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Measles is an acute, viral, infectious disease. References to 

measles can be found from as early as the 7th century. The 

disease was described by the Persian physician Rhazes in the 

10th century as “more to be dreaded than smallpox.”

In 1846, Peter Panum described the incubation period of 

measles and lifelong immunity after recovery from the disease. 

John Enders and Thomas Chalmers Peebles isolated the virus in 

human and monkey kidney tissue culture in 1954. The first live, 

attenuated vaccine (Edmonston B strain) was licensed for use in 

the United States in 1963. In 1971, a combined measles, mumps, 

and rubella (MMR) vaccine was licensed for use in the United 

States. In 2005, a combination measles, mumps, rubella, and 

varicella (MMRV) vaccine was licensed.

Before a vaccine was available, infection with measles virus 

was nearly universal during childhood, and more than 90% of 

persons were immune due to past infection by age 15 years. 

Measles is still a common and often fatal disease in developing 

countries. The World Health Organization estimates there were 

142,300 deaths from measles globally in 2018. In the United 

States, there have been recent outbreaks; the largest occurring 

in 2019 primarily among people who were not vaccinated. 

Measles Virus

The measles virus is a paramyxovirus of the genus Morbillivirus. 

It is 120 to 250 nm in diameter, with a genome of singlestranded, negative sense RNA, and is closely related to the 

rinderpest and canine distemper viruses. Two membrane 

envelope proteins are important in pathogenesis. They are the 

F (fusion) protein, which is responsible for fusion of virus and 

host cell membranes, viral penetration, and hemolysis, and the 

H (hemagglutinin) protein, which is responsible for binding of 

virus to receptors on host cells.

There is only one antigenic type of measles virus. Although 

studies have documented antigenic changes in the H protein, 

these changes do not appear to be epidemiologically important 

(i.e., no change in vaccine efficacy has been observed).

Measles virus is rapidly inactivated by heat, sunlight, acidic pH, 

ether, and trypsin.

Pathogenesis

Measles is a systemic infection. The primary site of infection 

is alveolar macrophages or dendritic cells. Two to three days 

after replication in the lung, measles virus spreads to regional 

lymphoid tissues followed by a systemic infection. Following 

further viral replication in regional and distal reticuloendothelial 

Paul Gastanaduy, MD; Penina Haber, MPH; Paul A. Rota, PhD; and Manisha Patel, MD, MS

Measles

● Acute viral infectious disease

● First described in 7th century

● Vaccines first licensed include

measles in 1963, MMR in 1971,

and MMRV in 2005

● Infection nearly universal

during childhood in

prevaccine era

● Still common and often fatal

in developing countries

Measles Virus

● Paramyxovirus (RNA)

● F (fusion) protein fuses virus

and host cell members and H

(hemagglutinin) protein binds

virus to host receptors

● One antigenic type

● Rapidly inactivated by heat,

sunlight, acidic pH, ether,

and trypsin

Measles Pathogenesis

● Primary site of infection is

alveolar macrophages or

dendritic cells

● Primary viremia 2 to 3 days

after replication

● Secondary viremia 5 to 7 days

after exposure

https://www.cdc.gov/vaccines/pubs/pinkbook/meas.html Aug 2021
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sites, a second viremia occurs 5 to 7 days after initial infection. 

During this phase, infected lymphocytes and dendritic cells 

migrate into the subepithelial cell layer and transmit measles to 

epithelial cells. Following amplification in the epithelia, the virus 

is released into the respiratory tract.

Clinical Features

The incubation period of measles from exposure to prodrome 

averages 11 to 12 days. The time from exposure to rash onset 

averages 14 days, with a range of 7 to 21 days.

The prodrome lasts 2 to 4 days, with a range of 1 to 7 days. 

It is characterized by fever, which increases in a stepwise 

fashion often peaking as high as 103°F to 105°F, cough, 

coryza, and conjunctivitis.

Koplik spots, present on mucous membranes, are considered 

to be unique to measles. They occur 1 to 2 days before the 

measles rash (i.e., during the prodromal period), and appear as 

punctate blue-white spots on the bright red background of the 

buccal mucosa.

The measles rash is a maculopapular eruption that usually 

lasts 5 to 6 days. It begins at the hairline, then involves the face 

and upper neck. During the next 3 days, the rash gradually 

proceeds downward and outward, reaching the hands and feet. 

The maculopapular lesions are generally individually distinct 

but may run together, particularly on the upper body. Initially, 

lesions blanch (become white or pale) with fingertip pressure. 

By 3 to 4 days, most do not blanch with pressure. The lesions 

peel off in scales in more severely involved areas. The rash fades 

in the same order that it appears, from head to extremities.

Other symptoms of measles include anorexia and 

generalized lymphadenopathy.

Complications

Approximately 30% of measles cases in the United States from 

1987 to 2000 were reported to have one or more complications. 

Complications include diarrhea, otitis media, pneumonia, 

encephalitis, subacute sclerosing panencephalitis, and death. 

Complications of measles were most common among children 

younger than age 5 years and adults.

Laboratory Testing

The most widely used methods for laboratory confirmation of 

measles are detection of measles virus RNA in nasopharyngeal 

aspirates, throat swabs, or urine by reverse transcriptase 

polymerase chain reaction (RT-PCR) or detection of measles 

specific IgM in serum samples by enzyme immunoassay (EIA). 

Measles Complications

● Diarrhea, otitis media,

pneumonia, encephalitis,

subacute sclerosing

panencephalitis, death

● Most common among children

younger than age 5 years

and adults

Measles Clinical Features

● Incubation period 11 to 12 days

■ Exposure to rash onset

averages 14 days (range,

7 to 21 days)

● Prodrome lasts 2 to 4 days

(range, 1 to 7 days)

■ Stepwise increase in fever

to 103°F–105°F

■ Cough, coryza, and

conjunctivitis

■ Koplik spots (on mucous

membranes)

● Rash

■ Persists 5 to 6 days

■ Begins at hairline, then

involves face and

upper neck

■ Proceeds downward

and outward to hands and

feet

■ Severe areas peel

off in scales

■ Fades in order

of appearance
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Collection of both a throat swab specimen for RT-PCR and a 

serum specimen for IgM detection is recommended from all 

patients with clinical features compatible with measles. 

Clinical specimens for viral detection should be collected 

at the same time as samples taken for serologic testing. In 

addition to RT-PCR for diagnosis, viral genotyping performed 

by state public health laboratories or CDC can help to track the 

transmission pathways of measles virus. Specimens for viral 

detection should be shipped to a state public health laboratory 

or CDC (at the direction of the state health department).

Laboratory testing can confirm the presence of measles 

vaccine virus in a recently vaccinated and potentially 

exposed individual.

Epidemiology

Occurrence

Measles occurs throughout the world. Interruption of 

indigenous transmission of measles was declared in the 

United States in the year 2000 and in other parts of the 

Western Hemisphere in 2016. However, outbreaks with 

sustained measles virus transmission have recently occurred in 

Venezuela and Brazil, leading to re-establishment of endemic 

transmission in these countries and loss of measles elimination 

in the Americas.

Reservoir

Measles is a human disease. There is no known animal reservoir, 

and an asymptomatic carrier state has not been documented.

Transmission

Measles transmission occurs person-to-person via large 

respiratory droplets and via airborne transmission of 

aerosolized droplet nuclei in closed areas (e.g., an office 

examination room) for up to 2 hours after a person with 

measles occupied the area.

Temporal Pattern

In endemic, temperate areas, measles disease occurs primarily 

in late winter and spring.

Communicability

Measles is highly communicable, with more than 90% 

secondary attack rates among exposed susceptible persons in 

close-contact settings. Measles is considered transmissible from 

4 days before through 4 days after rash onset. 

Measles Epidemiology

● Reservoir

■ Human

● Transmission

■ Person-to-person via large 

respiratory droplets

■ Airborne in closed areas for 

up to 2 hours

● Temporal pattern

■ Primarily late winter 

and spring

● Communicability

■ 4 days before through 

4 days after rash onset
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Secular Trends in the United States

Before 1963, approximately 500,000 cases and 500 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. More than 50% of persons 

had measles by age 6 years, and more than 90% by age 15 

years. In the years following licensure of vaccine in 1963, 

the incidence of measles decreased by more than 95%, and 

2- to 3-year epidemic cycles no longer occurred. From 1985 

through 1988, 68% of cases in school-aged children (age 5 to 

19 years) occurred among those who had been appropriately 

vaccinated – i.e., had received a single dose of measles 

vaccine as recommended. The occurrence of measles among 

previously vaccinated children (i.e., vaccine failure) led to a 

recommendation for a second dose in this age group in 1989.

In 2019, 13 outbreaks of measles were reported, accounting for 

663 cases; six were associated with underimmunized close-knit 

communities and accounted for 88% of all cases. Before 2019, 

the highest number of measles cases following elimination 

in the United States occurred in 2014 when 667 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 longstanding vaccination program has prevented outbreaks form 

imported cases. 

Among children born during 2016–2017, 90.7% received 

measles, mumps, and rubella-containing vaccine by age 24 

months; this was not statistically significantly different from 

the coverage of 90.3% for children born during 2014–2015.

Measles Vaccines

In 1963, both an inactivated (“killed”) and a live, attenuated 

(Edmonston B strain) measles vaccine were licensed for use in 

the United States. The inactivated vaccine was withdrawn in 

1967 because it did not protect well against measles. The original 

Edmonston B vaccine was withdrawn in 1975 because of a 

relatively high frequency of fever and rash in recipients. A live, 

further attenuated (Schwarz strain) vaccine was first introduced 

in 1965, but also is no longer used in the United States. Another 

live, further attenuated strain (Edmonston-Enders strain) vaccine 

was licensed in 1968. These further attenuated vaccines caused 

fewer reactions than the original Edmonston B vaccine. In 1971, 

measles vaccine was licensed as a combined measles, mumps, 

and rubella (MMR) vaccine. In 2005, a combination measles, 

mumps, rubella, and varicella (MMRV) vaccine was licensed. 

Measles vaccine is available as measles, mumps, and rubella 

vaccine (MMR [MMR-II]) and measles, mumps, rubella, and 

varicella vaccine (MMRV [ProQuad]). Both MMR and MMRV 

Measles Vaccines

● MMR (MMR-II)

● MMRV (ProQuad)

Measles Secular Trends 

in the United States

● About 500,000 reported cases 

and 500 deaths annually 

before vaccine

■ Actual cases estimated at 

3 to 4 million

● Following vaccine licensure in 

1963, incidence decreased 

by over 95%

● Measles occurrence among 

vaccinated school-aged 

children in the 1980s led to 

recommendations for a 

second dose

● In 2019, 13 outbreaks reported; 

underimmunized communities 

accounted for 88% of cases
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vaccine contain live, attenuated viruses. Single-antigen measles 

vaccine is not available in the United States. The Advisory 

Committee on Immunization Practices (ACIP) recommends that 

MMR or MMRV vaccine be used when any of the individual 

components is indicated.

Characteristics 

MMR vaccine is a lyophilized preparation of measles virus 

vaccine live, an attenuated line of measles virus, derived from 

Enders’ attenuated Edmonston strain and propagated in chick 

embryo cell culture; mumps virus vaccine live, the Jeryl Lynn 

strain of mumps virus propagated in chick embryo cell culture; 

and rubella virus vaccine live, the Wistar RA 27/3 strain of live 

attenuated rubella virus propagated in WI-38 human diploid 

lung fibroblasts. MMRV vaccine contains measles, mumps, and 

rubella virus of equal titer and identical to those in the MMR 

vaccine. The titer of Oka varicella zoster virus is higher in MMRV 

vaccine than in single-antigen varicella vaccine, a minimum of 

9,772 plaque-forming units (PFU) versus 1,350 PFU, respectively. 

MMR and MMRV vaccines are supplied as a lyophilized 

(freeze-dried) powder and are reconstituted with sterile, 

preservative-free water. Both vaccines contain gelatin. MMR and 

MMRV vaccines are administered by the subcutaneous route. 

Each dose of MMR and MMRV vaccine contains neomycin as an 

antibiotic. It contains no adjuvant or preservative. 

Vaccination Schedule and Use

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. For the first dose 

of measles, mumps, rubella, and varicella vaccines at age 12 

Measles Vaccine Characteristics

● Live, attenuated vaccine

● Available as lyophilized powder 

and reconstituted with sterile, 

preservative-free water

● Administered by subcutaneous 

injection

● Contains gelatin

● Contains neomycin

Measles Vaccination Schedule

● 2-dose series at age 12 through 

15 months and at age 4 through 

6 years

● Minimum age for dose 1 is 12 

months

● Minimum interval from dose 1 

to 2 is 4 weeks for MMR and 3 

months for MMRV (although a 

4-week interval is valid)

● Discuss risks and benefits of 

MMRV versus separate MMR and 

VAR 

■ Separate MMR and VAR 

vaccines preferred for dose 1 

in ages 12 through 47 months

■ MMRV preferred for dose 2 

and dose 1 at age 48 months 

or older
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through 47 months, either separate MMR and varicella (VAR) 

vaccines, or MMRV vaccine, may be used. However, the risk of 

febrile seizures is about twice as high for children receiving 

MMRV vaccine versus separate MMR and VAR vaccines. Providers 

who are considering administering MMRV should discuss the 

benefits and risks of both vaccination options with the parents. 

Unless the parent or caregiver expresses a preference for MMRV, 

separate MMR vaccine and VAR vaccine should be administered 

for the first dose in this age group. 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.e., MMR vaccine and VAR vaccine). 

Vaccination of Adults

Adults born in 1957 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 1957 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 1957 

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. This recommendation 

is based on serologic studies indicating that among hospital 

personnel born before 1957, 5% to 10% had no detectable 

measles, mumps, or rubella antibody. Adequate vaccination for 

health care personnel born during or after 1957 consists of 2 

appropriately spaced MMR doses for measles and mumps, and 

at least 1 dose of MMR for rubella.

MMR Vaccination of Adults

● Certain persons without 

acceptable presumptive 

immunity:

■ At least 1 dose MMR for 

unvaccinated adults

■ 2 doses MMR for students 

entering colleges, universities, 

technical and vocational 

schools, and other posthigh-school educational 

institutions

■ 2 doses MMR for measles 

and mumps and 1 dose MMR 

for rubella for healthcare 

personnel

● Healthcare personnel during 

an outbreak

■ 2 doses MMR for measles or 

mumps outbreak and 1 dose 

MMR for rubella outbreak
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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

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 1963 

through 1967 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.g., for international 

travel) should not be counted as part of the 2-dose series. 

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.e., the dose does 

not count) unless they have other acceptable current evidence 

of immunity. MMR series should be administered once effective 

cART has been established for at least 6 months and there is no 

evidence of severe immunosuppression.

Measles Immunity

Generally, persons can be considered immune to measles 

if they were born before 1957, 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 Vaccination of Travelers

● Adequate vaccination for 

persons traveling outside the 

United States

■ 1 dose MMR for children age 

6 through 11 months

■ 2 doses of age appropriate 

MMR or MMRV for children 

age 12 months and older 

and adults 

Measles Immunity

● Born before 1957

● Serologic evidence of measles 

immunity (equivocal tests are 

considered negative)

● Laboratory confirmation 

of disease

● Documentation of adequate 

vaccination for measles
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Immunogenicity and Vaccine Efficacy

Measles antibodies develop in approximately 95% of children 

vaccinated at age 12 months. Seroconversion rates are similar 

for single-antigen measles, MMR vaccine, and MMRV vaccine. 

Approximately 2% to 7% of children who receive only 1 dose of 

MMR vaccine fail to respond to it, i.e., they experience primary 

vaccine failure. 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. Studies indicate that more than 99% of 

persons who receive 2 doses of measles vaccine (with the first 

dose administered no earlier than the first birthday) develop 

serologic evidence of measles immunity.

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.

Contraindications and Precautions 

to Vaccination

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. 

MMR and MMRV vaccines both contain minute amounts of 

neomycin and gelatin. Persons with alpha-gal allergy may 

wish to consult their physician before receiving a vaccine that 

contains gelatin.

Severe immunocompromise (e.g., from hematologic and solid 

tumors, receipt of chemotherapy, congenital immunodeficiency, 

long-term immunosuppressive therapy or patients with 

HIV infection who are severely immunocompromised) is a 

contraindication for MMR and MMRV vaccination. If the person’s 

level of immunocompetence is uncertain, the decision to 

vaccinate should be made by the health care provider that 

prescribed the immunosuppressive medication for those 

Measles Vaccine Efficacy 

● Antibodies develop in 

approximately 95% of children 

vaccinated at age 12 months 

and over 99% of children who 

receive 2 doses

● Immunity long-term and 

probably lifelong in 

most persons

Measles Vaccine Contraindications 

● Contraindication

■ Severe allergic reaction 

to vaccine component or 

following a prior dose

■ Severe immunocompromise

■ Systemic high-dose 

corticosteroid therapy for 14 

days or more

■ HIV infection, regardless of 

immunocompetence status*

■ Family history of congenital 

or heredity immunodeficiency 

in first-degree relatives

■ Pregnancy

*MMRV only
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patients whom immunocompromise is due to medication. 

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. MMR 

vaccine is recommended for susceptible HIV-infected 

persons age 12 months or older with no evidence of current 

severe immunosuppression (“no evidence of current severe 

immunosuppression” is defined as CD4 percentages greater 

than or equal to 15% for 6 months or longer for persons age 5 

years or younger; and CD4 percentages greater than or equal 

to 15% and CD4 count greater than or equal to 200 cells/mm3

for 6 months or longer for persons older than age 5 years). 

MMR vaccine is not recommended for HIV-infected persons 

with evidence of severe immunosuppression. 

MMRV is not approved for and should not be administered to a 

person known to be infected with HIV.

A family history of congenital or hereditary immunodeficiency 

in first-degree relatives (e.g., parents and siblings) is a 

contraindication for MMR or MMRV vaccine, unless the immune 

competence of the potential vaccine recipient has been 

substantiated clinically or verified by a laboratory.

A history of thrombocytopenic purpura or thrombocytopenia 

is a precaution for MMR and MMRV vaccine. Such persons 

may be at increased risk for developing clinically significant 

thrombocytopenia after MMR or MMRV vaccination. 

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. 

Measles Vaccine Precautions 

● Precaution

■ Moderate or severe acute 

illness

■ Alpha-gal allergy (consult 

with physician)

■ Receipt of antibodycontaining blood products 

(wait 3 to 11 months 

to vaccinate)

■ History of thrombocytopenic 

purpura or thrombocytopenia

■ Need for tuberculin skin 

testing or interferon-gamma 

release assay testing

■ Simultaneous use of aspirin or 

aspirin-containing products*

■ Personal or family history of 

seizures of any etiology*

■ Receipt of specific antiviral 

drugs 24 hours before 

vaccination*

*MMRV only
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A personal or family (i.e., sibling or parent) history of seizures 

of any etiology is a precaution for MMRV vaccine but not MMR. 

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.

Spacing Considerations

The effect of the administration of antibody-containing blood 

products (e.g., immune globulin, whole blood or packed 

red blood cells, or intravenous immune globulin) on the 

response to MMR or MMRV vaccine is unknown. 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.

Need for tuberculin skin testing or interferon-gamma release 

assay (IGRA) testing is a precaution for MMR and MMRV 

vaccine. 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.g., acyclovir, famciclovir, 

or valacyclovir) 24 hours before vaccination is a precaution for 

MMRV vaccine due to the varicella component. These drugs 

should be avoided for 14 days after vaccination.

Vaccination in Pregnancy

Pregnancy is a contraindication for MMR or MMRV vaccine. 

Pregnancy should be avoided for 4 weeks following MMR or 

MMRV vaccine. Close contact with a pregnant woman is not a 

contraindication to MMR or MMRV vaccination of the contact.
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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. 

Vaccine Safety

Studies have shown MMR and MMRV vaccines are safe and 

well-tolerated. The National Academy of Medicine, formerly 

called the Institute of Medicine, reviewed the evidence 

between MMR vaccination and certain adverse events. 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. After MMR vaccination, 5% to 15% of susceptible 

persons develop a temperature of 103°F (39.4°C) or higher, 

usually occurring 7 to 12 days after vaccination and generally 

lasting 1 or 2 days. 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 3,000 

to 4,000 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.

MMR vaccine may cause a transient rash in approximately 

5% of vaccine recipients, usually appearing 7 to 10 days after 

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 1.8 to 14.4 cases per 

million doses. 

Arthralgias and other joint symptoms are reported in up 

to 25% of adult women following MMR vaccination and 

are associated with the rubella component. Transient 

lymphadenopathy sometimes occurs following receipt of 

MMR or other rubella-containing vaccine, and parotitis has 

been reported rarely (less than 1%) following receipt of MMR 

or other mumps-containing vaccine. 

Rarely, MMR vaccine may cause thrombocytopenia within 

two months after vaccination. The clinical course of these 

Measles Vaccine Safety

MMR

● Fever of 103°F (39.4°C) 

or higher

■ 5%–15%

● Rash

■ 5%

● Febrile seizures

■ 1 in every 3,000 to 4,000 

doses

● Anaphylactic reactions

■ 1.8 to 14.4 cases per million 

doses

● Arthralgias and other joint 

symptoms

■ 25% (adult women)

MMRV

● Fever of 102°F or higher

■ 21.5%

● Febrile seizures

■ 1 additional per 2,300 to 

2,600 children age 12 

through 23 months
204

Measles

 13

cases is usually transient and benign, although hemorrhage 

occurs rarely. Based on case reports, the risk for MMR vaccineassociated 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. 

In MMRV vaccine prelicensure studies conducted among 

children age 12 to 23 months, fever (reported as abnormal or 

elevated greater than or equal to 102°F oral equivalent) was 

observed 5 to 12 days after vaccination in 21.5% of MMRV 

vaccine recipients compared with 14.9% of MMR vaccine and 

VAR vaccine recipients. Two postlicensure studies indicated that 

one additional febrile seizure per 2,300 to 2,600 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.

Multiple studies, as well as a National Academy of Medicine 

Vaccine Safety Review, refute a causal relationship between 

autism and MMR vaccine or between inflammatory bowel 

disease and MMR vaccine. 

Vaccine Storage and Handling

For MMR-II and Proquad storage and handling specifics, refer 

to the manufacturer. For complete information on storage and 

handling best practices and recommendations, please refer 

to CDC’s Vaccine Storage and Handling Toolkit, www.cdc.gov/

vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf. 

Surveillance and Reporting for Measles

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, www.cdc.gov/

vaccines/pubs/surv-manual/chapters.html.
Measles

205

13

Acknowledgements

The editors would like to acknowledge Jennifer Hamborsky and 

Valerie Morelli for their contributions to this chapter.

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NOTES