Routine Measles, Mumps, and Rubella Vaccination
The Advisory Committee on Immunization Practices (ACIP) recommends that persons who do not have presumptive evidence of immunity to measles, mumps, and rubella should get vaccinated against these diseases with measles, mumps, rubella (MMR) vaccine or measles, mumps, rubella, varicella (MMRV) vaccine. Only combination MMR and MMRV vaccines are licensed in the United States.
- 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
- Laboratory confirmation of disease
- Birth before 1957 (see below for presumptive evidence of immunity criteria for health care personnel born before 1957)
CDC recommends 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.
CDC recommends that separate MMR and varicella vaccines be given for the first dose in children aged 12–47 months; however, MMRV may be used if parents or caregivers express a preference.
Adults should also be up to date on MMR vaccinations with either 1 or 2 doses (depending on risk factors) unless they have other presumptive evidence of immunity to measles, mumps, and rubella.
One dose of MMR vaccine, or other presumptive evidence of immunity, is sufficient for most adults. Providers generally do not need to actively screen adult patients for measles immunity in non-outbreak areas in the U.S. After vaccination, it is also not necessary to test patients for antibodies to confirm immunity. There is no recommendation for a catch-up program among adults for a second dose of MMR (e.g., persons born before 1989 or otherwise).
Students at post-high school educational institutions who do not have presumptive evidence of immunity should receive two doses of MMR vaccine, each dose separated by at least 28 days.
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.
Healthcare personnel without 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, in routine circumstances, healthcare facilities should consider vaccinating healthcare personnel born before 1957 who lack laboratory evidence of immunity or laboratory confirmation of disease.
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.
People 12 months of age and older with HIV infection who do not have presumptive evidence of measles immunity or evidence of severe immunosuppression should receive two doses of MMR vaccine, separated by 28 days. Severe immunosuppression is defined as CD4 percentages less than 15% for 6 months or longer (for children five years of age or younger) and CD4 percentages less than 15% and CD4 count less than 200 cells/mm3 for 6 months or longer (for persons older than five years).
A very small proportion of adults (less than 5%) may have received killed measles vaccine from 1963 through 1967 during childhood. The ACIP recommends re-vaccinating anyone who received measles vaccine of unknown type, inactivated measles vaccine, or further attenuated measles vaccine accompanied by IG or high-titer measles immune globulin (no longer available in the United States) during these years with 1 or 2 doses.
During measles outbreaks, health departments may provide additional recommendations to protect their communities. The at-risk population is defined by local and state health departments and depends on the epidemiology of the outbreak (e.g., only specific age groups are affected). In addition to the routine recommendations for MMR vaccine, health departments may recommend a second dose for adults or an earlier second dose for children 1 to 4 years of age who are residing in or visiting the affected areas, with the second dose given at least 28 days after the first dose.
If there is ongoing community-wide transmission affecting young infants, health departments may recommend an early dose for infants 6 to 11 months of age. The decision to vaccinate should be made carefully after weighing the risks of the potential long-term impact of lower immune responses when infants are vaccinated less than 12 months of age (versus greater than or equal to 12 months of age) compared to the benefit of early protection when measles is circulating in the community. Infants who get one dose of MMR vaccine before their first birthday should get two more doses according to the routinely recommended schedule (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).
During an outbreak of measles in a healthcare facility, or in healthcare facilities serving a measles outbreak area, two doses of MMR vaccine are recommended for healthcare personnel, regardless of birth year, who lack other presumptive evidence of measles immunity
There are no recommendations to receive a third dose of MMR vaccine during measles outbreaks.
Contraindications and precautions to vaccination generally dictate circumstances when vaccines will not be given. Most contraindications and precautions are temporary, and the vaccine can be given at a later time.
A contraindication is a condition in a recipient that greatly increases the chance of a serious adverse reaction (or due to the theoretical risk in the case of pregnant women).
People with a contraindication for MMR or MMRV vaccine should not receive the vaccine, including anyone who—
- Had a severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
- Has a known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, or long-term immunosuppressive therapy or patients with human immunodeficiency virus [HIV] infection who are severely immunocompromised)
- Is pregnant
A precaution is a condition in a recipient that might increase the chance or severity of a serious adverse reaction, or that might compromise the ability of the vaccine to produce immunity (such as administering MMR or MMRV vaccine to a person with passive immunity to measles from a blood transfusion).
Precautions for MMR or MMRV vaccine include—
- Moderate or severe acute illness with or without fever
- Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product)7
- History of thrombocytopenia or thrombocytopenic purpura
- Need for tuberculin skin testing or interferon gamma release assay (IGRA) testing
- Personal or family history of seizures
People exposed to measles who cannot readily show that they have adequate presumptive evidence of immunity against measles should be offered post-exposure prophylaxis (PEP). Public health officials can help identify eligible persons, assess any contraindications and weigh benefits. There are two types of PEP for measles:
- MMR vaccine, if administered within 72 hours of initial measles exposure, may provide some protection or modify the clinical course of disease.
- Immunoglobulin (IG), if administered within six days of exposure, may also provide some protection or modify the clinical course of disease.
For more information on measles outbreak control and post-exposure prophylaxis, healthcare providers should consult their health department and refer to the measles chapter of the Manual for the Surveillance of Vaccine-Preventable Diseases.
For more on routine MMR or MMRV vaccination, please see the Measles tab. Some special considerations for mumps vaccination are described below.
During a mumps outbreak, children 12 months of age to 4 years of age who are unvaccinated should receive one dose of MMR or MMRV. Persons 4 years of age or older who are unvaccinated or have received only one dose of MMR or MMRV should receive MMR (2 doses for unvaccinated, and 1 dose for people who previously received the first dose, administered 28 days apart).
During mumps outbreaks, public health authorities might also recommend that people who belong to groups at increased risk for getting mumps receive an additional dose of MMR (second dose for persons previously vaccinated with one dose or a third dose for persons previously vaccinated with 2 doses). Public health authorities will communicate to providers which groups are at increased risk and should receive a dose.
Unlike with measles, MMR vaccine is not effective at helping protect people who have recently been infected with mumps (post-exposure prophylaxis, or PEP). However, vaccination after exposure is not harmful and may possibly prevent later disease if re-exposed.
For more information on mumps outbreak control and post-exposure prophylaxis, healthcare providers should consult their health department and refer to the mumps chapter of the Manual for the Surveillance of Vaccine-Preventable Diseases.
For more on routine MMR or MMRV vaccination, please see the Measles tab. Some special considerations for rubella vaccination are described below.
All women of childbearing age, especially those who grew up outside the United States in areas where routine rubella vaccination might not occur, should be vaccinated with one dose of MMR vaccine or have other acceptable presumptive evidence of rubella immunity. Only a positive serologic test for rubella antibody or documentation of appropriate vaccination should be accepted as presumptive evidence of immunity for women who may become pregnant.
Women known to be pregnant or attempting to become pregnant should not receive a live virus vaccine, including MMR vaccine. Although there is no evidence that rubella vaccine virus is harmful to the fetus during pregnancy, as a precaution, women should not get pregnant for 4 weeks (28 days) after MMR vaccination.
Unlike with measles, MMR vaccine is not effective at helping protect people who have recently been infected with rubella (post-exposure prophylaxis, or PEP). However, vaccination after exposure is not harmful and may possibly prevent later disease if re-exposed.
For more information on rubella outbreak control and post-exposure prophylaxis, healthcare providers should consult their health department and refer to the rubella chapter of the Manual for the Surveillance of Vaccine-Preventable Diseases.