Measles Mumps and Rubella (MMR) Immunisation

MMR 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

• All children should be given the first dose prior to school entry, unless contra-indicated. The optimum age for the first dose is 12-15 months.² A booster dose should be given at 3-5 years.
• There is currently a UK catch up programme to immunise individuals who are currently not protected.³ The target group are, on 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 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.
• Children at special risk of measles should be specifically contacted rather than left to the vagaries of the routine recall procedure. These include children with chronic conditions such as congenital heart or kidney disease, cystic fibrosis, Down's syndrome, failure to thrive and those in residential or day care.
• 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.⁴ 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 reimmunisation with MMR.⁵
• Women who are seronegative for rubella of child-bearing age who are not currently pregnant should be given the vaccine.
• Unimmunised healthcare workers should be given the vaccine for their own benefit and to protect vulnerable unimmunised patients and their own unimmunised partners.
• Unimmunised sero-negative post-partum 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 over 6 months in contact with a case, within three days of exposure (these children should still have routine MMR at usual age). It is not suitable for prophylaxis against mumps or rubella, as the antibody response too slow.
• 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 and the future risk of exposure and disease. For patients who have never had the vaccine two doses should be given, one month apart.

• 1st dose @ 13 months
• 2nd dose @ 3 years 4 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 pre-school dose (a third dose) should be given in order to ensure full protection.

• Acute illness (postpone until condition 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 or gelatin.
• Untreated malignant disease or impaired immunity - e.g. immunosuppression, steroids, radiotherapy, cytotoxic drugs or within 6 months of receiving such treatment (immunisation still be possible in some circumstances depending on dosage and combination of drugs - check with specialist treating condition or local community paediatrician).
• Children who have received another live vaccine, including BCG, within three weeks.
• Within three months of an immunoglobulin injection.
• Pregnancy - but note Department of Health do not recommend termination as studies failed to demonstrate a link between rubella immunisation in early pregnancy and foetal damage.

Note that the following are NOT contra-indications:

• Family history of any adverse reactions following immunisation
• Previous history of pertussis, measles, rubella or mumps infection
• Contact with an infectious disease
• Asthma, eczema, hay fever or rhinitis
• Treatment with antibiotics or locally-acting (eg topical or inhaled) steroids
• Child's mother is pregnant
• Child being breast fed
• History of jaundice after birth
• Over the age recommended in 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)⁷
• Neurological conditions are not a contraindication, although if the condition is poorly controlled (e.g. epilepsy) immunisation should be deferred

Common

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

Rare

• Febrile convulsion may occur on 6th-11th day after immunisation . The incidence is 1 in 1000 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 thrombocytopaenic purpura occurs in 1 in 24,000 children, usually within 6 weeks of the first dose. The child should undergo serological testing before next dose given. This is offered free by the Specialist and Reference Microbiology Division, Health Protection Agency.⁸

Reassurance can be given on the following:

• Meningo-encephalitis - 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.^9,10,11 A recent study has confirmed this in relation to autistic spectrum disorder.¹² 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.¹³

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.¹⁴