# Presentation: 126903

## Measles and Measles Vaccine

**Epidemiology and Prevention of Vaccine-Preventable Diseases**
**National Immunization Program**
**Centers for Disease Control and Prevention**

**Revised January 2007**

## Note to presenters:

**Images of vaccine-preventable diseases are available from the Immunization Action Coalition website at ****http://www.vaccineinformation.org/photos/index.asp**

## Measles

**Highly contagious viral illness**
**First described in 7th century**
**Near universal infection of childhood in prevaccination era**
**Common and often fatal in developing areas**

## Measles Virus

**Paramyxovirus (RNA)**
**Hemagglutinin important surface antigen**
**One antigenic type**
**Rapidly inactivated by heat and light**

## Measles Pathogenesis

**Respiratory transmission of virus**
**Replication in nasopharynx and regional lymph nodes**
**Primary viremia 2-3 days after exposure**
**Secondary viremia 5-7 days after exposure with spread to tissues**

## Measles Clinical Features

**Incubation period 10-12 days**
**Stepwise increase in fever to ****103****°****F or higher**
**Cough, coryza, conjunctivitis**
**Koplik spots**

- Prodrome

## Measles Clinical Features

**2-4 days after prodrome, 14 days after exposure**
**Maculopapular, becomes confluent**
**Begins on face and head**
**Persists 5-6 days**
**Fades in order of appearance**

- Rash

## Condition
Diarrhea
Otitis media
Pneumonia
Encephalitis
Hospitalization
Death

**Diarrhea**
**Otitis media**
**Pneumonia**
**Encephalitis**
**Hospitalization**
**Death**

_**Percent reported**_
**8**
**7**
**6**
**0.1**
**18**
**0.2**

- Measles Complications

**Based on 1985-1992 surveillance data**

## Measles Complications by Age Group

## Measles Laboratory Diagnosis

**Isolation of measles virus from a clinical specimen (e.g., nasopharynx, urine)**
**Significant rise in measles IgG by any standard serologic assay (e.g., EIA, HA)**
**Positive serologic test for measles IgM antibody**

## Measles Epidemiology

**Reservoir****	****	**** Human**** **
**Transmission****	**** Respiratory****	****	****	****	****	****	****	****	**** Airborne**** **
**Temporal pattern****	**** Peak in late winter****–****spring**
**Communicability****	**** 4 days before to 4 days after****	****	****	****	**** rash onset**

## Vaccine Licensed

**Vaccine Licensed**

- Measles—United States, 1950-2005

## Measles—United States, 1980-2005

## Age Distribution of Reported Measles, 1975-2005

**5-19 yrs**

**<5 yrs**

_**>**_**20 yrs**

## Measles Resurgence—United States, 1989-1991

**Cases****	****	****	****	****   55,622**
**Age group affected****	****   Children <5 yrs**
**Hospitalizations****	****   >11,000**
**Deaths****	****	****	****   123**
**Direct medical costs  >$150 million**

## Measles 1993-2005

**Endemic transmission interrupted**
**Record low annual total in 2004****(37 total cases)**
**Many cases among adults**
**Most cases imported or linked to importation**

**Notes:**
 Endemic transmission believed to have been interrupted in 1996 or earlier.

## Measles Clinical Case Definition

**Generalized rash lasting >3 days, and**
**Temperature 101****°****F (>38.3****°****C), and**
**Cough or coryza or conjunctivitis**

## Measles Vaccines

**1965****	****	****Live further attenuated vaccine**
**1967****	****	****Killed vaccine withdrawn**
**1968****	****	****Live further attenuated vaccine**
**             ****	****(Edmonston-Enders strain)**
**1971****	****	****Licensure of combined measles-**
**              ****	****mumps-rubella vaccine**
**1989****	****	****Two dose schedule**
**2005****	****	****Licensure of MMRV**

## Measles Vaccine

**Composition****	****Live virus**
**Efficacy****	****	****95% (range, 90%-98%)**
**Duration of****Immunity****	****	****Lifelong**
**Schedule****	****	****2 doses**
**Should be administered with mumps and rubella as MMR, or with mumps, rub ella and v aricella as MMRV **

## MMRV (ProQuad)

**Combination measles, mumps, rubella and varicella vaccine**
**Approved children 12 months through 12 years of age (up to age 13 years)**
**Titer of varicella vaccine virus in MMRV is more than 7 times higher than standard varicella vaccine**

## MMR Vaccine Failure

**Measles, mumps, or rubella disease (or lack of immunity) in a previously vaccinated person**
**2%-5% of recipients do not respond to the first dose**
**Caused by antibody, damaged vaccine, record errors**
**Most persons with vaccine failure will respond to second dose**

## Measles (MMR) Vaccine Indications

**All children 12 months of age and older **
**Susceptible adolescents and adults without documented evidence of immunity**

## Measles Mumps Rubella Vaccine

**12 months is the recommended and minimum age**
**MMR given before 12 months should not be counted as a valid dose**
**Revaccinate at 12 months of age or older**

## Second Dose of Measles Vaccine

**Intended to produce measles immunity in persons who failed to respond to the first dose (primary vaccine failure)**
**May boost antibody titers in some persons**

## First dose of MMR at 12-15 months
Second dose of MMR at 4-6 years
Second dose may be given any time at least 4 weeks after the first dose

**Second dose of MMR at 4-6 years**
**Second dose may be given any time at least 4 weeks after the first dose**

- Second Dose of Measles Vaccine

## Adults at Increased Risk of Measles

**College students**
**International travelers**
**Healthcare personnel**

## Measles Immunity in Healthcare Personnel

**All persons who work in medical facilities should be immune to measles**

## Measles Immunity

**Born before 1957**
**Documentation of physician-diagnosed measles**
**Serologic evidence of immunity**
**Documentation of receipt of measles-containing vaccine**

## Measles VaccineIndications for Revaccination

**Vaccinated before the first birthday**
**Vaccinated with killed measles vaccine**
**Vaccinated prior to 1968 with an unknown type of vaccine**
**Vaccinated with IG in addition to a further attenuated strain or vaccine of unknown type**

## MMR Adverse Reactions

**Fever****	****	****	****	****  ****	****5%-15%**
**Rash****	****	****	****	****  ****	****5%**
**Joint symptoms****	****  ****	****	****25%**
**Thrombocytopenia****	****	****<1/30,000 ****doses**
**Parotitis****	****	****	****  ****	****rare**
**Deafness****	****	****	****  ****	****rare**
**Encephalopathy****	****  ****	****<1/1,000,000 ****doses**

## MMR Vaccine and Autism

**Measles vaccine connection first suggested by British gastroenterologist**
**Diagnosis of autism often made in second year of life**
**Multiple studies have shown no association**

## MMR Vaccine and Autism

**“****The evidence favors a rejection of a causal relationship at the population level between MMR vaccine and autism spectrum disorders (ASD).”**
**- Institute of Medicine, April 2001**

## MMR VaccineContraindications and Precautions

**Severe allergic reaction to vaccine component or following prior dose**
**Pregnancy**
**Immunosuppression**
**Moderate or severe acute illness**
**Recent blood product**

## Measles and Mumps Vaccines and Egg Allergy

**Measles and mumps viruses grown in chick embryo fibroblast culture**
**Studies have demonstrated safety of MMR in egg allergic children**
**Vaccinate without testing**

## Measles Vaccine and HIV Infection

**MMR recommended for persons with asymptomatic and mildly symptomatic HIV infection**
**NOT recommended for those with evidence of severe immuno- suppression**
**Prevaccination HIV testing not recommended**
**MMRV not approved for use in persons with HIV infection**

## Tuberculin Skin Testing (TST)* and Measles Vaccine

**Apply TST at same visit as MMR**
**Delay TST at least 4 weeks if MMR given first**
**Apply TST first and administer MMR when skin test read (least favored option because receipt of MMR is delayed)**** **

***previously called PPD**

## Vaccine Storage and HandlingMMR Vaccine

**Store ****35****o**** - 46****o****F (2****o**** - 8****o****C) (may be stored in the freezer)**
**Store diluent at room temperature or refrigerate**
**Protect vaccine from light**
**Discard if not used within 8 hours  reconstitution**

## Must be shipped to maintain a temperature of - 4oF (-20oC ) or colder at all times
Must be stored at an average temperature of 5oF (-15oC ) or colder at all times
May NOT be stored at refrigerator temperature at any time
Must be administered within 30 minutes of reconstitution

**Must be stored at an average temperature of 5****o****F (-15****o****C ) or colder at all times**
**May NOT be stored at refrigerator temperature at any time**
**Must be administered within 30 minutes of reconstitution**

- Vaccine Storage and HandlingMMRV Vaccine

## National Immunization ProgramContact Information

**Telephone****	****	****800.CDC.INFO**** **
**Email****	****	****	****nipinfo@cdc.gov**** **
**Website****	****	****www.cdc.gov/nip**