The capacity of vaccines to induce highly specific, effective, and long-lasting responses from the immune system without the dangers of infection is astounding, but confusion and misunderstanding among the public about the way vaccines work can have profound implications for vaccine uptake and disease control and elimination.
The immune response to live vaccines like MMR is complex, but the bottom line is simple: these vaccines are safe, they are effective, and they have saved—and continue to save—countless lives.
Login Toggle navigation Search. Measles cases reported by year as of July 18, The number of cases in is already higher than any years since Measles infection Measles vaccine-associated symptoms Symptoms High fever, rash, cough, nasal congestion and conjunctivitis that may last a week or more Mild and short-lived fever and rash Transmission Extraordinarily contagious Cannot be spread from person to person Complications Include pneumonia and ear infections as well as encephalitis and a fatal, untreatable late-onset condition subacute sclerosing panencephalopathy, SSPE Not associated with these types of complications Mortality Killed an average of people in the U.
Share This. Get published in an ASM journal Submit now. Measles infection. Measles vaccine-associated symptoms. High fever, rash, cough, nasal congestion and conjunctivitis that may last a week or more. Mild and short-lived fever and rash. Extraordinarily contagious.
Before , approximately , cases and measles deaths were reported annually, with epidemic cycles every 2 to 3 years. However, the actual number of cases was estimated at 3 to 4 million annually. The occurrence of measles among previously vaccinated children i. Before , the highest number of measles cases following elimination in the United States occurred in when cases were reported. Increasing incidence of measles globally contributes to increased opportunities for measles importation into the United States.
Fortunately, public health measures and a long-standing vaccination program has prevented outbreaks form imported cases. Among children born during —, The inactivated vaccine was withdrawn in because it did not protect well against measles. The original Edmonston B vaccine was withdrawn in because of a relatively high frequency of fever and rash in recipients. A live, further attenuated Schwarz strain vaccine was first introduced in , but also is no longer used in the United States.
Another live, further attenuated strain Edmonston-Enders strain vaccine was licensed in These further attenuated vaccines caused fewer reactions than the original Edmonston B vaccine. In , measles vaccine was licensed as a combined measles, mumps, and rubella MMR vaccine. Single-antigen measles vaccine is not available in the United States. MMR and MMRV vaccines are supplied as a lyophilized freeze-dried powder and are reconstituted with sterile, preservative-free water and vaccine contains gelatin.
It contains no adjuvant or preservative. MMR vaccine or MMRV vaccine can be used to implement the vaccination recommendations for prevention of measles, mumps, and rubella. MMR vaccine is licensed for use in persons age 12 months or older. MMRV vaccine is licensed for use in persons age 12 months through 12 years; MMRV vaccine should not be administered to persons age 13 years or older. Two doses of MMR vaccine, separated by at least 4 weeks, are routinely recommended for children age 12 months or older.
Dose 1 of MMR vaccine should be given at age 12 through 15 months. A second dose of MMR vaccine is recommended based on previous observations of the failure of some to generate an immune response to measles following dose 1.
Dose 2 is routinely given at age 4 through 6 years, before a child enters kindergarten or first grade. All students entering school should receive 2 doses of MMR vaccine with the first dose administered at age 12 months or older before enrollment. Dose 2 of MMR vaccine may be administered as soon as 4 weeks after dose 1. The minimum interval between doses of MMRV vaccine is 3 months, although when dose 2 is administered 4 weeks following dose 1, it can be considered valid.
Providers who are considering administering MMRV should discuss the benefits and risks of both vaccination options with the parents.
For the second dose of measles, mumps, rubella, and varicella vaccines at any age and for the first dose at age 48 months or older, the use of MMRV generally is preferred over separate injections of its equivalent component vaccines i. Adults born in or later should receive at least 1 dose of MMR vaccine unless they have documentation of vaccination with at least 1 dose of measles, mumps, and rubella-containing vaccine or other acceptable presumptive evidence of immunity to these three diseases.
Except for health care personnel who should have documented immunity, birth before generally can be considered acceptable evidence of immunity to measles, mumps, and rubella. Colleges and other post-high-school educational institutions are potential high-risk areas for measles, mumps, and rubella transmission because of large concentrations of persons. Prematriculation vaccination requirements for measles immunity have been shown to significantly decrease the risk of measles outbreaks on college campuses where such requirements are implemented and enforced.
All students entering colleges, universities, technical and vocational schools, and other institutions for post-high-school education should receive 2 doses of MMR vaccine or have other acceptable evidence of measles, mumps, and rubella immunity before entry.
For unvaccinated health care personnel born before who lack laboratory evidence of measles, mumps, or rubella immunity or laboratory confirmation of disease, health care facilities should have policies that offer 2 doses of MMR vaccine at the appropriate interval for measles and mumps and 1 dose of MMR vaccine for rubella, respectively.
Health care facilities should also have policies for such personnel that recommend 2 doses of MMR vaccine during an outbreak of measles or mumps and 1 dose during an outbreak of rubella. Adequate vaccination for health care personnel born during or after consists of 2 appropriately spaced MMR doses for measles and mumps, and at least 1 dose of MMR for rubella.
Persons who travel outside the United States are at increased risk of exposure to measles. Measles is endemic or epidemic in many countries throughout the world. Although proof of immunization is not required for entry into the United States or any other country, persons traveling or living abroad should have evidence of measles immunity. Adequate vaccination of persons who travel outside the United States is 1 dose of MMR vaccine for children age 6 through 11 months and 2 doses of an age-appropriate measles-, mumps-, and rubella-containing vaccine for children age 12 months and older and adults.
Revaccination is recommended for certain persons. The following groups should be considered unvaccinated and should receive at least 1 dose of measles vaccine: 1 persons vaccinated before their first birthday, 2 persons vaccinated with killed measles vaccine, 3 persons vaccinated from through with an unknown type of vaccine, 4 persons who received immune globulin IG in addition to a further attenuated strain or vaccine of unknown type, and 5 persons with perinatal human immunodeficiency virus HIV infection who were vaccinated before establishment of effective antiretroviral therapy ART and who do not have evidence of current severe immunosuppression.
Measles-, mumps-, or rubella- virus-containing vaccine administered prior to age 12 months e. Children vaccinated before age 12 months should be revaccinated with 2 doses of appropriately spaced MMR or MMRV vaccine, the first dose administered when the child is age 12 through 15 months 12 months if the child remains in an area where disease risk is high and the second dose at least 4 weeks later.
Persons who experienced perinatal HIV-infection who may have received MMR vaccine prior to the establishment of effective combined antiretroviral therapy cART should be revaccinated with 2 appropriately spaced doses of MMR i. MMR series should be administered once effective cART has been established for at least 6 months and there is no evidence of severe immunosuppression. Generally, persons can be considered immune to measles if they were born before , have serologic evidence of measles immunity equivocal test results should be considered negative , or laboratory confirmation of disease, or have documentation of adequate vaccination for measles.
MMR vaccine failure can occur because of passive antibody in the vaccine recipient, immaturity of the immune system, damaged vaccine, or other reasons. Most persons who fail to respond to the first dose will respond to a second dose. Although the titer of vaccine-induced antibodies is lower than that following natural disease, both serologic and epidemiologic evidence indicate that vaccine-induced immunity appears to be long-term and probably lifelong in most persons.
Most vaccinated persons who appear to lose antibody show an anamnestic immune response upon revaccination, indicating that they are probably still immune. Although revaccination can increase antibody titer in some persons, available data indicate that the increased titer may not be sustained. Some studies indicate that waning immunity may occur after successful vaccination, but this appears to occur rarely and to play only a minor role in measles transmission and outbreaks.
As with other vaccines, a history of a severe allergic reaction anaphylaxis to a vaccine component or following a prior dose is a contraindication to further doses. Moderate or severe acute illness with or without fever in a patient is considered a precaution to vaccination, although persons with minor illness may be vaccinated. Persons with alpha-gal allergy may wish to consult their physician before receiving a vaccine that contains gelatin.
Severe immunocompromise e. Patients who have not received chemotherapy for at least 3 months, whose disease remains in remission, and who have restored immunocompetence, may receive MMR or MMRV vaccine. Healthy, susceptible close contacts of severely immunocompromised persons should be vaccinated. Persons receiving systemic high-dose corticosteroid therapy 2 milligrams per kilogram of body weight or more per day or 20 milligrams or more per day of prednisone for 14 days or more should not receive MMR or MMRV vaccine because of concern about vaccine safety.
MMR or MMRV should not be administered for at least 1 month after cessation of systemic high-dose corticosteroid therapy. Although persons receiving high doses of systemic corticosteroids daily or on alternate days for less than 14 days generally can receive MMR or MMRV immediately after cessation of treatment, some experts prefer waiting until 2 weeks after completion of therapy.
Available data indicate that vaccination with MMR has not been associated with severe or unusual adverse reactions in HIV-infected persons who are not severely immunosuppressed, although antibody responses have been variable.
A family history of congenital or hereditary immunodeficiency in first-degree relatives e. Simultaneous use of aspirin or aspirin-containing products is a precaution for MMRV vaccine due to the varicella component. The manufacturer recommends that vaccine recipients avoid the use of salicylates for 6 weeks after receiving MMRV vaccine because of the association between aspirin use and Reye syndrome following chickenpox.
A personal or family i. Children with a personal or family history of seizures of any etiology should ideally be vaccinated with separate MMR and VAR vaccines because the risks for using MMRV vaccine in this group of children generally outweigh the benefits.
MMR vaccine may be administered to egg-allergic persons without prior routine skin testing or the use of special protocols. The effect of the administration of antibody-containing blood products e. Because of the potential inhibition of the response to vaccination by passively transferred antibodies, neither MMR vaccine nor MMRV vaccine nor VAR vaccine should be administered for 3 to 11 months after receipt of antibody-containing blood products.
The interval between the antibody-containing blood product and receipt of MMR or MMRV vaccine is determined by the type of product administered. Antibody-containing products should not be given for 2 weeks following vaccination unless the benefits exceed those of the vaccine. In such cases, vaccine recipients should either be revaccinated later at the appropriate intervals ranging 3 to 11 months or tested for immunity and revaccinated if seronegative.
Measles vaccine and possibly mumps, rubella, and varicella vaccines may transiently suppress the response to tuberculin skin test TST in a person infected with Mycobacterium tuberculosis. TST and measles-containing vaccine may be administered at the same visit if necessary. Simultaneously administering TST and measles-containing vaccine does not interfere with reading the TST result at 48 to 72 hours and ensures that the person has received measles vaccine.
If the measles-containing vaccine has been administered recently, TST screening should be delayed for at least 4 weeks after vaccination. Receipt of specific antiviral drugs e. These drugs should be avoided for 14 days after vaccination. If a pregnant woman inadvertently receives MMR or MMRV vaccine, termination of pregnancy is not recommended because the risk to the fetus appears to be extremely low.
Instead, individual counseling for these women is recommended. The experts determined that evidence supports a causal relation between MMR vaccination and anaphylaxis, febrile seizures, thrombocytopenic purpura, transient arthralgia, and measles inclusion body encephalitis in persons with demonstrated immunodeficiencies.
Most adverse events reported following MMR vaccination such as fever and rash are attributable to the measles component. Most persons with fever do not have other symptoms. MMR vaccine is associated with a very small risk of febrile seizures; approximately one case for every 3, to 4, doses of MMR vaccine administered. The febrile seizures typically occur 6 to 14 days after vaccination and do not appear to be associated with any long-term sequelae.
Children with a personal or family history of febrile seizures or family history of epilepsy might be at increased risk for febrile seizures after MMR vaccination. Laboratory testing can confirm the presence of measles or mumps vaccine virus in a recently vaccinated and potentially exposed individual. Allergic reactions following the administration of MMR vaccine are rare. Most of these are minor and consist of a wheal and flare or urticaria at the injection site.
Immediate, anaphylactic reactions to MMR vaccine occur in 1. Rarely, MMR vaccine may cause thrombocytopenia within two months after vaccination. The clinical course of these cases is usually transient and benign, although hemorrhage occurs rarely. Based on case reports, the risk for MMR vaccine-associated thrombocytopenia may be higher for persons who have previously had immune thrombocytopenic purpura, particularly for those who had thrombocytopenic purpura after an earlier dose of MMR vaccine.
Measles inclusion body encephalitis has been documented after measles vaccination in persons with immune deficiencies. The illness is also known to occur within 1 year after initial infection with wild-type measles virus and has a high death rate.
In the cases after MMR vaccination, the time from vaccination to development of measles inclusion body encephalitis was 4—9 months, consistent with development of measles inclusion body encephalitis after infection with wild-type measles virus. Two postlicensure studies indicated that one additional febrile seizure per 2, to 2, children age 12 through 23 months occurred 5 to 12 days after the first dose of MMRV vaccine, compared with children who had received the first dose of MMR vaccine and VAR vaccine administered as separate injections at the same visit.
Data from postlicensure studies do not suggest that this increased risk exists for children age 4 to 6 years receiving the second dose of MMRV vaccine. For information on guidance for state and local health department staff who are involved in surveillance activities for vaccine-preventable diseases, please consult the Manual for the Surveillance of Vaccine-Preventable Diseases.
The editors would like to acknowledge Jennifer Hamborsky and Valerie Morelli for their contributions to this chapter. American Academy of Pediatrics. The resurgence of measles in the United States, — Ann Rev Med ;—
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