MMR Vaccine

1. Precautions
   1. MMR Vaccination is safe, effective and prevents serious illness with potentially devestating consequences
      1. For every 1000 Measles cases, 50 will develop Pneumonia, 1 will develop Encephalitis and 2 will die
      2. Congenital Rubella (TORCH Virus) affected 20,000 U.S. newborns in 1964-5, prior to Rubella Vaccination
      3. Orchitis (with Infertility risk) occurs in up to 10% of males with Mumps
2. Indication
   1. Universally indicated for persons born after 1956
      1. Those born before 1957 in U.S. are presumed to have been exposed
   2. Primary Series for all children
      1. Dose 1: Age 12-15 months old
      2. Dose 2: Age 4-6 years old
   3. Catch-up doses for anyone born after 1956
      1. At least one MMR dose
      2. Two MMR doses at least 4 weeks apart
         1. Unvaccinated children ages 12 months to 12 years
         2. College students
         3. Healthcare workers
         4. Travelers to high risk international areas
         5. Close contacts of Immunocompromised persons
   4. Impending travel to endemic region
      1. Infants 6-11 months: Administer one MMR dose
      2. Children >12 months and adults should have received 2 doses prior to travel
         1. Doses should be at least one month apart
         2. Adults with only one MMR Vaccine, should receive a second dose
   5. Outbreaks (esp Measles, Mumps in close quarters such as dormitories, barracks)
      1. Third dose is per public health department (but not in pregnancy, and not in Immunocompromised)
      2. Give a second dose, if never immunized (or unknown status), at 4 weeks after the first
   6. References
      1. (2014) Presc Lett 21(8): 44
      2. (2018) Presc Lett 25(3)
3. Mechanism
   1. Live Vaccine
4. Contraindications
   1. Absolute contraindications
      1. Anaphylactic reaction to neomycin (egg allergy is no longer a contraindication)
      2. Pregnancy
      3. Severe Immunodeficiency (e.g. AIDS with CD4 Count <200 cells/ul)
   2. Relative contraindications
      1. IG administration with within 3 months
      2. Thrombocytopenia
      3. ThrombocytopeniaPurpura
   3. Conditions not contraindicating Vaccination
      1. Tuberculosis or positive PPD
      2. Concurrent PPD testing
      3. Lactation
      4. Pregnancy in household contact or mother
      5. Household contact with Immunodeficiency (e.g. HIV)
      6. Non-anaphylactic reaction to egg or neomycin
5. Dose
   1. Adult: 0.5 ml IM
   2. Primary Series
      1. Dose 1: Age 12-15 months
      2. Dose 2: Age 4 to 6 years (administer by age 12)
   3. Alternate protocol
      1. Need a waiting period following Ig Administration
      2. See Red Book for wait period (3-11 months)
6. Efficacy
   1. Protective after first dose in 93% of cases
   2. Protective after second dose in 97% of cases
7. Adverse Effects
   1. Immune Thrombocytopenic Purpura (<1 case per 40,000)
      1. Occurs up to 6 weeks after MMR Vaccine
   2. Anaphylaxis (0.65 cases per 1 million Vaccinations)
   3. Mortality related to Vaccine (Vaccine-strain death)
      1. Since 1990, there have been a total of 397 MMR attributed deaths case reports
   4. Encephalitis
      1. Occurs in 1 case per 3 million Vaccinations
      2. Contrast with 1 in 1000 with Measles
   5. Aseptic Meningitis
      1. Onset 2-3 weeks after Vaccination
   6. Febrile Seizures (uncommon)
      1. Occurs 7-10 days after first MMR dose
      2. Increased risk when first dose given after 12-15 months of age
   7. Orchitis
      1. Occurs in 0.3 cases per 1 million MMR doses
   8. Pneumonia
      1. Occurs in 2 cases per 1 million MMR doses
   9. Pruritic dermatitis
      1. Purpura may be present
   10. Parotitis
       1. Rare complication 10-14 days after Vaccination
   11. References
       1. (1996) MMWR Morb Mortal Wkly Rep 45(No. RR-12):1-35 [PubMed]
8. Drug Interactions
   1. Varicella Vaccine or Yellow Fever Vaccine
      1. Do not give MMR within 30 days or these Vaccines
      2. MMR may be given with varicella or Yellow Fever
9. Precautions
   1. Avoid in pregnancy (FDA Category X)
      1. See Immunization in Pregnancy
10. Safety
    1. Safe in HIV
    2. Safe for Egg-Allergic children (allergy unlikely)
       1. Allergic Reaction unlikely in 16 studies (n=1265)
       2. Skin Testing is not indicated
       3. Observe potentially allergic children for 90 minutes
       4. James (1995) N Engl J Med 332:1262-6 [PubMed]
    3. No association with Autism
       1. DeStefano (2001) Pediatr Infect Dis 20:887-8 [PubMed]
       2. Madsen (2002) N Engl J Med 347:1477-82 [PubMed]
       3. Patja (2000) Pediatr Infect Dis 19:1127-34 [PubMed]
       4. Smeeth (2004) Lancet 364:963-9 [PubMed]
11. References
    1. Spencer (2017) Am Fam Physician 95(12): 786-94 [PubMed]