Measles and Measles VaccineEpidemiology and Prevention of Vaccine-Preventable Diseases

National Immunization ProgramCenters for Disease Control and PreventionRevised January 2006

Note to presenters:

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

MeaslesHighly contagious viral illnessFirst described in 7th centuryNear universal infection of childhood in prevaccination eraCommon and often fatal in developing areas

Measles VirusParamyxovirus (RNA)Hemagglutinin important surface antigenOne antigenic typeRapidly inactivated by heat and light

Measles PathogenesisRespiratory transmission of virusReplication in nasopharynx and regional lymph nodesPrimary viremia 2-3 days after exposureSecondary viremia 5-7 days after exposure with spread to tissues

Measles Clinical FeaturesIncubation period 10-12 days

Stepwise increase in fever to 103F or higherCough, coryza, conjunctivitisKoplik spotsProdrome

Measles Clinical Features2-4 days after prodrome, 14 days after exposureMaculopapular, becomes confluentBegins on face and headPersists 5-6 daysFades in order of appearanceRash

Measles ComplicationsConditionDiarrheaOtitis mediaPneumoniaEncephalitisHospitalizationDeath

Percent reported8760.1180.2Based on 1985-1992 surveillance data

Measles Complications by Age Group

Measles Laboratory DiagnosisIsolation 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 EpidemiologyReservoir Human Transmission Respiratory Airborne Temporal pattern Peak in late winterspring

Communicability 4 days before to 4 days after rash onset

Measles 1993-2004Endemic transmission interruptedRecord low annual total in 2004 (37 total cases)Many cases among adultsMost cases imported or linked to importation

Measles Clinical Case DefinitionGeneralized rash lasting >3 days, andTemperature 101F (>38.3C), andCough or coryza or conjunctivitis

Measles Vaccines1963Live attenuated and killed vaccines1965Live further attenuated vaccine1967Killed vaccine withdrawn1968Live further attenuated vaccine (Edmonston-Enders strain)1971Licensure of combined measles- mumps-rubella vaccine1989Two dose schedule2005Licensure of MMRV

Measles VaccineCompositionLive virusEfficacy95% (range, 90%-98%)Duration of ImmunityLifelongSchedule2 dosesShould be administered with mumps and rubella as MMR

MMRV (ProQuad)Combination measles, mumps, rubella and varicella vaccineApproved 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 FailureMeasles, mumps, or rubella disease (or lack of immunity) in a previously vaccinated person2%-5% of recipients do not respond to the first doseCaused by antibody, damaged vaccine, record errorsMost persons with vaccine failure will respond to second dose

Measles (MMR) Vaccine IndicationsAll infants >12 months of ageSusceptible adolescents and adults without documented evidence of immunity

Measles Mumps Rubella Vaccine12 months is the recommended and minimum ageMMR given before 12 months should not be counted as a valid doseRevaccinate at >12 months of age

Second Dose of Measles VaccineIntended to produce measles immunity in persons who failed to respond to the first dose (primary vaccine failure)May boost antibody titers in some persons

Second Dose RecommendationFirst dose of MMR at 12-15 monthsSecond dose of MMR at 4-6 yearsSecond dose may be given any time >4 weeks after the first dose

Adults at Increased Risk of MeaslesCollege studentsInternational travelersHealthcare personnel

Measles Immunity in Healthcare PersonnelAll persons who work in medical facilities should be immune to measles

Measles ImmunityBorn before 1957Documentation of physician-diagnosed measlesSerologic evidence of immunityDocumentation of receipt of measles-containing vaccine

Measles VaccineIndications for RevaccinationVaccinated before the first birthdayVaccinated with killed measles vaccineVaccinated prior to 1968 with an unknown type of vaccineVaccinated with IG in addition to a further attenuated strain or vaccine of unknown type

MMR Adverse ReactionsFever 5%-15%Rash 5%Joint symptoms 25%Thrombocytopenia

MMR Vaccine and AutismMeasles vaccine connection first suggested by British gastroenterologistDiagnosis of autism often made in second year of lifeMultiple studies have shown no association

MMR Vaccine and AutismThe 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 VaccineContraindications and PrecautionsSevere allergic reaction to vaccine component or following prior dosePregnancyImmunosuppressionModerate or severe acute illnessRecent blood product

Measles and Mumps Vaccines and Egg AllergyMeasles and mumps viruses grown in chick embryo fibroblast cultureStudies have demonstrated safety of MMR in egg allergic childrenVaccinate without testing

Measles Vaccine and HIV InfectionMMR recommended for persons with asymptomatic and mildly symptomatic HIV infectionNOT recommended for those with evidence of severe immuno- suppressionPrevaccination HIV testing not recommendedMMRV not approved for use in persons with HIV infection

PPD and Measles VaccineApply PPD at same visit as MMRDelay PPD >4 weeks if MMR given firstApply PPD firstgive MMR when skin test read

Vaccine Storage and HandlingMMR VaccineStore 35o - 46oF (2o - 8oC) (may be stored in the freezer)Store diluent at room temperature or refrigerateProtect vaccine from lightDiscard if not used within 8 hours reconstitution

Vaccine Storage and HandlingMMR VaccineMust be shipped to maintain a temperature of