Measles, mumps and rubella (MMR) vaccine is a freeze-dried preparation containing live attenuated measles, mumps and rubella viruses. It provides protection for approximately 90% of recipients for measles and mumps and over 95% for rubella.¹

Two doses are given as part of the routine immunisation schedule but it is also important to identify special groups who need immunisation. It is also now an important vaccine in the control of outbreaks of measles.²

Target population¹

All children should be given the first dose prior to school entry, unless contra-indicated. See separate article Immunisation Schedule (UK).

• The optimum age for the first dose is 12-15 months.³
• A booster dose should be given at age 3 years and four months to 5 years.
• A UK catch-up programme to immunise individuals who are currently not protected was started in 2008.⁴ The target groups are, in order of priority:
  • Those aged 13 months to 18 years who have not received any MMR vaccine.
  • Partially immunised children aged 3 years 7 months (in September 2008) to 11 years.
  • Partially immunised children aged 12 to 18 years (school years 8 to 13).
  • Partially immunised individuals aged over 18 years leaving school to go to higher education or other further education establishment.
• If the child has missed the first dose, give two doses, three months apart. Give the vaccine irrespective of previous history of infection.
• Two doses, one month apart, should be given at school-leaving age if no previous dose has been given. If only one dose has been received previously, give a booster.

Special groups

Apart from the more routine vaccination of children as above, there are also target groups worthy of special mention. The immunisation can be given to individuals of any age. The decision on whether or not to vaccinate should take into account:

• Past immunisation history.
• The likelihood of an individual remaining susceptible.
• The future risk of exposure and disease.

For patients who have never had the vaccine, two doses should be given, one month apart.
Examples include:

• Children at special risk of measles include:
  • Children with chronic conditions such as congenital heart or kidney disease, cystic fibrosis, Down's syndrome and failure to thrive.
  • Children in residential or day care.
  These children should be specifically contacted rather than left to the vagaries of the routine recall procedure.
• Premature babies should be immunised after 2 months, irrespective of prematurity.
• HIV-positive individuals, even if symptomatic, are likely to benefit, although occasional cases of measles caused by MMR have been seen.⁵ For severely immunocompromised patients, check with a specialist.
  One study of HIV-positive children who had received highly active antiretroviral therapy (HAART) showed low levels of measles antibody, but that this was corrected by re-immunisation with MMR.⁶
• Women of childbearing age who are seronegative for rubella and who are not currently pregnant should be given the vaccine.
• Other unimmunised groups:
  • Healthcare workers - should be given the vaccine for their own benefit and to protect vulnerable unimmunised patients and their own unimmunised partners.
  • Unimmunised seronegative postpartum women should be offered the vaccine a few days after delivery. 60% of congenital abnormalities occur in babies born to women who have more than one child.
  • Immigrants arriving after school age of immunisation are particularly likely to require immunisation.
• During outbreaks of measles:
  • The vaccine should be given to susceptible children aged over 6 months in contact with a case, within three days of exposure.
  • These children should still have routine MMR at the usual age.
  • Note that MMR vaccination is not suitable for prophylaxis against mumps or rubella, as the antibody response is too slow.

Usual dosage schedule in children

• 1st dose at 13 months.
• 2nd dose at age 3 years and four months to 5 years.

Travellers to epidemic or endemic areas should be fully immunised. Children who were given the vaccine before one year of age should have two further doses at the recommended ages, as the response before one year is variable. Children who have received one dose at the routine age should have the second dose brought forward to at least one month after the first. If the child is under 18 months of age and the second dose is given within three months of the first dose, then the routine preschool dose (a third dose) should be given in order to ensure full protection.
Seroconversion rates are slightly lower if the vaccine is given at 9 months rather than 12 months but the World Health Organization (WHO) recommends that the age of measles vaccination must balance the earliest age at which high rates of seroconversion can be achieved with the age when the risk of severe infection and death is greatest. This means that, in countries where children under 1 year of age are at risk of complications and death from measles infection, earlier vaccination at 9 months is recommended.⁷

Contra-indications¹

• Acute illness (postpone until the condition has resolved), but note that minor illness without fever or systemic upset - e.g. mild otitis media, upper respiratory tract infection (URTI) and diarrhoea - is not a contra-indication.
• Severe local or generalised reaction to a previous dose - when in doubt, seek specialist advice.
• Allergy to neomycin, kanamycin (not licensed in the UK) or gelatin.
• Untreated malignant disease or impaired immunity - e.g. immunosuppression, steroids, radiotherapy, cytotoxic drugs or within 6 months of receiving such treatment (immunisation can still be possible in some circumstances depending on dosage and combination of drugs - check with the specialist treating the condition or the local community paediatrician).
• Children who have received another live vaccine, including bacillus Calmette-Guérin (BCG), within three weeks.
• Within three months of an immunoglobulin injection.
• Pregnancy - but note that the Department of Health does not recommend termination, as studies failed to demonstrate a link between rubella immunisation in early pregnancy and fetal damage.

Note that the following are NOT contra-indications:

• Family history of any adverse reactions following immunisation.
• Previous history of infection with pertussis, measles, rubella or mumps.
• Contact with an infectious disease.
• Asthma, eczema, hay fever or rhinitis
• Treatment with antibiotics or locally-acting (e.g. topical or inhaled) steroids.
• The child's mother being pregnant.
• The child being breast-fed.
• History of jaundice after birth.
• Over the age recommended in the immunisation schedule.
• 'Replacement' corticosteroids.
• Allergy to eggs (although, if there is a history of anaphylaxis to dietary eggs, immunisation by a paediatrician under controlled conditions is advisable).⁸
• Neurological conditions are not a contra-indication although, if the condition is poorly controlled (e.g. epilepsy), immunisation should be deferred.

Adverse reactions¹

Common

• Fever or a rash may occur one week after immunisation. It lasts 2-3 days and is more common after the first immunisation than after the second.
• Parotid swelling occurs in 1% of children of all ages up to four years. it is most common at the third week, occasionally later.

Rare

• Febrile convulsion may occur on the 6th-11th day after immunisation . The incidence is 1 in 1,000 children. This is less than the incidence after an infection of measles. There is no evidence that epilepsy occurs more frequently after febrile convulsion caused by MMR than after any other febrile convulsion.
• Idiopathic thrombocytopenic purpura occurs in 1 in 24,000 children, usually within 6 weeks of the first dose. The child should undergo serological testing before the next dose is given. This is offered free by the Specialist and Reference Microbiology Division, Health Protection Agency.⁹

Reassurance can be given on the following:

• Meningoencephalitis - this was rare and recovery was complete. It occurred with the previous Urabe mumps vaccine, but is no longer reported now that it has been replaced with the Jeryl Lynn vaccine.¹
• Link between MMR, bowel disease and autism - a Cochrane systematic review and several independent studies have found no evidence to support a link to the combined MMR vaccine.^10,11,12 A recent study has confirmed this in relation to autistic spectrum disorder.¹³ Some private clinics offer single vaccines, but the Department of Health recommends that parents be discouraged from using them. One study identified four cases of anaphylaxis following single component measles or rubella vaccine and has called for the NHS standards of data reporting to be extended to the private sector.¹⁴

Further research

Some adverse reactions are genetically determined and research is underway to produce 'personalised' vaccines which will take into account an individual's genotype and phenotype.¹⁵

Document references

1. Immunisation against infectious disease - 'The Green Book', Dept of Health (various dates)
2. Guidelines on Measles, Health Protection Agency (2009)
3. Redd SC, King GE, Heath JL, et al; Comparison of vaccination with measles-mumps-rubella vaccine at 9, 12, and 15 months of age. J Infect Dis. 2004 May 1;189 Suppl 1:S116-22. [abstract]
4. The MMR vaccination catch-up programme, CMO letter, (2008) PL/CMO/2008/5
5. McFarland E; Immunizations for the immunocompromised child. Pediatr Ann. 1999 Aug;28(8):487-96. [abstract]
6. Aurpibul L, Puthanakit T, Sirisanthana T, et al; Response to measles, mumps, and rubella revaccination in HIV-infected children with immune recovery after highly active antiretroviral therapy. Clin Infect Dis. 2007 Sep 1;45(5):637-42. Epub 2007 Jul 13. [abstract]
7. WHO EMRO Report, World Health Organization (2006)
8. Beck SA, Williams LW, Shirrell MA, et al; Egg hypersensitivity and measles-mumps-rubella vaccine administration. Pediatrics. 1991 Nov;88(5):913-7. [abstract]
9. Specialist and Reference Microbiology Tests and Services, Health Protection Agency
10. Demicheli V, Jefferson T, Rivetti A, et al; Vaccines for measles, mumps and rubella in children. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004407. [abstract]
11. Mayor S; Medical Research Council review sets research agenda for autism BMJ. 2002 January 5; 324(7328): 10.
12. Taylor B; Vaccines and the changing epidemiology of autism. Child Care Health Dev. 2006 Sep;32(5):511-9. [abstract]
13. Baird G, Pickles A, Simonoff E, et al; Measles vaccination and antibody response in autism spectrum disorders. Arch Dis Child. 2008 Oct;93(10):832-7. Epub 2008 Feb 5. [abstract]
14. Erlewyn-Lajeunesse M, Manek R, Lingam R, et al; Anaphylaxis following single component measles and rubella immunisation. Arch Dis Child. 2008 Nov;93(11):974-5. [abstract]
15. Poland GA, Ovsyannikova IG, Jacobson RM; Personalized vaccines: the emerging field of vaccinomics. Expert Opin Biol Ther. 2008 Nov;8(11):1659-67. [abstract]

Internet and further reading

• Measles, Clinical Knowledge Summaries (November 2009)

Acknowledgements