on MMR Vaccine
questions & answers
Vaccine Handling, Storage &
Vaccine Use, Recommendations &
Contraindications & Precautions
Adverse Events & Safety
Handling, Storage & Injection Technique
- A box of MMR
vaccine (undiluted) was left at room temperature for 3 hours. Is it
okay to use?
If you suspect that this vaccine or
any vaccine has been mishandled, you should contact the manufacturer
for guidance on its use. This is particularly important for labile
live virus vaccines like MMR and varicella. Unfortunately, errors in
vaccine storage and handling are common.
- Once MMR
vaccine has been reconstituted with diluent, how soon must it be
It is preferable to administer MMR
immediately after reconstitution. If reconstituted MMR is not used
within 8 hours it must be discarded. MMR should always be refrigerated
and should never be left at room temperature.
- I misplaced the
diluent for the MMR dose so I used sterile water instead. Is there
any problem with doing this?
Only the diluent supplied with the
vaccine should be used to reconstitute any vaccine.
- Can single
antigen preparations for measles and rubella vaccines be mixed
together? We have MMR vaccine and single antigen vaccines for those
who only need one.
Absolutely not. Vaccines should never
be mixed except when specifically approved by the FDA. Also, ACIP
recommends use of combined MMR whenever one or more of the antigens is
indicated, so there is little need to stock single antigen vaccines.
- Our clinic has
given MMR by the wrong route (IM rather than SC) for years. Should
these doses be repeated?
All live injected vaccines (MMR,
varicella, and yellow fever) are recommended to be given
subcutaneously. However, intramuscular administration is not likely to
decrease immunogenicity, and doses given IM do not need to be
Use, Recommendations & Schedule
- An 18-year-old
college student says he had measles and mumps at ages 4 and 5, but
never had MMR vaccine. Is rubella vaccine recommended in such a
Actually, this student should receive
two doses of MMR, separated by at least 28 days. (It is recommended
that all persons attending school receive two doses of MMR vaccine.) A
personal history of measles and mumps is NOT acceptable as proof of
immunity. Acceptable evidence of measles and mumps immunity includes a
positive serologic test for antibody, physician diagnosis of diseases,
birth before 1957, or written documentation of vaccination. For
rubella, only serologic evidence or documented vaccination should be
accepted as proof of immunity. Additionally, persons born prior to
1957 may be considered immune to rubella unless they are women who
have the potential to become pregnant.
- I have adult
patients going back to school who must show proof of MMR vaccine and
are unable to retrieve their immunization records. What are my
Your options are to either bring the
person into compliance with the school entry requirement by
vaccinating or to perform serologic testing for all the antigens for
which documented immunity is required. There is no evidence that
adverse reactions are increased when MMR is given to a person who is
already immune to one or more of the components of the vaccine.
- Why is a
second dose of MMR necessary?
About 2%-5% of persons do not develop
measles immunity after the first dose of vaccine. This occurs for a
variety of reasons. The second dose is to provide another chance to
develop measles immunity for persons who did not respond to the first
- If you can
give the second dose of MMR as early as 28 days after the first
dose, why do we routinely wait until kindergarten entry to give the
The second dose of MMR may be given
as early as a month after the first dose, and be counted as a valid
dose if both doses were given after the first birthday. It is
convenient to give the second dose at school entry, since the child
will have an immunization visit for other school entry vaccines. The
risk of measles is higher in school-age children than those of
preschool age, so it is important to receive the second dose by school
entry. The second dose is not a "booster"; it is intended to
produce immunity in the small number of persons who fail to respond to
the first dose.
- Do people who
received MMR in the 1960s need to have their dose repeated?
Not necessarily. Persons who have
documentation of receiving LIVE measles vaccine in the 1960s do not
need to be revaccinated. Persons who were vaccinated prior to 1968
with either inactivated (killed) measles vaccine or measles vaccine of
unknown type should be revaccinated with at least one dose of live
attenuated measles vaccine. This recommendation is intended to protect
persons who may have received killed measles vaccine, which was
available in 1963-1967 and was not effective.
- My patient has
had two documented doses of MMR. Her rubella titer was nonreactive
at a prenatal visit. What should I do?
It is possible that she failed to
respond to both doses. It is also possible that she did respond but
has a low level of antibody. Failure to respond to two properly timed
doses of MMR vaccine would be expected to occur in one or two persons
per thousand vaccinees, at most. A small number of people appear to
develop a relatively small amount of antibody following vaccination
with rubella and other vaccines. This level of antibody may not be
detectable on relatively insensitive commercial screening tests.
Controlled trials with sensitive tests indicate a response rate of
>99% following two doses of rubella-containing vaccine. I would
suggest you make a note of her documented vaccination and stop
testing. Another approach would be to administer one additional dose
of MMR. However, there are no data on the administration of additional
doses of rubella-containing vaccine in this situation.
- What is the
recommendation for MMR vaccine for health care workers?
All persons who work in a medical
facility should have evidence of immunity to measles and rubella. For
most persons born after 1956, this means documentation of two doses of
MMR vaccine, or serologic evidence of measles and rubella immunity.
Persons born before 1957 can generally be considered immune to all
three diseases, but age does not guarantee immunity. As a result, ACIP
recommends that facilities consider recommending a dose of MMR to
persons born before 1957 if there is no other evidence of immunity
(such as serologic testing).
- If a new
employee in a health care setting cannot produce documentation of
receiving any dose of MMR, what should be done?
Persons born in or after 1957 who
work in health care facilities of any kind and cannot document prior
vaccination should receive two doses of MMR separated by at least 4
weeks. Alternatively, serologic testing could determine if the person
is immune to measles and rubella. Persons born before 1957 are
generally considered immune to measles. However, ACIP recommends that
at least one dose of MMR be considered for persons in this age group
who do not have documentation of a measles-containing vaccination,
history of physician-diagnosed measles, or laboratory evidence of
measles and rubella immunity.
- What is the
recommended length of time a woman should wait after receiving
rubella (or MMR) vaccine before becoming pregnant?
Four weeks. In October 2001, ACIP
voted to change its recommendation for the waiting interval following
the administration of rubella vaccine. The interval was reduced from 3
months to 4 weeks. The waiting period for measles and mumps vaccine
was already one month.
- If a pregnant
woman had a positive rubella titer in the past, and now has a
negative rubella titer, she would not need another MMR vaccination.
Doesn't the negative rubella titer mean her immunity has waned and
she needs a booster dose?
Rubella antibody levels may decline
with time, and may even fall below the level of detection of standard
screening tests. However, data from surveillance of rubella and
congenital rubella syndrome suggest that waning immunity with
increased susceptibility to rubella disease does not occur (MMWR
1998;47[RR-8]:14). Studies of persons who have "lost"
detectable rubella antibody indicate that almost all had antibody
detectable by more sensitive tests, or demonstrated a booster-type
response (absence of IgM antibody and a rapid rise in IgG antibody)
- If a woman
has a negative rubella titer during her first pregnancy, should she
be given MMR vaccine or only rubella vaccine alone prior to hospital
She should be given MMR, unless she
has documentation of immunity to measles and mumps (birth before 1957,
documented vaccination, or serologic evidence of immunity).
- We require a
pregnancy test for all our 7th graders before giving an MMR. Is this
No. ACIP recommends that women
of childbearing age be asked if they are currently pregnant or
attempting to become pregnant. Vaccination should be deferred
for those who answer "yes." Those who answer "no"
should be advised to avoid pregnancy for four weeks following
- Should we
give an MMR to a 15-month-old whose mother is 2 months pregnant?
Yes. Measles, mumps, and rubella
vaccine viruses are not transmitted from the vaccinated person, so MMR
does not pose a risk to a pregnant household member.
- Can I give MMR
to a child whose sibling is receiving chemotherapy for leukemia?
Yes. MMR and varicella vaccines
should be given to the healthy household contacts of immunosuppressed
children. Oral polio is the only vaccine that should not be given to a
healthy child if an immunosuppressed person resides in the household.
- Is it true that
egg allergy is no longer considered a contraindication to MMR
Several studies have documented the
safety of measles and mumps vaccine (which are grown in chick embryo
tissue culture) in children with severe egg allergy. The AAP's
"Red Book" Committee no longer considers egg allergy a
contraindication to MMR vaccination. The new ACIP statement on MMR
also recommends routine vaccination of egg-allergic children without
the use of special protocols or desensitization procedures.
- Is it
contraindicated to give MMR to a breastfeeding mother or to a
No. Breastfeeding does not interfere
with the response to MMR vaccine. Vaccination of a woman who is
breastfeeding her infant poses no risk to the infant being breastfed.
Although it is believed that rubella vaccine virus, in rare instances,
may be transmitted via breast milk, the infection in the infant is
- Can I give a
PPD (tuberculin skin test) on the same day as a dose of MMR vaccine?
A PPD can be applied before or on the
same day that MMR vaccine is given. However, if MMR vaccine is given
on the previous day or earlier, the PPD should be delayed for at least
one month. Live measles vaccine given prior to the application of a
PPD can reduce the reactivity of the skin test because of mild
suppression of the immune system.
- A story on
"60 Minutes" suggested administering each component of MMR
in separate injections to decrease the risk of autism. Is there any
reason to do this?
There is no scientific reason for or
benefit to separating the antigens. There is no credible evidence that
measles vaccine or MMR increases the risk of autism. Separating the
doses puts children (and pregnant women who may be exposed to them) at
increased risk for these diseases by extending the amount of time
children remain unvaccinated. Studies have shown that if parents have
to schedule additional appointments for vaccinations, there is an
increased risk that their children may not receive all the vaccines
they need. Further information about autism and vaccines is available
- How likely is
it for a person to develop arthritis from rubella vaccine?
Arthralgia (joint pain) and transient
arthritis (joint redness or swelling) following rubella vaccination
occurs only in persons who were susceptible to rubella at the time of
vaccination. Joint symptoms are uncommon in children and in adult
males. About 25% of post-pubertal women report joint pain after
receiving rubella vaccine, and about 10% report arthritis-like signs
and symptoms. When joint symptoms occur, they generally begin 1–3
weeks after vaccination, persist for 1 day to 3 weeks, and rarely
recur. Chronic joint symptoms attributable to rubella vaccine are very
rare, if they occur at all.
- If a health
care worker develops a rash and low-grade fever after MMR vaccine,
is s/he infectious?
Approximately 5-15% of susceptible
persons who receive MMR vaccine will develop a low-grade fever and/or
mild rash 7-12 days after vaccination. However, the person is not
infectious, and no special precautions (e.g., exclusion from work)
need to be taken.