Measles is an acute, highly communicable viral disease with prodromal fever, conjunctivitis, coryza, cough, and Koplik spots on the buccal mucosa. A characteristic red blotchy rash appears around the third day of illness, beginning on the face and becoming generalized. Measles is frequently complicated by middle ear infection or diarrhea. The disease can be severe, with bronchopneumonia or brain inflammation leading to death in about 2 of every 1,000 cases.
Prior to widespread immunization, measles was common in childhood, with more than 90% of infants and children infected by 12 years of age. Since vaccine licensure in 1963, measles elimination efforts in the United States have resulted in record low numbers of reported measles cases. Fewer than 1,000 measles cases have been reported annually since 1993. Many of these cases were imported from outside the United States and occurred among adults; roughly half occurred in U.S. residents returning from visits to foreign countries. The risk of exposure to measles in the United States is low. Unvaccinated people can reach older ages still susceptible to measles.
Risk for Travelers
The risk of exposure to measles outside the United States could be high. Measles remains a common disease in many countries of the world, including some developed countries in Europe and Asia.
Measles vaccine contains live, attenuated measles virus. It is available as a single antigen preparation or combined with live, attenuated mumps or rubella vaccines, or both. Combined measles, mumps, and rubella (MMR) is recommended whenever one or more of the individual components are indicated.
Although vaccination against measles, mumps, or rubella is not a requirement for entry into any country (including the United States), people traveling or living abroad should ensure that they are immune to all three diseases. In general, travelers can be considered immune to measles if they have documentation of physician-diagnosed measles, laboratory evidence of measles immunity, or proof of receipt of two doses of live measles vaccine on or after their first birthday. Most people born before 1957 are likely to have had measles disease and generally need not be considered susceptible. However, measles or MMR vaccine may be given to these people if there is reason to believe they might be susceptible.
The first dose of MMR should be routinely administered when the infant is 12 to 15 months of age. A single dose of MMR vaccine induces antibody formation to all three viruses in at least 95% of susceptibles vaccinated at 12 months of age or older. A second dose is expected to induce immunity in most vaccinees who do not respond to the first dose. The second dose should be separated from the first dose by a minimum of 28 days.
MMR may be administered simultaneously (but in a different site) with any other live or inactivated vaccine. Inactivated vaccines and typhoid vaccines may be administered at any time before or after live measles-containing vaccine. However, if MMR vaccine and live yellow fever vaccine are not administered simultaneously, they should be separated by an interval of at least 28 days.
Fever and rash are the most common adverse reactions following MMR vaccine, and are usually attributable to the measles component. About 5% of vaccinees develop fever >39.4° Celsius (>103° Fahrenheit) or a generalized rash. Fever and rash usually occur 7 to 12 days following vaccination and last for 1 or 2 days. Transient lymphadenopathy sometimes occurs following MMR and is attributable to the rubella component. Parotitis has been reported rarely following MMR and is attributable to the mumps component of the vaccine. Joint symptoms (arthralgia or arthritis, or both) are reported in up to 25% of rubella-susceptible postpubertal women who receive MMR or other rubella-containing vaccine. Joint symptoms are usually mild and transient. Allergic reactions have been reported following MMR vaccine, and range from mild (urticaria or wheal and flare at the injection site,ic reactions are estimated to occur less than once per million doses. Clinically apparent low platelet counts have been reported at a rate of less than 1 case per 30,000 doses. Central nervous system conditions, including aseptic meningitis, encephalitis, and encephalopathy, have been reported following MMR, but are very uncommon (less than one case per million doses).
Adverse reactions occur only in susceptible vaccinees and do not appear to be age related. Reactions following the second dose of MMR (except allergic reactions) occur only among the small proportion of people who do not respond to the first dose.
Precautions and Contraindications
Allergy.--People with severe allergy (that is, hives, swelling of the mouth or throat, difficulty breathing, hypotension, and shock) to gelatin or neomycin, or who have had a severe allergic reaction to a prior dose of MMR, should not be vaccinated with MMR except with extreme caution.
In the past, people with a history of anaphylactic reactions following egg ingestion were considered to be at increased risk of serious reactions after receipt of measles- and mumps-containing vaccines, which are produced in chick embryo fibroblasts. However, recent data suggest that anaphylactic reactions to measles- and mumps-containing vaccines are not associated with hypersensitivity to egg antigens, but to other components of the vaccines (such as gelatin). The risk for serious allergic reactions following receipt of these vaccines by egg-allergic people is extremely low and skin testing with vaccine is not predictive of allergic reaction to vaccination. MMR may be administered to egg-allergic people without prior routine skin testing or the use of special protocols.
Pregnancy.--Women known to be pregnant should not receive MMR vaccine. Pregnancy should be avoided for 1 month following receipt of monovalent measles vaccine and 4 weeks following MMR or other rubella-containing vaccines. Close contact with pregnant women is not a contraindication to MMR vaccination of the contact (that is, the person who will be in close proximity to the pregnant woman).
Breast-feeding is not a contraindication to MMR vaccination of either a woman or an infant. MMR vaccination has no effect on antibiotics or antimalarial drugs, and the drugs do not reduce the immunogenicity of MMR. Women taking these products should be vaccinated as usual.
Immunosuppression.--Replication of vaccine viruses can be prolonged in people who are immunosuppressed or immunodeficient for any reason (for example, who have congenital immunodeficiency, human immunodeficiency virus [HIV] infection, leukemia, lymphoma, or generalized malignancy, or who are receiving therapy with alkylating agents, antimetabolites, radiation, or large doses of corticosteroids). Evidence based on case reports has linked measles vaccine virus infection to subsequent death in six severely immunosuppressed people. For this reason, people who are severely immunosuppressed for any reason should not be given MMR vaccine. Healthy, susceptible close contacts of severely immunosuppressed people may be vaccinated.
In general, people receiving large daily doses of corticosteroids (>2 milligrams per kilogram [mg/kg] per day or >20 mg per day of prednisone) for 14 days or more should not receive MMR vaccine because of concern about vaccine safety. MMR and its component vaccines should be avoided for at least one month after cessation of high-dose therapy. People receiving low-dose or short-course (less than 14 days) therapy; alternate-day treatment; maintenance physiologic doses; or topical, aerosol, intra-articular, bursal, or tendon injections may be vaccinated. Although people receiving high doses of systemic corticosteroids daily or on alternate days during an interval of less than 14 days generally can receive MMR or its component vaccines immediately after cessation of treatment, some experts prefer waiting until 2 weeks after completion of therapy.
People receiving cancer chemotherapy or radiation who have not received these treatments for at least 3 months may receive MMR or its component vaccines.
Measles disease can be severe in people with HIV infection. Available data indicate that vaccination with MMR has not been associated with severe or unusual adverse events in HIV-infected people without evidence of severe immunosuppression, although antibody responses have been variable. MMR vaccine is recommended for all asymptomatic HIV-infected people and should be considered for symptomatic people who are not severely immunosuppressed. Asymptomatic HIV-infected infants, children, and adolescents do not need to be evaluated and tested for HIV infection before MMR or other measles-containing vaccines are administered. A theoretical risk of an increase (probably transient) in HIV viral loading following MMR vaccination exists because such an effect has been observed with other vaccines. The clinical significance of such as increase is not known.
MMR and other measles-containing vaccines are not recommended for HIV-infected people with evidence of severe immunosuppression (for example, people with a very low CD4+ T-lymphocyte count), primarily because of the report of a case of measles pneumonitis in a measles vaccinee who had an advanced case of acquired immunodeficiency syndrome (AIDS). Refer to the Advisory Committee on Immunization Practices (ACIP) statement on MMR for additional details on vaccination of people with symptomatic HIV infection.
Acute Illness.--Vaccination of travelers with moderate or severe acute illness should be postponed until their condition has improved. Minor illnesses, such as upper respiratory infections with or without low-grade fever, do not preclude vaccination.
Immune Globulin (IG) or Other Antibody-Containing Blood Products.--MMR or its component vaccines should be administered at least 14 days before the administration of antibody-containing blood products, such as immune globulin (IG). Because passively acquired antibodies might interfere with the response to the vaccine, MMR should be delayed following administration of blood products. The length of delay varies from 3 to 11 months, depending on the type of blood product received.
Tuberculosis.--Tuberculosis can be exacerbated by measles disease. There is no evidence, however, that live measles virus vaccine has such an effect. Purified protein derivative (PPD) tuberculin testing is not a prerequisite for vaccination with MMR or other measles-containing vaccine. PPD testing has no effect on the response to MMR vaccination. However, measles vaccine (and possibly mumps, rubella, and varicella vaccines) can suppress the response to PPD in a person infected with Mycobacterium tuberculosis. To minimize the risk of a false-negative interpretation, PPD testing should be delayed for 4 to 6 weeks after MMR vaccination. If PPD testing is needed, it should be done prior to MMR vaccination. It is also acceptable to apply the PPD and administer MMR simultaneously, because the mild immunosuppressive effect of the vaccine will not occur for several days after vaccination.
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