Measles vaccination guidance

Adapted from AAP and AAFP guidance.

Presumptive evidence of immunity to measles can be established in any of the following ways:

• Written documentation of one or more doses of a measles-containing vaccine administered on or after the first birthday for preschool-age children and adults not considered high risk
• Written documentation of two doses of measles-containing vaccine for school-age children and adults at high risk, including students at post-high school secondary educational institutions, healthcare personnel, and international travelers
• Laboratory evidence of immunity, defined as a positive measles IgG at any time current or past.  (Exception: for those who have had ablative immune suppression such as for stem cell transplant, check the post-transplant serology and if negative or equivocal, revaccinate when safe to do so.)
• Laboratory confirmation of disease, defined as positive measles PCR (or positive measles IgM prior to availability of PCR testing)
• Birth before 1957 (except for health care personnel; see below). 

Children:

• The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) recommend two doses of measles-containing vaccine routinely for children, starting with the first dose at age 12 through 15 months and the second dose at age 4 through 6 years before school entry. This can be administered as MMR or MMRV vaccine. Children can receive the second dose of MMR vaccine earlier than 4 through 6 years, as long as it is at least 28 days after the first dose.  A second dose of MMRV vaccine can be given 3 months after the first dose up to 12 years of age.
• The AAP expresses no preference between MMR plus monovalent varicella vaccine or the combination MMRV vaccine for the first dose. Caregivers should be counseled about the rare possibility of the child developing a febrile seizure within 1 to 2 weeks after receiving MMRV as the first dose.

Adults:

• One dose of MMR vaccine, or other presumptive immunity, is sufficient for most adults; see Special Populations below for who needs 2 doses. Providers generally do not need to actively screen adult patients in non-outbreak areas for measles immunity (serum measles IgG). Screening for immunity delays vaccination and may result in a missed vaccination opportunity in patients who turn out to need MMR vaccine.
• If patients are unsure if they were previously vaccinated, they can try to find their records. If no records exist, we recommend that they be vaccinated.
• After vaccination, it is not necessary to test patients for antibodies to confirm immunity.

• Students at post-high school educational institutions should receive two doses of MMR vaccine, each dose separated by at least 28 days, unless they have other presumptive evidence of immunity.
• International travelers constitute a special population for measles immunity because many measles cases in the US have occurred following overseas travel. Thus, persons aged 6 months and older who will be traveling internationally to any country outside the United States, who do not have presumptive evidence of immunity should be vaccinated with measles-containing vaccine if they are not already protected against measles, mumps, and rubella. Before any international travel—
  • Infants 6 through 11 months of age should receive one dose of MMR vaccine. Infants who get one dose of MMR vaccine before their first birthday should get two more doses according to the routinely recommended schedule. (The first dose should be given at 12 through 15 months of age and the second dose at 4 through 6 years of age. The second dose can be administered earlier as long as at least 28 days have elapsed since the first dose).
  • Persons 12 months of age and older should receive two doses of measles-containing vaccine, separated by at least 28 days, unless they have other presumptive evidence of immunity against measles.
• Persons traveling to an active measles outbreak locality within the US should be brought up to date with measles immunization recommendations for international travelers.
• Healthcare personnel lacking presumptive evidence of immunity should get two doses of MMR vaccine, separated by at least 28 days. Although birth before 1957 is considered acceptable evidence of immunity, healthcare workers born before 1957 who lack laboratory evidence of immunity or laboratory confirmation of disease should have documentation of 2 doses of measles-containing vaccine.
  • Healthcare personnel include all paid and unpaid persons working in health care settings who have the potential for exposure to patients and/or to infectious materials, including bodily substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air.
• Household and close contacts of immunocompromised persons. People with compromised immune systems are at high risk for severe complications if infected with measles. All family and other close contacts of people with compromised immune systems 12 months of age and older should receive two doses of MMR vaccine separated by 28 days, unless they have other presumptive evidence of measles immunity.
  • Recipients of MMR vaccine do not transmit the vaccine virus to others
• People with Human Immunodeficiency Virus (HIV) infection who lack presumptive evidence of measles immunity and do not have evidence of severe immunosuppression should receive two doses of MMR vaccine, separated by 28 days.
  • Severe immunosuppression is defined as CD4 less than 15% for 6 months or longer (for those 5 years of age or younger ) and CD4 less than 15% and CD4 count less than 200 cells/mm3 for 6 months or longer (for those older than 5 years).
• Adults who know they got the killed (inactivated) measles vaccine. A very small proportion of adults (less than 5%) may have received killed measles vaccine from 1963 through 1967 during childhood.  Anyone who received measles vaccine of unknown type or the inactivated measles vaccine should be revaccinated with MMR.
• During a local measles outbreak, state and local public health may provide additional MMR vaccination recommendations for persons or groups at increased risk.

• In Canada, UK, and Australia, birth prior to 1970 is presumptive evidence of immunity. For persons born elsewhere outside the USA, use birth prior to 1957.
• “Live measles-containing vaccine” usually means MMR or (more recently, pediatric MMRV which includes varicella).  However, some adults have received live, monovalent measles vaccine (Attenuvax, available until 2015 in USA) or live measles-rubella vaccine (international).
• Two brands of MMR vaccine are available: MMR-II (Merck) and PRIORIX (GSK).  They are considered equivalent and can be used interchangeably. Both come as individual vials of freeze-dried vaccine and sterile water diluent, all of which must be refrigerated (36⁰ to 46⁰F).
• MMRV PROQUAD (Merck) includes live, attenuated varicella virus, and is licensed for age 12 months to 12 years only, May be used for both pediatric doses in order to reduce needlesticks, but the AAP notes that febrile seizures are slightly less likely in toddlers if separate MMR and Varicella vaccines are used for the first dose.  PROQUAD must be stored frozen (-58⁰ to 5⁰F) but the diluent should remain refrigerated or at room temperature.
• A 3rd dose of MMR is not indicated to prevent measles (but may be recommended in the context of mumps outbreak control)
• The immune response to one live-virus vaccine might be impaired if administered within 28 days of another live-virus vaccine.  Therefore, to minimize the potential risk for interference, administer MMR and other live-virus vaccines either together on the same day, or separated by at least 4 weeks. Live-virus vaccines administered to persons eligible for MMR may include varicella (Varivax), nasal flu (FluMist), and yellow fever (YF-vax).

Contraindications – do not vaccinate with MMR or MMRV

• Ever had a severe allergic reaction (e.g., anaphylaxis) to a vaccine component or after a previous dose of MMR or MMRV
  • MMR-II contains sorbitol, sucrose, gelatin, human albumin, fetal calf serum, and trace neomycin
  • PRIORIX contains lactose, sorbitol, mannitol, and trace ovalbumin, cow serum albumin, and neomycin (does not contain gelatin)
  • Vaccine virus is grown in eggs, but per the AAP egg allergy is not a contraindication after several studies and extensive observation
• Ever had a severe allergic reaction (e.g., anaphylaxis) to a vaccine component or after a previous dose of MMR or MMRV
• Currently has a known severe immunodeficiency, for example from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, or long-term immunosuppressive therapy or has HIV infection with severe immunocompromise
• Is currently pregnant

Precautions – defer vaccination with MMR or MMRV unless benefits clearly outweigh risk

• Moderate or severe acute illness with or without fever
• Untreated active tuberculosis (MMR may exacerbate; delay until TB treatment is established)
• Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product) – defer due to potential interference with immune response to MMR.
• History of thrombocytopenia or thrombocytopenic purpura (MMR may cause recurrence)
• Need for tuberculin skin testing or interferon gamma release assay (IGRA) testing (MMR may temporarily suppress tuberculin reactivity; administer MMR on the same day as TB skin testing or IGRA, or postpone testing until 4 weeks after MMR)
• Personal or family history of seizures of any etiology

• Avoid pregnancy for 1 month after MMR vaccination
• Avoid chickenpox, yellow fever, or FluMist vaccine for 1 month after MMR vaccination
• Provide the MMR Vaccine Info Statement (VIS)
  • MMR vaccine is well tolerated and only very rarely associated with serious adverse events or severe allergic reactions
  • Local soreness and redness at the injection site are common
  • Swollen lymph nodes in the upper body are less common
  • At 7-12 days after vaccination, fever with or without rash may appear in some recipients and last 1-2 days.  Seizures may rarely occur with the fever.
• Extensive, well-designed research studies have shown no connection between MMR vaccination and development of autism