Special Medical Reports

ACIP Issues Recommendations to Eliminate Measles, Rubella and Congenital Rubella Syndrome and to Control Mumps



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Am Fam Physician. 1998 Nov 1;58(7):1682-1686.

Since 1995, fewer cases of measles, rubella and mumps have been reported than at any time since disease reporting began. The year 2000 objectives of the U.S. Public Health Service include eliminating measles, rubella and congenital rubella syndrome and reducing the incidence of mumps to less than 500 reported cases per year. The Advisory Committee on Immunization Practices (ACIP) has issued recommendations intended to hasten the achievement of these disease elimination goals. The recommendations were published in the May 11, 1998, issue of the recommendations and reports series of Morbidity and Mortality Weekly Report.

The report includes discussions of the clinical characteristics of measles, mumps and rubella; preparations for the measles-mumps-rubella (MMR) vaccine; vaccine usage; documentation of immunity (Table 1); routine vaccination; special considerations for vaccination; adverse events; reporting adverse events; vaccine injury compensation; precautions and contraindications (pregnancy, severe illness, allergies, thrombocytopenia, recent administration of immune globulin [Table 2], altered immunocompetence and management of persons with contraindications to measles vaccine); and surveillance and outbreak control.

TABLE 1

Acceptable Presumptive Evidence of Immunity to Measles, Rubella and Mumps

Disease Routine Persons who work in health care facilities* International travelers Students at post-high school educational institutions

Measles

(1) Documentation of adequate vaccination†—preschool-aged children and adults not at high risk, 1 dose—school-aged children (grades K-12), 2 doses,‡ or

(1) Documented administration of 2 doses of live measles virus vaccine,† or

(1) Documented administration of 2 doses of live measles virus vaccine,†∥ or

(1) Documented administration of 2 doses of live measles virus vaccine,† or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(3) Born before 1957, or

(3) Born before 1957,ठor

(3) Born before 1957, or

(3) Born before 1957, or

(4) Documentation of physician-diagnosed measles

(4) Documentation of physician-diagnosed measles

(4) Documentation of physician-diagnosed measles

(4) Documentation of physician-diagnosed measles

Rubella

(1) Documented administration of 1 dose of live rubella virus vaccine,† or

(1) Documented administration of 1 dose of live rubella virus vaccine,† or

(1) Documented administration of 1 dose of live rubella virus vaccine,† or

(1) Documented administration of 1 dose of live rubella virus vaccine,† or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(3) Born before 1957 (except women of childbearing age who could become pregnant)¶

(3) Born before 1957 (except women of childbearing age who could become pregnant)¶

(3) Born before 1957 (except women of childbearing age who could become pregnant)¶

(3) Born before 1957 (except women of childbearing age who could become pregnant)¶

Mumps

(1) Documented administration of 1 dose of live mumps virus vaccine,† or

(1) Documented administration of 1 dose of live mumps virus vaccine,† or

(1) Documented administration of 1 dose of live mumps virus vaccine,† or

(1) Documented administration of 1 dose of live mumps virus vaccine,† or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(3) Born before 1957, or

(3) Born before 1957, or

(3) Born before 1957, or

(3) Born before 1957, or

(4) Documentation of physician-diagnosed mumps

(4) Documentation of physician-diagnosed mumps

(4) Documentation of physician-diagnosed mumps

(4) Documentation of physician-diagnosed mumps


*—Health care workers include all persons (i.e., medical or nonmedical, paid or volunteer, full- or part-time, student or nonstudent, with or without patient-care responsibilities) who work in facilities that provide health care to patients (i.e., inpatient and outpatient, private and public). Facilities that provide care exclusively for elderly patients who are at minimal risk for measles and rubella and complications of these diseases are a possible exception.

†—The first dose should be administered on or after the first birthday; the second dose of measles-containing vaccine should be administered no earlier than one month (i.e., minimum of 28 days) after the first dose. Combined measles-mumps-rubella (MMR) vaccine generally should be used whenever any of its component vaccines is indicated.

‡—May vary depending on current state or local requirements.

§—Health care facilities should consider recommending a dose of MMR vaccine for unvaccinated workers born before 1957 who are at risk for occupational exposure to measles and who do not have a history of measles or laboratory evidence of measles immunity.

∥—Children aged six to 11 months should receive a dose of monovalent measles vaccine (or MMR, if monovalent vaccine is not available) before departure. Children who receive a dose of measles-containing vaccine before their first birthdays should be revaccinated with two doses of MMR vaccine, the first of which should be administered when the child is aged 12 to 15 months (12 months if the child remains in a high-risk area) and the second at least 28 days later.

¶—Women of childbearing age are adolescent girls and premenopausal adult women. Because rubella can occur in some persons born before 1957 and because congenital rubella and congenital rubella syndrome can occur in the offspring of women infected with rubella virus during pregnancy, birth before 1957 is not acceptable evidence of rubella immunity for women who could become pregnant.

From the Centers for Disease Control and Prevention. Measles, mumps, and rubella—vaccine use and strategies for elimination of measles, rubella and congenital rubella syndrome and control of mumps. MMWR 1998;47(RR-8):11.

TABLE 1   Acceptable Presumptive Evidence of Immunity to Measles, Rubella and Mumps

View Table

TABLE 1

Acceptable Presumptive Evidence of Immunity to Measles, Rubella and Mumps

Disease Routine Persons who work in health care facilities* International travelers Students at post-high school educational institutions

Measles

(1) Documentation of adequate vaccination†—preschool-aged children and adults not at high risk, 1 dose—school-aged children (grades K-12), 2 doses,‡ or

(1) Documented administration of 2 doses of live measles virus vaccine,† or

(1) Documented administration of 2 doses of live measles virus vaccine,†∥ or

(1) Documented administration of 2 doses of live measles virus vaccine,† or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(3) Born before 1957, or

(3) Born before 1957,ठor

(3) Born before 1957, or

(3) Born before 1957, or

(4) Documentation of physician-diagnosed measles

(4) Documentation of physician-diagnosed measles

(4) Documentation of physician-diagnosed measles

(4) Documentation of physician-diagnosed measles

Rubella

(1) Documented administration of 1 dose of live rubella virus vaccine,† or

(1) Documented administration of 1 dose of live rubella virus vaccine,† or

(1) Documented administration of 1 dose of live rubella virus vaccine,† or

(1) Documented administration of 1 dose of live rubella virus vaccine,† or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(3) Born before 1957 (except women of childbearing age who could become pregnant)¶

(3) Born before 1957 (except women of childbearing age who could become pregnant)¶

(3) Born before 1957 (except women of childbearing age who could become pregnant)¶

(3) Born before 1957 (except women of childbearing age who could become pregnant)¶

Mumps

(1) Documented administration of 1 dose of live mumps virus vaccine,† or

(1) Documented administration of 1 dose of live mumps virus vaccine,† or

(1) Documented administration of 1 dose of live mumps virus vaccine,† or

(1) Documented administration of 1 dose of live mumps virus vaccine,† or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(2) Laboratory evidence of immunity, or

(3) Born before 1957, or

(3) Born before 1957, or

(3) Born before 1957, or

(3) Born before 1957, or

(4) Documentation of physician-diagnosed mumps

(4) Documentation of physician-diagnosed mumps

(4) Documentation of physician-diagnosed mumps

(4) Documentation of physician-diagnosed mumps


*—Health care workers include all persons (i.e., medical or nonmedical, paid or volunteer, full- or part-time, student or nonstudent, with or without patient-care responsibilities) who work in facilities that provide health care to patients (i.e., inpatient and outpatient, private and public). Facilities that provide care exclusively for elderly patients who are at minimal risk for measles and rubella and complications of these diseases are a possible exception.

†—The first dose should be administered on or after the first birthday; the second dose of measles-containing vaccine should be administered no earlier than one month (i.e., minimum of 28 days) after the first dose. Combined measles-mumps-rubella (MMR) vaccine generally should be used whenever any of its component vaccines is indicated.

‡—May vary depending on current state or local requirements.

§—Health care facilities should consider recommending a dose of MMR vaccine for unvaccinated workers born before 1957 who are at risk for occupational exposure to measles and who do not have a history of measles or laboratory evidence of measles immunity.

∥—Children aged six to 11 months should receive a dose of monovalent measles vaccine (or MMR, if monovalent vaccine is not available) before departure. Children who receive a dose of measles-containing vaccine before their first birthdays should be revaccinated with two doses of MMR vaccine, the first of which should be administered when the child is aged 12 to 15 months (12 months if the child remains in a high-risk area) and the second at least 28 days later.

¶—Women of childbearing age are adolescent girls and premenopausal adult women. Because rubella can occur in some persons born before 1957 and because congenital rubella and congenital rubella syndrome can occur in the offspring of women infected with rubella virus during pregnancy, birth before 1957 is not acceptable evidence of rubella immunity for women who could become pregnant.

From the Centers for Disease Control and Prevention. Measles, mumps, and rubella—vaccine use and strategies for elimination of measles, rubella and congenital rubella syndrome and control of mumps. MMWR 1998;47(RR-8):11.

TABLE 2

Suggested Intervals Between Administration of Immune Globulin Preparations for Various Indications and Vaccines*

Indications Dose Interval (months) before measles vaccination

Tetanus prophylaxis (TIG)

250 units (10 mg IgG per kg) IM

3

Hepatitis A prophylaxis (IG)

Contact prophylaxis

0.02 mL per kg (3.3 mg IgG per kg) IM

3

International travel

0.06 mL per kg (10 mg IgG per kg) IM

3

Hepatitis B prophylaxis (HBIG)

0.06 mL per kg (10 mg IgG per kg) IM

3

Rabies prophylaxis (HRIG)

20 international units per kg (22 mg IgG per kg) IM

4

Varicella prophylaxis (VZIG)

125 units per 10 kg (20 to 40 mg IgG per kg) IM (maximum: 625 units)

5

Measles prophylaxis (IG)

Standard (i.e., nonimmunocompromised) contact

0.25 mL per kg (40 mg IgG per kg) IM

5

Immunocompromised contact

0.50 mL per kg (80 mg IgG per kg) IM

6

Blood transfusion

RBCs, washed

10 mL per kg (negligible IgG per kg) IV

0

RBCs, adenine-saline added

10 mL per kg (10 mg IgG per kg) IV

3

Packed RBCs (hematocrit: 65 percent)†

10 mL per kg (60 mg IgG per kg) IV

6

Whole blood (hematocrit: 35 to 50 percent)†

10 mL per kg (80 to 100 mg IgG per kg) IV

6

Plasma/platelet products

10 mL per kg (160 mg IgG per kg) IV

7

Replacement therapy for immune deficiencies‡

300 to 400 mg per kg IV (as IVIG)

8

Respiratory syncytial virus prophylaxis

750 mg per kg IV (as RSV-IGIV)

9

Immune thrombocytopenic purpura

400 mg per kg IV (as IGIV)

8

1,000 mg per kg IV (as IGIV)

10

Kawasaki disease

2 g per kg IV (as IGIV)

11


HBIG = hepatitis B immune globulin; HRIG = human rabies immune globulin; IG = serum immune globulin; IGIV = immune globulin, intravenous; IM = intramuscularly; IV = intravenously; RBCs = red blood cells; RSV-IGIV = respiratory syncytial virus immune globulin, intravenous; TIG = tetanus immune globulin; VZIG = varicella zoster immune globulin.

*—This table is not intended for determining the correct indications and dosage for the use of immune globulin preparations. Unvaccinated persons may not be fully protected against measles during the entire suggested time interval, and additional doses of immune globulin or measles vaccine, or both, may be indicated after measles exposure. The concentration of measles antibody in a particular immune globulin preparation can vary by lot. The rate of antibody clearance after receipt of an immune globulin preparation can vary. The recommended intervals are extrapolated from an estimated half-life of 30 days for passively acquired antibody and an observed interference with the immune response to measles vaccine for 5 months after a dose of 80 mg IgG per kg.

†—Assumes a serum IgG concentration of 16 mg per mL.

‡—Measles vaccination is recommended for children infected with human immunodeficiency virus who do not have evidence of severe immunosuppression, but is contraindicated for patients who have congenital disorders of the immune system.

From the Centers for Disease Control and Prevention. Measles, mumps, and rubella—vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps. MMWR 1998;47(RR-8):24.

TABLE 2   Suggested Intervals Between Administration of Immune Globulin Preparations for Various Indications and Vaccines*

View Table

TABLE 2

Suggested Intervals Between Administration of Immune Globulin Preparations for Various Indications and Vaccines*

Indications Dose Interval (months) before measles vaccination

Tetanus prophylaxis (TIG)

250 units (10 mg IgG per kg) IM

3

Hepatitis A prophylaxis (IG)

Contact prophylaxis

0.02 mL per kg (3.3 mg IgG per kg) IM

3

International travel

0.06 mL per kg (10 mg IgG per kg) IM

3

Hepatitis B prophylaxis (HBIG)

0.06 mL per kg (10 mg IgG per kg) IM

3

Rabies prophylaxis (HRIG)

20 international units per kg (22 mg IgG per kg) IM

4

Varicella prophylaxis (VZIG)

125 units per 10 kg (20 to 40 mg IgG per kg) IM (maximum: 625 units)

5

Measles prophylaxis (IG)

Standard (i.e., nonimmunocompromised) contact

0.25 mL per kg (40 mg IgG per kg) IM

5

Immunocompromised contact

0.50 mL per kg (80 mg IgG per kg) IM

6

Blood transfusion

RBCs, washed

10 mL per kg (negligible IgG per kg) IV

0

RBCs, adenine-saline added

10 mL per kg (10 mg IgG per kg) IV

3

Packed RBCs (hematocrit: 65 percent)†

10 mL per kg (60 mg IgG per kg) IV

6

Whole blood (hematocrit: 35 to 50 percent)†

10 mL per kg (80 to 100 mg IgG per kg) IV

6

Plasma/platelet products

10 mL per kg (160 mg IgG per kg) IV

7

Replacement therapy for immune deficiencies‡

300 to 400 mg per kg IV (as IVIG)

8

Respiratory syncytial virus prophylaxis

750 mg per kg IV (as RSV-IGIV)

9

Immune thrombocytopenic purpura

400 mg per kg IV (as IGIV)

8

1,000 mg per kg IV (as IGIV)

10

Kawasaki disease

2 g per kg IV (as IGIV)

11


HBIG = hepatitis B immune globulin; HRIG = human rabies immune globulin; IG = serum immune globulin; IGIV = immune globulin, intravenous; IM = intramuscularly; IV = intravenously; RBCs = red blood cells; RSV-IGIV = respiratory syncytial virus immune globulin, intravenous; TIG = tetanus immune globulin; VZIG = varicella zoster immune globulin.

*—This table is not intended for determining the correct indications and dosage for the use of immune globulin preparations. Unvaccinated persons may not be fully protected against measles during the entire suggested time interval, and additional doses of immune globulin or measles vaccine, or both, may be indicated after measles exposure. The concentration of measles antibody in a particular immune globulin preparation can vary by lot. The rate of antibody clearance after receipt of an immune globulin preparation can vary. The recommended intervals are extrapolated from an estimated half-life of 30 days for passively acquired antibody and an observed interference with the immune response to measles vaccine for 5 months after a dose of 80 mg IgG per kg.

†—Assumes a serum IgG concentration of 16 mg per mL.

‡—Measles vaccination is recommended for children infected with human immunodeficiency virus who do not have evidence of severe immunosuppression, but is contraindicated for patients who have congenital disorders of the immune system.

From the Centers for Disease Control and Prevention. Measles, mumps, and rubella—vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps. MMWR 1998;47(RR-8):24.

These recommendations supersede previous recommendations published in 1989 and 1990. The following discussion is a summary of the updated recommendations from ACIP:

  • The use of combined MMR vaccine for most indications is emphasized. Two doses of the MMR vaccine separated by at least one month and administered on or after a child's first birthday are recommended for all children and for certain high-risk groups of adolescents and adults. The recommended one-month interval is based on the principle that live virus vaccines that are not administered at the same time should be separated by at least one month. Use of combined MMR vaccine should provide an additional safeguard against primary vaccine failures and help eliminate rubella and congenital rubella syndrome and continued reduction in the incidence of mumps. The benefit/cost ratio is even greater when the vaccines are combined.

ACIP recommends routine simultaneous administration of MMR, diphtheria and tetanus toxoids and acellular pertussis (DTaP) or diphtheria and tetanus toxoids and whole-cell pertussis (DTP) vaccine, Haemophilus influenzae type b (Hib) vaccine and oral poliovirus vaccine (OPV) or inactivated poliovirus vaccine (IPV) to children who are at the recommended age to receive these vaccines. In general, according to the report, simultaneous administration does not hinder antibody responses or cause increased rates of side effects among vaccinated persons.

  • ACIP has changed the recommended age for routine vaccination to 12 to 15 months for the first dose of MMR, and to four to six years for the second dose of MMR. Almost all children who do not respond immunologically to the first dose of MMR vaccine will respond to the second dose. Children with human immunodeficiency virus (HIV) infection should receive MMR vaccine at 12 months of age, if they do not have a contraindication to its use.

  • ACIP recommends that all states take immediate action to implement a two-dose MMR requirement for school entry and take any additional measures needed to ensure that all school-aged children are vaccinated with two doses of MMR by the year 2001.

  • Serologic screening for measles, mumps and rubella is appropriate only if persons who are identified as susceptible are subsequently vaccinated in a timely manner. Serologic screening ordinarily is not necessary for persons who have acceptable evidence of immunity. During outbreaks of measles or rubella, serologic screening before vaccination is not generally recommended because rapid vaccination is necessary to stop the spread of the disease. Prenatal serologic screening is indicated for all pregnant women who lack acceptable evidence of rubella immunity. Following completion of a pregnancy, women who do not have serologic evidence of rubella immunity or documentation of rubella vaccination should receive MMR vaccination before discharge from the hospital.

  • Only vaccination for which written documentation of the date of administration is presented should be considered valid. Neither a self-reported dose nor a history of vaccination provided by a parent is, by itself, considered adequate documentation. Persons who may be immune to MMR but who lack either adequate documentation of vaccination or other acceptable evidence of immunity should be vaccinated (Table 1). Documentations of all vaccinations should be included in a patient's medical record.

  • All persons who work in health care facilities should have acceptable evidence of measles and rubella immunity (Table 1).

  • Any person exposed to measles who lacks evidence of measles immunity and to whom immune globulin is administered should subsequently receive MMR vaccine. The recommended interval between administration of immune globulin and measles vaccination has been changed (Table 2).

  • Adverse events associated with administration of MMR vaccine range from local pain, induration and edema to rare systemic reactions such as anaphylaxis. Expert committees at the Institute of Medicine (IOM) recently reviewed all of the evidence concerning the causal relationship between MMR vaccination and various adverse events. The IOM determined that there is a causal relationship between MMR vaccination and anaphylaxis, thrombocytopenia, febrile seizures and acute arthritis. The report includes updated information on adverse events and contraindications, particularly for persons who have severe HIV infection, a history of egg allergy or gelatin allergy, a history of thrombocytopenia or are receiving steroid therapy.


Copyright © 1998 by the American Academy of Family Physicians.
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