wane over time.⁶

Vaccine Safety

Mild illness in people receiving their first dose of MMR can occur due to replication of the attenuated measles vaccine virus. Between 5% and 15% develop a 1-2 day fever up to 103°F approximately 7 to 12 days after the first dose. A transient rash may also appear during this time frame, occurring in approximately 5% of those vaccinated ¹.

Vaccines which may induce fever may also rarely induce febrile seizures. Febrile seizures are a common and typically benign childhood condition, occurring in 2-5% of children at some point during their first five years of life. Febrile seizures have an estimated background incidence of 240–480 per 100,000 person-years in children under five years, although this varies considerably by age, genetics, co-morbidities and environmental risk factors. There are no long-term effects of simple febrile seizures, with the possible exception of an increased risk of recurrence ^7-10. [5-8]. The rate of febrile seizures in the 7-10 days after vaccination was approximately 2-3 times higher for children who received MMRV as compared to MMR and varicella vaccines administered separately on the same day, and 4 times higher as compared to MMR alone ¹¹. There is no increased risk of fever or febrile seizures in children receiving their second dose of measles-containing vaccine at 4 to 6 years of age, whether given MMR or MMRV ^1,12. See the Do Vaccines Cause Seizures? summary for more details.

Mild, acute joint symptoms occur in approximately 25% of susceptible adult women after rubella vaccination, but are less common in men and rare in children. See the Do Vaccines Cause Arthralgia or Arthritis? summary for more details.

Rare adverse events from MMR vaccine include thrombocytopenia, parotitis, lymphadenopathy and encephalopathy. Very rare adverse events from MMR vaccine include measles inclusion body encephalitis (MIBE). Immune thrombocytopenia purpura (ITP) occurs after approximately 1 in 30,000 doses. Allergic reactions are also rare. See the Do Vaccines Cause Thrombocytopenia or Immune Thrombocytopenic Purpura?, the Do Vaccines Cause Meningitis or Encephalitis?, and the Do Vaccines Cause Hypersensitivity Reactions? summaries for more details.

There is convincing evidence that MMR does not cause autism.¹ See the Do Vaccines Cause Autism? summary for more details.

Contraindications and Precautions

Severe allergic reaction (e.g. anaphylaxis) to a previous dose or vaccine component such as neomycin is a contraindication to further vaccination with MMR. Other contraindications include pregnancy, immunosuppression, and family history of altered immunocompetence. Current moderate to severe acute illness is a precaution to any vaccination. Other precautions for MMR vaccination include recent receipt of antibody-containing blood products and personal or family history of seizures ^1,4.

Considerations in Pregnancy

Transplacental infection of the fetus with wild-type rubella virus can occur, causing congenital defects or stillbirth. Congenital Rubella Syndrome (CRS) can include deafness, cataracts, heart defects, neurologic abnormalities including severe retardation, autism, bone alterations, and liver and spleen enlargement. Infants with CRS may shed rubella virus for longer than a year. The greatest risk for congenital malformations from rubella is associated with infection in the first trimester, with as many as 85% of such infants affected. In contrast, congenital malformations are rare when the infection occurs after the 20^th week of gestation. The 1964-65 rubella epidemic was associated with an estimated 20,000 cases of congenital malformations, with deafness and heart disease the most common ^1,2.

Vaccination against rubella is emphasized for all non-pregnant individuals of childbearing age, especially those born outside of the United States. Rubella immunity should be verified by their health care providers either by documentation of at least one dose of rubella-containing vaccine given after the first year of life or by serology. Those without such evidence of immunity should be given MMR vaccine, excluding women who are pregnant or currently attempting to become pregnant (pregnancy should be avoided for at least 4 weeks following MMR vaccination). ACIP recommends that providers of MMR vaccine ask women if they are pregnant or likely to become pregnant in the next 4 weeks; those who respond “yes” should be excluded from vaccination, and those who respond “no” should be informed of the theoretical risks of MMR vaccination during pregnancy and the corresponding importance of not becoming pregnant during the 4 weeks following vaccination, and then vaccinated. Routine pregnancy screening before vaccination is not recommended ^1,2.  

If a pregnant individual is inadvertently vaccinated or becomes pregnant within 4 weeks after MMR vaccination, she should be counseled again as to the theoretical risks, but this should not be considered an indication for termination of the pregnancy. The theoretical concerns regarding MMR vaccination during pregnancy stem from the fact that MMR is a live attenuated viral vaccine and wild-type rubella virus is known to be teratogenic as described above. The CDC followed women who were vaccinated against rubella during pregnancy from 1971 to 1989 through the Vaccine in Pregnancy (VIP) Registry. Although subclinical fetal infection was detected serologically in about 1-2% of their infants, the VIP Registry showed no evidence of the occurrence of CRS ^1,2. Other studies have also found no evidence of CRS in women who were vaccinated while unknowingly pregnant ^13-16. However, because a small risk cannot be entirely ruled out, women should not be given MMR vaccine during pregnancy ^1,2.

References

1.         Epidemiology and Prevention of Vaccine-Preventable Diseases. Washington D.C.: Centers for Disease Control and Prevention, 2015.

2.         McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS. 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.

3.         Marin M, Marlow M, Moore KL, Patel M. 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 Morbidity and mortality weekly report 2018; 67(1): 33-8.

4.         Kroger AT, Duchin J, Vázquez M. General Best Practice Guidelines for Immunization. Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP). 2017. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html (accessed October 2017).

5.         Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C. Vaccines for measles, mumps and rubella in children. The Cochrane database of systematic reviews 2012; 2: Cd004407.

6.         Cardemil CV, Dahl RM, James L, et al. Effectiveness of a Third Dose of MMR Vaccine for Mumps Outbreak Control. The New England journal of medicine 2017; 377(10): 947-56.

7.         (AAP) AAoP. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics 2011; 127(2): 389-94.

8.         (AAP) AAoP. Febrile seizures: clinical practice guideline for the long-term management of the child with simple febrile seizures. Pediatrics 2008; 121(6): 1281-6.

9.         Bonhoeffer J, Menkes J, Gold MS, et al. Generalized convulsive seizure as an adverse event following immunization: case definition and guidelines for data collection, analysis, and presentation. Vaccine 2004; 22(5-6): 557-62.

10.       Tse A, Tseng HF, Greene SK, Vellozzi C, Lee GM. Signal identification and evaluation for risk of febrile seizures in children following trivalent inactivated influenza vaccine in the Vaccine Safety Datalink Project, 2010-2011. Vaccine 2012; 30(11): 2024-31.

11.       Klein NP, Fireman B, Yih WK, et al. Measles-mumps-rubella-varicella combination vaccine and the risk of febrile seizures. Pediatrics 2010; 126(1): e1-8.

12.       Centers for Disease Control and Prevention. Vaccine Information Statements (VIS). August 7, 2015. http://www.cdc.gov/vaccines/hcp/vis/current-vis.html).

13.       Badilla X, Morice A, Avila-Aguero ML, et al. Fetal risk associated with rubella vaccination during pregnancy. The Pediatric infectious disease journal 2007; 26(9): 830-5.

14.       Castillo-Solorzano C, Reef SE, Morice A, et al. Rubella vaccination of unknowingly pregnant women during mass campaigns for rubella and congenital rubella syndrome elimination, the Americas 2001-2008. The Journal of infectious diseases 2011; 204 Suppl 2: S713-7.

15.       Soares RC, Siqueira MM, Toscano CM, et al. Follow-up study of unknowingly pregnant women vaccinated against rubella in Brazil, 2001-2002. The Journal of infectious diseases 2011; 204 Suppl 2: S729-36.

16.       da Silva e Sa GR, Camacho LA, Stavola MS, Lemos XR, Basilio de Oliveira CA, Siqueira MM. Pregnancy outcomes following rubella vaccination: a prospective study in the state of Rio de Janeiro, Brazil, 2001-2002. The Journal of infectious diseases 2011; 204 Suppl 2: S722-8.