Version May 2024
Note: The same product (ie, M-M-R II or Priorix) should be used for all doses in the primary vaccination series; however, products are interchangeable if the first vaccine product cannot be determined or is unavailable (Ref). The minimum interval between 2 doses of MMR vaccine is 28 days (Ref).
Immunization: IM, SUBQ: ~0.5 mL (entire contents of reconstituted vial) per dose; 1 or 2 doses administered at least 28 days apart based upon the following criteria (Ref):
Adults born in or after 1957 should be vaccinated with ≥1 dose unless they have acceptable evidence of immunity.
Adults born prior to 1957 are considered immune to measles, mumps, and rubella but may be vaccinated with 1 or 2 doses if they do not have contraindications to the vaccine. Pregnant adults born prior to 1957 are not considered immune to rubella.
Adults who received inactivated or unknown type of measles vaccine during 1963 to 1967: One or two doses of MMR.
Adults who received inactivated or unknown type of mumps vaccine before 1979 and who are at high risk: Two doses of MMR.
Health care personnel: Persons born in or after 1957 should have 2 doses of vaccine unless they have acceptable evidence of immunity. Unvaccinated persons born prior to 1957 should also consider vaccination with 2 doses of MMR for measles and mumps or 1 dose of MMR for rubella unless they have laboratory evidence or laboratory confirmation of disease (Ref).
HIV infection (without severe immunosuppression): Two doses of MMR unless there is acceptable evidence of immunity.
Household/close contacts of immunocompromised persons: Two doses of MMR unless there is acceptable evidence of immunity.
International travelers: Two doses of MMR prior to travel unless there is acceptable evidence of immunity.
Measles, mumps, or rubella outbreak (community): Adults who received 1 dose of MMR should be considered for a second dose if the outbreak involves measles or mumps in adults. Vaccination should also be considered for persons born prior to 1957 without evidence of immunity who may be exposed to mumps. A single dose of a rubella-containing vaccine is considered adequate vaccination during a rubella outbreak. During a mumps outbreak, a third dose of MMR vaccine is recommended for at-risk persons who have been previously vaccinated with 2 doses (Ref); consult local public health authorities.
Measles, mumps, or rubella outbreak (healthcare facility): Unvaccinated health care personnel without evidence of immunity regardless of birth year should receive 2 doses during a measles or mumps outbreak and one dose during a rubella outbreak.
Students: Persons entering post high school educational facilities should receive 2 doses of MMR unless they have acceptable evidence of immunity prior to enrollment.
Women of childbearing potential: One dose of MMR unless they have acceptable evidence of immunity. Vaccination should not be given during pregnancy and pregnancy should be avoided for 28 days after vaccine administration.
There are no dosage adjustments provided in manufacturer's labeling.
There are no dosage adjustments provided in manufacturer's labeling.
(For additional information see "Measles, mumps, and rubella vaccines (MMR) (combined): Pediatric drug information")
Note: The same product (ie, MMR II or Priorix) should be used for all doses in the primary vaccination series; however, products are interchangeable if the first vaccine product cannot be determined or is unavailable (Ref). The minimum interval between 2 doses of MMR vaccine is 28 days (Ref). Refer to Additional Information for a description of acceptable evidence of immunity. Consult CDC/ACIP annual immunization schedules for additional information, including specific detailed recommendations for catch-up scenarios and/or care of patients with high-risk conditions. According to ACIP, doses administered ≤4 days before minimum interval or age are considered valid; however, local or state mandates may supersede this timeframe (Ref).
Primary immunization: Children: IM (MMR II only), SUBQ: ~0.5 mL (entire contents of reconstituted vial) per dose for 2 doses, with the first dose administered at 12 to 15 months of age and the second dose at 4 to 6 years of age. The second dose is recommended prior to entering kindergarten or first grade and may be administered at any time ≥28 days after the first dose (Ref).
Note: Patients with HIV without evidence of severe immunosuppression should receive 2 doses of MMR vaccine consistent with primary immunization recommendations. If a person with perinatal HIV infection was vaccinated before effective antiretroviral therapy was initiated, they should be revaccinated with 2 doses spaced ≥28 days apart once effective antiretroviral therapy has been established, unless they have other acceptable evidence of immunity to measles, mumps, and rubella (Ref).
Catch-up immunization: Children and Adolescents: IM (MMR II only), SUBQ: ~0.5 mL (entire contents of reconstituted vial) per dose for 2 total doses given ≥28 days apart (Ref).
International travel, without evidence of immunity or previous vaccination:
Infants ≥6 months: IM (MMR II only), SUBQ: ~0.5 mL (entire contents of reconstituted vial) per dose as a single dose before departure from the United States. Patients should be vaccinated again at ≥12 months of age with standard 2-dose series, with ≥28 days between doses (Ref).
Children and Adolescents: IM (MMR II only), SUBQ: ~0.5 mL (entire contents of reconstituted vial) per dose for 2 doses administered ≥28 days apart before departure from the United States (Ref).
Measles outbreak without acceptable evidence of immunity and at risk for exposure: Note: Should be administered within 72 hours postexposure.
Infants ≥6 months: IM (MMR II only), SUBQ: ~0.5 mL (entire contents of reconstituted vial) per dose as a single dose. Patients should be vaccinated again at ≥12 months of age with standard 2-dose series, with ≥28 days between doses (Ref).
Children <4 years who have previously received 1 dose of MMR: IM (MMR II only), SUBQ: ~0.5 mL (entire contents of reconstituted vial) per dose for a single dose ≥28 days after the first dose if the outbreak involves preschool-aged children (Ref).
Mumps outbreak (eg, community):
Children <4 years who have previously received 1 dose of MMR (without acceptable evidence of immunity and at risk for exposure): IM (MMR II only), SUBQ: ~0.5 mL (entire contents of reconstituted vial) per dose for a single dose ≥28 days after the first dose if the outbreak involves preschool-aged children (Ref).
Children and Adolescents (fully immunized [2 previous MMR doses]); community outbreak: IM (MMR II only), SUBQ: A third dose of MMR vaccine (~0.5 mL [entire contents of reconstituted vial]) may be considered as directed by public health officials (Ref); in a large cohort trial (N=20,496; treatment cohort: n=4,783; age range: 18 to 24 years), subjects who received a third dose of MMR vaccine had significantly decreased incidence of mumps compared to subjects who had only received 2 doses (Ref); consult local public health authorities.
There are no dosage adjustments provided in the manufacturer's labeling.
There are no dosage adjustments provided in the manufacturer's labeling.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Adverse reactions reported in children, adolescents, and adults unless otherwise indicated.
>10%:
Gastrointestinal: Anorexia (children: 21% to 45%)
Local: Injection-site reaction (including erythema at injection site [12% to 25%], localized vesiculation, pain at injection site [12% to 41%], swelling at injection site [6% to 11%])
Nervous system: Drowsiness (children: 27% to 45%), irritability (children: 63%)
Miscellaneous: Fever (3% to 35%)
1% to 10%:
Dermatologic: Morbilliform rash (children: ≤7%), rubella-like rash (children: ≤7%)
Neuromuscular & skeletal: Arthralgia (≤2%), arthritis (≤2%)
<1%:
Gastrointestinal: Parotitis, sialadenitis
Neuromuscular & skeletal: Neck stiffness
Frequency not defined:
Dermatologic: Pruritus, skin rash, Stevens-Johnson syndrome, urticaria
Gastrointestinal: Diarrhea, nausea, pancreatitis, sore throat, vomiting
Hematologic & oncologic: Leukocytosis, lymphadenopathy (regional), purpuric disease
Hypersensitivity: Angioedema, hypersensitivity angiitis (acute hemorrhagic edema of infancy), nonimmune anaphylaxis
Infection: Atypical measles, measles inclusion body encephalitis
Nervous system: Acute disseminated encephalomyelitis, dizziness, encephalopathy, headache, malaise, neuritis (polyneuritis), paresthesia, polyneuropathy, seizure (including febrile seizures), subacute sclerosing panencephalitis
Neuromuscular & skeletal: Myalgia, panniculitis
Ophthalmic: Conjunctivitis, oculomotor nerve paralysis, optic neuritis, optic papillitis, retinitis
Respiratory: Bronchospasm, cough, pneumonia, pneumonitis, rhinitis
Postmarketing:
Cardiovascular: Kawasaki syndrome, syncope, vasculitis
Dermatologic: Erythema multiforme
Genitourinary: Epididymitis, orchitis
Hematologic & oncologic: Henoch-Schnolein purpura, immune thrombocytopenia, thrombocytopenia
Hypersensitivity: Anaphylaxis
Nervous system: Cerebellar disorder (cerebellitis; including abnormal gait and ataxia), encephalitis, Guillain-Barré syndrome, meningitis, peripheral neuritis, transverse myelitis
M-M-R II: Hypersensitivity to measles, mumps, and/or rubella vaccine or any component of the formulation (including gelatin and neomycin); active febrile illness (fever >38.5°C [>101.3°F]); untreated tuberculosis (TB) disease (active TB); immunosuppressed or immunodeficient individuals due to disease or medical therapy; pregnancy.
Priorix: Hypersensitivity to measles, mumps, and/or rubella vaccine or any component of the formulation; severe humoral or cellular (primary or acquired) immunodeficiency; pregnancy.
Concerns related to adverse effects:
• Anaphylactoid/hypersensitivity reactions: Immediate treatment (including epinephrine 1 mg/mL) for anaphylactoid and/or hypersensitivity reactions should be available during vaccine use (ACIP [Kroger 2023]).
• Febrile seizures: Febrile seizures have been reported within 2 weeks following immunization with MMR vaccine; risk is increased in those who experienced previous febrile seizure from any cause and those with family history of febrile seizures.
• Shoulder injury related to vaccine administration: Vaccine administration that is too high on the upper arm may cause shoulder injury (eg, shoulder bursitis, tendinopathy) resulting in shoulder pain and reduced range of motion following injection. Use proper injection technique for vaccines administered in the deltoid muscle (eg, injecting in the central, thickest part of the muscle) to reduce the risk of shoulder injury related to vaccine administration (Cross 2016; Foster 2013).
• Syncope: Syncope has been reported with use of injectable vaccines and may result in serious secondary injury (eg, skull fracture, cerebral hemorrhage); typically reported in adolescents and young adults and within 15 minutes after vaccination. Procedures should be in place to avoid injuries from falling and to restore cerebral perfusion if syncope occurs (ACIP [Kroger 2023]).
Disease-related concerns:
• Acute illness: The decision to administer or delay vaccination because of current or recent febrile illness depends on the severity of symptoms and the etiology of the disease. Defer administration in patients with moderate or severe acute illness (with or without fever). Although fever is a contraindication per the manufacturer, current guidelines allow for administration to patients with mild acute illness (without fever) (ACIP [Kroger 2023]; CDC/ACIP [McLean 2013]).
• CNS disorders: Use with caution in patients with history of cerebral injury, seizures, or other conditions where stress due to fever should be avoided.
• Measles exposure: Exposure to measles is not a contraindication to vaccine; use within 72 hours of exposure may provide some protection.
• Mumps exposure: Postexposure vaccination has not been shown to prevent or alter disease following mumps exposure (CDC/ACIP [McLean 2013]).
• Rubella exposure: Postexposure vaccination has not been shown to prevent or alter disease following rubella exposure (CDC/ACIP [McLean 2013]).
• Thrombocytopenia: Thrombocytopenia (transient) has been reported 4 to 6 weeks after vaccination; use with caution in patients with thrombocytopenia and those who developed thrombocytopenia after a previous dose.
• Tuberculosis: Defer vaccination in patients with untreated tuberculosis (TB) disease (active TB).
Concurrent drug therapy issues:
• Immune globulins: Recent administration of immune globulins may interfere with immune response. Guidelines with suggested administration intervals are available (ACIP [Kroger 2023]).
• Vaccines: In order to maximize vaccination rates, the ACIP recommends simultaneous administration (ie, >1 vaccine on the same day at different anatomic sites) of all age-appropriate vaccines (live or non-live) for which a person is eligible at a single visit, unless contraindications exist. The use of combination vaccines is generally preferred over separate injections, taking into consideration provider assessment, patient preference, and potential adverse events. When using combination vaccines, the minimum age for administration is the oldest minimum age for any individual component; the minimum interval between dosing is the greatest minimum interval between any individual components. The ACIP prefers each dose of a specific vaccine in a series come from the same manufacturer when possible; however, vaccination should not be deferred because a specific brand is unavailable (ACIP [Kroger 2023]).
Special populations:
• Altered immunocompetence: Use is contraindicated in severely immunocompromised patients. The ACIP does not recommend vaccination for persons with primary or acquired immunodeficiency (including immunosuppression associated with cellular immunodeficiency, hypogammaglobulinemia, dysgammaglobulinemia and AIDs, or severe immunosuppression associated with HIV); persons with blood dyscrasia, leukemia, lymphoma, or other malignant neoplasms which affect the bone marrow or lymphatic system; persons with a family history of congenital or hereditary immunodeficiency in first degree relatives (unless immunocompetence can be established); persons taking systemic corticosteroid therapy for ≥2 weeks in doses of corticosteroids ≥2 mg/kg of body weight or prednisone (or equivalent) ≥20 mg/day for persons who weigh >10 kg. Patients with HIV infection, who are asymptomatic and not severely immunosuppressed may be vaccinated (severe immunosuppression is defined as CD4+ T-lymphocyte <15% at any age or CD4 count <200 lymphocytes/mm3 for persons >5 years) (CDC/ACIP [McLean 2013]). Patients with leukemia, lymphoma, or other malignancies who are in remission, have restored immunocompetence, and who have not received chemotherapy for at least 3 months may be vaccinated. In general, household and close contacts of persons with altered immunocompetence may receive all age-appropriate vaccines (ACIP [Kroger 2023]).
Dosage form specific issues:
• Albumin: Some products may contain human albumin.
• Egg allergy: Vaccine may contain trace amounts of chick embryo antigen. Use caution in patients with history of immediate hypersensitivity/anaphylactic reactions following egg ingestion. Generally, the MMR vaccine can be safely administered to persons with an egg allergy (ACIP [Kroger 2023]).
• Gelatin: Some products may contain gelatin. Use is contraindicated in patients with a history of anaphylactic/anaphylactoid reaction to gelatin.
• Latex: Some products packaging (needle cover of prefilled diluent syringe) may contain latex.
• Neomycin sensitivity: Some products may be manufactured with neomycin. Use is contraindicated in patients with history of anaphylactic/anaphylactoid reactions to neomycin. Contact dermatitis due to neomycin is not a contraindication to the vaccine.
Other warnings/precautions:
• Antipyretics: Antipyretics have not been shown to prevent febrile seizures; antipyretics may be used to treat fever or discomfort following vaccination (ACIP [Kroger 2023]). One study reported that routine prophylactic administration of acetaminophen prior to vaccination to prevent fever decreased the immune response of some vaccines; the clinical significance of this reduction in immune response has not been established (Prymula 2009).
• Appropriate use: Use of this vaccine for specific medical and/or other indications (eg, immunocompromising conditions, hepatic or kidney disease, diabetes) is also addressed in the annual ACIP Recommended Immunization Schedules (refer to CDC schedule for detailed information). Specific recommendations for vaccination in immunocompromised patients with asplenia, cancer, HIV infection, cerebrospinal fluid leaks, cochlear implants, hematopoietic stem cell transplant (prior to or after), sickle cell disease, solid organ transplant (prior to or after), or those receiving immunosuppressive therapy for chronic conditions as well as contacts of immunocompromised patients are available from the IDSA (Rubin 2014).
• Blood products: Recent administration of blood or blood products may interfere with immune response. Guidelines with suggested administration intervals are available (ACIP [Kroger 2023]).
• Effective immunity: Vaccination may not result in effective immunity in all patients. Response depends upon multiple factors (eg, type of vaccine, age of patient) and may be improved by administering the vaccine at the recommended dose, route, and interval. Vaccines may not be effective if administered during periods of altered immune competence (ACIP [Kroger 2023]).
• Risk of vaccine virus transmission: Rubella vaccine virus can be detected in nose and throat of vaccinated individuals for 7 to 28 days after vaccination.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, powder for reconstitution [preservative free]:
M-M-R II: Measles virus ≥1000 TCID50, mumps virus ≥12,500 TCID50, and rubella virus ≥1000 TCID50 [contains albumin (human), bovine serum, chicken egg protein, gelatin, neomycin, sorbitol, and sucrose 1.9 mg/vial; supplied with diluent]
Priorix: Measles virus ≥3.4 log10, mumps virus ≥4.2 log10, and rubella virus ≥3.3 log10 [contains bovine serum albumin, chicken egg protein, lactose, mannitol, neomycin sulfate, ovalbumin, sorbitol; supplied with diluent]
No
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, powder for reconstitution:
M-M-R II: Measles virus ≥1,000 CCID50, mumps virus ≥5,000 CCID50, and rubella virus ≥1,000 CCID50 [contains albumin (human), bovine serum, neomycin, sorbitol, sucrose; supplied with diluent]
Priorix: Measles virus ≥103 CCID50 3, mumps virus ≥103.7 CCID50 3, and rubella virus ≥103 CCID50 3 [contains chicken egg protein, lactose, mannitol, neomycin sulfate, sorbitol; supplied with diluent]
M-M-R II: IM, SUBQ: Administer by IM or SUBQ injection; not for IV administration. Do not mix with other vaccines or injections; separate needles and syringes should be used for each injection. To prevent syncope-related injuries, patients should be vaccinated while seated or lying down (Ref). US law requires that the date of administration, the vaccine manufacturer, lot number of vaccine, Vaccine Information Statement (VIS) edition date and date it was provided, and the administering person's name, title, and address be recorded.
Priorix: SUBQ: SUBQ administration preferred; may also be given by IM (Canadian product only) injection in the anterolateral aspect of the thigh or the deltoid muscle; do not administer intravascularly. Do not mix with other vaccines or injections; separate needles and syringes should be used for each injection. To prevent syncope-related injuries, patients should be vaccinated while seated or lying down (Ref). US law requires that the date of administration, the vaccine manufacturer, lot number of vaccine, Vaccine Information Statement (VIS) edition date and date it was provided, and the administering person's name, title, and address be recorded.
Parenteral: Administer as soon as possible following reconstitution. Do not mix with other vaccines or injections; separate needles and syringes should be used for each injection. To prevent syncope-related injuries, adolescents should be vaccinated while seated or lying down (Ref). US law requires that the date of administration, the vaccine manufacturer, lot number of vaccine, Vaccine Information Statement (VIS) edition date and date it was provided, and the administering person's name, title, and address be recorded.
MMR II: IM, SUBQ: Administer IM into the higher anterolateral aspect of the thigh or the outer aspect of the upper arm (deltoid muscle) or SUBQ over the anterolateral thigh or into the upper arm, over the triceps area; not for IV administration (Ref).
Priorix: SUBQ: SUBQ administration preferred (typically over the anterolateral thigh or into the upper arm, over the triceps area); may also be given by IM injection (Canadian product only) in the anterolateral aspect of the thigh or the deltoid muscle; do not administer intravascularly (Ref).
In the United States, the appropriate CDC-approved Vaccine Information Statement (VIS) must be provided to the patient/caregiver before administering each dose of this vaccine; the VIS edition date and date it was provided to the patient/caregiver should be recorded as required by US law; VIS is available at http://www.cdc.gov/vaccines/hcp/vis/vis-statements/mmr.html.
Measles, mumps, and rubella prevention: Active immunization for simultaneous vaccination against measles, mumps, and rubella in patients ≥12 months of age
The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination for the following (CDC/ACIP [McLean 2013]):
• All children (first dose given at 12 to 15 months of age)
• Adults born in 1957 or later (without evidence of immunity or documentation of vaccination). Vaccine may be given to adults born prior to 1957 if they do not have contraindications to the MMR vaccine.
• Adults at higher risk for exposure to and transmission of measles, mumps, and rubella should receive special consideration for vaccination, unless an acceptable evidence of immunity exists. This includes international travelers, persons attending colleges and other post high school education, persons working in health care facilities.
MMR (measles, mumps and rubella virus vaccine) may be confused with MMRV (measles, mumps, rubella, and varicella) vaccine
MMR (measles, mumps and rubella virus vaccine) may be confused with MCV (meningococcal conjugate vaccine; MCV4 is the correct abbreviation)
The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs that have a heightened risk of causing significant patient harm when used in error.
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Acetaminophen: May diminish the therapeutic effect of Vaccines. Management: Consider avoiding routine prophylactic use of acetaminophen before or during vaccine administration when possible. Acetaminophen is still recommended to treat fevers and/or pain that occurs after vaccination. Risk D: Consider therapy modification
Anti-CD20 B-Cell Depleting Therapies: May enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Anti-CD20 B-Cell Depleting Therapies may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination
Corticosteroids (Systemic): May enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination
Dimethyl Fumarate: May enhance the adverse/toxic effect of Vaccines (Live). Specifically, Dimethyl Fumarate may increase the risk of vaccinal infection. Dimethyl Fumarate may diminish the therapeutic effect of Vaccines (Live). Management: Non-US labeling for dimethyl fumarate states that live attenuated vaccine administration is not recommended during treatment. US labeling states that safety and effectiveness of live vaccines administered with dimethyl fumarate has not been assessed. Risk C: Monitor therapy
Dupilumab: May enhance the adverse/toxic effect of Vaccines (Live). Risk X: Avoid combination
Elivaldogene Autotemcel: May enhance the adverse/toxic effect of Vaccines. Specifically, there may be a greater risk for contracting an infection from any live vaccine. Elivaldogene Autotemcel may diminish the therapeutic effect of Vaccines. Management: Administration of vaccines is not recommended in the 6 weeks before myeloablative conditioning, and until hematologic recovery after elivaldogene autotemcel treatment. Risk X: Avoid combination
Etrasimod: May enhance the adverse/toxic effect of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Etrasimod may diminish the therapeutic effect of Vaccines (Live). Risk X: Avoid combination
Immune Globulins: May diminish the therapeutic effect of Vaccines (Live). Management: Live organism vaccination should be withheld for as long as 6 to 11 months following immune globulin administration. Recommendations vary by product and immune globulin dose, see full monograph for details. Risk D: Consider therapy modification
Immunosuppressants (Cytotoxic Chemotherapy): May enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination
Immunosuppressants (Miscellaneous Oncologic Agents): Mumps- Rubella- or Varicella-Containing Live Vaccines may enhance the adverse/toxic effect of Immunosuppressants (Miscellaneous Oncologic Agents). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination
Immunosuppressants (Therapeutic Immunosuppressant Agents): May enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination
Leniolisib: May diminish the therapeutic effect of Vaccines (Live). Risk C: Monitor therapy
Methotrexate: May enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Methotrexate may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination
Propacetamol: May diminish the therapeutic effect of Vaccines. Management: Consider avoiding routine prophylactic use of propacetamol before or during vaccine administration when possible. Propacetamol is still recommended to treat fevers and/or pain that occurs after vaccination. Risk D: Consider therapy modification
Rabies Immune Globulin (Human): May diminish the therapeutic effect of Vaccines (Live). Management: Avoid administering the measles vaccine within 4 months after administration of rabies immune globulin. Avoid administering other live vaccines within 3 months after administration of rabies immune globulin. Risk D: Consider therapy modification
Rho(D) Immune Globulin: May diminish the therapeutic effect of Measles, Mumps, and Rubella Virus Vaccine. Management: Do not delay administration of the measles, mumps, and rubella virus vaccine in women who have recently received Rho (D) immune globulin. If possible, women should be tested 3 or more months after vaccine administration to ensure immunity. Risk D: Consider therapy modification
Teplizumab: May enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Teplizumab may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination
Teplizumab: May enhance the adverse/toxic effect of Vaccines (Live). Specifically, the risk of vaccines-associated infection may be increased. Teplizumab may diminish the therapeutic effect of Vaccines (Live). Risk X: Avoid combination
Tezepelumab: May enhance the adverse/toxic effect of Vaccines (Live). Risk X: Avoid combination
Tildrakizumab: May enhance the adverse/toxic effect of Vaccines (Live). The risk for contracting an infection from the vaccine may be increased. Tildrakizumab may diminish the therapeutic effect of Vaccines (Live). Risk X: Avoid combination
Tralokinumab: May enhance the adverse/toxic effect of Vaccines (Live). Risk X: Avoid combination
Tuberculin Tests: Vaccines (Live) may diminish the diagnostic effect of Tuberculin Tests. Management: It is preferable to administer live vaccines simultaneously with tuberculin tests. If a live vaccine has been recently administered, the tuberculin skin test should be administered 4 to 6 weeks following the administration of the vaccine. Risk D: Consider therapy modification
Vaccines (Live): May diminish the therapeutic effect of other Vaccines (Live). Management: Two or more injectable or nasally administered live vaccines not administered on the same day should be separated by at least 28 days (ie, 4 weeks). If not, the vaccine administered second should be repeated at least 4 week later. Risk C: Monitor therapy
Patients who could become pregnant without documentation of rubella vaccination or serologic evidence of immunity should be vaccinated (for patients who could become pregnant, birth prior to 1957 is not acceptable evidence of immunity to rubella). Pregnancy should be avoided for 1 month following vaccination.
In unvaccinated patients, natural mumps infection may cause sterility in males and infertility in prepubescent females (CDC/ACIP [McLean 2013]).
Use of the measles, mumps, and rubella (MMR) vaccine is contraindicated during pregnancy because the risk to the fetus following maternal vaccination with a live vaccine cannot be ruled out. Vaccination prior to pregnancy prevents maternal measles, mumps, and rubella infection as well as congenital rubella syndrome (CRS). Patients should avoid pregnancy for 1 month following vaccination. The risk of CRS following vaccination is significantly less than the risk associated following natural infection; therefore, inadvertent administration of MMR during pregnancy is not considered an indication to terminate pregnancy (CDC/ACIP [McLean 2013]; WHO 2020).
Rubella vaccine virus can cross the placenta; the mumps vaccine virus has been detected in the placenta (Preblud 1981; Yamauchi 1974). Antibodies against measles, mumps, and rubella are present in cord blood following maternal vaccination as well as natural maternal infection (Muthiah 2021).
Based on available data, the risk of major congenital anomalies or miscarriage are not increased above the estimated background rates following maternal vaccination. A case report describes CRS following maternal vaccination with the MMR vaccine (Bouthry 2023). However, data from large registries collected over many years have not previously identified cases of CRS following inadvertent administration of a rubella-containing vaccine to pregnant patients (Laris-González 2020; Sukumaran 2015; WHO 2020).
Adverse consequences of natural infection in unvaccinated pregnant patients have been reported. Measles infection during pregnancy may increase the risk of premature labor, preterm delivery, spontaneous abortion, and low birth weights. Maternal mumps infection during the first trimester may increase the risk of spontaneous abortion or intrauterine fetal death. Rubella infection during the first trimester may lead to miscarriages, stillbirths, and congenital rubella syndrome (includes auditory, ophthalmic, cardiac and neurologic defects; intrauterine and postnatal growth retardation). Following maternal infection, fetal rubella infection can occur during any trimester of pregnancy (CDC/ACIP [McLean 2013]). When maternal rubella infection occurs just prior to conception or up to the first 10 weeks of gestation, stillbirth and multiple congenital anomalies may occur in up to 90% of pregnancies (WHO 2020).
Prenatal screening is recommended for all pregnant patients who lack evidence of rubella immunity. Patients who are pregnant should be vaccinated upon completion or termination of pregnancy, prior to discharge. Rho(D) immune globulin is not expected to interfere with an immune response to the MMR vaccine. Treatment should not be withheld in patients planning to be vaccinated or who recently received the vaccine. Household contacts of pregnant patients may be vaccinated (CDC/ACIP [McLean 2013]; WHO 2020).
Lactating patients may secrete the rubella component of the vaccine into breast milk. It is not known if the measles or mumps components of the vaccine are found in breast milk.
Serologic evidence of rubella infection has occurred in breastfed infants following maternal immunization. In infants with serological evidence of rubella infection, severe disease is generally not exhibited; however, mild clinical illness typical of acquired rubella has been reported.
According to the manufacturer, the decision to breastfeed following immunization should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and the benefits of vaccination to the mother. Breastfeeding is not a contraindication to vaccination. Breastfeeding infants should be vaccinated according to the recommended schedules (ACIP [Kroger 2023]).
Monitor for anaphylaxis and syncope for 15 minutes following administration (ACIP [Kroger 2023]). If seizure-like activity associated with syncope occurs, maintain patient in supine or Trendelenburg position to reestablish adequate cerebral perfusion.
As a live, attenuated vaccine, MMR vaccine offers active immunity to disease caused by the measles, mumps, and rubella viruses.
Onset of action: The median seroconversion after 1 vaccine dose is 96% (measles), 99% (rubella), mumps (94%) (CDC/ACIP [McLean 2013]).
Duration: The median duration of immunity after 2 doses is ≥15 years for all components of the vaccine (CDC/ACIP [McLean 2013]).
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